From apoplexy to stroke - review of medical literature on stroke over previous 2,000 years, especially sources from 18th and 19th centuries

Age and Ageing, Sept, 1997 by Pandora Pound, Michael Bury, Shah Ebrahim

Keywords: apoplexy, history, stroke

". . . it is a disease in which the functions of relation are suspended, while those of organic life continue. A fit of apoplexy, it has been often observed, resembles in many respects, profound sleep. There is the same insensibility to external impressions, the same unconsciousness of everything that is passing around; the action of the heart and respiration go on in both instances, but the individual is shut out from the world, sight, hearing, smell, touch and taste being abolished for the time" [1].

Introduction

In 1987 Elias [2] charged sociologists with retreating into the present and with failing to use the past to illuminate contemporary problems and issues. A similar charge may also be levelled in medicine, where there is a temptation to draw a firm line between the past and the present, and to dismiss the past as `quackery'. In the rare instances when medicine does look into the past there appear to be two tendencies: firstly, to concentrate solely on the pathological aspects of conditions and, secondly, to be interested only in the extent to which previous ways of conceptualizing diseases come close to the modern paradigm. This approach is problematic since it somehow assumes that contemporary knowledge offers the `truth', and that previous knowledge is valuable only insofar as it approximates to this truth. Even brief explorations of the history of contemporary conditions place current treatment approaches in perspective, allowing links to be drawn between the past and the present, but also reminding us that contemporary management is simply "a stage between the past and possible futures" [2].

This paper considers the history of stroke with particular attention to the eighteenth and nineteenth centuries. It considers humoral theories, supernatural explanations, the theory of `apoplectic habitue', moral notions of intemperance and immoderation and the management of prognosis throughout this period, and attempts to broaden the discussion beyond the existing historical literature on stroke pathology [3-6]. It also reviews the implications of the disappearance of the term `apoplexy' from medical discourse, the emergence of `cerebrovascular disease', and subsequently `stroke'. While it is suggested that each term symbolizes a distinct way of conceptualizing the condition, it is also argued that there are many threads and similarities linking past and present approaches to its management. An example of this is the continued onus of responsibility for the illness that is placed on the patient.

Meanings

The first recorded use of the word `stroke' in English literature is in 1599 when "an excellent Cinnamome water for the stroke of Gods hande" was recommended [7, 8]. The principal definition of the word today relates to the act of striking in the sense of a blow given or received [7]. The word conveys the sudden and seemingly random nature of the acute event, and as such describes some of the subjective experience of the person who has been `struck'.

Although there was some overlap between medical and lay terms, stroke seems to have been predominantly a lay term, while physicians from the time of Hippocrates up until the first half of the twentieth century favoured the word `apoplexy'. As Cooke wrote in 1820:

"The term Apoplexia was employed by the Greeks,

and is still used, to denote a disease in which the

patient falls to the ground, often suddenly, and lies

without sense or voluntary motion. Persons instantaneously

thus affected, as if struck by lightning,

were, by the ancients, denominated, attoniti, syderati" [9].

These terms come from `attonitus', the Latin for thunder-struck or stupefied, and `sideror', to be planet-struck [10].

Apoplexy and its treatment

Humoral theories

The Hippocratic tradition conceived of blood as one of the four humours--the one which held spirit or `vitality'. Consequently, theories about the causes of apoplexy drew upon this concept:

"The reason of an Apoplexy, and the cause of so

sudden a Deprivation of Life, that great Judge, the

Prince of Physicians, Hippocrates, resolves into a

Stagnation or Station of the Blood, whereby all

Motion and Action of the Spirits is taken away . . . and

that its Motion is stop'd either by sharp Humours, or

a Plethora, or an Afflux of cold Humours; the last of

which he makes not so sudden" [11] (emphasis in

original).

Galen (born AD 131) accepted and developed the teachings of Hippocrates. He believed that apoplexy was caused by anything interfering with the flow of the `vital spirit' to the brain, the purpose of which consisted in inspiration and expiration of the vital spirit [12]. The Galenic influence persisted for centuries and for a considerable period apoplexy seems to have been conceptualized mainly in terms of humoral theory in combination with various theories of obstruction. Many centuries later, Wepfer (1620-95) also believed that apoplexy was caused by an obstruction in the path to the brain, with the result that the brain did not receive enough "animal spirits". (He also clearly pointed to an association between cerebral haemorrhage and apoplexy [13].)