SPEC. I. Empresma GEN. VII. definition of this disease, to see how very little it has in common with apoplexy. This definition is as follows: apoplexy arising gradually; affecting infants, and the tion age below puberty, first with lassitude, feverishness (febriculá), and pain of the head; afterwards with a slower pulse, dilatation of the pupil, and somnolency." The definition includes two stages of disease, if not two distinct diseases, a primary and secondary: and it is only in the second stage or secondary disease, the mere result of the first, that it bears any analogy to apoplexy. brain. First and leading symptoms pyrectic. By whom regarded as an inflammation, The first and leading symptoms are evidently those of pyrexy, which is therefore the fundamental part of the disease; and had not Dr. Cullen been in some degree influenced by system, he would probably have coloured these symptoms a little more highly, as he might have done without any departure from the truth. And hence, while Dr. Parr, Dr. Young, and a few others, have adhered to Dr. Cullen's view of the subject, the great body of pathologists have been dissatisfied with it, and have correctly carried internal hydrocephalus over to the class of pyrexies, and regarded it as a fever or an inflammation. Thus in Dr. Macbride's table it occurs as a nervous fever, under the title of febris continua, nervosa, hydrocephalica: and more simply under that of febris hydrocephalica, in Professor Daniel's edition of Sauvages; whilst Dr. Quin of Dublin, Dr. Withering, Dr. Rush, Dr. Golis, Professor Martini, and a host of other writers of authority, have contemplated and treated it as an inflammation,-an inflammation of the brain,and consequently a cephalitis, in the language of Dr. Coindet of Geneva Céphalite interne hydrencéphalique*; in that of Dr. Golis wasserschlagt, or water-stroke, from its violence; the fever being regarded as a mild and somewhat irregular cauma, and the effusion into the • Mémoire sur l'Hydrencephale ou Céphalite Interne Hydrencéphalique, par J. F. Coindet, M.D. Médicin en chef des Hospices de Genève. Geneva, 1818. + Praktische Abhandlungen über die vorzüglicheren Krankheiter des kindLichen Alters. Band. 1. Wien, 1815. ventricles of the brain as a mere effect of the inflamma- GEN. VII. tion. SPEC. I. Empresma tion of the matory fever This is not the only instance, indeed, in which cauma Cephalitis. assumes a mild character. In various other species of Inflammaempresma it is often found to do the same, of which the brain. reader will find an interesting example under the species the inflamlaryngitis, a few pages further on: and of which every not always practitioner is meeting with daily instances in pneumo- acute, and nitis, and especially in inflammation of the parenchyma rapid: of the lungs producing suppuration. The general organ of the brain, however, seems to have less irritability than almost every other organ when in a state of health, and we often find it to be little irritable in a state of lesion ; since nothing is more common than for a bullet, or the broken point of a knife, sword, or other weapon, to be forcibly driven into it, and buried there for weeks, months, or years*, in one instance eleven years †, not only without danger, but sometimes with little inconvenience. Dr. Porter. In the third number of the Medico-Chirurgical Jour- still more nal, there is an excellent paper upon the subject before lately by us, by Dr. Porter of Bristol, which commences with a very correct pathological view of the disease, minutely coinciding with the present arrangement, and confirming this view by a variety of strongly marked and well selected cases. And I am glad to avail myself of Dr. Porter's authority in following up this second variety of cephalitis, into a distinct and extended illustration. dissection. In few words both varieties not only evince sym- Proofs deptoms of inflammation during the progress of the disease, rived from but anatomical proofs of the same upon dissection after the disease has terminated fatally; in the meningic subdivision the complaint commencing in and being ordinarily confined to the meninges or membranes of the brain, the blood-vessels chiefly affected with inflammatory action being the meningic branches of the external carotid; and in the deep-seated subdivision the com • Gooch's Cases. Hoegg. Diss. Observ. Medico-chir. Jen. 1762. Majanet, Journ. de Med. Tom. XLI. 65. Id. Tom. xx. 553. GEN. VII. SPEC. I. Empresma Cephalitis. Inflamma tion of the brain. Hence vari lies ex plained. plaint commencing in and being ordinarily confined to the posterior part of the brain, the blood-vessels chiefly affected being minute branches of the basilary artery. It is nevertheless possible, and appears often to become a fact, from the anastomoses that are occasionally found between different arteries of the brain, from the continuous spread of morbid action from neighbouring sympathy, or from some unknown cause, that either variety may pass still deeper or wider into the substance of the brain, and make an approach towards the other; and hence the mixt, anomalous, and even contradictory symptoms, by which the specific character is sometimes distinguished; a striking example of which, but too long to be quoted, is to be found in the Edinburgh Medical Commentaries +. "In three cases", says Dr. Sagar, "I have found suppuration of the brain after death; in each of which the patient during the progress of the disease breathed sonorously but without stertor." Whether, in the case of effusion between the membranes, the fluid be confined, where the disease commençes in the meninges, to the space between the dura mater and the arachnoid tunic, and where it commences in a contiguous part of the brain, to that between the arachnoid tunic and the pia mater, as asserted by Dr. Porter, I have not been able to determine. We may hence explain why the symptoms of irritaous anoma- tion and oppression should so much vary as we find they do in different cases; why there is sometimes no delirium and at other times a considerable degree; why the delirium is sometimes furious and impetuous, constituting the delirium ferox of medical writers; why in other instances it is mute or muttering, designated by the phrase delirium mite; why there should occasionally occur examples of that comatose or heavy stupor to * J. P. Frank, De Cur. Hom. Morb. Epit. Tom. 11. p. 48. Mannh. 8vo. 1792. Syst. Morb. Sympt. Cl. x1. Ord. 11. Gen. xii. Vol. 1x. p. 164. GEN. VII. Inflamma which the Greeks gave the name of typhomania; and SPEC. I. why the pain and pyrectic symptoms should vary from Empresma great acuteness to a mere disquieting head-ache and Cephalitis. slight increased action: as also why, in a few cases, there tion of the should not only be found suppuration, but examples of brain. that mollifaction, or softening of the brain, the Ramol- Ramollissement de cerveau, of M. Rouchoux*, and other French writers, which is more frequently traced in apoplectic subjects, and of which we shall have to treat when discussing the disease of apoplexy. lissement de cerveau. litis menin a E. Cepha Phrensy. Diagnos tics. PHRENSY is not often found as an idiopathic complaint, at least in this country; though it is a frequent attend- gica. ant upon other diseases, as synochus, worms, various Brain-fever. exanthems, trichoma, hydrophobia, injuries of the brain, and severe grief. It sometimes makes a near approach to mania, but is easily distinguished by the nature of the exciting cause, where this can be ascertained, the abruptness of the attack, and the violence of the fever; added to which there is in phrensy, for the most part though not always, a hurry and confusion of the mental powers, a weakness and unsteadiness of mind, which is rarely or perhaps never to be met with in genuine mania. It sometimes, however, runs into mania, of which Stoll has given a singular instance in a chronic case that continued for nine weeks before it assumed this change+. The remote causes are those of inflammation in general applied to the organ affected; such as sudden exposure to cold after great heat; cold liquors incautiously drunk in the same state; inebriation and especially from spirits; exposure of the naked head to the rays of a vertical sun; violent passions of the mind; obstructed menstruation; accidental injuries; suppressed eruptions of various kinds; and various kinds of poison. assumes Remote causes. Sometimes assumes a From some of these causes the inflammation a chronic character; is slow in its progress, and obscure chronic in its symptoms. The symptoms moreover, however character, * Dictionnaire de Medicine, Tom. II. Paris 1822. Rat, Med. Sect. 1. p. 179. Frank, ut suprà, Tom. I. p. 51, SPEC. I. Phrensy. M. GEN. VII. connected with a morbid consent in other organs, genea E. Cepha- rally point to the brain as the seat of lesion; and consist litis menin- of cerebral compression or acute pain in the head, irregica. gularity in the pulse, and some kind of paralysis. Brain-fever. Lallemand, who has industriously collected a multitude of anomalous cases of this kind, observes that where the inflammation runs into suppuration, an effort is usually made by nature to form a sack or barrier for its limitation: but that even this effort is often in vain, and still adds to the fatal issue, as the new membrane frequently becomes thickened and creates a fresh source of irritation*. Remedial treatment. The cure of phrensy must be attempted in the same manner as that of inflammation in general, or rather as the cure of inflammation by resolution; for resolution is the only means by which a cure can be effected in this case. Copious and repeated bleedings must here therefore hold the first place; and the nearer the blood is drawn from the affected organ the better chance it gives us of success. The temporal arteries and the jugular veins have hence been recommended as the most effectual vessels to open; but for various reasons it is better to begin with drawing blood liberally from the arm, and afterwards by a free application of leeches to the temples. The head should be shaven as soon as possible, and kept moist with napkins wrapped round it dipped in cold vinegar, or equal parts of water and the neutralized solution of ammonia; or, which is still better, with ice-water: all which is preferable to blistering, which is too apt to increase the morbid excitement, and has the authority of Hippocrates, who was in the habit of applying cold epithems, not only in inflammation of the brain, but even of the abdominal viscerat. The bowels should be thoroughly evacuated, and even stimulated at first by calomel alone or mixed with jalap, and afterwards kept open by cooling saline aperients: and nitre should be given in mode * Recherches Anatomico-Pathologiques sur l' Encéphale et ses Dépendances. Lettre quatrième, 8vo. Paris, 1823. † Περὶ Νουσῶν, p. 484. |