Popular Science Monthly/Volume 6/April 1875/Apoplexy
By J. R. BLACK, M. D.
IF there is any one disease that the diligent brain-worker, a little past middle life, has reason to fear, it is apoplexy. Although statistical evidence is wanting, the experience of the physician confirms the popular belief that more of our distinguished men are carried off by this disease, or by one of its sequels, paralysis, than by any other cause. The influences which tend to produce such a result, and the best means of avoiding them, are the objects we propose briefly to discuss.
A middle-aged physician said one day to the writer: "As I was walking down the street after dinner I felt a shock in the back of my head, as if some one had struck me; I have not felt well since. I fear I shall die, just as all my ancestors have, of paralysis. What shall I do?" The answer was, "Diminish the tension on the blood-vessels, and there need be no fear of tearing them in a weak place." Now, this expresses in plain terms the exact cause of apoplexy in the great majority of instances; and it is one, too, which every one has it in his power to prevent. A blood-vessel of the brain, from causes which will presently be mentioned, has lost some of its elastic strength; food is abundant, digestion is good; blood is made in abundance, but little is worked off by exercise; the tension on every artery and vein is at a maximum rate; the even, circuitous flow is temporarily impeded at some point, throwing a dangerous pressure on another; the vessel which has lost its elastic strength gives way, blood is poured out, a clot is formed, which, by its pressure on the brain, produces complete unconsciousness. This is the apoplectic stroke. It will be perceived that there are two leading conditions upon which the production of the stroke depends: a lessened strength in the vessel, and an increased tension on it.
There are no vessels carrying blood to and from the various organs of the body which so frequently rupture as those in the brain. The causes that produce this result are the fatty degeneracy of the middle arterial coat of the cerebral vessels, whereby their elastic strength is much impaired, the great irregularity of blood distribution to the contents of the cranium, and the little support which the pulpy substance of the brain gives to the weakened vessels embedded in it.
The forms of degeneracy that are found in the arteries of the brain are the fatty and the calcareous. The microscope has made some startling revelations on this fatty decay. The strong, elastic fibres, that should make up the substance of the middle arterial coat, are, in places here and there, no longer to be seen, their place being occupied by fatty globules, which have very little resisting power to a disturbing force.
The chief causes which produce this structural change are the habitual use of ardent spirits and tobacco. Every one is aware that the leading effects of these agents on the body are such as show that the functions of the nervous system are more affected than any other; and the physician also knows that, when symptoms of disorder arise from their use, they are such as denote that the nervous system is almost alone implicated. Delirium tremens, insomnia, tremulous hands, and nervous headaches, are some of the characteristic effects of the habitual use of stimulants and narcotics.
Ardent spirits also tend to produce an over-fullness of the cerebral vessels, and to affect the functions of the brain in a manner which strangely blends stupidity, brightness, and exhilaration. Effects so unnatural, and so frequently ending in disease, influence injuriously the nutrition of the nervous centres. And to interfere with the nutrition of any part of the body is simply to impair the life and power of its structure. The evidences of this impairment may not be felt immediately. In fact, the evidences of impairment by any bad habit are seldom apparent during the prime of youthful vigor. But the mischief is going on nevertheless, and the organ upon which the weight of infringement falls will be the one that will first manifest signs of disease, and through which death will make its conquest over the body.
Besides this weakening of the vessels upon which the strong impulse of blood from the heart falls at the rate of sixty times a minute, and the very little external support such defective vessels receive from the soft and pulpy brain, there is another source of danger by a break, in the extraordinary ebbs and tides of blood to which the contents of the cranium are subject. During sleep the brain is almost bloodless; its substance seems to shrink into a lifeless mass; but the moment that wakefulness occurs it swells out, gets red, its arteries and veins becoming distended with a great tide of blood. No other part of the body is subject to such droughts and floods in its blood-circulation. This inequality is yet further increased by severe mind-labor. The ardent student is well aware that deep thought heats the head and cools the feet. The brain is then receiving more than an ordinary supply of blood and the feet less.
The first apoplectic stroke, as a rule, is not a severe one. Sometimes the condition of the cerebral circulation is simply that of active congestion; but more commonly a little blood escapes by a tiny vent, the shock to the system slows and enfeebles the action of the heart, the distention of the ruptured vessel is thus lessened, the escape of blood ceases, and Nature, by means of a slight inflammation, heals the part torn, and in due time removes the blood-clot by absorption.
The process by which a weakened blood-vessel is ruptured by internal distention may be illustrated by observing the effect of attempting to force through an old water-hose attached to a fire-engine a large and rapid stream of water. The weakness of the hose is first shown by the escape of tiny jets of water; but by-and-by a larger vent occurs, allowing the water to escape in a flood. Just so it is with the progressive weakening with the blood-vessels in the brain—the escape of blood is at first small; then, under a greater tension than ordinary, a larger rent is made, allowing the blood to escape in hopeless profusion. It was probably these well-known features of apoplectic strokes that led the great Napoleon's medical adviser to make his celebrated reply in reference to this disease, of which the emperor stood in great dread: "Sire, the first attack is a warning, the second a summons, the third a summons to execution."
Those who have a family tendency to apoplexy and are desirous to escape it, will, of course, avoid all the causes above referred to, especially those which tend to destroy the elasticity and strength of the blood-channels in the brain, or, in other words, to weaken the structure and life of those parts. But suppose, as is too often the case, that the very sort of life has been led and the very habits indulged in which are most likely to produce a weakness and fragility in the coats of the vessels of the brain. What is to be done? Clearly to diminish and keep the tension on these vessels by the blood at a low rate all the time. As remarked at the commencement of this article, this is fully in our power by cutting off the supplies. A prudent fire-engineer, when his water-hose are old and weak, would not try to force as much water as he could into them. No; to prevent a rupture he would work them at a low pressure. But men seldom think of carrying out the same simple mechanical principle when there is reason to believe that the vessels of the brain are getting weak and brittle. They eat and drink just as much as they feel inclined to, and sometimes a little more. With a good digestion, nearly all they consume is converted into blood, to the yet further distention of vessels already over-distended. This high-pressure style of living produces high-pressure results. Its effects were painfully illustrated by the death of Charles Dickens. The brain-work he performed was immense; he lived generously, taking his wine as he did his meat, with a liberal hand. He disregarded the signs of structural decay, forcing his reluctant brain to do what it had once done with spontaneous ease, until all at once, under a greater tension than ordinary, a weak vessel gave way, flooding the brain with blood.
Medical writers on this disease all refer to the fact that a stroke of apoplexy quite frequently occurs just after eating a full meal. The experience of physicians also is that violent attacks of vertigo often attend a deranged or inactive condition of the liver. To explain in detail the causes of an unusual pressure of blood on the brain from certain states of the digestive organs would be somewhat tedious. Suffice it to say that it is produced by what may be termed a backwater action of an obstruction to the circulation of the blood, whereby distention occurs in one of the most distensible of the internal organs of the body, the brain. We have already stated that the distribution of blood to the brain is the most irregular in the body; that its blood-vessels are subject to be weakened by improper habits, and that the pulpy cerebral substance gives very little if any support to a weak vessel in it, so that all the conditions favorable to a rupture by a little more distention than ordinary very frequently coexist.
A not uncommon condition of the arteries of the brain, especially at its base, in those far advanced in years, is the displacement in places of the middle coat by lime-particles, which, of course, renders them easily torn. So far as known this condition is incurable, as well as unpreventable. It is one of the changes of structure incident to very old age. The only measure that can be relied upon to prevent a rupture under such conditions is to be cautious about distending them with blood. This is, in fact, the great fundamental principle of prevention when the vessels of the brain are weak from any cause.
To effect this, certain regulations in eating and drinking are far better preventives than any medicine, or even occasional bleedings. The latter method is particularly unsafe. After bleeding from the arm, new blood is often made more rapidly than under other circumstances, and so may become, before a person is well aware of it, very abundant, with a dangerous pressure on the weak vessels. The subject of such a practice is very apt to rely on the abstraction of blood for safety, and take no care otherwise of himself. Besides, he has no accurate means of knowing when the pressure of the blood is becoming dangerously great. The periodical bleeding from piles is a very different matter. They often act as a safety-valve to the high pressure from within, and regulate themselves on mechanical principles. Full-blooded persons, past middle life, and with a predisposition to apoplexy, should never try to remove such a safety-valve.
As soon as old age puts a decided check on the amount of daily exercise, it is time to put a decided check on the amount of food daily consumed. If the supply of new matter is greater than the waste of the old, an accumulation of surplus blood must be the result. The principle is an important one, yet it is little known and less practised. Men well past middle life, who do not exercise half as much as in their younger years, often eat as freely of highly-nutritious food as they ever did. Such a course is very dangerous. The tension on the vascular system must not be increased, but diminished, if the risk of an apoplectic stroke would be avoided.
The kind of food best adapted to keep down superfluous blood is the vegetable. Animal food makes blood with dangerous rapidity, nearly all its substance dissolving for this purpose in the stomach. Laboring-men, however, may eat of animal food in moderation, as the exercise of their muscles wastes their substance largely, requiring a good deal of blood to make up for the wear.
The amount of vegetable food should not be so great as in middle life. The true rule is, not to eat to entire satiety. Even those of younger years and sedentary habits will feel lighter and better in every way by leaving the table a little hungry.
All strong liquors are unsuited to those with an apoplectic tendency. One of their prominent effects, as we have seen, is to cause a degeneration in the coating of the blood-vessels, and another is to move more blood than ordinary upon the brain.