Hence probably the cause of the commencing hemiplegia, which gradually increases with the disorganization of the cerebral substance. I am inclined to attribute the successful termination of this operation in some cases to the opportune loss of blood from a wound in the throat prior to the application of the ligature or the same happy result may be ascribed to a cautious preparatory venesection before the common carotid has been secured. By such loss of blood the circulation has been quieted, and the difference in the momentum of the blood in different parts of the brain has been, if not obviated, at any rate very much diminished. It might be objected that the effects upon tying one of the carotids in the human subject are too diversified to admit of the foregoing explanation; but, in reply to such objection, it may be urged, that, although certain effects are usually produced by large abstractions of blood, still the results of blood-letting are very dissimilar in different individuals." P. 77.

The effects which result from obstructing the circulation of blood through the carotids have induced some practitioners to seek from it a remedial agency. Thus, Mr. Prescott of Calcutta, has tied the carotids for the relief of severe epilepsy and cephalea in two cases; and Dr. Parry employed compression of these vessels in mania, headache, vertigo, &c. When, however, we consider the irremediable disorganization which is often present in obstinate cases, the difficulty of assigning in many the precise causes of their production, and the temporary character of the remedy, by reason of the quick re-establishment of the circulation by anastomosis, we are surprised that so careful a practitioner as Dr. Burrows should recommend this operation.

66

Although the ligature of the common carotid is attended with risk to life in some cases, (perhaps in the proportion of one death in four operations) still experience proves that, where proper precautions have been taken, the operation is not so dangerous as many suppose. Therefore, in violent and hopeless cases of epilepsy and some kindred maladies, which are characterized by extreme cerebral congestion, it appears to me that, other remedies failing, this operation may be fairly resorted to. I am aware of the responsibility of advocating a remedy attended with risk of life; but are not all our best remedies most violent poisons in the hands of the unskilful? But this truth does not forbid their use to the

* An interesting case in which both carotids were successfully tied has been recently recorded by Dr. Ellis in the New-York Journal of Medicine, Sept. 1845. Pettish Hill, æt. 21, was accidently shot, Oct. 21, 1844. The ball passed from just above the spine of the left scapula along the neck into the mouth, making its exit through the upper lip. There was little hæmorrhage, and he was transported twelve miles in a litter. On the seventh day hæmorrhage from the wound of the tongue occurred, but was readily suppressed by compressing the left carotid. On the eighth day, hæmorrhage recurring, the left carotid was tied below the omo-hyoideus. No unpleasant symptoms followed, but on the eleventh day, when a slight pulsation of the temporal artery was felt, hæmorrhage recurred, and again the next day, being temporarily arrested by pressure on the right carotid and on the orifices of the wound. This, however, caused too much pain to be borne, so that, four days and a half after the first operation, the right carotid was tied. The only bad symptoms which followed were some dyspnea and cough, which were relieved by a small depletion and then giving small doses of aconite. At the date, June 18, 1845, the young man enjoyed comfortable health, and was attending to business. No pulsation could then be felt in either tem poral artery.—(For a Case by Dr. Warren, see our present Periscope.)

1846.]

ON APOPLECTIC COMA.

41

more expert. So may this powerful method of influencing the cerebral circulation be justifiable in aggravated cases of the class referred to, and where the precept of Celsus satius est anceps remedium experiri quàm nullum, may be fairly put into practice." P. 79.

it.

On Apoplectic Coma.-Upon the nature of coma in apoplexy authors afford us no efficient explanation, Abercrombie confessing his ignorance of Dr. Burrows believes that too exclusive an attention has been paid to the recognition of visible physical cause of pressure, and suggests that there are several causes capable of suspending the functions of the brain in the same manner as experiment proves their power in destroying those of the cerebro-spinal nerves. These are 1, pressure on the nervous fibres; 2, division of nervous substance; 3, disorganization of nervous matter; 4, interrupted supply, or deficient momentum of blood in the venous substance; 5, narcotics. Numerous cases have been recorded in which death with all the symptoms of apoplexy has occurred, and yet the brain found to be in its normal condition. Various explanations have been proposed by those who maintain the invariableness of the quantity of the blood contained in the cranium: but Dr. Burrows believes that in such cases a congested state of the vessels, produced either by determination of blood to or its detention in the brain, has existed. Of the three cases recorded by Abercrombie two had been freely bled, and no considerable turgescence of the vessels was observed; but in the third, treated only shortly prior to death, the vessels were turgid and the substance of the organ highly vascular. But, supposing this congested state of the brain be relieved by depletion, and no structural lesion be discovered, how do we explain the occurrence of death? This, Dr. Burrows is disposed to refer to the brain becoming saturated during the suspension of consciousness, and the existence of stertorous breathing, with undecarbonized blood, so that the patient actually dies from the effects of imperfect respiration, and not from pressure or lesion of the brain.

The ordinary explanation of the occurrence of death in sanguineous and serous apoplexy by the compression of the brain exerted by the effused fluids, is also deemed erroneous by Dr. Burrows. Portal, Abercrombie, and other high authorities admit that the distinction between serous and sanguineous apoplexy is not a real one, that the serum is only secondary upon pre-existing congestion, and that the symptoms bear no relation to the amount effused. The coma cannot then be dependent upon the effused serum, nor is it so when the extravasated fluid is blood; for large and old extravasations have been found with no coma, while this last has prevailed in cases in which slight and recent extravasation only existed. Two cases, which fell under the author's care, and in which transient coma only manifested itself with copious cerebral hæmorrhage, are related. These and numerous similar ones, prove that "extravasation of blood cannot of itself be looked upon as the cause of the coma, although it is so of the paralysis concomitant with the coma, and which remains after the coma has disappeared." The coma, in the majority of cases, is attributable to attendant and co-existent congestion.

"When extravasation of blood within the cranium takes place very slowly, as from the rupture of the diseased coats of an artery, independent of determina

tion of blood to the brain, or general congestion of its vessels, it is highly probable that the effusion does not produce the symptoms of apoplectic coma, but gives rise to some modification of hemiplegia, the paralysis being to a greater or less extent, according to the situation and quantity of effusion. As long as extravasation is actually going on, while the blood is pouring forth, it most probably produces pressure on the surrounding cerebral substance, just as the blood escaping from a divided artery in any other part of the body would compress any obstacle with a force equal to the momentum with which the blood was circulating in that vessel. When cerebral hemorrhage has stopped, I suspect the blood ceases to be a real source of general pressure, although, as it increases the quantity of extra-vascular matter in the cranium, it also offers additional resistance to the entrance of the normal quantity of blood into that cavity; hence healthy vascular distention becomes excessive, and the symptoms of general cerebral pressure are easily developed. Thus the compression produced by extravasation will depend more on the rapidity and situation of the effusion than on the amount. If the effusion be slow, and not near the base, although the amount be considerable, the effects will be slight in comparison." P. 101.

As the coma may exist without effusion and effusion without coma, in the majority of cases, the coma is therefore due to the pressure induced by vascular congestion. Other causes may induce coma, as for example the circulation of venous blood through the brain; but this is the explanation offered of the coma of apoplexy. That ordinary causes of determination of blood to the brain, such as violent exercise, vivid emotions, and intemperance, do not oftener lead to the production of coma may be attributed to the anatomical provisions for preserving the uniformity of pressure and an easier circulation of blood provided by the tortuosity of the arteries and the arrangement of the sinuses of the dura mater; while the facility with which the extra-vascular serum escapes into the spine is an additional protection against the effects of such sudden congestion.

II. On the connection of Apoplexy and Hemiplegia with Diseases of the Heart.-Dr. Burrows believes the profession is by no means sufficiently aware of the extent of the influence which diseases of the heart exert in inducing functional and structural diseases of the brain. If the explanation of the cause of apoplectic coma be correct, it may be expected that a diseased condition of the heart or its valves, so commonly found co-existent with congestion in other parts of the body, will be frequently present. But none of the standard writers on this disease seem to have noticed such connection prior to Portal, who was much in advance of his German and English cotemporaries. Drs. Kellie and Clutterbuck deny the connection between the diseased condition of the one organ and that of the other, and Dr. Abercrombie seems entirely to have overlooked it. Bright and Andral however admit this connection, but it is by Dr. Hope that it has been placed in the strongest light. He believed, with M. Bouillard and Bertin, that hypertrophy of the heart predisposes more strongly to apoplexy, than even what is termed the apoplectic constitution.* Richerand agrees in

* At a subsequent page (143) Dr. Burrows has an interesting note upon this so-called constitution. He says

"It is a popular belief that persons with a peculiar conformation of the body, namely with large heads, red faces, short necks, and capacious chests, are predis

1846.] CONNEXION OF APOPLEXY WITH DISEASE of the Heart. 43

1

this opinion; and Dr. Copland admits that the lesions co-exist too frequently to be explained by mere coincidence.

Amid such difference of opinion Dr. Burrows has endeavoured to form a statistical account of the frequency of disease of the heart in cases of apoplexy and hemiplegia; but has found this a matter of difficulty, inasmuch as few authors have afforded precise information as to the condition of the heart in this affection, being content with recording the lesions they have met with in the brain. However, from such sources as furnished the necessary data, and from cases observed by himself, he has drawn up the following table of 132 cases.

From this, it would seem that three-fifths of a given number of cases of apoplexy or sudden hemiplegia manifest distinct signs of disease of the heart. M. Rochoux, however, states that, of 42 cases examined by him prior to 1818, three only presented hypertrophy; but upon examination of the thirty cases detailed in his work, Dr. Burrows finds that the state of the heart was examined only 14 times, and in four of these there was disease of either the muscular or valvular structures. It is to be remembered too that lesions of the heart were very imperfectly appreciated prior to 1818, and that M. Rochoux restricts the term apoplexy to cases in which actual hæmorrhage is discoverable. In reference to the question of which of the cardiac lesions most frequently gives rise to cerebral affections, Dr. Burrows states that, of the 38 instances of diseased heart observed by Andral and himself in 59 cases of apoplexy and hemiplegia, 19 were examples of hypertrophy with valvular disease, 10 of simple hypertrophy and 8 of valvular disease.

"I have thus endeavoured by facts and arguments, to point out the frequent and intimate relation subsisting between structural changes in the heart and these cerebral affections. This relation appears to me in many cases to be that of cause and effect. I have already quoted the opinions of Portal and some others who have entertained a similar view of the pathology of these cerebral

posed to apoplexy: and that persons of spare habit with longer necks are exempt from that disease; so that if a person of this latter description is attacked with apoplexy or hemiplegia, considerable surprise is expressed. My experience causes me to doubt the accuracy of these opinions. The former class of individuals are usually the subjects of considerable hypertrophy of the heart, and hence suffer from habitual determination of blood to the brain, and perhaps hypertrophy of that organ. No wonder that they should suffer from attacks of apoplexy. But I have met with many instances of apoplexy and hemiplegia among the poor, where the individuals have been pallid and attenuated, with slight figures; in fact, presenting the very reverse of the so-called apoplectic make; and in such cases, upon making a careful scrutiny of the heart and lungs, I have discovered signs of valvular disease in the heart, or perhaps of extensive emphysema of the lungs ; and these diseases probably combined with changes in the arterial coats."

affections; but I am not aware that any other author has presented so connected and extended a review of the arguments and facts, which ought to have the effect of establishing a pathological doctrine of great importance in its application to the treatment of these disorders of the brain.

"Although I have thus maintained the paramount influence of the heart, both in its healthy and diseased states, upon the circulation and functions of the brain, still I am fully sensible that lesions of other organs, especially of the lungs, kidneys, and liver, have a similar, though less frequent and direct, influence in disordering the cerebral circulation, and producing apoplexy, hemiplegia, and epilepsy.

"In opposition to the opinions entertained by many respectable authorities, that the quantity of blood within the cranium is at all times nearly the same, and that the heart does not influence the cerebral circulation, my own observations, supported by facts already detailed, convince me that in many, perhaps the majority, of cases of apoplexy and hemiplegia, the primary disease is not situated within the cranium. I would go further, and affirm, that in many cerebral affections apparently depending on effusions of serum or blood, there is no farther primary disease of the brain than there is of the cellular tissue in anasarca, or of the peritoneum in ascites, or of the skin in purpura, or of the stomach in hæmatemesis. There is, indeed, a palpable morbid condition of these several tissues and organs where the effusion or ecchymosis takes place : but it is generally dependent upon a morbid state of some other viscus, which greatly interferes with the circulation in the parts where the effusions are detected. A hypertrophied left ventricle, or valvular obstruction in the heart, will lead to lesions within the cranium similar to those observed in the stomach and peritoneum, when there is obstruction to the circulation through the portal veins in the liver.

"If the pathology of the brain in apoplexy and hemiplegia be analogous to that of other organs which suffer from effusions of serum and blood, how much must this knowledge improve the routine treatment of apoplexy, which has so extensively prevailed. Does not this view of its pathology render more intelligible those different varieties of the disease, which are described by ancient writers, although they could not account for the differences?" P. 125.

Period of Life most prone to Apoplexy and Hemiplegia.-Dr. Burrows observes, that the statements of authors as to the liabilities of different ages are mostly erroneous in not being compared with the numbers living at such periods of life. He institutes an analytical comparison of this kind in 215 well-marked cases; whence it appears that the number of apoplectic cases increases in each successive decennial period from 20 to 70 years of age, while the numbers living gradually diminish. From the researches of Dr. Clendinning it also appears that the proportionate weight of the heart increases with advancing life-so that hypertrophy of that organ is a change which is concomitant to the period of life when apoplexy is most prevalent. Dr. Clendinning has moreover shown that, while the average weight of the adult brain, when the heart was healthy, was 50.5 ounces, in diseases of the heart it was 52.5 ozs.-a condition he regards as the effect of the cardiac disease. Even a moderate, temporary, congestion of a brain already abnormally large may easily induce an apoplexy; and in persons of advanced age, the cerebral arteries being diseased in structure, may easily give way to even moderate congestion.

1. Treatment of Apoplexy and Hemiplegia.-During the attack more attention to raising the head than is usually bestowed is desirable, for its power of depleting the cerebral vessels is, as proved by the author's ex