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Apoplexy




APOPLEXY (Greek apo, plesso, to strike down, to stun), as term in medicine which, though now also employed with other significations, is commonly understood to apply to a fit of sudden insensibility occurring in connection with some diseased condition of the brain. Apoplectic attacks vary both as regards their intensity and their attendant phenomena, but well-marked cases present the following symptoms: The person attacked becomes, more or less suddenly, deprived of consciousness and all power of voluntary motion. He lies as if in a deep sleep, with a flushed face, a slow pulse, stertorous breathing, accompanied with puffing of the cheeks during expiration, and with the pupils of the eyes insensible to light, and contracted or unequal. This state in many respects resembles the coma of narcotic poisoning, and us unfortunately too often mistaken by unskilled persons for alcoholic intoxication. The symptoms and history of the case, however, are usually sufficient to enable a medical man to form a correct diagnosis. In this condition of insensibility death may occur within a few hours, or there may be a gradual return to consciousness, in which case it is frequently observed that some trace of the attack remains in the form of paralysis of one side of the body, while occasionally there may also be noticed some impairment of the mental powers, pointing to damage done to the brain. (See PARALYSIS.)

Although thus generally sudden in its onset, it is seldom that an attack of apoplexy occurs without some previous warning. Persistent headache of a dull throbbing character, a sense of fullness in the head, vomiting, giddiness, noises in the ears, slight confusion of mind, and numbness of a limb or of the one side of the body, are among the more important premonitory symptoms; and these may exist for a variable length of time before the fit comes on. Such symptoms, more particularly the association of them, when occurring in a person at or beyond middle life are to be regarded with anxiety, as indicating danger of an apoplectic seizure. Various morbid conditions of the brain are capable of giving rise to fits of apoplexy. Hence different forms of apoplexy have been described of medical writers, such as the congestive, where the cause appeared to lie in an engorgement of the blood-vessels of the brain and its membranes; and the serious, where sudden effusion of fluid into the ventricles or substance of the brain seemed to have brought on a fit. But by far the most frequent and important occasions of apoplexy is haemorrhage into the brain by the rupture of blood-vessels. Indeed, by many modern writers the term apoplexy is applied only to cases of cerebral haemorrhage. The blood-vessels of the brain, like those in other parts of the body, are liable to undego degenerative changes after middle life. These changes affect the minute capillaries, as well as the larger vessels, rendering their texture fragile, and at the same time impairing their function in carrying on the healthy nutrition of the brain. Hence, in the immediate vicinity of the diseases blood-vessels, the substance of the brain itself undergoes degeneration, and becomes softened. The capillary vessels having thus lost the natural support of the surrounding tissues, and being themselves weakened by disease affecting their walls, are liable to give way, and blood escapes into the brain. The haemorrhage may be slight in amount and in parts of the brain where its presence gives rise to little disturbance; but where a large blood-vessels has ruptured, and more especially where the blood has been extravasated in or around the important structures at the base of the brain, the result is a fit of apoplexy as above described, and death not unfrequently follows within a short period. In favourable cases where a certain measure of recovery takes place, the effused blood undergoes gradual absorption, or becomes enveloped in a sort of capsule formed by the surrounding brain substance, and ceases to cause further disturbance. But even in such cases some degree of paralysis remains at least for a time. Moreover, the nutrition of the brain is so impaired as to render probable a recurrence of the haemorrhage, and thus the danger to life, as is well known, increases with each successive attack.

From what has been above stated, it will be observed that apoplexy is to be regarded as a disease of advanced life. Hippocrates states that it is of most frequent occurrence between the ages of forty and sixty, and all medical experience confirms the truth of this observation. Nevertheless it may occur at any period of life, and cases are not wanting of true apoplexy in very young children. It is said to be more common in men than in women, but this is denied by many observers, and appears at least doubtful. What has from early times been described as the apoplectic habit of body, consisting in a stout build, a short neck, and florid complexion, is now generally discredited, it being admitted that apoplexy occurs about as frequently in thin and spare persons who present no such peculiarity of conformation. A hereditary tendency is acknowledged as one of the predisposing causes of apoplexy, as are also diseases of the heart and kidneys. With respect to the exciting causes of a fit of apoplexy, it may be stated generally, that whatever tends directly or indirectly to increase the tension within the cerebral blood-vessels may bring on an attack. Hence, such causes as immoderate eating or drinking, severe exertion of body or mind, violent emotions, much stooping, overheated rooms, exposure of the head to the sun, sudden shocks to the body, and the sudden suppression of evacuations, such as the menstrual discharge, may precipitate the fit.

A knowledge of these facts is of the utmost importance in the treatment of apoplexy, as obviously much can be done in the way of warding off fits where they appear to threaten, and of preventing a recurrence in cases where there have been previous attacks. With respect, further, to the treatment of apoplexy, it must be admitted that little can be done during the state of unconsciousness. The practice of blood-letting, once so common in this disease, is now almost entirely abandoned, although there are physicians who still recommend its employment, especially where the attack occurs in stout, plethoric persons. Where death appears to threaten from failure of the heart’s action, warm application to the surface of the body, and, should there exist any power of swallowing, the cautious administration of stimulants, are to be recommended. The case must be anxiously watched, and symptoms treated as they arise. When consciousness returns, the utmost care and quietness are to be observed to prevent the occurrence of inflammatory action, so apt to be developed, as a result of haemorrhage into the brain.

The term Apoplexy is also applied in modern medical nomenclature to an extravasation of blood within the substance of any organ in the body, as for instance, pulmonary apoplexy, where blood has been effused into the tissues of the lung. This use of the word, however, is altogether objectionable. (J. O. A.)






The above article was written by J. O. Affleck, M.D., F.R.C.S., Senior Assistant Physician, Edinburgh Royal Infirmary; Lecturer on the Practice of Medical Surgery.




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