temperatures, and, if need be, may stand in a tub containing a few inches of warm water if there is a tendency to coldness of the feet. The patient being stripped, the nurse takes a linen sheet previously dipped in water at any temperature that is not too low for reaction to take place, and throws it around the patient's body and over the head, so that in a moment the entire surface is in contact with it.

FIG. 59.

Drip-sheet wrung out and thrown about the patient, who rubs himself in front while the attendant applies friction to the back of the body and limbs.

Then the nurse applies brisk friction all over the patient's body and limbs, while the latter rubs the front of the body with his own hands. The whole performance is over in a few moments, and the patient should then lie down, be lightly covered, and rest. Such a dripsheet will often be a cure for insomnia depending upon faulty cerebral circulation or nervous tension. In other instances it seems to be stimu

lating, and to arouse dormant functions. Once a day is usually sufficiently often to use it, and when treating neurasthenics the morning is the best time to employ it unless it is designed to cause sleep. (Fig. 59.)

Cold in Fevers.

The proper manner to employ cold water in fever should be thoroughly understood. It may be used at varying temperatures, according to the effect desired, such as cool, moderately cold, and very cold.

Very commonly in the course of a fever the patient is restless, uncomfortable, and sleepless, yet has not a temperature fraught with harm. Such a case may be sponged with tepid water or with alcohol and water, or salt and whiskey, with great benefit in the production of sleep, the reduction of fever, and the advantage of nervous quiet. Sometimes the sponging is successful when used only over the arms and legs, but more frequently it should be extended at least to the spinal column.

If tepid sponging does not lower the fever in a given case, then ordinary cool tap-water should be employed; and it is well to remeinber that the secret of successful sponging lies in the use of a sponge not saturated to overflowing, but only sufficiently wet to leave a thin film of moisture on the skin, which cools the patient by its rapid evaporation and does not. wet the bed-clothes.

When we come to a study of the use of cold water in prolonged and severe fevers we find that its use is now universally recognized as the proper treatment, and with good reason. At one time it was believed that all the good results from cold bathing were due to the reduction of the fever, but it is now known that this is the least important effect of the bath except when there is such a hyperpyrexia that there is danger from that source. The benefit derived from the external use of cold water in infectious fevers rests upon the stimulation of the vasomotor system and general circulation, so that local stasis or congestions of blood do not occur in vital organs, in the stimulation of the processes of oxidation and nutrition, and in the elimination from the body by the skin and kidneys of toxic materials. Further, the more frequent cleansing of the skin aids its normal function, prevents chafing and bed-sores, and lowers the temperature by aiding in the dissipation of heat directly and through the sweat, which, even if imperceptible, is an important factor in reducing body-heat.

Whenever cold is used for the reduction of fever and applied to the entire body, it should be applied rapidly and be accompanied by active rubbing of the skin of the entire body to bring the hot blood to the surface and to gain the valued effects of massage. As a rule, the water should be used at one temperature, and better results will be obtained if it is cold enough to produce something of a shock to the circulation and nervous system, for the effect sought is the production of a

"REACTION"-that is, a redistribution of the blood and an awakening of all the vital processes. For this reason the writer does not approve of graduated baths-that is, the use of water which is gradually cooled while the patient is being bathed. The whole idea of the cold-bath treatment of fever is to produce the reactive stimulating effect sought by the well man who takes a sea bath. Consequently individuals too feeble to react should be bathed in slightly cooled water at first, and the temperature reduced each day a few degrees until it is quite cold. The exact degree of cold depends upon the need of the patient as stated below.

Fever is then to be reduced by cool sponging, in old and feeble patients using water at 90°, 80°, or 70° F., according to the ability to react and the needs of the patient. Friction is to be used with one hand while the sponging is done with the other.

If the patient is young enough and sufficiently strong to react, then the water used should be from 70° to 32° F., according to the needs of the case; and if the fever is persistent and difficult of reduction, the nurse may rub a piece of ice over the skin rapidly, applying friction constantly with the other hand.

The patient should always be stripped and laid on a blanket spread over a rubber sheet which has been placed to protect the bed.

It is essential when sponging is used that more of it be applied to the back than the front of the body, for at the back the great muscles and thick skin retain the heat, and these parts are not cooled if only the front of the body is sponged. Further, the posterior surfaces are the ones apt to be congested and sore from the dorsal decubitus, and therefore need the stimulant effect of the bath, as do the kidneys and other deeply situated organs. That this treatment is of value in those who react is shown by the marked redness of the skin, the improvement of the circulation and respiration, and the cleared mind.

The use of the ice-rub with a piece of ice weighing about two pounds held in the nurse's hand requires more care than does the immersion bath, but I have yet to see the case of typhoid fever, after the first week, in which this plan fails to reduce the temperature if it is properly employed. Indeed, I have learned that when this method fails it is because the nurse does not know how to use it. The rubbing with the ice and with the other hand must be brisk and produce reaction.

In some cases where sponging is not efficient the patient may be placed on a small canvas cot placed by the side of the bed and covered by a large rubber cloth, which, by being raised at the head and depressed at the foot, forms a channel for the water. Over this, again, is placed an ordinary sheet. The patient, after being stripped, is laid upon this sheet, which is then folded over him, and a spray from an ordinary watering-pot for flowers allowed to play upon his body from head to feet. The temperature of the water depends upon the effect required. The bed should be so arranged that the water will not

A typical chart from a case of typhoid fever treated by cold sponging. The dotted lines show the fall in temperature produced by the use of the cold water, and the solid lines the reaction after the sponging. The horizontal broken line is the morning and evening temperature, showing that the bath exercises no permanent effect upon the fever, which in this case ended on the twentieth day. If a case of this disease fails to present these falls in temperature after the first week when sponging is used, it is evidence that the sponging is not given with water which is cold enough nor with sufficient friction. If, on the other hand, the temperature after it falls fails to rise, it is a sign that the power of reaction is absent, and tepid or warm water must be used with friction for several days until the reactive power is restored. This patient had eighty-five spongings.