Syncope, either from over-stimulation of the pneumogastric or from simple failure of the heart, may be put forward to explain some cases of sudden death, but seems to have no advantage as a universal theory over the older one, which meets with so little favor. Lidell gives no less than seventeen cases which he classifies as congestive or serous apoplexy. They are not all equally conclusive, and were almost all of alcoholics. In some of these there were absolutely no appearances which could account for death. The two most characteristic of congestive apoplexy were, first, a young negress who experienced a violent fit of passion, became unconscious, with stertorous breathing, and died, having had some tonic spasms. The brain contained a large amount of blood in the vessels, but no effusion. Second, a semi-intoxicated woman, aged thirty, became very angry, fell insensible, and expired almost immediately. The brain contained an excess of blood, with no effusion. In both these cases the patients were subject to fits under the influence of strong excitement, but in both the author took pains to inquire into and negative the probability of epilepsy of the ordinary kind; and a change of name does not go far toward clearing up the pathology.
Lidell's case (XXII.) was that of a man accustomed to alcohol, thin and pale, who had an apoplectic fit with coma and hemiplegia. He regained consciousness on the second day, and the hemiplegia disappeared in a fortnight. This rapid and complete recovery, exceptional to be sure, cannot be regarded as proof of the absence of hemorrhage or embolism. In fact, the latter is highly probable. It is possible that the clot may have been partially dislodged, so as to allow some blood to pass by it, or that an exceptionally favorable anastomosis allowed a better collateral circulation than usual to be established.
The following case occurred in the service of the writer: An elderly negress, who had extensive anasarca and signs of enfeebled action of the heart without any valvular lesion being detected, after washing her face was heard to groan, and found speechless and unable to swallow, with complete right hemiplegia. There was a slight improvement in a few hours, but she died two days later. The autopsy disclosed some hypertrophy and dilatation of the heart without valvular lesion. A careful search failed to discover any change in the brain or obstruction in its vessels, although there was chronic endarteritis.
The relations between epilepsy, apoplexy, and syncope are interesting and important, but are certainly far from clear. Little is gained by shifting obscure cases from one category to the other. If sudden deaths be synonymous with apoplexy, we shall certainly have to admit that apoplexy does not always demand for its cause cerebral changes sufficiently marked to be recognizable after death. If, on the other hand, we refer them to heart disease, we shall have to admit that a heart without valvular disease or extensive changes in its muscular substance may cease to beat under influences as yet not well understood.
Since the paralysis arising from hemorrhage resembles so closely in its progress that dependent upon occlusion of the cerebral vessels, a further description will be deferred until the latter lesion has been described; but this remark does not apply to the premonitory and initiative symptoms, which may be of great importance, and which are not always the same with the two or three sets of lesions. There are many of them, but, unfortunately, no one among them taken alone can be considered of high significance, unless we except what are sometimes called premonitory attacks, which are in all probability frequently genuine hemorrhages of so slight extent that they produce no unconsciousness, and but slight paralysis easily overlooked. A little indistinctness of speech or a forgetfulness of words, a droop of one angle of the mouth, or heaviness in the movement of a foot or hand, lasting but a few moments, may be real but slight attacks, which may be followed either by a much more severe one, by others of the same kind, or by nothing at all for a long time. They are sufficient to awaken apprehension, and to show in what direction danger lies, but they give little information as to the time of any future attack.
Retinal hemorrhage is admitted by all modern authors to be connected with disease of the vascular system, and hence also with renal inflammation and cerebral lesions. The writer is greatly indebted to Hasket Derby for the following facts: Out of 21 patients who had retinal hemorrhage, and of whose subsequent career he had information, 9 had some sort of apoplectic or paralytic attack; 1 had had such an attack before she was examined; 3 died of heart disease, 1 suddenly, the cause being variously assigned to heart disease or apoplexy; and 6 were alive when heard from, one of these, a man of forty-eight, being alive and well fourteen years after.
Bull25 describes four cases of his own where retinal hemorrhage was followed by cerebral hemorrhage, demonstrated or supposed in three, while in the fourth other symptoms rendered a similar termination by no means improbable. He quotes others of a similar character. The total number of cases which were kept under observation for some years is, unfortunately, not given. In a case under the observation of the writer a female patient, aged fifty-seven, who had irregularity of the pulse with some cardiac hypertrophy, was found to have a retinal hemorrhage two and a half years before an attack of hemiplegia. The hemorrhage was not accompanied by the white spots which often accompany retinitis albuminuria.
25 Am. Journ. Med. Sci., July, 1879.
In a case reported by Amidon26 retinal and cerebral hemorrhages seem to have been nearly simultaneous a few hours before death. There was diffuse neuro-retinitis and old hemorrhages besides the recent one.
26 N. Y. Med. Rec., 1878, xiv. 13.