VOL. XL.

ORIGINAL LECTURES.

CLINICAL LECTURE

ON THE ANTIPYRETIC TREATMENT OF
TYPHOID FEVER,

BY BATHS, SPONGING THE BODY, AND THE WET SHEET,
Delivered at Bellevue Hospital,

PROFESSOR OF THE

BY AUSTIN FLINT, M.D.,

PRINCIPLES AND PRACTICE OF MEDICINE AND OF
CLINICAL MEDICINE IN BELLEVUE HOSPITAL MEDICAL
COLLEGE, NEW YORK.

GENTLEMEN: As introductory to the subject of this lecture, I ask to be indulged in giving some personal reminiscences. More than thirty years ago my interest was enlisted in the clinical study of the continued fevers. This was not long after the publication, in this country, of the translation by Bowditch of the great work of Louis, containing researches which established the clinical history of the typhoid fever in France, of that day, and not less of the typhoid fever of to-day in all countries. The observations by Gerhard, Shattuck, and others had recently been published, showing that typhus fever, as existing in Ireland, and as imported into this country, was a species of fever distinct from the typhoid fever studied by Louis. It was a mooted question at that time whether typhus and typhoid fever were varieties of one species of fever, or essentially different diseases. This question elicited much discussion at the annual meeting of the New York State Medical Society in 1850, and a committee was appointed, of which I was made chairman, to collect facts relating to the question. I was in this way led to study analytically, following the numerical method of Louis, all the cases of continued fever which, up to that time, I had recorded. The number of cases amounted to fifty-two. The results of the analytical study of those cases were embodied in a report. In 1851 I had collected the recorded histories of fortyeight additional cases of typhus and typhoid fever. I subjected these cases to an analytical study, and embodied the results in a second report. Again, in 1852, I studied in the same manner sixty-four cases of typhoid and typhus fever, which I had recorded since 1851, and the results were embodied in a third report. The whole number of cases analyzed thus were one hundred and sixty-four.

One advantage in studying these three collections of cases separately was, the results obtained from the collections severally could be brought into comparison with each other. The three reports were published in a volume in 1852. I may be permitted to refer to this volume for several reasons. It was my firstborn of a bibliographical brood, which has since become somewhat numerous. It is not in a condition now to speak much for itself, as it has long been out of print. The edition was small, and, moreover, the volume was printed for the author, having only a nominal publisher, so that it never had a fair chance for much circulation. But it represents the employment of most of my leisure hours for a period of three years. Aside from the personal benefit derived from the studies, compensation for the labor was found in a remarkable correspondence with the results of Louis' researches as regards the clinical history of typhoid fever-a correspondence corroborating the accuracy of his researches, and going to show that the disease retains its historical characteristics in different countries and at different periods. I

No. 1.

I

wet-.

began the analytical studies with belief in the identity of typhus and typhoid fevers, but the studies converted me to the opposite opinion, and this opinion is now held by most, if not all, medical writers. In collecting my histories, I stumbled upon a number of cases of relapsing fever, and these were the only cases of this disease which, up to that time, had been reported in this country, except some recorded by Clymer, in 1846. My subject to-day is the treatment of cases of typhoid fever by the antipyretic employment of cold water. may mention the fact that, in my second report, I studied the effects of the wet-pack in five cases. By the pack" I mean enveloping the body in a wet sheet, and over it dry blankets, after the method of the so-called hydropathists of that time. This measure cannot act by the direct abstraction of heat; but it is entitled to be called an "antipyretic measure," for it is often followed by a considerable reduction of temperature. As such, it deserves more consideration than it appears to have received. Within late years I have known it to prove signally useful in many cases of febrile disease. When my reports were written, the thermometer had not come into clinical use, the intensity of fever being estimated by the subjective symptoms together with the sensation of heat communicated to the hand applied to the skin. The effect of the wet-pack, in my cases, was excellent; but I was deterred from continuing my observations by the occurrence of apoplectic coma in a case in which this measure had been employed with very marked immediate benefit. There was no ground for supposing that the treatment had anything to do with the occurrence of the coma; but, as the measure was then a novelty in medical practice, I considered that I would be held responsible for any accidents that might subsequently take place.

The following quotation from my second report expresses my ideas of the value of external refrigerating treatment at that time: "The direct effect of an increased disengagement of caloric, it is not improbable, may contribute to some of the evils of the febrile state. The most effective refrigerating measures, which possess much potency, are external applications, and these are cold water and cool air. Ablutions with cold water are usually grateful to the sensations of patients affected with fever, and abate, frequently in a striking manner, the increased heat and dryness. The simplicity of the measure causes it to be lightly esteemed by attendants, and sometimes, perhaps, by physicians. It is really an important part of the treatment of a large proportion of fever cases. The face, body, and extremities may be sponged, in succession, several times a day, or as often as the heat and dryness of the surface return. A faithful, judicious nurse may occupy a considerable portion of the time with these ablutions to the advantage of the patient. Should cold water occasion uncomfortable sensations (which is rarely the case), tepid or even warm water will secure, by evaporation, part of the refrigerating effect. The evaporation will be more rapid if spirit be added to the water. Cologne, or other perfumed spirits, may be employed for this purpose. Cold water, taken into the stomach, exerts a refrigerating effect on the skin and the system at large. Patients should be allowed to drink freely. The refrigerating effect of cool air is important. This is one of the useful ends of free ventilation. To secure this end, the patient should be lightly covered, and ventilation between the bedclothes attended to." These views, published thirty years ago, foreshadowed those which