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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

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

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

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

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

"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

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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