A system of practical medicine. By American authors. Vol. 5

by Unknown

The general functions are even less disturbed than with a hemorrhage producing an equal extent of paralysis. The temperature follows nearly the same course as in hemorrhage, except that the initial fall, if present—which is not always the case—is said to be less than with cerebral hemorrhage. To this succeeds a rapid rise, which, even in cases which are to terminate fatally, gives place to a fall to the neighborhood of normal, and another rise before death. These are the statements of Bourneville. The rise is said not to be so high as with hemorrhage.

The annexed chart is from a man (W. I. W.) who was in the hospital with ill-defined nervous symptoms, and was suddenly attacked with convulsions, vomiting, and unconsciousness. He had a small tumor at the point of the right temporal lobe, and softening of the left corpus striatum. The apoplectic symptoms occurred on the 15th—that is, as will be seen by the chart, one day after the temperature began to rise. The pulse and respiration show no characteristic changes.

FIG. 40.

It is much more common for the embolus or thrombus to give rise to a 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 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.