Imatges de pàgina

M. C. aged 4.--The account we received from the parents of this child was, that she continued in good health until about six months after birth, when a blueness of the surface was remarked, particularly on any exertion, and accompanied with perpetual difficulty of breathing. In this state she continued to grow, and became remarkably tall of her age. She was observed, however, to get daily worse; that is, the paroxysms of threatened suffocation became more frequent, during which the whole surface of her body appeared almost black. A strong beating was constantly to be felt in the region of the heart, and she was sometimes convulsed; muscular debility great. At her death she measured three feet four inches. The body continued warm for five hours after death.

Dissection. 1. External appearances. The countenance, feet, and body, were not all discoloured; the arms and fingers retained their usual dark colour.

2. Thorax. The lungs seemed sound, though dark-coloured; heart perhaps larger than usual; foramen ovale pervious, and pretty large. The aorta arose from both ventricles in such a manner, that the ventricles communicated with each other, and with the cavity of the vessel, which was much enlarged; its vasa vasorum distended with red blood. From the right ventricle there arose a pulmonary artery, very small in its diameter, (perhaps the size of a small goose quill) and feeble in its coats; it possessed all the characters of the artery, such as its valves and division into two branches. Not the smallest vestige of a ductus arteriosus; it seemed never to have existed. The passage

from the left ventricle into the artery, common to both, was more direct than that from the right. Every where the arteries were full of dark blood, not coagulated.

3. The abdominal viscera were of a very dark colour. The head was not examined.

Before leaving the house, the father of the child related to us a circumstance to which we all paid particular attention. The child, he informed us, had always been very fretful and peevish,

, (perhaps from indulgence,) and apt to have frightful paroxysms when spoken to harshly; but these happened much more fre. quently in the morning; indeed he observed that she was always ill in the early part of the day; so much so, that the smallest ex. ertion, an angry word, or even a cup of tea, would instantly bring on a paroxysm, each time threatening destruction. This tendency to these fits decreased from morning, till about 5, P. M. from which time she generally continued well till bedtime. The father detailed this with great minuteness, and seemed to wish for an explanation.

It will be easy to anticipate to what cause I would ascribe this increase of disorder in the circulation, during the forenoon. So disproportionate was the pulmonary artery to the aorta, it was with difficulty that life could be carried on; but, in the morning, when the susceptibility of the arterial system was greater, the inequality must also have been increased to such a degree as almost to have destroyed life. I may also remark that she died about 9, A. M.

5. To be convinced that an opinion, very different from that now brought forward, is the one more generally received, we have only to turn to the writings of a few celebrated physiologists. Thus, for example, in the Physiologie Positive" of

" Fodéré, a work of merit, we find the following remarkable passage: “ Relativement à la difference du jour et de la nuit, on remarque que le pouls de l'homme adulte bat de 60 à 65 fois par minute, au commencement du jour, et qu'il va continuellement en augmentant jusqu'à battre 80 fois dans le même temps, chez les plus excitables, sur la fin de la journée; dans la nuit, les pulsations diminuent de nouveau, jusqu'au matin, où elles se trouvent revenues insensiblement au nombre de 60 à 65."* In order to have an approximation to the truth, we have only to reverse the above statement. If we regard as accidental circumstances the accelerations of the pulse, occasioned at various times by our diet, and that, too, according to the caprice of the individual, the pulse shall be found gradually to diminish in velocity from an early hour until midnight, and generally later. This difference I have found to be great in winter, but less, though still existing, in summer; as the above experiments, performed during that period, sufficiently prove; and from this I am inclined to believe, that heat has no inconsiderable share in the production of the phenomenon, though totally inadequate solely to produce it. This gradual excitation in the number of the pulsations Fodéré conceives to be owing to the combined effects of exercise, of the action of the internal and external senses, of light, heat, purer air, &c. Violent exercise towards evening will certainly produce a considerable excitation of the pulse, but less than what takes place in the morning, in consequence of the same degree of exercise; neither will any degree of heat, nor quantity of food, raise the pulse in the evening to the height at which it is in the morning, almost without any such excitants, provided they be not used in an immoderate degree.* Thus, after fasting till 8 P. M. I found my pulse to be 58; at 9 P. M. after eating a moderate dinner, pulse 58.

* Essai de Physiologie Positive, Tom. I. p. 190.

The common mode of experimenting with unequal quanti. ties of food, taken at various hours of the day and night, was evidently insufficient to establish the principle in its full extent. I endeavoured, accordingly, to submit to a particular regimen, and examine the state of the pulse under the influence of a diet always similar at every hour of the day. This decisive experiment could not be pushed any length; so difficult a matter did I find it to break through, at once, those habits which a great number of years had firmly established.

6.“ All these things (continues Fodéré) singularly facilitate the return of the venous blood towards the heart; and this is one of the causes of the evening paroxysm which takes place in all fevers.” But, having denied that any such gradual increase of the pulse exists, we need scarcely stop to say, that this cannot be one of the causes of the evening paroxysms in fever.

This opinion appears to be borrowed from the celebrated Cullen. That author, however, increased the facility of explanation, by describing two exacerbatioos or augmentations of the pulse; one about mid-day, the other towards evening. This explains, in his opinion, the occurrence of the double paroxysm in hectic fever.t The whole is a pure hypothesis, which seems partly to have arisen from supposing that the pulse was governed by the same laws in health and disease. So far as my observa


* In experimenting on this point, care must be taken that the acceleration of the pulse, occasioned by indigestion, be not confoundled with the natural healthy pulse, produced by the simple stimulation of the fowd.

† First Lines of the Practice of Physic, Vol. I. c. 862.

tions go, the order of nature in disease is entirely reversed, and the observations of Cullen, Fodéré, and others, are applicable only to the unhealthy. That this acceleration of the pulse (which is really an aberration from the regular laws of nature) actually happens in fever, the testimony of Cullen, generally so accurate in the observance of disease, will sufficiently establish; and that this universally takes place in phthisis, we have, unfortunately, too many opportunities to verify. * It was from the sinking of the pulse towards evening that I ventured, independent of other circumstances, to prognosticate favourably in the case of a child labouring under typhus fever. It was this which induced me to hope that some of the functions had begun to resume their natural order, and that recovery was a probable event. Nor was I deceived; by proper attention the patient from that day rapidly amended.

7. The physiologists who invented the various diurnal accelerations of the pulse, one, two, or more, just as suited their fancy or necessity, will perhaps find little difficulty in explaining the gradual diminution of the pulse, should the phenomenon appear to them to be correctly stated. With me, I confess, the cause is yet excessively obscure, because I have not found it connected with any circumstance, to the influence of which I might ascribe it. Experiment showed me that no previous exhaustion from labour, excess in food, drink, &c. rendered the diurnal diminution of the pulsations more evident than usual; the want of food, perhaps, hastens and increases it, but certainly does not prevent or retard it. Neither is sleep the cause of the restoration of the susceptibilities and velocity of the morning pulse, since the negation of that does not at all destroy the excitability of the sanguiferous system, as manifested by the application of the accustomed stimulants.

August 30th, 1813, the day being moderately warm, I walked, between 1 and 11 P. M. a distance of nearly 40 miles. Not having much appetite, retired to rest about 1 A. M. after drink. ing a little coffee, but slept none, perhaps owing to over-fatigue. Next morning (31st) about 7, my pulse was 80 and rather fccble; after breakfast, before which I took a small glasulull of

• Beddoes' Essay on Consumption, p. 252.
f I use this word merely to avoid circumlor must

spirits, my pulse rose to 104. I was not feverish, and perform. ed a journey that day of 27 miles, at a tolerable pace.

To what, then, are we to attribute this daily diminution of velocity in the functions of the sanguiferous system? Its existence as a law of the sanguiferous system, has been demonstrated experimentally; and I shall endeavour to show, that a simi. lar revolution daily takes place in several other functions of the human frame. To this conclusion Dr. Cullen arrived, merely from observing the daily returns of sleep and watching, of appetites and excretions, and the changes which regularly occur in the state of the pulse. Of these changes he had, however, no clear ideas. When he proceeds to combine this diurnal revolution with the phenomena of fever, he unquestionably offers a conjecture, extremely probable, ingenious, and perhaps original; but unfortunately, there results from this fine idea nothing but conjecture and hypothesis, attributable principally to an incorrectness in the observance of the phenomena.

8. It required few experiments to convince me, that animal food raised the pulse much more than vegetable; the excitation of the pulse by wine is still greater, and that from spirituous liquors greatest of all. By these circumstances, but more espe. cially by diet, the regularity in the diurnal revolution in the pulse, is, as might have been anticipated, much disturbed. But it was impossible to perform these experiments without remarking, that something similar happened to various other functions. Thus, beyond all doubt, our perceptions in the early part of the day are clearer, our minds more acute, our whole intelligence more active. The functions of the stomach seem also much stronger at this time than towards the evening. Feverish, restless nights, are the invariable attendants on late meals, which injure in the ratio of their quantity.

I have repeatedly remarked, that digestion went on more easily in the morning than in the evening. Three or four times have I been induced (sometimes compelled), whilst following some favourite sport in the country, to defer the taking food until evening; a greater or less degree of fever and restlessness, in proportion to the quantity of food taken, has uniformly followed such indulgence.

It was long with me a problem difficult of solution, why digestion should go on laboriously during the evening, when the

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