Cool it Allen B. Weisse, MD
man awakens one morning and ﬁnds that one of his hands is painfully swollen. He rushes to his doctor’s oﬃce. The physician examines the hand and instructs his patient to go home and soak it in the hottest water bearable and return the next morning. The patient dutifully follows these instructions but ﬁnds, after immersing his hand in the tub, that instead of improving, the swelling and pain grow worse. At this point his housekeeper arrives and notices his dreadful state. She asks her employer why he is using hot water for the problem.“I always use cold water for something like this,” she states. With nothing to lose, the patient substitutes ice water for the hot tub and, miraculously, the swelling and pain subside. The following morning he appears before his doctor. “How is the hand?” the doctor inquires. “It’s just ﬁne now, but no thanks to you.” “What do you mean?” “I put my hand in hot water the way you told me to and it got worse. My housekeeper just happened to come by and she saw what was happening and told me that she always uses cold water for this problem. So I switched to cold water and it all cleared up perfectly.” Visibly perplexed, scratching his head, the doctor replies, “That’s funny. My housekeeper says always use hot water.” As with many funny stories, buried within an obvious absurdity there lies a kernel of truth. It would be absurd for any physician to handle the problem as described, while having a half dozen diagnostic modalities and a myriad of pharmaceuticals available to him. Nor would he ever consider calling in his housekeeper for a consultation. The kernel of truth lies in the fact that, for many minor illnesses and injuries that occur, patients see no need for professional care. They rely instead upon inherited traditions of home care, which we might well characterize as folk medicine. In this case we are confronted with competition between heat and cold for the treatment of the ﬁctional illness described. The frequent use of heat or cold as home care remedies calls to mind the very prominent role these modalities have also played well within the arena of clinical medicine. This is especially notable in the use of hypothermia. In the early 1950s, when cardiac surgery was really getting under way, the use of hypothermia was critical (1). When it was found that under hypothermia the human brain could tolerate a cardiac arrest of 6 to 8 minutes without harm, deft cardiac surgeons could
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open the heart for repair of an atrial septal defect within this time period. Although later introduction of reliable heart-lung machines enabled longer periods of surgery for more complicated abnormalities, hypothermia has frequently been used in concert with such procedures. In the presence of traumatic brain injuries, neurosurgeons routinely cool the body of the patient to minimize or avoid brain damage (2). It has been shown experimentally that induced hypothermia after potentially lethal hemorrhage can improve chances of survival (3). Perhaps, eventually, this will improve survival of humans as well after severe blood loss. Donated organs are packed in ice while in transit to recipients to maintain viability. A new twist on this has recently been introduced for kidney transplantation (4). In the deceased donor, it has been found that inducing mild hypothermia prior to removal of the organ results in a signiﬁcantly reduced rate of delayed graft function in the recipients. The future of kidney and other organ transplants may be made brighter through the institution of this simple adjustment in preparation. The clinical use of hyperthermia has historically been less beneﬁcial. When hypothermia occurs in patients subjected to freezing or subfreezing conditions, warming the body is clearly the naturally preferred mode of treatment. Beyond this, one looks in vain for examples of raising body temperature above normal resulting in improvements or cures. Indeed, one of the rare major blunders of the Nobel Prize committees occurred as a result of such an intervention. In 1927 Julius Wagner-Jauregg, a psychiatrist, was awarded the Nobel Prize in Medicine or Physiology for his treatment of neurosyphilis by infecting patients with malaria in hopes that the high fevers induced by malaria would be of beneﬁt in combating the disease. They were not. All of which brings us back to consideration of the more mundane type of complaint in question. For such local swellings, more likely to occur traumatically than in the joke above, what should be our guide? The body’s initial response involves the delivery of certain cellular elements and biologically active substances into the aﬀected area. This creates an inﬂammatory response which, rather than blocking or alleviating the pain From the Department of Medicine (retired), Rutgers–New Jersey Medical School. Corresponding author: Allen B. Weisse, MD, 164 Hillside Avenue, Springfield, NJ 07081 (e-mail: [email protected]
and swelling, actually exacerbates them. Applying heat will only worsen the situation by increasing blood ﬂow to the aﬀected area. The use of cold compresses instead, by causing vasoconstriction, can limit the inﬂammatory response. My dentist apparently agrees with this approach to therapy. I am prone to repeated periodontal problems. After each dental surgery, my periodontist gives strict instructions to apply ice packs over the treated area for several hours into the evening to prevent swelling. The one time I did not follow such instructions to the letter, swelling and discomfort resulted over the treated area. In the ﬁeld of sports medicine, the local application of cold is also recommended for a number of conditions (5). To varying extents in various locations, boxers, baseball pitchers, tennis players, and others apply cryotherapy for a variety of similar types of self-induced or external causes of trauma. With such abundant evidence about the beneﬁts of cooling, one wonders why heat continues to be advocated by some as the preferred home treatment for the type of injury described. Perhaps this is related to the well-known beneﬁt of heat in relieving the pain of many chronic nagging musculoskeletal conditions—what
old-timers would refer to as “rheumatism.” Perhaps the memory of soothing hot springs or spas in America and Europe helps propagate such beliefs. But for this observer, the proper choice is a “no-brainer.” As long as it is recognized that some serious neurological or musculoskeletal problems might initially appear with minor symptoms, once this is ruled out the way to go is cool—no matter what my housekeeper says. 1. 2. 3.
Cooper DKC. Open Heart. The Radical Surgeons Who Revolutionized Medicine. New York: Kaplan, 2010:105–142. Winn HR, ed. Youman’s Neurological Surgery, 5th ed., Vol 4. Philadelphia: Saunders, 1996. Alam HB, Rhee P, Honma K, Chen H, Ayuste EC, Lin T, Toruno K, Mehrani T, Engel C, Chen Z. Does the rate of rewarming from profound hypothermic arrest inﬂuence the outcome in a swine model of lethal hemorrhage? J Trauma 2006;60(1):134–146. Niemann CU, Feiner J, Swain S, Bunting S, Friedman M, Crutchﬁeld M, Broglio K, Hirose R, Roberts JP, Malinoski D. Therapeutic hypothermia in deceased organ donors and kidney-graft function. N Engl J Med 2015;373(5):405–414. Scuderi GR, McCann PD. Sports Medicine: A Comprehensive Approach, 2nd ed. Philadelphia: Elsevier/Mosby, 2005:592–593.
Baylor University Medical Center Proceedings
Volume 29, Number 1