The following case of continued fever which I frequently saw during its progress, as it is less complicate than usual, may ill.u.s.trate this doctrine. Master S. D. an active boy about eight years of age, had been much in the snow for many days, and sat in the cla.s.sical school with wet feet; he had also about a fortnight attended a writing school, where many children of the lower order were instructed. He was seized on February the 8th, 1795, with great languor, and pain in his forehead, with vomiting and perpetual sickness; his pulse weak, but not very frequent. He took an emetic, and on the next day, had a blister, which checked the sickness only for a few hours; his skin became perpetually hot, and dry; and his tongue white and furred; his pulse when asleep about 104 in a minute, and when awake about 112.
Fourth day of the disease. He has had another blister, the pain of his head is gone, but the sickness continues by intervals; he refuses to take any solid food, and will drink nothing but milk, or milk and water, cold. He has two or three very liquid stools every day, which are somtimes green, but generally of a darkish yellow, with great flatulency both upwards and downwards at those times. An antimonial powder was once given, but instantly rejected; a spoonful of decoction of bark was also exhibited with the same event. His legs are bathed, and his hands and face are moistened twice a day for half an hour in warmish water, which is nevertheless much colder than his skin.
Eighth day. His skin continues hot and dry without any observable remissions, with liquid stools and much flatulency and sickness; his water when observed was of a straw colour. He has asked for cyder, and drinks nearly a bottle a day mixed with cold water, and takes three drops of laudanum twice a day.
Twelfth day. He continues much the same, takes no milk, drinks only cyder and water, skin hot and dry, tongue hot and furred, with liquid stools, and sickness always at the same time; sleeps much.
Sixteenth day. Was apparently more torpid, and once rather delirious; pulse 112. Takes only capillaire and water; sleeps much.
Twentieth day. Pulse 100, skin dry but less hot, liquid stools not so frequent, he is emaciated to a great degree, he has eaten half a tea-cup full of custard to day, drinks only capillaire and water, has thrice taken two large spoonfuls of decoction of bark with three drops of laudanum, refuses to have his legs bathed, and will now take nothing but three drops of laudanum twice a day.
Twenty-fourth day. He has gradually taken more custard every day, and began to attend to some new play things, and takes wine syllabub.
Twenty-eighth day. He daily grows stronger, eats eggs, and and b.u.t.ter, and sleeps immediately after his food, can creep on his hands and knees, but cannot stand erect.
Thirty-second day. He cannot yet stand alone safely, but seems hourly to improve in strength of body, and activity of mind.
In this case the remote cause of his fever could not be well ascertained, as it might be from having his feet cold for many successive days, or from contagion; but the latter seems more probable, because his younger brother became ill of a similar fever about three weeks afterwards, and probably received the infection from him. The disease commenced with great torpor of the stomach, which was shewn by his total aversion to solid food, and perpetual sickness; the watery stools, which were sometimes green, or of a darkish yellow, were owing to the acrimony, or acidity, of the contents of the bowels; which as well as the flatulency were occasioned by indigestion.
This torpor of the stomach continued throughout the whole fever, and when it ceased, the fever ceased along with it.
The contagious material of this fever I suppose to have been mixed with the saliva, and swallowed into the stomach; that it excited the vessels, which const.i.tute the stomach, into the greatest irritative motion like a.r.s.enic; _which might not be perceived, and yet might render that organ paralytic or inirritable in a moment of time_; as animals sometimes die by one single exertion, and consequent paralysis, without a second struggle; as by lightning, or being shot through the back part of the brain; of both which I have seen instances. I had once an opportunity of inspecting two oxen, a few minutes after they were killed by lightning under a crab-tree on moist ground in long gra.s.s; and observed, that they could not have struggled, as the gra.s.s was not pressed or bent near them; I have also seen two horses shot through the cerebellum, who never once drew in their legs after they first stretched them out, but died instantaneously; in a similar manner the lungs seem to be rendered instantly inanimate by the fumes of burning sulphur.
The lungs may be sometimes primarily affected with contagious matter floating in the atmosphere as well as the stomach, as mentioned in article 9. of this Supplement. But probably this may occur much less frequently, because the oxygene of the atmosphere does not appear to be taken into the blood by animal absorption, as the saliva in the stomach, but pa.s.ses through the moist membranes into the blood, like the ethereal fluids of electricity or heat, or by chemical attraction, and in consequence the contagious matter may be left behind; except it may sometimes be absorbed along with the mucus; of which however in this case there appeared no symptoms.
The tonsils are other organs liable to receive contagious matter, as in the small-pox, scarlet-fever, and in other sensitive inirritated fevers; but no symptom of this appeared here, as the tonsils were at no time of the fever inflamed, though they were in this child previously uncommonly large.
The pain of the forehead does not seem to have been of the internal parts of the head, because the nerves, which serve the stomach, are not derived from the anterior part of the brain; but it seems to have been owing to a torpor of the external membranes about the forehead from their direct sympathy with those of the stomach; that is, from the deficient excitement of the sensorial power of a.s.sociation; and seemed in some measure to be relieved by the emetics and blisters.
The pulsations of the heart were weaker and in consequence quicker than natural, owing to their direct sympathy with the torpid peristaltic motions of the stomach; that is to the deficient excitement of the sensorial power of a.s.sociation.
The action of the cutaneous capillaries and absorbents were stronger than natural, as appeared by the perpetual heat and dryness of the skin; which was owing to their reverse sympathy with the heart and arteries. This weaker and quicker action of the heart and arteries, and the stronger action of the cutaneous capillaries and absorbents, continued throughout the disease, and may be said to have const.i.tuted the fever, of which the torpor of the stomach was the remote cause.
His tongue was not very much furred or very dry, nor his breath very hot; which shewed, that there was no great increase of the action of the mucous absorbents, nor of the pulmonary capillaries, and yet sufficient to produce great emaciation. His urine was nearly natural both in quant.i.ty and colour; which shewed, that there was no increase of action either of the kidnies, or of the urinary absorbents.
The bathing his legs and hands and face for half an hour twice a day seemed to refresh him, and sometimes made his pulse slower, and thence I suppose stronger. This seems to have been caused by the water, though subtepid, being much below the heat of his skin, and consequently contributing to cool the capillaries, and by satiating the absorbents to relieve the uneasy sensation from the dryness of the skin.
He continued the use of three drops of tincture of opium from about the eighth day to the twenty-fourth, and for the three preceding days took along with if two large spoonfuls of an infusion of bark in equal parts of wine and water. The former of these by its stimulus seemed to decrease his languor for a time, and the latter to strengthen his returning power of digestion.
The daily exacerbations or remissions were obscure, and not well attended to; but he appeared to be worse on the fourteenth or fifteenth days, as his pulse was then quickest, and his inattention greatest; and he began to get better on the twentieth or twenty-first days of his disease; for the pulse then became less frequent, and his skin cooler, and he took rather more food: these circ.u.mstances seemed to observe the quarter periods of lunation.
XIV. _Termination of continued fever._
1. When the stomach is primarily affected with torpor not by defect of stimulus, but in consequence of the previous exhaustion of its sensorial power; and not secondarily by its a.s.sociation with other torpid parts; it seems to be the general cause of the weak pulsations of the heart and arteries, and the consequent increased action of the capillaries, which const.i.tute continued fever with weak pulse. In this situation if the patient recovers, it is owing to the renovation of life in the torpid stomach, as happens to the whole system in winter-sleeping animals. If he perishes, it is owing to the exhaustion of the body for want of nourishment occasioned by indigestion; which is hastened by the increased actions of the capillaries and absorbents.
2. When the stomach is primarily affected by defect of stimulus, as by cold or hunger; or secondarily by defect of the power of a.s.sociation, as in intermittent fevers; or lastly in consequence of the introduction of the sensorial power of sensation, as in inflammatory diseases; the actions of the heart and arteries are not diminished, as when the stomach is primarily affected with torpor by its previous exhaustion of sensorial power, but become greatly increased, producing irritative or inflammatory fever. Where this fever is continued, though with some remissions and exacerbations, the excessive action is at length so much lessened by expenditure of sensorial power, as to gradually terminate in health; or it becomes totally exhausted, and death succeeds the destruction of the irritability and a.s.sociability of the system.
3. There is also another termination of the diseases in consequence of great torpor of the stomach, which are not always termed fevers; one of these is attended with so great and universal torpor, that the patient dies in the first cold fit; that is, within twelve hours or less of the first seizure; this is commonly termed sudden death. But the quickness of the pulse, and the coldness with shuddering, and with sick stomach, distinguished a case, which I lately saw, from the sudden deaths occasioned by apoplexy, or ruptured blood-vessels.
In hemicrania I believe the stomach is always affected secondarily, as no quickness of pulse generally attends it, and as the stomach recovers its activity in about two whole days. But in the following case, which I saw last week, I suppose the stomach suddenly became paralytic, and caused in about a week the death of the patient. Miss ----, a fine young lady about nineteen, had bathed a few times, about a month before, in a cold spring, and was always much indisposed after it; she was seized with sickness, and cold shuddering, with very quick pulse, which was succeeded by a violent hot fit; during the next cold paroxysm she had a convulsion fit; and after that symptoms of insanity, so as to strike and bite the attendants, and to speak furious language; the same circ.u.mstances occurred during a third fit, in which I believe a strait waistcoat was put on, and some blood taken from her; during all this time her stomach would receive no nutriment, except once or twice a little wine and water. On the seventh day of the disease, when I saw her, the extremities were cold, the pulse not to be counted and she was unable to swallow, or to speak; a clyster was used with turpentine and musk and opium, with warm fomentations, but she did not recover from that cold fit.
In this case the convulsion fit and the insanity seem to have been violent efforts to relieve the disagreeable sensation of the paralytic stomach; and the quick pulse, and returning fits of torpor and of o.r.g.a.s.m, evinced the disease to be attended with fever, though it might have been called anorexia maniacalis, or epileptica.
4. Might not many be saved in these fevers with weak pulse for a few weeks by the introduction of blood into a vein, once in two or three days; which might thus give further time for the recovery of the torpid stomach? Which seems to require some weeks to acquire its former habits of action, like the muscles of paralytic patients, who have all their habits of voluntary a.s.sociations to form afresh, as in infancy.
If this experiment be again tried on the human subject, it should be so contrived, that the blood in pa.s.sing from the well person to the sick one should not be exposed to the air; it should not be cooled or heated; and it should be measured; all which may be done in the following manner. Procure two silver pipes, each about an inch long, in the form of funnels, wide at top, with a tail beneath, the former something wider than a swan-quill, and the latter less than a small crow-quill. Fix one of these silver funnels by its wide end to one end of the gut of a chicken fresh killed about four or six inches long, and the other to the other end of the gut; then introduce the small end of one funnel into the vein of the arm of a well person downwards towards the hand; and laying the gut with the other end on a water-plate heated to 98 degrees in a very warm room; let the blood run through it. Then pressing the finger on the gut near the arm of the well person, slide it along so as to press out one gutful into a cup, in order to ascertain the quant.i.ty by weight. Then introduce the other end of the other funnel into a similar vein in the arm of the sick person upwards towards the shoulder; and by sliding one finger, and then another reciprocally, along the chicken"s gut, so as to compress it, from the arm of the well person to the arm of the sick one, the blood may be measured, and thus the exact quant.i.ty known which is given and received. See Cla.s.s I.
2. 3. 25.
XV. _Inflammation excited in fever._
1. When the actions of any part of the system of capillaries are excited to a certain degree, sensation is produced, along with a greater quant.i.ty of heat, as mentioned in the fifth article of this supplement. When this increased capillary action becomes still more energetic, by the combined sensorial powers of sensation with irritation, new fibres are secreted, or new fluids, (which harden into fibres like the mucus secreted by the silk-worm, or spider, or pinna,) from which new vessels are constructed; it is then termed inflammation: if this exists in the capillary vessels of the cellular membrane or skin only, with feeble pulsations of the heart and arteries, the febris sensitiva inirritata, or malignant fever, occurs; if the coats of the arteries are also inflamed, the febris sensitiva irritata, or inflammatory fever, exists.
In all these fevers the part inflamed is called a phlegmon, and by its violent actions excites so much pain, that is, so much of the sensorial power of sensation, as to produce more violent actions, and inflammation, throughout the whole system. Whence great heat from the excited capillaries of the skin, large and quick pulsations of the heart, full and hard arteries, with great universal secretions and absorptions. These perpetually continue, though with exacerbations and remissions; which seem to be governed by solar or lunar influence.
2. In this situation there generally, I suppose, exists an increased activity of the secerning vessels of the brain, and consequently an increased production of sensorial power; in less violent quant.i.ty of this disease however the increase of the action of the heart and arteries may be owing simply to the acc.u.mulation of sensorial power of a.s.sociation in the stomach, when that organ is affected by sympathy with some inflamed part.
In the same manner as the capillaries are violently and permanently actuated by the acc.u.mulation of the sensorial power of a.s.sociation in the heart and arteries, when the stomach is affected primarily by contagious matter, and the heart and arteries secondarily. Thus I suspect, that in the distinct small-pox the stomach is affected secondarily by sympathy with the infected tonsils or inoculated arm; but that in the confluent small-pox the stomach is affected primarily, as well as the tonsils, by contagious matter mixed with the saliva, and swallowed.
3. In inflammatory fevers with great arterial action, as the stomach is not always affected with torpor, and as there is a direct sympathy between the stomach and heart, some people have believed, that nauseating doses of some emetic drug, as of antimonium tartarizatum, have been administered with advantage, abating by direct sympathy the actions of the heart. This theory is not ill founded, and the use of digitalis, given in small doses, as from half a dram to a dram of the saturated tincture, two or three times a day, as well as other less violent emetic drugs, would be worth the attention of hospital physicians.
Sickness might also be produced probably with advantage by whirling the patient in a chair suspended from the cieling by two parallel cords; which after being revolved fifty or one hundred times in one direction, would return with great circular velocity, and produce vertigo, similar I suppose to sea-sickness. And lastly the sickness produced by respiring an atmosphere mixed with one tenth of carbonated hydrogen, discovered by Mr.
Watt, and published by Dr. Beddoes, would be well worthy exact and repeated experiment.
4. Cool air, cool fomentations, or ablutions, are also useful in this inflammatory fever; as by cooling the particles of blood in the cutaneous and pulmonary vessels, they must return to the heart with less stimulus, than when they are heated above the natural degree of ninety-eight. For this purpose snow and ice have been scattered on the patients in Italy; and cold bathing has been used at the eruption of the small pox in China, and both, it is said, with advantage. See Cla.s.s III. 2. 1. 12. and Suppl. I. 8.
5. The lancet however with repeated mild cathartics is the great agent in destroying this enormous excitement of the system, so long as the strength of the patient will admit of evacuations. Blisters over the painful part, where the phlegmon or topical inflammation is situated, after great evacuation, is of evident service, as in pleurisy. Warm bathing for half an hour twice a day, when the patient becomes enfeebled, is of great benefit, as in peripneumony and rheumatism.
6. When other means fail of success in abating the violent excitement of the system in inflammatory diseases, might not the shaved head be covered with large bladders of cold water, in which ice or salt had been recently dissolved; and changed as often as necessary, till the brain is rendered in some degree torpid by cold?--Might not a greater degree of cold, as iced water, or snow, be applied to the cutaneous capillaries?
7. Another experiment I have frequently wished to try, which cannot be done in private practice, and which I therefore recommend to some hospital physician; and that is, to endeavour to still the violent actions of the heart and arteries, after due evacuations by venesection and cathartics, by gently compressing the brain. This might be done by suspending a bed, so as to whirl the patient round with his head most distant from the center of motion, as if he lay across a millstone, as described in Sect. XVIII. 20.
For this purpose a perpendicular shaft armed with iron gudgeons might have one end pa.s.s into the floor, and the other into a beam in the cieling, with an horizontal arm, to which a small bed might be readily suspended.
By thus whirling the patient with increasing velocity sleep might be produced, and probably the violence of the actions of the heart and arteries might be diminished in inflammatory fevers; and, as it is believed, that no acc.u.mulation of sensorial power would succeed a torpor of the origin of the nerves, either thus procured by mechanical compression, or by the bladder-cap of cold water above described, the lives of thousands might probably be saved by thus extinguishing the exacerbations of febrile paroxysms, or preventing the returns of them.
In fevers with weak pulse sleep, or a degree of stupor, thus produced, might prevent the too great expenditure of sensorial power, and thus contribute to preserve the patient. See Cla.s.s I. 2. 5. 10. on stupor. What might be the consequence of whirling a person with his head next the center of motion, so as to force the blood from the brain into the other parts of the body, might be discovered by cautious experiment without danger, and might probably add to our ability of curing fever.
XVI. _Recapitulation._
1. The sensorial power causes the contraction of the fibres, and is excited into action by four different circ.u.mstances, by the stimulus of external bodies, by pain or pleasure, by desire or aversion, or by the previous motions of other contracting fibres. In the first situation it is called the sensorial power of irritation, in the second the sensorial power of sensation, in the third the sensorial power of volition, and in the fourth the sensorial power of a.s.sociation.
Many parts of the body are excited into perpetual action, as the sanguiferous vessels consisting of the heart, arteries, and veins; others into nearly perpetual action, as the conglomerate and capillary glands; and others into actions still somewhat less frequent, as the alimentary ca.n.a.l, and the lacteal and lymphatic absorbents with their conglobate glands: all these are princ.i.p.ally actuated by the sensorial powers of irritation, and of a.s.sociation; but in some degree or at some times by those of sensation, and even of volition. There are three kinds of stimulus, which may easily be occasionally diminished, that of heat on the skin, of food in the stomach, and of the oxygenous part of the atmosphere, which mixes with the blood in respiration, and stimulates the heart and arteries.
2. When any parts, which are naturally excited into perpetual action by stimulus, become torpid or less active from decrease of that stimulus; there first occurs a decrease of the activity of the parts next catenated with them; thus going into cold water produces a torpor of the capillary vessels of the lungs, as is known by the difficult respiration, which immediately occurs; for the sensorial power of a.s.sociation, which naturally contributes to actuate the lungs, is now less excited by the decreased actions of the cutaneous vessels, with which they are catenated. This const.i.tutes the cold fit of fever.
There next occurs an acc.u.mulation of the sensorial power of irritation in the parts, which were torpid from defect of stimulus, as the cutaneous vessels for instance when exposed to cold air; and a similar acc.u.mulation of the sensorial power of a.s.sociation occurs in the parts which were catenated with the former, as the vessels of the lungs in the example above mentioned. Whence, if the subduction of stimulus has not been too great, so as to impair the health of the part, the activity of the irritative motions returns, even though the stimulus continues less than usual; and those of the a.s.sociate motions become considerably increased, because these latter are now excited by the previous fibrous motions, which now act as strong or stronger than formerly, and have also acquired an acc.u.mulation of the sensorial power of a.s.sociation. This accounts for the curious event of our becoming warm in a minute or two after remaining in water of about 80 degrees of heat, as in the bath at Buxton; or in the cold air of a frosty morning of about 30 degrees of heat.
But if the parts thus possessed of the acc.u.mulated sensorial powers of irritation and of a.s.sociation be exposed again to their natural quant.i.ty of stimulus, a great excess of activity supervenes; because the fibres, which possess acc.u.mulated irritation, are now excited by their usual quant.i.ty of stimulus; and those which possess acc.u.mulated a.s.sociation, are now excited by double or treble the quant.i.ty of the preceding irritative fibrous motions, with which they are catenated; this const.i.tutes the hot fit of fever.
Another important circ.u.mstance occurs, when the parts, which are torpid from decreased stimulus, do not acc.u.mulate a quant.i.ty of sensorial power sufficient for the purpose of renewing their own natural quant.i.ty of action; but are nevertheless not so torpid, as to have the life of the part impaired. In this situation the superabundance of the acc.u.mulated power of irritation contributes to actuate the a.s.sociate motions next catenated with them. Thus, when a person breathes air with less oxygene than natural, as by covering his head in bed, and thus respiring the same atmosphere repeatedly, the heart and arteries become less active by defect of the stimulus of oxygene; and then the acc.u.mulation of sensorial power of irritation becomes instantly very great, as these organs are subject to perpetual and energetic action. This acc.u.mulation nevertheless is not so great as to renew their own activity under this defect of stimulus, but yet is in sufficient abundance to increase the a.s.sociability of the next link of catenation, that is, to actuate the capillaries of the skin with great and perpetual increase of energy. This resembles continued fever with weak pulse; in which the acc.u.mulation of the sensorial power caused by the lessened motions of the heart and arteries, actuates the capillaries with increase of energy.
3. When the acc.u.mulation of the sensorial power of a.s.sociation, which is caused as above explained by deficient excitement owing to the lessened quant.i.ty of action of the irritative fibrous motions, with which the a.s.sociate train is catenated, is not in quant.i.ty sufficient to renew the natural actions of the first link of an a.s.sociate train of motions; it is nevertheless frequently so abundant as to actuate the next link of the a.s.sociated train with unnatural energy by increasing its a.s.sociability; and that in a still greater degree if that second link of the a.s.sociated train was previously in a torpid state, that is, had previously acquired some acc.u.mulation of the sensorial power of a.s.sociation. This important circ.u.mstance of the animal economy is worthy our most accurate attention.