The danger seems to be chiefly proportioned to the difficulty of respiration; - if it be tolerably easy, and the patient can swallow, there are hopes; but if respiration be very difficult, or intermittent, and what is given the patient to drink returns immediately by the nose, a recovery is hardly to be effected. Old people, worn out constitutions, and those who have been formerly attacked with apoplexy, seldom recover; but in moderately healthy persons, in the prime of life, recovery is not uncommon.
Those who have been attacked with any kind of apoplexy are subject to relapses, each of which is more dangerous than the preceding. Suppers, hot rooms, violent exercise, particularly in the sun, going to bed late, long sleep, continuing in the cold, especially if the feet are subject to be cold, and whatever is suspected to dispose to this disorder, must be carefully avoided.
Were the distinction of the kinds of apoplexy formerly noticed as easy in its application as it appears simple and comprehensive, the treatment of the disease might be clear and scientific. There is not a doubt of its real accuracy; but in an organ so tender as the brain, a slight compression soon destroys the minute and complicated functions for which it is designed. We thus find, and the facts will be more clear when we treat of the lesser degrees of apoplexy, particularly palsy, that the practice must soon become general and indiscriminate.
In sanguine apoplexies, in the young or robust, there can be no doubt of bleeding copiously; nor in such circumstances can any limit be offered if the remedy can be early applied, except a melioration of the symptoms. The patient should be kept in an upright position in free cold air. In fact, the disease in this state is an haemorrhage of the brain: it however very seldom occurs except from blows on the head.
The shades between this and the serous apoplexy vary so imperceptibly, that, respecting bleeding, much must be left to the discretion of the physician. If the patient was previously of a full habit; if the remote causes have been such as very certainly to propel the blood from the extremities or surface to the head; bleeding may be admitted: yet we should hesitate in proportion to the age, the weakness, or the previous relaxed state of the patient. Topical bleeding by the cupping glass, or by leeches, may be perhaps allowed; but in doubtful cases it is best to abstain. Bleeding in these more often injures than relieves.
The use of emetics in apoplexy has lately occasioned a warm, perhaps a disgraceful, acrimonious controversy, and it is a subject of no little difficulty. During the operation of vomiting, the vessels of the head are undoubtedly distended, and a very slight reflection would at once seemingly show that it must be injurious. On the other hand, nature appears in such circumstances anxious to excite vomiting; but the force of this argument is lessened by the reflection, that vomiting equally follows an affection of the head from external violence. It may indeed be doubted, whether, in every haemorrhage, vomiting is not as useful by deriving to the surface, as injurious from any other effect. This consequence of vomiting we shall more fully examine in our treatment of haemoptoe, and even maenorrhagia. We think it at least established, that no partial determination from the action of vomiting itself is so injurious as to counterbalance its other good effects. These are the heads of what might be easily expanded into an ample disquisition on the subject; and, in this contention of doubts and difficulties, let us attend to experience. Vomiting, in apoplexy, has been spontaneously excited without injury. This has been evinced by frequent observation, and we can add, that, when produced artificially, as we have often seen, it has never increased the alarming symptoms. Totally independent of theoretical considerations, we consider therefore emetics as useful. Let them however be cautiously administered, and let the practitioner be decided by what he sees. If emetics are however to be exhibited, we must avail ourselves of the first moment of the patient possessing the power to swallow.
The next step, equally necessary in apoplexies of every kind, is to procure a passage through the bowels. The more violent resinous cathartics act slowly; the others require to be given in doses, which are with difficulty swallowed. An active clyster is, therefore, the first method of emptying the bowels: those who recommend lenient ones certainly never saw the disease. The remedy most easily obtained is the black soft soap, of which a full table spoonful may be dissolved in a pint and half of water. A handful of common salt may be dissolved in the same quantity of water if the soap is not at hand; or two ounces of common soap may be combined with a pint and a half of fluid. Should these not succeed, three drams of the pulp of colocynth may be boiled in a quart of water to a pint, and two ounces of common salt, with as much oil, added. When the patient can swallow, the pulv. jalapii with its tincture, and the tincture of senna, may be given in such doses as are necessary, or the patient can take.
While these measures are operating, a blister should be applied to the nape of the neck, or to the vertex, if the head is usually shaved. It has been a custom to apply with these, blisters to the legs and sinapisms to the feet, as if remedies could not be too fast accumulated. Such practice is highly injurious, for the stimulus, before the evacuation can take place, increases the disease. When the apoplexy proceeds from retro-cedent gout, sinapisms to the feet are useless or dangerous: for nothing more certainly prevents a return of gout to the joints, than inflammation excited on the integuments of the part.
When these medicines have produced their effects, the practitioner should carefully watch their influence on the disease. The patient should still be kept in free cool air, and the utmost quiet should prevail around. If with this plan the complaints increase, it must be soon fatal: if it continues stationary, we may yet hope: if the patient is relieved, our hopes are more alive. In general, we would advise, after a day or two, the opening of another drain; and, at all events, the discharge from the bowels should be kept up by clysters or cathartics. Light but generous food should be taken in small quantities, and the most strict tranquillity preserved. In this way the senses gradually revive, and the returning sense should be managed with address and caution. The patient should not be acquainted with the nature of the attack; it should be considered as a transient fainting; every symptom should be represented as trifling, and no anxiety should appear on the countenances of those around. Every thing should seem to follow the course the patient was accustomed to.
The means of prevention are to keep up a drain by X a blister, an issue, or a seton near the head, to keep the bowels free, and to prevent all agitation, or every cause of irregular action of the sanguiferous system. The diet should be light and easy, but nutritious and generous, except in the mere acute, sanguine apoplexies; and the bark, with valerian, we have sometimes found useful in the more irritable or the more relaxed habit.
A coup de soleil, of which we have some slight instances in this climate, occasionally assumes the appearance of apoplexy, but it never bears evacuations; and requires tonics, rest, and tranquillity. If this kind even arises from inflammation, the inflammatory stage is so slight and transitory that there is no time for the operation of medicines adapted to it.
Those apoplexies which arise from the diminished mobility of the nervous fluid require only active stimulants, free air, and perhaps air of greater purity. There is little room for choice in the stimulants we employ, but perhaps the Galvanic fluid will be found preferable. It follows the course of the nerves, and appears the best exciter of their activity. See Galvanism.
The consequences of apoplexy are sometimes singular; a weakness of the mental powers in general follows, with a degree of irritability that verges on the fretfulness of childhood. The patient laughs or cries, more frequently the latter, without any adequate cause, and is, amused by trifles adapted only to the inhabitants of the nursery. A singular effect is a forgetfulness of former acquired ideas, and it has happened that for years the patient has not been able to count five. These facts may admit in future of some application: it is sufficient to point them out in this place.
Dr. Flemmyng recommends trepanning as a powerful assi6tant in the cure of apoplexies, by taking off a degree of pressure from the brain. See his observations on this subject, in the Med. Mus. vol. ii. page 300, etc. Some of theasphixiae are considered as belonging to this disease. See Asphyxia.
Coelius Aurclianus, Lommii Opusculum Aureum, Arctaeus, Philumenus, Galen, Paulus AEgineta, Baglivi, Boerhaave, Hoffman, Stahl. Tissot's Practical Obs. on the Apoplexy. Wallis on Disease and Health. Cullen's First Lines, vol. iii. edit. iv.