A Treatise on Fever

by Southwood Smith

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.

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.