Hemiplegia

“ It gives an account of the existing knowledge of hemiplegia, paraplegia, paralysis of separate nerves, epilepsy, apoplexy, lethargy, and hydrocephalus internus. It shows considerable clinical acquaintance with the subject and a careful study of old writers, but the imperfect state of knowledge of this part of medicine is illustrated by the fact that apoplexy and hemiplegia are treated as subjects having no relation to one another. ”

“ A suddenly-developed, complete hemiplegia or other paralysis may be considered as in all probability either hemorrhagic or produced by a thrombus so large that the results will be disorganization of the brain-substance, and a future no more hopeful than that of a clot. ”

“ These may assume the form of a hemiplegia or may involve only certain groups of muscles. Ptosis is often noted. Paralysis of other eye muscles is common, and pupillary rigidity is sometimes a symptom. Hemianopsia and diplopia are often observed: An important feature of the disease is the fact that these conditions are more or less transitory and rarely become [312] permanent. Apoplectiform attacks followed by hemiplegia are results of gummatous growth or may be associated with areas of softening. These are due to vascular disturbances. Aphasia is not an unusual occurrence. ”

“ In the extremities it is evident, that they cannot exist; in the trunk, they are hardly ever seen behind, and not frequently before. If every pair of nerves gave examples of them, it is clear that hemiplegia would rarely take place, because the sound side of the brain or spinal marrow would through them have an influence upon the nerves of the affected side. ”

“ In most cases, however, hemiplegia arises from emboli obstructing one or more blood vessels of the brain, or the rupture of some vessel the wall of which had become weakened by degeneration and the extravasation of blood. Sensibility in most cases is not impaired, but in some there is a loss of sensibility as well as of motion. ”

“ The patient is then usually found to be in a condition of hemiplegia, and at this point the history of hemorrhagic apoplexy becomes identical with that of paralysis from hemorrhage where no truly apoplectic condition has been present.
Lidell states that in more than one-third of all cases of cerebral hemorrhage hemiplegia is developed without loss of consciousness or coma. In some, the paralysis precedes unconsciousness, which then slowly supervenes. ”

“ In case of hemiplegia or paraplegia, run the [129] current from the healthy side of the spine, (in hemiplegia,) or from a healthy part of the spine, (in paraplegia,) to and through the paralyzed parts, by placing P. P., long cord, on spine, and manipulating with N. P., metallic brush commonly, upon the parts paralyzed. Close the treatment with reversed poles for a moment or two, as in the preceding cases. Old paralysis requires considerable time to cure it. Treat about three times a week, occasionally omitting a week. ”

“ Hemiplegia is usually the result of a cerebral hemorrhage or embolism. It sometimes occurs suddenly without other marked symptoms, but commonly it is ushered in by an apoplectic attack and on return of consciousness it is observed that one side of the body is paralyzed, the paralysis being often profound in the beginning, and disappearing to a greater or less extent at a later period. ”

“ 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. ”

“ Occasionally the face is paralysed on one side and the arm and leg on the other side; this condition is termed alternate hemiplegia, which is due to the fact that the disease has damaged the motor path from the brain to the leg and arm before it has crossed over to the opposite side, whereas the path to the face muscles is damaged after it has crossed. In rare cases both leg, arm and face on one side may be paralysed—triplegia ”

“ When children, who have suffered an hemiplegia, begin to use the affected arm, the other hand should be tied up for half an hour three or four times a day; which obliges them at their play to use more frequent voluntary efforts with the diseased limb, and thus sooner to restore the dissevered associations of motion. ”

“ 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. ”

“ Alternating hemiplegia, or paralysis of one side of the body followed by a paralysis of the other side, is observed in tumors of the pons, and is readily accounted for by the close proximity of the motor tracts, a lesion which affects one tract first being very likely, sooner or later, to involve, partially at least, the other, as in Case 84. ”

“ In rare cases the whole motor area is destroyed—cortical hemiplegia; more generally the lesion affects one or more groups of muscles, and occasionally all the muscles of one limb are paralysed—cortical monoplegia. Lesions are often both irritative and destructive, and lead to paralysis of one or more groups of muscles associated with spasms and convulsions of the muscles governed by neighbouring areas of the cortex. Irritation or destruction of the sensory centres may also exist, giving rise to areas of paræsthesia and anæsthesia. ”

“ If the loss of consciousness be not complete, so that the presence or absence of paralysis can be ascertained, we can sometimes distinguish the situation of the hemorrhage. Right-sided hemiplegia, with paralysis of the face or tongue, or with aphasia, is most probably owing to hemorrhage or [p. 715] embolism somewhere in the left motor tract, and hence within the brain. If the absence of paralysis can be certainly ascertained, the probabilities are in favor of meningeal apoplexy. ”

“ December 28, the hemiplegia was better, although neurological examination showed weakness of left upper extremity, abolition of deep reflexes, and certain skin changes of the left hand with edema (main succulent) , decreased resistance of muscles of lower extremity to passive motion, especially of adductors and flexors, exaggerated polykinetic left knee-jerk, ankle clonus, Babinski reflex, abdominal and cremasteric reflexes absent on left, platysma paralysis left, with complete paralysis in the inferior distribution of the facialis; whistling impossible. ”

“ If the phenomena present be those of double spastic hemiplegia, there is surely degeneration of both pyramids.
(b) A systematic lesion affects the nuclei (origins) of the facial, hypoglossal, pneumogastric, spinal accessory, and the motor root of the trigeminus nerves, giving rise to a classical symptom-group. The symptoms thus produced are exclusively (?) motor and trophic, consisting of progressively increasing paresis, with atrophy of the muscles about the lips [p. 80] and cheeks, the intrinsic lingual muscles, the laryngeal and pharyngeal muscles. ”

“ An adequate doctrine of localization has to account for such increase of paralysis in compound order on increasing gravity of lesions. In the third degree of, or rather beyond, hemiplegia there is universal immobility. In this degree the patient has lost consciousness, and this loss may be said to explain why he does not move the other or "second" side of his body. ”

“ Cerebral syphilis occurring in an hysterical subject may be readily overlooked until fatal mischief is done. When any paralysis occurs a study of the reflexes may sometimes lead to a correct diagnosis. Thus in a hemiplegia the reflex on the affected side in cerebral syphilis is very frequently exaggerated, whilst in hysteria the reflexes are usually alike on both sides. When both motion and sensation are disturbed in an organic hemiplegia, the anæsthesia and motor paralysis occur on the same side of the body, whilst in hysteria they are usually on opposite sides. ”

“ An example of such an incompatibility might be that of a patient who should, three months after a sudden hemiplegia, show complete or almost complete flaccid paralysis and but slight exaggeration of tendon reflexes—yet the Babinski reflex. Of course, the Babinski reflex would permit a diagnosis of pyramidal tract disease. Yet a sudden intense hemiplegia lasting three months, if it were merely a matter of pyramidal tract disorder, ought to show hyperreflexia of a pronounced degree as well as contracture. ”

“ Hysterical hemiplegia and monoplegia may simulate almost any type of organic paralysis. The paralysis is usually in a case of hemiplegia, confined to the arm and leg, the face being slightly, if at all, implicated. Hysterical paralysis, limited to the muscles supplied by the facial nerve, is very rare. According to Rosenthal, it sometimes coexists with paralysis of the limbs of the same side, and is usually accompanied by anæsthesia of the skin and special senses. In a few rare cases, according to Mitchell, the neck is affected. ”

“ 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. ”

“ 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. ”

“ Since the electric fluid may act only as a more potent stimulus exciting the muscular fibres into action, and not by supplying them with a new quantity of the spirit of life. Thus in a recent hemiplegia I have frequently observed, when the patient yawned and stretched himself, that the paralytic limbs moved also, though they were totally disobedient to the will. ”

“ Sometimes we say that the extremities of the nerves have become callous; it is a vague expression, to which no meaning can be attached. When will medical language cease to refer to the empty and inaccurate hypotheses that formerly constituted medicine? Most of these hypotheses have passed away, yet the names to which they gave birth remain.
The nervous system and the brain frequently lose beforehand, in old people, a part of their functions; hence hemiplegia is almost as frequent at that age, as convulsions which are its opposite, are in infancy. ”

“ This condition may or may not be preceded by apoplectic or epileptic symptoms: it may occur gradually or suddenly. Although it is customary to say that in hemiplegia a patient is paralyzed on one side, this is not strictly correct, as careful observation shows that (1) in the face only the lower facial muscles are distinctly affected; the tongue itself is rarely paralyzed, but its projecting muscular apparatus is, so that when protruded it deviates as a whole toward the paralyzed side; the eye-muscles and masticatory muscles are unaffected ”

“ There was an anesthesia of hysterical type in the left arm, and also of the left leg as far as the middle of the thigh. He dragged his leg in walking (démarche en draguant: the toe is dragged along the ground, the trunk is bent forward, and at every step plunges somewhat toward the paralyzed side. The patient is able to walk, however, by means of a cane or crutches. This walk is characteristic of hysterical hemiplegia. According to Roussy and Lhermitte, the number of cases of hysterical hemiplegia (better, hemiparesis) is not large) . The plantar reflexes on both sides were those of flexion. ”

“ Functional paralyses and pareses of motion or sensation, or both, are occasionally observed. Paraplegia is of relatively frequent occurrence. Not infrequently this condition is of reflex origin, the eccentric irritant residing in the uterus and adnexa or the gastro-intestinal canal. Hemiplegia and general paralysis are observed less frequently. ”

“ Thus we have the alternating paralyses from tumors of the crus cerebri or of the lower part of the pons, and paraplegia, or perhaps what might be better called double hemiplegia, from multiple tumors which affect both sides of the brain. In rare cases paralysis of all four extremities has resulted from a growth in the middle line of the base of the brain. ”

“ Some muscles are completely paralysed, others are merely weakened, while others, e.g. the trunk muscles, are apparently unaffected. In many cases of even complete hemiplegia, improvement, especially in children, takes place after a few weeks or months, and is generally first indicated by return of movement in the muscles which are habitually associated in their action with those of the opposite unparalysed side; thus, movement of the leg returns first at the hip and knee joints, and of the arm at the shoulder and elbow, although the hand may remain motionless. ”

“ I know of no other basis on which cases of insanity, diseases of the highest centers, can be studied comparatively with non-mental diseases of the nervous system—diseases of lower centers.
I next speak of different depths of dissolution. The deeper the dissolution the shallower the level of evolution remaining. In hemiplegia, owing to lesion of the internal capsule, there are, according to the gravity of the lesion, three degrees or depths (of course the division into three degrees is arbitrary) . In the first degree there is some paralysis of the face, arm, and leg ”