A Treatise on Fever

by Southwood Smith

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.