Zoonomia/II.IV.S
SUPPLEMENT TO CLASS IV.
Sympathetic Theory of Fever.
As fever consists in the increase or diminution of direct or reverse associated motions, whatever may have been the remote cause of them, it properly belongs to the fourth class of diseases; and is introduced at the end of the class, that its great difficulties might receive elucidation from the preceding parts of it. These I shall endeavour to enumerate under the following heads, trusting that the candid reader will discover in these rudiments of the theory of fever a nascent embryon, an infant Hercules, which Time may rear to maturity, and render serviceable to mankind.
I. Simple fever.
1. When a small part of the cutaneous capillaries with their mucous or perspirative glands are for a short time exposed to a colder medium, as when the hands are immersed in iced water for a minute, these capillary vessels and their glands become torpid or quiescent, owing to the eduction of the stimulus of heat. The skin then becomes pale, because no blood passes through the external capillaries; and appears shrunk, because their sides are collapsed from inactivity, not contracted by spasm; the roots of the hair are left prominent from the seceding or subsiding of the skin around them; and the pain of coldness is produced.
In this situation, if the usual degree of warmth be applied, these vessels regain their activity; and having now become more irritable from an accumulation of the sensorial power of irritation during their quiescence, a greater exertion of them follows, with an increased glow of the skin, and another kind of pain, which is called the hot-ach; but no fever, properly so called, is yet produced; as this effect is not universal, nor permanent, nor recurrent.
2. If a greater part of the cutaneous capillaries with their mucous and perspirative glands be exposed for a longer time to cold, the torpor or quiescence becomes extended by direct sympathy to the heart and arteries; which is known by the weakness, and consequent frequency of the pulse in cold fits of fever.
This requires to be further explained. The movements of the heart and arteries, and the whole of the circulatory vessels, are in general excited into action by the two sensorial powers of irritation, and of association. The former is excited by stimulus, the latter by the previous actions of a part of the vital circle of motions. In the above situation the capillaries act weakly from defect of irritation, which is caused by deficient stimulus of heat; but the heart and arteries act weakly from defect of association, which is owing to the weak action of the capillaries; which does not now excite the sensorial power of association into action with sufficient energy.
After a time, either by the application of warmth, or by the increase of their irritability owing to the accumulation of the sensorial power of irritation during their previous quiescence, the capillary vessels and glands act with greater energy than natural; whence the red colour and heat of the skin. The heart and arteries acquire a greater strength of pulsation, and continue the frequency of it, owing to the accumulation of the sensorial power of association during their previous torpor, and their consequent greater associability; which is now also more strongly excited by the increased actions of the capillaries. And thus a fit of simple fever is produced, which is termed Febris irritativa; and consists of a torpor of the cutaneous capillaries with their mucous and perspirative glands, accompanied with a torpor of the heart and arteries; and afterwards of an increased action of all these vessels, by what is termed direct sympathy.
This fever, with strong pulse without inflammation, or febris irritativa, described in Class I. 1. 1. 1. is frequently seen in vernal intermittents, as the orgasm of the heart and arteries is then occasioned by their previous state of torpor; but more rarely I believe exists in the type of continued fever, except there be an evident remission, or approximation to a cold fit; at which time a new accumulation of the sensorial power of association is produced; which afterwards actuates the heart and arteries with unnatural vigour; or unless there be some stimulus perpetually acting on the system so as to induce an increased secretion of sensorial power in the brain, as occurs in slight degrees of intoxication. Since without one or other of these circumstances in continued fevers without inflammation, that is, without the additional sensorial power of sensation being introduced, it seems difficult to account for the production of so great a quantity of sensorial power, as must be necessary to give perpetual increase of action to the whole sanguiferous system.
3. On the contrary, while the cutaneous capillaries with their mucous and perspirative glands acquire an increased irritability, as above, by the accumulation of that sensorial power during their previous quiescence, and thus constitute the hot fit of fever; if the heart and arteries do not acquire any increase of associability, but continue in their state of torpor, another kind of simple fever is produced; which is generally of the continued kind, and is termed Febris inirritativa; which consists of a previous torpor of the capillaries of the skin, and of the heart and arteries by direct sympathy with them; and afterwards of an orgasm or increased action of the capillaries of the skin, with a decreased action, or continued torpor, of the heart and arteries by reverse sympathy with them. This orgasm of the cutaneous capillaries, which appears by the blush and heat of the skin, is at first owing to the accumulation of the sensorial power of irritation during their previous torpid state, as in the febris irritata above described; but which is afterwards supported or continued by the reverse sympathy of these capillaries with the torpid state of the heart and arteries, as will be further explained in article 8 of this Supplement.
4. The renovated activity of the capillaries commences as soon or sooner than that of the heart and arteries after the cold fit of irritative fever; and is not owing to their being forced open by the blood being impelled into them mechanically, by the renovated action of the heart and arteries; for these capillaries of the skin have greater mobility than the heart and arteries, as appears in the sudden blush of shame; which may be owing to their being more liable to perpetual varieties of activity from their exposure to the vicissitudes of atmospheric heat. And because in inirritative fevers, or those with arterial debility, the capillaries acquire increased strength, as is evinced by the heat of the skin, while the pulsations of the heart and arteries remain feeble.
5. It was said above, that the cutaneous capillaries, when they were rendered torpid by exposure to cold, either recovered their activity by the reapplication of external warmth; or by their increased irritability, which is caused by the accumulation of that sensorial power during their quiescence. An example of the former of these may be seen on emerging from a very cold bath; which produces a fit of simple fever; the cold fit, and consequent hot fit, of which may be prolonged by continuing in the bath; which has indeed proved fatal to some weak and delicate people, and to others after having been much exhausted by heat and exercise. See Sect. XXXII. 3. 2. An example of the latter may be taken from going into a bath of about eighty degrees of heat, as into the bath at Buxton, where the bather first feels a chill, and after a minute becomes warm, though he remains in the same medium, owing to the increase of irritability from the accumulation of that sensorial power during the short time, which the chilness continued.
6. Hence simple fevers are of two kinds; first, the febris irritativa, or fever with strong pulse; which consists of a previous torpor of the heart, arteries, and capillaries, and a succeeding orgasm of those vessels. Secondly, the febris inirritativa, or fever with weak pulse, which consists of a previous torpor of the heart, arteries, and capillaries; and of a succeeding orgasm of the capillaries, the torpor of the heart and arteries continuing. But as the frequency of the pulse occurs both in the state of torpor, and in that of orgasm, of the heart and arteries; this constitutes a criterion to distinguish fever from other diseases, which are owing to the torpor of some parts of the system, as paresis, and hemicrania.
7. The reader will please to observe, that where the cutaneous or pulmonary capillaries are mentioned, their mucous and perspirative glands are to be understood as included; but that the absorbents belonging to those systems of vessels, and the commencement of the veins, are not always included; as these are liable to torpor separately, as in anasarca, and petechiæ; or to orgasm, or increased action, as in the exhibition of strong emetics, or in the application of vinegar to the lips; yet he will also please to observe, that an increased or decreased action of these absorbents and veins generally occurs along with that of the capillaries, as appears by the dry skin in hot fits of fever; and from there being generally at the same time no accumulation of venous blood in the cutaneous vessels, which would appear by its purple colour.
II. Compound fever.
1. When other parts of the system sympathize with this torpor and orgasm of the cutaneous capillaries, and of the heart and arteries; the fever-fit becomes more complicated and dangerous; and this in proportion to the number and consequence of such affected parts. Thus if the lungs become affected, as in going into very cold water, a shortness of breath occurs; which is owing to the collapse or inactivity (not to the active contraction, or spasm), of the pulmonary capillaries; which, as the lungs are not sensible to cold, are not subject to painful sensation, and consequent shuddering, like the skin. In this case after a time the pulmonary capillaries, like the cutaneous ones, act with increased energy; the breathing, which was before quick, and the air thrown out at each respiration in less quantity, and cool to the back of the hand opposed to it, now becomes larger in quantity, and warmer than natural; which however is not accompanied with the sensation of heat in the membrane, which lines the air-vessels of the lungs, as in the skin.
2. One consequence of this increased heat of the breath is the increased evaporation of the mucus on the tongue and nostrils. A viscid material is secreted by these membranes to preserve them moist and supple, for the purposes of the senses of taste and of smell, which are extended beneath their surfaces; this viscid mucus, when the aqueous part of it is evaporated by the increased heat of the respired air, or is absorbed by the too great action of the mucous absorbents, adheres closely on those membranes, and is not without difficulty to be separated from them. This dryness of the tongue and nostrils is a circumstance therefore worthy to be attended to; as it shews the increased action of the pulmonary capillaries, and the consequent increased heat of the expired air; and may thus indicate, when colder air should be admitted to the patient. See Class I. 1. 3. 1. The middle part of the tongue becomes dry sooner, and recovers its moisture later, than the edges of it; because the currents of respired air pass most over the middle part of it. This however is not the case, when the dryness of the tongue is owing only to the increased mucous absorption. When however a frequent cough attends pulmonary inflammation, the edges of the tongue are liable to be as much furred as the middle of it; as during the action of coughing the middle of the tongue is depressed, so as to form half a cylinder, to give a greater aperture for the emission of air from the larynx; and the edges of it become thus as much exposed to the currents of air, as the middle parts of it.
3. When the internal capillaries or glands sympathize with the cutaneous capillaries; or when any of them are previously affected with torpor, and the external or cutaneous capillaries are affected secondarily; other symptoms are produced, which render the paroxysms of fever still more complicate. Thus if the spleen or pancreas are primarily or secondarily affected, so as to be rendered torpid or quiescent, they are liable to become enlarged, and to remain so even after the extinction of the fever-fit. These in some intermittent fevers are perceptible to the hand, and are called ague-cakes; their tumour seems to be owing to the permanent torpor of the absorbent system, the secerning vessels continuing to act some time afterwards. If the secretory vessels of the liver are affected first with torpor, and afterwards with orgasm, a greater secretion of bile is produced, which sometimes causes a diarrhœa. If a torpor of the kidneys, and of the absorbents of the bladder occurs, either primarily, or by sympathy with the cutaneous capillaries, the urine is in small quantity and pale, as explained in Class I. 2. 2. 5.; and if these secretory vessels of the kidneys, and the absorbents of the bladder act more strongly than natural afterwards by their increased irritability or associability, the urine becomes in larger quantity, and deeper coloured, or deposits its earthy parts, as in Class I. 1. 2. 4. which has been esteemed a favourable circumstance. But if the urine be in small quantity, and no sediment appears in it, after the hot fit is over; it shews, that the secerning vessels of the kidneys and the absorbent vessels of the bladder have not regained the whole of their activity, and thence indicates a greater tendency to a return of the cold fit.
4. When the stomach is affected with torpor either primarily; or secondarily by its sympathy with the cutaneous capillaries; or with some internal viscus; sickness occurs, with a total want of appetite to any thing solid; vomiting then supervenes, which may often be relieved by a blister on the skin, if the skin be cool and pale; but not if it be hot and flushed. The intestines cease to perform their office of absorption from a similar torpor; and a diarrhœa supervenes owing to the acrimony of their putrid, or of their acid contents. The loose undigested or fetid stools indicate the inability of the intestines to perform their proper office; as the mucus and gastric acid, which are vomited up, does that of the stomach; this torpor of the stomach is liable to continue after the cold paroxysm ceases, and to convert intermittent fevers into continued ones by its direct sympathy with the heart and arteries. See article 10 of this Supplement.
5. If the meninges of the brain sympathize with other torpid parts, or are primarily affected, delirium, stupor, and perhaps hydrocephalus internus occur, see Class II. 1. 7. 1. and I. 2. 5. 10; and sometimes the pulse becomes slow, producing paresis instead of fever. But if the membranes, which cover the muscles about the head, or of the pericranium, become torpid by their sympathy with other torpid parts, or are primarily affected, a head-ach supervenes; which however generally ceases with the cold paroxysm of fever. For as when the sensorial power of volition is exhausted by labour, a few hours, or half a solar day, passed in sleep recruits the system by accumulation of this sensorial power; so when the sensorial power of irritation is exhausted, one or two solar or lunar days of rest or quiescence of the affected part will generally restore its action by accumulation of irritability, and consequent increase of association, as in hemicrania, Class IV. 2. 2. 8. But when the heart and arteries become torpid, either primarily, or by their sympathy with the stomach, this accumulation of the sensorial power of irritation can take place but slowly; as to rest is death! This explains the cause of the duration of fevers with weak pulse, which continue a quarter, or half, or three quarters, or a whole lunation, or still longer, before sufficient accumulation of irritability can be produced to restore their natural strength of action.
6. If the absorbent vessels, which are spread around the neck of the bladder, become torpid by their direct sympathy with the absorbents of the skin in cold fits of fever; the urine, which is poured into the bladder in but small quantity from the torpid kidneys, has nevertheless none of its aqueous saline part reabsorbed; and this saline part stimulates the bladder to empty itself frequently, though the urine is in small quantity. Which is not therefore owing to any supposed spasm of the bladder, for the action of it in excluding the urine is weak, and as much controlable by the will as in ordinary micturition.
7. If the beginnings or absorbent mouths of the venous system remain torpid, petechiæ or vibices are produced in fevers, similar to those which are seen in scurvy without fever. If the skin was frequently moistened for an hour, and at the same time exposed to the common air, or to oxygen gas, it might contribute to turn the black colour of these points of extravasated blood into scarlet, and thus by increasing its stimulus facilitate its reabsorption? For oxygen gas penetrates moist animal membranes though not dry ones, as in the lungs during respiration.
8. When the sensorial power of sensation is introduced into the arterial system, other kinds of compound fevers are produced, which will be spoken of in their place.
III. Termination of the cold Fit.
1. If all the parts, which were affected with torpor, regain their irritability, and associability, the cold paroxysm of fever ceases; but as some of the parts affected were previously accustomed to incessant action, as the heart and arteries, and others only to intermitted action, as the stomach and intestines; and as those, which are subjected during health to perpetual action, accumulate sensorial power faster, when their motions are impeded, than those which are subjected to intermitted action; it happens, that some of the parts, which were affected with torpor during the cold fit, recover their irritability or associability sooner than others, and more perfectly, or acquire a greater quantity of them than natural; as appears by the partial heat and flushings previous to the general hot fit.
Hence if all the parts, which were previously torpid, regain their due degree of irritability, or of associability, the disease is removed, and health restored. If some or all of them acquire more than their natural degree of these sensorial powers; increased actions, and consequent increased secretions, and greater heat occur, and constitute the hot fit of fever. If after this hot fit of fever all the parts, which had acquired too great irritability, or associability, regain their natural degree of it; the disease is removed, and health restored. But if some of these parts do not regain their natural degree of these sensorial powers, the actions of those parts remain imperfect, and are more or less injurious to the system, according to the importance of their functions.
2. Thus if a torpor of the heart and arteries remains; the quick pulse without strength, which began in the cold fit, persists; and a continued fever is produced. If the torpor of the stomach and intestines remains, which are known by sickness and undigested stools, the fever is liable to be of considerable length and danger; the same if the kidnies and absorbent system retain some degree of torpor, as is shewn by the pale urine in not unusual quantity. If part of the absorbent system remains torpid, as the absorbent vessels of the spleen, a tumour of that viscus occurs, which may be felt by the hand; the same sometimes happens to the liver; and these from their tendency to more complete torpor are afterwards liable to give occasion to a return of the cold fit. If the cellular absorbents do not completely recover their activity, a pale and bloated countenance with swelled legs mark their want of action.
3. As the termination of the cold fit is owing to the accumulation of the sensorial power of irritation and of association during the previous quiescence of the system; and as those parts, which are in perpetual action during health, are more subject to this accumulation during their torpor, or quiescence; one should have imagined, that the heart and arteries would acquire this accumulation of sensorial power sooner or in greater degree than other parts. This indeed so happens, where the pulse is previously strong, as in febris irritativa; or where another sensorial power, as that of sensation, is exerted on the arterial system, as in inflammations. The heart and arteries in these cases soon recover from their torpor, and are exerted with great violence.
Many other parts of the system subject to perpetual motion in health may rest for a time without much inconvenience to the whole; as when the fingers of some people become cold and pale; and during this complete rest great accumulation of irritability may be produced, But where the heart and arteries are previously feeble, they cannot much diminish their actions, and certainly cannot rest entirely, for that would be death; and therefore in this case their accumulation of the sensorial power of irritation or of association is slowly produced, and a long fever supervenes in consequence; or sudden death, as frequently happens, terminates the cold fit.
Whence it appears, that in fevers with weak pulse, if the action of the heart, arteries, and capillaries could be diminished, or stopped for a short time without occasioning the death of the patient, as happens in cold bathing, or to persons apparently drowned, that a great accumulation of the sensorial powers of irritation or of association might soon be produced, and the pulse become stronger, and consequently slower, and the fever cease. Hence cold ablution may be of service in fevers with weak pulse, by preventing the expenditure and producing accumulation of the sensorial power of irritation or association. Stupor may be useful on the same account. Could a centrifugal swing be serviceable for this purpose, either by placing the head or the feet in the outward part of the circle, as described in Art. 15. 7. of this Supplement?
IV. Return of the cold Fit.
1. If the increased action of the cutaneous and pulmonary capillaries, and of the heart and arteries, in febris irritativa continues long and with violence, a proportional expenditure or exhaustion of sensorial power occurs; which by its tendency to induce torpor of some part, or of the whole, brings on a return of the cold fit.
2. Another cause which contributes to induce torpor of the whole system by the sympathy of its parts with each other, is the remaining torpor of some viscus; which after the last cold paroxysm had not recovered itself, as of the spleen, liver, kidnies, or of the stomach and intestines, or absorbent vessels, as above mentioned.
3. Other causes are the deficiency of the natural stimuli, as hunger, thirst, and want of fresh air. Other causes are great fatigue, want of rest, fear, grief, or anxiety of mind. And lastly, the influence of external ethereal fluids, as the defect of external heat, and of solar or lunar gravitation. Of the latter the return of the paroxysms of continued fevers about six o'clock in the evening, when the solar gravitation is the least, affords an example of the influence of it; and the usual periods of intermittents, whether quotidian, tertian, or quartan, which so regularly obey solar or lunar days, afford instances of the influence of those luminaries on these kinds of fevers.
4. If the tendency to torpor of some viscus is considerable, this will be increased at the time, when the terrene gravitation is greatest, as explained in the introduction to Class IV. 2. 4. and may either produce a cold paroxysm of quotidian fever; or it may not yet be sufficient in quantity for that purpose, but may nevertheless become greater, and continue so till the next period of the greatest terrene gravitation, and may then either produce a paroxysm of tertian fever; or may still become greater, and continue so till the next period of greatest terrene gravitation, and then produce a paroxysm of quartan ague. And lastly, the periodical times of these paroxysms may exceed, or fall short of, the time of greatest diurnal terrene gravitation according to the time of day, or period of the moon, in which the first fit began; that is, whether the diurnal terrene gravitation was then in an increasing or decreasing state.
V. Sensation excited in Fever.
1. A curious observation is related by Dr. Fordyce in his Tract on Simple fever, page 168. He asserts, that those people, who have been confined some time in a very warm atmosphere, as of 120 or 130 degrees of heat, do not feel cold, nor are subject to paleness of their skins, on coming into a temperature of 30 or 40 degrees; which would produce great paleness and painful sensation of coldness in those, who had been some time confined in an atmosphere of only 86 or 90 degrees. Analogous to this, an observing friend of mine assured me, that once having sat up to a very late hour with three or four very ingenious and humorous companions, and drank a considerable quantity of wine; both contrary to his usual habits of life; and being obliged to rise early, and to ride a long journey on the next day; he expected to have found himself weak and soon fatigued; but on the contrary he performed his journey with unusual ease and alacrity; and frequently laughed, as he rode, at the wit of the preceding evening. In both these cases a degree of pain or pleasure actuated the system; and thus a sensorial power, that of sensation, was superadded to that of irritation, or volition. See Sect. XXXIV. 2. 6.
2. Similar to this, when the energetic exertions of some parts of the system in the hot fit of fever arise to a certain excess, a degree of sensation is produced; as of heat, which particularly increases the actions of the cutaneous vessels, which are more liable to be excited by this stimulus. When this additional sensorial power of sensation exists to a greater degree, the pulse, which was before full, now becomes hard, owing to the inflammation of the vasa vasorum, or coats of the arteries. In these cases, whether there is any topical inflammation or not, the fever ceases to intermit; but nevertheless there are daily remissions and exacerbations of it; which recur for the most part about six in the evening, when the solar gravitation is the least, as mentioned in Sect. XXXVI. 3. 7.
3. Thus the introduction of another sensorial power, that of sensation, converts an intermittent fever into a continued one. If it be attended with strong pulse, it is termed febris sensitiva irritata, or pyrexia, or inflammation; if with a weak pulse, it is termed febris sensitiva inirritata, or typhus gravior, or malignant fever. The seat of the inflammation is in the glandular or capillary system, as it consists in the secretion of new fluids, or new fibres, which form new vessels, as they harden, like the silk of the silk-worm. See Art. 15. of this Supplement.
VI. Circles of irritative Associate Motions.
1. There are some associate motions, which are perpetually proceeding in our waking hours, and are catenated by their first link, or in some subsequent parts of the chain, with the stimuli or the influence of external things; which we shall here enumerate, as they contribute to the knowledge of fever. Of these are the irritative ideas, or sensual motions of the organs of sense, and the muscular motions associated with them; which, when the chain is disturbed or interrupted, excite the sensorial power of sensation, and proceed in confusion. Thus if the irritative ideas of sight are disturbed, the paralactic motions of objects, which in general are unperceived, become sensible to us; and the locomotive muscles associated with them, which ought to preserve the body erect, stagger from this decrease or interruption of the sensorial power of association; and vertigo is produced.
When the irritative sensual motions, or ideas, belonging to one sense are increased or diminished, the irritative sensual motions, or ideas, of the other senses are liable to become disturbed by their general catenations; whence occur noises in the ears, bad tastes in the mouth, bad odours, and numbness or tingling of the limbs, as a greater or less number of senses are affected. These constitute concomitant circles of disturbed irritative ideas; or make a part of the great circle of irritative ideas, or motions of the organs of sense; and when thus disturbed occasion many kinds of hallucination of our other senses, or attend on the vertigo of vision.
2. Another great circle of irritative associated motions consists of those of the alimentary canal; which are catenated with stimuli or with influences external to the system, but continue to be exerted in our sleeping as well as in our waking hours. When these associations of motion are disturbed by the too great or too small stimulus of the food taken into the stomach, or by the too great excess or deprivation of heat, or by indigestible substances, or by torpor or orgasm occasioned by their association with other parts, various diseases are induced under the names of apepsia, hypochondriasis, hysteria, diarrhœa, cholera, ileus, nephritis, fever.
3. A third circle of irritative associate motions consists of those of the absorbent system; which may be divided into two, the lacteals, and the lymphatics. When the stomach and intestines are recently filled with food and fluid, the lacteal system is stimulated into great action; at the same time the cellular, cutaneous, and pulmonary lymphatics act with less energy; because less fluid is then wanted from those branches, and because more sensorial power is expended by the lacteal branch. On this account these two systems of absorbents are liable to act by reverse sympathy; hence pale urine is made after a full dinner, as less of the aqueous part of it is imbibed by the urinary lymphatics; and hence the water in anasarca of the lungs and limbs is speedily absorbed, when the actions of the lacteals of the stomach or intestines are weakened or inverted by the exhibition of those drugs, which produce nausea, or by violent vomiting, or violent cathartics.
Hence in diabetes the lacteal system acts strongly, at the same time that the urinary lymphatics invert their motions, and transmit the chyle into the bladder; and in diarrhœa from crapula, or too great a quantity of food and fluid taken at a time, the lacteals act strongly, and absorb chyle or fluids from the stomach and upper intestines; while the lymphatics of the lower intestines revert their motions, and transmit this over-repletion into the lower intestines, and thus produce diarrhœa; which accounts for the speedy operation of some cathartic drugs, when much fluid is taken along with them.
4. Other circles of irritative associate motions of great importance are those of the secerning system; of these are the motions of the larger congeries of glands, which form the liver, spleen, pancreas, gastric glands, kidneys, salivary glands, and many others; some of which act by direct and others by reverse sympathy with each other. Thus when the gastric glands act most powerfully, as when the stomach is filled with food, the kidneys act with less energy; as is shewn by the small secretion of urine for the first hour or two after dinner; which reverse sympathy is occasioned by the greater expenditure of sensorial power on the gastric glands, and to the newly absorbed fluids not yet being sufficiently animalized, or otherwise prepared, to stimulate the secretory vessels of the kidneys.
But those very extensive glands, which secrete the perspirable matter of the skin and lungs, with the mucus, which lubricates all the internal cells and cavities of the body, claim our particular attention. These glands, as well as all the others, proceed from the capillary vessels, which unite the arteries with the veins, and are not properly a part of them; the mucous and perspirative glands, which arise from the cutaneous and pulmonary capillaries, are associated by direct sympathy; as appears from immersion in the cold bath, which is therefore attended with a temporary difficult respiration; while those from the capillaries of the stomach and heart and arteries are more generally associated by reverse sympathy with those of the cutaneous capillaries; as appears in fevers with weak pulse and indigestion, and at the same time with a hot and dry skin.
The disturbed actions of this circle of the associate motions of the secerning system, when the sensorial power of sensation is added to that of irritation, frequently produces inflammation, which consists in the secretion of new fluids or new vessels. Nevertheless, if these disturbed actions be of the torpid kind, the pain, which attends them, is seldom productive of inflammation, as in hemicrania; but is liable to excite voluntary actions, and thus to expend much sensorial power, as in the shuddering in cold fits of fever, or in convulsions; or lastly the pain itself, which attends torpid actions, is liable to expend or exhaust much sensorial power without producing any increased actions; whence the low pulse, and cold extremities, which usually attend hemicrania; and hence when inert, or inactive sensation attends one link of associated action, the succeeding link is generally rendered torpid, as a coldness of the cheek attends tooth-ach.
5. A fifth important circle of irritative motions is that of the sanguiferous system, in which the capillary vessels are to be included, which unite the arterial and venous systems, both pulmonary and aortal. The disturbed action of this system of the heart and arteries, and capillaries, constitute simple fever; to which may be added, that the secerning and absorbent vessels appending to the capillaries, and the bibulous mouths of the veins, are in some measure at the same time generally affected.
6. Now, though the links of each of these circles of irritative motions are more strictly associated together, yet are they in greater or less degree associated or catenated with each other by direct or reverse sympathy. Thus the sickness, or inverted irritative motions of the stomach, are associated or catenated with the disturbed irritative ideas, or sensual motions, in vertigo; as in sea-sickness. This sickness of the stomach is also associated or catenated with the torpor of the heart and arteries by direct sympathy, and with the capillaries and absorbents by reverse sympathy; and are thus all of them liable occasionally to be disturbed, when one of them is diseased; and constitute the great variety of the kinds or symptoms of fevers.
VII. Alternation of the cold and hot Fits.
1. When any cause occurs, which diminishes to a certain degree the supply of sensorial power in respect to the whole system; as suppose a temporary inexertion of the brain; what happens? First, those motions are exerted with less energy, which are not immediately necessary to life, as the locomotive muscles; and those ideas, which are generally excited by volition; at the same time this deficiency of voluntary motion is different from that which occurs in sleep; as in that the movements of the arterial system are increased in energy though not in frequency. Next, the motions of the alimentary canal become performed with less energy, or cease altogether; and a total want of appetite to solid food occurs, or sickness, or a diarrhœa occasioned by the indigested aliment. Then the absorbent vessels cease to act with their due energy; whence thirst, and pale urine, though in small quantities. Fourthly, the secerning vessels become affected by the general diminution of sensorial power; whence all the secreted fluids are produced in less quantity. And lastly, the sanguiferous canals feel the general torpor; the pulsations of the heart and arteries become feeble, and consequently quick; and the capillaries of the skin become inactive, acquire less blood from the arteries, and are consequently paler and shrunk.
In this last circumstance of the torpor of the sanguiferous system consists inirritative fever; as all the others are rather accidental or concomitant symptoms, and not essential ones; as fewer or more of them may be present, or may exist with a greater or less degree of inactivity.
2. Now as the capillaries of the skin are exposed to greater varieties of heat and cold, than the heart and arteries, they are supposed to be more mobile, that is, more susceptible of torpor or exertion, or to inflammation, by external stimuli or influences, than the other parts of the sanguiferous system; and as the skin is more sensible to the presence of heat, than the internal parts of the body, the commencement of the cold paroxysms of fever generally either first exists in, or is first perceived by, the coldness and paleness of the skin; and the commencement of the hot fits by the heat and redness of it.
3. The accumulation of sensorial power occurs in these organs soonest, and in greatest quantity, during their quiescence, which were most perpetually in action during health; hence those parts of the system soonest recover from torpor in intermittent fever, and soonest fall into the contrary extreme of increased activity; as the sanguiferous system of the heart and arteries and capillaries. But of these the capillaries seem first to acquire a renovation of their action, as the heat of the skin becomes first renewed, as well as increased beyond its natural quantity, and this in some parts sooner than in others; which quantity of heat is however not to be estimated simply by the rise of the mercury in the thermometer, but also by the quantity carried away into the atmosphere, or diffused amongst other bodies in a given time; as more heat passes through water, which boils vehemently, than when it boils gently, though the rise of the thermometer in both cases continues the same. This fact may be known by boiling an egg in water, the white of which coagulates in much less time, if the water boils vehemently, than if it boils moderately, though the sensible heat of the water is the same in both cases.
Another cause, which induces the cutaneous capillaries to renew their actions sooner than the heart and arteries after immersion in the cold bath, is, that their torpor was occasioned by defect of irritation; whereas that of the heart and arteries was occasioned by defect of association; which defect of association was owing to the decreased actions of the capillaries, and is now again excited by their renewed action; which excitement must therefore be subsequent to that increased action of the capillaries; and in consequence the increased action of the heart and arteries at the commencement of the hot fit of some fevers is subsequent to the increased action of the cutaneous capillaries. There is, however, in this case an accumulation of the sensorial power of association in the heart and arteries, which must contribute to increase their orgasm in the hot fit, as well as the increased excitement of it by the increased action of the capillaries.
4. Now this increased action of the system, during the hot fit, by exhausting the sensorial powers of irritation and association, contributes to induce a renewal of the cold paroxysm; as the accumulation of those sensorial powers in the cold fit produces the increased actions of the hot fit; which two states of the system reciprocally induce each other by a kind of libration, or a plus and minus, of the sensorial powers of irritation and association.
If the exhaustion of sensorial power during the hot fit of fever only reduces the quantity of irritability and associability to its natural standard, the fever is cured, not being liable to return. If the quantity of these sensorial powers be reduced only so much, as not to produce a second cold fit during the present quantity of external stimuli or influences; yet it may be so far reduced, that a very small subtraction of stimulus, or of influence, may again induce a cold fit; such as the coldness of the night-air, or the diminution of solar or lunar gravitation, as in intermittent fevers.
5. Another cause of the renovation of the cold fits of fever is from some parts of the system not having completely recovered from the former cold paroxysm; as happens to the spleen, liver, or other internal viscus; which sometimes remains tumid, and either occasions a return of the cold fit by direct sympathy with other parts of the body, or by its own want of action causes a diminution of the general quantity of heat, and thus facilitates the renovation of the torpor of the whole system, and gives cause to intermittent fevers catenated with lunar or solar influence.
VIII. Orgasm of the Capillaries.
As the remaining torpor of some less essential part of the system, as of the spleen, when the hot fit ceases, produces after one, two, or three days a return of cold fit by direct sympathy with the cutaneous capillaries, when joined with some other cause of torpor, as the defect of solar or lunar influences, or the exposure to cold or hunger, and thus gives origin to intermittent fever; so the remaining torpor of some more essential parts of the system, as of the stomach and intestines, is probably the cause of the immediate recurrence of the cold paroxysm, at the time the hot one ceases, by their direct sympathy with the cutaneous capillaries, without the assistance of any other cause of torpor; and thus produces remittent fever. And lastly the remaining torpor of some still more essential parts of the system, as the heart and arteries, after the hot fit ought to cease, is liable by reverse sympathy with the cutaneous capillaries to continue their orgasm, and thus to render a fever continual, which would otherwise remit or intermit.
Many difficulties here occur, which we shall endeavour to throw some light upon, and leave to future investigation; observing only that difficulties were to be expected, otherwise fevers would long since have been understood, as they have employed the unremitted attention of the physicians of all ages of the world.
1. Why do the same parts of successive trains of action sometimes affect each other by direct, and sometimes by reverse sympathy?—1st, When any irritative motion ceases, or becomes torpid, which was before in perpetual action; it is either deprived of its usual stimulus, and thence the sensorial power of irritation is not excited; or it has been previously too much stimulated, and the sensorial power has been thus exhausted.
In the former case an accumulation of sensorial power soon occurs, which is excitable by a renewal of the stimulus; as when the fingers, which have been immersed some time in snow, are again exposed to the usual warmth of a room. Or, secondly, the sensorial power of irritation becomes so much accumulated, that the motions, which were torpid, are now performed by less stimulus than natural; as appears by the warmth, which soon occurs after the first chill in going into frosty air, or into the bath at Buxton, which is about eighty degrees of heat. Or, lastly, this accumulation of the sensorial power of irritation so far abounds, that it increases the action of the next link of the associated train or tribe of motions; thus on exposing the skin to cold air, as in walking out in a frosty morning, the actions of the stomach are increased, and digestion strengthened.
But where the torpor of some irritative motion is owing to the previous exhaustion of the sensorial power of irritation by too great stimulus, the restoration of it occurs either not at all, or much more slowly than in the former instances; thus after intoxication the stomach is very slow in recovering its due quantity of the sensorial power of irritation, and never shews any accumulation of it.
2. When an associate motion, as described in the introduction to Class IV. 1. 1. acts with less energy, the sensorial power of association is either not sufficiently excited by the preceding fibrous motions; or it has been expended or exhausted by the too violent actions of the preceding fibrous motions. In the former case there occurs an accumulation of the sensorial power of association; exactly as, where the usual stimulus is withdrawn, there occurs an accumulation of the sensorial power of irritation. Thus when the actions of the capillaries of the skin are diminished by immersion in cold water, the capillaries of the lungs are rendered torpid by the want of the excitement of the sensorial power of association, owing to the lessened actions of the previous fibrous motions, namely, of those of the skin. Nevertheless as soon as the capillaries of the skin regain their increased activity by the accumulation of the sensorial power of irritation, these capillaries of the lungs act with greater energy also owing to their accumulated sensorial power of association. These are instances of direct sympathy, and constitute the cold and hot paroxysms of intermittent fever; or the first paroxysm of a continued one.
3. When the first link of a train of associated motions, which is subject to perpetual action, becomes a considerable time torpid for want of being excited by the previous exertions of the irritative motions, with which it is catenated; the sensorial power of association becomes accumulated in so great a degree as to affect the second link of the train of associated motions, and to excite it into stronger action. Thus when the stomach is rendered torpid by contagious matter swallowed into it mixed with the saliva, the heart and arteries act more feebly; because the sensorial power of association, which used to be excited by the fibrous motions of the stomach, is not now excited; and in consequence the motions of the heart and arteries act only by the sensorial power of irritation, which is excited by the stimulus of the blood.
But during this torpor of the stomach, and less action of the heart and arteries, so great an accumulation of the sensorial powers of irritation and of association occurs, that it adds to the action of the next link of this vital circle of actions, that is, to that of the cutaneous capillaries. Whence in this situation the torpor of the stomach occasions a diminished action of the heart and arteries by direct sympathy, and may be said to occasion an increased one of the cutaneous capillaries by reverse sympathy; which constitute continued fever with weak pulse.
Nor is this increased action of the capillaries in consequence of the decreased action of the heart and arteries, as in fevers with weak pulse, a single fact in the animal economy; though it exists in this case in the greatest degree or duration, because the heart and arteries are perpetually in greater action than any other part of the system. But a similar circumstance occurs, when the stomach is rendered inactive by defective excitement of the sensorial power of association, as in sea-sickness, or in nephritis. In these cases the sensorial power of association becomes much accumulated in the stomach, and seems by its superabundance to excite the absorbent system, which is so nearly connected with it, into great increase of action; as is known by the great quantity frequently in these situations rejected by vomit, which could not otherways be supplied. It is probable the increase of digestion by walking in frosty air, with many other animal facts, may by future observations be found to be dependent on this principle, as well as the increased action of the capillaries in continued fevers with weak pulse.
Whereas in continued fever with strong pulse, which may perhaps occur sometimes on the first day even of the plague, the stomach with the heart and arteries and the capillaries act by direct sympathy; that is, the stomach is excited into stronger action by increased irritation owing to the stimulus of contagious matter; these stronger irritative motions of the stomach excite a greater quantity of the sensorial power of association, which then actuates the heart and arteries with greater energy, as these are catenated with the stomach; and in the same manner the increased actions of the heart and arteries excite a greater quantity of the sensorial power of association, which actuates the cutaneous capillaries with increase of energy. See Class IV. 1. 1.
4. I shall dwell a little longer on this intricate subject. The commencement of fever-fits is known by the inactivity of the cutaneous capillaries, which inactivity is observable by the paleness and coldness of the skin, and also by the pain of coldness, which attends it. There is nevertheless in most cases, except those which are owing to exposure to external cold, a torpor of the capillaries of some internal viscus preceding this inactivity of the cutaneous capillaries; which is known, by the tumour or hardness of the viscus, or by an aching pain of it. The capillaries of the lungs are at the same time rendered inactive or torpid, as appears by the difficulty of breathing, and coldness of the breath in cold fits of fever, and in going into the cold bath; but the lungs are not affected with the pain either of coldness or of torpor.
One cause of this synchronous or successive inactivity of the cutaneous capillaries, in consequence of the previous torpor of some internal viscus, may be owing to the deficiency of heat; which must occur, when any part becomes inactive; because the secretions of that part cease or are lessened, and the quantity of heat of it in consequence. But the principal cause of it I suppose to be owing to the defect of the sensorial power of association; which power of association is excited by some previous or concomitant motions of the parts of every great circle of actions. This appears on going into the cold bath, because the shortness of breath instantly occurs, sooner than one can conceive the diminution of the heat of the skin could affect the lungs by the want of its stimulus; but not sooner than the defect of the sensorial power of association could affect them; because this must cease to be excited into action on the instant that the cutaneous capillaries cease to act; whence in the first moment of contact of the cold water the cutaneous capillaries cease to act from defect of irritation; which is caused by defect of the stimulus of heat; and in the second moment the capillaries of the lungs cease to act from the defect of association; which is caused by the defect of the motions of the cutaneous capillaries. Thus the universal torpor in the cold paroxysm of fever is an example of direct sympathy, though occasioned in part by defect of irritation, and in part by defect of association.
5. Thus in walking out in a frosty morning the skin is cooled by the contact of the cold air, whence the actions of its capillaries are diminished for want of their usual stimulus of heat to excite a sufficient quantity of the sensorial power of irritation. Hence there is at first a saving of sensorial power of irritation for the purpose of actuating the other parts of the system with greater energy. Secondly the sensorial power of association, which used to be excited by the motions of the cutaneous capillaries, is now not so powerfully excited; and in consequence the parts, which constitute the next links of the circles of associated motions, are for a time actuated with less energy, and a temporary general chillness succeeds; which is so far similar to the cold fit of intermittent fever.
In this situation there is a curious circumstance occurs, which merits peculiar attention: after a short time, though the external skin continues cool by its exposure to the cold air, and the actions of its capillaries are consequently diminished, yet the capillaries of the stomach act with greater energy; as is known by increased digestion and consequent hunger. This is to be ascribed to the accumulation of the sensorial power of irritation, which now excites by its superabundance, or overflowing, as it were, the stomach into increased action; though it is at the same time excited less powerfully than usual by the sensorial power of association. Thus the accumulation of the sensorial power of irritation in the vessels of the skin increases in this case the action of the stomach, in the same manner as an accumulation of the sensorial power of association in the heart and arteries in fevers with weak pulse increases the action of the capillaries.
If nevertheless the coldness of the skin be too long continued, or exists in too great a degree, so as in some measure to impair the life of the part, no further accumulation of the sensorial power of irritation occurs; and in consequence the actions of the stomach become less than natural by the defect of the sensorial power of association; which has ceased to be excited by the want of action of the cutaneous capillaries. Whence continued coldness of the feet is accompanied with indigestion and heartburn. See Class IV. 2. 1. 6.
6. Similar to this when the actions of the stomach are rendered torpid by the previous stimulus of a violent emetic, and its motions become retrograde in consequence, a great quantity of sensorial power is exerted on the lymphatics of the lungs, and other parts of the body; which excites them into greater direct action, as is evinced by the exhibition of digitalis in anasarca. In this situation I suppose the emetic drug stimulates the muscular fibres of the stomach into too great action; and that in consequence a great torpor soon succeeds; and that this inaction of the muscular parts of the stomach is not followed by much accumulation of the sensorial power of irritation; because that sensorial power is in great measure exhausted by the previous excessive stimulus. But the lymphatics of the stomach have their actions lessened by defect of the sensorial power of association, which is not now excited into action, owing to the lessened motions of the muscular parts of it, with which the lymphatics are associated. The sensorial power of association becomes therefore accumulated in these lymphatics of the stomach, because it is not excited into action; exactly as the power of irritation becomes accumulated in the hand, when immersed in snow; and this accumulated sensorial power of association excites the lymphatic of the lungs and of other parts, which are most nearly associated with those of the stomach, into more energetic actions. Thus the muscular fibres of the stomach act with the lymphatics of that organ in direct sympathy; and the lymphatics of the stomach act in reverse sympathy with those of the lungs and of other parts of the body; the former of which is caused by defect of the excitement of the sensorial power of association, and the latter by the accumulation of it.
Besides the efficient cause, as above explained, the final cause, or convenience, of these organic actions are worthy our attention. In this case of an acrid drug swallowed into the stomach the reverted actions of the muscular fibres of the stomach tend to eject its enemy; the reverted actions of its lymphatics pour a great quantity of fluids into the stomach for the purpose of diluting or washing off the noxious drug; and the increased actions of the other lymphatics supply these retrograde ones of the stomach with an inconceivable supply of fluids, as is seen in Ileus and Cholera.
7. The inquisitive reader will excuse my continuing this subject, though perhaps with some repetitions, as it envelopes the very essence of fever. When the first link of a train of actions is excited by excessive stimulus, or excessive irritability, and thus acts with unusual energy by the increased quantity of irritation, these increased motions excite a greater quantity of the sensorial power of association, which causes increased motions in the second link, which is catenated with the first; and then the excessive action of this second link excites also a greater quantity of the sensorial power of association, which increases the motions of the third link of this chain of association, and thus the increase of the stimulus on the irritative motions, to which the chain of association is catenated, increases the action of the whole chain or circle of associated motions.
After a time the irritative motions become torpid by expenditure of the sensorial power of irritation, and then the power of association also becomes less exerted, both because it has been in part exhausted by too great action, and is now less excited by the lessened action of the irritative motions, which used to excite it. These are both instances of direct sympathy, and frequently constitute the cold and hot fit of intermittents.
But though the accumulation of the sensorial power of irritation during the quiescence of some motion owing to want of stimulus generally induces torpor in the first link of the train of associated motions catenated with it; as the capillaries of the lungs become torpid immediately on immersion of the skin into cold water; yet in some situations an orgasm or excess of action is produced in the first link of the associated motions thus catenated with irritative ones; as in the increased action of the stomach, when the skin is for a time exposed to cold air; which may in part be ascribed to the general increase of action of the whole system, owing to the diminished expenditure of sensorial power, but particularly of the parts, which have habitually acted together; as when one arm is paralytic the other is liable to more frequent or almost continual motion; and when one eye becomes blind the other frequently becomes stronger; which is well known to farriers, who are said sometimes to destroy the sight of one eye to strengthen that of the other in diseased horses.
Hence there is sometimes a direct sympathy, and sometimes a reverse one succeeds the torpor occasioned by defect of stimulus, the latter of which is perhaps owing to a certain time being required for the production of an accumulation of the sensorial power of irritation by the nervous branches of the torpid organ; which accumulation is now in part or entirely derived to the next link of the association. Thus in going into a coldish bath, as into a river in the summer months, we at first experience a difficulty of breathing from the torpid action of the pulmonary capillaries, owing to the deficient excitement of the sensorial power of association in consequence of the torpor of the cutaneous capillaries. But in a very short time, as in one minute, the sensorial power of irritation becomes accumulated by the inactivity of the cutaneous capillaries; and as its superabundance becomes now expended on the pulmonary capillaries, the difficult respiration ceases; though the cutaneous capillaries continue torpid by their contact with the cold water, and consequently the sensorial power of association, which used to contribute to actuate the pulmonary capillaries, is less excited.
8. In like manner when there exists an accumulation of the sensorial power of association, owing to defect of its excitement by some previous irritative or associate motions, it is generally accompanied for a certain time by a torpor not only of the link first affected, but of the subsequent parts, or of the whole train of associated motions, as in the cold fits of intermittent fevers. Yet after a time an increased action of the next links of associated motions succeeds the torpor of the first, as the absorbent vessels of the lungs act more violently in consequence of the deficient action of those of the stomach; and the skin at the commencement of sickness is pale and cold, but in a little time becomes flushed and warm.
Thus we see in associate motions, which are rendered torpid by defect of excitement, that sometimes a direct, and sometimes a reverse sympathy succeeds in the subsequent links of the chain. But I believe where a torpor of irritative or of the associate motions is caused by a previous too great expenditure or exhaustion of the sensorial powers of irritation or association, no increase of action in the subsequent link ever occurs, or not till after a very long time.
Thus when the stomach becomes torpid by previous violent exertion, and consequent exhaustion of the sensorial power of irritation, as after intoxication with wine or opium, or after the exhibition of some violent emetic drug, the torpor is communicated to the heart and arteries, as in continued fevers with weak pulse. But where the torpor of the stomach is produced from defective association, as in sea-sickness; or in the sickness which occurs, when a stone stimulates the ureter; no torpor is then communicated to the heart and arteries. For in the former case there is no accumulation of sensorial power in the stomach, which was previously exhausted by too great stimulus; but in the latter case the accumulation of sensorial power in the stomach during its torpor is evinced by this circumstance; that in sea-sickness the patients eat and drink voraciously at intervals; and the pulse is generally not affected by the sickness occasioned by a stone in the ureter. For the action of the stomach is then lessened, and in consequence becomes retrograde, not owing to the exhaustion of the sensorial power of irritation, but to the want of excitement of the sensorial power of association; which is caused by the defective action of the ureter, which becomes occasionally torpid by the great stimulus of the stone it contains; or which is caused by the great exhaustion of sensorial power by the pain; which affects the ureter without exciting inflammation, or increased action of it.
9. Thus though the stomach after the great stimulus of intoxication from excess of wine or opium will continue many hours without accumulation of sensorial power, as appears from the patient's experiencing no appetite at the intervals of sickness; yet after long abstinence from food, at length not only the exhausted quantity of sensorial power is renewed, but an accumulation of it at length occurs, and hunger returns. In this situation the stomach is generally about a whole day before it regains its usual powers of digestion; but if it has been still more violently stimulated, and its actions further impaired, a still more permanent torpor along with a continued fever with weak pulse is liable to occur; and a fourth part, or a half, or three fourths, or a whole lunar period passes, before it recovers its due irritability and consequent action.
In similar manner, after a person has been confined in a very warm room for some hours, the cutaneous capillaries, with their secretory and absorbent vessels, become exhausted of their sensorial power of irritation by the too great violent exertions occasioned by the unusual stimulus of heat; and in coming into a colder atmosphere an inactivity of the cutaneous vessels exists at first for some time without accumulation of sensorial power; as is shewn by the continuance of the pain of cold and the paleness; but after a time both the pain of cold and paleness vanish, which now indicates an accumulation of the sensorial power of irritation, as less degrees of heat stimulate the system into due action.
In the same manner, after any one has been some time in the summer sunshine, on coming into a dark cell he continues much longer before he can clearly distinguish objects, than if his eyes had only been previously exposed to the light of a cloudy day in winter; because the sensorial power of irritation, and consequent sensation, had in the first case been previously much expended or exhausted; and therefore required a much longer time before it could be produced in the brain, or derived to the optic nerves, in such quantity as to restore the deficiency, and to cause an accumulation of it; whereas in the latter case no deficiency had occurred.
10. Thus the accumulation or deficiency of sensorial power in a torpid organ, which had previously been accustomed to perpetual action, depends on the manner in which it becomes torpid; that is, whether by great previous stimulus, or great previous excitement of the power of association; or by defect of its accustomed stimulus, or of its accustomed excitement of the power of association. In the former case the sensorial power is in an exhausted state, and therefore is not likely to become so soon accumulated, as after drunkenness, or exposure to great heat, or to great light; in the latter a great accumulation of sensorial power occurs, as after exposure to cold, or hunger, or darkness.
Hence when the stomach continues torpid by previous violent stimulus, as in the exhibition of digitalis, no accumulation of sensorial power of irritation supervenes; and in consequence the motions of the heart and arteries, which are associated with those of the stomach, become weak, and slow, and intermittent, from the defect of the excitement of the sensorial power of association. But what follows? as the actions of the heart and arteries are lessened by the deficient action of the sensorial power of association, and not by previous increased excitement of it; a great accumulation of the sensorial power of association occurs, which is exerted on the pulmonary and cutaneous absorbents by reverse sympathy, and produces a great absorption of the fluid effused into the cellular membrane in anasarca, with dry skin; constituting one kind of atrophy.
But if at the same time the secerning vessels of the stomach are stimulated into so violent activity as to induce great consequent torpor, as probably happens when contagious matter is swallowed into the stomach with our saliva, those of the heart and arteries act feebly from the deficient excitement of the power of association; and then the cutaneous and pulmonary secerning vessels act with greater force than natural, owing to the accumulation of the sensorial power of association; and unnatural heat of the skin, and of the breath succeed; but without frequency of pulse, constituting the paresis irritativa of Class I. 2. 1. 2. And lastly, if a paucity of blood attends this paresis, or some other cause inducing a frequency of pulse, the febris inirritativa, or fever with weak pulse, is produced.
But on the contrary when the stomach has previously been rendered torpid by defect of stimulus, as by hunger, if food be too hastily supplied, not only great exertion of the stomach itself succeeds, but fever with strong pulse is induced in consequence; that is, the heart and arteries are excited into more energetic action by the excess of the power of association, which catenates their motions with those of the stomach. For the redundancy of sensorial power of irritation, which was accumulated during the inactivity of the stomach, and is now called into action by stimulus, actuates that organ with increased energy, and excites by these increased motions the sensorial power of association; which has also been accumulated during the inactivity of the heart and arteries; and thus these organs also are now excited into greater action.
So after the skin has been exposed some hours to greater heat than natural in the warm room, other parts, as the membranes of the nostrils, or of the lungs, or of the stomach, are liable to become torpid from direct sympathy with it, when we come into air of a moderate temperature; whence catarrhs, coughs, and fevers. But if this torpor be occasioned by defect of stimulus, as after being exposed to frosty air, the accumulation of sensorial power is exerted, and a glow of the skin follows, with increased digestion, full respiration, and more vigorous circulation.
11. It may be asked, Why is there a great and constant accumulation of the sensorial power of association, owing to the torpor of the stomach and heart and arteries, in continued fever with weak pulse; which is exerted on the cutaneous and pulmonary capillaries, so as to excite them into increased action for many weeks, and yet no such exuberance of sensorial power produces fever in winter-sleeping animals, or in chlorosis, or apepsia, or hysteria?
In winter-sleeping animals I suppose the whole nervous system is torpid, or paralysed, as in the sleep of frozen people; and that the stomach is torpid in consequence of the inactivity or quiescence of the brain; and that all other parts of the body, and the cutaneous capillaries with the rest, labour under a similar torpor.
In chlorosis, I imagine, the actions of the heart and arteries, as well as those of the cutaneous and pulmonary capillaries, suffer along with those of the stomach from the deficient stimulus of the pale blood; and that though the liver is probably the seat of the original torpor in this disease, with which all other parts sympathize from defect of the excitation of the sensorial power of association; yet as this torpor occurs in so small a degree as not to excite a shuddering or cold fit, no observable consequences are in general occasioned by the consequent accumulation of sensorial power. Sometimes indeed in chlorosis there does occur a frequent pulse and hot skin; in which circumstances I suppose the heart and arteries are become in some degree torpid by direct sympathy with the torpid liver; and that hence not only the pulse becomes frequent, but the capillaries of the skin act more violently by reverse sympathy with the heart and arteries, owing to the accumulation of the sensorial power of association in them during their torpid state, as occurs in irritative fever. See Article 11 of this Supplement.
In apepsia chronica the actions of the stomach are not so far impaired or destroyed as totally to prevent the excitation of the sensorial power of association, which therefore contributes something towards the actions of the heart and arteries, though less than natural, as a weak pulse always I believe attends this disease.
There is a torpor of the stomach, and of the upper part of the alimentary canal in hysteria, as is evident from the retrograde actions of the duodenum, stomach, and œsophagus, which constitute the globus hystericus, or sensation of a globe rising into the throat. But as these retrograde actions are less than those, which induce sickness or vomiting, and are not occasioned by previous exhaustion of the sensorial power of irritation, they do not so totally prevent the excitement of the sensorial power of association, as to lessen the motion of the heart and arteries so much as to induce fever; yet in this case, as in apepsia, and in chlorosis, the pulsations of the heart and arteries are weaker than natural, and are sometimes attended with occasionally increased action of the capillaries; as appears from the flushings of the face, and hot skin, which generally form an evening febricula in diseases attended with weak digestion.
12. The increased action, or orgasm, of the cutaneous, pulmonary, and cellular capillaries, with their secerning and absorbent vessels, in those fevers which are attended with deficiency of vital action, exhausts the patient both by the additional expenditure of sensorial power on those organs of secretion, and by the too great absorption of the mucus and fat of the body; whence great debility and great emaciation. Hence one great indication of cure of continued fever with arterial debility is to diminish the too great action of the capillaries; which is to be done by frequent ablutions, or bathing the whole skin in tepid or in cold water, as recommended by Dr. Currie of Liverpool (Philos. Trans. for 1792), for half an hour, twice a day, or at those times when the skin feels dryest and hottest. Much cool air should also be admitted, when the breath of the patient feels hot to one's hand; or when the tongue, especially its middle part, is dry, and covered with a crust of indurated mucus; as these indicate the increased action of the pulmonary capillaries; in the same manner as the dry and hot skin indicates the orgasm of the cutaneous capillaries; and the emaciation of the body that of the cellular ones.
For this purpose of abating the action of the capillaries by frequent ablution or fomentation, water of any degree of heat beneath that of the body will be of service, and ought in accurate language to be called a cold bath; but the degree of coldness, where the patient is sensible, should in some measure be governed by his sensations; as it is probable, that the degree of coldness, which is most grateful to him, will also be of the greatest benefit to him. See Class III. 2. 1. 12. and Article 15 of this Supplement.
Another great use of frequent ablutions, or fomentations, or baths, in fevers, where the stomach is in some degree torpid, is to supply the system with aqueous fluid by means of the cutaneous absorbents; which is dissipated faster by the increased action of the secerning capillaries, than the stomach can furnish, and occasions great thirst at the intervals of the sickness.
IX. Torpor of the Lungs.
1. The lungs in many cases of contagion may first be affected with torpor, and the skin become cold by sympathy; in the same manner as a cold skin on going into the cold bath induces difficulty of breathing. Or the stomach may become affected with torpor by its sympathy with the lungs, as in the experiments of Mr. Watt with hydro-carbonate gas; a few respirations of which induced sickness, and even syncope. When the stomach or skin is thus affected secondarily by association, an accumulation of sensorial power occurs much sooner, than when these parts become torpid in consequence of previous excess of stimulus; and hence they sooner recover their accustomed action, and the fever ceases. The particles of contagious matter thus received by respiration somewhat resemble in their effects the acid gases from burning sulphur, or from charcoal; which, if they do not instantly destroy, induce a fever, and the patient slowly recovers.
2. I was some years ago stooping down to look, which way the water oozed from a morass, as a labourer opened it with a spade, to detect the source of the spring, and inhaled a vapour, which occasioned an instant sense of suffocation. Immediately recoiling I believe I inhaled it but once; yet a few hours afterwards in the cool of the evening, when I returned home rather fatigued and hungry, a shivering and cold fit occurred, which was followed by a hot one; and the whole disease began and terminated in about twelve hours without return. In this case the power of fear, or of imagination, was not concerned; as I neither thought of the bad air of a morass before I perceived it; nor expected a fever-fit, till it occurred.
In this case the torpor commenced in the lungs, and after a few hours, by the addition of fatigue, and cold, and hunger, was propagated by direct sympathy to the rest of the system. An orgasm or increased action of the whole system was then induced by the accumulation of sensorial power of irritation in the lungs, and of association in the other organs; and when these subsided, the disease ceased. It may be asked, could a torpor of the capillaries of the air-vessels of the lungs be so suddenly produced by great stimulation?—It appears probable, that it might, because great exertion of irritative motions may be instantly produced without our perceiving them; that is, without their being attended by sensation, both in the lungs and stomach; and the organs may become torpid by the great expenditure of the sensorial power of irritation in an instant of time; as paralysis frequently instantly follows too great an exertion of voluntary power.
3. When the capillaries of the lungs act too violently, as in some continued fevers; which is known by the heat of the breath, and by the dryness of the tongue, especially of the middle part of it; not only cooler air might be admitted more freely into a sick room to counteract this orgasm of the pulmonary capillaries; but perhaps the patient might breathe with advantage a mixture of carbonic acid gas, or of hydrogene gas, or of azote with atmospheric air. And on the contrary, when there exists an evident torpor of the pulmonary capillaries, which may be known by the correspondent chilness of the skin; and by a tickling cough, which sometimes attends cold paroxysms of fever, and is then owing to the deficient absorption of the pulmonary mucus, the saline parts of which stimulate the bronchiæ, or air-vessels; a mixture of one part of oxygen gas with 10 or 20 parts of atmospheric air might probably be breathed with great advantage.
X. Torpor of the Brain.
As the inactivity or torpor of the absorbent vessels of the brain is the cause of hydrocephalus internus; and as the deficiency of venous absorption in the brain, or torpor of the extremities of its veins, is believed frequently to be the cause of apoplexies; so there is reason to conclude, that the torpor of the secerning vessels of the brain, which are supposed to produce the sensorial power, may constitute the immediate cause of some fevers with arterial debility. And also that the increased action of these secerning vessels may sometimes constitute the immediate cause of fevers with arterial strength.
It is nevertheless probable, that the torpor or orgasm of the sanguiferous, absorbent, or secerning vessels of the brain may frequently exist as a secondary effect, owing to their association with other organs, as the stomach or lungs; and may thus be produced like the torpor of the heart and arteries in inirritative fevers, or like the orgasm of those organs in irritative fevers, or inflammatory ones.
Where there exists a torpor of the brain, might not very slight electric shocks passed frequently through it in all directions be used with advantage? Might not fomentations of 94 or 96 degrees of heat on the head for an hour at a time, and frequently repeated, stimulate the brain into action; as in the revival of winter-sleeping animals by warmth? Ether externally might be frequently applied, and a blister on the shaved head.
Where the secerning vessels of the brain act with too great energy, as in some inflammatory fevers, might it not be diminished by laying the patient horizontally on a mill-stone, and whirling him, till sleep should be produced, as the brain becomes compressed by the centrifugal force? See Article 15 of this Supplement.
XI. Torpor of the Heart and Arteries.
1. It was shewn in Class IV. 1. 1. 6. in IV. 2. 1. 2. and in Suppl. I. 6. 3. that a reverse sympathy generally exists between the lacteal and lymphatic branches of the absorbent system. Hence, when the motions of the absorbents of the stomach are rendered torpid or retrograde in fevers with arterial debility, those of the skin, lungs, and cellular membrane, act with increased energy. But the actions of the muscular fibres of the heart and arteries are at the same time associated with those of the muscular fibres of the stomach by direct sympathy. Both these actions occur during the operation of powerful emetics, as squill, or digitalis; while the motions of the stomach continue torpid or retrograde, the cellular and cutaneous absorbents act with greater energy, and the pulsations of the heart and arteries become weaker, and sometimes slower.
2. The increased action of the stomach after a meal, and of the heart and arteries at the same time from the stimulus of the new supply of chyle, seems originally to have produced, and to have established, this direct sympathy between them. As the increased action of the absorbents of the stomach after a meal has been usually attended with diminished action of the other branches of the absorbent system, as mentioned in Class IV. 1. 1. 6. and has thus established a reverse sympathy between them.
2. Besides the reverse sympathy of the absorbent vessels and the muscles of the stomach, and of the heart and arteries, with those of the skin, lungs, and cellular membrane; there exists a similar reverse sympathy between the secerning vessels or glands of the former of these organs with those of the latter; that is the mucous glands of the heart and arteries act generally by direct sympathy with those of the stomach; and the mucous glands of the cellular membrane of the lungs, and of the skin, act by reverse sympathy with them both.
Hence when the stomach is torpid, as in sickness, this torpor sometimes only affects the absorbent vessels of it; and then the absorbents of the cellular membrane and the skin only act with increased energy by reverse sympathy. If the torpor affects the muscular fibres of the stomach, those of the heart and arteries act by direct sympathy with it, and a weak pulse is produced, as in the exhibition of digitalis, but without increase of heat. But if the torpor also affects the glands of the stomach, the cutaneous and pulmonary glands act with greater energy by their reverse sympathy with those of the stomach, and of the heart and arteries; and great heat is produced along with increased perspiration both from the skin and lungs.
3. There is some difficulty in explaining, why the actions of the extensive system of capillary glands, which exist on every other membrane and cell in the body for the purpose of secreting mucus and perspirable matter, should so generally act by reverse sympathy with those of the stomach and upper part of the intestines. It was shewn in Class IV. 1. 1. 6. that when the stomach was filled with solid and fluid aliment, the absorbents of the cellular membrane, and of the bladder, and of the skin acted with less energy; as the fluids they were used to absorb and transmit into the circulation, were now less wanted; and that hence by habit a reverse sympathy obtained between these branches of the absorbents of the alimentary canal, and those of the other parts of the body.
Now, as at this time less fluid was absorbed by the cutaneous and cellular lymphatics, it would happen, that less would be secreted by their correspondent secerning vessels, or capillary glands; and that hence by habit, these secerning vessels would acquire a reverse sympathy of action with the secerning vessels of the alimentary canal.
Thus when the absorption of the tears by the puncta lacrymalia is much increased by the stimulus of snuff; or of an affecting idea, on the nasal dusts, as explained in Sect. XVI. 8. 2. a great increase of the secretion of tears from the lacrymal glands is produced by the direct sympathy of the action of these glands with those of their correspondent absorbents; and that though in this case they are placed at so great a distance from each other.
4. A difficult question here occurs; why does it happen, that in fevers with weak pulse the contractions of the heart and arteries become at the same time more frequent; which also sometimes occurs in chlorosis, and in some hysteric and hypochondriac diseases, and in some insanities; yet at other times the weak pulse becomes at the same time slow, as in the exhibition of digitalis, and in paresis irritativa, described in Class I. 2. 1. 2. which may be termed a fever with slow pulse? this frequency of pulse can not depend on heat, because it sometimes exists without heat, as towards the end of some fevers with debility.
Now as apoplexies, which are sometimes ascribed to fulness of blood, are attended with slow pulse; and as in animals dying in the slaughter house from deficiency of blood the pulse becomes frequent in extreme; may not the frequency of pulse in fevers with arterial debility be in general owing to paucity of blood? as explained in Sect. XXXII. 2. 3. and its slowness in paresis irritativa be caused by the debility being accompanied with due quantity of blood? or may not the former circumstance sometimes depend on a concomitant affection of the brain approaching to sleep? or to the unusual facility of the passage of the blood through the pulmonary and aortal capillaries? in which circumstance the heart may completely empty itself at each pulsation, though its contractions may be weak. While the latter depends on the difficulty of the passage of the blood through the pulmonary or aortal capillaries, as in the cold fits of intermittents, and in some palpitations of the heart, and in some kinds of hæmoptoe? in these cases the increased resistance prevents the heart from emptying itself, and in consequence a new diastole sooner occurs, and thus the number of pulsations becomes greater in a given time.
5. In respect to the sympathies of action, which produce or constitute fever with debility, the system may be divided into certain provinces, which are assentient or opposite to each other. First, the lacteals or absorbent vessels of the stomach, and upper part of the intestines; secondly, the lymphatics or all the other branches of the absorbent vessels, which arise from the skin, mucous membranes, cellular membranes, and the various glands. These two divisions act by reverse sympathy with each other in the hot fits of fever with debility, though by direct sympathy in the cold ones. The third division consists of the secerning vessels of the stomach and upper intestines; and the fourth of the secerning vessels of all the other parts of the body, as the capillary glands of the skin, lungs, and cellular membrane, and the various other glands belonging to the sanguiferous system. Many of these frequently, but the capillaries always, act by reverse sympathy with those of the third division above mentioned in the hot fits of fever with debility, though by direct sympathy with them in the cold fits. Fifthly, the muscular fibres of the stomach, and upper intestines; and sixthly, the muscular fibres of the heart and arteries. The actions of these two last divisions of moving fibres act by direct sympathy with each other, both in the cold and hot fits of fevers with debility.
The efficient cause of those apparent sympathies in fevers with weak pulse may be thus understood. In the cold paroxysm of fever with weak pulse the part first affected I believe to be the stomach, and that it has become torpid by previous violent exertion, as by swallowing contagious matter mixed with saliva, and not by defect of stimulus, as from cold or hunger. The actions of this important organ, which sympathizes with almost every part of the body, being thus much diminished or nearly destroyed, the sensorial power of association is not excited; which in health contributes to move the heart and arteries, and all the rest of the system; whence an universal torpor occurs.
When the hot fit approaches, the stomach in fevers with strong pulse regains its activity by the accumulation of the sensorial power of either irritation, if it was the part first affected, or of association if it was affected in sympathy with some other torpid part, as the spleen or liver; which accumulation is produced during its torpor. At the same time all the other parts of the system acquire greater energy of action by the accumulation of the sensorial power of association, which was produced, during their inactivity in the cold fit.
But in fevers with weak pulse the stomach, whose sensorial power of irritation had been previously exhausted by violent action, acquires no such quick accumulation of sensorial power, but remains in a state of torpor after the hot fit commences. The heart and arteries remain also in a state of torpor, because there continues to be no excitement of their power of association owing to the torpid motions of the stomach; but hence it happens, that there exists at this time a great accumulation of the power of association in the less active fibres of the heart and arteries; which, as it is not excited and expended by them, increases the associability of the next link of the associated chain of motions, which consists of the capillaries or other glands; and that in so great a degree as to actuate them with unnatural energy, and thus to produce a perpetual hot fit of fever. Because the associability of the capillaries is so much increased by the accumulation of this power, owing to the lessened activity of the heart and arteries, as to over-balance the lessened excitement of it by the weaker movements of the heart and arteries.
6. When the accumulation of the sensorial power of irritation caused by defect of stimulus is greater in the first link of a train of actions, to which associated motions are catenated, than the deficiency of the excitement of the sensorial power of association in the next link, what happens?—the superabundance of the unemployed sensorial power of the first link is derived to the second; the associability of which thus becomes so greatly increased, that it acts more violently than natural, though the excitement of its power of association by the lessened action of the first link is less than natural. So that in this situation the withdrawing of an accustomed stimulus in some parts of the system will decrease the irritative motions of that part, and at the same time occasion an increase of the associate motion of another part, which is catenated with it.
This circumstance nevertheless can only occur in those parts of the system, whose natural actions are perpetual, and the accumulation of sensorial power on that account very great, when their activity is much lessened by the deduction of their usual stimulus; and are therefore only to be found in the sanguiferous system, or in the alimentary canal, or in the glands and capillaries. Of the first of which the following is an instance.
The respiration of a reduced atmosphere, that is of air mixed with hydrogene or azote, quickens the pulse, as observed in the case of Mrs. Eaton by Dr. Reynolds and Dr. Thornton; to which Dr. Beddoes adds in a note, that "he never saw an instance in which a lowered atmosphere did not at the moment quicken the pulse, while it weakened the action of the heart and arteries." Considerations on Factitious Airs, by Thomas Beddoes and James Watt, Part III. p. 67. Johnson, London. By the assistance of this new fact the curious circumstance of the quick production of warmth of the skin on covering the head under the bed-clothes, which every one must at some time have experienced, receives a more satisfactory explanation, than that which is given in Class IV. 1. 1. 2. which was printed before this part of Dr. Beddoes's Considerations was published.
For if the blood be deprived of its accustomed quantity of oxygen, as in covering the head in bed, and thus breathing an air rendered impure by repeated respiration, or by breathing a factitious air with less proportion of oxygen, which in common respiration passes through the moist membranes of the lungs, and mixes with the blood, the pulsations of the heart and arteries become weaker, and consequently quicker, by the defect of the stimulus of oxygen. And as these vessels are subject to perpetual motion, the accumulation of the sensorial power of irritation becomes so great by their lessened activity, that it excites the vessels next connected, the cutaneous capillaries for instance, into more energetic actions, so as to produce increased heat of the skin, and greater perspiration.
How exactly this resembles a continued fever with weak and quick pulse!—in the latter the action of the heart and arteries are lessened by defect of the excitement of the sensorial power of association, owing to the torpor or lessened actions of the stomach; hence the accumulation of the sensorial power of association in this case, as the accumulation of that of irritation in the former, becomes so abundant as to excite into increased action the parts most nearly connected, as the cutaneous capillaries.
In respect to the circumstance mentioned by Sydenham, that covering the head in bed in a short time relieved the pertinacious sickness of the patient, it must be observed, that when the action of the heart and arteries become weakened by the want of the due stimulus of the proper quantity of oxygen in the blood, that an accumulation of the sensorial power of irritation occurs in the fibres of the heart and arteries, which then is expended on those of the capillary glands, increasing their actions and consequent secretions and heat. And then the stomach is thrown into stronger action, both by the greater excitement of its natural quantity of the sensorial power of association by the increased actions of the capillaries, and also by some increase of associability, as it had been previously a long time in a state of torpor, or less activity than natural, as evinced by its perpetual sickness.
In a manner somewhat similar to this, is the redness of the skin produced in angry people by the superabundance of the unemployed sensorial power of volition, as explained in Class IV. 2. 3. 5. Rubor ex irâ. From hence we learn how, when people in fevers with weak pulse, or in dropsies, become insane, the abundance of the unemployed sensorial power of volition increases the actions of the whole moving system, and cures those diseases.
7. As the orgasm of the capillaries in fevers with weak pulse is immediately caused by the torpid actions of the heart and arteries, as above explained, this supplies us with another indication of cure in such fevers, and that is to stimulate these organs. This may probably be done by some kind of medicines, which are known to pass into the blood unchanged in some of their properties. It is possible that nitre, or its acid, may pass into the blood and increase the colour of it, and thus increase its stimulus, and the same may be supposed of other salts, neutral or metallic? As rubia tinctoria, madder, colours the bones of young animals, it must pass into the blood with its colouring matter at least unchanged, and perhaps many other medicines may likewise affect the blood, and thus act by stimulating the heart and arteries, as well as by stimulating the stomach; which circumstance deserves further attention.
Another way of immediately stimulating the heart and arteries would be by transfusing new blood into them. Is it possible that any other fluid besides blood, as chyle, or milk, or water, could, if managed with great art, be introduced safely or advantageously into the vein of a living animal?
A third method of exciting the heart and arteries immediately is by increasing the natural stimulus of the blood, and is well worthy experiment in all fevers with weak pulse; and that consists in supplying the blood with a greater proportion of oxygen; which may be done by respiration, if the patient was to breathe either oxygen gas pure, or diluted with atmospheric air, which might be given to many gallons frequently in a day, and by passing through the moist membranes of the lungs, according to the experiments of Dr. Priestley, and uniting with the blood, might render it more stimulant, and thus excite the heart and arteries into greater action! May not some easier method of exhibiting oxygen gas by respiration be discovered, as by using very small quantities of hyper-oxygenated marine acid gas very much diluted with atmospheric air?
XII. Torpor of the Stomach and upper Intestines.
1. The principal circumstance, which supports the increased action of the capillaries in continued fever with weak pulse, is their reverse sympathy with those of the stomach and upper intestines, or with those of the heart and arteries. The torpor of the stomach and upper intestines is apparent in continued fevers from the total want of appetite for solid food, besides the sickness with which fevers generally commence, and the frequent diarrhœa with indigested stools, at the same time the thirst of the patient is sometimes urgent at the intervals of the sickness. Why the stomach can at this time take fluids by intervals, and not solids, is difficult to explain; except it be supposed, as some have affirmed, that the lacteal absorbents are a different branch from the lymphatic absorbents, and that in this case the former only are in a state of permanent torpor.
2. The torpor of the heart and arteries is known by the weakness of the pulse. When the actions of the absorbents of the stomach are diminished by the exhibition of small doses of digitalis, or become retrograde by larger ones, the heart and arteries act more feebly by direct sympathy; but the cellular, cutaneous, and pulmonary absorbents are excited into greater action. Whence in anasarca the fluids in the cellular membrane throughout the whole body are absorbed during the sickness, and frequently a great quantity of atmospheric moisture at the same time; as appears by the very great discharge of urine, which sometimes happens in these cases; and in ileus the prodigious evacuations by vomiting, which are often a hundred fold greater than the quantity swallowed, evince the great action of all the other absorbents during the sickness of the stomach.
3. But when the stomach is rendered permanently sick by an emetic drug, as by digitalis, it is not probable, that much accumulation of sensorial power is soon produced in this organ; because its usual quantity of sensorial power is previously exhausted by the great stimulus of the foxglove; and hence it seems probable, that the great accumulation of sensorial power, which now causes the increased action of the absorbents, is produced in consequence of the inactivity of the heart and arteries; which inactivity is induced by deficient excitement of the sensorial power of association between those organs and the stomach, and not by any previous exhaustion of their natural quantity of sensorial power; whereas in ileus, where the torpor of the stomach, and consequent sickness, is induced by reverse sympathy with an inflamed intestine, that is, by dissevered or defective association; the accumulation of sensorial power, which in that disease so violently actuates the cellular, pulmonary, and cutaneous absorbents, is apparently produced by the torpor of the stomach and lacteals, and the consequent accumulation of the sensorial power of association in them owing to their lessened action in sickness.
4. This accounts for the dry skin in fevers with weak pulse, where the stomach and the heart and arteries are in a torpid state, and for the sudden emaciation of the body; because the actions of the cellular and cutaneous absorbents are increased by reverse sympathy with those of the stomach, or with those of the heart and arteries; that is by the expenditure of that sensorial power of association, which is accumulated in consequence of the torpor of the stomach and heart and arteries, or of either of them; this also explains the sudden absorption of the milk in puerperal fevers; and contributes along with the heat of the respired air to the dryness of the mucous membrane of the tongue and nostrils.
5. Besides the reverse sympathy, with which the absorbent vessels of the stomach and upper intestines act in respect to all the other absorbent vessels, as in the exhibition of digitalis, and in ileus; there is another reverse sympathy exists between the capillaries, or secretory vessels of the stomach, and those of the skin. Which may nevertheless be occasioned by the accumulation of sensorial power by the torpor of the heart and arteries, which is induced by direct sympathy with the stomach; thus when the torpor of the stomach remains in a fever-fit which might otherwise have intermitted, the torpor of the heart and arteries remains also by direct sympathy, and the increased cutaneous capillary action, and consequent heat, are produced by reverse sympathy; and the fever is thus rendered continual, owing primarily to the torpor of the stomach.
6. The reverse sympathy, which exists between the capillaries of the stomach and the cutaneous capillaries, appears by the chillness of some people after dinner; and contrary-wise by the digestion being strengthened, when the skin is exposed to cold air for a short time; as mentioned in Class IV. 1. 1. 4. and IV. 2. 1. 1. and from the heat and glow on the skin, which attends the action of vomiting; for though when sickness first commences, the skin is pale and cold; as it then partakes of the general torpor, which induces the sickness; yet after the vomiting has continued some minutes, so that an accumulation of sensorial power exists in the capillaries of the stomach, and of the skin, owing to their diminished action; a glow of the skin succeeds, with sweat, as well as with increased absorption.
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 Class IV. 2. 1. 17. and 18.
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 Class II. 2. 2. 1. and III. 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 Class I. 3. 1. 3. and I. 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. Class IV. 2. 1. 10. in which the first link of association acts too strongly, and in consequence expends more than usual of the sensorial power of irritation; 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 vertigo eases for 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 Class IV. 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 Class IV. 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 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 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 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 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 Class 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 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 Class 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 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 Class 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 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 Class IV. 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 small quantity in 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, Class I. 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. Take here an addendum 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!