exception even in "the good old days," still the fact that she was tolerated, and the tales we have been told of the truly remarkable way sick people were cared for, makes us glad to be alive in the twentieth century, as long as it is ordained that mankind has to undergo the "ministry of suffering" in the shape of bodily ailments.

There are few modern towns, great or small, without a well appointed hospital, and staff of trained nurses; at the same time, there are thousands of homes scattered over the country, as well as in towns and cities, where, for obvious reasons a trained nurse is not available, and home talent takes her place.

The thoughts and suggestions gathered from the long experience of the writer, are gladly passed on to these home nurses, to be of service to them when "comforters are needed much, of Christlike touch."

AN UP-TO-DATE ROOM FOR THE SICK. Let us commence at the foundation, and build up for our use an up-to-date room for the sick.

Just picture to yourself, fair reader, the kind of room you would select should you be called upon to lay down for a time the life of active service, and take up the hard duty of serving by patient endurance.

A large room? Surely, because more airy, more restful, far less trying to tired nerves. With the many duties of the nurse, requiring much passing backwards and forwards, a good sized room is a help to both nurse and patient; again, a large room implies two windows, an untold advantage when we touch the question of ventilation and light. When a choice of room is possible, especially if preparing to battle through a long, tedious illness, always choose a room with a fireplace. A cheery open fire forms a bright spot, even on the gloomy days, and unconsciously has a strong influence in toning up the mental and physical health of the patient. It is difficult to remain depressed with such a bright comrade as an open fire, filled with beauty sparks, and we may add another advantage, its aid in securing good ventilation.

An important point to be remembered in our selection of a room is quietness.

Take your patient as far as possible from the family living room, and the noise of the kitchen. An upstairs room is best, even at the top of the house, and do not hesitate to take the sunny side.

"A glare of sunshine pouring in on the sufferer!" you exclaim. Far better, indeed, than a room without a ray from our life-giving friend; besides, dark blinds, window shades and screens will "temper" the glare to any desired tone, and for a few moments every day a warm bath of the glorious light will do more for your patient than oceans of medicine, and put color into his thoughts as well as his body.

Ventilation-few people, even in these modern days, understand the absolute need of good ventilation in health, and fewer still recognize its importance in sickness. We all acknowledge that oxygen is in reality the very breath of life, and know that in many severe illnesses a large supply of oxygen has frequently turned the balance when life has been shaking hands with death, and yet in many homes fresh air is resolutely shut out, day after day, and the used-up atmosphere breathed in and out of the lungs by all the family, until the doctor has to be called in to prescribe for many troubles that might have been avoided by the use of plain common sense.

When one comes to a sick man, battling for his very life, pure, fresh air is almost the best help one may give him, so through the open windows let in plenty of "God's out of doors," and the fight will be half won.

In the patient's room the windows should be left open at the top a few inches, night and day; hot air rises, and cold air descends, so the fresh air will circulate slowly around and down through the room without blowing directly on the bed, or causing a draft.

Should there be only one window in the room, open it a few inches above and below, slip a piece of firm cardboard, or thin slat of wood, over the lower opening, so that the air may enter in an upward direction, and a fresh supply of oxygen will always remain in the room, in "heaven's sweetest air."

One of the many foibles which have found their grave, in this age, is the one

claiming that the night air is bad for people, and should be shut out of the house. As a matter of fact, it has been proven that the night air is pure and healthy, and even more desirable than the air during the daytime, so let us gratefully inhale all we may.

If the patient still clings to the wornout theory of not changing the air of the sick room, do not try to argue-argument with a sick man is unwise, and utterly unconvincing-but open the window in an adjoining room, leave the door open between, and he will gain some benefit in spite of his perverseness. HOSPITAL TRAINING APPLIED IN HOME LIFE.

And now in regard to the furnishing of the room for the invalid: Infectious fevers, or major surgical cases, require a room specially prepared, about which we will talk in a succeeding chapter; at present we shall consider the preparations in an ordinary case of sickness.

First, the bed, a single iron bedstead, is, without doubt, the best, and in a severe illness is necessary, but under ordinary circumstances the patient remains in his own bed; one point of importance, however, is a hair mattress.

There may be a warm corner of the heart reserved by a few old-fashioned people for the feather bed of yore, but it may well be numbered amongst the relics of the past, and certainly has no place in a room where coolness, cleanliness, and facilities for nursing reign supreme.

The bed should stand out from the wall on all sides, to allow a free circulation of air, and sufficient room on three sides for the nurse to reach the patient easily.

On no account allow the bed to face the windows. If no other way is possible, put the patient's head at the foot, so that his back should be turned to the light. Have you ever remarked that in the majority of bedrooms one enters, the beds face the windows? and for two or three hours before rising, the occupant has a glare of light pressing in on the eyeballs, which eventually must cause trouble of some kind, for the eyes, obliged to face the light, and used every moment of the day, require eight or nine hours rest from light, if we would preserve their usefulness and clearness to the highest point.

Might not the early morning headache which clouds the temper of some people be due to the disregard of this fact?

To return to our sick room, in many diseases the eyes are weak, and must be guarded from too vivid a light, so let us think of this when arranging the bed, and, in addition, place a screen at hand that may be used when required between the window and the bed, or to screen the light from lamp, gas, or candle.

A screen is indispensable in the sick room, for many purposes, and if one is not obtainable, we must invent a substitute. The clothes horse from the laundry, covered with a soft shade of art muslin, makes an admirable screen, or one might fasten a strong cord, across the room, between the window and the bed, and hang a curtain on it to be moved backward and forward at will.

A small table close to the bed is most useful, also a couch, and one or two easy chairs without rockers-as the constant movement is trying to sick people; add to the list a bureau and side table, and the necessary furnishings of the room are complete. It is good policy to have the room as free from other furniture as possible; the air will circulate better, and the room is far easier to keep clean and in good order. Many people, when sick, are very nervous, and it confuses them to see a variety of things around, in the shape of bric-a-brac, drapery, or heavy ornaments. Apart from this is the all-important question of the hygiene of the sick room, and one may readily see how much time it would take to dust and cleanse an elaborately furnished room, to say nothing of the lodging house for germs caused by an accumulation of trifles.

Heavy curtains should be removed, and simple white muslin ones substituted. A few interesting books, pictures and magazines lend a home-like air to the room, while flowers-"God Almighty first planted a garden"-fill the very air with healing, so powerful they are to uplift our inner selves, and give us strength to overcome the bonds of sickness.

All the necessary appliances for use during the illness, viz., medicine bottles, glasses, feeding cups, surgical dressing, etc., are relegated to a closet, behind a

screen, or to an adjoining room well out of sight of the sufferer, for a model sick room must be so arranged as to contain nothing which may continually impress the patient with thoughts of sickness.

A long row of sticky bottles, or surgical dressings, ranged on a table in full view of the patient will never for a moment allow him to forget that some horrid tasting medicine has to be swallowed at regular intervals, or that a painful dressing has to be undergone.

Cheerfulness should be the dominant atmosphere, the keynote of the room, and no gloomy thoughts, or gloomy faces allowed to cross the threshold. When the "home mother" occupies the chamber of suffering, all knowledge of household cares and household disturbances should be rigorously excluded, and each member of the family do his share in promoting peace of mind to the invalid, by upholding this rule, and bringing only bright, cheery news, and pleasant out-door tales, to fill the mind of the invalid with happy thoughts, and thus hasten her recovery.

In regard to the temperature of the room, about 70° F. should be maintained, except in cases where the patient has a very high fever, when the thermometer should not average much over 65° F.

Early in the morning-between two and five o'clock-the atmosphere is cooler than at any other hour, and as the vitality of the body reaches its lowest point at the same period of time, extra blankets must be ready to throw over the patient; during a serious illness, especially in the care of an old person-hot drinks are required, in these hours, hot water bottles to the feet, and a close watch kept on the pulse, lest it flicker and die away in the "wee sma' hours anent the dawn." 202 West Seventy-fourth Street.

[Written for the MEDICAL BRIEF.] Cerebro-Spinal Meningitis.

BY R. M. GRISWOLD, M. D.,
Kensington, Conn.

In the June number of the BRIEF I note two articles upon the above subject, one by Dr. Annie K. Bailey, of Danbury, Conn., the other by Prof. Henry N. Read, of the Long Island Medical College, Brooklyn, N. Y.

In view of the gravity of this disease, and the great apprehension occasioned by its appearance in a community in epidemic form, not only among the laity, but among the profession as well, and in view of the further fact that little is really known either of its etiology or pathology, it becomes one writing upon the subject for publication to be at least reasonably sure of their facts before making positive and unguarded statements such as are made by both these writers. Such a course is especially to be deprecated when emanating from such a supposed source of authority as a professional teacher in a medical college, whose published statements are supposed to be founded on facts already demonstrated, or capable of demonstration.

Meningitis, both spinal and cerebral, has been specifically recognized and carefully studied for more than one hundred years. For the past two years, no disease, with the possible exceptions of cancer and tuberculosis, has been more thoroughly and scientifically investigated than cerebro-spinal meningitis, and yet there is no disease of whose cause and successful treatment we know so little.

Under the circumstances it is more commendable to admit one's ignorance than to pretend to a definite knowledge, which those of us who have had a long experience with this disease know is not possessed, at the present time, by either layman or profession.

With an assurance which should be displayed only in the presence of absolute knowledge, Dr. Bailey says, "Cerebrospinal meningitis, or spotted fever, is caused by a change in the blood constitution," or "a deterioration of the blood caused by a gradual accumulation of nitrogenous waste products therein," and then goes on to describe the poisonous effects of these waste products upon the nervous system, "causing the characteristic hemorrhagic spots."

This explanation might do very well, if it did not apply with equal force to rheumatism, gout, and other forms of autoinfection, but when we remember that the very large majority of cases of meningitis, especially cerebral, occur in children, often in infants, in whom the "gradual accumulation of nitrogenous

waste products" is very much less than in adults, I think the Doctor will pardon me for suggesting that this interesting, but delusive theory, could not have been evolved as the result of a large experience in the observation and treatment of this most elusive and deceptive disease. The Doctor further goes on to state that "The deterioration of the blood, which is an essential factor in spotted fever, is also caused by a solution of the red corpuscles of the blood, which manifests itself in the hemorrhagic spots, and is due in a proportion of cases to the pernicious effects of coal-tar products," etc.

In reply to this statement, I wish to say, first. hemorrhagic purpura is by no means characteristic of cerebro-spinal meningitis. It is as well characteristic of certain forms of scurvy in children, especially Westhoff's disease, is often seen in the rheumatism of children, also in splenomegalia, marked by gastric and cerebral disturbances, pain, diarrhea, and vomiting, a case of which I have seen diagnosed as cerebro-spinal meningitis by one of the best diagnosticians in New England (and no discredit to him). It was characteristic of the old-fashioned typhus fever, which usually had associated with it a more or less severe form of meningitis, from which came the name "spotted fever," now quite wrongly applied to all cases of cerebro-spinal meningitis, except traumatic. These hemorrhagic spots are much more characteristic of low forms of chronic malarial poisoning than of meningitis, and yet the Doctor assures us, with great positiveness, that they are due to coal-tar products, "in a proportion of cases." This is another case where we are constrained to ask, "How do you know?" and, do you not know that cerebro-spinal meningitis, typhus, malaria, scurvy, and all other conditions associated with purpuria, were common long before coal-tar products were known? Prof. Read now announces with equal positiveness that "the cerebro-spinal variety of meningitis is due to the diplococcus intracellularis."

At this point possibly an apology may be due for the presumption of an obscure country doctor, who for thirty years has been obliged to draw his deductions from his observations of, and experiences in,

combating actual disease, rather than from laboratory work, to one holding an honorable position in a high-class institution of learning, and whose spoken and written word should carry with it the weight of fact, unobscured by theoretical vagaries.

Perhaps I may also be pardoned for asking a pointed, but, it seems to us, pertinent question, which may seem to imply a doubt as to the positive certainty of the Professor's statements. Nevertheless we presume to put the question, viz., "How do you know that the diplococcus intracellularis alone produces cerebrospinal meningitis?"

The fact that it produces fatal meningitis in guinea pigs is not proof that it produces it in the human.

The fact that it is found in cases of spinal meningitis is not proof that it is the producing cause, any more than the fact that the Klebs-Loffler bacillus, found in diphtheria, is proof that the bacillus is the producing cause.

As the Klebs-Loffler is found in many people who have not diphtheria, so the diplococcus intracellularis is found in many who have not cerebro-spinal meningitis.

The presence of either germ is presumptive proof that it is productive of the disease attributed to it, but presumptive proof ought not to warrant positive assertion, and this same diplococcus is found in purulent empyema, and in certain forms of septicemia.

Dr. Read states, further, "Diagnosis of the cerebral variety of meningitis is readily made."

I should wish to modify this positive statement by saying that in an experience of thirty years, during which time I have seen a larger number of cases of cerebrospinal meningitis than falls to the lot of the average practitioner, either urban or rural, I have learned that the disease is frequently hidden in obscurity, and often not to be accurately and positively determined by the most acute diagnostician.

The late Prof. Alfred L. Loomis once said to me, while seeing a case in consultation, "It looks like a case of cerebrospinal meningitis, but the symptoms are quite obscure, and only a post-mortem will determine it."

Theoretically, the diagnosis of the disease is simple, but brought into frequent contact with it, we are often forced to admit there are many things we do not "know," and the more one sees of meningitis the less he will be inclined to express any very positive opinion upon either its causation or treatment.

Fre

One further criticism of Dr. Read's article: He says, "The fever, as a rule, is not very high." His modifying words, “as a rule," I believe to be correct, but one of the most frequent and characteristic signs of meningitis, especially cerebral, is the erratic temperature. quently decidedly sub-normal, it may, in a short time range from 103° to 106° F., and extremely high temperatures are not uncommon. Neither is the extremely high temperature of necessity an indication of fatality. I have a little patient now, whose temperature on one occasion, three weeks ago, reached 109° F., and he stands a good fighting chance of recovery.

A few words as to the results of my personal observations upon this disease:

First, I think it will be found that the history of cerebro-spinal meningitis epidemics for the past one hundred years will confirm the statement that the dis

ease

almost invariably follows a prolonged and cold winter.

Second, That a careful investigation of each case will show that most of them have been preceded by a recent and generally severe case of grip.

Third, That when two or more cases have occurred in the same family or house, both cases were due to the same primary cause, but there is a possibility, by no means yet proven, that there exists a certain amount of contagion capable of conveying the disease from the infected to the well.

Fourth, That no specific plan of treatment has yet been demonstrated as successful. The plan of Thomas Watson, and other observers of seventy-five and one hundred years ago, is not improved upon by later-day methods. Absolute quiet, plenty of fresh air, a nourishing liquid Cet, the judicious use of opiates, circumscribe our range of remedial agents.

In my own hands, I have had more than the usual per cent of recoveries following the use of hyoscyamine, codeia or mor

phine, and aconite, supplemented by the cold pack, and cold rectal injections, but I should not wish to recommend my method as specific, or commend it as superior to any other treatment which is dictated by ordinary common sense, and the only thing I object to in others is the putting forth of unfounded theories as facts.

The simple truth is, we do not know what causes cerebro-spinal meningitis, neither do we know what will cure. We know as much as our grandfathers did about it, but no more. We look to the future with hope and the belief that some investigator will shed the light of certainty upon a path which is now entirely dark, but we have to admit, if we are absolutely honest with ourselves, that at present our knowledge of the cause of meningitis is equaled only by the profundity of our ignorance as to its proper treatment, and that any theory as to its cause can be readily disproved by a fairly accurate observer of plain facts.

[Written for the MEDICAL BRIEF.] Malaria.

BY ALEX. B. MCCASKELL, M. D., Albany, Ga.

Thirty-six years ago, when fresh from college, where I had been lectured to give quinine in small doses, at frequent intervals, in order to subdue malarial influenza, I made plantation contracts to care for the sick in that notoriously malarial lime belt in Houston County, Georgia, and my patients as well as nurses were negroes exclusively and chills and fever the prevailing malady. I would give the purgative and leave the quinine to be given by the nurses in small doses and at frequent intervals (as I had been lectured to do). I found that some of my patients got well at once and others lingered, which fact puzzled me no little, and upon a close and vigorous investigation I discovered the cause, i. e., the nurses of those who rallied first, rather than be troubled to give the quinine as prescribed, would give it all in one or two portions: hence the results stated (experience vs. teaching).