On” the Pathology and Treatment of Cerebral Disease
247 ^RT yi.? No. IV. ( / :Author: Robert Hunter UNTER SEHPLE, II.D. Fellow of the Royal College of Physicians of London.
In former papers I have directed attention chiefly to those diseases of the brain which are usually classed as apoplectic, or in which there is more or less of insensibility or convulsions, the results being due, as proved by post-mortem investigation, to tumours, congestion or extravasation of blood, bony growths j or to softening or breaking down of the brain-substance. In some of the cases I recorded and which terminated favourably, it is, of course, to be assumed that the congestions or other changes were of a transient and curable character.
In the present paper I propose to consider the cases which may be regarded as inflammatory in their nature, but which, though exceedingly dangerous, are amenable to treatment. In elucidating this part of the subject, the question of diagnosis becomes a^very important one, both in determining whether a given case is inflammatory at all, and in deciding the category of inflammations to which it may belong. Here, in limine, however, lam met by the question, What is inflammation? and it must be confessed that at the present day we are less able to give a distinct answer than we might have given in years gone by. The old definition of inflammation, calor et tumor, rubor cum dolore, may still be held to be a good one when external textures are concerned ; and in a rough way, the existence of what is called inflammatory fever, in addition to local symptoms, points pretty clearly to the existence of many internal inflammations. But the word “inflammation” has lately been applied in so much more extended a sense that it includes many structural changes with which it was once supposed to have no relation ; and anything like a brief and comprehensive definition is almost out of the question. Many of the chronic enlargements and wastings of important organs, and a variety of structural changes and degenerations, are now supposed to be due to inflammatory action, although the old and familiar symptoms of inflammation are entirely absent, and the only evidence of the process having ever been set up is derived from the resulting lesions as revealed by the scalpel and the microscope.
I should state, then, that in using the words ” inflammation ” or ” inflammatory ” in the present paper I employ them in the old and familiar sense, as implying an acute process involving the capillary system, attended by turgescence of that system, and followed by the exudation of semen, lymph, or pus; and indicated during life to the medical observer by symptoms known as objective, and in which one of the principal features is abnormal heat. It is obvious that in all internal inflammations the objective signs must in many respects be deficient; redness cannot be seen, and swelling cannot always be detected, and even heat can only be estimated by the condition of the surface, or of parts near the surface. The subjective signs, again, and especially pain, are often exceedingly fallacious, this sign being very often present when no inflammation whatever exists, and being very often absent, even when important organs are the seats of the inflammatory process. This last remark is of very general application in the diagnosis of cerebral disease, in which pain is very often absent even in the acute inflammation; but it should not be forgotten that even if pain exists, the delirium which so generally accompanies the other symptoms in such cases, either masks the pain altogether or forbids its manifestation by language on the part of the patient. The foregoing remarks, although necessarily of a rather general character, will, I think, sufficiently denote what I mean by the words ” inflammation ” and ” inflammatory ” when treat- ing of cerebral disease. Inflammation of the brain is of two kinds, and the distinc- tion between these, although determined with difficulty, is of considerable pathological and practical importance. In the first, the substance of the brain only is involved, constituting the jphrenitis, cerebretis, or encephalitis of systematic writers; in the second, the membranes are concerned, and the disease is called by the general name of meningitis (from firjvLfy^, a membrane), and sometimes arachnitis, when the arachnoid membrane is supposed to be specially involved. But in fact it is impossible to distinguish practically the inflammation of the arachnoid membrane from that of the pia mater, and in very many cases the dura mater is also involved in the inflammatory process, as is shown by the adhesions so often found between this membrane and the inner table of the skull.
It is also to be observed that in opposition to the distinc- tion drawn by nosologists, contiguous structures, although differing in their anatomical peculiarities, are apt to suffer from the extension of the inflammatory process ; and just as we find that most cases of pneumonia are attended with more or less pleurisy, and most cases of pleurisy with more or less pneumonia, so the inflammations of the substance of the brain are usually associated with those of the membranes and vice, versa. This remark is not made to disparage or undervalue in any degree the distinctions drawn by systematic writers who justly seize upon anatomical structure as the basis of classifi- cation ; I intend only to point out, that in practice, artificial distinctions must often be forgotten or disregarded. Ho”w laboriously have we all learned from lectures and from anato- mical books the different layers constituting the coverings of an inguinal or femoral hernia ; and yet in practice the surgeon cuts through them all, cautiously it is true, but regardless of the numerous fascia he is dividing, and attentive only to catch the first glance of the glistening surface of the peritoneum which indicates the opening of the sac. Knowledge of all kinds, like chemical action, is made up of analysis and synthesis; the’first resolves all phenomena or conditions into their primitive elements ; the second unites them into new combinations for the purpose of practical application.
As it is necessary, then, to study disease as far as possible in a systematic manner, a distinction must be drawn between inflam- mation of the brain itself and that of its membranes; and what- ever may be the frequency with which these conditions are often associated together, their pathological phenomena are different and their consequences are often distinct. The first if not terminating in perfect restoration to health, is followed bv abscess or softening of the brain-substance ; the second is neces- sarily accompanied by effusion of serum or lymph either on the surface or into the cavities of the brain.
Inflammation of the brain-substance, phrenitis, was distinctly described by some of the former generations of medical writers as a recognised form of disease, denoted by well-marked symptoms and traceable, after death, by certain definite pathological ap- pearances. It was stated that phrenitis was characterised by the existence of inflammatory fever, great heat of the head full strong and hard pulse, violent delirium, blood-shot eyes,’con- tracted pupils, great thirst, white and furred tongue ; that the post-mortem appearances (excluding, of course, the’ cases of meningitis) consisted only or chiefly of a pink appearance of the white matter of the brain, and the existence with some matter of a number of bloody points, and these appearances were depicted in Sir Robert Carswell’s well-known series of beautiful paintings The treatment recommended was prompt, energetic, and decisive’ and it consisted in the immediate and copious abstraction of blood, either from a large orifice in a vein of the arm, or from the jugular vein, or even from the temporal artery; in’ shaving the head, and in applications of ice to the shaven scalp ; and in the copious administration of calomel and saline purgatives I am not prepared to maintain that this treatment was in all instances either unsuccessful or inappropriate, but experience has led me to doubt very much whether the cases described as pure and uncomplicated phrenitis were really of that nature, and whether indeed such a disease is not very rare. In order to make my meaning more clear, I would point to the advanced position of pathology and to the improved methods of diagnosis adopted in the present day, whereby we are able to distinguish more clearly than we formerly did the affections due to blood- poisoning and those which are of a so-called idiopathic character, and I call attention to the following points of diagnosis in reference to the affection now under consideration. Brain fever, as it is popularly called, was considered as synonymous with phrenitis, but although the so-called brain fever is perhaps quite as common as it ever was, there are but few cases which can justly be regarded as due to idiopathic in- flammation of the brain. I suspect that a great number of cases formerly described as phrenitis were really instances of typhoid or enteric fever, a disease which, as is well known, often presents, at its onset, the most marked cerebral symptoms. Typhus fever, although characteristically distinguished by delirium, was not likely to be mistaken for phrenitis, because the depression in this fever is so well marked almost from the very commencement as to obviate such an error. But enteric fever does really very often present the phenomena once de- scribed as belonging to phrenitis. I say, very often, because, as is well known by those who have seen much of this fever, the preliminary symptoms are very different in different cases. The disease usually commences as a feverish cold, followed after a certain interval by diarrhoea, and the fatal character of the malady is sometimes only detected a day or two before death, or perhaps not even then, and the result is registered as ” diarrhoea ” or ” exhaustion ” in the death registers. It has repeatedly fallen to my lot to detect this insidious malady while it was being treated as mere weakness or chronic purging, but, in reference to the diagnostic point now immediately under con- sideration, I have also seen it to commence with the most vio- lent maniacal symptoms, and thus to lead to serious errors in treatment. Instead of quoting instances from books, I refer to two cases occurring in my own practice which are very in- structive. I was once asked to see a gentlemen in consultation, who, I was informed, was suffering from ” brain fever,” and who was so violent that he had threatened to murder his wife, and who, in fact, presented most of the symptoms to which I have lately referred as those described to belong to phrenitis, namely, hot head, violent delirium, hot skin, full and rapid pulse, great thirst, furred tongue. But on very careful exami- nation of the surface of the body I detected one or two rose- coloured spots on the chest, which were so characteristic that I had no difficulty in pronouncing the case to be one of typhoid fever, and so indeed it turned out, and after a few weeks the patient completely recovered. I should here remark that it is by no means easy in many cases to distinguish the presence of typhoid fever, for the ” rose rash ” so fully described and so generally pointed out to students in the present day is sometimes, and indeed often, very scanty, being perhaps limited to one or two spots, and situated at uncertain localities on the trunk, so that it is necessary to expose the whole body before the rash can be detected. I may also observe, the number of the spots is by no means proportionate to the severity of the attack, but rather vice versa, and that in the most severe and fatal seizures the spots have often been very few, while, on the other hand, an abundant crop of them is perhaps rather a favourable indica- tion. It must not be forgotten, also, that in some cases, and especially in children, the spots may not be developed at all, and nevertheless the disease runs its course.
In another case, falling under my own observation in practice, I was requested to see in consultation a gentleman, a schoolmaster, of the most respectable character and habits, who was said to be suffering from ” brain fever,” and who was so furiously maniacal that his family were in terror from his violence. I saw him about midnight, and found the general symptoms the same as in the case last recorded ; but on careful examination, I discovered one or two small rose-coloured spots on the upper part of the trunk, and I immediately declared the nature of the disease. The case passed out of my hands, but I was subsequently informed that it went through the usual course of typhoid fever, and that the patient eventually quite recovered.
Although cases such as those now alluded to belong to the category of typhoid fever and not of the so-called phrenitis, it must not be supposed that they are devoid of danger. On the contrary, they are extremely dangerous, and the presence of only a few spots, as I have just remarked, rather indicates a more severe form of disease than when the spots are abundant. Although both the cases I have related completely recovered, it often happens that death very rapidly ensues, and this result is not due to exhaustion, or to protracted diarrhoea, or to hemorrhage, or to perforation of the intestine, but to the direct action of the poison, whatever that may be, upon the whole system, which is overpowered, as it were, before it is able to throw out upon the skin the characteristic eruptions, or from the intestines, tlie peculiar excretions of the malady. Such is also the case with many other serious diseases, as cholera, small- pox, scarlatina, and even measles, in which it often happens that the patient dies before the features of the disease are fully developed, the morbific poison appearing to overwhelm the organism at once, just as might happen from a large dose of ‘arsenic or prussic acid.
I have entered rather largely upon the question of the diagnosis between typhoid fever in its early stage, and phrenitis, because I am sure that the mistake has very often been made in former times and is perhaps sometimes made still in the present day. The characteristic ” rose rash ” of typhoid fever has been described only in comparatively recent years, and its existence was certainly overlooked by our ancestors, who also overlooked, or at all events failed to attach much importance to, the intestinal lesions now known to distinguish this form of fever. It is therefore beyond a question that many of the cases once described as ” phrenitis ” were really cases of typhoid fever; and the mistake was no doubt often attended with serious con- sequences, for the copious bleedings which might have been, and probably were useful in inflammation of the brain, are, ac- cording to our present experience, quite useless or very injurious in typhoid fever.
Again, although the etiology and the pathology of delirium tremens are well known to the medical profession, it is beyond a doubt that the popular term of “brain fever” is often applied to this malady. It cannot, therefore, be unnecessary to guard most carefully against any mistake in this particular, for delirium tremens and phrenitis are totally different diseases, agreeing only in the fact that there is in both delirium. I am anxious to insist the more strongly on the distinction, because I have seen even in some medical works a certain amount of confusion exhibited in treating of the subject of delirium tremens, which is occasionally divided into an inflammatory and a non-inflammatory variety. It should therefore be well understood that delirium tremens is not an inflammatory disease at all (that is to say, accepting the word inflammatory in its ordinary sense), and that it is characterised essentially by debility. The head, instead of being hot and dry, is cool and moist, and the skin is bathed in perspiration; the delirium, instead of being furious, is busy, and suspicious; the tongue, instead of being dry, is coated with a moist, creamy fur. When death ensues, as it often does, the result is due to exhaustion, and on post-mortem examination there may be nothing visible to the naked eye in the inter-cranial structures. The treatment will of course be guided by the accuracy of the diagnosis, and while phrenitis (if it really exist) may correctly be treated by ice to the head, by leeches, by starving, by calomel, and drastic purgatives, and even bleeding, delirium tremens, on the other hand, should be met by a totally different plan, and the supply of nourishment, and even stimulants, together with sedatives and careful watching, will form the most reasonable and successful therapeutical plan of manage- ment.
A paroxysm of acute mania may also simulate in some respects an attack of phrenitis, but the inflammatory symptoms are wanting, the pulse is not full or strong, the skin is not hot; and, indeed, the existence of furious delirium is the only symptom in common in the two diseases.
After fully considering these points of diagnosis between phrenitis or cerebritis, and other diseases which may resemble it, the question may fairly be asked whether such a disease as idiopathic phrenitis exists at all; and without exactly answering the question in the negative, I am inclined to think that such cases are very few, and that those which have been so described have been entered under the wrong category from mistakes in diagnosis. It is certain, however, that phrenitis does occur, and that not unfrequently, but I doubt whether it is ever idiopathic. It may arise from exposure to the sun, especially in hot climates; it may be caused by severe injuries to the head; it may be due to disease of the cranial bones; it may sometimes ensue from a large quantity of alcoholic drink taken at once; it may be the result of certain kinds of poisoning, such as that by belladonna. In all these cases (except when the disease is due to disease of the cranial bones) a perfect cure may result, and if, at any subsequent period, the brain should be examined after death, no trace of disease would be manifest. The structures, although inflamed during the course of the attack, would return to their original healthy condition, the capillaries would be unloaded, and the reasoning and other mental faculties, for a time disturbed, would return to their normal state. But it must be remembered that in all such cases there is great danger of a relapse, and that even after apparent recovery death may unexpectedly ensue from abscess. Inflammation of the brain, or phrenitis, may arise from exposure to the sun, and it might be expected that it would be a very common disease in hot climates. But the best writers on the diseases of tropical countries, while admitting its existence, by no means regard it as a very common occurrence. Dr Morehead, in his excellent and well-known Clinical Researches on Disease in India, agrees with most other writers in stating that elevation of temperature is not unfrequently the exciting cause of serious cerebral disease in tlie warmer climates of the globe, and in India these effects in their most aggravated forms are chiefly observed in the hot months of the year, and in those districts in which the thermometric range is the highest. But when continued fever and apoplexy are excluded from consideration, and when sudden deaths from coup de soleil are also omitted, it does not appear that phrenitis is by any means a very common disease in India. Phrenitis, or phrensy, is essentially characterised by active delirium, while the symptoms depending on the influence of elevated tempe- rature, as in India, usually consist of quiet delirium, or convul- sions, and, ” in a word,” as Dr Morehead remarks, ” the phrenitis of Cullen is, according to my experience and belief, as rare in tropical as in temperate countries.”
2. Phrenitis may be caused by severe injuries to the head, and this kind of inflammation offers, perhaps, the most typical form of the uncomplicated, but not idiopathic disease. In this affection there is not necessarily any disease of the membranes, but there is undoubtedly inflammation of the substance of the brain, which is attended by the ordinary phenomena of inflam- mation in other organs, and which may terminate in resolution, or, in other words, in a complete cure, but which may also, as in other organs, result in the formation of abscess of a fatal character. It must also be admitted that the membranes are often implicated in such cases, and I merely maintain that they are not necessarily involved, a conclusion which I draw from the undoubted fact that perfect recoveries do take place in many instances. The inflammation now referred to is that which attends what is called “concussion of the brain,” in which the brain is literally shaken, and by which in all pro- bability the molecular arrangement of its fibres and cells is so disturbed, that capillary congestion and its consequences ensue. As happens in other inflammations, this capillary congestion, which is undoubtedly the commencement of the pathological condition called inflammation, may proceed no further, and the congested vessels may become unloaded and restored to their normal calibre. But in other cases the inflammatory process may pass on to its destructive stages; pus-cells may escape from the overloaded vessels, and, in a word, abscess of the brain may result. In this form of disease the charac- teristic features of phrenitis present themselves usually about eight-and-forty hours after the receipt of the injury ; vomiting is a constant occurrence among the earliest symptoms; there is severe pain in the head ; the pupils are contracted ; the scalp is hot; there is intolerance of light and noise; the pulse is full, hard, and strong, and there is violent delirium.
3. A common cause of plirenitis is disease of the cranial bones, and this is one of the most fatal forms of the disease, although its approach is often very insidious, and its diagnosis, in the early stages, is sometimes impossible. It is often met with in young persons, especially those of a strumous diathesis, and when a patient of this class has had for some time a dis- charge from the ear, and is suddenly seized with pain in the head, vomiting, delirium, contracted pupils, hot skin, loaded tongue, and the other symptoms of inflammation within the cranium, there can be little doubt as to the true nature of the case. But the discharge from the ear is sometimes wanting, as in several cases under my own observation, and the true nature of the disease has been revealed only by post-mortem examina- tion. The caries of the bone, which is the exciting cause of the mischief, may, in fact, have its seat within the cranium, and may have no connection with the external meatus of the ear, or with any other outlet, and then the true nature of the case must be mere matter of conjecture. Sometimes, also, it happens, as I have previously remarked in another paper, that inflammation and fatal abscess of the brain have gone through their stages without giving rise to any of the usual symptoms of inflammation. When the symptoms are well marked, they follow upon the suppression of the discharge from the ear, and are probably due to the extension of the disease from the bony structures to the cerebral mass ; but sometimes it would appear that the phenomena are reversed, and symptoms of inflammation of the brain are present before the discharge takes place, in which case the patient may recover on the appearance of the discharge, or when this disappears or is suppressed, the symptoms suddenly return, and death may follow.
4. Phrenitis may arise from a large quantity of drink taken at once. This form of the disease is by no means uncommon, as it is unhappily met with in all classes of society, and in all climates. It is sometimes, as I have remarked in a previous page, confounded, even by some of the best medical writers, with delirium tremens, but, in my opinion, it is entirely a different affection, its pathology is altogether unlike, and its treatment must also be dissimilar. It immediately succeeds some debauch in drink, and is characterised by flushed countenance, full pulse, loaded tongue, furious delirium, hot skin, and indeed by all the symptoms usually indicative of phrenitis. It is not the disease of habitual drunkards, but rather of those who, being previously unaccustomed to drink, yield to some sudden tempta- tion and imbibe an excessive quantity of ardent spirits. It is therefore very common among the troops in India, occurring in persons not long resident there, and whose ages vary from twenty to thirty-five; and also in sailors, who are released from the discipline of the ship in which they are serving, and are allowed to go ashore on liberty. But this form of phrenitis is by no means confined to India or to other hot countries, and is common enough at any of our own seaports, and indeed in the ordinary practice of medical men. But delirium tremens is the disease of habitual drunkards, whose tissues are poisoned by the long continued use of alcoholic stimulants, and whose symptoms are those of exhaustion and debility, combined with excitement. The delirium is not furious, and the fact of the body being bathed in perspiration negatives the idea of acute inflammation. In fatal cases there is no peculiar morbid appearance observable in the brain, and none is to be expected, for the disease essentially consists in a chronic poisoning of the blood (a true intoxication, in the etymological sense of the word), and no structural lesions are likely to occur. In phrenitis from acute alcoholic poisoning the brain will be found turgid with blood.
5. The effect of certain poisons, such as belladonna, in causing phrenitis, is perhaps rather doubtful, although the symptoms certainly resemble that disease in some respects, and the brain, in the fatal cases, has been found gorged with blood. There is, especially in belladonna poisoning, great delirium, and vomiting, and there can be no doubt that the brain is inflamed; but the whole of the phenomena in this kind of poisoning are of a complex character, and the stomach is affected as well as the brain. One great feature in belladonna poisoning, as also in poisoning by other plants of the order of solanacese, as hyoscyamus, datura, and the like, is the dilatation of the pupil, whereas in ordinary phrenitis the pupil is con- tracted ; and this circumstance is of great diagnostic importance in every case where poisoning of this kind may be suspected. The Treatment of the above forms of inflammation of the brain, although similar in its main features, must be modified according to the peculiar circumstances of each case, and may be considered numerically under the respective heads which I have adopted.
1. Inflammation of the brain, from exposure of the head to the heat of the sun, especially in hot climates, is by no means so common as is generally supposed, but nevertheless it may and does occur. Whether many of the cases of the so-called coup de soleil belong to this category I am not quite sure, but I am inclined to think that some of them do, and although in many instances the patients rather present the symptoms of exhaustion than of inflammatory action, yet the great heat of the scalp and of the skin in some cases, together with the other characters denoting inflammation of the brain, demand the adoption of antiphlogistic treatment. In the case of coup de soleil falling under my own notice in this country, I have therefore adopted a treatment suitable to the features in each case, and while I have given wine and stimulants in some, I have directed ice to the scalp, and antiphlogistic remedies in others. I am inclined to think that this disease somewhat resembles concussion of the brain in the sequence of its phe- nomena, and that while the first effect is to produce sudden depression, the second is to cause reaction, with its usual con- comitants of excitement. In reference to the treatment of phrenitis from exposure of the head in hot climates, I lately heard from a distinguished military surgeon a curious illustra- tion of the effect of depletory measures on himself in very critical circumstances. He was travelling in the desert of Arabia on a scientific expedition, he himself being the only surgeon in the company, when, in the course of a day’s journey, exposed to a burning and cloudless sun, he suddenly felt great pain in the head and giddiness. He had the boldness and presence of mind to open a vein in his own arm, and with immedi- ate relief, and was able to continue and conclude the expedition without further inconvenience. In this case, as perhaps in many others, the abstraction of blood, at the very m,oment when inflammation is beginning to be set up, was of infinite service, and may have saved a valuable life.
2. In phrenitis caused by severe injuries to the head, it is universally admitted that, at the outset, when the patient is suffering from the immediate effect of the shock, all depletory measures are contra-indicated, and absolute rest and the adminis- tration of diffusible stimuli are the only measures to be recom- mended. But when reaction has set in, and the usual symptoms of inflammation have declared themselves, as vomiting, hot head and skin, full and hard pulse, there is a general agreement of opinion that antiphlogistic treatment is to be adopted, and, even in the present day, when bleeding is little practised, the abstraction of blood in some way is deemed not only justifiable but necessary. To this must be added the most perfect rest of the patient, and the exclusion of light and noise, the applica- tion of ice to the shaven scalp, and the administration of calomel in repeated doses, together with saline aperients, and the adoption of low diet. Under this treatment many cases have completely recovered, even under apparently the most unfavourable circumstances, and no return of the symptoms has occurred during the remainder of life. But, as I have previously remarked, such cases require to be carefully watched, and strict injunctions must be given as to the regulation of the diet and habits, because relapses are by no means unfrequent, and even a fatal issue may unexpectedly occur.
3. In phrenitis from disease of the cranial bones, the treat- ment is necessarily unsatisfactory, because the original seat of disease is out of reach. But when the osseous lesion is sus- pected, in consequence of the presence of a discharge from the ear, much mischief may be prevented by judicious manage- ment. The discharge should on no account be checked, but rather encouraged, and indeed there are many cases where, in all probability, there is serious disease of the temporal bone, but where the health is not much impaired, and deafness and the discharge itself are the only sources of inconvenience. Mild applications to the ear, such as warm water with a little milk, or a little almond oil, the application of blisters behind the ear, and mild antiphlogistic remedies, will in many cases afford great relief, and they may perhaps sometimes avert more serious symptoms. I have had a curious instance of this form of inflammation apparently attacking several members of the same family. In the first of the cases, which was a most dis- tressing one, that of a boy about fifteen, the pain in the head was exdruciating, and was the more so, as the unfortunate patient was not delirious. The diagnosis was not difficult, for there was a discharge from the ear, and after death, which was a real relief to the long-continued suffering, an abscess on the brain was discovered, as was anticipated. But the curious circumstance was that two other children, the sisters of the boy, were similarly affected, so far as the discharge from the ear was concerned, and still more was there a similarity, as they suffered great pain in the head, confusion of thought, and other alarming symptoms. As the mother had been deeply distressed at the death of the boy, she often brought the other children to me for advice, from alarm lest they should be alike carried off. I have recommended the frequent application of blisters behind the ears, and occasional pretty active doses of calomel; and it is so far satisfactory to know that, although the patients suffer to a considerable extent, they are still alive, and pursuing their ordinary avocations.
4. In phrenitis, from the immediate effects of alcohol, the so-called inflammatory delirium tremens of some authors, anti- phlogistic remedies are indicated, but of course they must be adopted with due precaution. As I have observed in reference to some other kinds of phrenitis, the morbific cause is sometimes so rapid and so overwhelming in its operation as to threaten life at the very outset; and such is the case very frequently with alcohol, and instances are very common where a very large quantity of this fluid taken at once causes almost immediate death. But there are also many cases in which the result is not immediately fatal, but where, though the brain is inflamed, the patient may recover. Such cases are common enough, and I have seen several such, especially in the early part of my medical career, when I was frequently called to attend persons involved in drunken rows, calling for the interference of the police. I remember perfectly well to have seen such persons in a state of furious delirium after a drunken debauch, with hot head, blood- shot eyes, attacking everyone who came within their reach, and held down with difficulty by a number of strong men. I remem- ber, too, that under these circumstances, I have succeeded, though not without great struggles, in placing a bandage round the patient’s arm, and drawing a copious stream of blood from the vein, and the effect of this depletion was to calm the violence, and after a short time to restore the health. I think, even now, that such treatment is perfectly justifiable, and that its effect is beneficial, taken in combination, of course, with other tran- quillising measures, such as ice to the head, saline aperients, and judicious physical restraint. But such treatment would be altogether useless, and in fact positively injurious, in delirium tremens, where the patient is broken down by a long course of previous excesses, and where the vital powers would rapidly sink under any antiphlogistic treatment whatever.
5. In the treatment of phrenitis, caused by certain poisons, such as belladonna, there is only one course to pursue, namely, to remove the poison, if possible, from the stomach, and this may be accomplished by the administration of emetics. There are but few poisons which act on the brain in the manner now indicated, but, nevertheless, there are some which do so, and which, from their influence on the brain and spinal cord, are called cerebro-spina,7its; but their peculiar action, and the mode of counteracting their effects, whether by antidotes or by other means, belong to the department of Toxicology and Forensic Medicine rather than of General Pathology and Therapeutics.
In the above paper I have confined myself, on pathological grounds, to the consideration of those affections of the brain in which the brain-substance is alone concerned, and in which the whole of that substance is involved. The special lesions of the membranes, and the symptoms attending these lesions, and their treatment, and the post-mortem appearances observed, belong to a different category.
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