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advantage — early application — I am free to con- fess that there are very many cases in which a strict execution of this systematic bath method is impossible or not indicated. If the principles of the method are understood and followed, any method of cold bathing may be usefully applied. What are these principles? It is a trite and long-accepted fact in physiology that cold is an irritant to the sensory terminals in the skin, and that, like all irritants, when ap- plied in mild form, it stimulates these sensory terminals, and when applied in more intense form it depresses, and that the stimulation or depres- sion evoked by cold is conveyed to the central nervous system, and thence reflected upon the organs which derive their functionating capacity from the latter. A brief application of cold water to the skin acts as a stimulant ; voltaren 100 mg retard a prolonged applica- tion acts as a depressant ; botli effects being in exact proportion to the degree of cold and to the extent of surface attacked. The truth of this physiological principle, and the correctness of the practice based upon it, is daily exemplified and clearly demon- strated in the familiar management of the still-born voltaren ec tablets 50mg infant. In a mild case simple sprinkling with inod- erately cold water suffices to arouse the flagging vitality ; in more pronounced cases a dip into cold water restores the almost inanimate creature: and, if these measures are inadequate, we resort to still colder water, or we render the skin more sensitive to the latter by alternate dipping into water of a high and low temperature. The resultant effect of these applications is one of the first lessons the med- ical student le^Trns in physiology and therapeutics, and yet mirahile dictii their self-evident application in the management of the typhoid fever patient is of comparatively recent date, and still calls for fre- quent insistence. For twenty years have I empha- sized that these trite pliysiological principles are the basis, and form the rationale of all water treatment in all diseases in which it is indicated. It is not men, nor is it methods, that I advocate, but princi- ples, accepted physiological principles. Applied to the management of the disease under consideration to-night, what effects are evoked by the cold bath ? Is so voltaren for sale heroic a measure expedient or necessarv when milder measures have proved effective? 'J"liese are important questions, and thev arc answered by strict voltaren 50mg diclofenac application of the principles involved and briefly re- cited above. Granted that they are correct, and that the reflex stimulating effects of cold water elicited in the still- born infant and its similar effect in svncope are undeniable as they are in that other and essentially different toxic depression of the nervous svstem encountered in opium poisonintr. it cannot be difificnlt to appreciate how the stimulating and sustaining effect of properly graded or dosed baths, or other water procedures, arouse the blunted nerve centers in typhoid fever, how the whole machinery of the depreciated organism is thereby revived, how the ai)athetic countenance brightens, the eye resumes its lost luster, how the breathing is deepened and the blood thus better oxygenated, how the heart, en- feebled by the toxic depression of its nerve supply, responds under the refreshing impulses, and how the secretions and excretions are thus revived. There are other equally important results arising from the local thermic stimulation of the cutaneous arterioles, enhanced as they are by the mechanica' stimulation of friction, which must never be omitted in any cold application. It has been shown by several voltaren 75 sr laboratory experi- ments that the Eberth bacillus not only exerts its baneful depressing influence upon the central nervous system, but that it manifests a somewhat specific depreciating and enfeebling influence upon the peripheral arterioles. To the latter may be ascribed that relaxed and sluggish condition of the cutaneous arterioles which is manifested in the deadly pallor of the skin of the trunk, in the feeble and dicrotic and compressible pulse, in the hypo- static congestions, ulcerations voltaren rapid 25mg of Peyer's glands, etc. These are the result of more or less cardiac inadequacy ; the resistance at the periphery being diminished, the vasomotor system is crippled, thus suffering at both ends. The voltaren ec 75 mg heart is called voltaren in canada uf)on to compensate for this failure at the periphery by increased action ; the pulse is accelerated, but the arteries do not fill, as is but too evident in the com- pressibility of the radial artery. In mild cases the self-regulating machinery of the organism readjusts itself; in severe cases heart failure, with all its dire effects, ensues ; stimulants fail because the nerve centers have voltaren topical lost their re- sponsive capacity, and the physician stands appalled in this trying emergency ; too often is he helpless to rescue the patient who, perhaps, in the earlier stages has been promising of better results. In such emergencies I have long ago asked myself the question, "Cannot these fatal heart voltaren xr 100 mg fail- ures be prevented?" Brand has answered this ques- tion in the affirmative. The ideal cold bath devised bv him is a preventive measure, and not a symp- tomatic one. Cold baths must not be regarded as cooling procedures — a fallacy arising from recrard- ing h\perpyre.xia a prominent cause of death in typhoid fever. The latter has been proven to be due to the toxemia. Cold baths prevent lethal com- plications by reason of their snstaininf^ effects upon the central nervous and circulatory systems. Let this truth become the ruling idea in typhoid fever, and let the accepted truth that therapeutic results are in proportion to the dosage of the remedial agent be added, and the aggreeate outcome of this mucli-to-be-desired consummation will be a rational application and consequent cessation of disputes ahout modes of voltaren sr 75 mg tablet bathing. Whether the ideal Brand bath is to be adopted in the concrete case, or some milder method, whether so-called sponging, ablu- tion, affusion, compresses, packs, whole baths or half baths, brief or prolonged, higher or lower tem- peratures are to be applied, must depend upon the individual case. There must be reaction, that is, refreshment, and not depression, following each application : the sum total of these must inure to the sustenance of the depreciated nerve centers, and thev must be adapted to t'lc voltaren in usa case with the same intellisjence as are diet and medication. By food, nutrition is sustained to pre- vent starvation ; hv baths, nerve force must be sus- Oct. 13, 1906] MEDICAL RECORD. 5O3 tained to prevent exhaustion. Both are prophylactic measures to enhance the patient's resisting capacity. The strict Brand method lias proven its elhcieiicy by the largest and most reliable statistics e.xtant in medicine, and it is based upon a correct rationale ; for this reason it became the leading treatment in hospitals. It has not remained popular, because its splendid reduction of mortality was obtained first in military hospitals, in which its most important elements — early application and systematic execution — were not difficult. When this method was applied on a large scale in civil hospitals, the same results were not attained, because in the latter typhoid cases are usually admitted after the fifth day, oftener after the first or second week. Nevertheless, the cold bath has proven an efficient aid, changing the mortality statistics and affording such comfort to the physician, who modified it in accordance with the stage generic name for voltaren of the disease, which, as is well known, changes the responsive capacity of the patient. This is the reason why the Brand bath has fallen into desuetude in Germany. Its strict application is not •adapted to the latter stages of tlie ilisease, unless if has been used with good results in the early stages. And this is the reason why this bath is better adapted for private than for civil hospital practice. If the principles here enunciated regarding the physiological action of the cold bath, and its prophylactic nerve-refreshing and heart-sustaining effect are borne in mind by the physician, he will be- gin with mild measures — ablutions, affusions, baths of go° F. reduced every four hours one or more degrees, until the temperature of the Brand bath, 70° F., is reached. ,-\nd if the bath is administered with friction for fifteen minutes, and repeated only voltaren ec readily yielded to a much more rational line of treatment. It is voltaren sr 100mg not always wise, therefore, to assume that, because a tumor appears in an organ which is known to be susceptible to can- cer, it is necessarily of a malignant type. There may be a possibility certainly — though the probabil- ity is remote — that, later on. it may develop malig- nancy. It is. I am sure, because this mistake in diagnosis is so frequently made that we hear occa- sionally of nonrecurrence after operation. Un the other hand, when the diagnosis has proved to have been correct, and the tumor to be cancer, recurrence is inevitable, and, 1 venture to add, it will be difiicuit to contest this assertion, for the cogent reason that it is a fact. How can it be otherwise, when wc know that in the majority of instances an injury is the exciting cause voltaren xr 100mg of cancer — the predisposing cause being so far latent in each instance — and when we realize that a much greater injury is infiicted by the mutilation of the parts, which is generic for voltaren necessarily the accompaniment of an operation of such magnitude? Is it not very suggestive that the recurrence invari- ably voltaren xr 100 manifests its presence primarily in the weakest structure, viz., the cicatrix, and thence radiates to the enfeebled tissues in its immediate neighborhood? Having admittedly such ample evidence of the mis- chief tlie knife inflicts in malignant disease, and knowing that in no instance can it hold out more than the remotest prospect of conferring any lasting benefit, but on the contrary shortens life and aggravates suffering, how can any right-think- ing man deceive both himself and his patients by having recourse to it? No; our line of duty points to our employing unremitting effort to dis- cover a more rational method of dealing with this formidable disease. In our endeavor, then, to attain this
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