PERIPHERAL TROUBLES. - Contract ures.—These may develop some weeks after the attack, and are usually spastic and functional rather than organic. Tbey are associated with great' increase of the tendon-reflexes. By a slow, steady counter-pressure complete ex tension can be effected, but the part quickly becomes flexed again on relaxa tion. This condition means little else than that the corresponding fibres of the pyramidal tract are involved. Sep arate from this is the early rigidity due to stimulation of the motor tracts by the irritative lesion.
CEdema.—This condition of the par alyzed part is not of very frequent oc currence. It bas been thought to be due to degeneration of the pyramidal tract, but it sometimes develops so early after the apoplectic seizure that the neural change could hardly have taken place. The amount of swelling may be little or much, and changes readily with the position of the patient. It collects at the most dependent part of the ex tremity.
a degenera tive neuritis develops in the affected area. Considerable pain may be asso ciated with it, though this must not be confused with the muscular tenderness that often follows directly on the paral ysis. The reason for the occurrence of this form of neuritis is not well under stood. Possibly it is an outside process ,rafted on such nerve-fibres as have least resistance.
is not, as a rule, as liable to occur or as resistant as in dis orders directly involving the peripheral neurons. Still, from the inability of the paralyzed patient to relieve pressure on prominent parts, from the maceration by the discharges when not scrupulously cared for, and from the frequently im paired sensation, it is very easy for bed sores to develop.
Trophic changes are supposed to be due to trouble with the innervation from the peripheral neurons; but Nothnagel and others have adduced some facts in dicative of trophic influence from certain parts of the brain. Vasomotor disturb ances, lowered arterial tension, etc., are observed on the paralyzed side.
Differential Diagnosis.—This has to be made between hmmorrhage and the following conditions: Embolism, throm bosis (including its precedent conditions, such as syphilitic arteritis), psendoseiz ures, certain toxtemias (as tirmia, gout, alcoholism, etc.), simple fainting, hys teria, and sudden death from various causes.
The practice of uniting nearly all of these under the one head of apoplexy is, unfortunately, too common. While our diagnostic methods are not sufficient for all cases, the following principles will usually suffice to differentiate. Good medical judgment is here a strict neces sity. To know our patients, their past histories, and any chronic disorders from which they may be suffering is of great advantage.
EMBOLISM.—Against embolism speak: the absence of any distinct mitral or aortic lesion, the presence of headache or other prodromal manifestation; deep coma, especially late development; vom iting, pronounced anisocoria, and ad vanced age.