Hydrotherapy, judiciously adapted to the indications of the case, has proven a valuable auxiliary in the management of these patients. In the croupous pneumonia of children, who are more easily handled, without great disturbance, the tub-bath is very useful when administered alongside of the bed, as in typhoid fever. The temperature should, however, rarely be below 85° F. Beginning with 95°, each bath may be reduced a few degrees, until the patient becomes accustomed to it, repeating every four hours until the temperature remains below 102.5°. Friction is a sine qua non, because chilling is more apt to occur in these patients than in typhoid fever, and for this reason the duration of the bath should be short--eight to ten minutes. The toxic agents which are operative in pneumonia appear to affect the heat-center quite differently from those evolved in typhoid fever. A bath of 80° F. often reduces the temperature in the former disease two to four degrees, while in the latter one degree would be a large reduction. Upon this clinical fact I have based a diagnostic bath which materially aids in the differentiation of typhoid fever from other diseases which so strongly resemble it during the first week. The value of the full bath in the pneumonia of children has been confirmed by the highest authorities, such as Penzoldt and Baginsky in Germany, Hutinel of Paris, our own Jacobi, and others.

If the pa

In adults, however, I have given up tub-baths, although very cold baths (50°-60°F.) have been lauded by Juergensen and commended (65° F.) by chief-surgeon Vogl of Munich in a letter to myself. While they proved useful in many cases, I am convinced that the disturbance and agitation incident to a cold tub-bath increase the lung disturbance. tient is very dull, cyanotic, and presents great nerve prostration, resembling the typhoid state, I do not hesitate to choose between the two evils, an increase of the local disturbance and a decrease of nerve prostration, by plunging the patient into a bath of 80° F., or less, or seating him in water at 100° and and pouring several basins of water at 65° to 75° F. over his head and shoulders. This is a valuable heart tonic. It serves, by deepening the inspirations, to dislodge accumulations in the bronchi, which have crippled the healthy as well as the affected lung.

The most useful hydriatric procedure in pneumonia is the wet compress. This consists of three folds of thin old linen stitched together at the edges, which has slits corresponding to the axillæ, so that it may be wrapped around the patient's chest snugly. The slits are made sufficiently deep to allow the upper edge of the compress to reach above the clavicles, and admit of the junction of the flaps thus formed on each side to cover the shoulders. Two such jackets,

and two pieces of closely woven thin flannel of the same shape, but an inch wider and longer, should be provided and fitted to the patient. One of the former is rolled up and soaked in a basin of water at 60° F., and wrung out so that it remains quite damp without dripping. The flannel is now spread out upon an even surface and the wet compress put upon it, so that there remains an edge of flannel about an inch wide all around. Both are rolled together half-way. While the patient is gently turned upon his left side, with the precaution of not allowing any exertion on his part, the compress is so placed upon the bed that the rolled part lies in close proximity to the left side of the patient, and the lower edge of the left slit is under the left axilla. Now the patient is quietly turned upon his back, so as to release the rolled-up portion. The latter is now unrolled, and both edges of the compress are brought forward upon the front of the chest and are thus made to envelop the latter snugly. The flannel cover, which has been allowed to lie upon the bed during the application of the wet compress, is now brought forward so as to quite cover the latter. It is secured by two safety-pins in front, and one upon each shoulder.

The well-known oiled silk jacket may serve as a model for the shape and manner of applying this wet compress. The latter should be changed every halfhour, unless the patient's temperature is below 102.5° F.; every hour unless it be 99.5° F., when it is discontinued. The removal is accomplished by preparing the second compress just like the first, paying attention to the water temperature being 60° F. When it and the flannel covering are rolled up in readiness, the first compress is removed and the second is applied. Thus a rotation is kept up every half-hour or hour as the case may require, night and day, unless the patient be asleep. The water in the basin should be renewed each time, and the compress rinsed off in another basin before it is rolled up for soaking, in order to insure thorough cleanliness and prevent furnuncles by furthering asepsis.

The technic of the procedure has been entered into with a detail that may seem needless. As will be shown later, these details insure precision, and upon their exact execution may depend success or failure. The physician should himself supervise the first application, just as he should supervise the first Brand bath in typhoid fever. A skilled nurse can apply these compresses with a minimum of disturbance.

There is need, too, of individualization. In the average case a temperature of 60° F. will be appropriate. Should the patient evince stupor or muttering delirium, a lower temperature should be adopted, and the chest should receive one or more dashes of colder water, before renewal of each compress. The

same procedure is useful in bronchopneumonia, when the bronchi are blocked by secretions, or cyanosis exists. In a case which I had the privilege of seeing with Dr. E. J. Ware, this application proved its worth. The patient had passed through an attack of typhoid fever lasting some ten weeks; her condition was so precarious that when I entered an adjoining room she was bidding her relatives adieu. By skilful manage

ment she had been sustained up to this time. The right lung in its entire posterior aspect was solidified. The temperature was usually below 102° F., and the pulse exceedingly rapid. There was no dyspnea.

In this case the modified procedure referred to was extremely valuable. Inspiration soon deepened, the heart slowed, and in a few days the patient rallied from a most desperate condition.

A higher temperature than 60° F. may be used if there be much jactitation, insomnia, or excitability. In the latter event great benefit will accrue from allowing the compress to remain two hours and moistening it more thoroughly, which converts the compress into a soothing fomentation that is not relaxing like a poultice.

о

In a colleague, whom I had the privilege of seeing with Dr. Palmer Cole, there was complete involvement of the entire right lung, with temperature ranging from 103° to 105 F., the heart action being fair. The patient being a morphin habitué, there was a decided neurotic element in the case, involving insomnia and great jactitation. The compresses were only applied hourly, despite the high temperature, but they were allowed to be quite moist, in order to obtain a calming effect. Although the left lung became involved later, Dr. Cole informed me that the patient recovered from his desperate condition, and that, in his opinion, his life was saved by the management here outlined. No remedial measure deserves adoption by the profession unless the rationale can be satisfactorily explained.

According to my view of pneumonia crouposa, the therapeutic indications are (1) to stimulate and invigorate the nerve centers with a view to enhancing the patient's vital powers, (2) to prevent and control heart failure, (3) to reduce temperature, (4) to eliminate toxins.

The nerve centers are well stimulated and rehabilitated by the repeated gentle shocks and subsequent reactive stimulation of the sensory fibers in the skin, both of which are conveyed to the central nervous system and thence reflected to the organs, upon whose functionating capacity depends the patient's ability to resist the toxic agencies circulating in the blood. We aim here to accomplish precisely the same object as with the Brand bath in typhoid fever. The milder form of shock is better adapted to pneumonia, because it is less disturbing, and because the toxemia,

induced by the diplococcus, is less intense in the average case, and certainly has only one-third of the life period of the Eberth bacillus.

After a few compresses the patient grows mor calm, the inspirations, which are deepened by each application, continue deeper, dyspnea is markedly relieved, sleep ensues, appetite improves, and the skir and kidneys begin to act more freely. These clinica evidences demonstrate the correctness of the rational enunciated above.

The maintenance of the heart action is accom plished by the wet compresses in the following man ner: When the cold compress is applied, there is a rapid contraction of the cutaneous vessels, which raises the tension at once, but gives way to a toni dilatation of these vessels, which is evidenced by a ruddy hue of the skin. This dilatation differs very decidedly from that relaxed condition of the cutane ous vessels produced by warm poultices. The latte: relax the vaso-constrictors, producing a paretic con dition of the vessels, or a stasis, while cold applica tions stimulate the vaso-dilators, giving rise to a active dilatation, with maintenance of the tone o the vessels, an active hyperemia, by reason of which the blood is propelled more vigorously through them The heart is thus relieved; not by a vis-a-tergo, as is the case after digitalis, but by a vis-a-fronte formed by broadening of the blood-stream in the cu taneous capillaries, whose enhanced tonicity aid a the same time in propelling the blood onward. Ar terial tension is increased, as is evidenced by the better filling of the radial arteries. The right hear is indirectly aided by this enhancement of the gen eral tone in the vascular apparatus, and may thus expend more force upon the pulmonary circulation, whose vessels contract more firmly by reason of the dilatation of the superficial vessels.

1

Romberg has recently confirmed what I have, several years ago, and repeatedly since that time, insisted upon, that in acute infectious diseases we encounter disturbances of the circulation which manifest themselves clinically as reduced tension and diminished filling of the arteries, and which are com monly described as heart failure. Undoubtedly the condition of the peripheral vessels bears a very large share in the production of cardiac atony, as I have sought to impress when explaining the rationale of cold applications in typhoid fever and pneumonia. Romberg has shown by experiments with injections into rabbits of Fraenkel's diplococci that the circu lation is damaged by a paralysis of the vasomotors, while the heart itself remains unaffected. It is true that the right ventricle is overloaded because of lung

1 Berlin klin. Wochenschrift, 1895, Nos. 51 and 52. 2" Uses of Water," vol. ii, p. 166.

infiltration, but that this does not so seriously cripple the heart as is generally supposed is proved by the fact, referred to above, that when crisis ensues, the compression due to the exudates is not removed at once, and yet the respiration and circulation are relieved as if by magic. This can only be accounted for, if I may be allowed to reiterate so important a statement, by the nervous system being suddenly relieved of the toxic elements generated by the diplococcus, whose activity ceases at once when it has reached the end of its natural life-period. It is probable that crisis ensues when the antitoxins evolved in the natural course of the disease have attained an overbalance of power. The battle between the diplococcus, with its allies, and the patient's vital powers, is at an end. The most important effect of cold applications in pneumonia is, therefore, the aid and sustenance they furnish to the nervous system, which bears the brunt of the fight. The improvement of cardiac action is one of the results of this effect.

Reduction of temperature is an important therapeutic element in these cases. Persistent high temperature may enfeeble the heart, and certainly depreciates the nerve centers. Some good clinicians, like Juergensen, claim that high temperature is the chief danger to patients suffering from pneumonia, and he advises in his latest work that very cold baths, some below 60° F., are demanded to meet this "great danger." I shall not discuss this doctrine fully to-night. Since my argument against it before the New York State Medical Society in 1889, I have repeatedly expressed adverse views in this and other societies to this unfortunately too firmly established error, an error which has given unhappy prominence to the coal-tar antipyretics in the therapy of fevers. If any further testimony is needed to lay this ghost, which has so long affrighted timid practitioners, to rest, the discussion on fever in the Fourteenth Congress of Internal Medicine in April, 1896, demonstrates that we should cease to regard elevation of temperature as the cardinal symptom for therapeutic attack. While, however, these conclusions fully corroborate my own views expressed eight years ago, I may say that high temperature, though not actually and directly a lethal factor by inducing fatty degeneration of the cardiac muscular fiber, as claimed by Ziegler and others, does seriously cripple the work of the heart by imposing upon it more rapid action, and it does seriously interfere with the patient's comfort. High temperature, therefore, demands careful attention by measures that are not harmful like the routine use of coal-tar antipyretics. As I said elsewhere, I do not hesitate to use the latter occasionally when high temperature is associated with sleepless

1 Penzoldt and Stinzing, "Allgemeine Therapie," 1896.

ness or great jactitation. They give great comfort to the patient, and are less annoying and disturbing than the wet compresses. But the latter are not used by me for their antithermic effect, which is only incidental.

It

The susceptibility of pneumonia patients to cold baths, and the great facility with which their temperature may be reduced, renders great care in the application of these measures imperative. For this reason I have abandoned cold baths, and have dwelt so minutely upon the method of application. That so mild a procedure as the wet compresses should be capable of reducing high temperatures in pneumonia, I have numerous charts to demonstrate. The decline is not as rapid as after cold baths, but it is pronounced and steady. It does not ensue after one or more compresses, nor does it follow the course of temperature reduction observed after cold baths in typhoid fever. It decreases day by day one or more degrees. is not the result of direct refrigeration; such an effect is neither aimed at nor obtainable. When a compress at 60° F. covered with flannel is applied around the chest of a pneumonia patient who presents a temperature of 102° to 106° F., there is an immediate cooling of the surface covered by it, which is followed by a gradual reaction with a more or less rapid rise of the surface temperature, until the latter is nearly the same as it was previous to the application. The surface is now bathed in a vapor produced by the heating of the compress. If the latter be allowed to remain sufficiently long, the flannel covering receives the vaporized water, and passes it outward until the compress becomes dry. But if the compress is changed as indicated above, the vapor is more slowly removed, and the skin and compress are found to be cooler than the flannel covering. Thus the gradual cooling process is continued until a fresh, cold compress is applied, when the skin, more sensitive by reason of having been bathed in this warm vapor, feels the shock more distinctly and reacts more fully. The error is not infrequently committed of covering a wet compress with oiled silk. While this would protect the bed and clothing of the patient, it would defeat the object of the compress by converting it into a poultice. If the body temperature is 103° F. or over, the compress applied as above becomes warm in half an hour, although evaporation of the moisture through the flannel renders the skin under it cooler than other parts of the body. When it is renewed, the repetition of the gentle shock and tonic dilatation occurs. Thus a slow cooling process, not relaxing or in any way depreciating, is maintained, which gradually lowers the general temperature, calms the patient, and contributes much to his re

covery.

value most earnestly failed to give definite directions for its application. Niemeyer illustrates this point. He simply advises "cloths wrung out of cold water to be applied to the chest" of the pneumonic patient. The temperature of the water, the duration, technic, frequency of repetition are left to the discretion and good or bad judgment of his hearers and readers, and yet these are far more important in hydrotherapy than are the dose, time of administration, frequency, etc., in prescribing medicinal agents.

In a paper on pneumonia, published several years ago by an eminent American teacher, the following sentence occurs: "If the temperature in pneumonia "rises to 104°, 105°, or 106° F., I use cold baths or "cold packs." Such indefiniteness is to be greatly deprecated when coming from one who is highly regarded as a teacher and guide. A cold bath, without stated temperature, is generally understood to be a bath to which neither hot water nor ice has been added. Such a bath would have a temperature of 75° F. in August, and 45° F. in December, in this city. Thirty degrees in the temperature of a bath are capable of producing an immense difference for good or evil; in pneumonia it would react very unfavorably, according to my personal observation. Just as Niemeyer failed to create a permanent following for the practice which he so highly lauded, so has the justly famous teacher referred to failed to impress upon the profession a practice which he had taught in 1870, as follows: "If there be anything I should rely on in "pneumonia, if the temperature is very high, it is "cold-water treatment." If this excellent teacher had been as explicit in giving temperature, duration, etc., of the cold-water treatment, as he was in giving the doses of digitalis, nitroglycerin, and camphor, the valuable lessons he endeavored to inculcate would not now (twenty-five years later) require to be taught anew; they would have served as a beacon-light to the vain searcher after reliable therapeutic methods in this fatal disease. Let me emphasize, therefore, that while I may have offered nothing novel or striking in this essay, its chief aim is to impress upon you the great import of giving definite prescriptions for all hydriatric measures in this as in other diseases, be they acute or chronic, for only by such precision may we obtain definite results.

Statistical evidence to prove the value of the measures here advocated, or of any other method of management, is indeed very difficult to produce. The type of the disease differs very much; in private practice the number of cases is too meager, and observations are too inaccurate and unreliable. I may say, however, that I have not lost a case of uncomplicated croupous pneumonia in private practice since the adoption of the management of patients suffering

from it, here outlined. In hospital work the chief element of success with this method, viz., its application in the early stages of pneumonia, is unfortunately absent. Its favorable influence upon the progress of the disease is attested, however, by the statistics of 156 cases in the J. Hood Wright Memorial (formerly Manhattan General) Hospital, in which the total mortality from pneumonia has been reduced onehalf, since the method here advocated has been adopted by the entire staff; while in the cases admitted before the fifth day the mortality has been twelve per cent. against thirty-seven per cent. under the formerly prevailing expectant plan. These cases were under the observation and treatment of my colleagues, Drs. Daniels and Knickerbocker, and myself. The method described above is, with slight modifications, equally favorable in catarrhal pneumonia.

The ice-pack method recently advocated by Dr. Mays of Philadelphia, which claims a mortality of 3.58 per cent. in private practice, is worthy of mention in this connection, because its success is applicaable upon the theory that it fulfils all the therapeutic indications almost as well as the cold wet compresses. Ice is applied in bags which are wrapped in towels and placed over the affected area, with a view to reduce the inflammatory process in the lung by direct cold. That the latter is an erroneous idea has been proven by the experiments of Silex,' who has shown by experiments on animals, that "ice applications increase the temperature of the organs over which they were placed and which were to be cooled." This effect of local cold has long been recognized by hydrotherapists, who know that intense cold applied externally produces a compensatory hyperemia in the parts beneath, thus protecting the latter against destruction if carried too far. The rationale of the favorable influence of the ice-compress treatment, however, is not difficult to explain upon recognized principles of hydrotherapy.

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The

The towels which envelop the bags of ice soon become thoroughly wet by condensation, and thus the application is practically a continuous wet compress. This together with its unevenness prevents the complete reaction which is so useful in arousing the nerve centers, but its being applied upon parts of the chest only prevents serious results from this source. objection to ice compresses would seem to be their uneven surfaces, which renders them uncomfortable when applied to the posterior portions of the lungs, the patient lying on the back; and also that their weight when applied anteriorly must render them inconvenient. In consideration of these facts I have not felt justified in applying this method of ice packs. 1 Münchener mediz. Wochenschrift, 1893.