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
48 Christian, Centralblatt f. d. Med. Wiss., 1873, 864.
Post-paralytic chorea might present difficulties of diagnosis from 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.