A Treatise on Fever

by Southwood Smith

I. Of the Modification of the Treatment in Cerebral Affection.

The treatment in a cerebral case of moderate severity has been already sufficiently explained. Blood must be drawn to the subdual of the inflammation, and if blood be abstracted early, two, or at most three, moderate bleedings will be all that will be required.

But when the attack commences with severe cerebral affection, the bleeding must be proportionally large, and early as it is copious. A bleeding adequate to subdue a moderate, will be utterly inert in a severe degree of cerebral disease. I give, as a specimen of what may be sometimes required, the case of Dr. Dill. I saw my friend at the very commencement of his attack, and was, therefore, able to carry into effect what I conceive to be the proper treatment with due promptitude and vigour. I saw him before there was any pain in the head, or even in the back, while he was yet only feeble and chilly. The aspect of his countenance, the state of his pulse, and the answers he returned to two or three questions, satisfied me of the inordinate, I may say the ferocious, attack that was at hand. Having taken an emetic without delay, as soon as its operation was over, blood was taken from the arm to the extent of twenty ounces. During the night, severe pain in the limbs, especially in the loins, and intense pain in the head came on. The blood that was taken on the preceding evening was not inflamed. Early in the morning he was again bled to the extent of about sixteen ounces, with great diminution, but not entire removal of the pain: the pain not lessening, towards the afternoon he was again bled to the same extent: the pain was now quite gone; the blood from both these bleedings was intensely inflamed. During the night the pain returned, and, in the morning, the eyes were dull and beginning to be suffused, while the pulse continued slow and intermittent, and the respiration suspirious; but the face was blanched, and the pulse, in addition to its other characters, was weak. Instead of opening the vein afresh, twelve leeches were applied to the temples; these very much relieved, but still did not entirely remove the pain; for this reason, he was cupped to the extent of sixteen ounces: this operation afforded very great relief, and he continued easy until the following evening, when the pain returned, and he was again cupped on the temples to the same extent. Immediate relief followed this second operation; but, unfortunately, the pain returned with great violence towards evening, and it was now impossible to carry the bleeding any farther. Within twenty-four hours, it was plain that typhoid symptoms in abundance would be present, for the fur on the tongue was becoming brown, and there was already slight tremor in the hands. No more blood could be taken with any prospect of advantage, nor even with safety; yet, without the aid of some powerful remedy the case was lost.

The whole scalp was now enveloped in ice, but so intense was the heat of the head that it was melted in a few minutes, and the clothes, steeped in the evaporating lotion, dried with extraordinary rapidity. Neither of these expedients produced the least perceptible effect.

What was to be done? Recourse was had to a measure the efficacy of which is but little known and less appreciated; a remedy the power of which is second only, if, under some circumstances, it be not even superior, to that of the lancet; a remedy which can never supercede the lancet nor dispense with it, but which, when added to it, forms by the combination a treatment so powerful and efficacious that it might render death, from the acutest cerebral inflammation, as rare as recovery is at present.

This remedy is known by the name of the cold dash. It consists of pouring a column of cold water upon the head in a continued stream from a height of from six to ten feet. The mode of applying it is as follows. The patient is seated in a large tub; a table is placed at the side of the tub upon which a man stands, and at as great an elevation as his arms can reach, pours upon the naked head of the patient a steady but continued stream of cold or iced water, from a watering-pot without the rose. The stream is made to fall as nearly as possible upon one and the same spot. At first the elevation must be slight, for the shock is too violent if the stream be poured at once from the highest point. There is a record, that in the East, where ingenuity so long laboured for tyranny to invent the most exquisite modes of torment, the victim was placed with his bare head under a small stream of cold water which was so directed as to fall unceasingly upon one spot. In this instance cruelty was cheated of its object by its ignorance of the mode in which its expedient operated. The device was well adapted to kill but not to produce pain, for insensibility must soon have put an end to suffering.

Employed as a remedy, there is no degree of burning heat which the animal economy is capable of producing, no intensity of vascular action, and no violence of pain that can resist its continued application. Sooner or later, usually in from ten to twenty minutes, the heat, though most intense, disappears, the skin becomes cold, the face pallid, the features shrunk, while the pulse is reduced to a mere thread, and the pain of the head, however violent and intolerable, entirely ceases. After the patient has been wiped dry, which he should be as rapidly as possible, and placed in bed, the symptoms may soon return in all their violence; the same process will again remove them, and as often as the former recur the latter must be repeated. Three or four repetitions will commonly suffice to subdue the most intense cerebral affection. In the case of Dr. Dill, the relief it brought was instantaneous and most complete. From a state of intense suffering it rendered him perfectly easy, and from a state of imminent danger, safe. I had no anxiety about him from the moment he came out of his tub, although it was necessary to pass him through the same ordeal three times; but he himself having tried this remedy on his sister, having in her case witnessed its efficacy, and now felt it in his own, was extremely desirous that it should be repeated as soon as he was conscious of any return of pain. In consequence of its application, together with the copious depletion that preceded it, at the period when under ordinary treatment, the most exquisite typhoid symptoms would have been present, he was convalescent.[^[36]] If we consider how powerful the abstraction of caloric must be by every fresh current of water that falls upon the head, to what a mere thread the minute external blood-vessels must be constringed, and consequently to what an extent the internal must be affected, we shall not wonder at its efficacy. Powerful as the cold affusion is when exhibited in its ordinary mode, yet the impression it makes upon the brain, compared with the effect produced by this remedy, may be said to be what the application of six leeches to the temples is to the abstraction of thirty ounces of blood.

Cold applications to the head, and evaporating or iced lotions, are useful in mild cases; they may keep up the effect produced by this in the more severe, but to hope to control the latter by their aid alone, is to expect to coerce a giant, by twisting around his arms a spider’s thread.