Compliments of the Author. 
THE 
TREATMENT OF APOPLEXY. 
BY 
CLARENCE BARTLETT, M.D., 
PHILADELPHIA, PA. 
Reprinted from the Hahnemannian Monthly, December, 1892. THE 
TREATMENT OF APOPLEXY. 
BY 
CLARENCE BARTLETT, M.D., 
PHILADELPHIA, PA. 
Notwithstanding the generally accepted views that but little 
can be done in the way of relief for a case of apoplexy, I believe that 
proper measures instituted promptly will do much to lighten the 
subsequent disabilities. Even preventive treatment is of consider- 
able use, but unfortunately the lesions that predispose to cerebral 
hsemorrhage escape recognition so frequently, that but little is ever 
done for the patient in this respect. 
It is pretty well recognized that apoplectic seizures can only occur 
in the presence of vascular degeneration. In all patients in whom 
this condition is likely to exist, all influences which serve to increase 
intra-arterial tension must be avoided. The most frequently observed 
pathological condition of the vessels producing apoplexy is miliary 
aneurisms. So far as we know, there is no known measure aside 
from such general ones as tend to maintain the normal standard of 
health, that will prevent their progress. Their rupture is only a 
question of time. Their diagnosis is entirely out of the question. 
Next to miliary aneurisms in frequency as a cause of intra-cerebral 
hsemorrhage is atheromatous changes of the bloodvessels. Here we 
depend upon the condition of the radial artery and the age of the 
patient as a means of diagnosis. This condition is likewise unpre- 
ventable, as it is one of the changes incident to advancing years. 
In young adults, practically the only cause ot apoplexy is syphilitic 
degeneration of the arteries. This of course may be obviated by 
efficient treatment of the syphilitic diathesis. 
Certain diseases of the kidneys act in a twofold manner to produce 
apoplexy. In the first place, they are not infrequently productive of 
vascular disease, and in the second, they are often associated with 2 
high arterial tension. Their proper treatment is practically one 
which lessens the chances of subsequent cerebral haemorrhage. 
Abstinence from meat diet and all alcoholic beverages, moderate 
indulgence in eating, a quiet life, the free drinking of water, the 
avoidance of exciting emotions, and the use of remedies like glonoin, 
arsenic, arsenic iod., phosphorus, belladonna, and nux vomica are 
simply invaluable. 
The treatment of the seizure itself is usually not very satisfactory, 
in that some permanent damage nearly always results, and yet I am 
satisfied that much may be done to alleviate the symptoms and ren- 
der these later phenomena of apoplexy less disabling. In the first 
place absolute rest is of the highest importance. It has been claimed 
by some authorities that the apoplectic attack coming on very sud- 
denly, that all damage is done in an instant. This is a mistake. 
One not infrequently meets with cases in which the symptoms are 
an hour or two, and even longer in developing. Often under these 
circumstances patients are encouraged by their friends to walk 
around, to throw their bad feelings off; most pernicious advice truly. 
The rest should be so absolute as to avoid even the making of pas- 
sive movements. 
Attention to the posture with the patient recumbent is not to be 
neglected. When stertor is a prominent symptom, the patient should 
be placed on his side. The effect of this change is sometimes won- 
derful. The loud snoring respiration ceases, the congested face pales, 
and the arterial tension diminishes at once. 
The clothing should be loosened, and the head should be so placed 
as to avoid flexion of the neck, thus doing away with all obstruction 
to the return flow of blood from the brain. 
When collapse is not present, the application of ice to the head 
has a beneficial effect, as it serves to excite contraction of the cerebral 
vessels. When collapse is present, mustard plasters to the nape of 
the neck have been recommended by Gowers as of value in inducing 
reflex contraction of the arteries. 
The lancet as a means of reducing arterial tension has been very 
properly abandoned by all intelligent physicians in the treatment of 
apoplexy. We may, however, employ the device first formally sug- 
gested by Dr. Dawbarn, of New York, to " bleed the patient into 
his veins," so to speak. As soon as possible the physician should 
cut oft* the return circulation from the lower extremities. This is 
done by the application of an Esmarch bandage, a tourniquet, or 
Spanish windlass to one or more of the extremities, and as near the 3 
trunk as possible. The apparatus should be made sufficiently tight 
to obstruct the return flow through the veins pretty thoroughly, but 
not so much so as to interfere with the arterial flow. Experimental 
evidence shows pretty clearly that this procedure lowers arterial ten- 
sion, and favors the cessation of internal haemorrhages. The pres- 
sure should be kept up for about an hour. Then the blood should 
be permitted to enter the general circulation very slowly. The only 
objection to Dawbarn's suggestion is that of possible danger in the 
hands of those who are unskilled and who lack judgment. Persons 
of that kind should never undertake the treatment of a human being, 
no matter how mild his ills ; consequently the objection fails to have 
weight. 
There are cases, many of them indeed, in which all our best- 
directed efforts fail of relief, and deep and long-lasting coma super- 
venes. These must be treated on general principles. The bedding 
requires the most careful attention, owing to the danger from bed- 
sores; in extreme cases the water-bed is advisable, if not absolutely 
necessary. Extreme cleanliness must be enjoined. 
When the extremities are cold, hot water bottles should be used. 
They should be applied with the greatest care, however. Owing to 
the patient's helpless condition the liability to produce burns is great, 
and a burn in a hemiplegic patient is a serious matter, for local 
nutrition is poor and the danger of sloughing correspondingly great. 
In all cases stimulation by alcohol is bad practice. 
Should there be a very high temperature (105° F. or higher) I 
should certainly have recourse to the ice pack. I have used it in 
other brain affections with high temperature with excellent results, 
though as yet not in apoplexy. 
As to medicines, if in the beginning there is an excited condition 
of the circulation, aconite should be administered. It will almost 
certainly have a beneficial effect. 
If the cerebral congestion be a prominent symptom belladonna 
should be thought of, especially with the characteristic circulatory 
disturbances of that remedy. 
Glonoin I would advise in cases in which the arterial tension is 
high and there is coexisting kidney disease. One drop of the first 
centesimal dilution should be given three times daily. As the ad- 
ministration of the drug is continued it may be given at shorter 
intervals until the patient is taking it every two or three hours. 
Opium should be thought of in cases characterized by marked 
venous congestion. The profoundness of the stupor is not an indi- 4 
cation for the drug, because that is dependent upon the severity of the 
case and therefore upon mechanical causes only. For this opium, 
or in fact any other drug, is powerless. 
Arnica is the drug that should be administered after the acute 
symptoms have subsided to promote absorption of the effused blood. 
For the subsequent paralyses causticum, has done more good in my 
hands than any other remedy. It is of course impossible to say how 
much of the improvement in these cases is due to drug and how 
much to time, which is certainly an essential element in their cure 
and improvement. 
Sulphur and baryta carb., the latter especially in old people, have 
likewise been recommended as remedies that will promote the ab- 
sorption of the clot. 
Attention to the kidneys is always an important matter. When- 
ever there is any albuminuria or excess of uric acid I advise the 
use of Londonderry or Buffalo lithia water, preferably the former 
carbonated. 
When the subject of cerebral surgery was first broached it was 
thought that a possible remedy for apoplectic extravasations had 
been announced. Unfortunately, this is not so, for it takes but a 
little thought to see at once that surgical interference in the vast 
majority of cases is worse than useless, probably harmful. When 
the symptoms are such as to point without question to a sub- or 
extra-dural haemorrhage, much may be accomplished, providing, of 
course, that the cerebral arteries are not too far advanced in their 
degeneration. When, on the other hand, the haemorrhage is in the 
corpora striata, the effused blood cannot be liberated without seri- 
ously damaging important brain fibres. 
Electricity is often proposed as a remedy in apoplectic paralysis. 
There is great danger that the pressure brought to bear by the 
family may lead to its use either too early in the case or in entirely 
unsuitable cases. I would advise that the patient be permitted to 
enjoy rest without electrical interference. In the course of a month 
or so the application of galvanism to the head may prove useful by 
promoting absorption of the clot. Galvanization of the contrac- 
tured muscles and faradism of their opponents have been recom- 
mended when the stage of late rigidity has come on. I have had 
very little success with these measures, and have ceased encouraging 
patients to resort to them. I have decidedly more confidence in the 
applications to the head. 
Horsley has recommended ligation of the common carotid on the 5 
side of the lesion as a means of stopping the internal haemorrhage. 
There can be no doubt, if we are to judge from experimental evi- 
dence, of the efficacy of this procedure, but the operation is of such 
a severe character, and requires so many precautions to render it 
safe, that by the time it has been performed the haemorrhage has 
ceased spontaneously. Carotid compression is probably as efficient. 
Something can be done in the late stages of post-apoplectic par- 
alyses by properly directed gymnastics of the paralyzed parts. The 
aim should be to call the healthy side of the brain into play to help 
the injured one. This may be done by directing similar movements 
to be performed on both sides of the body simultaneously. It is 
astonishing how much better are the movements of the paralyzed 
extremity when thus performed than when the limb is made to move 
by itself. This is a field that has not been thoroughly developed, 
but I think it one of some promise. 
The apoplectic patient is in every instance a disabled one. Though 
he should be so fortunate as to recover without a semblance of par- 
alysis he is still largely incapacitated for his former labors. Ever 
afterwards he should live, as far as possible, quietly and abstemiously, 
enjoying life as best he may.