Credible Information Why It Matters, What Are Its Limitations
FAKE NEWS TO THE FORE
On December 3, 2016, a twenty-eight-year-old man from North Carolina walked into a Washington, DC, pizza parlor, pointed a rifle at an employee, and then fired three shots (none of which hit anyone.)1 He wasn’t trying to rob the place. Following his arrest, the man told police he was investigating a conspiracy theory that claimed (without the backing of even one shred of credible evidence) that Hillary Clinton was running a child sex ring out of the restaurant. That particular conspiracy theory was one of many fanned by a worldwide fake news phenomenon. By the final months of 2016, fake news itself had grown to become one of the biggest non–fake news stories of the year.
While the phrase fake news rose to prominence in 2016, fake news is really just the latest name for the ancient art of lying. Since the dawn of language, humans have used lies for many purposes: blaming, persuading, winning arguments, exerting dominance. Lying can even be used as a form of entertainment, as evidenced by the many forms of comedy—such as tall tales, pranks, and absurdist humor—that depend on the bending or breaking of the truth. To lie is, in essence, to supply others with misinformation. Fake news, lies, rumors, fibs, propaganda—all are synonyms for misinformation. The consequences of misinformation can range from the trivial (because your car’s GPS system slightly misinformed you about the best route to your destination, you
drove a mile farther than necessary), to the alarming (three bullet holes in a pizza joint and a lot of terrified citizens), to the tragic (more than once in human history, propaganda has begotten genocide).
If anything good has come from the recent furor over fake news, it is that fake news has highlighted the importance of making sure that the information we take in and, especially, the information we share is credible. Perhaps more than at any time in history, people are at least discussing the importance of evaluating information before allowing it to drive their decisions, whether those decisions be who to vote for, what car to buy, or whether it is a good idea to take a rifle into a pizza parlor in the pursuit of imaginary pedophiles.
EVALUATING INFORMATION: AN ESSENTIAL SKILL IN THE DIGITAL AGE
Centuries from now it is likely that people will refer to the age in which we live as the Digital Age, just as we refer to earlier ages by such names as the Industrial Revolution, the Age of Enlightenment, and the Stone Age. The reason for this, of course, is that digital technology has so filled today’s world with information as to make information the defining characteristic of the times in which we live. Millions now make their living working with information, just as millions once made their living working with raw materials like steel or wood. In the twenty-first century, even productionoriented fields like agriculture, mining, and manufacturing employ modern information technology to improve productivity and increase profits. While living in a world filled with easily accessible information can be a wonderful thing, the problem for people who must use information to make important decisions impacting their private and public lives is that not all the information is credible. The challenge, therefore, for those of us living in the Digital Age is to develop skills for evaluating information, the skills for separating information that is credible enough to be useful from that which is not. Helping readers develop the skills for evaluating information is, in a nutshell, the purpose of this book.
SMOKING AND HEALTH : AN ALTERNATIVE HISTORY
Imagine that you are a resident of the United States and that the date is Saturday, January 11, 1964. Less than two months have passed since the shocking assassination of President John F. Kennedy in Dallas, Texas. It is almost certain that you know about the assassination due to the heavy coverage it received in both the print and broadcast media. In particular, the coverage of the assassination by the national television networks—of which there are only three—was unprecedented in its depth. In about a month from this date in 1964, the Beatles will appear on the Ed Sullivan Show for the first time. US news coverage of the Beatles has been, thus far, so scant that it is quite possible the names John, Paul, George, and Ringo mean nothing to you. Not yet, anyway.
What stands out about this particular Saturday is that Luther Terry, the surgeon general of the United States, has chosen it to release a 387-page document entitled Smoking and Health: Report of the Advisory Committee to the Surgeon General of the United States 2 Though not the first nor the last scientific report on the harmful effects of smoking, Smoking and Health emphatically and authoritatively connects the dots between smoking and a number of serious health conditions, including emphysema, heart disease, low birth weight, and lung cancer. Terry opts for a Saturday release so as to not cause any ripples in the stock markets. A Saturday release also ensures that the report will be covered in the Sunday newspapers, an important source of information for Americans in 1964.
Now imagine further that the digital technology of 2016 had existed on the day Smoking and Health was released. How might social media and other forms of digital communication respond?
Even before anyone has had time to read the entire report, Smoking and Health is being mocked as a nanny-government affront to individual liberty. Tweets and Facebook posts lead the attack (see figures 1.1 and 1.2). Satirical memes soon follow (figure 1.3).
Next are the many click-bait news stories with enticing headlines like
Have You Seen the Ten Reasons Why Cigarettes Cannot Possibly Cause Cancer? You’ll Be Amazed. . . .
Five False Conclusions Contained in the Surgeon General’s Report. Smoke Out the Facts. . . .
Within a few weeks, pro-smoking activists are promoting a heavily edited attack video in which US Public Health Service staff appear to admit that the surgeon general’s report is based on fake science and the connection between smoking and cancer is a complete fabrication. Even though the video is thoroughly discredited, it receives over five hundred thousand views on YouTube while generating tens of thousands of disparaging comments from outraged smokers.
FIGURE 1.1
Tweeting about Smoking and Health. National Archives photograph.
The surgeon general gets the meme treatment. Donald A. Barclay
FIGURE 1.2
A Facebook user weighs in. New York Public Library photo. U.S. Government Document.
FIGURE 1.3
Howard Cullman, a director of the Philip Morris company, bluntly says of the findings published in Smoking and Health, “We don’t accept the idea that there are harmful agents in tobacco.”3 Soon, ostensibly scientific articles reporting results contradicting the conclusions of Smoking and Health begin to appear in “predatory journals”—nominally scientific, online-only journals that will publish almost anything in exchange for payment. While at first glance these articles appear to be legitimate, they are not based on genuine scientific research and their findings are either exaggerated or simply made up. Many suspect that Big Tobacco is secretly funding both the wave of fake scientific articles and a good part of the social-media churn slamming the surgeon general’s report. Some accuse Big Tobacco of using machine-generated tweets and Facebook posts to make the opposition to Smoking and Health seem more widespread than it actually is.
Because 1964 is an election year, both houses of Congress respond to the growing digital uproar by holding hearings. During testimony, representatives and senators from tobacco-growing states, as well as their colleagues who receive campaign financing from Big Tobacco, are especially hostile to the surgeon general and the team of medical advisers who contributed to Smoking and Health. Sensing an opportunity, presidential candidate Barry Goldwater (a lifelong nonsmoker) repeatedly denounces the link between cancer and smoking as a communist-inspired hoax. With an eye on the opinion polls, President Lyndon Johnson (an on-again, off-again smoker) distances his administration from the surgeon general’s report, choosing instead to expend his political capital on addressing the growing crisis in Vietnam and shepherding civil rights legislation through the House and Senate. After all the uproar, Smoking and Health is filed away and forgotten. Across the country and around the world, cigarette smokers cough sighs of relief.
Of course, there was no digital social media in 1964. Rather than being filed away and forgotten, the scientific findings reported in
Smoking and Health were widely accepted (in spite of the best efforts of Big Tobacco to spread disinformation and discredit legitimate scientific research). Thanks to the many antismoking initiatives launched in the wake of Smoking and Health, the United States saw smoking rates for adults drop from 42.4 percent in 1965 (the peak year for smoking in the United States) to 16.8 percent in 2014.4 The transformation of cigarette smoking from an accepted part of daily life to a borderline-taboo habit was a major public health victory that directly led to millions of people living longer, healthier lives while saving the nation billions in health care costs associated with smoking and secondhand smoke.5 Even among present-day smokers, it is hard to find anyone who believes it would have been for the best if the scientific facts championed by Smoking and Health had been buried under a landslide of uninformed popular opinion. And while there are those who believe smoking is an individual choice that should not be controlled by government regulations, very few actively long for a society in which the population still smokes like it was 1964.
The box contains an exercise in alternative history; the point of this indulgence is simple: facts and truth matter. Information matters. Matters enough that it can change the world. Though some glibly claim that we now live in a “post-truth world,” the reality is that if human beings, both as individuals and as members of a larger society, are going to make the best possible decisions regarding just about everything that affects their lives, they had better base these decision on credible information rather than on wishful thinking, fantasies, or outright falsehoods.
INFORMATION, DECISION MAKING, AND PRACTICAL REASON
The study of information is a broad and complex topic with branches reaching into such academic fields as computer science, philosophy, and the
social sciences. Something as seemingly straightforward as the definition of information is, in fact, complex and controversial enough to spark intense philosophical debates. The approach throughout this book, however, is to consider information through the lens of practical reason, which has been defined as “the general human capacity for resolving, through reflection, the question of what one is to do.”6 Through this lens, the practical purpose of information can be seen as helping human beings decide what to do and, by extension, what to believe. While in some ways such an approach to information is overly simplistic, it lends itself to the real-world needs of information seekers who are trying to make the best possible decisions based on the best possible information.
INFORMATION AND THE INCIDENT COMMANDER
For a dramatic example of the way credible information informs decision making, consider the case of a professional firefighter who has been appointed the incident commander (i.e., the person in charge) of a growing wildfire. The fire has already spread to two thousand acres on a hot and windy summer day, and in order to safely and effectively respond to this fire, the incident commander must make the best possible decisions based on accurate and up-to-date information touching on a number of factors:
■ The fire’s current perimeter and rate of spread
■ Topography of the area in which the fire is burning
■ Amount, types, and dryness of the fuel in the area
■ Current and expected weather conditions
■ Location of roads, structures, and water sources
■ Whereabouts of civilians and firefighters
■ The type and number of firefighting resources currently available, additional resources on the way, and when those additional resources will arrive
While this is just a partial list of information an incident commander needs, it dramatically illustrates the fact that good decision making calls for credible information. If, for example, an incident commander were falsely informed that a fire was burning in sparse grass on flat ground when it was actually burning in heavy chaparral on a 60 percent slope, any decisions based on that faulty information could be disastrous, possibly even fatal, for firefighters and civilians alike.
SOME REALITIES OF INFORMATION
Becoming adept at evaluating information means understanding and accepting the fact that information, though powerful, has its limits. As a product of human thought and human effort, information is often problematic and always less than perfect. Anyone who approaches the evaluation of information with the idea that any information that falls short of perfection must be rejected is bound to be disappointed.
With that in mind, the realities of information described in the following pages are
■ the credibility continuum
■ information, knowledge, and skill
■ tricky facts
■ information, interpretation, and opinion
■ the expertise factor
The Credibility Continuum
For the purposes of evaluating information, it is vital to understand that credibility exists on a continuum rather than in separate spheres of true and false information. Indeed, those who approach the evaluation of information with a binary mind-set—“It’s either true or it’s false, no middle ground”—are setting themselves up for failure.
You will sometimes hear people speak of “bad information.” That phrase is problematic because thinking of information as either bad or good is overly simplistic. Yes, there is bad information of the sort that is completely made up out of whole cloth:
■ Albert Einstein invented the xylophone.
■ The fourth letter of the English alphabet is z.
■ The sun rises in the west and sets in the east.
And, yes, there is good information that is as 100 percent truthful as anything created by fallible humanity can be:
■ The speed of light is 186,000 miles per second.
■ π, the ratio of a circle’s circumference to its diameter, is approximated at 3.14.
■ Maya Angelou was born in St. Louis, Missouri, in 1928.
If all information fit neatly into the categories of “good information” (completely true) and “bad information” (completely false), then evaluating information would be relatively easy. The problem is that we inhabit a world in which vast amounts of information fall somewhere in between the two extremes of the credibility continuum. The challenge facing anyone evaluating information is not, in most cases, deciding between true or false, but rather where on the credibility continuum a piece of information lies and, in the end, deciding when any given piece of information is credible enough to fulfill a given information need.
THREE COMMON INFORMATION FRUSTRATIONS
Information can frustrate in a number of ways. The three frustrations listed here are so common that almost anyone who seeks information is bound to encounter them, usually sooner rather than later.
Intentionally Falsified Information
Human beings intentionally create false information. This, in essence, is what the fake news furor is all about. The reasons for intentionally creating false information vary widely. German industrialist Oskar Schindler famously falsified information to save the lives of Jewish inmates of Nazi concentration camps. Stockbroker Bernard Madoff notoriously falsified information to defraud thousands of investors. The Onion creates fake news stories for comedic purposes (and to earn advertising revenues). The list of reasons for intentionally creating false information goes on and on. Whatever the motivation of its creators, intentionally false information has the potential to sow confusion and spread misinformation.
Unintentionally False Information
False information can be created unintentionally. For example, someone may honestly believe with every fiber of their being that they saw Elvis singing to Bigfoot at a rest stop on Interstate 40; however, sincerity of belief does not make their Facebook post reporting Elvis in concert with Bigfoot a credible source of information. For a real-world example, there is the case of two physicists at the University of Utah who, in 1989, claimed to have produced energy using tabletop cold fusion and subsequently published a scientific paper outlining their methodology and re-
sults.7 If the physicists’ findings about cold fusion were correct, it would mean limitless clean energy for the entire world. However, no other scientists were ever able to replicate the results documented by paper’s authors and the research has been discredited. There is no evidence that the two physicists who conducted the experiment and published the paper were trying to deceive anyone; they simply made an error when measuring their results. Should they have been more careful? Yes. Were they being dishonest? No. Does it make any difference if the false information that misleads you was created by mistake rather than by intent? Not really.
Information That Is Not There
It can be extremely frustrating to learn that information you would very much like to have simply does not exist. Information is not a naturally occurring substance like oxygen or water. Unless someone has made a record of something by writing it down, drawing it, mapping it, capturing it on camera, entering it into a database, or otherwise recording it in a fixed format, the information about that something will not exist. A scholar who studies the history of slavery might very much wish for a database containing the age, sex, birth name, place of origin, native language, and tribal affiliation of every person ever forced onto a slave ship and transported from Africa to the New World. While that information could exist in theory, it does not exist in fact. Why? Because the data was never recorded in the first place. Those who profited from the slave trade could have recorded all that information—and a lot more—about the unfortunate individuals caught up in the horror of human slavery, but they did not put themselves to the trouble. A more modern example of missing information is the case of statistics on police shootings in the United States. Because local police agencies are not required to submit data on police shootings to the US Bureau of Justice Statistics, there is a dearth of reliable statistics on police shootings in the United States even though many people would like to have that information for both current and past years.8
Another random document with no related content on Scribd:
make a mistake on this basis, he will have the recompense of knowing that he has assisted in a very rare case, in which it was next to impossible for him to be right. This condition is said to be found more frequently when the brain lesion and paralysis are on the right side.
Severe pain in the head, followed by gradually but rapidly deepening coma and paralysis of one side, becoming more and more complete, probably means a hemorrhage into or just outside of the great ganglia and involving a large extent of one of the hemispheres.
If there have been moderate loss of power or complete paralysis lasting some hours, with, afterward, sudden loss of consciousness and general muscular relaxation, with sudden fall, soon followed by rapid rise, of temperature, it is very probable that a hemorrhage has broken through into the ventricles or beneath the membranes, and is still going on.
Rapidly-deepening unconsciousness, with general muscular relaxation and gradual manifestations of more paralysis on one side than the other, may come from meningeal hemorrhage.
Very sudden and complete hemiplegia without prodromata, with deep unconsciousness coming on rapidly or suddenly, but a little after the paralysis, is likely to denote the occlusion of the middle (and perhaps anterior cerebral) artery of the opposite side at a point sufficiently low down to produce extensive anæmia of the motor centres along the fissure of Rolando as well as the underlying great ganglia.
Aphasia with hemiplegia, often without the slightest disturbance of consciousness, is in a considerable proportion of cases connected with a lesion of the third left frontal convolution, and in a somewhat larger proportion with the frontal lobes in general and the island of Reil. This lesion is in a great majority of cases occlusion of the artery. Difficulty of speech, connected with difficulty of swallowing and associated with a certain amount of amnesic aphasia, has been found with lesions of the pons. As aphasia, however, may occur
without any fatal lesions at all, it is not certain in all these cases that the obvious lesion of the pons is a direct cause of all the symptoms.
Word-blindness is associated, according to a case reported by Skworzoff and a few others,49 with a lesion of the angular gyrus, pli courbe (P2 of Ecker), and word-deafness with a lesion of the first temporal (T1). These localizations agree with those experimentally determined.
49 West, Brit. Med. Journ., June 20, 1885.
Conjugate deviation is of importance as a localizing symptom, chiefly because it may be manifest when other signs of hemiplegia are difficult to elicit. I do not find it mentioned in twenty-seven cases of cerebellar hemorrhage not included in the table of Hillairet, but it is not infrequent with lesions of the pons; and when the lesion is in the lower third, it is in the opposite direction to that described as usual with lesions of the hemispheres.
Hemianæsthesia involving the organs of special sense, unilateral amblyopia, and color-blindness is supposed to be connected with a lesion of the posterior third of the internal capsule, or the thalamus in its immediate vicinity, sometimes also with a lesion of the pons. Bilateral hemiopia—blindness of the corresponding sides of both eyes—is apt to be connected with a lesion of the occipital lobe of the opposite side. Rendu and Gombault remark that hemianæsthesia of the limbs and face may be met with in certain lesions of the cerebral peduncles, but in this case the higher special senses (sight, smell) remain unaltered. Hemichorea points to the same localization as the more complete hemianæsthesia.
Alternate hemiplegia is due to a lesion of the pons upon the side of the facial paralysis, and opposed to the paralysis of the limbs and in the posterior or lower half. Care should be taken not to confound this with the accidental addition of a facial paralysis to a hemiplegia of the other side.
Irregular ocular paralyses are very likely to be due to lesion of the same region. In some of these forms an investigation of the electrical condition with reference to the presence of the degeneration reaction may be of great assistance.
With extensive lesions profound coma and relaxation without distinct hemiplegia are likely to be due to injury of the pons. A thrombus of the basilar artery may lead not only to rapid, but even to sudden, death. A phthisical patient died suddenly while eating his supper, and a thrombosis of the basilar artery, with softening of the pons, was found. Of course the lesion must have been of older date 50 Bright51 thought that when symptoms pointing to disease of the intracranial vessels were present the diagnosis was confirmed, and the location of the lesion in the vertebral arteries rendered highly probable, by a persistent occipital pain. In the upper part of one side of the pons the hemiplegia is not alternate, but of the ordinary form.
50 Bull. de Société anatomique, 1875.
51 Guy's Hospital Reports, 1836.
Any extensive lesion of the medulla must cause death so rapidly as almost to defy diagnosis, but such rarely occurs. The very rapid termination of certain cases of hemorrhage into the pons and cerebellum is due to the escape of blood into the fourth ventricle and consequent compression of the medulla.
Lesions of the lower and inner part of the crus are indicated by paralysis of the third nerve of the same, and hemiplegia of the opposite side of the body.
Obstinate vomiting, severe occipital headache, and vertigo, with or without a distinct paralysis, render a cerebellar hemorrhage probable, though no one of these symptoms is necessarily present or pathognomonic. Vomiting is very much more common with cerebellar hemorrhage than with cerebral. Ocular symptoms, like nystagmus and strabismus, accompany cerebellar lesions.
A difference in the temperature of the paralyzed and non-paralyzed sides, when amounting to one and a half to two degrees and lasting for a long time, is thought by Bastian to indicate a lesion of the optic thalamus.
The severe and rapid sloughing of the nates sometimes seen in rapidly-fatal cases is stated by Joffroy to be most frequently connected with a lesion of the occipital lobes.52
52 Arch. gén., Jan., 1876.
It is plain, from what has been said about the symptoms of the different kinds of lesion, that a distinction may be often very difficult, and at times impossible; and in this connection all observers are agreed, the apoplectiform shock, the hemiplegia, and the slighter attacks being common to two or three lesions. The diagnosis can be made, if at all, only by the consideration of more or less secondary symptoms and the careful weighing of the various probabilities against each other. Most of the statements of differences of symptoms are only relatively true.
A glance at the nature of the pathological processes involved may serve to systematize our observations.
Hemorrhage is a sudden accident, with a severity increasing as the amount of effusion increases. It has been prepared for by arterial disease, but this disease is one which may have no previous symptoms. It is at first an irritative lesion.
Embolism is a sudden attack which may be as severe at first as even a few minutes afterward. It is also prepared for by disease of other organs, which may or may not have symptoms according to the origin of the embolus. As embolism affects especially those regions where the motor centres are spread out, while hemorrhage attacks more frequently the conductors in their locality of concentration, the paralyses arising from the former affection may be more narrowly limited.
Thrombosis is a gradual affection, which may, however, manifest itself suddenly, from the obstruction reaching a certain point and suddenly cutting off the supply of blood. This also depends on previous disease which has more or less definite symptoms.
The severity of the attack is not conclusive, though the completely developed apoplectic attack is more frequent with hemorrhage. Rapidly increasing severity, especially if there have been prodromata, is in favor of hemorrhage. Convulsions, early rigidity, and conjugate deviation of the eyes of the spastic form, especially if afterward becoming paralytic, are strongly in favor of hemorrhage, and the latter possibly conclusive. Hughlings-Jackson states that he cannot call to mind a single case of hemiplegia from clot in a young person in which there were not convulsions.
Sudden paralysis without cerebral prodromata, unconsciousness, or pain can hardly be anything else than embolism; but, unfortunately for diagnosis, the initial paralysis from the embolus may be slight, and afterward added to by the secondary thrombus, so as to put on the appearance of more gradual approach.
Aphasia, and especially aphasia associated with but little or no paralysis, is very much more frequent with embolism than with hemorrhage.
The temperature, if we could always have it recorded from the very beginning, might be of value, as the initial depression is said to be less with embolism than with hemorrhage, but Bourneville,53 who lays down this rule, gives so many cases where no great depression occurred with hemorrhage that it cannot be considered decisive. Besides this, we are not likely to get the information at the time it is of the most value.
53 Op. cit.
Etiological information may have a very practical bearing on this part of the diagnosis. Age gives a slight amount of predominance to the chances of hemorrhage, and youth a considerably greater one to the
chances of embolism. Interstitial nephritis with hypertrophy of the heart, after the exclusion of uræmia, gives a strong probability in favor of hemorrhage. Valvular disease of the heart, especially a more or less recent endocarditis, is strongly in favor of embolism. A feeble action of the heart, slow and irregular pulse, are more likely to be connected with thrombosis.
Atheroma and calcification, as detected by examination of the visible and tangible arteries like the radial and temporal, is a condition either connected with the periarteritis aneurysmatica which gives rise to hemorrhage, or one which furnishes a suitable spot for the deposition of a thrombus; hence it can be considered conclusive in neither direction.
Arcus senilis, even of the fatty variety, can only show some probability of arterial degeneration.
Retinal hemorrhage, if present, favors the presence of a similar cerebral lesion, but nothing can be argued from its absence. Landesberg54 has reported a case in which embolism of the central artery of the retina, easily diagnosticated by the ophthalmoscope, preceded by a few days a similar accident in the middle cerebral; and Gowers55 another in which the two arteries were occluded simultaneously.
54 Archiv für Ophthalmologie, xv. p. 214.
55 Lancet, Dec. 4, 1875.
If a sudden paralysis arises in connection with a septic process, we may diagnosticate an embolus with a good deal of confidence; but it is not unusual to meet with small abscesses of septic origin which have given rise to no special symptoms whatever, or only to such as are covered up by the more general constitutional ones.
PROGNOSIS.—The prognosis quoad vitam of cases of apoplexy still in the unconscious state is based upon the general severity of the symptoms as indicated by general muscular relaxation, or, at a later
period, the extent of the paralysis, the amount of affection of the heart and respiration, and especially the progress during the first few hours. Too much weight should not be placed upon a very slight improvement at first, since this often takes place in cases soon to prove fatal.
Stertorous respiration with perfect tolerance of mucus in the throat, absolute loss of the reflexes, and immobility of the pupils signifies profound depression of the organic nervous centres, and is consequently of unfavorable augury.
The temperature is a valuable guide. In proportion as it moves steadily and rapidly upward is the prospect of an early fatal result. A person may die during the initial fall of temperature, but in such a case there would hardly be need of a prognosis.
In general, the prognosis from hemorrhage, supposing the symptoms to increase in severity for an hour or two, is worse than that from occlusion.
Age, aside from the fact that it makes hemorrhage more probable than occlusion, is not of great importance in prognosis, certainly not out of proportion to the general impairment of vigor in advanced years.
A renewal of the hemorrhage within a few hours cannot be predicted. It may be indicated by another fall of the temperature, which, if it have been previously on the rise, renders, of course, the prognosis more unfavorable.
After recovery, more or less complete, from the apoplectic condition the prognosis is favorable, for a time at least, except so far as one attack may be looked upon as the forerunner of another. After the temperature has reached a sort of standstill in the neighborhood of normal, its subsequent rise will furnish among the earliest indications of an approaching fatal termination.
Urinary trouble, retention, incontinence, or, much more, cystitis, is to be looked upon as a complication which materially increases the gravity of the situation. Bed-sores or abrasions may be placed in the same class, except that the early and extensive sloughing of the nates described by Charcot is of almost absolutely fatal significance.
After some days or weeks the progress of the paralysis either toward better or worse may be exceedingly slow, and as time goes on the danger to be apprehended from the latter becomes less and less.
When paralysis takes place in young persons and the primary attack is recovered from, it is doubtful if the chances of a long life are materially diminished. A case has already been referred to in this article where the consequences of a cerebral hemorrhage occurring in infancy were found in a woman of eighty-three in the form of atrophied limbs and an old pigmentary deposit in the brain.
Hemorrhage into the cerebellum would appear, from statistics, to be exceedingly fatal, but it is certain from old lesions occasionally found that it is not absolutely so, and its apparent severity is partly caused by the fact that it is very seldom diagnosticated except at the autopsy.
The prognosis quoad restitutionem ad integrum cannot be made to advantage at an early period. After the immediate danger to life has passed it is safe to say, if pressed for an answer, that it is highly probable that some recovery from paralysis may take place, but that it is highly improbable that it will be absolutely complete, and just how far improvement may go it is impossible to predict with accuracy at first. Time must be given, in the first place, for pressure to subside, compressed nerve-fibres to be restored, and for such collateral circulation as is possible to be established. How recovery takes place beyond this it is not easy to say. It is hardly supposable that any considerable portion of nerve-structure is renewed. A certain amount of substitution, by which one part of the brain takes up the functions of another part, is among the most plausible suppositions; but how this is accomplished it is hardly worth while in the present condition of cerebral physiology to speculate.
Practically, it may be said that physicians are apt to consider a paralysis absolute at too early a period, while the patient and his friends continue to hope for a complete restoration after it is evident that no really useful increase of power is to be looked for. Weeks, and even months, may elapse before any return of motion can be perceived in cases which are really susceptible of considerable improvement, and a year most certainly does not cover the limit of the time during which it may go on.
The most unfavorable symptom, one which probably precludes all hope of useful recovery in the limbs affected, is contracture, heralded for a time by increase of the deep reflexes, indicating degeneration of the motor tract in the white substance of the cord. Until this begins, certainly for many weeks, the patient may be fairly encouraged that some improvement is possible, though after a few weeks the chances diminish as time goes on. In the rare cases where the muscles undergo rapid wasting the prognosis is, if possible, worse still. The localization of the lesion after the early symptoms are passed does not greatly influence the prognosis.
A rapid recovery taking place in either hand or foot, and especially of the hand first, without corresponding improvement in the other limb, is of unfavorable import for the latter, and, in general, the prognosis is not exactly the same for both limbs involved. In the rare cases of hemiplegia from acute brain disease occurring in children the nutritive disturbances in the form of arrest of growth should be taken into the account in prognosis, since the result may be nearly or quite the same as is found after infantile paralysis from disease of the cord.
In regard to the slighter forms of paralysis, it may be said that the less extensive the original paralysis is, and the sooner improvement begins, the better is the chance of complete recovery.
TREATMENT, INCLUDING PROPHYLAXIS.—Cerebral Hemorrhage.—As the condition upon which the usual form of cerebral hemorrhage depends is so frequently aneurism, and probably nearly always some arterial disease, the prophylaxis must evidently consist in such
a mode of life as will least tend to this degeneration, or at least put it off as long as possible. This, of course, means the avoidance of all the special causes described under the head of Etiology. It is a disease of old age, but in a pathological sense old age begins in different persons after a different number of years. Fortunately for rules of hygiene, there is little that is contradictory in those to be given for most chronic and degenerative diseases. Abstinence from alcohol, as an agent tending at once to paralysis and dilatation of the vessels, is one of the most important rules and insisted upon by nearly all writers. The avoidance of over-eating, and especially of nitrogenous food as tending to lithæmia—a generally recognized cause of arterial degeneration—is perhaps the next. Over-eating is of course to be understood as a relative term, and to be estimated with reference to the habits of exercise of each person. Practically, it will be decided by its effects; that is, if careful thought be given to the matter and the statements of the gourmand as to his immunity from all risk of trouble are not accepted as of scientific value. On the other hand, insufficient food, producing anæmia, may be a factor in arterial degeneration. Keeping one's self free from anxiety, and getting through the world with as little experience of its roughnesses as possible, might be, properly enough, added in a purely theoretical point of view if any one ever asked a physician's advice in youth as to avoidance of the diseases of age, or if any one could or would profit by this advice if it were given.
Intellectual pursuits have been credited with a special tendency to apoplexy, but there is no good reason to suppose that healthy exercise of the mind is otherwise than beneficial to its organ. Hurry, over-anxiety, and mental tension are undoubtedly potent factors in general breakdown, but do not necessarily lead to this form. They are certainly not to be found by preference in those persons who lead an intellectual life.
Syphilis, one of the most important of the causes of organic cerebral disease, and that too in the form of thrombosis, is not specially concerned in the etiology of the forms here under consideration.
If symptoms have occurred that justify the apprehension of apoplexy or paralysis, such as frequent headaches in an elderly person, hemiopia, temporary aphasia, or slight and temporary paralyses, or if one have reached a time of life at which the risk of cerebral hemorrhage becomes considerable, a stricter attention to the rules laid down above, and even to some to which but little heed would be given in health, is not out of place. A certain amount of limitation of diet, moderate and regular but not violent exercise, clothing suitable to the season, and especially warm enough in winter, and, most of all, rest if the patient be doing wearing and anxious work, should be enjoined. Finally, it should be said that the real prophylaxis of cerebral hemorrhage is to be begun in early life.
Among the exciting causes to be avoided are those which obstruct the flow of blood from the head, like tight clothing around the neck. Increase of the arterial pressure by severe or prolonged muscular effort, as in lifting or straining at stool, is to be avoided, as well as violent fits of passion. The condition of the bowels should be regulated by mild laxatives.
When the apoplectic attack has actually occurred, treatment, though apparently urgently demanded, is really of little avail. If a patient is about to die in an hour or two from rapidly increasing pressure, nothing within the reach of medical science can stop him.
There is one danger, however, easily avoided, but probably often overlooked. A patient may die from suffocation. The stertor is often a result of the paralysis of the tongue and palate and of the amount of fluids collecting in the pharynx from the almost invariable position of the patient on his back; that is, if he have been seen by some one who wished to do something for him, but did not know what. Insensibility and paralysis combine to favor this accumulation, which obstructs the respiration, and which may find its way to the lungs, together with brandy and milk, and set up an inhalation-pneumonia. The simple and obvious thing to do is to place the patient sufficiently on his side, with the face somewhat downward, for the tongue and palate and secretions to fall forward, instead of backward into the
pharynx. Swabbing out the pharynx may be of some use, but cannot be so thorough. An easy position and proper ventilation should be secured in all cases of unconsciousness, even at the risk of treating a drunkard with undue consideration. Police-stations should be provided with rooms where these conditions can be secured, and the necessity avoided of placing persons picked up in the streets in the narrow, close, and perhaps distant cells provided for malefactors. The writer recalls the cases of two young men—one who had been drinking some time before, and the second roaring drunk—who were locked up in a suburban station-house in the evening, and found the next morning—one dying and the other dead.
Artificial respiration may be used to prolong life in some cases until the nervous centres have sufficiently recovered their functions to carry on the process without assistance. The condition of the bladder should be ascertained, and the urine drawn if necessary, though it is more frequently passed involuntarily.
Although it is manifestly impossible to remove the clot from the interior of the brain, it may appear that the further flow of blood may be stopped and the amount of damage done limited. For this purpose two remedies are proposed—namely, bleeding and purgatives. Both of these act to diminish arterial pressure, which is forcing the blood out of the rupture. Though the treatment seems reasonable, it would not be difficult to imagine a condition where sudden and premature diminution of pressure in the brain, which of course exists outside of the arteries as well as inside, would tend to set going again the flow which has ceased from the very force of the pressure it itself exerts, very much as if a tampon were prematurely removed from a bleeding cavity elsewhere. As the conditions are somewhat complicated, and at the same time only remotely to be estimated, it is safer to be guided by experience in the use of these remedies than by abstract reasoning. In some of the cases of temporary aphasia, as notably that of Rostan narrated by Trousseau, bleeding seems to have given immediate relief. Trousseau, however, is no advocate of that method of treatment. Most modern authors speak of venesection as to be used in cases where the pulse is
strong and full and the face red, but not to be thought of in the opposite class. When a case presents the appearances of plethora and an attack has come on suddenly, the loss of a few ounces of blood can certainly do no harm. Other forms of bleeding, such as cups and leeches, are not rapid enough to be of great value, though a large number of leeches about the head might be useful. Some French writers recommend leeches to the anus as revulsives. Cathartics may be more freely used, although they should be given cautiously when there is any tendency to cardiac depression. It can be clearly shown that a brisk purgative lowers the arterial tension decidedly. In case of cerebral tumor or injury with occasional socalled congestive attacks, the relief afforded by cathartics is very great, and, although the conditions are not exactly parallel, it is fair to assume a similar action in the congestion accompanying cerebral hemorrhage. From one to three drops of croton oil may be placed far back on the tongue or it may be diluted with a neutral oil. Ail enema may be desirable for the unloading of the bowels, but has a much less marked effect on the tension of the cerebral circulation.
In most cases of apoplectiform cerebral hemorrhage, and probably in all of simple paralysis, no very active treatment is called for. Measures directed to the prevention of another hemorrhage, and to allay any irritation that may supervene during the changes taking place about the clot and the formation of its capsule, are of the simplest, and consist in keeping the head high and cool, the clothing sufficient for warmth, and offering no obstruction to respiration or circulation, laxatives sufficient to keep the bowels in good order, and a diet not highly nitrogenous, but sufficient and digestible.
That which will tax most severely, however, the care and patience of attendants is the scrupulous and minute attention to cleanliness and pressure over the bony prominences which is necessary when a patient is helpless and unable to control the discharges from the rectum and bladder. Frequent change of clothing, bathing, change of position, and avoidance of wrinkles and roughnesses in the bed may be successful in keeping the patient free from bed-sores. Bathing
with alcohol hardens the skin and makes it less susceptible to pressure.
Surgical interference may perhaps be of value in cases where the portion of the clot outside the brain can be clearly demonstrated; and this would apply with special force where the hemorrhage arises from injury.
Trephining and removal of the clot has been done in a few cases of meningeal hemorrhage, though with indifferent success (3 cases—2 deaths, 1 unknown.)56 An intracerebral clot is obviously a step beyond, though possibly in some cases not absolutely without, the reach of the surgeon.
56 Med. Press and Circular, Oct. 14, 1885.
Treatment of Cerebral
Embolism.—The
prophylaxis is in the avoidance of such conditions as give rise to the formation of detachable vegetations or clots. Unfortunately, these are numerous, not completely known, and not always avoidable. Arterial disease is to be looked upon as of some importance, but cardiac valvular lesions of much greater, and the causes of these, like rheumatism, scarlet fever, and the puerperal condition, are not always to be escaped. The presence of a detachable piece of fibrin in the pulmonary veins, heart, or aorta being granted, nobody can possibly say what will prevent its being loosened and lodging in one of the cerebral arteries; so that, practically, the prophylaxis of embolism consists in the judicious treatment of acute rheumatism and the other conditions just mentioned. The treatment of the first attack must consist solely in the relief of respiration, bladder, and bowels, if they have not taken care of themselves. Stimulants may be of use for a short time, but there cannot be any call for even the slight amount of depletion suggested for some cases of hemorrhage. Bed-sores are to be looked out for, just as in hemorrhage, and the subsequent treatment conducted on the same principles. As regards the primary lesion, we can do nothing about it either in the way of removal of the embolus or restoration of the necrosed brain-tissue.
Treatment of Cerebral Thrombosis.—There being two factors in this affection, both of which are to a certain extent under control, something may be done toward diminishing the risk of its occurrence. Arterial disease and its prophylaxis have already been spoken of. The other condition which is necessary to the production of thrombosis—namely, an enfeebled circulation—is to some extent under the control of general hygienic rules: a nutritious, not too highly nitrogenous, diet, and especially sufficient exercise and the avoidance of completely sedentary habits. If there is a crasis which predisposes to the formation of coagula in the vessels, it is not known that there is any special treatment, medical or otherwise, which can prevent it. The attack is to be treated exactly on the principles already laid down. Bleeding is about the last thing to be thought of. Stimulants, though they cannot dislodge the clot, may be of use for a time to sustain the heart under the shock. The secretions and the condition of the skin are to be looked out for.
After a few weeks of waiting the patient and his friends not unnaturally feel as if something ought to be done to hasten recovery, and certain measures may be taken, in addition to careful hygiene, which have this object in view. It is very doubtful, however, whether anything really shortens the time necessary for such repair as is possible or diminishes the amount of damage which is to be permanent. As has already been said, improvement may go on slowly for months. In the first place, it is sometimes considered desirable to practise shampooing and massage of the affected muscles in order to keep them in as good a condition of nutrition as possible. This, as well as the regular use of the faradic battery if it be not begun too early, will prevent a certain moderate amount of atrophy, but could not have any influence in those rare cases where rapid wasting depends upon secondary degeneration of the anterior gray columns. It may be doubted, however, whether it is necessary to pay much attention to the condition of the muscles, as they do not ordinarily atrophy to the extent of becoming unsusceptible to the nervous stimulus from the brain so soon as it shall be transmitted to them. Faradism, like many other agencies, such as magnets, metals,
pieces of wood, and so forth, is said to produce a transfer of sensibility in cases of hemianæsthesia.
There is no sufficient reason to suppose that any drug is of any value in the restoration of the nervous structure. Iodide of potassium may possibly prove to have some effect as a sorbefacient. Very favorable results have been claimed for ammonia salts in the restoration of aged persons to a nearly complete use of paralyzed limbs. Phosphorus has been spoken of as assisting in repair, but the writer is not aware upon how wide a basis of facts. Silver and gold have been said to counteract the sclerosing myelitis. Strychnia is certainly useless, and probably worse. It may make the paralyzed limbs twitch, but this does just as little good as the involuntary spasmodic movements, which have never been considered desirable, except as awakening in the patient false notions of immediate recovery, and which are frequently a very annoying symptom. The galvanic current has been applied with a view to a sorbefacient or restorative action directly to the brain, or rather to the pericranium.
Something can be done for the comfort of such patients: the rubbing and kneading of the paralyzed limbs, if they do not hasten the recovery of motion, relieve many of the painful and unpleasant feelings. Since we do not know how far one part of the brain may supplement another, attempts at motion after it has once appeared to ever so slight a degree should not be abandoned by the patient. He should walk with crutches frequently as soon as he can, though not to the point of fatigue.
There is one faculty which seems capable of re-education to some extent: that is of speech in cases of ataxic aphasia, and even in others the attempt should be made to teach the patient the names of things. A very interesting case has been reported by Bristowe57 of a man who came under his observation after an attack which may have been anterior poliomyelitis with extensive paralysis, able to write well and intelligently, but unable to say anything. By gradual education, first in the sound and formation of letters and afterward of words, he reacquired the use of language. It is obvious that in this
case there could have been no loss of memory for the words themselves, but simply the loss of the knowledge of how to produce them. When his speech returned he spoke with his original American accent.
57 Clin. Soc. Trans., iii. p. 92.
In short, the therapeutics of hemiplegia from arterial disease in the brain is good nursing and attention to symptoms, with a moderate amount of care of the paralyzed muscles.
