I Do not intend to give you, to-day, a complete and didactic exposition of the different therapeutic indications which typhoid fever offers, and the measures of treatment that correspond to these indications. My chief object is to call your attention to a method of treatment, too little diffused among us, and which you have seen me apply to the patients in the Salle St. Antoine, whose disease I have just been studying with you. I wish to speak of the methodic use of cold plunge baths. I hasten to state that I do not partake of the exclusive enthusiasm which certain authors profess for this mode of treatment, nor do I recommend its universal and systematic employment. But I believe that we have here a real and efficacious progress, which I have made a point of exhibiting to you, and which I have it at heart to propagate and to popularise to the extent of my power.

The necessity of combating the symptom fever has for a long time past become a truth which is almost a childish truism.

1 From a clinical lecture delivered at the Hôtel-Dieu.

Bulletin de Thérapeutique.

NO. LXVIII.

Translated from the

G

The times are gone by in which, according to the old Hippocratic idea, the febrile movement was considered as an effort of nature destined to subdue or to eliminate the morbific principle, a salutary effort which the physician ought rather to favour than to oppose. We now know that this disorderly action is always dangerous and often fatal: dangerous by the exaggeration of internal oxidations and the rapid consumption which accompany the febrile movement: dangerous above all by the modifications of the blood which are produced by these excessive oxidations, which pour into the common medium organic débris which are often very abundant, and which are not sufficiently eliminated. But the elevation of temperature is the index and the result, if not the cause (or one of the causes) of this febrile state. We may hope, then, that the intensity and the consequences of the fever will be diminished by means which will reduce the temperature of the body.

But

if there be a malady in which the efforts of treatment should especially be addressed to the element fever, surely it is in the most obstinate and long-continued of our pyrexias—in typhoid fever.

It is about twelve years since I was one of the first to introduce into our country the employment of a valuable therapeutic agent in febrile affections. I speak of alcohol. This is not the time or place to speak of the internal action of this remedy. Does it diminish the combustion of the tissue by directly opposing itself to that process, just as, when in a certain degree of concentration, it hinders the continuation of alcoholic fermentation? I believe this, but it is of little consequence to us just now. An invariable fact is, that in sufficient dose it lowers the central temperature both in the normal and in the febrile states; it is therefore an antipyretic remedy. It is in this character, and not as a tonic, that you see me administer alcohol, in drinkable shape, to our febrile patients, often in considerable doses, under the euphemistic designation of potion de Todd. Observe carefully, however, that these doses are divided. Thus, you will prescribe 80 to 200 grammes (3 to 7 ounces) of brandy in 8 ounces of water with a drachm and a half of tincture of cannella and an ounce of syrup. You will give a tablespoonful of this every two hours, diluted with

three or four times as much water, if the patient finds the mixture too strong. This remedy, I repeat, gives good results; but I have no hesitation in saying that we are in possession of a much more energetic and habitually efficacious antipyretic remedy in the rational employment of cold water, of which I now wish to speak to you.

It was the English physician, James Currie, who first had recourse in a regular and scientific manner to the external employment of cold water in the pyrexias. The patient, in full fever, was placed in an empty tub, and several cans of water were poured over his head and trunk from a certain height. The method of Currie consisted, then, in the use of cold affusions more or less frequently repeated. The object which he proposed to himself was not to cause an abstraction of heat and a diminution of the internal temperature, but to obtain, by these smart and brief affusions with cold water, a consecutive excitement of the circulatory functions, or what is called reaction.1

There are a certain number of cases in which cold and sharp affusions are formally indicated: this is especially the case in adynamic conditions with profound intellectual torpor and a tendency to depression of the respiratory and circulatory functions. The affusions, by lashing, as it were, the activity of the nervous centres, dissipate, better than any other means, these conditions, which are allied rather to a defect of innervation than to febrile elevation of temperature. This is not the object which one attempts to gain in employing cold water according to the method which we are studying. In that method we propose, on the contrary, to abstract a certain quantity of the heat the augmentation of which is crushing the patient. To this end we employ cool water, more or less smartly applied. A first degree consists in cold washings of the entire body, repeated four or five times a day you saw me adopt this plan with the young girl in bed No. 8, Salle St. Antoine. In her, the affection of the bowel presented itself with an ensemble of moderate symptoms, and, on the whole, was but little formidable; above all, the fever kept at a reassuring level; the medium temperature was 39° C. (102°-2 F.) in the evening, and 38°5 C. (101°-5 F.) in the morning. There was thus no indication for an energetic anti1 This scarcely does Currie justice.-ED. Pract.

pyretic treatment, and we confined ourselves to giving 3 oz. of brandy, and using the cold spongings. We thus managed to keep the fever to its moderate type, and on the twentieth day the girl entered definitely the apyretic stage. I do not doubt that the cold spongings assisted this rapid and fortunate issue.

The man who restored to honour the treatment of the pyrexias, and especially of typhoid fever, by cold water, is a practitioner of Stettin, Ernest Brand. In 1861 he published the results of his treatment in a book entitled "Hydrotherapy of Typhus." This treatment constituted a true method in the rigorous and dogmatic acceptation of the word. In a recent publication M. Franz Glénard has expounded the system of the Stettin physician with talent, and has related observations on thirteen patients treated' at the Hôpital de la Croix-Rousse rigorously and in the spirit of the method. Liebermeister, in speaking of Brand's book, while acknowledging the decisive impulse which it has given to the therapeutics of febrile affections, regrets to find in it a too ardent and enthusiastic proselytism. We might pass the same criticism on the memoir, otherwise very interesting, by M. Glénard. We may say, in passing, that one can easily understand the enthusiasm of M. Glénard. The method, as you will see, offers great advantages; but, besides this, M. Brand has a right to the respectful gratitude of everyone in our country of France.1

This treatment of Brand's consists in the regular and systematic administration of cool baths (20° C. or 68° F.), with or without the affusion of cold water upon the head. The regular duration of each bath is fifteen minutes, even when shivering occurs quite at the commencement.

It requires a certain energy on the part of the physician to apply this method, considering the pitiable condition which the patient presents in some cases. On coming out of the bath the patient is enveloped in a woollen wrapper, and immediately covered with clothes.

On the average it is necessary to give at least eight baths in the twenty-four hours (a bath every three hours, night as well as day). According to Brand it is an error of the gravest kind

1 A few expressions of strong and painful feeling, growing out of the events of the war, are here omitted.-ED. Pract.

to wait till the temperature reaches a serious elevation; he says that we should prevent the rise of heat, and not wait to combat it. He denies that there is any efficacy in "those hybrid methods which give one or two baths a day, and which are nothing but a cruelty to the patient."

We see by these quotations that Brand is inspired with all the intolerances of a systematiser. In fact, the treatment by baths, one after the other, is, in his mind, not only directed against the symptom fever, but also against the essence of the morbid process; in a word, it is, what the author calls it, a specific treatment. It is evident that a treatment thus rigorously and mathematically formulated must rest upon a theory; that of Brand is the following. In agreement, so far, with recent mycological researches, he attributes the typhoid process to an internal fermentation, azymosis. But, says he, if we mix a solution of malt with a proper quantity of beer-yeast at a temperature of 16° C. (59° F.), we get a tumultuous fermentation producing alcohol after a determinate period of three days. If, then, we cool the mixture, which has risen to 35° C. (95° F.), below 16° C., the fermentation will cease; on the contrary, it will reappear if the temperature rises again. Brand, in view of these observations, supposes that the typhoid ferment, also, cannot develop and act except at a certain temperature, and hydrotherapy renders it powerless and arrests its production by incessant cooling of the blood.

I need not point out to you how much of the arbitrary there is in this theory; but it was important to direct attention to it, for it shows well what is the essential indication which Brand thinks that he fulfils by his treatment. What he seeks to obtain by this pitiless series of immersions is not only the lowering of temperature; his views are higher than this; he wishes to reach the very source of the evil; he aims at arresting in this manner the morbid fermentation which is the point of departure of the disease.

Hence the rigid inflexibility in his prescriptions; one must be incessantly on one's guard and watch the ferment for fear it should begin to work again and cause us to lose all the benefit of the treatment at once.

Such is the method by which hydrotherapy has made its