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

This gloominess persisted well into the nineteenth century, as MacLachlan indicates: "Although life may be preserved for the present, the mind is often permanently enfeebled, and the patient ever afterwards unfitted for his ordinary vocations" [1]. However, while pessimism about the chronic stages of apoplexy prevailed, there was evidence of honesty and frankness about prospects for the future. For example, a physician presenting the management of one of his patients wrote in 1715, "there was but small Hope left to expect his Recovery; which I freely told his Friends, they being very pressing with me to give my real Sentiments" [27].

In 1788 Rowley was similarly frank about prognosis: "though it appears a melancholy description, yet it is juster than those delusive doctrines which raise great expectations, and ende in painful disappointment" [25]. In the 1892 edition of Osler's textbook it was suggested that in cases where people were completely paralysed, the friends should be told at the outset that the chances of a full recovery were slight and, in cases where the hemiplegia had persisted for more than 3 months and contractures had developed, "it is the duty of the physician to explain to the patient, or to his friends, that the condition is past relief, that medicines and electricity will do no good, and that there is no possible hope of cure" [17].

The emergence of `cerebrovascular disease'

Lawrence [28] observes that towards the end of the eighteenth century a subtle shift began to occur in the conceptualization of disease. Attention began to be paid to the characteristics that people with disease shared, rather than what was particular to each case; diseases began to be classified as separate entities. Clinical observation and experience were a fundamental part of this new approach. However, with the increasingly popular practice of dissection, rather than classifying diseases according to the symptoms which people reported, diseases were classified according to changes inside the body that seemed to deviate from normality. As Lawrence writes:

"Doctors began to search, by post-mortem examination,

deep in the body for disorganized anatomy. This

morbid anatomy, which they found in the dead

house, they identified as the basis of those species of

disease which, in the Enlightenment, they had begun

to describe and classify by their symptoms" [28].

Whereas apoplexies caused by `obstruction' and those caused by haemorrhage had traditionally been considered as distinct, the theory developed that they were both dependent upon degeneration of the arterial wall [29]. The term `cerebrovascular disease' emerged and apoplexy faded from use. Additionally, evidence from post-mortem examinations from 1877 to 1961 showed that the ratio of cerebral haemorrhage to cerebral infarction had declined substantially over this period [30], raising the possibility that the word `apoplexy' disappeared at the same time because the pattern of onset observed by both lay and professional observers may have been less dramatic and somehow less deserving of the term.