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Apoplexy.In this case, although the individual be unconscious for a time, his breathing and the beating of his heart may not be interfered with ; he may survive an indefinite time, may recover consciousness, and indeed may finally recover the use of the paralyzed members. In other cases the hemorrhage may occur in ? 1cl1 a part of the brain as to compress the portion which is necessary to continue the breathing and the beating of the heart. In this jase death occurs immediately. It is such causes as these whicl result in the sudden death of individuals while quietly lying in bed. even during sleep. In other cases there is no perceptible hemorrhage, in fact, postmortem examination fails to show anything more than a congestion of the brain. In still other cases, an injury received months previously may suddenly cause death unexpectedly. Such was the case of Daniel Webster, who died six months after receiving an injury to the head. Shortly after this injury he addressed a public meeting in Boston without giving evidence of any unnatural condition of the brain. At the time of death a thick layer of fibrine was found covering a considerable part of his brain. Symptoms*- In a great majority of cases the attack occurs without warning. In some it is preceded by a sense of weight and fullness in the head, dizziness, roaring in the ears and flushing of the face; the appearance of sparks o'r motes before the eyes, and perhaps an unusual sense of sleepiness. It seems that in many instances, however, the attack occurs at a moment when the individual feels unusually well. The patient, if walking or standing, falls to the ground as if leveled by a blow ; in other cases the loss of consciousness is not so sudden, the patient having time to seat himself, or at least recognize the necessity and make the attempt to do so. In such cases the patient is aware that something unusual has happened to him, as several seconds, or even minutes, may elapse before he has lost consciousness. If this loss of consciousness be complete, the patient cannot be aroused by any efforts, but lies with puffed and livid face, breathing slowly and loudly, and often frothing at the mouth. In these cases there are no voluntary movements; except for the movements of breathing, the patient lies as if dead. In other cases the patient may be unconscious and still endeavor to make aimless movements of the limbs ; in the course of these movements it becomes apparent that some of the members are paralyzed ; for it is generally observed that while the arm and leg of one side are readily moved, the corresponding members of the other side are motionless, except as they are stirred by movements of the trunk. Another feature of apoplexy, which is important as enabling us to distinguish from certain conditions in which the patient is also unconscious, is exhibited by the pulse. The pulse is slow and very full, striking against the finger laid upon it with a great deal of force. The face is usually flushed and somewhat livid ; the skin is often warm and moist. If the eyelids be raised it will be observed that the pupils are often contracted to very small sizes ; and they are also of unequal diameter. The limbs which are paralyzed arc oftentimes rigid so that they cannot be bent by the patient nor by others. Early in the attack the patient usually vomits. The loss of consciousness varies extremely in its duration ; it may pass away in a few minutes, or it may persist for hours and even days. Generally speaking, the severity of the attack, so far at least as danger to life is concerned, may be estimated by the time during which the patient remains unconscious. If consciousness be recovered in a few minutes, there is not usually immediate danger to life; but if unconsciousness persist for ten or twelve hours, without manifesting signs of improvement, the outlook for the patient's ultimate recovery is very doubtful. It is important to be able to distinguish apoplexy from several other affections in which loss of consciousness is present. One of these, which, however, could rarely be mistaken for apoplexy, is the ordinary fainting fit. This, however, is marked by pallor of the face, and by unusual weakness of the heart's action, as shown by the pulse, and sometimes by almost complete suspension of the breathing. A condition which presents a much greater resemblance to the symptoms of apoplexy is epilepsy, or the " falling sickness. " After the epileptic patient has fallen to the ground, he lies in an unconscious state, breathing slowly and laboriously, his face swollen and livid, foam and blood issuing from his lips. In these symptoms there is an extreme resemblance to apoplexy, and from these alone it would be almost impossible to distinguish between them. Yet the attendant circumstances make the diagnosis easy, for the epileptic fit is usually preceded by convulsive movements, and frequently by a scream as the patient falls ; apoplexy, on the other hand, occurs suddenly without the convulsive movements or a scream. Then again, in a very few moments after the patient has fallen in an epileptic paroxysm his limbs, which at first were rigid, become strongly convulsed ; he executes jerking movements with the arms and legs, and usually with the face ; his eyes roll, and the lividity of the countenance gradually decreases. These symptoms are not present in apoplexy. It is quite important to make the distinction, because the patient recovers from an epileptic paroxysm without treatment, and no alarm need be felt, while the apoplectic stroke is always a matter of peril and apprehension. Another condition which may sometimes be mistaken for apoplexy is a hysterical convulsion. In these cases it is true the previous history of the individual, and her previous accomplishments in the same direction, render the diagnosis easy, even to the unprofessional friends. For a few moments the symptoms may simulate those of apoplexy with wonderful accuracy. There is however a point of difference which enables one to distinguish immediately between the two, and it is this : The apoplectic stroke is almost invariably accompanied by a loss of consciousness, and by the immobility of the face and eyes ; during the hysterical fit, on the other hand, the consciousness is not lost, notwithstanding the apparent stupor of the patient, for if the cold douche be brought into requisition, or any other decidedly unpleasant application be employed, the patient indicates at once by serious remonstrances that she is quite aware of the attention bestowed upon her. Another condition in which apoplexy is simulated, is profound alcoholic intoxication. This state must be carefully distinguished from apoplexy, since an error in either direction would be at least annoying, and might be the cause of serious results. The distinction is in most cases easy, if the possibility of error be remembered ; for intoxication is revealed at once by the odor of the breath, and by the matter ejected from the stomach ; moreover, the pulse is not slow and full, as in apoplexy, but rather rapid and weak. Then, again, the patient can be, by assiduous efforts, aroused to some manifestations of consciousness, if he be only drunk; but if he have received an apoplectic stroke, such efforts remain unsuc cessful. The duration of an attack of apoplexy varies considerably ; in some cases it results fatally in a few minutes ; in others, the patient sinks gradually, and dies in a few days; in still others, consciousness returns, but the paralysis remains - sometimes permanently, at other times disappearing in the course of some months, partially or completely. It is impossible to predict what the result will be, for instances have been known in which perfect recovery has occurred. Cases are known in which the bodily functions have been entirely recovered, while various impairments of the mind have persisted. Sometimes the patient is merely morose and irritable ; at other times he is easily affected to displays of emotion, laughing and weeping at trifles. In some cases the patient loses the power of speech, not from inability to utter sounds, but' from a loss of memory as to the meaning of words. This condition is called aphasia. Many of these cases are most interesting objects of study. They evidently think without being able to employ language. Sometimes the patient does not remember a single word ; at other times they are able to employ a few words, though evidently quite ignorant of the meaning. Thus, some will say yes or no, in reply to every question, without regard to the significance of the words. It is still more interesting that many of these patients understand everything perfectly, and may even be able to write with some degree of accuracy. In a few cases, such patients have been successful in learning to talk over again, but in most instances all attempts to make this acquisition have failed. This loss of speech in connection with apoplexy happens with especial frequency, if the right side of the body be paralyzed during the stroke. Cause. - Apoplexy is generally a hemorrhage into the brain, and in most instances there is a disease of the arteries, whereby the escape of blood occurs more readily than in the healthy condition of the vessels. At other times the fault seems to lie largely in the heart, which has become unusually large and powerful, and hence forces the blood through the vessels with extreme power. The disease of the vessels which renders the escape of blood so easy, is often the deposit of lime salts in the walls of the arteries - a condition known as atheroma. This condition occurs almost invariably after middle life, and attacks of apoplexy are known to happen also with especial frequency in elderly persons. The enlargement of the heart is usually associated either with chronic Bright's disease, or with some organic disease of the heart. These patients, the subjects of heart disease and Bright's disease, are especially apt to have apoplexy. But there are numerous cases of apoplectic stroke in which the kidney and the heart seem to be perfectly healthy, and indeed an examination of the vessels of the brain after death shows that they too are healthy. It seems probable that in these cases the apoplexy is produced by over work of the body or mind, the latter especially. The popular idea that high living is a frequent cause of apoplexy does not seem to be in accord with the fact. It is the general impression that there is a so-called apoplectic constitution, consisting in a good deal of fat and a short thick neck, constituting what is known as a " full habit. " But the examination of a considerable number of cases of apoplexy with regard to this very point, shows that the disease occurs more frequently in people of ordinary or even of rather spare habits, than in those addicted to corpulence. The occurrence of one attack of apoplexy seems to predispose to subsequent ones ; or to put it more correctly, the individual has acquired such a condition of the vessels as permits a hemorrhage upon even slight causes. There is a popular impression that the third stroke of apoplexy is invariably fatal. It can merely be said that the dangers increase with every attack, the patient's chances for recovery diminishing as the attacks recur. Treatment*-The most important part of the treatment of apoplexy consists in sanitary regulations and precautions. After the blood has once escaped into the brain, but little can be done to remedy the disastrous effects. Immediately after the stroke the head may be kept raised and cold cloths should be applied to it. Mustard plasters may be applied to the feet and to the calves for the purpose of drawing the blood from the head. A drop of croton oil may be placed upon the tongue in order to promote early and active discharges from the bowels. The paralysis which remains after apoplexy often persists in spite of all treatment. The best results are obtained of electricity and of massage; that is, rubbing and kneading with the hands. Yet in many cases changes occur in the brain which cannot be altered by any means at our command ; and in most cases there remains permanent impairment of either body or mind, or both. After suffering one attack of apoplexy the patient should take extreme care to avoid, so far as possible, a repetition of the disaster. On this point Dr. Flint says : " The liability to a recurrence of apoplexy, after the recovery from the attack, renders it important to observe all possible precaution in the way of prevention. Placing the system in the best possible condition by means of a well regulated diet and regimen, and avoiding exciting causes, will afford all the security which can be obtained. It is not probable that any protection is afforded by reducing the powers of the system, and other evils may thereby be induced. It is injudicious to adopt a diet which is insufficient for the wants of the system, or to resort to repeated blood-letting, cathartics or other lowering measures. In striving to avoid excesses and imprudences of all kinds, a care must be taken not to err in the opposite extreme. Mental occupation within certain limits is advisable. " The liability to apoplexy, if an attack has never occurred, cannot be estimated with any degree of certainty. This is one of the affections which persons are apt to apprehend, and if certain cerebral symptoms be experienced, especially dizziness, the fear of apoplexy is often a source of much unhappiness. The suggestion by the physician that there is danger of this affection is an indiscretion which I have known to prove most calamitous. When apprehension is felt the physician is warranted in giving assurances that dizziness and other cerebral symptoms are sufficiently common without being followed by apoplexy, and that an apoplectic attack is rarely preceded by obvious premonitions. Needless uneasiness may oftentimes be removed by these assurances. 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