GEN. VIII. SPEC. V. plexia en tonica. Entonic apoplexy. Duration of the par oxysm. Has extend ed to three days with recovery. Sequel of the disease. The paroxysm varies in its duration, from eight to a C. Apo- eight and forty hours, and sometimes exceeds this period. Dr. Cooke quotes from Forestus the case of a woman, who being seized with an apoplexy, which he calls fortissima, lay in the fit for three days, and afterwards recovered. We have already observed that where it does. not prove fatal, it predisposes to a relapse, and often terminates in a lesion of some of the mental faculties, or in a paralysis more or less general; commonly, indeed, in a hemiplegia, which usually takes place on the opposite side of the body from that of the brain in which the congestion or effusion is found, on examination, to have taken place. "This", says Dr. Baillie, " would seem to show that the right side of the body derives its nervous influence from the left side of the brain, and the left side of the body its nervous influence from the right side of the brain. It is rarely indeed, if ever, that some of the turgid vessels fused 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 extravasated fluid often escaping into these cavities *. When hemiplegia, usually on the opposite side of the body from that of the brain when there is ef $ C. Apoplexia atonica. Atonic apo plexy. A result of vascular debility rather than of vascular ATONIC APOPLEXY is the disease of a constitution infirm by nature or enfeebled by age, intemperance, or over-exertion of body or mind. It has more of a purely nervous character, as we have already observed, than the preceding variety, and is more a result of vascular debility than of vascular surcharge, and consequently where effusion of blood is found, as it often is, in the present form, surcharge: the vessels have been ruptured, not from habitual distention or vigorous plethora, but from accidental, often, inthe vessels deed, slight causes, that have produced a sudden excitement and determination to the head beyond what the vascular walls are capable of sustaining. Hence, a sudden fit of coughing or vomiting, a sudden fright, or fit of joy, and hence here also of the brain have been found ruptured, from their own weakness. * Morbid Anat. p. 227. SPEC. V. plexia ato an immoderate fit of laughter *, the jar occasioned by a GEN. VIII. stumble in walking, or a severe jolt in riding, have brought on the present form of apoplexy, and with so much the more danger as the system possesses less of a remedial or rallying power in itself. 66 In most of the cases the effusion detected after death has, therefore, been as truly sanguineous as in entonic apoplexy; and hence a valid objection to the use of the term sanguineous as descriptive of the entonic form alone. "It is", says M. Portal, an error to believe that the apoplexy to which old men are so much subject is not sanguineous." Daubenton and Le Roy, Members of the 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 +. nica. Atonic apo plexy. And hence an objection sanguineous apoplexy as descriptive of the en to the term tonic form alone. Illustrated. form often found with an effusion od of serum, and appa rently produced by it; as conjec tured by very high 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; and hence, notwithstanding the objections of Dr. Abercrombie, and, in the latter years of his practice, of M. Portal, to serous effusion as a cause at all, the experience and reasoning of Boerhaave and Hoffman, and Mead, and 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, 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 Aretæus de Sign. et Caus. Diut. Morb. Lib. 1. Cap. 7. VOL. IV. T T Prælect. p.367. become, SPEC. V. plexia atonica. GEN. VIII. which, from its symptoms is ordinarily denominated sanB C. Apo- guineous apoplexy; for it is possible for the exhalants of the brain to participate so largely in the high vascular excitement by which this form of the disease is characterized, as to secrete an undue proportion of effused fluid into any of its cavities, and thus become as direct a cause of apoplexy as extravasated blood. Atonic apo plexy. though rarely, a cause of en tonic apo plexy. Explained. Serous apo plexy as commonly This, however, is not what is generally understood by the term serous apoplexy as distinguished from sanguineous, and, indeed, ought only to be regarded as an effect of sanguineous distention. Serous apoplexy, properly so understood 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 the result of and may take place causes. 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. A serous effusion, under these circumstances, may take from three place from three causes. The mouths of the exhalants may be relaxed, and consequently let loose a larger portion of fluid than they are accustomed to do in a state of health, and a larger portion than can be carried off by the absorbents. 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 apoplexy as the result of general dropsy. Hence ato Hence, atonic apoplexy rarely makes its attack altonic apoplexy gether so incontinently as entonic; and is commonly precommonly more slow in ceded by a few warning symptoms. These are often, howits progress than entonic, ever, nothing more than the ordinary precursors of other Precursive nervous affections, as vertigo, cephalæa, imaginary sounds, signs. SPEC. V. Atonic apo Incursion. a faltering in the speech, a failure in the memory or some GEN. VIII. other mental faculty, and at length a sense of drowsiness, & C. Apoand a tendency to clonic spasms. On the attack of the plexia atoparoxsym the patient is as completely prostrated as in the nic 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 fit varies. 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. der one form or other equally comon to the poor and the rich. From these remarks on the two varieties of apoplexy, Disease unwe may readily see why this complaint, and its ordinary associate or sequel, palsy, should be about equally common to the poor and to the rich: for frequent exposure to cold and wet, severe and long protracted exercise, and a diet 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 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 from Blane's GEN. VIII. classes, and among such of the rich as are addicted to exhausting pleasures."* SPEC. V. BC. Apo plexia atoni ca. Atonic apoplexy. Prognostic. Atonic apoplexy more dangerous than entonic, and why. In other respects the danger parallel with of the symptoms. In forming our prognostic, a special regard must be had to the peculiar character of the disease. Generally speaking, atonic apoplexy is more dangerous than entonic, for we have here a more barren field to work upon, and nature herself, or the instinctive power of the living frame, has less ability to assist us. As to the rest in either modification, the degree of danger will be generally measured by the violence of the symptoms. Where, under the first variety, the breathing is not much disturbed, the pupil is relaxed, the violence and there is no appearance of spastic action; where the perspiration is easy, the skin warm rather than hot, the Favourable bowels are readily kept in a due state of evacuation, and 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 favourably. But where the symptoms are directly opposed to these; where the stertor is deep and very loud†, and particularly where it is accompanied with much foaming at the mouth; 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. signs. able. A contracted pupil a sign of great danger and why. The great hazard resulting from this tendency to spastic action, and particularly as evidenced in a strongly contracted pupil, is thus forcibly pointed out by Dr. Cooke. Among the dangerous signs in apoplexy, many authors mention a dilated state of the pupil of the eye: but the 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 §." Trans. Medico-Chir. Soc. Vol. IV. p. 124. + Dolæus, p. 144. Ş Burser. p. 280. |