THE WAY OF SAFETY
The pre-sclerotic state of raised pressure may last a considerable
time--two or three years--but this can never be relied upon; every
attack means extra work for the heart, and uses up for a time the
reserve power of that long-suffering organ. Some hearts will respond
well to the call for many years, but others give out and dilate.
Continued raised pressure means one of two things--increased resistance
and partial obstruction in the small arteries and capillaries, or
increased ventricular action and force. An example of the first, which
is far the more common, is seen in sclerosis; of the second, in aortic
regurgitation. In the one case the heart is overcoming resistance--in
the other, compensating for a leak. In the first, the error or
departure from the normal is in the pipes--in the second, in the pump;
but as both are vital organs and not mere bits of mechanism, they in
time react on each other and both become altered. This change is, if
vitality be strong, in the direction of conservatism, of accommodation
to the new order of things. It is compromise, which may be effectual
for a long time, but which, like most compromises, comes to failure in
the end. Occasionally we find the sclerosis attacking the heart muscle
itself or its arteries; such cases are obviously more serious. This
condition generally comes on more or less at the end of the disease,
but in a few cases quite early. Probably many of the cases of true
angina pectoris occurring in early middle life are of this nature, the
coronaries being the chief point of attack.
Besides excess of work and unwise work there is another cause which
seems to raise pressure, and that is absorption of ptomaines or
of the products of imperfect digestion; the overstrain cause and
the absorption cause very often act concurrently, for imperfect
assimilation is often the result of the unwise life. We see this more
often, perhaps, where the unwise life is accompanied by overeating and
injudicious alcoholic stimulation, even if this is not very excessive:
such people rarely give themselves time to digest. The supply of nerve
energy that is necessary for perfect digestion is turned off at the
main long before its proper time. We doctors have a first-hand personal
knowledge of this cause, for owing partly to the intensive nature of
our work and partly to the exigeant importunity of our patients, we
more often practise the vices we deplore than the virtues we praise;
this is one of the reasons that our profession is the shortest-lived
of all.
It is not quite clear how this absorption causes hypertension, but it
is probably through an effect on endocrine glands, chiefly perhaps
on the suprarenal and secondly on the thyroid. McGarrison has shown
how often Graves’ disease is caused by faulty intestinal digestion,
and by the colitis that ensues; this he thinks stimulates the thyroid
to overactivity or to faulty secretion. The suprarenals are probably
affected still more than the thyroid, and the hyperthyroidism may be
due to the upset of the balance of power; for these two glands through
the sympathetic act and react on one another. It is fairly established
that in some cases of Graves’ disease we get hypertension and in some
hypotension, though both conditions vary a good deal. It may be that
the hypotension cases are those that are accompanied by suprarenal
deficiency and that benefit by suprarenal treatment, and I believe it
to be so. This would explain the conflicting opinions as to the value
of this treatment. It has certainly succeeded admirably in some cases.
The co-ordination of all endocrine actions is so intricate that we can
only puzzle out the way by careful clinical observation and experiment.
In sclerosis, as a rule, we get evidence of hyperadrenalism and more
certainly of hypothyroidism. Victor Horsley considered premature
senility to be a form of myxœdema, which of course means pronounced
hypothyroidism.
Biedl says: “A special pathogenetic significance is ascribed to thyroid
insuffiency in the changes which occur in later life, and which are
included in the term ‘cachexia of old age,’ or senile degeneration. The
foundation for the theory that old age results from the changes in the
thyroid gland lies in the fact that in old age the thyroid becomes
atrophied, its follicles shrink, and retrogressive changes take place
in the epithelial cells. This is reinforced by the fact that there is
a profound analogy between the signs of advanced old age and myxœdema.
The falling of the hair and the dropping out of the teeth, the dry and
wrinkled skin, the lowered temperature, the diminished perspiration,
the indolent digestion and consequent emaciation, the decrease of
mental power and the diminution of the activity of the entire nervous
system--these are all symptoms that characterize chronic myxœdema.”
From the old partially true adage, that a man is as old as his
arteries, we must go a step further back and say that a man is as
old as his thyroid. This statement is probably not a final one,
but it gives us a very valuable pointer in the way of treatment.
Arterio-sclerosis and arterial degeneration are the almost universal
accompaniments of thyroid deficiency, and are in most cases the result
of that condition.
There is no main or royal road to the successful management of
sclerosis; every little cause must be thought out and righted if
possible, but as a foundation nothing is so important, I think, as a
clean, healthy intestine, which hitherto has been much neglected. A
microscopical examination of the fæces will often show what is wrong,
and also the direction and results of treatment.
If the condition is thoroughly bad I begin with this rather drastic
regime--twenty-four hours’ absolute starvation in bed, a tenth of a
grain of calomel every hour for twelve hours and as much hot water as
the patient can comfortably drink. This has a wonderful effect, and
one’s subjective feelings after it tell us that evil has gone out of us
and that good has taken its place.
The treatment by bowel antiseptics has been generally very
unsatisfactory. Beta naphthol helps, perhaps, but the most good comes
from duodenal extract in some form. Two grains of the dried powder
about two hours after each meal in pill or tablet act well. Carnrick’s
Secretogen tablets and the much-advertized Jubol are good, and both
depend on some extract from the duodenal mucosa. The unpleasant
flatulence and the fermentation in the bowel soon disappear, and with
them the mucus that is often shed from the coats of the colon. Better
assimilation of food goes hand-in-hand with improved health and vigour.
Intestinal dyspepsia is more far-reaching in its effects than gastric
dyspepsia, but is often ignored.
The questions of food and cooking need most careful consideration. In
the affairs of the soul Christ taught “that which cometh out of the
man, that defileth the man”; in the affairs of the body, that which
goeth into a man, that defileth the man. Both teachings are true and
both are purposeful exaggerations and in a sense untrue. Out of the
same mouth proceed blessings and cursings and into the same mouth go
good food and poisons. The sin lies sometimes in the nature, but more
often perhaps in the excess. The word “temperance” has been made to
apply far too much to the use of alcohol. As a fact, I believe, far
more nowadays are intemperate in eating than in drinking. As the tale
of our years increases and as our physical life gets less strenuous
and active, we require less food, or at any rate a different kind of
food; the strong nitrogenous foods, as meat, become less called for,
and if taken beyond our needs become poisons. The imperfect products
of assimilation have to be dealt with by our excretory organs, which
become overworked and unable to meet the demands. The scavengers
cannot clear the dust-heaps. Hence arise kidney disease, faulty liver
action, and raised blood pressure. And yet, how many of us seek to
restore failing strength by stronger food and more stimulation? In
this futility, kind but ignorant friends aid and abet. Think on what a
little food a baby lives and grows, and, at the other end of life, on
what a simple frugal diet really old people thrive and work.
It is all very well to lay down rules for food, calculated in calories
for strong working men and athletes, but in approaching old age every
one must become more or less a lawgiver to himself; this especially,
if there is any tendency to hyperpiesis, for any food in excess of
the body’s needs becomes for the time a poison. What we can digest
easily and what with difficulty must be largely a personal question,
but the direction should certainly be towards a non-meat regime. The
difference of climate makes comparison between the vegetable feeders
of the tropics and ourselves of uncertain value, but it is a lesson to
see what the Scotch gillie can do on a diet that is mostly oatmeal,
milk and cheese. The gluttonous man and the wine bibber seem to get a
pleasure out of life that the sober men miss, but we doctors see the
other side of the shield, the after-suffering and the failure: the
broken law brings its own punishment and there is no escape.
The physiological process of digestion is rather elaborate, and,
fortunately for us, somewhat elastic. It is not a question entirely of
certain substances in a test-tube exposed to certain digestive agents.
This, of course, is the foundation, the basic process, but there is
much variation in the nature of the food, in the external conditions of
season, of heat and cold, of youth and age, of greater or less physical
or mental demands on the food digested, and lastly on the supplies of
saliva, of pepsin, of hydrochloric acid and of duodenal and pancreatic
secretions. These are all under the control of the autonomous nervous
system, which in the stresses of life often breaks down and fails to
function properly. In the full tide of youthful energy our digestions
seem to respond effectually to many and unreasonable demands, but
this is more apparent than real; the bills may be a long time before
they are sent in, but they come. The recuperative power of youth is
marvellous, but probably never quite complete. After forty years of
age it fails more and more, and then bills come in more quickly, while
in old age it becomes almost a question of cash on delivery. Realizing
this we should, in our own interests, treat our digestive apparatus
with deep respect, and not with the scant courtesy we generally show,
for on its faithful working depend our life, our health, our happiness
and our powers of work. The farmer in his feeding of cattle, the head
of a racing stable in his feeding and training of horses is far more
scientific and wise than we and most other men are in the management
of ourselves. This is why we end our days so often prematurely, or in
paralysis and pain.
To go into actual details of diet is a thankless task, and not very
helpful to the mass of men; it is better, I think, to point out
directions only. If there are symptoms of hyperpiesis, the chief object
is to arrange a diet that contains a minimum of protein (especially of
animal protein) compatible with life and energy. Most of such cases are
leading a life of no great physical strain and will do well on a diet
calculated in calories, that contains:
Protein 90
Fat 75
Carbohydrate 330 = Calories 2,400.
If this is insufficient, add to the fat or carbohydrate rather than to
the protein.
The following tables from Dr. Sprigg’s excellent work classify the
common foods according as their energy production is due to protein,
carbohydrate or fat. It will be noticed that milk is the only food
in the lists which contains a good proportion of all three. Cheese,
Brazil nuts and bread contain a fair proportion of at least two of the
requisite food-stuffs.
If we take, for instance, the figures of lean beef in the first and
second column, viz.:
Lean beef 90 + 10 we get its value
Chicken 79 + 21 we get its value
Bread 13 + 6 + 81 we get its value
Cheese 25 + 73 + 2 we get its value
By roughly arranging foods according to such a table we can arrive
approximately at a suitable balance of its various constituents. But
the chemical side of the
PERCENTAGE OF TOTAL HEAT VALUE OF FOOD FURNISHED BY ITS
PROTEIN FAT CARBOHYDRATE
Per cent. Per cent. Per cent.
Lean beef (boiled) 90 Butter 99 Tapioca (cooked) 98
Chicken 79 Bacon 94 Prunes (dried) 97
Mackerel 50 Cream 87 Figs (dried) 95
Skim Milk 37 Brazil Nuts 86 Rice (boiled) 89
Eggs 32 Fat Ham 81 Oysters 89
Beef with fat 25 Fat Beef 75 Potatoes (boiled) 88
Cheese 25 Cheese 73 Bread 81
Fat Ham 19 Eggs 68 Peas 72
Milk 19 Boiled Mutton 65 Milk 29
Bread 13 Milk 52 Cream 8
Potatoes 11 Mackerel 50 Brazil Nuts 4
Boiled Rice 10 Chicken 21 Cheese 2
Brazil Nuts 10 Boiled lean Beef 10
Bacon 6 Bread 6
Cream 5 Bananas 5
Bananas 5 Potatoes 1
Butter 5
problem is not the only one to study. Idiosyncrasy, appetite for
certain foods, distaste for others, and personal experience must all
receive due consideration. The appetite for certain foods varies much
at different periods of life. Fat is abhorrent to many children, and
their lives and digestions are much troubled by the parental, but
unscientific order to “clear up their plates.” In later years the
same persons will welcome fat and need it. Sugar again is loved by
children, scorned in middle age, when its place is often supplied by
wine or beer, and is again welcomed and of great value in old age, for
it helps much to maintain the failing heat of the body, to keep the
home fires burning. Good cane-sugar at all stages of life seems to
act as a special food, or at any rate stimulant, to the heart muscle;
given in large quantities it often gives a failing heart a new lease
of life. The digestibility of food is not governed entirely by its
chemical composition. Twice cooked meat must contain nearly as much
potential nourishment as once cooked, but experience tells most of us
that we digest it with difficulty; and if the digestion of a food is
not perfect, there is more unwholesome waste product to be cleared
away; there is impure blood circulating in all our organs, but we
feel it perhaps more in our brains; the lethargy, the depression,
the irritability that we all recognize as the accompaniments of
indigestion, all stand as cause and effect. Again hot fat and cold
fat must contain the same constituents, but many can do well with
cold fat, while they get bilious with the other. The same thing
applies to butter. All these things we must honestly observe, each
man for himself, and we must not let our likes and our appetites,
nor our prejudices, sway the conclusions of personal experience and
scientific knowledge. Dr. Haig has shown us how many of our ailments
are connected with excess of uric acid in the blood, and how much
this excess is due to certain foods such as meat, which contains what
Fischer named purine bodies. The following extract from Halliburton’s
_Handbook of Physiology_ will partially explain this subject:
*Origin of Uric Acid.*--Uric acid is not made by the kidneys; when
these organs are removed, uric acid continues to be formed, and
accumulates in the organs, especially in the liver and spleen. After
extirpation of the liver in birds (in which animals uric acid is such
an important katabolite) the formation of uric acid practically ceases,
and its place is taken by ammonia and lactic acid, and the conclusion
is therefore drawn that in these animals ammonia and lactic acid are
normally synthesized in the liver to form uric acid. But in mammals
this is not the history of uric acid formation; in these animals,
including man, uric acid is the end-product of the metabolism of
nuclein, from the bases of which it arises by oxidization. Nuclein,
the main constituent of the nuclei of cells, yields on decomposition
certain products called purine substances, and their close relationship
to uric acid is shown by their formulæ:
PURINE BASES.
Purine C_{5}H_{4}N_{4}
Hypoxanthine (monoxypurine) C_{5}H_{4}N_{4}O
Xanthine (dioxypurine) C_{5}H_{4}N_{4}O_{2}
Adenine (amino-purine) C_{5}H_{3}N_{4}NH_{2}
Guanine (amino-oxypurine) C_{5}H_{3}N_{4}ONH_{2}
Uric acid (trioxypurine) C_{5}H_{4}N_{4}O_{3}
“Just as the ordinary protein metabolism is both exogenous and
endogenous, so is it the case with nuclein metabolism. There are
certain kinds of food (such as liver and sweetbread) which are rich
in nuclei, and others, such as meat, which are rich in purine bases
(especially hypoxanthine). The increase in uric acid excretion after
partaking of such food is exogenous, and those liable to uric acid
disorders should avoid such articles of diet. Other forms of diet
lead to an increase of uric acid formation by increasing the number
of leucocytes in the blood, and there is a consequent increase in
the metabolism of their nuclei. Increase in leucocytes may, however,
be present independently of diet, and in the disease known as
leucocythæmia this occurs to a marked degree; in such cases uric acid
formation increases. Although special attention has been directed to
the nuclei of leucocytes, because these can be readily examined during
life, it must be remembered that the nuclein metabolism of all cells
may contribute to uric acid formation. Uric acid, which originates by
metabolism, is spoken of as endogenous.”
These purine bodies taken in excess, it is almost certain, tend
to raise blood-pressure and to favour the production of gout and
arterio-sclerosis. Much can be done, when these threaten, by reducing
the amount of these in our food. There is, except in very extreme
cases, no need for an absolute purine-free diet, but the diet should
be in that direction and so towards a sensible, liberal vegetarianism.
The following table of ordinary foods, showing the purine contents in
grains per pound, pint or teacup, is from the _Lancet_, 1906, vol. ii,
p. 933, Potts:
Sweetbread 70.43
Liver 19.26
Beef Steak 14.45
Salmon 9.13
Chicken 9.06
Loin of Pork 8.48
Veal 8.13
Ham 8.08
Mutton 6.75
Halibut 7.14
Plaice 5.56
Cod 4.07
Beans 4.16
Lentils 4.16
Oatmeal 3.45
Coffee 1.70
Ceylon Tea 1.21
China Tea 0.75
In sclerosis perhaps the chief thing is to avoid the flesh extracts,
such as beef-tea, strong meat soups, and rich gravies; for this reason
boiled or stewed meats are better than fried or roast. This applies to
fish and chicken also; a plain grill is good, but the frying-pan is a
danger. Vegetable soups made with bone stock may be taken. Cheese, eggs
and milk should supply the greater part of the nitrogenous or protein
food. The better sorts of vegetable foods, such as oatmeal, lentils,
peas and nuts, will all help to take the place of albuminous animal
foods. A certain amount of fat should be taken. A fish and chicken diet
contains too little fat and should be perfected by bacon, hot or cold.
All the farinaceous foods are good, but the more starchy ones, such as
sago, rice and cornflour, are with some people more liable to cause
fermentative dyspepsia.
As age advances and our teeth fail in power we are apt to slip into
the way of eating chiefly soft, well-cooked foods, in which what are
known as vitamines are almost destroyed, but they are as essential as
ever, and some uncooked fruit, salads and unboiled milk should enter
into our diet.
When one thinks over the luxurious habits of our predecessors, the
enormous amount of food, in excess of body needs, taken at big dinners,
one must realize how we and they sinned against the light. The great
war has taught most of us, with the exception perhaps of the new rich,
how little we can live on and work on with complete efficiency. Economy
of food, simplicity of life, mean economy of waste and of expenditure
of vital force, and our bitter war experiences should prove to be the
path to longer lives, and to lives with a higher standard and greater
results.
The question of alcohol in sclerosis is difficult, but very
important. In the first place it depends somewhat on what a man has
been accustomed to take. If he has taken a moderate amount with his
food during the greater part of his life it does not always do to
stop it. Alcohol is not a pressure raiser, as many think, but rather
the reverse, and, if stopped suddenly, the digestive powers may be
lessened and the tone of the body depressed. Lauder Brunton says: “All
the Alcohols tend to dilate vessels, to diminish blood-pressure, and
ultimately to diminish activity of the nervous tissues, although at
first sight they may seem to have a stimulant action.”
Alcohol contains so little nutritious food (with the exception of
the sugars and extractives of wine and beers) that in itself it may
be said to give nothing to the body; but there is something a bit
beyond this--the bitter of the hop and the flavour, the bouquet of
the grape have a stimulating effect on the nerves of taste and smell,
and so produce, with some people, a better flow of saliva and gastric
juice. This probably is how wine and beer in moderate quantities help
digestion and appetite. There is still further the effect on the
general nervous system. Alcohol without doubt enables a man to draw
on his reserve of force, though it probably does not increase those
reserves. This is, of course, drawing on one’s capital, but the ability
to do this may be of great use in emergencies, for it can help a man to
live over evil times. But it must not be forgotten that such calls, if
too large or often repeated, must in the end empty the reservoirs and
leave him powerless and defenceless.
This question of alcohol must be regarded by physicians with common
sense backed by scientific knowledge. The world is never going to
be cured of alcoholic intemperance by intemperance in language and
inaccuracy in thought.
Before I go into the more detailed treatment of sclerosis, I must
just touch on the question of tobacco. Nicotine, without doubt, is
one of the most powerful raisers of arterial pressure known, but in
ordinary smoking very little gets into the system. Tobacco chewing and
snuff-taking, both nearly extinct, probably introduce more nicotine
into the body. The combustion in cigar smoking is so nearly complete
that very little poison remains except on the lips. In ordinary
cigarette smoking the combustion is about as complete as in the case of
cigars, but, if the smoke is habitually inhaled, the absorption through
the bronchial mucous membrane is much greater and, I think, must have
an appreciable effect on blood-pressure. As in alcohol, so in tobacco,
we must not lose sight of the effect on the general nervous system:
on many people tobacco, in moderation, has a distinctly soothing
influence, and so leads to a quietude of mind which compensates for
any other small evil effect. Used in excess, it certainly weakens
both nerve and will power, and often heart power. The first effect in
experimental nicotine poisoning is greatly raised blood pressure, but
at the end dangerously low pressure, and so we find that the ultimate
effect of excessive smoking is a feeble, low-tension pulse that is
often irregular. Oliver found that, in ordinary people who were not
excessive smokers, tobacco raised the systolic pressure 10 to 15 mm.,
but that the diastolic was unaffected; the variations between the two
thus becoming abnormal. This effect generally subsides in a quarter of
an hour after smoking is finished.
It follows, I think, that a man with sclerosis should think this out
for himself, for he is not in a position to take any unnecessary
chances. Of another of our daily habits, it is wise to remember that
coffee raises pressure more than tea, and China tea less than Indian.
There is no doubt that an indoor, sedentary life tends to high
pressure far more than an active, outdoor one. This is partly due to
the mental work and concentration that goes with it and partly to
oxygen deficiency. The inhalation of oxygen lessens the viscosity of
the blood and consequently the work of the heart and of the arterial
muscles, while an excess of carbon-dioxide in the air increases the
viscosity and the necessary heart force that must be expended. The
amount of oxygen we inhale in the open is necessarily more than in
confined buildings, and we all feel how difficult it is to drive our
brains in a close, stuffy atmosphere. This points to the economic value
of ventilation and space. Wise, moderate exercise also tends to lower
pressure by promoting a general quickening of circulation throughout
the whole body; the stagnant pools are flushed out and oxygenation
becomes more perfect. Even severe exercise in health only raises
pressure temporarily; the subsequent level in health is below the
original. But where there is evidence of cardio and arterial disease,
exercise must be taken wisely, moderately, and only slowly increased.
This is done very effectually in some health resorts, where the patient
is trained to mount gradually increasing slopes. The same effect is
reached by graduated exercises. In all these methods pulse rate and
arterial pressure are tested and serve as guides to further advance.
Certain Bath treatments, such as Nauheim and its English adaptations,
help materially to lower pressure and to hasten a sluggish blood flow.
These act chiefly by dilating the blood-vessels at the surface of the
whole body and thus relieving internal congestions and increasing
oxygen exchange.
The nature of our games and exercise in sclerosis needs careful
thought. Golf, for instance, is very good if taken quietly, but some
courses are so hilly that there is a good deal of strain put on the
heart. If one is compelled to play on such a course, one must take it
slowly, and not allow the spirit of the game to run away with one.
Quiet sculling is one of the best exercises, for it works all the
muscles of the body slowly and symmetrically, and the strain on heart
and lungs is entirely under one’s own control. Swimming, again, is a
most healthy exercise, if taken quietly and not in very cold water.
I know of nothing that improves one’s wind so quickly. But all these
exercises must be taken under advice and never pushed to the point of
real fatigue or exhaustion.
The need of rest is as great as the need of the right sort of
exercise. Late hours should be absolutely avoided and little brain work
should be done in the evening, so that the brain and all its important
arteries can sink into relaxation and sleep at once. The rest to the
heart and circulation is of course never so prolonged, but nature has
designed them to get their rest only in moments. The heart in an adult
rests more than thirteen hours out of the twenty-four, under quiet
normal conditions, the time of rest being the diastole, and the time
of work being the systole or contraction. There are few healthy men
who could not walk a thousand miles in six weeks, walking about eight
hours a day and resting for the remainder of their time; but there are
not many men who could walk a thousand miles in a thousand consecutive
hours, as the late Captain Barclay did, because the frequent
interruptions to their sleep would exhaust them completely. In the
same way, if the heart is forced to beat more quickly, it becomes
sooner exhausted, for the extra work is taken from the diastole, the
sleeping or resting time of the heart.
The blood pressure is generally ten degrees lower in the morning after
a good night’s rest; and for this reason, in severe cases, I often
advise people to take a whole day in bed once a week, so that this
lower pressure may be prolonged for twenty-four hours.
The non-medicinal treatment of sclerosis, prophylactic and curative,
consists then chiefly in a philosophical, calm mode of life, in a firm
restraint of passions, of worry and excitements, in a wise and economic
use of brain power, in great moderation in eating and drinking, in
giving as much of our time as is possible to fresh air and moderate,
unhurried exercise, and lastly to the avoidance of all severe strains
on mind or body. Very few of us are able to accomplish all these
positive and negative virtues, but as far as in us lies, they should be
our rule of life.