187

LECTURE XIII.

WARM FOMENTATIONS TO THE HEAD IN FEVER.-USE OF MERCURY.— SUBSULTUS TENDINUM.-CEREBRAL SYMPTOMS.

I HAVE already laid before you my views as to the use of general and local bleeding in fever, and pointed out the circumstances under which they might be employed. In treating of general bleeding, I stated that we used it at the commencement of fever, with a view of checking the disease altogether, or of rendering it milder and less dangerous, by moderating excessive inflammatory action, and controlling cerebral excitement. I have also spoken of the use of leeches and blisters, and it only remains for me to say a few words respecting the application of cold to the head as a means of moderating or removing symptoms of cerebral excitement.

In Dr. Southwood Smith's Treatise on Fever, you will find many cases and arguments to show that where headache and delirium are present, and where the lancet is inadmissible, if you place the patient in a warm bath, and direct a forcible small stream of very cold water on his head, he soon becomes more calm, experiences great relief of his headache, and is frequently brought back to bed quite free from cerebral symptoms. The burning heat of the skin is quickly replaced by a sensation of coolness, or even cold, the flushing of the face disappears, the delirium vanishes, and a favourable crisis is often produced. Indeed, the effects of this remedy are extremely remarkable, and I have no doubt that many of the cases in which I have employed tartar emetic with such signal advantage would derive equal benefit from this mode of treatment.

The cold affusion, as recommended by Dr. Smith, and practised at the Charité Krankenhaus at Berlin, is most certainly an excellent and energetic remedy, and I regret that we have not apparatus in this hospital for applying it; but I fear its utility must be, at least for some time, limited to public institutions,

and that it cannot be employed to any extent in private practice. There is a good deal of prejudice against applications of the kind in this country. At the time that cold affusions were used in the treatment of scarlatina, much mischief was done by their indiscriminate employment, and this added to the general feeling of dislike towards them. At all events, cold affusion is a remedy which requires an apparatus seldom at the command of the physician in private families, and, indeed, I think that in most cases we may do very well without it.

You are all aware that, in cases of determination to the head, the common practice is to shave the scalp, and apply cold lotions. In my lectures I have repeatedly pointed out the imperfect and even hurtful mode in which this remedy is ordinarily applied, and endeavoured to show that it is calculated rather to increase than diminish the heat of the integuments. Cold lotions act as a powerful refrigerant, if constantly repeated, so as to keep the part below the standard temperature of the body. But this is seldom or never done. The nurse applies the lotion, and then, perhaps, drops asleep, or occupies herself with some other business, until at last she is attracted by the vapour arising from the patient's head, and then she renews the application. I need not say, that in this way all the good effects of cold, as a refrigerant, are entirely lost, and that a degree of reaction is produced which must altogether mar and nullify its application. I have, therefore, given up, except in very few cases, the practice of applying cold lotions, and give a preference to the use of warm fomentations of equal parts of vinegar and hot water, applied to the temples and shaven scalp, and frequently repeated. I am quite sure we employ warm applications for the relief of headache and cerebral symptoms much less frequently than we ought. You are aware that surgeons are in the habit of treating some local inflammations with warm, and others with cold applications, and that the rules laid down for distinguishing the cases in which cold, and those in which warm fomentations should be used, are deficient in precision, and that most commonly the practitioner has to refer to his own individual experience for the guidance and determination of his choice. So it is, also, with respect to the use of fomentations to relieve the pain and congestion of internal parts, among which I include determination to the head in fever, accompanied by intense

headache, restlessness, and delirium. In some cases of this description, cold applications will give ease; in others most relief is obtained by fomenting the head with water as hot as it can be borne.

The idea of employing hot fomentations in cases of this description was first communicated to me in 1833, by the late Mr. Swift, who became accidentally aware of their value whilst washing his face one day in very warm water, at a moment when labouring under severe headache. The sudden relief obtained by the application of hot water induced him to try it exclusively in the headache of influenza, and with the most satisfactory results. In the influenza which appeared in this country in 1833 and 1837, and again recurred in 1847, one of the most remarkable symptoms was intense headache. This was accompanied by great debility, and was not amenable to the ordinary modes of depletion. Now, in the first of these epidemics, Mr. Swift found that by applying water as hot as it could be borne to the forehead, temples, and back of the head, great and almost instantaneous relief was obtained, and that in this way he was able to keep a most unpleasant symptom in check, while he was taking measures to remove the disease. I have also heard from my friend Dr. Oppenheim, of Hamburg, that he had discovered that this was the best means of affording relief under the same circumstances. Mr. Swift's observations first led me to think of applying hot fomentations to the head in other diseases, and although I cannot give you any particular rules for determining the cases in which you should employ them, I can say that you will generally find warm vinegar and water the best and most efficacious application in the ordinary headache of fever.

I shall next offer you a few observations on the use of mercury in fever; and, first, are we to have recourse to mercury or not in typhus? I do not allude here to its use as an aperient; but, when called to treat a case of fever, are you to proceed at once to bring the patient's system under the influence of mercury? Are you, in addition to the other measures usually adopted in the treatment of fever, to go on with the administration of mercury until you affect the mouth, and bring on salivation? This was the practice in my earlier days, and great confidence was placed in it by the majority of practitioners. It has been also very extensively recommended by army and navy surgeons

in the treatment of tropical fevers, but I must confess that I am not at all inclined to adopt this practice, and that I have seen abundant reasons why I should neither employ nor recommend it. In the first place, we have observed in our wards that patients with other diseases have frequently caught fever from exposure to infection, at a time when they were fully under the influence of mercury. In the next place, we have observed that persons who were thus attacked with fever while in a state of salivation did not escape better than others, and that in them the disease ran its full course, aggravated rather than diminished in its danger by the pre-existing mercurialization. These facts I have frequently seen verified in hospital and private practice.

You perceive, then, that mercurialization neither protects a man from the contagion of typhus, nor does it produce a favour. able modification in its type or progress. Again, I have repeatedly witnessed the daily and continued exhibition of mercury in fever, and I cannot recollect a single case in which it appeared to check the disease, moderate its symptoms, or bring about a favourable crisis. I am aware that, in entering my protest against this practice, I dissent from a very considerable body of my brethren, who, from the beginning to the end of fever, never cease in their attempts to bring the patient's system under the influence of mercury. I am convinced that, in the cases in which recovery is stated to have followed this practice, the post hoc has been mistaken for the propter hoc. Besides, fever is one of those affections in which you will find it extremely difficult, and often impossible, to bring the system fully under the influence of mercury. There are certain states of the system which prevent altogether the full operation of mercury, and bad typhus is one of these states. Where fever has laid deep hold of the constitution, you cannot affect it with mercury. When a patient recovers who has been mercurialized during the course of fever, he does not recover because his system came under the influence of mercury, but he comes under the influence of mercury because he recovers from the fever. Add to this, that mercury is a remedy which requires a peculiar regimen, and that it is very apt to engross the practitioner's attention, and prevent him from the exhibition of remedies which are more directly indicated, and in reality more useful.

These considerations, and others, have convinced me that the exhibition of mercury in fever, with the view of touching the gums, is injudicious and unnecessary. There are, however, cases in which you will be compelled to have recourse to mercury, whatever the stage or the type of the fever may be. Whenever inflammation of some internal organ-as, for instance, of the lungs-arises during the progress of fever, you must employ mercury at once; and cases of pneumonia, which would have proved fatal, have on numberless occasions been treated successfully by mercurialization. But under ordinary circumstances, and were there no indication similar to that which I have just pointed out, I do not see any advantage to be derived from the use of mercury. I am not, therefore, in the habit of employing mercury in fever. Sometimes I use calomel as an aperient, and I frequently prescribe small doses of hydrargyrum cum cretâ, with the view of gently stimulating the liver, and preventing the tendency to congestion of the intestinal canal; but farther than this I am not in the habit of going; and I never, except in cases of pneumonia, or inflammation of some internal organ, attempt to bring the patient's system under the influence of mercury during the course of typhus.

Allow me here to digress a moment from my subject, and make a few observations on the case of the man Cassels, which terminated fatally in our wards within the last twenty-four hours. I wish to call your attention to this case more particularly, as I think a different plan of treatment might have succeeded in saving the man's life. This man was admitted into the fever ward about the seventh or eighth day of his illness. I cannot exactly state how he was treated in the commencement, but I believe he was very badly attended, and that the state of the principal organs was wholly neglected. It will be sufficient to observe, that when he came under our care the chief features of his case were delirium, accompanied by total want of sleep, and a violence of conduct and behaviour calling for the restraint of the strait waistcoat. Now, under circumstances of this nature, the most diligent attention and promptitude are imperatively demanded on the part of the physician, and every step calculated to anticipate danger should be instantly taken. I regret to say that I did not at the time take a correct view of the treatment or precautions necessary to be adopted under such exigencies. I