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last, I cannot share this view, and I believe, on the contrary, that the plunge bath, and cold affusions, are one of the best agents that we possess for dissipating that tendency to paralysis of the vasculo-respiratory centres which is the primary cause of collapse. Our patient in No. 9 is a convincing example of this. On the morning of the fifteenth day she was threatened directly with collapse, the nose and extremities were cold, the axillary temperature was at 96°8 F., the pulse was thread-like and scarcely to be felt. Half an hour after the cold bath the patient had become warmer again, the pulse and temperature had risen, and all traces of collapse had disappeared.
In grave cases, of the pulmonary or intense cerebral form, Brand, Liebermeister, and Wunderlich recommend the application of iced compresses to the head and chest in the intervals of the baths.
Quite lately, some authors have endeavoured to perfect the machinery of refrigerant medication by proposing certain innovations which, to my thinking, are more ingenious than practical. Thus Senator, starting from the true observation that cold, by contracting the cutaneous vessels and anæmiating the skin, hinders the loss of heat, proposes the simultaneous employment of cold baths and of rubefacients to the skin. He says that he has had good results from applying numerous mustard-plasters to the surface of the chest and abdomen before the bath, plasters of such a kind that they can be left on when the patient is in the water. Lastly, of late a physician named Kemperdick has, in a case of typhoid fever, replaced the cold baths by injections of cold water into the rectum, by means of a catheter with a double current introduced a long way, and declares that in this way he succeeded in affecting the general temperature of the patient. It is doubtful whether such a practice offers sufficient advantages to compensate for the inconveniences which belong to it.
What are, definitely speaking, the advantages of this treatment, which have gained it so many fervent adepts, and which cause it, in certain countries-Germany for instance-to be employed to the exclusion of almost every other remedy? This is the final point for us to elucidate. A simple glance of the eye, cast upon our thermometric curves, will spare you, so to
speak, all commentary. You see that by means of a few baths administered in each twenty-four hours, we succeed in beating down and mastering a febrile movement which everything seemed to show would be violent and lasting. In satisfying this essential indication, the lowering of temperature, hydrotherapy weakens at the same stroke almost the whole group of the symptoms of typhoid pyrexia. The nervous centres are
the first and the most happily influenced; the delirium departs, the intellectual torpor is banished, the patient comes back to himself and interests himself in what surrounds him; at the same time the carphology, the subsultus tendinum, and all the other indices of profound nervous perturbation disappear. The respiratory centre also participates in this remarkable modification; the inspirations become deeper, slower, more powerful; hæmatosis is effected more completely, and the bronchi, resuming their contractility, expel the secretion which obstructs them. The skin resumes its tone and its suppleness; the blood, propelled by the heart in stronger and more regular waves, circulates more actively, and revives the stagnant secretions. Even the digestive canal presents a notable improvement, the tongue cleans and becomes moist, thirst subsides, and tympany diminishes.
Such is the detail of each important symptom: now let us address ourselves to that high criterion of every therapeutic method, the study of the mortality; we shall demonstrate an encouraging result. Brand declares that of 171 patients treated by his plan up to 1868, 170 were cured. According to him a fatal result cannot happen if the method be carried out rigorously. But it is proper to remark that Brand's figures have been made up mostly from practice in the towns, which is much more favourable than hospital practice. M. Glénard saw at Stettin, in 1870 and 1871, 89 patients all cured; and of 12 patients at Lyons, treated by M. Glénard himself, all were cured by the method of Brand.
Other authors, without obtaining such absolute success, have nevertheless proved the very remarkable efficacy of this method of treatment. We find, in the already quoted memoir of V. Wunderlich, the following statistical results:
In the Leipzig clinic there were treated without hydrotherapy,
from 1851 to 1867 (16 years), 1,178 cases of typhoid fever, with 213 deaths; i.e. a mortality of 18.1 per cent. From 1868 to 1872 there were treated, by cold baths, 251 cases with 18 deaths; i.e. a mortality of only 7.2 per cent.
Here, moreover, are other statistics from the same author, which are still more impressive :—
These figures appear to test the treatment well.
There remains one sole objection-the following: the cold, by forcing the blood towards the internal parts, may favour the production of intestinal hæmorrhages.
The statistics of the Leipzig clinic bear out this idea, in appearance at least. In fact, of 251 typhoid patients treated with cold water, 18 had intestinal hæmorrhage, or 7.1 per cent.; whereas, according to the tables of Louis, Griesinger, Ragaine, &c., with ordinary treatment hæmorrhage does not occur in more than 3 to 4 per cent. of the cases.
Wunderlich thinks that the Leipzig statistics are derived from too small a number of patients (251) to be decisive, and believes that we ought to consider the influence of series. He does not lay the blame of the greater frequency of hæmorrhage upon the baths, for these bleedings, in the 18 cases in which they were observed, were not produced immediately after immersion, but some hours, often half a day, afterwards, when the centripetal repulsion of the blood no longer existed. Finally, which is a fact of the highest importance, these cases of hæmorrhage were not serious, and the whole number ended in cure.
According to Wunderlich it would be precisely the employment of the baths which so singularly diminished the gravity of the complication in these cases. The patient, thanks to the treatment, is placed in such conditions that he bears these hæmorrhages much better, and they become, so to speak, innocuous. Thus, says he, if intestinal hemorrhages are made.
more frequent, their gravity is much diminished, by cold baths. But before accepting this dictum of Wunderlich, we must remember that I had occasion to point out to you that bleeding from the bowel in typhoid fever has not always the gravity which is usually ascribed to it, and that Graves, Trousseau, and myself had observed many cases in which hemorrhage terminated favourably. I shall not return to this point, which I have already studied in detail with you, but it is well to remember it when we are appreciating the dictum of Wunderlich.
The cases which you have witnessed in our wards, and in which cold water has been employed, have doubtless appeared to you significant in themselves; they were, as you observed, grave forms of disease, which gave us the most lively anxiety: their termination, so rapid and so fortunate, is evidence not only of the harmlessness, but of the power, of the treatment which we thought it our duty to employ. It will be objected, that the number of my cases is so small; agreed, but the statistics of others fill up this hiatus. There is always room for dispute respecting an indication which is based on the physiological action of a remedy; but figures are not so easily to be criticised. A therapeutic method which can show a mortality relatively so small ought to be universally applied; it is not so much a question of progress as of humanity. I shall therefore think myself very happy, gentlemen, if my voice find an echo among you, and if you consent to share my convictions and help to spread them. You have seen: say and repeat everywhere what you have seen; that will be the best and most honest propaganda that you can help me to make.
[The Editor feels that he need scarcely apologise for printing this most excellent lecture, instead of an "original" paper properly so called.]
THE BROMIDE QUESTION.
BY DR. J. WARBURTON BEGBIE.
EDINBURGH, Jan. 15, 1874. DEAR DR. ANSTIE,-I have read with much interest in the Practitioner for this month, your translation of the paper by Professor Binz, of Bonn, on "the therapeutic employment of bromide of potassium," and your own account of "the English stand-point respecting the value of bromide of potassium."
Were it not that you have inadvertently fallen into error in ascribing to me the authorship of the article on bromide of potassium which appeared in the Edinburgh Medical Journal for December 1866, I should not have troubled you with this letter. My appreciation of the value of bromide of potassium as a remedy in various diseases is, however, so high, that I am jealous of any testimony which has been borne to its therapeutic actions failing to exert the influence which such testimony justly possesses. Permit me therefore to state that the article in question was written by my father, the late Dr. Begbie, whose patient investigation of the virtues possessed by bromide of potassium and strong recommendation of its use did much to secure for it the confidence of the profession in this part of the country, and largely contributed to its general popularity.
Having made this correction, I am encouraged by the perusal of what you have written to add my testimony to the value of bromide of potassium in the treatment of various diseases. This I shall do in a categorical manner, in something of the same way as you have recently done.
1. Epilepsy. In this disease my experience of bromide of potassium entirely confirms the statements of Dr. Russell