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a rule, fifteen minutes, never longer than twenty minutes. DR. FRED P. HENRY, of Philadelphia, the latest writer on the subject, in HARE'S "System of Practical Therapeutics," says: "The method consists in giving baths at 644° to 68° Fahrenheit, every three hours, when the rectal temperature exceeds 101.3°;" while BRANDT, himself, tells us to repeat the baths when the rectal temperature exceeds 102° Fahrenheit.

DR. OSLER, who claims to follow the BRANDT treatment rigidly, says: "Every third hour, if the temperature is above 1024° Fahrenheit, the patient is placed in a bath at 70°." BRANDT says on this point: "The temperature of his baths varies with a number of circumstances, among which the most important are the intensity of the fever, and the resistance it offers to the cooling process. There are, however, limits which should not be transgressed, 15° to 20° centigrade or 60° to 70° Fahrenheit."

Such inaccurate teaching as the above, if followed, cannot fail to bring the BRANDT treatment into disrepute, as the careless or inaccurate carrying out of its details will not be productive of the desired results.

The method of BRANDT, Simply, is as follows:

When the temperature taken in the rectum exceeds 102° Fahrenheit the patient is completely submerged, with the exception of his head, in a bath of 65° Fahrenheit, with a compress with water of 60° Fahrenheit upon his head. He remains in the bath fifteen minutes, occasionally twenty minutes, during which time he is systematically rubbed by the attendants. He then steps out of the bath, or, if too weak, is lifted out, and is wrapped in a coarse linen sheet, over which a blanket is folded, the extremities being thoroughly dried and rubbed. A little brandy or wine may be given, if necessary, to assist reaction. This procedure is repeated every three hours, occasionally every two and onehalf hours, day and night, unless the temperature remains at or below 102° Fahrenheit. All temperatures should be taken in the rectum, between the temperature of which and the mouth I have seen a difference of five degrees. If there is much perspiration the patient should be dried before entering the bath. In the middle of the bath a glass of cold water should be given him. Three quarters of an hour after the bath the temperature should be again taken, as at this time it is usually the lowest, and the effect of the bath can be correctly estimated. Neither age, sex, menstruation, pregnancy or sweating offer contraindications to this method of treating typhoid fever. When the temperature before the bath is very high, or when the fall forty-five minutes afterwards is less than 2o, the normal amount of reduction to be expected, the temperature of the water may be lowered to 60°, and the duration extended to eighteen or twenty minutes. When the case has so far progressed towards recovery that the temperature does not exceed 102°, but yet exceeds 101°, baths of 70° of five to ten minutes' duration should be given to insure the patient good rest, to prevent the prolongation of the fever and the occurrence of relapses, and to shorten convalescence.

The teachings of many of our writers on typhoid fever is misleading in conveying the idea that the reduction of temperature is the main object of the treatment. Such, however, is not the case. BRANDT himself most emphatically disclaims any such idea; reduction of temperature is a secondary object. High temperature is not in itself the chief determining cause of fatality in typhoid fever. Minus infection, it does not produce those serious degenerations in the heart and other organs formerly ascribed to it. Heart failure and degeneration are now known to be due to the infective process, and a ptomaine intoxication resulting from it, and it is combatting these effects of the toxic agencies that the cold bath treatment yields its most triumphant results. Not only is the heat of the body dissipated by the bath, but heat-production is decreased, acting in this way like antipyrin, acetanilid, etc. Moreover, the nerve centers which preside over circulation, respiration, digestion, excretion and tissue formation are toned up and energized, so that they are enabled to tide over the dangers which would ensue from failure of these functions. The heart is made to beat more vigorously, and the pulse becomes slowed and more regular. Appetite and digestion are uniformly improved; respiration is slowed and deepened; nervous symptoms, such as headache, stupor, and delirium, are dispelled.

One very marked effect of the baths is to prevent or moderate the severe abdominal symptoms we are so accustomed to see in a severe case of typhoid. BRANDT claims that a rigid adherence to his method will prevent ulceration and perforations. One prime condition, however, is that the case come under treatment before the fifth day. He says that during the first five days the pathological changes in the intestines are confined to the stage of infiltration, and he furnishes the results of one autopsy in proof of this assertion.

* BRANDT's last statistics are really remarkable. He tabulates two thousand one hundred and twenty-three cases treated according to his method by himself and a few other clinicians. Only twelve deaths occurred-a mortality of one per cent. All of the fatal cases were of individuals who did not come under treatment until after the fifth day of the disease. He claims as a result of thirty years' experience that every case of typhoid fever will recover in which his method of treatment is commenced before the fifth day.

These remarkable results are explained by the fact that the baths have not only an antipyretic influence on the circulation, but they furnish the necessary conditions for the diseased structures to protect themselves, so that the pathological processes stay within certain changeless limits. Pathological anatomy teaches us that the formation of an ulcer is not necessary in a case of typhoid. In the milder cases the affection of the glands may proceed only as far as the stage of infiltration and then go back without having proceeded to the stage of ulceration. To this class of cases the typhoid treated with water from the beginning, five days. The bathing process makes a mild case out of what would otherwise be a severe one. Hence, the necessity for the early commencement of the treatment. The best effect of the baths, therefore, is seen upon cases coming under treatment before the fifth day. It may be said, however, that we rarely see cases of typhoid fever before the fifth day, or that we are usually unable to make a positive diagnosis by that time. But all cases of high temperature from whatsoever cause, are benefitted by cool baths, and should be so treated when possible. If the case turn out to be other than typhoid, so much the better. The antithermic effect of the bath is as beneficial in pneumonia, pleurisy, any of the acute exanthemata, or any other febrile disease, as in typhoid fever. The results of the treatment are also marked in cases coming under treatment *"PEPPER'S American Text-Book of the Theory and Practice of Medicine," Volume I,

page 120.

later in the disease, although their influence is not shown until a number of baths have been administered. This benign influence is probably not exhibited for a number of days.

When beginning the treatment of typhoid two years ago with baths I made use of the Ziemssen or gradually cooled bath in several cases, but it was found unsatisfactory for several reasons, and soon abandoned, except at the beginning of a case, when I now frequently use it a few times to acccustom a patient to the hydriatic treatment. The reduction of temperature is not so marked with the gradually cooled bath as with that of BRANDT, and the revivifying effect is comparatively slight. The amount of labor entailed upon the attendants in carrying water to and fro is great, and patients object strongly to the length of time, from twenty to thirty minutes, necessary to obtain the desired effect. The only modification of the BRANDT bath I now resort to is the so-called RIESS bath, a prolonged warm bath used by DR. L. RIESS, of Berlin, in over one thousand cases of typhoid fever with most brilliant results. It consists of immersing the patient in a bath of 88° Fahrenheit, prepared with a hammock to afford comfortable support. This is done whenever the rectal temperature reaches 102° Fahrenheit. The patient is allowed to remain in the bath usually during the day only, but if necessary, day and night, until his rectal temperature registers 100° Fahrenheit. He is then removed, and replaced in the bath when his temperature again reaches 102°.

While the results of these prolonged warm baths are by no means as good as those of the BRANDT baths, it is wise, I think, to substitute them for the latter in two conditions. First, when cerebral disturbances remain excessive; second, after late intestinal hemorrhages. Upon cerebral disturbances the RIESS baths often act more favorably than the cool baths. BRANDT distinguishes two kinds of hemorrhages in typhoid fever: an early or false, and a later or true hemorrhage. The early hemorrhages, which are capillary, do not require cessation of the baths, as they no doubt exert a favorable influence upon the intestinal hyperemia upon which the hemorrhage depends. It has been shown experimentally that the cool bath produces not an increased redness, but a pallor of the intestinal mucous membrane, and it is well known that hydriatic treatment diminishes the frequency of intestinal hemorrhages. But we will all agree that absolute rest is demanded after a true hemorrhage, due to the formation of sloughs and the erosion of arterial vessels. It is in this emergency that I think the prolonged warm bath of RIESS is of great value, forming a useful supplement to the treatment of BRANDT, as it enables us to keep down the temperature of the patient without subjecting him to the movements necessarily connected with cool bathing.

I wish to insist, in closing, upon strict adherence to BRANDT's rules if we wish to attain his wonderful results. Much of the so-called BRANDT treatment is such in name only. "It is to the minute attention to every detail of asepsis and antisepsis that modern wound treatment owes its triumphs. So it is with the cool bath treatment of typhoid fever. If the temperature of the bath is not correct, or its duration is changed, or frictions are omitted, it is no longer a BRANDT bath, and we do an injustice to the great devisor of the method if we claim that we have used it, and our results do not correspond with his."

* Editorial Journal of Balneology, August, 1892.

T

FOREIGN BODIES PENETRATING THE EYE.*

BY D. MILTON GREEN, M. D., GRAND RAPIDS, MICHIGAN. OPHTHALMIC AND AURAL SURGEON TO SAINT MARK'S AND U. B. A. HOSPITALS; EYE, EAR AND THROAT SURGEON TO HOLLAND HOME FOR THE AGED; LECTURER TO SAINT MARK'S AND U. B. A. TRAINING SCHOOL FOR NURSES, ETC.

I SELECTED this subject, not because I had any new discoveries to disclose, any new operation to propose, or new theories to advance, but because my experience, observation, and reading of the limited literature on the subject, have led me to believe that among the great majority of physicians these cases are not properly treated, and that the fault lies in the fact that many are too busy, while the lack of instruments and other conveniences, lack of courage and lack of experience in making examinations of the eyes enter as factors in many instances, and some, I am led to believe, lack a knowledge of just the technique of the examination necessary to arrive at the most correct conclusions, -but the worst of all is a lack of interest, of which I am sure but few physicians are guilty. Another reason for the selection, is the deep interest I have in the subject, and the hope from the discussion of the paper by the eminent gentlemen presènt, we may be able to glean much useful knowledge and be better able to conserve the sight and eyes of our patients.

The subject of foreign bodies in the eye is broad and extremely varied, so much so indeed, that it is beyond the limits of this paper to discuss, and while this be true, it is nevertheless as interesting and important as it is extensive and varied. The kinds of foreign bodies penetrating the eye with which we have to deal most frequently, are fragments of steel or other metals, and pieces of glass, also splinters of wood, parts of shells of percussion caps, blades of knives or scissors, and fork-tines. There are, indeed, innumerable forms of foreign bodies that may penetrate the eye, and of various shapes and sizes, and they may enter the eye from different directions, penetrating to various depths, therefore, each case is a special study in itself.

The object of my paper is to present a certain class of injuries, and not all forms of foreign bodies in the eye, and to enter a plea for true conservatism in their treatment, as against the careless, slipshod method of examining and prescribing, while the foreign body is allowed to remain until it has destroyed the eye, and perhaps its fellow, or has, at least, become so intensely inflamed that the only alternative is enucleation, thereby entailing great physical deformity and damage, as well as irreparable injury from a cosmetic point of view. The forms to which I refer and to which I shall confine my remarks are foreign bodies penetrating the eye, and whether immediately withdrawn, or still remain lodged within that organ.

Whenever a foreign body penetrates the eye it is of serious moment, as it may wound the lens, causing it to swell and become itself a foreign body, or by wounding the ciliary body and introducing microbes it may create a serious inflammation and entail loss of vision or of the eye itself, but when a foreign body is lodged in the interior of the eye it converts the injury into a most serious lesion, notwithstanding the fact that from external appearances it may seem but trivial; for it entails the destruction of the eye more or less complete, in the

* Read before the Surgical Section of the MICHIGAN STATE MEDICAL SOCIETY at Muskegon, May 16, and published exclusively in The Physician and Surgeon.

majority of instances, therefore, we must, in every injury of the eye, attended with perforation, propound the query whether or not a foreign body remains within it. I grant you that it is not always easy to determine when a foreign body remains lodged in the eye, and for that reason it is important that we proceed with the examination methodically and understandingly.

First.-The history of the case will materially assist in forming a conclusion. For instance, if the eye has been wounded by a knife-blade, blade of scissors, fork-tine or other similar instrument, we would naturally conclude that no foreign body remained; conversely, if a person had been pounding iron or steel, or firing a gun and received a perforating injury of the eye, we could fairly suppose that a foreign body remained therein. This being the case, we should search for the wound very carefully, for wounds made by small, thin bodies are sometimes difficult to detect, so much so as frequently to require the careful scrutiny of the most experienced observer to discover them. Corneal wounds close and heal very quickly, and if a day or two have elapsed since the injury, quite large wounds will have healed, and look as though they might have been caused by contusion.

Second.-Bifocal illumination should be the next step in the examination, by which we may discover the foreign body lodged in the anterior chamber, upon or imbedded in the iris, or on the surface of the lens. Failing to detect the foreign body, the ophthalmoscope next comes in play, and if the view is not obstructed by blood in the aqueous chamber or opacity of the lens we may be able to locate the offender. If we have yet failed, palpation may locate the body by finding a very tender spot, and we may thus be able to conclude that a foreign body remains in the eye.

If we have located a foreign body in the eye, the next consideration is, What shall we do? that is, What is the most conservative plan of treatment? Shall we attempt to remove the foreign body, or enucleate the eye? I shall not weary you with the technique of the various methods of removing foreign bodies, for that would be an endless task and serve no good purpose here, but it seems to me we are here confronted with the following problems:

(1) Can we save the sight of the injured eye?

(2) Should we attempt to save the eyeball in a sightly condition for cosmetic effect, with but little or no chance of useful vision?

(3) To save the sight of the injured eye, must we enucleate the offending member?

The answers, I grant you, do not figure out like mathematical problems, but each case will be the subject of serious consideration.

If the foreign body has been withdrawn the eye should be put at rest after careful cleansing. Atropine should be used in some cases, especially where synechiæ are not desired to close a wounded lens capsule, but no fixed rule can be applied to the use of atropia.

If the iris protrudes, cut it off and by closing the lids encourage healing of the wound. Later, if the lens becomes swollen, producing extreme tension, remove it as you would do a cataract operation, and you will often be able to save a useful eye, especially if the operation is done before there is much inflammation and the lens matter is carefully washed out.

If the lens is badly fractured or lacerated, it should be removed at once. Do not do too much, and above all do not be too ready to enucleate the eye.

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