The very hungry schoolboy

A case of fever attended by unusual appetiteThe name of Dr Richard Patrick Satterley is more or less unknown today, but in the early years of the nineteenth century he was regarded as one of the most talented young physicians in London. He died prematurely in 1815, before he had left much of a mark on his profession. But a few months before his untimely death he read a paper at the Royal College of Physicians (subsequently published in the College’s Medical Transactions) which is of more than passing interest. The case is bizarre, and may also be the first of its kind on record:

The subject was a young gentleman 16 years of age, who, immediately on his return from school, was observed to look pale and unwell. He complained of being cold, and of some pain in the fore part of his head. He passed a restless night, and in the morning came under the care of my neighbour Mr. Marshall; and the ordinary remedies in the treatment of fever were resorted to.

So far, so unexceptional.

After two or three days the disease seemed suspended, and even abating; but a high aggravation of the headache proved the fallacy of these hopes, and my attendance, and shortly after that of my friend Dr. Heberden was requested.

This was William Heberden the Younger (1767-1845). His father William Heberden the Elder (1710-1802) coined the term angina pectoris (literally: ‘pain of the breast’) to describe the chest pain characteristic of coronary artery disease.

The boy was at this time excessively flushed, had a hot dry skin, his eyes were suffused and inflamed, and he was restless and much agitated; but his pulse was quick and feeble, and his tongue dry and brown. The pain in the head was so acute, that it was deemed right, notwithstanding the evident existence of, and still stronger tendency to, debility, to take away blood, and leeches and blisters were applied to the head.

Bloodletting was a common treatment for headaches. As late as 1874 the physician Edward John Waring wrote that

In fevers attended with much headache, leeches are very useful, but they should only be applied in the early stages of the disease; when the patient is young and vigorous, four or six leeches to each temple may be applied, but they sometimes give most relief if put at the nape of the neck, close to the point where the head joins to the spine.

The following morning the headache had subsided somewhat, but the fever was if anything worse.

Up to this period, which was about the fifth day, it was with difficulty, and only by urgent importunities that the patient could be made to take the ordinary nourishment, but shortly afterwards I was informed that a desire for food had shown itself, which I hailed as an earnest of a beneficial change, and ordered it to be moderately complied with.

Nineteenth-century physicians paid great attention to diet, which was tailored to the patient’s condition. Hospitals offered ‘high’, ‘medium’, ‘low’ and ‘milk’ diets, and even a special fever diet, which typically consisted of bread, tea, and water gruel. Not terribly exciting; and this patient soon objected to it.

In a day or two my attention was again called to this return of appetite, by his aunt’s representing to me the impossibility of satisfying it by the diet allowed in sick rooms; and I was astonished to be told, that exclusively of several basins of sago and other slops, he daily ate some pounds of biscuits, etc.

As an experiment, the doctor started to allow his patient a small quantity of meat, in the hope that this would satisfy his cravings. But it had the opposite effect: the boy started demanding richer food, in ever more extravagant amounts.

At this period of the disease, the boy would eat a pound and a half of beef-steaks, a large fowl, or a couple of rabbits at a meal, without apparently satisfying his appetite, for in a few minutes after he had devoured, with indescribable greediness, meat adequate to the support of the stoutest labourer, he would deny his having tasted food, and earnestly entreat for a further supply, in which, if he were indulged, it would only be to be followed by similar demands; independently of three or four regular meals, he was uninterruptedly eating dry bread, biscuits, or fruits, many pounds of which he daily devoured.

This is, by any standards, an impressive amount of food for anybody, let alone a teenager confined to his bed by illness.

Every endeavour to abridge this quantity of food producing the greatest distress, and materially increasing his febrile symptoms, he was at last permitted to eat as much as he pleased, and the only restriction was to supply him, in the intervals of his meals, with such edibles, as from their hardness gave him the most trouble to masticate.

Even this extraordinary measure failed to curb his insatiable appetites, which grew daily more bizarre.

With the exception of animal food, which was the particular object of his desire, it seemed indifferent to him what he eat, substances the most incongruous were greedily swallowed, and when all other things failed, from the bedclothes, or his fingers, he would endeavour to obtain a supply; the latter he often, apparently from hunger, bit so as to make them bleed; the inclination for food came on regularly with the paroxysm of fever, and continued unabated until that subsided, when he usually fell into a sound sleep.

The ‘sound sleep’ turned out to be a significant symptom of its own, as we shall see.

The period of the recurrence of the paroxysm was very uncertain, but it was always marked by a distinct circumscribed redness of one or both cheeks; the moment this spot was visible, the boy would rouse himself (for he was at other times either sleeping, or dull and torpid) and immediately begin his craving for food as the fever advanced (and it ordinarily ran very high): this craving increased, until, after perhaps ten or twelve hours, both the fever and appetite subsided.

Dr Satterley observes that the boy’s digestive system behaved as it should, except that he could only evacuate his bowels with the help of a strong laxative:

Considerable doses of aloes, repeated draughts of the infusion of senna, together with the constant use of the sulphate of magnesia, and occasionally calomel, would produce six or seven copious, but solid evacuations, any one of them equal to the daily excretion of a man in health.

Charming.

All this time the strength of the patient was abating, and the disease, with the exceptions I have stated, pursuing the usual progress of typhous fever, of which a slow muttering delirium, a feeble pulse, a dry and brown tongue, high-coloured and scanty urine, and very great prostration of strength were the prominent symptoms. The disease was extended, with various alterations, for upwards of thirty days, when the fever subsided, and he gradually recovered.

And that is the last we know of Dr Satterley’s interesting patient. So what was wrong with him?  It was more than a century before anybody could suggest a plausible answer.  In 1925 a German neurologist called Willi Kleine described a previously unknown disorder which was characterised by long periods of sleep. Ten years later an American psychiatrist, Max Levin, wrote about a series of patients with similar symptoms, some of whom also experienced raging appetite.

The vanishingly rare condition they described is now known as Kleine-Levin syndrome, and several of its characteristic features are present in Satterley’s case: intense appetite (hyperphagia), periods of ‘slumber or torpor’, and abnormal behaviour. In addition, the condition usually follows a fever, and predominantly affects adolescent boys. It is difficult if not impossible to treat, but those who suffer from the condition generally grow out of it. It is a shame that we know no more about this patient, because another characteristic feature of Kleine-Levin is that it is episodic. If he really was a sufferer, it’s very likely that it would have recurred at a later date.

Postscript: what about Dr Richard Patrick Satterley? I was curious to find out more about this obscure figure, but there’s very little written about him; not even the year of his birth is recorded. He graduated from Cambridge (or Oxford, depending on which source you believe) in 1799, and seven years later was elected a Fellow of the Royal Society of Physicians.  Appointed to prestigious positions at the Middlesex and Foundling hospitals, he also had a lucrative private practice in the spa town of Tunbridge Wells.

Satterley was evidently cut out for this sort of work, for as one contemporary wrote:

Polite in his manners, and associating with fashionable life, at such a resort he could not fail of success, and with proper industry, joined to his accomplishments, we have no doubt he will in time also take a lead in the metropolis.

That description appeared in a hefty reference work entitled Authentic Memoirs, Biographical, Critical, and Literary, of the Most Eminent Physicians and Surgeons of Great Britain. This book, published anonymously but now known to have been written by one Dr William Nisbet, was a sort of early nineteenth-century medical Who’s Who. But alas, Dr Nisbet’s prediction of great deeds to come was premature. A footnote adds:

Since writing the above, this young physician has unfortunately paid the debt of nature.

He died at Tunbridge Wells, but nothing is known about the reason for his early death. A promising career, cut short without warning.

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