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van Swieten’s concept of cerebral embolic stroke
  1. J M S Pearce
  1. 304 Beverley Road, Anlaby, HULL HU10 7BG, UK; jmspearce{at}freenet.co.uk

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    The Swiss physician Johann Jakob Wepfer (1620–95) showed that apoplexy is due to cerebral haemorrhage.1 Vascular engorgement or congestion, not occlusion or stenosis, was at that time thought to cause non-haemorrhagic (serous) apoplexy. Indeed even at the turn of the 19th century, Pinel and others classed apoplexy as a form of cerebral neurosis. The distinction between thrombosis and haemorrhage was unclear until the mid 19th century,2 despite the clinical and pathological descriptions of Abercrombie,3 Cheyne,4 Cooke,5 and in France, Serres.6 Small softenings were first designated lacunes by Dechambres in 1838.7

    van Swieten postulated embolism arising in the heart and great vessels; far ahead of his time, he observed8:

    “It has been established by many observations that these polyps occasionally attach themselves as excrescences to the columnae carneae of the heart, and perhaps separate from it and are propelled, along with the blood, into the pulmonary artery or the aorta, and its branches … were they thrown into the carotid or vertebral arteries, could disturb—or if they completely blocked all approach of arterial blood to the brain—utterly abolish all functions of the brain.”

    Gerhard van Swieten (1700–72) was a student of the famous Boerhaave in the lovely Dutch city of Leiden. Boerhaave had adopted the clinically orientated teachings of Willis and of Sydenham (the British Hippocrates). His work reflects the importance paid to orderly and critical clinical observations made at the bedside. He became the personal physician to the Empress Maria Theresa.

    van Swieten published his Commentaria in Hermanni Boerhaave aphorismos de cognoscendis et curandis morbis, in six volumes (Lugduni Batavorum, J & H Verbeek) between 1742–76. It was translated into English in 18 volumes in 1771–76.8 In the commentaria he gave the first description, known to date, of episodic cluster headache. This text also includes his lucid accounts of podagra (gout), and of nominal aphasia in patients recovered from apoplexy.

    Amongst his many other important works, van Swieten’s idea that embolism could occlude the arteries of the brain and thereby be a major cause of loss of brain function—that is, stroke—ranks as a signal advance, though not appreciated until more than a century later.

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