Isaac Coombes, æt. 60, weaver. Admitted on 9th day of fever: at present no pain of head; some sleep; face pallid; great prostration; no thoracic or abdominal symptoms.
15th. Convalescent.
21st. Attacked suddenly with shivering, heat, vomiting; no pain of head or of any organ; pulse 96.
22d. Continues quite free from pain, but no sleep; extreme restlessness; great prostration; skin warm and dry; pulse 84. Died following morning.
Head. Between the pia mater and the arachnoid a large quantity of coagulable lymph of a yellow colour, with which indeed the arachnoid appeared to be universally lined, and which in some places was very thick. Substance of the brain highly vascular, being exceedingly full of bloody points, and in some places stained; three or four ounces of serum in the ventricles, at the bottom of each of which lay about a drachm of pus. The spinal sheath contained the same kind of substance, while the cord itself presented a healthy appearance. Thorax. Right lung gorged with blood and partly hepatized. Abdomen. Spleen soft; other viscera healthy.
Susanah Stammers, æt. 9, destitute. Admitted on the 8th day of fever. Attack commenced with severe pain of the head which continues with almost equal violence; little or no sleep; eyes dull and heavy; face flushed; pulse 126; slight uneasiness of chest on full inspiration; no cough; no tenderness of abdomen; tongue loaded with white fur; red at point; bowels purged.
9th. Pain of head quite gone; less sensible; countenance more dull and heavy; pulse 120; abdomen tender.
11th. Delirium, with much talkativeness; pulse 112.
14th. Coma; bowels continue purged.
15th. Abdomen tender, swollen, rounded at navel.
19th. More sensible; more tranquil sleep; delirium gone; pulse 110.
27th. No coma nor delirium; tranquil sleep; tongue moist, cleaning; pulse 108 feeble.
45th. Appeared upon the whole to be convalescing, but in an exceedingly slow and imperfect manner; there was a remarkable vacancy in her countenance, almost amounting to a fatuous expression; and her mind was peevish and childish. On this day she was seized suddenly with convulsions of extreme violence, and died within twenty-four hours after the attack.
Head. Arachnoid thickened and opake; effusion of gelatinous fluid beneath it; substance of brain highly vascular; in the inferior cornu of left ventricle a pint of purulent matter, somewhat resembling broken down cortical substance; it lay loose within the cavity. Thorax. Superior lobe of right lung gorged and partly hepatized. [Pleuræ of right side adherent;] Abdomen. Mucous membrane of cæcum and commencement of colon vascular.
Henry Brewer, æt. 59, labourer. Admitted on the 10th day of fever: states that he has no pain in the head, and that he is quite free from pain every where excepting in the right side, where he has some uneasiness, which is attended with slight cough; tongue brown and dry; bowels natural; pulse 96.
12th. No pain of head; that of chest gone; sleeps well; pulse 108.
16th. About an hour after yesterday’s visit became suddenly insensible; it has been impossible to rouse him from this coma which still continues profound; respiration stertorous. Died in the course of the day.
Head: Dura mater thickened but not vascular; arachnoid thickened and opake; beneath it gelatinous effusion; upon its external surface a large quantity of well-formed pus; a quantity of purulent matter at the base of the brain surrounding the corpora quadrigemina: walls of the fourth ventricle ragged; two ounces of serous fluid in lateral ventricles and at base. Thorax. [Pluræ adherent; lower and middle lobes of right lung hepatized.] Abdomen. Viscera healthy.
3. Vascularity of Brain, Membranes, &c. with copious Serous Effusion.
George Blackbeard, æt. 18, servant. Admitted on the 22nd day of fever: complaint commenced with violent head-ache attended with frequent fits of epistaxis; pain of the head still continues, chiefly confined to the occiput; little sleep; eyes injected and suffused; pulse 102, tongue loaded, dry.
23d. Scarcely any pain in the head.
25th. Pain of the head entirely gone; epistaxis.
26th. Delirium: muscular tremor.
28th. Delirium and muscular tremor increased; pulse 112; tongue more dry; lips and teeth sordid.
31st. Died.
Head. Membranes and substance of brain vascular; ventricles distended with serum; no characteristic disease in thorax or abdomen.
Ann Higgins, æt. 30, servant. Admitted on the 22d day of fever: pain of head from the commencement very severe; chiefly confined to the right side; still continues, together with severe pain in the limbs; some pain in the right side of chest; cough; abdomen not tender; tongue dry in middle; red and moist around edges and at point; pulse 105, feeble; much prostration; entire surface of the body preternaturally sensible.
23rd. The sensibility which from the commencement has been felt over the whole surface of the body is now particularly acute in the joints; in all of which there is severe pain; pulse 112.
25th. Pain of head gone; mind indistinct; tongue dry: stools passed in bed; pulse 105. Pains in the joints; swelling and redness of left fore-arm.
27th. Mind more and more indistinct; pressure on any part of the body produces extreme pain; joints the same; died next day. At this period attention had not been awakened to the peculiar disease of the joints hereafter to be described; they were not therefore examined; but without doubt the affection was of the same nature.
Head. Dura mater vascular, and adhered with preternatural firmness to the skull; pia mater vascular; substance of brain natural; pituitary gland suppurating; the lateral and the third ventricles full of serous fluid; one ounce at base. Thorax. [Lungs emphysematous; several points of tubercular suppuration in left.] Abdomen. Mucous membrane of small intestines inflamed without ulceration.
James Dennie, æt. 28, labourer. Admitted on the 8th day of fever, which attacked with usual symptoms: at present pain of head; little sleep; eyes dull and heavy; some cough; respiration hurried; abdomen not tender; tongue white; pulse 112, weak; prostration.
9th. Pain of head increased; delirium; eyes suffused; cough and hurried respiration continue.
10th. Pain of head gone; constant and violent delirium; no sleep; pulse 108.
11th. Delirium gone; profound coma; muscular tremor; respiration hurried; pulse 108.
12th. Coma deeper; extreme restlessness; respiration more hurried; stools and urine passed in bed. Died.
Head. Arachnoid vascular; substance both of cerebrum and cerebellum vascular; all the ventricles full of serum; viscera of thorax and abdomen healthy.
Charlotte Watts, æt. 9. Previous history of disease unknown: at present scarcely at all sensible; almost constant crying; frequent rolling of the head on the pillow; countenance anxious; pulse not to be counted from her extreme restlessness; respiration hurried; abdomen not tender; lips and teeth sordid. 2d day after admission constant noisy delirium; pulse 120.
17th. Almost imperceptible, but still gradual improvement since last report; more sensible; no delirium; but mind throughout extremely peevish and fretful; stools have constantly been and still are passed in bed; pulse 116.
19th. Large sloughing sores on loins and hips; erysipelas of surrounding integuments; pulse 112, weak.
27th. Sloughs have extended between the shoulders, along the back, and over both hips; great emaciation; extreme prostration; mind continues very fretful; pulse 110, very weak.
37th. Gradually grew weaker and weaker until this day, when she died.
Head. Arachnoid vascular; substance of brain and especially medulla oblongata highly vascular; between the arachnoid and the dura mater much limpid serum; all the ventricles distended with a similar fluid. Thorax. [Pleuræ adherent. Both lungs contained numerous tubercles in a state of suppuration. A large proportion of right lung hepatized.] Abdomen. Viscera healthy.
Mary Sullivan, æt. 26, married. Admitted on the 14th day of disease; pain of head severe from the beginning; continues unabated and even violent; no sleep; face pallid; expression depressed; pulse 81; abdomen tender; tongue foul and dry. V. S. ad ℥xij.
18th. Pain of head gone; delirium; pulse 70, soft; tongue more dry.
24th. Pain of head, which had returned slightly on some of the preceding days, was, from this period, finally lost in insensibility; no longer conscious; prostration; great restlessness; almost constant moaning; occasional retching; pulse 72.
26th. Continues perfectly insensible; all the stools passed in bed; pulse suddenly rose to 120, on the following day fell to 102; eyes half open and injected: no material change till 29th, died.
Head. Membranes and substance of brain appeared pretty healthy; all the ventricles enlarged, and contained about three ounces of limpid serum; a considerable quantity, also, at base; some coagulable lymph effused on that part of the arachnoid which covers the tuber annulare. Thorax. [Pleuræ adherent; substance of lungs full of tubercles, in different stages of disease.] Abdomen. [Liver hard;] other viscera healthy.
Ann Boon, æt. 14, admitted on 10th day of fever. Attacked in the beginning with severe head-ache, which still continues; abdomen tender; lips and teeth sordid; tongue brown and dry; pulse 120.
11th. Pain of head undiminished; eyes heavy and suffused; delirium; tongue red, dry, and glazed; pulse 108.
13th. Pain of head quite gone; delirium; pulse 118.
19th. Much noise through the night; peevishness during the day; pulse 108.
20th. More insensible; can give no answer to any question; pulse 118.
22d. Constant rolling of the head; pupils dilated; all the stools passed in bed; pulse 108.
29th. Eyes vacant and staring; pupils contracted; head sunk in bed; legs drawn up; stools passed in bed; urine abundant; pulse 117, regular and of good power.
30th. Skin covered in several places with vesicles, which discharge a thin ichor. Died.
Head. Membranes and substance of brain vascular; upwards of three ounces of serum in the ventricles and at base; much similar fluid in theca vertebralis. Thorax. Viscera healthy. Abdomen. Mesenteric glands greatly enlarged; some of them suppurating.
Richard Maciff, æt. 30, admitted on the 22d day of fever. No account can be obtained of its previous history: at present he lies quite prostrate and perfectly insensible; eyes wild and rolling; pupils dilated and insensible to light; constantly picking at the objects around him; pulse not to be counted, on account of his extreme restlessness, but it feels like a soft cotton cord, and nearly without pulsation.
23d. Profound coma; senseless muttering; constant muscular tremor; squinting; neither stool nor urine has been passed since admission; pulse 96, soft, not intermittent.
24th. Coma undiminished; one stool passed in bed; urine drawn off by the catheter; pulse 100, extremely feeble.
25th. No change.
26th. Died.
Head. Dura mater vascular; arachnoid highly vascular; that portion of it covering the tuber annulare distended into a bag of considerable size, filled with serum; all the ventricles enlarged and distended with serum. Thorax. [Right lung contained tubercles in various stages of disease.] Abdomen. [Liver of unusually deep red colour; in right and left lobes two small sacs, filled with calcareous matter; on surface of spleen a sac, containing matter similar to that in the liver.]
William Tennant, æt. 18, tailor. Admitted on the 8th day of fever; at present much pain of head back, and extremities; no sleep; face flushed; epigastrium tender: tongue red round margin, coated in middle; much thirst; pulse 99. V.S. ad ℥x.
9th. Pain of head continues; scarcely any sleep; pulse 96. C.C. ad ℥x. nuchæ.
10th. Pain of head unrelieved, particularly severe over the forehead; face flushed; tongue brown and dry; pulse 92.
11th. Pain of head quite gone; no longer conscious of any uneasiness in the limbs; much drowsiness; delirium; pulse 104.
12th. Rather more sensible; delirium; tongue unchanged; stools and urine passed in bed; pulse 112.
13th. Delirium increased; eyes glistening; pulse 120.
14th. Mind more distinct this morning; much delirium through the night; respiration hurried; pulse 130. Died next morning.
Head. Membranes and substance healthy; on the under surface of right hemisphere, corresponding with the middle lobe, a remarkably deep and extensive depression, the deepest part corresponding to the centre of the brain; this depression was lined with the arachnoid, which being reflected formed a sac, that contained 12 ounces of serous fluid, and completely filled the cavity. The cerebral substance beneath and around was perfectly sound and entire. Thorax. Viscera healthy. Abdomen. Mucous membrane of ilium and cæcum extensively and greatly ulcerated.
4. Vascularity &c. with preternatural Firmness of Brain.
Thomas Conolly, æt. 58, labourer. Admitted on 7th day of fever: severe pain of head early in the attack which has continued without intermission, accompanied with vertigo; scarcely any sleep; face flushed; no uneasiness of chest; abdomen not tender; no stool for four days; tongue loaded and dry; pulse 96, weak.
8th. Less pain of head; no improvement in other symptoms; pulse 92.
9th. Scarcely any pain of head; no sleep; delirium; muscular tremor; tongue brown and dry; pulse 111.
10th. Pain quite gone; more insensible; constant talkative delirium; colour of cheek dusky, almost livid; respiration hurried; stools and urine in bed; pulse 112, feeble.
11th. Died.
Head. Membranes vascular; arachnoid thickened and opake; substance of brain highly vascular and preternaturally firm; some fluid beneath membranes and in ventricles. Thorax. [Pleuræ adherent;] lungs gorged with blood. Abdomen. Liver and spleen exceedingly softened, readily breaking down beneath the finger.
Mary Tiffin, æt. 25, servant. Perfectly insensible: no account can be obtained of history or duration of disease: abdomen tender; tongue loaded, moist; pulse 99.
2d day after admission scarcely any sleep; delirium; muscular tremor.
3d. Insensibility continues; constant delirium; has passed neither stool nor urine; latter drawn off by catheter; pulse 124, feeble and fluttering. Died next morning.
Head. Dura mater and arachnoid natural; pia mater vascular; substance of brain highly vascular and unusually firm; cerebellum soft; effusion beneath arachnoid and at base. Thorax. [Substance of both lungs filled with miliary tubercles.] Abdomen. [Liver studded with tubercles, similar to those of the lungs; spleen full of the same kind of tubercles, excepting that they were larger, and some of them were suppurating;] pancreas extremely firm.
Mary Poulston, æt. 50. No account to be obtained of duration of disease: lies quite insensible and prostrate; frequent jactitation of the arms; face flushed; respiration stertorous; cheeks alternately expanding and collapsing during inspiration and expiration; tongue not to be protruded; stools and urine in bed; pulse 138, weak, and easily compressed.
2d. Died.
Head. Dura mater vascular; arachnoid thickened and opake; substance of brain highly vascular and firm. Thorax. All the viscera perfectly healthy. Abdomen. Mucous membrane of intestines vascular, without ulceration; mesentery inflamed; [contained a calcareous deposit of an oval shape included in a cyst.]
William Ashley, æt. 65, messenger. Admitted on 4th day of fever: slight occasional head-ache; mind distinct; scarcely any sleep; face flushed; no uneasiness of chest or abdomen; slight cough; pulse 81.
5th. Slight head-ache; little sleep; pulse 82.
6th. Pain of head gone; pulse 90.
8th. No pain; mind confused; delirium; stools in bed; pulse 108.
10th. Prostration; pulse 111.
11th. Perfectly insensible; great prostration; deglutition difficult; hiccup; pulse 116, extremely feeble.
12th. Died.
Head. Membranes and substances of brain intensely vascular; perhaps as much so as in pure phrenitis; substance exceedingly firm; viscera of thorax and abdomen healthy.
Francis Hodgkinson, æt. 15, servant. Admitted on the 8th day of fever: pain of head and vertigo, which ushered in the attack already gone; mind confused; scarcely any sleep; slight pain of chest on full inspiration; slight cough; abdomen not tender; tongue red at margin, centre covered with yellow fur; pulse 117, easily compressed.
9th. No pain; much confusion; much restlessness; respiration oppressed; tongue still moist; lips and teeth sordid; stools in bed; pulse 112.
13th. Petechiæ; tongue dry; pulse 110.
15th. No material change in symptoms. Died.
Head. Membranes vascular; substance exceedingly vascular and firm; some fluid in ventricles and at base. Thorax. Lower lobe of left lung of dark red colour and inflamed. Abdomen. Mucous membrane of small intestines vascular, and of dark red colour.
William White, æt. 17, labourer. Admitted on 6th day of fever: pain of head; especially over forehead; mind distinct; some sleep; face flushed; no thoracic or abdominal uneasiness; tongue white and dry; no stool for a week; pulse 126.
7th. Pain of head very severe; pulse 117; V. S. ad ℥xij.
8th. Died this morning most suddenly and unexpectedly, after having complained of violent pain of the head.
Head, not examined till three days after death, yet the substance of the brain was exceedingly firm, and seemed to distend and protrude its membranes, so that there seemed something like hypertrophy of its substance; viscera of thorax and abdomen healthy.
John Mullins, æt. 28, servant. Stated to be a relapse after a fever of three weeks duration: at present, lies perfectly senseless; noisy delirium; extreme restlessness; pulse 70.
2nd day after admission, continues perfectly insensible; respiration slow and stertorous; tongue not to be protruded; stools passed in bed; pulse 60.
6th. Remained nearly in the same state until this morning. Died.
Head. Dura and pia mater highly injected; surface of brain quite dry and hard; substance throughout exceedingly firm, and thickly crowded with bloody points; cerebellum soft; pituitary gland soft; all the ventricles, especially the third, exceedingly enlarged and quite full of limpid serum; communicating passages greatly distended; an ounce of serum at base. Thorax. [Left pleuræ completely adherent; both lungs full of tubercles, many of which in the left lung were softened and others were in a state of suppuration.] Abdomen. Mucous membrane of small intestines inflamed and thickened; no ulceration. [Sigmoid flexure of colon contracted into the form of a small white cord of very narrow calibre, the superior extremity of which was blocked up by a large scybala; and beyond it there was a great accumulation of fæces; spleen very small; right kidney weighed only six drachms; left seven ounces and a half; liver extremely small weighing only two pounds, six drachms; it lay across the epigastrium and adhered by a preternatural membrane to the diaphragm on the left side; mesentery wasted.]
5. Vascularity, &c. with Softening of the Brain.
Sarah Hampden, æt. 50. No account to be obtained of history of disease, but it is stated that this is the 22d day of her fever: at present mind quite fatuous; some uneasiness of chest; cough; abdomen not tender; tongue red and dry; pulse 99.
24th. Subsultus; urine in bed; no stool.
26th. Mind rather more distinct and more firm; less subsultus; submaxillary gland enlarged and painful; pulse 108.
28th. Much prostration; no other change.
30th. Increasing prostration; pulse 120, feeble.
32d. Died.
Head. Dura mater vascular and thickened; arachnoid white and opake; substance of brain slightly vascular, but very soft; pituitary gland suppurating; all the ventricles distended with serum. Thorax. [Universal adhesion of the pleuræ; lungs studded with tubercles.] Abdomen. Mucous membrane of small intestines inflamed; no ulceration; pancreas very hard; liver much softened.
Virgina M’Mahon, æt. 8, admitted on 14th day of scarlet fever. No account can be obtained of previous history; mind quite confused; extreme restlessness; abdomen tender; tongue very red and sore; tarsi red and irritable.
15th. Delirium; moaning; no sleep; more sensible to-day; abdomen less tender; pulse extremely quick and weak.
18th. Without any material change, died.
Head. Arachnoid opake; effusion between it and the pia mater; substance of brain exceedingly soft; two ounces of serum in the ventricles. Thorax. Mucous membrane of trachea and bronchi vascular; bronchial tubes filled with mucus. Abdomen. Mucous membrane of small intestines vascular; mesenteric glands enlarged.
Dorcas Wingrove, æt. 23, servant, admitted on the 6th day of fever. Attack commenced with violent pain in the head, preceded by no other symptom that was observed; this pain still continues exceedingly severe, and is confined chiefly to the right eye; mind distinct; no sleep; much restlessness during the night; countenance pallid; no uneasiness of chest; abdomen tender; bowels constipated; tongue pale, clean and moist; pulse 93, weak.
7th. Pain of head undiminished; delirium; three stools in bed; tongue brown and quite dry; pulse 100, firm, strong, and sharp. C.C. ad ℥xij. nuchæ.
8th. Pain of head gone; no sleep; noisy delirium; stools in bed; pulse 120, weak.
9th. Slight, but very transient amendment.
11th. Comatose; lies quite prostrate; stools in bed; pulse 130, feeble.
12th. Died.
Head. Membranes vascular; arachnoid opake; corpus striatum in part highly inflamed, in part softening to suppuration; viscera of thorax and abdomen healthy.
Thomas Proctor, æt. 45. Date and progress of disease unknown: at present perfectly insensible; extreme restlessness; eyes dull and vacant; tongue dry; pulse scarcely to be distinguished.
2d day after admission. Insensibility the same; almost constant moaning; features sunk; expression of countenance anxious; pulse 118. Next morning died.
Head. [In falciform process of dura mater an ossification, two inches and a half in length and half an inch in breadth, with several similar ossifications along the course of the longitudinal sinus;] the arachnoid and pia mater consolidated into one thick, opake and yellow membrane; substance of brain highly vascular and very soft; cerebellum quite disorganized, being broken down into a yellow, puriform mass of matter, a considerable portion of which lay loose on the floor of the cranium; all the ventricles full of serum, in which floated numerous flakes of lymph; base immersed in similar fluid. Thorax. Viscera healthy. Abdomen. Mucous membrane of jejunum and ilium much inflamed, neither thickened nor ulcerated; [liver greatly enlarged; walls of bladder half an inch thick.]
The following is placed at the end of the cerebral cases, not because it illustrates any new circumstance in the condition of the brain, but because, while the symptoms and the pathology are prominently cerebral, it affords one of the most complete examples of the peculiar affection of the joints already referred to.
George Carter, æt. 28. Admitted on the 4th day of scarlet fever: throat sore; deglutition painful; cough; no pain of chest or abdomen; nausea; tendency to vomiting; no pain of head; mind distinct; pulse 108, weak.
5th. No pain; eyes suffused; pulse 120, firmer.
6th. Mind confused; eruption partial, interspersed with papulæ; tongue of strawberry appearance, and rough from prominence of papillæ; pulse 124.
7th. Delirium, so violent as to require restraint; no sleep; pulse 120.
8th. Eruption changed to copper-colour; tongue dry; pulse 112.
10th. Inflammation of parotid gland.
18th. Tumour of left parotid exceedingly hard and slowly suppurating; slight difficulty in swallowing; pulse 96.
21st. Tumour opened last night and discharged two ounces of bloody pus; pulse 108.
28th. Alternately mended a little and then fell back to his former state until last night, when swelling of right wrist and left knee came on, attended with excruciating pain and great heat without any discoloration: 12 leeches have been applied with considerable relief: mind confused; no sleep; countenance anxious; face flushed; rigors; pulse 135.
24th. Other wrist and knee have begun to swell and are excessively painful; left wrist and knee which had been more easy, again extremely painful; vomiting; respiration hurried; pulse 116, weak. Died.
Head. Much serum both in ventricles and at base. Thorax. Viscera healthy. Abdomen. Mucous membrane of the ilium ulcerated and extremely dark.
All the large joints swollen and red: on opening the knee joints they were found to contain several ounces of serum mixed with pus; the cellular tissue in the neighbourhood was partly inflamed, and partly mortified and sloughing: both wrists were in a similar condition.
James Solden, æt. 44, plasterer. For symptoms see page 155.
Head. Membranes of brain vascular; substance highly vascular; some effusion beneath the arachnoid. Thorax. Viscera healthy. Abdomen. Mucous membrane of ilium vascular; no ulceration; mesenteric glands enlarged.
John Clark, æt. 17. For symptoms see page 156.
Head. Corresponding portions of the pericranium and dura mater detached from the occipital bone to the extent of four inches in length by three in width; coagulated blood effused between the dura mater and the cranium; vessels of the membranes turgid with blood; substance of brain vascular; effusion between the membranes; a little at base. Thorax. Viscera healthy. Abdomen. Mucous membrane of ilium greatly inflamed; cæcum ulcerated.
From the study of these cases we see that the process of disease is as uniform as that of health, or of any other process of nature; that certain phenomena constantly take place; that they follow a determinate order; that the events seldom or never vary; that their relations to each other never change; that in these cerebral cases of fever a preternatural fulness and apparently increase in the number of the blood-vessels of the brain and spinal cord, or of their membranes is always present; or that if a case do now and then occur in which even no preternatural vascularity can be discovered such an event is exceedingly rare; that this fulness and increase of the blood-vessels is either identical with, or passes into the state of inflammation; that the state of inflammation, after a certain period, produces results which are known to be effects of inflammatory action in other parts of the body; that these products of inflammation consist of a given number; that the whole of that number never concurs in any one case, but that two or more are frequently found in combination; that the laws by which any one of these is formed rather than any other are at present wholly unknown; while instances do occasionally occur, although they are extremely rare, in which the state of mere vascularity alone subsists without the formation of any inflammatory product that can be discovered.
From the study of the history of these same cases we further see that the indications of this inflammatory state of the brain and spinal cord or of their membranes are as uniform as the existence of the state itself; that certain symptoms invariably accompany it; that these symptoms not only declare with absolute certainty that this process is going on, but likewise, in general, clearly mark its progress; and that this series of symptoms and the place in which each stands in the series is as follows: namely,
Pain in the head, or giddiness, or some other uneasy sensation in this organ, attended with a loss of sleep and with a derangement in all the sensorial faculties,—these are the signs of the presence of the disease in the brain or its membranes. Pain in the back, loins, or limbs, or diminution of the power of voluntary motion—these are the signs which mark the existence of the disease in the spinal cord or its membranes. These symptoms having been present a certain time, and at length succeeded by—diminution of the pain or uneasiness without a corresponding diminution in the other febrile symptoms, but with an increase in some of them; for instance, with an increase of the sleeplessness and restlessness: at last, total cessation of all pain or uneasiness, together with a diminution of the sensibility—these are the signs which mark the progress of the disease, and which, in general, denote a transition from the state of mere inflammation to the formation of some inflammatory product. Thus far the change of state is certain and the signs which denote it invariable; to the latter other symptoms are added which occur in the great majority of cases, but not in all; namely, delirium, muscular tremor, involuntary and unconscious stools, acceleration, and in general, increased and increasing weakness of the pulse. Other accessory symptoms still frequently occur and with considerable regularity, but as these are more variable the student is referred to the cases themselves, the study of which can alone teach when they may be expected.
Since the diseased states of the brain and spinal cord or of their membranes, which the preceding pathology discloses, exist, as is there shown, in all degrees of intensity, so the signs by which these states are denoted may vary from a prominence which it is impossible to overlook to an unobtrusiveness which it requires careful attention to discover. And from causes which we do not yet understand, the prominence of the sign is not always in accordance with the intensity of the state; but the important truth here maintained is, (and the more the practitioner observes, the more satisfied he will become that it is a truth,) that whenever these states exist in sufficient intensity to produce death, their presence may be discovered during life. It is not affirmed that these states can be distinguished one from another; but it is contended that the existence of some one or more of them may be ascertained with absolute certainty. As we sometimes see death occur, preceded by the ordinary symptoms of cerebral inflammation, when, on examination after death, nothing can be discerned but preternatural vascularity of the membranes or substance of the brain, without the presence of any inflammatory product that can be distinguished; and as, moreover, when some inflammatory product is generated, we are in total ignorance of the laws by which, in one case, the blood-vessels pour out serum, in another secrete pus, in a third soften, and in a fourth indurate the cerebral substance; so the signs which indicate that these events have taken place are to us, at present, uncertain. There can be no question that the laws, according to which each of these events is produced, are fixed and invariable in their operation; and each may possibly be attended with its specific and therefore diagnostic sign; but it is certain that we have not yet discovered the one nor observed the other. And the preceding cases have been detailed under the heads assigned them, rather with the view of making the pathology clear, than in the hope from this arrangement of affording any guide to practice. In the mean time, what we may know, and ought to know, is when inflammation exists: what we may, in general, further know is, when some product of inflammation has been poured out still more to oppress the brain: to the thoughtful and discerning practitioner it would be without doubt a high satisfaction to be able to carry his diagnosis still further, and to ascertain what that product is: the desire to arrive at such precise and perfect knowledge appears to me to be in the highest degree meritorious: the constant and unwearied endeavour to acquire it may not always succeed with reference to the particular object immediately pursued, but it cannot fail to increase his power and to strengthen his habit of observation; and the sure reward of a devotion thus truly honourable and faithful to the duties of his profession, if it should not be, as it may not invariably be, the confidence and the gratitude of his patient, will at least be the proud consciousness that he has deserved both.
Were it possible to ascertain with absolute certainty and with perfect exactness in which of its various modes inflammation of the brain and its membranes terminates, it would be a subject of interest, as far as we can at present perceive, rather to the physiologist and pathologist than to the practical physician. To the latter the great fact which it is of paramount importance that he should know is, that inflammation is going on in the brain of his patient, and that if he cannot put a stop to it in the course of a day or two, it will in that short space of time terminate in some irreparable change of structure, of which death will be the inevitable consequence. This, it is again repeated, it is always in his power to know; and as there is no one fact which can or which ought to have so much influence upon his practice, so there is no diagnosis which it is of so much importance that he should acquire the habit of forming.
II. Cases in illustration of the Morbid Changes which take place within the Chest; or Thoracic Cases.
Angelica Fidgett.
For symptoms see page 125.
Thorax. Mucous membrane of bronchi, in all their ramifications, exceedingly inflamed; bronchial tubes full of mucus; [substance of left lung extremely inflamed; left pleuræ adherent; right pleuræ and lung much less severely affected.] Head. Substance of brain vascular. Abdomen. All the viscera healthy except the uterus and its appendages, which were slightly inflamed.
John Potter, æt. 21.
For symptoms see page 127.
Thorax. Mucous membrane of bronchi, in all their ramifications, of dark red colour; bronchial glands much enlarged; [pleuræ of right side generally adherent; substance of lungs consolidated; pericardium contained four ounces of serum;] heart natural. Abdominal and cerebral organs healthy.
Alexander Crombie, æt. 19, seaman.
For symptoms see page 159.
Thorax. Mucous membrane of bronchi, in all their ramifications, highly vascular; bronchial tubes full of mucus, mixed with pus. Head. Dura mater adherent with preternatural firmness to cranium; substance of brain unusually firm; posterior lobes crisp, and cut almost like cartilage; anterior lobes, when cut into, abound with bloody points; cerebellum exceedingly firm. Abdomen. Peritoneal coat of small intestines in general vascular; eight or ten portions of the jejunum and ilium, to the extent of three or four inches each, intussuscepted; mucous membrane of these parts extensively ulcerated, some of the ulcers circular, the greater number oblong, and at least two inches in length; mucous membrane in general highly vascular, but that surrounding the ulcers less so than the other parts; mesenteric glands corresponding to ulcerated portions of intestine enlarged and vascular; crimson spots on convex surface of liver; gall-bladder distended with a yellowish watery fluid; spleen enlarged, and so soft as to be easily broken down under the finger.