condition upon which the usual form of cerebral hemorrhage depends is
so frequently aneurism, and probably nearly always some arterial
disease, the prophylaxis must evidently consist in such a mode of life
as will least tend to this degeneration, or at least put it off as
long as possible. This, of course, means the avoidance of all the
special causes described under the head of Etiology. It is a disease
of old age, but in a pathological sense old age begins in different
persons after a different number of years. Fortunately for rules of
hygiene, there is little that is contradictory in those to be given
for most chronic and degenerative diseases. Abstinence from alcohol,
as an agent tending at once to paralysis and dilatation of the
vessels, is one of the most important rules and insisted upon by
nearly all writers. The avoidance of over-eating, and especially of
{975} nitrogenous food as tending to lithæmia—a generally recognized
cause of arterial degeneration—is perhaps the next. Over-eating is of
course to be understood as a relative term, and to be estimated with
reference to the habits of exercise of each person. Practically, it
will be decided by its effects; that is, if careful thought be given
to the matter and the statements of the gourmand as to his immunity
from all risk of trouble are not accepted as of scientific value. On
the other hand, insufficient food, producing anæmia, may be a factor
in arterial degeneration. Keeping one's self free from anxiety, and
getting through the world with as little experience of its roughnesses
as possible, might be, properly enough, added in a purely theoretical
point of view if any one ever asked a physician's advice in youth as
to avoidance of the diseases of age, or if any one could or would
profit by this advice if it were given.
Intellectual pursuits have been credited with a special tendency to
apoplexy, but there is no good reason to suppose that healthy exercise
of the mind is otherwise than beneficial to its organ. Hurry,
over-anxiety, and mental tension are undoubtedly potent factors in
general breakdown, but do not necessarily lead to this form. They are
certainly not to be found by preference in those persons who lead an
intellectual life.
Syphilis, one of the most important of the causes of organic cerebral
disease, and that too in the form of thrombosis, is not specially
concerned in the etiology of the forms here under consideration.
If symptoms have occurred that justify the apprehension of apoplexy or
paralysis, such as frequent headaches in an elderly person, hemiopia,
temporary aphasia, or slight and temporary paralyses, or if one have
reached a time of life at which the risk of cerebral hemorrhage
becomes considerable, a stricter attention to the rules laid down
above, and even to some to which but little heed would be given in
health, is not out of place. A certain amount of limitation of diet,
moderate and regular but not violent exercise, clothing suitable to
the season, and especially warm enough in winter, and, most of all,
rest if the patient be doing wearing and anxious work, should be
enjoined. Finally, it should be said that the real prophylaxis of
cerebral hemorrhage is to be begun in early life.
Among the exciting causes to be avoided are those which obstruct the
flow of blood from the head, like tight clothing around the neck.
Increase of the arterial pressure by severe or prolonged muscular
effort, as in lifting or straining at stool, is to be avoided, as well
as violent fits of passion. The condition of the bowels should be
regulated by mild laxatives.
When the apoplectic attack has actually occurred, treatment, though
apparently urgently demanded, is really of little avail. If a patient
is about to die in an hour or two from rapidly increasing pressure,
nothing within the reach of medical science can stop him.
There is one danger, however, easily avoided, but probably often
overlooked. A patient may die from suffocation. The stertor is often a
result of the paralysis of the tongue and palate and of the amount of
fluids collecting in the pharynx from the almost invariable position
of the patient on his back; that is, if he have been seen by some one
who wished to do something for him, but did not know what.
Insensibility and paralysis combine to favor this accumulation, which
obstructs the respiration, and which may find its way to the lungs,
together with brandy and milk, and set up an inhalation-pneumonia. The
simple and obvious thing {976} to do is to place the patient
sufficiently on his side, with the face somewhat downward, for the
tongue and palate and secretions to fall forward, instead of backward
into the pharynx. Swabbing out the pharynx may be of some use, but
cannot be so thorough. An easy position and proper ventilation should
be secured in all cases of unconsciousness, even at the risk of
treating a drunkard with undue consideration. Police-stations should
be provided with rooms where these conditions can be secured, and the
necessity avoided of placing persons picked up in the streets in the
narrow, close, and perhaps distant cells provided for malefactors. The
writer recalls the cases of two young men—one who had been drinking
some time before, and the second roaring drunk—who were locked up in a
suburban station-house in the evening, and found the next morning—one
dying and the other dead.
Artificial respiration may be used to prolong life in some cases until
the nervous centres have sufficiently recovered their functions to
carry on the process without assistance. The condition of the bladder
should be ascertained, and the urine drawn if necessary, though it is
more frequently passed involuntarily.
Although it is manifestly impossible to remove the clot from the
interior of the brain, it may appear that the further flow of blood
may be stopped and the amount of damage done limited. For this purpose
two remedies are proposed—namely, bleeding and purgatives. Both of
these act to diminish arterial pressure, which is forcing the blood
out of the rupture. Though the treatment seems reasonable, it would
not be difficult to imagine a condition where sudden and premature
diminution of pressure in the brain, which of course exists outside of
the arteries as well as inside, would tend to set going again the flow
which has ceased from the very force of the pressure it itself exerts,
very much as if a tampon were prematurely removed from a bleeding
cavity elsewhere. As the conditions are somewhat complicated, and at
the same time only remotely to be estimated, it is safer to be guided
by experience in the use of these remedies than by abstract reasoning.
In some of the cases of temporary aphasia, as notably that of Rostan
narrated by Trousseau, bleeding seems to have given immediate relief.
Trousseau, however, is no advocate of that method of treatment. Most
modern authors speak of venesection as to be used in cases where the
pulse is strong and full and the face red, but not to be thought of in
the opposite class. When a case presents the appearances of plethora
and an attack has come on suddenly, the loss of a few ounces of blood
can certainly do no harm. Other forms of bleeding, such as cups and
leeches, are not rapid enough to be of great value, though a large
number of leeches about the head might be useful. Some French writers
recommend leeches to the anus as revulsives. Cathartics may be more
freely used, although they should be given cautiously when there is
any tendency to cardiac depression. It can be clearly shown that a
brisk purgative lowers the arterial tension decidedly. In case of
cerebral tumor or injury with occasional so-called congestive attacks,
the relief afforded by cathartics is very great, and, although the
conditions are not exactly parallel, it is fair to assume a similar
action in the congestion accompanying cerebral hemorrhage. From one to
three drops of croton oil may be placed far back on the tongue or it
may be diluted with a neutral oil. Ail enema may be desirable for the
unloading of the bowels, {977} but has a much less marked effect on
the tension of the cerebral circulation.
In most cases of apoplectiform cerebral hemorrhage, and probably in
all of simple paralysis, no very active treatment is called for.
Measures directed to the prevention of another hemorrhage, and to
allay any irritation that may supervene during the changes taking
place about the clot and the formation of its capsule, are of the
simplest, and consist in keeping the head high and cool, the clothing
sufficient for warmth, and offering no obstruction to respiration or
circulation, laxatives sufficient to keep the bowels in good order,
and a diet not highly nitrogenous, but sufficient and digestible.
That which will tax most severely, however, the care and patience of
attendants is the scrupulous and minute attention to cleanliness and
pressure over the bony prominences which is necessary when a patient
is helpless and unable to control the discharges from the rectum and
bladder. Frequent change of clothing, bathing, change of position, and
avoidance of wrinkles and roughnesses in the bed may be successful in
keeping the patient free from bed-sores. Bathing with alcohol hardens
the skin and makes it less susceptible to pressure.
Surgical interference may perhaps be of value in cases where the
portion of the clot outside the brain can be clearly demonstrated; and
this would apply with special force where the hemorrhage arises from
injury.
Trephining and removal of the clot has been done in a few cases of
meningeal hemorrhage, though with indifferent success (3 cases—2
deaths, 1 unknown.)[56] An intracerebral clot is obviously a step
beyond, though possibly in some cases not absolutely without, the
reach of the surgeon.
[Footnote 56: _Med. Press and Circular_, Oct. 14, 1885.]
Treatment of Cerebral Embolism.—The prophylaxis is in the avoidance of
such conditions as give rise to the formation of detachable
vegetations or clots. Unfortunately, these are numerous, not
completely known, and not always avoidable. Arterial disease is to be
looked upon as of some importance, but cardiac valvular lesions of
much greater, and the causes of these, like rheumatism, scarlet fever,
and the puerperal condition, are not always to be escaped. The
presence of a detachable piece of fibrin in the pulmonary veins,
heart, or aorta being granted, nobody can possibly say what will
prevent its being loosened and lodging in one of the cerebral
arteries; so that, practically, the prophylaxis of embolism consists
in the judicious treatment of acute rheumatism and the other
conditions just mentioned. The treatment of the first attack must
consist solely in the relief of respiration, bladder, and bowels, if
they have not taken care of themselves. Stimulants may be of use for a
short time, but there cannot be any call for even the slight amount of
depletion suggested for some cases of hemorrhage. Bed-sores are to be
looked out for, just as in hemorrhage, and the subsequent treatment
conducted on the same principles. As regards the primary lesion, we
can do nothing about it either in the way of removal of the embolus or
restoration of the necrosed brain-tissue.
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 {978} 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 {979} 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 Bristowe[57] 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.
[Footnote 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.
Cases of localized softening are seen where no cause has been found,
except perhaps a thrombus in the heart, which has discharged its
softened and puriform contents; and it is probable that the connecting
links exist in the form of embolisms so minute as to escape ordinary
observation.
The consequences of capillary emboli if they block every minute
ramification of an arterial branch must be essentially the same as if
the branch itself were stopped; but if only a part are thus affected,
the resulting anæmia is not so complete, since the zones of capillary
congestion surrounding the part the supply of which is cut off may be
sufficient entirely to cover it and make more or less complete
compensation. The experimental emboli, in the form of tobacco-seed and
other insoluble substances, which have been traced into the brain in
considerable numbers, {980} often give rise to no distinct lesions in
the cases where the immediate effects are recovered from.
Among the other sources, ulcerative endocarditis may be mentioned as
of special importance, not from the size but the character of detached
emboli, which will give rise, not to simple anæmia, nor, on the other
hand, to merely negative results, but to septic changes at the place
of lodgment.
Aside from these conditions, which are almost the same on a small
scale as we find with the large emboli, we have several peculiar
substances formed in the body and floating in the blood which lodge in
the capillaries of the brain. These are pigment, fat, lime salts, and
white corpuscles. Every one of these, however, is much better known
anatomically than clinically.
Pigment scales, flakes, granules, or cells containing them, are formed
in the course of severe malarial fever, and deposits consisting of
this pigment are found in the spleen, liver, kidneys, heart, lungs,
and lymphatic glands, as well as the brain and spinal cord. The brain,
when a deposit of pigment has taken place, is of a slaty-grayish or
chocolate color, which is marked only in the cortical substance, the
white being unaffected. The pigment is found in the capillaries, and,
according to Frerichs, fibrinous coagula are often associated.
Punctiform hemorrhages in the brain have been seen, as well as
meningeal hemorrhages, in connection with this degeneration.
The point at which these masses are formed is still a matter of
theory. If the liver, as has been supposed, is one of the places of
formation, or if they originate in the blood, it is of course easy to
see how they reach the brain. If in the spleen, they must pass through
the wide portal capillaries before they are arrested in the narrower
ones of the brain.
It is by no means certain, however, that pigment reaches the brain in
the form of emboli. It is quite as probable that it is found in many
organs which undergo repeated congestions from the local destruction
of blood-corpuscles and changes in their pigment. The very general
deposition seems to point to a process of this kind rather than to a
local origin and a distribution through the blood. The punctiform
extravasations which may be found with deposits of pigment are also
found without it.
Minute particles of fat have been found in cerebral capillaries, but
are much less common here than in the lungs. They may be derived from
the decomposition of a thrombus, as described above, or they may come
from a fractured bone, when, of course, only particles fine enough to
pass through the pulmonary capillaries can reach the brain. This form
of embolism has an interest in connection with diabetic coma.
Collections of white corpuscles in considerable number have been
observed to form an embolus. These cannot be considered to differ very
widely in character from the ordinary fibrinous embolus, which
contains white corpuscles. It is, however, not certain that such
emboli are deposited during life.
Calcareous masses formed from the decomposition of bone have been seen
in cerebral arteries.
About the symptomatology of such emboli little is known. An array
{981} of minute emboli from the breaking up of a thrombus in the left
auricle, carotid, or even aorta, might possibly so block up large
numbers of arterial twigs as to give rise to the ordinary symptoms of
embolism; but considering the possibility of the re-establishment of
circulation, provided a certain proportion of the minutest vessels
escape, complete anæmia of a large tract produced in this way must be
rare. It is possible that some of the slighter and more transitory
attacks of hemiplegia or of more or less vague cerebral symptoms may
be referred to a lesion of this kind, the first action of a large
number of emboli being to cause an anæmia, which is compensated for
much more rapidly and thoroughly than would be the case if a single
considerable vessel were obliterated.
Various attempts have been made to connect definite and peculiar
diseases with capillary embolisms. Chorea in particular has been said
to depend upon a lesion of this kind, but, although cases have been
observed where the symptoms and lesion coexisted, yet they are very
far from being the rule, or even from constituting a respectable
minority of cases. The lesion of chorea in the great majority of cases
is not known, although attention has been directed to this theory long
enough to have established its truth.
The same may be said of the relationship between pernicious attacks of
intermittent and pigment embolism. There is occasional coexistence,
but far from invariable. Cerebral symptoms of the same kind and
severity occur without as with the pigment deposit. If pigment
embolism is the cause of coma, delirium, etc. in pernicious fever, it
is difficult to see why such cases can recover so rapidly, and why no
symptoms referable to a localized cerebral lesion are observed after
the primary unconsciousness.
Even less proof can be adduced as to any connection between leukæmic
embolisms and the cerebral symptoms occurring toward the end of severe
acute disease.
Calcareous embolism is a pathological curiosity.
DIAGNOSIS.—In the case of multiple capillary embolism it would be
impossible, if it were complete, to distinguish it from a blocking of
the main branch.
Cerebral symptoms arising in the course of ulcerative endocarditis
might be referred, with a high degree of probability, to an embolus,
but if they were distinct enough to be referred to a localized lesion,
the probability of a single embolus would be much greater than that of
a multitude of capillary ones occluding the same vascular territory.
The diagnosis of pigment embolism might be a probable, or at any rate
a possible, one if in a long-continued case of paludal fever, where
the liver and spleen were enlarged and the skin had the slaty hue
marking the deposit of pigment, there were decisive cerebral symptoms.
It could not, however, be a positive one.
Fatty embolism might be suspected in a case of diabetic coma, though
even if the condition were found it would not establish the relation
of causation.
PROGNOSIS AND TREATMENT can hardly have a definite basis in the
absence of all ground for a satisfactory diagnosis, but do not differ
essentially from those of the larger occlusions.
{982} Thrombosis of the Cerebral Veins and Sinuses.