transitory, in the course of general paralysis is not certain, but it
is probable that they are due to sudden congestions of regions of some
extent already in a condition of chronic periencephalitis or to
cerebral œdema. The question of the existence of the previous disease
can only be settled after the return of the patient to consciousness.
Usually, these attacks are not of the severest kind, and are not
necessarily attended with loss of consciousness, which, when it
occurs, is usually not of long duration. An apoplectiform attack
occurring in a young or middle-aged person who has neither cardiac nor
renal disease, rapidly recovered from or changing its character,
should awaken strong suspicions of either general paralysis or
syphilis, or both.
The characteristic of the so-called congestion of the brain, or coup
de sang, is a close resemblance to ordinary apoplexy, but without
hemiplegia and usually with a rapid and complete recovery. A diagnosis
from apoplexy cannot be made at once, except so far as hemiplegia can
be shown to be either distinctly present or absent.
{968} As has already been stated, the doctrine of the dependence of
real apoplectiform attacks upon cerebral congestion alone has been
vigorously combated by distinguished clinicians; and certainly the
diagnosis of congestive (and the same may be stated even more strongly
of so-called serous) apoplexy should never be made until after the
rigorous exclusion of every other possibility.
After the severer apoplectic symptoms have passed off, and in cases
where they have never been present, the diagnosis, so far as most of
the conditions mentioned above is concerned, is divested of many of
its difficulties when we are dealing with cases of well-marked
hemiplegia. The chief points left are the distinctions from the
apoplectiform attacks of general paralysis, cerebral syphilis, and
cerebral tumor, which are to be made as already pointed out.
Slighter and more localized paralyses, such as may occur with limited
lesion of the pons or where a hemorrhage having a large focus in the
substance has escaped under the membranes and presses on some cranial
nerve, would present more difficulties. Paralyses which are very
limited, and at the same time complete, are not likely to arise from
hemorrhage or embolism, though it is possible that they may do so, but
the diagnosis is to be considered rather under the head of local
palsies than of cerebral disease. General rules cannot be laid down
for slighter cases, and each case must be diagnosticated for itself.
In many of them the electrical diagnosis would be of great value and
often decisive.
Hysteria remains, as always, ready to counterfeit anything, but the
following case shows that the error is not always on that side: F.
S——, a young woman, was brought to the hospital, apparently conscious
and understanding what was going on, but unable or unwilling to speak
or to protrude her tongue. There was no history except that she had
probably been in the same condition for thirty-six hours. There was
paralysis of the right side, including the face, and marked anæsthesia
of the same side, quite distinctly limited at the median line;
temperature 97.8°, pulse 60, respiration 20. The next day she seemed
perfectly conscious, but did not speak. The faradic brush to her face
caused loud outcries, and the facial paralysis was diminished. This
condition remained nearly the same, the patient appearing half
conscious, but passing urine in bed. Four days later there was marked
diminution of sensation and motion on the left (previously sound)
side, as well as the right. The note two days later was, “Shuts and
opens her eyes when told, and moves eyeballs in every direction, but
there is apparently no voluntary motion except slight of the head.
Incontinence of urine and feces.” A week later the temperature rose to
100.4°, pulse 140, and she died. The autopsy showed red adherent
thrombus in the left carotid, extending into the cerebrals, with
extensive anæmic necrosis of the cortex and a part of the corpus
striatum. On the right there was a grayish thrombus and softening of
the cortex, while the great ganglia were not affected.
A woman of thirty-two had repeated attacks of loss of consciousness
and somnolence lasting several hours, but leaving her apparently well.
The case was considered hysteria, but the patient died in a similar
attack. Degeneration of the cerebral arteries and hemorrhage were
found.[48]
[Footnote 48: Christian, _Centralblatt f. d. Med. Wiss._, 1873, 864.]
Post-paralytic chorea might present difficulties of diagnosis from
{969} hysteria or malingering, though the difficulty is quite as
likely to be on the other side.
The diagnosis, however, is not complete until the lesion is located
with some precision and its nature determined, although it must be
confessed that when we have got as far as this the diagnosis in most
cases is of more interest to the physician than to anybody else,
except to a slight extent for prognosis, so that the event may be
anticipated by a few hours. As to the localization of the lesion,
recent experiments and observations, involving not only lesions of the
kind we are here discussing, but tumors and injuries as well, permit
this to be done with a reasonable degree of certainty. The general
article on Cerebral Localization may be referred to by the reader for
the minuter points, but certain groups of symptoms may be indicated
here which are available to some extent before the complete return of
the patient to consciousness.
In the vast majority of cases the lesion is situated upon the side of
the brain opposite to the paralysis, except in some instances of
cerebellar lesion, while in the peculiar form known as alternate
paralysis due to lesion of the pons it is on the opposite side to the
paralysis of the limbs and on the same side with the facial. It should
be distinctly stated, however, that there are exceptions which are
inexplicable on the present basis of cerebral anatomy. It is well
known that only a part of the motor tracts cross to the other side of
the cord at the decussation, and also that the proportion between the
fibres which do and those which do not cross is a variable one. It has
been suggested, in some cases of the kind mentioned, that all the
motor fibres, instead of only a minority, as is usual, pass down on
the same side of the cord as their origin. This has not been
demonstrated. The number of such cases are so small that it need not
be taken into account in diagnosis, and if the practitioner should
make a mistake on this basis, he will have the recompense of knowing
that he has assisted in a very rare case, in which it was next to
impossible for him to be right. This condition is said to be found
more frequently when the brain lesion and paralysis are on the right
side.
Severe pain in the head, followed by gradually but rapidly deepening
coma and paralysis of one side, becoming more and more complete,
probably means a hemorrhage into or just outside of the great ganglia
and involving a large extent of one of the hemispheres.
If there have been moderate loss of power or complete paralysis
lasting some hours, with, afterward, sudden loss of consciousness and
general muscular relaxation, with sudden fall, soon followed by rapid
rise, of temperature, it is very probable that a hemorrhage has broken
through into the ventricles or beneath the membranes, and is still
going on.
Rapidly-deepening unconsciousness, with general muscular relaxation
and gradual manifestations of more paralysis on one side than the
other, may come from meningeal hemorrhage.
Very sudden and complete hemiplegia without prodromata, with deep
unconsciousness coming on rapidly or suddenly, but a little after the
paralysis, is likely to denote the occlusion of the middle (and
perhaps anterior cerebral) artery of the opposite side at a point
sufficiently low down to produce extensive anæmia of the motor centres
along the fissure of Rolando as well as the underlying great ganglia.
{970} Aphasia with hemiplegia, often without the slightest disturbance
of consciousness, is in a considerable proportion of cases connected
with a lesion of the third left frontal convolution, and in a somewhat
larger proportion with the frontal lobes in general and the island of
Reil. This lesion is in a great majority of cases occlusion of the
artery. Difficulty of speech, connected with difficulty of swallowing
and associated with a certain amount of amnesic aphasia, has been
found with lesions of the pons. As aphasia, however, may occur without
any fatal lesions at all, it is not certain in all these cases that
the obvious lesion of the pons is a direct cause of all the symptoms.
Word-blindness is associated, according to a case reported by
Skworzoff and a few others,[49] with a lesion of the angular gyrus,
pli courbe (P_{2} of Ecker), and word-deafness with a lesion of the
first temporal (T_{1}). These localizations agree with those
experimentally determined.
[Footnote 49: West, _Brit. Med. Journ._, June 20, 1885.]
Conjugate deviation is of importance as a localizing symptom, chiefly
because it may be manifest when other signs of hemiplegia are
difficult to elicit. I do not find it mentioned in twenty-seven cases
of cerebellar hemorrhage not included in the table of Hillairet, but
it is not infrequent with lesions of the pons; and when the lesion is
in the lower third, it is in the opposite direction to that described
as usual with lesions of the hemispheres.
Hemianæsthesia involving the organs of special sense, unilateral
amblyopia, and color-blindness is supposed to be connected with a
lesion of the posterior third of the internal capsule, or the thalamus
in its immediate vicinity, sometimes also with a lesion of the pons.
Bilateral hemiopia—blindness of the corresponding sides of both
eyes—is apt to be connected with a lesion of the occipital lobe of the
opposite side. Rendu and Gombault remark that hemianæsthesia of the
limbs and face may be met with in certain lesions of the cerebral
peduncles, but in this case the higher special senses (sight, smell)
remain unaltered. Hemichorea points to the same localization as the
more complete hemianæsthesia.
Alternate hemiplegia is due to a lesion of the pons upon the side of
the facial paralysis, and opposed to the paralysis of the limbs and in
the posterior or lower half. Care should be taken not to confound this
with the accidental addition of a facial paralysis to a hemiplegia of
the other side.
Irregular ocular paralyses are very likely to be due to lesion of the
same region. In some of these forms an investigation of the electrical
condition with reference to the presence of the degeneration reaction
may be of great assistance.
With extensive lesions profound coma and relaxation without distinct
hemiplegia are likely to be due to injury of the pons. A thrombus of
the basilar artery may lead not only to rapid, but even to sudden,
death. A phthisical patient died suddenly while eating his supper, and
a thrombosis of the basilar artery, with softening of the pons, was
found. Of course the lesion must have been of older date.[50]
Bright[51] thought that when symptoms pointing to disease of the
intracranial vessels were present the diagnosis was confirmed, and the
location of the lesion in the vertebral arteries rendered highly
probable, by a persistent occipital {971} pain. In the upper part of
one side of the pons the hemiplegia is not alternate, but of the
ordinary form.
[Footnote 50: _Bull. de Société anatomique_, 1875.]
[Footnote 51: _Guy's Hospital Reports_, 1836.]
Any extensive lesion of the medulla must cause death so rapidly as
almost to defy diagnosis, but such rarely occurs. The very rapid
termination of certain cases of hemorrhage into the pons and
cerebellum is due to the escape of blood into the fourth ventricle and
consequent compression of the medulla.
Lesions of the lower and inner part of the crus are indicated by
paralysis of the third nerve of the same, and hemiplegia of the
opposite side of the body.
Obstinate vomiting, severe occipital headache, and vertigo, with or
without a distinct paralysis, render a cerebellar hemorrhage probable,
though no one of these symptoms is necessarily present or
pathognomonic. Vomiting is very much more common with cerebellar
hemorrhage than with cerebral. Ocular symptoms, like nystagmus and
strabismus, accompany cerebellar lesions.
A difference in the temperature of the paralyzed and non-paralyzed
sides, when amounting to one and a half to two degrees and lasting for
a long time, is thought by Bastian to indicate a lesion of the optic
thalamus.
The severe and rapid sloughing of the nates sometimes seen in
rapidly-fatal cases is stated by Joffroy to be most frequently
connected with a lesion of the occipital lobes.[52]
[Footnote 52: _Arch. gén._, Jan., 1876.]
It is plain, from what has been said about the symptoms of the
different kinds of lesion, that a distinction may be often very
difficult, and at times impossible; and in this connection all
observers are agreed, the apoplectiform shock, the hemiplegia, and the
slighter attacks being common to two or three lesions. The diagnosis
can be made, if at all, only by the consideration of more or less
secondary symptoms and the careful weighing of the various
probabilities against each other. Most of the statements of
differences of symptoms are only relatively true.
A glance at the nature of the pathological processes involved may
serve to systematize our observations.
Hemorrhage is a sudden accident, with a severity increasing as the
amount of effusion increases. It has been prepared for by arterial
disease, but this disease is one which may have no previous symptoms.
It is at first an irritative lesion.
Embolism is a sudden attack which may be as severe at first as even a
few minutes afterward. It is also prepared for by disease of other
organs, which may or may not have symptoms according to the origin of
the embolus. As embolism affects especially those regions where the
motor centres are spread out, while hemorrhage attacks more frequently
the conductors in their locality of concentration, the paralyses
arising from the former affection may be more narrowly limited.
Thrombosis is a gradual affection, which may, however, manifest itself
suddenly, from the obstruction reaching a certain point and suddenly
cutting off the supply of blood. This also depends on previous disease
which has more or less definite symptoms.
The severity of the attack is not conclusive, though the completely
developed apoplectic attack is more frequent with hemorrhage. Rapidly
{972} increasing severity, especially if there have been prodromata,
is in favor of hemorrhage. Convulsions, early rigidity, and conjugate
deviation of the eyes of the spastic form, especially if afterward
becoming paralytic, are strongly in favor of hemorrhage, and the
latter possibly conclusive. Hughlings-Jackson states that he cannot
call to mind a single case of hemiplegia from clot in a young person
in which there were not convulsions.
Sudden paralysis without cerebral prodromata, unconsciousness, or pain
can hardly be anything else than embolism; but, unfortunately for
diagnosis, the initial paralysis from the embolus may be slight, and
afterward added to by the secondary thrombus, so as to put on the
appearance of more gradual approach.
Aphasia, and especially aphasia associated with but little or no
paralysis, is very much more frequent with embolism than with
hemorrhage.
The temperature, if we could always have it recorded from the very
beginning, might be of value, as the initial depression is said to be
less with embolism than with hemorrhage, but Bourneville,[53] who lays
down this rule, gives so many cases where no great depression occurred
with hemorrhage that it cannot be considered decisive. Besides this,
we are not likely to get the information at the time it is of the most
value.
[Footnote 53: _Op. cit._]
Etiological information may have a very practical bearing on this part
of the diagnosis. Age gives a slight amount of predominance to the
chances of hemorrhage, and youth a considerably greater one to the
chances of embolism. Interstitial nephritis with hypertrophy of the
heart, after the exclusion of uræmia, gives a strong probability in
favor of hemorrhage. Valvular disease of the heart, especially a more
or less recent endocarditis, is strongly in favor of embolism. A
feeble action of the heart, slow and irregular pulse, are more likely
to be connected with thrombosis.
Atheroma and calcification, as detected by examination of the visible
and tangible arteries like the radial and temporal, is a condition
either connected with the periarteritis aneurysmatica which gives rise
to hemorrhage, or one which furnishes a suitable spot for the
deposition of a thrombus; hence it can be considered conclusive in
neither direction.
Arcus senilis, even of the fatty variety, can only show some
probability of arterial degeneration.
Retinal hemorrhage, if present, favors the presence of a similar
cerebral lesion, but nothing can be argued from its absence.
Landesberg[54] has reported a case in which embolism of the central
artery of the retina, easily diagnosticated by the ophthalmoscope,
preceded by a few days a similar accident in the middle cerebral; and
Gowers[55] another in which the two arteries were occluded
simultaneously.
[Footnote 54: _Archiv für Ophthalmologie_, xv. p. 214.]
[Footnote 55: _Lancet_, Dec. 4, 1875.]
If a sudden paralysis arises in connection with a septic process, we
may diagnosticate an embolus with a good deal of confidence; but it is
not unusual to meet with small abscesses of septic origin which have
given rise to no special symptoms whatever, or only to such as are
covered up by the more general constitutional ones.
PROGNOSIS.—The prognosis quoad vitam of cases of apoplexy still in the
unconscious state is based upon the general severity of the symptoms
{973} as indicated by general muscular relaxation, or, at a later
period, the extent of the paralysis, the amount of affection of the
heart and respiration, and especially the progress during the first
few hours. Too much weight should not be placed upon a very slight
improvement at first, since this often takes place in cases soon to
prove fatal.
Stertorous respiration with perfect tolerance of mucus in the throat,
absolute loss of the reflexes, and immobility of the pupils signifies
profound depression of the organic nervous centres, and is
consequently of unfavorable augury.
The temperature is a valuable guide. In proportion as it moves
steadily and rapidly upward is the prospect of an early fatal result.
A person may die during the initial fall of temperature, but in such a
case there would hardly be need of a prognosis.
In general, the prognosis from hemorrhage, supposing the symptoms to
increase in severity for an hour or two, is worse than that from
occlusion.
Age, aside from the fact that it makes hemorrhage more probable than
occlusion, is not of great importance in prognosis, certainly not out
of proportion to the general impairment of vigor in advanced years.
A renewal of the hemorrhage within a few hours cannot be predicted. It
may be indicated by another fall of the temperature, which, if it have
been previously on the rise, renders, of course, the prognosis more
unfavorable.
After recovery, more or less complete, from the apoplectic condition
the prognosis is favorable, for a time at least, except so far as one
attack may be looked upon as the forerunner of another. After the
temperature has reached a sort of standstill in the neighborhood of
normal, its subsequent rise will furnish among the earliest
indications of an approaching fatal termination.
Urinary trouble, retention, incontinence, or, much more, cystitis, is
to be looked upon as a complication which materially increases the
gravity of the situation. Bed-sores or abrasions may be placed in the
same class, except that the early and extensive sloughing of the nates
described by Charcot is of almost absolutely fatal significance.
After some days or weeks the progress of the paralysis either toward
better or worse may be exceedingly slow, and as time goes on the
danger to be apprehended from the latter becomes less and less.
When paralysis takes place in young persons and the primary attack is
recovered from, it is doubtful if the chances of a long life are
materially diminished. A case has already been referred to in this
article where the consequences of a cerebral hemorrhage occurring in
infancy were found in a woman of eighty-three in the form of atrophied
limbs and an old pigmentary deposit in the brain.
Hemorrhage into the cerebellum would appear, from statistics, to be
exceedingly fatal, but it is certain from old lesions occasionally
found that it is not absolutely so, and its apparent severity is
partly caused by the fact that it is very seldom diagnosticated except
at the autopsy.
The prognosis quoad restitutionem ad integrum cannot be made to
advantage at an early period. After the immediate danger to life has
passed it is safe to say, if pressed for an answer, that it is highly
probable that some recovery from paralysis may take place, but that it
is {974} highly improbable that it will be absolutely complete, and
just how far improvement may go it is impossible to predict with
accuracy at first. Time must be given, in the first place, for
pressure to subside, compressed nerve-fibres to be restored, and for
such collateral circulation as is possible to be established. How
recovery takes place beyond this it is not easy to say. It is hardly
supposable that any considerable portion of nerve-structure is
renewed. A certain amount of substitution, by which one part of the
brain takes up the functions of another part, is among the most
plausible suppositions; but how this is accomplished it is hardly
worth while in the present condition of cerebral physiology to
speculate.
Practically, it may be said that physicians are apt to consider a
paralysis absolute at too early a period, while the patient and his
friends continue to hope for a complete restoration after it is
evident that no really useful increase of power is to be looked for.
Weeks, and even months, may elapse before any return of motion can be
perceived in cases which are really susceptible of considerable
improvement, and a year most certainly does not cover the limit of the
time during which it may go on.
The most unfavorable symptom, one which probably precludes all hope of
useful recovery in the limbs affected, is contracture, heralded for a
time by increase of the deep reflexes, indicating degeneration of the
motor tract in the white substance of the cord. Until this begins,
certainly for many weeks, the patient may be fairly encouraged that
some improvement is possible, though after a few weeks the chances
diminish as time goes on. In the rare cases where the muscles undergo
rapid wasting the prognosis is, if possible, worse still. The
localization of the lesion after the early symptoms are passed does
not greatly influence the prognosis.
A rapid recovery taking place in either hand or foot, and especially
of the hand first, without corresponding improvement in the other
limb, is of unfavorable import for the latter, and, in general, the
prognosis is not exactly the same for both limbs involved. In the rare
cases of hemiplegia from acute brain disease occurring in children the
nutritive disturbances in the form of arrest of growth should be taken
into the account in prognosis, since the result may be nearly or quite
the same as is found after infantile paralysis from disease of the
cord.
In regard to the slighter forms of paralysis, it may be said that the
less extensive the original paralysis is, and the sooner improvement
begins, the better is the chance of complete recovery.