I cannot conceal from you the fact, which you have already ascertained from other sources, that you show the premonitory symptoms of a disease of the spinal cord. This admission is not, however, as you fear, synonymous with the sentence "the beginning of the end." There is no reason for you to despair. We doctors regard and welcome it as a marked advance in our scientific knowledge that we are now in a position to diagnose a nervous disease of this kind in its first commencement. This is undoubtedly a great gain for the patient, as on account of this knowledge a judicious, experienced physician may, at least in many cases, by the timely regulation of the mode of life and the prescription of certain remedies, arrest the progress of the disease or r.e.t.a.r.d its development. This advice may, however, and should as a general rule, be given without the patient himself being made aware of the diagnosis, for the ideas as to the nature of this disease which prevail in lay circles, and indeed among many doctors of the old school, arise from the knowledge of the disease in its advanced and fully established form, since it was only in this completely developed stage that it was recognized. Then, indeed, its very noticeable symptoms were obvious even to the uninitiated. This picture, sad enough indeed in itself, was rendered still gloomier by {512} the misery and despair which popular fancy has a.s.sociated with the conception of locomotor ataxia.

_Arteriosclerosis_.--Even with regard to so serious a disease and, of course, absolutely fatal in its progress as arteriosclerosis, it must not be forgotten that much can be done for the patients and especially for the nervous symptoms that develop in connection with the condition. For the progressive hardening of the arteries on which the nerve symptoms depend absolutely nothing can be done. A man is as old as his arteries, and we cannot bring back the years even though the patient has become prematurely old. For the symptoms so frequently seen in connection with arteriosclerosis, the paresthesia, the burnings, the numbness, the pruritus, the pains around joints and the difficulties in connection with them, even for the intermittent claudication which develops, much can be done. Above all, the patient must not be allowed to cherish the notion that his disease is not only incurable, but that nothing can be done for it. It is inevitable and progressive, but then according to one definition, life is a progressive disease and every day brings us nearer death. "Life is a dangerous thing at best," as an American humorist once said, "and very few of us get out of it alive."

These patients can be relieved of many physical symptoms, they can be encouraged, their attention can be diverted from their symptoms, and it is concentration of mind on them that often makes them intolerable, while occupation with something, especially if it is interesting, will often prove an efficient remedy for the discomforts complained of. Old people who have no interests, who have retired from business, who did not have the opportunity when young to acquire tastes in art and literature, above all, those who have no interests in children, no grandchildren nor close relatives near them, are likely to become centered on their ills in the midst of their arteriosclerosis, and this more than the advancing degeneration of arteries itself is at the root of their symptoms. The ideal old age is that which is pa.s.sed in the midst of younger people, with an occasional happy hour during the day with children in whom one is deeply interested. This is the best psychotherapeutic factor that we have.

Prof. Oppenheim has given the optimistic side of arteriosclerosis so suggestively that most patients suffering in this way should have the opportunity to read it. It occurs in his "Letters to Nervous Patients":

An eminent physician for whom I have much esteem has told you that your troubles, especially your vertigo, are caused by calcification of the arteries. You, sir, heard in this your death sentence, and since then the encyclopedia has revealed to you all the sufferings and terrors with which you may expect to be overtaken.

I would, however, explain to you, as the result of the most careful examination and the most absolute conviction on my part, that your anxiety is unfounded.

Since you have a certain amount of information and scientific knowledge, I may speak to you upon this matter almost as a colleague. One is certainly justified, when a man of your age complains of vertigo, in suspecting calcification of the arteries to be the cause of the trouble, since it const.i.tutes the common senile change, and vertigo forms one of its most frequent symptoms.

But--apart from the fact that in senile calcification of the vessels this vertigo is frequently a temporary and not always a serious sign--one is by no means justified in a.s.suming that the appearance of this symptom in later life is in itself, and without further evidence, the sign of such a cause. This is an error which in my experience is {513} far too frequently made, to the detriment of the patient. It is first of all essential to closely examine and a.n.a.lyze the symptom in itself. . . . Two years ago, after having overloaded your stomach, you had a real attack of vertigo, which was repeated several times during the day, until, by vomiting and diarrhea, the contents of your stomach were evacuated. Since that time the fear of vertigo has overpowered you. In my experience it is neither new nor uncommon to find that a man who has shown his intrepidity and his contempt of death on many a battlefield, who is a hero in war, may be overcome by some dread of illness, by some anxiety, or even by some pain, and may be distressed by it in a way that is in sharp contrast to his whole personality. Your remembrance of that vertigo is so lively that the mere idea of it suffices to reawaken the symptom, or at least an imitation of it which very nearly approaches the reality. That this idea is present in your case is quite certain from the consideration of your symptoms. You admit that you almost never have vertigo at home, but as soon as you leave the house, and especially if you find yourself alone in the street far from home, the remembrance of the vertigo comes over you, puts you into a state of anxiety, and is followed by a sensation of tottering and swaying, so that you have to stand still; and at last it has gone so far that you no longer venture to go out alone. And so the hero of X sits like a timid woman in his arm chair, making life bitter for himself and for those around him.

Even were I to find that signs of arterial calcification were present, I should still be satisfied that your vertigo is not due to this cause, but that it is a vertigo of recollection and of fear.

CHAPTER II

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 quant.i.ties into the delicate brain tissues, seriously injuring and perhaps destroying some of them forever, no amount of mental a.s.surance 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.

Rea.s.surance 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.

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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 a.s.sociated 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 rea.s.surance 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 appet.i.te 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 p.r.o.ne 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 p.r.i.c.kly "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 pa.s.s 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 a.s.sured almost without more ado. If his radial arteries on careful observation show no signs {515} 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 pa.s.sing 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 rea.s.sured 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 a.s.sociated with headache, point to an intracranial growth, or to a developing syphilitic brain lesion, and these must be carefully eliminated, but they const.i.tute 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 circ.u.mstances 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.

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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 rea.s.surance literally work wonders for such patients. In one case the young woman a.s.sured 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 b.u.t.ton dresses as they used to. Sometimes men will complain that they do not b.u.t.ton 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 p.r.o.ne to be disturbed by such thinking more than {517} 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 cla.s.s 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 {518} 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 pa.s.s 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 acc.u.mulates money, often acc.u.mulates 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 acc.u.mulated 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 circ.u.mstances 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 const.i.tution 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 p.r.o.ne to have serious consequences for such people. This warning is all the more needed because many a short, {519} 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 p.r.o.nounce 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 compet.i.tion, 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 rea.s.sert 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 appet.i.te 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.