In the Midst of Life

A DANGEROUS SUBJECT

‘Stroke’ is a good word. It is much better than medical words. There is no warning, no time to prepare when a stroke brings you down. Strokes can vary in severity from mild and transient, to catastrophic with permanent injury. They are caused by one of three things: thrombosis, embolism or haemorrhage, in order of severity.

Thrombosis is caused by the hardening and narrowing of the cerebral arteries, which can give rise to both chronic and acute changes in the oxygen supply to the brain. Blockages in the tiny cerebral arteries are associated with a slow, progressive disturbance of cerebral functions, punctuated at intervals by seizures or attacks, called transient ischaemic attacks (TIA) or mini-strokes. Stroke due to thrombosis is less common, nowadays, because of the early diagnosis of high blood pressure and hardened arteries, and drug treatments available to rectify these conditions.

An embolus is something floating freely in the circulatory system. Several things such as air or fat or necrotic material from a tumour are possible emboli, but the most common is a blood clot. Our blood gets thicker, and flows more sluggishly, with an irregular pulse, as we grow older, and clots are liable to form. When an embolus reaches an artery too narrow to allow it to pass, it becomes lodged, and the tissue beyond it is no longer fed with oxygen and will die. These blockages can occur in any part of the body, but if one of the cerebral arteries is blocked, the result will be a stroke. The severity can be mild or severe, and this will depend on the position in the brain and the size of the area affected. The incidence of a stroke due to an embolus has been greatly reduced by preventive measures – drugs such as Warfarin, which thin the blood, and those which reduce high blood pressure.

A stroke caused by haemorrhage cannot be foreseen and, therefore, cannot be prevented. It is due to the rupture of a weak spot in a cerebral artery. We all have weak patches in our blood vessels and they normally cause no trouble. But just as the strength of a chain is in its weakest link, so it is with blood vessels. Under tension, the weakest link will snap. In certain circumstances, the weak spot of an artery will burst and blood will escape into the surrounding area of the body. This can occur in any artery, in any part of the body, and the site of the haemorrhage will determine the severity of the damage. If it ruptures in the cranium, it causes a stroke. It can occur at any age and is quite unpredictable.

I was a ward sister at the Elizabeth Garrett Anderson Hospital for Women in London when Mrs Doherty was admitted. She was in a deep coma, and her skin was colourless and cold, although covered with perspiration. Her temperature, blood pressure, pulse and respiration were subnormal. We did not think she would live for long – such a severe stroke was usually terminal. The houseman who attended whilst we admitted the patient, said much the same as I had been thinking: ‘The kindest thing would be to let her die quietly. However, I must do a lumbar puncture to diagnose the cause.’ This she did, revealing abundant blood in the spinal fluid, which was diagnostic of a cerebral haemorrhage.

We contacted the next of kin. Jamie left work at once and came to the hospital, but Priscilla was in Durham, and Maggie was on an assignment. The consultant surgeon, Miss Jenner, explained to Jamie that the prognosis was uncertain, but that a craniotomy could be performed to open the skull and suck out the blood and fluids that had collected and would be causing pressure inside the cranium. It might also be possible, she said, to locate the origin of the bleeding and tie it off.

Jamie looked alarmed, and Miss Jenner explained that opening the cranium is not all that difficult, and trephining the skull had been performed since pre-Roman days, and that sucking out the blood is not a lengthy business and would certainly relieve pressure on the brain, which was essential if Mrs Doherty was to stand any chance of recovery. (Miss Jenner was a general surgeon. What she suggested was not brain surgery, for which a specialist brain surgeon would have been required. Also, a general surgeon in the 1960s had a far wider role than today.)

Jamie was asked to give consent for the operation. He hesitated. ‘I am not sure that she would want it. She wouldn’t want to be debilitated, I am quite sure of that. She is eighty-two, she has had a full and active life, and to go, while she is still getting about and enjoying herself, is what she would want.’

His words raised an element of doubt in Miss Jenner’s mind. ‘This is always a difficult moment, probably the hardest you will ever have to face. To treat or not to treat. To leave well alone, or to intervene. But I assure you, that if we do not operate quickly your mother will die later today.’

Poor Jamie. What a situation! And the decision was on his shoulders. His instinct said ‘leave well alone’, but he couldn’t bring himself to say it. He needed help. ‘I must speak to my sister. I will ring her office; please God let her be there.’

He went and telephoned Priscilla, who was at her desk. He explained what had happened, and what the consultant had said. Priscilla was unequivocal and immediate in her response. ‘She must be operated upon. You must sign the consent form. We cannot morally, or even lawfully, as far as I know, withhold from her the chance to survive.’

Jamie did not hesitate to give his consent for operation.

He remained in the hospital, and spoke again at length to Priscilla, who said that she could not come to London until the work she was engaged in had been concluded. She did not want to pass it to her junior, and, as there was nothing she could usefully do in London, she would remain. Jamie contacted his other sister, who sobbed uncontrollably when she heard the news. ‘Darling Mummy, my poor darling. I’ll come at once.’

The day dragged on, and the hours hung heavily for Jamie. His mother had looked ghastly when he saw her. She had appeared to be dead, but obviously was not, because she was taking in great noisy, sucking breaths, horrible to listen to. At the same time, the competent matter-of-fact attitude of the hospital staff had reassured him. She would be all right; she was a tough old bird, he told himself.

The operation was done under general anaesthetic. The cranium was opened, and blood and serum sucked out, but the source of the bleed could not be found. X-rays were taken from every angle, but were inconclusive. Clinical signs suggested that the bleed was in the left side of the brain, but natural clotting had halted the flow. No further probing would have been appropriate, and so the piece of skull bone was replaced, and the wound sutured. Mrs Doherty was returned to the ward.

We had prepared a side ward to receive her and she was lifted on to the bed. Her breathing was quieter, but very slow, and in other ways she looked worse than before, because her head had been shaved. The bandages on her skull were deeply bloodstained, because there are numerous small vessels on the scalp, and they bleed profusely. Two draining filaments had been left in situ, and were sticking out. She was attached to two drips, one blood, one saline, and a laryngeal airway for continuous oxygen. Frankly, she looked barely human.

Nurses are accustomed to these things, and we were neither surprised nor alarmed, but Jamie was still in the hospital, and wanted to see his mother. He could not be refused. Miss Jenner had already told him of the operative procedures, and said that when the nurses had made his mother comfortable he could be admitted.

I went to the visitor’s room myself, because I wanted to prepare him. I knew that the sight of a patient after cranial surgery can be a terrible shock. We were talking together, when suddenly the door flew open and a woman burst in, her hair dishevelled, her eyes swollen and her face red and blotchy.

‘Where’s Mummy?’ she cried, ‘I must see her. She needs me.’

Jamie introduced his sister Maggie.

‘It’s been a terrible journey. I’ve had four changes of train, and nothing to eat all day – but I’ve brought these flowers for her. I know she likes roses; they are her favourite flower. She will love them …’ She started to cry, and pulled out a wet handkerchief.

I told her that her mother had returned from the operating theatre only an hour earlier.

‘An operation? You didn’t tell me about an operation, Jamie,’ she said accusingly. ‘What operation?’

I said that it had been necessary to open her mother’s skull to suck out the blood.

‘Blood! You opened her skull! Oooh, Mummy!’

Jamie took hold of his sister and explained, quietly and sensibly, what had been done. He and I exchanged glances and I could read his thoughts – was Maggie in any fit state to see her mother? But we could not refuse her.

We went to the side ward. I told Maggie that we must be quiet, and not disturb her mother. We entered the ward and stood silently by the bed for a moment or two. Then Maggie said, ‘But where’s Mummy?’

What a dreadful moment for any ward sister. I bit my lip and said softly, ‘Here. This is your mother.’

‘No, it’s not. Do you think I don’t know my own mother? This must be the wrong room. Where is she?’

‘No. It’s not the wrong room. This is your mother.’

I could feel the panic rising in the woman beside me.

‘But it can’t be … that’s not Mummy!’ Her voice was trembling. ‘I don’t believe you. You’re lying. You must be!’ With every word there was a rise in decibels. Jamie took hold of her.

‘Maggie, come away. This is no place for you. Come with me.’

Firmly he led her out of the side ward. Hysterical screams could be heard echoing down the corridor.

Brother and sister left the hospital. Jamie telephoned at 10 p.m., and the night sister told him that his mother’s condition was stable, and that he should ring in the morning.

Jamie came to see his mother each day. He did not stay for long, because there was nothing he could do. His mother was unconscious, but there was no deterioration in her condition. Maggie did not come to the hospital, but her telephone calls were so frequent that I had to instruct the main switchboard to limit her calls to the ward to two a day.

I spoke to Priscilla in Durham, on the telephone. Her voice had a very clipped accent, pleasant to listen to, but somewhat intimidating. She sounded like the sort of woman who would assume she was in the right and brook no contradiction. There was not a lot that I could say, beyond what she had already heard from Jamie, that their mother’s condition was stable. She said she would remain in Durham.

About a week later, Mrs Doherty showed signs of regaining consciousness, first by the twitching of the legs and then restlessness which became extreme. Her pupils, which had been tightly closed, responded to light. Grunting was heard, and slurred attempts at speech. Jamie sat by the bedside for some time, holding her hand, and she obviously knew who he was and took comfort from his presence. Maggie came, but she cried so much it would have been better if she had not come at all.

Mrs Doherty gained consciousness and began to understand what was going on around her. She responded well to questions and instructions from the staff, such as ‘Can you raise your left arm? Can you raise your forefinger?’, but she was severely hemiplegic. She could not move the right side of her body at all, her right eye and her mouth and tongue slumped heavily to the right, and she could not speak. Several times she tried, but the sound was quite incomprehensible. Tears gathered in her eyes as she desperately tried to make herself understood.

Nursing her was difficult – but it always is with a patient in such a condition – and took a great deal of our time. We moved her every two hours, repositioning her limbs and treating pressure areas. We removed the naso-gastric tube, cleaned her mouth, and raised her into a semi-recumbent posture. We spoon-fed her with semi-solid feeds, but she found swallowing difficult, and the food frequently trickled out of her mouth. If any fluid went into her trachea, she started choking, and it had to be sucked out. The physiotherapist came daily, treating the paralysed limbs. The stitches and drainage tubes were removed from her scalp, and we put a little white cap on her head, which made her look more feminine.

Maggie informed her clients that she would be taking a break and would be living in her mother’s house for an indefinite period. She had become reconciled to her mother’s condition, and came in daily, sitting with her for long periods of time, talking to her about her life, her boyfriends, her plans for the future. Should she give up freelancing? But what would she do instead? Her mother could make no response.

Maggie chatted on, and she discovered what many people learn – that a hemiplegic, speechless person loves to be talked to as though nothing is wrong, and no verbal response is expected. Maggie talked about her father, and days in the old house when they were all little, about the tree house in the garden, and picnics in the summer by the stream, and ‘Do you remember, Mummy, when we thought a bull was coming for us, but it was only a cow which had strayed?’ She chatted endlessly, and the happiness it gave to both of them was beyond measure.

One day she said: ‘Priscilla is coming tomorrow to see you. She won’t stay with Jamie or me – she insists on staying in a hotel. I’m scared of Priscilla, Mummy, aren’t you? She’s so cold and stiff and correct and I’m sure she disapproves of me. But every time she looks at me in that way I think of when she was a little girl and we went to a birthday party and she put on roller skates and was wobbling and slipping all over the place. She wet her knickers, and when we sat down for tea she left a big wet patch on the cushion of the lady’s nice chair. That makes me feel better and I think, “Well, you weren’t always perfect, Miss Perfect”.’

They both laughed, and saliva trickled from the side of her mother’s mouth. Maggie tenderly wiped it away, and kissed her mother. She whispered, ‘We’ve had such fun, haven’t we, Mummy darling, and we’ll have fun again when you come out of hospital. I’ll always be there to look after you.’

Priscilla arrived the following day. She was tall, slim and dignified. Her features were composed as though nothing could ruffle her, and her nostrils were very close and narrow, which made her appear to be sniffing slightly all the time, an effect intensified when she pursed her lips and raised her eyebrows.

In spite of her apparent composure, Priscilla was very tense and ill at ease. A hospital was quite outside her experience; she was no longer in control. Before she had even seen her mother, she asked to speak with the consultant. I said that Miss Jenner was in theatre all morning, and had a clinic in the afternoon, and that I did not expect to see her on the ward that day. Her nostrils contracted and she said in a clipped, precise voice, ‘Please inform Miss Jenner that I am residing in London for a limited period and that I request an interview at her earliest convenience.’ I said that I would do so, and did she wish to see her mother? She replied, ‘Yes, of course.’

I led her to the side ward. Two nurses were there. They had washed Mrs Doherty and changed her nightie and managed to get her out of bed to sit her in a chair. One of them was on her knees on the floor, adjusting Mrs Doherty’s feet to rest on a footstool; the other was tying a bib round her neck to catch the saliva as and when it dripped. Her body slumped to the right, in spite of the pillows they had placed to try to keep her upright, and she looked up as best she could by moving her head and raising her left eye a fraction. She obviously recognised her daughter, because a gurgling sound came from her throat and she moved her left arm in greeting.

Priscilla did not say a word. I opened the window a little, and one of the nurses looked at me questioningly. Should they attempt to give Mrs Doherty her morning drink? We understood each other without a word being said – this woman was undoubtedly intimidating, and would probably be critical. To attempt to give a drink to her mother, even from a feeding cup, would probably be repellent to her. No morning drink. Not yet, anyway.

One of the nurses placed a chair beside Mrs Doherty. I asked Priscilla if she would like a cup of coffee, but she shook her head. She still had not spoken. We left the room and shut the door.

Five minutes later she came out and asked to see me. The confidence, the assumption of superiority, had been knocked out of her.

‘This is a bad business, Sister.’

‘Your mother has had a severe stroke, which is always distressing to see.’

‘I was not aware it would be as bad as this.’

I refrained from saying that she did not look nearly as bad as she had a fortnight earlier. Instead, I said, ‘Your mother is making progress as well as can be expected.’

She turned suddenly, almost angrily. ‘But she cannot speak!’

‘No.’

‘She can only make gurgling noises.’

‘The side of her brain controlling speech has been affected.’

‘Well, what are you going to do about it?’ she demanded.

‘There is very little we can do, apart from physiotherapy, to encourage the healing powers of nature.’

‘Healing powers of nature! Is that all you are doing? There must be some drugs she can have. What about all the miracles of modern medicine we hear so much about?’

I thought how the miracles of modern medicine can prevent someone dying from a stroke, but cannot restore the loss of speech nor the loss of muscular control that are its legacy.

‘I must see the consultant. I must discuss what can be done about this distressing situation.’

I was explaining again that Miss Jenner was not expected on the ward until the following day, when I heard a familiar voice in the corridor. ‘Excuse me a moment,’ I said, and went out. It was Miss Jenner.

‘Hello, Sister. We closed theatre earlier than expected, so I thought I would just pop down to see how Miss Patterson is getting on. Perhaps that drain can come out. And if you can find a cup of coffee, that would be nice.’

I told her that Priscilla, Mrs Doherty’s eldest daughter, was in the office and wanted to speak to her.

‘I’ll see Miss Patterson first, then have a chat with her.’

A little later, before we parted for lunch, I caught up with Miss Jenner, and she told me what Priscilla had said. ‘She seems to think that we can restore her mother’s speech and movement by drugs. It astonishes me, the ignorance of the most fundamental medical facts that intelligent, well-informed people sometimes display.’

‘Very true,’ I laughed.

‘She seems to think that because we have not already done so, we are being negligent, and have missed an obvious point.’ She shrugged her shoulders despairingly. ‘I don’t know what she thinks we should be doing, but she is demanding another medical opinion.’

‘And will you get one?’

‘Well, I shall have to get a geriatrician’s assessment for her mother. She can’t stay here indefinitely. This is an acute surgical ward. She will have to go to the geriatric ward. That will give her daughter the second opinion she requires.’

Miss Jenner sighed deeply. She was a lady in her fifties, about twenty years older than I was.

‘It used to be so much easier in the old days. When I was a medical student it was not expected that anyone would survive a massive cerebral haemorrhage. All the medical textbooks, all the lecturers, informed us that death would result within a few hours, or at most a few days.’

‘I doubt if anyone would say that now.’

‘Oh no!’ Miss Jenner said emphatically. ‘No one would dare to say such a thing. They would be in serious trouble. It is a very dangerous subject.’

Miss Jenner left, and I sat very still at my desk, my mind going back about twelve years. Miss Jenner had used exactly the same words that Matron Aldwinkle had used when I was a student nurse – ‘This is a dangerous subject.’