Treatment. — To be successful this must be prophylactic and directed to the prodromal stage. The trouble is of slower development than haemorrhage or embolism, and needs be met with less vigor, but more persistence and greater skill in adaptation of means to an end. There is one danger in the measures for relief; we are dealing with diseased ves sels, their walls being often much weak ened; there is no such disturbing fear in embolism, for there the vessels are pre sumably healthy; nor in haemorrhage, for there our efforts at relief involve no strain on the vessels.
When we find signs of such danger im pending, the first or immediate line of treatment is analogous to that in embo lism, though there is less need of increas ing the body-fluids. The vessels must be dilated to allow the blood to pass, and the pressure should be increased to get it through. Here, again, the nitrites are as yet our main stay, sometimes reinforced by strophanthus and strychnine. We de sire the slow. continuous-acting nitrites: 13radbury (95) found experimentally that there was a difference in this respect. In the practical use of the nitrites, how ever, there is one point not duly appre ciated. From nitroglycerin we rarely get any stomach disturbance; but from ni trite of sodium and unfortunately also from erythrol-tetranitrate there is very often complaint of much discomfort about the region of the stomach, and it is the same in whatever way adminis tered. The objection to these latter remedies is time and again so great that they have to be discontinued. Still, even then we can fall back on the nitroglyc erin and succeed fairly well.
Avoid digitalis and everything causing arterial contraction.
As soon as immediate relief is secured a course must be adopted looking to more lasting benefit.
For atheroma, small, long-continued doses of iodide of potassium are much used; for one reason or another (slow action, the occurrence of iodism, etc.) it has rarely given much satisfaction in my experience.
The nitrites should be accompanied or followed by brucia (in doses of 7„, to grain) or its allies in stout doses, and persisted in for months with more or less regularity according to immediate needs at any time.
Another useful line of remedies de pends upon the fact that most of the old patients are rheumatic, gouty, or suf ferers from what might be termed se nile lithTmia. Physical inactivity plays a part. Waste and refuse products of the
system are not eliminated with due promptness and aggravate the atheroma tons trouble.
alkalies and antilithic remedies have to be employed. Much aid is nished by certain of the sulphur-waters. it is possible for the patient to visit the springs, so much the better; otherwise the waters may be employed at home. A course of these waters can be repeated from time to time.
In the syphilitic form the whole power of our therapeutic resources should be promptly brought to bear and continued until all symptoms are well in hand. It should be borne in mind that often the so-called specifics will develop this de sired local action only after the vessels have been dilated. So long as they are almost closed, it is evident that little blood, and consequently little of the medicament, can reach the imperiled point. It is necessary, if possible, to open the vessel-path, and, while keeping the way open, follow up with the more direct specifics.
Thrombosis of the Brain-veins and Sinuses.
thrombosis of brain veins has been but rarely observed. Hence, despite the occasional descrip tion of cases in the literature, it is im possible to present anything very sys tematic in regard to the matter.
Without doubt it is of greater fre quency than appears from the above. The reason why it is not more recognized is that in itself it but. very exceptionally causes symptoms. All the pial veins have numerous and free anastomoses, so that serious stasis only results when whole net-works of contiguous veins are filled. In the latter event, softening of the cor responding drainage-area has been noted. In such a case a focal diagnosis is the most that one might expect to make. If other manifestations are present, they are usually clue, as in sinus trouble, to sepsis rather than the thrombosis as such.
The question of terminal veins in the brain is not fully decided, though only as regards the perforatings, the prepontile efferents, and parts of the internal or Galen's system: the same parts, it may be remarked, where the arteries are strictly terminal. The balance of evi dence favors the view that in these lim ited sections there are at least many con nections between the finer branches. The practical facts as regards Galen's system will, however, be summarized in discussing the straight sinus.