AN
INAUGURAL DISSERTATION
ON THE
APOPLEXY.
SUBMITTED TO THE EXAMINATION
OF THE
REV. JOHN EWING, S.T.P. Provost ;
THE
TRUSTEES AND MEDICAL PROFESSORS
OF THE
UNIVERSITY OF PENNSYLVANIA ;
For the Degree of
DOCTOR OF MEDICINE
On the 19th. day of May, A. D. 1794.
BY JOHN LAMB, JUN. of New-York.
But ah! permit to pity human state :
If not to help, at least lament their fate.
Homer's Iliad.
PHILADELPHIA:
PRINTED BY JONES, HOFF & DERRICK.
M. DCC.XCI V.



AN
INAUGURAL DISSERTATION
ON THE
APOPLEXY.
WHEN we take a retrospective view of the
different systems of physic, which have made
their appearance in different ages and coun-
tries ; likewise, the discordant opinions respecting
the causes and cure of diseases : we have just
reason to lament the contracted state of human
knowledge in general, and more particularly the
abstru[s]e nature of the science of medicine. Because,
I am pretty clearly convinced in my own mind,
that as much harm as well as good, has been com-
mitted by those who have undertaken to practice
this art among mankind, on such principles and
theories, as have been handed down to them at
particular periods of time ; principles and theories
which were evidently built on hypothetical con-
jectures.
FULLY impressed with an idea of so great im-
portance, I shall enter on my subject with diffidence:
and if any doctrines or opinions should be advanc-
B

[2]
ed in the following essay, not corresponding with
former experience and observation ; or that do not
meet the approbation of the candid and liberal, I
shall most certainly, with the greatest cheerfulness
discard them as imaginary and not well grounded,
for those which are allowed to be founded on a
more substantial basis:—for the only rational and
proper method to become versant in useful know-
ledge, is to hear the sentiments of others, and be
open to conviction.
PREVIOUS to entering on a discussion of the
disease, which is intended for this Inaugural Dis-
sertation, it may not be entirely improper to point
out its original derivation :—Apoplexy is then
derived from the Greek word αποπλεσςο, which in
that language signifies to strike, or knock down,
or smite suddenly :—Latin authors have consider-
ed the same disease under different appellations :—
viz, Sideratio, Attonitus Morbus, Attonitus Stu-
por, &c. But I shall for the sake of perspicuity and
conciseness, make use of the term apoplexy
throughout the whole of the following essay ; as
multiplying names, has only a tendency to con-
fuse, and make our ideas of no determinate signifi-
cation. This is a practice, it is presumable, should
be pursued particularly by every person, who at-
tempts to investigate any part or the whole of the
human economy ; either with a view to enlarge
his knowledge, or to understand in an accurate
manner, the healthy or morbid functions of the
animal  body ; so that he might be capable of dis-
charging the duties of his profession, with that
honor and dignity the science of medicine justly
merits.

[3]
IT has been a universal practice from the time
of Hippocrates to the present day, to distinguish
diseases into different genera and species; and even
the same disease is very frequently considered in
the latter point of view. Thus the disease under our
present consideration has been divided by medical
authors into several species, viz. sanguineous, serous,
spasmodic, symptomatic, &c. Doctor Cullen in his
methodical nosology, enumerates nine species, be-
sides those which are symptomatic.
MOST writers and practical physicians have
taken notice of two kinds of apoplexy, namely
the sanguineous and serous. There is no manner
of doubt, but effusions of blood or serum do fre-
quently happen in the head ; though these are cer-
tainly to be considered as effects and not as causes;
therefore it will be proper to seek for the cause of
the disease from some other source, and it will be
found to consist in an unequal excitement of the ar-
terial and nervous systems. Dr. Rush in his clinical
lectures, divides apoplexy into the tonic and atonic
states, and considers it as a disease of the whole sys-
tem, as much so as consumption or dropsy—and
depending either on direct or indirect debility. Let
us suppose for the sake of argument, that there is
some foundation for the distinction of sanguineous
and serous apoplexy; yet notwithstanding, it is
my opinion, it would be a difficult matter to dis-
tinguish one from the other before the death of the
patient: for the following reasons—1st. Because,
the symptoms in both are the same or very analo-
gous. 2d, Because, effusions of blood frequently
take place, in old persons who are far advanced
in years ; while on the other hand, serous effusions
B 2

[4]
take place in young persons, and in those who are
in the prime and vigor of life. These principles be-
ing admitted as true, and I trust no one will pretend
to deny them, as being uncontrovertable facts;
this important principle then ought naturally to
present itself, to the mind of every physician, who
takes into his hands the life of his fellow creatures;
That he should most inevitably prescribe re-
medies according to the state of the body, and
the most urgent symptoms, and not (as is too fre-
quently the case) for the name of a disease,
which may probably be arbitrary, and of no defi-
nite signification.
THIS is also the opinion of one of the Ameri-
can physicians. He observes in his nosological and
pathological lectures, and at the same time en-
deavours to impress on the mind of every student
in the most energetic language, that every prudent
and sensible physician will prescribe remedies ac-
cording to the " condition of the system, and not
for the name of a disease."
DEFINITION.
DOCTOR CULLEN, whose authority and name,
stood as high as any in medicine ; observes in his
first lines of the practice of physic, That " apo-
" plexy is that disease in which the whole of the
" external and internal, and the whole of the
" voluntary motions, are in some degree abolish-
" ed; while respiration and the action of the heart
" continue to be performed." This definition ap-
peared to me so comprehensive and explanatory of
the disease, that I chose to quote the Doctor's own
words and expressions on the subject.

[5]
HISTORY OF THE DISEASE.
THIS disease like many others to which the
human body is incident, spares neither sex; for I
believe it as generally seizes the female as the male:
no constitution or age can be said to be entirely ex-
empted from becoming affected with this direful ma-
lady: it even attacks persons in youth, in middle life;
and in declining years;—though the latter period
is supposed to be the most frequent. It is asserted
that apoplexy most commonly effects those persons
who are far advanced in life, and particularly
those above sixty years of age.*
AUTHORS consider predisposition, (or to speak
in more intelligible language,) a particular state of
the body, either as it respects its solids, fluids, con-
figuration, &c. to be absolutely necessary to exist in
many instances, previous to the system being in a
proper situation to become affected with disease :
Consequently, it is generally supposed, that per-
sons who have large heads, short necks, and con-
siderable irritability of the muscular and nervous
systems ; likewise those who are of a plethoric di-
athesis, and have pursued an inactive and se-
dentary course of life; and who have lived in a
luxurious manner, and made too frequent use of
intoxicating liquors, are peculiarly predisposed to
this melancholy complaint.
FROM the most early knowledge of the human
structure, and of sickness, many diseases have al-
* Vide Dr. Cullen's first lines of the practice of physic,
page 305.

[6]
ways been considered to be of an hereditary nature;
until Doctor Brown in his elements of medicine de-
nied their existence altogether :—notwithstanding,
he was certainly a man of erudition, and has in
my opinion, gone considerable length in eluci-
dating many parts of medicine ; yet I cannot agree
with him in this particular, because there does
evidently appear a foundation for such a distinction,
if we will only reflect on the great similitude there
frequently is, between parents and their offspring,
particularly, as it respects temperament, fabric of
body, and peculiarity of mind. But what is more
directly in point is, that there are innumerable in-
stances recorded in the histories of physic, by men
of the first eminence in their profession, of chil-
dren becoming affected with diseases which were
peculiar to their ancestors or parents ; when no
evident external or internal cause could be suppos-
ed to have produced them, except hereditary pre-
disposition, and peculiar organization of the solids
of the body.
FROM these circumstances, there is I think, great
reason to suppose that apoplexy might with as much
propriety, be ranked under the class of hereditary
disorders ; as even scrophula, mania or the pulmo-
nary consumption.
IT is an observation of medical writers, that
this disease happens more frequently in the winter
season, or in springs which are moderately warm,
and have followed severe and cold winters. There
may I think, be some foundation for such an opi-
nion, as it is well known, that the phlogistic dia-
thesis of the system, at such seasons, is more apt

[7]
to prevail; nevertheless it may happen and not
unfrequently, at every season of the year ; as ex-
perience and observation, must convince every
physician, who is the least conversant in a know-
ledge of diseases.
APOPLEXY like many other complaints comes on
oftentimes very suddenly; but at other times is pre-
ceded by certain premonitory symptoms. The
patient falls suddenly to the ground, and in a great
measure, a total and quick privation of all the pow-
ers and voluntary motion take place; with coma,
and frequently an entire suspension of the energy
of the mental faculties : There is somtimes a loss
of sensibility and motion on one side, whilst on the
other convulsive action continues.—The mouth is
pretty generally thrown open, owing probably to a
relaxation of the musels of the lower jaw; and the
tongue which is tumefied, is consequently thrust be-
tween the teeth; the patient does somtimes foam at
the mouth, but this is not a general pathognomonic
sign, as it only occurs in some cases and but rarely;
there is considerable floridity of the face with a
bloated countenance in many instances; but at
other times the reverse happens, and the face is
far less ruddy, attended with considerable degree
of paleness of the cheeks; the vessels about the
cranium, particularly the temples are full and tur-
gid with blood ; so much so that a hemorrhagy fre-
quently happens from the nasal passages, mouth,
and ears, which may give a temporary relief to the
patient; by lessening in some small degree, the
too forcible circulation of the blood through the
internal and external carotid arteries and their ram-
ifications, also making a revulsion from the ves-
sels of the head : The eyes are in a state of tu-

[8]
mefaction and pour out an aqueous fluid, they have
sometimes a vitreous and sparkling appearance.
A VIOLENT, rapid and forcible palpitation of
the heart frequently occurs, with a pulse generally
full, strange, hard and slow; and on other occasions,
it is slow and very languid, though the latter case is
supposed to take place towards the termination of
the disease.
In some instances (though not generally speak-
ing) there is a spontaneous discharge from the
urinary passages, with an involuntary evacuation
of feces per anum. The respiration is difficult
and laborious to perform, accompanied with ster-
tor or noisy respiration; which may be owing to
the mucus of the fauces being forced through the
nostrils; or more probably as Doctor Andrews'
observes in his Inaugural Dissertation, " To an ex-
" treme degree of relaxation in the palatum molle,
" and uvula, in consequence of which they interrupt
" the free passage of air to and from the glottis."
The hot and dry skin which frequently takes place
in this disorder, is owing to a diminution of per-
spiration in the perforatory vessels on the surface
of the body.
I SAID formerly that this disease was on some oc-
casions preceded by certain harbingers or precurso-
ry symptoms; and which are indicative of an im-
mediate approach of an apoplectic paroxysm. These
are of great variety, such as, uncommon slug-
gishness or inactivity of bodily motion ; with
some transitory degree of torpidity and diminution
of sensation, in the upper and lower extremities;
it is said that the patients, are at times affected

[9]
with a sensation of pricking of a peculiar na-
ture, as if insects were crawling over them, it is
analogous to the sensation which takes place in
epilepsy; vertigoes or frequent fits of giddiness,
with violent oppressive pains in the head, and a
sounding in the ears, known in medical language
by the name of tinnitus aurium ; some irregularity
of vision and hearing; hemorrhagy from the nares;
there is also considerable slowness of speech, or
faltering of the tongue in articulating words and
syllables, with an aversion to answer questions put
to them by others ; a failure of the memory fre-
quently comes on, a great propensity to drowsiness,
and frequent fits of incubus or the asthma noctur-
num.
FURTHER, a stridor dentium or grinding of the
teeth sometimes occurs when the patient is in a
state of somnolency, or actual sleep ; likewise, a
turgescency of the eyes which are in a state of debil-
ity, and pour out an aqueous flow of humors ; at-
tended with some slight degree of the imperfection
of the organs of vision, happen in some instances;
oppressions about the præcordia and organs of res-
piration during sleep, pituitous vomiting, and labo-
rious breathing on the least degree of motion of
the body ; tremblings in the greater part of the or-
gans of voluntary motion ; it is said there is an
unusual absence of the hæmorrhoids in those per-
sons who are subject to attacks of that disorder.
DIAGNOSIS.
THE diagnostic signs of diseases are in many in-
stances very difficult to comprehend, and sometimes
C

[10]
it is utterly impossible to point them out in so ac-
curate a manner, as to be capable of giving each
disease its proper generic appellation. For there
frequently is such a strong analogy between diffe-
rent diseases, in their causes, symptoms and method
of cure, that one would even suppose at first view,
that they were one and the same, though at the
same time, quite opposite in their nature and cir-
cumstances: Further, two or more disorders are
oftentimes united in the same patient in such a man-
ner, that a physician will be exceedingly embarrass-
ed, in giving a proper and decided diagnosis.
THERE are several diseases taken notice of by
practical writers under the denomination of carus,
cataphora, coma, catalepsis and lethargus :—But
they appear so analogous to apoplexy, or to be
only different degrees of it, that there would be
considerable difficulty, if not an entire impossibili-
ty to draw particular diagnostic signs, between
these and the one under present consideration ;
therefore, I shall place them, as belonging to the
same head as apoplexy.
INTOXICATION frequently presents phenomena,
so very analogous to those of the disease of which
I am now treating of in this dissertation, that they
have oftentimes alarmed by-standers exceedingly;
and even physicians of experience and observation,
if they are not particularly attentive to this circum-
stance, will frequently be deceived, and have a
very inaccurate idea of the real nature and cause
of the complaint. Where the phenomena arise
from intoxicating liquors, they may generally be
discovered by attending particularly to the state of
the breath, for it will be so fully saturated with

[11]
the odorous effluvia of certain spiritous liquors as
brandy, gin, &c. (and which are very commonly
used by persons who give themselves up to frequent
intoxication;) when this is the case, the cause of
the disease may with great certainty be pointed
out; but on the other hand, when they arise from
liquors that do not afford this distinguishing cha-
racteristic; such as strong beer, porter, and many
others, then the case will be more difficult, and
if the physician does not apprehend the cause,
from the state of the pulse, as to hardness and ten-
sion, he may continue for several hours in doubt
and painful anxiety, until the inebriating effects
of the liquor go off, and leave the patient in a state
of indirect debility.
DOCTOR RUSH says that apoplexy differs from
sleep, by coming on suddenly without any previous
fatigue : it also differs materially from the latter,
by the great difficulty there is, or indeed an utter
impracticability of rousing the patient from his apo-
plectic paroxysm. The coma which succeeds a fit
of epilepsy, has a striking similitude to apoplexy—
but is said to be distinguished from it by paying
particular attention to the previous convulsions.
THE narcotic and deleterious effects of many
substances when taken into the stomach in large
doses, as opium, belladonna, digitalis and the differ-
ent preparations of lead, &c. produce symptoms
strongly resembling those of apoplexy—that it will
be difficult to point out the difference with preci-
sion and exact "limitation—experience may have
some influence in determining by the peculiar cir-
cumstances of the countenance of persons in this
predicament, though they are not easily describ-
C 2

[12]
able, the pulse may be another criterion, which is
more frequent and not so full as in apoplexy. Some-
times phenomena similar to those of apoplexy have
been brought on by overloading the stomach with
food difficult of solution ;  when this happens it is
said, that the patient exhibits marks of oppression
and uneasy sensations of his stomach, and the
pulse is not so slow and full as in apoplexy. It will
certainly be proper in every case of this kind, to
free the stomach from the load and oppression; the
remedies suitable for this indication will be large
draughts of warm water, gentle emetics, if vom-
iting cannot be excited by any other means; it will
be of the greatest importance to throw out the con-
tents of the stomach as soon and early as possible,
because they may excite effusions in the brain. Ap-
oplexy is to be distinguished from palsy, by its be-
ing an affection of all the powers of sense and vo-
luntary motion, and from syncope, by its being
with the continuance of the action of the heart, ar-
teries and respiration.
THE PREDISONENT CAUSES.
WHATEVER causes or circumstances occa-
sion a preternatural accumulation of blood in
the vessels of the cranium, may with propriety be
considered as predisposing causes to apoplexy;
therefore I shall attempt to point out some of those
causes, which commonly produce a plethoric state
of the system, and endeavour to explain at the same
time, the manner how they operate as predispos-
ing causes, in producing the disease under our
present consideration.

[13]
1st. EXCESS in eating and drinking; this of course
will occasion an increase in the quantity of that fluid
which goes to nourish the body, (namely chyle)
likewise an augmentation of the general mass of
blood in the arterial and venous systems ; more-
over, when the stomach is distended with large
quantities of animal or vegetable food and drink,
the natural consequence resulting from such a con-
dition of that organ, is a compression of the differ-
ent vessels and viscera of the abdomen, and also the
midriff or diaphragm will not be capable of perform-
ing its important and regular action as before, and
of course the lungs cannot perform their office
with ease ; this being the case, there will be an
impediment to a considerable degree to the blood
returning in the veins from the head : I think
we may justly infer that this circumstance does take
place, if we will only attend particularly to persons
after eating large meals, for their countenances
become florid and turgid with blood, the eyes are
red, and on some occasions, there is a degree of
somnolency and stupefaction comes on; from the
different effects which are produced by intemper-
ance in eating and drinking, it must at once be
evident, that they will produce a very great pre-
disposition to this complaint.
2d. AN indolent life, with a nourishing and free
diet, will have the effect of producing a general
phlethoric state of the system, and in this way does
frequently prove a predisposing cause of apoplexy.
3d. SUPPRESSION of any customary discharge
from the different parts of the body, may be con-
sidered as occasioning a predisposition to this disease,
such as an evacuation of blood from the hœmor-

[14]
rhoidal vessels constituting the disease called the
bleeding piles ; likewise bleeding from the nose after
it has become habitual, is another predisposing
cause; for in consequence of a stoppage of this
nature, there will be an accumulation of blood in
the whole system.
4th. A LARGE head is generally taken notice of
by medical writers as another predisposing cause
to this disease, and many of them are of opinion
that it occurs more frequently in such instances,
than in any other ; whether the uncommon large-
ness of the head, as some suppose, is only an ef-
fect of the predisposing cause, and is to be consid-
ered as produced by the determination of the
blood, rather than occasioning it, I am not clear-
ly able to determine.
5th. A SHORT neck, is likewise said to occasion
a predisposition to apoplexy—this is very probable,
for the heart must be much nearer the head than
when it is long, the consequence of this will be,
the blood must circulate with considerable more
velocity through the arteries to the cranium; while
on the other hand, the return of the blood through
the veins will in some measure be impeded ; ow-
ing to the veins being too turgid with that fluid.
6th. CORPULENCY, is mentioned by authors as
another predisposing cause; and is said to produce
this effect, by compressing the vessels in every part
of the body except the head ; if this should be the
case, it must be evident that the blood will accu-
mulate and produce compression of the brain;
respiration becomes laborious to perform, and may

[15]
occasion an impediment to the free return of the
blood from the head.
7th. EXPOSURE of the feet to cold and wet,
will prove a predisponent cause, by producing a
feeble circulation, and diminishing the quantity of
blood in the lower extremities, which will be the
means of making a greater determination of it to
the head.
8th. PAINFUL and long application of the mind
to any one subject, particularly if it should be of
an abstruse nature, will frequently occasion a de-
termination of blood to the head ; therefore, may
prove a predisposing cause of apoplexy.
9th. OLD-AGE predisposes to this complaint by
exciting a determination of blood to the head, from
particular and accidental causes, not easy to point
out on all occasions.
THE EXCITING CAUSES.
These are such powers as when applied either
generally or partially to the human body, are capa-
ble of exciting a paroxysm of apoplexy, particular-
ly in those persons who have a strong predisposition
to become affected with this melancholy disease.
Their operation is either to increase the momentum
or velocity of blood in its circulation through the
vessels of the head ; or on the other hand, to sud-
denly augment the blood in the vessels of the brain.
They are of considerable number, therefore I shall
mention some of them.

[16]
1st. VIOLENT exercise, maybe considered as a
very common exciting cause, and produces its
effects by increasing the impetus of blood in the
general circulation.
2nd. WHEN the general application of heat is
applied to the body, it is very probable that its ac-
tion must operate in an analogous manner, as the
one we have just previonsly mentioned.
3rd. WHEN heat has been partially applied to the
head, as when a person is exposed to the direct
rays of the sun, it will frequently excite apoplexy.
4th. EXCESS of venery will on some occasions
excite a paroxysm.
5th. IT is said that the striking in of any erup-
tions, or suddenly drying up issues, setons, &c.
will prove exciting causes.
6th. MERCURIAL salivations carried too a great
length.
7th. FRACTURES and contusions of the head,
and poisonous exhalations, are also causes which
will produce apoplexy.
8th. VIOLENT passions of the mind, as anger,
grief, excessive joy, &c. these appear to occasion par-
ticularly a determination of blood to the head, as
is evident from the floridity of the countenance
which takes place.
10th. STOOPING too long with the head down,
or laying with it in too low a position, will occasion

[17]
in many instances an augmentation of blood in
the vessels of the head, by hindering its return
freely from the brain.
11th. ANY violent exertion, which is suddenly
brought on may be considered as another exciting
cause ; the manner in which this effect is produced
is by occasioning a long inspiration in breathing;
the consequence of which will be, the blood must be
retarded in its passage through the lungs from the
right side of the heart, and of course will interrupt
the return of blood from the head: this is also dis-
covered by the appearance of the countenance.
12th. FLEXION and twisting of the neck, lig-
atures drawn very tight round the neck, tu-
mors, &c. all occasion apoplexy, these act by com-
pressing the internal jugular veins, and obstructing
the blood through them.
13th. EXTREME intoxication, food difficult of
digestion in the stomach; Doctor Rush says he knew
an instance in Philadelphia of an apoplexy being
brought on by a person supping on toasted cheese.
14th. BREATHING the contaminated air in a
crowded assembly will frequently excite a fit of
apoplexy.
15th. NARCOTIC substances have sometimes the
same effect in producing this disorder.
16th. VOMITING is said to be a powerful ex-
citing cause. In this case, the contents of the
viscera of the abdomen are compressed in a violent
manner, the diaphragm and abdominal muscles are
brought into a state of convulsion, the consequence
of which will be, that the blood in the ascending vena
D

[18]
cava must be sent with much more velocity to
the right auricle and ventricle of the heart; where-
fore, obstructing the free discharge of blood in the
descending cava, there will also be some degree of
compression of the descending aorta; and thereby
must occasion a much greater determination of
blood to the head ; from the circumstance of vom-
iting respiration becomes obstructed, and the blood
which passes through the right ventricle of the
heart, is impeded and cannot be discharged into
the pulmonic vessels; therefore, the venal blood
returning from the head will be obstructed: though
there is at the same time a considerable quantity
sent to the head by the larger arteries, and apoplexy
is brought on by a rupture and extravasation of
blood in some of the vessels of the brain.
PROXIMATE CAUSE.
THE proximate cause of diseases has always en-
gaged the particular attention of physicians of the
greatest eminence, ever since the most early know-
ledge of the human body and its diseases : there-
fore, there have been (as one might naturally sup-
pose) a variety of opinions and theories on the
subject; many however, appear to have been mere-
ly hypothetical and visionary ; and it is certainly
at this present time, a part of the science of medi-
cine, which is exceedingly intricate to comprehend
in an accurate and satisfactory manner. There
have been at different periods of time, several the-
ories advanced to account for the proximate cause
of the disease we are at present considering; but
most of them appear to me not well founded in
fact.

[19]
THUS some suppose that apoplexy depends en-
tirely on sthenic diathesis, while on the other hand
it is asserted to depend on an asthenic diathesis
of the system ; and Doctor Hoffman in his practice
of physic, supposes that this disease is always ow-
ing to hæmorrhagy of the vessels, consequently he
gives the same proximate cause to it, as to hæmorr-
hagy in every other part of the body. Doctor Cul-
len, in his first lines of the Practice of Physic, sup-
poses the proximate cause to be whatever in-
terrupts the motion of the nervous power from
the brain to the muscles of voluntary motion, or
whatever has a tendency to destroy the mobility of
the nervous power from the sentient extremities
of the nerves to the brain.
THE opinion of Doctor Rush on this subject,
appears to me very plausible. He observes in his
clinical lectures, that the proximate cause of apo-
plexy, is a defect or excess of irregular action in the
vessels of the brain. This idea perfectly corres-
ponds with the theory the Doctor has laid down
reflecting the division of the disease, into to-
nic and atonic states. Therefore, I shall adopt
this theory of the proximate cause of apoplexy,
because it appears as consonant to just reason and
sound philosophy, as any which has been advan-
ced on the subject.
PROGNOSIS.
A PHYSICIAN should always be very much on
his guard, in giving a decided opinion respecting
the favorable termination of this disease ;
because, in many instances, the causes which oc-
P 2

[20]
casion an attack of an apoplectic paroxysm are so
powerful, and the disease runs its course with such
great rapidity, that animal life is very soon extin-
guished ; notwithstanding, the most efficacious re-
medies have been administred with vigilance and
circumspection : but at other times a physician
may be more safe and justifiable in giving a prog-
nosis if he will always be particularly attentive to
pay respect, (and which will be of the greatest im-
portance to him) to a consideration of the pati-
ent's time of life, vigor of constitution, and cus-
tomary habits ; likewise, to the nature of the symp-
toms, continuance of the disease, and its peculiar
predisposing and exciting causes.
CONSEQUENTLY, if the coma and other at-
tending symptoms are in a slight degree, and the
strength of the system not considerably exhausted;
there may be some reasonable hopes of a recovery ;
but on the contrary, if all of these symptoms increase
in force, and continue violent any length of time,
as for several days, the disease will most generally
terminate in the dissolution of the patient's life; or
proceed into some other complaint: and it is said
that before death, the pulse, which from the first
attack had been full and slow, now begins to be-
come quick and frequent in its pulsations.
IT has been a commonly received opinion that
a patient cannot survive a third attack of a fit of
apoplexy ; though this opinion certainly appears
to be fallacious and is without any just or reason-
able foundation ; as it appears very evident that
it must depend entirely on the violence and durati-
on of the paroxysms, and not on any fanciful or
particular number. As the patient's senses become

[21]
considerably diminished, so in proportion, will the
danger of death be apprehended. When the pulse
becomes very slow or very frequent, it is observed
to be an unfavorable sign, and when the pulse is
irregular and very feeble, it portends that death
is fast approaching, and will soon close the tragic
scene.
WHENEVER the sphincter muscle of the anus,
and also of the bladder, become much relaxed,
and loose their power of action, in the first onset
of the fit, there will be great reason to apprehend
that it will terminate in the death of the patient,
as it is an unfavourable symptom. Sometimes the
patient looses entirely all power of deglutition;
when this happens the danger is very considerable,
as it indicates a disease of great violence and sever-
ity ; when a cold and clammy sweat comes out on
the surface of the body, with a cadaverous or
deadly appearance of the countenance, floridity
and dulness of the eyes, the prognosis must be
unfavorable, as a recovery is scarcely, if ever to
be expected ; on the contrary, when the disease
comes on in consequence of a sudden cessation of
any customary evacuation, and if this should re-
turn again spontaneously, or by the means of arti-
ficial measures, accompanied with a gentle and
equable perspiration over the whole surface of the
body ; there may still be some hopes of a salutary
termination of the paroxysm ; it is mentioned that
a copious and free discharge of urine, containing
a sediment; also, spontaneous evacuations from the
intestinal canal; likewise, spontaneous vomiting,
have all of them been the means of bringing on
a resolution of the disease.

[22]
METHOD OF CURE.
WE come now to a part of our subject, which is
of the utmost consequence to be attended to, by eve-
ry physician, who values the life and health, of his
patient; because, the disease frequently proves
suddenly fatal, notwithstanding immediate assistance
has been resorted to and the most powerful remedies
have been administered without delay, but all in
vain; and the physician has to stand oftentimes an
humble and compassionate spectator, seeing his pa-
tient expire in the agonies of death, without being
able to afford any assistance :—what is of further
consequence and importance is, that whenever a
person has once been attacked with this direful
malady, however slight it might have been, he will
hardly ever enjoy so good a share of health, and
vigor of constitution as before, and will always be
very liable to a return of another paroxysm.
THIS will of course lead us to divide the cure into
two distinct part[s]. The first is to employ remedies
during the continuance of the disease ;  and the se-
cond is, after the complaint is removed, to admi-
nister those remedies which will be proper and suit-
able to prevent a relapse.
THE remedies for the first indication are, 1st.
Bleeding. It is of the greatest importance to bleed
in this disease, as much so, as in any inflamma-
tory complaint whatever, not even pneumonia and
phrenitis excepted.
DRAWING of blood from the occipital and fron-
tal veins, or temporal arteries as has been recom-

[23]
mended by different authors, must frequently prove
inconvenient and troublesome; therefore, should on
most occasions be laid entirely aside, particularly,
as it can be obtained from another source, with
more ease and equal advantage.
OPENING the carotid arteries and jugular veins
has been recommended, but as this operation
may sometimes be attended with serious consequen-
ces to the patient, it should never, in my opinion
be put in practice, except in some very urgent ca-
ses indeed.
CONSEQUENTLY, bleeding in one arm or both
arms has been substituted in their place by most
practitioners, and with great propriety.
THE quantity of blood necessary to be drawn,
must always be in proportion to the fulness of the
pulse and condition of the system ; but on most
occasions, it will be absolutely proper and urgent
to bleed immediately and copiously, as soon as a
person has been attacked, for by this mean, it
will lessen excessive action in the arterial and ve-
nous systems, and obviate to a considerable de-
gree indirect debility, and therefore prevent in a
great measure effusions taking place in the brain ;
when it arises from falls or violent contusions,
blood-letting should always be very copious, ex-
cepting there was great predisposing debility before,
to contraindicate so liberal a use of it.
WHEN blood-letting has been employed in as
sufficient quantities as the patient's strength will
admit of, and the violence of the symptoms con-
tinue; cupping on the temples and scarifying on

[24]
the back part of the head, may be practised with
advantage; as these means, may obviate the symp-
toms without increasing the debility of the system
in so great a degree.
2nd. PURGES. These are of the greatest im-
portance, and if any power of swallowing remain,
drastic purgatives should be preferred, given by the
mouth, but if deglutition is not capable of being
performed, then acrid glysters must be administer-
ed: although, purgatives have been objected to by
some, yet experience and observation, appear to
warrant their usefulness. They produce their good
effects by evacuating the contents of the intestines,
and making a revulsion from the head ; it is sup-
posed this organ is generally relieved in propor-
tion to the quantity discharged.
3rd. COLD water will lessen excess of action
in the vessels of the brain, and when poured on
the head, may prove a very powerful and useful
remedy in the cure of apoplexy.
4th. IT will be absolutely necessary that the pa-
tient should be placed in an erect posture, so that
the blood may flow as easily as possible from the
head ; all ligatures should be removed from the
neck and different parts of the body.
WHEN a patient has been in a paroxysm three
or four hours, before assistance is obtained, then
the above remedies may not be so proper or useful;
because the system must have run into such a state
of indirect debility, that they would not answer
the proper indication; therefore recourse must be
had to remedies of a more powerful and stimu-

[25]
lating nature. The following will be found pro-
per and sometimes very efficacious.
1st. BLISTERS applied to the whole head. It
will be necessary that the head should be shaved
sometime before their application.
2nd. THE actual cautery applied to the head.
3rd. ACRID stimulating cataplasms of mustard
and flour applied to the palms of the hands, and
soles of the feet, have proved very beneficial, in
rousing the patient.
4th. FRICTIONS and electricity are excellent sti-
mulants, and will be found very serviceable.
5th. COOL and pure air is of the greatest im-
portance in this disease; therefore all persons
should be turned out of the room immediately,
except those who are absolutely necessary to attend
on the patient; for they phlogisticate the air, and
render it unfit for the purposes of respiration ;
cool air may in some degree diminish the action of
the heart and arteries, and prove useful also in
that way.
THE remedies for the second indication. It will
be of considerable importance to pay particular at-
tention to those means, which may have a tendency
to prevent a return of an apoplectic paroxysm ;
particularly, as this disease is very much disposed
to return, after a person has once been attacked
with it; and the repeated attacks of it almost al-
ways sooner or later terminate in the death of the
patient. When it terminates in death, it is gen-
E

[26]
erally preceded by vomiting, cold sweats, and con-
vulions : sometimes it runs into an hemiplegia or
paraplegia : when this happens, there is pretty gen-
erally a loss or the internal senses, as of the mem-
ory accompanied with fatuity &c. and it does some-
times happen, that it terminates in perfect health ;
but this is not a frequent occurrence.
AND as the disease may depend on two different
states of action in the system, either tonic or
atonic ; the method of preventing the fits, must
be regulated according as one or other of these
should happen to prevail; as well as a due attention
likewise to the predisponent and exciting causes.
THEREFORE all those persons who are of a full
and plethoric habit of body, should pay particular
attention to sobriety in eating and drinking; they
should attend also strictly to the quantity and qual-
ity of their aliment, and should always be careful
to avoid overloading their stomachs with food at
any time, but at supper it should be particularly
abstained from altogether. Those who have hab-
ituated themselves to eating supper, it might
be improper for them to leave it off all at once ;
therefore, their food either animal or vegetable,
should be in small quantities, light and of easy
digestion.
IF the patient has been accustomed to drink wine
or other spirituous liquors of any kind, he should not
abstain from them immediately; but must use them
with great moderation, and it may not be improper
to dilute them with water. Wine being lighter and
much less nutritious, than either beer, porter or
indeed any malt liquor whatever ; will certainly be

[27]
most preferable and will not be so liable to produce
plethora of the system ; running, jumping, &c. or
violent exercie of any kind, should be particular-
ly avoided by every person, who is the least pre-
disposed, or has had an attack of this disorder.
EXERCISE is of very great advantage in this dis-
ease, as it will when united with a proper regimen,
obviate in a considerable degree plethora of the
system ; it ought to be of such a kind as may sup-
port the perspiration, without increasing the heat
of the body, or hurrying respiration ; therefore,
riding and walking will be found the most proper
and useful of any.
PERSONS who are not subject to frequent fits
of giddiness, and who have habituated themselves
to riding on horseback, should continue in the
practice of using it, as this mode of exercise is
preferable to all others: when however giddiness
does take place, then bodily exercise may be em-
ployed with beneficial effects ; though it will be
highly proper, and necessary to pay particular atten-
tion to the restrictions which I just now mentioned;
but in men who are very far advanced in years,
and also men of corpulent habits of body, the ex-
ercise of walking ought always to be in a moder-
ate degree, and frequently repeated.
VIOLENT passions of the mind which are sud-
denly brought on, should by all means be careful-
ly avoided, as anger, fear, excessive joy, &c. as
they would prove of the most mischievous conse-
quences to the patient.
WHEN symptoms do occur of a plethoric state
E 2

[28]
in the vessels of the head, a seton or pea-issue ap-
plied in the nape of the neck, may prove useful,
by obviating any turgescence of blood there.
WHERE there is a tendency to a plethora in the
vessels of the head, or it does actually exist, gen-
tle laxatives may be administered with propriety,
as they will in some measure prevent a turgescence
in those parts.
IT will be highly important, to guard particu-
larly against all the exciting causes, as they will
have a very great influence in bringing on a
relapse ; such as passions of the mind ; anxiety of
mind, intense application to study, too tight liga-
tures about the neck ; exposure of the feet to cold
and wet, &c. and if a person has been habituated
to have a discharge from the nose, hæmiorrhdal
vessels, or any other part of the system, and there
should be a cessation of them all of a sudden, he
ought by every possible means in his power to
bring back again the customary evacuation. If
this cannot be accomplished, recourse must be had
to an artificial discharge by a seton or issue, which
must be perpetually kept open.
ANY customs and habits, which the patient
has been long accustomed to, should not be
changed immediately, but in a gradual manner ;
further, all those who are of a delicate and weakly
habit of constitution, and have at the same time,
symptoms of plethora and turgescence in the ves-
sels of the head, should pay strict attention to tem-
perance in eating and drinking, and in every other
respect endeavour to avoid, as much as possible,

[29]
those causes which may increase the general circu-
lation of blood in the arterial and venous systems;
and they ought to use moderate exercise, and
every other gentle tonic which might have a ten-
dency to restore vigor and strength to the body.
Sometimes the premonitory symptoms which I for-
merly mentioned on another occasion do occur,
although remedies have been employed to prevent
them ; when this happens to take place, the most
proper method to be pursued is blood letting, mild
purgatives and vegetable diet.
THE phenomena which have appeared on dis-
secting those who have fallen victims to this insi-
dious disease, are effusions of red blood, sometimes
a quantity of fluid analogous to serum, and on some
rare occasions an effusion of pus; a distention fre-
quently of the plexus choriodes, and bodies something
similar to hydatids in other parts of the body have been
found conjoined with them, containing blood and
serum ; large tumors ; and the brain is sometimes
more flaccid and softer than in a natural state.
There is usually a distention of the arteries and
veins with blood, and an extravasation of blood or
serum is almost on all occasions found between
the cranium and dura mater, the dura and pia
mater or in the ventricles of the brain; and the elab-
orate dissections of the learned Morgagni, have
shown that effusions of blood have taken place in
every part within the cranium.
HAVING brought this dissertation to a conclusi-
on, I have only to bid a cordial and an affection-
ate farewell to this rising university. That she may

[30]
long continue to be the grand forum for the pro-
motion of medical science in the United States of
America ; and send forth her sons, eminent for
scientific knowledge and moral rectitude. That-
her medical professors may ever continue to be
the patrons and promoters of the healing art—
and walk through the scenes of human life un-
rivalled, and be a perpetual ornament in the
annals of mankind, is my most ardent and sincere
wish.
FINIS.