It has been already remarked, in speaking of semi-coma, that it may be equally associated with apoplexy and with epilepsy ; and in .the broad outline of the former, just given, a drawing of the face to one side, and convulsive movements of the whole or part of the frame, have been mentioned as noticeable in an un questionable case of apoplexy; and therefore it is evident that the "fit," and the semi-coma following, may be symptomatic of either disease ; in fact, it resolves itself into a question of degree, the amount of convulsion, the depth of coma. Apoplectic convur sion is rather a faint tremor than convulsion, and is most marked when paralysis of one side of the face leads to more distinct devia tion to the other. In epileptic convulsion, however slight, there is definite movement, forcible and almost irresistible, distinctly dragging the limb or the head into unnatural contortions, and these are rarely limited to one side. The physician has no chance in general of seeing the movement and judging for himself, but any intelligent bystander can comprehend the difference and say what he saw. Then, again, the coma differs in degree, and in the opposite direction ; if the convulsion of apoplexy be slighter, the coma is deeper. The difference can scarcely be made intel ligible by words, but the loss of consciousness and usual sleep of epilepsy are quite distinct from the stupor of apoplexy ; the one consists rather in confusion, the other in suspension of the mental faculties.
But there is another condition, which is called serous apoplexy. Here, too, there is a fit ; there is loss of consciousness and para lysis, and yet there has been no turgidity, no rupture of vessels— mere effusion of serum. This fact has been already referred to, and it is almost incredible that it should take place instantaneously. I think we must believe that a morbid process has been going on for some time ; that at a certain point the brain becomes in tolerant of pressure, this point being determined by momentary repletion of either arteries or veins, or of the capillary vessels, and that then the event occurs in a moment. This is not true apoplexy, and careful inquiry will always show that it is more nearly allied to epilepsy ; that it is, in fact, analogous to the con vulsive seizure which ushers in hydrocephalus, occasionally, even in the adult; but the paralysis has proved the stumbling-block, and has been thought distinctive of apoplexy. The diagnosis is difficult, but I can affirm, from personal experience, that it is not impossible, though perhaps nothing can teach it except watching such cases, with the knowledge that events of this nature do occur. and that they do manifest themselves by special features.
The condition of the pupils deserves consideration, although no very definite rules can be laid down. Contraction indicates
irritation ; dilatation, paralysis of the optic nerve. A want of correspondence between the two proves the existence of more severe lesion on one side than the other; and would, therefore, at once exclude the idea of epilepsy.
Be it remembered, that there is no one symptom by itself dis tinctive of sanguineous apoplexy, and it is often only after several examinations that a diagnosis can with confidence be pronounced. There are two points which, in the subsequent condition of the patients, serve very greatly to discriminate the cases ; these are, the recurrence of the "fits," and the relative consciousness on succeeding days. (1) When they recur at short intervals, and no paralysis follows, the case is certainly not sanguineous apo plexy ; even if the convulsive movements be only slightly marked, they are probably epileptic, and after their cessation, convalescence from the condition of coma may be confidently looked for. When recurring at longer intervals, sometimes of days, more often of weeks, with paralysis enduring throughout, it is probably an instance of serous apoplexy ; true sanguineous apoplexy only recurs at very much longer intervals. (2) Alike in epilepsy and in serous apoplexy, consciousness is not so entirely suspended as in sanguineous apoplexy; at least, it is so for a much shorter time ; when semi-coma follows upon epilepsy, the subse quent state is one of prolonged sopor, from which when the patient is roused, he manifests a certain degree of consciousness by placing himself comfortably in bed, drawing up the clothes, &c.; but no regard is paid to surrounding objects. In serous apoplexy the sopor is less prolonged, and it is followed by a kind of vague, dreamy consciousness, which is attracted by surround ing objects, without recognizing or understanding them, so that the impression made on the senses is not followed by any 001Te8 • ponding rational act. In apoplexy the patient wakes as from profound sleep, and the recollection is confused, the thoughts are collected with difficulty, and the reason used imperfectly ; but there is distinct consciousness in the waking movements.
The character of the pulse in cases of apoplexy is one which demands careful study on the part of the practitioner, because of its bearing on the all-important question of venesection: it has also its uses in diagnosis, inas much as a hard wiry pulse, or a condition of vascular congestion about the head and throbbing of the temporal arteries, are so many indications of san guineous apoplexy ; but the converse does not by any means exclude the possibility of rupture of a bloodvessel.