The hydriatic treatment of typhoid fever, according to Brand, Tripier and Bouveret, and Vogl

Front matter

tme:

HYDRIATIC TREATMENT

OF

Chapter I. Why are we justified in employing the cool baths in the treatment of Tjhoid Fever 12

Results obtained : Muenich 15

Stettin 25

German Army 31

France (Lyons) 34

Practice amongst children 48

Gross results 49

Perfect execution of the method 54

Is the method dangerous ? , 59

The pleasant and unpleasant features of

the method, 61

Resume of Chapter I. 03

Chapter II. The influence on the difierent

organs, functions and symptoms 65

Influence on temperature 66

Circulatory organs 82

Aespiratory organs 92

Digestive organs 93

Urinary secretion 104

Skin 112

Nervous system 113

General course of the disease 120

Resume of Chapter II 124

ix

Chapter III. Indications and method 127 Tlie til lee indications 128

Execution of metho'l in uurnial cases ]40

The cold full bath 143

Cold compresses 147

Temperature of bath 148

Frequency' of baths 150

Duration of bath 154

Number of baths , 156

Thermometrical measurements 158

The luke-warm bath with cold affusions.. 101

Ziemssen's method 163

Execution of the method in special types

and conditions 164

Grave cases and cases of medium gravity 164

Mild forma 168

Afebrile forms 168

Children 169

Old people, 170

Pregnancy and m. nstruation, obesity,

')rganic heart-disease sweating... 171 The treatment of complications and of

cases that come under treatment

late, after T. <S: B 172

The treatment of the "degenerated'\cases

after Brand. 195

Diet, Hygiene and Medication 235

Resume of Chapter III 238

Chapter lY. Illustrative Cases 242

5 cases after T. & B 242

10 cases after Brand 265

Appendix A. Personal experience in tlie execution of the method 299

Introcliictioi\.

i3i i^D <in (3i

The purpose of this little volume is to induce and enable the medical profession of the United States to use the hydriatic method in the treatment of typhoid fever. I think that any one who should feel inclined to try the method, would feel the want of a book, which might enabhi him to become thoroughly familiar with the details of the method, to enter fully into the views of the masters of the art, to give him a rationale or at least a theory for its mode of action, to inform him about modifications necessary in special cases, to detail to him a number of typical, illustrative and unusual cases, and to state the results obtained by others. There are now in existence excellent books in other languages meeting such demands, the latest one by the French professors and physicians Tripier and Bouveret. Being convinced of the great value of the hydriatic method, and wishing the same to be employed amongst my countrymen, I inquired of six prominent medical publishers, whether they would be interested in the publication of the translation of a standard Avork on this subject. All six declined, stating that such a book would not find a market, one of the answers being the following : ''Dear Sir. — Replying to yours of the 12th inst., oJffering a translation of a work on the hydropathic treatment of typhoid fever, we have to say, that it does not seem to us that such a work would find a very receptive market. That form of treatment has been talked of and written on by many of our medical men ; but so far as we know it has not as yet been received with the enthusiasm which is necessary to warrant the publication of a work on the subject. Later on, perhaps, there may be a market for such a book."

While the answers from the publishers were discouraging, shovring the lack of interest in this question amongst the profession of the United States, they on the other hand were a source of stimulation, to fresh activity, inasmuch as they revealed the fact, that there was here a chance for missionary work in a field which promised many good results. I therefore concluded to publish at my own expense a little volume presenting such points, as I myself, when untertaking the use of the method, was desirous of having access to, and which would enable any one to undertake and begin using the method. Tripier and Bouveret have kindly allowed me to inake translations from their book and Dr. Brand has sent me from his library books otherwise difficult to obtain.

The volume then is essentially a compilation (1) from the work of Tripier and Bouveret, La fievre typho'ide traitee par les bains fr olds. Paris, Baillere et fils, 1886, the German translation of which by Dr. A. PoUak, {Tripier and Bouveret, Die Kaltwasserhehandlung des Typhus, Arnoldische Buchhandlung, Leipzig, 1889.) w^as used in the preparation of this work; (2) from Brand, Die Wasserbehandhmg der typhdsen Fieber, 2, Auflage, Tuebingen 1877, Lauppsche Buchhandlung, (3) from the writings of Vogl the most important of which have been published in the Deutsche Archiv fiir klin. Medicin, Bd. 36, 37, 43, 44 and in other journals. It would of course have been just as easy a task, if not easier, to use my own words in reporting the work of others, but those, who should feel inclined to use the book as a guide, will undoubtedly do it with more confidence, if they can read the ipsissima verba of masters in the art, and I hope this fact will not detract from the value and usefulness of the book. Undoubtedly there are other men more competent for this task. But w^hen the Priest and the Levite pass by, without noticing a good thing along the roadside, the Samaritan may be excused for taking hold of the case. In ray opinion a book of the kind I present here, should have been made accessible to the medical profession of this country ten years ago, because Brand's second edition was published in 1877, and this book gave the results of over 8000 cases, the observations having been carried on over a number of years and by numerous competent observers, clinicians and private practitioners, civil and military physicians, the reports of all these observers speaking in favor of the method.

I myself had expected that such an authority, as the American System would at least have given an account of the method of Brand. It is true the article on enteric fever speaks of cold water in discussing the treatment. It is spoken of however as a remedy ajDplicable when typhoid fever assumes a severe form as a kind of dernier resort, while Brand says that it is used and must be used &e/o7'e the disease has assumed a severe type, and that Avhen it has reached that stage, the best chance for cold water to do good and produce its legitimate effects has passed by. ' 'One of the first symptoms to demand attention," the article continues, ''is the high temperature." But Brand advises the use of water just as well in the hypothermic forms, and where the tem2^eratures are not excessive, and in his first edition on the hydriatic treatment of typhoid fever, lie mentions inthe /fr,"?^ })lace those "stimiihiting' ' qualities of the cool bath, by virtue of which all the favorable changes in the digestive, circulatory, nervous, etc. organs are brought about. Further, the article says that the hydriatic method depends for its efficacy upon its power of abstracting heat from the body and is useful just in proportion as it does this and that, and there is no reason for believing that it has the power to modify the conditions, upon which the production of heat depends, while Vogi and others have shown that even before the maximum temperatures show a decided decrease, there is a permanent amelioration of many or most of the symptoms, and that a steady and sure redujction of the maximum temperature from day to day can be brought about, this fact showing that the treatment has indeed a power to modify the disturbed heat-regulating organs and not merely to relieve the organism for a short time of the high temperature. Finally Liebermeister is mentioned as the guide and authority for the application of the method, but Brand says: '^I am sorry to say, that I have to part company with Liebermeister, Hagenbach, Ziemssen and others, men towards whom I entertain the deepest feeling of gratitude and the highest respect. All of these men do not carry out the water-treatment systematically, as is generally taken for granted ; they use a treatment into which both the antipyretics and water enter and they have for their way of treatment different indications from those of the systematic water-treatment."

I must jDrotest then against the notion, that in the American system the hydriatic treatment of enteric feyer is jDresented and explained in an adequate way ; its commendation is so halfhearted, that I think I remain within the province of truth when I say, that on the strength of the treatment it has receiyed there, next to nobody will haye made use of it. And then if one reads the objections mentioned on page 328, one certainly feels as though the method was mentioned with the purpose of adyising others to let it alone rather than to employ it !

I cannot refrain from quoting a few lines more, to show how little the writer of the article has entered into the spirit of the method. ''I am indisposed," he says, to haye recourse to it (the cold bath) except in cases of hyperpyrexia of such intensity, that death seems imminent and only to be averted by energetic treatment, or in cases in which other antipyretic remedies have failed to reduce the temperature, and for the following reasons: 1. In the first place it is generally possible to produce a decided effect by the other methods of aj^plying the cold water treatment with much less discomfort to the patient. 2. In a private house it is not always practicable to liave a l^ath brouglit to the bedside of the patient, and in a general hospital to do so would occasion a good deal of annoyance to the other patients in the same ward, and I have seen ill results from carrying him some distance to the bath room. But even where the bath is brought directly to the bedside, it involves so much movement and is sometimes the cause of so much excitement, that its good effects are more than neutralized by its bad."

I think he, who will study the writings of men who have had much experience in the use of the cool baths, or he, who will try the method himself faithfully, will support me in my statement. If one should in describing the antiseptic method of treating wounds, fail to speak about cleaning the field of the operation, say nothing about clean sponges and instruments, if he should allow the wound to be plastered up as in old times, and only then, if the wound were surrounded by phlegmonous inflammation and the patient suffered from high fever, advise the opening of the wound and washing the same with antiseptics, — he would do as much justice to Lister as the American System has done to Brand. To my mind it is certain that such a presentation of this important method has done very little or nothing to propagate the use of the cold bath treatment in the United States.

The profession then lacking a convenient book illustrating the method, I have not considered it out of place to issue this little volume, especially if it is true what H. C. Wood says: have no doubt that very many persons have died in the United States of typhoid fever whose lives would have been saved (by Brand's method),, if the American medical profession had risen above the opposition of the laity and above its own prejudices."

How many then do die? In the census of 1880 Dr. Billings gives the number of deaths from enteric fever as over 22,000. Xow it has been found, that where the method has been, carried out Avithout any claims to great accuracy the mortality has been reduced 33 per cent, and where it has been carried out systematically the rate has been reduced 66 per cent, and where the j^hysicians had the aid of the public (by their reporting early and following the directions closely) the rate has been reduced 90 per cent and more. Using the lowest figures it may besaid that 7000 lives might be saved (not to speak about the comfort to many more thousands) in the United States per year. Here in Cleveland we lost from typhoid fever 180 persons in each of the last two years, and in the fcAv years that I have been connected with a medical school here, four students and one recent graduate have died from tlie disease. A further incitement to use all means at our command is the fact that persons in the best years of life are the victims and that the treatment will restore the patients to full health and vigor.

It is my hope then, that a good many lives will be saved if this litUe book will be read and the advice it gives, followed. May it be the fore-runner of a larger and more comprehensive publication ''later on," e. g. a translation of the work of Tripier and Bouveret to which I would refer 'the reader, who wishes more thorough in^ formation. Brand's work mentioned is out of print. It is to be regretted, for it would be read with pleasure on account of its freshness. Vogl's writings let us hope will be published sometime^ if for no other reason than to show how all ob-^ servers who employ the method, reach the same results.

Dr. Brand the author of the method is in private practice in Stettin, and his example ought to be sufficient to show that the methocl can be carried out in private practice, and that here m the very best field for its operation. Tripier and Bouveret are professors in the medical school of Lyons, France, and their book is based upon the study of 233 cases. Vogl is Oberstabsarzt in Munich and has been using the method for over 15 years in a most thorough manner ])articularly amongst soldiers.

The book consists of 4 chapters, and appendix A. In the I. chapter the results that have been obtained so far with the hydriatic method are presented. In the II. chapter the effects of the treatment on the various functions, organs and symptons, as the temperature, nervous, circulatory system are given, thus furnishing a rationale for the statistics. In this chapter Vogl as well as Tripier and Bouveret are allowed to speak on the same subject and their uniform experience will, I hope, not fail to make an impression on the reader. In the III. chapter the indications are given and the method is described; here Brand and T. and B. have been followed verbatim for the most part. Lack of space did not allow me to follow this method, when treating of the special conditions. ChapterlV. contains the histories of a number of cases, £ve after T. and B. and the rest after Brand. T. and B. have in their work described the treatment from beginning to end in a supposed ease, to illustrate the execution of the same. I think a careful study of these actual cases, where every measurement and every bath is reported, will answer the same purpose and will give a very accurate idea of the execution of the method. These cases have been selected to show a variety of forms, complications and difficulties and I hope this selection of cases may be useful in practice. lu appendix A I have allowed myself to add a few words on my own observations and to present a few reflections derived therefrom .

Chapter I

Why are we justified in employing the Brand method or cool baths in the treatment of typhoid fever ?

If we stop to ask ourselves why we employ certain remedies or follow certain lines of treatment, Ave have I think on the Avhole two answers to give: and these may be best given by using illustrations. Thus if I were asked why I use quinine in malarial attacks I should say, not because I have any theory as to how quinine acts, or any very definite knowledge of the cause of the malarial attacks, but because the giving of quinine has in so many cases been followed by amelioration of the disease, that I cannot any more believe that we have hei^ a simple pod hoc; it would be too improbable. If I were however asked why I give milk and alkalies in ulcer of the stomach, nutritive enemeta, prohibit the use of food, and prescribe opium, Ishould say that from their physiological action on the several conditions prevalent, I would expect ^ome good (more or less) certainly to accrue to my patient from the remedial agents, and in many cases a healing of the ulcer. As a matter of fact and not much to the credit of rational medicine, just for those very remedies and lines of treatment which are the most certain, useful and reliable we have either none or very insufficient reasons and in fact nothing but the post hoc, but a post of such a formidable nature that it equals a propter. Now in my opinion we can give for the employment of the cold water treatment both kinds of answers, we can say that under its use the mortality has been decreased so often and with such regularity, that we cannot any longer close our eyes and ears to this recurring coincidence, and in the second place the employment of the cool bath has such a favorable influence on the special symptons and the functions of the different organs, that it cannot be otherwise than that the final result must be influenced for good by its employment.

While the second chapter of the book treating of the influence of water on the special symptons and on the course of the disease will thus also be answer to the above question heading this chapter, — this I. chapter will be devoted principally to statistics showing what results have been obtained under the Brand treatment.

The American, or in fact any other physician, has in my opinion no difficult task to make up his mind as to the value of this method, in as much as it has been on trial now for thirty years. In 1861 Brand, who has put the method on an accurate or scientific basis, giving method and indications and very good provisional theories for its use, published his first work on this subject. At that time one certainly might have hesitated, as long as there was merely the testimony of the author of the method, upon which to base ones judgment, — because originators of new lines of treatment are apt to be so enthusiastic over their intellectual child, that they cannot see its faults and weaknesses, but at present the number of those having given the method an impartial trial has been so large, the time, 30 years, during which the method has been exposed to criticism and trial so long, that we should have no difiiculty in coming to some conclusion as to its value. In this first chapter then I shall give the statistics of typhoid fever as influenced by the water-treatment :

(1) of the military hospital of Munich.

(2) of the military hospital of Stettin and the II. German army corjDS, Stettin being the headquarters of the same.

(3) the results observed in the German army, comparing its mortality with other armies.

(4) the experience of French observers.

(5) the experience which the hydriatic method had amongst children.

(6) the gross available results of the method, comparing it with gross results of treatment in different hospitals and countries, other than hydriatic.

(7) the experience of those men, who have carried out the method in the most thorough and systematic manner and who were so situated and inclined to treat their cases from the very beginning of the sickness, thus showing what the method can do under the most favorable circumstances.

In 1885 Vogl published in the Deutsche Archiv fuer klinische Medicin, Vol. 36 an article entitled: Typhus TJierapie im Muenchener Garnisonlazareth containing the statistics from 1841 to 1882 ; it contains the number of cases treated, the morbidity per thousand, the mortality per thousand as well as the percentage of deaths. I give this as table ^o. 1 in a condensed form.

Table I.

Showing Xo. of eases of typhoid fever in military hospital of Munich from 1841 to 1882 with No. of deaths, percentage of deaths rate of morbidity and mortality per 1000.

'3

35.8

45.1

16.0

. 18.4

,28.3

5.2

38.9

8.6

9 I I

23.2

44.6

,, ,. 10.4

16.6

20.5

71.0

27.9

11.6

5 6

(6/

18.1

32.0

5.0

13.8

16.6

37.1

39.1

5.0

6.3

,,783

6.4

6.8

29.3

6.8

0.5

Yogi divided it into two periods.

A. the time before the cold water treatment 1841—1868. 5484cases— 1138 deaths.— 20. 7 per cent mortality.

B. the time after the introduction of the cold water treatment 1868 — 1882. 2841 cases, 348 deaths. — 12.2 per cent mortality. Difference -8.5 per cent mortality.

The treatment during the first period (A) w^as exclusively by medicine (cathartics, emetics) -and bloodletting in the first years, Avhile in the last years from the beginning of the fifties it was antipyretic and stimulating: (juinine, wine, baths.

Tlie treatment during the period resembled in its beginning for the most part that of the, latter part of A, the baths being exhibited rather sparsely. Only since the middle part of the seventies cold water was used more extensively, partly combined with quinine, salicylate of soda, partly however the Brand method was carried out systematically. 132 lives were saved."

Inasmuch as there may be prevalent in the minds of many the notion that if there are a great number of cases of a disease, there will be also a high percentage of deaths, it will be worth while to call attention to the figures in this table which show that in 1856 — 59 when an epidemic was prevailing and the morbidity was a very high one, the percentage of deaths to the number of cases was very low. Objections have been made to assigning the very low mortality prevailing under hydriatic treatment to this method by calling attention to the fact, that the disease has become rarer and consequently milder, but this table shows that such an argument is not sound; there is no correspondence between morbidity and the benign character of the disease .

Here I should like to say a few words on the great scientific value of statistics obtained in military hospitals. In the first place the mortality from tyyhoid fever amongst soldiers is naturally a high one (Brand) being as high as we find it in persons of more advanced years of life.

A low percentage of deaths to the number 2 of cases treated ^vill thus he of a good deal of significance. Further we all know that one of the many difficulties in forming an opinion of the value of any therapeutic measure is that the material which is subjected to the same treatment by different observers and in different periods of time — is not of the same character^ thus always opening the door to the legitimate doubt whether any given result depends more on the character of the material (the patients) than on the nature of the remedy. Xow in the case of soldiers we have persons of the same age. all of good constitution, of the same occupation, the same mode of living, diet, the source of infec-^ tion (in any single period) being also the same. We can therefore in this case with more accurac}^ compare different years, and on the other hand any method has a better chance to be carried out systematically because the soldiers being under medical supervision come under treatment early and on account of the spirit of discipline prevailing amongst them such a method especially as the hydriatic will be more apt to be carried out thoroughly. Hence the great value of sta^ tistics amongst soldiers.

But the value of the hydriatic treatment becomes more apparent by a further analysis of the facts. I shall quote Vogl himself ; he says: '"In the military hospitals at Munich the rate of mortality in the period B, after introduction of the cold water treatment was, (as remarked above) 12.6 per cent, 8.5 per cent less than in period A. This proportion cannot be satisfactory to any one, who knows by experience the efficiency and power for good of the water treatment. The figures here do not represent the rate of mortality under a systematic application of the hydriatic method: an average rate of 12.6 per cent must be brought about by high figures obtained under some other method; this is indeed the case, inasmuch as during the earlier period a case now and then only was subjected to Brand's treatment. It will therefore be of importance to isolate a series of cases which have been treated strictly and methodically, and to place them opposite, and compare them with a number of cases treated differently. The arrangement in the military hospital in which the medical cases are treated in two stations makes such a comparison possible. In these two stations the house physicians are replaced by new ones on October 15th of each year, and the patients are distributed in such a way that one is taken to Station I. and the other to Station II.; in both stations they have the same wards, frame pavillions and nursing, so that we have here material for comparison so much alike in regard to time, locality and individuals — as perfect as one could possibly desire. Different results in the number and completeness of recovery can therefore be reduced by different forms of treatment only. Although the (hydriatic) method of treatment had been in vogue here since 1869 it was more of an experiment, of the results of which no reports exist which can be utilized for our purpose. It is only since 1876 — 77 that accurate histories of cases are in existence describing the treatment in the different stations and the different years. Since then tyj^hoid fever cases were treated with cold water in both stations, with a difference in the energy and thoroughness of the execution of the method. Hence it seems in place to divide the whole material into two great groups, accordingly as the treatment was (A) a strictly methodical one, according to Brand: a bath of 12°— 14° R., of 15 minutes duration, when the body temperature reached 39° C. measured in the rectum; without any medication — place of treatment, hospital pavilions only, or (B) one deviating more or less from the formula of Brand, both in respect to intensity and duration of the abstraction of heat , combined with the exhibition of antipyretic remedies, place of treatment in pavilions during the summer only . ' '

''In making such a division we cannot make comparisons between the cold water treatment on the one hand and expectative or medicinal treatment on the other hand 5 but only between a perfect and an imperfect method of abstraction of heat, a circumstance which increases the precision (Schaerfe) of the comparison.

"The relation between therapeutics and mortality can be laid down in a few theses:

1. Almost in every year the therapeutic results in the two stations differ; being two, three and four times better in one than in the other.

2. In spite of the greatly lessened mortality in toto in comparison with the former years, we find here the rate of mortality as high as 10.8 — 18.8, as high as in more than half of the years of the period of 1841—1868.

3. This equality with the results of former years we find on the side of the combined method of treatment only.

4. The strict and systematic hydriatic method with an average of 2.7 per cent never exceeds (even in years with many cases of typhoid fever) the rate of mortality of 4.7 per cent, a figure to which the rate never sank in the years from 1841 to 1868.

5 . The combined hydriatic method occupies a place between the results of a former method of treatment and the strict method of late years, never reaching the highest figures of the former, 30 per cent, and never sinking to the lowest figures of the latter, 0. per cent. This method approaches in its results more the older than the method of to-day.

6. The total decrease of the mortality rate in the military hospital in 1876 — 1882 compared with the period from 1841 to 1875 is brought about principally by the reduced rate of the strictly systematic cold water treatment.

A further explanation of these figures, the language of which one cannot designate as ^'enthusiasm" I consider unnecessary.

Table II.

Showing No. of cases and rate of mortality in the military hospital of Munich from 1875 to 1882.

1875—76

1876— 77

1877— 78

1878 -79 1879—80

1880— 81

1881— 82 o

...76 ,..66 .194 .141

...0 ...7 .14 .12 ...3

...3 ...1 ...2

3.5

3.8

6.1

15.2

10.8

3.9

18.8

4.0

9.1

4.7

15.8 Combined .

. 6.7:Combined.

Combined .

Combined .

Pnre

Combined .

Combined .

Combined .

Pure

Combined .

Pure

Combined .

Pure

The combined method has 767 cases, 59 deaths, 7.6 per cent mortality.

The pure method has 221 cases, 6 deaths. 2.7 per cent mortality."

In 1889 Vogl published another essay on the same topic; here we read: ^^I am able to add to these favorable results those of the years following. AVe have not exceeded (with the exception of a few tenths in 1885 — 1886 )

the rate of 4.7.

We had in —

1882 — 83 a mortality rate of 2.9 per cent.

1883— 84 " 0.0