BLEEDING IN THE COLD STAGE OF INTERMITTENT FEVER.

357 and in very many of them stimulants are, from the great debility induced by the bleeding, afterwards necessarily resorted to. If, however, the administration of tartar emetic may be generally relied on, as I expect, the ill effects of taking much blood will frequently be obviated.

taxation,

cold; conjunctiva turgid ; heat of trunk

the natural standard. Thee sensations of cold now became almost insupportable, and he shivered to such a degree as actually to shake the bed he was lying on. I immediately determined to bleed him, although the man was frightat my doing so, as, to use his own Cold Water asa Means of restoring sushe thought he required blood pended animation.-I will take this oppor- instead of abstracting any. However, I tunity of adverting briefly to another sub- succeeded in persuading him, and with ject. I have for some years, in my lec- great difficulty (owing to the tremors) tures at this hospital, taught the propriety made a large orifice in the basilic vein. The of cold sprinkling the chests of children, blood at first oozed out by drops only; I when born in a state of suspended aniapplied hot bottles to his hands and mation, or in cases where the respiratory feet, and used friction to the arm, and had function was not sufficiently active, con- ! the of getting a full stream in a, ceiving it to be decidedly one of the best very little time; and when about ten means we have for the purpose referred to. ounces had been abstracted, a gradual But it should not be applied at all on the warmth wasfelt pervading the body, and face, as I have seen it, so directed, produce shivering had ceased. I tied up injurious and often destructive effects. Its the arm, and in a few minutes the exapplication on the face suddenly suspends tremities became quite warm, the breaththe respiration. ing free, the pulse 85 and soft. He here expressed great surprise at the relief which he had so suddenly experienced. I then had him lightly covered, and gave him the not below

ened

’ expression,

then

satisfaction

the

BLEEDING IN THE COLD STAGE OF

INTERMITTENT FEVER. To the Editor

following: Magnes.

Sulph. iss; Liq. Antim. Tart. 3.i;; Sp. Æther. Nitrosi iss ; Mist. Camphoræ iss. M. Fiat haustus ter die sumendus.

of THE LANCET.

In an hour afterwards he fell asleep, SIR,—I beg to forward you the following cases of intermittent fever, in which slept for four hours, and awoke quite rebleeding was employed in the cold stage freshed. The first thing he noticed was as recommended by Dr. Mackintosh of that no hot stage had supervened, but that Edinburgh, with the most successful re- he was in a gentle perspiration. This consults. May I beg the favour of their in- tinued in a very light degree for about sertion in your valuable periodical. I am, four hours ; he passed a very excellent Sir, yours respectfully, night, and the next day he was working in SAMUEL LA MERT, his office. He continued taking the MERT,.Surgeon, Surgeon, &c. 14, Bury-street, St. Mary-Axe, draughts for one week. It is now nearly May 14th, 1834. eighteen months past, and he has not had another attack, but is in the enjoyment of CASE 1.—M. Teulon, a printer, aged 45, excellent health.

of bilious temperament and spare habit, had been the subject of tertian intermittent fever for several years, which, from i, its continuance, had produced general de- !, rangement of his health. He had taken quantities of bark without producing any permanent effect, although it had relieved him from time to time, but immediately he caught cold he was certain of an attack.

CASE

2.—January 20th, 1833. Mrs. the City-Road, had

N—, aged 58, living in

been in a bad state of health for some time. When she applied to me, she was complaining that every other day she was attacked with an acute pain in the head, with shivering and intense cold, which in a few hours gave way excessive heat and thirst, and termiOn the morning of Tuesday, November the 27th, 1832, I was called to see him, nated in a profuse perspiration, when all and found him in the following state. pain and uneasy feelings subsided until Yawning and stretching, with feelings of the next attack. Bowels were costive, lassitude and debility, complaining of tight- tongue foul, pulse 110, and on her telling ness across his chest, which rendered his me that she expected the paroxysm in the breathing difficult and laborious. In a few afternoon, I went to see her, and found minutes a complete rigor set in; teethher in exactly the state she had described. chattered ; countenance lived; pulse 100,,After the rigor had well set in, I opened and much oppressed; extremities deadlyavein in the arm, and abstracted about-

accompanied to

358

Potassæ

ten ounces of blood, with immediate effect, for the coldness and shivering ceased, and

mon.

trosi

gentle perspiration ensued. I then gave her the same draughts as in Teulon’s case, and ordered her to be kept quiet, and have low diet.

a

Nitratis gr. x; Liq. Am. Acet. 5ij;Sp. Ætheris Ni3j ;Mist. Camph. ix. M.

Fiat haustus ter die 7. Had

sumendus.

perspired freely; pulse 80,

and

soft; (jedenia of the legs rather diminished, 22. Had felt better during the interval had passed a great quantity of water; than hitherto. Tongue cleaner; bowels tongue cleaner: bowels open; felt betfreely opened; the paroxysm came on in ter during the interval. Continue the the evening, but not so violent as before. I again abstracted blood. The pulse previous to this was 60. After eight ounces had been it mounted np to 80. Heat again returned, and the pain in the head had completely ceased; no hot stage followed.

draughts.

8. About noon had another rigor, which very severe ; was bled to 10ounces a decidedly good effect, no hot stage The blood in this instance was taken from the saphena vein. The bowels being costive, I gave her one ounce of cas24. Had scarcely perspired at all after tor oil, and ordered the draught to be conthe bleeding, and during the interval had tinued. 10. In the morning pulse was75 ; felt; no weakness. Tongue clean; appetongue quite clean; bowels had been tite improved; bowels open ; about eight in the evening felt a sense of coldness,Ifreely opened, and had made a great quantity of water. Legs were diminished to but not amounting to a rigor ; pulse the size they were previous to pain in the head not half so acute as be- one half the first bleeding. In the evening had fore. I again bled her, and took attack, and from this period she coiitwelve ounces, as I imagined I had not taken sufficient before. The result was valesced ; the legs became of a natural and she has since enjoyed excellent here highly satisfactory ; no hot or sweathealth. next of followed. The ing stage period atta.ck passed over without any unpleasant symptom; she gradually reco- Remarks.—The prcceding cases must, on vered her strength, and has been in ex-,reflection, afford convincing proofs that cellent health ever since. bleeding is a safe, efficient, and ceriain remedy in intermittent fever in the cold . CASE 3.-Dec. 4, 1832. Mrs. Goodson, stage. In Teulon’s case it effectually wife of a stable-keeper, aged 48, mother prevented any hot stage following; and of seven children, complains that every instead of an immense discharge taking other morning she has a violent pain in place from the excretory vessels of the the head, accompanied by a severe rigor, skin in the sweating stage, a slight perwhich lasts about an hour, and is suc- spiration merely ensued, and the next day ceeded by a hot sweating stage. The ! he was in perfect health, engaged at his. continuance of the disorder has produced I usual avocations. In the last case also, general b.td health, and œdema of the ex- although œdema of the extremities had tremities; tongue is furred; pulse 100;’ taken place, the effect of the bleeding was I gave her the following :- as decided as in the former. There are no appetite. Extract. Colocynth. c. gr. xii; Hy- many who say that bleeding must do considerable mischief where the patient, hav-drarg. Submur. gr. iij. Fiant piing been long affected by the ciisorder, lulæ tres statim sumendæ. has become weak and debilitated. But Dec. 6. This morning had a rigor, ac- they do not consider that the quantity of companied by all the symptoms of ague;’ fluid which exudes from the skin in the after it had well setin, I opened a vein on ! sweating stage, is very consi,lerable, and the back of the baud, and applied a hot! comes direct from the blood itself. In bottle to the palm. In a few minutes fact, nature herself effects the same proobtained a good stream, and when six cess, by removing a load from the system, ounces only had been abstracted, thoughat the expense of inducingfar shiveringceased, the coldness gave way greater debility than the bleeding would. to a gentle warmth, the pain in the head in the first stage ; added to this, by deplevanished, and the breathing became tion in the 1irst instance we prevent misand unaccompanied with tightness of the ; chief occurring from irregular determinachest. In fact the change was so sudden tion of blood to different vital organs, that the by-slanders were amazed. which frequently occurs in the hot stage, skin was moist, and bedewed with a. and lays foundation for future disease. It tle perspiration; no hct stage had is as notorious as it is remarkable, that all lowed. ;those who have expressed their opinion

was with

drawn,

following.

I ,

70 ;

aboutno

size,

the

i I

and

Ii

.

I the

free, The

gen-

foi-

359

opposition to this practice, have done manent, the form of the ventricles is from imagination only; for had they always the same during their active state. founded their opinions on the proofs If it were possibleto take a mould of the

in

so

elicited by the trial of the remedy, they ventricles at the commencement of cue would doubtless have published them to they would exactly fit that mould at I the commencement of each following best. the medical world long since.

! heat,

ventricles When in pressure at a would now occasion no depression, because the heart, when contracting, is hard and resisting; but if ON THE CAUSE OF THE the pressure had been applied when the ventricles were in a relaxed state, depnesHEART’S IMPULSE. sion, as previously observed, would have By E. L. BRYAN, Esq., Stowmarket. occurred, and immediately on their action the ventricles, reassuming their own peculiar and rounded form, would either THE investigation of the heart’s ’. strike back the finger to a, or themselves the in the opposite direction. requires a careful consideration mechanical states of the parts which are The parts which are passive in the plseactive, and of the parts which are passive, nomenon in question are those portions in its production. The ventricles, the active parts, have two of the parietes of the thorax, which form states; one in which their muscular fibres the outward walls of the cavity containare relaxed, and do not compress the ing the heart; and ther mechanical state blood; the other, in which they are con- is cf necessity connected with that of the whose walls they assist to form. In tracting, and powerfully compress that cavity fluid. When ina state of rest, the ventricles this cavity (which I shall here call the have no determinate form, but may be heart’s space) is contained the substance of moulded into any shape which the pres- the heart and the blood in its four cavities. sure of the parts in contact with them may Now the quantity cf the heart’s space occupied by the substance of the heart is happen to give them; they are soft and the same, whether the muscular fibres he and a slight upon any in action or at rest; but the blood i-,i this their surface would deof cause a portion heart’s cavities) is pression of that surface. For the sake of (i. e. the blood 1ll the elucidation, let Fig. 1 represent the out- constantly varying in quantity, or, at least, has a tendency so to do; because line of the ventricles in a relaxed state. from this space blood departs with arterial force and velocity, while it. enters it with venous force and velocity; the necessary consequence is, a tendency to vacuum in the heart’s space, equal to the difference of the two forces. The inevitable effect of this tendency to vacuum in the heart’s space is, that on the instant the ventricles have their contents and become re> laxed (the exact period at which the tenclency to vacuum is greatest), those por tions of the external parietes of the heart’s space, which are sufficiently elastic to yield to a slight force, close in upon that

Let

Fig.I represent the

action ;

impulse of ! recede

yielding,

pressure

discharged

space. Let Fig.2 represent the outline of a the end of the finger were’ heart and a section of the parts in conpressed upon them at a, it would occasiontact with it; let the line a represent a depression as represented by the dotted the form of the ventricles when in acline. tion ; when, powerfully compressing the In their state of action, however, the; blood, they are of their most rounded cr case is quite different, whatever mightt spherical form. On the instant they have have been the form of the ventricles dur-- ejected their contents and become relaxed, ing their relaxation, on the instant theirthe most elastic portions (a) of the extervalves are closed, their powerfully com-- nal walls of the heart’s space, close in pressed fluid causes them to take on thes slightly upon that space, as represented most rounded or spherical form which the 2 by the dotted lines, and depress the conarrangement of their muscular fibres will1 tiguous surface of the ventricles, the repermit, and as this. arrangement is per--v laxation of the ventricles permitting the

.

Suppose

,