ON THE PATHOLOGY AND DIAGNOSIS OF CEREBRAL DISEASES
BMJ (Clinical Research Edition)
Ox a former occasion, I introduced to the notice of this societv some Clinical Illustrations of Diseases of the Nervous System; and I then stated my intention, at some future period, to offer some general remarks upon the pathology, diagnosis, and treatment of this class of affections. 1 now proceed, as far as lies in my power, to redeem that promise, with the aid of such observations as I have subseilluently been enabled to make in this very obscure department of practical medicine. Bearing,
... edicine. Bearing, in mind the limited period allotted to papers like the present, I have no intention to present an elaborate essay upon cerebral diseases; biut while grouping together wiv observations for the sake of clearness of description, I shall carefully avoid availing nmy.sclf of the works of wellknown authors, and confine mv illustrations to those cases wlich havc fallen under my own care, and my reflections to those ideas which have occurred to my own mind. In order also to obviate unnecessary prolixity, I shall lightly pa-s over those sub.jects which are well understood, and on wvhieh little or no difference of opinion exists, and attach a due (legree of prominence to those points which have been butt litle investigated by authors, or on which the opinions of wvell informed praetitioners are diviided. With regard to the PATHOLOGY of cerebral diseases, it must be admitted that the greatest obscurity and difficulty still exist; and it is too freqluently a matter almost of impossibility to connect the symptoms observed during life witlh the appearances revealed after dteath by the sealpel. But as the term "p pathology" inieludes both classes of pheno!niena, it will tend to simplify the subjcct if I confine my remnarks, in the first place, only to the appearances observed after death, or, in other words, to the morbid anatuiosy of the textures. Before proceeding to the consideration of those alterations of structure which are seen in or upon the encephalon and its miiembranes, it is of extremc imiportance to notice the morbid anatomy of the calvarium, which is undoubtedly concerned in the production of many cases of cerebral disease. Independently of those iinstances of external injury whliel induce cerebral symptonms, andI of which I do not intelnd to treat, there are miiorbid changes in the bony structutres, occurring spontaneously, which involve serious disttrbances of the inervous system. Tlhe tfllowing cases will, I thini.k, prove the truth of this position:-CAiSE J. A woman in the Isliugtton Infirmiary suffered coldtinulially from epileptic seizures, and was under my ob-selvLtion for about ten years: the fits were frequent, occurrigat irregular intervals, and of a very violent character. In the intermissions between tllc fits, her health was tolerablv good, wvith the exception of occasional headache ; her intellectual faculties were quite unimpaired. She always deriVed benefit froinu the local abstraction of blood, and she weas thlercfore on several occasions cupped between the shoulders. Blisters were appliedi, and kept opein in the same situation; purgatives were adminiistered, and a strict anti$hlogistic regimen was maintained. Iler diet was of the lightest character; no solid food or beer was allowed; .and she derived her suistenance enitirely from a very moderate allowance of milk, egg,s, bread, and thin broth or beeftea. rhis treatment was so far successful as to afford her considerable relief; but at length the fits became more and nmore frequent and severe ; typhus supervened, and she die(l. The following appearances presented themselves at tlle post mortem examination. TheC body was plump and well formed and thcre was a layer of fat beneath the skin, about t of h inch in thickness over the abdomen rather r kable fact, considering the tenuity of her diet. Head. The scalp was natural; the skull externally presented no peculiar appearance; and no difficulty was experienced in sawing it through. On removing it, howrever, and examini'l it, it was found that there existed a remarkable want of uniformity between the two surfaces of the sklull in some parts, owing to thickening of the osseous structure, partcularly of the internal table, which, instead of being thin and brittle, was thick and solid. Along the line of the circular incision made by the saw, the skull was of about the average thickness. The os frontis was then sawn through, immediately in front of the coronal suture. Along the line of incision made in the usual process of removing the calvarium, the thickness of the cranium was one line and a half; but the part corresponding to the right frontal eminence was half an inch thick, and the same part on the left side was five lines in thickness. All the prominent bony processes were much increased in thickness and asperity, as the crista galli, the posterior clinoid processes, the bony ridge of the petrous portion of the temporal bone, the ridges on the internal surface of the occipital, etc. The dura matcr wvas congested, the vessels of the arachnoid membrane were also congested, and the membrane itself was opaque and thickened; beneath the membraine there were two or three drachms of serum mixed with blood. The brain was flattened in front, the depression exactly corresponding to the thickening of the internal table of the skull. The substance of the brain was firm, and(I the grey portion was of an unusually dark colour: but this organ presented no other pecuiliar appearance. The other organs of the body were carefully examined, but nio morbid appearances of importance, were observed. I consider that the epileptic attacks in this case were probably due to the thickening of the interlnal table of the skull, and the conseq-iuent abnorwal pressure exerted upon the surface of the brain. CASE Il. In the spring of the year 18,5i, I attended, in conjunction with MIr. Beaman, of Covent Garden, a tradesman who had suflered severely for a long periodI from a pain in the front part of the head, and who had likewise experienced onc or two epileptic fits. When I saw him, he had long been complaining of a fixed pain albout the root of the nose, at the part where the nasal bonies unite with the frontal bone. Ife felt his head rather confused, but his intellect was by no means impaired. AVhien he went oiit to walk, he was often seized with a kind of giddiness, and this feeling increased so much upon him, that he was afrid to walk out alone. The head was not lhot, the pupils were natural, the tonguc was moderately clean, the pulse was regular, the bowels were open. lie was a stout, healthy looking man, and told me that he had never had syphilis, nor had he suffere(I from any other disease before. The pain of wlhich he complained, however. and the giddiness and confusion he felt when walking out, distressed hini excessively, and made hini almost tired of his life. As couild discover no disease of any of the great visecra, I could come to no otlher conclusioni than that the cause of his suffering was probably a thickening of the internal table of the skull covering the anterior and inferior surface of the brain, an(d that the pressure thus produticed upon that organ was the cause of the symptomiis. I accordlingly re-commeTded four lecches to be applied over the root of the nose and lower part of the frontal bone; I also ordered a pill, containing two grains of calomel wit's four of compounid rhubarb pill, to be talken every night, anl fourl grains of iodide of p)otassium every four hours in pcppermint vater. I saw him again in a week, and lbnndl tlhat hie was slightly improved, but his chief symptoms still remairned. Idir&dnished the quantitv of calomnel but conitinudc(l the jodlde of potassium. In another week lie was still much the same, but he had no recurrenec of fits. I increased" the dose of iodide of potassium to five grains, and conltinlued the small doses of calomel. In another week, his gums were tender, so that he was unable to eat, and he had con-on 2 May 2019 by guest. Protected by copyright.