Cerebral Apoplexy





Cerebral apoplexy is an extremely serious organic disease that seems

surely to be an affection for which psychotherapeutics can mean little

or nothing. When an artery has burst in the brain and blood is either

actually flowing out or has flowed out in damaging quantities into the

delicate brain tissues, seriously injuring and perhaps destroying some

of them forever, no amount of mental assurance will do any good for

the organic lesions that have been produced. All that can be hoped is

that the hemorrhage will not prove fatal and that the powers of nature

will be sufficient to deal with it, and though not able to cure it in

the sense of restoring tissues to former conditions, will compensate

for the lesion in some way and dispose of its products so effectually

that but little interference will result with nerve functions within

the skull.



There is no pretence that by psychotherapy or any appeal to mental

powers anything can be done for the underlying pathological process.

And it may be frankly said that no remedy of any kind, physical or

mental, will avail much, while some of those that have been suggested

are just as likely to do harm as good. Position, with the head

elevated and quiet of mind and body are the only remedial measures

that promise definite help. Excitement greatly increases the danger.

Reassurance does more than anything else to lessen blood pressure and

lessen also the danger of a hemorrhage producing fatal effects. In

nervous, excitable people the first stroke is often fatal.

Occasionally the phlegmatic have three or more ruptures of brain

arteries before death supervenes. Psychotherapy, then, has a definite

role even at the time of the apoplexy.







The Mind Before and After.--Much can be accomplished for the patient

by proper attention to his state of mind both before and after

cerebral hemorrhage. There are many symptoms which point to the

possible occurrence of the rupture of a cerebral artery, and older

people are likely to know something about these and to dread them so

much that to some extent they may by worrying precipitate the evil

they fear. Many people, having read vaguely about apoplexy, having

seen a case or two of it perhaps, and having heard of others, develop

a dread of its occurrence in themselves that makes them miserable.

Finally, the shock of a cerebral hemorrhage is very great and its

after-effects likely to be very disturbing. It affects the whole

personality and often makes a strong, vigorous, healthy man a decided

hypochondriac. All of these associated mental states may be greatly

benefitted by psychotherapy.



A number of neurotic symptoms are always added to whatever

manifestations of mind and the somatic system may develop as a

consequence of the cerebral apoplexy, and these are treated more

effectually by mental reassurance than in any other way. Besides,

apoplexy confines people to the house who have often been vigorous and

active before, and this confinement with deprivation of exercise and

air and consequent disturbance of appetite and digestive functions,

acts as a serious factor in the production of neurotic symptoms. Tears

and hysterical manifestation are not uncommon, and for these

psychotherapy is the most important remedial measure.



In the period preceding true apoplexy there may be such symptoms as

persistent headache with peculiar sensations in one hand. These

sensations are variously described as creepy feelings or as of "pins

and needles," and occasionally as if the fingers and sometimes the arm

were asleep. The group of symptoms known as paresthesia are rather

common as premonitory symptoms of cerebral apoplexy. When these are

combined with headache patients often become seriously disturbed and

begin to dread the occurrence of apoplexy. While these are premonitory

symptoms of cerebral hemorrhage in those whose arteries are

degenerated, patients must be made to understand that just because the

fingers or hand or arm go to sleep occasionally, even though there may

be complaint of headache, these are not indications of impending

apoplexy unless other objective symptoms are present. Subjective

symptoms alone can never mean much as regards organic disease. It is

particularly neurotic individuals who are likely to exaggerate the

significance of their subjective sensations, who are also prone to be

so solicitous about apoplexy that they work themselves into a state of

fear with regard to it. Even children have their hands go to sleep

rather frequently, and at all ages if the arms or legs are placed in

certain positions or under certain conditions of pressure, they are

likely to develop that numbness which ends in the prickly "pins and

needles" feeling that is spoken of as "going to sleep."





Diagnosing Arterial Sclerosis.--Unless, then, some of the arteries at

the periphery of the body show signs of such degeneration as to

indicate advanced arteriosclerosis, any subjective symptoms, no matter

how bothersome, must not be allowed to depress the patient. Usually

they mean nothing at all, and would pass quite unnoticed but for the

patients' nervousness about themselves. If the temporal arteries are

not prominent and visibly thickened and tortuous, and this may be seen

at a glance, the patient may be assured almost without more ado. If

his radial arteries on careful observation show no signs of

degeneration, then it is extremely doubtful if there is sufficient

arterial change in the brain to justify a fear of arterial rupture. In

examining the radial artery it must not be forgotten that the pulse of

nervous people, especially such as have exerted considerable mental

control over themselves in order to come and see a physician about

what they think is a serious condition, is likely to be of high

tension. When the artery is rolled under the finger, then it may seem

that there is some thickening in its walls, though it is only

heightened blood pressure from emotion that causes the feeling. This

high blood pressure may, of course, of itself be an indication of

danger whenever there is heart or kidney disease, but it often occurs

as a passing event in nervous patients whose vasomotor control is so

capricious that arterial tension and blood pressure may change at very

short intervals as the result of excitement.



It may not be easy to obliterate the pulse in the usual way in many of

these cases and as a consequence the illusion of a thickened artery

may remain even when the vessel is quite normal. The important rule is

to ascertain whether the artery is tortuous. Whenever there is

thickening of the arterial wall the artery is lengthened as well as

thickened. If the artery is not lengthened the degenerative changes in

it are so slight, as a rule, as to be negligible. Indeed, the very

beginning of arteriosclerosis may thus be diagnosed. When this cannot

be found, patients may be completely reassured that their suggestive

symptoms have no significance as regards any possibility of cerebral

hemorrhage from the ordinary causes of advancing years and arterial

degeneration.





Differentiation.--Occasionally such paresthesiae as have been

described especially when associated with headache, point to an

intracranial growth, or to a developing syphilitic brain lesion, and

these must be carefully eliminated, but they constitute quite separate

problems which always present other accompanying symptoms that make

diagnosis possible once a suspicion as to the nature of the lesion is

aroused. Above all, these occur in much younger patients than are, as

a rule, the subjects of cerebral apoplexy.





Symptoms.--Dreads--Dizziness.--There are other symptoms of which

people have heard as preliminary signs of brain hemorrhage which

occasionally disturb them to a great degree and set up a set of dreads

that may be difficult to banish. Probably the one that is spoken

oftenest of is dizziness. There is no doubt that under certain

circumstances this may be a symptom of impending cerebral hemorrhage,

especially if it is accompanied by headache and by objective signs in

the arteries, but dizziness by itself is not enough to justify any

anxiety in even elderly people. If, when a man stoops over and then

straightens up rapidly everything becomes black before him and he must

immediately take hold of something to keep himself from falling, it is

probable that a pathological condition of his cerebral arteries is

present. This interferes with brain circulation and may have seriously

impaired the elasticity of the arteries which is so necessary to

overcome the rapid variations of the influence of gravity on the blood

current when there are sudden changes of position. Fits of dizziness

that come on immediately on rising in the morning, or that attack the

patient when he sits up suddenly in bed may have the same serious

significance. None of these signs are significant, however, unless

there are, as we have said, objective signs in the arteries.







But dizziness may come from many other causes besides degeneration of

arteries. A very common cause of it is the presence of gas in the

stomach which interferes with the heart action mechanically and so

disturbs the circulation. The column of blood to the head is more

easily affected than the rest of the circulation because it must be

pumped up directly against gravity when we are in a standing position,

and so any, even a slight, interference with the heart action is felt

at once in this portion of the body. Besides, the brain is extremely

sensitive to changes of circulation and even a slight disturbance of

the blood supply to it may cause dizziness. There occurs also

undoubtedly a feeling of dizziness that is entirely subjective. The

patient for some reason loses confidence in himself and has a feeling

of dismay, as if he could not support himself. Such a patient may

complain that when he comes down stairs, at the first step or two,

particularly of a high stairs, he has the dread that he may pitch

forward. Such people have never actually fallen, but they have to

grasp the railing and they have a dread of some accident of this kind.

This is, however, rather a form of akrophobia than a true dizziness.

Prof. Oppenheim has dwelt on vertigo as a dread (see preceding

chapter).





Vertigo.--Besides, there are pathological conditions that cause

dizziness yet have no connection at all with the dizziness that is a

premonitory symptom of apoplexy. Meniere's disease, for instance, even

in its milder forms, causes at times a vertigo that is extremely

annoying and that frequently gives rise to the fear that a serious

brain lesion is either actually occurring or is impending. I have seen

even comparatively young patients suffer so much from this dread that

life became miserable to them and they were unable to do their work

properly. A few words of explanation and reassurance literally work

wonders for such patients. In one case the young woman assured me over

and over again that my explanation meant a new lease of life for her.

She still has occasional dizziness, but now she knows that it is due

to her accompanying ear trouble and it does not worry her.





Motor Symptoms and Over-solicitude.--Besides dizziness, there are

other symptoms of which patients complain and which may indicate that

an apoplexy is impending or may mean only that a patient is occupying

himself too much with himself and his symptoms. Not infrequently when

there is degeneration of arteries in the brain there will be slight

weaknesses of the limbs or awkwardness in the use of them.

Occasionally women will complain of the fact that they do not button

dresses as they used to. Sometimes men will complain that they do not

button their collar or their suspenders at the back with facility, or

that they are awkward and grow fatigued easily in such strained

positions.



These symptoms may be indicative of some disturbance in the motor

areas of the brain, but it must not be forgotten that all of these may

be simulated by nervousness, especially if the person knows the

meaning that is attached by doctors to these symptoms. In this matter

particularly a little knowledge is a dangerous thing. We are only just

getting a generation of trained nurses to the age when they are likely

to suffer from dread of apoplexy and some of them are over-anxious

patients because of their knowledge without the balance of complete

practical experience with the meaning of such symptoms. Doctors

themselves are prone to be disturbed by such thinking more than

almost anyone else. The delusion of thinking apoplexy is not at all

uncommon in elderly physicians. In men it is important to insist that

objective symptoms are the only details of real value and that

subjective feelings are utterly illusory. If this cannot be brought

home to them they make themselves extremely miserable and may even

help to precipitate through worry the fatal complications they dread.





Prophylaxis.--There is no doubt but that heredity plays an important

role in apoplexy. In certain families most of the members terminate

existence by rupture of an artery in the brain, sometimes at

comparatively early ages. Apparently the resistive vitality of their

arteries is only sufficient to enable them to maintain themselves for

a limited length of time against blood pressure. They are destined to

have arterial degeneration that will predispose to arterial rupture

sometime before they are sixty. Father, grandfather and

great-grandfather had their apoplexies from fifty-five to sixty-five

and the son must realize that he probably will go the same way. Even

the delay of a year or two is important. Anything that will save the

wear and tear of existence may bring about such a delay and it is not

by drugs, nor even by dietetic precautions, so much as by attention to

the patient's state of mind that this decided benefit can be best

secured.





Over-indulgence.--People with such an unfortunate heritage should be

made to understand reasonably early in life that they must save

themselves from as much arterial wear and tear as possible. There are

certain occupations involving intense emotion and excitement that are

barred to them if they want to live out their lives, even to the

extent usual in the family. There are three causes that weaken

arterial walls. When the question of causation of aneurism is

discussed it is usually said that it is especially the devotees of

three pagan deities--Venus, Bacchus and Vulcan--who suffer from this

form of arterial trouble. Just this same class suffer particularly

from the tendency to early arterial rupture in the brain. Under the

head of devotees of Vulcan, the hard workers, must now also be placed

the advocates and exemplifiers of the strenuous life, who are

perpetually doing, though often it is hard to see what they

accomplish; the money-getters, who are really overworking as much as

the forced laborers of olden time. People with an apoplectic heredity

should not take up such professions as that of the actor, the broker,

the speculator of any kind, the lawyer absorbed by the strain of trial

work, perhaps not even that of the surgeon. Physicians generally are

not long lived because of the irregularity of their hours of eating

and sleeping and the responsibility of their professional life.



Many men will not be guided by such considerations and insist on

living their lives in their own way in spite of the possibility of the

family inheritance shortening their career in the late fifties. More

than one has said that he would prefer to have the life of the salmon

rather than that of the turtle. The strenuous life alone appeals to

them.



"Better fifty years of Europe than a cycle of Cathay."



This would be an admirable response if what these men accomplished

during their lives amounted to anything. Most of these who run out

their existences in the midst of excitement, however, only do harm by

adding to the swarm of speculators in life, or accomplish very little

because of the intense excitement under which they labor. It is

the quiet lives, doing a few things and doing them well, outside of

the strenuous current of the bustle of existence, that accomplish most

for mankind. The others may attract attention for the moment, but they

soon pass out, often having done rather harm than good.





Life-direction.--It is perfectly possible for the physician to make

this clear to a young man with a dangerous heredity and perhaps change

the current of life so as to make it effective in simplicity and

serious patient work. The young man will usually be quite impatient to

think that anything thirty years ahead should be expected to influence

his decision as to how or what he shall do with life, yet this motive

added to others may help to get at least some of this and the next

generation from wasting their lives in an over-strenuous existence

that at most merely accumulates money, often accumulates it only in

order to lose it, with consequent disappointment and worry, and

frequently leaves no real accomplishment but only the problem of the

disposal of accumulated wealth for future generations. Where large

wealth is left to the succeeding generation there is usually little

use to give any advice with regard to the possibility of early

apoplexy, because excitements of other kinds than those of business,

of the heart rather than the mind, are likely to wear out existence

even before the time when the family life of arteries ordinarily,

though precociously, runs itself out.



Certain people have what is called the apoplectic habitus, that is,

they are short in stature, rather stout, with short necks and florid

complexions. It seems not unlikely that the mechanical arrangement

within their bodies by which the distance from their heart to their

brain is so much shorter than in ordinary persons is responsible for

the tradition so generally accepted that there is a definite tendency

in such people for apoplexy to occur at a comparatively early age.

Such people should be warned gently but firmly of the danger that they

incur if they subject themselves to a life of excitement or emotional

stress or permit themselves to get into circumstances in which they

will worry much. It may seem as though a warning of this kind would

precipitate the worry of mind that it is meant to ameliorate, but in

present-day publicity such people are likely to have heard of the

meaning of their particular constitution of body and consequently

worry about it, but usually after it is too late to do any good. In

this matter, as in heart disease, the warning must come before there

are any symptoms, or else must not be used at all.





Certain Abuses.--In most of these cases definite warnings with

regard to habits of life and indulgence in stimulants and narcotics

should be given. Both Prof. Von Leyden and Prof. Mendel of Berlin

insist that for patients in whom there is any likelihood of the

development of early apoplexy indulgence in alcoholic liquors is

almost sure to be serious, but in addition to this generally accepted

warning, both of them also insist that smoking has a tendency to

produce serious, premature degeneration of arteries, especially in

people who already have tendencies in that direction. Overeating and

high living in general without moderate exercise causes a plethora of

the circulation that must be avoided. On the other hand, violent

exercise, running especially to catch trains or cars, haste in the

ascent of stairs or hills, heavy lifting, straining at stool, and the

like, are particularly prone to have serious consequences for such

people. This warning is all the more needed because many a short,

stout man acquires the idea that gymnastic work and various

exercises indoors may help him to reduce his weight and restore the

activity of his earlier years. This is practically always a delusion

and indoor gymnastic work is always of dubious value.



What these people need is not more muscle and the wearing off of fat

but more air and the burning of it off by increased oxidation. Such

patients must be taught to lead tranquil lives without any of the

excitement and strenuosity that, after all, accomplishes so little.

The sacrifice when first suggested, appears too great a one to make,

but after a few years patients instead of feeling that it was a

sacrifice at all pronounce it to be a blessing in disguise and are

proportionately grateful to their physician. Life for many of these

people may be prolonged not for a few years of hustle-bustle, but for

many years of good work in quiet and peace, without hurting others by

competition, but helping many because there is time in their

considerate lives to see something of the sorrow and suffering around

them and to relieve it.





Change of Occupation.--In the matter of prophylaxis it is

particularly important to insist on the fact that when men have worked

at hard manual labor when they are young and then, about middle life,

have turned to intense intellectual labor, such as the management and

administration of important affairs, they are a little more liable

than are the general average of humanity to have an apoplectic seizure

at sixty or a little later. Apparently inurement to a particular kind

of labor when young makes for the capacity to stand it longer than

would otherwise be the case. In this matter, however, the most

important factor is heredity. Men who come from long-lived families

are likely to live long--indeed far beyond the ordinary term of human

life. Even in them, however, certain of these directions are helpful

in securing the full measure of life.





After the Stroke.--After a stroke of apoplexy when it becomes clear

that nature is about to reassert her control over the circulation in

the brain and dispose of the remains of the old hemorrhage,

psychotherapeutics is more important than anything else that we have

for the treatment of these patients. As a rule, they have been active,

vigorous men who are stricken and who suffer more from doing nothing

and waiting to get better than from any pain they have to undergo.

They know that another stroke may come at any time. It is no wonder

that introspection plays its part, that every feeling that they have

becomes exaggerated in significance, that their appetite fails them,

that their bowels become sluggish, that they do not sleep, or that

after having fallen asleep they wake up and then for hours lie awake

thinking.





Lack of Air and Exercise.--As they usually have no exercise of any

kind, do not get out into the air, and have very little diversion of

mind, it is easy to understand that neurotic or hysterical symptoms

develop, that they lose all confidence of recovery and make themselves

even worse than they are by dwelling on their condition. The only way

that this group of symptoms can be treated is by favorable suggestion,

by encouragement, by mental reassurance and by occupation of mind.



I have always felt that the condition of affairs which developed in a

family immediately after the occurrence of an apoplexy usually makes a

very unfavorable environment for the treatment of these cases. It is

practically impossible for those who come to visit the patient or for

the members of the family for some time to wear anything but the

resigned air that indicates that they fear the worst.





Sympathetic Care.--After the stroke at once when survival is assured

comes the question of the management of the patient. A devoted

daughter seems to be able to do more for an apoplectic father than

anyone else. Somehow her youth appeals to him sympathetically, and he

has not that feeling of sadness mixed with a little envy that comes so

readily to all men when they find themselves slipping out of life

while their contemporaries and friends and relatives are left behind.

It is as if the idea of his daughter being young and strong, even

though he has lost vitality, docs not touch him poignantly because he

has always expected that she should have health and strength after he

was gone. On the other hand, a daughter is not always a good nurse for

a mother. Just why, is hard to say. A hired nurse must take, as a

rule, the place close to the mother which, in the case of the father,

so naturally falls to the daughter. These ideas may be founded on too

few cases to generalize very much about, but I have discussed them

with many physicians, including some women physicians, and they agree

with them, in general principle at least.





Trained Attendance.--As a rule, then, the first thing that has to be

done for a patient who has had apoplexy and who is beginning to

recover, is to have trained attendants near him who talk

professionally to him and reassure him and do not make him feel

constantly the possibility of an approaching end. If his improvement

has begun his family must not be allowed to bother him, his affairs

should not be talked over and, as far as possible, some occupation of

mind should be secured for him. He needs new interests at once. These

must be gradually awakened and he must be made to feel as early as

possible that though he may be more helpless than before and most of

his ordinary occupation in life may be cut off, there are still many

interests in life which he may thoroughly enjoy. I shall never forget

hearing Thomas Dunn English, the dear old poet to whom in his earlier

years we owed "Sweet Alice, Ben Bolt," say at an alumni dinner of the

University of Pennsylvania that he used to think that all the good

things of life were somehow contained in its first eighty years, but

that now since he had past his eightieth birthday (he was at the time

in his eighty-third year) he was beginning to agree with Bismarck, who

declared under similar circumstances that he had found many interests

in the second eighty years of life. At the time English was quite

blind, was almost completely deaf, had been seriously ill for several

months, and had suffered a rather severe stroke some years before; and

yet he made the best speech at the dinner that evening and had the

youngest heart of us all--joyous, uplifting, encouraging, optimistic.





Outlook.--Men who have been great workers are prone to think that a

stroke of apoplexy means the end of all serious work. Of course, it

means nothing of the kind for the majority of patients. Many men find

not only enjoyment in life after their recovery from even a serious

stroke, but also possibilities of accomplishment sometimes better than

they had done before. It has even been known that men who had been

occupying themselves with things scarcely worth while, with the mere

accumulation of money without any purpose, were awakened to a sense of

their responsibilities to life and to their fellowmen by a stroke and

planned in the after years institutions or aids to existing

institutions that did much to make life more livable for others.

Nothing makes a man face life in a better mood to do really effective

service for mankind than the prospect of possibly soon having to go

out of life.





Encouraging Examples.--On the other hand, many men have been able in

spite even of a severe stroke to go on after a time with the work they

had been at before and, though feeling its effects, accomplish the

best achievements of their lives. A typical example is the case of

Pasteur, the great French bacteriologist, to whom we owe most of our

modern preventive medicine and to whom Lord Lister frankly attributes

the germ idea of the antiseptic theory. When little past fifty,

Pasteur after years of hard work and worry suffered from a severe

stroke of apoplexy followed by several of slighter character. It

seemed absolutely the end of his labors. For more than a year he was

able to do nothing. For all his after life he was seriously lame as a

consequence of his stroke. In spite of this, which would seem to

preclude the possibility of great intellectual work, Pasteur's most

important discoveries were developed after this time and he continued

for over twenty years to be the leader of biological science. Had he

died at the age of fifty or given up his work we would scarcely know

him for the great scientist that he afterwards proved.



It is worth while to be able to tell the stories of such lives as

examples to patients who are dispirited and downhearted after a

stroke. Of course, men must be prevented from doing hard work or from

worrying during the time immediately following the hemorrhage of the

brain, and, indeed, for some months. Work and worry, though worry much

more than work, might easily hasten a recurrence of the seizure. It

has always seemed to me, however, that it is impossible to keep the

human mind utterly unoccupied. Men must think about something during

their waking hours, and if they have not some interests close at heart

they worry about themselves. Of the two things, worry is much harder

on the tissues, raises blood pressure more, disturbs the circulation

of the brain to a greater degree than does work. Anything that a man

will interest himself in, then, should be allowed to him, provided, of

course, that he is kept from getting into the state of mind which

precipitated the rupture of the artery in his brain. It is a change of

mental occupation above all that is needed and this is secured by

deliberate attempts to interest his mind in various ways and keep him

from dwelling on himself and his ills. This injunction cannot be

repeated too often.





Change of Mental Interest.--I have already insisted in the chapter

on Diversion of Mind that so far as we know at the present time

different portions of the brain are occupied with different subjects

in which we may interest ourselves. When a man by business worries,

occupation with financial affairs, or with political troubles, has

apparently worn out one portion of his brain, he may still use other

portions to decided advantage. Hence the necessity for finding new

interests for the apoplectic after their attack. The best interests

for them are those associated in some way with their fellows, because

these are accompanied by feelings of consolation, of encouragement, of

desire to live and do good to others. These do more to take men out of

their moodiness, their morbid introspection, and their

self-centeredness, than anything else. With the help of a good nurse,

herself of broad interests, this must become the main purpose of the

physician's treatment.







Misplaced Sympathy.--After the first few days, when the shock is

over, a strong, healthy man who has been suddenly taken down with

apoplexy, then rendered helpless as a consequence of the lesion in his

brain, rather resents the sympathy and, above all, the frequent

expression of the feelings of his friends towards him. Time is needed

for him to recover, there is no way of hastening it, he is already

impatient at the delay and words of sympathy do him very little good

and often add to his impatience. He is to be taken absolutely with

professional calm, made to understand that time is the most important

element in his cure, provided he will not worry and will have patience

to wait and to help as far as he can. I nearly always feel that it is

better for these patients to be away from home as soon as they can be

moved with safety. This enables them to avoid without much difficulty

what they are apt to consider the intrusive and obtrusive sympathy of

friends. Especially is this true of business friends, themselves in

good health, who come to offer their condolences.



Their hysterical condition is largely influenced by the fact that they

are indoors and have so little diversion of mind. Just as soon as

possible they must get out of doors. Over and over again I have found

that patients did not care to expose themselves to the inquisitive

gaze of neighbors and preferred to stay in the house, though the

outing would be of much benefit to them. Hence the necessity for

getting them away from home, among people whom they can observe

without attracting too much attention themselves and, above all,

without being the subjects of such obtrusive pity as will disturb

them. None of us likes to be pitied and least of all the strong,

vigorous man who often has had nothing the matter with him all his

life and is now suddenly stricken. It requires years of experience to

enable one to take sympathy properly and without resenting it.





Outings and Human Interests.--When patients care for carriage riding

I have found that the city park is an excellent place for patients

suffering from the effects of apoplexy, who require outdoor air and

diversion of mind, yet without exercise or much exertion. The children

in the park, if they play around, serve as a better diversion of mind

than almost anything else for elderly people thus stricken, for they

seem to renew their youth at the sight of the little ones.

Grandchildren make the best possible consolers even when they seem to

probe deep into old wounds by asking questions and by talking about

death. The talk of death from young lips has not the same disturbing

effect as from older people. The games of children interest the old

once more, and if there is occasional music and the chance to see the

passing throng of carriages and motor cars and the pleasure boats and

all the rest there is refreshment and reinvigoration in it all that

soon brings back to the patient deep, satisfactory, even dreamless

uninterrupted sleep at night, and appetite and strength. At first

there will usually be some objection to being thus treated as an

invalid, but only a few days of experience are needed to convert even

the most morbid to the idea that this outing will do them good. As a

rule, friends must be warned not to spoil the effect of it by fearing

lest the patient should be lonely and so go to the park to entertain

him. If the drive, the lake and the children, as well as the

passers-by, do not suffice to give the patient sufficient diversion of

mind, the visits of friends will not have any favorable effect. As a

rule, it is better for them to see the patient at home and even

that not too often unless they are of his immediate family.



Where people are able to go away and, above all, where they can have

some pleasant companionship, a seaside resort is an ideal place for

those recovering from apoplexy. The long ride in a wheel-chair on the

boardwalk at least several hours in the morning and afternoon soon

acts marvelously. There is constant diversion of mind at any season of

the year, for there are lots of people to be seen in all sorts of

costumes and the shops and the shows and the passing throng all have

their interests. Then the sea air is bracing and tempts to

sleepfulness and just as soon as sleep improves courage comes back. I

have known patients so hysterical that they were crying every day and

that seemed to have given up all hope, improve so much in two weeks at

Atlantic City that it seemed little short of marvelous. What is

needed, however, is not a stay of a few weeks but of several months.





Prognosis of Strokes.--While, of course, any single stroke may be

fatal and no one can tell anything about the prognosis of a rupture of

a brain artery, there are many favorable things that can be said to

patients, and they are so prone to think of all the unfavorable things

that this better side should be presented to them at once. The

physician is tempted to present the worst side of the case lest it

should be thought that he did not realize how serious the condition

was. All the seriousness of it may be impressed upon friends, but the

patient must be told all the possibilities of good. I have always felt

that the tonic quality of hope was worth more in preventing further

damage and in encouraging the beginning of repair than any drug that

we have. If patients have been unconscious, just as soon as

unconsciousness disappears, they should be told that very probably

this is the beginning of recovery and that the great majority of

people who have a stroke recover. The more rapidly the symptoms

disappear the better is the ultimate prognosis. Many a man who has had

a stroke has done years of good work afterwards and very few men who

recover fail to accomplish something that is of supreme satisfaction

to them. They have a new outlook on life as a consequence of the near

vision of death.



Those who have had one stroke usually die in a subsequent one, though,

of course, some intermittent disease such as pneumonia or some organic

complication may anticipate the second stroke. Those who have had two

strokes and survive are often much worried by the old tradition that a

third stroke is always fatal. I am reasonably sure that many old men

have not survived their third stroke when they felt its premonitory

symptoms and knew just what was coming from their previous experience,

because they had given up hope on account of this old tradition.

Ignorant people or those of the lower classes who have not heard this

axiom often survive their third stroke and I have seen a man who had

suffered from seven apoplectic seizures.





Complications.--Occasionally a patient, especially if of the educated

classes, may be much worried by the fact that while one side is

distinctly lamed after his stroke, yet there is also a pronounced

weakness on the other side of the body. This sometimes gives rise to

the rather appalling thought that there was perhaps a simultaneous

rupture on both sides of the brain. It needs to be explained to such

patients that this slight weakness, sometimes quite distinct, however,

on the side opposite that which is most affected is extremely

common. Ordinarily the rupture of an artery on one side of the brain

causes a paralysis on the other side of the body. This paralysis or

loss of control over muscular action is due to disturbance of the

motor tracts of nerves through which muscular action is controlled and

directed by the brain, and these normally cross to the other side on

the way to the periphery. In nearly everyone the tracts remain

uncrossed to some slight extent. In some so much of the pyramidal

tract remains uncrossed that there may be decided weakness on the same

side as the lesion in the brain.





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