APOPLEXY. 227 



guished from paraplegia of spinal origin by the presence of mental 

 derangement or of palsy of one of the facial cranial nerves ; it 

 being borne in mind, however, that cerebral and spinal palsies may 

 coexist. 



When an apoplectic effusion bursts its way to the meninges or 

 into one of the ventricles, death usually ensues. As a rule, such 

 penetrations are attended by convulsions, and by the very early 

 appearance of contractions upon the palsied side, sometimes even 

 upon the other. There are also epileptiform fits. Apoplexies of 

 small extent often are purely local in their effect, causing paresis of 

 a single extremity, thickness of speech, facial palsy without hemi- 

 plegia, sudden amaurosis or amblyopia of one eye, ptosis, etc. 

 Such small extravasations may form without the symptoms of a 

 fit, so that doubts as to the real nature of the disease may exist 

 until a subsequent grave apoplectic stroke clears up the mystery.] 



From the varied size and number of the haemorrhages, their dif- 

 ferent seats, the greater or less rapidity of their occurrence, as well 

 as from the more or less severe inflammation of the surrounding 

 brain, we have many varieties in the course of cerebral haemor- 

 rhages, of which we shall mention only the more important. 



A rather frequent appearance of the disease, which corresponds 

 to a rapidly-occurring extensive haemorrhage, or to the coincident 

 occurrence of several haemorrhages, is the following : After some 

 premonitory symptoms, or even without them, an apoplectic fit 

 suddenly occurs ; the patient does not again recover consciousness, 

 the paralysis extends to the medulla oblongata, the breathing be- 

 comes irregular, the pulse intermittent and slow, the pupils dilated, 

 and death occurs in a few minutes (apoplexie foudroyante), or after 

 some hours. 



In a second class, which is most frequently seen, and which is 

 also due to a rapidly-occurring but probably less extensive haemor- 

 rhage at the usual places, there is also first an apoplectic fit ; even 

 during unconsciousness we may see by the distortion of the face, by 

 the peculiar relaxation of the muscles on one side, sometimes also 

 by the dilatation of one pupil, which is the paralyzed side. After 

 a few minutes or some hours, or occasionally not till next day, the 

 patient gradually arouses from the stupor ; but he speaks indistinct- 

 ly, and hemiplegia, with the peculiarities above described, becomes 

 evident. On the second or third day there are fever and the other 

 symptoms of traumatic encephalitis. After these have disappeared, 

 the patient remains for the rest of his life paralyzed on one side of 

 his body, although the part of the paralysis due to oedema in the 

 vicinity of the apoplexy disappears after a time. 



