There is also this to bear in mind. Arteriosclerosis may be marked in some vessels and so slight in the peripheral vessels that it can not with certainty be made out. But when the radials are sclerosed, it is usually the case that similar changes exist in other parts. Then too, there may be marked changes at the root of the aorta leading to sclerosis of the coronary vessels alone, and the first intimation that the patient or any one else has that there is disease, may be an attack of angina pectoris. Except for symptoms on the part of the heart there is no way to make the diagnosis of sclerosis of the coronary arteries.

Differential Diagnosis

In arriving at a diagnosis, when the question is whether or not arteriosclerosis is the main etiologic factor, the most important fact to know is the age of the patient. Other points that have been dwelt on fully must of necessity also be borne in mind.

Possibly the chief conditions that may be confused with some of the results of arteriosclerosis are pseudo angina pectoris which may be mistaken for true angina pectoris, and ulcer of the stomach, appendicitis (?) or other inflammatory abdominal condition which may be mistaken for angina abdominalis.

Differential tables are sometimes of value in fixing the chief points of difference graphically.

In differentiating between ulcer of the stomach and angina abdominalis the following points may be of service:

Diseases in Which Arteriosclerosis Is Commonly Found

There are certain more or less chronic diseases in which arteriosclerosis is found either as a separate disease or as a result of the chronic disease itself, or the sclerosis may be the cause of the disease. As examples of the first class are diabetes mellitus and cirrhosis of the liver. As examples of the second class are chronic nephritis, gout, syphilis, and lead poisoning. Examples of the third class have already been fully described. Then certain rare diseases that have been briefly described in this chapter, viz.: Raynaud's disease and erythromelalgia are frequently associated with demonstrable arteriosclerosis.

CHAPTER XI.

It is much more dangerous for the patient when the process is in the ascending portion of the arch of the aorta than when it has attacked the peripheral arteries. Here, at the root of the aorta, are the openings of the coronary arteries and the arteries supplying the brain are close by. The coronary arteries here control the situation. When loud murmurs are heard at the aortic orifice and the heart is evidently diseased, it is useful to divide the endocarditis into two types, the arteriosclerotic and the endocarditic. The etiology of the former is sclerosis and the prognosis is grave because of the liability, nay the probability, that the orifices of the coronary arteries will become narrowed. The etiology of the second type is in most cases rheumatic fever or some other infectious disease, and the prognosis is far better than in the first type. True, the two may be combined. In such a case, the prognosis is entirely dependent upon the course of the arteriosclerosis.

The involvement of the arteries in the kidneys is of considerable importance, for it is usually bilateral and widespread. As a rule, the disease makes but slow progress provided that the general condition of the patient is good, but at any time from a slight indiscretion or for no assignable cause, symptoms of renal insufficiency may appear and may rapidly prove fatal.

It must not be thought that because the localization of the arteriosclerosis in the peripheral arteries is usually the most favorable condition that it is therefore devoid of ill effects. On the contrary, very serious, even fatal, results may be brought about by interference with the circulation with resultant extensive gangrene of the part supplied by the diseased arteries. The amputation of a portion of a leg, for instance, may relieve, to some extent, an overburdened heart and prove life-saving to the patient, but the neuritic pains are not necessarily relieved. The torture from these pains may be excruciating.

No stage of the disease is exempt from its particular danger. In the early stages of the disease before the artery or arteries have had time to become strengthened by proliferation of the connective tissue, there is the danger of aneurysm. Later, the very same protective mechanism leads to stiffening and narrowing of the arteries and hence to increased work on the part of the heart with all of its consequences. Thrombosis is favored, and where atheromatous ulcers are formed, embolism is to be feared.

As the complications and results of arteriosclerosis come to the front every one must be considered by itself and as if it were the true disease. There may be a slight apoplectic attack from which the patient fully recovers, but the prognosis is now of a grave character, as the chances are that another attack may supervene and carry off the subject. Yet, after an apoplectic attack, patients have lived for many years. Probably the most noted illustration of this is the life of Pasteur. He had at forty-six hemiplegia with gradual onset. He recovered with a resulting slight limp, did some of his best work after the stroke, and lived to be seventy-three years old. Yet the exception but proves the rule and the prognosis after one apoplectic stroke should always be guarded.

The first attack of cardiac asthma is to be looked upon as the beginning of the end. The end may be postponed for some time, but it comes nearer with every subsequent attack. One may recover from what appears to be a fatal attack of cardiac asthma accompanied by edema of the lungs and irregular, intermittent, laboring heart, but the recovery is slow and the chances that the next attack will be the fatal one are increased.

The significance of albuminuria is difficult to determine. The kidneys secrete albumin under so many conditions that the mere presence of albumin in the urine may have but little prognostic value. Many cases are seen where there is no demonstrable albumin, and yet the patient may suddenly have a cerebral hemorrhage. As a general rule the urine should be carefully examined, but not too much stress should be laid on the discovery of albumin and casts. It is not always possible to determine the extent of the kidney lesion by the urinary examination, yet at any time a uremic attack may appear and prove fatal.

After all the most important fact for the patient is not what the pathologist finds in his kidneys after he is dead, but what the living functional capacity of the kidneys is. This can now be determined in a variety of ways as the result of extensive work carried out in quite recent years. The simplest method of determining the functional capacity of the kidneys is by the injection into the muscles of the back of a solution containing 6 mg. of the drug phenolsulphonephthalein in one c.c. of fluid. This comes already prepared in ampules, with full directions for its employment.[16] Some clinicians use indigo-carmine in place of phthalein. The general consensus of opinion is in favor of phthalein.

The nephritic test meal carefully worked out by Mosenthal[17] gives much valuable information. The determination of the nonprotein nitrogen or the creatinin in the blood also reveals the functional capacity of the kidneys.[18]

One might say that the appearance of albumin in the urine of an arteriosclerotic where it had not been before, is a bad sign, and in making a prognosis this must be taken into consideration.

Bleeding from the nose is not infrequently seen in those who have arteriosclerosis. It can hardly be called a dangerous symptom as it can always be controlled by tampons. There are times when epistaxis is decidedly beneficial as it relieves headache, dizziness, and may avert the danger of a hemorrhage into the brain substance. It is rare to have nose bleed except in cases of high tension in plethoric individuals. My experience has been that it has saved me the trouble of bleeding the patient. It is always of serious import in that it indicates a high degree of tension, but there is scarcely ever any immediate danger from the nose bleed itself.

Intestinal hemorrhage is always a grave sign. As has been shown, arteriosclerosis of the splanchnic vessels not infrequently occurs, and an embolus or thrombus may completely occlude the superior mesenteric artery. The chances of the establishment of a collateral circulation are small, as the arteries of the intestines are end arteries. Necrosis of the part follows, blood is found in the stools, and perforation or gangrene, or both, are apt to follow. There may be blocking of small branches only, leading to ulceration of the intestine. Under all conditions the prognosis is serious.

The general condition of the patient, his build, physical strength, powers of recuperation, etc., must be taken into account in giving a prognosis. The more powerful the individual, the more favorable, as a rule, is the prognosis, with this reservation always in mind, that the greater the body development, the greater is the heart hypertrophy, and the accidents from high tension must not be overlooked. Many puny individuals with stiff, calcified arteries go about with more ease than a robust man with thickened arteries only. The differentiation as pointed out by Allbutt (page 186), is well to keep in mind in giving a prognosis. It can not be too strongly emphasized that it is the whole patient that we must consider and not any one system that at the time happens to be the seat of greatest trouble, and by its group of symptoms dominates the picture.

It is evident from what has been said that an accurate prognosis in arteriosclerosis is no easy matter. Were arteriosclerosis a simple disease of an acute character there might be grounds for giving a more or less definite prognosis. The most that can be said is that arteriosclerosis is always a serious disease from the time that symptoms begin to make themselves known. The gravity depends altogether on the seat of the greatest arterial changes, and is necessarily greater when the seat is in the brain than when it is in the legs or arms.

The attitude of the patient himself also determines to a great extent the prognosis. Some men, especially those who have always enjoyed good health, turn a deaf ear to warnings and instead of ordering their lives according to the advice of the physician, persist in going their own way in the hope that the luck that has always been with them will continue to stand at their elbows. Neither firmness nor pleadings avail with some men. The only salve for the conscience of the physician is that he has done his best to steer the patient away from the shoals and breakers. In others who realize their condition and take advantage of the advice given as to the regulation of their lives, the prognosis is generally favorable.

To sum up the chapter in a few words, I should say: Always remember that the patient is a human being; study his habits and character and mode of life; look at him as a whole; take everything into consideration, and give always a guarded prognosis.

CHAPTER XII.

The struggle for existence is keen. Competition 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 competition, the fittest only can survive for any period of time. The weaklings are bound to succumb. 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 multitudinous 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 institution 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 Association, 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 pass 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 quantities. 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 albumin 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.

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 assume 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 passive exercise in the form of massage, 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 instituted 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 assuredly 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 glass of water before breakfast, a regular time to go to stool, and abdominal massage 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 multitudinous. 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 assist digestion and assimilation. 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.

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.

Foodstuffs are composed of one or all of three classes: (1) proteins, (2) fats, (3) carbohydrates. As examples of the first are beef and white of egg; of the second, the oils, butter, lard; of the third, sugar, potato, beet, corn, etc.

The physiologists and chemists have shown us that both endogenous and exogenous uric acid in excess will cause a rise of blood pressure, but the bodies most concerned in the production of elevated blood pressure are the purin bodies, those organic compounds which are formed from proteins and represent chemically a step in the oxidation of part of the protein molecule to uric acid. Red meat contains more of the substances producing purin bodies than any other one common foodstuff, and for this reason the excessive meat eater is, ceteris paribus, more apt to develop arteriosclerosis comparatively early in life.

The fats and carbohydrates contain practically no substances that react on the body of the ordinary individual in a deleterious manner during their digestion. The extra work that is put on the heart by the formation of many new blood vessels in adipose tissue is the only harmful effect of overindulgence in these foodstuffs.

It has been found that nitrogen equilibrium can be maintained at a wide range of levels. Formerly 135-150 gms. of protein daily were considered necessary for a man doing light work. Now it is known that half that amount is sufficient to keep one in nitrogenous equilibrium, and to enable one to keep his weight. A person at rest requires even less than that. One who is engaged in hard physical labor burns up more fuel in the muscles, and so must have a larger fuel supply.

Although we habitually eat too much we drink too little water. For those who have any form of arterial disease an excess of fluid is harmful, as the vessels become filled up and a condition of plethora results, which necessarily reacts injuriously on the heart and circulation. The drinking of a glass of water during meals is, in the author's opinion, good practice. The water must be taken mouthful at a time, and not gulped down. If this is done, there results sufficient dilution of the solid food to enable the gastric juices successfully and rapidly to reach all parts of the meal.

Some are in favor of a rigid milk diet for those who have arteriosclerosis. Some men have lived on nothing but milk for several years and have not only kept in good health, but have actually gained weight and led at the same time active lives. It has been held by others that rigid milk diet is positively harmful on account of the relatively large quantity of calcium salts that are ingested. This was thought to favor the deposition of calcareous material in the walls of the already diseased arteries. While possibly there may be some danger of increased calcification, the majority of clinicians are in favor of a milk cure given at intervals. Thus the patient is made to take three to four quarts daily for a period of a month. There is then a gradual return to a general diet, exclusive of meat, for several weeks, then another rigid milk diet period.

If we are bold enough to follow Metschnikoff in his theories of longevity, we might advise resection of the large intestine, on the ground that it is an enormous culture tube that produces prodigious amounts of poisonous substances which are thrown into the general circulation. To combat such a grave (?) condition as the carrying of several feet of large intestine, we are recommended to take buttermilk or milk soured by means of the b. acidus lacticus. Clinical experience has taught that in arteriosclerosis buttermilk is of great value, whether it be the natural product, or made directly from sweet milk by the addition of the bacilli. The latter is a smoother product and has, to my mind, a delightful flavor. It may be diluted with Vichy or plain soda water. Cases that can not take milk or any other food will often take buttermilk, and do well on this restricted diet. From two to four quarts daily should be taken. It should be drunk slowly as should milk.

Medicinal

It has long been thought that the iodides have some specific effect on the advancing arteriosclerosis, checking its spread, if not really aiding nature to a limited restoration of the diseased arteries. It is possible that the eulogies upon the iodides owe their origin to the successful treatment of syphilitic arteriosclerosis, in which condition these drugs have a specific action. However that may be, there is no doubt that the administration of sodium or potassium iodide is good therapeutics in cases of arteriosclerosis.

Unfortunately many persons have such irritable stomachs that they can not take the iodides, even though they be diluted many times. They may be made less irritating by giving them with essence of pepsin. Unless the case is syphilitic, it is doubtful whether it is of value to increase the dose gradually until a dram or even more is taken three times daily after meals. Usually a maximum dose of ten grains seems to be quite sufficient. This may be taken three times a day, well diluted, for three months. There follows a month's rest, then the treatment is resumed for another period of three months, and so on. Either sodium or potassium iodide in saturated solution may be given. The sodium salt is possibly less irritating, and contains more free iodine than the potassium salt, although the latter is more generally used. The strontium iodide may also be used.

One sees a patient now and then who can not take the iodides, however they may be combined. For such patients one may obtain good results with iodopin, sajodin, or other of the preparations put up by reputable firms. Personally I have never yet seen a patient who could not take the ordinary iodides in some form or other, and I am opposed to ready made drugging.

The action of the iodides is to lower the blood pressure, and they are of greatest value when the blood pressure is high, and when headache and precordial pain are present.

When the case is moderately advanced, very mild doses, gr. ½, morning and evening, of the thyroid extract may be given. It is generally believed that the internal secretion of the thyroid and the adrenal are antagonistic. That the thyroid secretion lowers blood pressure in certain forms of hypertension is certain, possibly on account of its iodine content. Some combinations of iodine and thyroid such as the iodothyroidin have been used and have had some measure of success attributed to them.

Hypertension does not always demand active measures for its reduction. Viewed from the physiologic standpoint, hypertension is but the expression of a compensating mechanism which is designed to keep the blood moving through narrowed channels. Heart hypertrophy then is absolutely essential to the maintenance of life. It has been said that the highest blood pressures occur in chronic disease of the kidneys. The poisonous substances produced in the kidneys must exert their action through absorption into the general blood stream. This toxin may be completely eliminated, if we accept as our criterion the reduction of tension to normal together with the complete return of the affected individual to health. A concrete example is as follows: A man aged 44 years was brought to the Milwaukee County Hospital in coma. His systolic blood pressure was over 280 mm. Hg, diastolic 170 mm., his urine contained considerable albumin and many casts. He had general anasarca. Venesection was done at once and 300 c.c. blood obtained. Immediately following this operation the pressure was 210-150, but within twelve hours it was again above 280-170. He was given no medication to reduce pressure except that he was freely purged. He was given a steam sweat bath daily. Frequent blood pressure readings were taken. Within seven days the pressure was 130-86. He had, in the meantime, completely recovered from his symptoms. He was kept in the hospital for two weeks longer assisting in the work on the ward, and he was discharged with a pressure (systolic) between 130 and 136 diastolic 80-84. The treatment was rest in bed, free purging, venesection, and sweat baths, simple but exceedingly effective.

Should there be actual indications for reducing the blood pressure, I must admit that it can not always be done. The majority of cases will do well on the sodium nitrite or erythrol tetranitrate. However, these do not always lower blood pressure and keep it within normal limits. When a man has very high tension we do not wish to reduce it to what it should normally be for the age of the patient, as symptoms of collapse might set in at any time under such conditions.

Observations made with the sphygmomanometer[20] show that the effect of nitroglycerin is transient or of no effect except in doses which are relatively enormous (one drop of the one per cent solution given every hour). Sodium nitrite may lower the blood pressure but the effects will have worn off in two hours. It is the same with erythrol tetranitrate. Sodium sulphocyanate in doses of from one to three grains three times a day is highly recommended by some. My own experience with it does not lead me to believe that it is of any great value in hypertension. It, however, may be tried. Benzyl benzoate has been used recently to reduce the high blood pressure of hypertension. Macht has reported some success. In the author's hands it has been efficacious in a few cases. As long as the patient takes the drug the pressure may be slightly reduced, but upon the withdrawal of the drug the pressure returns to its former level. It is well worth a trial and further experimentation may reveal better methods of administration. The dose is from 2 to 6 c.c. mixed with water at intervals.

In the hypertension of the menopause some have had success with large doses of corpus luteum extract. As a matter of fact the drug treatment of hypertension, when it becomes necessary to treat this condition with drugs, has suffered a notable set-back since more careful control has been made with the blood pressure instruments. In giving any of the depressor drugs their action should be controlled by blood pressure measurements, for only in this way can we be sure that the drug is exerting its physiological effect and we may expect results. The individual reaction to these drugs varies greatly and no rule for dosage can be dogmatically laid down. The only successful therapy is rigid individualization. This is the keystone to treatment in cases of arteriosclerosis and high tension.

It must not be inferred from what has been said that the nitrites are of no value. They are of decided value but they have their limitations. The most evanescent of these drugs is amyl nitrite. This is put up in the form of capsules, or pearls, containing from one to three minims. When it is desired to dilate the peripheral vessels suddenly, one or two of these capsules are broken in a cloth held to the nose. The effect is almost instantaneous. There is flushing of the face and other peripheral vessels, particularly near the head, denoting a relaxation and widening of the bed of the blood stream, and a consequent decrease in pressure in the arteries. These effects are over in a short while. It is only used in attacks of cardiac spasm, as in angina pectoris. Nitroglycerin, the Spiritus Glonoini of the U. S. P., acts in about the same manner as amyl nitrite but the effects last usually a trifle longer. One drop of the one per cent solution may be given every hour until physiologic effects are produced. It may be given hypodermically. This may be a means of reducing pronounced high tension. This drug has been found of benefit especially in cases where arteriosclerosis combined with chronic nephritis causes cardiac asthma. The other drug which may be of service in these conditions, one whose sphere of action is somewhat broader, because its effects are more lasting, is sodium nitrite. This is given in water in doses of one to three or five grains every four hours. Some have objected to the use of this drug, but my experience has made me place considerable confidence in its harmlessness, provided that the patient is carefully watched. This, however, applies to all of the nitrite compounds. My experience with erythrol tetranitrate is not large. It may be used in place of sodium nitrite.

For a mild case, one often finds that sweet spirits of niter is sufficient to control the pressure and relieve the distressing symptoms, and it is undoubtedly the least harmful of all the nitrites. Drugs that are of great value, but of which little is noted in textbooks, are aconite and veratrum viride. Both of these drugs are well known to be marked circulatory depressors. Veratrum viride in my experience should be very cautiously used, and never used unless a trained attendant is constantly at hand. With regard to aconite I have no such feeling, and a mixture of tincture of aconite and spiritus etheris nitrosi may be given for several weeks with no fear of doing any harm. Personally, of all the drugs mentioned, I prefer the nitrite of sodium or the combination just given. They may be advantageously alternated.

My own feeling is that the most successful means of treatment of acute high tension is without the use of drugs. The most important measure is absolute rest in bed. This often suffices to lower the blood pressure and to arrest the symptoms produced by high tension. Venesection I believe is also of value. True the arterioles appear to contract almost immediately upon the lessened quantity of blood, or there is immediate interchange of serum from the tissues which brings the blood volume back to the original amount. Whatever happens the pressure is not greatly reduced, at times not reduced at all, but often the symptoms are relieved. Hot packs or sweat baths assuredly do reduce the pressure in many cases. This seems to me to be an exceedingly valuable measure. Finally the diet should be nourishing, but very light, not too much fluid should be ingested, and the bowels should be freely opened.

With the fibrolysin of Merck, I have had no experience. Some men assert that they have had good results from its use, but on the whole the evidence is not highly favorable.

Morphine is invaluable. No drug is of such value in the nocturnal dyspneic attacks that occur in the late stages of arteriosclerosis when the heart or the kidneys are failing. Morphine not only relaxes spasm and quiets the cerebral centers, but is an actual heart stimulant under such conditions, and should never be withheld, as the danger of the patient's becoming addicted to its use is more fanciful than real. However, morphine, at times, suppresses the secretion of urine. So that if after trial the urine becomes scanty and the edema increases, recourse must be had to other drugs. The various hypnotics may be used with caution. One which seems to be very useful is adalin.

As heart stimulants, one may use strychnine, spartein, caffein, or camphor. In desperate cases, where a rapidly diffusible stimulant is needed, a hypodermic syringeful of ether may be given, and repeated in a short while.

Several years ago a so-called serum was brought out by Trunecek which was said to have a favorable effect on the metabolism of the vessel walls. It was given at first hypodermatically or intravenously but the former method was painful. It was later stated that given by mouth it acted just as well. The results with the Trunecek serum have not come up to the expectations that the early favorable reports promised. The original serum was composed as follows: NaCl, 4.92 gm.; Na₂SO₄, 0.44 gm.; Na₂CO₃, 0.21 gm.; K₂SO₄, 0.40 gm.; aqua destil. q. s. ad. 100.0 c.c. Later this was modified for internal use to the following prescription:

℞  Natrii chlor.                10.     gm.
Natrii sulphat.                1.     gm.
Natrii carbonat.             0.40 gm.
Natrii phosphat.             0.30 gm.
Calcii phosphat.
Magnesii phosphat. aa.  0.75 gm.
M. Ft. cachets No. XIII.

The contents of every cachet corresponds to 15 c.c. of the fluid serum or to 150 c.c. of blood serum. The preparation called antisclerosin consists of the salts contained in the serum. As to its efficacy, I can not judge, as I have never felt that it was worth while to use it. Reports of cases in which it has been tried do not speak very highly of it.

In the general treatment of arteriosclerosis, there is no one factor of more importance than the regular daily bowel movement. Attention to this may save the patient much discomfort and even acute attacks of cardiac embarrassment. The choice of the purgative is immaterial, with this reservation only, that the mild ones, such as cascara, rhubarb, licorice powder and the mineral waters, should be thoroughly tried before we resort to the more drastic purgatives. Plenolphthalein in 3 to 5 grain doses acts remarkably well in some people as a pleasant laxative. Agar-agar with or without cascara may be useful.

Liquid paraffin under a variety of names is a most useful and efficacious laxative. As its action is purely mechanical it may be taken indefinitely without doing harm to the intestinal musculature.

The old Lady Webster dinner pill is an excellent tonic aperient. When the heart is embarrassed and edema of the legs and effusion into the serous cavities have taken place, then it becomes necessary to use the drastic purgatives that cause a number of watery movements. Epsom salts given in concentrated form, elaterin gr. 1-12, the compound cathartic pill, blue mass and scammony, or even croton oil may be used. Since the observation of a greatly congested intestine from a patient who had been given croton oil, I have ceased to use this purgative, and I doubt much whether its use is ever justifiable in these cases.

The management of the ordinary case of arteriosclerosis resolves itself into a careful hygienic and dietetic regime with the addition of the iodides, aconite, or the nitrites. A diet consisting of very little meat, alcohol in moderation or even absolutely prohibited, and not too much fluid should be prescribed. Condiments and spices should also be used sparingly. Cold baths, shower baths, cold and hot sheets alternating, are of great benefit in assisting the heart to do its best work by making the large capillary area of the skin more permeable. It is not true that such baths raise the blood pressure so markedly. Certain acts, as sneezing, violent coughing, etc., increase the blood pressure much more than judicious bathing.

Symptomatic Treatment

The fact that arteriosclerosis really loses much of its own identity and, in later stages, becomes merged with the symptomatology of the diseases of various organs, as the kidney, brain, heart, compels us, for completeness' sake, to say a few words about the treatment of these complications.

One of the results of arteriosclerosis of the coronary arteries, angina pectoris, demands prompt treatment. In the acute attack, the chief object is to relieve the spasm and pain. Pearls of amyl nitrite should be inhaled, and morphine sulphate with atropine sulphate given hypodermatically at the very earliest moment. It is senseless to withhold morphine. The only possible reason for withholding it would be uncertainty as to the diagnosis. It is probably better to err on the safe side, and should the case prove to be one of pseudo angina, in the next attack sterile water can be given instead of the morphine and atropine.

When a patient is seen in the condition of broken compensation with the much dilated heart, anasarca, dyspnea and suppression of urine, there is no better practice than venesection. Especially is this valuable when the tension is still fairly high and the individual is robust. Following the abstraction of six to eight ounces of blood (300-500 c.c.)[21] the whole picture changes, so that a man who a short while before was apparently at death's door, notices his surroundings and takes an interest again in life. This should be followed up with thorough purgation, and cardiac stimulants should be ordered. In such cases digitalis is useful, but its action is never so striking as in cases of this general character due to uncompensated valvular disease. It must be remembered that in arteriosclerosis the changes in the myocardium must be of a considerable grade for the heart to give away. Therefore, digitalis can not be expected to act on a diseased muscle as it acts on a comparatively healthy muscle. It is only in such cases of broken compensation that digitalis should ever be used.

Digitalis is not a general vasoconstrictor as used to be taught. Its action on the kidney is actually a vasodilator one. And in its action on the heart the digitonin dilates the coronary arteries, according to Macht, while the digitoxin acts on the heart muscle. Overdosing with digitalis has produced partial heart block in many cases. It is absolutely contraindicated in Stokes-Adams syndrome.

There are, however, some cases, especially those with transudations, when digitalis may be carefully tried even though high tension be present. It is sometimes of advantage to combine digitalis with the nitrites although they are said to be physiologically incompatible.

Still another drug, that is of great value in conditions such as have been described, is diuretin. This may be given in capsule or tablets, grs. x. three times daily. There is only one caution to express in the use of this drug. It should not be given when the kidneys are the seat of chronic inflammatory changes; in fact, actual harm may be done by administering the drug under such conditions.

The same is true even to a greater extent with theocin. This is a powerful diuretic. If given by mouth it should be well diluted as it is most irritating to the stomach. It is best given intravenously in doses of two and a half to three grains dissolved in five to six cubic centimeters of distilled water. One must be reasonably sure that the kidneys are not the subject of chronic disease and are functionally, therefore, below par. The intravenous dose should not be given oftener than once in four days.

For the pain in aneurysm, nothing (except, of course, morphine) is so valuable as iodide of potassium. Patients who are suffering agony, when put to bed and given KI grs. x. three times a day, soon lose all the distressing symptoms. This applies particularly to aneurysms of the arch of the aorta.

When the sclerosis has affected the cerebral arteries to such an extent that symptoms result, the case is, as a rule, exceedingly grave. Not much can be done except to relieve the headaches and keep down the blood pressure, if this is high, by means of rest in bed, the iodides, aconite, or the nitrites. The cases of transient monoplegias or hemiplegias can be much relieved by careful hygienic measures and judicious administration of drugs. Much ingenuity is sometimes required to overcome the idiosyncrasies of patients, but care and patience will succeed in surmounting all such difficulties.

The treatment of intermittent claudication is the treatment of arteriosclerosis in general. Sometimes the circulation in the affected leg or legs is much helped by daily warm foot baths. Light massage might be tried and the galvanic current may be used once or twice daily.

There are a few distressing symptoms that occur usually late in the disease, when complications have already occurred, which frequently baffle the therapeutic skill of the physician. The chief of these—insomnia, dyspnea, and headache—may not be late manifestations, but insomnia and headache are frequently associated with the moderately advanced stages of arteriosclerosis. At times all the symptoms seem to be due to the high tension, the relief of which causes them to disappear. There are, unfortunately, times when high tension is not responsible for the headache and insomnia. Under these circumstances such drugs as trional, veronal, amylene hydrate, ammonol, etc., may be tried until one is found which produces sleep. For the headaches, phenacetin, alone or in combination with caffein and bromide of sodium, may be tried. Acetanilid, cautiously used, is at times of value. There have been cases of arteriosclerosis with low blood pressure, accompanied by severe headaches, that have been relieved by ergot. Codeine should be used with care, and morphine only as a very last resource.

Great care must always be exercised in giving drugs that depress the circulation, for it is easily conceivable that more harm than good can come from injudicious drugging.