On the Pathology and Treatment of Cerebral Disease
40 Art. III.?O No. II. :Author: Robert Hunter Sejirle, 3I.D.
Fellow of the Eoyal College of Physicians of London. In discussing the pathology and therapeutics of cerebral disease, these subjects may be treated in two distinct modes?one of which is best adapted to the student of medicine, and the other is more suitable for the contemplation of the practitioner. The former mode would be founded upon the basis of classifica- tion, which in all cases must be artificial, but would aim at presenting to the view a series of mental pictures, displaying certain types or forms of disease, and such canons of treatment as might dwell in the memory, and constitute starting- points for subsequent illustration and investigation. The latter mode would be based on clinical experience, which, although often failing to corroborate the dicta of nosologists, and even, in many instances, directly contradicting them, is 110 less useful in teaching the necessity of examining carefully every case as it arises, and of disembarrassing the mind, if need be, of any pre- conceived ideas derived from the authority of books, however well written, and of teachers however eminent.
Thus, it is only necessary to examine the records of Medicine for a few years in order to become convinced of the fallacy of almost all attempts to establish unerring principles of nosological arrangement, or to institute dogmatic principles of treatment. Much of the change observable in these respects is no doubt due to the influence of what maybe called ” fashion” in medicine; but much more is unquestionably attributable to the increased spread of knowledge, to the improved methods of medical teaching, to the closer attention paid to anatomical investigation, to a better appreciation of physiological laws, and to more extended opportunities of medical research offered by the invention of the precise instruments in which our age lias lately been so prolific. To pass over the stethoscope, the laryngoscope, the sphygmograpli, as being unconnected with the present subject, the introduction of the ophthalmoscope has literally thrown a vivid ray of light into one of the darkest cliambersof cerebral pathology, and has enabled the surgeon and the physician to infer, from the condition of the retinal vessels, the existence of structural changes in the cerebral arteries calculated eventually to lead to the host of diseases which, under the names of apoplexy, ramollissement, epilepsy, coma, &c., may threaten the integrity of the vital and intellec- tual functions, or cut the thread of life asunder in a moment. In reference, too, to therapeutical appliances, a complete revolu- tion has been wrought in the treatment of cerebral diseases? partly by the guidance of the scientific principles and instru- ments just referred to, partly by the sceptical tendencies of the present age (using the word sceptical in the etymological sense),* and partly even, we must confess, by the lessons afforded by some forms of quackery, which have shown that many cerebral and other diseases may be improved, or at all events not rendered worse, by leaving them, unassisted, to the vis medicatrix natures.
It must at once be admitted that the pathology of cerebral disease is still involved in great obscurity in many respects, although modern physiological research and clinical experience have done much to remove some of the difficulties of the sub- ject. It is almost a trite remark, that some of the most serious diseases of the brain may exist and reach a fatal termination without giving any appreciable notes of warning during the life of the patient; and, on the other hand, that derangements of certain parts of the cerebral mass, though apparently slight, may give rise to the most serious and alarming symptoms. One of the most recent instances of the existence of serious organic disease of the brain, unaccompanied by any pathogno- monic symptoms during life, was afforded in the post-mortem ?examination of a distinguished member of our own Profession, who died last September, apparently from the results of an operation for lithotomy, but in whom there was found a large tumour pressing upon the cerebral mass, and which is thus described in the careful notes made of the appearances: ” On raising the calvarium, a soft tumour was discovered, situ- ated on the right side of the head, about an inch above the ear, between the dura mater and the bone. It was about the size of ?a hen’s egg, and projected towards the brain, so as to produce a deep pit or hollow into which it fitted. The convolutions were flattened and pressed down, but not otherwise altered?no softening, no congestion. The dura mater covering the tumour was somewhat thickened. The tumour had a cystoid character, with a distinct investing membrane, and its contents consisted of a blackish pulpy material resembling the interior of a recent aneurism, or more closely of a myeloid tumour. Under the microscope there were seen cells of various descriptions, plates of cholesterine, fatty granules, and altered blood-corpuscles.” * The Greek -word aKeirrofxcu, it is almost unnecessary to state, means ” to contemplate,” ” to consider attentively,” ” to meditate upon.”
The name of the physician in question I do not mention, but the case will be well remembered by the medical world, and it is almost unnecessary to remark that no symptoms of cerebral disease had ever manifested themselves during life. Yet there can be little doubt that the existence of this cerebral tumour was the immediate cause of death, and, had not the brain been examined, the whole case would have been involved in utter obscurity, for the surgical operation was quite successful, and the patient was little past the prime of life. In this case it will be urged, and no doubt with truth, that the growth of the tumour was gradual, and that the cerebral mass thus became accustomed to the slowly increasing pressure, until a point was reached when tolerance could no longer exist, or when some collateral cir- cumstance (in the present instance, perhaps, the shock of the surgical operation) overthrew the feeble balance which had so long kept life and death in a tottering and uncertain equi- librium.
There can be no doubt that when Ave discard the mere dry details of the descriptive anatomy of the brain, and regard the organ rather in its physiological relations with the spinal cord and the origins of the nerves, a considerable insight will be gained during life as to the seat of mischief, if any exist. In making this remark, I omit, for the present, the consideration of those cases where the whole of the cerebral mass or of its peripheral portion is involved, and where any diagnostic or differential decision as to the exact seat of the lesion is impracticable or unnecessary. But I refer particularly to those cases where the seat of disease is indicated by the objective manifestations offered by the nervous cords which form the media of communication between the central cerebral mass and the external world. Viewed in the light of modern science, the spinal cord is really the fundamental and essential structure to which all the other parts of the nervous system are subsidiary or subordinate, and it is well known that, although even a human being may be bom without a brain, it is impossible for existence to be continued without a spinal cord. Anencephalous monsters, by means of the reflex action of the c^rd, are enabled to draw their supply of milk from the mother’s breast, the brain being wholly unnecessary in this function. Instead, therefore, of the spinal cord being a mere appendage to the brain, as was once supposed, the fact is just the reverse, and the brain is an offshoot or development of the spinal cord. Into the relation existing between the assem- blage of moral and intellectual faculties constituting the Mind, and the mass of matter composing the brain, I do not at present enter, as my object is to show the pathological connection existing between diseased structure and impaired functions of certain parts of the intra-cranial organs. In this very interesting but most difficult investigation, Dr Hughlings Jackson has displayed conspicuous ability, rare sagacity, and unwearied diligence, and the results he has obtained, though necessarily imperfect, have revealed some of the most mys- terious operations of the nervous system. I do not, however, refer in detail to his researches, because I wish, as far as pos- sible, to illustrate my remarks by cases which have fallen under my own observation.
It may be stated, generally, that the exact seat of cerebral disease is indicated,more or less clearly, according to its greater or less connection with those nervous fibres which control or direct the communications between the inner and the outer world, or, in other words, between the cerebral mass and those external objects with which the animal fabric is placed in relation. The anatomist will readily recall to mind the direction taken by the nervous fibres as he traces them, upwards and outwards, from the so-called medulla .oblongata, through the Pons Varolii, then through the ganglia called the optic thalami and the corpora striata, till they expand into, and becomc merged in, the general mass of the hemispheres. In this extensive course they necessarily fall upon the track of many of the nerves which proceed outwards to various parts of the body, endowing those parts respectively with sensation, or motion, or special sense, as the case may be. Thus, speaking generally,, the posterior columns of the cords, passing through the medulla oblongata and the other structures just mentioned, are con- nected with the sensitive branches of what is called the fifth pair of nerves; while the anterior columns, pursuing a similar course, are connected with the motor branches of the fifth pair, and also with the third pair, the fourth pair, and the sixth pair, and what is called the portio dura of the seventh pair, and the ninth pair, all of which are exclusively endowed with motor powers. By pursuing the investigation in a reverse direction,, and tracing the nervous fibres of the brain downwards and backwards, these threads are found successively passing through the corpora striata, the thalami optici, the Pons Varolii, and then crossing or decussating in the medulla oblongata, so that the fibres from the right side of the brain pass for the most part to the left side of the cord, and vice versa. The explana- tion is thus readily afforded of the fact that paralysis on one side of the body almost always denotes some disease of the opposite side of the brain; and it is equally easy to understand that when the central part of the motor or sensitive tract is affected, the paralysis will be on both sides. I do not propose to give any illustrations of these well-known principles, whicli are verified by daily observation.
It is not equally well known that when the seat of disease is in that part of the brain which is not immediately in the track of the motor or sensory nerves, there may be no paralysis at all, although the lesion may be very serious and extensive. It must be borne in mind that the great bulk of the hemispheres of the brain are, so to say, expansions or outgrowths from the divergent fibres of the spinal cord, and are, as it were, outside the motor and sensory tracts, or are only blended with them in a loose and general connction. The following curious case is a remarkable illustration of the observations just offered : Case.?Some little time ago I was requested to see a gentleman who was suffering from several anomalous symptoms, but all pointing to some serious cerebral disease. He was ?about sixty years of age, and somewhat plethoric. I learned from his sister that he had been ill for about a year and a half, and that he had been obliged to give up his business, owing to obscure cerebral symptoms, which were attributed to ” softening ?of the brain,” and for which lie was recommended to travel about various parts of this country and on the Continent. I was told that his intellect was somewhat impaired and his memory was imperfcct, and that he was unable to manage his affairs satisfactorily. I first saw him in London on a Monday, he having landed from Boulogne on the previous Saturday. I was informed that he walked to the steamer at Boulogne, but was helped out of it at Folkestone, and arrived at his residence in London the same evening, and walked from the cab into the house. He soon complained of feeling ill, and accordingly went to bed, where he remained. It was noticed that he was very sleepy and snored much, and he also vomited.
When I saw him first, he complained of sickness and vomit- ing, and great pain in the head. He was rational, and answered questions satisfactorily enough. The eyes seemed rather intole- rant of light, and the pupils were contracted, remaining so during all the rest of life. The bowels were confined. I con- tinued to attend him till his death, which occurred about three weeks after I first saw him. The treatment consisted in the application of blisters to the nape of the neck, although he tore them off; in the administration of purgative medicines, which partially succeeded in their object; and in the cautious regulation of his diet. I carefully examined him from day to day as to the existence of paralysis in any of the limbs, but I could detect none. I caused him to lift both his arms, and to place them in various positions, and also to move both his legs, but he showed no indication of loss of power, and wlien I pinclied the limbs I elicited the expression of pain. His mental condition was rather peculiar, for although, as has just been mentioned, he answered questions rationally enough, he adopted, in conversa- tion, a jocose tone which was unsuitable both to his acquaintance with me (for I knew nothing of him before) and to the serious illness under which he was labouring. He was always very somnolent, but he could be roused without much difficulty. The urine was passed involuntarily. It is unnecessary to record the progress of the case further than to state that the symptoms gradually became worse, the prognosis unfavourable, and lie finally became comatose and died.
The post-mortem examination was made twenty-four hours after death, the time being winter, and the weather very cold. The head only was examined, owing to the objections offered by the relations, but the appearances observed were very interesting. The skull was thickened, and there were strong- adhesions existing between it and the dura mater. There were patches of old lymph on the surface of the brain at the vertex. The arteries at the base were atheromatous, but no plug was found in any of them, although they were carefully examined. The consistence of the brain generally was normal, and no softening existed in any part. But on the right side of the brain, on the posterior lobe, and very near the surface, there was a large cavity of about the size of a hen’s egg, filled with a clot of blood, and opening on the surface of the hemisphere- This cavity and the contained clot presented the characteristic appearances of such a lesion gradually in progress of cure, for a membrane was in process of formation on the circumference of the cavity, and the clot was beginning to lose its dark sanguineous colour, and to assume a yellowish tint. The effusion of blood was probably to be dated from the period of the sea-passage from Boulogne to Folkestone, and from this time more than three weeks elapsed until the death, during which interval it would seem that nature was endeavouring to effect a cure by the usual process of absorbing the clot, forming a membrane to the cavity, and restoring the rest of the brain to its normal state. In the present instance, however, the age of the patient, the long duration of the disease, and the large size of the effused mass, all combined to render a favourable issue of the case all but hopeless.
Here, then, was a case where an extensive effusion of blood existed in the right posterior lobe of the brain, but in which during life there was no paralysis, the reason obviously being that the seat of the effusion was out of the track of the ordinary motor and sensory nerves. The more common seat of apoplectic effusions is in one of the lateral ventricles affecting- the corpora striata or the thalarai optici, which are both of them continuations of the motor and sensory fibres proceeding upwards from the columns of the spinal cord. In the present instance, too, it must be observed that the primary lesion appears to have been a chronic inflammation of the membranes of the brain, together with an atheromatous condition of the arteries, and the immediate cause of death mast be referred to the rupture of some minute branch near the periphery of the organ. Besides the mental condition, the persistent contraction of the pupils is a remarkable circumstance, and it indicates, I believe, the existence of some irritation on the surface or periphery of the brain, while the continuous dilatation of the pupil is a pretty unerring test of effusion of fluid into the ventricles or between the membranes. In ordinary apoplexy, and in some other dangerous conditions of the brain resembling that disease, it is very common to find one pupil contracted, and the other dilated.
In contrast to the above case, I shall now adduce another, in which the brain was proved to be the only organ diseased, but the disease was of a very serious and complicated character : Case.?M. T., aged 54, a person of dissolute character, was seized at the beginning of July, some years since, with a paralytic attack, for which lie was bled to the extent of thirty ounces, but not by myself. After this treatment and the administration of purgatives he partially recovered, but his intellect became almost obliterated; he passed his urine un- consciously, and became offensive to the persons in the same ward, and was therefore placed in one by himself. From July until the end of May of the succeeding year he remained bed- ridden, but at the latter period he was again seized with an attack resembling apoplexy ; the pulse was 180, full and strong, and there was stertorous breathing. There was also paralysis of the left side. He was bled to sixteen ounces, and during the bleeding the stertorous breathing ceased, and did not sub- sequently return. He remained, however, insensible; the pupils were fixed in a state between contraction and dilatation; the pulse fell to 160, and was rather feeble; the bowels were con- fined, and the urine continued to pass involuntarily. He died some days afterwards, and the following post-mortem appear- ances were observed:?
On opening the head, I found the vessels of the dura mater turgid with blood. The arachnoid membrane was slightly thickened and opaque ; a large quantity of serous fluid, tinged with blood, was found beneath it, and flowed copiously, both from beneath the membranes of the brain, and from the theca vertebralis. A large quantity of fluid was also found in the lateral ventricles and in the third ventricle. The vessels of the brain itself were not congested, and the general structure of the organ, except in the parts about to be described, presented a tolerably healthy appearance. At the posterior part of the corpus callosum, immediately above the tubercula quadrigemina, there was a considerable amount of softening, the cerebral substance in that situation being of the consistence of thick cream, but of a white colour. In the anterior part of the right corpus striatum there was a cavity of about the size of a hazelnut, lined witli a smooth membrane. On the left corpus striatum there was a large but not deep excavation, of about the size of a halfcrown, presenting a ragged appear- ance, and of a dark-brown colour. The texture of this ulcerated portion was much softer than that of the surrounding tissue, from which it was not separated by any distinct line of demarcation. The viscera of the thorax and abdomen were carefully examined, but I could find no marks of disease, and the kidneys especially were particularly healthy.
This, therefore, was a case of chronic disease, confined alto- gether to the brain, and producing palsy, mental imbecility, involuntary discharge of urine, apoplectic seizures, and eventually death. There were no symptoms during life specially indi- cative of softening. The first attack of paralysis was clearly connected with an effusion of blood into the right corpus striatum, and the apoplectic cell was the result of that event. After this first attack it would appear that a liypercemic condi- tion of the cerebral vessels continued to exist, and at last the structure of the organ broke down ; and congestion of the mem- branes, with copious effusions of fluid into the arachnoid sac and into the ventricles, and central softening of the brain- structure, were together the immediate causes of death. With respect to the important but very difficult question of treatment in cases such as those just referred to, I have some observations to offer, but I am far from having any dogmatic views on the subject. Opinions must now be formed and expressed with the more reserve, because the progress of modern pathology has proved the existence of so many hitherto unsus- pected circumstances leading to softening, extravasation of blood, neoplastic formations, and other serious diseases in the intracranial mass, that the relief or removal of such conditions must be a most serious problem. It is evident that in the case last recorded treatment could have been of no avail; in the preceding case it must have been equally unsuccessful; whereas in the first case referred to (that of the deceased physician), the cerebral malady was not even suspected during life.
However, as Celsus observes, ” proposito metu, spes tamen superest,” and there are many circumstances which afford gleams of hope in some of the cases of cerebral disease which are apparently of the most desperate character. For it must not be forgotten that, although the brain-substance is liable to the formidable lesions already alluded to, yet the symptoms indicating brain-disease may be present and the organ itself be perfectly healthy. For, as is now well known, in conse- quence of the researches of Marshall Hall, Brown-Sequard, and others, the brain may be affected only functionally and secondarily in many cases, the real seat of disease being situ- ated elsewhere, and being, perhaps, only of a transient or curable character. If space allowed, I could adduce numerous instances where, although convulsions, spasms, or coma existed, yet the brain was perfectly unaffected in its structure, and in which, the local cause being removed, the brain-symptoms entirely disappeared. How often has it happened that appa- rent apoplexy has been dependent on kidney-congestion, and has vanished when such congestion has been relieved; that coma and convulsions, which have excited the most anxious fears, have ceased, as if by magic, 011 the expulsion of an intes- tinal worm; that cerebral congestion in a female lias been relieved by the appearance or reappearance (as the case may be) of the menstrual discharge; that spurious hydro- cephalus in a child has disappeared on the cutting of a tooth ! But even when all such cases of excentric origin are ex- cluded, and the attention is fixed upon the presence of actual disease within the cranial cavity, it by no means follows that the malady is incurable or hopeless. Mere congestion of the brain, without extravasation, although often fatal, may be and is very often relieved by remedial, dietetic, and hygienic measures; and even when rupture of a vessel has taken place, and extravasation has ensued into the cerebral mass, nature, assisted by art, may still effect a cure. In the two cases just recorded from my own experience, it will be seen that in the second case there was an apoplectic cell, resulting from the cure of a sanguineous effusion which had occurred ten months before; and in the first case, the enormous effusion of blood in the posterior lobe of the brain was actually in process of absorption, although the patient lived only three weeks after the apoplectic attack. Hence, in a given case of apoplexy, it is reasonable to hope (unless there be some direct evidence to the contrary) that the case may be only one of congestion; and even if there be an effusion from a ruptured vessel, it may be anticipated, mil ess the effusion be very con- siderable (of which no very distinct opinion can be formed during life) that nature will absorb the effused blood, and, though leaving a cyst, may restore the brain to its normal con- dition. It is quite true that the occurrence of an apoplectic attack, attended or followed by paralysis, is a most serious warning; but, nevertheless, in innumerable instances, life may’ be prolonged and enjoyed by means of the application of judicious remedial measures on the one hand, and by the removal of injurious influences on the other.
In former times, as is well known, and in the memory of many of the present generation, the universal rule of treatment in apoplexy was to bleed the patient, and to a large amount; and the practitioner who neglected this measure was considered guilty of malapraxis. Some years since a very distinguished member of the medical profession, long deceased, incurred almost universal censure because, on a point ot etiquette (he being a physician) he had neglected to bleed a medical friend with whom he happened to be travelling, and who was suddenly seized with a fit of apoplexy of which he died. It is hardly too much to state, that had the physician in question adopted the opposite course in the present day, he would be subjected to censure just as loud and general, and the death of the patient would perhaps be attributed to the adoption of the very measure the omission of which was formerly supposed to cause the fatal result. In either case, however, the censure would be unjust. The public is too apt to attribute to human interven- tion, or non-intervention, a number of fatal occurrences which are really due to causes over which human art has no control, and in many cases of apoplexy the result would be unfavourable whether the patient were bled or not. In the two cases which I have recorded and contrasted in the present paper, bleeding was largely adopted in one of them, and entirely omitted in the other. In the second case it will be seen (whether post hoc or propter hoc is not very certain) that temporary relief of the urgent symptoms followed the first copious bleeding; and in the first case, where the patient was not bled at all, the sym- ptoms gradually became worse, and the patient died.
The true rule of treatment probably lies between the two extreme views which have been entertained in the present century, and may be laid down as follows:?When the attack is quite recent, and the pulse is full, hard, and strong, the breathing stertorous, and the patient plethoric, the abstraction of blood is admissible, and in all probability will be beneficial. If? on the contrary, the patient be weak and anaemic, the pulse feeble, and there be a tendency to syncope, blood-letting will only accelerate the fatal result. Even in cases where the pulse appears to admit of bleeding, the effusion may be so extensive that all chance of recovery is lost; but it must be remembered that the amount of effusion can be proved only after death, and although that event has happened it does not follow that the bleeding has therefore been injurious.
As I wish to support my views from cases derived from my own experience, I adduce the following, of which I have pre- served notes. I have written out and published so many cases of post-mortem examinations occurring in my own practice, that I cannot be accused of any attempt to paint my expe- rience with a couleur de rose, or to pretend that bleeding or any other treatment is a care for apoplexy; but still I adduce the cases as honest records of the consequences of treatment. In this sceptical age I do not even assert that the patients would not .have recovered if no depletion had been practised, but I think I may confidently declare that the measure did no harm:? Case.?E. S., female, aged 70. I was sent for and re- quested immediately to visit this patient, who was said to be either dying or dead. I arrived in a few minutes, and ascer- tained that she had previously been in the enjoyment of her usual health, and had never suffered from any dangerous dis- ease ; but that in walking upstairs she had suddenly fallen backwards with such a noise that it was heard by the neigh- bours, who immediately ran to her assistance, placed her in bed, and sent for medical aid. When I saw her she was lying on her back, with her eyes half-closed ; her mouth drawn to one side, and convulsively agitated; the limbs motionless; the breathing loud and stertorous; the pupils fixed in a state between dilatation and contraction, not altering their size by the admission or withdrawal of light. She appeared quite insensible, and could not answer questions, seeming not to understand their meaning; the pulse was full and strong, and the action of the carotid arteries powerful. I opened a vein in the arm, and obtained ten ounces of blood. I also ordered a drop of croton-oil to be taken immediately, and also some saline purgative. I visited her the next day, expecting to find her either dead, or at least growing worse; but to my great surprise she was much better, in full possession of her faculties, and without any symptom of palsy; her speech was clear, and she possessed the full use of all her limbs. On the day fol- lowing, the patient was engaged in her usual occupations and declared herself perfectly well.
Case.?J. L., male, aged 60, had experienced several apoplectic attacks, for the last of which he had been bled, put upon low diet, and ordered to take purgative medicines. Under this treatment, which was pursued in an infirmary, his health became materially improved, but all his requests for full allowance of meat and beer were disregarded. However, after a continuance of this regimen for five months, he pro- cured his discharge from the infirmary, and of course returned to his usual diet. About nine months after the attack just alluded to, he was seized with another, and I saw him very soon afterwards. There was total insensibility and immobility of the limbs; the pulse was full and strong, the pupils fixed in a state between contraction and dilatation; breathing loud and stertorous, and the intellect totally deficient. I bled him to eight ounces, and ordered a drop of croton-oil to be taken, and some saline purgatives. The next day he was much better; he had regained the use of his limbs, and his intel- lectual faculties had returned. He was able to move both arms, but could not use the right so well as the left. He was put upon low diet, with the occasional administration of pur- gative medicines, and under this treatment he regained his usual state of health.
Case.?A. K., female, aged 66. I was requested to see this patient immediately, as she was said to be in a fit. On visiting ^leiI ascertained that while conversing with a friend she felt suddenly very giddy, and appeared to lose the use of her arms and hands, for she let fall a candlestick which she was holding at the time. Her condition when I saw her was as follows She was tying in bed; the features were not distorted, but her speech was thick and confused, and almost unintelligible; she appeared to have the use of both her hands and arms, and could move them without difficulty; when asked to grasp my hand she did so, and there was no perceptible difference in the muscular power of either hand; the pupils were contracted, and did not dilate when the light was withdrawn; action of “the carotids powerful; pulse strong and full, frequently beating double; action of the heart corresponding to the pulse at the “wrist, and the impulse strong. The intellect was impaired, but not lost; she seemed to understand questions, but answered them in a confused and hurried manner. She was continually moving about in the bed and pulling the bed-clothes with her hands. I bled her in a full stream to sixteen ounces, which did not cause her to faint. On the next day she appeared much better ; the intellect unclouded; speech clear and dis- tinct ; pulse 96, small and irregular. The blood drawn the day before showed a disproportionately large amount of crassa- menturn, which had a buffy coat. She was ordered to take three grains of calomel every four hours, and saline purgatives. I watched this case from day to day, and the improvement was rapid, the cure at last being complete. A fortnight after the original attack I find in my notes, which were taken at the time, that the patient was then enjoying her usual state of health and had no bad symptoms whatever.
This case I suspect to have been one of inflammation of the arachnoid membrane, perhaps attended with the effusion of serum or lymph ; and my opinion is based on the facts that the pupils were contracted?a sign usually denoting peripheral in- flammation or irritation : that the blood drawn was buffy, a cir- cumstance generally indicative of serous inflammation : that the intellect was impaired, but not abolished : that the affection of the limbs was convulsive rather than paralytic: and finally, perhaps, that the recovery took place under the circumstances described.
In all these cases I cannot help adverting to the fact, which I think is worthy of attention, that I saw them almost immediately after the seizure in each instance, and that the bleedings were performed at the very onset of the malady. It is right to mention that these cases occurred at a time when bleeding was still regarded as indispensable in the treat- ment of apoplexy and apoplectiform seizures.
Case.?A. B., aged 38, a tall, powerful, and plethoric man, weighing about seventeen stone, an innkeeper, not immoderate in his habits for a person in his business, but still eating and drinking much more than was necessary, was seized with symptoms denoting an approaching attack of apoplexy. “When I saw him, he was lying on a couch, breathing heavily, and almost stertorously; he could be raised, but with difficulty, and answered questions imperfectly ; the pupils were fixed between contraction and dilatation, and did not alter their dimen- sions under the influence of light; the head was hot; the pulse was full and strong. Although this case occurred rather recently, and after the tide of professional opinion had turned against the abstraction of blood in apoplexy, I did not hesitate? especially as I had, fortunately, a lancet in my pocket?to bleed him at once, and I took away a large quantity of blood. I do not know exactly how much he lost, as no professional assist- ant was with me, and the blood was drawn into a large wash- hand basin. But the effect was most striking: the patient, who was before sleepy and lethargic, began to open his eyes, and to assume a look of intelligence, and to answer questions readily.. I ordered him some calomel and some saline medicine, and when I saw him the next day, he was in all respects much better, and, in short, he was entirely restored to health in a few days.
Disclaimer
The historical material in this project falls into one of three categories for clearances and permissions:
Material currently under copyright, made available with a Creative Commons license chosen by the publisher.
Material that is in the public domain
Material identified by the Welcome Trust as an Orphan Work, made available with a Creative Commons Attribution-NonCommercial 4.0 International License.
While we are in the process of adding metadata to the articles, please check the article at its original source for specific copyrights.