Medical Therapy of Acute Stroke

69 it is not wise for sociology to become involved with trying to bring about social change, its viewpoint could be quite valuable to practitioners of medicine. Perhaps with an eye toward the more global perspective of medical sociology, medicine will be better able to formulate solutions to its problems in the future. Renaissance student of the brain, was one of the earliest physicians to study the pathogenesis of stroke. He made the following astute observations in his work de Apoplexia (1658): ". .. apoplexy is produced in the first place, either because the afflux of the blood through the arteries is denied to the brain, or because the efflux of animal spirits from the cerebrum and cerebellum through the nerves and spinal cord is prohibited ...." Although his observations are almost three hundred and fifty years old, they are in large part correct. While our present understanding of the causes and treatment of stroke may be more advanced, we still know surprisingly little, especially given the incidence of stroke. Medical Therapy ofAcute Stroke, edited by Mark Fisher, is a collection of thirteen essays on a variety on modalities which have been used in the treatment of stroke. Two additional introductory essays briefly cover the epidemiology and basic causes of cerebral ischemia, making fifteen chapters in all. While this is a relatively small volume of fewer than three hundred pages, it covers a diverse array of new and old modalities, including antiplatelet therapy, barbiturate therapy, calcium channel blockers, steroid therapy, percutaneous transluminal angioplasty, and fibrinolytic therapy. Perhaps the most interesting chapter is the one which examines the role of anticoagulation in cerebral ischemia. The author aplty summarizes the present situation: "Anticoagula-tion is widely used, relatively poorly studied, and substantially of unproven value .... there is major controversy over its value in preventing infarction in patients with transient ischemic attacks, in arresting progression in evolving stroke, and in preventing cerebral reinfarction. Nevertheless, most clinicians believe it 'works' in some situations." This statement is rather startling, given the incidence of this disease and the number of patients who are routinely anticoagulated with either heparin or coumadin. The chapter on hemorheology is also interesting from a theoretical perspective. More practically, rheological observations predict the pathological finding that atherosclerotic changes are more prone to develop along the posterior wall of the internal carotid artery. Overall, this is a fine set of essays. Each essay …