FIG. 42.
Temperature chart of hemiplegia
The modifications undergone by the urine in a case of cerebral hemorrhage are increase of quantity amounting to polyuria, the urine becoming limpid and afterward returning to the usual color; a diminution in the quantity of urea coinciding with the fall of temperature, and afterward a return to the normal or even above it. When this augmentation is considerable, it constitutes at the same time with a marked elevation of temperature an unfavorable prognostic sign.46In a case under the observation of the writer, probably of thrombosis, the acid urine has beenremarkable for the amount of mucus contained in it, so that it pours from one vessel to another like white of egg. There is a small amount of pus, but no vesical irritation whatever.
46Ollivier,Archives de Physiol., 1876.
Since the trophic centres for the muscles are situated in the spinal cord, cerebral hemiplegia, which does not cut off their connection, does not produce the rapid wasting seen in some cases of spinal paralysis, unless descending degeneration involves the anterior gray columns. The limbs preserve their fulness for a time, although the muscular masses become flabby and slowly atrophy for want of use. This atrophy, however, seldom becomes extreme. The skin of the hands becomes dry, the folds at the knuckles disappear, and the hand loses its expression, looking more like a stuffed glove. The change, however, is not much greater than may be seen in a hand kept for a long time in a bandage. The growth of the nails is retarded, as may be seen by staining them with nitric acid.
If there is any tendency to œdema, as when nephritis is complicated with hemiplegia, the swelling is likely to be much greater upon the paralyzed side. In the adult, of course, there can be no question of the growth of limbs, but when a child becomes hemiplegic from cerebral disease, the limbs grow more slowly and remain smaller, as in a case of ordinary infantile palsy or anterior poliomyelitis.
Much importance has been attached to the fact that large sloughs form with great rapidity upon the nates of the paralyzed side, and Charcot says that this tendency is greater than can be accounted for in any mechanical way. He therefore thinks that a direct trophic influence of the brain upon nutrition is shown. At the very most, however, that can only be a contributory cause, and the freedom of other portions from a similar condition—and that, too, in regions farther removed from the centres of circulation—makes it highly improbable that anything more is necessary to account for it than the less sensitiveness of that side to irritation from urine, roughnesses in the bed, or pressure, and hence neglect. The writer, among a very considerable number of hemiplegias, fatal and otherwise, does not remember to have seen a well-marked case of the kind. Scrupulous cleanliness and changing the position sufficiently often make the preference for the paralyzed side a very slight one.
Arthropathies, consisting in a vegetating, and sometimes an exudative, synovitis, and accompanied by swelling, redness, and pain, are sometimes observed, especially in the upper extremity. They do not appear until fifteen days or a month after the attack.
The most significant change which occurs in the course of a hemiplegia is the development of increased reflexes and rigidity and contracture. After some weeks or months, during which the aspect of the case has not essentially changed, the limbs remaining in the same condition, it will be found on examination that the patellar reflex has become quite energetic, and ankle clonus developed upon the paralyzed side; the arm reflexes from the triceps, biceps, and supinator longus are much exaggerated. This has the same meaning as when similar phenomena are found with spinal disease, and signifies descending degeneration of the postero-lateral columns of the spinal cord, the crossed peduncular tracts. This degeneration may sometimes be traced completely down from the situation of the lesion in the cortical motor centres through the basal ganglia, crura, decussation, and cord. The fuller development of this condition is thecontracture or rigidity, which was at one time referred to secondary changes taking place in the neighborhood of the original lesion, as well as to a purely reflex action having no relation to the degeneration of the cord.
The arms are usually flexed at the elbow, the wrists on the arm, and the fingers in the hand. Sometimes, however, the arm is straight. The leg, which is not always affected to the same extent, is generally in extension, though the toes are likely to be flexed. Attempts to move the limbs are resisted strongly, and in such a way as to show the reflex nature of the phenomenon. If an attempt be made to open the fingers of a contractured hand slowly and carefully, it can be often accomplished and the hand held open with but little pressure, but if it is twitched the fingers resist like a spring. The violent attempt to overcome rigidity is often painful.
In some rare cases rapid atrophy of the muscles of one limb may take place. This has been found to coincide with extension of degenerative changes in the cord to the anterior gray columns.
Late rigidity is an unfortunately clear symptom. There is little if any hope of complete recovery of the use of the limb after it has made its appearance, though it does not prevent walking. After long-continued contracture the activity of the muscles diminishes, but the increase of connective tissue and changes in the joints hold the limb in its fixed position, and the contracture is a more passive one. The electrical reactions of the muscles and their nerves in cerebral hemiplegia are not materially altered, but the neuro-muscular irritability may be somewhat increased for a time by the irritating influence of the cerebral lesion.
In most cases of flaccid cerebral hemiplegia the electrical irritability is somewhat decreased, though retaining the normal character with both currents. Since the muscles and their nerves retain their connection with the spinal nuclei which are their trophic centres, and these nuclei are uninjured, their nutrition does not undergo the changes which affect electric excitability.
When descending degeneration takes place there may be found, coinciding with increased reflex activity and contracture, increased sensitiveness to the electric currents. If the degeneration extend to the anterior columns, as happens in rare cases, the muscles waste rapidly and exhibit the reactions of anterior poliomyelitis—i.e.degenerative.
What has just been said applies to the muscles paralyzed by a central lesion. If, however, with or without a complete hemiplegia, a limited lesion, as in the pons, affects the nucleus of a nerve, the peripheral distribution of that nerve is cut off from its nutritive centre, and it undergoes the usual changes which lead to the reaction of degeneration, so that, in some unusual forms of paralysis, the two kinds of reaction, normal and degenerative, may be present in different sets of muscles.
DIAGNOSIS.—The apoplectiform attack due to hemorrhage or occlusion of the cerebral arteries is to be distinguished from narcotic poisoning, specially by opium or alcohol, or by coal gas; epilepsy with its succeeding coma; uræmia (so called) or cerebral symptoms connected with renal disease; comatose form of pernicious intermittent; diabetic coma; sunstroke; hysteria, and various other forms of intracranial disease, especially meningitis; concussion and compression of the brain, which ofteninvolve hemorrhage; the apoplectiform attacks of intracranial syphilis and of general paralysis, as well as the congestive attacks (coup de sang, rush of blood to the head).
The first of these distinctions is, in a practical point of view, among the most important and often the most difficult, so that distinguished authorities insist not only on the difficulty, but impossibility, of making a positive diagnosis in every case. The physician who is most familiar with all the different conditions which may cause coma is least likely to jump at a conclusion.
Persons are constantly being picked up in the street partially or wholly unconscious, or found alone in a room without history and away from friends. The physician must then form his opinion from the present condition, which without a history may be very obscure, though with one it might present no difficulty. An empty laudanum- or whiskey-bottle may be of assistance, the former of much, but the latter of less. The smell of the breath may give a hint, but even if the smell of alcohol be detected, considering the widespread belief in its virtues as a panacea, it may be as well the result of amateur therapeutic attempts as an indication of the cause of the attack. Neither does it follow that because a man has been or is drunk he has no organic disease in his brain. Alcohol should simply make us more careful to examine for possible injuries. In regard to both these poisons—and in fact in the diagnosis of these conditions generally—the first thing to be sought for, after assuring one's self that the patient can breathe and is likely to do so for a few minutes, is some evidence of hemiplegia. This is not so easy as it might appear at first sight, since the general muscular relaxation may be so complete as to cover up local manifestations. The face, however, may show inequality in its lines or one cheek flap more loosely than the other. The patient is not likely to undertake voluntary movements at the request of the physician, but he may make semi-voluntary ones if annoyed by the examination. The flaccidity of the arms may vary. Irregularity of the pupils is a piece of evidence to be received with some caution, as it may be habitual or the result of disease in the eye. Conjugate deviation of the eyes and head is a form of paralysis, or sometimes of unilateral spasm, which when present is of great significance. In opium-poisoning—and to a less extent in alcoholic coma—the pupils are much contracted, while they are not always so in apoplexy. Respiration is usually much more rapid in apoplexy than in opium-poisoning, and this, in the absence of distinct signs of hemiplegia, would be one of the most important means of distinction. The pulse is more nearly normal in frequency, while that of opium is either slow and hard or more often frequent and feeble.
After the time for the initial depression has passed, rapidly-rising temperature is very strong evidence in favor of apoplexy. If the patient be only partially unconscious and able to protest against being handled, to make some short answers, or even be inclined to be combative, this is not to be taken as evidence of alcohol. Hemiplegia may then be noticed. This condition of excitement may be observed in the early stage of an apoplectic attack before it deepens into coma. Unfortunately, when the lesion is situated in certain portions of the brain, as in the extremities of either the frontal or occipital lobes, there may be no paralysis, but then also there is less likelihood of the extreme symptoms we are supposingto be present. In the cerebellum, however, the symptoms may be very severe without hemiplegia, and the diagnosis correspondingly difficult. Vomiting, not caused by the presence of large quantities of food or liquor, and persisting after the stomach is once emptied, would be of some value in this case, but it would often be necessary to wait for a diagnosis. Cerebellar hemorrhage is, however, a very rare accident, and cerebellar embolism sufficiently large to cause apoplectiform symptoms still more so. A limited lesion in the pons may cause gradually-increasing stupor without distinct paralysis.
Chloroform, especially if swallowed, and chloral might possibly give rise to difficulties in the way of diagnosis, and would have to be distinguished on the same general principles as alcohol and opium.
The poisonous gases arising from burning coal, consisting chiefly of carbonic oxide and dioxide, or illuminating gas, consisting of carburetted hydrogen with a little carbonic oxide, cause unconsciousness, coma, and sometimes convulsions and vomiting. In case of a person found unconscious in bed the possibility of poisoning by one of these should not be lost sight of, nor, on the contrary, assumed to be a cause without investigation. A case has been reported where, after acute poisoning by coal gas, there occurred, presumably as the result of local anæmia, alternate paralysis, convulsions, and aphasia.47The new water-gas process is said to furnish a product considerably richer in the poisonous carbonic oxide than that now most in use.
47Boston Med. and Surg. Journal, Nov. 26, 1885.
The stupor succeeding an epileptic convulsion resembles apoplexy, and the fact that cerebral hemorrhage may be accompanied by some convulsions increases the possible similarity, but it requires only a short time for epilepsy to make itself manifest, either by a renewal of the convulsions or a rapid recovery without paralysis. According to Trousseau, however, many attacks of so-called congestion of the brain are really epilepsy. Puerperal eclampsia comes under the same head, but when convulsions are violent they may give rise to actual hemorrhage. Unilateral epileptiform convulsions are likely to be dependent on organic disease of the brain, usually not of the kind at present under consideration, but more frequently of a tumor.
Among the cerebral symptoms connected with renal disease, and not involving organic change in the brain, may be found unconsciousness, deep coma, and convulsions. It is obvious that the presence of a few hyaline casts and a little albumen will not decide the matter, since these may be present from many causes, and especially the changes in the circulation accompanying apoplexy. Neither will the most indubitable evidence of Bright's disease, such as dropsy, hypertrophy of the heart, rigid arteries, with fatty and waxy casts in the urine, do so, for, as we have already seen, not only is there nothing in the presence of nephritis to exclude apoplexy, but the very form, the interstitial, which, from the supervention of coma not preceded by other very severe symptoms, most nearly counterfeits apoplexy, is also the most likely to give rise to actual cerebral hemorrhage. The extreme and frequent cephalalgia which is so distressing a symptom in cases where there is no cerebral lesion may also be the precursors of hemorrhage.
If we have a history, the gradual onset of the symptoms, deepeningunconsciousness without any paralytic or unilateral symptoms, especially if accompanied by a diminution in the amount of urine or contained urea or a marked change in the character of the casts, renders it probable that we are dealing with so-called uræmia alone. In the absence of history hemiplegia must be the chief dependence, but it would not be difficult to imagine a case of embolism of the basilar artery with softening of the pons which would defy a positive diagnosis.
Pernicious intermittent fever appears in a so-called comatose form, which, if it were to be accompanied, as in a case related by Bemiss in the second volume of this work, by paralysis of one arm, might present difficulties of diagnosis. If it were known that the attack had been only of short duration, the elevation of temperature would, as in the case of sunstroke, decide in favor of the fever, but if it had lasted some hours, this symptom would be of no value, as the temperature may rise to an equal height in apoplexy.
Diabetic coma is a much less common affection than apoplexy. The peculiar odor (aceton) of the breath, if present—which is not always the case—might be diagnostic. The peculiar long and deep respirations would awaken suspicion which would be confirmed by an examination of the urine.
Sunstroke, with its sudden onset, complete unconsciousness, and rapidly rising temperature, may present a very close resemblance for a while to apoplexy, and in fact has been known as heat apoplexy. Age, temperature, and surroundings would give strong probabilities one way or the other, and if the temperature of the patient were at first below the normal and did not rise for an hour or two, it would certainly not be sunstroke and would be apoplexy, while if the temperature were very high a few minutes after the patient had been observed to cease work or become unconscious, the evidence in favor of sunstroke would be equally strong.
It might appear that hysteria need hardly enter into our consideration, and could hardly be mistaken for apoplexy, but most experienced physicians could relate instances where serious organic disease has been made light of under the name of hysteria, and many inexperienced ones could tell of the opposite and safer mistake. An occasional case of deep coma presents itself where, although the age and sex of the patient awaken strong suspicion, we cannot at once be sure that no organic lesion is present; and if, in addition, the patient should be affected with hemiplegia—a combination which, although rare, is by no means beyond the limits attainable by this perplexing disease—an immediate positive diagnosis would be difficult. Absence of facial paralysis, which might be made manifest by some irritation like pinching or an attempt to raise the eyelids, would be of much value under these circumstances. The hysterical physiognomy might be well enough marked to be almost conclusive by itself. The urine and feces are not likely to be passed involuntarily in hysteria, as they are in apoplexy.
Injuries to the head should be carefully looked for in any case with unknown history. Actual fracture, which perhaps leads to no depression of bone, may give rise to hemorrhage, probably meningeal, which will cause the usual symptoms, and a shock which is not accompanied by fracture may cause considerable laceration of the brain with consequent hemorrhage. In the latter case, however, unless the brain be alreadypredisposed by arterial disease, the laceration and hemorrhage will not be extreme and the symptoms will be those of concussion. The diagnosis can hardly be said to be between hemorrhage and concussion, but whether the hemorrhage be the result of concussion—a question which can hardly be answered without the history and observation of the further progress. Cuts and bruises may result from a fall caused by the shock, and pericranial ecchymoses may result from cerebral hemorrhage through the vaso-motor system without the intervention of accident.
Rapid meningitis of the vertex, with predominance of the effusion upon one side, may closely simulate compression from hemorrhage. At the base, by the time it has become severe enough to cause unconsciousness, it is likely to have affected the ocular muscles, and perhaps given rise to other paralyses less regular in their distribution than the ordinary hemiplegia. Ophthalmoscopic examination would be of value in these cases if—which is not very likely to happen—there is no history. The temperature in meningitis is more likely to be irregular and less rapidly and uniformly rising than in a severe hemorrhage or occlusion. In many cases emaciation, dry tongue, and constipation with sunken abdomen will testify to a previous illness, while after a few hours' observation the progress of the case will make the diagnosis more clear.
In differentiating cerebral hemorrhage or ordinary embolism from the apoplectiform attacks met with in syphilitic intracranial disease, it is rather a question of etiology than of diagnosis in the narrower sense, since unconsciousness and hemiplegia coming on with syphilis are often dependent upon a condition of the vessels closely resembling that which gives rise to the ordinary forms; that is, we are dealing in either case with an endarteritis which has furnished the basis for the deposit of a thrombus, and the question is, Of what nature is the endarteritis? It is obvious that this is only to be answered by a knowledge of the history, not necessarily of a primary or secondary lesion, but of previous disease. The syphilitic taint may often be suspected from the irregularity of the paralysis, the cranial nerves, for instance—especially the ocular—being much more frequently affected in syphilitic than in ordinary hemiplegia. After partial recovery or amendment the characteristics of irregularity and changeableness will be more strongly marked.
The pathology of hemiplegia and apoplectiform attacks, often 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.
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
48Christian,Centralblatt f. d. Med. Wiss., 1873, 864.
Post-paralytic chorea might present difficulties of diagnosis fromhysteria 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.
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,49with a lesion of the angular gyrus, pli courbe (P2of Ecker), and word-deafness with a lesion of the first temporal (T1). These localizations agree with those experimentally determined.
49West,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.50Bright51thought 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 occipitalpain. In the upper part of one side of the pons the hemiplegia is not alternate, but of the ordinary form.
50Bull. de Société anatomique, 1875.
51Guy'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
52Arch. 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. Rapidlyincreasing 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,53who 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.
53Op. 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. Landesberg54has 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 Gowers55another in which the two arteries were occluded simultaneously.
54Archiv für Ophthalmologie, xv. p. 214.
55Lancet, 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 symptomsas 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 ishighly 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.
TREATMENT, INCLUDINGPROPHYLAXIS.—Cerebral Hemorrhage.—As the condition upon which the usual form of cerebral hemorrhage depends is so frequently aneurism, and probably nearly always some arterial disease, the prophylaxis must evidently consist in such a mode of life as will least tend to this degeneration, or at least put it off as long as possible. This, of course, means the avoidance of all the special causes described under the head of Etiology. It is a disease of old age, but in a pathological sense old age begins in different persons after a different number of years. Fortunately for rules of hygiene, there is little that is contradictory in those to be given for most chronic and degenerative diseases. Abstinence from alcohol, as an agent tending at once to paralysis and dilatation of the vessels, is one of the most important rules and insisted upon by nearly all writers. The avoidance of over-eating, and especially ofnitrogenous food as tending to lithæmia—a generally recognized cause of arterial degeneration—is perhaps the next. Over-eating is of course to be understood as a relative term, and to be estimated with reference to the habits of exercise of each person. Practically, it will be decided by its effects; that is, if careful thought be given to the matter and the statements of the gourmand as to his immunity from all risk of trouble are not accepted as of scientific value. On the other hand, insufficient food, producing anæmia, may be a factor in arterial degeneration. Keeping one's self free from anxiety, and getting through the world with as little experience of its roughnesses as possible, might be, properly enough, added in a purely theoretical point of view if any one ever asked a physician's advice in youth as to avoidance of the diseases of age, or if any one could or would profit by this advice if it were given.
Intellectual pursuits have been credited with a special tendency to apoplexy, but there is no good reason to suppose that healthy exercise of the mind is otherwise than beneficial to its organ. Hurry, over-anxiety, and mental tension are undoubtedly potent factors in general breakdown, but do not necessarily lead to this form. They are certainly not to be found by preference in those persons who lead an intellectual life.
Syphilis, one of the most important of the causes of organic cerebral disease, and that too in the form of thrombosis, is not specially concerned in the etiology of the forms here under consideration.
If symptoms have occurred that justify the apprehension of apoplexy or paralysis, such as frequent headaches in an elderly person, hemiopia, temporary aphasia, or slight and temporary paralyses, or if one have reached a time of life at which the risk of cerebral hemorrhage becomes considerable, a stricter attention to the rules laid down above, and even to some to which but little heed would be given in health, is not out of place. A certain amount of limitation of diet, moderate and regular but not violent exercise, clothing suitable to the season, and especially warm enough in winter, and, most of all, rest if the patient be doing wearing and anxious work, should be enjoined. Finally, it should be said that the real prophylaxis of cerebral hemorrhage is to be begun in early life.
Among the exciting causes to be avoided are those which obstruct the flow of blood from the head, like tight clothing around the neck. Increase of the arterial pressure by severe or prolonged muscular effort, as in lifting or straining at stool, is to be avoided, as well as violent fits of passion. The condition of the bowels should be regulated by mild laxatives.
When the apoplectic attack has actually occurred, treatment, though apparently urgently demanded, is really of little avail. If a patient is about to die in an hour or two from rapidly increasing pressure, nothing within the reach of medical science can stop him.
There is one danger, however, easily avoided, but probably often overlooked. A patient may die from suffocation. The stertor is often a result of the paralysis of the tongue and palate and of the amount of fluids collecting in the pharynx from the almost invariable position of the patient on his back; that is, if he have been seen by some one who wished to do something for him, but did not know what. Insensibility and paralysis combine to favor this accumulation, which obstructs the respiration, and which may find its way to the lungs, together with brandy and milk, and set up an inhalation-pneumonia. The simple and obvious thingto do is to place the patient sufficiently on his side, with the face somewhat downward, for the tongue and palate and secretions to fall forward, instead of backward into the pharynx. Swabbing out the pharynx may be of some use, but cannot be so thorough. An easy position and proper ventilation should be secured in all cases of unconsciousness, even at the risk of treating a drunkard with undue consideration. Police-stations should be provided with rooms where these conditions can be secured, and the necessity avoided of placing persons picked up in the streets in the narrow, close, and perhaps distant cells provided for malefactors. The writer recalls the cases of two young men—one who had been drinking some time before, and the second roaring drunk—who were locked up in a suburban station-house in the evening, and found the next morning—one dying and the other dead.
Artificial respiration may be used to prolong life in some cases until the nervous centres have sufficiently recovered their functions to carry on the process without assistance. The condition of the bladder should be ascertained, and the urine drawn if necessary, though it is more frequently passed involuntarily.
Although it is manifestly impossible to remove the clot from the interior of the brain, it may appear that the further flow of blood may be stopped and the amount of damage done limited. For this purpose two remedies are proposed—namely, bleeding and purgatives. Both of these act to diminish arterial pressure, which is forcing the blood out of the rupture. Though the treatment seems reasonable, it would not be difficult to imagine a condition where sudden and premature diminution of pressure in the brain, which of course exists outside of the arteries as well as inside, would tend to set going again the flow which has ceased from the very force of the pressure it itself exerts, very much as if a tampon were prematurely removed from a bleeding cavity elsewhere. As the conditions are somewhat complicated, and at the same time only remotely to be estimated, it is safer to be guided by experience in the use of these remedies than by abstract reasoning. In some of the cases of temporary aphasia, as notably that of Rostan narrated by Trousseau, bleeding seems to have given immediate relief. Trousseau, however, is no advocate of that method of treatment. Most modern authors speak of venesection as to be used in cases where the pulse is strong and full and the face red, but not to be thought of in the opposite class. When a case presents the appearances of plethora and an attack has come on suddenly, the loss of a few ounces of blood can certainly do no harm. Other forms of bleeding, such as cups and leeches, are not rapid enough to be of great value, though a large number of leeches about the head might be useful. Some French writers recommend leeches to the anus as revulsives. Cathartics may be more freely used, although they should be given cautiously when there is any tendency to cardiac depression. It can be clearly shown that a brisk purgative lowers the arterial tension decidedly. In case of cerebral tumor or injury with occasional so-called congestive attacks, the relief afforded by cathartics is very great, and, although the conditions are not exactly parallel, it is fair to assume a similar action in the congestion accompanying cerebral hemorrhage. From one to three drops of croton oil may be placed far back on the tongue or it may be diluted with a neutral oil. Ail enema may be desirable for the unloading of the bowels,but has a much less marked effect on the tension of the cerebral circulation.
In most cases of apoplectiform cerebral hemorrhage, and probably in all of simple paralysis, no very active treatment is called for. Measures directed to the prevention of another hemorrhage, and to allay any irritation that may supervene during the changes taking place about the clot and the formation of its capsule, are of the simplest, and consist in keeping the head high and cool, the clothing sufficient for warmth, and offering no obstruction to respiration or circulation, laxatives sufficient to keep the bowels in good order, and a diet not highly nitrogenous, but sufficient and digestible.
That which will tax most severely, however, the care and patience of attendants is the scrupulous and minute attention to cleanliness and pressure over the bony prominences which is necessary when a patient is helpless and unable to control the discharges from the rectum and bladder. Frequent change of clothing, bathing, change of position, and avoidance of wrinkles and roughnesses in the bed may be successful in keeping the patient free from bed-sores. Bathing with alcohol hardens the skin and makes it less susceptible to pressure.
Surgical interference may perhaps be of value in cases where the portion of the clot outside the brain can be clearly demonstrated; and this would apply with special force where the hemorrhage arises from injury.
Trephining and removal of the clot has been done in a few cases of meningeal hemorrhage, though with indifferent success (3 cases—2 deaths, 1 unknown.)56An intracerebral clot is obviously a step beyond, though possibly in some cases not absolutely without, the reach of the surgeon.
56Med. Press and Circular, Oct. 14, 1885.
Treatment of Cerebral Embolism.—The prophylaxis is in the avoidance of such conditions as give rise to the formation of detachable vegetations or clots. Unfortunately, these are numerous, not completely known, and not always avoidable. Arterial disease is to be looked upon as of some importance, but cardiac valvular lesions of much greater, and the causes of these, like rheumatism, scarlet fever, and the puerperal condition, are not always to be escaped. The presence of a detachable piece of fibrin in the pulmonary veins, heart, or aorta being granted, nobody can possibly say what will prevent its being loosened and lodging in one of the cerebral arteries; so that, practically, the prophylaxis of embolism consists in the judicious treatment of acute rheumatism and the other conditions just mentioned. The treatment of the first attack must consist solely in the relief of respiration, bladder, and bowels, if they have not taken care of themselves. Stimulants may be of use for a short time, but there cannot be any call for even the slight amount of depletion suggested for some cases of hemorrhage. Bed-sores are to be looked out for, just as in hemorrhage, and the subsequent treatment conducted on the same principles. As regards the primary lesion, we can do nothing about it either in the way of removal of the embolus or restoration of the necrosed brain-tissue.
Treatment of Cerebral Thrombosis.—There being two factors in this affection, both of which are to a certain extent under control, something may be done toward diminishing the risk of its occurrence. Arterial disease and its prophylaxis have already been spoken of. The othercondition which is necessary to the production of thrombosis—namely, an enfeebled circulation—is to some extent under the control of general hygienic rules: a nutritious, not too highly nitrogenous, diet, and especially sufficient exercise and the avoidance of completely sedentary habits. If there is a crasis which predisposes to the formation of coagula in the vessels, it is not known that there is any special treatment, medical or otherwise, which can prevent it. The attack is to be treated exactly on the principles already laid down. Bleeding is about the last thing to be thought of. Stimulants, though they cannot dislodge the clot, may be of use for a time to sustain the heart under the shock. The secretions and the condition of the skin are to be looked out for.
After a few weeks of waiting the patient and his friends not unnaturally feel as if something ought to be done to hasten recovery, and certain measures may be taken, in addition to careful hygiene, which have this object in view. It is very doubtful, however, whether anything really shortens the time necessary for such repair as is possible or diminishes the amount of damage which is to be permanent. As has already been said, improvement may go on slowly for months. In the first place, it is sometimes considered desirable to practise shampooing and massage of the affected muscles in order to keep them in as good a condition of nutrition as possible. This, as well as the regular use of the faradic battery if it be not begun too early, will prevent a certain moderate amount of atrophy, but could not have any influence in those rare cases where rapid wasting depends upon secondary degeneration of the anterior gray columns. It may be doubted, however, whether it is necessary to pay much attention to the condition of the muscles, as they do not ordinarily atrophy to the extent of becoming unsusceptible to the nervous stimulus from the brain so soon as it shall be transmitted to them. Faradism, like many other agencies, such as magnets, metals, pieces of wood, and so forth, is said to produce a transfer of sensibility in cases of hemianæsthesia.
There is no sufficient reason to suppose that any drug is of any value in the restoration of the nervous structure. Iodide of potassium may possibly prove to have some effect as a sorbefacient. Very favorable results have been claimed for ammonia salts in the restoration of aged persons to a nearly complete use of paralyzed limbs. Phosphorus has been spoken of as assisting in repair, but the writer is not aware upon how wide a basis of facts. Silver and gold have been said to counteract the sclerosing myelitis. Strychnia is certainly useless, and probably worse. It may make the paralyzed limbs twitch, but this does just as little good as the involuntary spasmodic movements, which have never been considered desirable, except as awakening in the patient false notions of immediate recovery, and which are frequently a very annoying symptom. The galvanic current has been applied with a view to a sorbefacient or restorative action directly to the brain, or rather to the pericranium.
Something can be done for the comfort of such patients: the rubbing and kneading of the paralyzed limbs, if they do not hasten the recovery of motion, relieve many of the painful and unpleasant feelings. Since we do not know how far one part of the brain may supplement another, attempts at motion after it has once appeared to ever so slight a degree should not be abandoned by the patient. He should walkwith crutches frequently as soon as he can, though not to the point of fatigue.
There is one faculty which seems capable of re-education to some extent: that is of speech in cases of ataxic aphasia, and even in others the attempt should be made to teach the patient the names of things. A very interesting case has been reported by Bristowe57of a man who came under his observation after an attack which may have been anterior poliomyelitis with extensive paralysis, able to write well and intelligently, but unable to say anything. By gradual education, first in the sound and formation of letters and afterward of words, he reacquired the use of language. It is obvious that in this case there could have been no loss of memory for the words themselves, but simply the loss of the knowledge of how to produce them. When his speech returned he spoke with his original American accent.
57Clin. Soc. Trans., iii. p. 92.
In short, the therapeutics of hemiplegia from arterial disease in the brain is good nursing and attention to symptoms, with a moderate amount of care of the paralyzed muscles.