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Gen. VIII. The paroxysm varies in its duration, from eight to Spec. V.
C. Apo eight and forty hours, and sometimes exceeds this period. plexia en- Dr. Cooke quotes from Forestus the case of a woman,
who being seized with an apoplexy, which he calls forapoplexy. tissima, lay in the fit for three days, and afterwards reDuration
covered. We have already observed that where it does of the par. oxysm not prove fatal, it predisposes to a relapse, and often terHas extend- minates in a lesion of some of the mental faculties, or in ed to three days with a paralysis more or less general; commonly, indeed, in a recovery. hemiplegia, which usually takes place on the opposite Sequel of
side of the body from that of the brain in which the conthe disease. Side
gestion or effusion is found, on examination, to have taken miplegia, place. “ This”, says Dr. Baillie, “ would seem to show usually on the opposite that
that the right side of the body derives its nervous influence side of the from the left side of the brain, and the left side of the body from
of the body its nervous influence from the right side of the brain. brain when It is rarely indeed, if ever, that some of the turgid vessels there is effused blood.
of the brain are not ruptured in this form of the disease, and consequently produce an effusion of blood into some part of the organ of the brain.” And, according to the same distinguished writer, the part where the rupture most commonly takes place is its medullary substance near the lateral ventricles, some portion of the extrava
sated fuid often escaping into these cavities *. B C. Apo
ATONIC APOPLEXY is the disease of a constitution inplexia ato
firm by nature or enfeebled by age, intemperance, or Atonic apo- over-exertion of body or mind. It has more of a purely plexy.
nervous character, as we have already observed, than the A result of vascular preceding variety, and is more a result of vascular debility debility than of vascular surcharge, and consequently where effurather than of vascular sion of blood is found, as it often is, in the present form, surcharge: the vessels have been ruptured, not from habitual distenand hence
tion or vigorous plethora, but from accidental, often, inhere also the vessels deed, slight causes, that have produced a sudden excite
ment and determination to the head beyond what the vashave been found rup cular walls are capable of sustaining. Hence, a sudden
" fit of coughing or vomiting, a sudden fright, or fit of joy, their own weakness.
. .Morbid Anat. p. 227.
of the brain
an immoderate fit of laughter *, the jar occasioned by a Gen. VIII. stumble in walking, or a severe jolt in riding, have brought
6 C. Apoon the present form of apoplexy, and with so much the plexia atomore danger as the system possesses less of a remedial or "
Atonic aporallying power in itself.
plexy.. In most of the cases the effusion detected after death And hence
an objection has, therefore, been as truly sanguineous as in entonic apoplexy; and hence a valid objection to the use of the sanguineous term sanguineous as descriptive of the entonic form alone.al “ It is ”, says M. Portal, “an error to believe that the of the en
tonic form apoplexy to which old men are so much subject is not alone sanguineous.” Daubenton and Le Roy, Members of the Illustrated. Institute, died of this precise kind of the disease at an advanced age: and Zulianus describes a case marked by a pale countenance, and a pulse so weak as scarcely to be felt, which, on examination after death, was found to be an apoplexia verè sanguinea : and another in which, after all the symptoms of what is ordinarily called serous apoplexy had shown themselves, extravasated blood was discovered in the brain without any effusion of serum, or the smallest moisture in the ventricles t.
It is nevertheless true that atonic apoplexy is often Yet this found with an effusion of serum instead of an effusion of blood, and apparently produced by such sereus effusion ; an effusion
of serum, and hence, notwithstanding the objections of Dr. Aber- i crombie, and, in the latter years of his practice, of M. Por- rently pro
duced by it; tal, to serous effusion as a cause at all, the experience and reasoning of Boerhaave and Hoffman, and Mead, and tured by Sauvages, and Cullen, must not be abruptly relinquished authorities. without far graver proofs than have hitherto been offered: for if it be a question, as Stoll has made it, whether effused serum, when discovered in the brain of those who have died of apoplexy, be a cause of the disease or an effect I, we may apply the same question to effusion of blood. It is possible, indeed, for effused serum to become Effused occasionally a cause even of entonic apoplexy, or that serum may
ften 1 with
understood the result of
GEN. VIII. which, from its symptoms is ordinarily denominated sanSpec. V.
po guineous apoplexy; for it is possible for the exhalants of plexia ato- the brain to participate so largely in the high vascular exAtonic ano citement by which this form of the disease is characterized, plexy. as to secrete an undue proportion of effused fluid into any though of its cavities, and thus become as direct a cause of aporarely, a cause of en- plexy as extravasated blood. tonic apo- This, however, is not what is generally understood by plexy. Explained. the term serous apoplexy as distinguished from sanguiSerous apo- neous, and, indeed, ought only to be regarded as an effect plexy as commonly of sanguineous distention. Serous apoplexy, properly so
called, is strictly the result of a debilitated constitution, a debilitated and especially of debility existing in the excernent vessels constitution: of the brain, whether exhalants or absorbents. I say ab
sorbents, because although lymphatics have not yet been discovered in this crgan, there must be vessels of some kind or other to answer their purpose, and the extremities of the veins have been supposed thus to act; a supposition which has derived countenance from various experiments of M. Magendie, to which we shall have to advert in the Proem to the sixth class, and which may at least stand as
an hypothesis till the proper system of vessels is detected. and may A serous effusion, under these circumstances, may take
place from three causes. The mouths of the exhalants may be relaxed, and consequently let loose a larger portion of Auid than they are accustomed to do in a state of health, and a larger portion than can be carried off by the absorb ents. Or the extremities of the absorbents may be torpid and inactive, and not imbibe the fluid that is thus thrown forth, and the balance may be disturbed in this as well as in the preceding way. Or the blood itself, may be of too watery a crasis, and too large an effusion take place from this cause; whence, indeed, we frequently meet with apo
plexy as the result of general dropsy. Hence ato. Hence, atonic apoplexy rarely makes its attack alto.
leky gether so incontinently as entonic; and is commonly premore slow in ceded by a few warning symptoms. These are often, how
ever, nothing more than the ordinary precursors of other Precursive nervous affections, as vertigo, cephalæa, imaginary sounds, signs,
take place from three causes.
the fit varies
a faltering in the speech, a failure in the memory or some Gen. VIII.
Spec. V. other mental faculty, and at length a sense of drowsiness, and a tendency to clonic spasms. On the attack of the plexia atoparoxsym the patient is as completely prostrated as in the entonic variety, but the symptoms are less violent, though plexy.. not on this account less alarming, in consequence of the greater debility of the system. The countenance is here pale or sallow, instead of being flushed, but at the same time full and bloated; the pulse is weak and yielding, sometimes, indeed, not easy to be felt; and the breathing though always heavy and laborious, not always, as we have already observed, noisy or stertorous. If spasms occur, they are uniformly of the convulsive or clonic kind. The Duration of duration of the fit varies as in the preceding variety, and the if the patient recover, he is more liable to a relapse, and more in danger of hemiplegia or some other form of paralysis than in the stronger modification of the disease.
From these remarks on the two varieties of apoplexy, Disease unwe may readily see why this complaint, and its ordinary
umaly or other associate or sequel, palsy, should be about equally common equally comto the poor and to the rich: for frequent exposure to cold
poor and the and wet, severe and long protracted exercise, and a diet rich. below what is called for, will often be found to produce the same debilitating effects as ease, indolence, luxury, and indulgence at too sumptuous a table. And hence, contrary to what many would expect, Sir Gilbert Blane has Illustrated,
from Blane's observed from accurate tables kept with minute attention tables. and derived from a practice of ten years in St. Thomas's Hospital, and his private consultations, that “ there is a considerably greater proportion of apoplexies and palsies among the former than among the latter”: or, in other words, that these disorders bear a larger proportion to other diseases among the lower classes than among those in high life. “Some cases of hemiplegia," says he,“ occur in full habits; some in spare and exhausted habits. The former, being most incident to the luxurious and indolent, most frequently occur in private practice, and among the upper ranks of life. The latter occur more among the laborious
n to the
In other re
Gen. VIII. classes, and among such of the rich as are addicted to ex
Spec. V. 6. C. Apo hausting pleasures."* plexia atoni- In forming our prognostic, a special regard must be had Atonic apo- to the peculiar character of the disease. Generally speakplexy.. ing, atonic apoplexy is more dangerous than entonic, for Prognostic.
apo we have here a more barren field to work upon, and nature plexy more herself, or the instinctive power of the living frame, has less dangerous than entonic, ability to assist us. As to the rest in either modification, and why. the degree of danger will be generally measured by the
the violence of the symptoms. Where, under the first variety, danger pa- the breathing is not much disturbed, the pupil is relaxed, rallel with the violence and there is no appearance of spastic action; where the of the
perspiration is easy, the skin warm rather than hot, the symptoms. Favourable bowels are readily kept in a due state of evacuation, and signs.
more especially where there is any spontaneous hemorrhage, as from the nose or hemorrhoidal vessels, and of sufficient abundance, we may fairly venture to augur fa
vourably. But where the symptoms are directly opposed able.
to these; where the stertor is deep and very loudt, and particularly where it is accompanied with much foaming at the mouthf; where the teeth are firmly clenched, or a spasm has fixed rigidly on the muscles of deglutition, and the pupil, instead of being dilated, is contracted to a point, we have little reason to expect a favourable termination.
The great hazard resulting from this tendency to spastic
action, and particularly as evidenced in a strongly conA contract- tracted pupil, is thus forcibly pointed out by Dr. Cooke. ed pupil a sign of great
“ Among the dangerous signs in apoplexy, many authors danger and mention a dilated state of the pupil of the eye: but the why.
contracted pupil, which I consider to be a still more dangerous appearance, has been scarcely noticed. I am of opinion that this ought to be reckoned among the very worst symptoms of the disease. I never knew a person recover from apoplexy when the pupil was greatly contracted. My opinion on this subject is confirmed by that of Sir Gilbert Blane and Dr. Temple 8.”.
* Trans. Medico-Chir. Soc. Vol. av. p. 124.
Burser. p. 97.
+ Dolæus, p. 144. S Burser. p. 280.