7. Nevertheless in some circumstances the stomach and the heart and arteries seem to act by direct sympathy with the cutaneous capillaries, as in the flushing of the face and glow of the skin of some people after dinner; and as in fevers with strong pulse. In these cases there appears to be an increased production of sensorial power, either of sensation, as in the blush of shame; or of volition, as in the blush of anger; or of irritation, as in the flushed face after dinner above mentioned.
This increased action of the capillaries of the skin along with the increased actions of the stomach and heart is perhaps to be esteemed a synchronous increase of action, rather than a sympathy between those organs. Thus the flushing of the face after dinner may be owing to the secretion of sensorial power in the brain being increased by the association of that organ with the stomach, in a greater proportion than the increased expenditure of it, or may be owing also to the stimulus of new chyle received into the blood.
8. When the stomach and the heart and arteries are rendered torpid in fevers, not only the cutaneous, cellular, and pulmonary absorbents are excited to act with greater energy; but also their correspondent capillaries and secerning vessels or glands, especially perhaps those of the skin, are induced into more energetic action. Whence greater heat, a greater secretion of perspirable matter, and of mucus; and a greater absorption of them both, and of aerial moisture. These reverse sympathies coincide with other animal facts, as in eruption of small pox on the face and neck the feet become cold, while the face and neck are much flushed; and in the hemiplagia, when one arm and leg become disobedient to volition, the patient is perpetually moving the other. Which are well accounted for by the accumulation of sensorial power in one part of an associated series of actions, when less of it is expended by another part of it; and by a deficiency of sensorial power in the second link of association, when too much of it is expended by the first.
9. This doctrine of reverse sympathy enables us to account for that difficult problem, why in continued fevers the increased action of the cutaneous, cellular, and pulmonary capillaries proceeds without interruption or return of cold fit; though perhaps with some exacerbations and remissions; and that during a quarter, or half, or three quarters, or a whole lunation; while at the same time the pulsations of the heart and arteries are weaker than natural.
To this should be added the direct sympathy, which exists between the peristaltic motions of the fibres of the stomach, and the pulsations of the heart. And that the stomach has become torpid by the too great stimulus of some poisonous or contagious matter; and this very intricate idea of continued fever with feeble pulse is reduced to curious simplicity.
The direct sympathy of the stomach and heart and arteries not only appears from the stronger and slower pulse of persons exhausted by fatigue, after they have drank a glass of wine, and eaten a few mouthfuls; but appears also from the exhibition of large doses of digitalis; when the patient labours under great and incessant efforts to vomit, at the same time that the actions of the absorbent system are known to be much increased by the hasty absorption of the serous fluid in anasarca, the pulsations of the heart become slow and intermittent to an alarming degree. See ClassIV. 2. 1. 17. and18.
10. It would assist us much in the knowledge and cure of fevers, if we could always determine, which part of the system was primarily affected; and whether the torpor of it was from previous excess or defect of stimulus; which the industry of future observers must discover. Thus if the stomach be affected primarily, and that by previous excess of stimulus, as when certain quantities of opium, or wine, or blue vitriol, or arsenic, are swallowed, it is some time in recovering the quantity of sensorial power previously exhausted by excess of stimulus, before any accumulation of it can occur. But if it be affected with torpor secondarily, by sympathy with some distant part; as with the torpid capillaries of the skin, that is by defective excitement of the sensorial power of association; or if it be affected by defect of stimulus of food or of heat; it sooner acquires so much accumulation of sensorial power, as to be enabled to accommodate itself to its lessened stimulus by increase of its irritability.
Thus in the hemicrania the torpor generally commences in a diseased tooth, and the membranes about the temple, and also those of the stomach become torpid by direct synchronous sympathy; and pain of the head, and sickness supervene; but no fever or quickness of pulse. In this case the torpor of the stomach is owing to defect of the sensorial power of association, which is caused by the too feeble actions of the membranes surrounding the diseased tooth, and thus the train of sympathy ceases here without affecting the motions of the heart and arteries; but where contagious matter is swallowed into the stomach, the stomach after a time becomes torpid from exhaustion of the sensorial power of irritation, and the heart and arteries act feebly from defect of the excitement of the power of association. In the former case the torpor of the stomach is conquered by accumulation of the power of association in one or two whole days; in the latter it recovers by accumulation of the power of irritation in three or four weeks.
In intermittent fevers the stomach is generally I believe affected secondarily by sympathy with the torpid cutaneous capillaries, or with some internal torpid viscus, and on this account an accumulation of sensorial power arises in a few hours sufficient to restore the natural irritability of this organ; and hence the hot fit succeeds, and the fever intermits. Or if this accumulation of sensorial power becomes excessive and permanent, the continued fever with strong pulse is produced, or febris irritativa.
In continued fevers the stomach is frequently I suppose affected with torpor by previous excess of stimulus, and consequent exhaustion of sensorial power, as when contagious matter is swallowed with the saliva, and it is then much slower in producing an accumulation of sensorial power sufficient to restore its healthy irritability; which is a frequent cause of continued fever with weak pulse or febris inirritativa. Which consists, after the cold fit is over, in a more frequent and more feeble action of the heart and arteries, owing to their direct sympathy with the muscular fibres of the torpid stomach; together with an increased action of the capillaries, glands, and absorbents of the skin, and cellular membrane, owing to their reverse sympathy with the torpid capillaries, glands, and absorbents of the stomach, or with those of the heart and arteries.
Or in more accurate language. 1. The febris inirritativa, or fever with weak pulse, commences with torpor of the stomach, occasioned by previous exhaustion of sensorial power of irritation by the stimulus of contagious matter swallowed with the saliva. 2. The whole system becomes torpid from defect of the excitement or the sensorial power of association owing to the too feeble actions of the stomach, this is the cold fit. 3. The whole system, except the stomach with the upper intestines, and the heart and arteries, falls into increased action, or orgasm, owing to accumulation of sensorial power of association during their previous torpor, this is the hot fit. 4. The stomach and upper intestines have not acquired their natural quantity of sensorial power of irritation, which was previously exhausted by violent action in consequence of the stimulus of contagious matter, and the heart and arteries remain torpid from deficient excitement of the sensorial power of association owing to the too feeble actions of the stomach. 5. The accumulation of sensorial power of association in consequence of the torpor of the heart and arteries occasions a perpetual orgasm, or increased action of the capillaries.
11. From hence it may be deducted first, that when the torpor of the stomach first occurs, either as a primary effect, or as a secondary link of some associate train or circle of motions, a general torpor of the system sometimes accompanies it, which constitutes the cold fit of fever; at other times no such general torpor occurs, as during the operation of a weak emetic, or during sea-sickness.
Secondly. After a time it generally happens, that a torpor of the stomach ceases, and its actions are renewed with increase of vigour by accumulation of sensorial power during its quiescence; as after the operation of a weak emetic, or at the intervals of sea-sickness, or after the paroxysm of an intermittent fever.
Thirdly. The stomach is sometimes much slower in recovering from a previous torpor, and is then the remote cause of continued fever with weak pulse; which is owing to a torpor of the heart and arteries, produced in consequence of the deficient excitement of the power of association by the too weak actions of the stomach; and to an orgasm of the capillaries of the other parts of the system, in consequence of the accumulation of sensorial power occasioned by the inactivity of the heart and arteries.
Fourthly. The torpor of the stomach is sometimes so complete, that probably the origin of its nerves is likewise affected, and then no accumulation of sensorial power occurs. In this case the patient dies for want of nourishment; either in three or four weeks, of the inirritative fever; or without quick pulse, by what we have called paresis irritativa. Or he continues many years in a state of total debility. When this torpor suddenly commences, the patient generally suffers epileptic fits or temporary insanity from the disagreeable sensation of so great a torpor of the stomach; which also happens sometimes at the eruption of the distinct small pox; whence we have termed this disease anorexia epileptica. See ClassII. 2. 2. 1. andIII. 1. 1. 7. and Suppl. I.14. 3.
Fifthly. When this torpor of the stomach is less in degree or extent, and yet without recovering its natural irritability by accumulation of sensorial power, as it does after the cold fit of intermittent fever, or after the operation of mild emetics, or during syncope; a permanent defect of its activity, and of that of the upper intestines, remains, which constitutes apepsia, cardialgia, hypochondriasis, and hysteria. See ClassI. 3. 1. 3. andI. 2. 4. 5.
Sixthly. If the torpor of the stomach be induced by direct sympathy, as in consequence of a previous torpor of the liver, or spleen, or skin, an accumulation of sensorial power will sooner be produced in the stomach; because there has been no previous expenditure of it, the present torpor of the stomach arising from defect of association. Hence some fevers perfectly intermit, the stomach recovering its complete action after the torpor and consequent orgasm, which constitute the paroxysm of fever, are terminated.
Seventhly. If the torpor of the stomach be owing to defect of irritation, as to the want of food, an accumulation of sensorial power soon occurs with an increase of digestion, if food be timely applied; or with violent inflammation, if food be given in too great quantity after very long abstinence.
Eighthly. If the torpor of the stomach be induced by defect of pleasurable sensation, as when sickness is caused by the suggestion of nauseous ideas; an accumulation of sensorial power soon occurs, and the sickness ceases with the return of hunger; for in this case the inactivity of the stomach is occasioned by the subduction of agreeable sensation, which acts as a subduction of stimulus, and not by exhausting the natural quantity of sensorial power in the fibres or nerves of the stomach.
Ninthly. If the torpor of the stomach be induced by a twofold cause, as in sea-sickness. See Vertigo rotatoria. ClassIV. 2. 1. 10. in which the first link of association acts too strongly, and in consequence expends more than usual of the sensorial power ofirritation; and secondly in which sensation is produced between the links of association, and dissevers or enfeebles them; the accumulation of sensorial power soon occurs in the stomach; as no previous expenditure of it in that organ has occurred. Whence in sea-sickness the persons take food with eagerness at times, when the vertigoeasesfor a few minutes.
Tenthly. If the gastric torpor be induced by previous violent exertion, as after intoxication, or after contagious matter has been swallowed, or some poisons, as digitalis, or arsenic; an accumulation of sensorial power very slowly succeeds; whence long sickness, or continued fever, because the quantity of sensorial power already wasted must first be renewed, before an accumulation of it can be produced.
12. This leads us to a second indication of cure in continued fevers, which consists in strengthening the actions of the stomach; as the first indication consisted in decreasing the actions of the cutaneous capillaries and absorbents. The actions of the stomach may sometimes be increased by exhibiting a mild emetic; as an accumulation of sensorial power in the fibres of the stomach is produced during their retrograde actions. Besides the evacuation of any noxious material from the stomach and duodenum, and from the absorbents, which open their mouths on their internal surfaces, by their retrograde motion.
It is probable, that when mild emetics are given, as ipecacuanha, or antimonium tartarizatum, or infusion of chamomile, they are rejected by an inverted motion of the stomach and œsophagus in consequence of disagreeable sensation, as dust is excluded from the eye; and these actions having by previous habit been found effectual, and that hence there is no exhaustion of the sensorial power of irritation. But where strong emetics are administered, as digitalis, or contagious matter, the previous exhaustion of the sensorial power of irritation seems to be a cause of the continued retrograde actions and sickness of the stomach. An emetic of the former kind may therefore strengthen the power of the stomach immediately after its operation by the accumulation of sensorial power of irritation during its action. See ClassIV. 1. 1.
Another method of decreasing the action of the stomach for a time, and thence of increasing it afterwards, is by the accumulation of the sensorial power of irritation during its torpor; is by giving ice, iced water, iced creams, or iced wine. This accounts for the pleasure, which many people in fevers with weak pulse express on drinking cold beverage of any kind.
A second method of exciting the stomach into action, and of decreasing that of the capillaries in consequence, is by the stimulus of wine, opium, bark, metallic salts of antimony, steel, copper, arsenic, given in small repeated quantities; which so long as they render the pulse slower are certainly of service, and may be given warm or cold, as most agreeable to the patient. For it is possible, that the capillaries of the stomach may act too violently, and produce heat, at the same time that the large muscles of it may be in a torpid state; which curious circumstance future observations must determine.
Thirdly. Hot fomentation on the region of the stomach might be of most essential service by its stimulus, as heat penetrates the system not by the absorbent vessels, but by external influence; whence the use of hot fomentation to the head in torpor of the brain; and the use of hot bath in cases of general debility, which has been much too frequently neglected from a popular error occasioned by the unmeaning application of the word relaxation to animal power. If the fluid of heat could be directed to pass through particular parts of the body with as little diffusion of its influence, as that of electricity in the shocks from the coated jar, it might be employed with still greater advantage.
Fourthly. The use of repeated small electric shocks through the region of the stomach might be of service in fevers with weak pulse, and well deserves a trial; twenty or thirty small shocks twice a day for a week or two would be a promising experiment.
Fifthly. A blister on the back, or sides, or on the pit of the stomach, repeated in succession, by stimulating the skin frequently strengthens the action of the stomach by exciting the sensorial power of association; this especially in those fevers where the skin of the extremities, as of the hands or nose or ears, sooner becomes cold, when exposed to the air, than usual.
Sixthly. The action of the stomach may be increased by preventing too great expenditure of sensorial power in the link of previous motion with which it is catenated, especially if the action of that link be greater than natural. Thus as the capillaries of the skin act too violently in fevers with weak pulse, if these are exposed to cold air or cold water, the sensorial power, which previously occasioned their orgasm, becomes accumulated, and tends to increase the action of the stomach; thus in those fevers with weak pulse and hot skin, if the stomach be stimulated by repeated small doses of bark and wine or opium, and be further excited at the same time by accumulation of sensorial power occasioned by rendering the capillaries torpid by cold air or water, this twofold application is frequently attended with visible good effect.
By thus stimulating the torpid stomach into greater action, the motions of the heart and arteries will likewise be increased by the greater excitement of the power of association. And the capillaries of the skin will cease to act so violently, from their not possessing so great a superfluity of sensorial power as during the greater quiescence of the stomach and of the heart and arteries. Which is in some circumstances similar to the curious phenomenon mentioned in ClassIV. 2. 2. 10; where, by covering the chill feet with flannel at the eruption of the small-pox, the points of the flannel stimulate the skin of the feet into greater action, and the quantity of heat, which they possess, is also confined, or insulated, and further increases by its stimulus the activity of the cutaneous vessels of the feet; and by that circumstance abates the too great action of the capillaries of the face, and the consequent heat of it.
XIII.Case of continued fever.
The following case of continued fever which I frequently saw during its progress, as it is less complicate than usual, may illustrate 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 classical 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 ratherdelirious; 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 butter, 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 constitute the stomach, into the greatest irritative motion like arsenic;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 grass; and observed, that they could not have struggled, as the grass 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 article9. 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 passes 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 association; 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 association.
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 constituted 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 quantity 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 circumstances 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 association 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 constitute 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 association, 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 associability 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 circumstances 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 orgasm, 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 associations 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 passing 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 quantity 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 quantity known which is given and received. See ClassI. 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 quantity 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 quantity of this disease however the increase of the action of the heart and arteries may be owing simply to the accumulation of sensorial power of association 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 accumulation of the sensorial power of association 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 ClassIII. 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 pass 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 accumulation 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 ClassI. 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 circumstances, 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 association.
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 canal, and the lacteal and lymphatic absorbents with their conglobate glands: all these are principally actuated by the sensorial powers of irritation, and of association; 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 association, 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 constitutes the cold fit of fever.
There next occurs an accumulation 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 accumulation of the sensorial power of association 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 associate 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 accumulation of the sensorial power of association. 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 accumulated sensorial powers of irritation and of association be exposed again to their natural quantity of stimulus, a great excess of activity supervenes; because the fibres, which possess accumulated irritation, are now excited by their usual quantity of stimulus; and those which possess accumulated association, are now excited by double or treble the quantity of the preceding irritative fibrous motions, with which they are catenated; this constitutes the hot fit of fever.
Another important circumstance occurs, when the parts, which are torpid from decreased stimulus, do not accumulate a quantity of sensorial power sufficient for the purpose of renewing their own natural quantity of action; but are nevertheless not so torpid, as to have the life of the part impaired. In this situation the superabundance of the accumulated power of irritation contributes to actuate the associate 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 accumulation of sensorial power of irritation becomes instantly very great, as these organs are subject to perpetual and energetic action. This accumulation 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 associability 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 accumulation of the sensorial power caused by the lessened motions of the heart and arteries, actuates the capillaries with increase of energy.
3. When the accumulation of the sensorial power of association, which is caused as above explained by deficient excitement owing to the lessened quantity of action of the irritative fibrous motions, with which the associate train is catenated, is not in quantity sufficient to renew the natural actions of the first link of an associate train of motions; it is nevertheless frequently so abundant as to actuate the next link of the associated train with unnatural energy by increasing its associability; and that in a still greater degree if that second link of the associated train was previously in a torpid state, that is, had previously acquired some accumulation of the sensorial power of association. This important circumstance of the animal economy is worthy our most accurate attention. Thus if the heart and arteries are deprived of their due quantity of the stimulus of oxygene in the blood, a weak and quick pulse ensues, with an accumulation of the sensorial power of irritation; next follows an increase of the action of the capillaries by the superabundance of this accumulated power of irritation; but there also exists an accumulation of the power of association in these acting capillaries, which is not now excited by the deficient actions of the heart and arteries; but which by its abundance contributes to actuate the next link of association, which is the sick stomach in the case related from Sydenham in ClassIV. 1. 1. 2. and explained in this Supplement I.4. And as this sick stomach was in a previous state of torpor, it might at the same time possess an accumulation of some sensorial power, which, if it was of association, would be thus more powerfully excited by the increased actions of the capillaries; which existed in consequence of the weak action of the heart and arteries. This also resembles in some respects the continued fevers with weak pulse, and with increased activity of the capillaries.
4. When a torpor of some irritative motions occurs from a previous exhaustion of the sensorial power of irritation by the action of some very great stimulus, it is long before any accumulation of the sensorial power of irritation is produced; as is experienced in the sickness and languor, which continues a whole day after a fit of drunkenness. But nevertheless there occurs an accumulation of the sensorial power of association in the first link of the associate train of motions, which is catenated with these torpid irritative ones; which accumulation is owing to deficient excitement of that sensorial power in the first link of the associate train. This first link therefore exists also in a less active or torpid state, but the accumulation of the sensorial power of association by its superabundance contributes to actuate the second link of the associate train with unnatural quantity of motion; and that though its own natural quantity of the power of association is not excited by the deficient action of preceding fibrous motions.
When this happens to the stomach, as after its irritative motions have been much exerted from the unnatural stimulus of wine, or opium, or of contagious matter mixed with the saliva, a torpor or inactivity of it succeeds for a greater or less length of time; as no accumulation of the sensorial power of irritation can occur, till the natural quantity, which has been previously expended, is first restored. Then the heart and arteries which are next in catenation, become less active from the want of sufficient excitement of the sensorial power of association, which previously contributed to actuate them. This sensorial power of association therefore becomes accumulated, and by its superabundance contributes to actuate the link next in association, which has thus acquired so great a degree of associability, as to overbalance the less quantity of the excitement of it by the torpid action of the previous or first associate link. This happens to the capillaries, when the heart and arteries are affected as above by the torpor of the stomach, when it is occasioned by previous great expenditure of its sensorial power, and thus constitutes fever with weak pulse, which is here termed inirritative fever, typhus mitior.
5. When a deficiency of stimulus is too great or too long continued, so as to impair the life of the part, no further accumulation of sensorial power occurs; as when the skin is long exposed to cold and damp air. In that case the link in catenation, that is, the first of the associate train, is rendered torpid by defect of excitement of its usual quantity of the sensorial power of association, and from there being no accumulation of the sensorial power of irritation to increase its associability, and thus to contribute to actuate it by overbalancing the defect of the excitement of its association.
Thus on riding long and slowly on a cold and damp day, the exhalation of the vapour, which is impinged on the skin, as the traveller proceeds, carries away his warmth faster, than it is generated within the system; and thus the capillaries of the skin have their actions so much impaired after a time, that no accumulation of the sensorial power of irritation occurs; and then the stomach, whose motions are catenated with those of the capillaries, ceases to act from the deficient excitement of the power of association; and indigestion and flatulency succeed, instead of the increased digestion and hunger, which occur, when the cutaneous capillaries are exposed to a less degree of cold, and for a shorter time. In which latter situation the accumulation of the sensorial power of irritation increases by its superabundance the associability of the fibres of the stomach, so as to overbalance the defect of the excitement of their association.
6. The stomach is affected secondarily in fevers with strong pulse, as in those with weak pulse it is affected primarily. To illustrate this doctrine I shall relate the following case of Mr. Y——. He was a young man rather intemperate in the use of wine or beer, and was seized with a cold fit, and with a consequent hot one with strong pulse; on examining his hypochondrium an oblong tumour was distinctly felt on the left side of the stomach, which extended six or eight inches downward, and was believed to be a tumour of the spleen, which thus occasioned by its torpor the cold fit and consequent hot fit of fever with strong pulse. This fever continued, though with remissions, for two or three weeks; and the patient repeatedly lost blood, used cathartics with calomel and sena, and had frequent antimonial and saline medicines. And after he was much weakened by evacuations, the peruvian bark and small doses of steel removed the fever, but the tumour remained many years during the remainder of his life.
In this case the tumour of the spleen was occasioned by the torpor of the absorbent vessels; while the secerning vessels continued somewhat longer to pour their fluids into the cells of it. Then the inactivity of this viscus affected the whole system with torpor by the deficient excitement of the sensorial power of association, which contributes along with the irritation caused by their specific stimuli to actuate the whole sanguiferous, secerning, and absorbent vessels; and along with these the stomach, which possesses perhaps greater mobility, or promptitude to torpor or to orgasm, than any other part. And after a time all these parts recover their actions by the accumulation of their sensorial power of association. But the spleen not recovering its action from the accumulation of its power of irritation, as appeared from the continuance of the tumor, still affects the stomach by its defective irritative motions ceasing to excite the association, which ought to contribute to actuate it.
Hence the stomach continues torpid in respect to its motions, but accumulates its power of association; which is not excited into action by the defective motions of the spleen; this accumulation of the sensorial power of association now by its superabundance actuates the next link of associate motions, which consists of the heart and arteries, into greater energy of action than natural, and thus causes fever with strong pulse; which, as it was supposed to be most frequently excited by increase of irritation, is called irritative fever or synocha.
Similar to this in the small pox, which is given by inoculation, the stomach is affected secondarily, when the fever commences; and hence in this small-pox the pulsations of the heart and arteries are frequently stronger than natural, but never weaker, for the reasons above given. Whereas in that small-pox, which is caused by the stomach being primarily affected, by the contagious matter being swallowed with the saliva, whether the tonsils are at the same time affected or not, the pulsations of the heart and arteries become weak, and the inirritative fever is produced, as explained above, along with the confluent small-pox. This unfolds the cause of the mildness of the inoculated small-pox; because in this disease the stomach is affected secondarily, whereas in the natural small-pox it is frequently affected primarily by swallowing the contagious matter mixed with saliva.
In the measles I suppose the contagious matter to be dissolved in the air, and therefore not liable to be mixed with the saliva; whereas the variolous matter is probably only diffused in the air, and thence more readily mixed with the saliva in the mouth during respiration. This difference appears more probable, as the small-pox I believe is always taken at a less distance from the diseased person than is necessary to acquire the measles. The contagion of the measles affects the membranes of the nostrils, and the secretion of tears in consequence, but never I suspect the stomach primarily, but always secondarily; whence the pulsation of the heart and arteries is always stronger than natural, so as to bear the lancet at any period of the disease.
The great mildness sometimes, and fatality at other times, of the scarlet fever may depend on the same circumstance; that is, on the stomach being primarily or secondarily affected by the contagious matter, observing that the tonsils may be affected at the same time with the stomach. Should this prove to be the case, which future observations must determine, what certain advantage must arise from the inoculation of this disease! When it is received by the skin primarily I suppose no sore throat attends it, nor fever with weak pulse; when it is received by the stomach primarily, the tonsils are affected at the same time, and the torpor of the stomach produces inirritative fever, and the mortification of the tonsils succeeds.
We may hence conclude, that when the torpor of the stomach is either owing to defect of stimulus, which is not so great as to impair the life of the part, as in moderate hunger, or in swallowing iced water, or when its torpor is induced by its catenation or association with other torpid parts, as in the commencement of intermittent fevers, and inoculated small-pox, that the subsequent action of the heart and arteries is generally increased, producing irritative fever. Which is owing to the accumulation, of the sensorial power of irritation in one case, and of association in the other, contributing to actuate the next link of the catenated or associated motions. But when the torpor of the stomach is induced by previous exhaustion of its sensorial powers of irritation or of association by continued violent action, as by the stimulus of digitalis, or of contagious matter, or after intoxication from wine or opium, a weaker action of the heart and arteries succeeds, because there is no accumulation of sensorial power, and a deficient excitement of association. And finally, as this weak action of the heart and arteries is not induced by exhaustion of sensorial power, but by defect of the excitement of association, the accumulation of this power of association increases the action of the capillaries, and thus induces inirritative fever.
7. When any part of the system acts very violently in fevers, the sensorial power of sensation is excited, which increases the actions of the moving system; whereas the pain, which arises from decreased irritative motions, as in hemicrania, seems to exhaust a quantity of sensorial power, without producing or increasing any fibrous actions.
When the stomach is primarily affected, as in inirritative fevers from contagion, and in such a manner as to occasion pain, the action of the capillaries seems to be increased by this additional sensorial power of sensation, whence extensive inflammation or mortification; but when the stomach and consequently the heart and arteries continue their torpidity of action; as in confluent small-pox, and fatal scarlatina; this constitutes sensitive inirritative fever, or typhus gravior.
But when the stomach is secondarily affected, if the sensorial power of sensation is excited, as in pleurisy or peripneumony, the actions of the heart and arteries are violently increased, and of all the moving system along with them. Thus the peripneumony is generally induced by the patient respiring very cold air, and this especially after being long confined to warm air, or after being much fatigued and heated by excessive labour or exercise. For we can cover the skin with more clothes, when we feel ourselves cold; but the lungs not having the perception of cold, we do not think of covering them, nor have the power to cover them, if we desired it; and the torpor, thus produced is greater, or of longer duration, in proportion to the previous expenditure of sensorial power by heat or exercise.
This torpor of the lungs affects the skin with shuddering, and the stomach is also secondarily affected; next follows the violent action of the lungs from the accumulation of the power of irritation, and an inflammation of them follows this violent action. While the stomach recovers its activity by the increase of the excitement of the sensorial power of association, and along with it the heart and arteries, and the whole moving system. Hence this inflammation occurs during the hot fit of fever, and no cold fit succeeds, because the excess of the sensorial power of sensation prevents a succeeding torpor.
These new motions of certain parts of the system produce increased secretions of nutritious or organic mucus, which forms new vessels; these new vessels by their unusual motions produce new kinds of fluids; which are termed contagious, because they have the power, when introduced into a healthy body, of producing similar actions and effects, with or without fever, as in the small-pox and measles, or in the itch and venereal disease.
If any of these contagious matters affect the stomach with torpor either by their stimulus immediately applied, or by its sympathy with the parts first diseased, a fever is produced with sickness and want of appetite; as in small-pox, and scarlatina. If the stomach is not affected by contagious matter, no fever succeeds, as in itch, tinea, syphilis.
All these contagious matters are conceived to be harmless, till they have been exposed to the air, either openly or through a moist membrane; from which they are believed to acquire oxygene, and thence to become some kinds of animal acids. As the preparations of mercury cure venereal ulcers; as a quarter of a grain of sublimate dissolved in wine, and given thrice a day; this effect, seems to be produced either by its stimulating the absorbents in the ulcer to absorb the venereal matter before it has acquired oxygene; or by afterwards uniting with it chemically, and again depriving it of its acquired acidity. On either supposition it might probably be given with advantage in small-pox, and in all infectious diseases, both previous to their commencement, and during their whole progress.
8. The cold fits of intermittent fevers are caused by the torpor of some part owing to deficient irritation, and of the other parts of the system from deficient association. The hot fits are owing first to the accumulation of irritation in the part primarily affected, if it recovers its action, which does not always happen; and secondly to the accumulation of association in the other parts of the system, which during health are subject to perpetual action; and lastly also to the greater excitement of the power of association, when the part primarily affected recovers its irritability, and acts with greater energy than natural.
The deficient secretions in the cold fit depend on the torpor of the glandular system; and the increased secretions in the hot fit on their more energetic action. The thirst in the cold fit is owing to the deficient absorption from the skin, cellular membrane, and bladder; the thirst in the hot fit is owing to the too great dissipation of the aqueous part of the blood. The urine is pale and in smallquantityin the cold fit from deficient secretion of it, and from deficient absorption of its aqueous parts; it is high coloured, and sometimes deposits a sediment, in the hot fit from the greater secretion of it in the kidneys, and the greater absorption of its aqueous and saline part in the bladder. The dryness and scurf on the tongue and nostrils is owing to the increased heat of the air expired from the lungs, and consequent greater evaporation of the aqueous part of the mucus. The sweats appear in consequence of the declension of the hot fit, owing to the absorbent vessels of the skin losing their increased action sooner than the secerning ones; and to the evaporation lessening as the skin becomes cooler. The returns of the paroxysms are principally owing to the torpor of some less essential part of the system remaining after the termination of the last fit; and are also dependent on solar or lunar diurnal periods.
The torpor of the part, which induces the cold paroxysm, is owing to deficient irritation occasioned either by the subduction of the natural stimuli of food, or water, or pure air, or by deficiency of external influences, as of heat, or of solar or lunar gravitation. Or secondly, in consequence of the exhaustion of sensorial power by great previous exertions of some parts of the system, as of the limbs by great labour or exercise, or of the stomach by great stimulus, as by contagious matter swallowed with the saliva, or by much wine or opium previously taken into it. Or lastly a torpor of a part may be occasioned by some mechanic injury, as by a compression of the nerves of the part, or of their origin in the brain; as the sitting long with one leg crossed over the other occasions numbness, and as a torpor of the stomach, with vomiting frequently precedes paralytic strokes of the limbs.
As sleep is produced, either by defect of stimulus, or by previous exhaustion of sensorial power; so the accumulation of the sensorial power of volition in those muscles and organs of sense, which are generally obedient to it, awakens the sleeping person; when it has increased the quantity of voluntarity so much as to overbalance the defect of stimulus in one case, and the exhaustion of sensorial power in the other; which latter requires a much longer time of sleep than the former. So the cold paroxysm of fever is produced either by defect of stimulus, or by previous exhaustion of the sensorial power of some part of the system; and the accumulation of the sensorial power of irritation in that part renews the action of it, when it has increased its irritability so much as to overbalance the defect of stimulus in one case and the exhaustion of sensorial power in the other; which latter requires a much longer torpor or cold fit than the former.
But in the cold paroxysm of fever besides the torpor of one part of the system from defect of irritation, the remainder of it becomes torpid owing to defect of excitement of the sensorial power of association by the lessened action of the part first affected. This torpor of the general system remains, till the accumulation of the sensorial power of association has increased the associability so much as to overbalance the defect of the excitement of association; then the torpor ceases, and if the first affected part has recovered its activity the other parts are all thrown into excess of action by their increased associability, and the hot fit of fever is produced.
9. In the continued fevers with strong pulse the stomach is affected secondarily, and thus acts feebly from deficient excitement of the power of association; but the accumulation of the power of association thus produced in an organ subject to perpetual and energetic action, is so great as to affect the next link of the associate train, which consists of the heart and arteries; these therefore are exerted perpetually with increase of action.
In continued fevers with weak pulse the torpid stomach is affected primarily by previous exhaustion of its irritability by stimulus, as of contagious matter swallowed into it. The heart and arteries act feebly from deficient excitement of the power of association, owing to the torpor of the stomach, with which they are catenated; but the accumulation of the power of association, thus produced in organs subject to perpetual and energetic motion, is so great, as to affect the next link of the associate train; which consists of the capillaries of the skin or other glands; these therefore are exerted perpetually with great increase of action.
The continued fevers with strong pulse terminate by the reduction or exhaustion of the sensorial power by violent action of the whole system; which is followed either by return of health with the natural quantity of irritability, and of associability, or by a total destruction of them both, and consequent death.
In continued fevers with weak pulse the stomach remains torpid during the whole course of the fever; and at length by the recovery of its irritability and sensibility effects the cure of it. Which generally happens about the first, second, or third quarter of the lunar period, counted from the commencement of the disease, or continues a whole lunation, and sometimes more; which gave rise to what are termed critical days. See Sect. XXXVI. 4. on this subject. If the stomach does not recover from its torpor, the patient becomes emaciated, and dies exhausted by the continuance of the increased action of the capillaries and absorbents, and the want of nourishment.
The cure of continued fever with weak pulse consists first in weakening the undue action of the capillaries of the skin by ablution with cold water from 32 to 80 degrees of heat; or by exposing them to cool air. Secondly by invigorating the actions of the stomach, by decreasing them for a time, and thence accumulating the power of irritation, as by an emetic, or by iced water, or iced wine. Or by increase of stimulus, as by bark, wine, opium, and food, in small quantities frequently repeated. Or by renewing the action of the stomach by slight electric shocks. Or by fomenting it frequently with water heated to 96 or 100 degrees. Or lastly by exciting its power of association with other parts of the system, as by a blister; which succeeds best when the extremities are cool; or by swinging, as in vertigo rotatoria.
If by the stimulus of the Peruvian bark on the fibres of the stomach, they regain their due action, the heart and arteries also regain their due action; as their sensorial power of association is now excited, and expended as usual. And as there is then no accumulation of sensorial power in the heart and arteries, the capillaries cease to act with too great energy, and the fever is cured.
Thirdly. If the heart and arteries could be themselves stimulated into greater action, although the stomach remained torpid, they might probably by expending a greater quantity of the sensorial power of irritation, prevent an accumulation of the sensorial power of association, (for these may possibly be only different modes of action of the spirit of animation,) and thus the too great action of the capillaries might be prevented and the fever cease. This new mode of cure might possibly be accomplished, if the patient was to breathe a gallon or two of pure or diluted oxygene gas frequently in a day; which by passing through the moist membranes of the lungs and uniting with the blood might render it more stimulant, and thus excite the heart and arteries into greater action.
Fourthly. Greater energy might probably be given to the whole system, and particularly to those parts which act too feebly in fevers, as the stomach and the heart and arteries, if the action of the secerning vessels of the brain could be increased in energy; this is probably one effect of all those drugs, which when given in large quantity induce intoxication, as wine and opium. And when given with great caution in small quantities uniformly repeated, as from three drops to five of the tincture of opium, but not more, every six hours, I believe they supply an efficacious medicine in fevers with great arterial debility; and the more so, if the Peruvian bark be exhibited alternately every six hours along with them. There are other means of exciting the vessels of the brain into action; as first by decreasing the stimulus of heat by temporary cold fomentation; secondly, increasing the stimulus of heat by long continued warm fomentation; thirdly, by electricity, as very small shocks passed through it in all directions; and lastly by blisters on the head. All those require to be used with great caution, and especially where there exists an evident stupor, as the removing of that is I believe frequently injurious. See stupor, ClassI. 2. 5. 10.
The cure of fever with strong pulse consists in the repeated use of venesection, gentle cathartics, diluents; medicines producing sickness, as antimonials, digitalis; or the respiration of carbonated hydrogen; or by respiration of atmospheric air lowered by a mixture of hydrogen, azote, or carbonic acid gas, or by compressing the brain by whirling in a decumbent posture, as if lying across an horizontal mill-stone. See the former parts of this supplement for the methods of cure both of fevers with strong and weak pulse.
10. When any difficulty occurs in determining the weak pulse from the strong one, it may generally be assisted by counting its frequency. For when an adult patient lies horizontally in a cool room, and is not hurried or alarmed by the approach of his physician, nor stimulated by wine or opium, the strong pulse seldom exceeds 118 or 120 in a minute; and the weak pulse is generally not much below 130, and often much above that number.Secondly in sitting up in bed, or changing the horizontal to a perpendicular posture, the quickness of the weak pulse is liable immediately to increase 10 or 20 pulsations in a minute, which does not I believe occur in the strong pulse, when the patient has rested himself after the exertion of rising.
XVII.Conclusion.
Thus have I given an outline of what may be termed the sympathetic theory of fevers, to distinguish it from the mechanic theory of Boerhaave, the spasmodic theory of Hoffman and of Cullen, and the putrid theory of Pringle. What I have thus delivered, I beg to be considered rather as observations and conjectures, than as things explained and demonstrated; to be considered as a foundation and a scaffolding, which may enable future industry to erect a solid and a beautiful edifice, eminent both for its simplicity and utility, as well as for the permanency of its materials,—which may not moulder, like the structures already erected, into the sand of which they were composed; but which may stand unimpaired, like the Newtonian philosophy, a rock amid the waste of ages!