HYDROTHERAPY IN TYPHOID FEVER. SIMON BARUCH, M.D., BY OP NEWYORK. FROM THE MEDICAL NEWS, April 2S, 1890. [Reprinted from The Medical News, April 25, 1896.] HYDROTHERAPY IN TYPHOID FEVER. SIMON BARUCH, M.D. OF NEW YORK. The Medical News of February 8, 1896, con- tains an article on this subject, which may mis- lead by its ad captandum arguments, and which it may therefore be profitable to analyze and dis- cuss in the interest of therapeutics. The author does not claim any practical experience with the Brand method, on the contrary, he “ confesses to a prejudice against the immersion treatment of typhoid fever. ” But he is correct in the state- ment that ‘ ‘ an overwhelming majority of the prof es- sion is against the method." Being convinced by earnest investigation for five years that “ the majority of the profession” is, as a rule, biased by the same ideas and prejudices, which pervade the article, and as a proper presentation of the latter may serve to dispel some of the mist that seems to envelop the ordinary conception of the rationale of hydrotherapy, it may be profitable and interesting to analyze this author’s views and conclusions, and extract their logical gist, without wearying the reader with polemics. The author starts out with the statements that, with rare exceptions, at “present all typhoid pa- tients in hospitals in this country are treated by immersion, and all the private patients by methods that are hydrotherapeutic only to the extent of cool sponging; and that, although most expressions of opinion heard in societies or read in journals, favor the Brand treatment, a secret ballot would show an overwhelming majority of the profession against this method. ” This may be true; but it is not reasonable to presume that men like “ Osier and other eminent clinicians, ” would “ enthusiastically indorse ” a method of treatment that has so little to commend it. These gentle- men mold the minds of the rising generation of physicians; they have large clinical material under the strict supervision of intelligent assistants, and they may therefore be accepted as reliable guides to the general practitioner. The cause of the overwhelming “secret ballot,” which would be cast against the Brand method by “practitioners in the small towns,” is not to be sought, as the author curiously enough claims, in their having “not only relatively, but absolutely better oppor- tunities for studying typhoid than city physicians;” but in the fact that they rarely have the oppor- tunity or the facilities for the bath treatment, and that they are generally prejudiced against it by reason of inexperience. That it is impossible to form a correct judgment of the comparative value of two methods of treatment unless both are practised under approximately similar condi- tions, goes without saying. Since 1889, only three outspoken opponents have been encountered besides this author, and the first of these has seen the error of his way. These gentlemen did not claim to have any personal experience with the method. They frankly ex- pressed a prejudice against it, just as the author has done. I would not impugn the sincerity of the 3 advocates on the adverse side, but I must protest against deductions not drawn from actual experi- ence. That one positive witness with experience is worth all the theoretical and sentimental nega- tions that may be marshaled will be conceded by the fair-minded reader. The author concludes from his observations that “bathing oftener than twice daily would produce depression in all but the most robust; that fifteen minutes is the proper limit of the bath; that boys often grow livid, and are en- feebled by bathing, etc.” The reader must de- cide for himself how far these conclusions may be accepted. Then he may be able to answer the author’s question. “ Can it be expected that the typhoid fever patient would receive all the bene- fit from immersion that a healthy person gains and be immune from the possible disadvan- tages ? The advocates of immersion practically answer this question in the affirmative,” says the author. This seems to be of slight moment, however, for he simply brushes it aside and pro- ceeds to make a comparison between the Brand bath and the swimming exploits of healthy persons from four to seventy years of age. He argues that the former must be injurious because “ it is as cold and as long-continued as the latter, and is repeated two to four times as often as that which a healthy swimmer of average vigor can endure without depression; the typhoid patient has not the benefit of exercise during or after the bath,” etc. “The fact that depression follows a course of bathing without obvious chilling (in the 4 healthy), is well established” in the author’s mind. Such is the drift of his argument. Even if the proposition regarding the depressing effects of a course of bathing in health, could receive acceptance, it would be illogical to apply observations made on boys (the majority of his sub- jects),who are apt to exhaust their reactive capac- ity by pranks, before, during, and after swimming under a hot sun, in the open air, and in water of 70 to Bo°, to fever patients, most of whom are adults, who are quietly placed into the tub, who are well rubbed by two attendants, who are in addition stimulated by brandy before the bath, and well dried and wrapped up after it. Such a compari- son needs but to be stated to be its own refuta- tion. Moreover, if there is anything positively established it is the tonic effect upon the heart of a Brand bath properly administered.- The pulse almost always becomes less compressible, less frequent, and loses its dicrotism; the respiration is deepened and slowed. All this was illus- trated on page 224 of the Medical News, February 22, 1896. The same nonchalance with which the author dismisses the denial of unfavorable effects of the Brand bath by the advocates of the latter, char- acterizes his denial of the value of the “magni- ficent accumulation of statistics.” He reminds the reader of the misleading character of num- bers, and of the tendency of advocates to doctor the returns in the interest of preconceived notions, etc. In his zeal for “ conservatism, ”he does not hesitate even to “doubt-the good faith of some 5 who practise immersion in hospitals, but who do not urge it upon their private patients.” That all this is written in lieu of actual evidence, is patent from the fact he frankly admits that “it is not possible at the present time to refute the case reports of hospital attendants, nor to show that the post hoc, ergo propter hoc fallacy has been com- mitted. ” That figures may mislead is doubtless true; but it happens that there are some statistics in typhoid fever that cannot mislead. These were not made by the originator of the Brand method, but by a man, occupying a high military position, Dr. A. Yogi, the chief of the medical staff at Munich. Without entering into details, this painstak- ing search of the records of forty years of a hos- pital governed by strict military discipline shows, that a reduction of mortality from an average of twenty per cent, under all kinds of treatment, and during epidemics of different intensities, to 2.7 per cent, under Brand baths. Dr. Yogi summarizes these excellent comparative statistics as follows: Cases. Treatment. Mortality. 5884 Expectant, 1841-78, 20.7 per cent. 2841 Expectant and bath combined, 1868-81, 12.2 per cent. 702 Strict cold baths and antipyretics, 1877-87, 7.6 per cent. 144 Strict cold baths and less antipyretics, 1882-89, 4.1 per cent. DIVISION 11. 428 Strict cold baths, 1880 2.7 per cent. DIVISION I. Excluding all other statistics these alone pro- tect the Brand method against carping criticism, unfounded skepticism, and baseless prejudice. By 6 these statistics carefully studied, I was convinced of the folly of my own prejudice; there cannot be a reasonable doubt cast upon a military record of eight thousand cases, prolonged through forty years. In the “ Uses of Water in Modern Medi- cine,” page 109, Volume 11, I have presented a table of comparative statistics which furnishes an instructive view of this whole question. To this may be added the following statistics, presented by the translator of my book in the German edition. Mortality. Jiirgenson, Tubingen, under expectant treatment, 22.1 percent. “ “ faulty bath treatment, 7.1 per cent. “ “ strict “ “ 1.8 per cent. Brand, Stettin, “ “ “ “ 3.5 per cent. Leichtenstein, Stettin, “ “ “ “ 5.4 per cent. Ratjen, Hamburg, “ “ “ “ 4.0 per cent. Drasche, Vienna, “ “ “ “ 9.3 per cent. Before “ “ “ “ 16.2 per cent. FROM GERMAN SOURCES. FROM FRENCH SOURCES. Tripier & Bouveret, Lyon, before bath treatment, 25.0 per cent. “ “ “ under “ “ 7.5 per cent. Richard, in 38 cases, “ “ “ 5.2 per cent. Jubel-Renoy, expectant treatment, 14.2 per cent. collective report under bath treatment, 7.3 per cent, own cases under strict bath, 4.7 per cent. Dr. Kelly, Philadelphia, before bath treatment, 17.0 per cent. after introduction of “ 4.5 per cent. Dr. Elliot, Philadelphia, before bath “ 24.0 per cent. after bath treatment, since 1891, 7.4 per cent. Dr. Thompson, New York, before bath treatment, 19.0 per cent. after “ “ 7.0 per cent. FROM AMERICAN SOURCES Among the remarkable italicized propositions submitted in the author’s article is No. 4: “The cold bath removes comparatively little excrementitious matter from the body, it checks the tendency to sweating and throws the flow 7 inward to organs already infiltrated or irritated by toxic principles.” This ex cathedra statement is not supported by any evidence furnished, either by the author’s observation or that of others. And it is directly contradicted by the exact experiments of Roque and Weil, who found that the urotoxic coefficient of the urine in patients suffering from typhoid fever is de- creased; that while the coal tar antipyretics still more diminish it, the cold bath, increases it very materially—threefold in some experiments. That the blood is not “ thrown inward ” as the author fears,1 is proved by the ruddy hue of the skin of the patient when emerging from a properly administered Brand bath. “In conclusion let me say that I am not writing to support a theory, nor to assail the advocates of an opposite theory, but to elicit the truth. lam open to correction and ready to acknowledge an error. ” These words of the author I heartily re-echo, for if any equally suc- cessful method of treating typhoid fever were de- vised, I would gladly abandon the justly unpopu- lar cold bath. Until this is done, it is our bounden duty to save lives by overcoming the prejudices and objections of its opponents. The enthusiastic advocacy of the Brand bath with which I am credited is not due to the recog- nition of its merits only. A large share is due to the fact of which Brand himself has jocularly re- minded me, viz.,that my prejudice against it found 1 A recent editorial in the Philadelphia Medical and Surgical Reporter, quoted in the Medical Record, reiterates this fallacy, •which cannot be too earnestly contradicted. 8 expression in the Academy of Medicine, where I said in 1887, “ The cold bath may be adapted to the German soldier, but it is too severe for the average American citizen.” Having myself been a doubting Thomas, and being convinced that I was in error, I am the more desirous of making amends. In conclusion it may be of interest to quote from a recent letter of Dr. A. Vogl, the medical director of the army at Munich, whose statistical records have been quoted above. Under date of the 20th of February, Dr. Vogl writes me: “I regret very much that the Brand method is not yet universally acknowledged, especially as none of the opponents have thoroughly tested it. We use it in the army whenever opportunity presents, with the best results, never over four per cent, mortality. Your recognition of its value is grati- fying. The adverse position of the profession toward hydrotherapy injures the respect for our science; it would not otherwise be possible that so crude a water quack as ‘Father Kneipp,’ could maintain his position. In many desperate cases this empiric has obtained successes, which cannot be denied, and in cases in which physicians had tried all medicinal agents, but not even a cold compress. ” In this country too, the medical profession will lose much vantage ground, if it continues to neglect hydrotherapy in chronic diseases, in which its effect is just as striking as in typhoid fever. How much more favorable the results would be if physicians would give attention to the rationale 9 and applications of water in the treatment of dis- ease, and not entrust it, as is but too frequently is done, to bath attendants and nurses, who possess only the most superficial, crude, and mechanical knowledge of the subject? Hydrotherapy should be applied in chronic diseases as it is in typhoid, under the frequent supervision of the medical attendant. The technic should be adapted to the condition of the patient and the indications of each case, which are liable to change, and which cannot be appreciated by bath attendants, no matter how familiar they may claim to be with the treatment. These water-cure establishments, not under skilled medical supervision, should be avoided. This may be the more readily done now, because several institutions exist in the city and are beginning to spring up in other medical centres, in which not alone the well-to-do, but also the poor may obtain a judicious hydrotherapy under supervision of physicians. The importance of an exact technic was emphasized in my paper before the Philadelphia County Medical Society, a report of which may be found in the Medical News of February 22, 1896. The Medical News. Established in 1843. A WEEKLY MEDICAL NEWSPAPER. Subscription, $4.00 per Annum. The American Jottrnal OF THE Medical Sciences, Established in 1820. A MONTHLY MEDICAL MAGAZINE. Subscription, $4.00 per Annum. COMMUTATION RATE, $7.50 PER ANNUM. LEA BROS. CO. NEW YORK AND PHILADELPHIA.