Handwriting practice
(When practising handwriting, first trace the letters following the direction of the arrows, and then try writing them on lined paper.)
The Arabic script is written from right to left, so the letters should be formed starting from the right:
Finish the main shape of the letter first and then add the dots:
Tip: There are no capital letters in Arabic.
On the companion website (www.bloomsburyonlineresources.com/ mastering-arabic-series) you can find videos and printable worksheets that will show you how to form the letters.
Vowels
Arabic script is a form of shorthand. Not all the vowel sounds are included. The short vowels in Arabic (a, i, u) are written above and below the main script. If you read an Arabic newspaper, novel or website you will rarely see these vowels, as they are not usually written. The Arabic reader is expected to deduce the meaning of words from experience and context. Imagine the English sentence ‘They can find the key’ as ‘thy cn fnd th ky’.
Mastering Arabic 1 will begin by showing all the short vowels and will gradually drop them as you become more proficient.
Look at these letters and listen to the recording:
(ba)
From this you can see:
(bi)
(bu)
• A dash above the letter ( ) is pronounced as a short ‘a’ following the letter, as in ‘bat’. This vowel is called fat˛a
• A dash below the letter ( ) is pronounced as a short ‘i’ following the letter, as in ‘hit’. This vowel is called kasra
• A comma shape above the letter ( ) is pronounced as a short ‘u’ following the letter, as in ‘book’. This vowel is called ∂amma.
Exercise 2
Listen to the recording and write the correct vowels on these letters:
Exercise 3
Now practise saying these letters with their vowels; then check your pronunciation in the answer section at the back of the book.
You can learn more about the alphabet in the Introduction of the accompanying Grammar Book
Joining letters: group 1
Written Arabic is ‘joined up’. When letters come at the end of a word they look very much as they do when standing alone. However, when they come at the beginning or in the middle of a word they get ‘shortened’. Look at how these letters combine:
(read from right to left)
Notice how the letter gets ‘chopped’ and loses its final flourish, or ‘tail’, when at the beginning or in the middle of a word, but still keeps its dots for recognition.
The letters nün and y’ have exactly the same shape as the other letters in this group when they come at the beginning or in the middle of a word, but they retain their differences when at the end:
On the Mastering Arabic website you can find a teaching grid with a unit-byunit overview of how the Mastering Arabic companion books can support your learning, including handwriting practice and additional activities to reinforce your learning.
Notice how these letters are joined when written by hand:
It’s easiest if you complete the main shape of the word and then go back to the right-hand side and add all the dots from right to left.
On the Mastering Arabic website you can find videos and a printable worksheet that will help you practise handwriting these combinations.
Exercise 4
Look at the newspaper headline below. Two examples of the letters in group 1 are circled. How many others can you find?
Tip: When y’ is by itself or at the end of a word, you may see it without the two dots.
Exercise 5
Handwrite these combinations of letters. The first is an example:
Adding vowels to words
We can now add vowels to the combinations of letters to make words:
You can practise your new skills in the accompanying Activity Book: Unit 1 (Activities 1–4).
Sukün
A small circle (sukün) above a letter ( ) indicates that there is no vowel sound after that letter – see bint and bayna above. Notice that the sukün is not usually put above the last letter of a word.
Exercise 6
Listen to the recording and write the vowels on these words. Each word will be given twice.
01:04 01:05
Shadda
In addition to the three short vowels and the sukün, there is another symbol: the shadda. This is a small w shape ( ) written above the letter to indicate that the sound is doubled. For example: (bathth) ثب = (th) ث + (th) ث + (ba) ب (bunn) نب = (n) ن + (n) ن + (bu) ب
The sound of a letter is doubled when there is a shadda. Take care to pronounce this by lingering on the doubled sound, otherwise you may change the meaning of the word.
Listen to these examples and repeat them with the recording. Each example is given twice. Notice that kasra is often written below the shadda rather than below the letter itself – see example 5:
* To hear the shadda compare the pronunciation of examples 2 and 3.
Exercise 7
Write these letter combinations and then try to pronounce them. Check your pronunciation with the recording or answer section.
Exercise 8
Look at these words and try to remember the meanings:
E
نب D
C
B
A
01:07
Handwrite the Arabic words on a separate piece of paper and cover the pictures. Then match the Arabic words you have written with this English: 1 girl/daughter 2 coffee beans 3 house 4 hay 5 between
Conversation sections
The Conversation panels are designed to introduce you to basic conversational Arabic in social and everyday situations. They appear in all the units in the first half of the course, and then as appropriate in the later units. You’ll often be given the opportunity to take part in short dialogues with native speakers. Concentrate on speaking and listening in these sections. At first you may not be able to read all the Arabic script, but you will be able to recognize some of the letters and words.
Conversation (
Greetings and leave-taking
One of the most important conversational skills initially in any language is to know how to greet people. Arabic greetings can be elaborate and prolonged, but some all-purpose expressions will get you by:
(ahlan) Hello, and also
(mar˛aban) Hello
(ahlan wa sahlan) Hello and welcome
(ahlan bik/biki) Hello to you (talking to a male/female)
(ßab˛ al-khayr) Good morning
(ßab˛ an-nür) Good morning (reply)
(mas’ al-khayr) Good evening
(mas’ an-nür) Good evening (reply)
(maعa s-salma) Goodbye
Tip: The reply to a greeting often varies from the original, although it is also acceptable simply to repeat the original phrase in reply.
You can practise your new skills in the accompanying Activity Book: Unit 1 (Activities 5–8).
Video: Greetings
To play the videos, go to www. bloomsburyonlineresources.com/ mastering-arabic-series. You’ll also find a wealth of useful additional material online.
There is a video for every unit (except for the review units). In this first unit you will hear six people greet you in different ways. Try to match the photo with the correct greeting.
Don’t worry if you don’t understand everything. Just listen for the key information. You’ll find a transcript, a translation and an extension activity on the website.
Vocabulary in Unit 1
(bint) girl/daughter نب (bunn) coffee beans
تيب (bayt) house نيب (bayna) between
(tibn) hay
(tın) figs
(ahlan/mar˛aban) Hello
(ahlan wa sahlan) Hello and welcome
(ahlan bik/biki) Hello to you
(ßab˛ al-khayr) Good morning
(ßab˛ an-nür) Good morning (reply)
(mas’ al-khayr) Good evening/afternoon
(mas’ an-nür) Good evening/afternoon (reply)
(maعa s-salma) Goodbye
You’ll find a PowerPoint presentation on the companion website to help you remember the key words in every unit.
Putting words together 2
Letters of the alphabet: group 2
Look at the next group of letters and listen to the recording:
Name of letter Pronounced
alif
(see page 19)
dl ‘d’ as in ‘dad’
dhl ‘th’ as in ‘that’
r’ rolled ‘r’ as in Spanish ‘arriva’
zy ‘z’ as in ‘zone’
ww ‘w’ as in ‘wet’
Pizza and olives
You can see that the dl and dhl have the same basic shape, as do r’ and zy. The only difference is that dhl and zy have the dot over the basic shape. Pay special attention to the position and shape of these four letters –dl and dhl sit on the line while r’ and zy fall under the line.
Ww and alif have very distinctive shapes, but their connection with the other letters in this group will become clear later in this unit.
Exercise 1
Draw a line between the printed letters and the names of the letters, as in the example:
Handwriting practice
Remember, finish the shape first and then add any dots:
On the Mastering Arabic website you can find videos and a printable worksheet that will help you practise forming and handwriting these letters.
Another random document with no related content on Scribd:
been no paralysis, and the hemorrhages were probably not the immediate cause of death.
Durand-Fardel gives a table of supposed causes in 21 cases of persons over fifty: 8 of these were connected with either habitual use of liquor or a debauch; 9 had an attack immediately after a meal.
After naming all these causes, it must be said that in many cases it is impossible to find any reason for the occurrence of the hemorrhage at the particular moment it comes. A person may go to bed in apparent health, and be found some hours afterward unconscious and comatose, or unable to stir hand or foot on one side, or to speak. Gendrin, as quoted by Aitken, states that of 176 cases, 97 were attacked during sleep. The attack may come on when the patient is making no special muscular effort and under no special excitement. It is simply the gradual progress of the lesion, which has reached its limit.
SYMPTOMATOLOGY.—If we take as a point of departure the fullydeveloped attack, such as most frequently is found with a large and rapid hemorrhage into the cerebral hemispheres, pons, or cerebellum, the symptoms are those usually spoken of as an apoplectic attack, shock, or stroke, or, as the Germans say, Hemorrhagische Insult. Trousseau quotes as a satisfactory definition the words of Boerhaave: “Apoplexia dicitur adesse, quando repente actio quinque sensuum externorum, tum internorum, omnesque motus voluntarii abolentur, superstite pulsu plerumque forti, et respiratione difficili, magna, stertente, una cum imagine profundi perpetuique somni.”
Loss of consciousness, abolition of voluntary motion and sensation, and usually stertor, the appearance of the patient being that of one in deep sleep, are found in the extreme cases. In others the loss of consciousness and sensation are not complete; the patient can be aroused enough to utter a grunt or raise a hand to his face in order to brush away a fly or the hand of the physician who is trying to raise his eyelids, or can make a grimace to show that he is hurt, the face returning to its indifferent expression as soon as the cause of
irritation is removed. Although the grade of action, both sensitive and motor, seems to be a little above the purely reflex, it is but very slightly so, and probably is not sufficient to remain an instant in the memory.
The rapidity with which this condition comes on varies widely, from a very few minutes, or even seconds, to some hours. It may even diminish for a time and return. The cases in which unconsciousness is most rapidly produced are apt to be meningeal and ventricular, and presumably depend upon the rupture of vessels of considerable size, although the location among the deeper ganglia, where the conductors of a large number of nervous impulses are gathered into a small space, will, of course, make the presence of a smaller clot more widely felt. Even in these, however, the onset is not absolutely instantaneous, and the very sudden attack is rather among the exceptions. Trousseau denies having seen, during fifteen years of hospital and consulting practice, a single case in which a patient was suddenly attacked as if knocked down with a hammer, and that since he had been giving lectures at the Hotel Dieu he had seen but two men and one woman in whom cerebral hemorrhage presented itself from the beginning with apoplectiform phenomena. In each of these the hemorrhage had taken place largely into the ventricles.
Lidell gives the following case: A colored woman, aged forty-nine, was engaged in rinsing clothes, and while in a stooping posture suddenly fell down upon her left side as if she had been struck down by a powerful blow. She was picked up insensible, and died in ten or fifteen minutes. The hemorrhage was chiefly meningeal, and especially abundant about her pons and medulla oblongata. The fourth ventricle was full of blood, and there were clots in the lateral ventricles.
A woman, aged about forty, had been hanging out clothes in an August sun. She was observed to run out of the house screaming, and fell to the ground unconscious. This was at 1 P.M., and she died at 3.30 P.M. Her temperature just after death was 107.2°. The neighborhood of the posterior surface of the pons Varolii was
occupied by a broken-down-looking mass, appearing like an aggregation of small apoplexies (hemorrhages), involving and breaking down the middle crura of the cerebellum. There was no fatty degeneration nor any miliary aneurism. (I do not know upon how thorough an examination this last statement rests.)
In a large number of cases it is difficult to say, in the absence of any observation, intelligent or otherwise, exactly how rapid the onset of the symptoms may have been, but in those which occur where the patient is watched or is in the company of observant persons it is almost invariable to meet with symptoms less than unconsciousness which denote the actual beginning of the hemorrhage. From the nature of the lesion it can rarely give rise to symptoms which justify the epithet of fulminating in the sense of struck with a thunderbolt. The unconsciousness, so far as can be known, does not depend on the injury of any one special small point of the brain in which consciousness resides, but upon the compression of a considerable portion, which must necessarily take place gradually, but with a rapidity proportioned to the size of the current which issues from the ruptured vessel and the ease with which pressure can diffuse itself over a large area. It is undoubtedly the greater facility offered to such diffusion by the communication of the hemorrhage with the so-called cavity of the arachnoid and the ventricles which gives to these forms a peculiar severity. The difference between a hemorrhage spreading through all the ventricles or over a large surface of the brain, and one which is limited to a focus in the substance of one hemisphere, being restrained by more or less firm tissue, may be illustrated by the gain in power in the hydraulic press from the transfer of the stream of water from a small cylinder to a larger one.
Vomiting is a symptom of some importance in diagnosis, being not very common in cerebral hemorrhage, but very frequent in cerebellar.
Whether of sudden, rapid, or slow development, the apoplectic attack is, in its main features, described in the aphorism of Boerhaave given above. The muscular relaxation of the face imparts
to it an expressionless, mask-like character; the limbs lie motionless by the side, unless they can be excited to some slight movement by some painful irritation or are agitated by convulsions, or in a condition of rigid spasm; the face may be pale or flushed; the cheeks flap nervelessly—le malade fume la pipe.
Swallowing, in the deepest coma, is not attempted. The fluid poured into the mouth remains, and distributes itself according to the laws of gravity without exciting reflex movements of the pharynx. When the depression is less profound, it may excite coughing or be swallowed. An attempt to swallow when the spoon touches the lips indicates a considerably higher degree of nervous activity. Respiration may be slow, but when the case is to terminate fatally rises with the pulse and temperature. It is often stertorous and difficult, the obstruction consisting partly in the gravitation backward of the soft palate and tongue, and partly in the accumulation of fluids in the pharynx. Hence stertor is in some cases only an accidental phenomenon, depending upon the position of the patient on the back, and can be relieved by turning him on his side and wiping out the mouth as far back as can be reached. Cheyne-Stokes respiration occurs in severe cases, though not confined to necessarily fatal ones.
The general temperature in cerebral hemorrhage has been studied enough to make it of considerable value, especially in prognosis. In a case which extends over a sufficiently long time several stages can be distinguished which in shorter ones may be wanting. An initial period of depression is described by Bourneville17 as occurring immediately after an attack, in which the temperature falls a degree or two below the normal, and, according to his view, continues depressed if death takes place rapidly. He gives the case of a man who died very shortly after an attack (his second one), where the temperature, taken in the rectum at the moment of death, was 35.8°. In cases which survive longer this initial fall passes either into a stage where it oscillates within the neighborhood of the normal or immediately begins to rise; the latter occurrence indicates an impending fatal termination (unless, of course, something else can be found to account for it). In the former condition we find patients
whose life may be indefinitely prolonged for days or weeks, when, if a fatal termination is to result, the thermometer again indicates a rise.
17 Études cliniques et thermométriques sur les Maladies du Système nerveux, 1872.
The initial fall of temperature is not so likely to be observed except in institutions like the Salpêtrière, where large numbers of old persons are collected and under close medical surveillance; and, indeed, it may be doubted, even from Bourneville's own table, whether the rule is one without exceptions. At any rate, the rise is a more important phenomenon than the fall. When the rise of temperature is interrupted by a fall, and then continues again, it is due, according to the author already quoted, to a renewal of the hemorrhage.
These changes of temperature may be noted with various locations of the lesion, but it seems probable that further study might make them useful in diagnosis as well as prognosis. Hale White reports the case of a boy aged six and a half years, who was found unconscious with right hemiplegia, and who afterward had many and various paralyses with hyperpyrexia, the highest temperature being 107°. He lived long enough for secondary degeneration to extend down the crura and into the anterior cornua. A small soft patch a quarter of an inch in diameter existed at the anterior part of each corpus striatum.18
18 Guy's Hosp. Rep., 1882.
FIG. 37.
The chart W. H. (Fig. 37) is from a man aged fifty who fell in the street while returning from work at noon, and whose axillary temperature was taken at 5 P.M. and every two hours thereafter until death. The hemiplegia was not very marked, but the hemorrhage was extensive, involving the pons and left crus cerebri, the external capsule, left crus cerebelli, and medulla, bursting through into the fourth ventricle.
IG. 38.
F
The chart M. M. (Fig. 38), as taken from Bourneville, represents the course of the temperature in a rapid case: each perpendicular line denotes an hour.
The difference in the temperature of the two sides has been variously stated, and probably depends on a number of factors besides the length of time that has elapsed since the first attack. There is probably, however, a tendency to excess of heat on the paralyzed side soon after the attack, owing to vaso-motor paralysis; and this difference will be more marked in the hands than in the axillæ. After a length of time which may be from days to months the temperature becomes equalized, or more frequently the relation is reversed, the paralyzed side being colder as atrophy takes place. Lepine19 gives a case where the axillary temperatures of the two
sides continued the same within a small fraction of a degree for three days, and then separated very slowly, until at death the paralyzed side was six-tenths of a degree (Cent.) hotter than the other, in both being inferior to the rectal (107° Cent.).20
19 Mémoires de Société de Biol., 1867.
20 The chart in the original, and as reproduced by Bourneville, is wrongly lettered. The text says that the left side was the hotter
FIG. 39.
The chart C. M. (Fig. 39) shows the excess of temperature in a case of meningeal hemorrhage. The dotted line is from the paralyzed side. The first observation was made two and a half hours after the attack.
A very interesting case is reported by Johnson21 of crossed hemiplegia, where the temperature was about a degree higher on the paralyzed side of the body, and, corresponding to this, the sphygmograph showed a great diminution of tension; the lesion is supposed to have been a hemorrhage in the pons. Johnson, in commenting on the statement of Lorain that in all cases of hemiplegia the pulse is more full on the paralyzed side, says that it is incorrect for ordinary cases of hemorrhage into the corpus striatum, though true in his own case.
21 Brit. Med. Journ., Jan. 6, 1877.
The most marked differences of temperature have been observed where the lesion has been in the neighborhood of the pons, crus cerebri, or medulla oblongata. In a case reported by Allbutt there was a difference of 1.6°; the radial pulse was softer and fuller on the paralyzed side, and the cheek upon that side was flushed.22 The pulmonary hemorrhages which have been noticed by BrownSéquard and others in animals after cerebral lesions, and the extravasation, congestion, subpleural ecchymoses noted by Ollivier23 in cerebral apoplexy, are probably to be referred to vaso-motor disturbances.
22 Med. Times and Gaz., Dec. 4, 1869.
23 Archives générales, 1873, 167.
Much more attention has been paid to the pulse than to the temperature, but it is less easy to lay down definite rules in regard to it. It may vary in either direction. When the case is approaching a fatal termination the pulse is apt to accompany the temperature in a general way in its rise, though not necessarily following exactly, as is seen in the chart in Fig. 38.
The throbbing or bounding of the arteries often described may indicate increased activity of heart, but means at the same time vaso-motor relaxation. The urine and feces are often passed involuntarily.
In some rare cases symptoms closely resembling those produced in animals by section of the sympathetic have been seen. These are false ptosis, narrowing of the palpebral opening and sinking of the globe of the eye into the orbit, diminution in the size of the pupil, higher temperature on the paralyzed side of the face and the corresponding ear, abnormal secretion of the eye, nose, and mouth on the same side.24 They are supposed to indicate a paralysis of the sympathetic.
24 Nothnagel, quoted by Grasset.
The condition of general relaxation may be so profound as to cover up everything else, but in many cases true paralytic symptoms may be discovered or provoked, which even at an early period give us information as to the locality and nature of the lesion.
A greater degree of muscular relaxation may be manifest on one side of the face than the other; the forehead may be a little smoother on one side, the corner of the mouth drooping, the downward line from the ala of the nose flattened, and the cheek flapping. There may be a little greater resistance to passive motion of the limbs on one side; one hand on being raised may drop helplessly back to the bed, while the other is laid slowly down; the right hand when pinched lies motionless and without power to escape the pain until the left comes to its assistance. Irregularity of the pupils, if present, is an important sign, but its absence signifies nothing.
One of the most significant signs is the conjugate deviation of the eyes, both eyes and the head being turned strongly to one side or the other. When the lesion is above the pons and is irritative, as in the early stage of hemorrhage, the deviation is toward the side of the body affected and away from the lesion; when paralysis is established, away from the paralysis and toward the lesion. Below the pons the rule is reversed. The spastic stage of conjugate deviation may coincide with stiffness (early rigidity) of the paralyzed limbs. This deviation must not be mistaken for an accidental position of the head. The patient should be addressed from the side away from which he is looking. Sometimes the eyes can be brought to the
median line, and not beyond. An attempt to turn the head forcibly beyond the median line occasionally causes pain. The value of this symptom in diagnosis has been denied, but a part at least of the apparent contradictions have arisen from the neglect to notice whether it were of a paralytic or spastic character.
As the condition of unconsciousness gradually passes off, the face regaining, at least in part, its natural and more intelligent expression, the eyes trying to follow the movements of surrounding persons, an attempt being made, perhaps only by an unintelligible sound or by a nod, to answer questions, the tongue being protruded, or at least an attempt toward it made, and some motions being made with the limbs,—the exact extent and intensity of the paralysis become more apparent. Conjugate deviation, if it have existed, may disappear before the other symptoms, or, if it has been of the rigid form depending on an irritative lesion, it may become paralytic, and is then in the opposite direction. The patient is then usually found to be in a condition of hemiplegia, and at this point the history of hemorrhagic apoplexy becomes identical with that of paralysis from hemorrhage where no truly apoplectic condition has been present.
Lidell states that in more than one-third of all cases of cerebral hemorrhage hemiplegia is developed without loss of consciousness or coma. In some, the paralysis precedes unconsciousness, which then slowly supervenes.
Hemiplegia (ἥμι, half, πληγη blow) is a paralysis or paresis of a part of the voluntary muscles of one side of the body, and a few, in some cases, on the other, and is undoubtedly to be referred to a lesion interrupting the nervous communication between the cortical centres of motion and the nuclei of the motor nerves, cerebral and spinal; the conductors passing through the corpora striata, the internal capsule, the peduncles, and crossing in great part to the other side above or at the lower border of the medulla oblongata, and passing down the crossed pyramidal tracts of the cord, to be finally connected with the anterior gray columns of the cord. The portion which does not decussate passes down the inner border of the anterior columns
under the name of columns of Türck. The amount of decussation which takes place varies somewhat, and the suggestion has been made, in order to explain certain cases of paralysis occurring on the same side with the lesion, that possibly in some rare cases there may be no decussation. It has never been shown, however, that this condition, highly exceptional if even it ever occurs, is present in such cases.
It may be said in a general way, although exceptions to the rule can be found, that it is those muscles trained to separate, specialized, or non-associated movements which are chiefly affected, while those which are habitually associated in function with those of the other side are less or not at all so. It would not, however, be in the least correct to say that specialized or educated movements of any set of muscles are alone paralyzed, since the fingers, which are trained to the most independent movements, are often just as incapable of making the slightest movement of simple flexion as of writing or sewing.
We have in ordinary hemiplegia more or less paralysis of the upper facial, the patient not being able to close his eye or to wink quite so well as on the paralyzed side. The forehead may be smoother on the paralyzed side. This condition is usually slight and of short duration, but varies in different cases. Paralysis of the lower facial angle of the mouth and cheek is usually better marked, but not absolute. The corner of the mouth droops, perhaps permits the saliva to escape; the naso-labial fold is less deep, and the glabella deviated away from the paralyzed side. The cheek flaps with respiration. The difference between this facial paralysis connected with hemiplegia and that dependent upon a lesion of the trunk or distribution of the nerve (Bell's), as in caries of the temporal bone or the so-called rheumatic paralysis, is very striking, the latter being so much more complete, and, by affecting the orbicularis palpebrarum so as to prevent closure of the eye, giving a very peculiar expression to the countenance. This distinction between the two portions of the facial seems to make an exception to the rule stated above, since in most
persons the movements of the corner of the mouth and of the cheek are quite as closely bilaterally associated as those of the eyelids.
Paralyses of the third, fourth, and sixth pairs upon one side of the body are comparatively rare in hemiplegia, and when present are usually referable to localized lesions in the pons. They are to be looked upon as something superadded to the ordinary hemiplegia. These nerves, however, are affected in the peculiar way already spoken of as conjugate deviation, which phenomenon would seem to denote that muscles accomplishing combined movements in either lateral direction of both eyes, rather than all the muscles of each, are innervated from opposite sides—i.e. that the right rectus externus and the left rectus internus are innervated from the left motor centres, and vice versâ. Exactly the same remark will apply to the muscles of the neck which cause the rotation of the head seen together with the deviation of the eyes. The muscles controlling deviation to one side, although situated upon both sides of the median line, are apparently innervated from the side of the brain toward which the head is turned in paralysis.
The tongue is usually protruded with its point toward the paralyzed side; and this is simply for the reason that it is pushed out instead of pulled, and the stronger muscle thrusts the tongue away from it. The motor portion of the fifth is, according to Broadbent, affected to a certain extent, the bite upon the paralyzed side being less strong.
The hand and the foot are the parts most frequently and most completely affected, but one or the other may be partially or wholly spared, though the latter is rare. The muscles of the limbs nearer the trunk may be less affected, so that the patient may make shoulder or pelvis movements when asked to move hand or foot. In severe cases even the scapular movements may be paralyzed. The muscles of the trunk are but slightly affected, though Broadbent states that a difference in the abdominal muscles on the two sides may be perceived as the patient rises from a chair The respiratory movements are alike on the two sides. A woman in the hospital service of the writer had a quite complete left hemiplegia at about the
seventh month of pregnancy There was some return of motion at the time of her confinement. None of the attendants could perceive any difference in the action of the abdominal muscles of the two sides, although, of course, the usual bracing of the hand and foot upon the left side was wanting. The pains were, however, generally inefficient, and she was delivered by turning. Muscular weakness often exists, and in some cases the non-paralyzed side shows a diminution of power.
The sphincters of the bladder and rectum frequently, and in severe cases almost invariably, lose their activity for a time. It is possible, however, that in some cases of alleged inability to retain urine and feces the defect is really mental, and akin to the dirty habits of the demented. The involuntary muscles probably take no part in hemiplegia, with the very important exception of the muscular coats of the arteries, which apparently share to a certain extent, and sometimes the iris.
Speech may be attempted, and the words be correct, so far as they can be understood, though the patient is apt to confine his remarks to the shortest possible answering of questions. It is, however, thick and indistinct, since the muscles of the tongue and lips are but imperfectly under the control of the will. This condition may be connected with paralysis of either side, and is to be sharply distinguished from aphasia or mental inability to select the proper word or to determine the necessary movements for its pronunciation. Aphasia is almost invariably connected with paralysis of the right side, and will be minutely spoken of hereafter. There is, of course, nothing to prevent the coexistence of the two conditions, but aphasia cannot well be shown to exist until we have reason to suppose, first, that the patient has ideas to express, and secondly, that the paralysis of the muscles of the lips and tongue has more or less completely disappeared. The patient may indistinctly mumble a word which, however, can be understood to be appropriate to the occasion (defective articulation, glosso-labial paralysis), or, on the other hand, pronounce with distinctness an entire wrong word or a number of sounds without meaning (aphasia).
Sensibility—that is, ordinary cutaneous sensation—and, so far as we can judge, the special senses, are not greatly affected after the deep coma has passed off, but exceptions to this rule will be noted later.
Having described this most typical but not most common form of cerebral hemorrhage—that is, the form in which both lesion and symptoms are most distinct and can be most clearly connected—we have a point of departure for conditions less clearly marked and less easily explained.
It is probable that cerebral hemorrhage is much less likely than cerebral embolism to take place without any disturbance of consciousness or abnormal sensations; but there can also be little doubt that a certain amount of paralysis is often accompanied by no other symptoms, and post-mortem appearances often show the remains of small hemorrhages which have passed unnoticed or are lightly estimated. It is highly probable that small hemorrhages may give rise to symptoms which pass for only a little accidental vertigo or a slight feeling of faintness, until a later and more serious attack gives a more definite explanation.
On the other hand, we have a set of cases in which all the symptoms of cerebral hemorrhage may be present without the lesion. Many of these are of course due to embolism, which will be considered later; but besides this condition, recognized as softening for many years, we find described under the head of simple, congestive, serous, and nervous apoplexy cases where sudden or rapid loss of consciousness occurs with general muscular relaxation, which, when fatal, show nothing beyond changes in the circulation—i.e. in the amount of blood in the cerebral vessels or of serum in the meshes of the pia or at the base of the brain.
Besides these, there are cases of temporary unconsciousness with complete recovery—the coup de sang of the French, or rush of blood to the head, which are attributed to congestion of the brain—a theory difficult to prove or disprove, but not in itself unreasonable. Trousseau, without denying the possibility, or even probability, of such a condition, says that which has been called apoplectiform
cerebral congestion is in the greater number of cases an epileptic or eclamptic accident, sometimes a syncope. Simple epileptic vertigoes, vertigoes connected with a bad condition of the stomach or diseases of the ear, are wrongly considered as congestions of the brain. He speaks of various conditions, such as violent attacks of whooping cough, the expulsive efforts of women in labor, the congested faces of laborers under heavy burdens, to show that cerebral congestion does not give rise to an apoplectiform attack; and it is undoubtedly true that, as a rule, no long-continued attack is the result; but it must be within the personal experience of almost every one that decided cerebral disturbance is produced for a few moments by such efforts, as, for instance, blowing a fire with the head down. Besides this, a laborer under a heavy load is presumably healthy and accustomed to his work, so that his arteries may be supposed capable of maintaining a due balance between arterial and venous blood in the brain; and, again, although the ordinary efforts of women in labor do not cause unconsciousness, puerperal convulsions, involving a longer period of violent muscular action, may do so, and even give rise to hemiplegia.
Whatever name we may adopt for the temporary cases which recover, there are others, and fatal ones, which are not explained by any change in nomenclature. Epilepsy may, it is true, occur under such circumstances that no convulsion is observed, but, on the other hand, convulsions may accompany not only an attack of unconsciousness, but actual cerebral hemorrhage.
Cases of sudden death with no discoverable lesion furnish abundant opportunity and temptation for conjecture, and it is well known that too much dependence must not be placed upon the post-mortem appearances as to the amount of blood in the brain before death, and probably just as little upon the amount of serum, except as indicating a condition of atrophy.
Syncope, either from over-stimulation of the pneumogastric or from simple failure of the heart, may be put forward to explain some cases of sudden death, but seems to have no advantage as a universal
theory over the older one, which meets with so little favor Lidell gives no less than seventeen cases which he classifies as congestive or serous apoplexy. They are not all equally conclusive, and were almost all of alcoholics. In some of these there were absolutely no appearances which could account for death. The two most characteristic of congestive apoplexy were, first, a young negress who experienced a violent fit of passion, became unconscious, with stertorous breathing, and died, having had some tonic spasms. The brain contained a large amount of blood in the vessels, but no effusion. Second, a semi-intoxicated woman, aged thirty, became very angry, fell insensible, and expired almost immediately. The brain contained an excess of blood, with no effusion. In both these cases the patients were subject to fits under the influence of strong excitement, but in both the author took pains to inquire into and negative the probability of epilepsy of the ordinary kind; and a change of name does not go far toward clearing up the pathology.
Lidell's case (XXII.) was that of a man accustomed to alcohol, thin and pale, who had an apoplectic fit with coma and hemiplegia. He regained consciousness on the second day, and the hemiplegia disappeared in a fortnight. This rapid and complete recovery, exceptional to be sure, cannot be regarded as proof of the absence of hemorrhage or embolism. In fact, the latter is highly probable. It is possible that the clot may have been partially dislodged, so as to allow some blood to pass by it, or that an exceptionally favorable anastomosis allowed a better collateral circulation than usual to be established.
The following case occurred in the service of the writer: An elderly negress, who had extensive anasarca and signs of enfeebled action of the heart without any valvular lesion being detected, after washing her face was heard to groan, and found speechless and unable to swallow, with complete right hemiplegia. There was a slight improvement in a few hours, but she died two days later. The autopsy disclosed some hypertrophy and dilatation of the heart without valvular lesion. A careful search failed to discover any
change in the brain or obstruction in its vessels, although there was chronic endarteritis.
The relations between epilepsy, apoplexy, and syncope are interesting and important, but are certainly far from clear. Little is gained by shifting obscure cases from one category to the other. If sudden deaths be synonymous with apoplexy, we shall certainly have to admit that apoplexy does not always demand for its cause cerebral changes sufficiently marked to be recognizable after death. If, on the other hand, we refer them to heart disease, we shall have to admit that a heart without valvular disease or extensive changes in its muscular substance may cease to beat under influences as yet not well understood.
Since the paralysis arising from hemorrhage resembles so closely in its progress that dependent upon occlusion of the cerebral vessels, a further description will be deferred until the latter lesion has been described; but this remark does not apply to the premonitory and initiative symptoms, which may be of great importance, and which are not always the same with the two or three sets of lesions. There are many of them, but, unfortunately, no one among them taken alone can be considered of high significance, unless we except what are sometimes called premonitory attacks, which are in all probability frequently genuine hemorrhages of so slight extent that they produce no unconsciousness, and but slight paralysis easily overlooked. A little indistinctness of speech or a forgetfulness of words, a droop of one angle of the mouth, or heaviness in the movement of a foot or hand, lasting but a few moments, may be real but slight attacks, which may be followed either by a much more severe one, by others of the same kind, or by nothing at all for a long time. They are sufficient to awaken apprehension, and to show in what direction danger lies, but they give little information as to the time of any future attack.
Retinal hemorrhage is admitted by all modern authors to be connected with disease of the vascular system, and hence also with renal inflammation and cerebral lesions. The writer is greatly
indebted to Hasket Derby for the following facts: Out of 21 patients who had retinal hemorrhage, and of whose subsequent career he had information, 9 had some sort of apoplectic or paralytic attack; 1 had had such an attack before she was examined; 3 died of heart disease, 1 suddenly, the cause being variously assigned to heart disease or apoplexy; and 6 were alive when heard from, one of these, a man of forty-eight, being alive and well fourteen years after.
Bull25 describes four cases of his own where retinal hemorrhage was followed by cerebral hemorrhage, demonstrated or supposed in three, while in the fourth other symptoms rendered a similar termination by no means improbable. He quotes others of a similar character. The total number of cases which were kept under observation for some years is, unfortunately, not given. In a case under the observation of the writer a female patient, aged fifty-seven, who had irregularity of the pulse with some cardiac hypertrophy, was found to have a retinal hemorrhage two and a half years before an attack of hemiplegia. The hemorrhage was not accompanied by the white spots which often accompany retinitis albuminuria.
25 Am. Journ. Med. Sci., July, 1879.
In a case reported by Amidon26 retinal and cerebral hemorrhages seem to have been nearly simultaneous a few hours before death. There was diffuse neuro-retinitis and old hemorrhages besides the recent one.
26 N. Y. Med. Rec., 1878, xiv. 13.
The highly interesting observation has been made by Lionville27 that when miliary aneurisms are present in the brain, they may often be found in the retina also. In one case where they were very numerous in the cerebrum, cerebellum, pons, and meninges, aneurismal dilatations were found also in the pericardium, mesentery, cervical region, and carotids (the latter not being more minutely described). There was very general atheroma and numerous points of arteritis. The retinal aneurisms varied in size from those requiring a power of ten or twenty diameters to be examined up to the size of a pin's head
or a millet-seed. He thinks they might have been recognized by the ophthalmoscope.
27 Comptes Rendus de l'Acad. des Sci., 1870.
The hemorrhages accompanying idiopathic anæmia and other diseases with a similar tendency are not to be taken into this account. Hemorrhage accompanying optic neuritis is likely to be due to some disease of the brain other than the one under consideration.
Mental disturbances of various kinds have been considered as significant, and Forbes Winslow gives a great many instances of different forms, but they are to be looked upon rather as indicating chronic cerebral changes which may result in various conditions, of which hemorrhage may be one, than as furnishing any definite indication of what is to be expected. Loss of memory should be regarded in this way Some acute or temporary conditions of depression may affect the nutrition of the brain in such a way, without having anything to do with hemorrhage actual or anticipated.
Aberrations of the special senses are often observed, such as noises in the ears more or less definite, the sight of colors (red), or being unable to see more than a portion of an object. The fact to which these testify is probably a localized disturbance of the circulation which may not precede rupture of the vessels.
Distinct hallucinations of hearing, followed by those of smell and succeeding irritability, sleeplessness, were observed by Savage28 in a case which terminated soon after in apoplexy.
28 Journ. Ment. Sci., 1883, xxix. 90.
There are few symptoms which are more likely to excite alarm and apprehension of a stroke of paralysis than vertigo or attacks of dizziness, but it is too common under a great variety of circumstances to have much value, and is, as a matter of fact, rarely a distant precursor of intracranial hemorrhage, although it frequently appears among the almost initiatory symptoms, especially when the
