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THE DOCTOR HAS A STROKE
574
Special
Articles
THE DOCTOR HAS A STROKE * SEDGWICK MEAD M.D. Harvard MEDICAL DIRECTOR, KAISER FOUNDATION REHABILITATION VALLEJO, CALIFORNIA, U.S.A.
CENTER,
THE professor of neuropathology says: "II have before me the brain of a man who lived for some time with a massive hemispherical infarct produced by occlusion of the middle cerebral artery. The tissue formerly perfused by this artery is quite dead. I doubt if it could have been revived by any amount of passive exercise of the paretic limb. Just what is it that you people think you accomplish in a rehabilitation programme for victims of neurological disease ? " The objectives of a rehabilitation programme are to substitute good medical advice for bad medical advice to the victim; to avoid the consequences of inactivity and all its train of catabolic disasters; to salvage a paretic hand if possible, and, if not, to concentrate on increasing the self-care, efficiency, and wellbeing of the patient. A neuropathologist imagines that all one has to do to accomplish this is to sit down and have a thirty-minute, heartto-heart talk with the victim. The patient will then understand the whole matter, rise from his bed and walk, and then, all by himself, carry out the physiological and psychological adaptations needed for rehabilitation. In a few persons this is sometimes possible, but the vast majority require a different approach. A DESPERATE
GAME
I should like to ask you to imagine that you are the victim of a stroke. The work of a rehabilitation centre cannot be adequately described in words, cannot be presented in a scientific article in a scientific journal. The reason is not that we deal in the occult, but that the kinds of communication available to human beings are verbal and non-verbal, and for some kinds of conviction only non-verbal transfers of intelligence will do the
trick. I do
literally wish you to have a my point-God forbid-so that
stroke in order to make you will finally understand about rehabilitation. If you have a vivid imagination you will get a clearer description in this way than in a dry presentation of facilities and procedures. If you are successful the verbal will become non-verbal. not
THE FIRST WEEK: A DOCTOR DISCOVERS HOSPITALS
stroke-a most inconvenient happening at a doubly inconvenient time. The only warnings leading up to it were an uncomfortable family history of strokes, and one minor myocardial infarct five years ago. You shrugged it off with aplomb, and did not develop a frozen shoulder or a cardiac neurosis. Add one more datum-seven years of (allegedly benign) systolic hypertension, and 15 lb. overweight. You had two brief periods of disordered speech, lasting about five minutes each, during the preceding six months. Then as you were getting up from the supper table, heading for your journal and easy chair, you fell inexplicably to the floor and could not explain to your frightened family So here you
are
with
a
* This article will form part of a chapter in Treatment Patient to be published by C. V. Mosby Co., St.
of the Geriatric Louis, U.S.A
what had happened to you. You knew what you wanted to say, but the words sounded strange even to you as they came out, and you could not be sure they were what you meant to say. Somehow they got you to a bed and called a fellow practitioner. There was a look of deep concern on his face as he went through the familiar, useless manoeuvres. You were not in pain. You lay there with a kind of comfortable numbness and a strange weakness of the right side of your body. You were not frightened, but you were unable to focus your mind on something that seemed important, something you had to do tomorrow, but you could not for the life of you remember what it was.
hit you. Your friend and addressing silently weeping family in colleague words you struggled to understand, but very few of them came through. The scene dissolved into one thirty years earlier-you were no longer the patient, but a resident in hospital, standing by during morning rounds. The speaker was no longer your present-day colleague, but your chief of that long-ago day. His words at last came through: " Put this man in a back room. He has had a stroke. There is nothing I or anyone else can do for
Then
a
sudden
was
terror
really the
him."
Your wife began to coo to you, as though to a small child. Your terror and expostulations mounted, but everyone decided to shut you up (since they could not understand you) by transparent reassurances that everything would be all right. This was also the first occasion on which people addressing you began to speak loudly, as though you had suddenly gone deaf. You were sent to hospital. Then, of all possible complications, the one you feared most came to pass. You spent thirty minutes trying to say to the little nurse that you wanted the urinal. She beamed on you. She brought the water jug and the morning paper. Finally she frowned in disapproval and disappeared. By the time someone in the end did bring the urinal (it was on the wrong side of the bed to reach with your good hand, and the side rails were up), your bladder was overdistended, and you could no longer void. Then that invention of the devil, the
indwelling catheter, appeared. And why cannot the hospital staffunderstand, when you are huddled in the hollow of the bed, that the sheets are wrinkled, that your paralysed leg is cramping, that you’d dearly love a change of position? Mutely you implore, and callously they walk by. I spare you all the frustrations and travail of the
aphasic patient in a general hospital; to be treated like an idiot; to be ignored or shouted at; the transparent stupidities of having things done for the patient which he can well do for himself; and the insane failures to realise what he cannot possibly do; to be kept futilely in bed when the patient wants to be up-too often for the sole reason that the doctor cannot think of any other positive thing to do. A carotid arteriogram is done, but the result does not seem to change anything. THE SECOND WEEK: YOU LEARN YOU ARE A CRIPPLE
Patients have endured these goings-on for weeks, sometimes for months and even years. But I am going to make a charitable assumption-namely, that you are transferred to a rehabilitation centre at the end of the
575 time this is written, this is in most of the towns and cities of the United States. But the further description of life with three shifts of special nurses in a general hospital for week after week is too harrowing, and I draw a curtain over it. Your first impression of the centre is likely to be unfavourable; for in this supposedly affluent land most rehabilitation centres are located in the basement of a medical centre, somewhere between the dead storage room and the power plant-or out on some remote mountain, far from vital resources like a laboratory, X-ray department, and consultants. Moreover, the centre looks just like the hospital you left-the same cluttered rooms, the same nurses, orderlies, and doctors. And something much more sinister is discovered. You no longer had privacy or the doting attention of the hand maidens called special nurses. The suspicion dawns that the family is trying to save money on you. You did not learn until much later how spiritedly your wife argued for those special nurses, although in her heart of hearts she had no idea where the$60-00 additional per day to pay for them was coming from. Your income stopped the very first day you fell ill. And the insurance arrangements-attractive though they looked when you made them-were now scaring your poor wife to death. She had no idea whether she should sell the practice and equipment and stop paying rent on the office, try to get a locum tenens, or to try to get your colleagues to hold the practice together. The next terrifying discovery was that the centre is peopled with disabled persons like yourself. You are in a two-bedded room, and the man in the next bed has Parkinson’s disease. He has had a pallidotomy, but still has a great deal of rigidity and weakness. His voice is nearly inaudible, and his movements are so deliberate that they are infuriating. There are lots of other people with strokes. It is all rather appalling. You dislike the enforced intimacy, such as waiting your turn in the lavatory, or using a communal bathtub, into which you have to be helped. You hate the wheelchair, which with malevolent perversity zigzags around in the corridor instead of proceeding directly forward. In a sense it is worth it, though, because at least you are up out of bed
first week. Mind you, a most
at the
improbable happening
now. THE PARAMOUNT PARAMEDICAL PERSONNEL
You have a doctor, but he is a shadowy figure, neither very threatening nor very comforting. The key figures in your life are the orderly, the physiotherapist, and the speech therapist. (Not until long afterward do you learn what a comfort and unfailing resource the centre social worker was to your distraught wife.) Someone remembers that perhaps you are continent and takes out the hated catheter. Your urine is infected now, and the centre personnel also discover on admission that you have a serious fxcal impaction. They have the good sense to offer you a commode instead of a bedpan and to continue patiently with a programme of bowel training. Virtually all day you are out of your bed. You expect massage from the physical therapist; your right shoulder constantly aches from the drag downward, and the hand, which has no intrinsic movement, is puffy and tender. With your good left hand you cannot force the right fingers into the palm. But the physical therapist does not give you massage, and the staff also does not waste time
on reassurance.
They simply
go ahead with
a
calm
com-
petence which inspires you with confidence that here for the first time are persons who know what they are doing to get you back to doing for yourself. Before starting you on more strenuous exercise, and because of the past history of myocardial infarct, the doctor monitors you during exercise with an electrocardiographic tracing. Instead of using heat on your shoulder they startle you by applying an ice compress. At first you shiver with apprehension, but you learn to appreciate the anodyne and antispastic qualities of cold. You are perturbed because no-one seems to pay much attention to the paralysed upper limb. Will it perish from neglect ? Meanwhile the leg is doing very well indeed. A rubber shock cord from the calf to the toe helps to snub the toe upward and outward. Soon you graduate from the parallel bars to independent walking in the gym. Resistive
exercises, given by
an
energetic
young
woman to
neck,
facial muscles, tongue, upper and lower trunk, and both lower limbs, are alternated with pulley exercises which you do on your own, and with rolling and other mat routines. The right shoulder and elbow are moving now in an incoordinate, rigid sort of way. In occupational therapy you do sanding with a weighted sander which is fastened to your paralysed right hand with a glove device. You stand during this period, to increase your endurance. A key person in your life now is the speech therapist. When this person begins to treat you like an equal, rather than one from a foreign country with only partially intelligible speech, your shattered ego begins to mend. The sessions are fatiguing, more so than any kind of learning with which you can ever remember being faced. Some days you feel that no progress at all is being made. At first numbers were the only things you found easy, and one really pleasurable activity was playing gin with the speech therapist. Gradually reading clears up. It is a shock when they tell you in both the occupational therapy and the speech departments that you had better begin learning left-handed writing-this is a slow business. Meanwhile others have been working on the vexing business of self-care. There are some things a hemiplegic does not mind doing, but others are simply annoying and not basically important. The therapists teach you how to struggle into your clothes. They tried to teach you to tie your shoelaces with the left hand. Well, you can do it, but hate to be forced. On the other hand, you do like a tight shoe-corset over the instep and do not like loafers such as the teenagers wear. YOU ARE INTRODUCED TO PROGRESSIVE PATIENT CARE
When you can do most of your personal grooming and get to treatment unaided, they move you to a ward with less nursing hours, called intermediate care. (Your expenses thereupon dropped$10 per day.) You do not like your new room mate, a cigar-chewing former racetrack hanger-on, also with a stroke but no speech problem. You misconstrue the reason for progressive patient care-it seems more like exile than promotion. The centre insists on your shaving and grooming every day, and on your getting dressed and out of bed. With the really fatiguing exercise during the day you find
576
better at night. You also begin to go home for weekends. The family is both fearful and delighted. You are now from time to time getting out whole sentences without blocking. Persons with the best intentions keep putting words in your mouth-sometimes the wrong ones-or supplying a word for which you were struggling. The speech therapist stops this at a conference with the family and warns them that this practice slows your recovery. At last you are no longer considered an idiot. One day you see yourself in the mirror!i You appear drawn and grey and have lost at least 20 lb. But you pull your hat at a rakish angle over your eye and smile a one-sided smile at your reflection.
yourself sleeping
Before you go home you spend two weeks in a completely self-care ward-the third stage of progressive patient care. The daily bill drops another$14. The self-care staff check you out for safety. You can now go to the dining-room for meals. Arrangements are made for you to continue speech therapy for another six months or so as an outpatient for three times a week. You have an intelligible left-handed signature and can do All the other some fairly creditable left-hand typing. patients whose disabilities seemed so threatening at first or whose intellectual and social strata seemed so far from yours-even the parkinsonian and the cigar-chewer-are now for the most part close friends and fellow-pilgrims. All of you have largely abandoned both your fantasies of miraculous total recovery and your dark preoccupations with progressive dissolution, perhaps of suicide. It seems incredible that all this happened and that you are at last discharged home just short of eight weeks from the day you had your stroke. MIDDLE AND END OF STORY
It is a year later. You still block on abstractions and with strangers. You have an undeniable hemiparetic gait; you are ashamed of some of the sloppy habits you have got into, especially walking habits. But you are driving your car with the aid of special equipment. You don’t drive it on long trips or in heavy traffic. You have given up your private practice after receiving good advice and after much searching reflection. You have a job with a state agency, reviewing medical reports, and ruling on matters requiring a medical consultant’s opinion. The work is not very hard or very exciting-in fact, it contains a good deal of plain drudgery. But you consider yourself lucky-especially lucky for having regained your dignity and some of your old abilities. You are indebted to a wide range of talented persons at the centre. *
*
*
*
second imperative (the first being to do no his patient): he is to care for the patient, no matter what the circumstances. The recent medical graduate often takes a " let’s wait until " position about many of these questions. The reasoning goes something like this: if things are not ideal at the moment, they soon will be; if the cure of cancer is not here, it is just around the corner; if the automobile keeps supplying us now with lifelong serious brain injuries and spinal-cord transections, surely a scientific breakthrough will soon end all motor accidents. In short, he subscribes to the naive belief of the layman, that some day a medical millenium will find us with an explanation and a cure for every morbid state, and disease will vanish. A few technicians will keep it at bay with vaccines. And, quite logically, the profession of physician would then
physician’s harm
to
disappear. Sober reflection should dispel this childish Each new scientific advance brings a train of
plications : threatening detergent foams, radioactivity, pesticide-resistant insects, antibiotic-resistant bacteria, and greater injuries from higher speeds. If we prolong life and broaden the scope of automation we find a myriad of eager hands with no work to do and no acceptable or dignified alternative to work. If we bring preventive medicine-and we must do so-to underdeveloped countries, we may find ourselves in a malthusian horror of famine as the population outstrips its nutritional resources. Thus, the problems could mount instead of receding. I believe there is a definition of the physician and his place in society which, glimmering from time to time through the darkness of superstition, fraud, and quackery of the past, should endure for all time, regardless of scientific renascences like that of the present, and regardless of future dark ages that may succeed it. The role of the physician is to give compassionate and responsible
troubled, harassed, pain-ridden, questioning beings-to care for the patient. That is all the cura means in European languages-not necessarily
to
care
human word to
terminate the illness.
Public Health INDIGENOUS MALARIA IN ENGLAND SINCE THE FIRST WORLD WAR P. G. SHUTE M.B.E., F.R.E.S.
*
The modern era of medicine began just a quarter of a century ago, with the introduction of prontosil by Gerhard Domagk. It would help medical students who have graduated since that time to go back and spend a year before 1900 in the company of Osler, when there were few things to do for sick persons, and there were very few preventive measures. Now the medical student often acts as if his sole obligation lies in applying specific remedies to specific ills. If the cause, prevention, and treatment of a disease is unknown; if the patient is senile or seriously mentally retarded; if he has an irreparable physical handicap-today’s young doctor feels completely unprepared to deal with the problem and is resentful when society places responsibility on him for the care of these patients. He has therefore forgotten the true
nonsense. new com-
ASSISTANT DIRECTOR, MALARIA REFERENCE LABORATORY, HORTON HOSPITAL, EPSOM, SURREY
As far as is known, no case of indigenous malaria has been reported in England for six years. But on recording the decline of the disease since the first world war, I must
emphasise
the
continuing danger
of
imported cases.
THE INDIGENOUS INFECTIONS
Of the 520 reported cases, at most 3 were infected by the bites of Anopheles plumbeus 1: in all the others the vector was A. labranchiae atroparvus.2 With 1 doubtful exception, the parasite was Plasmodium vivax. There were no deaths.3 Shute, P. G. Mon. Bull. Minist. Hlth lab. Serv. 1954, 13, 48. Shute, P. G. In discussion on paper by N. H. Swellengrebel. Trans. R. Soc. trop. Med. Hyg. 1950, 43, 467. 3. Blacklock, R. Ann. trop. Med. Parasit. 1921, 15, 59.
1. 2.
Special
Articles
THE DOCTOR HAS A STROKE * SEDGWICK MEAD M.D. Harvard MEDICAL DIRECTOR, KAISER FOUNDATION REHABILITATION VALLEJO, CALIFORNIA, U.S.A.
CENTER,
THE professor of neuropathology says: "II have before me the brain of a man who lived for some time with a massive hemispherical infarct produced by occlusion of the middle cerebral artery. The tissue formerly perfused by this artery is quite dead. I doubt if it could have been revived by any amount of passive exercise of the paretic limb. Just what is it that you people think you accomplish in a rehabilitation programme for victims of neurological disease ? " The objectives of a rehabilitation programme are to substitute good medical advice for bad medical advice to the victim; to avoid the consequences of inactivity and all its train of catabolic disasters; to salvage a paretic hand if possible, and, if not, to concentrate on increasing the self-care, efficiency, and wellbeing of the patient. A neuropathologist imagines that all one has to do to accomplish this is to sit down and have a thirty-minute, heartto-heart talk with the victim. The patient will then understand the whole matter, rise from his bed and walk, and then, all by himself, carry out the physiological and psychological adaptations needed for rehabilitation. In a few persons this is sometimes possible, but the vast majority require a different approach. A DESPERATE
GAME
I should like to ask you to imagine that you are the victim of a stroke. The work of a rehabilitation centre cannot be adequately described in words, cannot be presented in a scientific article in a scientific journal. The reason is not that we deal in the occult, but that the kinds of communication available to human beings are verbal and non-verbal, and for some kinds of conviction only non-verbal transfers of intelligence will do the
trick. I do
literally wish you to have a my point-God forbid-so that
stroke in order to make you will finally understand about rehabilitation. If you have a vivid imagination you will get a clearer description in this way than in a dry presentation of facilities and procedures. If you are successful the verbal will become non-verbal. not
THE FIRST WEEK: A DOCTOR DISCOVERS HOSPITALS
stroke-a most inconvenient happening at a doubly inconvenient time. The only warnings leading up to it were an uncomfortable family history of strokes, and one minor myocardial infarct five years ago. You shrugged it off with aplomb, and did not develop a frozen shoulder or a cardiac neurosis. Add one more datum-seven years of (allegedly benign) systolic hypertension, and 15 lb. overweight. You had two brief periods of disordered speech, lasting about five minutes each, during the preceding six months. Then as you were getting up from the supper table, heading for your journal and easy chair, you fell inexplicably to the floor and could not explain to your frightened family So here you
are
with
a
* This article will form part of a chapter in Treatment Patient to be published by C. V. Mosby Co., St.
of the Geriatric Louis, U.S.A
what had happened to you. You knew what you wanted to say, but the words sounded strange even to you as they came out, and you could not be sure they were what you meant to say. Somehow they got you to a bed and called a fellow practitioner. There was a look of deep concern on his face as he went through the familiar, useless manoeuvres. You were not in pain. You lay there with a kind of comfortable numbness and a strange weakness of the right side of your body. You were not frightened, but you were unable to focus your mind on something that seemed important, something you had to do tomorrow, but you could not for the life of you remember what it was.
hit you. Your friend and addressing silently weeping family in colleague words you struggled to understand, but very few of them came through. The scene dissolved into one thirty years earlier-you were no longer the patient, but a resident in hospital, standing by during morning rounds. The speaker was no longer your present-day colleague, but your chief of that long-ago day. His words at last came through: " Put this man in a back room. He has had a stroke. There is nothing I or anyone else can do for
Then
a
sudden
was
terror
really the
him."
Your wife began to coo to you, as though to a small child. Your terror and expostulations mounted, but everyone decided to shut you up (since they could not understand you) by transparent reassurances that everything would be all right. This was also the first occasion on which people addressing you began to speak loudly, as though you had suddenly gone deaf. You were sent to hospital. Then, of all possible complications, the one you feared most came to pass. You spent thirty minutes trying to say to the little nurse that you wanted the urinal. She beamed on you. She brought the water jug and the morning paper. Finally she frowned in disapproval and disappeared. By the time someone in the end did bring the urinal (it was on the wrong side of the bed to reach with your good hand, and the side rails were up), your bladder was overdistended, and you could no longer void. Then that invention of the devil, the
indwelling catheter, appeared. And why cannot the hospital staffunderstand, when you are huddled in the hollow of the bed, that the sheets are wrinkled, that your paralysed leg is cramping, that you’d dearly love a change of position? Mutely you implore, and callously they walk by. I spare you all the frustrations and travail of the
aphasic patient in a general hospital; to be treated like an idiot; to be ignored or shouted at; the transparent stupidities of having things done for the patient which he can well do for himself; and the insane failures to realise what he cannot possibly do; to be kept futilely in bed when the patient wants to be up-too often for the sole reason that the doctor cannot think of any other positive thing to do. A carotid arteriogram is done, but the result does not seem to change anything. THE SECOND WEEK: YOU LEARN YOU ARE A CRIPPLE
Patients have endured these goings-on for weeks, sometimes for months and even years. But I am going to make a charitable assumption-namely, that you are transferred to a rehabilitation centre at the end of the
575 time this is written, this is in most of the towns and cities of the United States. But the further description of life with three shifts of special nurses in a general hospital for week after week is too harrowing, and I draw a curtain over it. Your first impression of the centre is likely to be unfavourable; for in this supposedly affluent land most rehabilitation centres are located in the basement of a medical centre, somewhere between the dead storage room and the power plant-or out on some remote mountain, far from vital resources like a laboratory, X-ray department, and consultants. Moreover, the centre looks just like the hospital you left-the same cluttered rooms, the same nurses, orderlies, and doctors. And something much more sinister is discovered. You no longer had privacy or the doting attention of the hand maidens called special nurses. The suspicion dawns that the family is trying to save money on you. You did not learn until much later how spiritedly your wife argued for those special nurses, although in her heart of hearts she had no idea where the$60-00 additional per day to pay for them was coming from. Your income stopped the very first day you fell ill. And the insurance arrangements-attractive though they looked when you made them-were now scaring your poor wife to death. She had no idea whether she should sell the practice and equipment and stop paying rent on the office, try to get a locum tenens, or to try to get your colleagues to hold the practice together. The next terrifying discovery was that the centre is peopled with disabled persons like yourself. You are in a two-bedded room, and the man in the next bed has Parkinson’s disease. He has had a pallidotomy, but still has a great deal of rigidity and weakness. His voice is nearly inaudible, and his movements are so deliberate that they are infuriating. There are lots of other people with strokes. It is all rather appalling. You dislike the enforced intimacy, such as waiting your turn in the lavatory, or using a communal bathtub, into which you have to be helped. You hate the wheelchair, which with malevolent perversity zigzags around in the corridor instead of proceeding directly forward. In a sense it is worth it, though, because at least you are up out of bed
first week. Mind you, a most
at the
improbable happening
now. THE PARAMOUNT PARAMEDICAL PERSONNEL
You have a doctor, but he is a shadowy figure, neither very threatening nor very comforting. The key figures in your life are the orderly, the physiotherapist, and the speech therapist. (Not until long afterward do you learn what a comfort and unfailing resource the centre social worker was to your distraught wife.) Someone remembers that perhaps you are continent and takes out the hated catheter. Your urine is infected now, and the centre personnel also discover on admission that you have a serious fxcal impaction. They have the good sense to offer you a commode instead of a bedpan and to continue patiently with a programme of bowel training. Virtually all day you are out of your bed. You expect massage from the physical therapist; your right shoulder constantly aches from the drag downward, and the hand, which has no intrinsic movement, is puffy and tender. With your good left hand you cannot force the right fingers into the palm. But the physical therapist does not give you massage, and the staff also does not waste time
on reassurance.
They simply
go ahead with
a
calm
com-
petence which inspires you with confidence that here for the first time are persons who know what they are doing to get you back to doing for yourself. Before starting you on more strenuous exercise, and because of the past history of myocardial infarct, the doctor monitors you during exercise with an electrocardiographic tracing. Instead of using heat on your shoulder they startle you by applying an ice compress. At first you shiver with apprehension, but you learn to appreciate the anodyne and antispastic qualities of cold. You are perturbed because no-one seems to pay much attention to the paralysed upper limb. Will it perish from neglect ? Meanwhile the leg is doing very well indeed. A rubber shock cord from the calf to the toe helps to snub the toe upward and outward. Soon you graduate from the parallel bars to independent walking in the gym. Resistive
exercises, given by
an
energetic
young
woman to
neck,
facial muscles, tongue, upper and lower trunk, and both lower limbs, are alternated with pulley exercises which you do on your own, and with rolling and other mat routines. The right shoulder and elbow are moving now in an incoordinate, rigid sort of way. In occupational therapy you do sanding with a weighted sander which is fastened to your paralysed right hand with a glove device. You stand during this period, to increase your endurance. A key person in your life now is the speech therapist. When this person begins to treat you like an equal, rather than one from a foreign country with only partially intelligible speech, your shattered ego begins to mend. The sessions are fatiguing, more so than any kind of learning with which you can ever remember being faced. Some days you feel that no progress at all is being made. At first numbers were the only things you found easy, and one really pleasurable activity was playing gin with the speech therapist. Gradually reading clears up. It is a shock when they tell you in both the occupational therapy and the speech departments that you had better begin learning left-handed writing-this is a slow business. Meanwhile others have been working on the vexing business of self-care. There are some things a hemiplegic does not mind doing, but others are simply annoying and not basically important. The therapists teach you how to struggle into your clothes. They tried to teach you to tie your shoelaces with the left hand. Well, you can do it, but hate to be forced. On the other hand, you do like a tight shoe-corset over the instep and do not like loafers such as the teenagers wear. YOU ARE INTRODUCED TO PROGRESSIVE PATIENT CARE
When you can do most of your personal grooming and get to treatment unaided, they move you to a ward with less nursing hours, called intermediate care. (Your expenses thereupon dropped$10 per day.) You do not like your new room mate, a cigar-chewing former racetrack hanger-on, also with a stroke but no speech problem. You misconstrue the reason for progressive patient care-it seems more like exile than promotion. The centre insists on your shaving and grooming every day, and on your getting dressed and out of bed. With the really fatiguing exercise during the day you find
576
better at night. You also begin to go home for weekends. The family is both fearful and delighted. You are now from time to time getting out whole sentences without blocking. Persons with the best intentions keep putting words in your mouth-sometimes the wrong ones-or supplying a word for which you were struggling. The speech therapist stops this at a conference with the family and warns them that this practice slows your recovery. At last you are no longer considered an idiot. One day you see yourself in the mirror!i You appear drawn and grey and have lost at least 20 lb. But you pull your hat at a rakish angle over your eye and smile a one-sided smile at your reflection.
yourself sleeping
Before you go home you spend two weeks in a completely self-care ward-the third stage of progressive patient care. The daily bill drops another$14. The self-care staff check you out for safety. You can now go to the dining-room for meals. Arrangements are made for you to continue speech therapy for another six months or so as an outpatient for three times a week. You have an intelligible left-handed signature and can do All the other some fairly creditable left-hand typing. patients whose disabilities seemed so threatening at first or whose intellectual and social strata seemed so far from yours-even the parkinsonian and the cigar-chewer-are now for the most part close friends and fellow-pilgrims. All of you have largely abandoned both your fantasies of miraculous total recovery and your dark preoccupations with progressive dissolution, perhaps of suicide. It seems incredible that all this happened and that you are at last discharged home just short of eight weeks from the day you had your stroke. MIDDLE AND END OF STORY
It is a year later. You still block on abstractions and with strangers. You have an undeniable hemiparetic gait; you are ashamed of some of the sloppy habits you have got into, especially walking habits. But you are driving your car with the aid of special equipment. You don’t drive it on long trips or in heavy traffic. You have given up your private practice after receiving good advice and after much searching reflection. You have a job with a state agency, reviewing medical reports, and ruling on matters requiring a medical consultant’s opinion. The work is not very hard or very exciting-in fact, it contains a good deal of plain drudgery. But you consider yourself lucky-especially lucky for having regained your dignity and some of your old abilities. You are indebted to a wide range of talented persons at the centre. *
*
*
*
second imperative (the first being to do no his patient): he is to care for the patient, no matter what the circumstances. The recent medical graduate often takes a " let’s wait until " position about many of these questions. The reasoning goes something like this: if things are not ideal at the moment, they soon will be; if the cure of cancer is not here, it is just around the corner; if the automobile keeps supplying us now with lifelong serious brain injuries and spinal-cord transections, surely a scientific breakthrough will soon end all motor accidents. In short, he subscribes to the naive belief of the layman, that some day a medical millenium will find us with an explanation and a cure for every morbid state, and disease will vanish. A few technicians will keep it at bay with vaccines. And, quite logically, the profession of physician would then
physician’s harm
to
disappear. Sober reflection should dispel this childish Each new scientific advance brings a train of
plications : threatening detergent foams, radioactivity, pesticide-resistant insects, antibiotic-resistant bacteria, and greater injuries from higher speeds. If we prolong life and broaden the scope of automation we find a myriad of eager hands with no work to do and no acceptable or dignified alternative to work. If we bring preventive medicine-and we must do so-to underdeveloped countries, we may find ourselves in a malthusian horror of famine as the population outstrips its nutritional resources. Thus, the problems could mount instead of receding. I believe there is a definition of the physician and his place in society which, glimmering from time to time through the darkness of superstition, fraud, and quackery of the past, should endure for all time, regardless of scientific renascences like that of the present, and regardless of future dark ages that may succeed it. The role of the physician is to give compassionate and responsible
troubled, harassed, pain-ridden, questioning beings-to care for the patient. That is all the cura means in European languages-not necessarily
to
care
human word to
terminate the illness.
Public Health INDIGENOUS MALARIA IN ENGLAND SINCE THE FIRST WORLD WAR P. G. SHUTE M.B.E., F.R.E.S.
*
The modern era of medicine began just a quarter of a century ago, with the introduction of prontosil by Gerhard Domagk. It would help medical students who have graduated since that time to go back and spend a year before 1900 in the company of Osler, when there were few things to do for sick persons, and there were very few preventive measures. Now the medical student often acts as if his sole obligation lies in applying specific remedies to specific ills. If the cause, prevention, and treatment of a disease is unknown; if the patient is senile or seriously mentally retarded; if he has an irreparable physical handicap-today’s young doctor feels completely unprepared to deal with the problem and is resentful when society places responsibility on him for the care of these patients. He has therefore forgotten the true
nonsense. new com-
ASSISTANT DIRECTOR, MALARIA REFERENCE LABORATORY, HORTON HOSPITAL, EPSOM, SURREY
As far as is known, no case of indigenous malaria has been reported in England for six years. But on recording the decline of the disease since the first world war, I must
emphasise
the
continuing danger
of
imported cases.
THE INDIGENOUS INFECTIONS
Of the 520 reported cases, at most 3 were infected by the bites of Anopheles plumbeus 1: in all the others the vector was A. labranchiae atroparvus.2 With 1 doubtful exception, the parasite was Plasmodium vivax. There were no deaths.3 Shute, P. G. Mon. Bull. Minist. Hlth lab. Serv. 1954, 13, 48. Shute, P. G. In discussion on paper by N. H. Swellengrebel. Trans. R. Soc. trop. Med. Hyg. 1950, 43, 467. 3. Blacklock, R. Ann. trop. Med. Parasit. 1921, 15, 59.
1. 2.