A Lecture on ACUTE CEREBRAL LESIONS AT DIFFERENT AGES
Authors: S. A. K. Wilson
Journal: BMJ (1929)

ACUTE cerebral lesionis may be reckoned among what mny old teaclher, the late Sir William Gowers, oniCe called " the uncoinmoiiplaces of medical practice."Not occurring often enouigh to become familiar, if not banal, yet niot so rare as to render ignorance of their nature and treatment pardonable, they are seeni bv the practitionier more frequently than by the consultant, and in nearly every instance necessitate hiis coining to quick decisions and adoptinig prompt therapeutic measures.Obviously he must have a certain confidence in his own diagnosis when such cir cumstances prevail, anld must have at ready disposal some formulation of diagnostic elements on which to rely diuring the first hours after the lesion reveals itself.A waitinig policy does not always serve at these times.In tlhis, as in many otlier instances, the problem is to know lhow to approach the problem.Working rules are necessary if he is to grasp the essential features of the situation and avoid being misled by non-essentials.Textbook descriptions doubtless cover all eventualities, but their application to the practice of medicinle leaves him on occa- sion in p-erplexitv.I do not pretend that the problem can be simplified by any rltle of thumb devoid of exceptions and inifallible in its working; all of us commit errors of diagnosis anid of judgemenlt, anld somiietimes lhesitate niot so miuch from ignloraiice as fromii fullniess of knowledge.Wlhen this situation develops, another dictum of the same great cliniical teaclher deserves to be recalled: " Be decisive in Youn.inidecision "-in otlher words, be sure of your reasonss for not being sure, and adopt measures calculated at least to do nio harm.One of the most con-venieint and practical wavs of dealinog witlh the piroblem of an acute cerebral lesion is by attenldinig to the age of the patient.At aniy given age period, what are tlhe probabilities?The generalization-s sketched below have their valte, relative though niot absolute, and are wortlh bearinig in mind. I. 1T CHILDREN AND YOUNG, PEOPLE.Nuimer-ically an-d proportionatelv less commiion in clhild- hood and early adolescenice, abrupt cerebral affections con- stituite no actual rarity and aire often nlot a little dis- conlcerting.Since" thle observer is able to dismiss all thlought of degenitive lesions from his miiind-in such cases, the piathological p'ossibilities are 'more or less estricted to toxic anid toxi-infective pr ocesses, pressure, trauma, anid blood-vascular states.Of these, the firstnamed form the majoritv.Much tlhe most frequ-ient is one or other variety of encephtalitis, by wlhich pathological term is to be-under- stood a brain infection, whether specifically kn-owni or not.-A sporadic encephalitis (not, in all problability, identical witlh what is niow called-epidemic encephalitis)-somnetimes described as acute nion-suppurativ'e encephalitis-is a fairly coimnoii affection of childhiood, producing usually-a hemi- plegia and less often a diplegia.Wlhen a preliminary stage of malaise, fever, and vomiting, wvitlh headache, -ossibly w-itlh delirium and stupor, is succeeded by generalized con- v-ulsive attacks with unconsciousnless, rigility, -Yanosis, and so folrthl, aand followed by paralysis on one sid_e of the body, the syndrome is not so, sudden as-to -preclude a vcty good idea of its niature being formiied.-But in a miiinority of cases the paralysis super veines abruptly on a con1vulsioln, or even withoxut the latter, just as it appears uinheralded in a small l)roportion of cases of acute polio-