General considerations in
clinical electroencephalography
GEORGE H. SCHEURER, B.S., D.O.,° Kirksville, Missouri
For approximately the past 27 years, in the United States, electroencephalography has been serving as an electrodiagnostic modality in clinical medi-cine: A review of the literature indicates that during this period the diagnostic value and the limitations of this modality have been receiving considerable attention. Evidence continues to accumulate to enhance understanding of its value and to clarify its usefulness. It has been gaining wide acceptance in clinical medicine as a valuable adjunct to the diagnosis of disease processes originating within the nervous system. In addition to its usefulness in the identification of primary nervous system dis-orders, electroencephalography is of assistance to the clinician in the diagnosis of encephalopathies associated with disorders in other systems of the body. Encephalopathies related to hepatic and renal dysfunction illustrate this latter use of the electroencephalogram (EEG).
The present discussion of this subject is con-cerned primarily with the presentation of a brief historical review and a synopsis of the relationship of electroencephalography to such clinical
con-This report was prepared as part of a training program involving the study of electrophysiologv and electrodiagnosis. This program re-ceived support from the National Osteopathic Foundation through a grant from Wyeth Laboratories, Philadelphia, Pennsylvania. Dr. Scheurer is an assistant professor of osteopathic medicine at Kirks-ville College of Osteopathy and Surgery.
°Address, Kirksville Osteopathic Hospital, 800 W. Jefferson
ditions as convulsive disorders, space-occupying lesions of the brain, head injuries, vascular
dis-orders of the brain, and psychiatric disturbances.
The literature contains almost innumerable ar-ticles relative to electroencephalography. Certain illustrative articles have been selected from the current and past literature to identify a few indi-viduals whose work has been outstanding in this field, to indicate the usefulness of this electrodiag-nostic modality in clinical medicine, and to point out areas in need of further investigation.
Historical review
The brief historical review herewith presented is a condensation of the historical material published in the Atlas of Electroencephalography, 1
Diagnos-tic Electroencephalography, 2 and Electroencepha-lography in Clinical Practice. 3 For a more detailed
description of the history of this subject, the reader is referred to these sources.
During the latter part of the nineteenth century, Caton, von Marxow, and Beck presented evidence that the brains of living animals produced electrical currents; that these currents were endogenous; and that this electrical activity could be detected with electrodes outside the skull.
Soon after the turn of the century, about 1902, Hans Berger, a German psychiatrist, began investi-gating this electrical activity of the brain; on July 6, 1924, he successfully recorded the first human elec-troencephalogram. However, it was not until 1929
that he made public the observations of any of his investigations.
Among Berger's observations was one indicating that the electrical activity of the brain could be recorded during rest. This information was in op-position to knowledge relating to the electrical activity of muscle. At that time, it was known that the electrical activity of muscle appeared silent during rest and became more evident with increas-ing muscular activity. In part because of this differ-ence between the electrical activity of brain and muscle, Berger's findings were not fully accepted by members of the scientific world at that time.
One of these members, E. D. Adrian, neurophysi-ologist and Nobel prize winner, was skeptical of Berger's findings. Considering the electrical rhythms of the brain, reported by Berger, to be artifacts resulting from electrical interference, Adrian began investigating the electrical activity of the brain with instruments from his own well-equipped lab-oratory. His findings substantiated those of Berger.
In 1934, Adrian publicly recognized the validity of Berger's work.
Public recognition of Berger's work by Adrian resulted in increased interest and further investi-gation of the brain's electrical activity by persons throughout the world. In the United States the first clinical electroencephalographic laboratory was established at the Massachusetts General Hos-pital in 1937.
During World War II, the armed forces of the various countries became intensely interested in this relatively new diagnostic modality. It was utilized to assist in the selection of flying personnel and to assist in the localization of brain lesions. The extensive use of electroencephalography by the armed forces resulted in the accumulation of many recordings and numerous publications which de-scribed favorably its diagnostic usefulness.
In an effort to standardize the recording and improve the quality of work in this field, societies of electroencephalography were formed in several countries. In 1947, Electroencephalography and
Clinical Neurophysiology ("The EEG Journal")
was originated; it began publication in 1949. In that same year, an International Federation of Societies for Electroencephalography and Clinical Neurophysiology was established, and "The EEG Journal" was proclaimed the official publication of this Federation.
In clinical medicine, electroencephalography con-tinues to provide a service to the patient and to the diagnostician, whether he be specialist or gen-eral practitioner.
Convulsive disorders
One of the first uses of electroencephalography in
JOURNAL A.O.A., VOL. 63, JAN. 1964
clinical medicine in the United States was to in-vestigate the electrical activity of the brain of indi-viduals with convulsive disorders. Gibbs and Gibbs,4 Penfield and Jasper, 5 and Lennox and Lennox6 have extensively investigated this activity as it relates to epilepsy and have written volumi-nously on the subject. Probably no other clinical condition has been so extensively studied with electroencephalography.
The contributions of these people, along with others, have greatly enhanced the usefulness of the EEG in differentiating epilepsy from the other convulsive disorders. Electroencephalographic clas-sifications of epilepsy 4 '7 were formulated with the intention of providing the clinician with information that would be used in the diagnosis and prognosis of the various forms of epilepsy. Generally, these classifications were based on specific electroenceph-alographic patterns, their site of origin in the brain, and the characteristics of their electrical spread to various regions of the brain.
The diagnostic and prognostic value of the clin-ical EEG in the study of epilepsy is enhanced by serial recordings and by the performance of pro-cedures intended to elicit or accentuate abnormal electrical activity from the brain. These procedures are referred to as "activation"8 or "provocation"9 techniques. Among the numerous techniques avail-able for use, hyperventilation, sleep, photic stimu-lation, and photic-Metrazol activation appear to be the most commonly used.
Although activation techniques are used primarily to elicit or accentuate the electroencephalographic patterns associated with epilepsy, they may be of value in other areas of clinical electroencephalog-raphy. For example: Silverman i° and Silverman and Morisaki" have recommmended sleep as a general activation procedure whenever the waking EFiG appears inconclusive or contains diffuse ab-normalities. Further, Ulett, Johnson, and Mills12 conducted a comparative review of hyperventila-tion, sleep, and photic stimulation. From their find-ings they proposed that activation be construed to indicate general brain excitability as a response to stress. They conceived that if this concept of activa-tion were considered in place of the older concept of attempting to correlate electroencephalographic response with pathologic entities, valuable infor-mation regarding cortical instability and a person's vulnerability to stress might be forthcoming.
Convulsions are associated with various clinical disorders. Although epilepsy is one of the major conditions responsible for convulsive attacks, other important causes of seizures need differentiation. In this respect the diagnostic value of the EEC may be realized. A report by Gastaut and Gastaut13
will illustrate the practical value of such a proce-dure in clinical medicine.
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An interest in differentiating epileptic seizures from ischemic-asphyxic convulsions in children led these workers 13 to study 172 children (mean age, 28 months) referred to their EEG laboratory for examination. This study consisted of the simul-taneous recording of an electroencephalogram, electrocardiogram, and pneumogram, using ocular pressure as a means of activation. Ocular pressure not exceeding 10 seconds was applied from one to three times during an examination. It was the im-pression of these investigators that the reason some children with convulsive seizures do not develop epilepsy is that these children do not actually have epilepsy. These authors believed that the convul-sions in these children were ischemic-asphyxic con-vulsions resulting from excessive stimulation of the cardiorespiratory center in the medulla. They con-sidered this excess stimulation to be the result of increased interoceptive, exteroceptive, and proprio-ceptive stimuli to the medulla by way of the vagus nerve.
The literature contains numerous reports relating the EEG to the convulsive disorders. Suffice it to say here that little doubt should exist in the clin-cian's mind regarding the usefulness of the EEG as an aid to the diagnosis of clinical seizures. How-ever, it must be borne in mind that, as with most diagnostic procedures, the value of the EEG is greatly enhanced by its integration into the broad clinical context of signs and symptoms.
Space-occupying lesions
Electroencephalography involves the recording of the bioelectric activity of the brain. Because this activity can be influenced by many causes, there are no specific recordable bioelectric patterns that
can be directly associated with a specific type of space-occupying lesion in the brain. However, serial recordings of the EEG and correlation of its abnormalities with clinical signs and symptoms of the patient9 may reveal the presence of a space-occupying lesion in the brain. Therefore, the EEG is of assistance to the clinician in the diagnosis of this type of lesion.
It has been reported that tumor tissue does not of itself produce recordable electrical activity;9 therefore, the changes in the electrical activity of
the brain as recorded on the EEG are probably caused by a combination of various mechanisms. Pressure, edema, vascular insufficiency, or a com-bination of these effects can alter cellular metab-olism in neighboring areas of the brain or related neuronal pathways. In this manner the electrical activity of the brain may be influenced to reveal generalized or focal cellular dysfunction.
In a study of 38 patients with supratentorial tumors, focal arrhythmic activity on the EEG was reported by Daly and Thomas. 14 They suggested that the best electroencephalographic evidence of deterioration was the observation of focal abnor-mal activity which became progressively more severe. In addition, they reported that in the pres-ence of a supratentorial tumor abrupt changes in the electrical activity of the brain could occur. These abrupt changes were detected through the performance of repeated electroencephalographic examinations.
Although focal abnormalities on an EEG may be associated with an intracranial space-occupying lesion, electroencephalography does not separate surgical from nonsurgical lesions, according to the report of Small, Bagchi, and Kooi. 16 However, from their study of 117 patients with deep-seated intra-cerebral tumors they indicated that the EEG was of assistance in identifying the presence of deep-seated intracerebral tumors. It was their impression that approximately three fourths of their proved cases were correctly interpreted as indicating a deep-seated intracerebral lesion.
Further, in the consideration of space-occupying lesions of the brain, the value of the EEG in the identification of infratentorial lesions merits atten-tion.
In a study of 121 subjects with infratentorial lesions, of which 113 were tumors, Bagchi and co-workers 16 reported statistically significant correla-tions between bianterior burst activity on the EEG and increased intracranial pressure, along with sta-tistically significant correlations between electro-encephalographic abnormalities and mental signs. However, no statistically significant difference be-tween the degree of electroencephalographic ab-normality and increased intracranial pressure was observed. In this study, 69.4 per cent of the cases were correctly identified with a deep level
dis-turbance or lesion; these were confirmed during surgical exploration or postmortem examination.
Illustrative of the influence of metabolic effect upon the electrical activity of the brain are the investigations of Boselli and Jefferson 17 and of Hughes and Summers.18
These investigators studied the electroencephalo-grams of 59 patients with pituitary chromophobic adenomas and 17 patients with Rathke pouch cysts. The electroencephalographic changes attributed to the adenoma were believed to be caused by metabo-lic dysfunction from endocrine deficiencies. The basis for this belief was the observation of regres-sion of electroencephalographic abnormalities with endocrine replacement therapy. Hughes and Sum-mers 18 reported similar observations during a study of 14 cases of hypopituitarism from postpartum necrosis. Gross abnormalties on the EEG were noted in severe hypopituitarism, and milder electroenceph-alographic changes were observed in less severe cases of hypopituitarism. The latter investigators indicated that the electroencephalographic changes were the result of metabolic disturbances and not the result of organic damage to the brain.
Generally, clinicians recognize the importance to the patient of the early diagnosis of a space-con-suming lesion in the brain. Although the size and location of such a lesion may limit the diagnostic value of the EEG, repeated recordings can enhance its usefulness in the early detection of cerebral dysfunction associated with an expanding lesion in the brain.
Head trauma
Trauma to the head can produce varied injuries to the brain, including concussion, contusion, and laceration of brain tissue. These injuries, as well as their clinical effects, may be mild or severe; they may or may not be associated with changes on the EEG.
To correlate the electroencephalographic changes with the clinical effects of head trauma, it is neces-sary to have an understanding of the effects of such trauma to the brain. These effects and associated changes on the EEG have been widely investigated. Williams,"° studying the effects of concussion, implicated the mesencephalon as the primary area of involvement. He considered the associated elec-troencephalographic changes to be the result of secondary changes in the cerebrum. Also Gurdjian, Webster, and Lissner,2° from experimental studies with animals, considered the area of involvement
to be in the upper brain stem.
From this study, Gurdjian, Webster, and Liss-ner concluded that pressure changes at the cranio-spinal junction produced microscopic changes in
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Generally, clinicians recognize the importance of early diagnosis of a
space-consuming lesion in the brain. Although the size and location of such a lesion may limit the diagnostic value of the EEG, repeated recordings can enhance its usefulness
in early detection of cerebral dysfunction associated with an expanding lesion
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the cells of the upper brain stem; they considered these changes to be the cause of concussion. On the other hand, Meyer and Denny-Brown' attrib-uted the cause of concussion to temporary neuronal paralysis from damaged cellular membranes.
Gurdjian, Webster, and Lissner2° further reported that contusions and lacerations of the brain, follow-ing traumatic impact, result from various causes. These included deformities and distortions of the skull and dural septa, cavity formation from sub-normal pressure, and movements of the brain. Meyer22 investigated contusion, laceration, and brain-stem injury in monkeys and cats. His report related that the first effect of trauma to the brain was local, transient paralysis of neurons, which later was overshadowed by metabolic disturbances
(ischemia and anoxia ).
Miiller23 reported on clinical electroencephalo-graphic findings which he associated with the late effects of cerebral contusion. His observations in-cluded the local reduction of alpha waves in the posterior part of the head and local dysrhythmic theta activity in the frontal and temporal areas of the brain.
In many instances, altered states of consciousness are known to result from head trauma. Generally, it is recognized that there is a correlation between the level of consciousness and the degree of electro-encephalographic abnormality. However, Kaada, Harkmark, and Stokke24 reported the recording of a normal EEG from a patient in deep coma. At autopsy, evidence of hemorrhage in the pontine region of the brain stem was observed. From their study of this one case and from other reports in the literature, these workers concluded that coma and organized slow-wave electroencephalographic activity ( commonly associated with coma) might
be independent of each other. These same authors reported that similar cases in the literature show evidence of lesions in the middle and upper portion of the pons. Chatrian, White, and Daly 25 reported the finding of sleep spindles, K complexes, and vertex sharp waves (normal sleep pattern) on the EEG's of 11 patients with altered states of con-sciousness resulting from trauma. It is of interest that a favorable outcome was reported in each such case.
As has been stated previously, serial recordings and correlation of electroencephalographic findings with clinical signs and symptoms increase the diag-nostic usefulness of the EEG. However, it is pos-sible to observe, simultaneously, clinical improve-ment and deterioration on the EEG; this has been referred to as "Williams paradox."9
Attention should be paid to the fact that electro-encephalographic changes observed following head trauma may not be the result of the traumatic in-cident. If a pretraumatic EEG is not available for comparison with the post-traumatic recording, it cannot be said with certainty that the abnormalities observed following trauma were the result of the ascribed incident.
Vascular disorders
With a rising number of older citizens among our population, it is becoming increasingly important to have available methods which will assist the clinician in differentiating vascular disorders from other pathologic entities in the brain. The EEG may provide such a method.
Bruens, Gastaut, and Giove 26 reported the pres-ence of electropres-encephalographic paroxysmal theta and delta activity in the frontotemporal or temporal regions of the brains of patients believed to have vascular insufficiency, resulting from internal
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Trauma to the head can produce varied injuries to the brain, including concussion, contusion, and laceration of
brain tissue. These injuries, as well as their clinical effects, may be mild or severe; they may or may not be associated with changes on the EEG
tid or middle cerebral artery involvement. They suggested this pattern of electrical activity to be indicative of ischemia of the sylvian region, with resultant functional disturbance but not organic disturbance. Further, they reported that, in these cases, no significant disturbances in the normal background rhythms were observed on the EEG's. It was the impression of these authors that the EEG may serve as an indicator of impending cere-bral vascular decompensation. In addition, they observed in the posterior regions of the head theta and delta activity which they considered might be• attributed to vertebral or basilar artery insufficiency. Similarly, Tucker27 suggested that, in cases of medullary or pontine infarction, the EEG might serve as an indicator of impending involvement of structures of the brain supplied by the basilar artery.
Additional information regarding the electro-encephalographic findings associated with vascular disturbances can be found in the report of van der Drift and Magnus. 28 They indicated that focal changes on the EEG were associated with ischemic disorders resulting from internal carotid and middle cerebral artery involvement. Similarly, focal changes were reported to be associated with occlusion of the anterior and the posterior cerebral arteries. These focal changes associated with involvement of the latter arteries were not so marked as the focal changes associated with the former ones.
It is of interest to note that they reported longer lasting, more extensive delta activity and rnore epileptiform discharges on the EEG's associated with cerebral embolism than on the ones associated with cerebral thrombosis.
Also, it was the opinion of van der Drift and Magnus28 that cerebral hemorrhage, as contrasted with ischemia, was associated with less unilateral electroencephalographic changes. Further, it was their impression that the site of hemorrhage, rather than the cause, accounted for the observed electro-encephalographic abnormalities.
In an era when vascular disorders are of con-siderable importance to the health of our popula-tion, it is conceivable that clinicians will give addi-tional consideration to the EEG as a diagnostic modality for the differentiation of such disorders.
Psychiatry
Electroencephalography has been of limited value as an aid to the diagnosis of psychiatric disturb-ances. 9 The reasons for this appear to be many. The inadequacies of psychiatric nosology are legend. The ill-defined criteria used by various psychiatric centers as a basis for the establishment of specific psychiatric entities has made the comparison of findings between such centers difficult, if not
tically impossible. Also, studies of groups of patients of varying ages without adequate controls for com-parison have yielded unreliable results. Similarly, the inclusion of a variety of diagnostic categories in the same group without comparable controls has resulted in misleading or invalid studies.
Isolated case reports and small group studies may be of interest to the reader. However, the accept-ance of such published reports as representative of the usual requires careful evaluation. The report by Hes 29 of a 19-year-old woman with manic-de-pressive psychosis is interesting but not represent-ative. He reportedly observed normal findings on the EEG recorded during the depressed stage of the illness and paroxysmal, symmetrical, high-voltage, slow activity, predominant in the frontal regions, on the EEG recorded during the manic stage. Following 150 seconds of hyperventilation the EEG was composed almost exclusively of sym-metrical, high-voltage, slow activity, predominant in the precentral areas.
In regard to mental and autonomic disturbances, Petersen and Sorbye3° reported a high incidence of related symptoms associated with a group of EEG's which displayed 2.5 to 4.5 cycle per second, sinusoidal, slow waves in the posterior regions of the head. These slow waves generally had an ampli-tude of approximately 50 microvolts, and rarely exceeded 70 to 80 microvolts.
In a study of electroencephalography as it re-lates to aging, Silverman, Busse, and Barnesm studied the EEG's of elderly hospitalized senile subjects and community volunteers. They found that with increasing age a higher incidence of ab-normal EEG's was observed. Further, they reported a relationship between socioeconomic level and electroencephalographic abnormality—decreasing abnormality with progressively better socioeco-nomic adjustment.
A group of patients with chronic brain syndrome (mean age, 77) was compared with a group of patients classified as functional (mean age, 72) by Obrist and Henry. 32 The group with chronic brain syndrome presented evidence of mental deteriora-tion, whereas the group classified as functional showed evidence only of emotional and behavioral disturbances. From their observations of this study, the authors reported more slow activity on the EEG's of the group with chronic brain syndrome and more alpha and beta activity on the EEG's of the group with functional disturbances.
Mental illness is referred to frequently as one of the major health problems in the United States. The fact that electroencephalography may distin-guish organic from functional brain disturbances could be of significance to clinicians involved with the diagnosis and management of mentally dis-turbed individuals. It is anticipated that with
JOURNAL A.O.A., VOL. 63, JAN. 1964
further studies and improved methods of electro-encephalographic analysis, the future use of the
EEG in psychiatry will be more rewarding.
Summary
This discussion has included a condensation of the historical highlights relating to the development and growth of electroencephalography. In addi-tion, material from the literature relating the EEG to clinical conditions such as convulsive disorders, space-occupying lesions of the brain, head trauma, vascular disorders of the brain, and psychiatric disturbances, has been reported. Certain procedures intended to enhance the usefulness of the EEG to the clinician have been considered.
It has been the intention of this presentation to indicate various uses of electroencephalography in clinical medicine and to stimulate thought among clinicians regarding the value of electroencephalog-raphy as an aid to diagnosis.
1. Gibbs, F. A., and Gibbs, E. L.: Atlas of electroencephalography; vol. I, methodology and controls. Ed. 2. Addison-Wesley Press, Cambridge, Mass., 1950.
2. Strauss, H., Ostow, M., and Greenstein, L.: Diagnostic electro-encephalography. Grune & Stratton, New York, 1952.
3. Schwab, R. S.: Electroencephalography in clinical practice. W. B. Saunders Co., Philadelphia, 1951.
4. Gibbs, F. A., and Gibbs, E. L.: Atlas of electroencephalography; vol. II, epilepsy. Addison-Wesley Press, Cambridge, Mass., 1952.
5. Penfield, W., and Jasper, H.: Epilepsy and functional anatomy of human brain. Little, Brown & Co., Boston, 1954.
6. Lennox, W. G., and Lennox, M. A.: Epilepsy and related dis-orders. Little, Brown & Co., Boston, 1960.
7. Penfield, W.: Epileptic manifestations of cortical and supra-cortical discharge. Electroencephalog. & Clin. Neurophysiol. 1:3-10, Feb. 1949.
8. Kaufman, I. C., and Watson, C. W.: Brief review of methods used to elicit or accentuate abnormalities in electroencephalogram. Electroencephalog. & Clin. Neurophysiol. 1:237-240, May 1949.
9. Kiloh, L. G., and Osselton, J. W.: Clinical electroencephalog-raphy. Butterworths, London, 1961.
10. Silverman, D . : Sleep as general activation procedure in
elec-troencephalography. Electroencephalog. & Clin. Neurophysiol.
8:317-324, May 1956.
11. Silverman, D., and Morisaki, A.: Re-evaluation of sleep
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In an era when vascular disorders are of considerable importance to the
health of our population, it is conceivable that clinicians will give additional consideration to the EEG
as a diagnostic modality for the differentiation of such disorders
w
encephalography. Electroencephalog. & Clin. Neurophysiol. 10:425-431, Aug. 1958.
12. Ulett, G. A., Johnson, L. C., and Mills, W. B.: Pattern, sta-bility and relationship among electroencephalographic "activation" techniques. Electroencephalog. & Clin. Neurophysiol. 11:251-266, May 1959.
13. Gastaut, H., and Gastaut, Y.: Electroencephalographic and clinical study of anoxic convulsions in children; their location within group of infantile convulsions and their differentiation from epilepsy. Electroencephalog. & Clin. Neurophysiol. 10:607-820, Nov. 1958.
14. Daly, D. D., and Thomas, J. E.: Sequential alterations in electroencephalograms of patients with brain tumors. Electroen-cephalog. & Clin. Neurophysiol. 10:395-404, Aug. 1958.
15. Small, J. G., Bagchi, B. K., and Kooi, K. A.: Electro-clinical profile of 117 deep cerebral tumors. Electroencephalog. & Clin. Neurophysiol. 13:193-207, April 1961.
16. Bagchi, B. K., et al.: Subtentorial tumors and other lesions; electroencephalographic study of 121 cases. Electroencephalog. & Clin. Neurophysiol. 13:180-192, April 1961.
17. Boselli, F., and Jefferson, A. A.: Electroencephalogram with chromophobe adenumata and Rathke pouch cysts; modification by associated metabolic disorder. Electroencephalog. & Clin. Neuro-physiol. 9:275-290, May 1957.
18. Hughes, R. R., and Summers, V. K.: Changes in electro-encephalogram associated with hypopituitarism due to post-partum necrosis. Electroencephalog. & Clin. Neurophysiol. 8:87-98, Feb. 1956.
19. Williams, D.: Neurological and EEG aspects of head injury. Electroencephalog. & Clin. Neurophysiol. 7:495, Aug. 1955.
20. Gurdjian, E. S., Webster, J. E., and Lissner, H. R.: Mechanism of brain concussion, contusion and laceration. Electroencephalog. & Clin. Neurophysiol. 7:495, Aug. 1955.
21. Meyer, J. S., and Denny-Brown, D.: Studies of cerebral cir-culation in brain injury; cerebral concussion. Electroencephalog. & Clin. Neurophysiol. 7:529-544, Nov..1955.
22. Meyer, J. S.: Studies of cerebral circulation in brain injury;
cerebral contusion, laceration and brain stem injury.
Electroenceph-slog. & Clin. Neurophysiol. 8:107-118, Feb. 1956.
23. Miller, IL: Correlations eleetroencephalographiques et c.liniques
dans les anciens traumatismes crimio-cerebraux fermes avec foyer de
contusion corticale en EEG. Electroencephalog. & Neurophysiol.
7:75-84, Feb. 1955.
24. Kaada, B. R., Harkmark, W., and Stoklce, 0.: Deep coma
associated with desynchronization in EEG. Electroencephalog. &
Clin. Neurophysiol. 13:785-789, Oct. 1981.
25. Chatrian, G. E., White, L. E., Jr., and Daly, D.:
Electro-encephalographic patterns resembling those of sleep in certain
coma-tose states after injuries to head. Electroencephalog. & Clin.
Neuro-physiol. 15:272-280, April 1963.
26. Bruens, J. H., Gastaut, H., and Giove, G.:
Electroencephalo-graphic study of signs of chronic vascular insufficiency of sylvian region in aged people. Electroencephalog. & Clin. Neurophysiol. 12: 283-295, May 1960.
27. Tucker, J. S.: Electroencephalogram in brain stem vascular
disease; some observations relating electroencephalographic Endings
to various combinations of infarction and vascular insufficiency. Electroencephalog. & Clin. Neurophysiol. 10:405-418, Aug. 1958.
28. van der Drift, J. H. A., and Magnus, 0.: Significance of EEG
in cerebro-vascular disorders. Electroencephalog. & Clin.
Neuro-physiol. 11:620, Aug. 1959.
29. Hes, J. P.: Manic depressive psychosis; case report.
Electro-encephalog. & Clin. Neurophysiol. 12:193-195, Feb. 1980.
30. Petersen, I., and Sorbye, R.: Slow posterior rhythm in adults.
Electroencephalog. & Clin. Neurophysiol. 14:161-170, April 1962. 31. Silverman, A. J., Busse, E. W., and Barnes, R. H.: Studies in processes of aging; electroencephalographic findings in 400 elderly subjects. Electroencephalog. & Clin. Neurophysiol. 7:67-74, Feb. 1955. 32. Obrist, W. D., and Henry, C. E.: Electroencephalographic frequency analysis of aged psychiatric patients. Electroencephalog. & Clin. Neurophysiol. 10:621-632, Nov. 1958.
Diffuse gastric eosinophilic granuloma
with transient pulmonary infiltration:
Case simulating gastric carcinoma
HAROLD KATZEN, D.O.,* Chicago, Illinois
This presentation was stimulated by a recent oppor-tunity to examine a patient exhibiting a diffuse eosinophilic infiltration of the stomach associated with a peripheral blood eosinophilia and transient pulmonary infiltration. This particular triad is ob-viously rare, as evidenced by the fact that an initial review of the literature disclosed only one similar
This paper was submitted in partial fulfillment of the requirements for certification by the American Osteopathic Board of Radiology, March 1983.
°Address, Chicago Osteopathic Hospital, 5250 S. Ellis Ave.
case; this was reported by Ruzic and associates' in 1952. The only basic difference appears to be that their patient had a definite allergic history, whereas there was none in the case to be presented here. Similar striking gastrointestinal manifesta-tions, with or without eosinophilia, have been de-scribed, but to my knowledge these uncommon cases did not display roentgen evidence of associ-ated pulmonary infiltration.
Case report
A 46-year-old, moderately obese Negro woman was admitted to the Chicago Osteopathic Hospital on
