Paradox Lost: Logical Solutions to Ten

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Michael Huemer
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 m icha e l h u e me r

PARADOX LOST

Logical Solutions to Ten Puzzles of Philosophy

Paradox Lost
 Michael Huemer

Paradox Lost
Logical Solutions to Ten Puzzles
of Philosophy
Michael Huemer
Philosophy Department
University of Colorado Boulder
Boulder, CO, USA

ISBN 978-3-319-90489-4    ISBN 978-3-319-90490-0 (eBook)

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For those to whom this book is dedicated
 Preface

I wrote this book because I like paradoxes … but even more than para-
doxes, I like solutions. If you like such things too, then you might enjoy
this book. I have offered my solutions to ten of what I found to be par-
ticularly fascinating and mind-boggling philosophical paradoxes. I hope
that when you read the paradoxes, you feel puzzled and challenged, and
that when you read the solutions, you feel a sense of things falling into
place. In some cases, I hope you also come away with philosophically
significant lessons.
I have written this book in such a way that, I hope, the generally edu-
cated reader can follow it. That is, although I assume you are generally
smart and educated, I do not assume that you have read any of the litera-
ture on the paradoxes, nor any other specialized literature. Thus, I explain
each paradox as if you don’t know what it is. When I want to address an
idea that other philosophers have advanced, I explain that idea. I have
made my explanations as clear and concise as I knew how to do, hoping
neither to confuse you nor to waste your time. Complications and quali-
fications, as well as references to the literature, appear in footnotes.
At the same time, I have tried to write something of interest to profes-
sional philosophers. In many cases, my take on a paradox is distinctive
and unorthodox. (If not for this, I would not have been motivated to
write the book.) This is true particularly for chapters 2, 3, 6, 8, and 10.

vii
viii Preface

Academic authors routinely overestimate their audiences – whatever

our topic, we tend to vastly overestimate both the number of people
interested in it, and the level of background knowledge people have about
it. I think we overestimate the knowledge and interest even of other aca-
demics. (This involves a certain failure of reflection – we know, or should
know, that our own knowledge of almost every other subject is minimal,
yet we fail to consider that almost everyone else has about the same level
of knowledge of our area of specialization.) Thus, there are many books
that can only be usefully read by a handful of people in the world. I wrote
this book in the way that I did because I wanted to make an intellectually
valuable contribution, without adding to the stock of nearly-unread aca-
demic volumes. That is why it is as complex as it is, and why it is not
more complex.
Now I would like to thank several other thinkers for discussion of
some of the ideas in this book, including Iskra Fileva, Randall
McCutcheon, Roy Sorensen, Eddy Chen, Christian Lee, Sam Director,
David Barnett, Ari Armstrong, an anonymous referee for Palgrave, and
the philosophers at the University of Vermont (to whom I presented
chapter 3). Without their help, this book would be worse than it is.
Naturally, none of these people can be blamed for any errors that remain.
In the preface to my last book, I laid the blame for any errors on my PhD
advisor, Peter Klein. I now realize that this was unfair and highly inap-
propriate. So I want to be clear that Peter is not to blame for the errors in
this book. Of course, the blame for any errors falls entirely on my research
assistant, Jasmine Carter, and my former student Matt Skene. I specifi-
cally instructed them to correct all errors in the manuscript. I thank them
for their comments, and I will graciously accept their apology for my
mistakes.
Fortunately, however, if the sentence you are now reading is true, then
there are no errors in this book.

Boulder, CO, USA Michael Huemer

 Contents

1 Introduction   1

Part I Semantic Paradoxes   15

2 The Liar  17
3 The Sorites  45

Part II Paradoxes of Rational Choice   89

4 The Self-Torturer  91
5 Newcomb’s Problem 107
6 The Surprise Quiz 133
7 The Two Envelopes 149

Part III Paradoxes of Probability 159

8 The Principle of Indifference 161
9 The Ravens 203
10 The Shooting Room 209
11 Self-Locating Beliefs 219
12 Concluding Remarks 245

Index 255

ix
 Analytical Contents

1 Introduction 1
1.1 What Is a Paradox? 1
Paradoxes are robust, widespread intellectual illusions
in which seemingly compelling reasoning generates an
absurd or contradictory conclusion.
1.2 What Is a Solution? 5
A solution should dispel the illusion, so that the
paradoxical reasoning no longer seems compelling.
1.3 How to Seek Solutions 7
We should not expect a common approach to apply
to all paradoxes – but self-evident principles such
as those of classical logic must always apply.
1.4 Why Paradoxes? 10
Paradoxes are charming, fun, and may reveal deep
confusions about important philosophical matters.
1.5 Paradoxes Not Covered 11
I address only philosophical paradoxes that do
not depend on controversial views and that I have
not previously addressed.

xi
xii Analytical Contents

2 The Liar 17
2.1 The Paradox 17
The liar sentence, “This sentence is false”, is apparently
both true and false.
2.2 A Third Truth-Value 18
Some say the liar sentence is “indeterminate”.
But what about the sentence, “This sentence is false or
indeterminate”?
2.3 True Contradictions 19
The view that there are true contradictions is confused.
2.4 Meaninglessness 22
Perhaps the liar sentence is meaningless for one
of the following reasons.
2.4.1 Self-Reference 23
Due to self-reference? But there are benign cases
of self-reference.
2.4.2 False Presupposition 24
Due to containing a false presupposition?
But we can easily remove the putative
presupposition.
2.4.3 Lack of Communicative Use 25
Because it cannot be sincerely asserted? But other
paradoxical sentences can be sincerely asserted.
Because it cannot be used to convey information?
But very similar sentences can be so used.
2.5 Putting the Blame on Truth 26
Some say that there is something wrong with the general
concept of truth. But this approach is self-undermining
and rules out too many innocent sentences.
2.6 A Solution 29
2.6.1 An Inconsistent Language 29
Our language contains inconsistent rules for
how to interpret certain sentences, which results
in sentences with no propositional content.
2.6.2 Meaning Deficiency 32
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   xiii

The liar sentence is not meaningless; it merely

has a defective meaning that fails to pick out a
proposition.
2.6.3 The Truth-Teller 33
“This sentence is true” also fails to express
a proposition.
2.6.4 “The Liar Sentence Is Not True” Is True 34
It is permissible for a sentence other than L
itself to say that L is not true.
2.6.5 This Sentence Is False or Meaning-Deficient 36
“This sentence is false or meaning-deficient”
also fails to express a proposition.
2.6.6 Liar Cycles 36
In cases where a group of sentences generate
a liar-like paradox, all the members of the group
fail to express propositions.
2.6.7 Prohibiting Liars 38
There is no need to devise new syntactic rules
for identifying liar-like sentences or ruling them
“ungrammatical”.
2.7 Curry’s Paradox 40
Given a sentence, “This sentence is false, or p”,
we can seemingly prove that p must be true. Again,
the sentence fails to express a proposition.
2.8 The Paradox of Non-Self-Applicability 41
The property of “not applying to oneself ” seemingly
must apply to itself if and only if it does not apply
to itself. Solution: there is no such property.
2.9 Russell’s Paradox 42
The set of all sets that don’t contain themselves must
contain itself if and only if it doesn’t contain itself.
Solution: there is no such set.
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3 The Sorites 45
3.1 The Paradox 45
Removing a single grain from a heap of sand does not
convert the heap to a non-heap. This principle entails
that if a million grains of sand make a heap, then
one grain of sand makes a heap.
3.2 Deviant Logic 47
Some respond with theories of indeterminacy or
degrees of truth. These views have trouble explaining
second-order vagueness. Degrees of truth introduce
more precision than is plausibly present. Also,
classical logic is self-evident.
3.3 Supervaluationism 52
Some say that a sentence is true provided that it would
be true on any acceptable way of making the vague
terms precise. This view has trouble with second-order
vagueness. It also violates classical logic, conflicts with
the T-schema, and implies that a statement of the
theorist’s own view is false.
3.4 Epistemicism 55
Some say vague terms have precise boundaries that
we merely fail to know. This is implausible since there
is nothing that could make a particular boundary the
correct one.
3.5 A Moderate Nihilist Solution 59
3.5.1 Fit Determines Content 59
Mental states can be satisfied to varying degrees
by different possible states of the world. The
idea of the “propositional content” of a mental
state is only a rough description of a mental
state’s meaning, as if the state were always fully
satisfied or fully unsatisfied.
3.5.2 When Thoughts Are Vague 63
Thoughts are vague when they have inter-
mediate degrees of satisfaction in some possible
situations. There are degrees of vagueness.
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3.5.3 Uncertainty About Vagueness 65

We can be introspectively uncertain whether a
thought is vague.
3.5.4 Vague Thoughts Make for Vague Language,
and Vice Versa 66
The vagueness of thought makes language vague,
and vice versa.
3.5.5 An Argument that Vague Statements
Do Not Express Propositions 69
Vague sentences and thoughts do not express
precise propositions, and there are no vague
propositions, so vague sentences and thoughts
don’t express propositions at all.
3.5.6 Arguments by Analogy 72
In other cases of semantic indecision, we accept
that sentences fail to express propositions.
3.5.7 Logic Is Classical 74
This view of vagueness preserves the law
of excluded middle and bivalence, properly
understood.
3.5.8 How to Almost Say Something 76
Vague sentences often come close to expressing
propositions.
3.5.9 Almost Is Good Enough 77
It is common and appropriate to use language
approximately.
3.5.10 Applying Logic to Vague Sentences 79
We can apply our logical faculties to sentences
even when they fail to express propositions.
3.5.11 Interpreting ‘Truth’: Strict Truth vs. Loose Truth 81
It is unsettled whether “is true”, as applied to
sentences, means “expresses a true proposi-
tion” or instead means “expresses a thought
that the world satisfies to a high degree”.
3.5.12 Why Is There Second-Order Vagueness? 84
First- and second-order vagueness both arise from
the same features of mental states described above.
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3.6 Conclusion 85
The sorites argument fails since none of its sentences
express propositions. The premises almost express truths
and the inference form is valid, but this does not
guarantee a true or nearly true conclusion.

4 The Self-Torturer 91
4.1 The Paradox 91
The self-torturer repeatedly increases his torture level
by undetectable increments, each time receiving a large
financial reward. Seemingly rational individual
choices lead to an intolerable end result.
4.2 Quinn’s Solution 93
Quinn holds that it is not always rational to choose
the best option available at the time, and that rational
choice is not always forward-looking.
4.3 An Orthodox Solution 95
4.3.1 In Defense of Undetectable Changes 95
The case actually shows that there can
be unnoticeable changes in subjective
experience.
4.3.2 Indeterminacy 97
It cannot be indeterminate how bad a pain is.
4.3.3 In Defense of an Optimal Setting 99
Since pain has constant marginal disutility,
while money has diminishing marginal utility,
there is an optimal point for the self-torturer
to stop.
4.3.4 Detectable and Undetectable Values 103
It is not so strange that an undetectable bad
can outweigh a detectable good. Undetectable
quantities can often be larger than detectable ones.
4.3.5 Advantages of This Solution 105
My solution to the problem preserves classical
logic and decision theory, without positing
anything particularly strange.
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5 Newcomb’s Problem 107

5.1 The Paradox 107
You are asked to choose between taking box A and
taking both A and B, where B contains $1000, and A
contains either $1 million (if a reliable predictor
thought you would take only A) or $0 (if the predictor
thought you would take both). Dominance reasoning
supports taking both, but expected utility
maximization seemingly supports taking only A.
5.2 Objections to the Scenario 110
The scenario can be made more realistic without
eliminating the paradox.
5.3 The Right Expected Utility Principle 112
5.3.1 The Right Way to Make Good Things
More Likely 112
Rational agents seek to “make more likely”
the achievement of their goals in a causal
sense, not an evidential sense.
5.3.2 Two-boxing Maximizes Expected Utility:
Doing the Math 115
When we incorporate the above insight into
the notion of expected utility, Dominance and
Expected Utility principles agree.
5.3.3 Why This Is the Best Solution 119
The causal decision theorist’s solution preserves
central intuitions about rational choice.
5.4 The Case of Perfect Reliability 119
What if the predictor is 100% reliable? This requires
either backward causation (making one-boxing
rational) or determinism (ruling out free choice).
5.5 Rationality and Long-Run Benefit 122
One-boxers say that rationality must be tied to how
much one benefits in the long run. They then appeal
to one of the following claims.
xviii Analytical Contents

5.5.1 One-Boxers as a Group Do Better 122

But the wellbeing of the group one belongs
to is irrelevant in rational choice theory.
5.5.2 One-Boxers Tend to Do Better in any
Given Case 124
But this rests on a mistaken interpretation
of the probabilities used in rational
choice theory.
5.5.3 One-Boxers Do Better in Repeated Games 124
But this changes the scenario in a way
that may also change the causal decision
theorist’s answer.
5.5.4 Being a One-Boxer Is Predictably Advantageous 125
But this only shows that there are scenarios
that systematically reward irrationality.
This applies to any paradigmatic form
of irrationality.
5.6 Uncertainty About Decision Theory 128
In decision-making, it can be rational to give some
weight to each of two conflicting theories of
rational choice.

6 The Surprise Quiz 133

6.1 The Paradox 133
The teacher announces a surprise quiz next week. It
can seemingly be shown that there is no day on
which the quiz can occur.
6.2 Rejecting the Assumptions 134
The scenario uses idealized assumptions about the
students’ reasoning. But these assumptions can be
relaxed without detriment to the paradox.
6.3 What Is Surprise? 136
We may assume that there is a threshold level of
antecedent credence in an event that renders the
event non-surprising.
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6.4 Quiz Comes if and only if Surprising 138

In one version of the story, we assume that the professor
has no interest in giving a quiz unless it will be a surprise.
6.4.1 Self-Undermining Beliefs with a Vague
Surprise Threshold 139
If the quiz has not come by Thursday, the
students should adopt a credence that would
make a Friday quiz a borderline case
of a surprise.
6.4.2 Self-Undermining Beliefs with
a Precise Threshold 140
Or they should adopt a credence such that
they will merely not know whether the Friday
quiz would count as a surprise.
6.4.3 The Rest of the Week 142
Thursday and earlier quizzes will then
count as surprising.
6.5 Quiz Comes, with or without Surprise 143
In another version of the story, we assume the
professor will give a quiz whether or not it will surprise.
6.5.1 No Friday Surprise 144
In this version, a Friday quiz would
not surprise.
6.5.2 Borderline Thursday Surprise 144
A quiz on Thursday would be a borderline
case of a surprise, or it would be unknown
whether it counted as a surprise.
6.5.3 The Rest of the Week 145
A quiz on any earlier day would be a surprise.
6.6 Surprising as Not-Most-Expected 146
If a quiz counts as “surprising” only when it was not
antecedently considered most likely to occur on that
day, then a surprise quiz cannot be given.
xx Analytical Contents

7 The Two Envelopes 149

7.1 The Paradox 149
There are two indistinguishable envelopes containing
money, one with twice as much as the other. It can
be argued that each envelope has a higher
expected value than the other.
7.2 The Use of Probability in the Paradox 151
7.2.1 An Objection 151
Some think the paradoxical reasoning misuses
the concept of probability.
7.2.2 Three Interpretations of Probability 152
Probability can be interpreted epistemically,
subjectively, or physically.
7.2.3 Rational Choice Uses Epistemic Probabilities 153
Epistemic probability is the correct
interpretation for rational choice theory.
The paradox thus does not misuse the concept
of probability.
7.2.4 Probabilities in Causal Decision Theory 154
This does not conflict with our earlier
defense of causal decision theory.
7.3 The Use of Variables in the Paradox 155
The paradoxical reasoning confuses variables
with constants.
7.4 The Correct Analysis 156
A correct analysis would assign a coherent probability
distribution to each possible way of distributing money
across the two envelopes. This leads to both envelopes
having the same expected value.

8 The Principle of Indifference 161

8.1 The Principle of Indifference 161
The PI holds that, given no reason for preferring any
of a set of alternatives over any other, all are
equally probable.
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8.2 The Paradoxes of the Principle of Indifference 162

There are cases in which the PI can seemingly be used
to justify incompatible probability assignments.
8.2.1 The Colored Book 162
Given that a book is red, green, or blue,
what is the probability that it is red?
8.2.2 France and England 163
Given that England is a proper part of
the U.K., what is the probability that England
is smaller than France? That the U.K. is
smaller than France?
8.2.3 The Car Ride 163
Given a 100-mile car trip with duration
between 1 and 2 hours, what is the probability
of a duration between 1 and 1.5 hours? What
about a velocity between 66.7 and 100 mph?
8.2.4 The Cube Factory 165
Given that a cube is between 0 and 2 inches on
a side, what is the probability of a side between
0 and 1 inch? What about a volume between
0 and 1 cubic inch?
8.2.5 The Circle and Chord 165
Given a circle with an equilateral triangle
inscribed inside, what is the probability of a
random chord being longer than a side of the
triangle?
8.3 Wherefore Indifference? 168
8.3.1 Theories Rejecting the PI 168
Empiricists say we can have no probabilities
prior to empirical evidence. Subjectivists say
any coherent initial probabilities
are permissible. These views reject the PI.
8.3.2 The PI Is Intuitive 169
The PI is extremely intuitive in many cases.
xxii Analytical Contents

8.3.3 The PI Is an Analytic Truth 170

The PI seems to follow from the meaning of
epistemic probability. Without a priori
probabilities, there are no epistemic
probabilities at all.
8.3.4 The PI Underlies the Least Controversial
Probability Assessments 172
Probability assessments based on randomization
or statistical evidence also depend on the PI.
8.4 Interpreting the Principle of Indifference:
The Explanatory Priority Proviso 174
The PI should be applied to the most explanatorily
basic set of possibilities.
8.5 Solutions 175
8.5.1 The Colored Book 175
A uniform probability density should be
assigned over the color solid.
8.5.2 France and England 177
Equal probabilities should be assigned to each
possible complete set of “larger than” relations
involving England, France, and the U.K.
8.5.3 The Car Ride 178
Velocity is privileged over time since velocity
causally determines duration, given
a fixed distance.
8.5.4 The Cube Factory 179
Quantity of material is privileged over width
or volume since quantity of material causally
determines size.
8.5.5 The Circle and the Chord 180
The PI should be applied by averaging over
all known methods of random selection
of a chord.
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   xxiii

8.6 A Philosophical Application: The Problem of Induction 183

8.6.1 The Traditional Problem 183
Skeptics say that there is no reason to believe
the course of nature is uniform, and hence no
justification for relying on induction.
8.6.2 A Probabilistic Formulation of the Problem 184
Skepticism can be defended by applying the
PI to all possible sequences of observations.
8.6.3 A Solution 186
We should instead apply the PI to all possible
values of the objective chance of a given event.
8.6.4 The Mathematics of the Inductivist Solution 188
This can be used to derive Laplace’s Rule
of Succession.
8.7 Another Application: The Mystery of Entropy 189
8.7.1 Why Entropy Increases 189
There is a probabilistic argument for why,
starting from a low-entropy state, the
entropy of a physical system should spon-
taneously increase.
8.7.2 The Reverse Entropy Law 191
A time-reversed version of that argument
can be used to conclude that any given low-
entropy state was probably preceded by a
higher-entropy state.
8.7.3 Reverse Entropy Is Crazy 193
This has all sorts of ridiculous implications.
8.7.4 The Reverse Argument Misuses the Principle
of Indifference 196
The argument for Reverse Entropy seems
to ignore that the past is explanatorily prior
to the present.
8.7.5 The Isolated Box 199
The diagnosis of the preceding subsection may
prove too much. It is only plausible in a certain
range of cases.
xxiv Analytical Contents

9 The Ravens 203

9.1 A Paradox of Confirmation 203
It seems that, in general, the observation of an A that
is B supports “All A’s are B.” Therefore, observation
of a purple shoe supports “All non-black things are
non-ravens.” This is logically equivalent to
“All ravens are black.” So purple shoes provide
evidence that all ravens are black.
9.2 Solution 204
Whether an observation of a purple shoe supports
“All ravens are black” or not depends upon how the
observation was gathered – e.g., whether it was gathered
by selecting randomly from the class of non-ravens, or
selecting randomly from the class of non-black things.
10 The Shooting Room 209
10.1 The Paradox 209
The Shooting Room is set up such that
(i) it is guaranteed that at least 90% of people who
ever enter it are shot, but (ii) for any given person,
whether they are shot or not depends on the flip
of a fair coin. Q: Given that V is called into the
room, what is the probability that V is shot?
10.2 Solution 211
10.2.1 Solving the Finite Case 211
In any finite version of the shooting
room scenario, the correct probability
comes to 50%.
10.2.2 The Impossibility of the Infinite Case 217
The paradox depends on metaphysically
impossible assumptions about an infinite
population of potential victims, and
infinite speed or elapsed time.
11 Self-Locating Beliefs 219
11.1 The Sleeping Beauty Paradox 219
Beauty is put to sleep and woken up either once or
twice, depending on the flip of a coin; after each
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   xxv

waking, she will fall asleep and forget having woken.

Upon waking, what should be her credence that the
coin came up heads? Some say 1/2; others say 1/3.
11.2 The Fine Tuning Argument 221
The apparent fine tuning of the universe’s physical
parameters, which is required for life to exist,
might be evidence that there are many universes.
11.3 The Doomsday Argument 224
The number of people who have existed before you
might constitute evidence that not many more
will exist after you.
11.4 The Multiverse: Pro and Con 227
11.4.1 The “This Universe” Objection 227
Some object that the fine tuning evidence
does not support multiple universes, because
the existence of other universes would not
explain anything about this universe.
11.4.2 In Defense of the Multiverse 229
The “this universe” objection seems parallel
to some incorrect objections in other cases.
11.4.3 Four Cases Resolved 231
Evidence supports a theory (for you) when
your having that qualitative evidence would
be more likely if the theory were true than
if it were false. This view gives the right
verdicts in four cases of interest.
11.4.4 Personal Identity and the Multiverse Theory 234
Conclusion: the fine tuning evidence supports
multiple universes, if and only if it would be
possible for you to exist in another universe.
11.5 Against Doomsday 236
The Doomsday Argument fails since, given the
impossibility of backward causation, no hypothesis
about humanity’s future affects the probability
of your now having the evidence that you have.
xxvi Analytical Contents

11.6 Sleeping Beauty: For a Third 239

Upon waking, Beauty should update on the evidence,
“I am awake now”. This results in a credence of 1/3
that the coin came up heads.

12 Concluding Remarks 245

12.1 Seven Varieties of Error 245
The preceding paradoxes exhibit several kinds
of problem that also beset human thinking in more
ordinary cases. These include: hidden assumptions,
neglect of the small, confusion, binary thinking,
oversimplification, inappropriate idealization,
and inference from partial data.
12.2 Against Radical Revision 251
We should not give up extremely obvious principles,
such as those of classical logic, to avoid paradox.
We should prefer to qualify principles rather than
rejecting them outright. Our mistakes are likely to
be subtle, not blatant.
12.3 Reality Is Intelligible, with Difficulty 252
The world is not inconsistent or incomprehensible.
Human reason is highly fallible but correctable
with effort.
 List of Figures

Fig. 1.1 Zeno’s paradox 2

Fig. 2.1 Classical concept of negation 20
Fig. 2.2 A non-classical conception of negation 21
Fig. 3.1 Satisfaction profile of a desire 61
Fig. 3.2 Simplified desire profile 62
Fig. 3.3 Profile of belief that H is a heap 63
Fig. 3.4 Degrees of vagueness 77
Fig. 3.5 A vague belief 85
Fig. 4.1 Optimal stopping point for the self-torturer 101
Fig. 4.2 A case with constant disvalue of pain and no optimal
stopping point 101
Fig. 4.3 A case with diminishing disvalue of pain and no optimal
stopping point 102
Fig. 6.1 Optimal credence with a vague surprise threshold 140
Fig. 6.2 Credences with a precise surprise threshold 141
Fig. 8.1 Mapping between time and velocity 164
Fig. 8.2 Bertrand’s Paradox: (a) solution 1, (b) solution 2, (c) solution 3 166
Fig. 8.3 Two-Way Entropy Law 193
Fig. 8.4 Migrant from Indonesia to the Netherlands 199
Fig. 9.1 Ways of collecting an observation of a non-black non-raven 205
Fig. 11.1 Sleeping Beauty problem 220
Fig. 11.2 The multiverse 223

xxvii
 1
Introduction

1.1 What Is a Paradox?

First, some words about what a paradox isn’t. Some people understand the
word “paradox” to refer to a case in which reality is contradictory, that is,
a situation that you would correctly describe by contradicting yourself. I
do not use the word this way, because I find it inconvenient. If we use
“paradox” to denote a situation containing a true contradiction, then we
will have to say that, by definition, there are no paradoxes, since contradic-
tions are necessarily false – thus apparently depriving this book of its sub-
ject matter. I should then have to say that this is a book about “apparent
paradoxes”, that the next chapter is about “the Liar Pseudo-paradox”, and
so on. This would be tedious. So I won’t understand “paradox” that way.
Some people use “paradox” simply to refer to a contradictory state-
ment, or apparently contradictory statement, such as “Nobody goes to
that restaurant anymore because it is too crowded.” That also is not what
I mean by “paradox”. Such statements are either false, or simply have an
alternate meaning that is different from the most superficial interpreta-
tion (as in the statement, “I am nobody”, which really just means “I am
unimportant”). In either case, there is no real puzzle.

© The Author(s) 2018 1

M. Huemer, Paradox Lost, https://doi.org/10.1007/978-3-319-90490-0_1
2 M. Huemer

Fig. 1.1 Zeno’s paradox

I understand a paradox, roughly, as a situation in which we have seem-

ingly compelling reasoning for a contradictory or otherwise absurd con-
clusion.1 We feel that we cannot accept the conclusion, but nor can we
readily identify a flaw in the reasoning. For example, consider Zeno’s
famous paradox of motion (figure 1.1):

In order for an object to move from point A to point B, the object must
first travel half the distance. Then it will have to travel half the remaining
distance. Then half the remaining distance again. And so on. This is an
infinite series. An infinite series has no end; hence, it is impossible to com-
plete an infinite series. Therefore, it is impossible for the object to reach
point B. Thus, no object can move anywhere.

The conclusion is absurd, so the reasoning must be wrong. Nevertheless,

the reasoning has a certain obvious, intuitive force, and it is difficult to
say exactly what is wrong with it.
To count as “paradoxical”, the reasoning for the absurd conclusion
must have widespread appeal – that is, the reasoning must be of a sort
that would seem compelling to typical human reasoners; an idiosyncratic
error that I personally can’t seem to shake does not qualify. Thus, if I
make a calculation error in multiplying a string of numbers, which results
in my deriving a logically impossible conclusion, this will not count as a
paradox – not even if I personally cannot find the error after many tries.
To count as “paradoxical”, a piece of erroneous reasoning must also have
a certain sort of robustness: paradoxes bear extended contemplation and
discussion. Paradoxes can have solutions and attempted solutions, but the
correctness of a given solution will be a matter of debate, at least for some

1
Similarly, Sainsbury (2009, p. 1) defines a paradox as “an apparently unacceptable conclusion
derived by apparently acceptable reasoning from apparently acceptable premises”. But see below in
the text for further conditions on paradoxicality.
 Introduction 3

time, even among the experts. A paradox is not merely a problem whose
solution, though known to experts, is unknown to most non-experts.
Thus, for example, I do not consider the Monty Hall Problem to be a
paradox. The Monty Hall Problem goes like this:

You are a contestant on the game show Let’s Make a Deal, with host Monty
Hall. You know how the game works: at a certain point in the game, Monty
shows the contestant three closed doors. One of the doors has a nice prize
behind it (say, a new car); the other two have goats behind them (assume
that no one wants a goat). The contestant is allowed to choose one of the
doors, and will be allowed to have whatever is behind it. After the contes-
tant chooses, but before he reveals what is behind the chosen door, Monty
opens one of the other two doors and shows the contestant a goat.2 He
never opens the door with the car behind it; he always shows the contestant
a goat.3 Monty then asks if the contestant would like to change their choice,
that is, to switch to the other closed door. Thus, suppose you initially

2
This is not exactly how the real game worked, but pretend the game works this way for purposes
of the problem. In the real game, Monty was not required to show the contestant a goat or offer the
chance to switch, and usually he did not do so (Tierney 1991).
3
The stipulation that Monty always opens a door with a goat behind it is sometimes erroneously
omitted from the statement of the problem, as in vos Savant (1990–91) (vos Savant makes the
assumption in her solution, but the original problem statement did not contain it). Without this
stipulation, the correct probability is ½. That is, suppose we assume that Monty, rather than delib-
erately avoiding the door with the prize, simply chooses randomly which door to open, from the
two doors that the contestant didn’t pick. Let h1 = [The car is behind door 1], h2 = [The car is
behind door 2], h3 = [The car is behind door 3], and e = [Monty opens door 3 and there is a goat
behind it]. After you have chosen door 1 but before Monty opens door 3, you should have the fol-
lowing credences: P(h1) = P(h2) = P(h3) = ⅓; P(e|h1) = ½; P(e|h2) = ½; P(e|h3) = 0. Then the prob-
ability of door 1 having the prize behind it, given that Monty opens door 3 and reveals a goat, is
given by Bayes’ Theorem as follows:

P ( h1 ) P ( e|h1 )
P ( h1|e ) =
P ( h1 ) P ( e|h1 ) + P ( h2 ) P ( e|h2 ) + P ( h3 ) P ( e|h3 )

=
(1 / 3)(1 / 2 ) 1
= .
(1 / 3)(1 / 2 ) + (1 / 3)(1 / 2 ) + (1 / 3)(0 ) 2

The key is that in this version of the problem, P(e|h2) = ½. In the standard version (where Monty
always avoids opening the door with the prize), P(e|h2) = 1. Substituting 1 for P(e|h2) in the above
equation changes the final answer to ⅓, the standard answer.
4 M. Huemer

choose door #1. Monty then opens, say, door #3 and shows you a goat
behind it. He then asks if you would like to change your choice from door
#1 to door #2. Should you switch?

Most people have a strong intuition that it doesn’t matter whether you
switch to door #2 or stick with door #1; that’s because most people think
that the prize is now 50% likely to be behind door #1 and 50% likely to
be behind door #2. The correct answer, however, is that you should defi-
nitely switch to door #2: door #1 has a 1/3 probability of having the real
prize behind it, and door #2 now (after you saw the goat behind door #3)
has a 2/3 probability of having the real prize.
It can be difficult to convince people of this. In fact, almost everyone,
on first hearing the problem, gives the wrong answer, and persists in that
answer until bludgeoned for a while with probability calculations or
experiments.4 In this case, there are compelling arguments (discussed
below and in fn. 3) for a highly counter-intuitive answer. Nevertheless, I
do not consider this a paradox. One reason is that this problem is not
robust enough to bear debate among experts. The Monty Hall Problem
has a well-known, objectively correct solution that can be shown to be so
in a fairly brief span of time; it does not, for example, bear years of
reflection.
Why does the prize have a 2/3 probability of being behind door B?
This is beside my present point (which, remember, was just to define
“paradox”); however, in case you can’t sleep until you know, an explana-
tion follows. (You can also do a calculation employing Bayes’ Theorem,
but the following is probably going to be more satisfying.)
Suppose Monty runs the game 300 times. Each time, the location of
the good prize is randomly selected from among the three doors. We
would expect that in about 100 of these games, the contestant’s initial
guess is correct, that is, the first door they pick has the prize behind it.
The other 200 times, the initial guess is wrong. Therefore, if the contes-
tants always stick with their initial guess, then 100 of the 300 will win the
real prize, and 200 will receive goats. (The 200 who initially selected a
goat door can’t possibly improve their result by sticking with that choice!)

4
See the responses to Marilyn vos Savant’s famous column on the problem (vos Savant 1990–91).
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 so-
called 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.

Capillary Embolism.

It may be remarked, in the first place, that the lesions known by this
name are not necessarily strictly capillary, but are situated in the very
small arteries. The microscope marks the transition from the larger to
these smaller embolisms.

More is known about very small embolisms experimentally than

clinically, since they have been produced by the injection of small
seeds and insoluble particles of various kinds. Embolisms arising
from natural causes and deposited in the minutest arteries may have
very similar origin to the larger ones already described, but there are
also other conditions which give rise to particles which pass through
larger arteries without any disturbance, and are arrested in smaller
ones. The softening of thrombi is undoubtedly one source. The same
thrombus which, if detached en masse, would block the carotid
artery, may, if broken up into a number of minute fragments of fibrin
and fat, pass into the ultimate distribution of the cerebrals. The same
thing may of course happen if the thrombus have already undergone
one transportation.

Cases of localized softening are seen where no cause has been

found, except perhaps a thrombus in the heart, which has
discharged its softened and puriform contents; and it is probable that
the connecting links exist in the form of embolisms so minute as to
escape ordinary observation.

The consequences of capillary emboli if they block every minute

ramification of an arterial branch must be essentially the same as if
the branch itself were stopped; but if only a part are thus affected,
the resulting anæmia is not so complete, since the zones of capillary
congestion surrounding the part the supply of which is cut off may be
sufficient entirely to cover it and make more or less complete
compensation. The experimental emboli, in the form of tobacco-seed
and other insoluble substances, which have been traced into the
brain in considerable numbers, often give rise to no distinct lesions in
the cases where the immediate effects are recovered from.

Among the other sources, ulcerative endocarditis may be mentioned

as of special importance, not from the size but the character of
detached emboli, which will give rise, not to simple anæmia, nor, on
the other hand, to merely negative results, but to septic changes at
the place of lodgment.

Aside from these conditions, which are almost the same on a small
scale as we find with the large emboli, we have several peculiar
substances formed in the body and floating in the blood which lodge
in the capillaries of the brain. These are pigment, fat, lime salts, and
white corpuscles. Every one of these, however, is much better
known anatomically than clinically.

Pigment scales, flakes, granules, or cells containing them, are

formed in the course of severe malarial fever, and deposits
consisting of this pigment are found in the spleen, liver, kidneys,
heart, lungs, and lymphatic glands, as well as the brain and spinal
cord. The brain, when a deposit of pigment has taken place, is of a
slaty-grayish or chocolate color, which is marked only in the cortical
substance, the white being unaffected. The pigment is found in the
capillaries, and, according to Frerichs, fibrinous coagula are often
associated. Punctiform hemorrhages in the brain have been seen, as
well as meningeal hemorrhages, in connection with this
degeneration.
The point at which these masses are formed is still a matter of
theory. If the liver, as has been supposed, is one of the places of
formation, or if they originate in the blood, it is of course easy to see
how they reach the brain. If in the spleen, they must pass through
the wide portal capillaries before they are arrested in the narrower
ones of the brain.

It is by no means certain, however, that pigment reaches the brain in

the form of emboli. It is quite as probable that it is found in many
organs which undergo repeated congestions from the local
destruction of blood-corpuscles and changes in their pigment. The
very general deposition seems to point to a process of this kind
rather than to a local origin and a distribution through the blood. The
punctiform extravasations which may be found with deposits of
pigment are also found without it.

Minute particles of fat have been found in cerebral capillaries, but

are much less common here than in the lungs. They may be derived
from the decomposition of a thrombus, as described above, or they
may come from a fractured bone, when, of course, only particles fine
enough to pass through the pulmonary capillaries can reach the
brain. This form of embolism has an interest in connection with
diabetic coma.

Collections of white corpuscles in considerable number have been

observed to form an embolus. These cannot be considered to differ
very widely in character from the ordinary fibrinous embolus, which
contains white corpuscles. It is, however, not certain that such
emboli are deposited during life.

Calcareous masses formed from the decomposition of bone have

been seen in cerebral arteries.

About the symptomatology of such emboli little is known. An array of

minute emboli from the breaking up of a thrombus in the left auricle,
carotid, or even aorta, might possibly so block up large numbers of
arterial twigs as to give rise to the ordinary symptoms of embolism;
but considering the possibility of the re-establishment of circulation,
provided a certain proportion of the minutest vessels escape,
complete anæmia of a large tract produced in this way must be rare.
It is possible that some of the slighter and more transitory attacks of
hemiplegia or of more or less vague cerebral symptoms may be
referred to a lesion of this kind, the first action of a large number of
emboli being to cause an anæmia, which is compensated for much
more rapidly and thoroughly than would be the case if a single
considerable vessel were obliterated.

Various attempts have been made to connect definite and peculiar

diseases with capillary embolisms. Chorea in particular has been
said to depend upon a lesion of this kind, but, although cases have
been observed where the symptoms and lesion coexisted, yet they
are very far from being the rule, or even from constituting a
respectable minority of cases. The lesion of chorea in the great
majority of cases is not known, although attention has been directed
to this theory long enough to have established its truth.

The same may be said of the relationship between pernicious

attacks of intermittent and pigment embolism. There is occasional
coexistence, but far from invariable. Cerebral symptoms of the same
kind and severity occur without as with the pigment deposit. If
pigment embolism is the cause of coma, delirium, etc. in pernicious
fever, it is difficult to see why such cases can recover so rapidly, and
why no symptoms referable to a localized cerebral lesion are
observed after the primary unconsciousness.

Even less proof can be adduced as to any connection between

leukæmic embolisms and the cerebral symptoms occurring toward
the end of severe acute disease.

Calcareous embolism is a pathological curiosity.

DIAGNOSIS.—In the case of multiple capillary embolism it would be

impossible, if it were complete, to distinguish it from a blocking of the
main branch.