SPEC. V. Carus Apo quisitely intense, CARUS Asphyxia is more likely to be GEN. VIII. produced than CARUS Apoplexia; for we have already observed under the preceding species that the very same plexia. cause which, operating in a vehement degree, excites the Apoplexy. former, operating less powerfully has often a tendency to quisitely excite the latter. When ex intense it produces asphyxy and only less degree Other and apoplexy. more mani→ fest predisposing causes. when in a How far a daily use of wine in mo deration may pre The other predisponent causes, so far as they have been traced out, are more obvious to the senses, and, for the most part, more directly referable to the state of the sanguineous function; as plethora, corpulency, and grossness of habit, a short thick neck, and an inordinate indulgence in wines and heavy fermented liquors. Dr. Cheyne, indeed, believes the last to be so common a cause, as even to produce the disease when employed without any inordinate indulgence whatever: "the daily use", says he, " of wine or spirits will lead a man of a certain age and constitution to apoplexy, as certainly as dispose. habitual intoxication."* This may be true as here limited, but then the limitation must be attended to; in which case we are only told in other words, that whereever such a kind of sensorial debility exists as that which we have already adverted to, the result of age, or habit, or constitution, one man will be as readily led to apoplexy under a moderate use of wine, as another man destitute of such predisposition will be under a state of habitual intoxication. With this explanation, however, a moderate use of wine becomes only an accessory, and not a primary cause. mon efficient cause compres sion of the How far there may be any other EFFICIENT or EXCIT- The comING causes of apoplexy than compression of some kind or other, it is difficult to determine, though various cases on record should induce us to suppose there are. Hydatids, brain. tumours of almost every consistency, gelatinous, steato- How far matous and bony, pus, and polypous caruncles and in- the durations of the membranes, have, in various cases, been discovered on dissection, and are generally supposed to operate by compression, in the same manner as an accu there may be any other excitas detering cause, minable by dissections. GEN. VIII. Carus Apo- The ordi nary mor bid ances mostly ineffective otherwise than as concomitants: though they may where a mulation of blood or serum. But in many instances these appearances seem to have been too minute for any such effect; and, if causes of any kind, can only fairly be regarded as concomitants or allied powers-as local irritants, stimulating and exhausting the sensorium, and preparing appear it for attacks of apoplexy against the accession of some superinduced and occasional cause. Though where there exists already a strong predisposition to the disease from hereditary or any other affection, it is not improbable that such local irritants may alone be sufficient to perfect the complaint. And we may hence account for that form of apoplexy which is said to proceed from intestinal worms, or some other acrimony of the stomach, or from teething; and which, consequently, occurs at an early instead of at a late period of life, and has been specially denominated infants from apoplexia infantum. Other organs, however, besides the teeth and the stomach, seem not unfrequently to have given occasion to apoplectic attacks from irritation, disAs also apo- tention, or organic lesion. Thus, according to M. Porplexy from other remote tal, superinducing tumours and congestions have been found in the neck, in the breast, or in the abdomen; these morbid ossifications in the thoracic and ventral aorta, as well as in the arteries of the upper and lower extremities, in the superior vena cava, and in the right ventricle and valves of the heart, which has also indicated various other the sensorial changes." strong predisposition exists. Hence the apoplexy of teething or ventricular acrimony. irritations. Most of actions and appearances as common to other affections of system as to apoplexy: and hence, wherever they become causes, the disease immediately Most of these morbid actions and appearances, however, are as common to various other affections of the sensorial system as to apoplexy. We have already noticed them in lethargy, convulsion, epilepsy, various species of cephalæa, and some forms of insanity: and hence, whereproduced ever they become causes at all, it is most probable that must be de- the disease they immediately produce, is regulated by the a pre-exist- predisposition of the individual to one rather than to ing tenany other of the above sensorial affections, resulting from family taint, idiosyncrasy, habit, or period of life: and, than to any consequently, that the same exciting or occasional cause, termined by dency to such dis ease rather other. * Portal, Ch. Resultats de l'Overture des Corps, p. 329. which, in one person, would produce apoplexy, in a second, would form epilepsy, in a third, convulsion, and in a fourth, madness. Carus Apo plexia. Apoplexy. Singular that this view of the subject scarcely have been attended to: either in the description or practice of the disease. This point far investi It is highly singular that this view of the subject should scarcely ever have been attended to by physicians; and that, whilst all the writers have pretended to regard apoplexy as a disorder of the nervous system, none of should them have suffered such ideas to enter fairly into their pathology, or in any way whatever into their practice: the nervous organ being supposed by all of them to be in a state of soundness at the time of the attack; and whatever mischief it suffers to be merely secondary and consequent upon a morbid state of the blood-vessels, or of some other cause that as suddenly and effectually interrupts the secretion or flow of the sensorial power, as retrocedent gout, mephitic vapours, or narcotic poisons. Now all these accidental or effective causes of ароplexy are well known to be causes, also, of the other nervous affections we have just referred to. But if this be the case, how comes it that they should thus vary in their result, and that what in one person, and at one period of life, should produce apoplexy, should in another person, and in another period of life, produce lethargy, palsy, convulsions, or epilepsy? or that some of them should exist without producing any of these diseases or any other disease whatever? It is not, perhaps, possible for us to develope the precise condition of the sensorium that leads to any one of these effects, rather than to any other; but that there is such a condition forming a predisponent or remote cause of the specific disease that shows itself, must, I think, be allowed by No other every one who seriously considers the subject. gated. view than the present capable of reconcili various dis Nor is there, in effect, any other means of reconciling the discrepant and opposite opinions that have been held concerning the proximate cause of the disease. This crepant we have stated to be, for the most part, compression, and opinions especially sanguineous compression. Mr. John Hunter was so strenuously attached to this cause that he would allow of no other; M. Rochoux has followed his footSS 2 concerning the proxi- John GEN. VIII. SPEC. V. Carus Apo plexia. Apoplexy. compression brain in steps; and if a man died of apoplexy from atonic gout, and without effusion, the former distinguished it as a disease similar to apoplexy. He regarded apoplexy and palsy as one and the same disease, merely differing in or determin- degree: and he gives us his sentiments very forcibly, ation to the in the following words: "For many years," says he, "I have been particularly attentive to those who have stance pro- been attacked with a paralytic stroke forming a hemiducing extravasation. plegia. I have watched them while alive that I might have an opportunity to open them when dead: and in all I found an injury done to the brain in consequence of the extravasation of blood.—I must own I never saw one of them which had not an extravasation of blood in the brain, except in one who died of a gouty affection in the brain with symptoms similar to apoplexy."+ every in In direct hostility to this hypothesis, many other writers of great eminence and experience have contended that compression is no cause whatever, and that an accumulation of blood in the head, as a prominent symptom in apoplexy, is a doctrine rather than a fact. Of this sentiment is Dr. Abercrombie, who, after examining the question with much ingenuity, brings himself to the following conclusion: "Upon all these grounds," says he, "I think we must admit that the doctrine of deter mination to the head is not supported by the principles of pathology, and does not accord with the phænomena of apoplexy." M. Serres, however, a physician of considerable distinction in France, and who followed up this subject for many years by a careful examination of the bodies of persons who died of apoplexy and paralysis, both at the Hôtel Dieu, and the Hôpital de la Pitié, has carried his inroad upon the popular doctrine of the day still farther; for he has not only, in his own opinion, completely subverted it, but has endeavoured to establish another doctrine, of a very different character upon its + * Dict. de Medicine, Tom. II. Paris, 1822. Treatise on Blood, &c. P. 213. Treatise on Apoplexy, &c. p. 19. SPEC. V. ruins. To determine the question, he has gone through GEN. VIII. a long scries of experiments upon the brains of dogs, Carus Apopigeons, rabbits, and other animals, whose crania were plexia. Apoplexy. trepanned, their lateral, or longitudinal sinuses laid open, and their brains lacerated and excavated in various ways, so as to be gorged with effused blood, yet in none of them did somnolency or any other apoplectic symptom take place. And he hence triumphantly concludes that extravasation of blood does not produce apoplexy, whether lodged between the cranium and the dura mater, or between the dura mater and the brain: whether the blood occupy the great interlobular scissure, and thus lies upon the corpus callosum; whether cavities be made in the fore, the back, or the middle part of the hemispheres, or run from the one into the other; or, lastly, whether piercing through the corpus callosum we reach and fill up the ventricles of the brain. "On whatever animal", says he, "we try these experiments, whether on birds, rabbits, or dogs, the result is the same, and hence apoplexy in man ought not to be ascribed to such effusions." Reconcilia tion of these opposite How are these discrepancies to be reconciled? by what means are we to account for it, that pressure may be a cause, and may not be a cause? and that apoplexy is facts. sometimes found with it, and sometimes without it? It is the peculiar state of the sensorium or nervous system at the time that makes all the difference-it is the morbid predisposition or debility, or whatever other deviation from perfect health it may labour under at the moment of the application of the exciting cause, that gives an effect which would not otherwise take place and something of which, in many cases, often discovers itself by precursive signs for a considerable period before the apoplectic incursion. The facts stated by Mr. John Hunter no one can call in question: and we have as little right to ques tion the experiments of M. Serres: the error consists in Experitaking an unsound and a sound state of brain for like premises, and reasoning from the effects produced on the * Annuaire Medico-Chirurgicale, Avril, 1820. ments of Serres inde cisive, how ever cor rectly stated, and why. |