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The next step is the dripping sheet. The patient standing in a tub of water at 100° F. has a sheet dip ped in water at 70° thrown over his head and body from behind and is wrapped completely and snugly in it. The attendant now rapidly passes his outstretched hands over successive parts of the body, with some pressure upon the sheet. He rubs the sheet, not with the sheet. One or more pitchers of water, five to ten degrees colder, are thrown upon the parts that have been subjected to friction. The sheet is removed and the patient rapidly dried. This method requires great care and skilful application. Its success or failure depends upon ascertaining by previous treatment the reactive capacity of the patient. The most useful hydriatic procedure in phthisis, however, is the rain bath. Unfortunately, this finely-divided douche can only be administered in institutions. The patient stands within a frame constructed of six semi-circles of inch tubing, the upper one on a line with the clavicles. Each tube has three lines of fine perforations, the upper line directed upward, the middle straight forward, the lower downward. The water should have a fall of not less than forty feet. The temperature adapted to the average case of phthisis is 65° F. Here the pressure with which the water strikes the body affords a kind of massage which assists in producing reaction even in feeble individuals. But it should not be applied without previous training of the skin as above described. The rain-bath is an antipyretic of great value, if its temperature is not below 60° nor above 70°; it is a stimulant and tonic if between 55° and 65°F. The skin should become pink while under it, and the patient must not be chilled by it; at least any coldness he may experience should disappear after he is dried. This, indeed, is a test of the efficiency of all hydriatic procedures. Decided chilliness continuing after thorough drying and friction is an evidence of improper selection of the temperature, duration or method of the bath. These should be modified as indicated by their effects.
The following cases taken from the records of the Montefiore Home, by Dr. M. Rosenthal, the senior resident physician, may serve as an illustration of the clinical results of this treatment:
J. J., tailor, æt 33, German; admitted February 2, 1890.-Family history negative. Illness of one and one-half years' duration. Began with a Began with a pulmonary hemorrhage, followed by cough; spat blood two days and felt better after it. Continued to cough until December, 1889, when he had a most severe hemorrhage, became very weak and was confined to bed. Continues weak; cannot work; coughs a great deal; expectorates a little mucus, often mixed with blood. Complains of pains in back, tickling in larynx ; appetite is good, bowels regular. Physical signs.-Dulness over right upper lobe, as far as first rib, posteriorly to border of scapula; slight dulness,
March 27.-Weight, 152.
April 5.-No complaint. Weight 156.
May 5.-In the last few days appetite is not so good; otherwise feels very comfortable. Coughs sometimes in the morning; no expectoration. Weight, 160.
Dr. Dessau examined patient to-day. He found : Very slight broncho-vesicular respiration in the left apex. Impaired resonance on percussion over the same, and very few mucous râles. On the left below the scapula very few subcrepitant râles, probably due to some old pleuritic adhesions.
May 11.-Right apex, vesicular respiration and very slight impaired resonance, which is often found normally in right chest, so that practically we can find now only a very slight infiltration of left apex with some old pleuritic adhesions.
Weight, 161 (a gain of 26 pounds).
Discharged at his own request. He has been at work since that time.
I. D., aged 36 years. ill two years and a half. Had hemorrhage two years ago; since then night-sweats, cough, expectoration and pain in left side. Has been treated twice at Mount Sinai Hospital for phthisis.
Physical Signs.-On admission dulness over left apex, impaired breathing; pleuritic friction râles on right side along auxiliary space. Weight, 1624 pounds. Treatment.-General sustaining measures, with daily rain-bath at 65° for thirty seconds; damp compresses to chest.
Result.-Improvement of all symptoms, and gain of fourteen pounds and a half during ten weeks.
December 16, 1890.-He was subjected to tuberculin treatment until April 29, other treatment being suspended. The reactions were accompanied by marked changes in the physical signs, several times amounting to positive evidence of localized pneumonia, with temperature of 104°; bronchial respiration and voice over left apex to third rib, and sibillant râles over right chest anteriorly. These usually disappeared in forty-eight hours.
The patient lost so much weight and general appearance that I frequently felt misgivings as to the
propriety of subjecting him to the experiment. The rain-baths were resumed, and his general condition at once improved and appetite returned. At the present time there is no cough, the least amount of expectoration, and but few pleuritic friction sounds over left apex. His weight is 178 pounds. Dr. Hodenpyl, who kindly examined all sputa, reported: First examination, about 10 bacilli to the field; second examination, very few bacilli; third, fourth and fifth examinations, no bacilli.
This patient may be regarded as recovered, judging from the physical signs, subjective symptoms, his general condition and the absence of bacilli.
He steadily lost in flesh and strength and appetite until he resumed the rain-baths, when he again began to improve until he gained seven pounds over his weight just before the injections, and twenty-one pounds over his weight on entering. He was discharged on July 14, weighing 183 pounds, and is looking for work.
H. S., aged 31, admitted May 2, 1890. Family history negative; always well until May, 1889, when he had first pulmonary hemorrhage; was confined to bed eight weeks with cough, night-sweats and afternoon fevers. In September, 1889, and January, 1890, he had hemorrhages and went to Mount Sinai Hospital, whence he was discharged improved in seven weeks. He had cough, expectoration and pain in the chest; no appetite when admitted.
Physical Examination.-Dullness over right third anteriorly and posteriorly; subscrepitant and friction râles; broncho-vesicular respiration with prolonged expiration. On left side prolonged expiration with with some friction sounds over left apex. Weight 1293 pounds.
August, 1890.-Sputum found to contain bacilli. In September, 1880, he had a hemorrhage. During this time he received rain-baths, syrup of the hypophosphites and creosote; at times cod liver oil. Under this treatment he steadily improved, so that when he was subjected to tuberculin injections, on December 16, 1890, heweighed 146 pounds-a gain of 16 pounds in six months and a half-and no bacilli were found by Dr. Hodenpyl in his sputum. There were still, however, dullness over right apex, broncho-vesicular respiration and subscrepitant râles. His temperature was 90°. April 15 tuberculin injec
There being no tubercle bacilli in the sputum and no cough or expectoration, and the physical signs being only a slight, jerky respiration, he was discharged as cured April 29, weighing 149 pounds. He has there
fore increased twenty pounds since his admission, and 3 pounds since injections were begun, during the ontinuance of which he lost very considerably He is now at work in Bronxville, N. Y.
Physical Examination revealed impaired resonance over left apex, jerky, exaggerated respiration, fine, moist and pleuritic râles. Bacilli abundant in the sputum. Weight 126 pounds on January 5, when she was subjected to tuberculin injections.
She received 21 injections, progressively increased. They were always followed by decided febrile reaction. The last injection of 45 milligrammes was administered on the 1st of April, and was followed by very slight reaction. During the entire treatment she had daily rain-baths.
April 10.--Cough, expectoration, night-sweats and physical signs have ceased; her weight increased to 132 pounds, and, no bacilli being found in the sputum, she was discharged at her own request as cured.
She is now working as a private nurse, feeling perfectly well.
In these cases the effect of the tuberculin was either deleterious or negative, while that of the rain butts was excellent.
The following case is cited to illustrate the tonic effect of hydrotherapy in a desperate and advanced case of phthisis:
B. S., aged 18, architect, admitted November 19, 1890. Mother died of chronic phthisis. Has been ill since he had an attack of pneumonia, two years. ago, with night-sweats, troublesome cough and loss of flesh.
Phyiscal Signs.-Tympanitic dullness over the upper third of left lung anteriorly, cracked-pot sound, cavernous râles, tubercular breathing, signs of catarrh in right apex. Complains of palpitation greatly. Weight one hundred and fifteen pounds. Bacilli
Treatment.-Rain-baths, 70° to 65°, for 30 seconds. Cod-liver oil and creosote.
December 16.-Up to this time his weight had increased eight pounds, although the physical signs are the same as on admission. Temperature normal. He was now subjected to tuberculin treatment, under which he increased (as an exception to the rule), on April 10, to 138 pounds. Cough does not trouble him now, and he expectorates very little. A few bacilli at every examination. Physical signs not so pronounced. Râles few, and there is evidence of contraction of cavity. The palpitations, which troubled him greatly, have disappeared.
Dr. Hodenpyl's report of examination is interesting: December 16.-One hundred tubercle bacilli to each cover-glass.
January 7.-One hundred tubercle bacilli to each
A. V., a nurse in the Montefiore Home, weighed, in cover-glass.
February 2.-Two bacilli to field.
May 7.-His weight is one hundred and thirty-nine pounds. He has been receiving rain-baths since the injections were stopped. He looks well, and may be regarded as markedly improved. He was discharged on July 14, weighing 140 pounds, and looking the picture of health.
Bear with me while I cite a case from private practice, which illustrates the air and water treatment, which has given me such satisfactory results that I would commend it to your attention despite the fact that it involves much trouble and demands much judgment.
Mr. H. M., aged 28 years, whose brother died of phthisis, was sent to Minnesota seven years ago by Dr. A. L. Loomis, with the diagnosis of incipient phthisis. He settled in St. Paul, married, and his health improved, so that he regarded himself as cured. Last Winter, his father, whose family I attend, begged me to subject him to the lymph treatment. He had been rapidly running down of late with cough, nightsweats and fever. As I had no lymph for private patients, I advised him to come to this city for observation and possible hospital treatment. He arrived January 9, 1891. Without entering into his physical signs, suffice it to say that there was infiltration in right apex as far as the second rib. The general signs indicated a more advanced lesion. His temperature ranged from 101 to 104; his cough was incessant, accompanied by uniformly blood-stained expectoral tion, containing bacilli abundantly; his appetite was entirely gone, sleep unsatisfactory, and accompanied by exhausting sweats. Altogether he presented a picture of rapidly advancing process, although there was no evidence of breaking up.
The weather was extremely severe, snow being frequent. Being exhausted from the journey, he was allowed to rest a few days. The principle of the pure air treatment was adopted in the following simple fashion. During the night the windows of the parlor floor were allowed to remain partly open. An hour before entering the room the windows in the parlor were closed, and a fire was lighted in the stove (this disadvantageous mode of heating was insurmountable). The patient was now brought down, placed upon a steamer-chair, wrapped in furs from head to foot, the face alone being left exposed. All the windows, except one in his immediate vicinity, were opened. He remained in this position from one to four hours, daily increasing the time. The windows were closed at 12, when he was taken to his bedroom, which had been in the meantime thoroughly aired and warmed just before his return. He now received the treatment which will be presently referred to, after which he had luncheon and was again placed in his
steamer-chair on the parlor floor. The bedroom windows, having a Southern exposure, were again left open until he returned. When he was snugly in his bed one window was left open from the top over night.
The remainder of the treatment consisted in meeting the second indication above referred to, viz., an effort to endow the system with power to resist the inroads of the disease. The chief element in this treatment is hydrotherapy, as above stated. He was gradually educated to bear water treatment during the first five days. He then received the dripping sheet at 70°, with affusions at 65°; reducing both two degrees every third day until the former was 64° and the latter 58°. He had abundance of milk, which he formerly loathed; and as his appetite improved, eggs, strong farinaceous broths and mushes. On March 14 he had so far improved that he had registered a normal temperature for two weeks, even in the evening; he was entirely free from cough and expectoration, except early in the morning; there were no nightsweats, he slept soundly. The physical signs had improved, so that it required a very careful auscultation to discover them. Bacilli continued to appear but in diminished numbers. He had attained his normal weight, gaining twelve pounds in flesh. I did not resist the importunities of the patient to allow him to return to St. Paul, inasmuch as he insisted that he was now in far better condition (feeling quite well) thau he was when Dr. Loomis sent him there seven years ago.
The second chapter in this case is equally interesting and relevant to my subject. A few days after his return home he rode in an open cable car in inclement weather, contracting a cold which brought him to bed. Imperfect water treatment which he obtained at home probably contributed to this issue. Reports reached me that he was desperately ill, his physicians declaring it useless to treat him any longer. Felling that hydrotherapy had rescued him from desperate straits before, he determined to make the journey to New York. He arrived the latter part of April in a most forlorn condition. Examination revealed a catarrhal pneumonia, involving the entire lower half of the left lung, with evidences of softening anteriorly just under the nipple. His temperature ranged from 102° to 105°, he had night-sweats, severe cough and expectoration, no appetite. Nevertheless I subjected him to the same course as in the first instance, without any result however. Wet packs, too, failed to reduce his fever. He now entered the Montefiore Home for the purpose of more systematic treatment. Here the rain-baths always reduced his temperature; otherwise he did not improve. He then was treated at home by my private nurse, but steadily failed. As a last resort, regarding the treatment at home as imperfect in some way, I had him brought to
Long Branch, in order to have him under my personal supervision. The night-sweats were now so exhausting that I gave him atropine without effect. He was again subjected here to a systematic water and air treatment. He was ordered to lie in a hammock under the trees all day; he had wet packs and the dripping-sheet under my personal direction. Improvement was marked, showing itself first in a normal morning temperature, and better appetite. In three weeks he was so much better that he committed the imprudence of walking a mile to the Iron Pier to receive his wife. This act came near being fatal to him. The local process was again lighted up. He was put to bed, linen compresses wrung out of water at 65°, and later out of 50°, were wrapped around his chest and covered by a flannel bandage, renewed every hour, renewal being preceded by an ablution of the chest with water at 70°. He had a general ablution morning and evening. Under this treatment of absolute rest, and without any medicine except a creosote mixture he again improved, with the exception of a brief relapse caused by another imprudence. When he left Long Branch in September his appetite and general symptoms were greatly improved; there had been no sweats in four weeks, no fever in two weeks; he had gained flesh, coughed very little; there were evidences that the cavity was contracting. He was sent to D. V. Ruck's Sanitarium in Asheville, N. C., in good condition.
This case is given somewhat at length because it illustrates the necessity for rest and care as well as the method and value of the air and water treatment in mild and desperate cases.
CHRONIC GOUT AND RHEUMATISM.
THE IMPORTANCE OF NORMAL DIET,
WM. THORNTON PARKER, M. D. M. M. L. L.
An excellent article on diet and exercise in the treatment of simple chronic inflammation by Dr. J. C. Mulhall has lately appeared in the New York Medical Record. Dr. Mulhall is a very decided believer in physical culture, and demonstrates very clearly how many diseases are induced by lack of exercise or the omission of accustomed exercise on the one hand and onthe other, how many ailments which obstinately refuse to be benefited by ordinary therapeutic agents yield rapidly when rational physical exercise is again assumed by the patient. We need not go very far to prove this, as every lover of horseback riding will be able to witness if after a longer or shorter course of healthful gallops and trots in the open roads he gives up his favorite pastime for only a few months. Depression of spirits, constipation, headaches, dyspepsia, backaches and general maloit are very frequently the result of his loss of the splendid muscular exercise the real horseback rider always enjoys.
We will not in this paper demonstrate any further the advantages of the gallop and the trot as a therapeutic agent of the highest value, but what can give greater pleasure than when one is well mounted in a comfortable saddle on an active, intelligent horse, the bodily muscles all brought into play, and the lungs expanded by the pleasant exhilarating motion! The whole body and mind are alert, and the soul itself rejoices in the pleasure and is uplifted in grateful appreciation. The character is improved with such manly sport, and there is just risk enough to act as a tonic to courage and a stimulant to fearlessness. Dr. Mulhall believes thoroughly in scientific dietary, no fussy meddling and tyrannical bullying of one's stomach by doctor or patient, but good, honest common sense. Here is where the advantage comes in in having a wife whose practical and valuable experience in cooking brings from the kitchen wholesome food which, if her own hands have not prepared, her wisdom has faithfully directed. The American Public Health Association did a very great good work for "preventive medicine," and the public in general, when, with generous mind and hand, it gave us the useful present of the little book so worthy of the most careful attention and study, "Sanitary and Economic Cooking."
Chronic gout is a diathetic disease in which there is misdirected tissue change. This essay being chiefly clinical, it is not my province to enter into a description of the opinions held regarding the nature of gout. Fortunately, most observers are agreed upon the essential point that gout is practically a uric acid diathesis, or rather a disease in which there is a disturbed relation of the processes resulting in uric acid formation in the body. Whether there be decreased formation or elimination due, as Cullen claimed, to vicious nervous influences, or as Todd and the older writers, and more recently Charcot held, to disturbance of the digestive organs, especially the liver, or to interruption of the urea Excretions as Garrod insists, the undisputed fact is that an accumulation and retention of uric acid, resulting from insufficient elimination, occurs in the juices. Cantani has probably given us the most judi- quently how it should be prepared. This presupcious therapeutic indication.
To be Continued.
Dr. Mulhall says "to simply tell a patient to diet himself is usually utterly meaningless to him. He must be informed about every article of diet, and fre
poses on the part of the physician knowledge not only of the nutritive value and digestibility of the various foods, but also a certain knowledge of the art
of cooking; for the method of preparing food creates dyspepsia as well as the nature of food. Many physicians have no time to go into such detail. I may inform them that the great London physician, Sir Andrew Clark, takes the trouble to write out these things for his patients. He has no printed dietary. Every patient has peculiarities that modify prescriptions of diet and exercise."*
Considering the question of late dinners, Dr. Mulhall shows very clearly that there is much to be said pro and con--for healthy people, yes; for others, no. "Is it not reasonable to assume," the same author writes, "that the heavy meal of the day is better taken when the day's work is done, when one can take time to eat, surrounded, perhaps, by the cheerful influence of wife and children, and afterward quietly sit and give digestion a chance. Every animal, including man, is disposed to mental and physical quietude after a full meal. Mothers often protest against the late dinner for their children, on the plea that they would not sleep or digest well. I have nearly always found this observation based upon imperfect reasoning. Such children do not sleep well after a hearty meal because of enfeebled stomachs, produced by long-continued improper diet. The child which has been reared with strict regard to proper diet sleeps peacefully, even directly after a hearty meal. English child gets stale bread, the American child is allowed hot bread, to give a single illustration of the different plans pursued."
While it may be true that the late dinner is not desirable for those that are over-tired, or for others who cannot have a little wholesome exercise in the evening, yet the fact remains the same that the lack of some warm nutriment just before going to bed, is the cause of much sleeplessness and discomfort. An oyster stew, some hot beef tea or some of the delicious soups which we are now able to obtain ready for warming. These, and many other little formularies which can be prepared with the aid of the chafing dish, the blazer or the alcohol lamp, are, or should be, known to the well-informed housekeeper. For wholesome late evening meals like these, the open wood-fire or the alcohol flame should be preferred. To heat fluids over the open-grate fire or over gas or kerosene flame is not so good, and sometimes may be injurious. And this is where the chafing dish as a therapeutic agent comes in to be of the greatest value. How many tired people with empty stomachs and, perhaps, chilled bodies, after a long evening of reading or writing go up to bed, tired, indeed, and anxious for sleep, but to whom the sweet restorer is so often a stranger. They spend the night in vain hopes and wishes for repose; "they toss to and fro and are at
*Practical Sanitary and Economic Cooking adapted to Persons of Moderate and Small Means." American Public
their wits' ends," but weary, anxious hours bring naught of rest or of quietude to mind or body, and, perhaps, more tired than when they went to bed. They dress and,gaining a little tonic from the morning sponge-bath, go down to breakfast out of sorts with themselves, their families, and the world in general.
In the work on sanitary cooking, already referred to, this truth stands at the introduction of the work. "Few things are of more importance than that we should find ourselves physically and mentally equal to our day's work, but not many of us realize how largely this depends upon the food we eat "; and under the heading "Cooking for the Sick," it goes on to state : "It is comparatively easy for your family to live on a small income while all the members are in good health.*** Sickness is always a severe drain on the limited income. During a severe illness, the food, as well as the medicine, is under the care of the physician, but when the danger is over" he leaves you with only general directions."
What did he mean by saying the patient must be "built up?" "How is the wasted frame to get back the fat and muscle that were burned away in sickness? Chiefly by the digestion of food, the proteids and fats and carbohydrates, * * and still another, a real food so often forgotten, the oxygen of the air. ***When an invalid is shut up in a sick room we must bring the fresh air to him with as much care and regularity as we do his jellies and broths. Day and night we must minister to his necessities, fresh air and nourishment." How welcome is the sight of the chafing-dish, with its bright warm blaze, and the hot nutriment to cheer and bring back the needed strength. The hygiene of the table contains much of useful consideration. If we would have wholesome meals we must have happy meals. We must eat slowly and peacefully. Every soldier knows the rush and excitement peculiar to war and danger. We see the anxious and hurried soldier eating in haste. We note that even his horse shares the rush and of worry meal time in the common excitement of danger. We note in our cities the meals of business men, from those dealing in "millions," to those dealing in rags; hurry-imperfect mastication is surely followed by sickness, which runs from simple intestinal indigestion up through all the ills attributable to hasty eating, to fatal apoplexy. The homelife of honorable wedlock is a blessed life, and tends to longevity, and one reason is because the meal time is blessed. In Germany, at all private dining-tables, we hear the common wish, meaning more than mere form, "Blessed meal time to you." Gesegnete Mahlzeit. How worthy is that custom, how happy the home where these simple words are heard. The psalmist has blessed the meal time, and the Saviour unmistakably did honor to quiet and grateful repasts. Contentment, friendship and family love make the humblest repast a feast.