CHAPTER IX.
Of the Treatment of Fever.
We have seen that the first indication of disease in fever is traceable to the nervous system; that the nature of this primary affection of the nervous system is unknown; that it may possibly be the commencement of inflammation, modified by the nature of the nervous substance, in which the inflammatory action has its seat, and by the nature of the cause that excites it, namely, a peculiar poison: or, on the other hand, it may possibly be something distinct from inflammation, but having a peculiar tendency to excite it. In either case, the inflammation that is present in fever, is peculiar and specific, differing essentially from ordinary or simple inflammation. Whether the affection of the nervous system consist merely of inflammation of the nervous substance excited by a peculiar poison; or whether it consist of some unknown condition of the nervous system to which inflammation is superadded, and by which the character of that inflammation is modified, the great practical result is the same, namely, that febrile inflammation and ordinary inflammation are not identical, and that the difference between the two affections is such as to require a very considerable modification in the treatment appropriate to each.
The only morbid condition of fever, of which we have any knowledge, and over which the medical art has any control is that of inflammation. Although, as has been so often stated, inflammation be not the primary febrile affection, as far as regards the order of events, yet it is, at least, the primary affection, as far as regards the treatment, if it be not the sole affection that admits of treatment. The remedies proper for febrile inflammation do not differ from those which are adapted to ordinary inflammation; but they differ materially in the mode in which they ought to be applied, and the extent to which they ought to be carried. They can be understood neither in their mode nor measure, until the following questions are determined; namely, What is the precise object that should be aimed at in the treatment of fever? What is it which it is most important to do, and which it is in the power of the medical art to accomplish? An exact and true answer to these questions will afford an invaluable guide in practice: it will point out with clearness what is to be attempted; and it will put a stop to useless and pernicious aims.
It is in vain to hope to terminate fever by a stroke of art. The pursuit of a remedy, so long and so earnestly sought, endowed with the power of cutting short the disease, is to the physician what the search after the philosopher’s stone was to the alchymist, with this difference, that the alchymist, engaged in a vain pursuit, lost only his time and labour; but the physician, engaged in a pursuit equally hopeless, will often, in addition, lose his patient. Fever cannot be cured instantaneously; and to bring a fever patient under the influence of agents capable of exciting a powerful influence upon the system, in the expectation of at once removing fever, is pregnant with danger; and the expectation upon which such practice is adopted, must appear fallacious to whoever has studied the nature of the disease.
Fever cannot be cured instantaneously: it may be moderated; it may be gradually subdued; from being violent and dangerous, it may be rendered mild and safe: the physician may bring it to this condition; and this is all that he can accomplish. If it come under his care early, and he know with promptitude and decision at what to aim, he will rarely fail in his efforts to secure this object.
Since the various forms or types of fever differ in nothing but the degree of their intensity, in detailing the treatment, it will be necessary only to state first of all, the remedies which are appropriate to the disease; and, secondly, the modification of these remedies, which may be required by the different degrees of intensity in which it is commonly found to exist.
1. The common continued fever of this country, in its mildest form, requires little or no treatment. There is no affection of any organ intense enough to need the application of a powerful remedy. All the organs which constitute the febrile circle are deranged in their functions, but that derangement is so slight that a cure takes place spontaneously in the course of a few days. Confinement to the bed; the abstraction of stimuli; fever diet; a calomel purgative at night, consisting of one or two grains of calomel with six or ten of rhubarb, followed in the morning with half an ounce of castor oil; and these remedies repeated every day, or every alternate day, constitute the whole treatment which is required.
2. Whenever the fever passes beyond this, its mildest form, it becomes a serious disease. It is never for a moment to be trifled with; never for a moment to be neglected. Because it is moderate in the commencement, it is not to be presumed that it will continue moderate through its subsequent course: it may become most formidable; if the proper remedies are not applied early and vigorously, it generally does become truly alarming; the train only is apparent; the mine is concealed; the only safety for the patient is to prevent the train from being kindled; if that be once kindled, it may be no longer possible to save the patient from destruction.
When the mildest case of fever passes to a severer form, what is the event that happens? What is the change that takes place in the organs? The preceding pathology will, indeed, have been written in vain, if there can now be any doubt in the mind of the reader on that point. The great value of the facts there disclosed is, that they teach us what happens in organs which we cannot see, and declare to us by the external signs or symptoms, the internal actions that are going on. Out of the hundred cases which have now been recorded, and the history of which has been made known from its commencement to its termination, take any one, or fix upon any number, in which the symptoms from being slight became moderate, and from moderate severe, or, in which the symptoms were severe from the beginning, what is found after death? Inflammation, in general, rising in degree, and increasing in extent, or both, in proportion to the intensity of the febrile affection. If this, which may be justly considered as the law of the disease, be not absolutely constant and uniform, it may be safely affirmed, at least, that there are as few apparent exceptions to it, as to any general law that can be named.
The object to be aimed at in practice, then, is clear: it is to prevent, or to remove inflammation. Accomplish this, the fever will not be cured at once; it will still go on for some time; but it will come sooner to a close, and it will proceed mildly and safely to its termination. Fail to accomplish this, and the fever, however mild at first, will increase more and more in severity until it become truly formidable, and death take place at last, in consequence of the destruction of the organs by the process of inflammation.
If excitement be set up in an organ which has as invariable a tendency to terminate in inflammation as a stone to fall to the ground, what is the proper remedy to prevent the transition of excitement into inflammation? Bleeding. Before we can say that inflammation is established we may foresee that it will come: if the preceding excitement be not stopped, we know that it will as surely come as that blood will flow from a wounded blood-vessel. Because we cannot tell the precise moment when increased vascular action passes into actual inflammation, are we quietly to look on and do nothing until we have made that discovery? We know that inflammation is at hand; we know what will prevent it, or, at any rate, what has a powerful tendency to prevent it: shall we not bring into immediate and vigorous use our means of prevention, or shall we wait until the inflammatory action shall have given unequivocal and alarming indications of its presence and operation before we interfere? To trifle in such a manner, to lose these precious moments when we have such a fearful, such an active, and, if once it be allowed to become active, such a masterless enemy to contend with as fever, is as great a folly as it would be when a building is on fire to stand idle by as long as the fire is smouldering, and to take no measure to extinguish it until it has burst into flame, nay, not until the flame has spread from the floor to the ceiling, and from the ceiling to the roof. We may not be able to see a single spark, but if we see the smoke and feel the heat, we know that there is fire somewhere, and that however concealed at present it will soon make itself visible enough, and that it will consume not only the structure in which it originates, but others with which it may come in contact if it be not put out. With equal certainty we know that fever, though apparently mild in the commencement, will excite inflammation in vital organs, and that that inflammation, if it be allowed to establish itself, will place the fabric of the body in the most imminent danger. The physician, in the first stage of fever, armed with his lancet, is to his patient what the fireman with his engine, before the flames have had time to kindle, is to a building that has taken fire. At this early stage, the former can check inflammation with almost as much ease and certainty as the latter can prevent the flames from bursting out. On the contrary, the physician who is called to treat inflammation in the later stage of fever is in the position of the man who arrives with the apparatus for saving the house when its stories have been already consumed and its roof has fallen in.
Bleeding in fever cannot be performed too early. The very first moment of excitement, could that be discovered, is precisely the moment when the employment of this powerful remedy would produce the greatest effect. The earlier the bleeding, the greater will be the impression made upon the disease, and the less upon the patient; or, the more effectually will the inflammatory action be stopped by the loss of the smallest quantity of blood.
When inflammation has actually come on, there is then not a moment to be lost; that inflammation must be stopped; the accomplishment of this object is the great end which the practitioner should aim at in every thing he attempts; until he has done this he has done nothing; until he has done this he ought to give neither sleep to his eyes nor slumber to his eye-lids; until he has done this he ought to feel that there should be no rest for himself, because there is no safety for his patient. Until the inflammation is subdued blood must be taken; be the quantity it may be necessary to abstract, in order to accomplish this object, what it may; be the bleedings it may be requisite to repeat what they may; the vein must be allowed to flow, and it must be opened again and again until this object is secured. If this golden opportunity be allowed to escape, and this object be not obtained, the risk is most imminent. During this early period the physician is master over the disease; if he allow it to pass away without obtaining the victory, the disease becomes master over the physician. From that moment his control over it is gone. Never can he regain his lost advantage. Fever is a process that advances with a step as steady as time, and like time it never retraces a step. At a subsequent period its progress may be sometimes retarded, and now and then it may be weakened; but, after the lapse of a few days, this is all which the most complete success is then capable of accomplishing.
Mere relief of inflammation is nothing; to render a severe inflammation a less severe inflammation is to do nothing; because the less severe inflammation may be fatal just as certainly as the more severe: the inflammation must be subdued, or the case, if not wholly lost, becomes dangerous and doubtful.
The abstraction of blood must be carried to the extent of subduing the inflammation: there is no other limit to the quantity to be taken but that which is adequate to subdue the inflammation. To attempt to measure the quantity by drachms or ounces is wholly vain; because, if the remedy be properly employed, the quantity will vary in every individual case. To take an ounce more than the subdual of the inflammation requires is injurious; to take an ounce less is still more pernicious; to take the quantity necessary to accomplish the object, and no more, is to use the lancet—that powerful instrument, so dangerous in rash hands, and no less dangerous in weak, with the discernment and decision of a master. He who with a knowledge which gives and which justifies boldness and decision, is able thus to employ this great remedy, is a skilful physician, who has derived from study and experience the best fruit they can yield: he who has not yet reached this perfection of his art, (and who among us can pretend to the attainment?) must still go on to observe and to learn.
The object to be accomplished then is clear; that means of obtaining it are known; and when these means are promptly, boldly, and effectually employed, what is the result of experience? That after all, the quantity of blood it is necessary to abstract is not large. The tendency of the preceding observations is not to countenance frequent and large abstractions of blood in fever, but to save the blood of the patient, by taking the due quantity at the proper time. Smaller bleedings will subdue febrile than pure inflammation. Febrile inflammation, as has been so often stated, is a modified inflammation, the modification consisting in less activity in the vascular system and greater depression in the nervous. Whence a moderate bleeding will make an impression upon febrile inflammation which can be equalled in pure inflammation only by a large bleeding. He who takes away sixteen ounces of blood in fever adopts a bolder and more decisive practice, and brings more effectual relief to his patient, than he who abstracts thirty ounces of blood in some other forms of inflammation; and he who takes away six ounces of blood in one febrile case, does more than he who takes away sixteen in another. But the question never can be whether the bleeding should be small or large: that is nothing. The thing to be considered is the condition of the organs, the state of the system; not the ounces of blood to be taken, nor the number of periods at which it is to be removed. Abstract blood to the subdual of the inflammation—that is the rule; abstract blood at the very commencement of the inflammatory action; if you are in time to do it, at the very commencement of the febrile excitement. Then little blood will be lost, and the patient will be safe. And when this is done, nothing of importance remains to be done. The practitioner who has been thus active in the commencement will be idle during the future progress of the disease. Daily as he repeats his visit he will find that his interference is not required, and will admire to see with what ease a disease of frightful power is disarmed, and rendered innoxious, if it be attacked in infancy, and not neglected or trifled with until it be nurtured to maturity, and allowed, at last, to put forth unchecked the strength of that maturity.
If, after the abstraction of sixteen ounces of blood at the commencement of the attack, the vascular excitement be not completely subdued, in the course of three or four hours the same quantity must be again taken; and if, the next morning, that excitement continue, it will probably have already passed into inflammation; and, therefore, the vein must be once more opened, and the blood allowed to flow until the pain, wherever seated, be entirely removed. To check the disease, instead of subduing it, does not in the least diminish its future strength, and, by weakening the powers of life, it even hastens the period of mortality. Nothing is more common than the appearance of typhoid symptoms, on the second or third day after bleeding has done nothing but lessen the inflammatory action; whereas, had it been carried somewhat, and generally only a little, farther, the patient would have been convalescent at the very period when his danger becomes most imminent. In cases where general bleeding produces a decided impression on the inflammation, but does not stop it, cupping, or even leeches, will often complete what the lancet commenced.
A due impression having been made upon the inflammation by bleeding, the subsequent treatment should consist of purgative medicines, given to the extent of producing three, or at most four stools in the twenty-four hours: beyond that number no advantage is obtained by purging; more frequent evacuations, indeed, weaken the patient, but not the disease. The best purgatives consist of one or two grains of calomel, with six or eight of rhubarb, repeated every night, or every other night, and followed the next morning by two drachms, or half an ounce of castor oil, or by the common senna draught. Cold sponging, if the skin be hot; acidulated drink, if there be thirst; perfect quiet, a dark room, a silent nurse, affording prompt attendance, with a noiseless step, a cheerful countenance, and no words—this, together with three tea-cups full of thin arrowroot or gruel, in the twenty-four hours, given in divided portions, at intervals of about two or three hours, comprises all else that will be required, or that will be useful, until the period of convalescence.
Such is the simple, but most efficient treatment appropriate to the common fever of London and its neighbourhood (and I do not speak of the treatment proper for any forms of the disease as it exists elsewhere, and which I have not seen) in its ordinary degree of severity.[[35]]
Suppose, however, the proper treatment not to have been applied; suppose the case to have been neglected or mismanaged; either not to have been seen at all, or to have been too much contemned; suppose the pain in the head to have been not severe; that no complaint was made of it; or that giddiness only was felt; that the skin was not burning hot, but moderately warm; that the pulse was neither strong, nor bounding, nor hard; but of moderate strength, and soft; that the mind was tolerably distinct, and the restlessness not great: why should blood be drawn? what indication is there for the employment of so violent a remedy in so mild a case? No symptom is prominent; no symptom is urgent; the case will do well.
Such is the view that would be taken by the great majority of practitioners of this kind of case, and their treatment, without doubt, would be correspondingly inert. And this is the true origin, in many cases, of typhus symptoms; of adynamic fever. The disease is allowed to take its own course; and the product of every fever, at a certain stage of its process, is adynamia: the physician does not perform his office; the disease advances; the restlessness increases; there is no sleep; delirium comes on; muscular tremor begins to be perceptible; the pulse rises; the sensibility diminishes; and stupor, if it be not already present, is close at hand. And now the disease, it is sufficiently obvious, is severe; now, it is admitted, it calls for a powerful remedy; and, now for the first time, the lancet is thought of. But the bleeding relieves no symptom; it increases some; the progress of the inflammation is not checked; the adynamic symptoms are more fully developed; the patient is more prostrate, and the fever, in all respects of a worse character: the inference is, that bleeding is a most inefficient and dangerous remedy in fever; and this inference is deduced from experience; those who draw the conclusion, judge from what they see; they disclaim reason; they pretend only to understand and to respect the lessons of experience.
I appeal to the attentive observer, whether this be not a faithful history of the progress and termination of hundreds of fever cases; whether such a history may not be recorded as of daily occurrence; whether what has been stated be not commonly the view, the practice, the result, and the lesson.
I will not appeal to the different history that belongs to cases that are differently treated. But I do earnestly appeal to the pathology that has been stated; that, at least, is experience, and it teaches a lesson, which it is worse than foolish to despise or to forget. Every symptom just enumerated, has been detailed over and over again in the cases that have been laid before the reader: inspection after death must have made the conditions of the organs, as indicated by those symptoms, familiar to his mind. Of what avail can bleeding be, when the patient is brought into the condition which first excites alarm, in the case here supposed? The blood is no longer in its vessels; it is beneath the membranes, or in the ventricles, or at the base of the brain; the inflamed capillaries have done their work upon the cerebral substance and upon its membranes; and have left proof enough of their activity, in the thickening of the one, and the softening or the induration of the other. What can blood-letting do in this state of the organs? What can shaving the head, and applying cold do? What can blisters do? What can purgatives do? And above all, what can wine do? Nothing can be done; at least, nothing effectually or certainly.
If there be still pain, if the sensibility be little diminished, if the pulse be not very quick and weak, it may yet be possible to check the further progress of the inflammation; to prevent the disorganization of the brain from advancing; but the means to accomplish this, must now be tried with the most extreme caution: perhaps, in the whole compass of medical practice, there is no case which requires a nicer discrimination than this, when it has arrived at this point. The abstraction of a few ounces of blood may stop the inflammatory action of the vessels before they have produced such a change of structure as is incompatible with life, and such as the powers of life cannot repair. But if the abstraction, even of this minute quantity of blood, at this point of the inflammatory process, do not put a stop to that process, the remedy will co-operate with the disease, to depress the powers of life, and will deprive the patient of what chance of recovery he might otherwise have had. To decide in a case which requires such nice discernment, and in which, even with the best discernment that can be exercised, the event must always be so doubtful, is a task which few physicians, who understand the nature of it, find either easy or agreeable.
But instead of bleeding, the proper remedy may possibly be the very reverse: it may be requisite to afford a stimulus. The change of structure produced by the inflammatory process may not have proceeded to such an extent as to be absolutely incompatible with life; but the powers of life maybe so exhausted by the inflammatory excitement that, unless aid be brought to them, they will be overpowered, and sink: afford them appropriate aid, and they will rally, and, although slowly, ultimately repair the lesion which the organs have sustained.
This is precisely the condition, and perhaps it is the only condition, under which stimuli are really beneficial in fever. Whenever such remedies are indicated, the vascular action is weak, and there appears to be a want of due supply of arterial blood to the brain. Of all stimuli, wine or brandy is the best. If it be doubtful whether a stimulus can be borne, or will prove beneficial, a few ounces of wine may be administered. It will soon be manifest whether it be the appropriate remedy. If the restlessness, the heat, the delirium increase under its use, it will be obvious that it cannot be borne; if, after some hours, no perceptible impression be made upon any symptom, it is seldom of the least service, given to any extent, or persevered in for any length of time. If it be capable of doing any good, some improvement in the symptoms is commonly perceptible in a few hours after it is first administered. Sometimes that improvement is sudden and most striking; more commonly it is slight, slow, but still easy to be seen. If the pulse become firmer, and especially slower, the tremor slighter, the delirium milder, the sleep sounder, the skin cooler, and, above all, if the sensibility increase, and the strength improve, it is then the anchor of hope. It will save the patient if it be not pushed too far, and if it be withdrawn as soon as excitement is reproduced, should that happen, which it often does.
No certain indication for the administration of wine can be drawn from one or two symptoms alone: neither from the state of the pulse, nor of the skin, nor of the tongue; neither from the tremor, nor from the delirium. There is an aspect about the patient, an expression not in his countenance only, but in his attitude, in the manner in which he lies and moves, being, in fact, the general result, as well as the outward expression of the collective internal diseased states, that tell to the experienced eye when it is probable that a stimulus will be useful. Depression, loss of energy in the vascular system, as well as in the nervous and the sensorial, indicated by a feeble, quick, and easily compressed pulse, no less than by general prostration, afford the most certain indications that the exhibition of wine will be advantageous: and if the skin be at the same time cool and perspiring, the tongue tremulous, moist, or not very dry, and the delirium consist of low muttering incoherence, these symptoms will afford so many additional reasons to hope that it will prove useful. On the contrary, if the skin be hot, the eye fierce or wild, the delirium loud, noisy, requiring restraint, and the general motions violent, it is as absurd to give wine, as to pour oil upon a half-extinguished fire, with the view of putting out the yet burning embers.
When wine is indicated, but does not produce a decided effect, brandy may be substituted. I have seen no benefit arise from giving either in large quantity. When the condition is really present in which alone it can be useful, a moderate quantity will accomplish the only purpose it can serve. In every other condition, wine may be administered to any extent, (and I have given half a pint every hour) until the stomach return it, by vomiting, without the slightest impression being made upon the disease, or any, or scarcely any, upon the system. The malady is in possession of the seat of sensibility; it has destroyed the organ; it has abolished the function: what advantage can result from the application of stimuli? The spirit that could feel their impression, and answer to it, is gone: organs destroyed by overstimulation, cannot be regenerated by the application of additional stimuli: the apparatus is broken; the wheels are clogged; the obstruction lies in that part of the mechanism in which the main power that works the machinery is generated; that obstruction cannot be removed; the movements of the machine must cease. Even when the case is not thus utterly hopeless, wretched is the physician whose only dependence for the safety of his patient is in wine.
These considerations ought not to make us desponding, or inert, even under the worst circumstances, as long as the case is not absolutely desperate; but they ought to impress deeply and indelibly upon the mind of the practitioner who has the first charge of a fever patient, that the disease must be conquered in the very first days, or it will conquer, and that there are no means by which that conquest can be rendered sure or probable, but that afforded by the lancet.
Very much the same observations apply to the exhibition of opiates. There is a condition of the system in which an opiate puts a stop to a state of exhausting agitation and restlessness; procures tranquil sleep; lessens delirium, and operates most favourably on all the symptoms. This may be when the skin is cool and perspiring; the tongue moist, or not very dry; the delirium low, and the pulse and the patient weak. No kind of opiate in any form in which it can be administered ever proves in the least degree beneficial whenever the skin is very hot, the tongue very dry, or the general motions and actions of the patient are violent.
Now and then the powers of life rally unexpectedly and wonderfully: they throw off a load which appeared to have oppressed them totally and for ever. It is therefore the duty of the medical attendant to be always at hand until the termination even of the most desperate case, and carefully to watch every change that takes place; for changes may suddenly occur which may give him a clue to bring in invaluable assistance. He may be suddenly called upon to give a stimulus; he may be suddenly called upon to check re-excited and inordinate action. To describe in words the countless variety of circumstances under which it may be necessary that he should take very unexpected and decided measures, and not a few of which may demand of him clear discernment and nice discrimination, is quite impossible: he can acquire the power of performing the most difficult and arduous duty he has undertaken only by studying the disease, and by rendering himself perfectly familiar with the principle of its treatment.
When the inflammatory action has proceeded unsubdued and has terminated in some change of structure, probably accompanied with copious effusion, as indicated by the symptoms detailed under the cases illustrating cerebral affection, advantage is sometimes obtained by affecting the system with mercury. In this condition of the brain it is not easy to bring the system under the influence of mercury; when it can be accomplished, the patient is commonly, though not invariably, snatched from death. In several instances I have known this treatment successful under apparently the most hopeless circumstances. When the success is most complete, the convalescence is invariably tardy, and often appears to be doubtful; the mind for a long time remains feeble, infirm, and almost fatuous; and, as in the two cases recorded by Pringle, though such patients recover of their fever, it is long before the nervous and the sensorial systems are restored to a sound state. The best mode of exhibiting mercury is in the form of a pill, consisting of two grains of calomel with half a grain of opium, given every three, four, or six hours.
3. To a fever which is severe from the commencement the preceding observations apply with double force. Then, if the most powerful remedies are not immediately employed, and if they are not brought to bear at once upon the severe symptoms in the completest combination, the case is wholly lost. The delay of an hour is pregnant with danger; the delay of a few hours places the efficacy of any measures that can be taken in great uncertainty; and the delay of a day or two renders their most vigorous application utterly useless. Whereas, knowing, as we now know, the condition of the organs upon which the severity of every case depends, and knowing remedies appropriate to that condition of sovereign efficacy, exceedingly few of such cases would be lost were these remedies employed with due vigour at the commencement of the attack. The typhoid symptoms with which it is commonly thought such cases commence would never appear. The patient would be convalescent, or at least would labour only under a mild form of fever at the period when, without these remedies, his condition would be hopeless. The practitioner ought never for a moment to forget that it is in the power of early and active treatment to deprive these severe cases of all their severity and, consequently, of all their danger; but that, after the lapse of a day or two, all human skill will be exerted in vain.
It remains to say a word or two relative to the modification of the more powerful remedies, as the prominent affection may have its seat in the brain, the lungs, or the intestines.