A system of practical medicine. By American authors. Vol. 1

by Unknown

The cold bath is the most effective of all the methods of applying the cold-water treatment. Liebermeister recommends that the bath for an adult should be at the temperature of 68° F., and its duration should be about ten minutes; if, however, the patient shows signs of great weakness, it should not exceed seven. After the bath he should be wrapped up in a dry sheet or light blanket and put back in bed. If the pulse should then show signs of failing, or if there should be shivering or any other evidence of weakness, he should be given a glass of wine or brandy or a dose of some other diffusible stimulus, and bottles containing hot water should be applied to his feet. The process of cooling goes on for some time after the patient's removal from the bath, for while a thermometer placed in the axilla will show that the external temperature is immediately affected by it, the same instrument placed in the rectum will indicate a gradual fall, which will continue in many cases for at least half an hour. Shortly after this the temperature will be observed to rise, and in many cases it will not be more than two hours before it has attained its former height. Liebermeister therefore recommends that the thermometer should be frequently used, and that the baths should be repeated as often as the temperature rises to 103° F. or above it. He has himself given them as often as every two hours, or as many as two hundred during an entire illness, but usually finds that not more than six or eight a day are required. It often requires some persuasion to overcome the repugnance which most patients feel at first for these baths, and the shock of being suddenly immersed in cold water is agreeable to very few. Later, this repugnance, he says, entirely disappears. Intestinal hemorrhage, perforation of the bowel, and great weakness of the heart's action are all contraindications to the use of the cold bath. They are especially to be avoided, according to Liebermeister, when the force of the circulation is so far reduced that the surface of the body is cold while the interior is very hot. On the other hand, the advocates of this plan of treatment contend that the existence of pneumonia or of hypostatic congestion of the lungs is not a sufficient reason for abandoning it, the congestion often disappearing under its use.

The graduated bath possesses some advantages over the cold bath, as its use involves less of a shock to the system. It is therefore more suitable than the latter for nervous and excitable patients, for persons of advanced age or of general feebleness of constitution, or for very young children. In it the temperature of the water, which at the time of the immersion of the patient should be at or above 95° F., is cooled by the gradual addition of cold water until it is reduced to 72°, or below this point. These baths, to produce the same effect as the cold baths, must be of longer duration. They are contraindicated in the same conditions as the latter, but to a less degree.

Although fully willing to admit the good effects of the cold bath in many cases, having been, of course, myself a witness of them, I am indisposed to have recourse to it except in cases of hyperpyrexia of such intensity that death seems imminent and only to be averted by energetic treatment, or in cases in which other antipyretic remedies have failed to reduce the temperature; and for the following reasons: 1. In the first place, it is generally possible to produce a decided effect by the other methods of applying the cold-water treatment, with much less discomfort to the patient. 2. In a private house it is not always practicable to have a bath brought to the bedside of the patient, and in a general hospital to do so often would occasion a good deal of annoyance to the other patients in the same ward, and I have seen ill result from carrying him some distance to the bathroom. But even where the bath is brought directly to his bedside, it involves so much movement, and is sometimes the cause of so much excitement, that its good effects are more than neutralized by its bad.

Cold affusions, while not nearly so efficacious in reducing the temperature of the body as the cold bath, are open to many of the objections which may be urged against the latter mode of treatment. They are, therefore, rarely employed at the present time. Liebermeister, however, thinks that they may sometimes be resorted to with good effect for their brisk stimulating effect on the psychical functions or the respiration.

The cold pack possesses the advantage over the cold bath and cold affusions of involving less movement on the part of the patient and of being less terrifying to children, and may therefore be resorted to in cases in which the latter method of applying the cold-water treatment is contraindicated, as, for instance, in persons of feeble circulation. It is, however, inferior to either of them in its cooling effects, and must be longer applied to produce the same effect. Liebermeister estimates that a course of four consecutive packs, of from ten to twenty minutes' duration apiece, is about equivalent in effect to a cold bath of ten minutes.

Cold sponging is assigned a very low place among the methods of abstracting heat from the body by many writers. It has, however, often been in my hands of much service, and its easy application and the comfort which patients derive from it are certainly strong recommendations in its favor. I have employed it frequently in cases of intestinal hemorrhage, and even in cases of great debility, and have never yet had any reason to repent my having done so. The addition of a little vinegar to the water has seemed to me to increase the effect of the sponging.

Cold compresses, either in the form of cloths wet with cold water or bladders filled with ice, can only produce a local fall of temperature, and therefore, except when applied to the head, can be of little service.

Frictions with ice are a powerful means of depressing the temperature of the body, and may therefore be resorted to in cases of intense hyperpyrexia when for some reason the cold bath cannot be obtained, and when there are no contraindications to the latter.

Liebermeister classes cold drinks, the internal administration of ice, and the injection of cold water among the means of cooling the body in fevers; but it is doubtful if any great reduction of temperature can be brought about by any of these remedies in the quantities in which it would be safe to use them. The first two, and to a less extent the last, meet a very important indication, that of supplying water to the system. Their free use, therefore, forms a very important part of the treatment of typhoid fever.

Luton of Rheims⁹⁹ extols the Diæta hydrica in the treatment of typhoid fever. The patient receives absolutely nothing else to drink but water, which is given in large quantities, for from four to six days. No nourishment is given until the beginning of the third week, and first of all milk. If fever returns, the water is given again. Medicines such as quinia and eucalyptus are given in adynamic conditions, which Luton says are rare under this treatment. He believes that the increase of the typhoid germs is prevented by absolute diet and abundant supply of water.