APOPLEXY.
Restricting the term to the more or less sudden loss of consciousness and motor power arising from a vascular lesion inside the cranium, due either to the rupture of an artery in the cerebral tissue, with the extra vasated blood ploughing up the brain substance, or to the lodgment of an embolus from the heart, or to thrombotic occlusion occurring in a diseased cerebral vessel, the treatment of these three conditions in theory is widely different; nevertheless, owing to the difficulty of diagnosis, which is in many instances insuperable, the physician will be wise in the absence of differentiating factors to regard all cases as due to cerebral hwmorrhage.
It may be safely said that there are few conditions in whose presence the physician feels so powerless, but there are also few in which so much harm can be done by active meddling and unwise attempts at heroic treatment. The first duty of the attendant is to insure absolute rest regardless of the wishes of the patient's friends, who are often anxious to have him removed from the place in which the seizure has taken place. He should be placed upon his back on a sofa, or on a bed extemporised in the room in which he has fallen by laying a mattress upon the floor. His head and shoulders should be elevated slightly, all constrictions about the neck being removed. If there be any urgent necessity for the removal of his clothing this should be effected in the most gentle and cautious manner by cutting up the seams and removing the garments piecemeal, whilst a reliable assistant takes charge of the head to prevent its being shaken. The next step is to turn his face to one side in order to prevent the tongue falling directly backwards, and to permit of the saliva dribbling from the angle of the mouth.
Attempts should not be made to arouse consciousness by shouting into the ear, shaking the body, or flapping with towels or other methods of stimulation, and certainly nothing should be administered by the mouth of the nature of food or stimulating drinks. Rubber bottles, filled partially with warm water, should be placed at his feet and along each side of the trunk. In their, absence warm blankets may be used, but friction or massage of the cold limbs had better be avoided. Ice, when available,
should be applied to the head, or an evaporating lotion to the forehead and temples. Counter-irritants, used with the view of determining a flow of blood to the surface of the body, are as a rule to be avoided. The best of these agents would be a sinapism applied to the nape of the neck, but, especially in heavy and muscular subjects, this can scarcely be carried out without shaking the cranium. The dangers of subsequent aspiration pneumonia should be minimised by maintaining an aseptic condition of the mouth, any dental plates being removed, and the tongue and lips smeared with Glycerin of Borax.
Nothing should be done to combat any symptoms of shock or collapse beyond the above palliative measures. To administer hypodermically or by rectum powerful cardiac stimulants will only cause the heart to beat more vigorously and pump more blood into the ruptured cerebral tissue; hence even the use of irritating smelling-salts may be injurious through their power of increasing the general blood-pressure.
The question of blood-letting should be considered if the profound coma remains, with a high tension pulse, vigorously acting heart and signs of asphyxia. Before this is finally settled, a brief trial may be made of compression of the carotid trunk in the neck with the view of arresting the circulation in the branches of the middle cerebral. If carefully and skilfully carried out this procedure can do no harm. Ligature of the vessel has been recommended by Horsley and others. The antique practice of opening the temporal artery is now universally condemned, but unquestionably speedy and sometimes permanent benefit follows the opening of a vein in the arm when asphyxia is increasing and threatening life. Of late years a bolder surgical measure has been advocated, and found acceptance in some quarters. This consists in trephining a large opening in the skull and evacuating the area of haemorrhage; but as pointed out by Russell and Sargeant, this is only admissible when the case is going on from had to worse, and when in the coma it can be confidently ascertained that the paralysis of motion is hemiplegic.