Mrs Doherty had suffered a stroke.
The difficulty of getting the unconscious woman out of the sewer was considerable. Two ladies tried to carry her, but the slippery surface of the tunnel made it impossible. Others said they would go to get help, but the guide assured them they would get lost if they tried. With great courage and strength, he hoisted Mrs Doherty across his shoulders and carried her the half mile to the exit shaft. One of the ladies was supporting her head, and several times the guide slipped and nearly went over, but not quite, and he did not drop Mrs Doherty. ‘It was a nightmare,’ the ladies said afterwards. The journey, the bumping, and the length of time taken probably added to the injury sustained after the initial stroke.
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.