GEN. VIII. SPEC. V. Carus Apoplexia. Apoplexy. tients after death. one, to those that are found to follow on the other. This, in truth, is an error too often committed; and hecatombs of quadrupeds and other animals in a condition of perfect health, are tortured in a thousand ways for the purpose of determining what they never could determine, though the trials were to be repeated to the end of time; I mean the effects of certain causes on a diseased state of body in man, from their influence on a sound state of body in brutes. Hence views M. Serres's actual examinations of apoplectic patients of Serres not after death, however, though conducted also upon a large supported by his examina- scale, do not seem to afford much countenance to his hy. plectic pa pothesis, nor, in effect, to offer any thing out of the common way. In a considerable number of subjects there was serous effusion, sanguineous effusion, or both; sometimes in the circumvolutions of the brain, sometimes in the ventricles, sometimes in all these; and not unfrequently the vessels of the meninges appeared distended with blood, and the membranes themselves thickened. Such appearances seem to furnish something of a stumblingblock to M Serres's new doctrine, yet he readily gets over the difficulty by satisfying himself that, in all these cases, the effusion did not produce the apoplexy, but the apoplexy the effusion. In other dissections he found some material alterations in the structure of the brain, but without effusion; and, as the last class of individuals had evinced palsy rather than apoplexy, he is inclined to think that apoplexy, or that state of the disease in which the stupor is greater and more general, is occasioned by a morbid irritation of the membranes of the brain; and palsy, or that state in which the stupor is less, by a morbid change in its substance; in consequence of which he proposes to call the first meningic, and the second cerebral apoplexy. In this conclusion, however, there seems to be a striking mistake; and the very reverse is what we with the best should have expected; for if there be one pathological pathological principle more established than another, it is that stupor and dulness of pain appertain to the parenchymatous irritation or inflammation of an organ, and rousing, restless, His subdi vision of the disease at variance established facts. SPEC. V. and acute pain to its membranous irritation; a principle GEN. VIII. we have already explained at some length; and whence, Carus Apoindeed, the lancinating pain of pleuritis compared with plexia. Apoplexy. pneumonitis, and of meningic or brain-fever, compared with acute dropsy of the head*. There is far more dependence to be placed upon the painful and unjustifiable series of experiments performed several years since by M. Rolando upon the brain of animals of almost all kinds; and which seem to show, as we have already observed, that animals which possess a perfect brain derive their sensific power and motific power not jointly from the cerebrum and cerebellum, but separately, the one affording the one power, and the other the other†. Stupor and apoplexy were in all these cases produced, not by a morbid irritation of the membranes of the brain, as conjectured by M. Serres, but by a morbid irritation of the substance, while irritation of the membrane took away neither the sensific nor the motific power. pression ing cause of apoplexy. By what means it operates. The brain therefore may be rendered comatose by Hence comvarious causes: but we hold, after all, that the grand must still be exciting cause of apoplexy, is compression; and this allowed the shows itself in various ways, which are well enumerated grand excit by Dr. Cheyne in the following passage: "I mention first," says he, "the remains of an excited state of the minute arteries of the brain and its membranes, this probably being the most important, as it is the most unvarying appearance; then the extravasation of blood, probably the consequence of the excited state of the vessels; the turgescence of the venous system; the enlargement of the ventricles, partial or general; and lastly, the serous effusion which is generally found in various parts of the brain, and which would seem to imply previous absorption of the brain."+ The concluding sentence in this passage appears to indi * See Vol. 11. Empresma Cephalitis, Cl. III. Ord. 11. Gen. vII. Spec. L † Saggio sopra la vera Struttura del Cervello, &c. e sopra le Fanzioni de Sistema Nervosa. Sassari, 1809. Cheyne, p. 24. SPEC. V. Carus Apo plexia. Apoplexy. Disorgani zation of the brain, some Mollities ce GEN. VIII. cate that this correct and discriminating pathologist was by no means inattentive to that extraordinary change which is not unfrequently produced in the structure and tenacity of the brain by various causes of excitement; and consists in a more or less extensive demolition of its substance, so that it is sometimes found to be pulpy or pasty, times pulpy and at others the disorganization having proceeded further, or diffluent. to be as liquescent or diffluent as soup. Morgagni has collected various examples of these and other modes of disintegration; Dr. Baillie has occasionally adverted to them; and Dr. Abercrombie has brought them into a still more prominent notice by an ingenious pathological explanation of their causet. But, in France, the subject has been pursued with peculiar activity, since the publication of the first edition of the present work, and has excited rebri or Ra- an interest of no ordinary standard. To this change, M. Rochoux has given the name of Ramollissement de Cerveau, or Mollities Cerebrit, and its nature and varieties Regarded as have since been followed up, and systematically arranged idiopathic by with considerable nicety and precision, by M. Rostan, and M. Lallemand§, who have regarded it as an idiopathic affection, and, attempted a developement of its entire paActual cause thology and mode of treatment. Its actual cause is often doubtful; and still more doubtful is it whether it ever exists as a primary disease. That inflammation consequent on congestion or rupture of the blood-vessels of the brain is a frequent cause is clear, because the minute and colourless arteries of the part affected are often found striatrapid and aced or infiltrated, as the French call it, with red blood, companied with inflam- and a clot of effused blood is traced in the centre. mation. inflammatory process hereby produced is sometimes violent and passes rapidly into the suppurative stage, accom mollisse ment de cer veau. some writers. doubtful. Disease sometimes * Morbid Anatomy Fascic. x. Pl. 1. p. 213, and Pl. ví. 227, 228. The † Edinb. Med. and Surg. Journ. vol. xiv. p. 265. Observations on Chronic Inflammation of the Brain. Recherches sur l'Apoplexie, 8vo. 1814. Recherches sur un Maladie encore peu connue qui a reçu le nom de Ramollissement de Cerveau. Svo. 1820. § Recherches Anatomico-pathologiques sur l'Encephale et ses dependances. SPEC. V. Carus Apo panied with severe lancinating pains, and a feeling of con- GEN. VIII. striction round the head, and even delirium; and, hence this condition is as common a result of cephalitis as of what plexia. we shall presently have occasion to call entonic apoplexy. Apoplexy. The soft, pulpy disorganization of the brain is in this case often intermixed with masses of pus, while the general hue of the diseased part is brown or reddish from a diffusion of the red particles of the blood that have been let loose; and as the extravasated blood becomes more or less decomposed and intermixed with the white or grey matter of the brain, and with effused serum, the colour is found to vary considerably through all the diversities of white, grey, yellow, rosy, amaranthine, deep red, brown, chocolate, and greenish. The grey substance of the brain, however, as less tenacious, is found more generally diffluent and more completely decomposed than the white. chronic, and symptoms. More usually, however, the inflammation is far less vio- Sometimes lent and chronic; and the symptoms are those of an ob- inflammation tuse pain in the head, general oppression, occasional ver- doubtful. tigo, with indistinctness of memory, and confusion of thought, the pulse evincing but little if any change from a state of health. But as these symptoms are common to various other diseases, their pathognomic value is small. There are two other signs, however, pointed out by the Supposed French monographists as more essentially distinctive, but pathognomie which the present writer has never had an opportunity of noticing these are a mouse-smell, or odour issuing from the body of the patient like that which is exhaled from the bodies of mice; and a movement of the lips on one side,, accompanied with a rushing or whizzing sound like what is often exhibited by smokers in the act of smoking tobacFor the production of these last symptoms, however, it is necessary that the disease should be accompanied with hemiplegia, so that one side of the mouth only is capable of motion. co. In general cated rather atony indi By far the greater number of these symptoms, however, indicate atony rather than entony of action; and hence, though inflammation is not unfrequently a proximate than entony. cause, debility whether consequent upon inflammation, or SPEC. V. Carus Apoplexia. Apoplexy. GEN. VIII. any other morbid change, is, perhaps, a more common cause. Hence in our own country this organic mollescence has usually been regarded as a gangrene of the brain, and many of the French pathologists, and especially M. Recamier, incline to interpret it as a result of low atonic or malignant fevers, rather than of phlogotic action. With M. Rostan and M. Lallemand, however, it is ranked as a direct phlogosis, or plegmasia, not resulting from apoplexy, but necessarily conducting to it and producing it. Yet, as, according to their own showing, the leading symptoms are those of turgescence and oppression, with little increase of pulse or other excitement, it should seem to follow that they have in a considerable degree mistaken the cause for the effect, even where inflammation is co-existent. In reality, though there is no difficulty in accounting for the extravasated blood or the vascular infiltration, or the depraved colours which are found in this state of the brain upon the principle of inflammation, there is a considerable difficulty in explaining upon the same principle the mollifaction of the diseased area: and it is upon this point that the pathology of the French writers seems chiefly to fail. The real mode of action, as it appears to the present writer, is the same as that which takes place in mollifaction of the bones, which we shall explain in a subsequent of the brain part of this system; but which, as well as its opposite, Morbid ac tion explained. Hardness and softness accounted for. fragility of the bones, is always a disease of weakness local or general. Now we meet with a like deviation from a healthy tenacity of the brain in both these ways; for we find it sometimes too tough, and indeed almost horny *; as well in the grey as in the white compartments, occasionally indeed interspersed with masses of bony matter; and at other times, as in the disease before us, too, soft and unresisting; and in both these cases also, if I mistake not, debility will be found the immediate cause even where inflammation has preceded. The firm and tenacious material which enters so largely into the subMorgagni, passim. + See the accounts of Duverney, Giro, and Moreschi, especially in Gazette de Santé, Paris, Nov. 11, 1809. |