Treatment And Prevention Of Premature Senility
( Originally Published 1912 )
FORTY or more years ago surgery, under the influence of Listerism, started a new life, and the world stood astounded at the brilliancy of its achievements. During this time the science of medicine seemed to stand still, but there was much silent good work going on all the time, and for the last twenty years there has been such growth and development as no former period of the world's history has ever seen. Bacteriology, organic chemistry, and the organic remedies chiefly derived from the ductless glands, have revolutionized our methods, and have enormously increased our powers over disease, and perhaps more especially over the diseased conditions peculiar to the elderly and the old.
I think the future of therapeutics lies chiefly in the direction of organic remedies, in the medicines which are more or less native to the human body and not foreign to it. I should be the last to disparage the value of drugs obtained from plants, such as strychnine, digitalis, aloes, etc., but they are foreigners, and will be gradually superseded, I believe, by those remedies which are more nearly related to the animal organism. Iron, phosphorus, and perhaps arsenic, stand midway; the first two are natural constituents of the body, and should be looked upon as special foods and not as drugs. I make an earnest appeal to my medical brethren to study closely modern physiological therapeutics, and not to be content with the old, so-called orthodox, routine methods. Our watchword, to paraphrase the old French proverb, should be " Progres, progres, toujours progres et quelquefois L'audace. "
We can have no " Quicunque vult among our creeds. The past is ours to profit by, but the future is ours to make. In therapeutics we must be optimists, for we carry about in our own bodies most of the remedies we shall need. Many a fall we shall get, but—and this is the chief thing—we must always be found in the saddle again.
I think we may safely say that the natural term of life, since David wrote, has been much prolonged. The term to ordinary healthy folk should be nearer ninety years than seventy, and the extra years should not be years of labor and sorrow; and yet what a number fail to reach even the old goal !
Dr. de Havilland Hall, who may be considered one of the first authorities on both arterio-sclerosis and on the life insurance aspect of that disease, says that though the average duration of life has considerably increased during the last fifty years, there has been an actual increase in the mortality-rate among males between the years of forty-five and sixty-five; and that between the ages of fifty-five and sixty-five one-third of the total deaths are due to disease of the heart and bloodvessels. The fearful mortality from cancer, and our powerlessness in face of it, make our hearts ache, but here we have probably a far more frequent cause of death and of incapacity, and we almost ignore it. These statistics are obtained from the Registrar-General's Reports; and are, of course, beyond dispute, but I should roughly estimate that 50 per cent. of the deaths of people over sixty years of age are due to these causes, to Bright's disease, or to the non-tubercular chronic chest diseases that are so often mixed up with them, and many of which belong to a common origin, and which are not fully or scientifically classified on ordinary death certificates; and to the study of these diseases, then, I ask my readers to accompany me.
The critic, even the friendly critic, will perhaps say, " This is a man with one idea, and he sees one side of the problem only." To a certain extent I admit the justice of this, but I have taken my course deliberately. The other causes of premature and diseased old age, such as the acute febrile diseases, pneumonia and influenza, and all the various forms of malignant disease, are to a large extent outside our control, and compared numerically 'to arterio-sclerosis are almost negligible. It has been my fortune, good or bad, to hear many sermons and many preachers, and I have been forced to this conclusion, that the ordinary preacher who tries to cover the whole ground, who divides his lengthy sermon into divisions and subdivisions, rarely gets his message home; after a few minutes the drowsy nebulosity of his hearers' minds passes into complete intellectual sleep.
"The braw words rumm'le ower his heid,
But the preacher who is content, in a short sermon, to make one or two good points, to touch those points with a little spice or mustard and to ram them home, is the man who fulfils his mission. Such must be my excuse for the limitations of this little book.
How, then, shall we approach this great fight? Most of us are apt to look upon diseases and their beginnings as mere happenings, as the unlucky chances of life, but surely it is not so.
There are some diseases that come from without, as the infectious fevers, against which we cannot entirely guard, but the ordinary diseases are the logical results of a long chain of causes, most of which are under our control. Even the infections from without become diseases only when our powers of resistance are absent or their tide at a low ebb. The first thing we must do, then, is to inquire carefully into causes, into the way of life, and into hereditary tendencies. We must try to remove excessive pressure of bodily or mental work, improper feeding, careless eating and drinking, and we must insure plenty of quiet rest. It goes without saying that to insure any success, we must get our patients' honest and willing cooperation. Without this we can do but little. Secondly, I would say that every man and woman of fifty years of age should have their hearts and arteries carefully examined. A rise of arterial tension or blood-pressure is almost certainly the earliest symptom that we can detect and rely on in threatening diffuse arterio-sclerosis or thickening of the arteries.
Arterial tension may be described thus : During the resting-time of the heart, between each beat, the circulation of the blood is maintained by the contractile power of the arteries, which steadily urges the blood onward into the capillary vessels and so into the veins. This power is known as arterial tension or pressure, and it is estimated fairly accurately by the syphygmomanometer. A large number of observations have taught us what is the average pressure at different ages of life, and thus we are able to talk about a normal or abnormal pressure. To fix in our minds a clear idea of the physiology of the arterial system I cannot do better than quote Sir Lauder Brunton (Lancet, VII. xxvi. 15) : " The whole of the arterial system from the aorta down to the smallest arterioles has the power of contraction, but there is much more elasticity and less contractility in the aorta than in the arterioles, where the contractility is great and the elasticity comparatively slight. The whole system is richly supplied with nerves, some of which, the vaso-motor nerves, induce contraction, while the vaso-dilator nerves have the opposite effect. The arteries have three functions. First, by means of their elasticity, to store up the energy excited by the left ventricle during its systole or contraction, and to expend this again in keeping up the flow of blood during the diastole, when, in the healthy heart, the ventricle is completely shut off from the aorta by the sigmoid valves. The second function is to regulate the flow of blood to those parts which need it, by those vessels which supply the acting organs dilating, while those of the other parts of the body contract. The third function, which is less generally recognized, is to pass the blood on from the arteries into the veins by peristaltic action, an action which causes the arteries to be empty after death." This description may be rather difficult for a lay mind to thoroughly appreciate, but it will at any rate show the main working principle of the circulation. Sir Lauder Brunton again describes arteriosclerosis thus : " Diffuse or general arterio-sclerosis is a condition in which the walls of the arteries be-come thickened by a deposit of hyaline tissue between the muscular and endothelial coats. This deposit, which is so liable to occur in kidney disease, is of great importance because a lessening of the lumen or calibre of the arterioles increases the peripheral resistance, leads to hypertrophy of the heart, and thus to an enormous increase of blood-pressure, with consequent danger of rupture of blood-vessels and apoplexy."
With this knowledge in our minds it must be evident that the perfection of physical life depends on the structural perfection and on the physiological well-being of the heart and of the bloodvessels. The blood is not the life and the heart is not the life—the secret of this mystery lies far deeper-but both are life's indispensable ministers.
Hitherto, perhaps, our voyage through life has been a smooth and easy one, possibly too easy : a fair wind has kept our sails comfortably filled; but for many of us, at about a certain age, the weather changes, the wind blows first on one beam, then on the other, or sometimes draws dead ahead, and we have to keep trimming our sails or making wearisome tacks to windward. These signs should be a warning to us that the voyage is no longer going to be so easy as in the past, and the wiser ones will take careful stock of themselves. It is now that a good physician will be able to give help that is literally invaluable, not so much by medicines as by advice. Let us try and find out for ourselves individually what are the causes of this threatening breakdown and premature decay.
The first cause, but not the most frequent one, is, I think, hereditary gout and an hereditary tendency to Bright's disease, if they can be separated, but both these tendencies can be kept well in check by a wise régime. The second cause, which comes into action far more frequently, is external and is to a large extent preventable or removable. It is the speed, the intensity and high pressure of modem life, and this not only in business and professional men, but in the men and women of society. In the latter class late hours, overfeeding, overdrinking, oversmoking, and continual excitement, are to blame. Among business men anxiety and the excitement of speculation are the chief factors.
We know that among the educated classes at any rate actual drunkenness has very much lessened, but the men and women who lead these intense lives have more often than not to keep themselves going with some form of stimulant : with small doses of alcohol, the small whisky-and-soda, the liqueur, etc. ; others fly to tea or strong coffee and take them to excess. And some, men and women both, are never happy and think they can do nothing without the eternal cigarette, that pernicious form of smoking, in which one never knows when one has had enough.
The still more disastrous effects of morphia and cocaine must be mentioned, but they are outside the scope of this work.
All these things are without doubt temporary helps; as men say, they clear the brain and help them to think more clearly for the time, and to make another spurt. In great moderation and in certain circumstances they are legitimate helps and may carry us through some crisis ; but how do they do this? One and all by whipping up the heart and by increasing the rapidity of the circulation, so that more blood is poured through the brain. This, again I say, may be a legitimate action for a reason-able cause and under exceptional circumstances. But if the brain is already tired, this whipping up can only end in still greater fatigue and exhaustion, and it is thus that a vicious circle of over-excitement, overwork, and over-stimulation is set up. The brain itself no doubt suffers, but not appreciably for some time. What is first evident to the physician is the injury done to the heart and blood-vessels. In a normal state the heart is a very busy organ. It has to contract and dilate about seventy times a minute, and that whether we sleep or wake.
Sir Lauder Brunton, in his "Therapeutics of the Circulation," says : " We are sometimes accustomed to speak of this unresting organ,' but this is a total mistake. The heart, in an adult rests more than thirteen hours out of the twenty-four, the time of rest being the diastole, and the time of work being the systole or contraction. We may say, then, that the heart practically sleeps more than the brain or body; but the great distinction between the sleep of the heart and that of the brain is that the sleep is for so short a time. There are very few healthy men who could not walk a thousand miles in six weeks, walking a little over eight hours a day and resting for the remainder of the period; but there are not many men who can emulate the feat of Captain Barclay, of walking a thousand miles in a thousand consecutive hours, because the frequent interruptions to their sleep would exhaust them completely.
" In the same way, when the heart is forced to beat more quickly than normal, it becomes more and more quickly exhausted the higher the pulse-rate rises, because nearly the whole time for the extra work is taken from the diastolic pauses, from the resting or sleeping time of the heart."
This extract will clearly show how conservative and careful we should be in the expenditure of the heart's force. Fortunately for us, it is a most long-suffering organ, and has a marvellous power of adjusting itself to meet altered circumstances and strains; and besides this, the natural heart under ordinary conditions is working only at a part of its power and there exists always a considerable re-serve of latent force. This varies, of course, in different individuals, and in them under different circumstances. It is this latent force that enables us in health to make unusual and prolonged physical effort, and it is the steady development of this force that gets a man into what we call training and condition. But as we pass our zenith the power of readjustment to varying strains and circumstances, and also the latent force, become gradually less. A sharp run or a climb that we could do easily at forty-five suddenly, it seems, becomes a big effort that leaves us pumped. No doubt the change has been gradually coming on, but we have not been tested. This change may be in the heart muscle or in the arteries—more often, probably, it begins in the arteries. When these symptoms occur we ought to deeply consider them and profit by them. It is now that we should get our hearts, our arteries, and especially our blood-pressure, tested ; now is the chance for our physical salvation. A man may have to reconstruct or rearrange his whole life; this to a busy man is often a very difficult matter, but he must ask himself these questions : Shall I go on as I am doing, do a few more years' work and then die or become a wreck, with a miserable old age? Or shall I pull myself together, get out of my unhealthy ruts, and lead a wise and reformed life, with a reasonable hope of living to a good age, free from paralysis and disease? Many of us, perhaps, shirk such disagreeable questions, put the answer off to another day, or say to ourselves, " As likely as not the doctor is all wrong." But at any rate it is our clear duty as physicians to put the facts plainly before such patients and to advise them as strongly as we can. The choice of roads rests with them.
To the general practitioner it is a very important thing to keep his patients who are approaching old age in good health and to prolong their lives as far as possible. It should not only be his interest to do this, but also his delight; for one's old patients are often one's best friends. Too many of us get into the way of looking on arterio-sclerosis as in-curable and unmanageable, but this is a great mistake. The successful treatment of it is a complicated problem, no doubt, but that should not deter us ; it should rather be an attraction to a scientific mind. The writings of some of our best men—Sir Lauder Brunton, Sir Clifford Allbutt, and Dr. George Oliver—have thrown so much light on the subject that there is no longer any excuse for ignorance or apathy on our part.
It is not the hard body worker, as a rule, not the man who lives an outdoor, athletic life, that develops arterio-sclerosis, but the anxious, careworn brain worker, the man who works chiefly indoors and who oftentimes takes his work and his worries home with him and to bed with him. For such a man there can seldom be any real rest or freedom from the sense of strain. His sleep is rarely the sound, restoring unconsciousness that the body worker gets. The physiological result of such a life must be, in the first place, fatigue, exhaustion, and general impairment of vital energy, but (in the second place hypertrophy of the overused parts of the body, and these parts are chiefly the heart and the arteries. The athlete may call on his heart and bloodvessels to do much abnormal work, but it is only for a sudden and a short time, and the intervals of rest are long and sufficient for restoration; but the man I am describing is the bow always bent. "Nec semper arcum tendit Apollo " is a proverb he constantly ignores. The activity of his mind is making demands on his circulation night and day, and the vaso-motor nerves that govern the blood-supply to his brain have no rest from toil. The hunting, shooting, golfing outdoor man may and often does lead an injudicious, rather self-indulgent life, eating and drinking more than is necessary, or than is good for him, but he rarely gets sclerosis.
Dr. George Oliver, in his studies on " Blood-Pressure," says : " Nervous anxious temperaments and occupations which involve much anxiety, worry, and nerve strain tend to produce somewhat higher levels of arterial pressure, especially in the latter half of life. On the other hand, placid temperaments and routine occupations—especially of the physical order—dispose to the lower degrees of pressure. I have observed that, as a rule, in subjects in good condition and training, such as athletes, the actual pressure is certainly not raised, and is, indeed, very often below the average normal point, a fact which shows the importance of maintaining the functional activity of the peripheral circulation by exercise. And this conclusion is sup-ported by the observation that in those normal subjects who follow sedentary indoor occupations for many hours daily, the pressure, though generally normal, is more frequently above than below the mean normal pressure line."
Hypertrophy, or overgrowth of muscles that are in special demand, seems to be a physiological law in health, and is a law that makes for efficiency; for instance, the blacksmith's biceps and the boxer's shoulder muscles. If these muscles did not increase and respond to the call made on them, the particular work could not be effectually done; and so in the diseased condition we call arterio-sclerosis the thickening and increased growth of the heart muscle and of the muscular coats of the arteries is, in the first place, a natural and conservative effort to meet increased demands. But then we come into dealings with another law of nature, which ordains that an abnormally developed muscle is much more prone to degeneration than a normal one. It does not matter if, when his life's work is done, a black-smith's biceps shrinks, and degenerates, but it matters a good deal if our hearts and arteries degenerate. And it is this degeneration and failure that is the essence of the disease I am trying to describe.
Briefly, then, the chain of events is this over-work, overdemand, overgrowth, which is sufficient and effectual for a time, and then, if the over-demand persists, degeneration and disease.
Biedl, in his work on the internal secretory organs, says : " Every increase in normal activity, whether this be an improved secretion, a strong muscular action, or any other augmented performance, is always associated with an increased disassimilation which is the work of a disassimilatory hormone. But it must be remembered that in the organism, as elsewhere, no work can be performed without expenditure. So long as the metabolic equilibrium is maintained, every decomposition must inevitably be succeeded by a regeneration. Even in the case of hyper-activity, so long as exhaustion does not supervene, there will be a continual regeneration of the living substance, and therewith a restitution of provision for labor. With the cessation of the disassimilatory stimulus assimilation becomes excessive, and if the process is frequently repeated, the well-known phenomena of organic hypertrophy will make their appearance."
Such is the scientific explanation of hypertrophy. But we see the same laws working in national and political life. The hypertrophy, the overgrowth of militarism run riot; a thing in moderation not bad in itself, which, indeed, will often include and develop such virtues as discipline, self-denial, and patriotism, becomes a great and dangerous evil. Its inevitable consequences, the lust of power, of wealth and conquest, lead surely to a deterioration or degeneration of the whole moral and religious tone of a nation. All God's laws are made for our use. It is little to our honor that we defeat them by our misuse.
There can be no doubt, I think, that there is a stage—probably lasting for two or three years—of almost constantly but slightly raised arterial tension or pressure before any real sclerosis or thickening takes place, and it is in this stage, of course, that we can do so much for our patients and that patients can do so much for themselves; they should learn how to rearrange their lives and habits and so to avoid the grave symptoms and dangers that must otherwise ensue. Dr. Oliver says on this point : " In diffuse arterio-sclerosis the accessible arteries may not be appreciably thickened, especially in the earlier stages of the disease, and yet the arterial pressure may be raised persistently and definitely. It would seem as if the disease begins more particularly in the terminal divisions of the arterial system—splanchnic and systemic, especially splanchnic. In this stage the peripheral resistance is apparently due mainly to muscular contraction in the arterioles; for these respond readily to vaso-dilator remedies, and the increase of arterial pressure, which is not so high as it subsequently becomes, quickly subsides after each dose. In this hypertonic stage (the stage of presclerosis described by Houchard) the diastolic pressure rarely rises above 120 mm. and is often only 110 mm., and the systolic pressure does not, as a rule, exceed 16o mm. and is frequently only 145 mm. or 150 mm., and the arteriometer also demonstrates the contraction of the radial calibre and the favorable effect of the treatment in dilating it. But as the disease advances organic changes in the arterial wall develop, when vaso-dilators only partially relieve the pressure, and when they may ultimately fail to lower it at all. In this stage the accessible arteries, such as the brachial, become thickened and the arterial pressure rises consider-ably; the systolic armlet reading advances to such high figures as 200 to 260 mm." We may take it, then, that a small but persistent rise of tension is the first objective symptom that we can discover in threatening sclerosis; the objective heart symptoms belong to a later stage; but there are. subjective symptoms that should be a warning, and frequently it is these symptoms that bring the patient for medical help; they are chiefly an increasing shortness of breath on exertion, uncomfortable feelings about the head, such as giddiness and singing in the ears, especially on stooping, and more particularly, perhaps, a constant sense of fatigue that is quite out of proportion to the work that has been done. This is one type of case, but there is another type that often eludes the physician and deludes the patient. A full-blooded, sanguine man of fifty to sixty has without knowing it persistent high tension; he feels at the top of his form, and lives at the top of his form; his output of energy and work is large and good, and to all appearances his end is not yet; he reminds one rather of the men in the 73rd Psalm who " are in no peril of death, but are lusty and strong; they come into no misfortune like other folk, neither are they plagued like other men." It is an undoubted fact that high arterial pressure in some men leads to increased energy and efficiency, at any rate for a time, but the breakdown comes very suddenly, and their day's work is done. Unconsciously they walk in slippery places, and their precarious foothold on the mountain of life is often only discovered by some accident, such as an attack of gout or an examination for life insurance. If such discovery should be their good-fortune, they may find safety, but only by a revision of their lives, by much self-denial, and by a sensible humility.
As practical physicians, then, our aim must be to get hold of our patients in this presclerotic stage of hypertonus, and to wisely anticipate and prevent the development of the serious organic changes that belong to the later stages of the disease.
Anyone who lives to sixty years without a rise of tension, and who has a sound heart, is likely to live to a full old age, but anyone who between fifty and fifty-five develops raised arterial tension is not likely to live anything like the full span, unless he take himself seriously in hand. His life, his work, and all his habits, must be carefully considered and arranged, and he should certainly place himself under his physician's care. The proverb that says " A man is as old as his arteries " should be considered no longer a proverb, but a working principle.
Hitherto I have considered overwork and over-stimulation, with their inseparable ally, want of rest, as the chief causes of the heart and vascular changes, but there is certainly another and most important agency at work also, and that is the absorption from the stomach and the bowels of poisons, the result of imperfectly digested food.
We all know the serious, even the sometimes fatal, results of ptomaine-poisoning. That, in a minor degree, is going on all the time with some people, and probably there is also chronic poisoning from morbid bacteria in the intestines or from normal bacteria in excessive numbers. What is known as the bacterial flora of the intestines has a marvellous capacity for extravagant growth. It is all very well for us to blame these wicked microbes " clans le pays bas "; just now they are made to be the universal scapegoats, but it is largely our own habits that are at fault. It is not so much that we are gluttonous men and winebibbers," but that we eat and drink richer and more stimulating food than we need. And we rarely give ourselves time for perfect digestion. Either from eating too much, or from hurrying away from our food into some new work or excitement, our stomachs seldom get that physiological rest and sleep that is so necessary to perfect digestion. Our whole digestive apparatus becomes a fertile field for poisonous weeds, a seething caldron of discontent. That arterial disease can be produced by this absorption is proved, I think, partly by the results of a reformed diet and life and partly by the results of treatment of the digestive errors. Without any other direct treatment, we often see the tension come down and the symptoms pass away. Another collateral proof is seen also in chronic bronchial asthma. In this disease after a time there is always a great growth of morbid bacteria in the bronchial tubes—pneumococci, streptococci, or staphylococci—and they, of course, get absorbed into the general system. It is very common to find in this condition arterial tension raised to a considerable degree. If we cure that bronchial affection and destroy the morbid bacteria by a wise vaccine treatment, we shall see the raised tension come down to the normal, and all its other symptoms disappear. I shall go more thoroughly into food questions in the next chapter.
Before approaching the more direct treatment of the disease it will be wise to gain a clear and accurate conception of its arterial condition and pathology, and of the relative importance of the abnormalities one may find. To do this one must study carefully the literature of the subject. I would mention two small and inexpensive books, whose authorship is their own guarantee : " Studies in Blood-Pressure," by Dr. George Oliver (H. K. Lewis), " Therapeutics of the Circulation," by Sir Lauder Brunton (John Murray); and a newer and larger work is " Diseases of the Arteries," by Sir Clifford Allbutt. From these clear and reliable works the busy practitioner will soon get a good working acquaintance with the subject. The estimation and significance of systolic and diastolic blood-pressure and the use of the sphygmograph and sphymomanometer are all amply explained. It is hardly necessary to say that the use of the manometer in arterio-sclerosis is absolutely essential.
If a patient come to us in the presclerotic stage, when the tension is raised and when there are the uncomfortable head symptoms that I have before described, but when there are no real organic changes to be discovered in heart or kidneys, what can we do? Firstly, much can be done by comparative rest, by early hours and long nights (the arterial tension after a good night's rest is often 10 mm. below the average day's pressure), by cutting down extremes of work or social pleasures, and by the avoidance of excitement and over-stimulation. A complete rest from business and change of scene when practicable are very useful also. The diet should be plain and simple; red meat should be eaten in great moderation and not more than once a day. There is, as a rule, no need for an absolute purinfree diet, but it should be in that direction. It will be well, perhaps, to give here the purin contents of foods in grains per pound, pint, or teacup :
(Potts, Lancet, 1906, Vol. II., p. 933.)
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 a bone stock may be taken. Cheese, eggs, and milk should supply the greater part of the nitrogenous 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 always 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. Of equal importance as the quality of the food is the quantity. We most of us take more food than we really need, and more than we can easily dispose of. This is especially the case as our strength and vitality lessen; the whipping up of the tired horse helps little towards the journey's end. Coffee is a good stimulant, especially as café au lait for breakfast, but strong black coffee taken after lunch or dinner is certainly a raiser of tension. Tea, as far as we know, has not the same effect on the arteries, but taken in excess or too strong may cause an over-worked heart to get irregular and feeble. Good China tea seems, to have less of this bad effect than other growths, but is not quite such an effective stimulant. Sugar in moderate quantities, especially cane-sugar, certainly helps the heart to do its work, and is a fuel and especially a muscle food. This is well recognized in the feeding of our soldiers on long marches. With regard to alcohol, one must say that the majority of such patients are better without it, but when a person has been accustomed to a moderate amount, taken with his food, it does not always do to stop it. Alcohol is not a tension-'raiser, as many seem to think, but has rather the opposite action, and if stopped suddenly the power of digestion may be lessened and the whole tone of the body depressed.
So many people in this presclerotic stage have gouty tendencies that strong wines and liquors are certainly unsuitable; a little light wine, such as claret, still Moselle, or Grave, may do no harm if taken with the meals only; the same rule applies also to small quantities of well-matured spirits. Alcohol, wisely chosen and only used as a digestive tonic, may help, but when used as a frequent stimulant to enable the body or mind to do more work, or to increase endurance for pleasure, it certainly does harm. The Americans have a proverb which contains a good deal of truth, " It is not the drinks that do the harm, but the drinks between the drinks."
Sir Lauder Brunton says : " All the alcohols tend to dilate vessels, to lessen blood-pressure, and ultimately to diminish activity of the nervous tissues, although at first they may seem to have a stimulant action." In another place he says : " Alcohol produces dilation of the peripheral vessels and tends to lower blood-pressure, while at the same time it stimulates the heart." Alcohol contains so little nutritious food (with the exception of the sugars and extractives of wines and beers) that in itself it may be said to give nothing to the body; it only, enables a man to draw on his reserves. This may be very useful in emergencies—and of course is so '—or when used in great moderation, but unless great care is taken, its inevitable tendency must be to exhaust the reservoirs of nervous energy. The deleterious effect on the other organs when taken in excess is well known, but is outside the scope of this article. This question of the use of alcohol must be argued and handled by physicians on a thoroughly scientific basis. We shall do more for the cause of temperance by sober judgment and advice founded on scientific fact than by hot-headed, prejudiced generalizations. For a wise scientific and temperate article on this subject I would advise my readers to study Sir Lauder Brunton's " Mono-graph on Alcohol: What it Does and What we Ought to Do with it," issued by The True Temperance Association, Caxton House, Westminster.
The question of tobacco is very often presented to us, and it is not always an easy one to answer. Nicotine, no doubt, is one of the most powerful raisers of arterial tension known, but in ordinary forms of smoking not very much gets into the system. Tobacco-chewing and snuff-taking—both of which are happily nearly extinct—probably. introduce more nicotine into the body than any form of smoking. With cigars the combustion is so complete that very little of the poisonous parts of the plant remains; rather more remains in pipe-smoking. In cigarette-smoking the combustion is nearly as complete as with cigars, but an ordinary cigarette smoker uses much more tobacco in the course of a day than a cigar smoker, for he seldom arrives at the satisfaction point. The habit of inhaling cigarette smoke is, however, the real danger; the absorption of nicotine from the bronchial mucous membrane is very rapid, and much more is absorbed in this way than by those who smoke through the mouth and nose alone. The other chemical products of tobacco combustion, pyridine and the picoline bases, have probably their effects on the vaso-motor nerves also, but their evil influence is chiefly shown by irritation of the mucous membrane of the throat.
Oliver, in his experiments, found that in ordinary people, not excessive smokers, tobacco raises the systolic pressure from 10 to 15 mm., but that it does not raise the diastolic, so that the variation between the two becomes abnormal; this effect soon subsides after smoking is finished—in a quarter of an hour or so.
We all know from experience that excessive smoking often produces very rapid action of the heart, with irregularity and, in some cases, even pretty severe cardiac pain. Nicotine, like many other vegetable poisons, has two actions : first it raises blood-pressure, but after long or excessive use a rebound takes place and the pressure falls far below normal, and so the ultimate effect of excessive smoking is a feeble, low-tension pulse, often irregular.
It is the first pressure-raising effect that clears the brain and helps one, for a time, to think more rapidly and clearly; it is the second that produces the tiredness, the feebleness, and the absence of initiative that we see so often in the man saturated with tobacco. It will readily be seen that a drug which affects the circulation so strongly should be used with great caution and moderation in cases of abnormal or diseased arteries. Tobacco, no doubt, has somewhat of a soothing and quieting effect on many people with irritable nerves, and to this extent is useful, but one cannot help coming to the conclusion that the average man, with a tendency to arterio-sclerosis, had better give it up entirely; this applies especially to men who lead indoor lives. Moderation in smoking is very rare and difficult to maintain. The man threatened with this disease has to face a serious enemy, and should take no unnecessary chances.
It has been shown that an indoor, sedentary life conduces to high blood-pressure more than an out-door, active one. It follows, then, that we must try to reform our patients in this matter also; but when we find such a one with his pressure much above the normal, it is very necessary to proceed slowly. Till the tension has been reduced considerably and the heart is able to do its work easily, no violent exercise should be taken. When the heart has to force the blood through tightened, narrowed arteries, it will be readily understood that more force, more vis a tergo, has to be used. A mathematician would astonish one if, by his calculations, he showed the great increase of force necessary to pump or force fluid through tubes of diminished calibre. Any great exertion or strain under such circumstances produces weakening and dilation of the heart itself, and this not only causes much discomfort and in-ability, but makes the recovery to be slower. Over-strain, with high tension, may cause even a breakage of the valves of the heart themselves, and so the heart becomes a leaky pump as well as an inefficient one. This shows that the treatment of these early cases needs very careful watching. Walking at a moderate pace, on the flat at first, and then up graduated slopes, is the best exercise for most; but they should always stop short of the pumped or out-of-breath stage. Riding on horseback, if the horse is not a puller, is also very good. As the symptoms improve, golf may be allowed, but not on a hilly course, and here the temptation to hurry on to the next hole must be avoided, and also the temptation to lose your temper. People with sclerosis cannot afford to indulge in temper : it is too risky. Cicero says : " Not every sort of temper nor every kind of wine grows sour with age," but, as far as we know, he was not a golfer. Cycling is good if the conditions are good, but riding uphill and against a head wind may very soon become a dangerous strain. In all forms of exercise some distraction or diversion of the mind helps to a better result, and this is in favor of games such as golf and lawn-tennis. Croquet hardly comes under the head of exercise, but is, I suppose, a diversion. Mountain air is good for such folk, but not at too great an altitude. Above 3,000 or 3,500 feet the alteration of barometic pressure causes shortness of breath, and at still higher altitudes a tendency to haemorrhage, The stimulus of the good air often leads one on to do more than is advisable and so to overstrain the heart. With these guides and reservations in our minds, the fact remains that open air and steady exercise are Nature's way of preventing the degeneration of the body.
The medicinal treatment of this arterial condition, in the first place of high tension and in the second place of sclerosis or thickening, is a subject full of interest and full, also, of hope. Till the last few years we have been almost powerless. That disagreeable drug, iodide of potassium, was almost our only weapon. Its action was very uncertain, especially in the early stage, and many people could not take it on account of its effect on the stomach and of its tendency to cause iodism. The first step in advance was the discovery of the effects of the nitrite group—sodium nitrite, amyl nitrite, etc. These have a rapid action in lowering tension, and are very useful in emergencies where an immediate effect is desired; but their action is very short-lived, and in some people they cause troublesome headache. Their action in true angina pectoris, especially that of amyl nitrite, is of great value. The comparative freedom from acute pain and the lengthened years of life that such sufferers owe to Lauder Brunton and Murrell form a debt unpayable. Erythrol tetranitrate and mannitol nitrate belong to the same group, but their action is more prolonged. As a groundwork of successful treatment all these remedies cannot be relied upon, for their effect is never permanent. The real hope of successful therapeutics lies in the organic animal remedies.
A few years ago Dr. George Oliver of Harrogate, one of our greatest pioneers in the study of this condition and in the accurate knowledge of all that pertains to the circulation of the blood, brought into notice the good action of the hippurate salts (this is a true animal remedy). They have many great advantages : their action lasts for a long time, they cause no headache and no gastric disturbance, and unless they are pushed too far—to the lowering of the blood-pressure below the normal point—they are not debilitating.
The relief to the heart and brain discomforts of the early days of high blood-pressure is very marked.
Hippuric acid, which can be produced synthetic-ally by treating glycocol with benzoyl chloride, is used in the form of its salts, the chief of which are the lithium, the sodium, and the ammonium hippurate. The ammonium salt is, I think, only half as strong in its action as the other two. It was first used as a solvent of uric acid, but is now chiefly used as a tension depressor. It is interesting to note that it is excreted daily to the extent of about 1/2 to gramme in man on a mixed diet, but that it may reach 2 to 3 grammes on a vegetarian diet.
The hippurates and benzoates are closely related chemically, and are very similar in their action, but the hippurates are the more easily digested. It is very rarely that 5 to 10 grains daily of one or other of these salts fail to reduce abnormal blood-pressure to the normal point or near it in the early stages, and the relief they give to all the uncomfortable head symptoms and to the feelings of heart distress is very satisfactory. I wish I could give a scientific explanation of this good effect. I was in communication with Dr. Oliver on the subject, but his untimely death prevented his final report. The lithium salt is perhaps the best where there are symptoms of gout or rheumatism ; the ammonium where there is debility.
There is still another class of remedy which I believe to be still more valuable, especially in the later and more confirmed stages of the disease—viz., the extracts of some of the ductless glands, of which thyroid is the chief. We may roughly say that all the gland extracts we have at present are tension depressors, with the exception of the suprarenal and the pituitary, and in the skilful use of these, either singly or in combination, we have most powerful remedies.
The original experiments of Oliver and Schafer show the effects of the thyroid on aterial tension. These are confirmed by Brunton, who says : " Thyroid gland, when taken by the mouth, dilates the peripheral vessels, makes the skin warm and moist, and quickens the pulse. In this respect it antagonizes the suprarenal secretions. Besides this effect on the blood-pressure, it has other effects on the metabolism, which is important."
Biedl says : " If thyroid extract or iodothyrin be given continually for two or three weeks, the amount of carbonic acid excretion will be increased by 15 to 25 per cent. The nitrogenous interchanges are Invariably disturbed by thyroid extract; the increased decomposition of albumin is expressed by an in-creased excretion of nitrogen. (By increasing the caloric food-supply the nitrogen losses may be avoided.) In obesity, owing to the large reserves of fat, the loss of albumin is not so great as in the normal subject.
" Thyroid feeding also brings about a considerable increase of calcium excreted, the calcium carrying off with it a large proportion of phosphorus."
It is very evident, then, that we have in thyroid medication something much more than a mere tension depressor. Its other properties, influencing the excretions, explain to some extent its sphere of usefulness, and also its drawbacks. The increased excretion of calcium may be very helpful in sclerosis, especially, perhaps, when there is atheroma; the loss of phosphorus accounts in some measure for the debility and for the nervous symptoms that often follow its use. The increased excretion of carbonic acid and of nitrogen are probably helpful, but all these by-effects should be produced slowly and cautiously.
The loss of phosphorus, which shows itself in nervous depression and feebleness, can be met by giving phosphorus in some form, and the best form is, I think, lecithin. I have thought that thyroid treatment in sclerosis is more satisfactory in the cases where there is no serious kidney complication ; this seems reasonable, for in Bright's disease the kidneys would only imperfectly carry off the results of increased nitrogen metabolism, and this failure of excretion would leave the blood overcharged with these products. In thyroid treatment we must stop short, as far as possible, of producing its disagreeable effects—palpitation of the heart, giddiness, and their accompanying distress; the sphygmomanometer should here be our guide. If the tension fall to normal or below, and the above symptoms appear, a 5-grain tablet of suprarenal extract once or twice a day will soon relieve them. This sounds like an illogical proceeding when you are trying to lower pressure, but in practice it succeeds well. It. is a well-known fact that in health thyroid feeding increases the amount of adrenine (the suprarenal secretion) in the blood; this is probably a wise compensation, and one can readily understand how, in diseased conditions, this compensation may fail to take place.
In using these natural gland extracts as medicines, we must not lose sight of those important properties which enable them to act as hormones (stimulants) or chalones (inhibitors) to the other glands; and in imitating Nature we shall get the best results.
Though in obesity thyroid often causes loss of weight, in thin people who show signs of hypothyroidism it often has the opposite effect, In thyroid treatment, especially as old age draws near, we have before us a most interesting field of study, full of possibilities and hope.
For many years iodide of potash has had a great reputation in the treatment of arterio-sclerosis, a reputation far beyond its deserts; but it apparently does some good in certain cases. As far as experiments go, it has no direct effect in lowering blood-pressure. It almost certainly acts, as all preparations of iodine do, by stimulating and increasing the output of thyroid secretion. Rendle Short says : " An increased thyroid secretion may be obtained by giving iodides. There we find the explanation, so long sought in vain, of the effects of iodides on gummata, arterio-sclerosis, and aneurism. The beneficial agent is really the increased internal secretion of the thyroid gland. Two important results of observation and experiment confirm this theory. In the first place, in cases of myxoedema, arterio-sclerosis is early and intense, and the same is true in animals after removal of the thyroid.
" Eiselberg gives a number of very convincing photographs of intense atheroma in the aorta in his cretin lambs from which the thyroid has been re-moved. In the second place, thyroid extract has a wonderful power over young connective tissue, as is seen by the way in which it absorbs the subcutaneous thickening of myxoedema and cretinism.
" It is not surprising, therefore, that it should be able to deal also with gummata and atheroma."
This question of thyroid treatment is so intimately connected with the symptoms of senile degeneration and with its preceding years that one is compelled to give it the greatest consideration.
At the risk of wearying my readers, I must give them the general conclusions arrived at by those eminent men Biedl and Eppinger. (My readers can, if they like, skip the scientific arguments and try to grasp the lessons that are taught.)
" The thyroid and the suprarenal system, together with the infundibular portion of the pituitary, constitute a group of vascular glands which augment and accelerate the processes of metabolism. The balance is maintained by the antagonistic activity of those other vascular glands, like the pancreas and the parathyroids, which exercise a restraining influence upon metabolism. These two groups of internal secretory glands possess physiological inter-relationship with one another. The extirpation of a vascular gland is followed by differing sets of phenomena : firstly, there are the direct results due to the supression of the specific secretion; secondly, there are the indirect results due to derangement of the other glands, the functions of which, under normal conditions, were either stimulated or inhibited by the secretion of the removed gland.
" The thyroid is believed to promote the activity of the suprarenal or chromaffin system and to inhibit that of the pancreas. The direct results of the removal of the thyroid consist in reduction of the metabolism of albumin, fat, and salts ; the indirect results are, on the one hand, the absence of stimulation of the chromaffin system, and on the other a hyperactivity of the pancreas, due to the removal of the inhibitory agent.
" It is believed that the nervous system is the agent by which the interactivities of the vascular glands are affected. That group of them which promotes metabolism has a sympathetic innervation and stimulates the sympathetic nerves, at the same time exercising an inhibitory effect upon the autonomous nerves. The group which retards metabolism, on the other hand, possesses an autonomous innervation, and, while stimulating the autonomous, inhibit the sympathetic.
" The thyroid possesses a double function, being furnished with both classes of nerves, and is thus able to affect both divisions of the nervous system."
It will thus be seen what an important position the thyroid holds in our economy, and what enormous hints for treatment of morbid conditions and for the explanation of them, the study of this subject suggests. The great abdominal sympathetic gang-lion has been called the Clapham Junction of the nervous system; in like manner the thyroid seems to be the principal centre of the system that receives and transmits the hormonic or chalonic messages which, passing from gland to gland, stimulate and control the problems of growth and nutrition in our bodies.
The results of total removal of the gland described above have been obtained partly from experiments on animals and partly from those cases in human beings where the gland has had to be removed for some growth in the gland itself. It is a well-known, ascertained fact that removal of the thyroid in man produces the disease called myxoedema. This organ, like many others, has a surplus of power in health, so that extraordinary demands can be met. This is shown by the experience of surgeons that if a quarter of the gland be left the symptoms of myxoedema will not show themselves.
This wonderful machine that we call our body differs from a man-made machine in its wonderful elasticity and reserves of force. If we could only devise spare parts to add to the spare force, we could enter into a race with Methuselah. In the great majority of cases of premature senility, accompanied by the early symptoms of sclerosis, raised blood-pressure, etc., we shall find many of the signs that belong to that form of myxoedema that we see after total removal of the thyroid. Here thyroid administration will give good results, but in those cases of subthyroidism where there is subnormal pressure we often find a very poor state of the venous circulation—cold and blue hands and feet, and chilblains often. The vitality is low. In such cases much benefit is obtained from the addition of suprarenal extract to the thyroid, and by giving good doses of calcium salts. With regard to the importance of these calcium salts, Rendle Short says : " It has long been recognized that they are essential to the continued success of perfusion fluids, and now we know that they control the coagulation and viscosity of the blood, and probably the functions of the ovary and parathyroid glands also." Remarkably good results have been obtained by giving 15 grains of calcium lactate in solution three times a day before food for three days consecutively, and by occasionally repeating the process.
As we pass on to real old age we often find the symptoms of thyroid deficiency still more marked and of much graver import. We are only beginning to realize how much senility depends on internal gland insufficiency. Biedl says : " A special pathogenetic significance is ascribed to thyroid insufficiency in the changes which occur in later life, and which are included in the term senile degeneration.' The foundation for the theory that old age results from changes in the thyroid lies in the fact that in old age this gland 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 those of myxoedema. The falling of the hair and the dropping out of the teeth, the dry and wrinkled skin, the lowered body temperature, the diminished perspiration, the indolent digestion and consequent emaciation, the reduced metabolism, the decrease of mental power, and the diminished activity of the whole nervous system—these are all symptoms which characterize chronic myxoedema."
The late Sir Victor Horsley held the view that " Senility is due, at any rate in part, to thyroid degeneration, while myxoedema may be described as a condition of premature senility."
The following case is an illustration of my argument : A man aged eighty years, who for some time had shown the early signs of brain degeneration, suddenly, after some extra fatigue, collapsed. He was almost unconscious and lay prostrate on his back. For days he could hardly swallow, the power over both sphincters was completely in abeyance, bedsores formed, and he seemed to be a hopeless dying case; yet there was no aphasia and no true paralysis; he could just move every limb if pressed to do so; reflexes were present, but feeble. Arterial tension was 165 mm. As a forlorn hope I gave him thyroid extract, 5 grains of fresh gland daily. He at once began to improve; in a fortnight all incontinence was gone; he could swallow well, and the bedsores healed. After three months' continuous thyroid treatment, he could walk two miles a day, his tension was 140 mm., and his mental condition was somewhat improved. No other medicinal treatment was given, and I think thyroid may fairly claim the honor of the results." (This man lived for eighteen months after the attack described.)
In many cases of bladder weakness in old age and in both sexes where there is partial incontinence, the careful use of thyroid will often give good results. In old men with enlarged prostates we see no rapid effects, but there is accumulating evidence to show that thyroid feeding controls and lessens the growth of the gland, and so in time relief may come. When one considers how much the thyroid and parathyroid glands are concerned with calcium metabolism, one must realize how much assistance they may give in the circulatory troubles of thyroid disturbance ; and is it not reasonable to think that this increased metabolism and excretion of calcium may have some beneficial effect on the atheromatous deposits that in the later stages of sclerosis so often occur in the arteries, and which are probably the site and cause of cerebral hemorrhage? If the depressing effects of thyroid feeding are too great, there is no need for alarm; they soon pass off, and the treatment can be continued with lesser doses or with some compensating help. In treating a case of high blood-pressure, it is very necessary to estimate care-fully the condition of the heart. We may find no murmurs, but we shall often find dilatation, the heart's apex-beat in the nipple line or outside it. If this is so, it is very important to brace up the heart's muscle at the same time as we lower the peripheral resistance, otherwise the heart's muscular action may become irregular and disturbed ; it has been timed to work against a certain resistance, and it does not quickly tune its timing apparatus to fit the new circumstances. Strophanthus, I think, is the best vegetable medicine for this purpose, as it has no effect on the blood-pressure in the smaller arteries ; it should be given in full doses. Spartein sulphate also does fairly well. In a few cases digitalis may be necessary, but it should be given for a very few days. There is much variance of opinion as to whether digitalis increases arterial blood-pressure or not, but 'from many observations I feel pretty sure that it does so when the arteries are diseased. I have come across many cases where this drug has been given to meet the heart symptoms of arterio-sclerosis and where the symptoms have become steadily worse. Sodium nitrite or a good dose of hippurate given at the same time will help much, but there are few cases that will not answer to strophanthus.
This question as to the action of digitalis on the arterioles, and consequently on blood-pressure, is a very important one, and should be definitely decided by experimenting physiologists. Mackenzie, in his experiments at the Mount Vernon Hospital, has come to the conclusion that it does not often raise pressure, and Dr. F. W. Price confirms this view. On the other side Brunton says : " It is now generally recognized that digitalis has (1) the power of slowing the heart, (2) of making it stronger, (3) of contracting the vessels." Later on he says : " Digitalis acts on the cardiac muscle, the intrinsic cardiac nerve, and the vagus centre in the medulla. It also affects the arterioles, causing them to contract; and probably it has upon them also a twofold action, as on the heart, stimulating both the con-tractile muscular walls and the nerves which go with them." Sir William Whitla, a very careful observer, says : " Its action upon the arterioles must always be remembered, for by increasing peripheral resistance it raises the renal and general blood-pressure." Clifford Allbutt, " Dictionary of Medicine," vol. v., p. 961, says : " Tone we may define as that property in heart, artery, or other hollow viscus, which preserves the mean diameter of the part; contraction as that which enables the organ, nevertheless, to obey stimulus and to perform particular acts. The vermicular movements of the bowel and of an arteriole are due to the quality of contractibility; their tone preserves their mean diameter in spite of distension or contraction. Were it not for tone a hollow organ, often subject to extravagant demands, would be strained and perhaps ruptured. In the heart it is tone which does much, if not all, to prevent loss of form under the great variations of internal pressure." Farther on he says : " Digitalis produces a distinct increase of tone, which may be pushed to a degree inconsistent with normal function." Again he says : " Tone, then, is the quality to be watched and supported, and in digitalis we have a means of intensifying tone and of moderating distensibility. Now tone, like any other quality in excess, may be injurious, and the output of the constringed ventricle may fall short of the demands of the system. Again, when the muscle falls into degeneration digitalis seems to have other injurious actions, the nature of which is obscure."
May we not extend this argument from the heart muscle to the arterial muscular coats? And will not careful observation of arterial pressure be the guide to the use of this powerful remedy? If we give enough digitalis to render perfect the tone of the ventricle and not to pass beyond that point, we shall probably be doing the same for the musculature of the arterioles, and thereby improve the general condition of the circulation and also the nutrition of the arterial coats themselves. But if we press beyond this normal tone-point, it is easily seen that we increase peripheral resistance and so embarrass and add to the work of the heart. In arterio-sclerosis, I think, we often get signs of arterial degeneration before the heart muscle is affected, and it may be in those cases that digitalis is especially harmful.
I have gone rather fully into this question, as I have so often seen this most valuable drug misused, and by misuse do harm. Neither men nor medicines should lose their reputations by being used in the wrong way and in the wrong place.
A most useful way of giving digitalis is the old St. George's Hospital pill composed of blue pill, squills, and digitalis :
Pil. hydrarg gr. 1
Here the mercury, which is one of the most powerful tension depressors we have, counteracts the effect of the digitalis on the arteries; it at the same time helps the liver to unload, while the squills act as a diuretic and as a heart tonic also. It is no exaggeration to say that this happy combination has pulled many a failing heart back into safety. A dose of calomel or blue pill once a week is a very good rule for this disease. Whether it acts by unloading the liver or by its bactericidal power in the intestines, or by both, I know not; but the result is undoubtedly good.
In treating the blood-pressure with thyroid, some heart tonic is often required. The manufacturing chemists of England and America have lately introduced some very good combinations of internal, gland extracts. The English preparations, so far as I know, have all got pituitary or suprarenal in them, and this renders them unsuitable for most cases of sclerosis; they are excellent nerve and body tonics, but they all tend to raise pressure. Carnrick and Company of New York have placed on the market a most useful tablet which they call " Hormotone." There are two preparations, one with pituitary and one without; the latter, of course, is for use in sclerosis and in high blood-pressure; it is one of the most valuable preparations that I have used for reducing tension. It causes no headache and little or no cardiac depression. It is composed of thyroid, ovary, and testis. The stimulating effects of the ovary and testis extracts, both on the nervous system and on metabolism, seem to help the good effect of the thyroid and to counterbalance its depressing effect on the heart. I hope some of our big manufacturing chemists will place such a tablet on our market before long. In my experience better effects are obtained by this combination than by thyroid alone. In January, 1917, Carnrick and Company put on our market another hormotone, which has the addition of an extract of the anterior portion of the pituitary gland. As far as I can at present judge this is a distinct improvement in some cases, in the treatment of high blood-pressure.
A most interesting problem for solution has been opened in Italy by Dr. MarabOtto. With intravenous injections of a watery extract of suprarenal, he has produced decided atheroma in the aorta of rabbits (no such effect was produced by subcutaneous or oral administration). The removal of the thyroid or great thyroid deficiency is known to cause atheroma also. Is this result due merely to absence of thyroid secretion? Or it is due to the suprarenal secretion losing its natural counterweight and so acting on the arterial system unchecked? Thyroid is supposed, and rightly, I think, to be an activator or hormone to the chromaffin glands, of which suprarenal is one of the most important. It looks as if it were at the same time an activator and an antidote, or at any rate a check. An interesting complement to this experiment of Marabotto's would be to give full thyroid feeding to the rabbits while under this suprarenal treatment.
Dr. Marabotto's further experiments and results with a suprarenal toxic serum are full of interest and hope from the therapeutic point of view, and his final results may turn out to be most important.
There is a temptation to take narrow views about the properties of all the internal secretion glands. We think of thyroid as a tension depressor and of suprarenal and pituitary as tension raisers, and to a 'certain point we are right. We gain our immediate object, at any rate, when we administer one or other of them by the mouth or by subcutaneous injection, but when one thinks of all these glands of the animal economy working simultaneously, and in health harmoniously, and of all of them linked up together by a sort of wireless telegraphy, the problem becomes much more intricate. We may use gland extracts such as thyroid or suprarenal for one definite action and purpose, but we must not forget that their influence may spread far beyond our original plan.
The thoughtful study of the physiological and therapeutic properties of all these internal glands seems to me to be of the utmost importance; they are Nature's own remedies; they are the chief weapons with which she meets all emergencies, not only of disease, but of abnormal external circumstances. Take, for example, the case of suprarenal extract. Dr. George Murray, in his article in the Practitioner )of February, 1915, says : " It has been clearly shown :hat under the influence of a strong stimulus, such as fright, adrenine is rapidly discharged into the adrenal veins and so into the general circulation. It is interesting to follow up the effects of this condition of adrenalxmia and to see how useful they may be to an animal either in contending with or in escaping from the cause of fear. The excess of adrenine dilates the coronary arteries, gives the heart a larger supply of blood, increases the strength of the cardiac contractions, and raises the blood-pressure. It tends to divert the chief flow of blood from the abdominal vessels to those of the central nervous system, heart, lungs, and muscles. The adrenine thus stimulates just those activities which an animal employs either in fighting a foe or in escaping from an enemy. In addition to this, the adrenine mobilizes the store of glycogen in the liver, thus increasing the amount of sugar in the blood and rendering it available for use in the muscular action entailed in effort."
With the leucocytes of the blood, they stand at the door and guard against the entry of the poisonous bacteria from without. An everyday proof of this is the increased liability to tuberculosis and the other bacterial invasions that we find in Addison's disease and in cretinism, these being examples of suprarenal and thyroid deficiency respectively.
These glands are like the keyboard of an organ, by the trained and skilful use of which we can produce effects fortissimo and pianissimo, by which we can produce harmonies and discords, and by which we can resolve the discords of disease into the harmonies of health. The study of these internal glands only belongs to the recent years, and one may question whether our knowledge or our ignorance of them would weigh down the balance, but I think we know enough to see in part their great value and to have the assurance that patient and honest use and investigation will largely increase that value.
It is not alone in morbid abnormal conditions that these glands are of such value, but, as Brown-Sequard thought and experienced, they can maintain the vitality and activity both of body and mind in advancing years, and this they do, not by artificial temporary stimulation, but by supplying from with-out the life and power giving secretions, whose sup-ply is failing within. For this work the best gland extracts are, I think, those of the ovary, testis, and thyroid; with them should be combined infundibulin or pitglandin (the former coming from the posterior portion of the pituitary and the latter from the anterior) ; a supernormal or subnormal blood-pressure will indicate the right combination, but I have no doubt that a wise combination acts better than any single gland. In extreme old age, when blood-pressure naturally falls, suprarenal extract may also be of great value. The value of pitglandin is as yet hardly recognized. I ask my confreres who are getting old and tired to try this treatment on them-selves, for I feel sure that their strength and the value of their work will increase.
There has been some confusion and doubt as to dosage, caused by some writers using the fresh gland and some the dried extract; it will, I think, be a help if I give the following relations, which are approximately correct:
1 grain of dried thyroid=3 1/2 parts of fresh gland.
Armour's Dried Powder.
1 grain dried orchitic =7 grains fresh gland
It will be well in prescribing to use the dried extract as far as possible, but most of our English makers have issued tablets containing 5 grains or 2 1/2 grains of fresh gland; this especially applies to the thyroid and suprarenals. Carnick's Hormotones without pituitary contain only 1/10 grain of dried thyroid extract, and from three to six tablets are taken daily. The larger dose (6 tablets) would represent 3/5 grain of dried thyroid a day, whereas one of our English 5-grain tablets would contain about I% grains. Most people cannot take so much as this, 1 1/4 grains daily, without showing some of the depressing effects of the remedy. A very good formula for a combined tablet for use in sclerosis as a tension depressor is:
Dried thyroid gr. 1/4
This is about double the strength of Carnick's Hormotones, and consequently two or three daily would be an efficient dose. These are made and supplied by S. Hardwick, Poole Hill, Bournemouth.
The original hormotone, which contains pituitary, is a very good tonic, but generally raises pressure. As I have said before, suprarenal extract may safely be used as a counterbalance to thyroid, especially in quite old people. Suprarenal is the most useful tonic we at present possess in the physical weakness of extreme old age, and may be used fearlessly; combined with phosphorus (especially in the form of lecithin) as a brain food it often gives astonishing results.
There are other gland extracts, such as thymus, pancreas, etc., which are used with success in other morbid conditions, but this is not the place for their consideration. The whole subject is so full of interest that one knows not where to stop, but if one Iet oneself go the chief points of one's sermon would run a risk of being overwhelmed under the boredom of the unhappy reader.
The condition of the blood itself I have not yet mentioned, but it is an important consideration. There can be no doubt that the viscosity or thickness of the blood fluid varies, and it must be evident that increased viscosity means a call for increased driving power from the heart. This is a subject which has not been fully worked out. Many people drink far too little fluid even in health; half a pint or a little more for breakfast, half a pint or less for lunch, half a pint for tea, and half a pint for dinner, is nearly the usual custom, and this represents about 3o ounces of fluid daily. There is some more taken, of course, in the food, but the total is not enough. Another pint taken between or before meals would generally be beneficial, and would tend to thin the blood. There seems to be little doubt that oxygen-lessens the viscosity of the blood. Sir Lauder Brunton has found that in bleeding from a vein, the inhalation of oxygen will cause blood too thick to flow to come readily, and I can corroborate his experience. Probably with a sedentary indoor life the viscosity of the blood increases. This points the lesson that everyone with this tendency should live and sleep as much as possible in good pure air, and that he should take what outdoor exercise he can. Well-regulated exercise spreads the circulation of the blood over a much larger area ; in rest the blood to a large extent collects in our internal reservoirs and becomes partially stagnant, but exercise sends it coursing through all the arteries and veins of our limbs, and thus internal congestion and viscosity are simultaneously relieved.
Here I must emphasize the great value of bleeding in cases of very high tension, especially where there is evidence of congestion in the brain (this is generally marked by a feeling of fulness and pain at the back of the head and neck), and also in those cases where there is much difficulty in breathing. Owing to the embarrassed state of the heart and circulation generally, we see, not infrequently, sudden attacks of engorgement of the lungs, causing great dyspnoea and the expectoration of blood-stained, frothy mucus, the face and lips becoming blue. Here bleeding acts like a charm; as the blood flows, all the distress quietly but quickly subsides.
In such cases bleeding from the arm veins is no doubt the wisest method, but in the head cases, I think, we get better results by applying leeches to the back of the neck; the blood should be encouraged to flow quietly for an hour or so after the leeches have fallen off. If the pain is in front, the leeches can be put on the temples. Any faintness that may arise is quickly relieved by a hypodermic injection of strychnine. The good that results is no doubt due, not to the mere emptying of the bloodvessels, but to the alteration of the quality of the blood; for as soon as the vessels are partially emptied, they fill up again, by extracting the watery constituents of the tissues, and thus the viscosity of the blood is reduced.
In dieting patients with arterio-sclerosis, we should be careful not to give them food that contains too much calcium; in ordering them to give up meat we often err by giving them too much milk. We should bear in mind that coagulability of the blood is increased by carbonic acid, calcium, magnesia, and milk, and diminished by oxygen, alcohol, diminution of lime salts, and by the fruit acids; the effects of carbonic acid and oxygen in this relation strengthen the argument for a non-sedentary, open-air life. Sir James Barr says that " fixed lime (in the albumin molecule) increases viscosity and coagulability, while the free calcium ions, in association with the suprarenal and pituitary secretions, increase the tone and contraction of the arteries and arteripies, heighten blood-pressure, and maintain force and efficiency of the cardiac contractions." The popular view that milk in quantity is a wholesome food for adults in all circumstances is thus shown to be wrong. It points also to the great value of fruit in the diet of old people; even the much-abused rhubarb, though injurious in some ways, lessens the viscosity of the blood. The thoughtful man will see that in this disease a wide and philosophical view must be taken of the whole subject. The heart, the bloodvessels, the circulating fluid, the vaso-motor nervous system, and the whole method of life, have to be taken into careful consideration.
There remain in the treatment of this disease the questions of balneology and electricity. The Nauheim treatment, whether carried out there or in England, acts, perhaps, as much by reducing arterial tension and peripheral resistance as by any direct action on the dilated heart; the immediate effect of the bath is to produce great dilatation of the surface arterioles and capillaries of the skin-in fact, cutaneous hyperoemia of a most active kind; this naturally lessens the amount of blood in the internal reservoirs, and enables the heart to do its work with more ease and less resistance. In the Practitioner of August, 1912, is a clear and instructive article by Dr. Thorne on the effect of Nauheim treatment on arterio-sclerosis when carried out at home. Other natural waters, such as those of Llangammarch Wells in Wales, can be used, but the imitations with ordinary waters, or especially with sea-water, seem to have nearly as good results. Judicious hydropathic treatment may often give help in many ways. In the early stages of the disease the high-frequency electrical treatment is often successful as an aid to other methods, and its action is more than a passing one. In the later stages it is not of much use in my experience, but in these the Bergonié Faradic method seems very promising, especially, perhaps, where there is obesity. It is, perhaps, hardly necessary to say that these treatments must be carried out by physicians who have made a study of electricity, and who know its risks and its limitations.
I will now endeavor to condense the foregoing theories and facts into a more practical shape. We may roughly divide the cases of arterio-sclerosis into three divisions; the first in which there is only raised blood pressure, and that not constant, in which there is no sign of kidney disease nor of palpable arterial thickening; in this stage we often find a tendency to heart dilatation, but it is often only evident after exertion. This class occurs very frequently in women about fifty, and should be treated quickly and thoroughly; for now it is easily cured, but if neglected may drift on insidiously into real disease. This condition one finds also in men, but generally earlier in life; about forty-five to fifty the anxious, overworked man or the intemperate may show the first symptoms. In both sexes 5 or 6 grains daily of hippurate, with some strophanthus, will bring the tension down to normal, but to get a permanent result the treatment must be continued in lessening doses for some months. It is well to take such patients fully into one's confidence, and to explain the treatment and the dangers of neglect. If on careful examination one finds signs of subthyroidism, one may bring down the tension with thyroid or, better still, with the compound tablet I have mentioned—Carnrick's without pituitary. In using either of these the weight should be watched—naturally stout people stand them better than the thin; with this gland treatment the heart may require toning up also. The rules for diet, rest, and exercise must, of course, be given. These and the next class are they that run about the world seeking for some new nerve tonic or some new stimulant, and that spend their money on something that is worse than vain, for they know not their own disease.
In the second class the symptoms are much the same, but more constant; the blood-pressure yields with difficulty to treatment, or cannot be brought below 150 to 160 mm. The heart is generally permanently, though slightly, enlarged, and there are early signs of kidney troubles. Women in this stage are often unhappy and depressed, but men are often brimming over with a sort of false energy; in both there is generally shortness of breath on exertion. The treatment is much the same as in the first class, but will need more perseverance and watching, and no real cure can be expected. The evil day may, however, be long postponed. In both these classes the electrical and the bath treatments mentioned be-fore are often of much help.
In the third class, where there is distinct heart and kidney disease, and especially where there is atheroma, one must proceed very cautiously. In these there is no normal point of tension. One must find out in each case the point at which the patient feels most comfortable and capable. One will live fairly easily at a pressure of 165 to 175 mm., and will be good for nothing at 145 mm. Nature, as she usually does in abnormal circumstances when left to herself, has established a fair working equilibrium which should not be roughly disturbed. The extreme degrees of tension, such as 200 mm. or over, should certainly be attacked, but should be brought down very gradually. These patients, if they lead careful and abstemious lives, may still live to real old age, but they cannot afford to run any risks nor to make exceptions to their self-denying ordinances. After eighty the tendency to progressive sclerosis generally ceases, the arteries become softer, and the circulatory stress relaxes.
The chief danger in this third class is atherorna, specially when it occurs in the aorta or in the cerebral arteries. In such cases we may not find much pressure—sometimes, indeed, it may be below normal; these will often need cardiac tonics. 'Thyroid or the combined glands with pituitary should be carefully given and watched. If there is advanced kidney disease, thyroid may do harm ; the results of increased metabolism which it causes may have no sufficient outlet, and the system becomes over-charged with effete materials. In the second and third classes it is very necessary to keep the liver acting freely; occasional doses of blue pill or calomel at night, with sulphate of soda in the morning, are most beneficial, and, by relieving the portal circulation, lower the general blood-pressure and ease the work of the heart.
These three classes have, of course, no clear lines of subdivision, and may merge into each other almost insensibly, but they form a fairly accurate guide to prognosis and treatment.
When all has been said about the treatment of this morbid condition we call arterio-sclerosis, we are sure to be faced with a somewhat sceptical criticism. One will ask, " Is not this thickening of the arterial coats with the increase of tension Nature's method of keeping up a failing circulation?" And one must honestly answer, " Yes." The same criticism would apply equally to the case of hyper-trophy of the heart, which grows stronger and bigger only to meet an increased and unnatural demand : yet no one would hesitate to treat and rest such a heart. The sclerosis is a fault to compensate in a measure for another fault; but if one can remove or partially cure the original and causative error one surely may and should treat and cure, if possible, the resulting error. It cannot be our pharisaical duty to stand by and see the vicious circle of disease go on to its end unbroken. The original causes of the disease, except in those unhappy cases in which the tendency is inherited, are largely removable, for mostly they arise from physiological law-breaking and from nervous overstrain. Let us, then, throw aside this weight of paralyzing hypercriticism, a sin that doth so easily beset us, and let us march fearlessly but cautiously on in the path of restoration and of healing. After all our arguments and speculations, the court of appeal that has to pronounce judgment is formed by our patients themselves. Ask any man or woman who has suffered from the miseries and discomforts of arterio-sclerosis, when accompanied by high blood-pressure, how they feel after that pressure has been carefully and judiciously reduced, and you will get no uncertain answer. They can work and think far better, their breathing is easier, and they lose the cardiac and the brain discomforts that have made their lives so miserable. Their sleep becomes again quiet and refreshing; and beyond the improvement in these subjective symptoms, there is a condition of far better general health, and, what is perhaps equally important, of greater safety. It must be evident that anyone at-tempting to lead a strenuous life in mental or bodily work, with a pressure much above the normal, is in daily danger of a bad breakdown, of one that will practically end his working days. It should, there-fore, be our manifest duty to bring all such to the knowledge of their danger, to persuade them to lead 'a new life and to grasp the means of safety that we can offer them. During the last few years it has been the fortunate lot of many of us to be able, with our sclerotic patients, to steer them safely through the dangerous years and shoals of later middle life into the quiet and restful harbor of real old age, free from paralysis and with mind unclouded.