Apoplexy

The old, very popular and quite international term apoplexy (or its equivalents apoplectic attack, attack, apoplectic ictus or ictus) today generally means stroke. The word "apoplexy" comes from the Greek apoplexia, which is derived from the verb apoples-sein, meaning, respectively, "stroke" and "to strike." To define apoplexy is therefore to relate the history of the word and of its different successive significations. The history of apoplexy, from the Greeks to the twentieth century, will be presented first, followed by the medical details of stroke.

History

In the Hippocratic corpus, "apoplexy" appears as an obviously clinical term. For many centuries after Galen's-jvritings of the second century A.D., it was thought that apoplexy involved brain matter, whereas epilepsy represented a disturbance of brain function. From the invention of the printing press to the late nineteenth century, several hundred monographs were devoted to apoplexy. Indeed the medical history of A. Dechambre (1866) listed some 150 such references between 1611 and 1865.

The first autopsies involving postmortem examinations of the brain were performed in the seventeenth century. Many more were done, however, after the publication of De Sedibus, et Causis Morborum per

Anatomen Indagatis, Libri Quinque by Giovanni Battista Morgagni in 1761. Morgagni reported numerous cases of postmortem examinations of apoplexy cases, which he separated into serous apoplexy (apoplexia serosa) and sanguineous apoplexy (apo-plexia sanguinea).

In his 1820 treatise On Apoplexy, John Cooke considered that hemorrhagic lesions were commonest and that the other types of lesions (e.g., tumors, suppuration, cysts) were questionable cases of apoplexy. In his volume Cases of Apoplexy and Lethargy with Observations upon the Comatose Diseases published in 1812, John Cheyne thought that apoplexy might be "serous" or "sanguineous," but he was skeptical of the former entity. The periodic apnea, now known as the Cheyne-Stokes respiration, was first described by Cheyne in an 1818 article. "A case of apoplexy in which the fleshy part of the heart was converted into fat." For John Abercrombie, writing on Pathological and Practical Research on Diseases on the Brain and Spinal Cord in 1828, the cerebral lesion of apoplexy might be either a hemorrhage or a serous effusion, but sometimes there seemed to be no apparent anatomic lesions.

In his well-known LAnatomie pathologique du corps humain . . ., Jean Cruveilhier, professor of morbid anatomy in Paris, used the word "apoplexy" as a synonym for "hemorrhage" (in its anatomic, pathological meaning). He distinguished "apoplexy without loss of consciousness" from "apoplexy with loss of consciousness" and wrote of pontine or spinal apoplexies as well as cerebral ones. This pathological point of view was strengthened by Richard Bright who, in his book Diseases of the Brain and Nervous System (1831), described and illustrated under the term "apoplexy" several cases of cerebral hemorrhage.

This association of apoplexy with hemorrhage in the central nervous system led gradually to the use of apoplexy as a synonym for hemorrhage and to the creation of expressions such as "spinal apoplexy" (in place of "spinal hemorrhage"), "pulmonary apoplexy" (in place of "hemorrhagic pulmonary infarct"), "abdominal apoplexy" (in place of "massive abdominal hemorrhage"), "renal apoplexy" (in place of "renal hemorrhage"), "splenic apoplexy" (in place of "hemorrhage of the spleen"), and so forth.

From the second half of the nineteenth century to the beginning of the twentieth century, the semantic confusion between apoplexy and hemorrhage continued. J. Russell Reynolds, for example, in his Diagnosis of Diseases of the Brain, Spinal Cord, Nerves and Their Appendages (1866), stated that an apoplectic attack could result from congestion, hemorrhage, tumor, uremia, or vascular obstruction. A. Trousseau, a professor in Paris, however, had attacked this problem of confusion in his famous Clinique médicale de l'Hôtel-Dieu de Paris (1865), and the French neurologist J. M. Charcot later (1881) emphasized that apoplexy was a clinical syndrome that unfortunately had often been used synonymously with cerebral hemorrhage.

Thus, Trousseau and Charcot, along with individuals such as Dechambre (1866), E. Bouchut and A. Desprès (1889), and J. Déjerine (1914), concluded that apoplexy could arise from conditions other than intracerebral hemorrhage, and that the use of the term should be restricted to the clinical syndrome that involved a "sudden and simultaneous loss of all the brain functions, consciousness, feeling and movement, without conscpicuous change of respiration and blood circulation" (Déjerine 1914). Surprisingly, in 1921, J. Lhermitte, in his well-known Traité de pathologie médicale, nonetheless persisted in the use of apoplexy as a synonym for hemorrhage and opposed the "hemiplegy of the apoplexy" and "the hemiplegy of the infarctus."

The term "apoplexy" has since become obsolete and disappeared from the indices of most contemporary textbooks of neurology and neuropathology and from the usual vocabulary of the modern physician. Nevertheless, it remains widely used in popular language and literature. Its proper use, however should be restricted to the field of the history of medicine, from Hippocrates to the beginning of the twentieth century. In the present medical vocabulary, the term "apoplexy" must be replaced either by "stroke" or by "hemorrhage" according to the context.

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