THE COOL-BATH TREATMENT OF TYPHOID FEVER IS "FEASIBLE” IN PRIVATE PRACTICE.

BY CHR. SIHLER, M.D., CLEVELAND, OHIO.

It cannot be expected that the Brand method of treating typhoid fever should be extensively adopted in this country before the most influential teachers. and text books shall have not only described it, but also recommended it, urged it and impressed their students and readers with the truth that they will not have done full justice to their typhoid fever patients if they have failed to make use of the hydriatic method.

It cannot be expected from such works as that of Loomis or Pepper's* system, that they should recommend a method which they have failed to describe and the splendid results of which they have neglected to communicate to their readers.

When I read, however, the report of Prof. Osler, that the method had been adopted in the Johns Hopkins Hospital, with the customary two-third reduction of the mortality, I hoped that he would do more justice to the Brand method, and was anxious to see what he would say about it when discussing the treatment of typhoid fever in his recent work on the Principles and Practice of Medicine. But, in a review of the work in this journal, I find the following passage: "The results of this treatment have been so excellent as to almost compel its use in hospital practice, but the difficulties attending its manipulation are such as to render its use in private practice scarcely feasible."

I was more than sorry to find these words "scarcely feasible" (in private practice), in Osler's work, because they will be the cause of hundreds of persons losing their lives, inasmuch as they will prevent a great many from giving the method a trial. All the conventionalists in the profession, all the men who act not on their independent judgment, will not be moved by what Osler may have said in favor of the method but will use the words as a pretext, behind which they can hide themselves when their lack of energy will not allow them to use the baths. Instead of words of discouragement, I had expected that Osler would have enlisted the interest of the profession in this method and would have encouraged the physicians, by showing them that there are no more difficulties connected with the Brand method than

with a great many other procedures which are daily accomplished. Osler might have become a benefactor of the American people if he had taken this course. Not having Osler's work before me, I cannot say what reasons he may have had for the words mentioned. But I shall try to answer the objections which may be made if the method is proposed to the laity, assuming that the physician is convinced in his own mind of the superiority of the Brand method over the methods in use, as well as that it is not dangerous. The objections which one may expect to

hear are:

(1.)

The method is dangerous.

(2.) The method is too painful a procedure.

(3.) The method is too difficult to carry out. 1. The first objection is easy or difficult to overcome, according to the amount of confidence which the patient will have in the doctor. Of course a physician who has the confidence of his patients to such a small degree that they will not trust his judgment and skill sufficiently to allow him to carry out the water treatment, is to be pitied. Why his patients are willing to follow his advice when they have to take chloroform, or undergo an operation, or take any drug, I do not understand. But, if this objection. should be the main reason for making the use of the method not feasible in private practice in the United States, then the proper relation between patient and medical adviser does not exist in this country, and Osler is right. But I cannot for a moment believe that such is the case.

2. The objection that the patient has to suffer from the treatment, is the only one which has some validity, and on this point I desire to say : The unpleasant sensations which the patient experiences on entering the bath, as well as the shivering and chilliness during the last part of the bath, and for some time after, are facts which cannot be denied, and which always will be an obstacle to the use of the method. But I would insist upon this, that at least. all patients (or friends) who are willing to undergo (or have the patient undergo) the unpleasant sensation in order to vastly increase the chance of recovery, ought not to be denied the privilege of having the method used, and no physician has the right to decide the question for his patient in the negative. The physician ought to encourage the patient, and point out to him that not only will he almost certainly recover, but for his painful sensations he will be paid by many hours of sweet sleep, and "feeling first-rate ' in the intervals between the baths.

3. The third objection, that the method is too difficult, looks reasonable at first sight; but facts are more powerful than theories. If experience shows that the method has been carried out in private practice, then the objection does not hold good. And

this has been done. Brand's 342 cases with one death, occurred in private practice, excepting a small number during the war of 1871. In Lyons, France, likewise the method has been carried out to a large extent in private practice, and I have been carrying out the method now for nearly three years in private practice; between 60 and 70 cases having been treated, and not far from 3,000 baths given, and I wish to emphasize the fact that these cases have occurred almost exclusively amongst laborers and artisans, whose means were limited. Now why, in heaven's name should not other physicians be able to do what I have done, especially those practicing amongst the well-todo and intelligent class of the community?

But let us look at the difficulties of the treatment; are they really so great, or of such a nature that the method is "scarcely feasible?" What does the method really demand? Of course one needs a bath tub, and if my advice be taken, the physician will have his tubs on hand. I consider my tubs as useful and necessary as my pocket-case or any other instrument. This tub is brought near the bed, and is filled with water of a temperature which the physician orders for the next 12-24 hours. The temperature of the patient is taken by the rectum, and if it is over 102° he is undressed and put in the bath; after 15 minutes (of good friction, Ed.) he is taken from the bath, dried off and put back to bed, his feet wrapped in a warm blanket, or a jug with hot water placed against them. Before, during or after the bath, a cup of hot punch, tea or coffee is administered, and in the intervals of the bath the anterior surface of the body is kept cool by compresses taken out of cold

water.

It will seem that it is not the judgment of the nurse or sensation of the patient which is the indication for action, but the therapeutic procedures are regulated by the watch and thermometer. Where in the United States are there persons who cannot be instructed in the use of the clinical and ordinary thermometer, and who are not able to read the clock? Of course the physician will have to spend 15 or 30 minutes at times, to instruct the family in the application of the method, but does he not spend that much day after day to save a few fingers or a hand? It will not require more than one person to do the nursing, providing the treatment is carried out from the beginning, under which circumstances the patient will always be able to step into the bath himself. Thus a small woman nursed a six-foot man through a severe attack, requiring over 100 baths, all alone. I am now treating a 16-year-old young man, whose mother is a widow, and who goes out to do washing, and have had two other such cases, one requiring over 50, the other over 100 baths. Now, these women certainly did not belong to the class called intelligent, and they were

all poor; yet the method was carried out to perfection. If, however, it was carried out here, and under such circumstances, where, let me ask, can the method not be carried out?

It is unnecessary to remark that where the means of the patient will allow the employment of a nurse, the objection as to the difficulty of the method cannot be urged.

I would advise any one who should wish to adopt this in his practice, to look around for a suitable person whom he can instruct in the carrying out of the method. While the majority of my patients have been treated by members of the family, yet there were cases where an excellent nurse, whom I trained in the use of the method, was almost indispensable. At times the reluctance of the patients to the baths is so great that the family has not the necessary energy to carry out the instructions, or the family is of such a timid or nervous make-up that they have not the courage to follow the direction, or the case is of such a nature that modifications in the treatment have to be made; in all such cases a nurse is almost a necessity. If he has such a nurse at his command, the physician has merely to give a short order, and he knows that everything is carried out as well as though he were present himself, and as he can thus restrict the number of his visits, and as the family is spared expense because but little money has to be expended for drugs, a nurse will not throw extra cost on the patient, and he will receive much more for his money than if he spent it on the doctor and druggist. Where the patient cannot afford to retain a nurse, I at times send a nurse to the house of the patient a day or two to instruct the attendants in the use of the baths and to encourage them by showing them all the details. Incidentally, such a nurse will be of good moral influence, because she will be apt to speak of the good effect of the baths which she has witnessed in other cases.

I believe that the method can be carried out even in country practice; at least I have not so far been called on account of any mishap due to the baths, and in but a very few cases was there a modification of the instructions necessary.

In connection with what I have said, the following case, which Brand relates, would seem to be in place, showing that impediments which the method has to encounter are more of a moral than physical nature:

2.

with an indifference to external surroundings, and with an apathetic expression of the countenance. Fever, more noticeable at night. 3. Gastro-intestinal disturbances. 4. Rose-spots. In infants we do not, of course, find them complaining of headache.

I must confess that I do not place very much im portance on the condition of the spleen as a diagnostic feature. It is a difficult symptom to be obtained by the majority of practitioners. I do not expect to find the four cardinal symptoms present in every case, a continuation of two or three of these symptoms into the third week is enough for me to base a diagnosis. I see no reason for holding that all of these symptoms must be present before the case is said to be typhoid.

Meningitis, either simple or tubercular is difficult to diagnosticate in the face of a suspected typhoid. The rapidity of the invasion in the simple form, and the previous history of a tubercular child usually assists us in arriving at a correct conclusion.

Gastro-intestinal Catarrh of considerable duration is another difficult disease to differentiate from typhoid. Attention to the temperature range, the presence or absence of rose spots, and the probable source of infection will usually lead us in the correct direction.

Treatment. I oppose from first to last to prescribing for symptoms; to-day something for the liver, to-morrow a drug either to stimulate or diminish the activity of the kidneys, and next day something for the tongue. I am weary listening to talk about the

secretions.

It occurs to me that there are about four cardinal principles which should guide us in the treatment of typhoid fever in children. The first is, rest in bed; the second, is restriction to fluid food; the third, is the administration of a general tonic treatment with particular attention to intestinal antisepsis; and fourth, is attention to the temperature.

Rest in Bed.--This should be absolute and should be commenced as soon as we suspect the disease, and continued until the patient has gone from four to ten full days without temperature.

Diet. The instruction in regard to fluid food should be explicit. There must be absolutely no deviation, no half-hearted directions, no concessions. The food which I directed each patient to have was milk or its equivalent in some fluid form. Children two or three years of age take frequently a quart or a quart and a half each day, and they usually desire it to any other food. If it disagrees with the stomach or if they insist upon some change add a little lime water or seltzer, or a small quantity of the ordinary pop; kumyss is relished by some patients.

The egg water which I have suggested so many times, is frequently well taken by these little people,

This is prepared by taking the white of one egg, (say three drachms) as much sterilized water, ten or fifteen drops of whiskey or brandy, and a little. sugar; mix moderately. I need not say that this is very nourishing and usually relished. I use also the liquid peptonoids.

When two days have elapsed without fever, I allow a small amount of cream or milk toast, and if this is easily digested and there is no temperature upon the following day, I allow the child a baked potato with plenty of butter; if the patient goes four days upon this increased diet without any rise in temperature and with no symptoms of indigestion, I allow them to commence to sit up and in the course of two or three days to commence to chew beefsteak or mutton chops. In every instance relapse was brought on by my assistants or myself having yielded to the importunities of the little patient or some of its friends. We have been accused of starving the patients, but when we have deviated from the course suggested, in almost every instance some bad symptoms have been the result.

Medication. The general tonic or restorative medication should be some pleasant combination of pepsin with a mineral acid and a concentrated nutrient. A general order is given that the bowels. shall be moved every other day by glycerine enemata, if constipated.

Temperature.-I have learned that a moderate temperature is not to be dreaded, and unless it goes to 103°, I am not usually in the habit of administering any of the anti-pyretic remedies.

From two to three grains of phenacetine given to a child from eight to ten years of age with a temperature of 104°, will reduce the temperature to 100° or 100 1-2°.

I am in the habit of controlling the temperature by the use of the cool bath, where children do not oppose it in a great degree. I believe in it decidedly but do not order it in those cases where the children seem to be frightened or exhausted by it. I had an adult recently covered with a cold sheet for an hour and a quarter with a reduction of only a fifth of a degree; and a child to whom I have already referred whose temperature marked 105 6-10°, the continuous cold sheet did not reduce it to any considerable degree. I believe the treatment useful however, and the child made a happy recovery.

When there is much diarrhea, I find nothing which gives such good results as turpentine and a very small amount of an opiate in combination with syrup acacia. Great tympany is controlled by intestinal antisepsis, bichloride of mercury and asafoetida. In my judgment asafoetida is one of the most valuable drugs for many diseases of children, given either by mouth or rectum. mouth or rectum. When the distension is great I

am in the habit of placing these little people in the knee elbow position when giving the enema.

During the last weeks of typhoid I always stand ready to stimulate the heart. Nux vomica, digitalis and the alcoholics in full doses are indicated.

Dr. Christopher said: The occurrence of wellmarked cases of typhoid fever in infancy is sufficiently uncommon as to excite comment when individual cases are reported, but it by no means follows that the disease itself is rare at this time of life, as the text books would seem to imply.

I have met very frequently in infants, mild cases which seemed to justify the diagnosis of typhoid fever.

ment of Peyer's patches in children was a familiar sight. He had observed it in at least 150 out of 2,000 autopsies, in all kinds of intestinal diseases.

Enlargement of the spleen could not be determined by percussion. Palpation is the only reliable means of determining this point.

Dr. Blackader thought he had met with typhoid fever in young children. He had always supposed that the freedom which young children had from typhoid fever was due to the fact that they were not brought so much into contact with the sources of infection. Their food was more frequently cooked.

It is very difficult to determine enlargement of the spleen by percussion. The principal symptoms upon

Upon the skin of the abdomen, the typical roseola appears. When carefully looked for the eruption will almost invariably be found. It certainly occurs in as large a proportion of the cases of typhoid as does the scarlatina eruption in that disease. I have been unwilling to make the diagnosis of typhoid in infants unless the eruption was present. The spots occur as early as the third day, and rarely exceed eight or ten in number; more often but three or four are to be found.

The pulmonary symptoms are particularly important. The specific bronchitis which is always present in the adult to a greater or less degree, is exaggerated in the child, and becomes the prominent feature of the disease.

The tongue does not enlarge, nor does it become flabby nor indented by the teeth when they are present. It remains of normal size and shape, and is covered by a white or creamy coating which leaves the edges and tip free. Often the redness of the tip extends backwardly in the median line for a short distance. The appearance of the tongue is so well marked as to be almost diagnostic.

The face does not assume the typhoid expression, nor do severe, nervous phenomena ensue. I have never seen nose bleed in one of these case.

The diagnosis is to be based upon the presence of fever, the bronchitis, the peculiar tongue, the roseola and the enlarged spleen. In the absence of any one of the first four of these conditions, I should be unwilling to make a diagnosis of typhoid fever.

Dr. Koplik said the Society owed much to Dr. Northrup for having called attention to the fact that certain of the post mortem appearances which in the adult were so characteristic of typhoid fever might in children be due to other things.

rose spots and bronchitis.

Dr. Winters could not recall a single instance of typhoid fever under two years of age. The rash was almost constantly present, so that he would not be willing to make the diagnosis in young children in the absence of the rash. Considerable distention of the abdomen occurred in most cases.

Dr. Huber could recall only two instances of typhoid fever under two years of age, in one of which Dr. Jacobi had made the diagnosis, and in the other case there were five older children sick from typhoid fever at the same time.

Dr. Seibert had never made the diagnosis under two years. He called attention to the fact that a severe acute gastritis with high temperature and rapid pulse might be mistaken for typhoid fever. In the treatment of all cases of typhoid fever he used systematic irrigation of the colon with plain water, in order to remove whatever typhoid poison had accumulated in the bowels. In four years he had never given a bath except to wash the patient for cleanli

ness.

Dr. Adams did not question that typhoid fever occurred in young children, but claimed that the diagnosis was not uniformly made. He did not find the typical symptoms of typhoid fever in very young children. Too much attention was paid to high temperature. A high temperature which was not continuous was not dangerous. He had seen some unfortunate results from the use of anti-pyretics in case of high temperature, and had come to discard as routine practice any method of treatment as far as anti-pyretics or drugs were concerned. He had never practiced irrigation in typhoid fever. While the principle seemed good he would hesitate to recommend it in young children; first, because the intestinal tract should be kept as quiet as possible, and,

Dr. Northrup, in reply, stated that ulceration was not such a constant feature, but that marked enlarge

treatment, unless in a very low condition.

Dr. Rotch thought cases of typhoid fever in young children were rare. The diagnosis in young babies