eyes, both eyes and the head being turned strongly to one side or the
other. When the lesion is above the pons and is irritative, as in the
early stage of hemorrhage, the deviation is toward the side of the
body affected and away from the lesion; when paralysis is established,
away from the paralysis and toward the lesion. Below the pons the rule
is reversed. The spastic stage of conjugate deviation may coincide
with stiffness (early rigidity) of the paralyzed limbs. This deviation
must not be mistaken for an accidental position of the head. The
patient should be addressed from the side away from which he is
looking. Sometimes the eyes can be brought to the median line, and not
beyond. An attempt to turn the head forcibly beyond the median line
occasionally causes pain. The value of this symptom in diagnosis has
been denied, but a part at least of the apparent contradictions have
arisen from the neglect to notice whether it were of a paralytic or
spastic character.
As the condition of unconsciousness gradually passes off, the face
regaining, at least in part, its natural and more intelligent
expression, the eyes trying to follow the movements of surrounding
persons, an attempt being made, perhaps only by an unintelligible
sound or by a nod, to answer questions, the tongue being protruded, or
at least an attempt toward it made, and some motions being made with
the limbs,—the exact extent and intensity of the paralysis become more
apparent. Conjugate deviation, if it have existed, may disappear
before the other symptoms, or, if it has been of the rigid form
depending on an irritative lesion, it may become paralytic, and is
then in the opposite direction. The patient is then usually found to
be in a condition of hemiplegia, and at this point the history of
hemorrhagic apoplexy becomes identical with that of paralysis from
hemorrhage where no truly apoplectic condition has been present.
Lidell states that in more than one-third of all cases of cerebral
hemorrhage hemiplegia is developed without loss of consciousness or
coma. In some, the paralysis precedes unconsciousness, which then
slowly supervenes.
{940} Hemiplegia (_ἥμι_, half, _πληγη_ blow) is a paralysis or paresis
of a part of the voluntary muscles of one side of the body, and a few,
in some cases, on the other, and is undoubtedly to be referred to a
lesion interrupting the nervous communication between the cortical
centres of motion and the nuclei of the motor nerves, cerebral and
spinal; the conductors passing through the corpora striata, the
internal capsule, the peduncles, and crossing in great part to the
other side above or at the lower border of the medulla oblongata, and
passing down the crossed pyramidal tracts of the cord, to be finally
connected with the anterior gray columns of the cord. The portion
which does not decussate passes down the inner border of the anterior
columns under the name of columns of Türck. The amount of decussation
which takes place varies somewhat, and the suggestion has been made,
in order to explain certain cases of paralysis occurring on the same
side with the lesion, that possibly in some rare cases there may be no
decussation. It has never been shown, however, that this condition,
highly exceptional if even it ever occurs, is present in such cases.
It may be said in a general way, although exceptions to the rule can
be found, that it is those muscles trained to separate, specialized,
or non-associated movements which are chiefly affected, while those
which are habitually associated in function with those of the other
side are less or not at all so. It would not, however, be in the least
correct to say that specialized or educated movements of any set of
muscles are alone paralyzed, since the fingers, which are trained to
the most independent movements, are often just as incapable of making
the slightest movement of simple flexion as of writing or sewing.
We have in ordinary hemiplegia more or less paralysis of the upper
facial, the patient not being able to close his eye or to wink quite
so well as on the paralyzed side. The forehead may be smoother on the
paralyzed side. This condition is usually slight and of short
duration, but varies in different cases. Paralysis of the lower facial
angle of the mouth and cheek is usually better marked, but not
absolute. The corner of the mouth droops, perhaps permits the saliva
to escape; the naso-labial fold is less deep, and the glabella
deviated away from the paralyzed side. The cheek flaps with
respiration. The difference between this facial paralysis connected
with hemiplegia and that dependent upon a lesion of the trunk or
distribution of the nerve (Bell's), as in caries of the temporal bone
or the so-called rheumatic paralysis, is very striking, the latter
being so much more complete, and, by affecting the orbicularis
palpebrarum so as to prevent closure of the eye, giving a very
peculiar expression to the countenance. This distinction between the
two portions of the facial seems to make an exception to the rule
stated above, since in most persons the movements of the corner of the
mouth and of the cheek are quite as closely bilaterally associated as
those of the eyelids.
Paralyses of the third, fourth, and sixth pairs upon one side of the
body are comparatively rare in hemiplegia, and when present are
usually referable to localized lesions in the pons. They are to be
looked upon as something superadded to the ordinary hemiplegia. These
nerves, however, are affected in the peculiar way already spoken of as
conjugate deviation, which phenomenon would seem to denote that
muscles accomplishing combined movements in either lateral direction
of both eyes, {941} rather than all the muscles of each, are
innervated from opposite sides—_i.e._ that the right rectus externus
and the left rectus internus are innervated from the left motor
centres, and vice versâ. Exactly the same remark will apply to the
muscles of the neck which cause the rotation of the head seen together
with the deviation of the eyes. The muscles controlling deviation to
one side, although situated upon both sides of the median line, are
apparently innervated from the side of the brain toward which the head
is turned in paralysis.
The tongue is usually protruded with its point toward the paralyzed
side; and this is simply for the reason that it is pushed out instead
of pulled, and the stronger muscle thrusts the tongue away from it.
The motor portion of the fifth is, according to Broadbent, affected to
a certain extent, the bite upon the paralyzed side being less strong.
The hand and the foot are the parts most frequently and most
completely affected, but one or the other may be partially or wholly
spared, though the latter is rare. The muscles of the limbs nearer the
trunk may be less affected, so that the patient may make shoulder or
pelvis movements when asked to move hand or foot. In severe cases even
the scapular movements may be paralyzed. The muscles of the trunk are
but slightly affected, though Broadbent states that a difference in
the abdominal muscles on the two sides may be perceived as the patient
rises from a chair. The respiratory movements are alike on the two
sides. A woman in the hospital service of the writer had a quite
complete left hemiplegia at about the seventh month of pregnancy.
There was some return of motion at the time of her confinement. None
of the attendants could perceive any difference in the action of the
abdominal muscles of the two sides, although, of course, the usual
bracing of the hand and foot upon the left side was wanting. The pains
were, however, generally inefficient, and she was delivered by
turning. Muscular weakness often exists, and in some cases the
non-paralyzed side shows a diminution of power.
The sphincters of the bladder and rectum frequently, and in severe
cases almost invariably, lose their activity for a time. It is
possible, however, that in some cases of alleged inability to retain
urine and feces the defect is really mental, and akin to the dirty
habits of the demented. The involuntary muscles probably take no part
in hemiplegia, with the very important exception of the muscular coats
of the arteries, which apparently share to a certain extent, and
sometimes the iris.
Speech may be attempted, and the words be correct, so far as they can
be understood, though the patient is apt to confine his remarks to the
shortest possible answering of questions. It is, however, thick and
indistinct, since the muscles of the tongue and lips are but
imperfectly under the control of the will. This condition may be
connected with paralysis of either side, and is to be sharply
distinguished from aphasia or mental inability to select the proper
word or to determine the necessary movements for its pronunciation.
Aphasia is almost invariably connected with paralysis of the right
side, and will be minutely spoken of hereafter. There is, of course,
nothing to prevent the coexistence of the two conditions, but aphasia
cannot well be shown to exist until we have reason to suppose, first,
that the patient has ideas to express, and secondly, that the
paralysis of the muscles of the lips and tongue has more or less
completely disappeared. The patient may indistinctly mumble a word
which, {942} however, can be understood to be appropriate to the
occasion (defective articulation, glosso-labial paralysis), or, on the
other hand, pronounce with distinctness an entire wrong word or a
number of sounds without meaning (aphasia).
Sensibility—that is, ordinary cutaneous sensation—and, so far as we
can judge, the special senses, are not greatly affected after the deep
coma has passed off, but exceptions to this rule will be noted later.
Having described this most typical but not most common form of
cerebral hemorrhage—that is, the form in which both lesion and
symptoms are most distinct and can be most clearly connected—we have a
point of departure for conditions less clearly marked and less easily
explained.
It is probable that cerebral hemorrhage is much less likely than
cerebral embolism to take place without any disturbance of
consciousness or abnormal sensations; but there can also be little
doubt that a certain amount of paralysis is often accompanied by no
other symptoms, and post-mortem appearances often show the remains of
small hemorrhages which have passed unnoticed or are lightly
estimated. It is highly probable that small hemorrhages may give rise
to symptoms which pass for only a little accidental vertigo or a
slight feeling of faintness, until a later and more serious attack
gives a more definite explanation.
On the other hand, we have a set of cases in which all the symptoms of
cerebral hemorrhage may be present without the lesion. Many of these
are of course due to embolism, which will be considered later; but
besides this condition, recognized as softening for many years, we
find described under the head of simple, congestive, serous, and
nervous apoplexy cases where sudden or rapid loss of consciousness
occurs with general muscular relaxation, which, when fatal, show
nothing beyond changes in the circulation—_i.e._ in the amount of
blood in the cerebral vessels or of serum in the meshes of the pia or
at the base of the brain.
Besides these, there are cases of temporary unconsciousness with
complete recovery—the coup de sang of the French, or rush of blood to
the head, which are attributed to congestion of the brain—a theory
difficult to prove or disprove, but not in itself unreasonable.
Trousseau, without denying the possibility, or even probability, of
such a condition, says that which has been called apoplectiform
cerebral congestion is in the greater number of cases an epileptic or
eclamptic accident, sometimes a syncope. Simple epileptic vertigoes,
vertigoes connected with a bad condition of the stomach or diseases of
the ear, are wrongly considered as congestions of the brain. He speaks
of various conditions, such as violent attacks of whooping cough, the
expulsive efforts of women in labor, the congested faces of laborers
under heavy burdens, to show that cerebral congestion does not give
rise to an apoplectiform attack; and it is undoubtedly true that, as a
rule, no long-continued attack is the result; but it must be within
the personal experience of almost every one that decided cerebral
disturbance is produced for a few moments by such efforts, as, for
instance, blowing a fire with the head down. Besides this, a laborer
under a heavy load is presumably healthy and accustomed to his work,
so that his arteries may be supposed capable of maintaining a due
balance between arterial and venous blood in the brain; and, again,
although the ordinary efforts of women in labor do not cause
unconsciousness, puerperal {943} convulsions, involving a longer
period of violent muscular action, may do so, and even give rise to
hemiplegia.
Whatever name we may adopt for the temporary cases which recover,
there are others, and fatal ones, which are not explained by any
change in nomenclature. Epilepsy may, it is true, occur under such
circumstances that no convulsion is observed, but, on the other hand,
convulsions may accompany not only an attack of unconsciousness, but
actual cerebral hemorrhage.
Cases of sudden death with no discoverable lesion furnish abundant
opportunity and temptation for conjecture, and it is well known that
too much dependence must not be placed upon the post-mortem
appearances as to the amount of blood in the brain before death, and
probably just as little upon the amount of serum, except as indicating
a condition of atrophy.
Syncope, either from over-stimulation of the pneumogastric or from
simple failure of the heart, may be put forward to explain some cases
of sudden death, but seems to have no advantage as a universal theory
over the older one, which meets with so little favor. Lidell gives no
less than seventeen cases which he classifies as congestive or serous
apoplexy. They are not all equally conclusive, and were almost all of
alcoholics. In some of these there were absolutely no appearances
which could account for death. The two most characteristic of
congestive apoplexy were, first, a young negress who experienced a
violent fit of passion, became unconscious, with stertorous breathing,
and died, having had some tonic spasms. The brain contained a large
amount of blood in the vessels, but no effusion. Second, a
semi-intoxicated woman, aged thirty, became very angry, fell
insensible, and expired almost immediately. The brain contained an
excess of blood, with no effusion. In both these cases the patients
were subject to fits under the influence of strong excitement, but in
both the author took pains to inquire into and negative the
probability of epilepsy of the ordinary kind; and a change of name
does not go far toward clearing up the pathology.
Lidell's case (XXII.) was that of a man accustomed to alcohol, thin
and pale, who had an apoplectic fit with coma and hemiplegia. He
regained consciousness on the second day, and the hemiplegia
disappeared in a fortnight. This rapid and complete recovery,
exceptional to be sure, cannot be regarded as proof of the absence of
hemorrhage or embolism. In fact, the latter is highly probable. It is
possible that the clot may have been partially dislodged, so as to
allow some blood to pass by it, or that an exceptionally favorable
anastomosis allowed a better collateral circulation than usual to be
established.
The following case occurred in the service of the writer: An elderly
negress, who had extensive anasarca and signs of enfeebled action of
the heart without any valvular lesion being detected, after washing
her face was heard to groan, and found speechless and unable to
swallow, with complete right hemiplegia. There was a slight
improvement in a few hours, but she died two days later. The autopsy
disclosed some hypertrophy and dilatation of the heart without
valvular lesion. A careful search failed to discover any change in the
brain or obstruction in its vessels, although there was chronic
endarteritis.
The relations between epilepsy, apoplexy, and syncope are interesting
{944} and important, but are certainly far from clear. Little is
gained by shifting obscure cases from one category to the other. If
sudden deaths be synonymous with apoplexy, we shall certainly have to
admit that apoplexy does not always demand for its cause cerebral
changes sufficiently marked to be recognizable after death. If, on the
other hand, we refer them to heart disease, we shall have to admit
that a heart without valvular disease or extensive changes in its
muscular substance may cease to beat under influences as yet not well
understood.
Since the paralysis arising from hemorrhage resembles so closely in
its progress that dependent upon occlusion of the cerebral vessels, a
further description will be deferred until the latter lesion has been
described; but this remark does not apply to the premonitory and
initiative symptoms, which may be of great importance, and which are
not always the same with the two or three sets of lesions. There are
many of them, but, unfortunately, no one among them taken alone can be
considered of high significance, unless we except what are sometimes
called premonitory attacks, which are in all probability frequently
genuine hemorrhages of so slight extent that they produce no
unconsciousness, and but slight paralysis easily overlooked. A little
indistinctness of speech or a forgetfulness of words, a droop of one
angle of the mouth, or heaviness in the movement of a foot or hand,
lasting but a few moments, may be real but slight attacks, which may
be followed either by a much more severe one, by others of the same
kind, or by nothing at all for a long time. They are sufficient to
awaken apprehension, and to show in what direction danger lies, but
they give little information as to the time of any future attack.
Retinal hemorrhage is admitted by all modern authors to be connected
with disease of the vascular system, and hence also with renal
inflammation and cerebral lesions. The writer is greatly indebted to
Hasket Derby for the following facts: Out of 21 patients who had
retinal hemorrhage, and of whose subsequent career he had information,
9 had some sort of apoplectic or paralytic attack; 1 had had such an
attack before she was examined; 3 died of heart disease, 1 suddenly,
the cause being variously assigned to heart disease or apoplexy; and 6
were alive when heard from, one of these, a man of forty-eight, being
alive and well fourteen years after.
Bull[25] describes four cases of his own where retinal hemorrhage was
followed by cerebral hemorrhage, demonstrated or supposed in three,
while in the fourth other symptoms rendered a similar termination by
no means improbable. He quotes others of a similar character. The
total number of cases which were kept under observation for some years
is, unfortunately, not given. In a case under the observation of the
writer a female patient, aged fifty-seven, who had irregularity of the
pulse with some cardiac hypertrophy, was found to have a retinal
hemorrhage two and a half years before an attack of hemiplegia. The
hemorrhage was not accompanied by the white spots which often
accompany retinitis albuminuria.
[Footnote 25: _Am. Journ. Med. Sci._, July, 1879.]
In a case reported by Amidon[26] retinal and cerebral hemorrhages seem
to have been nearly simultaneous a few hours before death. There was
diffuse neuro-retinitis and old hemorrhages besides the recent one.
[Footnote 26: _N. Y. Med. Rec._, 1878, xiv. 13.]
{945} The highly interesting observation has been made by
Lionville[27] that when miliary aneurisms are present in the brain,
they may often be found in the retina also. In one case where they
were very numerous in the cerebrum, cerebellum, pons, and meninges,
aneurismal dilatations were found also in the pericardium, mesentery,
cervical region, and carotids (the latter not being more minutely
described). There was very general atheroma and numerous points of
arteritis. The retinal aneurisms varied in size from those requiring a
power of ten or twenty diameters to be examined up to the size of a
pin's head or a millet-seed. He thinks they might have been recognized
by the ophthalmoscope.
[Footnote 27: _Comptes Rendus de l'Acad. des Sci._, 1870.]
The hemorrhages accompanying idiopathic anæmia and other diseases with
a similar tendency are not to be taken into this account. Hemorrhage
accompanying optic neuritis is likely to be due to some disease of the
brain other than the one under consideration.
Mental disturbances of various kinds have been considered as
significant, and Forbes Winslow gives a great many instances of
different forms, but they are to be looked upon rather as indicating
chronic cerebral changes which may result in various conditions, of
which hemorrhage may be one, than as furnishing any definite
indication of what is to be expected. Loss of memory should be
regarded in this way. Some acute or temporary conditions of depression
may affect the nutrition of the brain in such a way, without having
anything to do with hemorrhage actual or anticipated.
Aberrations of the special senses are often observed, such as noises
in the ears more or less definite, the sight of colors (red), or being
unable to see more than a portion of an object. The fact to which
these testify is probably a localized disturbance of the circulation
which may not precede rupture of the vessels.
Distinct hallucinations of hearing, followed by those of smell and
succeeding irritability, sleeplessness, were observed by Savage[28] in
a case which terminated soon after in apoplexy.
[Footnote 28: _Journ. Ment. Sci._, 1883, xxix. 90.]
There are few symptoms which are more likely to excite alarm and
apprehension of a stroke of paralysis than vertigo or attacks of
dizziness, but it is too common under a great variety of circumstances
to have much value, and is, as a matter of fact, rarely a distant
precursor of intracranial hemorrhage, although it frequently appears
among the almost initiatory symptoms, especially when the lesion is in
the cerebellum, so that, if continuous, it is not likely to mean that
anything worse is coming. It has been said to be strongly significant
if occurring without the digestive derangements or circulatory
disturbances likely to cause it, and be unconnected with disease of
the ear. Unfortunately for diagnosis, but fortunately for the
patients, the so-called vertigo a stomacho læso, may arise in cases
where the stomach trouble is very difficult or impossible to detect,
and it often continues for weeks or months after the most careful
regulation of the diet, and yet is followed by no cerebral lesion.
Although a vertigo for which every other cause can be excluded
certainly justifies a suspicion of cerebral trouble, the tendency to
exaggerate its prognostic importance should not be encouraged by the
physician, as it may exist a long time, and disappear without another
sign of the catastrophe which has been keeping the patient in dread.
{946} Among the more significant and immediate symptoms are to be
reckoned paræsthesiæ of the side about to be paralyzed, such as
numbness or tickling. Headache of great severity is often, but not
invariably, present. It has nothing characteristic about it, except
that it may be different from those the patient has been in the habit
of having, or may be of unusual severity, so that the patient says it
is going to kill him. Such a headache in a person in whom there is
good reason, from age, interstitial nephritis, or other symptoms, to
suspect the existence of vascular lesions is likely to be an immediate
precursor of a hemorrhage. Persistent early waking with a slight
headache, which passes off soon after rising, is said by Thompson[29]
to be a somewhat frequent premonition. Vomiting is hardly a
premonitory, but may be an initial, symptom, especially in hemorrhage
of the cerebellum.
[Footnote 29: _N. Y. Med. Record_, 1878, ii. p. 381.]
Reference is had in these statements chiefly to the ordinary form of
cerebral hemorrhage. Of course if, during a leucocythæmia or purpura,
large hemorrhages occur elsewhere, it may be taken as a hint that
possibly the same thing may take place in the brain.