I. Synochus Gravior with Cerebral Affection,
occurs under two degrees of intensity: when the cerebral affection is moderate, it may be termed subacute; when great, acute.
1. Synochus with Subacute Cerebral Affection, may be attended for several days with no symptom which has not been already enumerated in the account of the mildest form of the disease. The accession is the same as in synochus mitior: the progress up to a certain period is also the same. But at the time when the pain of the head diminishes in the latter, it increases in the former. Still the pain is often not severe. He who looks for intense pain, and suspects no cerebral affection, unless accompanied with this symptom, will be surprised by what will appear to him the sudden occurrence of new symptoms, such as are immediately to be stated, which will at length open his eyes to the danger of the case, and excite his wonder, which it is not unfrequent to hear expressed, that an affection hitherto so mild, should, without any previous warning, become so formidable, and show but too manifestly that it is beyond control, and will certainly proceed to a fatal termination. The warning was given, but the sign was not understood. The descriptions of disease are commonly taken from its most acute form; and it was long the practice to derive them from this form alone, and the consequences were truly fatal. Even with the best care that can be taken in drawing up the history, these descriptions are exceedingly apt to become ideal, and not real entities: to consist of a collection of all the circumstances that exist in all cases, and not of that particular combination only which is found in any one case: and thus to be not the portrait of any individual, but a fancy picture bearing a general resemblance to all individuals without being the true likeness of any. The consequence is, that at the bed-side of the sick the original from which the picture is supposed to be taken is not to be seen, and the practitioner remains in doubt, if he do not fall into error. Error serious and fatal many have fallen into, and, on this very account, still continue to fall into, with regard to the existence of cerebral disease in fever. Abundant evidence will be given in the pathology, that it is not uncommon for the most unequivocal and extensive changes of structure to take place in the brain and its membranes without severe pain having ever been felt. Pain, however, though it be not great, is almost always present. It is seldom that the pain extends over the whole head; the patient generally points to some particular part where it is peculiarly felt. In the majority of cases the seat of the pain is either in the forehead, or at the temples, or over the eyes; but occasionally it is in the occiput, and extends down the neck, and in these instances it is often severe between the shoulders.
Now and then no pain whatever is felt. Question the patient as much as you please, and he will tell you that he never has felt any pain. In this case giddiness is the substitute. Giddiness in the commencement, and in the early stage of fever, is as certain a sign of cerebral affection as pain. Striking illustrations of this are afforded by several cases detailed in the pathology; by consulting which, the reader will see that precisely the same morbid changes take place in the structure of the brain, although nothing but giddiness be complained of, as occur in those which are attended with the acutest pain. The practitioner will therefore fall into a fatal error who is seduced into security because pain is absent; and who neglects the remedies proper for inflammation of the brain, because the patient complains only of giddiness. If giddiness be combined with pain, or alternate with it, which is not uncommon, the giddiness being slight if the pain be severe, and the pain being slight if the giddiness be distressing, it indicates a more severe affection than if either exist alone.
2. In the majority of cases, as long as the pain continues, the heat of the skin remains considerably above the natural standard. But often the heat over the general surface of the body is not great. Commonly, however, it is hotter than natural over the head, and it is hottest wherever the seat of the pain be fixed: so that the contrast is often striking between the temperature over the forehead or at the occiput, and the heat of the body in general.
3. The dull and heavy expression of the eye is greater than in the milder form of fever. The conjunctiva generally becomes brighter and more glistening than natural: though instead of this the vessels are often more numerous and more turgid than usual, and give it the appearance which is termed “muddled.” The eye at the same time is commonly preternaturally sensible, and cannot bear a strong light, although sometimes no complaint is made if the curtains of the bed be withdrawn, or the window-blind be drawn up.
4. There is usually a corresponding increase in the general sensibility; and what is remarkable, this is quite as much indicated by the increased sensibility to sound as to light. A loud noise is invariably distressing to the patient, and a continuance of it greatly aggravates all the symptoms. Exposure to a glare of light and a loud noise, would alone rapidly change a slight into the severest cerebral affection.
The expression of the countenance is now very peculiar: it cannot be described, but the experienced eye can seldom fail to recognize it. It is indicative of suffering without the strength to bear it: it is not anxious; that expression does not come on until a later period. The face is sometimes flushed, but it is often pallid, which does but add to the peculiar character of its expression.
5. As long as the pain of the head, the giddiness, and the increased sensibility continue, there is invariably a want of sleep. The degree of sleeplessness is not always in proportion to the head-ache or to the other symptoms; but while the latter are present, the former is never absent. That condition of the brain upon which sleep depends appears to be easily disturbed by a great variety of causes; but whatever be capable of affrighting this heavenly visitant, “tired Nature’s sweet restorer,” whether in the mansion, the palace, or the prison, and whether from the bed of healthful slumber or from the couch of sickness, nothing so effectually and so constantly banishes it as that febrile uneasiness of which we have already spoken; and which, instead of declining, as in the milder form of fever, now increases in strength and activity, and will scarcely allow the restless body to remain in one position for a moment. He who has felt its influence in this stage and degree of fever, will admit that there is nothing comparable to the wretchedness it produces, except it be the sweetness of the first waking moment after the first tranquil slumber of returning health.
6. And now, sometimes closing this train of symptoms, but more frequently being the first harbinger of another, delirium appears. Delirium is usually first observed when any slight sound rouses the patient from that disturbed slumber which is the only substitute allowed for sleep. The delirium is seldom violent or long-continued, but, when present, is like the talking of a person during sleep in a disturbed dream. This symptom, however, is by no means invariably present, and when it does come, it often postpones its visit to a somewhat later period.
7. The pulse, during all this time, may not be much quicker than in the mild form; and the state of the tongue and of the evacuations does not materially differ.
Such is the train of symptoms when the brain becomes prominently affected. These symptoms continue without intermission, and with little change, for several days. The period of their duration, when only in this degree of violence, is commonly from eight to ten days: when their character is still milder or more subacute, or when they have been mitigated by appropriate remedies, it may be protracted fifteen days.
About this period a remarkable change takes place; an entirely new train of symptoms supervenes, which is different, and which, indeed, presents a striking contrast, according as the patient is destined for life or death.
If it be for life, that sleep, of the long absence of which we have already spoken, returns; and nothing can more truly express its character than its familiar name, “balmy;” and healing is its influence. From two or three hours of such slumber, the patient awakens a new being. Not that the change is at first striking to an inexperienced eye; but there is no fever nurse who does not recognize it in a moment, and it is not long before the patient tells you that he feels it. The febrile uneasiness is now much diminished: the headache is greatly relieved; and the skin is cooler and softer. The pulse may not yet be altered, or it may be a few beats slower than before, but there is almost always already an improved appearance in the tongue, which shews a beginning disposition to clean. These favourable changes gradually increase. If the sleep the next night be longer and more refreshing, which it generally is, on the following morning a decided improvement is visible in the countenance. The eye is clearer and more lively, and the expression of the countenance is more natural. The skin continues cooler and softer; the tongue is still cleaner, and the pulse, perhaps, slower by a beat or two; and from this period, if no untoward event happen, the convalescence proceeds just as has been described in the return of health in the milder form of fever.
If, on the contrary, the case proceed unfavourably, a totally new train of symptoms at this period sets in.
1. In the first place, the pain of the head obviously, and sometimes strikingly, diminishes. Often it disappears altogether, or, if any uneasiness remain, it is rather a sense of dullness and heaviness than pain. In like manner the giddiness, if that were urgent, is no longer perceptible: but it is remarkable that the pain in the back and loins not unfrequently continues for some time after the headache has disappeared: but, ultimately, that also ceases. The period at which this important change takes place depends upon the severity of the attack, and is materially influenced by the activity or inertness of the treatment. In the subacute form, it usually takes place about the tenth day from the commencement of the disease.
2. Simultaneously with the disappearance of the head-ache, there is a remarkable diminution of the sensibility. The mind is duller and more heavy. The patient may still be roused to answer with tolerable coherence if spoken to; but when left to himself he is confused and stupid. The eyes now become injected: often suffused; and the heaviness and dullness of their expression is increased.
3. It is at this time that delirium, if it appear at all, most commonly comes on. The increasing insensibility, if not attended with decided delirium, is almost always accompanied with moaning or incoherent muttering, especially during the short and interrupted slumbers which form the substitute for sleep.
4. Striking as these changes are in the functions of the spinal cord and brain, those which take place in the number and character of the pulse are no less important. Even in cases the most decidedly subacute, it is seldom that it does not rise ten beats, so that if before it were 90, it will now be 100, and it is always weaker.
5. Now, too, signs of disease in the chest and abdomen are almost always to be distinguished. A case purely cerebral, from the commencement to the termination of the disease, is rarely to be met with. If there be not cough, there is almost always a short and hurried respiration, and more or fewer of the indications of abdominal affection hereafter to be stated. Even in cases the most purely cerebral the tongue always becomes more loaded and often dry; and it is strikingly characteristic of the state of the nervous system, that while the tongue becomes dry, the thirst diminishes.
Thus far it is possible that the disease may proceed towards a fatal termination without proving mortal. It is not often that its course is turned back or stayed after it has made this progress; but still such an event is sometimes witnessed. When it does occur, the amendment, both in its origin and progress, is very similar to that of the favourable change which has already been described. More tranquil and longer-continued sleep is almost always the earliest sign that, in this severe struggle, life has obtained the victory. If, on awaking from such sleep, there be less delirium, were delirium present, or greater tranquillity, were the restlessness urgent; and if there be any increase, although slight, in the sensibility, or any improvement in the expression of the countenance, hope may be entertained that that victory will be won; and hope may become assurance, if the tongue which had been loaded become clean at the edges, or the dry tongue become moist. Even under apparently the most desperate circumstances, if these three symptoms concur, a favourable prognosis may be pronounced with tolerable certainty. Two or three days may elapse after their occurrence, before any remarkable change is observable in the pulse; but it is seldom that they continue twenty-four hours before the pulse falls at least ten beats. Now and then, on leaving a patient in the evening with a pulse at 120, we are surprised and delighted to find it in the morning as low as 100. When the pulse has thus fallen towards the natural standard, when the tongue has begun to clean, and when the skin has become cool and soft, however desperate his condition but a few days before, the patient may be said to be convalescent.
But though this favourable change is sometimes witnessed, yet, from the point at which we left off the description of the progress to a fatal termination, the too common history is, increasing restlessness and sleeplessness; insensibility lapsing into coma; further acceleration of the pulse; greater dryness of the tongue and decreasing strength, until, at length, the powers of life receiving less and less supply from the great systems in which they have their seat, become completely exhausted.
Those who have been placed in situations which have afforded them opportunities of witnessing much of the disease will, I trust, acknowledge that the account now given is an accurate narrative of the symptoms that occur, and of the order in which they succeed, in the great majority of cases. Upon what conditions of what organs they depend will be illustrated in the pathology.
Sometimes to these, other trains of symptoms are added—namely, muscular tremor, frequent and sudden screaming; rolling of the head upon the pillow; constant tossing of the hands about; picking at the bed-clothes or other surrounding objects; partial paralysis of the upper eyelid, so that one or both of the eyes remain half or almost wholly closed; the ball of the eye unsteady or constantly rolling; the expression of the eye and countenance at one time wild and anxious, at another fatuous; squinting; the respiration now slow and laborious, now exceedingly rapid; the pulse either slow, full and regular, or slow and intermittent, or so quick that it cannot be counted, or these states succeeding each other or alternating with each other at short intervals; convulsions; involuntary and unconscious stools—all these symptoms are never found combined in any one case; but certain assemblages of them occur with some degree of constancy, and depend upon certain conditions of the brain and spinal cord. Since, however, the description of these conditions cannot be given here, the further account of the signs which denote them must be postponed until we treat of the pathology of the disease.
2. Synochus Gravior with Acute Cerebral Affection.—Such is the history of the synochus gravior with cerebral affection in its subacute form. When its attack is the most acute, the history is precisely the same, excepting that the symptoms are more severe, and their progress quicker. The head-ache is much more intense; the giddiness is more violent; the sensibility is excessive; the least noise is intolerable; the slightest motion either of the head or of the body aggravates all the symptoms; the eye is muddy, and very soon becomes injected, and is perfectly intolerant of light; the pain in the back, loins, and limbs, is nearly as great as it is in the head. The skin is intensely hot, and sometimes impresses the hand with the sense of pungency; but though every where thus hot and dry, its temperature is peculiarly great over the scalp, so that if the head be shaved, and wet clothes applied, they are quite dry in a minute or two. The febrile uneasiness is excessive; the patient can scarcely remain a moment in the same posture, and he is wholly without sleep. The pulse at one time is strong, full, bounding, and not easily compressed, but even in this acute form it is almost always soft; at least it is very different from the hardness characteristic of an acute attack of pure phrenitis; at another time it is oppressed, the stroke giving an impression directly opposite to that produced by the free and bounding pulse.
But one of the most remarkable modifications of the pulse, one that is characteristic of an exceedingly acute attack of cerebral disease, and one with the import of which it is of the highest consequence to the life of the patient that the practitioner should be perfectly acquainted the moment he meets with it, is the slow and intermitting pulse. Whenever, in the onset of fever, a patient is found with intense head-ache or intense pain in the back and loins, and a slow pulse, the physician ought to be greatly alarmed at the severity of the symptoms that are to follow, and if he do not take the most active measures to break the violence of the disease at this early period, it will be beyond all control in a day or two, and the patient will be dead before the fever is well formed in milder cases. The affection of the brain is sometimes so violent and sudden that the pulse is not only slow, but intermitting, and the respiration is suspirious. Frequent and deep sighing is not uncommon in severe cerebral cases, and it is highly characteristic of intense cerebral affection; but in such a violent attack as that of which we are now speaking, the suspirious breathing, even in the very commencement of the disease, is so great that it cannot be overlooked. This happened in the case of my friend Dr. Dill, whom I saw a few hours after the commencement of an attack of one of these intense forms of fever. I saw him in the afternoon at a public meeting. I met him an hour afterwards at his own apartment. He was still going about engaged in his ordinary occupations; but his countenance was pale as death; his eye was dull and heavy; his mind was confused, and as it seemed to him paralysed; he had other sensations, which were new to him, and which were most distressing; but he had no pain: at that time there was not the slightest pain either in his head or his back or loins: there was only that general and undefined uneasiness which gave to him sufficient warning of what was coming, as the slow and labouring pulse, coupled with the uneasy sensations of which he complained, and the peculiar aspect of his countenance, afforded to me an abundant confirmation that his apprehensions were just. He was bled immediately to the extent of twenty ounces: the blood then drawn was not sizy: he passed a wretched night. I saw him early the following morning: he had now intense headache; his eye was already injected; his skin was not hot but burning; his respiration was suspirious; almost every breath was a sigh, and his pulse was still slower than on the preceding evening, and was now intermittent: blood being drawn to a large extent, the crassamentum was now buffed and cupped; but the detail of the progress of this instructive case must be postponed until we speak of the treatment of fever, because it is still more illustrative of the effects produced by the vigorous application of the appropriate remedies than of the peculiarity of the symptoms which usher in the attack. It may suffice for the present to observe that this case affords not only a striking example of the concurrence of these peculiar symptoms, but also a decisive proof that pain of the head is far from being the first symptom that occurs even in the most intense cerebral attack.
In these acute forms of the disease, if the proper remedies be not vigorously employed, the pain ceases within the fourth day; it rarely extends beyond the fifth; the pain passes into insensibility; delirium comes on, sometimes so violent as to require restraint, but delirium is by no means an invariable concomitant of the other symptoms, even when these are the most violent: when it is present it is almost always rapidly followed by muscular tremors, and these by subsultus tendinum, which now and then usher in general convulsions; but this last event is rare, and I have never yet seen convulsions unaccompanied with a particular condition of the brain hereafter to be described. Sometimes the muscular tremors succeed immediately to the transition of the pain into insensibility, while the insensibility rapidly increases to stupor, and that to profound coma. The breathing is occasionally as stertorous as it is in apoplexy, but this is also rare, and when it does occur, is probably dependent on a peculiar condition of the brain hereafter to be pointed out. Together with these there is a concurrence of a greater or a lesser number of the symptoms enumerated at page 107, but the particular combinations that are found most usually to accompany particular conditions of the brain, it will be most instructive to state in connexion with the pathology.
In synochus with acute cerebral disease there is less indication of thoracic and abdominal affection than in the subacute form, because the intensity of the cerebral disease obscures the signs of derangement in the other organs; but the signs of their derangement are never absent, although they are less obtrusive, and they trace in indelible characters proofs of their activity in the ravages they commit upon their structures in which they have their seat.
Such is the course of synochus under different degrees of violence. When it is combined with subacute cerebral affection, that course is usually terminated in from three to six weeks; when with acute cerebral affection, in from seven to ten days.
As an illustration of each form of the disease, as it is commonly met with in practice, I subjoin the following cases.
Case I.
John Colebert, æt. 28, admitted into the Fever Hospital August 1, 1828.
Attacked five days ago with chilliness, alternating with heat, pains of limbs, head-ache, and sense of weakness. At present complains of pain of head, with slight giddiness; pains of limbs, especially of back and lower extremities; skin moderately warm; tongue loaded with white fur; much thirst; three stools; respiration natural; no cough, no uneasiness in chest; no epigastric or abdominal tenderness on full pressure; pulse 96, soft.
6th. Skin natural; pain of head gone; pain of back and limbs continues; slept better; tongue more clean; three stools; pulse 102.
7th. Pain of head not returned; pain of limbs better; tongue still cleaning; three stools; pulse 96.
9th. Pain of limbs gone; tongue nearly clean; two stools; pulse 84.
10th. Convalescent.
13th. Dismissed cured.
Case II.
George Walker, aged 17. Admitted May 5th, 1828.
Six days ago seized with shivering, succeeded by heat, loss of strength, and pain of head. At present complains especially of head-ache; ardent thirst; no pain of chest; no cough; no pain of abdomen, back, or extremities; skin cool; face natural; tongue, except at the point, covered with a thick dirty fur; much thirst; no appetite; sleeps badly; bowels costive, having had no stool for the last three days; pulse 98, of good strength.
7th. Heat of skin nearly natural; pain of head almost gone; no pain of limbs; tongue still much loaded; some thirst; three stools; pulse 72; slept much better.
8th. Tongue much less loaded; less thirst; five stools; pulse 60.
11th. Convalescent.
14th. Return of head-ache, and, on the day following, the tongue again became white; but these symptoms disappeared the succeeding day, and, on the 27th, he was dismissed cured.
These two cases afford fair specimens of the combination of symptoms, and of the degree of their severity, in the synochus of London, as it occurs in its mildest form.
Case III.
Emma Gladish. Admitted into the hospital on the 12th day of fever. Attack commenced with usual symptoms. The pain in the head, which had been severe for some time, had entirely subsided on the day of her admission. The mind was now quite indistinct; she could scarcely answer any question that was put to her; the eyes were dull and heavy; she had no sleep; there was great restlessness, and occasionally wandering delirium; there was no tenderness of abdomen; the tongue was red, furred and dry; the stools were passed in bed; the pulse 105, of good power.
13th. Sleep rather more tranquil; less wandering; mind a little more distinct; stools still passed in bed; pulse 100.
14th. Much noise through the night; occasionally started out of disturbed sleep with screaming; tongue red, glazed and dry; stools passed in bed; pulse 96.
15th. Rather more sleep; talkative delirium; tongue somewhat cleaner; pulse 100.
16th. Longer and more tranquil sleep; mind more distinct; expression of eyes still dull and heavy; tongue more clean, more moist; stools only partly passed in bed.
17th. More sleep than on the preceding night; mind still more distinct; complains to-day of some tenderness of abdomen on pressure; tongue nearly clean; two stools no longer passed in bed; pulse fallen to 72.
19th. Slept well; mind clearer; eyes more animated; expression of countenance brighter; other symptoms the same.
26th. Continues to improve; skin cool, soft, and moist; pulse 78.
27th. Convalescent; but the convalescence was slow and tedious, as it almost always is after so severe an attack of cerebral disease; she was dismissed cured on the 40th day from the commencement of the attack. The reports of the 15th, 16th, and 17th days illustrate very clearly and strikingly the changes which have already been stated to indicate recovery.
Case IV.
Elizabeth Price, æt. 26, servant; admitted on 11th day of disease. Attacked with ordinary symptoms of fever: at present complains of very severe head-ache; face flushed; intolerance of light; some deafness; mind confused during night; visions of various kinds, such as “waves of the sea rolling,” appear occasionally before her with great vividness; had been on sea four days before she became ill; skin warm; sense of general soreness; abdomen rather hard, but not tender; tongue furred, rather red; much thirst; no appetite; scarcely any sleep, and, when she does, dreams of a frightful nature interrupt her rest; pulse 114, intermittent, of good power, but easily compressed; bowels constipated. C. C. ad ℥xviij. nuchæ. Abradat. Capillitium. Lot. Gelid. cap. Haust. Sennæ Sal. c. m.
12th. More sensible since cupping; mind still confused; occasional wandering; scarcely any sleep; pulse 124, sharp, yet easily compressed.
14th. Quiet night, with considerable sleep; head giddy and slightly painful; respiration hurried, apparently cerebral; pupils active; tongue dry; much thirst; pulse 123. Empl. Lyttæ cap.
15th. Much screaming; great restlessness during night; complains much of head-ache; pupils active; urine copious, but passed in bed; all the stools passed in bed; pulse 108, easily compressed; has visions before her almost constantly; head very hot. Four leeches have been applied to the temples this morning without relief. Affus. Frigid. cap. ℞. Hydrar. Submuriat. gr. ij. Pulv. Scillæ, gr. j. Pulv. Antimon. gr. iij. M. sumat 4tâ q. h.
16th. No screaming; head less painful, especially when in half-erect posture; mind quite sensible now, but much wandering occasionally; pulse 120, feeble; five stools passed in bed.
24th. No material change until this day; sleep now greatly improved; mind much more itself; tongue beginning to clean; pulse 93; ptyalism.
28th. Ptyalism continues; feels greatly better; appetite returning.
From this period she continued to improve, although with several threatenings of relapse; the convalescence was slow and precarious, but she ultimately left the hospital quite well, though not until the 60th day from the commencement of the fever.
Case V.
Mary Sullivan, æt. 36. Admitted on 14th day of disease; complaint commenced with shivering; pains in the limbs; severe head-ache. Complains now of violent pain of the head; face pallid; expression depressed; scarcely any sleep; abdomen tender on pressure; only one stool for eleven days; tongue foul and dry; pulse 81, not strong; complains, also, of pain under right mamma, preventing inspiration and decubitus. V.S. ad ℥xij. Lotio Gelida cap. Abrad. Capillitium.
15th. Blood with firm buff; pain of head not at all relieved; pain of back, sides, and abdomen severe; no delirium; no sleep; pulse 78, pretty strong. Hirudines viij. temporibus. Pt. Med.
16th. Pain of head much relieved; slept very much better; pulse 66, full and strong.
17th. Pain of head returned, exceedingly severe over the fore-part; pulse 66, full and strong. C.C. ad ℥xij. nuchæ. Pulv. Aper. Mit. h. s. Ol. Ricini c. m.
18th. Pain of head gone; countenance more natural; tongue more clean and moist; pulse 76, more soft. Pt. Med.
20th. Pain of head returned; mind confused; pulse 60, strong and full. C.C. ad ℥viij. nuchæ. Pt. Med.
21st. Pain of head gone; mind confused; pulse 66, pretty strong.
22d. Pain of head returned, but in a slighter degree; mind more confused and dull; scarcely any sleep; tongue more foul; pulse 72, soft. Pt.
24th. No longer conscious of pain; mind quite indistinct; lies prostrate on the back perfectly helpless; incapable of turning on the side; occasional retching; some tenderness of abdomen on pressure; pulse 72, strong and full.
25th. Much restlessness; aspect of countenance greatly depressed; stools passed in bed; pulse 75.
26th. Perfectly senseless; almost constant moaning; extreme restlessness; difficult deglutition; pulse 120.
27th. Not spoken since last report; lies prostrate on back; eyes half open and injected; pulse 102, feeble.
29th. Died.
If the reader can doubt of the condition of the brain in this case, he is requested to turn to the pathology, where the morbid appearances on dissection are detailed. Slowness of the pulse, with severe and obstinate pain in the head, attended with confusion of mind, is always a highly dangerous-symptom: it invariably denotes intense cerebral disease. Whenever there is such a struggle, as this case exhibits, between the physician and the disease, the disease is sure to conquer. For if the physician, terrified at the name or the duration of the malady, while he resolve to use the lancet, hesitate to employ it to the extent of subduing the disease by the first bleedings, the patient is lost. The partial relief afforded by partial measures is most delusive. The malady speedily recovers its lost strength: the patient never does. There is no practitioner who is capable of being taught by experience that can reflect on the history and progress of such a case as this, on the temporary relief afforded by such treatment, on its ultimate failure, and on the appearances presented on dissection, without regretting that more blood was not taken on the 15th and 16th days, and without at the same time resolving, that the aid he offers in future, under similar circumstances, shall be more decisive. The diminution of the pain of the head on the 22d, accompanied with increasing confusion and dullness, with a tongue growing more and more foul, and with a pulse only at 72, might well excite alarm; and accordingly, on the following day, the case was utterly without hope.