The Guardian from London, Greater London, England • 25

Health THE GUARDIAN Tuesday May 10 1994 John lllman A theatrical masterpiece is highlighting turmoil that can torment stroke victims RICHARD NIXON'S death at the age of 81 perpetuated the myth that strokes are just an affliction of the elderly. Certainly, the elderly account for the lion's share, but strokes can affect teenagers and even babies in the womb. You can protect yourself by cutting down your "risk An isolated risk factor is unlikely to cause trouble, but an accumulative effect means that the more you have, the greater the risk. The factors include: High blood pressure: This is probably the single most important factor that you can influence. Reducing high blood pressure (hypertension) can halve the chances of stroke.

People under the age of 40 should have a blood pressure check every few years; those over 40 every two years. Do not assume you have nothing to worry about. Hypertension is dubbed "The Silent it kills without warning. Heart disease: Diseased heart valves may result in clots in the heart moving to the brain. Chock out palpitations or abnormal heart rhythms with more than just the odd extra beat.

Diet: Limit dairy foods and fatty meals. Go for fish and lots of high fibre fruit and veg. Cutting down on salt may help. After studying 552 middle-aged men for 15 years, Dutch researchers found that those eating more than 20g offish daily halved the risk compared with men eating less fish. This might be due to polyunsaturated fats reducing clotting and the narowing of arteries, they report in this month's Stroke journal.

Oily fish (such as mackerel, herring and salmon) are particularly good. Lack of exercise: Research suggests that individual risk is determined, in part, by activity between the ages of 15 and 25. Those who run, swim or play squash seem less vulnerable than more sedentary types. A study at Birmingham University found that active young adults were more likely to exercise in later life. Smoking: Various studies have not shown the expected link between smoking and stroke, but they involved old people whose cigarette consumption was low.

The heavy smokers may already have been killed off by heart attacks or cancer. Why is smoking bad? Between 30 and 50 per cent of blood comprises cells, mainly red blood cells. People whose blood has more than 50 per cent cells have "thick blood" and are at increased risk to clotting. Smoking is a common cause of thick blood. Carbon monoxide in cigarette smoke makes 10 to 15 per cent of blood cells ineffective; the number of red cells goes up to compensate.

Alcohol: Moderation is the key. A big slug of booze is believed to have a harmful effect on the circulation of blood in the brain, not to mention the brain itself. Blood fats: Abnormally high levels of blood fats among them cholesterol may trigger heart attack or strokes. Obesity: Don't get neurotic if you're a few pounds overweight. It probably doesn't matter, but being 20 to 301b overweight does.

Rehabilitation after a stroke is also much more difficult for overweight people. Family history: Seek regular check-ups if several members of your family have had strokes. Hypertension, blood fat problems and diabetes (another risk factor) are inherited in some families. and Sotigui Kouyate (top) and The Man Who photos: oilles abegg Brian Butterworth DN PETER BROOK'S play The Man Who, which opened last week at tho National Theatre, we are presented with a series of neurological patients who seem, at first sight, to be impossibly exotic. A man with a detailed memory for 30 years ago cannot remember what happened in the last few minutes.

Another man thinks his left leg is someone else's amputated limb, and tries to hurl it out of bed, throwing himself to tho floor in the process. Most famously, there is the professor of music who mistakes his wife for a hat. In fact, such cases are not at all exotic, but are usually due to the most mundane of causes: strokes. What makes them puzzling for doctor and layman alike is the way they create a conflict between the patient's true and mistaken beliefs about reality. How could the professor mistake his wife for a hat? And how could he know he that was mistaken? This makes these conditions seem like a form of madness, where belief and reality also fall apart.

Indeed, patients suffering them are still misdiagnosed as being schizophrenic or demented. A central theme of Brook's marvellous play based on Oliver 'Sacks' book is the conflict between everyone else's reality and a patient's view of the world. A stroke can distort this view in incredibly precise ways. It may affect part of the right hemisphere of the brain, making the patient "neglect" just the left side of bus world. There is no fuzzlncss.

The right side is as clear as it is for you or me. The patients will not see a friend standing to the left of his midline. If he hears the friend speaking from the left, he will turn to the right to find him. The Italian neurologist Eduardo Bisiach found that, in some patients, the neglected left side was not of the visible world only, but of the mental world. If the patient was asked to describe a familiar place, such as the Piazza del Duomo in Milan, looking, in his mind's eye, from the cathedral door, he would accurately record the north (right) side of the square, and completely ignore the south side.

When the patient is asked to imagine himself looking across the square towards the cathedral, he would then describe the south side. In one of the most moving moments in the Brook's play, a patient with left-sided neglect, brilliantly portrayed by the Japanese actor Yo-shi Oida, shaves himself looking into a mirror. With groat care he shaves exactly the right half of his face, and is entirely convinced the job is finished. The doctors force him to confront reality by asking him to look at himself in a video monitor. Of course, the left half of his face is now presented to the right side of his visual world.

When ho puts his right hand to his right cheek he can feel that he has shaved himself completely, but lie can see in the monitor that half of his face is not shaved. The conflict cannot be resolved and he says, with desperate incomprehension: "Please stop. Stop that." STROKES that damage the left hemisphere can lead to problems with speech and language called Some patients become almost speechless, and can utter at will, only a few phrases. David Howard, an English psychologist, reported the case of a woman who could say just "cor blimey" and "flippln' 'eck." In The Man Who, there is a character who can only say "yes" or "difficult" to whatever the doctor asks. Other patients can be fluent.

Words pour out, but they are incomprehensible although the speaker believes he is making perfect sense. Art illuminates life Bruce Myers Yoshi Oida (above) in the National's This condition is called "jargon When one patient I studied was asked to name a box of kitchen matches, he said: "Waitress. Waitrixes. A backland and another bank. For bandicks I tliink they are.

I believe they're zandicks. I'm sorry, but they're called like flitters landocks." Many people hearing an old man talking like this would think he was mad. Even some doctors might diagnose dementia. After all, he could not name a common household object; he seems to ramble incoherently. In fact, on non-verbal IQ tests, this man was well above average.

It was tho language regions of the brain that were affected. Wondering whether the patient was talking some sort of code, I enlisted the help of war-time code-breakers from Cambridge to help me break it. It turned out, not surprisingly perhaps, not to be a code, but nevertheless it did seem sometimes to convey a meaning. Bruce Myers, in The Man Who, depicts a character based in part on this patient. Brook's script and Myers' performance bring out very effectively the gap between the speaker's intention and the scrambled words.

Tho audience can sense the general meaning and tho emotional tone of the speech, without understanding one of the sentences. The doctor in the play confronts the patient with a recording of his scrambled speech. The conflict between the patient's belief that he is making sense and the reality is at its sharpest. There is a moment of terrible lucidity as the patient realises he is condemned to talk like this. Brook and his cast have been developing this play, first in French and then in English, for more than three years.

They have studied patients at the Salpetriore Hospital in Paris, attended medical conferences, and talked to endless specialists. Their portrayal of the patients is scrupulously accurate and unsentimental. The cast of four alternate between playing patients and doctors a reminder that any of us could become an "exotic" case. Brian Butterworth is Protessor of Cognitive Neuropsychology at University College, London..