Arteriosclerosis comes to almost every one who lives out his allotted time of life. As has been noted within, many diseases and many habits of life are conducive to the early appearance of arterial degeneration.

Decay and degeneration of the tissues are necessary concomitants of advancing years and none of us can escape growing old. From the period of adolescence certain of the tissues are commencing a retrograde metamorphosis, and hand in hand with this goes the deposit of fibrous tissue which later may become calcified. The arterial tissue is no exception to this rule, and we have already shown that certain changes normally take place as the individual grows older, changes which are arteriosclerotic in type and are quite like those caused in younger people by many of the etiologic factors of the disease.

We are absolutely dependent upon the integrity of our hearts and blood vessels for the maintenance of activity and span of life. Respiration may cease and be carried on artificially for many hours while the heart continues to beat. Even the heart has been ma.s.saged and the individual has been brought back to life after its pulsations have ceased, but such cases are few in number. We can not live without the heart beat and the prophylaxis of arteriosclerosis consists in the adjustment of our lives to our environment, so that we may get the maximum amount of work accomplished with the minimum amount of wear and tear on the blood vessels.

The struggle for existence is keen. Compet.i.tion in every profession or trade is exceedingly acute, so much so that to rise to the head in any branch of human activity requires exceptional powers of mind. Among those who are entered in this keen compet.i.tion, the fittest only can survive for any period of time. The weaklings are bound to succ.u.mb. A scion of healthy stock will stand the wear and tear far better than will the progeny of diseased parentage.

It is only necessary to call attention to the part that alcohol, syphilis and insanity play in heredity. These have been discussed fully in the earlier part of this book.

We live rapidly, burning the candle at both ends. It is not strange that so many comparatively young men and women grow old prematurely. While heredity is a factor as far as the prophylaxis of arteriosclerosis is concerned, of far more importance is the mode of life of the individual.

Scarcely any of us lead strictly temperate lives. If we do not abuse our bodies by excessive eating and drinking and so wear out our splanchnic vessels and cause general sclerosis by the high tension thereby induced, we abuse our bodies by excessive brain work and worry with all their mult.i.tudinous evils. The prophylaxis of arteriosclerosis might well be labeled, "The plea for a more rational mode of life." Moderation in all things is the keynote to health, and to grow old gracefully is an art that admits of cultivation. Excesses of any kind, be they mental, moral, or physical, tend to wear out the organism.

People habitually eat too much; many drink too much. They throw into the vascular system excessive fluid combined frequently with toxic products that cause eventually a condition of high arterial tension. It has been shown how poisonous substances absorbed from the intestines have some influence on the blood pressure. Anything that causes constant increase of pressure should be studiously avoided.

Mild exercise is an essential feature of prophylaxis. One may, by judicious exercise and diet, make of himself a powerful muscular man without, at the same time, raising his average blood pressure. The man who goes to excess and continually overburdens his heart, will suffer the consequences, for the bill with compound interest will be charged against him. It is a great mistake for any one to work incessantly with no physical relaxation of any kind, and yet, after all, it is not so much physical relaxation that is necessary, as the pursuit of something entirely different, so that the mind may be carried into channels other than the accustomed routes. Diversification of interests is as a rule restful. That is what every man who reaches adult life should aim at.

Hobbies are sometimes the salvation of men. They may be ridden hard, but even then they are helpful in bearing one completely away from daily cares and worries. The man who can keep the balance between his mental and physical work is the man who will, other things being equal, live the longest and enjoy the best health.

Nowadays the trend of medicine is toward prophylaxis. We give the state authority to control epidemics so far as it is possible by modern measures to control them.

We urge over and over again the value of early diagnosis in all chronic diseases, for we know that many of them, and this applies particularly to arteriosclerosis, could be prevented from advancing by the recognition of the condition and the inst.i.tution of proper hygienic and medicinal treatment.

_It is the patent duty of every physician to instruct the members of his clientele in the fundamental rules of health._ Recently the President of the American Medical a.s.sociation, in his address before the 1908 meeting, urged the dissemination of accurate knowledge concerning diseases among the laity. While this may be done by city and state boards of health, it seems far better for the modern trained physician to work among his own people. With concise information concerning the modes of infection and the dangers of waiting until a disease has a firm hold before consulting the health mender, people should be able to protect themselves from infections and be able to nip chronic processes in the bud. But it is difficult to turn the average individual away from the habit of having a drug-clerk prescribe a dose of medicine for the ailment that troubles him. It is really unfortunate that most of the pains and aches and morbid sensations that one has speedily pa.s.s away with little or no treatment. Herein lies the strength of charlatanism and quackery. Unfortunate, yes, for a man can not tell whether the trivial complaint from which he suffers is any different from the one that was so easily conquered six months ago. But instead of recovering, he grows worse. Hope that springs eternal in the human breast, leads him to dilly-dally until he at last seeks medical advice, only to find that the disease has made such progress that little can be done.

_Instruct the public to consult the doctors twice a year._ The dentists have their patients return to them at stated intervals only to see if all is well. _How much more rational it would be if men and women past the age of forty had a physical examination made twice a year to find out if all is well._

The prophylaxis of arteriosclerosis is moderation in all the duties and pleasures of life. This in no sense means that a man has to nurse himself into neurasthenia for fear that something will happen to him. As one grows in years exercise should not be as violent as it was when younger, and food should be taken in smaller quant.i.ties. Many forms of exercise suggest themselves, particularly walking and golf. Walking is a much neglected form of exercise which, in these modern days with our thousand and one means of locomotion, is becoming almost extinct. There is no better form of exercise than graded walking. To strengthen the heart selected hill climbing is one of the best therapeutic methods that we have. The patient is made to exercise his heart just as he is made to exercise his legs, and as with exercise of voluntary muscles comes increase in strength, so by fitting exercise may the heart muscle be increased in power. A warning should be sounded, however, against over exercise. This leads naturally to hypertrophy with all its disastrous possibilities. Men who have been athletes when young should guard against overeating and lack of exercise as they grow older. Many of the factors which favor the development of arteriosclerosis are already there, and a sedentary, ordinary life, such as office all day, club in afternoon, a few drinks and much rich food, will inevitably lead to well-advanced arterial disease.

Karl Marx in his famous Socialistic platform said: "No rights without duties; no duties without rights." So we may paraphrase this and say: "No brain work without moderate physical exercise in the open air; no physical exercise without moderate brain work."

There is yet one other point that is important, the combination of concentrated brain work and constant whiskey drinking. This is most often seen in men of forty-five to fifty-five, heads of large business concerns who habitually take from six to twelve drinks of whiskey daily, and with possibly a bottle of wine for dinner. Such men appear ruddy and in prime health but, almost invariably, careful examination will reveal unmistakable signs of arterial disease. There is usually the enlarged heart and pulse of high tension with or without the trace of alb.u.min in the urine. The lurking danger of this group of manifestations has so impressed the medical directors of several of the large insurance companies that a blood pressure reading must be made on all applicants over forty years of age. Should high blood pressure be found, the premium is increased, as the expectation of life is proportionately shorter in such men than in normal persons.

Therefore, let every physician act his part as guardian of health. Only in this way is the prophylaxis of arteriosclerosis possible.

CHAPTER XIII

TREATMENT

Although it has been rather dogmatically stated (vide supra) that every one who reaches old age has arteriosclerosis, it must not be inferred that absolutely no exceptions to this rule are found. Cases are known where persons of ninety years even had soft arteries, and we have seen persons of eighty whose arteries could not be palpated. When infants and children are seen with considerable sclerosis, it proves that, after all, it is the quality of the tissue even more than the wear and tear, that is the determining factor in the production of arteriosclerosis. It would be well if those who can not bring healthy progeny into the world were to leave this duty to those who can.

In general the treatment of arteriosclerosis is prophylactic and symptomatic. In the preceding chapter I had something to say about prophylaxis in general; I must again refer to it in detail.

Arteriosclerosis is essentially a chronic progressive disease, and the secret of success in the management of it is not to treat the disease or the stage of the disease, but to treat the patient who has the disease.

To infer the stage of the disease from the feeling of the sclerosed artery, may lead to serious mistakes. Persons with calcified arteries may be perfectly comfortable, while those with only moderate thickening may have many severe symptoms. The keynote is individualization. It is manifestly absurd to treat the laboring man with his arteriosclerosis as one would treat the successful financier. The habits, mode of life, every detail, should be studied in every patient if we expect to gain the greatest measure of success in the treatment. One may treat fifty patients who have typhoid fever by a routine method and all may recover. Individualizing, while of great value in the treatment of acute diseases, yet is not absolutely essential in order that good results may be obtained. Far different is it when treating a disease like arteriosclerosis. One who relies on textbook knowledge will find himself at a loss to know what to do. Textbooks can only outline, in the briefest manner, the average case, and no one ever sees the average book case. At the bedside with the patients is the place to learn therapeutics as well as diagnosis. All that can be hoped for in outlining the treatment of arteriosclerosis is to lay down a few principles. The tact, the intuition, the subtle something that makes the successful therapeutist, can not be learned from books. So the man who treats cases by rule of thumb is a failure from the beginning. There are certain general principles that will be our sheet anchors at all times and for all cases. The art of varying the application of these fundamentals to suit the individual case, is not to be culled from printed words.

=Hygienic Treatment=

Every man is more or less the arbiter of his own fate. Granted that he has good tissue to begin life, his own habits and actions determine his span of comfortable existence. No one cares to live after his brain begins to fail, and the failing brain is often due to disease of the cranial arteries. The hygienic treatment resolves itself into advice in regard to prophylaxis.

First and foremost is exercise. It has seemed to us that the revival of out-of-door sports is one of the best signs of promise of the preservation of a virile, hardy race. That women, as well as men, indulge in the lighter forms of out-of-door exercise should bring it about that the coming generation will start in life under the most advantageous conditions of bodily resistance.

Among all the forms of exercise, golf probably is the best. It is not too violent for the middle-aged man, yet it gives the young athlete quite enough exercise to tire him. It is played in the open. One is compelled to walk up and down in pleasant company, for golf is essentially a companionable game, while he reaps the full benefit of the invigorating exercise. The blood courses through the muscles and lungs more rapidly; the contraction of the skeletal muscles serves to compress the veins and so to aid the return of blood to the heart: the lungs are rendered hyperemic, deeper and fuller breaths must be taken; oxidation is necessarily more rapid, and effete products, which if not completely oxidized would possibly act as vasoconstrictors, are oxidized to harmless products and eliminated without irritating the excretory organs.

Other forms of out-door exercise that can be recommended are tennis, canoeing, rowing, fishing, horseback riding, swimming, etc. Tennis is the most violent of all the sports mentioned and might readily be overdone. Rowing as practiced by the eights at college is undoubtedly too violent a form of exercise, and may be productive in later life of very grave results. Canoeing is a delightful and invigorating exercise.

The muscles of the arms, shoulders, and trunk are especially used, the leg muscles scarcely at all. Nevertheless, the deep breathing that necessarily comes with all chest exercises aerates every portion of the lungs, and is of great benefit to the whole body.

Swimming as an exercise has much to recommend it. In this sport all the muscles take part and at the same time the chest is broadened and deepened.

All these methods of using the muscles to keep oneself in trim, so to speak, are part and parcel of the general hygienic mode of life that is conducive to a healthy old age. Exercise can be overdone, as eating can be overdone. Both are essential and yet both can be the means of hastening an individual to a premature grave.

When the arteriosclerosis has advanced so far that it is easily recognizable, certain forms of exercise should be absolutely prohibited.

Such are tennis, rowing and swimming. Horseback riding to be allowed must be strictly supervised. At times this may be an exceedingly violent exercise. As an out-of-door sport, there is nothing that equals golf.

The physician, knowing the character of the course, and the length of it, can say to his patient that he may play six, nine, twelve, or eighteen holes, depending on the patient's condition.

For those who are not able to get out, exercise in the room with the windows open must take the place of out-of-door sports. Here the use of chest weights is a most excellent means of keeping up the tone of the muscles. By adjusting the weights, the exercise may be made light, medium, or heavy. Every physician should be familiar with the chest weight exercises. They are not as good as open air exercise but they undoubtedly have been the means of saving years of life to many patients with arterial disease.

There comes a time when all forms of exercise must be prohibited on account of the dyspnea, edema, dizziness, etc. It seems unwise to keep such a patient in bed, even though the edema be considerable. Once on his back in bed he becomes weak, and the danger of edema of the lungs or hypostatic congestion of the bases, with subsequent bronchopneumonia, is very great.

Such patients may be allowed to sit up in a comfortable chair with the legs supported straight out on a stool or other chair. The half reclining position is not easy to a.s.sume in bed. Considerable ingenuity must often be exercised by the physician in making the patient comfortable without increasing the symptoms from which the patient suffers following the least amount of exercise. Although such persons can not exercise actively, they should have pa.s.sive exercise in the form of ma.s.sage, carefully given, so that no injury is done to the rigid vessels. It is possible to rupture a vessel, the walls of which are encrusted with lime salts, and full of small aneurysmal dilatations.

Every patient must be watched carefully and measures inst.i.tuted for the individual.

=Balneotherapy=

As a tonic and invigorator, the cold or cool bath (shower or tub), in the morning on arising can be highly recommended. It promotes skin activity, is a stimulant to the bowels and kidneys and to the general circulation, besides being cleansing. We find today that the morning bath has become such a necessity to the average American that all new hotels are fitted with private baths, and old hotels, in order to get patronage, are arranging as many baths connected with sleeping rooms as is possible. Our generation a.s.suredly is a ruddy, clean-bodied one. What the actual results of this out-door life and frequent bathing will be for the race remains to be seen, but one can not but feel that it must build up a stronger, more resistant race of people, who not only enjoy better health than did their forefathers, but enjoy it longer.

Not every one can stand a cold bath. It is folly to urge it on one to whom it is distasteful, or on one who does not feel the comfortable glow that should naturally result. For the well, or those with a tendency to arteriosclerosis, or those in whose families there have been several members who had early arteriosclerosis, such proceedings as recommended could not be improved upon. However, for the person who has well recognized sclerosis, only warm baths should be advised, and these not daily. The water should be at a temperature of 90-95 F. Care should be taken that persons sent to spas be cautioned against hot baths. It is not inconceivable that the increased force of the heart beat that accompanies a hot bath might be sufficient to rupture a small cranial vessel. Hence, Turkish and Russian baths should be most unqualifiedly condemned. As a matter of fact, persons vary so in their habits with regard to bathing that what might suit one person would do another much harm.

=Personal Habits=

The personal habits of the individual, more than any other factor, determine whether or not arteriosclerosis sets in early in his life. The man or woman who is moderate in eating and drinking, sees that the kidneys are kept in good condition, and attends strictly to regularity of the bowels, lays a good basis for the measure of health which is so essential for happiness. It has been shown that sclerosis of the splanchnic vessels may be due to constant irritation of toxic products elaborated in digesting constantly enormous meals. In obstinate constipation, many poisons, the nature of which we do not know, are absorbed and circulate in the blood. We have not sufficient data to prove that constipation favors the production of arteriosclerosis, but our impression has been that it does favor it. Constipation can often be relieved by a gla.s.s of water before breakfast, a regular time to go to stool, and abdominal ma.s.sage or exercises. Some maintain that it is a bad habit only, and can be readily overcome. Whatever is done, avoid leading the patient into the drug habit, for the last state of the patient will be worse than the first. Habits of sleep are not of such great importance. Most persons get enough sleep except when under severe mental strain. Most adults need from seven to eight hours' sleep, although some can do all their work and keep in prime health on five or six hours' sleep.

Tobacco has been accused of causing many ills and has been thereby much maligned. We can not see that the use of tobacco in any form in moderation is harmful to most men. Undoubtedly the blood pressure is raised when mild tobacco poisoning occurs, and individual peculiarities of reaction to the weed are mult.i.tudinous. But to condemn offhand its use is the height of folly. There is no reason why the arteriosclerotic who has always used tobacco in moderation, should not continue to use it, whether he smoke cigarettes, cigars, or pipe. His supply should be decreased, but there is no sense in depriving a man of one of the solaces of life, unless, as is sometimes the case, abstinence is easier for the patient than moderation.

As for alcohol, opinions differ widely.[19] Some see in alcohol one of the most frequent causes of arteriosclerosis; others do not believe that the part played by alcohol is a serious one, only in conjunction with other poisonous substances is it dangerous. Probably unreasoning fanaticism has had much to do with the wholesale condemnation of alcoholic beverages. The general effect of alcohol is to lower the blood pressure by causing marked dilatation of all the vessels of the skin.

True, the alcohol circulates in the blood, and is broken up in the liver, and this organ would seem to bear the brunt of the harm done.

Alcoholic drinks in moderation, I do not believe have any deleterious effect on health. On the contrary, I believe that they may in some cases a.s.sist digestion and a.s.similation. Indiscriminate indulgence is to be condemned, as is overindulgence in exercise or eating. What may be moderate for A, might be excessive for B. Every man is then the arbiter of his own fortune and within his own limits can indulge moderately (a relative term after all) without fear of doing himself harm. In advanced arteriosclerosis it is necessary to decrease the supply of alcohol just as it is necessary to cut down the food supply. This must rest entirely on the judgment of the physician, who must not act arbitrarily, but must have his reasons for every one of his orders.

[19] Discussion of alcohol at present has value only as it relates to the past. The present is dry. The future is in the lap of the G.o.ds.

=Dietetic Treatment=

Most persons eat too much. We not only satisfy our hunger, but we satisfy our palates, and, instead of putting substantial foodstuffs into our stomachs, we frequently take unto ourselves concoctions that defy description.