The result of this morbid examination proved that the case had long been beyond the skill of medicine. But a question arises, whether there had not been a time when the application of the trephine on the injured part of the skull, and the removal of the bone, might not have prevented the subsequent consequences. The years which had passed without complaint of pain or uneasiness in the head, and the talent and uniform correct conduct of this gentleman, till within three or four years of his death, lulled all apprehension of mischief from an accident so long gone by. But if the trephine had been applied upon the elevated part of the skull, and a portion of the bone removed before the dura mater became diseased, and converted into an ossific substance with projecting spicula, which, by their increasing growth, at last became the sources of irritation to the brain, judging from analogy, I see no reason why all the consecutive symptoms might not have been prevented, and his life prolonged.

4. Apoplexy.

There is no appellation in the whole nomenclature of diseases which has led to more confusion in medicine than the word apoplexy, which, referring to its derivative, aτoτλhoow, percutio, means simply a final effect, i. e. a sudden stroke, and not a disease.

No malady is so intimately connected with mental derangement as this affection; but its affinity is recognised in the two-fold light of cause and effect.

Esquirol computes, that apoplexy constitutes a sixth of the physical causes of insanity, and an eighth of the deaths. But in this country the proportion is comparatively small of those in whom mental derangement originates apoplexy. However, a great number of insane persons are cut off suddenly, and these are vulgarly said to die of this malady.

Numerically, perhaps, more cases of insanity complicated with paralysis will be found, because the latter does not, like apoplexy, suddenly destroy life; but paralysis itself has its origin generally in the latter affection, and is in reality an extension of the apoplectic attack.

That any specific disease should be both the cause and effect of another disease, as is imputed to apoplexy in relation to insanity, appears paradoxical. I conclude, however, that in this instance, as in many others, error has arisen from the misapplication of a word which has an equivocal meaning.

Authors describe various species of apoplexy, originating in different causes; but we rarely hear of any other than the sanguineous and serous. The conditions of the brain, however, whence these two distinctions are derived, in reference to the apoplexy which is complicated with insanity, do not apply to the actual state of that organ in most cases of sudden death among maniacs.

In fact, the apoplexy which originates insanity, and that which terminates the life of the insane, is distinctly and essentially different.

Sanguineous apoplexy is the species commonly originating insanity and those in whom the sanguineous apoplectic diathesis prevails, may be considered as almost equally possessing the maniacal diathesis: it is difficult. to pronounce which attack is most threatened.

A great change, both in the moral and mental character, is often perceived preceding an apoplectic, as well as a maniacal paroxysm; and if one do not occur, the other may. Hence, the affinity of sanguineous apoplexy and mania is evident.

Sanguineous apoplexy, too, may happen in concurrence with insanity; but then it is almost always during the incipient or active stage of the latter. So rarely is the former the cause of death in lunatics, that even

in those of the apoplectic diathesis, Georget says, he never met in dissecting but two fatal instances in La Salpetrière; and even in these there was no effusion of blood into the brain; but an excessive engorgement of the meningeal sinus, and of the external and internal veins of the head, was apparent.

I have, however, seen two cases where effusion of blood into the brain was detected; but the death in each occurred in the early period of the maniacal attacks. Indeed, such an attack is only to be expected on the first access of insanity, and when the system is not yet weakened by debilitating causes. When insanity has assumed the chronic form, the vascular system has scarcely power for the production of sanguineous apoplexy.

The above author describes an affection to which lunatics are liable, and which, though similar to sanguineous apoplexy in several of the outward signs, differs materially from it. In this singular affection a furious patient suddenly loses his recollection, which is succeeded by strong and continued convulsions, and he lives only a few hours. On dissection, a marked sanguineous injection of the cerebral substance is perceived, the colour of which is not like blood, but that of wine lees; sometimes the brain has a perfectly healthy appearance. As death so soon succeeds this attack, it has often been mistaken. for sanguineous apoplexy.

Serous apoplexy is also, I apprehend, a frequent condition of the insane. At least, many die suddenly whose bodies, on examination, exhibit no cause for it, nor any morbid appearance, except large effusions of serum into the cavities and between the membranes of the brain.

Such effusions are generally considered as the evidence of increased vascular action of the cerebral vessels, and therefore as emanations from a disorder of the circulation.

There is a peculiar and fatal disease often attacking old lunatics, which has been also confounded with sanguineous effusion, and in which the sudden termination of life seems the only character, etymologically, of apoplexy.

Pinel first mentioned it; and Esquirol says, that suddenly the fury is most violent, then ceases, and in an instant the patient dies. Two short cases aptly illustrate it. A lunatic, aged sixty-two, dry and meagre, was for three months in an extreme agitation and continual delirium. Upon awaking from his sleep he calmly asked his servant for his snuff-box, took a pinch, and died. Another, aged forty-three, of the same temperament, was for a month in a delirious fury. On the thirty-first day he looked pale, begged to sit down, and expired.

It appears in these cases as if all the vital powers were exhausted by the excess of the maniacal excitation; for the interior of the cranium presents no alteration, and the body is always singularly disposed to putrefaction.

From the uniform absence of all indications of vascular excitement in the brain, and from its occurring only in old cases and cachectic habits, it may fairly be supposed, that in these cases the access of furious delirium is the result of the nervous power completely acquiring the ascendancy over the vascular power; and that this proceeds from a deficiency in the supply and determination of blood to the brain, which Boerhaave, Van-Sweiten, Vogel, and others, pronounce to be one of the causes of apoplexy. This condition of the circulation in the brain would justify the designation given by Boerhaave of apoplexia defectiva.

This conclusion is further confirmed by the well-known circumstance, that constitutions rendered cachectic by agues, excessive evacuations, depletions, and depressing passions, or want of nutriment, are as much exposed to apoplexy as to mania, fatuity, and idiocy.

The apoplectic termination of mania has been ascribed to a total exhaustion of the irritable and contractile power of the system, such as is experienced in asphyxia from the effect of the electric fluid; but this theory is founded upon the doctrine of the circulation of a fine invisible fluid through the nervous apparatus, and therefore is untenable.

Hence we may infer, that apoplexia sanguinea is a source of insanity— apoplexia serosa, and apoplexia defectiva, the consequences.

These distinct species of apoplexy being acknowledged, will reconcile the apparent paradox of this disease both originating and terminating so very large a proportion of cases of mental derangement.

Dr. Abercrombie conceives, that where persons are attacked by apoplexy, and lie some time in a state of perfect coma, and no morbid appearances are found on dissection of the brain, that the cause is to be sought for in an interruption of the due relations betwixt the arterial and venous systems of that organ, as well as sometimes in the peculiarities of the structure of the head. He has found in his dissections that these relations of the circulation are often at variance. The operations of the mind, as well as of the nervous and muscular powers, may be equally affected when the adjustment between these two systems is disturbed, as when that of the nervous and vascular systems is so.

Comatose affections of every kind may equally terminate in apoplexy, paralysis, or mania; and on the former may supervene demency complicated with paralysis, as paralysis derived from the brain often originates demency.

The best efforts sometimes are unsuccessful in preventing such effects. The learned Dr. Cooke mentions

*Path. and Pract. Researches on Diseases of the Brain and Spinal Chord, p. 301.