Clinical Lectures ON THE COMMON FORMS OF PARALYSIS FROM BRAIN DISEASE
ASSISTANT-PHYSICIAN TO THE NATIONAL HOSPITAL FOR THE PARALYSED AND EPILEPTIC. LECTURE III. GENTLEMEN,—We turn now to the consideration of another mode of onset of the hemiplegic state- (2) The Epileptiform. This is merely a variety of the apoplectic mode of onset, which we considered in the last lecture; only in it the patient drops down, either with or without prodromata, not merely insensible, but actually convulsed. He has, in fact, a kind of epileptic fit, though he may never have bad one
... ever have bad one before; and after a time, when consciousness is restored, or perhaps sooner, it is discovered that the patient is paralysed on one side of his body. This mode of onset of hemiplegia is interesting in many respects, but principally on account of its complicated relations with the epileptic condition. You must not forget, however, that there are two distinct classes of cases included under this head. There are, first, the cases referred to in a previous lecture, in which a very brief and temporary hemiplegia is apt to follow certain severe attacks of unilateral convulsions ; the hemiplegic condition in these cases being due merely to vascular spasms plus certain minute but undiscoverable molecular changes in definite parts of the brain. Secondly, there is the much more formidable group of cases in which we have to do with distinct and obvious organic lesions in the brain, giving rise both to the epileptiform mode of onset and to the more persistent hemiplegic condition thus initiated. There is no reason of course why this second state of things, due to the occurrence of a new and obvious brain lesion, should not take place in persons who have been previously epileptic, although in their case an epileptic fit has never previously been followed by hemiplegia. Actually, however, this mode of onset occurs more frequently in those who, previous to the commencement of the paralysing lesion, had not been epileptic-simply because such persons are so much more numerous than those who have been afflicted with epileptic attacks. Although prodromata may be absent altogether, or, if present, may be most variable in nature, still I think that two sets of symptoms, either singly or in concert, are especially apt to precede this mode of onset : these are, pains in the head and muscular twitchings in different parts of the body. Where they have been present a fit may subsequently occur (though the person has never previously bad one), and this may be followed by other epileptiform attacks at short intervals, after one of which the patient is discovered to be hemiplegic. A good instance of this mode of onset occurred in a patient who was under my care a few years ago. A woman, thirty-four years of age, had a first fit whilst in the street; but she was able to walk home, and during the next forty-eight hours she had twelve other attacks. She was then brought to this hospital, and was not at the time paralysed; but soon after her admission she had another series of epileptiform convulsions affecting both sides of the body, though the twitchings were more marked in the right limbs and right side of the face. During the intervals between these latter convulsive attacks it was found that the face was partially paralysed on the right side, the right arm was completely paralysed, and the right leg was powerless to a less extent. The convulsions then ceased, but the patient remained hemiplegic for several months, and probably longer, though she was after a time lost sight of. In another patient, a girl eight years old, who was seen elsewhere, prodromata occurred in the form of a slight maniacal condition. This was brought to a close at the expiration of three weeks by the occurrence of four fits, one after another in quick succession, in each of whidh there was a general convulsive condition. The patient was then found to be paralysed on the right side of the body, and the paralysis persisted for more than twelve months. In this child there was hypertrophy of the heart, together with loud basic systolic and diastolic murmurs. run fh occasions the initial attack is characterised by uniltiterit convulsions. An instance of this occurred in a woman wh'0 was under my care at the National Hospital for the Parslysed and Epileptic. She was forty-two years of age, and, whilst dressing, was suddenly seized with convulsions affecting the left limbs and face. She became unconscious at once, and the convulsions continued, with occasional intermissions, for an hour and a half. She was then found to lpe. paralysed on the left side, and she remained in a more or less unconscious state for fourteen days. The paralysis persisted, and her speech continued indistinct, for a long time. Some of the patients whose hemiplegic condition is thus initiated are subsequently liable to a recurrence of epileptic attacks at variable intervals; but in many cases no subsequent attack occurs, even though the patient may live for many years: from which we may conclude that the epileptiform symptoms were probably due to the early irritative stage of a brain lesion which rapidly advanced so as to leave no tendency to the recurrence of epileptic attacks. The' early pathological state becomes blotted out by the fully developed lesion by which it is more or less immediately followed, and upon which the persistent paralysis depends.