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 [{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 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.