«> ^^z.^ ^% %^. IMAGE EVALUATION TEST TARGET (MT-3) y A y. y. 1.0 I.I 11.25 2.5 ■-IM |50 = S us. 112.0 U III 1.6 Photographic L>ciences Corporation 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 CIHM/ICMH Microfiche Series. CIHM/ICIVIH Collection de microfiches. Canadian Institute for Historical Microreproductions / Institut canadien de microreproductions historiques Technical and Bibliographic Notes/Notes techniques et bibliographiques The Institute has attempted to obtain the best original copy available for filming. Features of this copy which may be bibliographically unique, which may alter any of the images in the reproduction, or which may significantly change the usual method of filming, are checked below. [1 □ n D D n n n Coloured covers/ Couverture de couleur Covers damaged/ Couverture endommagee Covers restored and/or laminated/ Couverture restaurde et/ou pelliculde Cover title missing/ le titre de couverture manque Coloured maps/ Cartes y^ographiques en couleur Coloured ink (i.e. other than blue or black)/ Encrf.' de couleur (i.e. autre que bleue ou noire) Coloured plates and/or illustrations/ Planches et/ou illustrations en couleur Bound with other material/ Relie avec d'autres documents Tight binding may cause shadows or distortion along interior margin/ La reliure serree peut causer de I'ombre ou de la distortion le long de la marge intdrieure Blank leaves added during restoration may appear within the text. Whenever possible, these have been omitted from fl'ming/ II se peut que certaines pages blanches ajoutdes lors d'une restauration apparaissent dans le texte, mais, lorsque cela 6tait possible, ces pages n'ont pas 6t6 filmdes. Additional comments:/ Commentaires suppl6mentaires: L'Institut a microfilm^ le meilleur exemplaire qu'il lui a 6t6 possible de se procurer. Les details de cet exemplaire qui sont peut-dtre uniques du point de vue bibliographique, qui peuvent modifier une image reproduite, ou qui peuvent exiger une modification dans la mdthode normale de filmage sont indiqu6s ci-dessous. □ Coloured pages/ Pages de couleur □ Pages damaged/ Pages endommagdes □ Pages restored and/or laminated/ Pages restaurdes et/ou pellicul6es I I Pages discoloured, stained or foxed/ Pages d6color6es, tachet6es ou piqu^es Pages detached/ Pages ddtach^es Showthrough/ Transparence I I Quality of print varies/ Quality in6gale de i'impression includes supplementary material/ Comprend du materiel supplementaire D Only edition available/ Seule Edition disponible Pages wholly or partially obscured by errata slips, tissues, etc., have been refilmed to ensure the best possible image/ Les pages totalement ou partiellement obscurcies par un feuillet d'errata, une pelure, etc., ont dt6 film^es d nouveau de fapon d obtenir la meilleure image possible. This item is filmed at the reduction ratio checked below/ Ce document est filmd au taux de reduction indiqu6 ci-dessous. 10X 14X 18X 22X 26X 30X ./ 1 12X 16X 20X 24X 28X 32X The copy filmed here has been reproduced thanks to the generosity of: National Library of Canada L'exemplaire film6 fut reproduit grdce d la g6n6rosit6 de: Bibtiothdque nationale du Canada The images appearing here are the best quality possible considering the condition and legibility of the original copy and in keeping with t:he filming contract sipecifications. Les images suivantes ont dt6 reproduites avec le plus grand soin, compte tenu de la condition et de la nettetd de Texempiaire film6, et en conformity avec les conditions du contrat de filmage. Original copies in printed paper covers are filmed oeginning with the front cover and ending on the last page with 3 printed or illustrated impres- sion, or the back cover when appropriatn. All other original copies are filmed beginning on the first page with a prin*^ i or illustrated impres- sion, and ending on \. 3St pago with a printed or illustrated impression. Les exemplaires originaux dont ia couverture en papier est imprim^e sont filmds en commenpant par le premier plat et en terminant scit par la dernidre page qui comporte une empreinte d'impression ou d'illustration, soit par le second plat, selon le cas. Tojs les autres exemplaires originaux sont filmds en commenpant par la premidre page qui comporte une empreinte d'impression ou d'illustration et en terminant par la dernidre page qui comporte une telle empreinte. The last recorded frame on each microfiche shall contain the symbol ^^ (meaning "CON- TINUED"), or the symbol V (meaning "END"), whichever applies. Un des symboles suivants apparaitra sur la dernidre image de cheque microfiche, selon le cas: le symbole — »> signifie "A SUIVRE". le symbole V signifie "FIN". Maps, plates, charts, etc., may be filmed at different reduction ratios. Those too large to be entirely included in one exposure are filmed beginning in the upper left hand corner, left to right and top to bottom, as many frames as required. The following diagrams illustrate the method: Les car..es, planches, tableaux, etc., peuvent §tre filmds d des taux de reduction diffdrents. Lorsque le document est trop grand pour dtre reproduit en un seul clich6, il esc filmd d partir de Tangle supdrieur gauche, df; gauche d droite, et de haut en bas, en pranant le nombre d'images ndcessaire. Les diagrammes suivants illustrent la mdthode. 1 2 3 1 2 3 4 5 6 r [^•■t ON thp: TREATMENT '^'<¥- ■V ■>'■ r :-.-'.,V.:. SOME FEBRILE DISEASES ,ER)1ALJpELICATI0.I OF bOLD. >-, »*- ..i>*^:(S-.^^^':^■ J,./ ."he Canada Medical Association in London, ^^^'V :^ v^^t "":' Septennber 11, 1879. :^'<*' '^.^'^i:,^:!. .!;y'^VP*",'''-'*^il ->* ijtantwal $ T N G A N D P r 13 1. T S H I N G C M PA N Y. 1879. / ./ V ( /i^ / ^ ^' , ON THE TREATMENT OF SOME FEBRILE DISEASES BY THE External JlPPLiGATioN of Cold, By T. K. holmes, M. D. Chatham, Ojst. Read before the Canada Medical Association in London, September i i, 1879- LOVELL PRINTING AND PUBLISHING COMPANY. / 1879. /^ f^ ON THE TREATMENT OF SOME FEBRILE DISEASES BY THE EXTERNAL APPLICATION OF COLD. Gentlemen,— I intend in this paper to present for your consideration some observations on the therapeutic uses of cold applied externally. The subject commends itself to me on account of the great efficiency of this agent in pro- perly selected cases, and also on account of the neglect it has "suffered at the hands of the profession generally. There is reason for believing that beyond sponging the bodies of fever patients with cold water for a few minutes night and morning, its employment is seldom resorted to by medical men in general practice. While sponging the skin Jor ten minutes with cold water may cleanse it, and so render a patient more comfortable, it will not reduce the temperature when much above the normal o«e half of one degree Fahr. It is as an antipyretic that cold appli- cations will be considered in this paper; it is therefore desirable to inquire into some of the phenomena of the febrile state. No question in experimental science presents greater difficulties than that of the causes of fever and their mode of action in producing it. By the light already shed on this subject it is justifiable to believe that essential fevers result in most cases from the introduction of a poison into the syHtcm, ami Lli.it its prcsonco initiates that coni])loxiis of morliid pliononieiia known as essential fovei*. As heat is only a mode of motion, all ahnormal elevation of temiieratnre in the animal or<^anism must ho the result of excessive mo- tion therein, and is only an index of morhid processes taking place in disturbed cystogcny ami retrograde metamor- phosis. An eminent English writer, whoso name I forget, ho- lieves the heat of fever to bo the result of intensely rapid coll generation ; but as the elevation of proto])lasm to more complex matter is a synthetical process, heat would be used and not produced in accomplishing it. It nniy be, however, that cells thus ra])idly formed, being c)>hemeral in their nature, undergo equally ra])id disintegi-ation, and are decomposed into substances much sim])ler in chemical com- position than the protoplasm from which they were form- ed, and that the excess of heat so produced over the amount used in the cell formation accounts for the increased heat observed in the ji^n-exial state. If to heat so produced be added that resulting from ra])id retrograde metamorpho- sis of tissue previously formed, a plausible explanation of the rise in temperature is reached. In whatever way i)ro- duced, the abnormal temperature becomes the chief factor in a chain oi morbid action always injurious and often dau- gerous. 1 have here the heart of a turtle recently removed froju the body. It will be observed that when heat is applied by holding the plate over a lamp the pulsations become more frequent, and that placing it on a piece of ice causes the heart to beat more slowly. Placing it again over the lamp the pulsations immediately increase in frequency, and again changing it to the ice the pulsations fall as before. This phenomenon was iirst observed by Dr. Brunton, and sug- gested to my mind the propriety of instituting a series of observations on the action of cold a})plied to the surface of the human body during febrile action. The result of those observations has convinced me that in tho external appliculion of cold wo posHOHS an u^^Mit that merits far more attention from the profoHnion than it ro- eive.s. Allhoiii^h wo cannot apply heat and cold directly to the human heart, an han hecn witnessed in tho exi)erimcnt just made, wo can deprive the blood in tho sui)erticial ca- pillaries of ilH heat, and send it back in a cooler stream to the lalM)rin])li- cation of cold. Ileat generally produces such violent action in tiie circulatory organs as to rapidlj' exhaust them., and render them incapable of bearing further dcjU'ession by the- ra])eutic agents, so that many drugs acting as most of those just named are inadmissible. Their action, moreover, is often too slow to render them availing in the preservation of life. It is under those circumstances thar, the rapid abstraction of heat becomes of paramount importance in aft'ording relief or in saving life. Wo know that a !em2:)erature of 107° F., or higher, is incompatible with life if continued for oven a comparatively short time, whatever the disease may be, and wo know of no internal remedy that will reduce it to the health standard as quickly, safely and certainly as cold applied externally. If a well-developed child, weighing thirty pounds, and having a temperature of 106° F., be placed in a bath of water at 50° F., there will bo no perceptible fall in the axil- lary temperature for three minutes; the mei'cury will then begin to fall very slowly, and in about fifteen minutes will stand at 98^°, falling much more rapidly the last three degrees. The rapidity with which tho temperature falls is not tho same in every case, and cannot be prognosticated ; it is well, therefore, to always keep a clinical thermometer in the axilla, and remove the patient from the water when tho mercury haa fallen to 99^°, as there will bo a farther fall after removal from the bath. The tem])eraturo may bo reduced with almost equal faci'ity by sponging tho whole body with whiskey or brandy, and fanning the wet skin at the same time to promote evapora- tion. This method, in'deod, is often preferable, as cold water is apt to alarm young patients and is unpleasant. At first it is better to have the bath tepid, and rapidly cool it by the addition of cold water or ice until our object is attained. Til is precaution is unnecessary when fronj any cause the patient is insensible, which ia generally the case in infan- tile convulsions. Tho most notable changes that accompany the fall in temperature are those pertaining to tho nervous and circu- latory systems. The pulse becomes loss frequent, slower and softer, nervous excitability is allayed, muscular spasm ceases, sleep is often induced while tho patient is still in tho water, and is almost certain to supervene c i removal from it. In some cases, the temperature having been thus reduced, ti.ore is no subsequent rise, the case progressing to rapid recovery; but in many diseases it is necessary to repeat the bath at such intervals as will bo indicated by the rise in temperature. By keeping the patient in a cool, well-ventilated room, and resorting to tho use of the spongo bath and tho use of a fan, tho repetition of the cold bath will only be required at long intervals, and may not be required at all. Experience has led me to the conclusion that children are riore intolerant of increased temperature than adults, an(' that it is in febrile diseases of the former we can accomplish most by tho use of cold externally. The febrile diseases in which I have found this treatment to bo most useful are diarrhoea, dysentery, scarlet fever, acute bronchitis and convulsions complicating febrile action. I have also treated acute pleurisy, pneumonia and cerebro- spinal meningitis in this way, but not a sufficient number of 8 cashes on which to base any conchisions. I may say, however, that the cases of pleurisy seemed to be benefited, but the cases of iincumonia and cerebro-spinal meningitis terminated fiitally, although not, I believe, on account of the cold water treatment. A large number of children die eveVy summer from acrte diarrlui^i. The attack usually comes on su.ldenly, the stools are iVoquent, the stomach sick and the temperature high. If seen a few hours from the beginning of the disease the child will be found restless and pained, the stools x^m^.^ve and unnatural in color, the features pinched and'taii, the eyes sunken, and often the feet and hands cold. The patient moans and moves the tongue about the mouth in a peculiar manner, and often makes efforts to vomit when no food or drink has been taken. If the jase be allowed to go on, the pupils become contracted, the breathing labored, the extremi- ties oolder and bluish in color, the pulse frequent and feeble, the fontanelles depressed, and the child r.^lls its head from side to side on the pillow. If the axillary temperature of that child be tested, it will almost certainly be found to be between 103^ and 106° F., notwithstanding the coldness of the exti-emities. Such cases must have relief promptly or they will all die. The indications are to rid the bowels of offensive accumulations, to arrest the vomiting, to preserve the strength and to reduce the temperature. Purgatives will seldom remain on the stomach, nourishment and stimulants are rejected in the same manner ; it is generally useless to administer anti-emetics, and even if we could wait for the action of drugs that reduce the temperature, they would as a ride be inadmissible on account of their depressing influence on the circulation. If a child in this condition be placed in a cold bath for from five to twenty minutes, according to the heat o^. its body and the coldness of the w^ater, the tempei-ature will fall to the normal standard, the heart will beat with more force, the thirst will be less intense, the circulation will become equalized, sleep will generally bo procured, and the stomach will retain nourishment and medicine. If after a few hours th' temperature rise again, the bath can be repeated, but, by ullovving tlie chikl to he naked and be sponged and fanned, its repetition may not be necessary, for if, in the meantime, a purgative dose of rhubarb or castor oil be given, the tendency to a rise of temperature will not be so great. I have frequently seen children, that had tossed and moaned for hours, ftiU into a quiet sound sleep in the water in a few minutes, and continue to sleep well after being taken out. , As an illustration I have transcribed from my case book the follow! n a- typical cases. CvsE I. July 27th, 1878._J. Ellson, a^t. 5 months, strong and well nourished, has had diarrhea for forty eight hours, and the mother thinks fever also. Looks distressed, tem- perature 105° F., pulse 130, evacuations greenish and ot^en- Bivo, and about twelve a day. Ordered rhubarb and soda bic. aa gr. iv. every two hours. 28th 10 o'clock a.m.-The child has not rested, but cries and to'sses about incessantly. The extremities cold, and temperature 105^ F. No pulse at wrist, breathing labored fontanelles depressed, eyes sunken, features pinched and bluish, and it refuses to nurse. Put it into water from the well until axillary temperature fell to 99-r, when the child fell asleep. Soon after its remo- val from the water the pulse returned at the wrist, and the body and extremities became of about uniform warmth At .1 ^0 p.m. the temperature had risen to 104°, and the child was again restless. Repeated bath with same result as '29th.-Eested well all night, and has nursed several times. Temperature 99^- l^^^^'^^^ts had used sponge bath and fan frequently through the night. Stools greenish Or- dered a dose of castor oil, and chloral enough to make it rest. 30th.— Passed a comfortable night, and nurses well ; has been sponged several times during last twelve hours ; tem- perature 99f°. After this an occasional dose of rhubarb and 10 soda was the only medicine given, and the child aoon recov- ered entirely. Case TI. July 12th, 1876, 10 o'clock a.m.— Caspar Schvvein- ler, a robust child five months old, has had diarrlioea for three days, but net very ill until yesterday, since when it haa neither nursed nor slept, but has constantly uttered half sup- pressed cries. It is pale, hands and feet cool f.nd skin dry. Gave a purgative dose of rhubarb and calomel. 3 o'clock p.m. — Bowels well moved by the medicine, the last evacuation being natural in color. Extremities cold, pulse imperceptible, pupils contracted, face leaden hue, and thirst intense. The axillary temperature to my surprise was 105°, for I had been deceived by the coldness of the extremities and the general appearance of the patient, and did not expect to find temperature so high. Gave half a drachm of brandy, and put it into a tepid bath, and rapidly cooled it by the addition of cold water. In ten minutes the temperature fell to 102°, and sleep came on for the first time in thirty hours. When the mercury fell to 100° I removed the child from the water, and it slept most of the afternoon, and was not thirsty. As the temperature fell, the pulse became better and the pupils larger. 8 o'clock p.m.— Temperature 103°, child sleeps well, and looks comfortable. Bath repeated, and temi^erature reduced to 99° in five minutes. 13th, 10 o'clock a.m.— Eested well all night and nurses, temperature 103°. Ordered a dose of castor oil. 11 o'clock a.m.— Child has had two convulsions within last few minutes, is insensible, and temperature 105|. Ee- peated the bath, and reduced temperature to 98|°. After this the temperature never rose above 101°, the bath was not resorted to again, and in a few days the child was well. Case III. Bronchitis. Jan. 5th, 1879.— N. Clarke, set. 14 months, ill five days with what the parents thought an ordinary cold. 11 I saw it on the fifth day of its illness, and found it with well-marked acute bronchitis, temperature 105^ pulse 140. Abundant rales over both lun^s. For the next five days the treatment consisted of hot fomentations to the thorax, with occasional applications of turpentine to keep up slight counter-irritation and the ad- ministration of quinine with small quantities of Dover b pow- der. An aperient was given when required, and the child was allowed to nurse. The symptoms underwent but little change until the 10th, when great restlessness came on. The breathing was very rapid, and there was constant moaning and rolling of the head. Extremities cold, pupils small, tongue dry, pulse too frequent to count, and temperature 106°. Fearing the child would die unless relieved promptly, I felt justified in trying the effect of cold externally, which I did by removing hot fomentations, sponging the body witu brandy and fanning it vigorously. At the end of ha f an hour the temperature had fallen to 99<=> and the patient was sound asleep, pulse slower and fuller, breathing easy and extremities warmer. I then instructed the atterdants in the use of the thermometer, with the request to keep the axillary temperature as nearly 100° as possible by the means just used. 11th— Instructions have been observed, and child has rested well and has not been very thirsty. Temperature 100^ respiration 35, pulse 130. Thinking the disease had passed the climax, and that convalescence would goon, I ad- vised the mother to put on the child a thin night dress and to omit the applications of the brandy. 12th —The parents informed me that in four hours from the time the sponging was stopped the child became rest- less and seemed worse in every respect, and that tiie tem- perature rose to 101^ when they again resorted to the cold Bponpira- tion, they reduce the temperature, but every medical man knows that they often fail to arrest the convulsions The cold bath fails so seldom that it may be considered a specific. The spasms will frequently continue until the tem- perature has been reduced to 98^°, but at this point they are almost invariably arrested. Several years' experience with this plan of treatment has inspired me with the strongest confidence in its usefulness, and yet a desire not to have its value over-estimated compels me to admit that there are cases in which convulsions will return or continue not- withstanding the reduction of temperature, but such cases are rare, and probably are complicated by organic lesions, as tubercular meningitis. The following cases will illustrate the comparative value cf the cold water treatment of convulsions complicating fever : 13 Case IV. July 3r1, 1870.— M. A., .'ot. 2 year.s, ntroiio- ami well-dcvoloped, was taken suddenly ill last oveni/ig with dvsentcry and fever, which lasted ail iiiii;i)t, and at seven this morniiifj there was a convulsion. At 8 o'clock i saw him, temperature 108°, restless. Ordered a lai-n-e dose of castor oil, and one-third of a drop of the fluid extract of aconite every hour while fever lasted. Anotiier convulsion occurred at ten a.m., and another at halt[-past ten, when I beo-an the administration of chloroform. At noon the oil had operated Avell. At 2 p.m. the convulsions i-ecurred, and continued for two hours with no intermission, although the patient was partially under the influence of chloi-oform during the time. At 4 p.m. the}- were as violent as ])ossihlo, temperature 105°, pulse 150, breathing noisy and labored, a light frothy foam was constantly discharging from the mouth a ;! nostrils, and death seemed inevitable. I now put child into bath at 50°, and added ice and ice water. In ten minutes the breathing became easier, in fifteen minutes the temperature was 102°, and in twenty minutes 99° and the pulse 110. All spasm had ceased, and the child was replaced in bed. It slept soundly for half an hour, and awoke with no bad symptoms. There was no return of fever, and no further treatment was required. Case V. Feb. 5th, 1871. — L. Lamont, set. G years, was first ill this morning with chill followed by fever (mala- rious). At one p.m. convulsions came on, and continued without intermission^when she died. The treatment consisted of warm baths, castor oil, injec- tion to move bowels, bromide of potassium and hydrate of chloral. The temperature the whole afternoon was 104^. Chloroform was administered part of the time. Case VL. Sept. 26th, 1872.— P. T., a strong boy, 8 years old, was well until noon to-day when chill came on, fol- lowed by fever and convulsions, which still continued when I arrived, at one o'clock p.m. The attendants had just removed him from a warm bath. It was impossible 14 to eet him to swallow anything. Applied cold to the hoad, gave an enema, and put him under chloroform, which con- trolled the spanms, but they always returned when it was omitted. , , „ x- i The enema acted well, the chloroform was continued, the temperature remained at 106«, the pulse became gradu- ally weaker and more frequent, and after three hours ho ^Case VII. Oct. 28th, 1876.— C. Gore, let. one year, was never ill till last evening, when fever came on and lasted all ni'rht At 7 o'clock this morning convulsions began, and lasted°without intermission until half-past eleven a.m., when I saw the child, and found him convulsed and senseless, with a temperature of 104«. tised cold bath, and in ten minutes temperature fell to 99^, the spasms ceased, and consciousness returned The child remained well until the following Thursday (4 days), when it again had fever, and convul- sions beo-an as before. The parents, having witnessed the beneficial eftects of the former treatment, put the child into a cold bath, and in a few minutes he was well and re- mained so afterwards. ^ In carrying out this plan of treament care is required to protect the bulb of the thermometer from contact with the water, by keeping Lhe arm pressed firmly to the side. The application of cold should not be continued after the temperature has been reduced to 99^, as there will be a further fill I after it has been stopped. .