CHAPTER III

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 theone 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 reasonsthat 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 deficiencyand 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 oldage 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 universalaccompaniments 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 defileththe 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, ourhappiness 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:

Protein90Fat75Carbohydrate330 = 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 beef90 + 10 we get its valueChicken79 + 21 we get its valueBread13 + 6 + 81 we get its valueCheese2 + 7 + 2 we get its value

90 + 10 we get its value

79 + 21 we get its value

13 + 6 + 81 we get its value

2 + 7 + 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.

PERCENTAGE OF TOTAL HEAT VALUE OF FOOD FURNISHED BY ITSPROTEINFATCARBOHYDRATEPer cent.Per cent.Per cent.Lean beef (boiled)90Butter99Tapioca (cooked)98Chicken79Bacon94Prunes (dried)97Mackerel50Cream87Figs (dried)95Skim Milk37Brazil Nuts86Rice (boiled)89Eggs32Fat Ham81Oysters89Beef with fat25Fat Beef75Potatoes (boiled)88Cheese25Cheese73Bread81Fat Ham19Eggs68Peas72Milk19Boiled Mutton65Milk29Bread13Milk52Cream8Potatoes11Mackerel50Brazil Nuts4Boiled Rice10Chicken21Cheese2Brazil Nuts10Boiled lean Beef10Bacon6Bread6Cream5Bananas5Bananas5Potatoes1Butter5

PERCENTAGE OF TOTAL HEAT VALUE OF FOOD FURNISHED BY ITS

PROTEIN

FAT

CARBOHYDRATE

Per cent.

But the chemical side of the 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 notgoverned 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’sHandbook of Physiologywill 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 thisis 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.

PurineC5H4N4Hypoxanthine (monoxypurine)C5H4N4OXanthine (dioxypurine)C5H4N4O2Adenine (amino-purine)C5H3N4NH2Guanine (amino-oxypurine)C5H3N4ONH2Uric acid (trioxypurine)C5H4N4O3

“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, whichare 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 theLancet, 1906, vol. ii, p. 933, Potts:

Sweetbread70.43Halibut7.14Liver19.26Plaice5.56Beef Steak14.45Cod4.07Salmon9.13Beans4.16Chicken9.06Lentils4.16Loin of Pork8.48Oatmeal3.45Veal8.13Coffee1.70Ham8.08Ceylon Tea1.21Mutton6.75China Tea0.75

70.43

7.14

19.26

5.56

14.45

4.07

9.13

4.16

9.06

4.16

8.48

3.45

8.13

1.70

8.08

1.21

6.75

0.75

In sclerosis perhaps the chief thing isto 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 inpower 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 isdifficult, 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 theflavour, 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 alcoholicintemperance 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 manypeople 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 anyunnecessary 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 bypromoting 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 internalcongestions 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 needof 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. Veryfew 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.

Back to Index Next