Clinical Lecture on a Case of Hemiplegia
Authors: J. H. Jackson
Journal: BMJ (1874)

LECTURE I.-( Concluded.) Limbs.-The arm was not absolutely paralysed; it Was mttch weakened.As most frequently happens, it suffered far more than the leg.That limb which has the more voluntary or more special uses, suffers the more.Whilst the patient was lying in bed, there was seemingly no loss of power in his leg; but, when we got him up to walk, we found that the leg was decidedly weakened, although he could walk without help.We ascertained two things, each equally important: first, that the leg wzas weakened; and second, that it was only slightly weakened.You are not warranted in saying that a patient's leg is not somewhat paralysed in a case of cerebral disease, unless you can get him up to walk and see that he walks well, however fully he may seem to move it in bed.Unless you bear this in mind, you will misinterpret your cases when you have obtained necropsies.You will infer, for instance, that a lesion founid in the corpus striatum had caused paralysis of the upper, not of the lowrer, limb.This would be a most unfortunate mis- take; it wNvould encourage the popular notion that there are abruptly demarcated localisations of movements of the limbs-one centre for the arm, and another for the leg.The method of representation only approaclhes this.There are parts where movements of the arm and leg have respectively the leading representation.It is very rare indeed to find considerable palsy of the arm without some paralysis of the leg; not very rare to find that the leg has recovered whilst the arm remains paralysed.For not only does the stress of the palsy fall on the more voluntary limb), but that limb remains paralysed longer.This illus- trates a rule, that the more automatic parts recover first.But, even when the patient is up and about, it is, I believe, very common for mis- takes to be made as to the condition of the leg, or rather as to its con- dition relative to that of the arm.Let me give you an illustration.A hemiplegic patient, who had been in the hospital, and who came to show himself in the out-patient room, said that he had recovered muclh power over his leg,, but not over his arm.The facts were exactly the opposite-viz., that he had regained scarcely any power over the leg; for, when I examined him, he could not milove a toe, nor cotsld he bend the knee, excel)t to the most trivial extent.He had lost, or nearly lost, movements of separate parts of the leg.On the other hand, his arm had regained a gootl deal of power.He could move the arm a good deal, but he could not use it.He could scarcely move the leg-its separate parts-but could use it as a w-hole for wvalking long distances.The leg, when stiff, serves as a sort of crutch ; it can be swung forwards, although its separate movements are almost extinct.But the deli- cately miioving arm would be useless in this condition, and practically useless if the patient had iiiuch pon-er over many of the coarse or very general movements of the limb, such as extension, flexion, etc.This case was not, as the one which is the text of this lecture was, according to rule : the leg suffered more than the arm, although, as I say, it seemed to suffer less.But there is in these exceptional cases some kind of order.When the more automatic limb (the leg) suffers more than the more voluntary limb (the arm), the rule is, that the more automatic part of the arm-its upper part-suffers more than the hand.To this rule there are niumerous exceptions.We could not determine defect of sensation in our patient.There was certainly no considerable defect of it.Now let us see Nhat n-e have got in this first degree of the common form of hemiplegia.There is paresis of the right side of the face, of the right side of the tongue (this we will infer), of the right arm and leg.This form of paralysis points to disease of the highest parts of the motor tract, and, considering that the arm suffered much more than the leg, and that speech was lost, to disease of the corpus striatum.I do not, of course, say to disease limited to that centre.And again I remind you that it points to nothing more than position of lesion.Hemiplegia is only a localising symptom; it does not point to the pathological process.The destruction of the corpus striatum causing such hemiplegia may be by clot, by softening, or there may be exhaus- tion of the nerve fibres and cells of the organ from a strong epileptic discharge (epileptic hemiplegia, see page 69).In the last case, the