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reappearance in the treatment of typhoid fever it is the same which M. Glénard recommends. But in these latter years our conceptions of fever are singularly modified, and the water treatment of pyrexias-especially of typhoid fever-has shared in that progress. It is this last phase into which the question that occupies us has entered.
The febrile elevation of temperature can only be due to two causes; either a diminution of the waste of heat, production remaining the same; or else an increased production of heat, the sources of waste remaining unaltered. The first of these views is maintained by Traube, the second by the majority of observers, who support it especially by reference to the increase, during the febrile act, of the excretion of urea and carbonic acid, which is an indisputable proof of a positive augmentation of organic combustion. Quite recently, in a memoir containing laborious researches on the inner significance of febrile phenomena, Senator1 arrived at a mixed conclusion, which unites the two views; according to him, the febrile heat is due at once to increase of combustion and to retention of caloric.
I propound these theories to you only in order better to prepare your mind for appreciating the treatment. Whatever may be the fate of the doctrines which have just been laid before you, the therapeutic indication in these cases appears to be a simple one; to increase the loss of heat by plunging the patient into a cooler medium with which he will tend to equalise his temperature. Bnt affairs are far from proceeding with such simplicity; man, like all warm-blooded animals, enjoys the privilege of striving against the sources of heatwaste, in virtue of what is called the heat-regulating power.
If we place a healthy person in a cold bath, the loss of heat will be moderated by a double mechanism. On the one hand the spasmodic contraction of the peripheral vessels, by diminishing the cutaneous circulation, repels the mass of the blood towards the deeper cavities, where it is better shielded from loss of heat by radiation. At the same time, the production of heat itself is notably increased, as it has been proved by the quantity of carbonic acid which is exhaled. It is thus not easy to reduce the internal temperature of a healthy person, con
1 Neue Untersuchungen über den fieberhaften Process. Berlin, 1873.
siderably, by a cold bath. We only produce a slight lowering, which is quickly compensated, and more than that, from the period known as that of reaction. It is only when the bath has been excessively prolonged or of a very low temperature that the cooling presents a certain intensity and duration, and it is then not free from danger.
As Liebermeister has pointed out, the conditions of regulation of temperature are the same in the fevered as in the healthy subject; and we may, like him, regard fever as a transitory but more or less enduring condition, during which the organism tends to maintain its equilibrium of temperature at a higher degree than the normal, at 39° C. (102°-2 F.) instead of 37° C. (98°-6 F.) The means by which the fevered organism lowers its temperature are the same as those employed by the healthy body; the resistance, however, is less energetic and less efficacious; in other terms, it is much more easy to lower the temperature by a degree or two in a fevered, than in a healthy man.
It is this, in fact, which favours the antipyretic action of hydrotherapy, and it is for want of taking heed of this capital difference between the normal and the febrile states that various authors have contended, on à priori grounds, against the employment of cold water in the treatment of pyrexias.
We see, then, that if cold water moderates fevers, it is not, perhaps, by moderating combustions (for it is proved, on the contrary, that it tends rather to increase them), but by hastening the departure, the waste, of caloric. Its action is thus diametrically opposed to that of alcohol, quinine, and other agents which directly attack and moderate the febrile combustion; its role is that of spoliation, not of economy of waste. In an absolute point of view, hydrotherapy, in whatever form, does not constitute an anti-febrile remedy in the rigorous sense of the word; it does not restrain combustion, it only masks and attenuates to some extent the consequences of combustion, especially the elevation of the temperature of the blood.
Fever does, in fact, betray its action on the economy by two results which are distinct, though closely allied; the rapid consumption of the tissues on the one hand, and the elevation of
temperature on the other. Each of these conditions has its own dangers, and consequently affords precise indications. In the slow, chronic fevers (hectics, in a word), the danger consists less in the elevation of the temperature than in the gradual and progressive deperishing of the organism; it has therefore never entered the mind of any physician to employ cold water in these cases, and thereby to render more active the very wasting which threatens the patient. On the contrary, that which constitutes the immediate and direct danger in pyrexias when the fever is more acute, so to speak, is not so much the exaggerated histolysis as the very fact of the febrile increase of heat; the delirium, the convulsions, the drowsiness, the tendency to syncope or asphyxia, the whole ensemble of ataxic and adynamic phenomena, is due, we can hardly permit ourselves to doubt, to the pernicious action of a superheated blood upon the nervous centres. In a position such as this, our duty before all things is to cool the blood by the rapid extraction of heat from it; an indication which hydrotherapy alone is capable of fulfilling.
As I have now endeavoured to throw some light for you upon this question, it remains for me to describe to you the mode of treatment which I employed for our patients, and the way in which I believe it is best to arrange the cold baths in the treatment of typhoid fever. Here are the cases :—
I. A young girl of 19 years, lying in No. 9, Salle St. Antoine. sion (Nov. 1) she presented all the symptoms of grave typhoid fever. then in the sixth day of the disease; the morning temperature was 40°2 C. (104° 3 F.); that of the day,1 40°.6 C. (105°1 F.) The pulse was 120 to 130. The adynamia was more distinct; the patient was deaf. The gaze was fixed, stupefied, the features sombre and concentrated; she answered questions drily, brusquely, and incoherently. There were subsultus tendinum and fibrillary muscular tremors. The tongue and the teeth were foul, the belly moderately tympanitic, gurgling in the iliac fossa. No rose-coloured spots.
In the first days of her stay in our wards she was submitted to the treatment which we habitually apply in cases of this nature (cool spongings, application of many  dry cups to the trunk and limbs, potion de Todd 100 grammes).
But we did not find any sensible amendment, and on Nov. 8 (fourteenth day of the disease) the weakness was more and more pronounced; she lay on her back, in extreme prostration, with continual sub-delirium. small and contracted, the breathing short, hurried, and facial.
1 Mid-day?-ED. Pract,
The pulse was
marked relative dulness at the bases of both lungs, and abundance of fine subcrepitant râles (hypostasis).
In presence of such a condition I thought of some more energetic measures; and I prescribed the use of cold baths. On the evening of the 9th the patient was placed in a bath of water at 20° C. (68° F.) She was kept in for about twelve minutes, when she began to shiver; she was then immediately taken out, rubbed briskly with a warm blanket, and replaced in bed.
Next day (the fifteenth) we found the patient in a veritable state of collapse. The temperature, which on the previous evening had been 40°6 C. (105°1 F.), was now 35°.8 C. (96°4 F.); the pulse was small, hardly perceptible, 140 a minute. Nevertheless we gave a bath of thirteen minutes' duration. Half an hour after the bath, the patient being warmer again, the axillary temperature was 38°4 C. instead of 35°.8 (a difference of nearly 5° F.) The pulse was also improved; it was firmer and slower (120).
From the date of this change that marked the beginning of the treatment, the latter was continued without any incident; it consisted of three baths daily of 20° C. (68° F.) temperature, and fifteen minutes' duration. After the 11th of Nov. the axillary temperature never exceeded 33°.2 C. (100°.8 F.); intelligence was completely restored, the sordes on the teeth disappeared, the tongue was moist, with only a thin covering of mucus. The numerous fine sub-crepitant râles that were heard before the treatment were replaced by fewer and coarser sounds; the hypostasis had almost entirely disappeared.
On the 17th we stopped the baths. Temperature normal, tongue moist and clean, appetite fairly good, intelligence perfect, convalescence frankly estab lished. The duration of the disease had been twenty-four days. [Here follows a chart of the pulse and temperature which shows the striking change produced by the baths, but which we are obliged to omit.-ED. Pract.]
II.-Marie C- aged 19, No. 25, Salle de Antoine, admitted Nov. 2, 1873. She is a robust nurse, who has lived in Paris for six months, ill for the last four days. Tongue white, with red edges. Diarrhoea, gurgling in the right iliac fossa, numerous rose spots, deafness. Countenance stupid; subsultus tendinum, agitated delirium, absolute mutism. The first eight days of her stay in hospital she was treated with simple cold spongings, and potion de Todd 100 grammes; the mean temperature was 40° C. (104° F.) in the evening, and 39° C. (102°·2 F.) in the morning. On Nov. 8 (eleventh day of disease) there was stiffness of the neck, deglutition was impossible, and there were very distinct cerebro-spinal phenomena. We prescribed cold baths of 20° C. (65°·5 F.), given in the same way as to the former patient, three times in every twenty-four hours. From that day forward the temperature fell and remained always at a moderate level, only once over 39o C. (102°-2 F.) Intelligence and speech returned gradually ; on the 20th (twenty-fourth day of the disease) the baths were stopped, the temperature was normal, and we began to feed the patient.
Assuredly we should not be in a position, on the mere authority of two cases, to pronounce definitely on the value of a treatment. Nevertheless, I determined to place these facts before you, because they are instructive in themselves; and for the rest, to establish their value, we can turn to the already very numerous documents which we meet with, on this subject, in medical literature.
In the mode of administering the baths I did not confine myself blindly to the (I had almost said) tyrannical orders of Brand. Each time that we gave a bath we did so because we thought it to be rendered necessary not by the exigencies of a programme laid down beforehand, but by some disquieting symptom-fever with temperature at or over 102°.2 F., delirium, collapse, &c. For the rest, the majority of the physicians who have adopted Brand's treatment-Bartels, Jürgendsen, Liebermeister, C. Schutzenberger, &c.-have not followed his empiric formula, and it is only very exceptionally that they have practised those frequent immersions which the Stettin physician recommends.
In a recent and interesting memoir, Wunderlich the younger describes the method in which the water treatment of typhoid fever is applied by his father in the hospital at Leipzig. There they do not give baths unless the morning temperature is at or over 39° C. (102°2 F.), and that of the evening at or over 40° C. (104° F.) The baths are at 18° or 20° C. (64° 4 or 68° F.); they last from fifteen to twenty minutes. If cerebral symptoms are early declared, Wunderlich employs baths even though the temperature be below 102°.2 F. An intense bronchitis or pneumonia is for him a primary and formal indication for hydrotherapic intervention. In our No. 9, we saw that a genuine hypostatic pneumonia existed, which disappeared very rapidly after the first immersions. Without doubt, the action of the cold stimulates the reflex activity of the pulmonary vessels, as it revives the cutaneous functions, and thus dissipates pain or congestions.
Brand allows of no contra-indication, unless it be that of intestinal perforation. Wunderlich is less absolute, and without refusing the benefits of hydrotherapy to patients who have attendant diarrhoea, albuminuria, heart-mischief, or pregnancy, he stipulates for a less energetic treatment, and the use of warmer and less prolonged baths. It is in these cases, I think, that we may usefully adopt the method of Ziemssen, which consists in placing the patient in a warm bath, the temperature of which is gradually lowered by adding cold water to it.
As a formal contra-indication, besides hæmorrhage and intestinal perforation, Wunderlich mentions collapse. As to the