417 



APOPLEXY. 



APOPLEXY. 



413 



On examining the state of the brain after death from this variety of 

 the disease, the blood-vessels of every part of the cerebral substance 

 and of the delicate membranes that invest it, are found gorged with 

 blood ; there is also sometimes an effusion upon its surface, beneath its 

 membranes, and within its cavities, of the thinner portion of the blood 

 called serum, while, in many cases, pure blood itself is poured^ out on 

 various parts of the brain from some ruptured vessel. Occasionally no 

 morbid appearance can be detected sufficient to account for the attack, 

 or for death, the consequence of it. 



2. In the second form of the disease, in which the attack is less 

 violent in the commencement, but progressively increases in severity, 

 the loss of sensation and voluntary motion is neither sudden nor com- 

 plete, or, if it be so, the abolition of these functions is only of mo- 

 mentary duration. Instead of stupor and coma, the patient is seized 

 with a sudden and violent attack of headache, attended often with 

 sickness and vomiting. The pain of the head is sometimes so severe 

 that the patient sinks down under it, pale, faint, and exhausted, occa- 

 sionally with a slight convulsion ; but from this state of depression he 

 recovers rapidly, still however remaining weak, faint, and chilly, with 

 a quick and feeble pulse, a sunk countenance, and occasional vomiting. 

 This state having continued from one hour to three, or more, the heat 

 increases, the pulse acquires strength, the face becomes flushed, the 

 sunk expression of the countenance disappears, and torpor or stupor 

 rapidly supervenes, the patient appearing dull and heavy, answering 

 questions slowly and with difficulty, and sinking at last into a state of 

 profound coma. From the first invasion of the attack to the coming 

 on of perfect coma, the period may vary from one hour to three days 

 and more. This form of the disease is at least equally dangerous with 

 the preceding, and, in fact, generally proves fatal. 



On examining the state of the brain after death from this variety, 

 there are found extensive effusions of blood ; softening of the substance 

 of the brain ; sometimes ossification (conversion into bone) of portions 

 of its membranes ; but far more constantly ossification of the coats of 

 its blood-vessels, which organic change in the structure of the blood- 

 vessels diminishes their strength, renders them incapable of resisting 

 the current of the blood and of carrying on the circulation, and thus 

 predisposes them to rupture. 



3. The third form of the disease commences with a distinct apo- 

 plectic paroxysm, which terminates in paralysis. When the apoplectic 

 symptoms disappear, some part of the body is found to be paralysed ; 

 it may be the muscles of the face, giving rise to various kinds of dis- 

 tortion ; or the muscles of the limbs, occasioning inability to move the 

 affected member ; or the muscles of one side of the body, producing 

 what is called hemiptegia ; or the muscles of one half of the body, 

 paraplegia. In the great majority of cases the speech is more or less 

 affected, the power of articulation being either wholly lost or greatly im- 

 paired. Often the sensibility seems unimpaired, the patient endeavouring 

 to express himself by words or signs ; but, at other times, the mind 

 itself is indistinct, confused, rambling, and incoherent. Occasionally 

 in this form of the disease, the apoplectic state disappears rapidly, 

 while the paralysis remains for years. Sometimes the paralysis slowly 

 diminishes until suddenly another apoplectic attack supervenes, leaving 

 the paralysis greater than before; at other times the paralysis con- 

 tinues undiminished for days, months, and years, until a second, or 

 a third, or a fourth apoplectic paroxysm at length destroys the patient. 

 In the few cases in which there is a perfect recovery from the para- 

 lyris, the mind is always slow in recovering its energy, and often never 

 regains it. 



On examining the state of the brain after death from this variety, 

 there is commonly found an extravasation of blood into a defined cavity 

 formed in the substance of the brain, constituting what is termed an 

 apoplectic cell ; but although this be the most ordinary form in which 

 the blood is effused in this variety of the disease, yet there may also be 

 a general extravasation of it, as in the other varieties, or mere effusion 

 of serum ; or softening of the cerebral substance, or ossification of the 

 membranes, or of the blood-vessels, or several of these morbid conditions 

 may be combined. 



4. In the fourth and last form of the disease, in which the attack 

 commences with paralysis and terminates in a complete apoplectic 

 paroxysm, the premonitory symptoms are in general very distinctly 

 marked. Drowsiness, giddiness, disordered vision, impaired memory, 

 arfd pain of the head especially, commonly precede the attack. While 

 the brain is thus affected, the limbs about to become paralytic are 

 troubled with pricking, tingling, numbness, weakness, and cramp. 

 These local ailments progressively increasing, the limbs at length 

 become decidedly paralytic, and the paralytic state having continued 

 for an indefinite period, an apoplectic paroxysm supervenes, often pre- 

 ceded and denoted by spasms or convulsions in the unparalysed limbs. 

 The coma, which forms a part of the apoplectic proxysm, sometimes 

 comes on gradually, and is manifestly progressive hi intensity, the 

 patient at first being capable of giving a coherent answer when strongly 

 roused, but by degrees the loss of sensation becomes more and more 

 complete, until at last the stupor pawws into a state of total insensi- 

 bility, from which there is no recovery. Now and then the patient 

 recovers from the apoplectic xtatv, and slowly regains the condition he 

 was in previously to the apoplectic attack ; more frequently, on the 

 contrary, th paralytic :il!i'ctj<,ii in<;rvn*:s, and another apoplectic 

 seizure quickly supervenes, which proves mortal. 



ABTS ASD 801. DIV. VOL. I. 



In some cases the morbid appearances that present themselves on 

 inspection of the brain after death from this variety, differ in no respect 

 from those which have been described as belonging to the preceding 

 form ; but the most frequent and characteristic morbid change is the 

 softening of some portion of the substance of the brain. This softening 

 of the cerebral substance is the result of inflammation, which is generally 

 not acute in its nature, and is slow in its progress. The vessels belong- 

 ing to this softened portion lose their vitality, and allow the red particles 

 of the blood to pass through them, so that the part morbidly changed is 

 not only soft but red, from the infiltration of blood through the diseased 

 blood-vessels. 



From this account of the phenomena of the disease, and of the morbid 

 changes apparent in the brain in fatal cases, we are enabled to form an 

 accurate conception of the pathological condition of the brain in apo- 

 plexy. Two of the conditions essential to the performance of the 

 functions of the brain, are a supply of a certain quantity of blood, 

 flowing with a certain impetus, and freedom from pressure. Without 

 a certain portion of blood flowing with due impetus, the functions of 

 the brain fail ; with more than a certain portion, or with the velocity 

 of the current quickened or retarded beyond a certain point, they 

 equally fail ; and when the pressure induced by either of these states 

 exceeds a certain degree, they also immediately cease. The substance 

 of the brain is tender and delicate, and abounds beyond all other organs 

 with blood-vessels. It is of a soft and yielding nature, but it is inclosed 

 in a firm, unyielding case. Coupling this fact with the phenomena of 

 the circulation, it is easy to conceive how almost its entire mass, and 

 still more readily how particular portions of it, may become subject to 

 undue pressure, and how, as an inevitable consequence, the functions 

 of the brain may become deranged. Any cause which quickens or 

 which retards the circulation through it may produce this effect : for 

 example, a preternatural distension of the arteries with blood, or a 

 preternatural intensity in their action, and a consequent increased 

 impetus of the circulation ; or, on the contrary, a relaxation of the 

 veins, a preternatural turgescence of them from a too great quantity of 

 blood poured into them, and a consequent retardation of the circulation 

 through them. Either from a too great velocity or intensity of the 

 circulation in the arterial vessels, or from too great distension of the 

 veins in consequence of an impeded flow of the blood through them, 

 the thinner portion of the blood or serum may be poured out upon the 

 brain, which in this manner may become subject to undue pressure. In 

 consequence of either of these diseased states, the coats, whether of the 

 arteries or veins, may suddenly give way and break, and the blood 

 poured out upon the brain from the ruptured vessels may exert such a 

 pressure upon it as instantly to destroy its functions. Again, tumours 

 occasionally form in the brain, which progressively increase in magni- 

 tude, and at length exert such a degree of pressure upon the cerebral 

 substance, as is no longer compatible with the performance of its 

 functions. Disease of the heart also is known to affect the circulation 

 in the brain, and is present in a large number of apoplectic cases. 



Prognosis. When once an attack has come on, even though it be 

 slight, it places the individual in imminent danger ; both because it 

 greatly increases the predisposition to a recurrence of the paroxysm, 

 and because, when it does not destroy life, it gives a shock to the con- 

 stitution which is seldom entirely repaired, and never without much 

 time and most judicious management. In the paroxysm the immediate 

 danger is proportioned to the profoundness of the coma, the degree of 

 stertor, the slowness and laboriousness of the respiration, and the 

 frequency and intermission of the pulse. Other unfavourable signs are, 

 delirium, convulsions, paralysis, involuntary and unconscious discharge 

 of the urine and faces, and above all, the continuance of the paroxysm 

 without material diminution of its severity after the judicious employ- 

 ment of powerful remedies. When the respiration is exceedingly slow 

 and laborious when the pulse sinks to such a degree than it can be 

 scarcely felt, and when the head, chest, and limbs are covered with a 

 cold, clammy sweat, dissolution is near. On the other hand, the 

 favourable signs are, mildness of the paroxysm, diminution of the 

 symptoms after the exhibition of the appropriate remedies, and more 

 especially restoration to consciousness, return of the power of voluntary 

 motion, with a calm and soft pulse, a gentle, warm, and general pers- 

 piration, and a spontaneous flow of blood from the nose, the rectum, 

 and so on. 



Causes. The causes of the disease are either predisposing or exciting. 

 The predisposing causes are : 1. Sex. It is decidedly more common in 

 the male than in the female, because the male is more exposed to the 

 exciting causes, and nothing so surely generates a predisposition to tlio 

 disease, as the long-continued operation of an exciting cause. 2. Age. 

 It may occur hi childhood and youth : it is indeed rare in the former, 

 but it is not uncommon in the latter ; still, however, the great majority 

 of cases without doubt occur at the more advanced stages of life. The 

 period commonly conceived to be that in which it most frequently 

 occurs, is the interval between forty and seventy. Out of sixty-three 

 cases, two were between twenty and thirty years of age ; eight from 

 thirty to forty ; seven from forty to fifty ; ten from fifty to sixty ; 

 twenty-three from sixty to seventy ; twelve from seventy to eighty ; 

 and one from eighty to ninety years. 3. Conformation of the body. 

 The largo head, short neck, full chest, xanguinc and plethoric tempe- 

 rament, have from time immemorial been considered as forming the 

 apoplectic constitution ; and though the disease may and often docs 



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