set of symptoms less severe than a fully-developed apoplectic fit.
During such a fit—or, more clearly, as it is passing off—we find more
or less marked paralytic symptoms, but these are quite as frequently
present without the loss of consciousness. The patient states that he
waked up and found one side of his body helpless, or that he was
reading the paper when it fell from his hand, and upon trying to walk
found that he could not do so. Loss of speech may be an initial
symptom. It has been spoken of as premonitory, but it is probable that
it is in reality only the beginning, which, in some cases may go no
farther, but is usually succeeded by more extensive paralysis, which
makes its meaning unmistakable. These symptoms may be hours or even
days in developing, with occlusion as well as with hemorrhage. Very
slight attacks may occur which hardly excite attention, and lesions
are found after death in many cases to which there is nothing in the
history to correspond.
Improvement may begin very rapidly in some cases where the lesion is
small, a sufficient amount of collateral circulation being developed
to {954} prevent the structure from being disorganized. In others a
specially favorable anastomosis may preserve even a larger area, but
in others still it is not easy to account on entirely anatomical
grounds for the amount of improvement which takes place.
From this point onward the history of hemorrhagic and of embolic and
thrombotic paralysis is essentially the same, and the description of
the principal phenomena and progress of hemiplegia will apply to all.
SYMPTOMS AND PROGRESS OF HEMIPLEGIA DEPENDING ON CEREBRAL HEMORRHAGE
OR OCCLUSION OF THE CEREBRAL VESSELS.—The cerebral cortex represents
the centres for many of the higher nervous functions, spread out in
such a way that they may be more or less separately affected, while
the corpora striata and internal capsules are the regions where the
various conductors are crowded together, so that embolism, when
affecting small vessels and limited areas of the cortex, more
frequently gives rise to narrowly-defined groups of symptoms than
hemorrhage, which, taking place oftener in the central ganglia, is
able to cut off the communication from large masses of cerebral tissue
at once. This is a general remark, tending to explain why aphasia, for
instance, is often spoken of as especially a symptom of embolism,
while it is in reality common to all the lesions that affect the
proper locality.
The motor paralysis, more or less complete, which has been described
under the head of Hemorrhage continues indefinitely. It may disappear
rapidly, so that motion begins to return in a day or two, and goes on
to complete recovery in a short time. On the other hand, it may be
months before the flexion of a finger or a toe gives the slightest
token of the will resuming its control. The face often recovers its
symmetry before the limbs are fully restored, but the leg may be used
in locomotion before the complete recovery from paralysis, since the
tone of the muscles is sufficient to keep the knee straight enough for
support, as if the leg were all in one piece, while it is swung around
at each step by the pelvic muscles. We may meet with all degrees of
recovery—from that which is absolutely complete and comparatively
rare, through the case where a little want of play upon one side of
the face, a little thickness of speech, a feeble or awkward grasp of
the hand, betrays what has happened, or that of the man so often seen
in the streets with a mournful or stolid face, the arm in a sling or
dangling straight down by the side, and swinging one leg awkwardly
around, to the helpless paralytic lifted in and out of his chair or
lying almost motionless in bed, and living only to be fed and be kept
clean.
Involuntary movements may take place in limbs entirely incapable of
voluntary ones, and may occur under conditions of excitement or with
other involuntary movements, such as gaping. On the other hand, the
patient often moves the well hand while making utterly ineffectual
attempts on the paralyzed side. Involuntary twitching of the feet may
be annoying. Reflex movements, especially of the feet, are often
exaggerated, and in fact the twitching just spoken of is often excited
by some trifling, perhaps unperceived, irritation. A touch with the
point of a penknife upon the sole of the foot may call out a movement
which the patient is utterly incapable of executing by the force of
the will, and the appearance of volition is often increased by the
grimace or exclamation of pain or annoyance.
{955} Epileptiform attacks may be a sequence of hemiplegia, occurring
at irregular intervals, and not of great severity. Sometimes the
patient seems depressed or less talkative for a day or two previously,
and relieved after the fit has occurred, as in true epilepsy.
Comparatively little attention has been given to the condition of
sensation in hemiplegia. In the more complete apoplectic stupor it is
apparently abolished, like nearly all the functions above those of
respiration and circulation, but it often happens when the patient is
unable or unwilling to make any voluntary response to the voice, and
lies apparently perfectly indifferent, that any moderate irritation
like a pinch will bring out evidence of sensation. It is often stated
that in hemiplegia the sensation is not at all affected; and this is
probably true of many cases, but a more attentive examination will
often disclose a decided diminution on the affected side. Broadbent,
who has tested with pricking, touch, the compasses, and hot
substances, says that it is frequently diminished, and often greatly
so, and not only in the limbs, but in the face, chest, and abdomen.
Tripier[34] says that a lesion of the larger part of the
fronto-parietal region determines at the same time a paralysis of
motion and a diminution of sensibility; and one may conclude that this
region holds under its dependence sensitive as well as motor phenomena
intimately connected with each other. The zone called motor, of which
the limits are difficult to fix, may with more reason be called
sensori-motor.
[Footnote 34: _Revue mensuelle de Méd. et Chir._, 1880, p. 18.]
Anæsthesia probably in most instances disappears more rapidly than
motor paralysis, which accounts for its being frequently overlooked.
The more common location of lesions causing motor paralysis—_i.e._ the
corpus striatum and the motor portion of the cortex—is one not likely,
unless extensive, to concern sensation; but there are cases where a
very complete hemianæsthesia, including the special senses, may be
found; and when, in such cases, the motor paralysis is slight, a
picture is presented almost identical with that of hysterical
hemianæsthesia with great diminution or abolition of the special
senses, hearing, taste, smell, with concentric diminution of the field
of vision and of the color-field, or complete color-blindness on the
affected side.
A man aged thirty-five while at work suddenly felt a prickling
sensation upon his left side, and became unconscious. The bystanders
say he was convulsed. On returning to consciousness after three hours
he had lost his speech, which, however, was rapidly recovered, and his
left side was not so strong as his right, though there was no distinct
history of paralysis. Two or three days afterward it was noticed that
sensation was much diminished upon the left side, two sharp points of
the æsthesiometer being felt as one at two inches on the forearm and
three-quarters of an inch on the tongue. He could feel the touch of a
spoon, but could not tell whether it was cold or hot. Odors were not
recognized upon the left side of the nose, except faintly ammonia and
chloroform, and a watch was heard on that side only when in contact
with the ear. The field of vision was much diminished and
color-blindness was almost complete. A few days later the field of
vision had increased, and there was color-sense, the field of
perception for the different colors being arranged almost exactly as
laid down by Charcot, vision for red being largest, but not so {956}
large as for simple perception of objects; those for blue, green, and
yellow nearly the same and smaller; and that for violet limited to a
small space in the centre of the field.
Less regular forms of anæsthesia may be met with, as well as
hyperæsthesia. These are said to be especially connected with various
lesions of the pons.[35] A case is recorded[36] of complete
hemianæsthesia in a man, coming on like a blow. There was no loss of
motor power; the face was symmetrical, sight and hearing unimpaired.
Taste was lost and smell doubtful. There was aortic and mitral
disease. Hughlings-Jackson speaks of a man who experienced a severe
apoplectiform attack which it was thought would be fatal in a few
hours. He recovered, however, with almost complete loss of hearing.
[Footnote 35: Conty, _Centralblatt f. d. Med. Wiss._, 1878, 571.]
[Footnote 36: _Med. Times and Gaz._, 1871, i. 246.]
Neuralgic pains of long continuance are not infrequent accompaniments
of hemiplegia, and may be lasting even after nearly complete recovery
from the paralysis. A peculiar restlessness, a constant desire for
change of position, has been referred to derangement of the
muscle-sense. It is sometimes very distressing, and causes much
annoyance to attendants as well as to the sufferer, as the patient is
no sooner placed in one position, no matter how comfortable, than he
desires to change it.
The mental condition seldom fails to suffer more or less in cases of
hemiplegia, but the limits are very wide between a slight emotional
excitability on the one hand and almost dementia on the other. This
is, of course, applicable to cases where the lesion is a single or
limited one, and not where a hemorrhage or thrombus is merely a part
of a general vascular degenerative change with chronic meningitis or
atrophy of the brain, where the mental decay can hardly be called the
result of any single lesion. In cases of aphasia the mental condition
is harder to make out, from the peculiar inability to communicate
ideas if present. It is very safe to say, however, that many such
patients possess much greater intelligence than would appear to a
casual observer, and yet the apathy with which they often bear the
deprivation of speech and consequent isolation speaks more strongly in
favor of some blunting of the perceptions than of Christian
resignation. A patient whose general appearance is that of tolerable
comfort is likely to cry when attention is called to the helpless
condition of the hand. It is probable that memory suffers in such
cases, if not the reasoning faculties.
Trousseau cites the case of Lordat, who became aphasic, and after
recovery described his own case. The learned professor claims to have
been in full possession of his faculties, and to have arranged a
lecture with the divisions and subdivisions of the subject, and all
this without the thought of a single word passing through his mind.
Trousseau ventures to doubt the possibility of carrying on complicated
mental processes without words, and thinks Lordat may have
overestimated the precision of his mental processes. It appears in
confirmation of this view that after his attack he always read his
lectures, whereas before he had been distinguished as an extempore
speaker.
McCready, in an excellent article in the _New York Journal of
Medicine_ (September, 1857), discusses this subject at length, and
details a number of cases where it was evident that paralytics and
aphasics (who, however, {957} he did not know by that name, nor the
special lesion connected with their condition) possessed not only
ordinary intelligence, but excellent business judgment and ability. He
says that the confusion of mind and difficulty in pursuing a train of
thought of which apoplectics are apt to complain is, to a great
extent, the mere result of diminished nervous energy—that they
comprehend well and judge correctly. It is fair to say that while the
mind is almost certainly impaired, it is not necessarily in exact
proportion to the severity of other symptoms, aphasia included. The
memory, either special or general, is most apt to be impaired.
The testamentary capacity of a person who has had an apoplectic fit or
who is paralyzed at the time of making a will may be called in
question. The only general remark to be made is that these facts alone
are not sufficient to prove incapacity; neither should the presence of
aphasia or agraphia do so without further evidence of want of
comprehension of the meaning of language used by others; so that if,
for instance, a person were seized with hemiplegia and aphasia between
the drawing up of a will and its signature, it should not be
invalidated unless there be further evidence to show that the testator
was incapable of understanding it when read over to him. In cases of
word-blindness, a patient, like one described by Magnan, may be able
to draw up a will with full comprehension of what he is doing, and yet
be unable to read it understandingly. Inability to signify
intelligibly assent or dissent would, of course, entirely disqualify
one from signing a will.
It is seldom that a paralytic attack fails to leave its mark, though
perhaps slight, for years, if not for the remainder of life. An
extreme ease of shedding tears is a very common symptom, and sometimes
laughter comes on very slight provocation.
Among the most interesting groups of phenomena connected with
hemiplegia, and sometimes the sole representative of this
condition—that is, existing alone without any motor paralysis—is that
embracing the means of communicating with the outer world by means of
language spoken or written. Corresponding to, and usually but not
always connected with, right motor paralysis we have the inability to
use words in speaking, known as aphasia, aphemia, alalia, and others.
The first of these names is the one most frequently used. Agraphia is
the inability to use words in writing.
On the receptive side we have the inability to understand language as
presented to the eye (word- or psychic blindness) or to the ear
(word- or psychic deafness). A case of the former condition has
already been spoken of. One still more singular was reported by Mdlle.
Skwortzoff,[37] where the patient, not being blind, could not
understand letters presented to the eye, but could read with the
fingers and understand raised letters like those used by the blind. In
a case of the latter kind a man whose ears were normal, and who could
distinguish different sounds, answered questions, but entirely at
random, though he could read and understand what was written. All
these defects are manifestly connected with a peculiar loss of memory,
and hence the word amnesia is used sometimes to cover part of the
group, and amnesic as an adjective to qualify aphasia.
[Footnote 37: _Comptes Rendus de la Société de Biologie_, 1883, p.
319.]
It should, of course, be understood that the muscles are not
paralyzed, so that glottis, lips, tongue, and fingers are capable of
making the {958} necessary movements to produce words, and, on the
other hand, that the senses of sight and hearing are intact. Aphasia
was confounded by some of the older writers with paralysis of these
organs, and the whole grouped together under the name of alalia. Even
now the distinction is not always clearly observed.
The act of speaking, according to Kussmaul,[38] consists in three
stages or processes: the preparation in the intelligence and feelings
of the matter to be uttered; the diction, or the formation of the
words internally, together with their syntax; the articulation, or
formation of words outwardly, irrespective of their connection with
one another in the matter spoken. Defects in the first condition have
already been spoken of. In the entire absence of mind, as in the
deepest apoplexy, aphasia can hardly be said to exist, and it is only
later that it becomes manifest. If the second stage is defective,
amnesic aphasia exists, and if the third, ataxic. In the great
majority of cases of aphasia the loss of memory is the most important
factor; and as this exists whatever be the mode in which it is desired
to express the idea, amnesic aphasia is accompanied by agraphia. In
those cases, however, in which the patient retains a few words, they
are not always the same for speech and writing. Occasionally an
instance is found where a person can write perfectly well and
possesses complete intelligence, but is unable to speak a word. This
is pure ataxic aphasia, and is certainly rare. An ataxic agraphia is
less easy to detect, since the aphasic patient is likely to be
paralyzed upon the right side, and thus unable to write, even if he
remembers the words, until educated upon the left side.
[Footnote 38: _Ziemssen's Cyclopædia_.]
There are many degrees and kinds of amnesic aphasia, and, in fact,
every case is a study by itself. The slightest might be called
physiological; at any rate, it is sufficiently common among people
supposed to be well, and consists in the failure to recollect in time
for use the name, most frequently of a person, but sometimes of a
thing, which is really well known, is recognized at once if suggested,
and perhaps returns spontaneously at a later period. Another person
may forget only some words which are not recalled at any time, or
parts of words. A man appeared among the out-patients at St.
Bartholomew's Hospital who had his name written on a piece of paper,
because he could not say it, but could carry on a long conversation.
There were a few other words he could not say. The more complete cases
have no vocabulary at all, or only a few words or syllables applied to
all purposes, and perhaps an exclamation or two. In these cases the
patient may know perfectly well that he is not expressing his ideas,
and he may recognize perfectly well the word when it is told to him or
reject a wrong one. If he be, as happens in nearly all cases, unable
to pronounce the word after he has recognized it as the one he wished
for, there is a combination of ataxic and amnesic aphasia. Incorrect
or deficient words may be corrected or supplemented by gestures or
intonation. “Yes” may do duty without confusion for “yes” or “no,”
according to the tone.
Oaths may be retained, and sometimes an exclamation may be uttered
with perfect propriety of application which cannot be repeated
deliberately a moment afterward. This emotional use of words may be
considered akin to the movement executed by paralyzed limbs under the
{959} stimulus of a movement taking place elsewhere, and may lead to
an erroneous prognosis of recovery. This curious fact, that more or
less automatic expressions are possible when deliberately-willed
pronunciation is not, is a probable explanation for the observation
which has occasionally been made that an aphasic patient is able to
sing words which he cannot speak.
Paraphasia is the use of the wrong words, or of phrases which carry an
entirely different meaning from that intended, as when Trousseau's
patient receives a guest with politeness and invites her to be seated
with the words “cochon, animal, fichue bête,” or an old paralytic,
when a lady declines to drive with him, answers with great suavity,
“It don't make any damnation to me whether you go or not.”
Word-blindness is more common than word-deafness, and is a frequent
accompaniment of aphasia. Rostan, the well-known author of the work on
softening of the brain, experienced an attack of aphasia lasting a few
hours. The symptom which first attracted his attention was the
inability to understand the book, by no means abstruse, which he was
reading. He was, however, able carefully to observe his own symptoms,
and made signs to be bled, which operation was followed by relief.
Gouty aphasia has been described in a man aged thirty-seven who on
several occasions became aphasic, with recovery in a short time. This
condition was connected with localized paralysis, and once with entire
right hemiplegia. Afterward it was accompanied by convulsions. In the
intervals the patient was in fair health.[39] It is difficult to
imagine the lesion in this case. The reporter speaks of “sudden
blocking by a gouty thrombus,” but nothing is known of any thrombus
which can disappear so rapidly. Ball[40] describes twelve attacks of
aphasia occurring within nine months, and accompanied by slight
paresis and convulsive movements in the right hand. The patient
suffered habitually from migraine. He supposes the cause to have been
a temporary anæmia.
[Footnote 39: _Brit. Med. Journ._, Aug. 28, 1880.]
[Footnote 40: _L'Encephale_, 1883, 2.]
Aphasia may be entirely unconnected with motor paralysis, and is then
likely to be of shorter duration, though just as complete. Most of
these cases probably do not depend upon a lesion of the same kind as
when aphasia is only one of several severe symptoms. It shows how
delicate a function of the brain memory for words may be, and is
possibly the result of a temporary malnutrition or a change in the
vascular supply. It has been observed in various conditions of
debility and after acute disease. Rostan was diabetic. It has been
seen after chloroform narcosis, after santonin (5 cgr.), after fright,
and is said to be one of the ordinary symptoms after the bite of
venomous serpents. Aphasia and paraphasia may be met with in thorough
bromization, and, naturally enough, may be part of the symptomatology
of general paralysis. In other cases, even when it is the principal
symptom, it depends upon an organic lesion, and is not infrequently
the precursor of a more fully-developed attack. The diagnosis is of
great importance, and other traces of paralysis should be carefully
sought for. This symptom is far more common with occlusion of the
vessels than with hemorrhage, though not unknown with the latter.[41]
[Footnote 41: _Lancet_, Oct. 11, 1884, p. 655.]
By far the most common situation of the softening or hemorrhage which
gives rise to aphasia is in the third left frontal convolution {960}
(convolution of Broca) or the white substance immediately underlying
it. The island of Reil may be involved in some cases where but little
damage is done to the third frontal.
In a respectable minority of cases aphasia may be associated with left
hemiplegia. A case where a tumor in the third right frontal
convolution was found in a case of aphasia is reported by
Habershon.[42] It is not stated whether the patient was left-handed.
Some of these cases constitute those exceptions which prove the rule,
inasmuch as the patient is left-handed, and Hughlings-Jackson has
shown that the relationship of aphasia to the side which is
congenitally pre-eminent, and which is in the vast majority of human
beings the right side, is not destroyed by a partial education of the
other side to such acts as writing or using a knife.
[Footnote 42: _Med. Times and Gaz._, 1881, i.]
A lesion in the pons may give rise to aphasia or something closely
resembling it, but it is probable that a careful distinction of true
aphasia, both amnesic and aphasic, from paralysis or inco-ordination
of the muscles of speech, would reduce the number of these cases, and
bring the symptom into closer relations with the usual cortical
lesions.
A case of congenital aphasia with right hemiplegia has been
described.[43] When six years old the boy was well developed, though
less so on the paralyzed side; intelligent; heard well, but could say
only a few words, and those badly. Whatever the lesion, which is
thought by the author to have been in the speech-centre, but which may
not improbably have been in the pons, it is interesting, as showing
that the development of the speech-centre is certainly not
accomplished by education.
[Footnote 43: _Centralblatt f. d. Med. Wiss._, 1873, p. 299.]