Biographies de neurologues
Nouvelle Iconographie de La Salpêtrière
 L'histoire des neurosciences à La Pitié et à La Salpêtrière J Poirier
The history of neurosciences at La Pitié and La Salpêtrière J Poirier 

mise à jour du
30 mars 2008
J. Churchill
A practical treatrise on apoplexia
William Boyd Mushet


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.