FRESH AIR IN THE TREATMENT OF DISEASE.

BY W. P. NORTHRUP, M.D.,

New York.

There are two points to be discussed: First, the class of cases to which this treatment is especially adapted and in which it has been thoroughly tried; second, the practical application of the method, its working out in detail after much observation and experience.

There is no doubt that open-air, boldly administered, is a method of cure; that it is being promptly accepted and almost universally adopted by the younger members of the profession, and that it has come to stay.

The title reads "fresh air," etc. I could wish that it had in some way included the words "open air," "cool air," or "cold, flowing air." Every musty text-book in the back row of the stack-room ceremoniously includes under "treatment" the words "fresh air," and forthwith proceeds to recommend exclusion of drafts, to hint at blankets in the windows, lint in the sash cracks, etc. In other words, "fresh air" is an indefinite term, a conventional expression, and may mean nothing.

Hot air may contain the requisite oxygen, cellar air may be cool, both may miss the invigorating effect so conspicuously present in open air; that is, in uninclosed, atmospheric air. If it ever is entered in the U. S. P. and standardized for therapeutic use, it should read something like this: "Open air, or cold, fresh, flowing out-door air, dosage regulated to individual needs."

SOME OF THE PHYSIOLOGICAL EFFECTS OF COLD, OPEN AIR. When the New York Health Department first began to put the tuberculous insane out in the open air to sleep, in shacks, the first important observation noted was, that the patients slept, slept without their usual sleeping mixture, without dope. This was the regular result. I have observed the same in fever children. From being restless, dusky, and even delirious, they become quiet, of good color and given over to sleep. They often sleep for several hours together, quietly. Next, it is noted that

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they take their food better; finally that recovery is hastened and completed earlier. These remarks apply more completely to those acutely sick, dopy from toxemia, their case running an acute course. Pneumonia furnishes the best illustration of an acute infectious disease benefited by open-air treatment.

CLASS OF CASES.

I am most familiar with the open-air treatment of pneumonia, scarlet fever and several of the exanthemata, including those with bronchitis and marked cough. I do not hesitate in any of the above cases to put them out of doors in all sorts of weather. As to measles, I am not prepared to state that I have had much experience. I leave it to the members of this society to say whether measles, with its accompanying moist skin, its bronchitis, its tendency to ear complications and its lurking tendencies to accidents, shall be put out of doors. To be consistent, I should say these accidents are due to spreading infectious lesions, and that out-door air would not unfavorably affect them, but at this moment, I am not willing to give a final judgment. I may add just here, that apart from measles, I do not hesitate to put in the open air bronchitis, nasopharyngitis and laryngitis. I do not find that the cough is made worse or the lesions increased. Rather the contrary; the cough becomes less and sleep follows.

PRACTICAL APPLICATION.

In speaking of open-air treatment, I have constantly in mind the conveniences and methods to be observed at the Presbyterian Hospital (New York), open-air ward. A cold ward, or cold open room, presupposes an adjacent warm "grooming" room. Dressing and washing of patients should be done in warm rooms. Patients when once made comfortable, can then be exposed for hours to cool or cold fresh flowing air, and remain comfortable. Here let me say-the patients and nurses should be made comfortable all the time. The nurses should wear overcoats or blankets about their shoulders. They have not the appearance of thoroughly applying the open-air treatment in winter until they wear heavy wraps. The patients should be comfortable; then they will like the treatment. To this end the dressing of the bed should be carefully studied out. The following is our present plan in the Presbyterian Hospital. The first requisite is that there should be

as much bedding below the patient as above. First a huge, enveloping, extra-sized blanket should be spread upon the bedsprings. Upon this, a rubber blanket or thick paper; then the mattress; upon this a blanket; upon this, again, the sheets, and over these other blankets. After the patient has been well tucked in with the usual bed-blankets, the aforesaid extra-sized, first blanket should be brought round the sides and up from the foot and pinned from chin to toe. At last, the top surface of the bed should look like a huge postal envelope fastened along the middle line, the foot piece coming up to be joined to that line. The copious head folds should envelop the mattress and come down beside the head, the face and chin just emerging. The primal requisition is to construct a huge bag in which the patient may move somewhat without air getting in between the blankets. One other requisite is that the patient should wear a complete suit of light flannel underwear under the nightdress. Whether he wear a night-cap may depend on the individual patient's wishes, upon the amount of hair, etc., etc. He must be made comfortable.

In presenting the subject for discussion, these two points have been emphasized:

(1) All febrile cases, measles possibly excepted, may be safely and to advantage treated in the open air.

(2) The comfort of patient and nurses is essential. To this end the bed must be carefully prepared, as much clothing below the patient as above. The patient should wear a complete flannel suit next to the skin. The nurses should have no false pride about wrapping themselves sufficiently to be comfortable. The best success is to be obtained only in facing the problem fairly and taking for a motto: "Make everyone comfortable."

RESULT.

I have no percentages, no tabulations to present. The success of the treatment must rest on the individual impressions of those making use of it. My own impressions and convictions from my own experience justify the following statement: Openair treatment has killed no one, has injured no one, has helped everyone, and determined a cure in a few.

FRESH AIR IN THE TREATMENT OF DISEASE.

BY EDWIN E. GRAHAM, M.D.,

Professor of Diseases of Children in The Jefferson Medical College, Philadelphia.

One must always study all the factors leading up to, and possibly causing disease, and before deciding the positive influence of one factor, eliminate wholly or in part, other etiological influences.

In considering, therefore, the rôle that fresh air plays, "controls" should be employed, as far as possible, for the comparison of a series of cases of the same disease in the same type of cases living under similar conditions, should enable one to draw fairly accurate conclusions.

My first work in fresh air treatment began some eight years ago in the children's ward of the Philadelphia Hospital. The wards were large, the milk fairly good, enough nurses were on duty to keep the children fed according to my directions, they were bathed regularly and kept clean; but in the wards where the very young infants, mostly foundlings, were placed, the results were very unsatisfactory. Much depended upon the physical condition of the infant on admission. A frail infant, perhaps premature and under normal weight, would gain for a few weeks at best, then remain stationary in weight, finally gradually lose weight, begin to have diarrhea and die. Robust infants on admission often did well for three months. The same symptoms after this period began to develop as in the infants admitted in at condition of malnutrition and in spite of my best efforts, many of these robust children died.

The same type of infants in my private practice were almost without exception, doing well. Convinced that neither the food, nursing, nor general care of these hospital infants was at fault, and that the so-called hospitalism was nothing but lack of fresh air, and lack of out-door air, I ordered these children, in the month of January, placed for two hours each day on the fireescapes.

The cribs were simply moved out upon the fire-escapes, and

towels pinned over the top of both ends of the crib, as wind shields. The infant mortality began to lessen immediately, and I began to see some hope for my infant hospital patients. In the following two or three years, during my service in January, February and March of each year, I had the children, for a number of hours each day, unless it was raining or snowing, carried down to the large open space facing the hospital buildings, and kept in small hammocks. These infants were always bundled up in blankets, their heads well covered, and their eyes, nose and mouth covered with a gauze veil. They did remarkably well; so well, in fact, that instead of my infants dying, most of them began to gain in weight and health, and the deaths were almost entirely in infants under three months of age, whose condition was distinctly bad upon admission to the hospital.

During the past five years the infants have been placed in the new modern and up-to-date building of the Philadelphia Hospital. The wards are large, the air space ample, the milk the very best; porches surround the hospital on two sides, the infants practically have an abundance of fresh air day and night, and they do as well as could be hoped for. I am no longer a pessimist when in the infants' ward, but an optimist. In the new Jefferson Hospital, where I am on duty the entire year, the children have an ideal ward on the eighth floor, large windows on three sides with a large roof garden adjoining, the latter fitted up with every convenience, such as hammocks, shade, wind shields, etc. The roof garden is used all the year round, winter and summer, and the results are most encouraging.

Of all the factors which have contributed to the reduction of this infant mortality, fresh air has, in my opinion, been the one of prime importance.

During the last three years in my service in the Philadelphia Hospital, I have treated all my severe cases of broncho and lobar pneumonia in children of all ages by the fresh air treatment. These infants and children, as soon as taken ill, are removed from the general ward and placed in a special room provided for such cases. The room holds six cribs comfortably, and rarely, during my service in the last three years, has a bed been vacant. Many of these cases are secondary bronchopneumonia. A large percentage of the children, in fact most of them, are hospital children, but the results have been so different from the old plan as