A Treatise on Fever

by Southwood Smith

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.

Case VII.

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.

Case VIII.