A FURTHER REPORT IN REGARD TO THE 
TREATMENT OF ENTERIC OR TYPHOID 
FEVER BY MEANS OF SYSTEMATIC 
COLD BATHING, IN THE GERMAN 
HOSPITAL, PHILADELPHIA. 
BY / 
J. C. WILSON; M.D., 
PHYSICIAN TO THE HOSPITAL AND PROFESSOR OF THE PRACTICE OF MEDICINE 
in the Jefferson medical college. 
FROM 
THE MEDICAL NEWS, 
November 26, 1892. 4 FURTHER REPORT IN REGARD TO THE 
TREATMENT OF ENTERIC OR TYPHOID 
FEVER BY MEANS OF SYSTEMATIC 
COLD BATHING, IN THE GERMAN 
HOSPITAL, PHILADELPHIA. 
BY J. C. WILSON, M.D., 
PHYSICIAN TO THE HOSPITAL AND PROFESSOR OF THE PRACTICE OF 
MEDICINE IN THE JEFFERSON MEDICAL COLLEGE. 
The treatment of enteric fever by systematic cold 
bathing, according to the method of Brand, has 
now been practised in the German Hospital since 
the first of February, 1890. It is the only treat- 
ment employed, and all patients suffering from this 
disease are submitted to it, except very rare cases 
brought into the hospital moribund, or those that 
are brought in late in the course of the attack-i. e., 
during or after the third week. 
I have already published some accounts of the 
treatment as practised in the hospital, and its 
results. These publications1 cover the work to June 
1, 1891, and contain the results of the analysis of 
three series of cases, as follows: 
1. February 1 to July 15, 1890, under my service, 
40 cases, no deaths; average number of days in 
hospital, 36.2. 
2. July 15, 1890, to February 1, 1891, services 
of Dr. Trau and Dr. Wolff, 54 cases, 1 death; 
average number of days in the hospital, 38.2. 
3. February 1 to June 1, 1891, under my service, 
66 cases, 7 deaths; average number of days in hos- 
pital of the non-fatal cases, 26. 
Total in 16 months, 160 ; total deaths, 8, or 5 per 
cent. 
1 The Medical News, December 6, 1890, p. 588. Inter- 
national Clinics, July, 1891. 4 
In the above series of cases relapses occurred 
eleven times, multiple relapses once. The average 
number of baths in the cases of the first series was 
42 ; the smallest 10 ; the largest, 138. 
The medical service during the year is divided 
into three periods of four months each. As the 
treatment is a matter of routine, and systematically 
carried out in each of the services, the cases may 
hereafter be reported in annual series. 
The following table, compiled from the records 
of the hospital by Dr. Woodward, late resident phy- 
sician, shows the statistics for the year, June 1, 
1891, to June 1, 1892 : 
Cases of Enteric Fever Treated by Systematic 
Cold Bathing. 
Series No. 4. June 1, 1891, to June 1, 1892. 
No. 
Admis- 
sion. 
Sex. 
Age. 
Day of 
disease 
Max. 
temp. 
tst day 
norm, 
temp. 
Days 
in 
house. 
Num- 
ber of 
baths. 
I 
1891. 
June 7 
F. 
22 
7 
105.4 
21 
36 
43 
2 
" 8 
M. 
22 
IO 
105.2 
28 
36 
80 
3 
" 12 
F. 
20 
7 
104.6 
20 
41 
291 
4 
" 25 
M. 
18 
8 
107.6 
32 
49 
103 
5 
" 27 
M. 
27 
8 
105.0 
31 
38 
65 
6 
" 28 
F. 
24 
11 
103.6 
17 
27 
17 
7 
" 28 
F. 
18 
6 
104.8 
25 
23 
48 
8 
July 6 
M. 
24 
7 
106 O 
27 
35 
27 
9 
" 9 
M. 
28 
3 
102.4 
10 
18 
2 
IO 
" 22 
M. 
31 
7 
I04.0 
18 
29 
28 
II 
" 22 
M. 
18 
7 
104 4 
18 
26 
31 
12 
" 28 
M. 
25 
8 
IO4.4 
30 
38 
57 
13 
" 29 
M. 
40 
4 
103.6 
34 
47 
4l2 
14 
Aug 4 
M. 
28 
5 
105.4 
45 
09 
343 
15 
" 5 
F. 
20 
9 
104.0 
29 
4i 
4i4 
16 
" 7 
M. 
18 
8 
104.8 
3^ 
33 
86 
17 
" 8 
M. 
29 
7 
104.0 
26 
33 
29 
18 
" 18 
M. 
30 
10 
103.6 
18 
35 
11 
19 
" 20 
F. 
28 
3 
104.4 
23 
37 
3i 
20 
" 27 
M. 
25 
6 
104.4 
18 
27 
40 
21 
Sept. 4 
F. 
42 
7 
103.6 
32 
42 
13 
22 
" 14 
M. 
19 
108.0 
54 
23 
14 
F. 
32 
103.4 
20 
15 
24 
" 19 
F. 
42 
102.2 
x5 
I 
25 
" 21 
F. 
26 
103.4 
24 
20 
26 
" 22 
F 
18 
... • 
104.8 
27 
39 
27 
" 22 
F. 
32 
104.2 
26 
8 
1 One relapse. 
3 Two relapses. 
2 One relapse. 
4 One relapse. 5 
No. 
Admis- 
sion. 
Sex. 
Age. 
Day of 
disease 
Max. 
temp. 
i st day 
norm, 
temp. 
Days 
in 
house. 
Num- 
ber of 
baths. 
28 
" 22 
F. 
26 
103.6 
16 
9 
29 
" 27 
F. 
21 
105.8 
53 
33 
30 
" 28 
F. 
24 
102.6 
19 
5 
3i 
Oct. 6 
M. 
17 
102.4 
48 
5* 
32 
" 13 
M. 
29 
105.4 
42 
73 
33 
" 19 
F. 
22 
105.0 
70 
92 
34 
Nov. 4 
M. 
22 
103.0 
45 
17 
35 
" 7 
M. 
22 
104.0 
14 
4 
36 
" 9 
M. 
27 
103.0 
35 
14 
37 
" *3 
M. 
26 
103.8 
22 
15 
3« 
" 14 
M. 
24 
104.6 
30 
54 
39 
" 18 
F. 
18 
105.8 
61 
1218 
40 
Dec. 13 
M. 
22 
103.2 
37 
5 
4i 
" 17 
M. 
35 
104.2 
52 
62? 
42 
Jan. 5 
M. 
18 
104.4 
28 
32 
43 
" 6 
M. 
3i 
103.6 
26 
39 
44 
" 16 
M. 
20 
103.8 
32 
34 
45 
" 17 
M. 
19 
104.6 
6 
34s 
46 
" 17 
F. 
U 
6 
106.6 
33 
66 
138 
47 
" 20 
M. 
22 
5 
105.2 
24 
3i 
80 
48 
" 23 
M. 
18 
7 
105.0 
15 
23 
38 
49 
" 24 
F. 
26 
10 
108.4 
II 
50s 
50 
" 3i 
M. 
*3 
3 
104.0 
15 
75te 
5i 
" 26 
F. 
27 
I 
102.8 
13 
21 
8 
52 
Feb. 1 
M. 
19 
7 
105.0 
48 
26 
37 
53 
I 
M. 
25 
5 
104.6 
3t 
48 
io6u 
54 
" I 
F. 
16 
IO 
104.6 
20 
29 
23 
55 
" 6 
F. 
18 
5 
103.4 
24 
32 
35 
5b 
" 8 
M. 
26 
2 
103.0 
13 
21 
25 
57 
" 18 
M. 
27 
9 
105 2 
34 
41 
47*2 
58 
" 19 
F. 
29 
II 
IO3.6 
30 
38 
43 
59 
" 20 
F. 
22 
5 
105 4 
15 
17 
41 
60 
" 28 
M. 
24 
8 
106.0 
16 
761s 
61 
Mar. 21 
F. 
28 
9 
IO5.2 
26 
29 
33 
62 
April 5 
F. 
22 
6 
IO4.4 
15 
23 
8 
63 
" 7 
M. 
26 
4 
103.4 
24 
31 
II 
64 
" 12 
M. 
14 
7 
IO3.4 
20 
24 
If 
65 
" IO 
M. 
29 
7 
IO4.8 
48 
65 
I49u 
66 
May 7 
M. 
26 
7 
105 O 
28 
45 
105 
Total, 66 
cases. 
Deaths, 4. 
Mortality, 
6 per cent. 
5 (Insane before admission.) Developed, insanity. 
6 One relapse. 
7 Relapse after ten days of normal temperature. 
8 Death-croupous pneumonia. 
9 Death. Pronounced nervous symptoms from outset. 
50 Death from cerebral meningitis. 
11 Intestinal hemorrhage. 
12 One relapse; intestinal hemorrhage. 
13 Death-pneumonia and intestinal hemorrhage. 
14 One relapse. 6 
The fatal cases were as follows : 
No. 45.-H. S., male, nineteen years of age, a 
barber, died six days after admission, of double 
pneumonia. 
No. 49.-A. S., female, twenty-six years of age, 
was admitted on the tenth day of the disease. From 
the outset the temperature ran very high. The 
nervous system was greatly affected, culminating in 
delirium five days before death. She lived eleven 
days in the hospital. One half hour after death the 
thermometer registered 109.8°. 
No. 50.--L. H., male, thirteen years old, was 
admitted on the third day of the disease. He died 
on the fifteenth day, with symptoms of cerebral 
meningitis. 
No. 60.-O. C., male, twenty-four years old, 
was admitted on the eighth day of the disease. He 
developed pneumonia on the seventeenth day; 
intestinal hemorrhage on the nineteenth day, twen- 
tieth day, twenty-second day; and died on the 
twenty-third day. 
The foregoing table shows the main facts in 
regard to this series of cases. 
The patients were chiefly adolescents and young 
adults, their ages ranging from thirteen to forty-two 
years, as follows : 
Under 15 years . . . , . .3 cases. 
From 15 to 20 years . . . . . 14 " 
" 20 " 25 " 18 " 
" 25 " 30 " 22 " 
" 30 " 35 " 5 " 
" 35 " 40 " 1 case. 
" 40 " 42 " 3 cases. 
Relapses occurred in 8 cases, 12 per cent., in 
1 of which a second relapse took place. 
The average number of baths administered was 
about 44; the smallest, 1; the largest, 149. In 
2 cases 5 baths only were given ; in 1 case, 4 baths ; 
in 1, 2 baths; and in 1, 1 only. These were either 
abortive cases or cases admitted late in the course 
of the disease, in which the axillary temperature 
after the last bath never rose to 101.50. 7 
The average number of days in the hospital of the 
aion-fatal cases was about 35. 
The total number of cases treated by this method 
$o June 1, 1892, is 226; the total deaths, 12-5.3 
per cent. In the entire series of 226 cases relapses 
occurred in 19 instances; more than 1 relapse oc- 
curred in 2 cases. 
The statistics of the German Hospital now rest on 
a sufficient number of cases and extend over time 
•enough to warrant conclusions as to the efficiency 
of the treatment in an American hospital. It has 
reduced the death-rate in this institution nearly 
50 per cent, from the best showing of previous years, 
and 66 per cent, from the most favorable statistics 
of the hospitals of the city under other methods. 
It is our custom at the German Hospital to ad- 
minister to the patient upon admission, if before the 
10th day, a laxative dose of calomel, from gr. vijss-x, 
and in cases entering the hospital during the first 
week this dose is very often repeated; otherwise, 
the management of the cases in almost all instances 
conforms strictly to the method of Brand. The 
necessity to depart from the routine plan in any par- 
ticular has scarcely ever arisen in my service. In 
the services of Dr. Trau and Dr. Wolff it has been 
infrequent, but not to the same extent. 
When patients are admitted after the disease has 
made some progress, at the end of the first or during 
the second week, pending the influence of the baths 
in controlling some of the more important symp- 
toms, an influence which does not show itself until a 
number of baths have been administered, it has 
been thought necessary occasionally to administer 
strychnine as a cardiac stimulant; and to control a 
troublesome diarrhea not moderating after the action 
of the calomel, by an occasional opium-suppository. 
The maxim of universal application, that the patient, 
and not the disease, is to be treated, is constantly 
observed. 
The details of the method of Brand are fortu- 
nately becoming well understood, but as these may 8 
Hot be familiar to some, I reprint the following 
from The Medical News, of December 6, 1890 
The method of Brand consists in the following sys- 
tematic procedure: 
Whenever the temperature taken in the rectum< 
reaches 102.2° F. (390 C.) the patient is placed in a bath 
of 65° F. A compress, wet with water about five degrees- 
lower, is placed upon the head, or water at a lower tem- 
perature is poured upon the head and shoulders. The 
patient remains in the bath fifteen minutes, during which 
time he is systematically rubbed by the attendants and 
encouraged to rub himself. At the expiration of that 
time he is removed from the bath, and wrapped in a 
coarse linen sheet, over which a blanket is folded, the 
extremities being thoroughly dried and rubbed. A little 
wine or spirits is then given. This is repeated every 
three hours, unless the temperature remains below 102.2&' 
F. The alimentation is liquid, nutritious, and carefully 
regulated. No drugs are administered. 
Glenard2 gives the following outline of the technique ' 
" If the diagnosis of typhoid fever is probable, recourse 
should be had to the baths, whatever may be the symp- 
toms. The full tub should be placed in the ward or 
chamber, parallel to the bed at a distance of one or two 
meters, the floors properly protected by oilcloth, and a 
screen placed between the bed and the bath-tub. A 
sufficient quantity of water should be used to cover the 
patient's body to the neck. It should be of a tempera- 
ture of from 64.4° to 68° F. (180 to 20° C.). The baths 
should be prepared without disturbance or noise. There 
should be placed on the floor near the head of the tub 
two pitchers of cold water of a temperature of from 46.4° 
to 500 F. (8® to io° C.), each containing four or five quarts 
(liters). A glass of water should be at hand. The first 
bath should be given preferably about four o'clock in the 
afternoon, unless there is some urgent reason for select- 
ing a different hour, and the physician should be present. 
The rectal temperature is taken, the urine is voided, and 
the patient is assisted into the full tub, the screen having 
been removed. If there is perspiration the patient is 
dried before entering the bath. Cold water from the 
pitchers is poured upon the head and the back of the 
neck, for one or two minutes, the amount being from two 
to three quarts (liters). Then a swallow of cold water 
or red wine is given. This being done, the whole surface 
of the body is briskly rubbed with a sponge or brush, 
and the patient is made to rub his abdomen and chest. 
These frictions stimulate the peripheral circulation, pre- 
1 " The Treatment of Enteric Fever, with Special Reference to 
the Method of Brand. An Address before the Lycoming County 
Medical Society, delivered at Williamsport, Pa., Nov. 4, 1890." 
2 Le Bulletin Medical, February 26, 1888 9 
vent the accumulation of heat at any one point, moderate 
the sensation of cold, and help to pass the time; they 
are not indispensable. Shivering appears, as a general 
rule, in between eight and twelve minutes ; this is a neces- 
sary evil to which too much attention is not to be paid. 
Toward the middle of the bath, or at its termination, 
cold water is again poured over the head and neck. The 
time occupied ought to be at least fifteen minutes, longer 
if the head is still warm and the cheeks red, or if the 
temperature of the patient was very high before the bath. 
" The patient should leave the bath without precipita- 
tion. He cannot take cold; thoracic complications are 
caused by typhoid fever and not by chilling. The air of 
the apartment should be pure and not too warm; the 
window should be opened in the intervals between the 
baths; during the bath it ought to be closed. On leaving 
the bath, the patient should be gently dried with a towel. 
The bed should be carefully made during each bath. If 
on returning to the bed shivering takes place, the limbs 
should be rubbed and a hot bottle placed at the patient's 
feet. A cold compress, covered with oil-silk or flannel, 
should be placed over the abdomen, and a little warm 
nourishment administered. 
" Three-quarters of an hour after the bath the rectal 
temperature should again be taken. If, however, it is 
found to be below ioi° F. (38.5° C.), it is not necessary 
to take it again for three hours. 
"Alimentation should consist of the following articles : 
Milk diluted with coffee or tea or cocoa (a quarter of a 
liter at each administration); thoroughly cooked gruel, 
oatmeal, tapioca, or vermicelli; veal, mutton, or chicken 
broth, freed from fat when cold, and reheated at the 
moment of administration. As a drink, pure cold water 
should be given; the indication for wine or spirits is 
urgent only in cases that are subjected to this treatment 
late in their course. If the patient does not sleep, or 
sleeps badly, he is to have a draught of iced water, and 
the abdominal compress is to be changed every quarter 
of an hour. The discharges from the bowels are to be 
preserved for inspection, and the total quantity of urine 
may be collected in the same vessel. Neither age, sex, 
menstruation, pregnancy, nor sweating (except that 
which occurs at the end of defervesence) in any way 
modifies the treatment. In women who are weaning 
their children, cold compresses should be applied to the 
breasts and be frequently renewed. If diarrhea persists, 
it is to be combated by cold compresses, which may be 
kept cold by the aid of a bladder of ice. If there is con- 
stipation, it is to be treated by cold enemata, and, if these 
fail, by enemata consisting of one part of cold water and 
one part of fresh ox-gall. 
" When the temperature before the bath is very high, 
or if the fall forty-five minutes after the bath is less than 10 
J.8° F. (i° C.), the bath must be prolonged to eighteen 
or twenty minutes. It is very rarely necessary to modify 
the general formula. After the temperature does not 
exceed 109 20 F. (390 C.), but yet reaches 101.30 F. (38.5° 
C.), it is necessary to treat these slight exacerbations by 
baths of 68° F. (200 C.)( and of five minutes' duration, in 
order to prevent the prolongation of the fever or the 
occurrence of relapse, and to shorten convalescence. If 
relapse occurs, it must be treated according to the gen- 
eral formula. When the temperature no longer exceeds 
101.30 F. (38.50 C.), defervescence being established, the 
baths are discontinued, and the patient should be treated 
as convalescent, but is to be kept in bed until the tem- 
perature has not exceeded 100.40 F. (38° C.) for four days. 
He may then rise and in a short time walk in the open 
air; he may prolong his promenades according to his 
strength, and one will be struck by the rapidity with 
which his strength increases after every outing. Proper 
precautions are to be taken against cold As to alimenta- 
tion, already during defervescence there may be added 
to his soup, milk, or bouillon, either one or two raw eggs 
daily, or, a little later, one or two teaspoonfuls of scraped 
raw meat or a little toasted bread or biscuit; but the 
aliment must always be given in liquid form. 
" The regime of the convalescence should be gradually 
established, and may consist of solid food after the tem- 
perature has not risen above 100.40 F. (38° C.) for four 
days.1 At this period the intervals between the feedings 
should be at first three hours during the day; afterward 
one regular meal daily may be given ; and a little later 
the patient may have roast beef and fish, morning and 
evening, and bread in small quantities. The appetite is 
excellent, and it is necessary to control it. For the first 
two days of the convalescence the temperature is to be 
taken as before; after that, for a week, morning and 
evening. At the end of that time temperature observa- 
tions may be discontinued. 
" During the treatment by baths, one attendant is 
required for the day and one for the night; these duties 
may be fulfilled by members of the family. In a hos- 
pital one bath-tub may be used for a dozen patients, 
but it is better to use one for six patients. Two attend- 
ants are sufficient for twelve patients. It is not neces- 
sary to renew the water of the bath every three hours; 
once in twenty-four hours is sufficient. The patient 
treated from the beginning in this manner never suffers 
from fecal incontinence. As a rule, the patient should 
pass his water before entering the bath. During epi- 
demics the water of the bath, if it is not soiled, should 
1 Better not until the evening temperature has not risen above 
normal, say 99 5°, for a week. The unstable temperature of con- 
valescence deprives transitory rises to 100.40 or thereabouts of any 
great significance.-J. C. W. 11 
serve for several patients, and should only be renewed 
two or three times a day." 
This is the line of treatment to which, rigorously car- 
ried out, the extraordinary results which I have indicated 
are ascribed. That it seems heroic, thus briefly stated, 
cannot be denied. That it is heroic to those who see it 
practised for the first time is more than true. Precon- 
ceived notions in regard to the management of typhoid 
cases are violated. The frequent disturbance for the 
purpose of taking temperatures and bathing, the fact 
that the patients are compelled to rise from their bed, and 
with the aid of the attendants, to step into the bath, the 
pallor, shivering, and the blueness of the extremities 
which show themselves during the course of the bath, 
and continue for a varying time after the patient is put to 
bed, demand conviction on the part of the physician, 
and the courage of conviction to continue. 
It is only when the favorable effect upon the condition 
of the patient is seen, and when we reflect that in every 
hundred cases at least ten lives, which would be lost 
under the expectant-symptomatic treatment, are saved by 
strict cold bathing, that we dare to proceed. 
What is the effect upon the course of the disease in 
cases treated from the beginning ; that is, before the fifth 
day ? Brand declares that the classical picture of typhoid 
fever is no longer seen. It may be objected to this that 
we do not get our cases before the fifth day; and even 
if they come under observation so early a positive diag- 
nosis cannot always be made at that time. Only in 
garrison life and in epidemics will a treatment so radical 
be justifiable at the onset of a vague febrile disease. 
But Brand's statement is true of cases in which treat- 
ment is instituted at a later period, even so late as the 
middle of the second week. After six or eight baths the 
familiar picture is no longer seen. Delirium ceases, 
stupor gives way to light somnolence, from which the 
patient is easily aroused with a bright expression and a 
clear mind. The tongue becomes moist and clean, and 
remains so. There is desire for food, and very com- 
monly a complaint of hunger. The abdomen is not 
tympanitic. Diarrhea is rarely excessive or troublesome. 
In short, there remains, in the words of Brand, of the 
ordinary picture of typhoid nothing more than («) a 
moderate fever, (<5) an unimportant bronchial catarrh, (c) 
enlargement of the spleen, (d) the rose rash, and (e) in- 
filtration of the intestinal glands. Everything else is 
prevented, and what might have been a severe case runs 
its course as a mild one if the patients are brought under 
treatment sufficiently early. Exceptions to this state- 
ment occur only when complications develop at the 
onset. There are rapid wasting and progressive anemia, 
as in all prolonged febrile diseases, but severe enteric 
fever is changed to mild, the mild to a still milder form. 12 
This is brought about through the control of the tem- 
perature and by preventing disturbances of normal 
functions. The treatment is directed against the typhoid 
process as an entirety. 
It does, it is true, not only reduce the temperature; 
the repetition of the bath also controls the temperature 
and keeps it down. But the bath does much more than 
this. It acts upon the nervous system in such a manner 
as to enable it to withstand the toxic influences of the 
infecting principle and the product of its evolution. 
This it doubtless does by the action of cold water upon 
the peripheral nerve-endings, a reflex stimulus being 
transmitted to the nerve-centers presiding over the circu- 
lation, respiration, digestion, excretion, and nutrition. 
This general reinforcement of function is shown by im- 
proved action of the heart, the first sound continuing 
distinct, the pulse being slower and more regular, and 
the improvement in the arterial tension showing itself 
by an absence of dicrotism; by persistence of appetite 
and digestive power, permitting freer alimentation with- 
out gastric disturbances; by deepening and slowing of 
the respiration; and by the absence of nervous symp- 
toms, the increased excretion, the prevention of compli- 
cations, and the rapid convalescence. 
As was pointed out by Jurgensen, every attempt to 
deviate from the routine treatment as above laid down 
is followed by less satisfactory results. The treatment 
thus stands by itself as a definite procedure, to be dis- 
tinguished from treatment by graduated baths, the cold 
pack, cold affusions, spraying, and other hydro-thera- 
peutic measures. It is especially to be looked upon as 
something distinct and different from the antipyretic 
treatment. Upon this Brand and his followers insist.