Inequality of the pupils may occur in large effusions that by pressure weaken the oculomotor on that side and thus allow that pupil to dilate. It is conse quently not rare in cases involving the frontal lobe or basal portions of the cere brum. In pons troubles anisocoria is common, though both pupils may be large or small according to the degree of third-nerve involvement. In menin geal forms the pupils are often affected, though there is no rule here for our guidance.
Conjugate deviation of the eyes very often points to a lesion on the same side, but this is not an invariable rule.
Diplopia or more distinct evidence of paralysis of external ocular muscles is unusual except in comatose conditions. Its interpretation depends on the indi vidual case.
Ophthalmoscopical changes are not sufficiently marked in the early stages to be of any value, nor are they often much more so in the later. After development of the full apoplectic state there may be some choking of the retinal veins, espe cially on the side of the lesion. Miliary aneurisms have been observed in the retina, but are quite unusual. Hasmor rhages of the retina may indicate ne phritis; but only to that extent suggest the cause of any cerebral condition.
frequently pre cedes or accompanies the attack. Or, on the contrary, where there is deep uncon sciousness or prolonged stupor, and espe cially if drastic purgatives are given, in voluntary discharges may occur. Their chief importance lies in the necessity, then, of scrupulous care lest eczema and bed-sores develop, and in the commen tary they offer on the state of con sciousness or the possibility of dementia.
the onset the urine is usu ally acid. Transient glycosuria is a pos sible accompaniment of liTmorrhage in any- part of the brain. The sugar usu ally disappears from the urine in from a few hours to a couple of days. Pre sumably it originates from shock to the so-called sugar-centre. When this spot in the floor of the fourth ventricle is directly involved, the sugar may persist longer, though it usually subsides, even then, in a week or two.
As a part of the same manifestation there may be a polyuria simply, that is then even more fleeting in character.
Albuminuria is a frequent and more serious accompaniment. Like the pre ceding symptoms, it may be but tran sient in character; but its presence is always a cause for anxiety. Many cases of apoplexy are due to Bright's disease, and an examination of the urine, there fore, should be a routine procedure in all cases.
is of rare occur rence. It may either precede the attack (prehemiplegic chorea), though this is unusual where hmmorrhage is the cause, or it may develop during the recovery stage (posthemiplegic). It is thought to be due to irritation either of the motor tracts or else of some band of fibres closely associated with these. It is a symptom of irritation rather than of de struction, and hence is never present where tbe paralysis is complete. If an inaugural symptom, then it disappears as the paralysis deepens; otherwise it comes on as the paralysis begins to mend, and in turn also disappears as the paralysis wears away: Hence its appearance in convalescence is a good omen, however annoying to the patient.
It is not a symptom of the attack itself.
This affection involves strictly one side of the body only. It may take in principally an arm or the lower extrem ity, but usually involves both more or less. In degree it varies much according to the stage; but is often severe and con tinuous in character. The type of move ments is hardly different from that of ordinary chorea of childhood.
Tendon-reflexes.—At the onset and during the period of development no great changes in the reflexes can be made out, unless diminution. But so soon as the effusion seriously interferes with the motor path and even more after the sub sidence of shock the tendon-reflexes of the paralyzed parts show a decided in crease; this may apply both to the force of the reflex and to the extent of area from which it is elicitable. In gross lesions tbe pathological jerks like ankle clonus and wrist-clonus may also be demonstrable, either immediately and temporarily, or later on after descend ing degeneration. It is necessary to compare the two sides to settle the relevancy of the symptom. Even then there are cases in which both knee-jerks are increased from unilateral lesion, in proportion, perhaps, to an incomplete decussation of tbe pyramidal tracts, as is further shown by the somewhat bi lateral paralysis of the lower extremi ties. As a rule, however, we find a purely-unilateral exaggeration of the tendon-reflexes.
-Those pertaining to the period of the seizure are almost described by their enumeration.
A slightly-subnormal temperature (one to two degrees) may frequently be found for an hour or two after the onset. Later an increase of temperature is not unusual. It amounts to but a few de grees at most and is transient in char acter, lasting only a few hours, as a rule. These variations in temperature are somewhat commensurate with the sever ity of the seizure. From the experi ments of Ott and others it is known that there are so-called heat-centres as far corticad as the caudate nucleus. and it is to disturbance of these that the hyper thermia is doubtless due. It is claimed for pons hremorrhage that the tempera ture may rise from the start.
Trouble in swallowing (dysphagia) may- be simply an expression of the gen eral weakness, though at times it seems to partake of the nature of a central paralysis. It necessitates extra care lest food slip down the trachea.
The respiration is often affected. Stertorous breathing is an attendant on the deeply-comatose state. In .the sub sequent weak condition of the severe cases Cheyne-Stokes respiration may ap pear at any time and is especially prone to do so in the hours of deep sleep. It may also occur in the primary coma.
The subsequent mental condition often shows impairment of intelligence, psychical functions, memory-, and mental grasp. These incline to be the greater, the severer the attack. Laughing or crying on inadequate provocation, an anxious haste in carrying out anything planned, and many other aberrations might be cited.