From apoplexy to stroke - review of medical literature on stroke over previous 2,000 years, especially sources from 18th and 19th centuries

Age and Ageing, Sept, 1997 by Pandora Pound, Michael Bury, Shah Ebrahim

One of the ironies of the contemporary approach to stroke is that more uncertainty now appears to exist. The frankness that is found in eighteenth and nineteenth century discussions of prognosis seems to have been due to the greater certainty that existed then, which in turn was based on the fact that there were no treatments in the long term for apoplexy: people either died, got better or lingered on miserably. Now rehabilitation is one of the main contemporary treatment responses to stroke, suggesting a more positive outcome, yet uncertainty remains about its efficacy. The contemporary atmosphere of uncertainty gives rise to considerable ambiguity in communications between patients and health professionals about prognosis. The more treatment becomes available, the more uncertainty this appears to give rise to, as has been found elsewhere [38].

The contemporary management of stroke will doubtless be superseded by many other fashions and phases--some foreseeable, others at present unimaginable. Some may simply be new versions of the past. Responsibility for the cause of the stroke has always been laid firmly at the feet of the individual over the centuries. As noted above, physicians used to believe that overindulgence or excess might bring about a stroke, signifying a moral tone connected with religious ideas about moderation as virtue. This moral tone, often set by doctors, persisted throughout the eighteenth and nineteenth centuries and is still resonant today, despite the increasing salience of a pathological view of disease. For example, Davison and colleagues, in the context of heart disease prevention, found that lay as well as medical theories emphasized abstinence from indulgence [23]. Today people who smoke, do not exercise and consume high cholesterol diets may be regarded as having had the stroke coming to them [39]. Moral explanations will probably always co-exist with pathological explanations, but perhaps they are stronger in contexts where there are no cures since they move the onus of responsibility from the doctor to the patient.

Perhaps another version of past approaches is the increasingly popular trend towards regarding people as `at risk'. In the field of stroke, a person's risk score can be calculated on the basis of factors such as age, blood pressure, whether they smoke and how much exercise they pursue [40]. In this way, healthy populations are monitored and pathologized; if they do not exercise sufficiently, give up smoking, eat `properly' and have their blood pressure monitored, they are seen as healthy people waiting to get ill [41], a stroke about to happen. But the desire to identify people `at risk' is perhaps not quite as new as we think: in the eighteenth century the `apoplectic habitue' would easily have given it away.

Acknowledgements

This work was conducted while Pandora Pound was supported by a grant from the Stroke Association. We are grateful to the Wellcome Institute Library for the use of their facilities.

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