Compliments of the Author Some Desperate Cases of Typhoid Fever Treated With and With- out Cold Baths BY SIMON BARUCH, M.D., NEW YORK Reprint from the Medical Record, October /, iSgS NEW YORK THE PUBLISHERS’ PRINTING COMPANY 32, 34 Lafayette Place iBoB SOME DESPERATE CASES OF TYPHOID FEVER TREATED WITH AND WITHOUT COLD BATHS. SIMON BARUCH, M.D. NEW YORK. The trend of medical opinion may be readily ascer- tained by consulting the files of a wide-awake medi- cal journal. The true position of the bath treatment of typhoid fever within the past decennium may be gathered from the following quotations from the Medi- cal Record. Referring to a paper on this subject, read before the State Medical Society, the Medical Record of February 16, 1888, says editorially, that “if the author succeeds in arousing the profession to a reali- zation of the fatality of typhoid fever in our midst, and in directing attention to the success of the cold- bath treatment, which, for obvious reasons, has not yet obtained firm footing, the outcome may be valuable. “It wall be difficult to persuade the profession, which has been long under the dominion of the laissez- faire policy, to adopt the heroic method of cold bath- ing. The most important point made by the author seems to us the emphasis placed upon the object of the cold bath being antifebrile rather than antither- mic, inasmuch as its action is chiefly directed toward the neutralization of the febrile toxaemia due to the typhoid process.” That the continued agitation of the latter point has “aroused” the leading teachers and practitioners of this city and country to the “realization” referred to by the Medical Record is evident from the follow- ing quotation from an editorial in the issue of May 7, 1898, nine years later: 2 "Advocates of the bath treatment seem to be in- creasing in number. It is generally cr ''ceded that excellent results are to be obtained by judicious cold- water treatment, and the closer the Brand method has been followed the better the reports seem to be,” That the Medical Record voices the opinions of the leaders of medical thought may be gathered from discussions in our medical societies and from the rec- ords of our great hospitals. In his first plea for the Brand bath the writer in- sisted upon the necessity of following the strict tech- nique of Brand. While he still holds that when cases are seen in the first stages of the disease the latter is absolutely essential to success, a large experience has convinced him that in the later stages of cases which have not in the beginning been treated by the Brand bath a decided deviation from the latter is imperative. Some of the following histories will illustrate the proposition ; Mr. G—-—, aged thirty-two years, seen with Dr. Nicolai, in the fourth week of a severe typhoid. The patient had suffered during the past few days from de- cided cardiac failure, with its frequent accompaniment of renal inadequacy. An eminent consultant had sug- gested alcoholic stimulation and digitalis, but the patient’s condition grew worse until his life was de- spaired of. I found him in a semicomatose con- dition, with eyes half closed, occasional twitchings of the facial muscles, subsultus tendinum, tympanites, and muttering delirium. Touching his body produced short but mild convulsive movements. The urine was scant; the quantity drawn during the past twelve hours had been ten ounces. Several bloody stools had been passed. The indications of treatment seemed to be to stimulate the failing cardiac innervation, and to remove uraemic poisoning by enhancing cutaneous and renal activity. The external use of cold water in any form was contraindicated by the condition of the cerebro- spinal centres. Hence hypodermics of strychnine, one-thirtieth of a grain every three hours unless contra- 3 indicated by trismus, were substituted for digitalis, and the nude patient was snugly wrapped in woollen blan- kets and given six ounces of cold water every two hours, alternated with six ounces of milk, until he per- spired freely. During the next twenty-four hours forty ounces of urine were drawn. The first sound of the heart was stronger, despite the passage of another bloody stool. Improvement of cardiac and renal ac- tion continued and the patient made a slow recovery. Mr. L , aged twenty-six years, seen with Dr, Baran, had been ill with typhoid fever five weeks. The morning temperature had during the past week registered 990 F., but usually reached 102° F. or more in the evening. An eminent consultant had advised large doses of quinine and other judicious treatment, which, however, failed to control the fever. I found the patient greatly emaciated, too feeble to move in bed, but with clear intellect; pulse, 150; first sound feeble; no intestinal or other complication. The fever seemed to be due to sepsis, as was also the car- diac adynamia, both being the sequels of an exhausting typhoid which he had survived only under the most judicious management. Cold baths wer out of the question. With little hope of benefit, ablutions of 65° F., carefully made, with friction over portions of the trunk only, every two hours, and guardedly re- peated in accordance with reactive capacity, were ad- vised. The patient being so feeble, the technique was carefully explained to the nurse. Intelligently and actively executed under Dr, Baran’s supervision, this simple hydriatric measure, added to the judicious nutrition and stimulation already in operation, rescued this man from most desperate straits. How much so simple a procedure may accomplish even in the earlier stages of the disease also, is illus- trated by the following history: M. W , aged thirty-five years, seen with Dr. Simpson, had been ill five days, temperature ranging from 1020 to 1060 F., pulse from 120 to 140, Urine, examined by Dr. Simpson, contained albumin and 4 granular casts; quantity during past twenty-five hours, twenty-seven ounces. The patient was delirious, muttering, sleepless. Up to this time the treatment had been homoeopathic, with alcohol sponges for tem- perature reduction. This was withdrawn and for it were substituted ablutions at 65° F. every two hours, and hourly compresses at 6o° F.; internally, five drops of diluted hydrochloric acid in water, followed by six ounces of cold water. Under these the temperature fell to 1020 F. It fluctuated between ioi° and 102.50 F. for five days, gradually falling every day or two until it reached normal in four weeks, so that a tub which had been ordered proved unnecessary. The pulse never exceeded 100 after the second day of the simple hydriatic treatment, and averaged, 80 during the last two weeks of the disease. The kidneys responded in a marked manner. The quantity of urine increased in one day to 60 ounces, registering afterward 87, 92, 98, 117, 113, 123, 90, 116, 82, 119, 82, 112, 81, 83, 90, 76, 86, 86, 90, 70, 80, 82, 79, 60 ounces by exact measurement. Albumin and casts disappeared in ten days. That these results were accomplished without cold baths is worthy of remark, and may encourage those who are timid in advising the latter in the more systematic hydrotherapy of typhoid fever. The following case, from the records of the J. Hood Wright Hospital, is of interest as demonstrating how a modification of the Brand method and a substitution of affusions may lead to a successful issue in the most desperate condition: E. J. C , aged twenty-seven years, was sent to the hospital by Dr. Frank Daniels, after thirteen days’ treatment in a boarding-house, where his temperature had ranged from 103° to 105° F., and his pulse from 12 oto 15 o; he had most of the time muttering delirium. When admitted he was dull and apathetic, his tongue was dry and brown, the teeth were covered with sordes, the skin was cyanotic, abdomen tympanitic, subsultus marked. Three baths of Bo°, 75°, and 70° F. for fifteen minutes during the night reduced the tempera- 5 ture one degree but did not remove the subsultus and mental apathy. The temperature being 102.2° F., affusions at 6o° F. were substituted for the bath, to; relieve stupor and improve the heart action, six ounces of milk, alternated each two hours with the same quan- tity of cold water, were also used. In two days the quantity of urine was forty-five ounces, containing al- bumin and hyaline and granular casts. The mental condition was decidedly improved by these cold affu- sions. Stimulants were discontinued and two ounces of strong coffee substituted before each bath, alternat- ing with affusions, according to the condition of the patient; the former being used when the temperature reached 103° F., the latter when it was below. Com- presses at 65° F. were continued hourly when the pa- tient was awake. After seven days’ treatment the mind became more clear and tympanites disappeared; the temperature was ioi° F, Affusions were now given as a cardiac tonic. On the following day the tem- perature rose to 105° F., and the abdomen was again distended. Baths at 70° F. every three hours, with friction, given three times at four-hour intervals, re- duced the temperature to ioo° F., when affusions were resumed. During the next five days the temperature did not go above 102.8° F. A half-pack at 65° F. was given every hour; the temperature again rose to 103.40 F., but was reduced by one bath at 70° F. for ten minutes. The faeces now containing blood clots, baths were discontinued. After the temperature had been below ioo° F. for several days, new rose spots appeared on the abdomen, and the temperature again rose to 103° F. Baths at 70° F, for ten minutes were now resumed every six hours until the temperature remained below 102.5° F. One month after the pa- tient’s admission the temperature registered normal. Six weeks later he was discharged. Commenting upon the case before the Harvard Medi- cal Society, Dr, Daniels, who had followed the case after its transfer to the hospital, said: “I have no doubt whatever that the man was saved by the appli- 6 cation of the Brand baths and cold affusions over the head and shoulder, although begun in the third week.” Mrs, P , aged forty years, was seen with Dr. E. J. Ware at midnight, when I found the family engaged in taking a sad leave of the patient, who was said to be dying. She had been ill six weeks and had been seen by several consultants. Pulmo- nary hypostasis, a feeble rapid pulse, anxious coun- tenance, absence of first sound, were some of the manifestations encountered. The temperature had re- cently ranged between xoo° and 103° F. The most judicious treatment had been assiduously applied, and during the past few hours hypodermics of brandy had been used. Here cardiac adynamia due to sepsis again confronted us, for which the following treatment was suggested: Hypodermics of strychnine, one-thirtieth of a grain every three or four hours; wet chest com- presses at 6o° F., cautiously applied every hour, the method being explained to the nurse; ablutions at 70° F, every two hours; regular alternate administra- tion of milk and water, six ounces, every two hours. These measures stimulated the failing heart, removed hypostasis, and initiated a tedious convalescence. Miss P , aged thirty years, was seen at Long Branch with Dr. Harry Pemberton. She had been ill with typhoid fever four weeks and had been treated with cold tub baths. She was now sleepless, actively delirious, singing and muttering constantly, failing to recognize any one. Large hypodermics of hyoscine had somewhat controlled these threatening manifes- tations. The temperature had also yielded, and had been running below ioo° F. for several days. Sud- denly it had risen to 105° F.; a new crop of spots ap- peared, the abdomen became more tympanitic, diar- rhoea again ensued, and the whole case assumed a most desperate aspect. The first indication being to produce sleep, a wet pack at 70° F. was applied by a skilful nurse, with gratifying result. This was re- peated once in twenty-four hours, and full baths at 70° F. for ten minutes, every four hours when the temper- 7 ature was 103° F. or over, were applied, followed by hourly trunk, compresses at 6o° F. The temperature and pulse improved under the treatment, until blood clots in the faeces demanded cessation of baths. The temperature rose again. Baths were resumed when blood disappeared, and they were continued for a week, when the temperature remained below 103° F. Com- presses were continued until the temperature ceased to rise above roo° F, The wet pack continued to pro- duce sleep, although the mind had not cleared before my departure from Long Branch. The patient made a slow recovery, as I was kindly informed by Dr. Pemberton. I had the singular experience of receiv- ing a letter from this young lady, in which she ex- pressed her gratitude to me, of whom she knew only through Dr. Pemberton’s courteous mention, not re- membering my presence during an attendance of ten days. Remarks.—lt may be noticed that in the recital of the above short histories, neither sponging nor the ice coil has any place. The writer has abandoned both. They are relics of the time when temperature was the point of attack in the treatment of typhoid fever, and cold water was applied for its reduction. Since the discovery of coal-tar products, it has become known that water cannot vie with these in antipyretic value, and that temperature reduction alone does not fulfil the therapeutic indication. Abundant clinical obser- vation has also demonstrated that the lethal element in typhoid fever is a toxaemia which overwhelms the nervous system, according to its intensity, and depre- ciates all the vital organs which depend upon the in- tegrity of the nerve centres for normal activity. To this toxaemia may be ascribed the high temperature, stupor, delirium, feeble heart action with its hypo- static conditions, renal stasis, etc., to which the pa- tient so often succumbs. The application of cold to the cutaneous surface by ablutions, affusions, or baths produces a shock. This is followed, if judiciously graded, by a reaction, the stimulating effect of which is conveyed to the central nervous system, arousing it 8 from a lethargy which, in mild cases, is manifested by the rapid pulse, shallow respiration, elevated tem- perature, scant secretions, and in severe cases by cardiac failure, delirium, stupor, hypostasis, etc. Re- newed energy is conveyed to the organs which main- tain life and which have been crippled by reason of defective innervation. This is the prominent and important therapeutic principle, the recognition of which by the lamented Brand has saved many lives, and a correct understanding of which makes the phy- sician independent of methods. The histories are cited to demonstrate the latter proposition; they show that while the full cold bath with friction is the ideal method, the ablution and affusion may with ad- vantage be substituted for it in some cases, judi- ciously selected and applied. Sponging cools by evap- oration. The small quantity of cold water used, and the slight friction produced by a soft sponge passed over the skin, create little or no shock and subsequent excitation of the cutaneous nerves, which in other pro- cedures stimulate the depreciated nerve centres and counteract the lethal effect of the toxic agents circu- lating in the blood. The ice-water coil cools only the part beneath it. It contracts the cutaneous arterioles, as is evident from the cyanosed appearance of the skin, and thus prevents all other effect. The continuity of its action prevents the shock and subsequent reaction required. While frequent sponging is far better than no water treatment at all, it may be advantageously discarded, when the cold bath is strenuously objected to or contraindicated, for ablutions, affusions, and trunk compresses, the technique of which may be gathered from works on hydrotherapy, and which should be closely followed. Si West Seventieth Street.