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is especially in the broncho-pneumonias caused by pneumococci that we are more apt to succeed. The broncho-pneumonias caused by the streptococci, are generally of a protracted nature, and exhibit quite extensive lesions. In these cases the cold bath is useless.
It remains for us to find out whether a cold bath is useful in the broncho-pneumonias caused by the colibacillus ; these inflammations are not yet thoroughly understood, and are besides quite rare. Moreover, it may be said that the nature of these broncho-pneumonias is less easy to establish. To do this it would be necessary to puncture the lung, in order to examine what kind of microbes had invaded this organ; but I do not believe that such a method should be resorted to.
To summarize then: It seems to us that cold baths are useful, especially in those cases in which the general symptoms are marked, exceeding in importance and gravity the local phenomena; as, for example, in those cases characterized by a suffocating catarrh, and in those broncho-pneumonias in which the nervous symptoms predominate. When the temperature the temperature marks 41° C. the cold bath is always indicated, because the hyperthermia constitutes by itself danger. The same indication holds good, when, with the existence of more or less extensive local lesions, the temperature and the reactions are excessive.
When the local lesions are quite extensive, and the fever is intense, the cold bath may sustain the patient by producing a certain amount of defervescence, but it does not generally bring about a cure.
In the presence of serious local lesions, with little febrile reaction, the cold bath is contra-indicated. It is similarly contra-indicated when the action of the heart is disturbed, although this is exceptional in children; or when there is a condition of marked adynamia. Age does not constitute a contra-indication. In fact, cold bathing produces in young children marvelous results, because in such subjects the general symptoms predominate, and do not always bear any relation to the local lesions.
The manner in which I generally give a cold bath, is as follows: For the first bath, the water must be at 28° C. (92° F.), the duration being from five to ten minutes. The child must be taken out before it is chilled. For the other baths the temperature of the water may vary from 24° to 18° C. (75-64° F.); it is not necessary that it should be lower. The child is to be put into the bath entirely naked, and thus kept there, the temperature of the water being regulated gradually by adding more cold water, as required. [Constant friction over the entire body should be practiced by a rough towel or glove.-ED.] The head of the child is then to be bathed by affusion. In about five, eight or ten minutes the little patient is taken out, wrapped
in woollen sheets (linen better), and made to take some nourishment. An hour later the temperature of the body is taken, in order to see if it has diminished. Two hours after, that is, three hours after the bath, the thermometer is again applied. If the temperature is still above 38° C. a new bath is given ; if below, it is better to wait. The temperature, however, must be taken every two hours, and the child put back into the cold bath if the bodily heat is above 39° C., unless the excitement and the dyspnoeac symptoms have disappeared.
The baths should be continued while the hyperthermia lasts, given as many as seven during the first day. In favorable cases the number should be diminished on the following days.
As an adjuvant I advise the administration of quinine, which, instead of depressing, sustains the heart, and also hypodermatic injections of caffeine and ether, if there be tendency to collapse or syncope. The child should be nourished with milk and water, broths, and made to drink as much as possible, in order to increase the urinary secretion, coffee, and especially grog and cognac. A child one year old can take from 15 to 30 grammes of alcohol a day; 22 one to three years of age as much as 60 grammes. Alcohol has the advantage of aiding the favorable reaction which is produced after the bath. When such a result is not observed, it is generally because the bath has been prolonged; it is, therefore, important to see that the duration of the following baths is diminished.
The cold baths are not only indicated in the catarrhal or grippal broncho-pneumonias; they are similarly of service in those occurring during an attack of measles or of whooping cough. The prognosis in these latter cases is always exceedingly bad. It is almost fatal when the pulmonary inflammation is secondary to diphtheria.
I hope, gentlemen, that I have been able to impress you with the fact that cold baths constitute a useful means to employ in the treatment of broncho-pneumonias of children; they do not constitute, however, a sovereign remedy, nor is the treatment applicable to all cases.
Employed when specially indicated, cold baths produce excellent results; but employed indiscriminately they are often the source of disappointment.— (Le Bulletin Medical.)
THE NEED OF METHOD IN CHANGING
BY J. WELLINGTON BYERS, M.D., CHARLOTTE, N. C. As the season approaches for the annual migration of northern invalids to southern localities, it is not inopportune to direct attention to some of the methods commonly pursued in making these changes,
Climate, like all therapeutical resources, must be employed rationally and scientifically in so far as is possible. The well-nigh universal custom of directing invalids of every class, condition and circumstances to the South in winter, imbued with the idea that this region is a great natural sanitarium for the healing of the nations, is neither wise nor proper. It is the opinion of the best informed, through experience upon such questions, that it would be a good plan for those physicians who undertake to prescribe a change of climate for such of their patrons as it is deemed necessary that they familiarize themselves with more of the details of this process, and that they inform themselves, not only concerning the general climatic features of a given locality or section, but also should become acquainted with the distances between places, the best routes, the accommodations by the way and their equipments, and, in addition to these, which is probably the most important of all the issues, the objectionable and deleterious effects of a locality, and the points about which the invalid should inform and guard himself against. Important as these several details are, there is another which will commend itself in particular, and that is the routine of the journey. I am strongly of the opinion that it is decidedly to the advantage of the invalid to make a change of climate in a gradual and methodic manner. In other words that the trip should be made in relays or stages rather than in the hasty manner in which it is usually done. The reason for this lies in the fact that a gradual change in environment tends to lessen or to altogether obviate the dangers of acclimation, a process which experiences show to be often fraught with the most disastrous consequences to the feeble. Indeed, even in the robust and healthy, this process is not without evil effects, and sometimes is the cause of permanent illhealth. The practice of crowding the sick into passenger and sleeping cars in the far regions of the North, when the surroundings are cold and ice, and in a few hours disembarking them in the hot, moist and debilitating sub-tropics, is contrary to nature and reason, and the former resents these violations of her laws by dire and fatal effects upon these helpless victims. The organism already debilitated by the inroads of disease cannot adapt itself rapidly to this radical change of external environment and often perishes in the effort of acclimatization. In prescribing a change of climate for the invalid the physician should become acquainted with the facts herein set forth, and should be prepared to advise how the change can be made in a rational manner. They should be instructed to do so gradually, and to stop over at points between whenever the journey is a long and tiresome one, calculated to undermine and consume their remaining energy. A journey con
ducted in this way will not only obviate this wear and tear, but will give them a change of scene, differences in fare and surroundings, and in this avoid the ennui and homesickness, a factor of no small amount in the well-being and progress of the case. In addition to what has been stated it may be said that experiences demonstrate very generally that patients suffering from a pulmonary disease invariably manifest decided changes for the better during the first few days or weeks of their arrival at a suitable locality. This frequently lasts for a period of four to six weeks, then there is a stasis of the case, soon to be followed by a decline to the condition manifested upon arrival. To obtain this period of beneficial effects and avoid those of the second is obviously of the first importance. From what has been said it is seen to be possible by keeping the case on the move and to start them onward just before the stage of decline sets in. In sending invalids South in the winter by this plan I am certain of better results than those heretofore obtained. Those in the farther North and New England States should start in the Fall and thus gradually work themselves down to lower Florida by midwinter. Suitable places to stop over, with the proper distances between-from one hundred and fifty to two hundred and fifty miles-will be found at Washington, Lynchburg, Asheville, Charlotte, Aiken, Augusta, Thomasville, and finally Florida.
Medical Society Notes.
AMERICAN PEDIATRIC SOCIETY. Fourth Annual Meeting held in Boston, May 2, 3 and 4, 1892.
TYPHOID FEVER IN CHILDREN.
Dr. Northrup read a paper on Typhoid Fever in Children Under Two Years. He believes that typhoid fever, as a rule, avoided the first two years of life. At the New York Foundling Hospital there had never been a case in the observations of twenty years. Cases had been suspected, but on autopsy did not prove to be such. A great many institution-reared children under one year, on autopsy, show the gross lesions of typhoid, judged by the scale of adult life. Peyer's glands were enormously swollen and abruptly limited at their margins, sometimes showing a partial ulceration; mesenteric lymph nodes swollen; spleen enlarged, etc. Illustrative cases were narrated showing such lesions. Bacteriological investigation showed no typhoid bacilli (Prudden.)
Dr. Northrup raised the inquiry, whether, in the experience of those present, typhoid fever has been observed in children under two years. He had never
met it in the wards or in private practice nor in two thousand autopsies.
Dr. Charles Warrington Earle, of Chicago, said : Typhoid fever has justly been considered an infrequent disease among children. Indeed, prior to 1840 the opinion quite universally prevailed, that infancy and childhood enjoyed an immunity from it.
Vogel in 1,017 cases records seven under one year, and in one case the disease took place three weeks after the child's birth, the mother having typhoid. Montmollin had fifteen under two years of age out of 295 cases. In 280 cases reported by Henoch, eight were under two years of age.
Murchison makes mention of three cases in younger infants, namely eight days old, fifteen days old, and in a fœtus of seven months.
I shall report a case of an infant five months and three days old, at whose autopsy we found all the evidences usually present after enteric fever. So we are certainly discovering that typhoid fever is not so infrequent in infants as we had been led to suppose.
Typhoid Fever in Children.-The proportion of children affected with typhoid fever over five years of age, is about as follows: In 280 cases observed by Henoch, 154 were between five and ten years and sixtytwo between eleven and fourteen years of age. In 1,070 cases observed by Vogel, 412 were between five and ten years and 393 between the ages of eleven and fifteen. My deductions in typhoid in children are based upon twenty-one cases whose histories are very complete, in the city of Chicago, during the last year and a half. My practice extends over a period of period of twenty-two years, and the epidemic of typhoid fever upon which this paper is based has given me a larger
experience in this disease among children in that time than I have had in the twenty-one preceding years of my practice.
The youngest of my cases was five months and four days. Seven occurred before the fifth year; nine between the fifth and tenth; and five between the tenth and fifteenth. Of these twenty-one cases, one was lost.
I desire to place on record a comparatively large number of cases of typhoid fever in children in private practice; and secondly, to discuss very briefly the cause of this disease as it has occurred with us during the time mentioned. There must at this day be some tangible cause for typhoid fever. The time has passed when it is sufficient to state that typhoid fever comes from decomposing logs, or from an odor from the sewer or from tainted food. There is a specific recognized bacillus which is found in every lesion of typhoid fever. I shall confess that I believe that our drinking water contains the infection which has caused this epidemic. I shall, however, take occasion to criticise the statement that the water supply of our city is at present derived from the river. There never was a more unjust or untruthful state
ment, for as a matter of fact not a drop of the drinking water for the inhabitants of our city comes from the river.
Our city extends along Lake Michigan from Hyde Park to Lake View, a distance of probably twenty miles. The main part of the city extends toward the west from two to ten miles. There is a distinct water supply to the southern part of the city, which I will designate the Hyde Park supply; a distinct water supply to the northern part, which I will designate the Lake View supply; and the supply to the main city.
The water to the city proper comes from a tunnel which extends into the lake two miles, Hyde Park from a tunnel which extends into the lake one mile, and Lake View from a tunnel 2,000 feet from the land.
The water from the lake during the greater part of the time is simply beautiful. It is clear, cool, and absolutely uncontaminated. It compares very favorably with the water which many of us have seen in Vienna. Occasionally it is slightly impregnated with organic matter. No one with any regard for the truth can say otherwise.
We have nearly 900 miles of sewers; the one from the north to the south extending probably a distance of fourteen miles, and the one taking the sewage from the west commencing about seven miles from the lake.
There is no disputing the fact that the sewage of probably 300,000 people of our city empties into Lake Michigan; the rest of it in the main, is conducted into the river and goes away from the city, except at certain times of the year when the current of the river is turned into the lake, and at this time there is water pollution. Now this is all wrong, it is unscientific, it is criminal to the poor, who cannot be to the expense of buying pure water.
Now what is being done to obviate these defects? We are working in two directions: 1st. To obtain a water supply at greater distance from the lake shore, and secondly, to conduct all our sewage down the river so as to remove the last chance of the pollution of our drinking water. By next October our new eight-foot tunnel will be in operation, which will take water four miles into the lake, at which point no contamination at present and for several years can take place. We have in process of construction undertakings and improvements, which, within a year will give us the best and purest water that can be obtained in any large city. This will be true with our present sewerage system, and when the drainage canal is completed we shall be safe with a population of three or four millions.
Clinical History.--The typhoid fever which we have observed during the last two or three years in children conforms very fairly to the disease as we have noticed it during the same time in adults.
The irritation of the gastro intestinal canal in typhoid fever seems less than it was a few years ago. That a change has been wrought is certain. Whether this is through treatment or from the rest in bed, which we make absolute in the treatment of this disease, or because we feed more and medicate less, I am unable to say.
In our present epidemic the duration of the disease in children was from seventeen to forty-five days, with an average of twenty-six days.
Vomiting was present in eight cases; slight in six and severe in two. In Henoch's cases, there were forty-two cases of vomiting, and Vogel remarks that this symptom takes place with greater frequency than in adults.
As a rule in this epidemic we have had about as many cases of constipation as diarrhoea.
Rose spots were found in all the cases except one, which was seen late, and in three which either were not examined for them or no record was made of their appearance.
Henoch says that rose spots were absent in fifteen cases, but were usually found in other cases.
Tympany.-Henoch speaks of tympany as being rare. This was not true with us, as a majority of cases showed more or less tympany.
Hemorrhage of the Bowels was present in one case, while in our recent epidemic none took place. Henoch noticed it nine times. Vogel says intestinal perforations are rare.
Epistaxis was severe in two cases, slight in several. Vogel says that nose-bleed in typhoid in children is
cases. Vogel states that the laryngeal inflammation is rare, but that inflammatory conditions of the cartilages may take place followed by necrosis. The same authority remarks that bronchial catarrh is frequent. Henoch noticed bronchial catarrh with frequency; pneumonia took place in several cases and gangrene of the lung followed in three. Bronchitis was present in a considerable number of our cases. Pharyngeal diphtheria is recorded as a frequent complication by Vogel.
Continued crying took place with some of my patients, especially at night. There was also jerking of the muscles and grinding of the teeth and stiffness of the neck; in older children these symptoms did not make their appearance. Delirium and hallucination
(To be continued.)
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The temperature ranged from 103° to 105 1-2, aspirants for medical honors in this city, will recogthe last being the highest that was noticed. Henoch states that the temperature is usually from one-half to one degree higher in the evening.
Pulse ranged from 90 to 180, and usually its rapidity corresponded with the temperature tracings. Henoch says that this is usually his observation.
Splenic Tumor was found in seventy per cent. of the cases, and can usually be demonstrated by percussion and rarely by palpation. Vogel demonstrated a splenic tumor six hundred and six times out of six hundred and sixty-two; it was palpable thirty-six times in one hundred and one. Henoch found splenic dulness in one hundred and forty cases.
Parotitis occurred in one case on the right side. Resolution took place without suppuration. Vogel says that the parotid gland swells sometimes in children during the second week of typhoid.
Phlebitis occurred in one case, the infection making its appearance in the profunda femoris vein.
Periostitis was observed in one case, the parietal bone being the one involved.
Henoch reports ulceration of the larynx in four
nize among the authors many names whose connection with this Quiz series offer a guarantee that the student will obtain the most practical help from these books. TREATISE ON GYNECOLOGY, MEDICAL AND SURgical. By S. Pozzi, M.D., Prof. Agrégé, &c. Translated from the French under the supervision of and with additions by Brooks H. Wells, M.D., Lecturer in Gynecology at the N. Y. Polyclinic, &c. Vol. II. With 174 new engravings and 9 full page plates in color. New York: Wm. Wood & Co., 1892.
The second volume of this work entitles it to become a classic in its department. The author's broad and comprehensive view of the entire field, as indicated by the text of the first volume, is again evident in the second volume. There is not a single subject connected with gynecology omitted.
In this brief notice we can but voice our convictions that the practitioner will not seek in vain if he resorts to this magnificent work for information upon any branch of gynecology.
The brilliant achievements of modern surgery, based upon the recognition of a bacterial etiology, have borne results in internal medicine, which, sooner or later, must bring the true physician to grief.
Since antiseptics have led to such remarkable triumphs in the open field of surgery, why should not the same results be achieved in the hidden field of internal diseases, which have also been traced to micro organisms? This appeared to be a legitimate corollary. And yet, it has already proved so fallacious that it is time to call a halt in the eager pursuit of parasiticides that are supposed to pursue the microbe to its innermost hiding-place and destroy its vitality, ere it jeopardizes life and health. A little reflection must demonstrate that the treatment of infectious diseases by antiseptics is one of the Will-o'-the-wisps of the present progressive era.
First. It is not probable that the action of parasiticides, as demonstrated in the test tube, may be relied upon in the remote recesses of the human body. Conditions exist here which must modify or neutralize their effect. The various acid and alkaline fluids, through which the anti-parasitic remedy must pass, the osmotic conditions to which it may be thus subjected, its possible entanglement in mucous or purulent fluids all these operate more or less antagonistically against the precision which is attainable in the laboratory.
Second. A large proportion of the organisms to which are attributed baneful results in many diseases, are usually not accessible to the action of parasiticides. In typhoid fever, for instance-a disease in which superficial reasoning would direct their attack to the main lesions in the intestinal tract, a deeper study would develop the fact that ere the disease is diagnosed, these organisms have already passed into the lymphatic glands, the spleen and even into the small lenticular spots on the skin, which are the chief characteristic of the disease. How naphthaline, or salicylate of soda, or salol, or sulpho-carbolate of zinc, or bismuth is to enter the blood and pursue these enemies into their very innermost lairs, "passeth the understanding."
Third. Even if this were possible, the experiments of Koch and others have shown conclusively that certain concentrations are required for certain bacteria. No sane man would venture to apply these concentrated solutions of antiseptics to any large surface of the body, lest their local or general effect resulting from absorption produce the most dire consequences. Nor would it be possible to maintain the integrity of the blood in which they are supposed to be dissolved.
Fourth. Even if this were possible, we are confronted with the fact that it is not the micro-organisms themselves which are to be dreaded, but the ptomaines and toxines, whose effect is so destructive to the animal economy. Since the organisms are already firmly entrenched in the latter and have already begun their productive career when the physician's aid is invoked, the attempt to destroy them would be futile.
Arguing upon these briefly stated premises, it may be assumed that the internal administration of antiseptics in infectious diseases is not so promising as many enthusiasts would have us believe.
This pessimistic view may be met by the clinical demonstration of the value of the antiparasitic treatment in some diseases. Reports are constantly published of favorable results which are ascribed to antiseptics. Among these we may take as an illustration the application of sulpho-carbolate zinc in typhoid fever, which is advocated by capable and intelligent physicians. As it is impossible to formulate definitely the results of any treatment in a self-limited disease, the simple clinical result cannot be accepted. unless the rationale of its attainment appeals to our reason. The destructive effect of sulpho-carbolate of zinc upon the bacillus of Eberth has never been demonstrated even in the laboratory. Were this possible it would surely have been done. As has been well said in a recent able paper on this subject by Dr. J. J. Berry, in the N. E. Medical Monthly:
"That germicides, as such, have at times curative