Cerebral Hemorrhage.

Synonym.—Apoplexy.

Definition.—Hemorrhage in the brain or its meninges, usually from the arteries and capillaries, though occasionally from the veins.

Etiology.—Eighty per cent of cerebral hemorrhages occur after the age of forty, though it has taken place in a child of nine. It is more frequent in men than women, no doubt from greater dissipations and more severe physical exertions of the former, which tend to diseases of the blood-vessels. A feeble condition of the cerebral vessels, due to disease of their walls, is essential for the lesion, when a variety of causes may be responsible for the accident.

In certain families there is a tendency to degeneration of the arteries, hence heredity must figure as a predisposing cause. A large number of cases are preceded by some lesion of the heart. It may be endocarditis with its accompanying- hypertrophy, especially where the hemorrhage occurs in young persons, or it may be due to endarteritis or atheromatous condition of the vessels; again, it may be due to rupture of small aneurisms (miliary) of the branches of the cerebral arteries.

Another common condition is nephritis and diabetes, while alcohol, syphilis, rheumatism, and gout are not infrequent factors in the case. Certain infectious diseases, especially ulcerative endocarditis and diphtheria, may be mentioned, while leukemia and anemia are not to be overlooked as causal conditions.

Pathology.—While any part of the brain may be the seat of hemorrhage, the most frequent site is the base in the neighborhood of the corpus striatum and optic thalamus, since their chief supply comes from the branches of the cerebral artery. The majority of the severe hemorrhages of the brain occur in the internal capsule and lenticular nucleus, by the rupture of the lenticulo-striate artery; so frequently is this artery ruptured that Charcot has termed it the "artery of cerebral hemorrhage."

"Under different circumstances the blood effused may be small in quantity, or amount to several ounces. In the latter case it tears up the brain-tissue, destroying, for instance, the great ganglia, and the internal capsule, and extending thence into the centrum ovale; or it may burst through the optic thalamus or caudate nucleus into the lateral ventricle. Thence the blood flows by the aqueduct of Sylvius into the fourth ventricle. Such cases are rapidly fatal, and post-mortem examination reveals a mass of black clot, filling the ventricle, and occupying much of the hemisphere, surrounded by brain-tissue, which is ragged and discolored by blood. The pressure exerted by the clot is shown by one, or even both, hemispheres being enlarged, with flattened convolutions and closed sulci. In cases which have lasted a few days, there is the same black-red clot, and the brain-tissue around is soft and discolored yellow, from absorption of hemoglobin. In later stages, the clot becomes brown, or brownish-yellow, consisting of disintegrated blood and nerve-tissue; and the surrounding tissue is frequently softened (white softening), and contains granule-corpuscles. Finally, in patients that survive, the blood becomes absorbed, and leaves a tawny or orange-colored spot, in which crystals of hematoidin can be found; or a cyst may remain, containing serous fluid; or a distinct, tough, fibrous scar, discolored also by the remains of blood-pigment.

"Secondary Degeneration.—Permanent lesions of the pyramidal tract, or of the cortical motor area, are followed by descending secondary degenerations, like those which occur in disease of the spinal cord. Such degenerations follow the course of the pyramidal fibers below the lesion; thus, a lesion of the internal capsule (and it is to be observed that lesions of the corpus striatum and optic thalamus alone are not followed by secondary degeneration) cause's this change to take place in the middle third of the crus cerebri, in the anterior part of the pons, in the pyramid of the medulla oblongata on the same side, in the column of Turck, also on the same side, but in the posterior part of the lateral column of the spinal cord for its whole length on the opposite side." (Taylor.)

Symptoms.—Although unusual, premonitory symptoms may be present, and consist of headache, more or less dullness, ringing in the ears, vertigo, and sometimes choreiform movements. There also may be motor impairment, as seen in the slow step or movement of the arm.

Generally, with the rupture of the vessel, comes the apoplectic stroke or apoplectic shock, and the patient drops unconscious on the ground. The face is dusky or ashen gray; the pulse, at first small, soon becomes full, slow, and of increased tension; the breathing is noisy, stertorous, and the cheek is blown out at each expiration. Sometimes there is the Cheyne-Stoke respiration.

There is usually complete relaxation on the paralyzed side, though there may be twitching of the muscles or slight convulsive movements for a time. Soon, however, these cease, and there is present the characteristic flaccidity and loss of muscular control. This may be seen by lifting the affected member, when it drops heavily to one side.

The pupils vary, usually dilated, though when the hemorrhage is in the pons or ventricles, irritating the nucleus of the third nerve, the pupils are contracted. The temperature is not, infrequently, slightly subnormal, though when the hemorrhage is of the base of the brain, there is apt to be a high temperature. There is loss of control of the sphincters, and the feces and urine are passed involuntarily.

Where the disease does not terminate fatally in twenty-four or forty-eight hours, the breathing becomes less labored, and the patient gradually regains consciousness. The eye is turned towards the affected side or away from the paralyzed side. Hemiplegia, paralysis of one entire side, is the rule.

Sometimes the symptoms come on gradually, when it is termed ingravescent apoplexy. Here the patient feels dull, there is heaviness in the head, moves slowly and with difficulty, and it is several hours before the patient loses consciousness and the loss of voluntary motion, and sometimes consciousness is retained till after the paralysis appears, or, with the onset of motor paralysis, the patient is assisted to bed, drops asleep, and passes into a comatose condition, the failure to waken the patient being the warning note of his true condition.

The evidence of hemiplegia, before consciousness returns, may be overlooked; but if we note carefully the fare, we will notice a slight dropping of the angles of the mouth on the affected side, and the muscles of the extremities are flaccid and baggy. In rare cases the muscles are rigid on the affected side.

Although the tongue may not be paralyzed, it goes to the affected side when protruded. When it is paralysed there is great difficulty in articulation.

Sensation may be but slightly impaired, and only for the first few days, but early disappears.

Although the tendon reflexes are generally abolished in the early stage, they are nearly always increased on the affected side later in the disease. A continued failure in the reflexes should be regarded as an unfavorable sign.

Trophic symptoms are seen in an increased temperature, puffiness of the eyelids and hands, coolness and moisture of the feet, and, in some cases, rapid necrosis and gangrene of the tissues over the sacrum, the "acute malignant decubitus" of Charcot.

General nutrition is usually maintained, though, in rare cases, there is general atrophy.

Where partial recovery takes place, the mental faculties, as a rule, remain unimpaired.

Diagnosis.—The diagnosis is many times extremely difficult and often it is impossible to differentiate between cerebral hemorrhage, embolism and thrombosis. Care must also be observed, or it may be mistaken for diabetic coma, uremic poisoning, epilepsy, opium poisoning, or alcoholism.

The most characteristic signs of apoplexy are sudden unconsciousness, deep, heavy stertorous breathing, a full oppressed pulse, and hemiplegia, which can be determined, even during unconsciousness, by the flaccidity of the muscles.

In a case of drunk, the patient can usually be aroused if only for a moment, and the breathing is not stertorous; the breath may be of but little significance, for apoplexy frequently occurs among alcoholics. In' epilepsy there is generally the telltale frothing at the mouth, and a history of previous attacks. In uremic coma, the urine should be examined for albumin and casts, and for sugar in diabetic coma. Opium poisoning comes on slowly, and the patient can usually be aroused if but for a moment, and the breathing, while slow and labored, does not give the characteristic stertor. The head should be examined carefully for injuries, that concussion of the brain may be excluded.

Prognosis.—This depends largely upon the location and extent of the lesion. Unless the hemorrhage is severe in the pons, death is not likely to occur suddenly. Usually, where the hemorrhage is extensive, the patient will live ten, twelve, or more hours. Where slight, the patient may recover within a few weeks. Should the patient fail to show improvement in three months, the outlook is unfavorable.

The muscles of the face are the first to show improvement; then the patient will be able to move the toes, and later the limbs may be flexed, till finally he can step and bear his weight. At first his feet seem too heavy to lift, the patient shuffling or dragging the foot, though in time there may be but little use of a cane. The muscles of the hand respond slowly, and complete recovery may not take place, the hand being puffy, bluish, and cold.

Where the coma deepens the second or third day after the attack, or the temperature rapidly increases within the first forty-eight hours, the prognosis is decidedly unfavorable.

Treatment.—The clothing about the neck should be loosened, and -the head slightly elevated. If the pulse be full and strong, veratrum should be given in full doses, say one dram to four ounces of water, and a teaspoonful given every one, two, or three hours. A brisk cathartic should be given early. Sinapisms may be applied to the spine, hot applications to the feet, and the head sponged with hot water, while an assistant uses the fan. Some prefer the ice-bag to the head.

When consciousness returns, the patient should be kept perfectly quiet, all efforts at conversation prohibited for a few days, and liquid nourishment given.

Where the capillary circulation is feeble, belladonna will be found useful. Massage and electricity will be found efficient in restoring tone to the muscles during convalescence.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.