During a period of twenty years (1868-88) Reimer 5 saw 978 grave or hyperpyretic cases of scarlet fever which he treated by hydrotherapeutic measures. Cold compresses and cold ablutions, he says, had a soothing effect, but did not shorten the fever. The cold pack in 28 cases of great nervous excitement was followed not unfrequently by cyanosis and heart failure, whilst a cold pack prolonged an hour or more sometimes ended in fatal collapse. The cold pack with cold irrigation employed in 131 cases was satisfactory as regards its effect on the pulse, circulation and respiration, but it exerted little influence on the subsequent course of the fever. A tepid bath employed in 72 cases was useless, and was decidedly injurious if continued more than half an hour, causing a weak pulse. A bath of 95°F. gradually cooled to 81°F. or 75°F., employed in 186 cases, caused collapse and sudden death more frequently than any other therapeutic measure. A cold bath of from 60°F. to 75°F. continued from five to eight minutes. and accompanied by energetic friction over the whole body, employed in 363 cases, gave the best results of all the modes of applying water.

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Leichtenstern, from his experience, says that he considers the use of the cold bath to be the best form of treatment from the beginning of the invasion of scarlatina to the remission of the severe general symptoms. For children he recommends that the bath should have a temperature of about 68°F. and be limited. in duration to five minutes. For older patients the temperature may be reduced to 59°F., and still limited to five minutes, since he agrees with Reimer that cold but short baths are to be preferred. This practice may be said to be essentially in agreement with that of Currie, since this writer informs us that the temperature of the water used by him was in general from 40° to 50°F., varying with the season of the year.

One can perhaps obtain the best idea of the present divided state of opinion upon this method of treatment in scarlet fever by a reference to one or two recent writers on the subject. Dr. F.

Foord Caiger says: "The high temperature usually proves refractory alike to the influence of cold applications and of antipyretic drugs, but the cold pack is not without value as a sedative." Dr. Clement Dukes, though postponing ablutions save for purposes of cleanliness in mild cases until the close of the third week, yet

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admits that in certain severe cases cold sponging or the wet pack reduces fever, diminishes the frequency of the pulse, abates the cerebral symptoms, and induces sleep. Dr. J. Lewis Smith9 concludes that "through the alleged benefit obtained by Dr. Currie the cold water treatment of scarlet fever came into use, and it has been continuously employed until the present time, often with benefit, but sometimes with harm and even death." Henoch 10 in severe cases with protracted high pyrexia recommends that the head should be covered with an ice-bag, a large dose of quinine given and the child placed in a lukewarm bath, not below 88°F. He is decidedly opposed to "cooler baths because in scarlatina which presents a tendency to heart failure, cold may produce an unexpected rapid collapse more than in any other affection."

Probably the most complete and most recent resumé upon the subject is given by von Jürgensen.11 This is essentially a recapitulation of Leichtenstern's conclusion, which I have already quoted. This observer, amongst a number of other beneficial reflex effects, noted the diminution of restlessness and the production of sleep as well as the lowering of the pulse-rate which he found occurred before and lasted for a longer time than the reduction in the body temperature. In addition the same writer specified the conditions in which the giving of cold baths is contraindicated. These are tabulated by von Jürgensen as follows:(1) When cardiac weakness is so severe that attempts to increase the action of the heart by stimuli fail; (2) with laryngeal stenosis: (3) when hæmorrhage occurs from the nose, mouth, etc.; (4) with inflammation of the joints. It is interesting in connection with the first two conditions to record the verdict of Currie, who directed that the cold affusions should never be given when the extremities are cold, no matter what may be the heat of the central parts, nor when the respiration is laborious, since "the oppression might be dangerously augmented by the sudden stimulus."

My own experience is based on a number of cases treated by the lukewarm bath as recommended by Henoch, but without the use of the ice-bag or the regular administration of quinine. When collecting the cases I was more particularly interested in the possible supervention of nephritis, and therefore excluded all those which recovered or died before the third week of the disease. This fact accounts for the paucity in the number of the cases in the accompanying table:

At the time this treatment by baths was carried out I was ignorant of the conclusions reached by Leichtenstern, Reimer, etc., and lacked the courage or boldness to adopt on my own initiative the severer measures favoured by them. I was nevertheless much impressed by the benefits received from the lukewarm baths, and strongly inclined to consider that this constituted the best method of treatment, since in no instance had any untoward accident arisen. The baths were given as a rule every four hours, each bath lasting 15 to 20 minutes and at a temperature, save in one or two instances, of 90°F. In these respects I followed the method which had undoubtedly given excellent results in the treatment of typhoid fever, raising the temperature of the water, however, on account of the age of the patients, and adopting the baths largely with the view of their antipyretic influence, as well as for their tonic effect on the circulatory system, and reflexly on the excretory system and tissues generally. At the same time there was no relaxation in other treatment. The patients were regularly and suitably fed, and careful and frequent cleansing of the mouth, throat, nose and ears was of course continued. Of the 14 cases, of which seven were males and seven females, it will be noted that no fewer than nine were under five years of age. Some idea of the severity of the attacks will be gathered from the fact that the length of the pyrexial period associated with the onset of scarlet fever was in only one case as short as 16 days. In ten it was over 20 days, the longest having a duration of 32 days. In such a collection of cases the occurrence of only one death in a child three years of age after a continuous pyrexia averaging between 101°F. and 102°F. for 30 days, seems in itself to speak favourably for the treatment. It must not for a moment be assumed that I am claiming this as a percentage mortality. As I have already stated, the series of cases is a specially selected one, and therefore not suitable for any ordinary comparison. I am, however, of opinion that a better result would not have been obtained without the use of the baths, whilst, on the contrary, one might reasonably have expected a worse one.

It will be noted that there was considerable variation in the length of time subsequent to the onset of the attack of scarlet fever before the baths were begun. This was largely dependent

on the gravity of the case or the failure to observe satisfactory progress with indications of an unusually protracted pyrexia. In instituting this hydrotherapeutic treatment I was at first not personally convinced, not only of its value, but of its advisability, so that it was not resorted to until the need apparently arose. Whatever objections might be urged against this lack of uniformity, it is evident that upon one point it constitutes an especially severe test. At the present time there is a widespread belief that chill acts as a potent factor in the etiology of scarlatinal nephritis. Under these circumstances one would expect its influence to be greater the nearer the commencement of the administration of the baths approached to the usual time of the supervention of that complication. Apparently, however, in all cases there was no evidence, from an examination of the urine, of any deleterious influence on the kidneys even when they were begun as late as the 14th and 18th days of the attack. the contrary, considering the average age of the patients, the degree and persistence of pyrexia and the severity of the associated scarlatinal and septic toxæmia a greater cause for surprise would seem to exist in the small amount of albumen generally found in the urine. I do not think it unnatural to suggest that the occurrence of nephritis in scarlet fever may in some cases have a connection with the alterations in the skin (inflammation and subsequent desquamation) which constitute such a prominent feature of the disease.

On

There is no need for me to emphasise the close association which has been proved to exist between the kidneys and the skin. As I have already suggested in view of this association, it would be surprising if the dry, scaly and even eczematous condition of the latter, which is especially seen in severe, protracted and septic cases did not prejudicially affect the kidneys. Under these circumstances it may be that careful investigation would demonstrate rather a prophylactic influence, from the hydrotherapeutic treatment, against the supervention of nephritis. It would indeed be interesting for the elucidation of this point to have a large number of cases treated in an exactly similar manner, save that one-half received regular and frequent tepid or cold baths with friction, whilst the other half received only the usual