When a patient has sunk into a state of unconsciousness from brain compres sion from intraeranial hwenorrhage, a re covery from this state will not occur unless the compression is relieved. War basse (I3rooklyn Med. Jour., Jan., '99).
Sometimes thc vomiting in such a ca.se appears to be eased by turning the person on the right side; it is further claimed that turning the person on the paralyzed side eases the stertor.
proper use of these remedies is our most valuable single re source. Ergot can well be discarded. The cardiovascular depressants—gelse mium, veratrium, or aconite—are suffi ciently powerful and yet ordinarily safe means. Either of these can be admin istered hypodermically, though they also act promptly by the mouth. 1Vhere the pulse warrants its use, it is well to begin with gelsemium. In adults the fluid extract can be started with an initial dose of 2 to 5 drops and fol lowed by drop-doses at intervals de pendent on the closeness with which the case can be watched. It should be pushed until its physiological action is manifest, whether little or much is re quired. The full benefit of the drug is not obtained unless its paralyzing effect is secured.
When medication on this line has to be continued for any length of time, it may be necessary to change, especially from full doses of gelsemium. Then the others become useful. Veratrium is next in order; and both because of the more general familiarity of the profession with this drug, and of our knowledge of its safety from the ample experience with its use in puerperal eclampsia, it will, with most practitioners, prove the most acceptable remedy from the start.
With the use of aconite for this purpose I have no experience; but, relying on its physiological action, there is no doubt that in the absence of either of the other drugs this might be a fair substitute. It is usually advisable to keep up some influence of this kind for from a couple of days to a week.
The use of nitroglycerin in this stage of brain Immorrhage almost certainly does harm, and should be abandoned.
All stimulants, vascular tonics, mor phine, or opiates, and, for the time, strychnine should be carefully avoided.
The possibility of increasing the co agulability' of the blood by internal agencies does not yet seem to have been realized.
Autodepletion. — This can be prac ticed by constriction of the extremities near the trunk. This is a very promptly acting, but temporary, expedient with many limitations. A coarse binder should be used. Brittle vessel-walls are a distinct contra-indication. Only suf ficient force should be used to more or less shut off the veins without affecting the arteries (if too much we but strangle the extremity; if too little we fail of our purpose). Care must be had lest the extremity become too cold. Filially the constriction must be eased up gradually, lest the sudden influx into the general circulation again start up hminorrhage.
Warm bottles to the extremities, mus tard to the soles, and gentle frictions are, of themselves, useful in drawing blood to the parts, and. are doubly so when constriction is resorted to.
Compression of the carotids is a doubt ful measure, as the vessels in older pa tients are easily injured and a steady control of the current for any length of time is rarely possible. Ligature of a carotid is literally adding injury to in sult.
Ice to the head is a popular plan, but also of very uncertain value. If used at all for this purpose, it might far better be applied over the carotids in the neck.
Depletion of Body-fluids. —Formerly this was the main treatment, and prac ticed in the form of venesection. Many still think highly of this procedure for vigorous patients with a tense pulse. "The indications for venesection are a regular, strongly-acting heart, and an incompressible pulse." The most common and still accepted method is by purgatives, as a drop of croton-oil on the tongue, a good dose of calomel, or a glycerin-and-sulphate-of soda enema.
Pilocarpine might be admirable, since it acts both as a depressant and a fluid depleter, but for certain risks, as of pul monary cederna.
There may be other matters that re quire attention. Convulsions should be promptly stopped, and for this purpose a few whitTs of chloroform may suffice. The efforts of vomiting are injurious, but it is seldom possible to arrest them.