Treatment of Cerebral Thrombosis.—There being two factors in this affection, both of which are to a certain extent under control, something may be done toward diminishing the risk of its occurrence. Arterial disease and its prophylaxis have already been spoken of. The other condition which is necessary to the production of thrombosis—namely, an enfeebled circulation—is to some extent under the control of general hygienic rules: a nutritious, not too highly nitrogenous, diet, and especially sufficient exercise and the avoidance of completely sedentary habits. If there is a crasis which predisposes to the formation of coagula in the vessels, it is not known that there is any special treatment, medical or otherwise, which can prevent it. The attack is to be treated exactly on the principles already laid down. Bleeding is about the last thing to be thought of. Stimulants, though they cannot dislodge the clot, may be of use for a time to sustain the heart under the shock. The secretions and the condition of the skin are to be looked out for.
After a few weeks of waiting the patient and his friends not unnaturally feel as if something ought to be done to hasten recovery, and certain measures may be taken, in addition to careful hygiene, which have this object in view. It is very doubtful, however, whether anything really shortens the time necessary for such repair as is possible or diminishes the amount of damage which is to be permanent. As has already been said, improvement may go on slowly for months. In the first place, it is sometimes considered desirable to practise shampooing and massage of the affected muscles in order to keep them in as good a condition of nutrition as possible. This, as well as the regular use of the faradic battery if it be not begun too early, will prevent a certain moderate amount of atrophy, but could not have any influence in those rare cases where rapid wasting depends upon secondary degeneration of the anterior gray columns. It may be doubted, however, whether it is necessary to pay much attention to the condition of the muscles, as they do not ordinarily atrophy to the extent of becoming unsusceptible to the nervous stimulus from the brain so soon as it shall be transmitted to them. Faradism, like many other agencies, such as magnets, metals, pieces of wood, and so forth, is said to produce a transfer of sensibility in cases of hemianæsthesia.
There is no sufficient reason to suppose that any drug is of any value in the restoration of the nervous structure. Iodide of potassium may possibly prove to have some effect as a sorbefacient. Very favorable results have been claimed for ammonia salts in the restoration of aged persons to a nearly complete use of paralyzed limbs. Phosphorus has been spoken of as assisting in repair, but the writer is not aware upon how wide a basis of facts. Silver and gold have been said to counteract the sclerosing myelitis. Strychnia is certainly useless, and probably worse. It may make the paralyzed limbs twitch, but this does just as little good as the involuntary spasmodic movements, which have never been considered desirable, except as awakening in the patient false notions of immediate recovery, and which are frequently a very annoying symptom. The galvanic current has been applied with a view to a sorbefacient or restorative action directly to the brain, or rather to the pericranium.
Something can be done for the comfort of such patients: the rubbing and kneading of the paralyzed limbs, if they do not hasten the recovery of motion, relieve many of the painful and unpleasant feelings. Since we do not know how far one part of the brain may supplement another, attempts at motion after it has once appeared to ever so slight a degree should not be abandoned by the patient. He should walk with crutches frequently as soon as he can, though not to the point of fatigue.
There is one faculty which seems capable of re-education to some extent: that is of speech in cases of ataxic aphasia, and even in others the attempt should be made to teach the patient the names of things. A very interesting case has been reported by Bristowe57 of a man who came under his observation after an attack which may have been anterior poliomyelitis with extensive paralysis, able to write well and intelligently, but unable to say anything. By gradual education, first in the sound and formation of letters and afterward of words, he reacquired the use of language. It is obvious that in this case there could have been no loss of memory for the words themselves, but simply the loss of the knowledge of how to produce them. When his speech returned he spoke with his original American accent.
57 Clin. Soc. Trans., iii. p. 92.
In short, the therapeutics of hemiplegia from arterial disease in the brain is good nursing and attention to symptoms, with a moderate amount of care of the paralyzed muscles.
Capillary Embolism.
It may be remarked, in the first place, that the lesions known by this name are not necessarily strictly capillary, but are situated in the very small arteries. The microscope marks the transition from the larger to these smaller embolisms.
More is known about very small embolisms experimentally than clinically, since they have been produced by the injection of small seeds and insoluble particles of various kinds. Embolisms arising from natural causes and deposited in the minutest arteries may have very similar origin to the larger ones already described, but there are also other conditions which give rise to particles which pass through larger arteries without any disturbance, and are arrested in smaller ones. The softening of thrombi is undoubtedly one source. The same thrombus which, if detached en masse, would block the carotid artery, may, if broken up into a number of minute fragments of fibrin and fat, pass into the ultimate distribution of the cerebrals. The same thing may of course happen if the thrombus have already undergone one transportation.