Introduction

The general thickening of the arterial wall which is characteristic of arterio-sclerosis, is too commonly regarded as essentially a disease of adult and later life. This condition, however, is very frequently present in young subjects, more especially in men who lead a life of physical strain, e.g. miners and athletes, and it is occasionally met with in young people in whom it has developed as a sequel of an acute infective disease. In its later stages it is usually associated with chronic renal or chronic cardiac disease, and in practice well-marked cases of arterial sclerosis are frequently met with which have escaped recognition until the onset of symptoms of heart failure or of renal disease. The dietetic treatment in the earlier stages of the disease will now be considered.

Arterio-sclerosis is frequently but by no means invariably dependent on prolonged high blood-pressure, this increase of blood-pressure being due to the action of some poison or poisons in the circulation, which constrict the bloodvessels and induces hyperplasia of the vessel walls. The source of this poison is usually the intestinal tract. Diet undoubtedly plays an important part in the development of arterio-sclerosis, and we must, therefore, look upon diet as a factor with prophylactic and to some extent curative properties. Defective feeding may induce arterio-sclerosis in one of the following ways.

1. By the action of toxins produced by abnormal digestion of proteins and especially animal protein foods in the digestive tract, more particularly in constipated subjects.

2. By the action of toxins produced by abnormal fermentation of the carbohydrates of the food. In such cases flatulent dyspepsia and constipation are usually prominent clinical features. In these cases it is possible that the carbohydrates of the food are only indirectly the source of the poison, the toxin being derived from the protein elements of the food, the normal digestion of which has been deranged by the excess of carbohydrate food.

3. By the development of toxins produced either in the digestive tract or in the tissues from an excess of nutrient material - over-eating. Here again constipation is an important predisposing factor (see also Auto-intoxication, P. 346).

As the disease is insidious in its origin, and has, as a rule, been of long duration when the patient first comes under observation, it follows that the full beneficial effects of a more physiological diet may not be attained for many months. Treatment must therefore be prolonged over a lengthened period, the state of the blood-pressure serving as a useful guide in the treatment. In addition to diet, it is of the first importance to promote free and regular evacuation of the bowels, and to regulate, or it may be, forbid indulgence in alcohol and tobacco. The main principles to be followed in the dietetic treatment may be summarised as follows: -

(a) In young subjects there should be a marked restriction in the amount of animal protein foods. In some cases a prolonged course of an exclusive milk diet may be adopted with advantage.

(b) In adults and elderly subjects a restriction in the total amount of foods is important. Here also a diminution in the animal protein food is advisable.

(c) Drinking of fluid between meals should be encouraged. The urine of these patients is frequently concentrated, and deficient in quantity, and it is advisable to bring the specific gravity of the water down to about 1016. This is best accomplished by ordering a measured amount of fluid, e.g., half a pint of plain water, hot or cold, Salutaris, or Apollinaris water to be taken tin first thing in the morning and the last thing at night. If this does not suffice to bring down the specific gravity of the urine to 1016 or thereby, another half pint of fluid may be ordered to be taken an hour before lunch and dinner.

(d) Thorough mastication of the food, the prevention of oral sepsis, careful regulation of the bowels, with an occasional course of mercurials and salines, and abstinence or moderation in the use of alcohol and tobacco, are essential adjuvants in treatment.

A practical illustration of the foregoing points may be given by a reference to illustrative examples of the disease. In the case of young subjects it may be advisable to prescribe a few weeks' complete rest in bed, with an exclusive milk dietary for this period. When this is not called for, the dietetic regime should be as follows: -

In a youth of 14 years of age, in whom the condition has de\ eloped as a sequel to an acute infective disease such as typhoid or scarlet fever. The chief point here is a restriction in the amount of animal protein foods, and especially every variety of red meat. Special injunctions should be given as to thorough mastication of the food, and promotion of a regular action of the bowels.

Breakfast should be largely a farinaceous diet, consisting of porridge and milk, bread and milk, with perhaps fruit.

Dinner

A simple three-course dinner, with fish, white meat (sweetbreads, tripe, rabbit), and red meat on alternate days.

Tea and Supper should comprise chiefly milk and breadstuffs. Eggs and cheese may be allowed occasionally. Weak tea may be taken in the earlier meal.

In A Man At. 22

It is not unusual to find that the routine diet of a young man with thickened vessels includes a large amount of meat foods taken three or four times daily, carbohydrates forming a relatively small proportion of the total food. In rarer cases the diet is too exclusively carbohydrate in character, and associated with the drinking of tea, three or four times daily, often with excess of sugar, jams, etc. Both of these extremes are to be avoided. In well-marked instances it is advisable to place the patient on a milk diet for a month or longer, rest from work and complete rest in bed being at the same time necessary. Subsequently, the chief point to attend to is to diminish the intake of meat foods, substituting soup, thickened with farinaceous substances, with vegetables and puddings. The meals should not exceed three in number. The drinking of water should be encouraged. Alcohol in every form is better withheld. Special injunctions should be given as to thorough mastication of the food, and the promotion of a regular action of the bowels. An appropriate dietary is appended: -

Breakfast

Bowl of porridge and milk, tea, bread and butter, and jam.

Dinner

A plain three-course dinner, in which white meat frequently takes the place of red meat.

Tea

Tea, bread, butter, cheese, with an egg.

A regime along these lines should be continued permanently.

In An Elderly Subject

Most elderly people eat more than they require, and more than is good for their arteries. It is therefore advisable to give detailed instructions as to the amount and nature of the foodstuffs appropriate to the age, the body-weight, and the general circumstances of the patient as to work, social conditions, and the like. The leading points in dietetic treatment may here be summarised as: -

(a) An all-round restriction in the total amount of food consumed.

(b) Meat meals, and especially red-meat meals, should be reduced to not more than one meat meal a day. In many cases white meats only can be prescribed with advantage. (c) Highly spiced foods should be avoided.

Some patients learn by experience that they enjoy the best health on a diet which is largely vegetarian in character. With regard to alcohol, no universl rule can be laid down. Speaking generally, it is better withheld; but for patients with feeble digestion, and for others who have long been accustomed to take stimulants in strict moderation, it is sometimes advisable to recommend a glass of light wine or spirit to be taken with food.

It is important to bear in mind that there are occasionally met with cases of pronounced arterio-sclerosis, sometimes but not always associated with increased blood-pressure, who have not been in the least addicted to excess of animal protein foods, but who have lived very largely on a carbohydrate regime. In these cases, if there is reason to suspect the immoderate use of vegetable foods these should be restricted, as benefit may undoubtedly accrue thereby. It should be clearly understood that cases of pronounced arteriosclerosis are met with in which the diet does not appear to have been a factor of importance in the development of the disease.

Hyperpeiesis (Increased Blood-Pressure)

Reference must be made to an important class of case characterised by increased blood-pressure without obvious thickening of the vessel wall, a condition to which special attention has long been drawn by Clifford Allbutt. In these cases the long-maintained increased blood-pressure sooner or later induces marked thickening and degenerative changes in the arterial walls, and for practical purposes they may therefore be regarded as cases of arterial sclerosis. The dietetic treatment of these cases is a matter of great importance; the principles of treatment and the practical details being similar to those indicated for arterio-sclerosis.