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, [{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 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 [{520}] 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 [{521}] 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.