- Presence of premonitory
symptoms.
- Diagnosis of cerebral
hemorrhage.
-
- It is certain that premonitory symptoms are
sometimes absent, although the following are
systematically enumerated as respectively
preceding the attack in various cases. To me it
appears contendible whether they generally
occur, and if so, should be regarded as true
prodromata, rather than indications of
pre-existing disease of brain, heart, or kidney,
or of the actual occurrence of effusion.
-
- Rochoux, much of the same opinion,
maintained that it is rare to observe precursory
symptoms in cases of cerebral hemorrhage. He
writes, "Sur soixante-neuf apoplectiques dont
j'ai recueilli les histoires, onze ont
présenté des symptômes
précurseurs, et parmi eux, cinq
étaient habituellement sujets des
vertiges qui ne se sont pas sensiblement
augmentés aux approches de l'attaque.
Ainsi, pour être tout-à-fait exact,
il faut dire, que six malades seulement ont
éprouvé des symptômes
précurseurs, et qui réduit les
individus, dans ce cas, à moins d'un
dixième."-(Dict. de Méd., tom. IV.
p. 104.)
-
- The symptoms referred to are weight and pain
in the head, vertigo, tinnitus, deafness,
throbbing of the temporals or carotids,
epistaxis, lacryination, diplopia, heteropiae,
muscae, ptosis, trembling speech, sighing,
yawning, vomiting, change of countenance,
deviation of the mouth, starting of the limbs,
excitement, agitation, numbness of the
extremities, vacillation, stumbling, chilliness,
flushing, pallor, grinding of the teeth,
especially during sleep, wakefulness,
drowsiness, incubus, incoherence, and loss of
memory.
-
- Were this group of symptoms ever aggregated
in one person, it must be allowed that though
they point to cerebral disorder, they are not
pathognomonic of imminent apoplexy. It may be
they are honoured as traditiouary, as the chief
of them were distinctly described long long ago
by Coelius Aurelianus, who added that they are
often absent, and, with additions, centuries
after by Ettmuller; but the former sagaciously
explained that they equally presage the advent
of mania and epilepsy (sod hoec communiter
antecedunt vol preunt etiam his qui in
epilepsiam vel furoreni venturi videntur).-Lib.
III. cap. V.
-
- The character and intensity of the symptoms
of hemorrhage, of course, vary, according to its
suddenness, situation, and amount; death being
most certain and rapid, as a rule, when the
extravaaation occurs at the base of the brain;
next, into the ventricular or arachnoiavities;
being less so when limited to the neighbourhood
of the cerebral ganglia or the substance of the
hemisphere. The issue is likewise much
determined by the coincident morbid condition of
the individual, as very feeble or previously
hemiplegic persons will sometimes succumb to a
very trifling sanguineous effusion-a fact
apparently unnoticed in articles on the
disease.
-
- A patient may suddenly stagger and fall, and
die almost instantaneously in very rare cases,
but more commonly he becomes soporose and
gradually merges into coma. The face is usually
flushed, the pulse at first slow, full, hard,
thrilling, and as it were resentful; but it may
be small, weak, and quick in feeble cacheotic
patients and exceptional instances. The face
also may be pale, livid, or bloated, and there
is often marked hebetude of eipression. The
breathing is generally infrequent, and more or
less stertorous; but it may be calm and natural,
or suspirious at the outset. Frequently there is
hemiplegia, the opposite side remaining
unaffected, or it may be rigid and convulsed, or
there may be rigidity of the limbs with or
without convulsion, or the upper extremities may
be flaccid, the lower rigid or convulsed, or
there may be, mostly at a later period, general
loss of muscular power. The pupils may be
natural, contracted, or dilated, or one
contracted the other dilated, and sensible or
insensible to light. The mouth frequently
deviates, but occasionally this is not observed.
This state may terminate in perfect recovery
(P), recovery with paralysis, or death.
-
- Or the patient may suddenly become
hemiplegic and speechless, with or without loss
of consciousness, or unconsciousness may be
transient, or again gradually pass into coma,
which may be recovered from, or prove more or
less speedily fatal. Or perfect recovery may
ensue (P), or the 'patient may suffer from
permanent hemiplegia and loss of speech, or
imperfectly recover, or the paralysis may be
succeeded by early or late rigidity and
contraction of the muscles.
-
- In very sudden and extensive effusion
(apoplexia fulminans, apoplexie foudroyante) the
patient may become pale and faint, the surface
cold, the pulse small and feeble. Frequently
there is vomiting, yawning, and some
impairment of speech.and consciousness, which
more or less quickly lapse into absolute coma,
preceded, accompanied, or followed by
hemiplegia, convulsions or general paralysis,
spasmodic twitchirigs of the face and limbs,
whiffing expiration, foam at the mouth, clammy
perspirations, widely-dilated pupils,
involuntary evacuations, and speedy
dissolution.
-
- It must be remembered that types of apoplexy
more abound in books than in practice.
-
- In our present state of knowledge it is
impossible to localize cerebral extravasation,
or always to affirm positively even that
hemorrhage has occurred. In fact, it may be
absolutely asserted that sanguineous apoplexy
does not furnish one diagnostic, or rather
pathognomonic symptom; yet collectively a
certain series of objective phenomena, in most
instances, will render an opinion tolerably
certain. Oases are, however, occasionally
presented, which are but slightly pronounced,
especially on invasion, and prove very
embarrassing. It must in addition be remarked
that all comatose diseases in their last 8tages
8inwlate true apopleay, and cannot be
discriminated in default of their previous
history, which is unfortunately often deficient
or absent in patients found insensible and
brought to a hôspital. The age may be'of
some assistance, as cerebral hemorrhage is not
common until after the meridian of life. The
condition of the heart, if known beforehand, may
also aid us. After the access of the disease
this is difficult to examine, and the value of
physical signs is doubtful, as coma, from
whatever cause, is usually accompanied by
oppressed quasi. hypertrophous action of the
organ, in consequence of altered
innervation.
-
- Cœteris paribus, in a case of coma, the
ascertainment of previous temperate habits,
non-existence of arm, and the exclusion of
cardiac ailment augur favourably. Flushing or
pallor of the countenance is an unsafe guide,
without due correction, as the face is for the
most part pale in the worst or ingravesoent
attacks, and it may be pallid, with lividity,
throughout, if the hemorrhage be complicated
with uremia.
-
- The most certain indications of intracranial
hemorrhage are sudden hemiplegia, with more or
less immediate and profound loss of
consciousness with or without rigidity or
convulsion stertorous breathing, deviation of
the mouth, flushed face, and a full slow pulse.
Tonic or clonic contraction of the muscles of
the limbs frequently testifies to the
co-existence of ventricular or arachnoid
sanguineous effusion, and general paralysis of
the extremities is usually associated with
diffuse hemorrhage or the moribund state. Not
any constant or special symptoms (as Gall and
Serres maintained) attend apoplectic
extravasation into the cerebellum, which may
serve to distinguish it from effusion into other
parts of the brain. (Brown-Sequard.) In a very
circumscribed apoplexy, the slightness or almost
negation of symptoms may render a decision
difficult or impossible. If an attack,
apparently apoplectic, entirely subside, i. e.
without sequel, hemorrhage, if pro-existent,
must have been exceedingly limited, and in the
immense majority of cases the symptoms will
depend, not on hemorrhage, but on other
disorder.
-
- The most common affections with which
apoplexy may be confounded in practice, are
uremia and poisoning by opium. In urœmia,
the premonitory symptoms, if ascertained, are
headache, vertigo, muscœ volitantes,
anomalous pains and epileptiform attacks in many
cases. The aspect is usually sallow and
cachectic, the ankles often oedematous, and the
urine more or less charged with albumen. In the
uræmic paroxysm the coma is more gradual,
and generally less profound (sopor) than in
apoplexy. There is absence of paralysis at the
outset, or it is less marked. Subsultus or
convulsion is common, there is less stertor, and
the breath fumes with hydrochloric acid-a very
unsatisfactory test. Oedema, or anasarca, should
not be overlooked in the diagnosis.
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