Before, however, considering such a serious step, the physician should resort to the use of other agents possessing the power of reducing the general blood-pressure after venesection has been tried. These are vaso dilators and purgatives. Nitrite of Amyl is practically the only drug available of the former class, as it can be so readily administered by in halation, and it is innocuous unless asphyxia be already urgently threaten ing life. It is therefore worth a trial when the pulse is bounding and the tension high. Owing to its evanescent action, the effects must be kept up for some time before its trial is abandoned. Owing to the slow action of purgatives in the apoplectic state, even of Croton Oil—the only avail able cathartic—this drug should be administered without delay.
Whilst it is true that remedies which reduce the general blood-pressure are injurious in thrombotic cases, and should not be used when the clinical symptoms or the history of former attacks of syphilitic thrombosis clearly indicate this condition, it is to be remembered that the.diagnosis is often almost impossible, and of all the agents used to reduce blood-pressure purgation is the least objectionable or dangerous. Hence under the conditions now being considered, it may be used as a routine with com parative safety. No good usually can be expected by enemata, and much harm may be done by the necessary changes produced by the moving about and turning of the patient's body during their administration. An enema is, however, clearly indicated if the rectum is impacted with scybabe, which prevent the action of croton oil. One or two drops, of croton oil, with 5 grs. of calomel mixed with a little butter or a few grains of moistened sugar, should be placed far back upon the tongue, and often this dose will require repetition. The necessity of relieving the bladder should not be lost sight of.
Should the patient survive the comatose stage, the period of returning to consciousness demands close attention. This is often accompanied by febrile reaction, which necessitates the removal of all external aids to the keeping up of the body heat, as it clearly also is indicative of the con tinuous use of the ice-cap and the enjoinment of absolute rest of both body and mind. Nothing is more reprehensible at this stage than the attempts to test the patient's consciousness by tempting him to recognise his friends and answer questions and otherwise rousing him. As soon as swal lowing power has returned, a few teaspoonfuls of milk may be cautiously administered from time to time, and it is a wise precaution taught by the experience gained from surgical head injuries to withhold all animal foods, even in the form of soup, for a long period after convalescence. The rest during convalescence should be prolonged and thorough.
The after-treatment of cerebral hxmorrhage is identical in most cases with that of the hemiplegic condition usually remaining, and will be dealt with under its own heading. The primary condition causing the hemor rhage, as Bright's Disease, arterio-sclerosis, &c., will of course require attention in all cases.
It only remains to mention the treatment of an apoplectic seizure, where the history or symptoms indicate thrombosis or embolism as the cause of the loss of consciousness.
In thrombosis, after the patient has been put to bed with his head and shoulders but slightly if at all raised and heat applied to his surface, the immediate indication is to check the coagulable power of the blood.
Owing to the urgency of the symptoms drugs for this purpose are too slow in their action to be relied upon, though the writer once injected Ammonia into the carotid artery with the hypodermic needle, a procedure followed by most striking relief for a time to all the symptoms. In relapsing cases where time permits the blood may be decalcified by the administration of Citric Acid or its potash salt.
As the extension of the thrombotic change is favoured by that tends to render the circulation languid stimulants arc indicated. The best of these is Ammonia, for as already mentioned it diminishes the coagulability of the blood, and at the same time quickens and strengthens the heart's contractions. 3o mins. of the diluted liquor may be mixed with ro oz. normal saline and injected into a vein or hypodermi cally, and the strong liquor may be held near to the nostril. Guthrie emphasises the view of Mott that the deep coma in thrombosis is due to the pressure of venous congestion consequent upon arterial blockage; hence the necessity of relieving the asphyxia by moderate venesection, leeching, or dry-cupping, and purgation in the later stages, as in cases of cerebral hmmorrhage. In syphilitic cases where warnings of the threatening attacks are not rarely seen the proper after-treatment will consist of full doses of the Iodides, always combined with large doses of Ammonia, whilst Mercurial Inunctions should be commenced without delay. Sometimes in cases of cerebral haemorrhage, especially where there are reasons for believing that small foci of softening have previously existed, these warnings, if promptly met by absolute rest and remedies capable of reducing the blood-pressure, may save the patient from a severe and fatal apoplectic seizure.
Embolism causing apoplexy must originate in the detachment of a fibrinous mass from the endocardium, or pulmonary veins, or from a vessel between the heart and the cranium. The immediate effect is the shutting off of blood from an area in the brain, and the tendency to further coagula tion of the blood around the fibrinous focus brings the treatment of the case practically into the same category as that of thrombosis, and Am monia in normal saline solution, hypodermically or by the rectum, affords the best prospect of success, followed up by full doses of Citric Acid should the patient survive the initial shock and pressure symptoms.
The plug being of a septic nature in the embolism following ulcerative endocarditis, thrombosis is certain to follow, and a fatal issue is always to be expected from subsequent cerebral abscess. In the sinus thrombosis which is often secondary to disease of the middle ear or mastoid cells, and which sometimes demonstrates its presence by the gradual onset of apoplectic symptoms, the treatment should consist of the prompt removal of the original septic focus in the temporal bone by the active surgical measures detailed under Ear Disease. The intense headache following all the forms of cerebral apoplexy after consciousness has been restored is best relieved by large doses of Bromides combined with moderate amounts of Antipyrine, and some practitioners still believe that the absorption of the clot in the cerebral tissue may be hastened by the continuous administration of Iodides.