52. NECESSITY OF VENTILATION—MEANS OF HEATING THE SICK-ROOM—RELATIVE MERITS OF OPEN FIRES, STOVES AND FURNACES.

Next to its intrinsic value, our method gives the patient the great advantage of enjoying pure fresh air, either in or out of bed, as it keeps the skin and the whole system in such order as to resist the effects of atmospheric influences better than under a weakening process. And every body knows, or, at least, every body ought to know, that free circulation of fresh air is one of the most important means, in contagious diseases, of preventing the malady from becoming malignant, and of lessening the intensity of the contagion. Although the times are passed, when patients in the heat of fever were almost roasted in their beds, whilst a drink of cooling water was cruelly and stupidly denied them; the temperature of the sick-room is, in general, still kept too high, and not sufficient care is taken to renew the air as frequently, I ought to say as constantly, as necessary for the benefit of the patient. Usually there is no ventilation; very seldom a window is opened, especially in the cold season, when epidemics of scarlatina are most common, and commonly the room is crowded with friends of the patient, who devour the good air, which belongs to him by right, and leave him their exhalations to breathe instead. There is nothing better able to destroy contagious poisons than oxygen and cold; and if we consider that every human being absorbs every minute a volume of air larger than the bulk of its own body, we must understand how necessary it is to keep people away from the sick-room, who are not indispensably necessary to the patient, and to provide for a constant supply of fresh air. But whatever may be the arrangement for that purpose, the patient should not be exposed to a draught. Stoves and fire-places are pretty good ventilators for drawing off the bad air from the room; if you take care not to have too much fire, and to allow a current of pure air to enter at a corresponding place, the top of a window, or a ventilator in the wall opposite the fire-place, there will always be pure air in your sick-room. The air coming from furnaces, which unfortunately have become so general, is good for nothing, especially when taken from the worst place in the house, the cellar or basement. I consider the worst kind of stoves better than the best kind of furnaces; only take care not to heat the stove too much, or to exclude the outer air, which is indispensable to supply the air drawn off by the stove for feeding the fire. The difference between a furnace and a tight stove or fire-place is this: The furnace takes the bad air from the basement or cellar, frequently made still poorer through its passing over red hot iron, which absorbs part of its oxygen, and fills the room with it. The room being filled with poor air, none of the pure air outside will enter it, because there is no vacuum. Thus the bad air introduced into the room, and the bad air created by the persons in it, will be the only supply for the lungs of the patients. But should the furnace take its air from outside the house, as it is the case with some improved kinds, there would still be no ventilation in the sick-room, except there be a fire-place beside the register of the furnace. With the stove or fire-place it is different: The stove continually draws off the lower strata, i. e. the worst part, of the air to feed the fire, whilst pure air will rush in through every crevice of the doors and windows to supply every cubic-inch of air absorbed by the stove. Thus the air in the room is constantly renewed, the bad air being carried off and good air being introduced. However, the openings through which the pure air comes in, must be large enough in proportion to allow a sufficient quantity of air to enter the room to make fully up for the air absorbed by the stove; for, if not, the air in the room will become thin and poor, and the patient will suffer from want of oxygen. An open fire, from the necessity of its burning brighter and larger to supply sufficient heat, a comparatively large part of which goes off through the chimney, will require a greater supply of air, and consequently larger ventilators or openings for the entrance of the pure air from outside the room. In very cold weather, and in cold climates in general, stoves are preferable to fire-places, the latter producing a draught, and not being able to heat a room thoroughly and equally, causing one side of the persons sitting near them to be almost roasted by the radiant heat in front, whilst their backs are kept cold by the air drawing from the openings in the doors and windows towards the fire to supply the latter. In merely cool weather, and in moderately cold climates, especially in damp places, I would prefer an open fire to a stove. In cold climates stoves are decidedly preferable, especially earthen ones, as they are used in Germany and Russia. Iron stoves must never be heated too much, as the red hot iron will spoil the air of the room, by absorbing the oxygen, as you can easily see by noticing the sparks, which form themselves outside the stove in very hot places.

The temperature of the sick-room should not be much above 65° Fahrenheit; in no case should it rise above 70, whilst I do not see the necessity of keeping it below 60, as some hydriatic physicians advise.[31] The patient, in the heat of fever, will think 60° high enough, and rather pleasant; and if others do not like a temperature as low as that, they may retire. The person necessary for nursing the patient may dress warmly and sit near the fire. Let the sick-room be as large as possible; or open the door and windows of a room connected with it. Towards the close of the disease, after desquamation has begun, the temperature of the room may be kept at 70°, as then the fever and heat have subsided and the delicate skin of the patient requires a comfortable temperature.

I have little to say with regard to diet, at least to physicians. During great heat and high fever, the patient should eat little or nothing; but he should drink a good deal. Substantial food must be avoided entirely. When the fever abates, he can take more nourishment, but it should be light. Meat and soup should only be given, when desquamation has fairly begun. Stewed fruit (especially dried apples) will be very agreeable to the patient. In great heat, a glass of lemonade may be given occasionally; however, great care must be taken not to spoil the patient's taste by sweets, or to allow him all sorts of dainties, such as candies, preserves, &c., as it is the habit of weak parents, who like to gratify their darlings' momentary desires at the expense of their future welfare. In torpid cases, some beef-tea, chicken-broth, and even a little wine with water, will raise the reactive powers of the patient. During convalescence, meat may be permitted to such patients as have been accustomed to eat it, and, in general, the patients may be allowed to gradually resume their former diet (provided it were a healthy one), with some restriction in regard to quantity. In general, under water-treatment, the digestive organs continuing in a tolerably good state, and the functions in better order, we need not be quite so careful with respect to diet, as if the patient were left to himself, or treated after any other method of the drug-system. Let the food be plain, and the patient will scarcely ever eat too much. To stimulate his appetite by constantly asking him whether he would not like this or that, is sheer nonsense; and to satisfy his whims, against our better conviction, is culpable weakness.

From this general outline, I shall now pass to the treatment adapted to the different forms of scarlatina.

When the period of efflorescence, or standing out of the rash, is over, packs ought to be given, to extract the poison completely from the system, and to prevent any sequels, such as anasarca, &c. (25). Should the rash suddenly disappear before the fifth or sixth day, or should it linger in coming out, a long pack will bring it out and remove all danger. The packs, once begun, should be continued, once a day, during and a few days after desquamation. The patient may go out on the tenth or twelfth day warmly dressed, after his pack and bath, and walk for half an hour; sitting down or standing still to talk in the open air is not to be permitted. During, and some time after convalescence, the patient should take a cool bath, or a cold ablution every morning, immediately on rising from bed, and walk after it as soon as he is dressed. In very cold and disagreeable weather, the walk should be taken in the house; but the patient should not sit down, or stand about, before circulation and warmth are completely restored in every part of the body, especially in the feet. I cannot insist too much upon exercise being taken immediately after every bath, as, without it, the bath may do more harm than good, and dressing, with many, will take so much time, that they will take cold before getting their clothes on.

If the patient should take cold, or feel otherwise unwell, during convalescence, the packs must be resorted to again, and continued till he is quite well.

1) the reaction is mild, the heat of the body not being much above 100° Fahr. and the pulse full, but not above 110 to 120, the pain and swelling of the throat moderate, the brain little or not affected; or

2) violent, the heat from 106 to 112, the pulse 120 to 150 beats or more, the inflammation of the throat decided and extensive, the brain very much affected; or

3) torpid, little or no heat, the pulse quick and weak, the inflammation of the throat undecided, varying, the rash appearing slowly or not at all, and what there appears of a pale, livid color, the patient more or less delirious.

59. If the patient becomes restless soon after having been packed, the heat and fever increasing, as may be ascertained from the pulse at the temples and the general appearance of the face, the sheet must be changed, as directed above (46) till the patient becomes quiet and feels more comfortable. In case of repeated changing of sheet, the patient should stay in the last sheet, till he has perspired about half an hour, or longer, before he is taken out to the bath, which should be of about 70°, as in all the mild forms of scarlatina. The length of the bath depends on the heat, and reaction of the patient, who should be well cooled down all over, before going to bed again or dressing. He ought not to be out of bed for a long time, and only after a bath, as this will protect him from taking cold.

60. The throat should be covered with a wet compress, i. e. a piece of linen four to eightfold, according to its original thickness, dipped in cold water (60°-50°), well wrung out and changed as often as it grows hot. It should be well covered to exclude the air. This compress should be large enough to cover the whole of the throat and part of the chest; it should closely fit to the jaw, and reach as far up as the ear to protect the submaxillary and parotid glands located there.

61. When the period of eruption is over, there is commonly less fever, and the packs and baths may be diminished.

62. Towards the end of the period of efflorescence, when the rash declines, fades, disappears, and the skin begins to peal off, an ablution in the morning of cool water, with which some vinegar may be mixed, and a pack and bath in the afternoon, are quite sufficient, except the throat continue troublesome, when a pack should also be given in the morning. The packs, once a day, should be continued about a week after desquamation. The patient may safely leave the house in a fortnight. I have frequently had my patients out of doors in ten or twelve days, even in winter.[32]

63. This going out so early, in bad weather, is by no means part of the treatment. I mention it only to show the curative and protective power of the latter, and have not the slightest objection to others using a little more caution than I find necessary myself. It is always better, we should keep on the safe side, especially when there is no one near that has sufficient experience in the matter. I can assure my readers upon my word and honor, that though I never kept any of my scarlet-patients longer in-doors than three weeks (except a couple of malignant cases), I have never seen the slightest trouble resulting from my practice.

64. In case of some trouble resulting from early and imprudent exposure, which is about as apt to occur in the house as out of it, a pack or two will usually be sufficient to restore order again. As long as the patient moves about, warmly dressed, there is no danger of his taking cold after a pack, and provided packing be continued long enough, and the patient be forbidden to sit down or stand still in cool places, or expose himself to a draught, there is nothing to be apprehended.

65. I have no objection to homœopathic remedies being used at the same time, nor would I consider acids, as mentioned above (39, note), to be objectionable in cases of severe sore throat; but I must caution my readers against the use of any other remedies, especially aperients, except in cases, which I shall mention hereafter (72). In a couple of cases, where I acted as consulting physician, I have observed dropsical symptoms proceeding from laxatives and the early discontinuation of the packs during convalescence. Let the bowels alone as long as you can: there is more danger in irritating them than in a little constipation. As for the rest we have injections, which will do the business without drugs, of which I confess I am no friend, especially in eruptive fevers.

The violent, or sthenic form of scarlatina anginosa becomes dangerous only through the excess of reaction, when the heat is extreme (upwards of 105° Fahrenheit, sometimes 112 to 114), the pulse can scarcely be counted, as it hammers away full and hard in a raging manner, the throat being inflamed and swollen to suffocation, and the patient in a high state of delirium; but it need not frighten the physician or parent acquainted with the use of water. We have the means of subduing that violence without weakening the patient. It is in this form of scarlatina that the greatest mistakes are committed by physicians unacquainted with the virtues of water, and that our hydriatic method shows itself in all its glory; for where there is an abundance of heat, water cannot only be safely applied, but it is also sure to bring relief. It is in this form of the disease that the cold affusions recommended by Currie and his followers, have shown themselves so beneficial, and that the wet-sheet, used properly and perseveringly, is almost infallible.

68. LENGTH OF PACK—PERSPIRATION.

To make quite sure of the reaction, the single sheet may be tried first, except in exceedingly violent cases, and the double sheet may be resorted to, if the single sheet prove inefficient. Or, should there be any doubt, the double sheet may be dipped in water of a higher temperature than that given above, say 55 to 60°. With young and delicate children I prefer this course, especially if they be very excitable, and the shock of very cold water may be expected to be too much for their nerves. In these matters some discrimination should be used: it is always better we should keep on the safe side, and rather give a pack more than frighten the little patients out of their wits. Proceed safely, but firmly and try to obtain your object in the mildest manner possible.

69. Before perspiration comes on, there is a little more excitement for a few minutes (41), which must not induce the friends of the patient to take him out of the pack; only when it continues to increase, instead of the perspiration breaking out and relieving the patient, it will be necessary to change the sheet, another time, as in that case the organism is not fully prepared for perspiration. After the breaking out of the latter, the patient invariably feels easier, and continues so for some time. When the feverish symptoms increase, during perspiration, which can be ascertained by feeling the pulse on the temples and by the thermometer, it is time to remove the patient from the pack, to give him his bath. Half an hour's perspiration is commonly sufficient; if the patient feel easy, however, and can be prevailed upon to stay an hour, or longer, till a good thorough perspiration brings permanent relief, it will be better. It would be unwise to let the patient stay too long and get him in a state of over-excitement; but, on the other hand, parents ought to remember that very few children like to be packed, and that a patient in high fever is a bad judge of his own case. I have always found those children the best patients, who had been brought up in strict obedience to their patients' dictates, before they were sick, and this, as well as the daily habit of taking baths, and the quiet and firm behavior of the physician and friends of the patient under treatment generally remove all difficulty.

After the bath, the patient is rubbed dry, and either taken to his bed, or, if he feels well enough, dressed and induced to walk about the room, or placed in a snug corner (not near the fire, however), till he feels tired and wishes to go to bed. During his stay out of bed, the rash ought to be an object of constant attention for his friends; for as soon as it becomes pale, the patient ought to be sent to bed immediately and covered well, or should then the rash continue to become paler and paler, the pack should be renewed, and the patient kept in bed ever after, till desquamation is over.

If the throat is in a highly inflamed condition, repeated packing is the surest means of allaying the inflammation and preventing croup. Although I have had very bad cases under my hands, I never saw a case of scarlet-croup under water-treatment. All you have to do is, to pack your patient early enough and often enough to keep the inflammation down, to keep a wet compress on his throat and chest, and, in general, treat him as I have prescribed. The condition of the throat will improve in proportion to your perseverance in packing.

76. The sitz-bath may be taken in a small wash-tub, if there is no proper sitz-bath-tub at hand. It should be large enough to allow the water to come up to the navel of the patient, and to permit rubbing. Too large a tub would not allow the patient to sit in it comfortably. If there is no tub to fit, a common bathing-tub may be raised on one end, by putting a piece of wood under it, so as to keep the water all in the other end, allowing the feet of the patient to be kept out of the water. This latter practice is more convenient with very small children, with whom, however, the sitz-bath will scarcely be required, a half-bath of sufficient duration being almost always efficient. It is not advisable for persons little acquainted with the use of water as a curative, to let the patient stay very long in the sitz-bath, it being safer to pack the patient again, and to repeat the sitz-bath after the pack, if his delirium is not removed, or not lessened in half an hour or three-quarters of an hour. This alternating with the pack and sitz-bath should be repeated, till the head becomes clear.

77. In excessive heat and continuous delirium, a half-bath may be given, also, every time the packing sheet is changed. The rule is that we ought not to yield, but the symptoms must; and they will, if the treatment is persevered in. Only go at it with courage and confidence. There is nothing to be apprehended from the treatment: where there is too much heat, there is no danger of a lack of reaction, and consequently no occasion for fears that the rash might be "driven in." A physician afraid of using water freely in violent cases of scarlet-fever, would resemble a fireman afraid of using his engine, for fear of spoiling the house on fire.

The sitz-bath acts in a direct manner upon the abdominal organs and the spine, and through the latter on the brain. Indirectly, it helps in removing the inflammatory and congestive symptoms in the throat and head, by cooling the blood, which circulates through the parts immersed in the water, and by doing so cools also the upper parts of the body, equalizes the temperature, and diminishes the volume of the mass of the blood, thus making its circulation easier, whilst it has no tendency to impede the action of the skin. Besides, the abstraction of electricity, by the sitz-bath, should be taken in account of its action. After the sitz-bath, the reaction takes place in those parts which were immersed in the water, thereby making the relief of the upper parts more lasting.

81.—3. TREATMENT OF TORPID FORMS OF SCARLATINA—DIFFERENCE IN THE TREATMENT POINTED OUT.

When the reaction is torpid, the pulse small, weak, quick, the skin dry, the rash slow to appear, and when it appears in small, pale, livid spots, instead of bright scarlet patches (16-25); the treatment ought to be calculated to produce a short, but powerful, stimulus upon the surface of the body, after which a long pack should assist the organism in producing a slow, continuous and increasing reaction. If in violent reaction a repetition of short packs and long cooling baths is indicated,—in torpid reaction, cold and short tonic baths or affusions and long packs are required, in proportion to the degree of the reactive power of the patient. Therefore the packing sheet should be very cold, but thin and well wrung out, so as to make a strong, but transitory, impression, soon overcome by the reaction it calls forth, upon which all our success depends. The patient stays in the pack till he becomes quite warm and tired. Perspiration is seldom produced; if it is, it may be considered a favorable symptom. I have had patients stay in the pack for four, five, six and seven hours, and almost always, when I took them out, their skin was covered with eruption. The only phenomenon, which should induce the physician to relieve the patient of the pack before he becomes perfectly warm, is increased delirium, which in torpid reaction, indicates a tendency to a typhoid character of the disease, when the warm and moist atmosphere of the long pack would be more favorable to the disease than to the patient, by weakening the nerves still more. In that case, a long half-or sitz-bath is required, the former, under constant rubbing, from 15 to 20 minutes, the latter from 30 to 40 minutes; the temperature of either from 65° to 70°.

82. LENGTH OF PACK.

Usually it is time for the patient to come out from his pack, when the pulse becomes fuller and stronger, the face begins to flush and the head to be affected. Frequently he sleeps till awakened by the increasing heat. A drink of cold water will quiet him for a while, which may be administered by means of a glass tube (julep-tube), in order not to disarrange the pack by lifting him up. As long as the head is not affected, there is no danger of his staying too long. The longer he can stay, the surer the eruption will appear.

If no rash appear during the first pack, which will scarcely fail, the proceeding should be repeated, and the patient stay longer in the pack than the first time. In very bad cases, when the patient fails at once under the action of the poison (malignant scarlet-fever) iced water or snow may be resorted too. I know several instances of patients, having been given up by their physicians, reviving again under the influence of a snow-bath, which produced a healthy reaction, when nothing else was of avail. I have never had occasion myself to resort to such extremes, cold water having always answered my purposes; but I would not hesitate a minute to use snow and ice in a case where I could think it useful and necessary. Such proceedings look cruel; but it is decidedly more cruel to let the patient's life be destroyed from want of timely assistance. I distinctly remember a case, which occurred in Cassel, when the physician objected to "tormenting the poor boy," and wanted the father to "let him die in peace." But the father,[33] who had some knowledge of, and a great deal of confidence in hydriatics, put the little patient, a boy of 8 or 9 years, into a bathing-tub filled for the greater part with snow, covered him over with the cold material, and left him there till he became conscious; then he was rubbed all over, placed in a dry pack (without a sheet), and left to perspire, which ensued and brought out the rash. The patient was out of danger in four hours' time, and Dr. S., on calling again in the evening, was quite astounded at seeing him alive, out of bed, and covered with a tolerably bright eruption.

Should the patient remain cold in his pack for longer than an hour,—a case, which will seldom occur,—a little wine and water may be given him to assist the organism in producing a reaction; and, in case of need, the dose may be repeated once or twice in intervals of half an hour. The quantity should be adapted to the age and constitution of the patient, and by no means sufficient to affect the head. Instead of water, it may also be mixed with warm broth or tea, or hot water and sugar, to make it agreeable to the little patient.

If the circulation of air is necessary in any other form of scarlet-fever, it is all-important in torpid reaction, especially when it inclines to a typhoid type. We should never forget that it is the oxygen of the air that nourishes the process of combustion going on in every living body, and that in the same manner as no fire can burn bright without a sufficient supply of air, the combustion within the patient will be slower in proportion as there is less pure air in the sick-room, and consequently his reaction will be weaker, and vice versa. A sick-room, filled with a number of people, and with a large fire in it, or fed with the corrupted air of a furnace, without the access of pure air, will always prove a dangerous place for a patient in torpid fever, the fire and every living soul in it absorbing the oxygen indispensable to his recovery. And if the case become typhoid, there is little hope of saving the patient's life without plenty of pure air.