Charles Gottleib Raue.

Special pathology and diagnostics : with therapeutic hints online

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Tlierapeutic Mints cannot be given aj)riori. Each individual
case mxU.st be studied by itself Compare Hypertemia.



20 HEAD.

Atrophy of the Bram

Is the opposite of hypertrophy, a shrinking, toasting away of the train.

Deficiencies of growth have been found congenital, being confined
either — 1, to both hemispheres of the cerebrum ; or, 2, to both hemis-
pheres of the cerebellum ; or, 3, there are certain parts of the brain
not developed at all. In such cases the children are idiots. In some
other cases the deficiency has been found confined — 4, to one-half of
the cerebrum and to the opposite half of the cerebellum, (the usual
condition,) or to the corresponding half of the cerebellum ; then the
children are not idiots, but mostly affected with hemiplegia of the
opposite side and in a great many cases with epileptic fits. We
ought not, however, to consider the above as cases of atrophy of the
brain, because they do not present a wasting away of what has been
already developed, but a deficiency in the proper development itself;
the causes of which we do not know.

Keal atrophy is a shrinking — wasting away — of the cerebral sub-
stance. This occurs, occasionally, in old age, in consequence of
marasmus senilis, where a want of general nutrition causes a waste
of the brain ; the lost substance being at once replaced by an exuda-
tion of serum, constituting hydrocephalus senilis. It also occurs as
a result of exhausting diseases and chronic alcoholism j almost always
leading to general paralysis and imbecility of mind.

But it may develop itself in portions of the brain only — partial
atrophy — when in consequence of apoplexy, inflammation or exuda-
tion, as we have already seen, by destruction or pressure upon the
capillaries or arteries, such portions become deprived of the necessary
nutrition. Its consequences are, in almost all cases, aberrations of
the intellect, imbecility of mind, and paralytic afl'ections.

Therapeutic Hints. — A lost portion of the brain can be as
little restored as a lost limb. Congenital deficiencies are therefore
clearly out of the reach of any medicine. Where we suspect an
atrophy in consequence of exhausting disease, we must select our
remedies according to these circumstances. Destroyed portions will
ever remain destroyed in spite of medicine.



DISEASES OF THE BRAIN AND ITS MEMBRANES. 21



GROUP Y.

PSEUDO-FORMATIONS,

Post-mortem examination has revealed quite a variety of these
morbid growths, and proves that they are not of infrequent occur-
rence. Their presence during life, however, is, like many other
cerebral affections, scarcely ever recognizable.

Tubercles.

Tubercles are usually of a slow growth, when they develop singly.
Miliary tubercles, however, in combination with meningitis or acute
hydrocephalus, run an acute course. When single, they are found
everywhere in the brain in various numbers. Their size varies from
that of a hempseed to the size of a pea, or even to that of a hen's
egg. Their form is roundish ; their color yellowish, sometimes
greenish; and their consistency that of cheese. In the course of
further development they change, more or less, either by softening,
into a yellowish matter, or, by assimilating calcareous matter, into a
hard, mealy, chalky, or even a stony mass.

Most cases of brain tuberculosis have been observed in children ;
with grown persons this disease is rather exceptional, although cases
have been observed after the age of forty or fifty, and even sixty years.

Tumors.

We find cancerous, sarcomatous, and pearl-tumors, (which latter have
their name from the pearly lustre of their granulated surface,) cysts,
and lony tumors ; none of which can be diagnosticated during the life
of the patient, unless they perforate the skull. In the event of per-
foration, they present the following signs : the integuments over the
tumor are raised, but not broken, look red, and are interwoven with
numerous enlarged blood-vessels, and destitute of hair. When the
opening in the skull is large and not overlapped by the tumor, the
edges of the bones may be felt around the circumference of the tumor.
The tumor itself feels soft and uneven, and pressure upon it does
not particularly hurt the patient. Sometimes a slight crepitation of
small, loose, bony particles is felt, and sometimes a deceiving fluctua-
tion. Pulsation is of rare occurrence in such tumors ; and a rising



22 HEAD.

up and clown of tlie swelling during respiration takes place only when
tlie tumor is in immediate connection with the brain and does not ad-
here to the bones. In cases where the opening is large, and there is
no adhesion of the tumor to the surrounding tissues, it may be pressed,
wholly or partially, into the cavity of the skull. This, however,
generally causes violent spasms, although there are cases in which the
patient has experienced relief from this operation.

Therapeutic Mints, — Tumors, which perforate the skull, may

indicate : Calc. c. or Calc. phosphorica, Ars., Carb. an., Bell., Lach.,
Phos., Silic, and many other remedies.

Aneurysms.

These are spherical or cylindrical enlargements of parts of an
artery, and are mostly found at the base of the brain. Hasse does
not know of any that have been found in the cerebellum. They vary
in size, from that of a pea to the size of a hen's egg. They cause no
characteristic signs by which they can be recognized.

Animal Parasites.

There are known two kinds : the cysticercus cellulosa and the echino-
coccus hominis. Both have the shape of a bladder, and are as large as a
pea, and some as large as a hen's egg. The cysticercus has been found
most frequently, whilst the echinococcus is much more common in
the liver and kidneys. They produce no characteristic symptoms, and
sometimes none at all ; sometimes, however, they cause more or less
frequent attacks of epilepsy.

It is altogether a remarkable fact, that in cases of tumors within
the cavity of the skull, the brain does not seem to suffer from the
pressure of such tumors, even if they are of a considerable size, pro-
vided they grow slowly ; so that in some cases no symptoms, which
in the least degree indicated any cerebral disorder, were observed
during the life of the patient.

Cerebral Symptoms, which appear objective to our senses
during the life of the patient.

Delirium^ an aberration of mental action. It shows itself in the
most various forms, from a still murmuring of single words, some-



DISEASES OF THE BRAIN AND ITS MEMBRANES. 2B

times scarcely audible, to tlie most violent furibund utterances and
actions ; sometimes continually turning around one and the same idea,
and at other times connecting and mixing the most different objects.
Sometimes the patient seems sad or frightened, at other times jocose
or audacious ; in fact manifesting itself in the expression of all possi-
ble ideas and emotions of the mind.

It never denotes any 'particular form of brain disease; but it is
a bad sign when it occurs in consumptive persons 5 in jaundice, during
pregnancy, or parturition ; after apoplexy or external injuries of the
head.

Droiosiness, sleepiness^ sopor, stupor, coma. Sleep is that state of the
brain in which it recuperates its lost energies ; and therefore it comes
naturally after a well-finished day's work. According to Dr. W. A.
Hammond, sleep is directly caused by the circulation of a less quantity
of blood through the cerebral tissues than traverses them while we
are awake. The condition of the brain, which is favorable to sleep,
may also be induced by various other causes, such as heat, cold, nar-
cotics^ ansesthetics, intoxicating liquors^ loss of blood, &c. If these agents
are allowed to act excessively, or others, such as carbonic oxide, and
all those which interfere with the oxygenation of the blood, are per-
mitted to exert their influence, sopor, stupor, coma, results. Stupor and
sleep are two entirely different conditions. " In the first place, stupor
never occurs in the healthy individual, while sleep is a necessity of
life ; secondly, it is easy to awaken a person from sleep, while it is
often impossible to arouse him from stupor ; thirdly, in sleep the mind
is active, in stupor it is as it were dead ; and fourthly, pressure upon
the brain, intense congestion of its vessels, the circulation of poisoned
blood through its substance, cause stupor, but do not induce sleep. For
the production of the latter a diminished supply of blood to the brain
is necessary." Wm. A. Hammond, M.D., on Wakefulness, p. 18,

Sleeplessness, ivahefulness, insomnia, may be induced by every cause
capable of increasing the amount of blood ordinarily circulated through
the brain. Such are :

1st. " Long-continued or excessive intellectual action, or any pow-
erful emotion of the mind.

2d. " Those positions of the body which tend to impede the flow of
blood from the brain, and at the same time do not obstruct its passage
through the arteries.

3d. " An increased amount of blood is determined to the brain by
certain substances used as food or medicine, such as alcohol, Opium,
Belladonna, Stramonium, Indian hemp, tea and coffee, &c.



24: HEAD.

4tli. " Functional derangement of certain organs of the body, where-
by an increase in the amount of blood in the brain is produced ; such
as, exalted sensibility of the nervous system, nervous debility, disor-
dered menstruation, deficient action of the heart, habitual cold feet,
indigestion, &c." Hammond.

Though wakefulness may be the forerunner of serious cerebral dis-
turbances, it is otherwise of no diagnostic value.

Full of sleep and yet unable to slee'p is a symptom which most fre-
quently denotes an irritation of the brain or its membranes ; but any
particular kind of disturbance it does not indicate, (Bell., Apis,
Opium.)

Starting^ and screaming out, in sleep are symptoms which frequently
foretell spasms and meningeal inflammations, although they are some-
times mere symptoms of disorders of the digestive apparatus. From
the " screaming out in sleep" we must distinguish that shrill scream
which we meet with in meningitis, a peculiar shrill, piercing, short,
agonizing sound, without tears, repeated every now and then. Once
heard, it is not easily forgotten.

Spasms, convulsions. As spasms and convulsions may originate at
the periphery as well as at the centre of the nervous system, all
spasms do not indicate cerebral disturbances.

Spasms may consist of single jerks of single limbs or muscles, or
they may be general, all over the body ; in which case they are called
convulsions. They may occur periodically in alternate contraction
and relaxation of the flexors, and then are called clonic spasms ; or,
they may continue uninterruptedly for a longer time, and are then
called tonic spasms. If they occur on one side only, accompanied by
loss of consciousness, they generally originate in the brain, caused
either by an internal injury of the head, or by inflammatory processes ;
apoplexy ; exudation ; formation of pus or tumors within the cavity
of the skull. They appear mostly on the side which is affected, whilst
the opposite side becomes paralyzed. If they attack the muscles of the
neck, causing a contraction of the nape of the neck, with or without
a rigid bending of the lower limbs backwards, it denotes a basilar
meningitis.

Epilepsy is a peculiar form of spasms, which, according to the
observation of a French physician, is said to have the following charac-
teristic features : It commences with a sudden deadly paleness of the
face, the patient gives at the same time a shriek, and falls down in
spasms; this lasts from a quarter of a minute to a whole minute.
After this the face becomes red and turgid, the patient is generally



DISEASES OF THE BEAIN AND ITS MEMBRANES. 25

convulsed and entirely insensible ; tHs lasts one and a half to two
minutes. After tlais the convulsions gradually cease, the stage of the
decrease lastino- from three to eight minutes, followed by a heavy

sleep.

About its nature we know very little, and it is mentioned here
merely as a symptom, which frequently accompanies parasites in the
brain, and some deficiencies in its normal growth.

Paralysis. In apoplexy it comes on suddenly, but slowly in the
case of tumors and softening of the brain; it generally befalls the side
opposite to that in which the lesion of the brain exists. In meningeal
affections and also in general atrophy, the paralysis is frequently of a
general character.

Ahnornial motions of the head consist either in a constant rolling of
the head from side to side ; a lifting up of the head from the pillow ;
or a bending of the head backwards and boring it into the cushions; —
all of which denote irritation of the brain. The rolling and lifting up
of the head is most generally observed in hydrocephahis, whilst the
bending backwards of it is a sign of basilar meningitis.

The constant reaching with the hand to the head is caused by pain,
either in the head or in the ears.

Another peculiar abnormal motion is the heating xoith one arm and
one leg of the same side uji and down, constantly, sometimes for days
and nights ; whilst the other side is paralyzed. It is almost always
observed after exudation has taken place in acute hydrocephalus.
Those changes which are produced externally by hydrocephalus,
hypertrophy, and also some pseudo-formations, when they perforate
the skull, have been already detailed under their respective heads.

Ptosis, or paralysis of the eyelids^ sometimes follows apoplexy and
other degenerations of the brain.

Strabismus, or squinting^ is an effect of apoplexy and meningitis ;
but it is likewise occasioned by irritations within the intestines.

The pujjils of the eyes are mostly contracted in the beginning of
cerebral anaemia and meningitis; but they groio larger during the
progress of the disease. Sometimes one pupil is large and the other
small.

During the progress of an acute hydrocephalus, the inner canthi of
the eyes become gradually injected, and there form a semi-transparent
glutinous substance under the lids, which here and there covers the
cornea; so that the eye looks as thongh it were broken. Whenever
I have found such injected inner canthi, and at the same time that



2G HEAD.

glutinous substance floating upon the ball, I have never seen tbe
patients recover.

The /ace indicates a deeply-seated illness, has a sunken appearance ;
sometimes flushing up and then growing pale again, sometimes only
one side of it. In some cases these flushes form only circumscribed
round red spots on the cheeks, coming and going continually. This
latter I have always found to be a bad sign. All these symptoms
belong to meningeal affections, whilst apoplexy, softening of the brain,
or similar destructive processes, are almost always associated with
paralysis of one side of the face and tongue ; so that talking and eat-
ing becomes difficult or even impossible.

Thfe constant vomiting without any apparent disorder of the stomach,
worse when being raised up, and associated with constipation of the
bowels, is a sign of meningitis.

The hreathing in acute brain diseases is mostly irregular and sigh-
ing. There are one or two deep inspirations, and then follow one or
two, which are scarcely perceptible. It appears as though the breath-
ing ceased altogether for a while.

The pulse is mostly slower than natural about the time and after-
wards when exudation takes place, but later it increases again to
great frequency and smallness.

A peculiar bright redness on the palms of the hands and points of
the fingers, spreading around to the dorsal portion of hands and
fingers, is observed in some cases of meningitis after exudation has
set in. It is a kind of suggillation of blood under the skin, and is a
very bad sign. If it turns purple, death is near.

A -peculiar lifting the feet high when walking, the so-called cocVs
gait, is said to be with children a characteristic sign of threatening
hydrocephalus acutus, and in grown persons a symptom of some
organic lesion of the brain.

Tottering^ reeling, stumbling in walking^ maybe in children one of
the premonitory signs of approaching acute hydrocephalus, or, after
injuries upon the head, a sign of inflammation of the brain.

Walking backwards involuntarily has been observed in softening
of the cerebellum.

These are the most prominent and constant signs by which internal
disorders of the brain and its membranes manifest themselves exte-
riorly, and we may call them, with good right, brain symptoms.
Their presence, especially, if they come in groups, will enable the phy-
sician to come to the conclusion that he has to deal with a cerebral
afiection; but further diagnostic distinction will be a matter of con-



DISEASES OF THE CRANIUM AND ITS INTEGUMENTS. 27

jecture, except in those plain cases of hjdrocephalus, meningitis, and
apoplexy, where the symptoms are of a less dubious character, and
therefore less susceptible of being falsely interpreted. In most brain
diseases, however, it is impossible to diagnosticate with certainty,
how and where the brain is affected. Thus all these cerebral symp-
toms have only a general diagnostic value.



SECTION II.

DISEASES OF THE CRANIUM AND ITS INTEGUMENTS.

If we look at the head as a whole, the first impression received
from it is concerning its size. This varies very much, as is well
known even from trying on hats in a hat store. A hat, that fitted a
Webster, might fall down to the root of many a man's nose ; whilst
a little boy's cap would cut a figure upon the crown of any ordinary
man's head. To define the normal size of the skull, therefore, might
be a matter of great difficulty ; unless we should allow a certain num-
ber of inches in circumference as a standard. And yet we can dis-
tinguish a head of an abnormal size at the first glance. It is not then
the relative size of a head compared with others, but it is the dispro-
portion which it bears to the face and the remainder of the body.
'And this disproportion strikes the eyes at once so unmistakably, that
special measurement is not required at all. We call a head abnormal
in size, if it is either too large or too small in proportion to the body.

A. Abnormal Largeness of the Head

May be caused, as we have seen, by hydrocephalus ; hypertrophy of the
brain; and by pseudo -formations within the cavity of the skull, when
they perforate the skull. To this are to be added morbid conditions
of a more external nature.

Dropsy of the Scalp.

This is a collection of serum either in the cellular tissue (cellular
dropsy) or between the aponeurosis and the pericraniuin (aponeurotic
dropsy). When the watery fluid collects in the cellular tissue, it is
apt to spread down to the face; and on pressure with the finger it
leaves a pit ; as is seen on all parts of the body, where dropsical effu-



28 HEAD.

sions exist within its cellular tissue. When it is helow the aponeu-
rosis or the galea capitis, the swelling is tight, elastic, fluctuating, and
leaves no pits on pressure, and never spreads over the ears or eyelids ,
and this for obvious reasons.

Both forms exist without cerebral symptoms, and may be the con-
sequence of either a general dropsical condition, or of erysipelas,
external injuries, stings of insects, eruptions, and so on.

Hypertrophy of the Skull.

This may either involve a part only of the cranium, in which case
it fo-rms exostosis or hony protuhera^ices ; or the ivhole skull ; whereby
the bony walls may attain a thickness of one inch and a half. Both
forms cause an enlargement of the head, and are mostly found as a
concomitant to rhachitis or syphilis.

Those bony protuberances which grow out from the inner plate of
the skull have been already mentioned as pseudo-formations within
the cavity of the skull; and, as they do not cause any external
enlargement of it, they are not recognizable with any degree of
certainty.



The Bruised Head of a Child after Bii



"J



Caused by the pressure during birth, is either an extravasation of
lymph or hlood into the cellular tissue ; in which case it is called caput
succedaneum ; or it may be a7i extravasation of blood between the bones
and the pericranium, causing the affection called thrombus neonatorum.

The caput succedaneum may extend over the fontanelles or sutures
of the bones ; it may even be formed on any part of the head suf-
ficiently exposed to a great pressure of the pelvis, or the forceps,
during labor. It has a soft, downy feel, and the outer skin looks
bruised.

The thrombus, however, is confined generally to the parietal bones,
and never extends over the sutures of the bones, because there the
pericranium adheres firmly to the skull. It feels elastic and fluctuat-
ing, and shows no discoloration of the external skin.

Both forms are in their nature bruises, and ought to be treated,
should treatment be necessary at all, like bruises. Arnica will almost
always do all that is required; in some cases, however, Bar. mur.
and Merc, have been successfully applied.



DISEASES OF THE CRANIUM AND ITS INTEGUMENTS. 29

B. Abnormal Smallness

Of tlie head is found in idiots. It may be partial or general, con-
genital, or caused after birth., before ossification is completed. Al-
ways, however, it will be found in connection with an imperfect
development or derangement of the brain.

C. AjErections of the Skull withotit Enlargement.

The cranium consists of two tables, which run parallel with each
other, and are separated by an intermediate cellular structure, which
is called diploe. The whole, however, consists of eight different
bones, which are connected to each other by sutures. Before these
sutures consolidate, there are, of course, on those places where dif-
ferent bones are to meet, larger or smaller openings, which are called
fontanelles. At the time of birth, however, as a general thing, only
one of these fontanelles exist, and that is the anterior opening, whilst
lh.Q, posterior 2a\A parietal openings have already closed.

The anterior fontanelle closes normally in the second year of life.
If it stays open much longer than two years, it shows a want of
proper nutritive action in the system; if it grows larger^ dividing the
frontal bone and parting the parietal bones, it is a sign of chronic
hydrocephalus, or of hypertrophy of the brain. If you lay your
hand softly upon it, or watch it closely, you will observe a constant
motion up and down, a kind of breathing of the brain. Screaming or
coughing causes momentary distention and protrusion of the integu-
ment over it. If, however, as in cases of meningitis, this opening
swells out permanently^ it is a sign of exudation of water in the brain.
Its suddenly sinJnng in denotes a collaiDSUs of the hrain, which is soon
followed by death. In like manner, the posterior fontanelle^ by a
morbid process of absorption of the already- formed bony substances,
may reopen again ; or there may form several holes near by, — the
bony structure withering away gradually, leaving only the integ-
uments. This is called the soft occiput or craniotahes. It has been
observed mostly towards the end of the first year, especially in chil-
dren of rhachitic or scrofulous parents. It is doubtless a deep-seated,
constitutional disorder, and can be successfully treated only by a
careful study of all the symptoms. Nevertheless, Sulphur, Calcarea
c, Calc. phos., and Silicea might often be indicated. If not checked,
it becomes frequently complicated with meningitis, or pneumonia, or
tuberculosis, and diarrhoea, which soon end the scene.



30 HEAD.

To this I may add —

r

Atrophy of the S

This may be a consequence of internal pressure from pseudo-for-
mations within the cavity of the skull, which may even perforate the
cranium ; or from hypertrophy of the brain ; all which have been
already mentioned.

We also meet with inflammation of the skull or ostitis, with all its
sequela3 — caries and necrosis — which is mostly of a syphilitic or tuber-
cular origin, or is caused b}^ external wounds badly treated.

Therapeiitic Hints. — Caries calls for Asa f, Cal. c, Calc.
phosph., Fluoric ac, Puis., Silic, Sulph., and perhaps other remedies.

D. Diseases of the Integuments.

The integuments of the cranium consist of the following five differ-
ent layers:

1. The external skin or derma is covered thickly with hair, and
contains innumerable sebaceous and sudoriparous glands, of which the
former secrete an oily, fatty substance, and the latter are the organs
of perspiration.

2. The subcutaneous celhilar tissue, in which lies imbedded the net-



Online LibraryCharles Gottleib RaueSpecial pathology and diagnostics : with therapeutic hints → online text (page 4 of 65)