THERMAL PHENOMENA IN INJURIES OF THE NERVOUS SYSTEM. A. Chatham Gka?, M.B. (Edin.), H. By Surgeon, Bengal Medical Service. One of the great physiological problems that yet awaits solution, and that has been lately demanding attention, is the cause of the variations of temperature in different injuries of the nervous system ; these injuries in many instances seemingly alike and yet differing diametrically in their heat-phenomena? apparently-like nerve lesions?produce unlike results, and thus the problem has assumed an enigmatical aspect. I say apparently because it is unphilosophical to hold that the same nerve lesion, uncomplicated, can produce a high temperature at one time, and a low one at another. In these enigmatical cases it is highly probable, nay almost certain, that there are other elements at work in varying the result?subtile nerve lesions, of
molecular nature invisible to the unaided or aided eye and of animal heat, at present undiscovered or ignor-
a
potent factors
The difficulties that attend the study of nerve lesions, and their functional results, are evident to all acquainted with the general anatomy and delicate molecular constitution of the ed.
nervous system. Errors and misconc eptions creep in and get inextricably entangled with scientific truths even when skilfully guarded against. The complete elimination of extraneous factors is well-nigh impossible ; the physiological equation can therefore yield but an approximate value ; apparently exactly similar equations lead to different values, and thus the scientific experimenter or observer becomes bewildered at inconsistent and incongruous results. Hence wo cannot be too careful in drawing conclusions in cases in which a crucial test is inadmissible and impossible. Hasty conclusions, especially by eminent men, are exceedingly detrimental to the progress of true science, and are instrumental in the propagation and perpetuation of error. These remarks derive exemplification from the subject under consideration. The factors that enter into the production of animal heat have not been exhaustively worked out, some
factors have been left out and others brought in. How then can it be expected for any one to obtain a proper comprehension of thermal phenomena ? As yet we are not in possession of definite knowledge on the influence which motor, sensory, and vaso-motor nerves exert on temperature by virtue of their Thermal phenomena, connection with the nervous centres. clearly the result of nervous derangement, force themselves
tissues and to the upon us for explanation and yet we go to the circulation for help in the elucidation of these phenomena! The force of this remark will be seen when I treat of the heatresults under the head of injuries to the cervical spinal cord, and
especially
of the true relation that exists between
temper-
ature and cardiac energy.
impetus was given to the investigation of the subject by publication of that extraordinary case by Mr. Teale, of Scarborough, in which a remarkable elevation of temperature (122? Fahr.) took place after injury to the spine. An abstract of the case appeared in The Lancet" of March 6th 1875. In the numbers for May 22nd and 29th there is a clinical lecOn the temperature and circulation after injuries to the ture cervical spinal cord," delivered by Mr. Jonathan Hutchinson at the London Hospital; and in the number for July 3rd of the same year, there is a paper by Mr. C. A. Rayne, M.B., Lond. On the dynamical origin of animal heat in its relation to the temperature alterations observed in certain injuries and diseases of the nervous system." My paper on the Conversion An
the
"
"
"
"
energy into heat" was sent in to the Editor on the 21st June 1875, and appeared in the September number of the Indian Medical Gazette. In that paper I gave a brief resume
of
nerve
of the evidence
favouring
the idea of the
"
conversion of nerve
Mat 1,
THERMAL PHENOMENA, &C.-BY H. A CHATHAM GrBAY, M.B.
1877.]
wlio are interested in this physiologienergy into lieat." Those cal question might refer to it in order to better follow me out in my remarks in this paper. I then came to the conclusion that it
almost certain that
was
nerve
energy was
largely
verted into heat, especially in abnormal states of the
con-
nervous
The fact that the temperature of a muscle rises during contraction, and the more conclusive fact that the temperature rises higher when the muscle is prevented from shortening, were particularly dwelt upon as being very contissues.
firmatory of this view. Yaso-motor paralysis, sections of mixed nerves, injuries to the spinal cord and brain, and tetanus were considered in their temperature results. If the direct conversion of nerve energy into heat is admitted, then, I think,
insuperable in the way of comprehending the phenomena that now puzzle us. In The Lancet" of 26th September 1874, Mr. C. A. Kayne drew attention to a mode of origin of animal heat that had been overlooked, viz., the lieat-producing effect of the retardation of the blood-stream in the capillaries. The mechanical energy of the heart was calculated to produce one-tenth of the whole heat produced in the body in the twenty-four hours. the difficulties will not be "
doubt that all the visible energy of the heart heat, but there' can be no doubt also that the heart derives its energy from the nervous system. The mechanical energy of the heart is thus dependent on nerve
There is
can
be
changed
no
into
energy and subordinate to it. It is of the greatest importance to bear this in mind, for it will help us to explain the true relation that exists between the action of the heart and tempera-
misconception on this point has led to great confusion. The factors that enter into the production of animal heat are, so far as we are aware at present:? (a). Chemical action in the tissues, (I). Nerve energy, and (c). Mechanical energy of the heart.
ture.
A
With the first
wo are
not here concerned; we have to do
with the second, and of this I must premise a few remarks before dealing with the phenomena of temperThe ature that characterize injuries to the nervous system.
principally
nerve-centres originate nerve energy for the various purposes of muscular action and nutrition, secretion and excretion. When these nerve-centres arc irritated they produce a greater amount of
energy, and when they are destroyed by inthey originate a less quantity than normal. This nerve energy is conducted by the efferent or centrifugal nerves to the tissues they supply, and the flow of the nerve current is
jury
or
nerve
disease
In the tissues, the nerve energy ministers to the tissue functions ; a portion of it that is not thus used becomes converted into heat. This latter is best marked in abnormal
constant.
excitement of the nerve centres or nerves, when a great quantity The nerve energy is produced to be only changed into heat.
of
trunks must preserve their continuity and molecular integrity in order to convey the nerve current to the tissues.
nerve
I shall
now proceed to consider the temperature phenomena injuries to the cervical spinal cord. It might be stated, as a general rule, that the temperature rises after such injuries; that this is so, one has simply to turn over some of the pages of The Lancet" for the past two or three years to convince himself. Mr. Hutchinson in the lecture alluded to gives three cases. He also mentions a most extraordinary case in which the temperature was rather low. Of this I shall speak subsequently.
in
"
It is needless to quote recorded give us a better
not
cases
understanding
in extenso, for it will subject, and besides
of the
this paper will be unnecessarily lengthened. Xow, why does the temperature rise ? My answer is that the to the spinal cord causes irritation of the nervous
injury
tissue,
the result of which is a much greater production of nerve This energy is conducted energy than normal. away by the nerves that arise from the cord above and below the seat of
221
injury to tlie tissues, then to be converted into heat. Nerve energy is essential for the tissue functions as nutrition, &c., and in a normal state they get just so much as is sufficient for their cannot utilize a much greater amount. purpose, in fact, they
Hence when under abnormal conditions a large amount of energy is sent to the tissues, the surplus must be transformed into anotherform of energy. That it disappears without leaving behind an equivalent amount of energy is absurd?unphilosopliical. What, then, is that other form of energy into which it is
going to say impossible, to directly converted into thersurely, when one mode of motion disappears mode of motion takes its place, it is rational to
converted ? It is
demonstrate that mal motion, but and another
difficult,
nerve
I
was
motion is
with some reserve, that the former has been convertThere is more heat in the tissues: but whence this increase if not from the nervous system ? There
conclude,
ed into the latter.
is greater reason to think that this is nearer the proper explanation. I must call attention to the fact that if life is preserved for a sufficiently long time, the increased temperature
gradually
declines until it falls below normal.
The irritation
at the seat of
injury has subsided, and production of nerve energy has, therefore, diminished. Moreover, a portion of the nervous centre has been destroyed and rendered incapable of generating nerve energy. It is not surprising then to find that, after a time, the temperature falls and remains below normal. a
I would here quote from Mr. Hutchinson's lecture
paragraph bearing on this topic :? It is far more difficult, however, "
to
the influence
explain
of either sensory, motor, or mixed nerves. When, for instance, after section of the ulnar nerve, the temperature at a late stage becomes
much altered that several
degrees of ^oss are reput in the cleft between the little and ring-fingers of the injured hand, we are quite unable to call in to our aid any theories of altered blood-supply. The vaso-motor is uninjured, and the arteries supplying the cooled parts are branches of the same trunk which feeds others, which remain warm. We are almost obliged to conjecture that the cell changes to which the temperature of living tissues is due are reduced when the nerve supply is cut off. I know indeed of no other reasonable explanation of the commonly observed fact that paralyzed parts become cold." The cell changes that Mr. Hutchinson refers to are presided over and produced by nerve energy to some extent, and therefore diminution of nerve energy would produce a diminution of cell changes. But how are we to explain the rise of temperature by the theory of cell changes in the early stage of the injury ? Are cell changes at that period more actively performing the functions of nutrition, secretion, excretion, &c. ? In gistered
so
when the thermometer is
section of the ulnar
the vaso-motor element is eliminat-
nerve
ed; therefore, the fall of temperature is due only to the
ulnar.
to my
According
theory it is not difficult to understand temperature, for by the section so much been cut off from the tissues supplied by
the reduction of the nerve
energy that nerve.
has
In those very the cervical
rare
spinal
cases
of
loio
cord alone?an
temperature after injury to injury to all appearances like
those in the first class of cases in which there
temperature?we
cannot at
want of sufficient data.
present
was
decide with
a
rise of
certainty
for
recorded by Mr. J. Hutchinson is the only one of the kind that I am aware of, and it is certainly not very extraordinary. No rise of temperature took place even soon after death. It must be remembered that in this case the injury could not have been like the usual infor there was evidence that another element of injury?a The
case
juries; complication?was present. The extraordinarily slow action of the heart (35 per minute) indicated that there was some serious implication of cardiac innervation, and this might have been the cause of the low temperature. After all, the temper-
THE INDIAN MEDICAL GAZETTE.
122
ature was not very low that which was recorded just before being 95.? Fahr. I shall now turn to the influence that vaso-motor nerves exert on the temperature of the body. In Claude Bernard's death
experiment of section of the cervical sympathetic (thus causing paralysis of the vaso-motor nerves), there was a great inIt is now crease of temperature which lasted for a long period.
contended that this rise is not permanent, that in a later stage temperature falls below normal. This, I think, is almost certain from the clinical evidence that has been brought forward. the
But Mr. Rayne in the paper already alluded to, writes:? It will thus be seen that there is much probability that, contrary to the views usually accepted, vaso-motor irritation, and "
paralysis, is the condition most frequently met conjunction with elevation of temperature in lesions of spinal cord; and that the increased heat is at least largely
not vaso-motor with in the
due to direct mechanical conversion." It is new for us to hear that vaso-motor irritation, and not paralysis, is the cause of the elevation of temperature, and the statement is subversive of M. Claude Bernard's conclusion from experiment. In my a settled scientific truth that vaso-motor paralysis
it is
opinion, produces
of temperature. Bernard's experiment has been perand over again, and I can bear witness to the veracity of the above conclusion. By reading the above quotation carefully I have an impression that Mr. Eayne himself is rather doubtful of the statement he mates contrary to the for it will be observed he qualifies it views usually accepted ; by saying in lesions of the spinal cord." His line of argument seems to be this?that because vaso-motor irritation is usually found associated with lesions of the spinal cord, and a high temperature is almost always associated with the latter, that therefore tfie high temperature is the production of the vasomotor irritation. This is certainly not logical; for it remains for Mr. Eayne to prove that the high temperature is not due directly to the irritation of the spinal cord itself, caused by the injury. It seems to me that Mr. Rayne has been drawn into this error by an over-anxiety to make his theory, or rather fact, of conversion of cardiac energy into heat bear out the phenomenon of rise of temperature in spinal cord injuries; and he does this in the following way :?Vaso-motor irritation, he says, contracts the capillaries, and thus offers an increased resistance to the passincrease
formed
over
"
"
"
age of blood. The cardiac action increases in force to overcome this resistance, and thus the cardiac energy being greater than normal, the temperature is raised. In pursuing this train of
argument he entirely ignores to consider the part that the spinal irritation might take in this elevation of temperature, as in the following paragraph : When the vaso-motor centres are so injured as to lead to their irritation and excessive action, what results may be expected to follow F This is probably by far the most common condition after spinal injury, and is, therefore, the more interesting. For it is far from probable that a spinal crush should be so absolute and complete as quite to destroy, through a considerable tract, the grey centres in its interior, although it may be sufficient to destroy its powers of connection to parts below. "
Therefore, when
inflammatory
irritation supervenes, many of the nerve cells will be thrown into excessive action, and amongst them no doubt many of those belonging to the vaso-motor centres. In support of this statement I may point out that it is usual in these cases to
get
evidences of
spinal irritation elsewhere,
spasm of certain mnscles, &c , but that where the injury is so great as to produce total vaso-motor paralysis such evidences are rare, as in Mr. Hutchinson's case already mentioned." The italics are mine. While he attaches so much such
as
pain,
importance
to
the excessive action of
the nerve
cells of
centres, he passes over a similar condition, existing certainly to a greater extent, in the grey matter of the spinal cord. I have written enough on this subject to show the vaso-motor
[Mat 1,
1877.
that this vasomotor influence on rise of temperature in spinal injuries is greatly exaggerated, and that the vaso-motor irritation of Mr Rayne is a gratuitous assumption. He has been begging
the question at issue. I must now pass on to the consideration of the true relation hetiveen cardiac action and temperature. It is the generally received notion that increased cardiac action and high tempera-
ture stand in the relation of cause and effect. This notion has been the natural outcome of the commonly observed canon in the physical world, viz., that the constant occurrence of two events in association implies their relation as cause and effect. This rule is a very useful one, but it is not infallible. In the present instance it has led to an erroneous conception, for cardiac action and temperature do not stand in the relation of cause and cause,
viz,
effect;
nerve
but
energy.
they
both,
are
effects of
a common
The diseases in which increased temperature are associated are nu-
cardiac action and high and this must be
so ; for any thing that circulates in the blood and irritates the nervous system, as a whole, must give rise to an increased production of nerve energy?which, as said before, is not only converted into heat, but is also
merous,
instrumental in increasing the action of the heart. We all know readily the heart is affected by the nervous system. Whenever the nervous system is excited we find the heart excited,
how
versa. But in some injuries to the cervical spine we do not find this to be the case, for the nervous system is excited as evidenced by high temperature and spasms, &c., and the cardiac action is either unaffected or diminished. In
and vice
yet
these cases they become dissociated and lose the seeming relation of cause and effect. Ilence these cases are very valuable for the study of the temperature phenomena, because cardiac action is here eliminated
factor in the
production of the the amount of mechanical energy of the heart affects the temperature to a certain extent? an increase of the former producing a rise of the latter, and
high temperature.
as a
Undoubtedly,
When, therefore, augmented cardiac energy is a high temperature, a few degrees of the latter is due to the former; and conversely when the heart's vigour is below normal there is a lowering of temperature by a few degrees. In the case recorded by Mr. Hutchinson in which every part of the surface was cold to the touch," the pulse was 35, and the respiration 12 per minute, and the vaso-motor system was seriously injured as evidenced by the florid condition of his cheeks, lip, and ears; by the contracted state of the pupils, and the existence of priapism. The state of the circulation and respiration was such as to indicate great impairvice
versa.
associated with
"
I ment of innervation of the organs concerned in them. believe that there would have been a high temperature in this of the case, if the respiration permitted a proper oxygenation and if the heart possessed sufficient vigour to take ad-
blood, vantage
of it. The heat normally produced in the tissues by chemical action was diminished under these unfavourable conditions, to such an extent that the subtraction overbalanced the the nerve lesion, and produced a result addition of heat
by
below the normal standard. Those cases of cervical injury, in which the circulation and respiration is impaired, are
vigour
of the
undoubtedly com-
plicated with lesions of the pnenmogastric and cardiac nerves. Their continuity and molecular integrity being to a certain extent destroyed, they are unable to conduct nerve energy, in Hear what these injuries increased, to their destinations. Mr. Hutchinson has to say on the subject of effects of inThe manner in juries to the cord upon the heart itself." which the heart seems exempted from all share in the patient's general excitement is sometimes very curious. I recollect well going to the bed side of a poor fellow who had been "
"
1
admitted vical.
a
few hours before with
a
fracture of the fifth
It was one of those cases in which the
boundary
cer-
tract
May 1,
1877.]
MALARIAL CACHEXIA IN THE GARO HILLS ?BY J. SLANE, L.R.C.P.
quite paralyzed and tliat enjoying perfect excessively tender. He was screaming with pain and his countenance expressive of the utmost suffering and anxiety, yet his pulse, which we might have expected to be quick and excited, was slow, full, and deliberate, about 48 in the minute. Although the pulse after injuries to the cervical of
skin,
between that
sensation,
was
cord becomes slow, it does not intermit." I do not see anything very curious in this. For it is quite evident that there must have been some lesion of the cardiac nervous supply, some destruction of the molecular integrity of
channel, through which the emotional causes, originating brain, react on the heart. The reason why the signs and symptoms in these injuries look enigmatical is the loose and meagre records of the post-mortem examinations, in which the condition of the cord and membranes is noted, but the state of the surrounding nerve and ganglia is not observed. Thus, doubtless, important nerve lesions escape notice, and thereby we lose the key which might unlock these mysteries. We sadly need more carefully and systematically recorded cases to reclaim this most interesting problem from the mazes of erroneous speculation, to disentangle the threads of truth from those of fallacy, and to supply the loom of science with the warp and woof of indisputable facts. I would, therefore, in the sacred name of science, ask the intellect and energy of the profession in India to exert their powers in dispelling the mists that now envelope the subject. Carefully recorded cases, and renewed and extended physiological experimentation *? will soon bring about this result. the
in the
123
molecular nature invisible to the unaided or aided eye and of animal heat, at present undiscovered or ignor-
a
potent factors
The difficulties that attend the study of nerve lesions, and their functional results, are evident to all acquainted with the general anatomy and delicate molecular constitution of the ed.
nervous system. Errors and misconc eptions creep in and get inextricably entangled with scientific truths even when skilfully guarded against. The complete elimination of extraneous factors is well-nigh impossible ; the physiological equation can therefore yield but an approximate value ; apparently exactly similar equations lead to different values, and thus the scientific experimenter or observer becomes bewildered at inconsistent and incongruous results. Hence wo cannot be too careful in drawing conclusions in cases in which a crucial test is inadmissible and impossible. Hasty conclusions, especially by eminent men, are exceedingly detrimental to the progress of true science, and are instrumental in the propagation and perpetuation of error. These remarks derive exemplification from the subject under consideration. The factors that enter into the production of animal heat have not been exhaustively worked out, some
factors have been left out and others brought in. How then can it be expected for any one to obtain a proper comprehension of thermal phenomena ? As yet we are not in possession of definite knowledge on the influence which motor, sensory, and vaso-motor nerves exert on temperature by virtue of their Thermal phenomena, connection with the nervous centres. clearly the result of nervous derangement, force themselves
tissues and to the upon us for explanation and yet we go to the circulation for help in the elucidation of these phenomena! The force of this remark will be seen when I treat of the heatresults under the head of injuries to the cervical spinal cord, and
especially
of the true relation that exists between
temper-
ature and cardiac energy.
impetus was given to the investigation of the subject by publication of that extraordinary case by Mr. Teale, of Scarborough, in which a remarkable elevation of temperature (122? Fahr.) took place after injury to the spine. An abstract of the case appeared in The Lancet" of March 6th 1875. In the numbers for May 22nd and 29th there is a clinical lecOn the temperature and circulation after injuries to the ture cervical spinal cord," delivered by Mr. Jonathan Hutchinson at the London Hospital; and in the number for July 3rd of the same year, there is a paper by Mr. C. A. Rayne, M.B., Lond. On the dynamical origin of animal heat in its relation to the temperature alterations observed in certain injuries and diseases of the nervous system." My paper on the Conversion An
the
"
"
"
"
energy into heat" was sent in to the Editor on the 21st June 1875, and appeared in the September number of the Indian Medical Gazette. In that paper I gave a brief resume
of
nerve
of the evidence
favouring
the idea of the
"
conversion of nerve
Mat 1,
THERMAL PHENOMENA, &C.-BY H. A CHATHAM GrBAY, M.B.
1877.]
wlio are interested in this physiologienergy into lieat." Those cal question might refer to it in order to better follow me out in my remarks in this paper. I then came to the conclusion that it
almost certain that
was
nerve
energy was
largely
verted into heat, especially in abnormal states of the
con-
nervous
The fact that the temperature of a muscle rises during contraction, and the more conclusive fact that the temperature rises higher when the muscle is prevented from shortening, were particularly dwelt upon as being very contissues.
firmatory of this view. Yaso-motor paralysis, sections of mixed nerves, injuries to the spinal cord and brain, and tetanus were considered in their temperature results. If the direct conversion of nerve energy into heat is admitted, then, I think,
insuperable in the way of comprehending the phenomena that now puzzle us. In The Lancet" of 26th September 1874, Mr. C. A. Kayne drew attention to a mode of origin of animal heat that had been overlooked, viz., the lieat-producing effect of the retardation of the blood-stream in the capillaries. The mechanical energy of the heart was calculated to produce one-tenth of the whole heat produced in the body in the twenty-four hours. the difficulties will not be "
doubt that all the visible energy of the heart heat, but there' can be no doubt also that the heart derives its energy from the nervous system. The mechanical energy of the heart is thus dependent on nerve
There is
can
be
changed
no
into
energy and subordinate to it. It is of the greatest importance to bear this in mind, for it will help us to explain the true relation that exists between the action of the heart and tempera-
misconception on this point has led to great confusion. The factors that enter into the production of animal heat are, so far as we are aware at present:? (a). Chemical action in the tissues, (I). Nerve energy, and (c). Mechanical energy of the heart.
ture.
A
With the first
wo are
not here concerned; we have to do
with the second, and of this I must premise a few remarks before dealing with the phenomena of temperThe ature that characterize injuries to the nervous system.
principally
nerve-centres originate nerve energy for the various purposes of muscular action and nutrition, secretion and excretion. When these nerve-centres arc irritated they produce a greater amount of
energy, and when they are destroyed by inthey originate a less quantity than normal. This nerve energy is conducted by the efferent or centrifugal nerves to the tissues they supply, and the flow of the nerve current is
jury
or
nerve
disease
In the tissues, the nerve energy ministers to the tissue functions ; a portion of it that is not thus used becomes converted into heat. This latter is best marked in abnormal
constant.
excitement of the nerve centres or nerves, when a great quantity The nerve energy is produced to be only changed into heat.
of
trunks must preserve their continuity and molecular integrity in order to convey the nerve current to the tissues.
nerve
I shall
now proceed to consider the temperature phenomena injuries to the cervical spinal cord. It might be stated, as a general rule, that the temperature rises after such injuries; that this is so, one has simply to turn over some of the pages of The Lancet" for the past two or three years to convince himself. Mr. Hutchinson in the lecture alluded to gives three cases. He also mentions a most extraordinary case in which the temperature was rather low. Of this I shall speak subsequently.
in
"
It is needless to quote recorded give us a better
not
cases
understanding
in extenso, for it will subject, and besides
of the
this paper will be unnecessarily lengthened. Xow, why does the temperature rise ? My answer is that the to the spinal cord causes irritation of the nervous
injury
tissue,
the result of which is a much greater production of nerve This energy is conducted energy than normal. away by the nerves that arise from the cord above and below the seat of
221
injury to tlie tissues, then to be converted into heat. Nerve energy is essential for the tissue functions as nutrition, &c., and in a normal state they get just so much as is sufficient for their cannot utilize a much greater amount. purpose, in fact, they
Hence when under abnormal conditions a large amount of energy is sent to the tissues, the surplus must be transformed into anotherform of energy. That it disappears without leaving behind an equivalent amount of energy is absurd?unphilosopliical. What, then, is that other form of energy into which it is
going to say impossible, to directly converted into thersurely, when one mode of motion disappears mode of motion takes its place, it is rational to
converted ? It is
demonstrate that mal motion, but and another
difficult,
nerve
I
was
motion is
with some reserve, that the former has been convertThere is more heat in the tissues: but whence this increase if not from the nervous system ? There
conclude,
ed into the latter.
is greater reason to think that this is nearer the proper explanation. I must call attention to the fact that if life is preserved for a sufficiently long time, the increased temperature
gradually
declines until it falls below normal.
The irritation
at the seat of
injury has subsided, and production of nerve energy has, therefore, diminished. Moreover, a portion of the nervous centre has been destroyed and rendered incapable of generating nerve energy. It is not surprising then to find that, after a time, the temperature falls and remains below normal. a
I would here quote from Mr. Hutchinson's lecture
paragraph bearing on this topic :? It is far more difficult, however, "
to
the influence
explain
of either sensory, motor, or mixed nerves. When, for instance, after section of the ulnar nerve, the temperature at a late stage becomes
much altered that several
degrees of ^oss are reput in the cleft between the little and ring-fingers of the injured hand, we are quite unable to call in to our aid any theories of altered blood-supply. The vaso-motor is uninjured, and the arteries supplying the cooled parts are branches of the same trunk which feeds others, which remain warm. We are almost obliged to conjecture that the cell changes to which the temperature of living tissues is due are reduced when the nerve supply is cut off. I know indeed of no other reasonable explanation of the commonly observed fact that paralyzed parts become cold." The cell changes that Mr. Hutchinson refers to are presided over and produced by nerve energy to some extent, and therefore diminution of nerve energy would produce a diminution of cell changes. But how are we to explain the rise of temperature by the theory of cell changes in the early stage of the injury ? Are cell changes at that period more actively performing the functions of nutrition, secretion, excretion, &c. ? In gistered
so
when the thermometer is
section of the ulnar
the vaso-motor element is eliminat-
nerve
ed; therefore, the fall of temperature is due only to the
ulnar.
to my
According
theory it is not difficult to understand temperature, for by the section so much been cut off from the tissues supplied by
the reduction of the nerve
energy that nerve.
has
In those very the cervical
rare
spinal
cases
of
loio
cord alone?an
temperature after injury to injury to all appearances like
those in the first class of cases in which there
temperature?we
cannot at
want of sufficient data.
present
was
decide with
a
rise of
certainty
for
recorded by Mr. J. Hutchinson is the only one of the kind that I am aware of, and it is certainly not very extraordinary. No rise of temperature took place even soon after death. It must be remembered that in this case the injury could not have been like the usual infor there was evidence that another element of injury?a The
case
juries; complication?was present. The extraordinarily slow action of the heart (35 per minute) indicated that there was some serious implication of cardiac innervation, and this might have been the cause of the low temperature. After all, the temper-
THE INDIAN MEDICAL GAZETTE.
122
ature was not very low that which was recorded just before being 95.? Fahr. I shall now turn to the influence that vaso-motor nerves exert on the temperature of the body. In Claude Bernard's death
experiment of section of the cervical sympathetic (thus causing paralysis of the vaso-motor nerves), there was a great inIt is now crease of temperature which lasted for a long period.
contended that this rise is not permanent, that in a later stage temperature falls below normal. This, I think, is almost certain from the clinical evidence that has been brought forward. the
But Mr. Rayne in the paper already alluded to, writes:? It will thus be seen that there is much probability that, contrary to the views usually accepted, vaso-motor irritation, and "
paralysis, is the condition most frequently met conjunction with elevation of temperature in lesions of spinal cord; and that the increased heat is at least largely
not vaso-motor with in the
due to direct mechanical conversion." It is new for us to hear that vaso-motor irritation, and not paralysis, is the cause of the elevation of temperature, and the statement is subversive of M. Claude Bernard's conclusion from experiment. In my a settled scientific truth that vaso-motor paralysis
it is
opinion, produces
of temperature. Bernard's experiment has been perand over again, and I can bear witness to the veracity of the above conclusion. By reading the above quotation carefully I have an impression that Mr. Eayne himself is rather doubtful of the statement he mates contrary to the for it will be observed he qualifies it views usually accepted ; by saying in lesions of the spinal cord." His line of argument seems to be this?that because vaso-motor irritation is usually found associated with lesions of the spinal cord, and a high temperature is almost always associated with the latter, that therefore tfie high temperature is the production of the vasomotor irritation. This is certainly not logical; for it remains for Mr. Eayne to prove that the high temperature is not due directly to the irritation of the spinal cord itself, caused by the injury. It seems to me that Mr. Rayne has been drawn into this error by an over-anxiety to make his theory, or rather fact, of conversion of cardiac energy into heat bear out the phenomenon of rise of temperature in spinal cord injuries; and he does this in the following way :?Vaso-motor irritation, he says, contracts the capillaries, and thus offers an increased resistance to the passincrease
formed
over
"
"
"
age of blood. The cardiac action increases in force to overcome this resistance, and thus the cardiac energy being greater than normal, the temperature is raised. In pursuing this train of
argument he entirely ignores to consider the part that the spinal irritation might take in this elevation of temperature, as in the following paragraph : When the vaso-motor centres are so injured as to lead to their irritation and excessive action, what results may be expected to follow F This is probably by far the most common condition after spinal injury, and is, therefore, the more interesting. For it is far from probable that a spinal crush should be so absolute and complete as quite to destroy, through a considerable tract, the grey centres in its interior, although it may be sufficient to destroy its powers of connection to parts below. "
Therefore, when
inflammatory
irritation supervenes, many of the nerve cells will be thrown into excessive action, and amongst them no doubt many of those belonging to the vaso-motor centres. In support of this statement I may point out that it is usual in these cases to
get
evidences of
spinal irritation elsewhere,
spasm of certain mnscles, &c , but that where the injury is so great as to produce total vaso-motor paralysis such evidences are rare, as in Mr. Hutchinson's case already mentioned." The italics are mine. While he attaches so much such
as
pain,
importance
to
the excessive action of
the nerve
cells of
centres, he passes over a similar condition, existing certainly to a greater extent, in the grey matter of the spinal cord. I have written enough on this subject to show the vaso-motor
[Mat 1,
1877.
that this vasomotor influence on rise of temperature in spinal injuries is greatly exaggerated, and that the vaso-motor irritation of Mr Rayne is a gratuitous assumption. He has been begging
the question at issue. I must now pass on to the consideration of the true relation hetiveen cardiac action and temperature. It is the generally received notion that increased cardiac action and high tempera-
ture stand in the relation of cause and effect. This notion has been the natural outcome of the commonly observed canon in the physical world, viz., that the constant occurrence of two events in association implies their relation as cause and effect. This rule is a very useful one, but it is not infallible. In the present instance it has led to an erroneous conception, for cardiac action and temperature do not stand in the relation of cause and cause,
viz,
effect;
nerve
but
energy.
they
both,
are
effects of
a common
The diseases in which increased temperature are associated are nu-
cardiac action and high and this must be
so ; for any thing that circulates in the blood and irritates the nervous system, as a whole, must give rise to an increased production of nerve energy?which, as said before, is not only converted into heat, but is also
merous,
instrumental in increasing the action of the heart. We all know readily the heart is affected by the nervous system. Whenever the nervous system is excited we find the heart excited,
how
versa. But in some injuries to the cervical spine we do not find this to be the case, for the nervous system is excited as evidenced by high temperature and spasms, &c., and the cardiac action is either unaffected or diminished. In
and vice
yet
these cases they become dissociated and lose the seeming relation of cause and effect. Ilence these cases are very valuable for the study of the temperature phenomena, because cardiac action is here eliminated
factor in the
production of the the amount of mechanical energy of the heart affects the temperature to a certain extent? an increase of the former producing a rise of the latter, and
high temperature.
as a
Undoubtedly,
When, therefore, augmented cardiac energy is a high temperature, a few degrees of the latter is due to the former; and conversely when the heart's vigour is below normal there is a lowering of temperature by a few degrees. In the case recorded by Mr. Hutchinson in which every part of the surface was cold to the touch," the pulse was 35, and the respiration 12 per minute, and the vaso-motor system was seriously injured as evidenced by the florid condition of his cheeks, lip, and ears; by the contracted state of the pupils, and the existence of priapism. The state of the circulation and respiration was such as to indicate great impairvice
versa.
associated with
"
I ment of innervation of the organs concerned in them. believe that there would have been a high temperature in this of the case, if the respiration permitted a proper oxygenation and if the heart possessed sufficient vigour to take ad-
blood, vantage
of it. The heat normally produced in the tissues by chemical action was diminished under these unfavourable conditions, to such an extent that the subtraction overbalanced the the nerve lesion, and produced a result addition of heat
by
below the normal standard. Those cases of cervical injury, in which the circulation and respiration is impaired, are
vigour
of the
undoubtedly com-
plicated with lesions of the pnenmogastric and cardiac nerves. Their continuity and molecular integrity being to a certain extent destroyed, they are unable to conduct nerve energy, in Hear what these injuries increased, to their destinations. Mr. Hutchinson has to say on the subject of effects of inThe manner in juries to the cord upon the heart itself." which the heart seems exempted from all share in the patient's general excitement is sometimes very curious. I recollect well going to the bed side of a poor fellow who had been "
"
1
admitted vical.
a
few hours before with
a
fracture of the fifth
It was one of those cases in which the
boundary
cer-
tract
May 1,
1877.]
MALARIAL CACHEXIA IN THE GARO HILLS ?BY J. SLANE, L.R.C.P.
quite paralyzed and tliat enjoying perfect excessively tender. He was screaming with pain and his countenance expressive of the utmost suffering and anxiety, yet his pulse, which we might have expected to be quick and excited, was slow, full, and deliberate, about 48 in the minute. Although the pulse after injuries to the cervical of
skin,
between that
sensation,
was
cord becomes slow, it does not intermit." I do not see anything very curious in this. For it is quite evident that there must have been some lesion of the cardiac nervous supply, some destruction of the molecular integrity of
channel, through which the emotional causes, originating brain, react on the heart. The reason why the signs and symptoms in these injuries look enigmatical is the loose and meagre records of the post-mortem examinations, in which the condition of the cord and membranes is noted, but the state of the surrounding nerve and ganglia is not observed. Thus, doubtless, important nerve lesions escape notice, and thereby we lose the key which might unlock these mysteries. We sadly need more carefully and systematically recorded cases to reclaim this most interesting problem from the mazes of erroneous speculation, to disentangle the threads of truth from those of fallacy, and to supply the loom of science with the warp and woof of indisputable facts. I would, therefore, in the sacred name of science, ask the intellect and energy of the profession in India to exert their powers in dispelling the mists that now envelope the subject. Carefully recorded cases, and renewed and extended physiological experimentation *? will soon bring about this result. the
in the
123
