A Treatise on Fever

by Southwood Smith

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.