SECT. XXXIII.
DISEASES OF SENSATION.
- I. 1. Motions excited by sensation. Digestion. Generation. Pleasure of existence. Hypochondriacism. 2. Pain introduced. Sensitive fevers of two kinds. 3. Two sensorial powers exerted in sensitive fevers. Size of the blood. Nervous fevers distinguished from putrid ones. The septic and antiseptic theory. 4. Two kinds of delirium. 5. Other animals are less liable to delirium, cannot receive our contagious diseases, and are less liable to madness. II. 1. Sensitive motions generated. 2. Inflammation explained. 3. Its remote causes from excess of irritation, or of irritability, not from those pains which are owing to defect of irritation. New vessels produced, and much heat. 4. Purulent matter secreted. 5. Contagion explained. 6. Received but once. 7. If common matter be contagious? 8. Why some contagions are received but once. 9. Why others may be received frequently. Contagions of small-pox and measles do not act at the same times. Two cases of such patients. 10. The blood from patients in the small-pox will not infect others. Cases of children thus inoculated. The variolous contagion is not received into the blood. It acts by sensitive association between the stomach and skin. III. 1. Absorption of solids and fluids. 2. Art of healing ulcers. 3. Mortification attended with less pain in weak people.
I. 1. As many motions of the body are excited and continued by irritations, so others require, either conjunctly with these, or separately, the pleasurable or painful sensations, for the purpose of producing them with due energy. Amongst these the business of digestion supplies us with an instance: if the food, which we swallow, is not attended with agreeable sensation, it digests less perfectly; and if very disagreeable sensation accompanies it, such as a nauseous idea, or very disgustful taste, the digestion becomes impeded; or retrograde motions of the stomach and œsophagus succeed, and the food is ejected.
The business of generation depends so much on agreeable sensation, that, where the object is disgustful, neither voluntary exertion nor irritation can effect the purpose; which is also liable to be interrupted by the pain of fear or bashfulness.
Besides the pleasure, which attends the irritations produced by the objects of lust and hunger, there seems to be a sum of pleasurable affection accompanying the various secretions of the numerous glands, which constitute the pleasure of life, in contradistinction to the tedium vitæ. This quantity or sum of pleasurable affection, seems to contribute to the due or energetic performance of the whole moveable system, as well that of the heart and arteries, as of digestion and of absorption; since without the due quantity of pleasurable sensation, flatulency and hypochondriacism affect the intestines, and a languor seizes the arterial pulsations and secretions; as occurs in great and continued anxiety of the mind.
2. Besides the febrile motions occasioned by irritation, described in Sect. XXXII. and termed irritative fever, it frequently happens that pain is excited by the violence of the fibrous contractions; and other new motions are then superadded, in consequence of sensation, which we shall term febris sensitiva, or sensitive fever. It must be observed, that most irritative fevers begin with a decreased exertion of irritation, owing to defect of stimulus; but that on the contrary the sensitive fevers, or inflammations, generally begin with the increased exertion of sensation, as mentioned in Sect. XXXI. on temperaments: for though the cold fit, which introduces inflammation, commences with decreased irritation, yet the inflammation itself commences in the hot fit during the increase of sensation. Thus a common pustule, or phlegmon, in a part of little sensibility does not excite an inflammatory fever; but if the stomach, intestines, or the tender substance beneath the nails, be injured, great sensation is produced, and the whole system is thrown into that kind of exertion, which constitutes inflammation.
These sensitive fevers, like the irritative ones, resolve themselves into those with arterial strength, and those with arterial debility, that is with excess or defect of sensorial power; these may be termed the febris sensitiva pulsu forti, sensitive fever with strong pulse, which is the synocha, or inflammatory fever; and the febris sensitiva pulsu debili, sensitive fever with weak pulse, which is the typhus gravior, or putrid fever of some writers.
3. The inflammatory fevers, which are here termed sensitive fevers with strong pulse, are generally attended with some topical inflammation, as pleurisy, peripneumony, or rheumatism, which distinguishes them from irritative fevers with strong pulse. The pulse is strong, quick, and full; for in this fever there is great irritation, as well as great sensation, employed in moving the arterial system. The size, or coagulable lymph, which appears on the blood, is probably an increased secretion from the inflamed internal lining of the whole arterial system, the thinner part being taken away by the increased absorption of the inflamed lymphatics.
The sensitive fevers with weak pulse, which are termed putrid or malignant fevers, are distinguished from irritative fevers with weak pulse, called nervous fevers, described in the last section, as the former consist of inflammation joined with debility, and the latter of debility alone. Hence there is greater heat and more florid colour of the skin in the former, with petechiæ, or purple spots, and aphthæ, or sloughs in the throat, and generally with previous contagion.
When animal matter dies, as a slough in the throat, or the mortified part of a carbuncle, if it be kept moist and warm, as during its abhesion to a living body, it will soon putrify. This, and the origin of contagion from putrid animal substances, seem to have given rise to the septic and antiseptic theory of these fevers.
The matter in pustules and ulcers is thus liable to become putrid, and to produce microscopic animalcula; the urine, if too long retained, may also gain a putrescent smell, as well as the alvine feces; but some writers have gone so far as to believe, that the blood itself in these fevers has smelt putrid, when drawn from the arm of the patient: but this seems not well founded; since a single particle of putrid matter taken into the blood can produce fever, how can we conceive that the whole mass could continue a minute in a putrid state without destroying life? Add to this, that putrid animal substances give up air, as in gangrenes; and that hence if the blood was putrid, air should be given out, which in the blood-vessels is known to occasion immediate death.
In these sensitive fevers with strong pulse (or inflammations) there are two sensorial faculties concerned in producing the disease, viz. irritation and sensation; and hence, as their combined action is more violent, the general quantity of sensorial power becomes further exhausted during the exacerbation, and the system more rapidly weakened than in irritative fever with strong pulse; where the spirit of animation is weakened by but one mode of its exertion: so that this febris sensitiva pulsu forti (or inflammatory fever,) may be considered as the febris irritativa pulsu forti, with the addition of inflammation; and the febris sensitiva pulsu debili (or malignant fever) may be considered as the febris irritativa pulsu debili (or nervous fever), with the addition of inflammation.
4. In these putrid or malignant fevers a deficiency of irritability accompanies the increase of sensibility; and by this waste of sensorial power by the excess of sensation, which was already too small, arises the delirium and stupor which so perpetually attend these inflammatory fevers with arterial debility. In these cases the voluntary power first ceases to act from deficiency of sensorial spirit; and the stimuli from external bodies have no effect on the exhausted sensorial power, and a delirium like a dream is the consequence. At length the internal stimuli cease to excite sufficient irritation, and the secretions are either not produced at all, or too parsimonious in quantity. Amongst these the secretion of the brain, or production of the sensorial power, becomes deficient, till at last all sensorial power ceases, except what is just necessary to perform the vital motions, and a stupor succeeds; which is thus owing to the same cause as the preceding delirium exerted in a greater degree.
This kind of delirium is owing to a suspension of volition, and to the disobedience of the senses to external stimuli, and is always occasioned by great debility, or paucity of sensorial power; it is therefore a bad sign at the end of inflammatory fevers, which had previous arterial strength, as rheumatism, or pleurisy, as it shews the presence of great exhaustion of sensorial power in a system, which having lately been exposed to great excitement, is not so liable to be stimulated into its healthy action, either by additional stimulus of food and medicines, or by the accumulation of sensorial power during its present torpor. In inflammatory fevers with debility, as those termed putrid fevers, delirium is sometimes, as well as stupor, rather a favourable sign; as less sensorial power is wasted during its continuance (see Class II. 1. 7. 1.), and the constitution not having been previously exposed to excess of stimulation, is more liable to be excited after previous quiescence.
When the sum of general pleasurable sensation becomes too great, another kind of delirium supervenes, and the ideas thus excited are mistaken for the irritations of external objects: such a delirium is produced for a time by intoxicating drugs, as fermented liquors, or opium: a permanent delirium of this kind is sometimes induced by the pleasures of inordinate vanity, or by the enthusiastic hopes of heaven. In these cases the power of volition is incapable of exertion, and in a great degree the external senses become incapable of perceiving their adapted stimuli, because the whole sensorial power is employed or expended on the ideas excited by pleasurable sensation.
This kind of delirium is distinguished from that which attends the fevers above mentioned from its not being accompanied with general debility, but simply with excess of pleasurable sensation; and is therefore in some measure allied to madness or to reverie; it differs from the delirium of dreams, as in this the power of volition is not totally suspended, nor are the senses precluded from external stimulation; there is therefore a degree of consistency, in this kind of delirium, and a degree of attention to external objects, neither of which exist in the delirium of fevers or in dreams.
5. It would appear, that the vascular system of other animals are less liable to be put into action by their general sum of pleasurable or painful sensation; and that the trains of their ideas, and the muscular motions usually associated with them, are less powerfully connected than in the human system. For other animals neither weep, nor smile, nor laugh; and are hence seldom subject to delirium, as treated of in Sect. XVI. on Instinct. Now as our epidemic and contagious diseases are probably produced by disagreeable sensation, and not simply by irritation; there appears a reason, why brute animals are less liable to epidemic or contagious diseases; and secondly, why none of our contagions, as the small-pox or measles, can be communicated to them, though one of theirs, viz. the hydrophobia, as well as many of their poisons, as those of snakes and of in insects, communicate their deleterious or painful effects to mankind.
Where the quantity of general painful sensation is too great in the system, inordinate voluntary exertions are produced either of our ideas, as in melancholy and madness, or of our muscles, as in convulsion. From these maladies also brute animals are much more exempt than mankind, owing to their greater inaptitude to voluntary exertion, as mentioned in Sect. XVI. on Instinct.
II. 1. When any moving organ is excited into such violent motions, that a quantity of pleasurable or painful sensation is produced, it frequently happens (but not always) that new motions of the affected organ are generated in consequence of the pain or pleasure, which are termed inflammation.
These new motions are of a peculiar kind, tending to distend the old, and to produce new fibres, and thence to elongate the straight muscles, which serve locomotion, and to form new vessels at the extremities or sides of the vascular muscles.
2. Thus the pleasurable sensations produce an enlargement of the nipples of nurses, of the papillæ of the tongue, of the penis, and probably produce the growth of the body from its embryon state to its maturity; whilst the new motions in consequence of painful sensation, with the growth of the fibres or vessels, which they occasion, are termed inflammation.
Hence when the straight muscles are inflamed, part of their tendons at each extremity gain new life and sensibility, and thus the muscle is for a time elongated; and inflamed bones become soft, vascular, and sensible. Thus new vessels shoot over the cornea of inflamed eyes, and into scirrhous tumours, when they become inflamed; and hence all inflamed parts grow together by intermixture, and inosculation of the new and old vessels.
The heat is occasioned from the increased secretions either of mucus, or of the fibres, which produce or elongate the vessels. The red colour is owing to the pellucidity of the newly formed vessels, and as the arterial parts of them are probably formed before their correspondent venous parts.
3. These new motions are excited either from the increased quantity of sensation in consequence of greater fibrous contractions, or from increased sensibility, that is, from the increased quantity of sensorial power in the moving organ. Hence they are induced by great external stimuli, as by wounds, broken bones; and by acrid or infectious materials; or by common stimuli on those organs, which have been some time quiescent; as the usual light of the day inflames the eyes of those, who have been confined in dungeons; and the warmth of a common fire inflames those, who have been previously exposed to much cold.
But these new motions are never generated by that pain, which arises from defect of stimulus, as from hunger, thirst, cold, or inanition, with all those pains, which are termed nervous. Where these pains exist, the motions of the affected part are lessened; and if inflammation succeeds, it is in some distant parts; as coughs are caused by coldness and moisture being long applied to the feet; or it is in consequence of the renewal of the stimulus, as of heat or food, which excites our organs into stronger action after their temporary quiescence; as kibed heels after walking in snow.
4. But when these new motions of the vascular muscles are exerted with greater violence, and these vessels are either elongated too much or too hastily, a new material is secreted from their extremities, which is of various kinds according to the peculiar animal motions of this new kind of gland, which secretes it; such is the pus laudabile or common matter, the variolous matter, venereal matter, catarrhous matter, and many others.
5. These matters are the product of an animal process; they are secreted or produced from the blood by certain diseased motions of the extremities of the blood-vessels, and are on that account all of them contagious; for if a portion of any of these matters is transmitted into the circulation, or perhaps only inserted into the skin, or beneath the cuticle of an healthy person, its stimulus in a certain time produces the same kind of morbid motions, by which itself was produced; and hence a similar kind is generated. See Sect. XXXIX. 6. 1.
6. It is remarkable, that many of these contagious matters are capable of producing a similar disease but once; as the small-pox and measles; and I suppose this is true of all those contagious diseases, which are spontaneously cured by nature in a certain time; for if the body was capable of receiving the disease a second time, the patient must perpetually infect himself by the very matter, which he has himself produced, and is lodged about him; and hence he could never become free from the disease. Something similar to this is seen in the secondary fever of the confluent small-pox; there is a great absorption of variolous matter, a very minute part of which would give the genuine small-pox to another person; but here it only stimulates the system into common fever; like that which common puss, or any other acrid material might occasion.
7. In the pulmonary consumption, where common matter is daily absorbed, an irritative fever only, without new inflammation, is generally produced; which is terminated like other irritative fevers by sweats, or loose stools. Hence it does not appear, that this absorbed matter always acts as a contagious material producing fresh inflammation or new abscesses. Though there is reason to believe, that the first time any common matter is absorbed, it has this effect, but not the second time, like the variolous matter above mentioned.
This accounts for the opinion, that the pulmonary consumption is sometimes infectious, which opinion was held by the ancients, and continues in Italy at present; and I have myself seen three or four instances, where a husband and wife, who have slept together, and have thus much received each other's breath, who have infected each other, and both died in consequence of the original taint of only one of them. This also accounts for the abscesses in various parts of the body, that are sometimes produced after the inoculated small-pox is terminated; for this second absorption of variolous matter acts like common matter, and produces only irritative fever in those children, whose constitutions have already experienced the absorption of common matter; and inflammation with a tendency to produce new abscesses in those, whose constitutions have not experienced the absorptions of common matter.
It is probable, that more certain proofs might have been found to shew, that common matter is infectious the first time it is absorbed, tending to produce similar abscesses, but not the second time of its absorption, if this subject had been attended to.
8. These contagious diseases are very numerous, as the plague, small-pox, chicken-pox, measles, scarlet-fever, pemphigus, catarrh, chincough, venereal disease, itch, trichoma, tinea. The infectious material does not seem to be dissolved by the air, but only mixed with it perhaps in fine powder, which soon subsides; since many of these contagions can only be received by actual contact; and others of them only at small distances from the infected person; as is evident from many persons having been near patients of the small-pox without acquiring the disease.
The reason, why many of these diseases are received but once, and others repeatedly, is not well understood; it appears to me, that the constitution becomes so accustomed to the stimuli of these infectious materials, by having once experienced them, that though irritative motions, as hectic fevers, may again be produced by them, yet no sensation, and in consequence no general inflammation succeeds; as disagreeable smells or tastes by habit cease to be perceived; they continue indeed to excite irritative ideas on the organs of sense, but these are not succeeded by sensation.
There are many irritative motions, which were at first succeeded by sensation, but which by frequent repetition cease to excite sensation, as explained in Sect. XX. on Vertigo. And, that this circumstance exists in respect to infectious matter appears from a known fact; that nurses, who have had the small-pox, are liable to experience small ulcers on their arms by the contact of variolous matter in lifting their patients; and that when patients, who have formerly had the small-pox have been inoculated in the arm, a phlegmon, or inflamed sore, has succeeded, but no subsequent fever. Which shews, that the contagious matter of the small-pox has not lost its power of stimulating the part it is applied to, but that the general system is not affected in consequence. See Section XII. 7. 6. XIX. 9.
9. From the accounts of the plague, virulent catarrh, and putrid dysentery, it seems uncertain, whether these diseases are experienced more than once; but the venereal disease and itch are doubtless repeatedly infectious; and as these diseases are never cured spontaneously, but require medicines, which act without apparent operation, some have suspected, that the contagious material produces similar matter rather by a chemical change of the fluids, than by an animal process; and that the specific medicines destroy their virus by chemically combining with it. This opinion is successfully combated by Mr. Hunter, in his Treatise on Venereal Disease, Part I. c. i.
But this opinion wants the support of analogy, as there is no known process in animal bodies, which is purely chemical, not even digestion; nor can any of these matters be produced by chemical processes. Add to this, that it is probable, that the insects, observed in the pustules of the itch, and in the stools of dysenteric patients, are the consequences, and not the causes of these diseases. And that the specific medicines, which cure the itch and lues venerea, as brimstone and mercury, act only by increasing the absorption of the matter in the ulcuscles of those diseases, and thence disposing them to heal; which would otherwise continue to spread.
Why the venereal disease, and itch, and tenia, or scald head, are repeatedly contagious, while those contagions attended with fever can be received but once, seems to depend on their being rather local diseases than universal ones, and are hence not attended with fever, except the purulent fever in their last stages, when the patient is destroyed by them. On this account the whole of the system does not become habituated to these morbid actions, so as to cease to be affected with sensation by a repetition of the contagion. Thus the contagious matter of the venereal disease, and of the tenia, affects the lymphatic glands, as the inquinal glands, and those about the roots of the hair and neck, where it is arrested, but does not seem to affect the blood-vessels, since no fever ensues.
Hence it would appear, that these kinds of contagion are propagated not by means of the circulation, but by sympathy of distant parts with each other; since if a distant part, as the palate, should be excited by sensitive association into the same kind of motions, as the parts originally affected by the contact of infectious matter; that distant part will produce the same kind of infectious matter; for every secretion from the blood is formed from it by the peculiar motions of the fine extremities of the gland, which secretes it; the various secreted fluids, as the bile, saliva, gastric juice, not previously existing, as such, in the blood-vessels.
And this peculiar sympathy between the genitals and the throat, owing to sensitive association, appears not only in the production of venereal ulcers in the throat, but in variety of other instances, as in the mumps, in the hydrophobia, some coughs, strangulation, the production of the beard, change of voice at puberty. Which are further described in Class IV. 1. 2. 7.
To evince that the production of such large quantities of contagious matter, as are seen in some variolous patients, so as to cover the whole skin almost with pustules, does not arise from any chemical fermentation in the blood, but that it is owing to morbid motions of the fine extremities of the capillaries, or glands, whether these be ruptured or not, appears from the quantity of this matter always corresponding with the quantity of the fever; that is, with the violent exertions of those glands and capillaries, which are the terminations of the arterial system.
The truth of this theory is evinced further by a circumstance observed by Mr. J. Hunter, in his Treatise on Venereal Disease; that in a patient, who was inoculated for the small-pox, and who appeared afterwards to have been previously infested with the measles, the progress of the small-pox was delayed till the measles had run their course, and that then the small-pox went through its usual periods.
Two similar cases fell under my care, which I shall here relate, as it confirms that of Mr. Hunter, and contributes to illustrate this part of the theory of contagious diseases. I have transcribed the particulars from a letter of Mr. Lightwood of Yoxal, the surgeon who daily attended them, and at my request, after I had seen them, kept a kind of journal of their cases.
Miss H. and Miss L. two sisters, the one about four and the other about three years old, were inoculated Feb. 7, 1791. On the 10th there was a redness on both arms discernible by a glass. On the 11th their arms were so much inflamed as to leave no doubt of the infection having taken place. On the 12th less appearance of inflammation on their arms. In the evening Miss L. had an eruption, which resembled the measles. On the 12th the eruption on Miss L. was very full on the face and breast, like the measles, with considerable fever. It was now known, that the measles were in a farm house in the neighbourhood. Miss H.'s arm less inflamed than yesterday. On the 14th Miss L.'s fever great, and the eruption universal. The arm appears to be healed. Miss H.'s arm somewhat redder. They were now put into separate rooms. On the 15th Miss L.'s arms as yesterday. Eruption continues. Miss H.'s arms have varied but little. 16th, the eruptions on Miss L. are dying away, her fever gone. Begins to have a little redness in one arm at the place of inoculation. Miss H.'s arms get redder, but she has no appearance of complaint. 20th, Miss L.'s arms have advanced slowly till this day, and now a few pustules appear. Miss H.'s arm has made little progress from the 16th to this day, and now she has some fever. 21st, Miss L. as yesterday. Miss H. has much inflammation, and an increase of the red circle on one arm to the size of half a crown, and had much fever at night, with fetid breath. 22d, Miss L.'s pustules continue advancing. Miss H.'s inflammation of her arm and red circle increases. A few red spots appear in different parts with some degree of fever this morning, 23d. Miss L. has a larger crop of pustules. Miss H. has small pustules and great inflammation of her arms, with but one pustule likely to suppurate. After this day they gradually got well, and the pustules disappeared.
In one of these cases the measles went through their common course with milder symptoms than usual, and in the other the measly contagion seemed just sufficient to stop the progress of variolous contagion, but without itself throwing the constitution into any disorder. At the same time both the measles and small-pox seem to have been rendered milder. Does not this give an idea, that if they were both inoculated at the same time, that neither of them might affect the patient?
From these cases I contend, that the contagious matter of these diseases does not affect the constitution by a fermentation, or chemical change of the blood, because then they must have proceeded together, and have produced a third something, not exactly similar to either of them: but that they produce new motions of the cutaneous terminations of the blood-vessels, which for a time proceed daily with increasing activity, like some paroxysms of fever, till they at length secrete or form a similar poison by these unnatural actions.
Now as in the measles one kind of unnatural motion takes place, and in the small-pox another kind, it is easy to conceive, that these different kinds of morbid motions cannot exist together; and therefore, that that which has first begun will continue till the system becomes habituated to the stimulus which occasions it, and has ceased to be thrown into action by it; and then the other kind of stimulus will in its turn produce fever, and new kinds of motions peculiar to itself.
10. On further considering the action of contagious matter, since the former part of this work was sent to the press; where I have asserted, in Sect. XXII. 3. 3. that it is probable, that the variolous matter is diffused through the blood; I prevailed on my friend Mr. Power, surgeon at Bosworth in Leicestershire to try, whether the small-pox could be inoculated by using the blood of a variolous patient instead of the matter from the pustules; as I thought such an experiment might throw some light at least on this interesting subject. The following is an extract from his letter:—
"March 11, 1793. I inoculated two children, who had not had the small-pox, with blood; which was taken from a patient on the second day after the eruption commenced, and before it was completed. And at the same time I inoculated myself with blood from the same person, in order to compare the appearances, which might arise in a person liable to receive the infection, and in one not liable to receive it. On the same day I inoculated four other children liable to receive the infection with blood taken from another person on the fourth day after the commencement of the eruption. The patients from whom the blood was taken had the disease mildly, but had the most pustules of any I could select from twenty inoculated patients; and as much of the blood was insinuated under the cuticle as I could introduce by elevating the skin without drawing blood; and three or four such punctures were made in each of their arms, and the blood was used in its fluid state.
"As the appearances in all these patients, as well as in myself, were similar, I shall only mention them in general terms. March 13. A slight subcuticular discoloration, with rather a livid appearance, without soreness or pain, was visible in them all, as well as in my own hand. 15. The discoloration somewhat less, without pain or soreness. Some patients inoculated on the same day with variolous matter have considerable inflammation. 17. The discoloration is quite gone in them all, and from my own hand, a dry mark only remaining. And they were all inoculated on the 18th, with variolous matter, which produced the disease in them all."
Mr. Power afterwards observes, that, as the patients from whom the blood was taken had the disease mildly, it may be supposed, that though the contagious matter might be mixed with the blood, it might still be in too dilute a state to convey the infection; but adds at the same time, that he has diluted recent matter with at least five times its quantity of water, and which has still given the infection; though he has sometimes diluted it so far as to fail.
The following experiments were instituted at my request by my friend Mr. Hadley, surgeon in Derby, to ascertain whether the blood of a person in the small-pox be capable of communicating the disease. "Experiment 1st. October 18th, 1793. I took some blood from a vein in the arm of a person who had the small-pox, on the second day of the eruption, and introduced a small quantity of it immediately with the point of a lancet between the scars and true skin of the right arm of a boy nine years old in two or three different places; the other arm was inoculated with variolous matter at the same time.
"19th. The punctured parts of the right arm were surrounded with some degree of subcuticular inflammation. 20th. The inflammation more considerable, with a slight degree of itching, but no pain upon pressure. 21st. Upon examining the arm this day with a lens I found the inflammation less extensive, and the redness changing to a deep yellow or orange-colour, 22d. Inflammation nearly gone. 23d. Nothing remained, except a slight discoloration and a little scurfy appearance on the punctures. At the same time the inflammation of the arm inoculated with variolous matter was increasing fast, and he had the disease mildly at the usual time.
"Experiment 2d. I inoculated another child at the same time and in the same manner, with blood taken on the first day of the eruption; but as the appearance and effects were similar to those in the preceding experiment, I shall not relate them minutely.
"Experiment 3d. October 20th. Blood was taken from a person who had the small-pox, on the third day of the eruption, and on the sixth from the commencement of the eruptive fever. I introduced some of it in its fluid state into both arms of a boy seven years old.
21st. There appeared to be some inflammation under the cuticle, where the punctures were made. 22d. Inflammation more considerable. 23d. On this day the inflammation was somewhat greater, and the cuticle rather elevated.
"24th. Inflammation much less, and only a brown or orange-colour remained. 25th. Scarcely any discoloration left. On this day he was inoculated with variolous matter, the progress of the infection went on in the usual way, and he had the small-pox very favourably.
"At this time I was requested to inoculate a young person, who was thought to have had the small-pox, but his parents were not quite certain; in one arm I introduced variolous matter, and in the other blood, taken as in experiment 3d. On the second day after the operation, the punctured parts were inflamed, though I think the arm in which I had inserted variolous matter was rather more so than the other. On the third the inflammation was increased, and looked much the same as in the preceding experiment. 4th. The inflammation was much diminished, and on the 5th almost gone. He was exposed at the same time to the natural infection, but has continued perfectly well.
"I have frequently observed (and believe most practitioners have done the same), that if variolous matter be inserted in the arm of a person who has previously had the small-pox, that the inflammation on the second or third days is much greater, than if they had not had the disease, but on the fourth or fifth it disappears.
"On the 23d I introduced blood into the arms of three more children, taken on the third and fourth days of the eruption. The appearances were much the same as mentioned in experiments first and third. They were afterwards inoculated with variolous matter, and had the disease in the regular way.
"The above experiments were made with blood taken from a small vein in the hand or foot of three or four different patients, whom I had at that time under inoculation. They were selected from 160, as having the greatest number of pustules. The part was washed with warm water before the blood was taken, to prevent the possibility of any matter being mixed with it from the surface."
Shall we conclude from hence, that the variolous matter never enters the blood-vessels? but that the morbid motions of the vessels of the skin around the insertion of it continue to increase in a larger and larger circle for six or seven days; that then their quantity of morbid action becomes great enough to produce a fever-fit, and to affect the stomach by association of motions? and finally, that a second association of motions is produced between the stomach and the other parts of the skin, inducing them into morbid actions similar to those of the circle round the insertion of the variolous matter? Many more experiments and observations are required before this important question can be satisfactorily answered.
It may be adduced, that as the matter inserted into the skin of the arm frequently swells the lymphatic in the axilla, that in that circumstance it seems to be there arrested in its progress, and cannot be imagined to enter the blood by that lymphatic gland till the swelling of it subsides. Some other phænomena of the disease are more easily reconcileable to this theory of sympathetic motions than to that of absorption; as the time taken up between the insertion of the matter, and the operation of it on the system, as mentioned above. For the circle around the insertion is seen to increase, and to inflame; and I believe, undergoes a kind of diurnal paroxysm of torpor and paleness with a succeeding increase of action and colour, like a topical fever-fit. Whereas if the matter is conceived to circulate for six or seven days with the blood, without producing disorder, it ought to be rendered milder, or the blood-vessels more familiarized to its acrimony.
It is much easier to conceive from this doctrine of associated or sympathetic motions of distant parts of the system, how it happens, that the variolous infection can be received but once, as before explained; than by supposing, that a change is effected in the mass of blood by any kind of fermentative process.
The curious circumstance of the two contagions of small-pox and measles not acting at the same time, but one of them resting or suspending its action till that of the other ceases, may be much easier explained from sympathetic or associated actions of the infected part with other parts of the system, than it can from supposing the two contagions to enter the circulation.
The skin of the face is subject to more frequent vicissitudes of heat and cold, from its exposure to the open air, and is in consequence more liable to sensitive association with the stomach than any other part of the surface of the body, because their actions have been more frequently thus associated. Thus in a surfeit from drinking cold water, when a person is very hot and fatigued, an eruption is liable to appear on the face in consequence of this sympathy. In the same manner the rosy eruption on the faces of drunkards more probably arises from the sympathy of the face with the stomach, rather than between the face and the liver, as is generally supposed.
This sympathy between the stomach and the skin of the face is apparent in the eruption of the small-pox; since, where the disease is in considerable quantity, the eruption on the face first succeeds the sickness of the stomach. In the natural disease the stomach seems to be frequently primarily affected, either alone or along with the tonsils, as the matter seems to be only diffused in the air, and by being mixed with the saliva, or mucus of the tonsils, to be swallowed into the stomach.
After some days the irritative circles of motions become disordered by this new stimulus, which acts upon the mucus lining of the stomach; and sickness, vertigo, and a diurnal fever succeed. These disordered irritative motions become daily increased for two or three days, and then by their increased action certain sensitive motions, or inflammation, is produced, and at the next cold fit of fever, when the stomach recovers from its torpor, an inflammation of the external skin is formed in points (which afterwards suppurate), by sensitive association, in the same manner as a cough is produced in consequence of exposing the feet to cold, as described in Sect. XXV. 17. and Class IV. 2. 1. 7. If the inoculated skin of the arm, as far as it appears inflamed, was to be cut out, or destroyed by caustic, before the fever commenced, as suppose on the fourth day after inoculation, would this prevent the disease? as it is supposed to prevent the hydrophobia.
III. 1. Where the new vessels, and enlarged old ones, which constitute inflammation, are not so hastily distended as to burst, and form a new kind of gland for the secretion of matter, as above mentioned; if such circumstances happen as diminish the painful sensation, the tendency to growth ceases, and by and by an absorption commences, not only of the superabundant quantity of fluids deposited in the inflamed part, but of the solids likewise, and this even of the hardest kind.
Thus during the growth of the second set of teeth in children, the roots of the first set are totally absorbed, till at length nothing of them remains but the crown; though a few weeks before, if they are drawn immaturely, their roots are found complete. Similar to this Mr. Hunter has observed, that where a dead piece of bone is to exfoliate, or to separate from a living one, that the dead part does not putrify, but remains perfectly sound, while the surface of the living part of the bone, which is in contact with the dead part, becomes absorbed, and thus effects its separation. Med. Comment. Edinb. V. 1. 425. In the same manner the calcareous matter of gouty concretions, the coagulable lymph deposited on inflamed membranes in rheumatism and extravasated blood become absorbed; which are all as solid and as indissoluble materials as the new vessels produced in inflammation.
This absorption of the new vessels and deposited fluids of inflamed parts is called resolution: it is produced by first using such internal means as decrease the pain of the part, and in consequence its new motions, as repeated bleeding, cathartics, diluent potations, and warm bath.
After the vessels are thus emptied, and the absorption of the new vessels and deposited fluids is evidently begun, it is much promoted by stimulating the part externally by solutions of lead, or other metals, and internally by the bark, and small doses of opium. Hence when an ophthalmy begins to become paler, any acrid eye-water, as a solution of six grains of white vitriol in an ounce of water, hastens the absorption, and clears the eye in a very short time. But the same application used a few days sooner would have increased the inflammation. Hence after evacuation opium in small doses may contribute to promote the absorption of fluids deposited on the brain, as observed by Mr. Bromfield in his treatise of surgery.
2. Where an abscess is formed by the rupture of these new vessels, the violence of inflammation ceases, and a new gland separates a material called pus: at the same time a less degree of inflammation produces new vessels called vulgarly proud flesh; which, if no bandage confines its growth, nor any other circumstance promotes absorption in the wound, would rise to a great height above the usual size of the part.
Hence the art of healing ulcers consists in producing a tendency to absorption in the wound greater than the deposition. Thus when an ill-conditioned ulcer separates a copious and thin discharge, by the use of any stimulus, as of salts of lead, or mercury, or copper externally applied, the discharge becomes diminished in quantity, and becomes thicker, as the thinner parts are first absorbed.
But nothing so much contributes to increase the absorption in a wound as covering the whole limb above the sore with a bandage, which should be spread with some plaster, as with emplastrum de minio, to prevent it from slipping. By this artificial tightness of the skin, the arterial pulsations act with double their usual power in promoting the ascending current of the fluid in the valvular lymphatics.
Internally the absorption from ulcers should be promoted first by evacuation, then by opium, bark, mercury, steel.
3. Where the inflammation proceeds with greater violence or rapidity, that is, when by the painful sensation a more inordinate activity of the organ is produced, and by this great activity an additional quantity of painful sensation follows in an increasing ratio, till the whole of the sensorial power, or spirit of animation, in the part becomes exhausted, a mortification ensues, as in a carbuncle, in inflammations of the bowels, in the extremities of old people, or in the limbs of those who are brought near a fire after having been much benumbed with cold. And from hence it appears, why weak people are more subject to mortification than strong ones, and why in weak persons less pain will produce mortification, namely, because the sensorial power is sooner exhausted by any excess of activity. I remember seeing a gentleman who had the preceding day travelled two stages in a chaise with what he termed a bearable pain in his bowels; which when I saw him had ceased rather suddenly, and without a passage through him; his pulse was then weak, though not very quick; but as nothing which he swallowed would continue in his stomach many minutes, I concluded that the bowel was mortified; he died on the next day. It is usual for patients sinking under the small-pox with mortified pustules, and with purple spots intermixed, to complain of no pain, but to say they are pretty well to the last moment.
Recapitulation.
IV. When the motions of any part of the system, in consequence of previous torpor, are performed with more energy than in the irritative fevers, a disagreeable sensation is produced, and new actions of some part of the system commence in consequence of this sensation conjointly with the irritation: which motions constitute inflammation. If the fever be attended with a strong pulse, as in pleurisy, or rheumatism, it is termed synocha sensitiva, or sensitive fever with strong pulse; which is usually termed inflammatory fever. If it be attended with weak pulse, it is termed typhus sensitivus, or sensitive fever with weak pulse, or typhus gravior, or putrid malignant fever.
The synocha sensitiva, or sensitive fever with strong pulse, is generally attended with some topical inflammation, as in peripneumony, hepatitis, and is accompanied with much coagulable lymph, or size; which rises to the surface of the blood, when taken into a bason, as it cools; and which is believed to be the increased mucous secretion from the coats of the arteries, inspissated by a greater absorption of its aqueous and saline part, and perhaps changed by its delay in the circulation.
The typhus sensitivus, or sensitive fever with weak pulse, is frequently attended with delirium, which is caused by the deficiency of the quantity of sensorial power, and with variety of cutaneous eruptions.
Inflammation is caused by the pains occasioned by excess of action, and not by those pains which are occasioned by defect of action. These morbid actions, which are thus produced by two sensorial powers, viz. by irritation and sensation, secrete new living fibres, which elongate the old vessels, or form new ones, and at the same time much heat is evolved from these combinations. By the rupture of these vessels, or by a new construction of their apertures, purulent matters are secreted of various kinds; which are infectious the first time they are applied to the skin beneath the cuticle, or swallowed with the saliva into the stomach. This contagion acts not by its being absorbed into the circulation, but by the sympathies, or associated actions, between the part first stimulated by the contagious matter and the other parts of the system. Thus in the natural small-pox the contagion is swallowed with the saliva, and by its stimulus inflames the stomach; this variolous inflammation of the stomach increases every day, like the circle round the puncture of an inoculated arm, till it becomes great enough to disorder the circles of irritative and sensitive motions, and thus produces fever-fits, with sickness and vomiting. Lastly, after the cold paroxysm, or fit of torpor, of the stomach has increased for two or three successive days, an inflammation of the skin commences in points; which generally first appear upon the face, as the associated actions between the skin of the face and that of the stomach have been more frequently exerted together than those of any other parts of the external surface.
Contagious matters, as those of the measles and small-pox, do not act upon the system at the same time; but the progress of that which was last received is delayed, till the action of the former infection ceases. All kinds of matter, even that from common ulcers, are probably contagious the first time they are inserted beneath the cuticle or swallowed into the stomach; that is, as they were formed by certain morbid actions of the extremities of the vessels, they have the power to excite similar morbid actions in the extremities of other vessels, to which they are applied; and these by sympathy, or associations of motion, excite similar morbid actions in distant parts of the system, without entering the circulation; and hence the blood of a patient in the small-pox will not give that disease by inoculation to others.
When the new fibres or vessels become again absorbed into the circulation, the inflammation ceases; which is promoted, after sufficient evacuations, by external stimulants and bandages: but where the action of the vessels is very great, a mortification of the part is liable to ensue, owing to the exhaustion of sensorial power; which however occurs in weak people without much pain, and without very violent previous inflammation; and, like partial paralysis, may be esteemed one mode of natural death of old people, a part dying before the whole.