Facts versus Theories: An Everlasting Struggle

Rather than a complete overview of the contribution of Utrecht to stroke research, I have selected a few subjects and attempt to put these in historical context. Johann Jakob Wepfer (1620–1695) was unique in that he approached ‘apoplexy’ through post-mortem observations, in the tradition of Padua. However, the interpretation of his findings in haemorrhagic and especially non-haemorrhagic stroke was still heavily influenced by the authority of Galen’s writings. Wepfer’s category of ‘serous apoplexy’ assumed that extravasation of blood serum might lead to compression of brain substance and blockage of ‘nerve pores’ through which mental ‘spirit’ was supposed to flow. This notion of ‘cerebral congestion’ or ‘cerebral hyperaemia’ lived on, at least to the middle of the 20th century! The pitfalls of theorizing are also evident from recent history (the facile assumption that cerebral ischaemia occurs in the same way as leg ischaemia). By implication, similar errors may well be hidden in present ideas about stroke. Probable or possible examples are the idées reçues that 30 mg of aspirin is less efficacious in the secondary prevention of stroke than 100 mg, that vasospasm is the cause of delayed ischaemia after aneurysmal subarachnoid haemorrhage and that perimesencephalic haemorrhage is not caused by rupture of an artery. Physicians still speculate more often than they care to admit. Copyright © 2010 S. Karger AG, Basel Three years ago, I retired from the chairmanship of neurology in Utrecht. Coincidentally, it was around that time that two major journals asked our group to summarize the state of the art in acute ischaemic stroke and in subarachnoid haemorrhage, including our own work [1, 2] . After those parting shots, I still see outpatients but very few patients with stroke. As a consequence, my interests are gradually shifting to new areas. On one of these, the borderland between neurology and psychiatry, especially somatoform disorders, I will remain silent. The other new challenge is the history of medicine and of stroke in particular. I will therefore start with a historical perspective. To some extent, this interest is a question of age: the past for me is now larger than the future. On the other hand, we all often forget that we build on the work that has been done by countless generations of predecessors, particularly when we are young. From the times from which writing has been preserved, efforts to understand life and disease have woven an unbroken thread, connecting past, present and future. A study of medical history makes clear that we can learn not only from past achievements, but also from past mistakes. The history of stroke, like the history of science in general, is not a tale of one discovery after another, not simply a consecutive series of triumphs and of the great men who achieved them. New observations have almost never prompted sudden and radical changes in medical thinking. Rather, in an erratic process with many blind alleys, new ideas were, if not resisted (think of Galileo and Darwin), at least always interpreted in the light of existing theories. Theories about nature provide indispensible scaffolding that helps to support our daily lives: the sun will rise every morning, physical exercise is healthy and sex with strangers may cause disease. From the very beginning of mankind there have been theories about the mechanics of the body and its derangements in disease; those from Europe and the Arabic world are best known to us. Ancient medical heritage converged in the writings of Galen (131–201), which dominated medical teaching throughout the Middle Ages. The first book on diseases of the nervous system, published in Basle in 1549 and written by Jason Pratensis (1486–1558) [3] , is still steeped in galenic notions of humoral medicine: stroke (apoplexy) was defined as a condition in which a person is deprived of all motion and sensation, apart from breathing. This means that the admixture of air to the blood still produces life spirit (spiritus vitalis) in the heart, but that for some reason its passage to the brain is blocked, where it should be transformed into mental spirit (spiritus animalis). An important difference with present notions is not only that we would substitute both kinds of spirit by oxygen and glucose, but also that the term ‘apoplexy’ implied generalized dysfunction of the brain. The treatments advised by Pratensis were in keeping with the fluidist tradition: purging, bloodletting or administration of complicated herbal remedies, by mouth or as ointment. Johann Jakob Wepfer: Pioneer as well as Child of His