When the apoplectic attack has actually occurred, treatment, though apparently urgently demanded, is really of little avail. If a patient is about to die in an hour or two from rapidly increasing pressure, nothing within the reach of medical science can stop him.
There is one danger, however, easily avoided, but probably often overlooked. A patient may die from suffocation. The stertor is often a result of the paralysis of the tongue and palate and of the amount of fluids collecting in the pharynx from the almost invariable position of the patient on his back; that is, if he have been seen by some one who wished to do something for him, but did not know what. Insensibility and paralysis combine to favor this accumulation, which obstructs the respiration, and which may find its way to the lungs, together with brandy and milk, and set up an inhalation-pneumonia. The simple and obvious thing to do is to place the patient sufficiently on his side, with the face somewhat downward, for the tongue and palate and secretions to fall forward, instead of backward into the pharynx. Swabbing out the pharynx may be of some use, but cannot be so thorough. An easy position and proper ventilation should be secured in all cases of unconsciousness, even at the risk of treating a drunkard with undue consideration. Police-stations should be provided with rooms where these conditions can be secured, and the necessity avoided of placing persons picked up in the streets in the narrow, close, and perhaps distant cells provided for malefactors. The writer recalls the cases of two young men—one who had been drinking some time before, and the second roaring drunk—who were locked up in a suburban station-house in the evening, and found the next morning—one dying and the other dead.
Artificial respiration may be used to prolong life in some cases until the nervous centres have sufficiently recovered their functions to carry on the process without assistance. The condition of the bladder should be ascertained, and the urine drawn if necessary, though it is more frequently passed involuntarily.
Although it is manifestly impossible to remove the clot from the interior of the brain, it may appear that the further flow of blood may be stopped and the amount of damage done limited. For this purpose two remedies are proposed—namely, bleeding and purgatives. Both of these act to diminish arterial pressure, which is forcing the blood out of the rupture. Though the treatment seems reasonable, it would not be difficult to imagine a condition where sudden and premature diminution of pressure in the brain, which of course exists outside of the arteries as well as inside, would tend to set going again the flow which has ceased from the very force of the pressure it itself exerts, very much as if a tampon were prematurely removed from a bleeding cavity elsewhere. As the conditions are somewhat complicated, and at the same time only remotely to be estimated, it is safer to be guided by experience in the use of these remedies than by abstract reasoning. In some of the cases of temporary aphasia, as notably that of Rostan narrated by Trousseau, bleeding seems to have given immediate relief. Trousseau, however, is no advocate of that method of treatment. Most modern authors speak of venesection as to be used in cases where the pulse is strong and full and the face red, but not to be thought of in the opposite class. When a case presents the appearances of plethora and an attack has come on suddenly, the loss of a few ounces of blood can certainly do no harm. Other forms of bleeding, such as cups and leeches, are not rapid enough to be of great value, though a large number of leeches about the head might be useful. Some French writers recommend leeches to the anus as revulsives. Cathartics may be more freely used, although they should be given cautiously when there is any tendency to cardiac depression. It can be clearly shown that a brisk purgative lowers the arterial tension decidedly. In case of cerebral tumor or injury with occasional so-called congestive attacks, the relief afforded by cathartics is very great, and, although the conditions are not exactly parallel, it is fair to assume a similar action in the congestion accompanying cerebral hemorrhage. From one to three drops of croton oil may be placed far back on the tongue or it may be diluted with a neutral oil. Ail enema may be desirable for the unloading of the bowels, but has a much less marked effect on the tension of the cerebral circulation.
In most cases of apoplectiform cerebral hemorrhage, and probably in all of simple paralysis, no very active treatment is called for. Measures directed to the prevention of another hemorrhage, and to allay any irritation that may supervene during the changes taking place about the clot and the formation of its capsule, are of the simplest, and consist in keeping the head high and cool, the clothing sufficient for warmth, and offering no obstruction to respiration or circulation, laxatives sufficient to keep the bowels in good order, and a diet not highly nitrogenous, but sufficient and digestible.
That which will tax most severely, however, the care and patience of attendants is the scrupulous and minute attention to cleanliness and pressure over the bony prominences which is necessary when a patient is helpless and unable to control the discharges from the rectum and bladder. Frequent change of clothing, bathing, change of position, and avoidance of wrinkles and roughnesses in the bed may be successful in keeping the patient free from bed-sores. Bathing with alcohol hardens the skin and makes it less susceptible to pressure.
Surgical interference may perhaps be of value in cases where the portion of the clot outside the brain can be clearly demonstrated; and this would apply with special force where the hemorrhage arises from injury.
Trephining and removal of the clot has been done in a few cases of meningeal hemorrhage, though with indifferent success (3 cases—2 deaths, 1 unknown.)56 An intracerebral clot is obviously a step beyond, though possibly in some cases not absolutely without, the reach of the surgeon.
56 Med. Press and Circular, Oct. 14, 1885.
Treatment of Cerebral Embolism.—The prophylaxis is in the avoidance of such conditions as give rise to the formation of detachable vegetations or clots. Unfortunately, these are numerous, not completely known, and not always avoidable. Arterial disease is to be looked upon as of some importance, but cardiac valvular lesions of much greater, and the causes of these, like rheumatism, scarlet fever, and the puerperal condition, are not always to be escaped. The presence of a detachable piece of fibrin in the pulmonary veins, heart, or aorta being granted, nobody can possibly say what will prevent its being loosened and lodging in one of the cerebral arteries; so that, practically, the prophylaxis of embolism consists in the judicious treatment of acute rheumatism and the other conditions just mentioned. The treatment of the first attack must consist solely in the relief of respiration, bladder, and bowels, if they have not taken care of themselves. Stimulants may be of use for a short time, but there cannot be any call for even the slight amount of depletion suggested for some cases of hemorrhage. Bed-sores are to be looked out for, just as in hemorrhage, and the subsequent treatment conducted on the same principles. As regards the primary lesion, we can do nothing about it either in the way of removal of the embolus or restoration of the necrosed brain-tissue.