Heart disease [full issue]

VIKNRLD HEALTH The magazine of the World Health Organization August- September 1970 UK: 4/6d USA: 0.75 This X-ray shows places where arteries have narrowed. contents Cover design by Peter Davies The modern epidemic: ischaemic heart disease, by Professor J. Lenegre Stroke—a problem in Japan today, by Dr S. Hatano 12 Hypertension—towards better con- trol, by Professor P. Duchosal . 18 Nutrition and the present epidemic, by Dr J. Stamler 26 Rehabilitation—return to living, by Dr E. Helander 32 A look at the future—the broad approach, by Dr Z. Fejfar and Professeur J. N. Morris . . . . 39 Books • 45 flindArn epidemic ischaemic heart disease by Professor J. Leriegre* Ischaemic disease (from the Greek iskhaimos—literally "that which stops the blood") occurs when the supply of blood to part of the body is considerably reduced or cut off. If the channel of an artery supplying a tissue or an organ is narrowed to less than half its normal capacity or, even more serious, if it is blocked com- pletely, then the nutrition of that tissue or organ will be compromised and its function impaired. When there is major interference with the blood supply, the cells of the bloodless or ischaemic area die (this is known as necrosis or necro- biosis) and are replaced by an "infarct", which in turn becomes fibrosed, the dead tissue being replaced by a scar. When this occurs in the brain it is known as softening of the brain and often leads to paralysis on one side the body (hemiplegia). When the legs are affected, gangrene of the feet or the toes may ensue. The most common of all the ischaemic diseases is, however, ischaemic disease of the heart. The term covers those diseases or disorders which result from a major reduction in the blood supply to all or part of the heart. This may be brought on by various diseases and by various mech- anisms. For example, a narrowing of the aortic orifice may interfere with the flow of blood to the coronary arteries which supply the heart walls and muscles, or a syphilitic inflammation of the aorta may leave a fibrosed aortic plaque which forms a diaphragm, or curtain, across the orifice of one of these arteries, blocking it com- pletely. In almost 90 per cent of cases, however, ischaemic heart disease is due to atherosclerosis, a general disease of the walls of the large arteries which shows a marked tendency to attack the arteries forming the coronary tree. The direct causes of atherosclerosis re- main a mystery but an increasing number of facts about the disease are known. Coronary atherosclerosis is far more common in men than in women, but while almost all patients under the age of 40 are men, this ceases to be true as people grow older; from 60 on, and more particularly after 70, it strikes equally at both sexes. Thus women are in general affected later in life than men. It occurs more frequently with age. Coronary atherosclerosis before the age of 20 is most unusual and is fairly uncom- mon up to the age of 40. Between 45 and 50, there is a substantial increase, most cases occurring between 50 and 80. It runs in certain families whose mem- bers, particularly the males, may for gen- eration after generation be the unfortunate victims of the disease. It figures high on the list of causes of death. In industrialized countries such as the USA or Great Britain, coronary atherosclerosis is by far the most frequent cause of death. It is responsible for 50 to 60 per cent of all deaths from cardio- vascular disease, which itself accounts for more than half the total number of deaths. Coronary atherosclerosis kills three out of every thousand inhabitants of these two countries every year, not to speak of the one million work-days lost annually in the United States alone. The figures for Canada, Australia, the Federal Repub- lic of Germany and the Scandinavian countries are proportionally almost as high. In these countries it is the number one health problem—a plague of modern society. The same applies to France, possibly to a lesser degree. However, in spite of the frequency of cardiovascular diseases, the efforts made at prevention remain far below what is required. If the same effort were made in France, for example, to prevent cardio- vascular diseases as is made for tuberculosis or cancer, mortality would indisputably decline. Discovering the truth Over the last twenty years, doctors have been making a great effort to find out how atherosclerosis in general, and heart disease due to coronary atherosclerosis in parti- cular, develops. Although they still have not found the whole "scientific truth" about' the direct causes of the disease, they are getting nearer to it and have brought to light a certain number of "clues" to the mystery. Since certain families show a marked predisposition to coronary atherosclerosis, hereditary or genetic factors have been * Professor of Clinical Cardiology, Hopital Boucicaut, Paris. 3 Young people begin smoking to show that they "belong", to assert themselves as "adults" or simply to seek pleasure. suspected. Heredity most probably influ- ences the disease in a variety of ways. Metabolic and enzymatic disorders, such as familial hypercholesterolemia (excess of cholesterol in the blood) or diabetes mellitus and some endocrine defects, may all play their part. However, it is unlikely that the heredity factor is a simple mechan- ism of gene mutation or translocation. Statistics show us that arterial hyper- tension is a predisposing factor: at least 25 per cent of men and 50 per cent of women with coronary heart disease suffer from high blood pressure (see page 18). Even a mild degree of hypertension in an adult may have serious consequences. In the same way diabetes can be said to predispose to atherosclerosis. Typical diabetes mellitus is actually present in over 10 per cent of patients suffering from coronary heart disease. Paradiabetic con- ditions, where one of the parents, usually the mother, has a history of diabetes and/or the results given by blood sugar tests are clearly abnormal, are even more frequent. Hidden defects in sugar metabo- lism are often found in association with abnormalities of fat metabolism. Thus, some patients should follow a "diabetic" diet and cut out simple sugars and fruit so as to lower abnormally high blood levels of cholesterol, triglycerides or lipids. A theory that hypercholesterolemia may be responsible for coronary atherosclerosis has been gaining ground over the last fifty years. More and more frequent reports have appeared of its coexistence with other diseases of a completely different nature such as diabetes. All these diseases, however, have a common denominator—a permanently raised blood cholesterol level. Even when other disease is not present, patients suffering from coronary atherosclerosis are found to have a higher blood cholesterol level than normal healthy individuals of the same age. The incidence of coronary heart disease varies widely from country to country but epidemiolog- ical studies show that such factors as race, climate and geographical situation are less closely related to its distribution than diet and the level of economic devel- opment. Obesity, or excess fat, is almost invar- iably due to overeating, although in some cases another factor may operate—such as an inherited family tendency to put on weight more easily when calorie intake is high. In certain individuals every calorie in excess of the number required to satisfy 4 the body's metabolic requirements is stored in the form of fat and leads slowly but surely to increasing obesity. The signi- ficance of obesity in coronary heart disease has been variously assessed. It may not be the main factor but there is no doubt that it plays some part. This is borne out both by the statistical tables compiled by life insurance companies, which show how life expectancy falls as body weight in- creases, and by clinical studies, some of which have shown that deaths from cardiovascular disease are twice as frequent among those who are overweight as among comparable individuals whose weight is normal (60 per cent as against 30 to 35 per cent). Other factors have been suspected of causing coronary atherosclerosis, among them cigarette smoking, especially when the smoke is inhaled. Almost all the statistics agree that mortality from various diseases is much greater among smokers than among non-smokers. This is true for bronchopulmonary cancer, chronic bron- chitis, ischaemic diseases of the lower limbs and, although perhaps to a lesser degree, myocardial infarction (coronary thrombosis). Sedentary habits, the stress and strain of modern life, and some psychological and emotional factors may also play a part, though this is not yet fully proved and requires further study. The disease of the century The very fact that coronary heart disease strikes more frequently in nations that are economically rich and whose popu- lations are predominantly sedentary and well-fed has led to atherosclerosis in gen- eral, and coronary atherosclerosis in parti- cular, being considered as a disease of the privileged—the price we pay for belonging to what has rightly been called the "con- sumer society". What, then, lies behind this steep in- crease in coronary heart disease? It has sometimes been alleged that the increase is more apparent than real since, with the improved diagnostic methods at our dis- posal, it is possible to diagnose forms of the disease today which at one time would not have been recognized. It has also been said that the increased incidence of the disease in the second half of life is due, above all, to the fact that we live longer than we used to. Indeed, the proportion of deaths from cardiovascular disease in the total of deaths is, depending on the country, from 21 to 37 per cent among male deaths at about age forty, 33 to 51 per cent at about fifty, 39 to 57 per cent at about sixty and 48 to 62 per cent at seventy. There is thus some truth in these allegations, but Osler, who a century ago in one year met only rare cases of angina pectoris among his numerous pa- tients, was as capable of diagnosing it as we are today. Moreover, it is difficult to explain away the increasing number of cases among younger people (under 40). Comprehensive analysis of all the circum- stances in which coronary heart disease makes its appearance and of the various other disorders associated with it confirms the existence of a certain number of factors whose influence is undeniably harmful. They have been called the "factors of risk". These factors have been closely studied and their "pathogenic power" measured. The Framingham prospective study shows that when several factors of risk are present at the same time the chances of developing the disease are considerably increased. Obviously these findings are of more than academic interest. They provide prac- tical guidelines for the preventive and therapeutic measures to be taken. While we have only a sketchy know- ledge of the direct causes of atherosclerosis we do know quite a lot about the histo- logical structure of the lesions associated with it. They consist of diffuse and seg- mentary changes in the arteries, remarkable in that they show a predilection for the male sex and the middle-aged. The first anatomic changes occur early in life, from 10 or 20 onwards. The yellowish fatty streaks, or striae, which appear in the internal lining of the artery are small at first and remain inactive for many years— almost indefinitely in most cases. With the passing of time, slowly and imper- ceptibly, the lesions develop, showing a preference for certain regions and partic- ularly for the arteries forming the coronary tree. Within these regions, they most frequently attack the point at which the main body of an artery divides or curves. In these "chosen" areas, the insoluble lipid substances circulating in the blood (cholesterol and fatty acids) are preci- pitated on to the internal wall of the artery and form circumscribed yellowish deposits which in turn are soon covered by a gradually thickening fibrous shell. Thus an atherosclerotic plaque or stenosis is formed which infiltrates deeply into the arterial wall, eroding or compressing the middle muscular coat of the artery and, even more serious, bulging out into the blood channel, which becomes progressively narrower as the atherosclerotic plaque grows larger. Narrowing arteries This stenosis, or narrowing of the arteries, progresses very slowly. The failing blood supply is to a certain extent com- pensated for by a supplementary or anas- tomotic circulatory system as those coro- nary arteries which remain open respond to the appeal for blood from the ischaemic areas of the heart muscle whose normal supply has been diminished by the growing stenosis. These stenoses usually begin to interfere with the functioning and nutrition of the myocardium, to cause accidents and to give rise to clinical complications between the ages of 50 and 70. The normally slow course of the disease—progression as the arteries narrow alternating with regression as the supplementary anastomotic circu- lation comes to the aid of the failing heart—may be accelerated by the for- mation of a coronary thrombosis. A clot of blood suddenly forms around or near an atherosclerotic plaque, completely blocking the artery, and the supplementary circu- lation is unable to meet the extra demand for blood. That part of the myocardium which depends on the blocked coronary artery becomes acutely anaemic and the incident usually ends in a classic case of myocardial infarction. This can be defined as complete ischaemia of a well-defined area of the heart wall—usually part of the wall of the left ventricle. The stricken area ceases to contract, fails to assist the ventricular pump in its work, degenerates and, over a period of several months, is 5 ;~'"A ~; q transformed into a fibroid scar, incapable of taking any further part in the working of the heart. The clinical signs of the disease and the electrocardiogram findings usually reflect broadly the changes taking place in the coronary arteries and the myocardium. Thanks to coronary arteriography, we can today observe and follow these changes. First signs When the progressive stenosis, or even occlusion, of the coronary arteries reaches a stage where the anastomotic circulation is no longer able to compensate fully, any occasion when the heart is called upon to increase its output may reveal the anaemic or ischaemic state of the myo- cardium. This usually happens when the patient makes a physical effort, particularly when he is walking. After he has walked a short distance, a hundred yards or less, especially if the weather is cold or the pace too rapid, if the road is steep or if he has just eaten a heavy meal, the coronary insufficiency betrays its presence by a transient pain in the chest. This pain, known as an angina pectoris, comes on suddenly, varies in its intensity, and is usually felt in the midline of the anterior wall of the chest, the retrosternal region. It brings with it a feeling of constriction of the chest, without breathlessness, but unpleasant enough to cause the sufferer to come to a halt or, at least, to slow down considerably. It goes as quickly as it comes—usually in less than two minutes. Its passing is often accompanied by sto- mach gurglings or by belching of wind, which leads the patient to think mistakenly that he is suffering from indigestion— especially if he has just eaten. Although the pain usually comes on while the patient is walking, it may also appear for no apparent reason when he is at rest. It varies in frequency, some patients suffering several attacks in one day, others only two or three in a month. In the intervals between these brief attacks, which never last for more than five to ten minutes, the patient is not conscious of any difficulty or discomfort and usually claims to feel very well. Obesity favours to hypertension. Between the attacks, medical examination often reveals no signs of abnormality, the heart appearing normal to auscultation and to X-ray examination. The most accu- rate diagnostic tool at our disposal is the electrocardiogram. In one-third of cases, it shows abnormalities suggestive of chronic coronary insufficiency, sub-endocardiac le- sions or sub-epicardiac ischaemia; in a further third, the electrocardiogram is not absolutely normal but the irregularities are slight and non-typical; in the remain- ing third, an electrocardiogram taken at rest is quite normal. Whenever the electro- cardiogram is normal, negative or difficult to interpret, it is advisable to give the patient a controlled exercise tolerance test, after which the electrocardiogram will usually reveal the typical irregularities of a transitory, acute, coronary insufficiency. This test often brings on an attack of pain which, however, disappears spon- taneously within a few minutes—even more rapidly with the help of a tablet of nitro- glycerine. In certain cases, coronary arteriography is indicated and may be helpful. A catheter is introduced into a peripheral artery such as the femoral or the brachial artery, and is passed as far as the orifice of the coronary arteries. The coronary arteries are rendered opaque by an injection of a fluid containing iodine and any ste- noses, obstructions or abnormalities be- come visible. Sudden heart attacks When the arteries become so narrow that the flow of blood to the ischaemic areas approaches the absolute minimum necessary to maintain the action of the heart muscle—usually so pressing in its demands for oxygen—the blood supply to the affected areas becomes very uncer- tain. Anginal pain becomes more or less continuous, coming on after ever slighter exertion and sometimes even when the patient is at rest. The deterioration in the patient's condition is apparent in an in- crease in the frequency, intensity and duration of the attacks and, sometimes, even by definitive changes in the electro- cardiogram. The patient is then living under a constant threat of myocardial 7 Grey sections show where pain originates; lines indicate some of the pain pathways. These pains can be felt in the shoulder, in the arms, the back and around the chin. This chart was established on the basis of 658 cases of recent myocardial infarction. Percentages refer to the frequency with which pain is felt in different areas of the body. infarction. In these circumstances, any one of many "incidents" may cause the blood supply, and therefore the oxygenation and nutrition of the myocardium, to fall below the minimum vital level and bring on a heart attack. The immediate cause may be unaccustomed physical effort (though this is rare) or a violent emotion such as anger. A meal that is too heavy or too rich in fatty foods may affect the blood supply in various ways. It may precipitate an attack by upsetting the water-salt balance in the blood, by increasing the work load on the heart, or by modifying the blood chemistry and causing a sudden rise in the level of triglycerides and fatty acids. Heavy cigarette smoking with inha- lation and widely varying intercurrent "incidents", such as an attack of another unconnected illness—influenza, for in- stance, accidental injury or a surgical operation—may also trigger an attack. In most cases, however, a major heart attack occurs suddenly and without warn- ing. It may surprise the victim at his work, while he is resting or, without apparent reason, in bed at night. These cases of unexpected myocardial infarction, particularly when there are no premonitary signs such as recurrence of pre-existing anginal pain, are usually due to coro- nary artery thrombosis. Whether pre- ceded by a recrudescence of anginal pain (in 40 per cent of cases) or apparently linked with an "incident" such as those described above (less than 10 per cent of cases) or striking suddenly and without warning, the heart attack is characterized by a violent bout of pain which spreads to the whole of the thorax, often radiates along the arms, and lasts not minutes, but hours. The immediate risk to a patient suffering such a major attack is even greater than was once thought. Recent prospective epidemiological studies show that the victim often dies within an hour or two of its onset. If he survives this first critical period, myocardial infarction usually develops within the next few days —a consequence of the partial destruction of a segment of the wall of the left ventricle. Once the pain has subsided, the arterial blood pressure falls and there is usually a transient rise in temperature to about 38 or 39 degrees Centigrade (100 to 101 degrees Fahrenheit). Blood tests carried out in the first few days after an attack show abnormal amounts of certain sub- stances (enzymes), indicating that some degeneration of the cardiac muscle cells has taken place. Their presence and the characteristic cyclical irregularities of suc- cessive electrocardiograms confirm the diagnosis. There is nothing to do but to put the patient to bed for three weeks or so with appropriate treatment and wait patiently for the damaged cardiac tissue to heal. Thus, death from myocardial infarction may be immediate, occurring before the infarct has had time to form, or it may occur after several hours or days in cases where the infarct is so large that it inter- feres irremediably with heart function or when it is accompanied by rhythmic com- plications such as ventricular tachycardia (excessive rapid heart beats, at more than 120 to the minute) or heart-block brady- cardia (less than 50 beats to the minute). The first days and particularly the first hours after the cardiac accident being the most dangerous, it is of the utmost importance to establish an early diagnosis and to begin suitable treatment without delay. In this way it may be possible to avoid some of the "illegitimate" deaths which sometimes occur even when the cardiac damage is not particularly exten- sive. This calls for well-organized facilities for the immediate transfer of urgent cases 8 to hospitals where they can be treated in intensive care units. In the majority of cases, the patient can be expected to survive the dangers of the first few days and normally the infarct will cicatrize within a few months. In more than 50 per cent of cases, although the electrocardiogram still shows the pre- sence of a scar, clinical recovery is com- plete. The patient is soon able to resume his normal life and is almost always able to return to full-time work in his former occupation after about three months. If, however, he has suffered several such attacks, the prognosis is somewhat less favourable. A second or third myocardial infarction in a heart already damaged by previous infarcts is more serious. The immediate risk of heart failure is greater and, in the long term, functional recovery is less certain and sometimes less than complete. In 15 per cent of cases, according to some studies, atherosclerosis, even when severe enough to interfere with cardiac function, causes no symptoms and the patient feels no pain. These asymptomatic forms of the disease may be responsible for some cases of sudden death or pro- gressive heart failure whose origin would remain unrecognized without a systematic search for coronary atherosclerosis, this being, after all, one of the most frequent causes of primary cardiac insufficiency in middle age. Heart attacks can be foreseen and treated Although it is so obviously "public health enemy number one", heart disease in general, and heart attacks resulting from atheroma of the coronary arteries in particular, do not always receive the sys- tematic treatment they require. This is probably because it is looked on by many as part of the inexorable running-out of a human life. Nothing could be further from the truth. Heart disease, particularly ischaemic heart disease, strikes more and more frequently in all age groups. Its causes may be more or less accidental, or may be the consequence of years of accu- mulated neglect. It is often predictable and avoidable on the one hand, and curable on the other. Treatment may bring about On the way to the coronary care unit of the Royal Victoria Hospital in Belfast, Northern Ireland, treatment is started in a specially equipped ambulance. As a result of using this ambulance, the death rate among patients admitted to the unit was lowered by 7 per cent. a more or less complete cure or may limit or postpone the ill effects and keep the disease under control for many years. Much of this treatment becomes a matter of extreme urgency when there is a major heart attack and, as is often the case, the patient's life is in immediate danger. Every minute counts and it is vital that the incipient heart attack be recognized as such right from the outset. Like the fire brigade This calls for education not only of the public but also of doctors, whose medical training may not always have prepared them to undertake the modern and some- times "revolutionary" treatment called for in these cases. The classical treatment of the heart attack which forbade moving the patient during the acute stage and insisted on his being treated "in situ" (that is, in his own home) is losing ground. This was perhaps logical in the days when treatment of myocardial infarct was almost all "wait and see". Now, however, we know that the first few hours are by far the most dangerous and during these first few hours "illegitimate" deaths may occur, not as the result of irreversible cardiac damage, but following a sudden rhythmic "accident" such as ventricular fibrillation or cardiac arrest. Such tragic mishaps, against which we are impotent owing to a lack of suitable equipment when the patient is treated at home, are often remediable if treated in centres specializing in the handling of heart disease, where "reanimation" and "de- fibrillation" are common practice. In view of the immediate risk, the patient should immediately be transferred to one these specialized "coronary units". Therefore, in addition to the re-education of the public and doctors, it is essential to organize a special ambulance service to provide immediate intensive care and to be capable of going into action as rapidly as a fire engine, and to set up special units in most hospitals for the treatment of heart attacks. These suggestions are not entirely novel—such centres have been in operation in hospitals in many of the world's cities for years. Any large modern hospital should find it possible to meet the cost of 9 In an intensive care unit, monitoring by electrocardiograph continues day and night. such a unit without overstraining its budget. Heart attacks and myocardial infarction usually follow an uncomplicated course. If there are no complications, treatment is limited to continuous veinous infusion of heparin (an anti-coagulant) while a close watch is kept on cardiac rhythm and arterial blood pressure. If the severe initial attack of pain does not pass spontaneously, sedatives will bring rapid relief. Once the crisis is over, convalescence begins—usual- ly after a few days. Rest in bed for about three weeks remains the standard and logical treatment for recent myocardial infarction. This allows the damaged tissue of the heart wall to begin its process of cicatrization and consolidation. Physical activity should be resumed very slowly and progressively, and it will be at least three weeks—longer if the infarct is se- vere—before re-education and re-adap- tation enable the patient to reintegrate fully into his family and professional life and to resume all his social activities. In the great majority of cases, recovery from a first attack of myocardial infarction is complete and the patient may even be permitted to practise certain sports, pro- vided that he is careful and that they cause him no physical discomfort or other difficulty. Whether or not anti-coagulant treatment should be continued must be decided in the light of the condition of each individual patient. Precautions after an attack It should not be forgotten, however, that even when "cured" myocardial in- farction should never be taken lightly. An infarct, even when healed, or indeed any anginal pain, however brief, coming on spontaneously or during exercise, may signal the presence of coronary athero- sclerosis and indicate that certain pre- cautionary measures should be taken. The patient should be asked to avoid any physical effort which causes him discom- fort and particularly any movement which brings on anginal pain. If pain does occur, a tablet of nitroglycerine should be crushed in the mouth without delay. This drug is harmless when taken in the recommended dosage and its effect is little short of miraculous. It may cause a headache in 5 to 10 per cent of cases (disagreeable but transient). It is erroneously believed by many that nitroglycerine loses its powers if taken frequently; on the contrary, it continues to be effective indefinitely. Of all the drugs known today it is the most reliable, the most rapid and the most spectacular in its results : in 90 per cent of cases it relieves the pain of angina pectoris in less than one minute. No other drug can do this. Other drugs, generally thought to be capable of dilating the coronary arteries, diminishing the labouring of the heart, or improving the metabolism of the myo- cardium by reducing its oxygen (and therefore blood) requirements, may be used with varying success to complete the treatment. There is a long list of products recommended to ward off the ill effects of coronary atherosclerosis; the most frequently used are the nitrate deriv- atives, the mono-amine-oxydase inhibitors and the drugs known as the Beta-blocking agents. Treatment by graft American surgeons have recently per- fected a satisfactory surgical method of restoring the blood supply to ischaemic regions of the myocardium in cases where angina pectoris proves resistant to medical treatment alone. The presence of these bloodless areas, indicated by irregularities in the electrocardiogram, is confirmed by coronary arteriography, which also shows the exact location of coronary stenoses and occlusions. The affected areas can then be revas- cularized by a graft. A long segment of the internal saphenous vein is taken from the thigh and one end of it is im- planted at the beginning of the aorta, the other end being grafted on to a peripheral sector of the coronary artery beyond the point where it is blocked by the obstruction or obstructions. This op- eration, logical and simple to perform and involving very little risk, has proved to be extremely effective in controlling anginal pain, but it is essentially a pallia- tive measure and does not cure the coro- nary atherosclerosis itself. Any treatment must include advice on principles of general health and on the diet to be followed. This is of the greatest importance both to those patients who already suffer from the effects of the disease and to those who, though appar- ently in good health, are "at risk" in the sense that various clinical and bio- logical tests reveal them to be affected by one or more of the "factors of risk". In either case the patient should be advised to take dietetic and hygienic meas- ures which may halt the progress of the developing atherosclerosis. The most im- portant of these preventive measures are to give up smoking (in some patients smoking is one of the most important aggravating factors and should be stopped completely and permanently); to lead a reasonably active life, avoiding sedentary occupations and taking sufficient exercise to keep the muscles in good order; last but not least, to adopt a diet designed to counteract any metabolic disorder which may be discovered by careful biological checks. In conclusion, it can be affirmed that in most cases it is better to prevent than to cure. This underlines the need to set up special centres for the diagnosis and pre- vention of atherosclerotic disease in general and ischaemic heart disease in particular. Our present knowledge of the "factors of risk" is such that a relatively simple examination should enable us to find those populations, or those individuals in a population, who are carriers of one or more of these factors. Those at risk should then be given all the advice we are able to offer them in the light of our knowledge of the factors predisposing them to coronary artery disease. If this advice is carefully followed, it is to be hoped that within the next few years there will be a dramatic fall in the number of victims of heart disease, and particularly of heart disease due to coronary athero- sclerosis. ■ Death rates from arteriosclerotic and degenerative heart disease (45-54 years) Country Death rate per 100,000 inhabitants Changes in % 1955 1960 1966 1967 1967/55 T 159.8 182.4 203.9 204.6 + 28 Australia M 247.0 287.0 324.4 325.0 + 32 F 65.2 71.9 81.3 82.1 + 26 T 72.4 83.3 80.8 88.6 + 22 Austria M 113.9 144.7 147.1 165.7 + 45 F 37.1 34.7 31.9 32.2 -13 T 171.6 191.5 185.9 187.4 + 9 Canada M 277.0 307.6 312.0 314.7 + 14 F 59.0 69.0 59.3 60.5 + 3 T 74.1i--; 76.8 93.9 101.3 + 37 Czechoslovakia M 114.1 Le, 127.2 159.7 178.1 + 56 F 36.5 29.3 32.3 29.7 - 19 T 90.0 97.3 107.6 102.3 + 14 Federal Republic M 134.2 159.5 186.5 179.7 + 34 of Germany F 51.9 48.5 49.7 46.0 -11 T 173.8 186.1 226.1 244.7 + 41 Finland M 305.8 340.1 436.7 468.6 + 53 F 59.2 53.4 51.4 60.1 + 2 T 30.3 40.2 42.1 41.7 + 38 France M 49.2 67.8 73.3 72.4 + 47 F 12.0 13.5 12.2 12.2 + 2 T 84.5 91.7 104.1 111.2 + 32 Hungary M 109.2 119.2 148.5 160.7 + 47 F 61.9 67.2 65.3 67.9 + 10 T 69.7 75.7 78.0 78.9 + 13 Italy M 97.2 114.7 125.1 127.5 + 31 F 43.6 38.8 34.2 34.0 - 22 T 53.6 45.7 39.2 39.1 - 27 Japan M 58.3 52.9 51.5 50.4 -14 F 49.0 39.1 28.9 29.9 - 39 T 69.9 73.3 98.0 106.9 + 53 Netherlands M 115.1 128.7 173.7 191.2 + 66 F 27.2 20.9 25.6 26.2 - 4 T 69.5 69.4 76.5 79.7 + 15 Sweden M 106.9 108.3 125.7 133.7 + 25 F 32.5 30.1 26.8 25.4 - 22 T 78.0 79.3 85.7 75.9 - 3 Switzerland M 117.1 124.7 135.8 126.2 + 8 F 41.8 33.9 37.1 27.3 - 35 United Kingdom: England T 109.1 121.2 144.5 140.9 + 29 35 + and Wales only M F 181.3 40.1 208.3 37.6 248.0 44.6 244.0 41.6 + 4 T 210.6 216.0 215.7 211.8 + 1 United States M 342.2 358.5 357.7 351.8 + 3 F 82.2 78.2 81.9 80.3 - 2 T 97.5 118.6 96.7 102.1 + 5 Venezuela M 127.3 158.1 126.8 139.6 + 10 F 65.1 75.1 65.2 61,7 - 5 This table lists death rates in the 45-54 year age group which is the most significant, because the factor of old age does not intervene. It shows, between 1955 and 1967, with the exception of the United States, Japan and Switzerland, a general increase in the rates. The death rates for men are approximately three times higher than for women. Any comparison between countries should be done with extreme prudence because of different habits of diagnosis. T = total M = male F = female Source: World Health Statistics Annual. 1 1 stroke a problem in japan today by Dr S. Hatano What an appetizing odour of miso soup ! The freshly prepared pickles in the bowl nearby also smelled good. And what a good taste the fresh rice had tonight! Mr Fujiyama was in particularly good humour, thought his wife, as she watched him carrying on a lively conversation with all the family. Outside it was cold, but indoors all was cosy, peaceful and warm; warmed by the table fire, they watched television until late, then prepared for bed. Mrs Fujiyama's husband went to the bathroom; minutes passed, but he did not return. Becoming anxious, she went to look for him and found her husband lying on the cold floor in the corridor in a state of unconsciousness. Extremely upset, she immediately telephoned the emergency service at the hospital for an ambulance. The family breadwinner, Mr Fujiyama had rarely been ill or suffered from any disease. Only a couple of months ago, however, he had consulted a doctor because he felt a stiffness, almost paralysis, on the left side of his body, and had been advised to take medicine continually because of high blood pressure. The para- lysis disappeared the same day and noth- ing further had happened until now. The whole family had almost forgotten the medicine and the illness. However, now something serious seemed to have happen- ed; Mrs Fujiyama thought of her father- in-law who had had apoplexy and had been ailing and confined to his bed for many years. Her children were still attend- ing school: they needed their father and the home needed its breadwinner. While she waited for the ambulance to arrive, all these thoughts passed rapidly through Mrs Fujiyama's mind—somehow she could not quite believe in her husband's sudden collapse. Apoplexy, such as her father-in-law and her husband had experienced, is indeed a ve- ry common disease in Japan, particularly in middle-aged and older people. In Japan, one out of three deaths after the age of 55 is caused by apoplexy, compared with one out of six in European and American countries. In Japan, after an attack, one- third of patients die within a month, one- third contract disabilities and need help in their daily life after recovery, and only the remaining third can return to a more or less normal life. What causes such an accident that can change the life of a family so suddenly? The brain is very sensitive to a shortage of oxygen, and a sudden interruption of arterial blood supply rapidly leads to a disturbance of its function. If this inter- ruption persists for even a few minutes, the damage cannot be repaired and be- comes irreversible. Nature provided man with multiple safety measures to secure a continuous supply of blood to the brain; four main arteries form a loop at the base of the brain before entering into the brain tissue itself. This loop, connecting all four vessels, helps to distribute the blood evenly to all parts of the brain even when one or more of the four arteries is blocked. If a part of the brain should nevertheless become short of blood it may lose its function and symptoms such as coma, paralysis of one side of the body, or speech disturbance may appear. These sudden impairments of the brain caused by damage to the arteries are called "cerebro- vascular disease", "apoplexy" or "stroke". Lesions may narrow or block the artery and a haemorrhage may be caused by rupture of the vessel. The symptoms and their severity differ according to where and how rapidly the damage arises. If obstruction progresses slowly, new routes of blood supply develop and either no symptoms appear or only a limited part of the brain is impaired, which results in a mild neurological defect such as a slight disturbance of mental function or weak- ness in some part of the body. When sudden disturbance of the circulation occurs, symptoms are usually severe; often sudden loss of consciousness appears as the dominant sign. About a quarter of patients die in coma on the day of onset. On the other hand, there are milder cases characterized, for example, by para- lysis of part of the face or leg, collapse, a shadow before the eyes, impaired vision or blindness in one or both eyes with or without dizzy spells. Such symptoms may last from a few minutes to hours; recovery may be complete. These cases arise through 12 Mk, . • l' 'V % i:4;0? ***. %.04411 • ••Vt• 14 ' ••N'ir; 41/4* W. . It ";* s ' \ i While baby sits in the sun, Mrs Fujiyama prepares miso soup, the national Japanese dish containing vegetables, fermented wheat and salt fish. Japanese diet, however, may play a part in certain diseases such as apoplexy, more common in Japan than elsewhere. the obstruction of brain arteries by small clots which travel along the blood stream from the heart or by an ulcerated athe- rosclerotic lesion in a larger artery. The clot is usually soon dissolved by enzymes, blood supply improves and brain function is quickly recovered. Three major threats The three major types of severe stroke are subarachnoid haemorrhage, intra- cerebral haemorrhage and cerebral infarc- tion. The arachnoid membrane is a thin cover over the brain and the arteries lying on the brain surface. When an artery ruptures, haemorrhage may occur into the fluid space between the brain and the arachnoid membrane. This haemorrhage is accom- panied by severe headache and can be diagnosed if blood is found in the spinal fluid. Subarachnoid haemorrhage occurs regardless of age, and in fact frequently strikes young people. It occurs from a congenital malformation of the wall of the artery; it is usually manifested by a bulging of the artery, called aneurysm. Recurrence is frequent, particularly within the first six weeks and prognosis is worse after each recurrence. Aneurysm may occur in the brain in the smaller arteries-0.1 to 0.2 millimetres in diameter—when the arterial wall is weakened. The rupture of these tiny arteries causes intracerebral haemorrhage; the blood expands in the brain, com- pressing the surrounding areas and inter- fering with their function. Intracerebral haemorrhage is the most severe type of stroke-80 per cent of cases die during hospitalization. This type of vascular lesion can be produced by experimental hypertension in rats and rabbits, and is frequently encountered among hyperten- sive patients. We may conclude that hyper- tension is its most important cause. The third type is called cerebral infarc- tion. When the main artery is blocked, the part of the brain perfused by this artery dies. Obstruction of the blood flow is usually a consequence of atherosclerotic narrowing and occlusion of the artery. The occlusion, or cutting-off of the flow, is often caused by thrombosis (blood clot) Heating systems old and new: at their . eet a brazier, on the roof a modern system using solar energy. Brought by the ambulance, the physician begins to treat Mr Fujiyama before taking him to the hospital. in the part damaged by atherosclerosis. The artery may also be blocked by a blood clot which is torn away from the heart cavity or from an atherosclerotic plaque in the neck arteries or in the aorta. Any one of these conditions may have been responsible for Mr Fujiyama's stroke. Within half an hour the doctor arrived in an ambulance; Mr Fujiyama was now semi-conscious. His eyes were slightly open but his face was red, his left cheek distended and his breathing deep and stertorous. The doctor found that the patient had high blood pressure but that the heart beat was regular. Immediately, the windpipe was cleared by suction and oxygen was given through a mask. This treatment was continued during the trans- fer to hospital, where Mr Fujiyama was placed in a department for acute cardio- vascular emergencies. The spinal fluid did not contain blood, the electro-cardiogram showed only a slight possible hypertensive change, and Mrs Fujiyama was reassured after these preliminary examinations that there was a good chance of her husband's recovery. One million deaths Cerebrovascular disease is the third leading cause of death in 54 out of 57 coun- tries where national statistical data for international use are available; it is sur- passed only by ischaemic heart disease and cancer. Almost one million people, in these countries alone, died from cerebro- vascular disease in 1966. The disease is increasing in most countries simultane- ously with the increase in longevity of the population, and is commonly found in all parts of the world. There is no great difference in frequency between men and women. However, differ- ent rates of mortality and morbidity have been found in countries with different natural and cultural environments. In the age group 55-64 years its rate of frequency is higher in Japan, Taiwan, Mauritius, Trinidad and Tobago, Portugal, Bulgaria, Malta, Scotland and Chile; it is lowest in Central America, the Philippines and Thailand. Even within the same country, regional differences have been found. For example, in Japan it occurs most frequently in the northern part of Honshu Island; in the USA, it appears mostly in the south-eastern states and is more frequent among negroes than among whites. Cerebrovascular disease strikes more frequently among Japanese in Japan than among expatriate Japanese in Hawaii and the American continent: on the other hand, ischaemic heart disease increases among the expatriate groups. It is estimated that there are about 4 million people in the 15 - -- Since 1961, a study has been under way on the island ofKyushu where systematic cardiac examina- tions are given to everyone over the age of 40. Here Drs Yasuo Hirota and Okwni, who are in charge of the study. at a more advanced age. Apoplexy among the Japanese, particularly in the north, seems related to their diet, which contains large amounts of salt, and to their un- heated, cold and drafty wooden houses. Both high salt intake and cold are regarded as important contributory factors to the development of hypertension. The frequency of lethal stroke is about three times higher in American negroes than among the white population; one explanation is the more frequent severe hypertension among the former. The road to recovery world surviving after stroke. Annually, two to five white Americans and three to ten Japanese out of 1000 middle-aged people are affected. While Mr Fujiyama was still semi- conscious in the hospital, the lower part of his body was elevated slightly to help involuntary expectoration and the oxygen supply was maintained. Every two hours he was slightly turned to relieve body weight pressure on the skin over bony prominences such as hips, back or heels. The skin was cleaned, massaged and powdered with talc. He had paralysis of his left arm and leg; these limbs were placed in a special position to avoid muscular contraction and thus help func- tional recovery. When he regained full consciousness, six hours after the onset of his attack, he still could not move his left arm or leg and had a funny, numb feeling down the whole left side of his body. He could speak, however, and with help he managed to take a few sips of a warm Japanese tea. The doctor found that his circulation and respiration were functioning normally, and his blood pres- sure was much lower than at the first examination. Within the next 24 hours the clinical picture became stable and rehabili- tation could begin, with passive movements of the paralyzed extremities. Hypertension is the most common cause of stroke in most countries. In those where myocardial infarction is less fre- quent, brain haemorrhage often occurs as a complication of hypertension. Hyper- tension, however, also accelerates the development of atherosclerosis and result- ing brain infarction, which usually occur A number of studies have shown that reduction of high arterial pressure can reduce the incidence of cerebrovascular accidents. A subject with high blood pressure may have no symptoms and therefore not know that he is hypertensive, but the chance of a sudden attack of apoplexy exists nevertheless; hence the importance of regular check-ups in middle- age. Obviously every community pro- gramme for stroke prevention must aim to seek out and take care of subjects with hypertension. The recovery of Mr Fujiyama proceeded normally without any complications. The whole family celebrated the day when he could for the first time hold a bowl of rice in his left hand. He himself had been busy every day moving the paralytic limbs with his right hand, regaining step by step the possibility of active movement of the left leg, hand and arm, and he was even able to manage a few first steps. The improvement in his general condition per- mitted a more detailed examination of the brain vessels to be made. The angiogram, i.e. an X-ray picture using contrasting opaque substances injected into the ar- teries, showed that the major vessels in the neck leading to the brain had been only slighthly disturbed by atherosclerosis and that there was no obstruction. 16 Occlusion or blood clots in arteries out- side the skull are common among middle- aged American whites but less among US negroes and Japanese; in the latter, occlu- sion is more often found in vessels inside the brain. According to a study in the USA, three-quarters of patients with cere- brovascular accidents have surgically ac- cessible lesions in the extra-cranial arteries. In these cases, removal of blood clots, or reconstructive surgery of the brain vessels by patch or graft, can be effected in order to prevent future cerebrovascular accidents. However, surgery of this type has little value after a stroke, and therefore early detection is important. In fact, surgery after the stroke may even be more dangerous than not having any operation. Recurrence of subarachnoid haemorrhage can be prevented by surgical correction of the malformation of the brain artery, and effusion of blood inside the brain may also, in some cases, be eliminated surgi- cally. Mr Fujiyama was lucky. The treatment started very soon after the onset of his attack and swelling of the brain in the tissue surrounding the damage could be limited. He had no further complications during his stay in hospital, and appro- priate rehabilitation speeded up his recov- ery so that in three months he was able to resume work. Only his left leg was a little stiff, and he limped when he was tired. He had no severe atherosclerosis and his hypertension could be reasonably well controlled. His case is one of the many examples of how immediate, ade- quate care may help to restore the dam- aged function. Prevention of cerebrovascular accidents depends largely on the control of hyper- tension and atherosclerosis. How far we have gone in this direction is discussed elsewhere in this issue. One thing is clear, however-stroke is a disease which is widespread, not only in Japan, but it can be treated and prevented, and is not an inevitable consequence of the ageing process. ■ Death rates from vascular lesions affecting central nervous system 45-54 years Country Death rate per 100,000 inhabitants Changes in % 1955 1960 1966 1967 1967/55 T 77.5 62.5 55.7 57.9 - 25 Australia M 71.3 59.2 51.9 58.0 - 19 F 84.2 66.1 59.7 57.8 - 31 T 42.3 40.0 31.2 29.7 - 30 Austria M 44.3 43.1 37.6 40.1 - 9 F 40.6 37.6 26.5 22.1 - 46 T 42.8 34.4 29.5 31.1 - 27 Canada M 39.9 34.9 30.4 32.9 -18 F 45.9 34.0 28.7 29.4 - 36 T 43.7,3 30.1 27.4 28.4 - 35 Czechoslovakia M 44.7?,, 32.9 33.7 32.4 - 28 F 42.77- 27.4 21.5 24.8 - 42 T 38.9 34.2 30.2 27.2 - 30 Federal Republic M 40.1 37.1 35.5 33.6 -16 of Germany F 37.8 32.0 26.3 22.5 - 40 T 66.9 59.8 69.5 67.4 + 1 Finland M 68.2 64.8 72.8 75.0 + 10 F 65.7 55.5 66.8 61.1 - 7 T 55.7 43.8 34.8 33.0 - 41 France M 64.7 49.7 43.7 40.4 - 38 F 47.0 38.1 26.2 25.9 - 45 T 63.2 51.1 43.6 40.0 - 37 Hungary M 60.0 49.8 42.9 44.2 -26 F 66.2 52.2 44.2 36.4 - 45 T 44.3 42.4 40.7 38.6 -13 Italy M 47.2 46.2 45.3 44.0 - 7 F 41.5 38.8 36.4 33.6 -19 T 152.2 140.3 113.2 104.6 - 31 Japan M 168.8 168.0 145.9 135.7 -20 F 136.1 115.0 86.0 79.0 - 42 T 23.6 21.2 22.1 25.9 + 10 Netherlands M 20.1 20.3 22.3 28.8 + 43 F 26.9 22.1 21.9 23.2 -14 T 45.7 30.3 27.0 25.6 - 44 Sweden M 38.9 31.0 29.4 27.8 - 29 F 52.5 29.7 24.7 23.3 - 56 T 39.6 25.9 21.5 22.6 - 43 Switzerland M 38.1 24.9 22.3 24.9 -35 F 41.0 26.9 20.8 20.3 - 50 United Kingdom: T 52.5 46.9 42.0 41.0 - 22 England M 51.1 49.0 43.3 41.4 -19 and Wales only F 53.9 44.9 40.6 40.6 -25 United States T 56.0 48.9 43.4 43.5 -22 of America M F 56.3 55.7 51.9 45.9 47.3 39.7 46.2 41.0 -18 - 26 T 36.8 48.9 45.3 44.4 + 21 Venezuela M 33.9 53.9 48.6 44.0 + 30 F 40.0 43.3 42.0 44.8 + 12 This table, like that on page 11, also covers, for the same reason, the 45-54 age group. With the exception of the Netherlands and Venezuela, it shows a general drop in death from cerebrovascular diseases between 1955 and 1967. This noticeable drop seems to be due in part at least to better control of hypertension. Unlike cardiovascular diseases, cerebrovascular diseases are as frequent as a cause of death among women as among men. Any comparison between countries should be done with extreme prudence because of different habits of diagnosis. T = total M = male F = female Source: World Health Statistics Annual. 17 towards better control by Professor P. Duchosal World Health: What is hypertension, W.H.: The figure exactly ? Prof Duchosal: The shortest and also the most correct definition of hypertension is a rise in systolic and diastolic arterial pressure above the normal. But, since such a rise in blood pressure may eventually be a cause of disease, hypertension has come to be considered as a disease itself. This form of illness may lie dormant or already be serious and produce symptoms. W.H.: A doctor often tells a patient that his blood pressure is, say, 150 over 100; what is the level above which a person may be said to suffer from hyperten- sion? Prof Duchosal: This question has been the subject of much discussion between various countries and groups of profes- sionals. Today it is universally agreed that a blood pressure of 150 over 90 may be considered normal. That is to say a minimum, or diastolic pressure, of 90 mm of mercury and a maximum, or systolic pressure, of 150 mm. Thus, strictly speak- ing, a patient with a maximum of 160 mm is already suffering from hypertension. However, such factors as the patient's age must be taken into account; a pressure of 160 is a more serious matter at 20 than at 50 or 60 years of age. must, then, be weighted for age? Professor Pierre Duchosal. Prof Duchosal: There is nothing ab- solute about the figures, for there are other factors besides age that have to be considered. A person's blood pressure may vary at different times of the day. After a night's rest, the blood pressure may be much lower than at the end of a tiring day. It is therefore always preferable to measure it under the same conditions. The figure obtained in the morning after a good night's rest should be taken as the basic blood pressure. However, this is rarely possible with patients who just drop by to consult a doctor. There are also hypersensitive people whose blood pressure rises to some extent under the influence of quite a small degree of stress or excitement. This may be con- sidered as an initial hypertension. One often has to examine patients who are tired or nervous, who have had a heavy meal or even who have just been running because they were late. For one or more of these reasons their blood pressure rises. In such cases, several tests must be made under comparable conditions before diag- nosing hypertension. If constant results are not obtained—if, for instance, a patient has 170 over 100 at one time and 150 over 80 at another, he may be considered as labile and a possible future candidate for hypertension. W.H.: So, with the reservations you have just mentioned, 150 over 90 re- presents a normal blood pressure. Can you tell us some more about the causes of hypertension? Prof Duchosal: They are many. Hyper- tension occurs when the cardiac output increases either because of higher periph- eral resistance or because of some altera- tion in the viscosity of the blood. It must be remembered that the heart has a reserve of energy which is drawn upon in cases of hypertension in order to meet increased 18 * Professor at Geneva University. The doctor has inflated a cuff over the patient's arm and is now watching the pressure in the instrument; at the same time, she is listening to the artery beneath the cuff. Appearing and disappearing sounds will inform her of the height of systolic and diastolic blood pressure in the artery: a simple, reliable, rapid and painless test. needs. Heart function is flexible in order to meet the demand that is made on it and cannot really be considered a cause in itself of hypertension which is basically caused by some peripheral obstacle pro- ducing what is called systemic resistance. Such systemic resistance can actually raise blood pressure to twice the normal. This does not tell us where the site of resistance is located because all the organs of the body are perfused with blood brought by arteries, small arteries and capillaries which represent distinct centres of resis- tance to the blood flow over all the circuit. That each receives its correct quota, in spite of these myriad compartments, thanks to a harmonious distribution of blood as a result of almost invariable central arterial pressure, is one of nature's marvels. As long as this irrigation meets the demand of the body, particularly the brain but also the kidneys, the viscera, muscles and skin, as a result of the heart's constant effort, all is well. The brain is the best protected organ whose perfusion is almost always constant. In physical exer- cise there is temporary high blood pressure as the flow through the kidneys diminishes and that of the muscles increases. The heart thus plays the role of a versatile and sensitive pump. An imbalance in any one of these can cause hypertension or low blood pressure. W.H.: Are there any external causes that can produce such changes in the body? Prof. Duchosal: There are many such causes connected with the environment, such as climate, temperature, nutrition, nervous tension and stress. Indeed certain authors consider that emotional stress is responsible for essential hypertension, that is hypertension for which no organic cause can be discovered. W.H.: But what is "emotional stress"? It seems to be something that is more talked about than defined. Prof Duchosal: Every emotion produces some stress. A distinction should however be made between stresses associated with high and low pressures. Some emotions induce pallor and faintness—a depressive state. Other tend to raise pressure and produce redness of the face and a fast pulse—these are always associated with some discharge of catecholamines, like adrenalin, induced by emotion. W.H.: But is not emotional stress rather of a psychological nature? For instance, would not fear of hunger give rise to emotional stress? Prof Duchosal: It certainly would and hunger as a result of malnutrition would produce an even more severe stress : however, as a rule hunger eventually produces a drop in blood pressure. Generally speaking, emotional stress is only important for hypertension if it is repeated or permanent, namely something that continually recurs to trouble or torment someone. Unfortunately, such situations are all too frequent in this world of ours. Nevertheless, even the theory of stress as a cause of disease is disputable, since there are too many exceptions to the rule, i.e. people subjected to emotional stress for years who never develop hyper- tension. W.H.: In short, the question of causes is very complex. How does a person know whether he is suffering from high blood pressure? Are there any definite signs? Prof Duchosal: It is true that many people have high blood pressure without being aware of it. That is either because they do not feel anything unusual or because they fail to notice symptoms such as palpitations, noticeable acceleration in the heart beat, headaches, dizzy spells or muscular pains. Obviously many patients who learn from their physician that they have hyper- tension will be a little uneasy at first and perhaps on the lookout for further symp- 19 toms. This raises the question whether it helps people to make them aware of their condition. In the long run it is a good thing to be able to advise them how to take care of themselves and stop the further pro- gression of the disease. W.H.: Would you consider someone to be ill as soon as hypertension has been confirmed? Prof. Duchosal: Theoretically, yes. However, I often see patients with pres- sures of 170/100 or 180/105 who seem perfectly well, practise sports and do not suffer from headaches, palpitations or redness of the face. Therefore, though it is important to discover hypertension, it is not necessary to be alarming. In fact, a large number of people, as a result of a change in way of life including a change of diet and some specific remedies, can soon be classified among those with normal hypertension. W.H.: Do you advise against sport in cases of high blood pressure? Prof Duchosal: Yes, after a certain age, where hypertension goes above 180/100, and taking into account how strenuous the sport is, there may be a risk of brain haemorrhage or atherosclerosis. For a person with constant high blood pressure, violent sports are definitely out. On the other hand, someone with only slight hypertension, whose heart is in good condition, would be well advised to take a walk for an hour or two each day or indulge in some form of light exercise which he enjoys. Personally, I advise against a sport like tennis practised late in life and against mountaineering or skiing, except perhaps cross-country skiing which is now very popular and can be carried out at low altitudes and on reasonably flat terrain. W.H.: But don't you think that every- body discovers his own limitations? walking... bathing... Prof Duchosal: Not always. There are three kinds of people. Some are well- balanced, conscious of their state of health and careful not to overdo things. Others refuse to admit to any weakness or handicap and in spite of having high blood pressure declare "I don't care, I shall go on as before". They take a great risk. Lastly there are timid souls perma- nently besieged by fear. They retire into themselves, refuse the least exertion, and won't even walk a step. Yet by growing fat and losing muscle tone they expose their circulatory system to further hazards; their metabolism becomes unbalanced and actually accelerates the process of athero- sclerosis. W.H.: Given the diversity of the forms hypertension can take, and the variety of individual reactions, how do you go about treating your patients? Prof Duchosal: First of all, the physi- cian must try to discover the psychological structure of the patient and take this into consideration; too many prohibitions may have unfortunate repercussions. First of all it will be necessary to try to bring the patient's weight and his diet into line with what should be best for him. Medicine should almost never be used as a first step; only later, if restrictions and counselling have proved ineffective, does the use of specific remedies become indispensable. W.H.: You say that you advise against mountaineering. Yet I believe that some recent research among people living at high altitudes has shown that they do not suffer from high blood pressure. Prof Duchosal: You are no doubt referring to what has been done by WHO, and by research workers such as my colleague Dr Pierre Moret, who studied the indigenous population living at over 14,000 feet in the Andes. It is important to remember that such people live perma- cross-country skiing are all recommended. nently under those conditions and have done so for generations. A hereditary factor is no doubt operating. Life at 14,000 feet, generation after generation, seems to encourage the development of the blood vessels in number and strength thus improving the circulation and giving greater tolerance to conditions of high altitude. That would explain why hyper- tension is so rare among such populations. W.H.: Doctors often speak of primary and secondary hypertension. What do these terms mean? Prof. Duchosal: Primary hypertension, or essential hypertension as it is also called, is simply one whose causes are unknown. In secondary hypertension the mech- anism is known and, perhaps, the weak point at the origin of the vicious circle. W.H.: Which cases are more common, primary or secondary hypertension; is there any difference in their severity? Prof. Duchosal: Numerically speaking, the majority of cases are those of essential hypertension because large numbers of people go above the 150/90 rate while rested and are still not classed as being sick. Essential hypertension is more fre- quent but also less serious. However, with the passage of time, essential hypertension can become worse and lead to coronary diseases. Secondary hypertension falls into three principal categories according to site: renal, vascular or endocrine. Cases are fewer but lead to more complications. The number of essential hypertension cases tends to decrease progressively as more becomes known about their causes and they can be classified as secondary hypertensions. This means that the prob- lem keeps changing its aspect. For ex- ample, only recently we discovered a vaso- depressor is secreted by the kidney which may play an important role in causing essential hypertension when produced in insufficient amounts. W.H.: So, as our knowledge increases, more and more cases are becoming sec- ondary? Prof Duchosal: Precisely. Essential hy- pertension is slowly becoming less com- mon. W.H.: Do atherosclerosis and hyper- tension go together? Prof. Duchosal: Yes, particularly during the latter half of life. This association is especially striking in the case of the kidney, the brain and the heart; a large number of coronary diseases and myo- cardial infarcts are the result. Further- more, hypertension fatigues the heart because of the additional labour demanded every day and, in extreme cases, this brings on cardiac insufficiency and heart failure. The heart's pumping begins to fail as is shown by oedemas, breathing difficulties or visceral blockages and leads eventually to death. This is called left ventricular insufficiency or "forward failure". W.H.: What degree of additional strain is placed upon the heart by high blood pressure? Prof Duchosal: The heart may be required to work twice as hard, day and night, as it would normally. You can imagine the result if, in addition, any strain is put on it. It does not necessarily beat more rapidly. Nevertheless, it has to work harder each time it pumps. After 20 years of hypertension, a patient's heart may reach twice its normal volume and it then requires twice as much blood to supply all its own cells. You can see why cardiologists attach so much im- portance to controlling hypertension. We always measure a patient's blood pressure in the hope that it will help us to explain his case or at least to know how to deal with it. But you cannot always tell; figures can be deceiving. For example, this morning I saw a patient whose case is worth mentioning. He is a man of 67 whom I had known in 1958, twelve years ago. At that time he suffered from extreme hyper- tension, 190 over 115, and had palpitations. Then he went to another country, where he had a heart attack in 1965. When I saw him again the other day his blood pressure was back to normal, 145 over 88. But his heart was in a shocking state; it was hypertrophic and pains in the chest had reappeared. The initial hypertension noted twelve years ago was certainly responsible for some of the development of his cardiac condition even though it seemed to dis- appear when his heart became seriously ill. W.H.: Is it not rather unusual to return to normal after an infarction? Prof Duchosal: It is not extremely common but it has happened. Usually the "improvement" only refers to blood pressure and not to the heart itself, as in the case I have just mentioned. All cases of hypertension who have a heart attack do not necessarily progress in the same manner. W.H.: What can be done in the way of prevention—that seems to be the best hope for the future? Prof Duchosal: There are two forms of prevention, primary and secondary, and we cardiologists are usually obliged to practise the latter kind which is concerned with preventing an already existing condi- tion from getting worse. In the case of a patient with high blood pressure and some heart damage we can only try to prevent the hypertension from getting worse and the heart from deteriorating further. Primary prevention of arterial hyper- tension is a vast project whose methods are not completely fixed because there is 22 Hypertension is rare among the people of the high Andes. • IV Hypertension is nearly unknown among the Eskimos who eat almost no salt. Too much salt exerts pressure on the circulatory system. still too much that remains unkn( about the causes. This is an epiden logical problem on a world scale whic why wHo is tackling it presently. prevent dangerous hypertension is so thing beyond the means of the aver practitioner. WHO, which has consider activities in this field, as do a number universities in various countries, is gc over a series of possible causes such stress, toxic elements, diet, race, herec etc. Salt has been isolated as an import factor since it has a certain tendenc3 raise blood pressure by means that c rate indirectly. Different populations widely different quantities of salt their rates of hypertension vary acc( ingly; among the Eskimos who little there is hardly any hypertens whereas it is extremely common am , inhabitants in the north of Japan wh diet contains large quantities of s Therefore, a reasonable diet with salt intake is one means of prevent arterial hypertension from making appearance or from getting worse. W.H.: Haven't you just given a rule general good health? Prof Duchosal: Yes. In any cooking should be low on salt and low calories. A general practitioner is placed for spotting hypertension cL - before they become too serious. He sho look them over very carefully, find ou they have a very salty diet and wha worse, if they smoke. His first imps should not be to prescribe a remedy rather to begin by enquiring about patient's habits including his phys: activity, his diet and any worries he n have. The essential step is to gain patient's confidence so that he can persuaded to correct or break certain 1 habits or cut down his food intake. L of weight or a sharp drop in salt consur tion often gives surprising results. He ever, if tension is very high and o Unlike the Eskimos, people in the northern part of Japan eat large quantities of salt, and among them hypertension is common. Doctors are accordingly recommending a low salt diet. responds slightly to a change in diet, then the physician will have to prescribe a variety of effective medicines he has at his disposal. Needless to say, they should be only taken upon medical prescription. W.H.: So you begin by trying to change bad habits and only, as a last resort, you begin to use medicine? Prof. Duchosal: Yes. Persuasion comes first. Next it is important to determine what sort of hypertension is involved. To do this we carry out a series of routine tests, biological, radiological, isotopical, urinary. Medical chemotherapy has made enormous progress in dealing with hyper- tension. Carefully used, it can slow up or even stop what would otherwise be dangerous hypertension. W.H.: As a cardiologist you are con- fronted with two series of developments. On the one hand there is an increase in cardiovascular disease which is the leading cause of death in most countries, and, on the other, substantial progress in diagnostic methods and in medicaments can produce, if not a cure, at least marked improvement. In view of these two con- flicting tendencies, how do you regard the future? Prof Duchosal: With only a moderate degree of optimism. We are trying to cope with an increasing number of patients and, on the other hand, with certain facets of human nature. Many risk factors have been identified but the fact that they do not always cause ill health prevents too many people from taking them seriously. This is particularly true of overeating, high salt intake, lack of physical exercise and cigarette smoking. For the physicians, the only thing we can do is increase research and carry on the struggle as best we can. ■ Epidemics of cholera, malaria, pellagra, plague, tuberculosis, typhus have come and gone in recent centuries. Some of them seem to have waned spontaneously; others have retreated before man's coun- ter-attack. Bitter experience and careful research have taught us a great deal about epidemics, and these lessons are invaluable in dealing with the newest enemy, the mounting tide of early heart attacks. Rudolf Virchow, one of the pioneers of modern medicine, went to the core of the matter over a century ago : "The history of ... epidemics is ... the history of disturbances of human culture. Changes in epidemics announce in gi- gantic signs the turning points towards new directions. "Epidemics resemble great warning signs on which the true statesman is able to read that the evolution of his nation has been disturbed." Tuberculosis illustrates the point. The bacterium necessary to produce TB has existed in human beings throughout mil- lenia ; only in the nineteenth century did the great white plague of clinical tuber- culosis burst forth—the major health prob- lem of the age. The precipitating causes of this epidemic were the new social conditions generated by the industrial revolution: chaotic expansion of villages into cities; grossly inadequate housing resulting in overcrowding and slums; long hours of dirty, gruelling work; child la- bour; poor sanitation and medical care. These social disturbances were just as much responsible for the outbreak as the TB bacteria. The conclusion is evident: epidemics are due to multiple causes, the result of faulty social evolution. In the twentieth century, tuberculosis has been replaced by coronary or ischaemic heart disease as the epidemic in indus- trialized countries. Tuberculosis was the epidemic of this society in its childhood and adolescence: there is a great deal of evidence that coronary heart disease, par- ticularly early coronary heart disease, is the epidemic disease of mature, advanced, industrial society. A rich diet is the most important of the many factors that are responsible. For the first time in history, large segments of the population are able to "live off the fat of the land" on a diet high in animal products such as meat, eggs and dairy products, instead of being obliged by harsh conditions to exist on bread, potatoes, pasta, oatmeal, cornmeal or other cheap, starchy foods. This remarkable socio-economic devel- opment is still the exception rather than the rule in terms of the whole world. Hunger still sleeps each night with hun- dreds of millions of people in Asia, Africa and Latin America—and some in Europe and North America as well. Starvation kills babies; undernutrition robs gaunt millions of adults of their vigour. It is therefore anomalous that some of the Dr J. Stamler giving a talk on the caloric content commonest foods of prosperous peoples are contributing to the plague of heart attacks, that in affluent countries overnu- trition is one of the major causes of disease, disability and death. Full awareness of this problem has come slowly and haltingly, which is not surprising. Nutrition is a young discipline which deals with a complex subject—op- timal diets for man. In the beginning the question was: what is an adequate diet? The first concern was quantity—calories. As the science developed, qualitative needs appeared: essential nutrients, proteins, amino acids, vitamins, minerals. Until recently the emphasis was on minimal, adequate and optimal amounts of food to avoid malnutrition. Derived from Latin, mal means bad. Malnutrition nevertheless was synonymous with undernutrition, and rightly so, since for most of mankind, especially the hundreds of millions with low incomes in the developing countries, undernutrition was the mal. It is now evident, however, that there are two broad types of malnutrition- undernutrition and overnutrition, the latter significantly responsible for the current epidemic of premature heart attack. It is widely recognized that a fundamental re- evaluation of the principles of optimal nu- trition is needed, a re-evalution that takes into account both aspects. For example, the precept that high intakes of the so- called "protective" foods—butter, cream, cheese, eggs and meat—are vital and that children, youth and adults must be encou- nutrition and the present epidemic by Dr Stamler* 26 * Executive Director, Chicago Health Research Foundation. of various foods. raged to eat them in large quantities must be reconsidered. The developed countries, by following this precept and thereby preventing one set of problems, the results of undernutrition on a mass scale, have willy-nilly created another set of problems, among them the increase in coronary heart disease. But is diet really the cause of the coronary epidemic? What is the scientific evidence? The nature of the enemy It is essential to be absolutely clear about the nature of the enemy. Heart attacks are more often a consequence of severe atherosclerosis, the major specific type of arteriosclerosis (hardening of the arteries), the culmunation of a pathological process that develops insidiously over decades, from childhood on. Its hallmark is the accumulation of lipids (fats)—mostly cho- lesterol, on the inner wall of major arteries, and particularly the coronary arteries that supply blood to the heart. This was recognized over a century ago by the pathologists and clinicians, and led to further questions: what is the source of the cholesterol that piles up when arteries harden? Is there any relationship between the fats people eat, the fats circulating in the blood, and the fats in the arterial wall? Early in this century, animal studies and international comparisons of findings in man provided initial answers. In 1908, a group of young research workers in St. Petersburg did an experi- ment on the effects of feeding rabbits with animal tissues such as muscles, pan- creas and liver. They were interested in blood pressure and kidney function, but autopsies showed that atherosclerosis had been produced as an unexpected by-pro- duct. The young men recognized the im- portance of this chance finding and pursued it. They noticed that the blood serum of the rabbits was creamy, and that the lesions were loaded with cholesterol and other fats. The animal tissues eaten by the rabbits contained not only fat but protein. What produced the lesions, they asked themselves, the animal protein or the animal fat? The rabbits were fed pure fat and cholesterol, and developed severe atherosclerotic lesions. Since that time atherosclerosis has been repeatedly produced in every species used in the laboratory; rabbits, dogs; chickens, rats, guinea pigs, hamsters and, particu- larly interesting, monkeys. In fact, all aspects of severe atherosclerotic disease seen in man, including coronary throm- bosis and fatal heart attack, have been produced in the monkey. In all animals a pre-requisite for the production of severe atherosclerosis is a change in diet with increased intake of fat and cholesterol, resulting in a sustained rise in the level of these substances in the blood serum. Without this, it is virtually impossible to produce severe atherosclerosis in any animal species. If the thyroid gland is functioning badly the atherosclerotic pro- cess is aggravated. Damage to the kidneys may occur which in turn accelerates the production of atherosclerotic lesions. Hy- pertension can be another contributing factor. By inference from animal studies—un- less human beings are entirely different from other species in the animal king- dom—one could expect a similar phe- nomenon to occur spontaneously in human beings, when similar diet patterns are followed. From these studies it is also evident that there is a complex interplay between diet and other factors such as blood pressure and thyroid function if a high-cholesterol, high-fat diet is consumed. When the dietary prerequisite for athero- sclerosis is present, certain factors interact to aggravate the condition, demonstrating the multiple origins of the disease. However, the atherosclerotic lesion is, within limits, reversible. Animals on high- fat, high-cholesterol diets that have devel- oped overt disease show more or less complete regression when taken off these diets, depending on the species and on the severity of the lesion. Very severe lesions do not heal easily but lesser lesions may show remarkable reversal in time. Experi- mental evidence recently obtained on reversal of lesions in monkeys is especially intriguing and encouraging. This crucial finding of animal research compels atten- tion to dietary factors in the etiology—and prevention—of this disease. 27 28 Specifically, severe atherosclerotic dis- ease was invariably found to be common among peoples habitually eating diets high in animal foodstuffs—dairy products, eggs, meats—and therefore high in choles- terol and animal fats. In contrast, the occurrence of the disease was low in popu- lations with predominantly vegetarian diets, low in cholesterol and animal fats. This conclusion has been extensively confirmed by research since World War II. Analyses of data from the World Health Organization and the UN Food and Agricultural Organization have shown a close relationship between national diet patterns and death rates from coronary measures his respiratory capacity. heart disease of middle-aged men. The greater the habitual intake of animal fats, cholesterol and calories, the greater the toll from premature heart attacks. The dif- ferences are especially marked between populations of highly developed and under- developed countries, but are apparent even when the analysis is limited to economically advanced countries. For example, coronary heart disease mortality rates for men aged 45 to 54, in 22 developed nations, range from a low of 51 per 100,000 per year for Japan, to a high of 442 for Finland. For these same countries, coronary heart disease death rates are closely related to national per capita consumption of satu- rated or "hard" fats (chiefly of animal origin), cholesterol and calories. The studies reveal other significant correlations as well: for example, the relation between mortality from coronary heart disease and per capita use of cigarettes and between During the first decades of this century, at the same time that the major break- through was being made on atherosclerosis in animals, important observations were also being made on man. European phy- sicians working in Asia, Africa and Latin America repeatedly found that athero- sclerotic disease was less frequent and less severe there than in their own countries. By the mid thirties the findings of these studies were extensive and consistent enough to permit an initial generalization: the development of significant athero- sclerosis in human populations seems to be related to diet. Vegetables spell health The examination begins by weighing the patient; then he is made to blow into a spirometer which the number of motor cars per 100 people. Multiple aspects of life in modern indus- trial society combine to work against the human heart. This is further supported by recent finding of the International Atherosclerosis Project, a comprehensive study of athero- sclerosis of the aorta and coronary arteries at autopsy in over 31,000 persons of 10 to 69 years of age who died from 1960 to 1965 in 15 cities throughout the world. This mass investigation showed marked geographical differences in the extent and severity of atherosclerotic lesions which were found to correlate particularly with intake of animal fat and serum cholesterol level. Research findings on living populations are consistent with these data from au- topsy and vital statistics studies. Results are now becoming available from a long- term international investigation of 18 population samples in seven countries— Finland, Greece, Italy, Japan, Netherlands, United States and Yugoslavia. Approxim- ately 12,000 men, originally aged 40 to 59, have been under investigation for about a decade. On initial examination, marked differences in the prevalence of coronary disease were recorded among the population samples. The highest inci- dence was recorded for men from eastern Finland (120 cases per thousand examined) and the United States (80 per thousand). In contrast, rates were under 20 per thousand for men in Dalmatia, Crete and Japan. Prevalence, incidence of and total mortality rates from coronary heart disease in these populations were highly and significantly correlated with saturated fat intake and serum cholesterol level. The data relating overnutrition to the coronary epidemic are massive. They have been verified and confirmed again and again in man and experimental animals. No so-called "exceptions" or "confound- ing factors" negate or invalidate the basic conclusion : an habitual diet high in saturated fats, cholesterol and calories is a prerequisite—a necessary and primary (but not a sole) cause—for the epidemic occurrence of premature heart attacks in any population. Other contributory causes such as cigarette smoking may interact with diet to compound the problem. Heart attacks in young adulthood or middle-age are rare occurrences without such a diet even when other potential contributory causes such as high blood pressure or cigarette smoking are common. What then are the mechanisms whereby "rich" diets exert their harmful effect? Such diets have a marked tendency in both animals and man to raise levels of serum cholesterol and other fats. Thus, national differences in diet induce sizeable differences in mean serum cholesterol levels and in rates of hypercholesterolemia. The average serum cholesterol level in middle-aged men in the USA, for example, is about 230 milligrams per 100 millilitres. It is much the same in Scotland, the Netherlands and even higher in Finland. High proportions of adults in all these countries have grossly elevated serum cho- lesterol levels. However, in Japan, southern Italy, Greece, Yugoslavia, the countries of Asia, Africa and Latin America, average serum cholesterol levels are much lower and such high levels are rarer. These basic differences are not racial, genetic or cli- matic in origin. They are brought about by differences in diet, from childhood on, especially differences in the intake of "hard" (satured) fats and cholesterol. Cardinal risk factor Rates of early heart attack are closely related to serum cholesterol levels. The higher the cholesterol, the greater the risk of coronary troubles in young adult- hood or middle age. The risk as shown in the United States can be doubled, trebled or even quadrupled, depending on degree of serum cholesterol elevation. This is why a high serum cholesterol level has been designated one of the cardinal coro- nary risk factors, one of the several traits known to be intimately related to suscep- tibility to heart attack. Atherosclerotic disease is only one aspect of the role of nutrition in the coronary heart disease epidemic. "Rich" diets gene- rate other risks, along with sedentary living habits so common in industrialized, urbanized societies—they frequently lead to obesity. Fat babies, fat children and fat teenagers are no longer unusual in the developed countries and most adults—al- though they may have been lean and fit as youngsters—put on large amounts of weight as they advance into middle age. Marked obesity increases the likelihood that high blood pressure and diabetes will develop. It also leads to high serum levels of triglycerides, another blood fat invol- ved in atherogenesis, along with choles- terol. Obesity is also associated with a tendency to high serum uric acid levels. All of these factors have been implicated as significant coronary risk factors in long- term research studies on man. That is, they are all associated with increased likelihood of experiencing premature heart disease in population groups. "Rich" diets therefore operate through multiple me- chanisms to produce the abnormalities generating the coronary epidemic. All this is pregnant with meaning in terms of our ability to bring the epidemic under control. Obviously, if "rich" diets are deeply implicated then the possibility arises of prevention by changes in eating habits. And prevention, primary prevention above all, that is the prevention of first heart attacks, must be the central strategy of the effort to control this epidemic, if for no other reason than the high toll of disability and death taken by first heart attacks. The objective is to retain the posi- tive features of nutrition in the developed countries, especially optimal intakes of essential nutrients (proteins, amino acids, vitamins, minerals), while ending dietary excesses, particularly the inordinate inges- tion of "hard" fats, cholesterol and calories. Calorie intake, of course, has to be related to the physical activity of the individual. Another outstanding advance of recent years is the demonstration that dietary modifications can markedly reduce high levels of serum cholesterol and trigly- cerides in human beings. This has been shown repeatedly, in large groups of people, studied for years. Moreover, long- term follow-up of several such groups—in Chicago, Helsinki, Los Angeles, New York—has yielded data indicating that changes in diet habits, reduction in serum lipids and control of other coronary risk factors seem to be associated with decreases in incidence and death rates from heart attack. Thus, encouraging evidence is now available that the disease can be prevented, the epidemic curbed and controlled. Even very high risk, coronary-prone, persons can be helped rather "late in the game" —in middle age, after decades of an athe- rogenic diet. Control of saturated fat and cholesterol intake requires simultaneous attention to all five major sources of these nutrients: 29 Dietary habits vary greatly from country to country. To the left, a French farmer partakes of a meal of bread, cheese and wine. To the right, an Indian family eats a meal of vege- tables in gravy and bread. high-fat meats, dairy products, commerial baked goods, spreads (butter, margarine, shortening) and egg yolks. Lean meats and poultry, round steak, veal, game, chicken, turkey, in moderate servings : fish and sea food, skim milk, cottage cheese, beans, peas, pulses, whole grain and enriched flour products, fruits (including citrus), and vegetables (including dark green and yellow), vegetable oils, and the new soft margarines can be recommended. On the other hand, fat cuts of meat, table spreads, and solid cooking fats (butter, the "older" marga- rines, suet, lard, hydrogenated vegetable fats, bacon, salt pork), and cooking methods involving the addition of solid fat rather than its removal, should be avoided as much as possible. Cheese, cream, ice cream, whipped cream, sour cream, eggs, other "rich" foods (pastries, pies, cookies, cakes), alcoholic and "soft" drinks—all high in calories per serving because of their high content of processed fats and refined carbo-hydrates should be consumed in moderate amounts. It is not necessary to "go on a diet", to abandon the pleasures of eating, in order to protect one's health. Such an approach is almost always shortlived and doomed to failure. Instead the aim should be to learn a new set of eating habits, to adopt a new life style, nutritionally—as pleasur- able as any, perhaps even more enjoyable than the "rich" diet, and certainly healthier. In a sense, it's a matter of taking to heart the lessons implicit in the more natural eating habits such as those followed in southern Italy, Greece, Dalmatia, China, etc. When this is understood, many people find that the effort becomes reasonable and realizable, although adult habits are never easy to change. In the long run, the wise approach is to modify eating habits as early in life as possible, to acquire good habits from infancy on, for it is much easier to establish good habits early in life than to get rid of bad ones later on. This is also true of exercise and smoking. This is the only way to end the present situation, and assure that in the decades ahead proneness to premature heart attack becomes rarer and rarer. Changes in diet patterns would be made easier for people in the industrialized countries if governments, food processors and the mass media would support the effort. So far little has been done, although recent research has shown that it is entirely possible to prepare foods commercially in ways that will contribute substantially to the reduction of hyperlipidemia, for exam- ple. In the US National Diet-Heart Study, many foods were prepared with marked reductions in the cholesterol, total fat, saturated fat, calorie content. This was done with dairy and meat products, baked goods, frozen desserts and other foodstuffs. The study showed that such 30 foods can be made highly acceptable to the consumer. The food industry should be encouraged and supported by govern- ments to meet its responsibility. Such assistance to individuals by the community is wholly in keeping with the history of preventive medicine. Great successes in controlling disease are often achieved by community action to alter the environment. For example, the devel- opment of community water purification systems has relieved the individual of having to boil water to free himself and his family of water-borne diseases. Pas- teurization of milk, eradication of insect vectors of disease, fluoridation, the sup- plementation of foods with vitamins and iron, all represent modifications of the environment at the community level to prevent disease. Control of the epidemic of atheroscle- rotic disease requires national programmes of three complementary parts educational programmes to encourage better living habits, particularly concerning eating and smoking; programmes to alter the social and cultural environment, particularly as this involves food processing in order to improve dietary habits; expanded and intensified case-finding and treatment programmes for very high- risk, coronary-prone persons. The third aspect is also based on wide public health experience. Effective com- munity programmes for the prevention of disease invariably include concentrated measures for the detection and care of individuals especially likely to develop the condition as well as for the whole popula- tion. Persons highly susceptible to pre- mature heart attack must receive special attention. Since several coronary risk factors can be controlled by long-term alterations in eating habits, nutrition is a fundamental component of the treatment. The alternatives for the years ahead are very clear. If a continuation of the present mode of life in the developed countries is accepted, every signpost indi- cates that the epidemic of early atheroscle- rotic disease will persist, or even get worse, as the \Arm Executive Board has warned. There is no evidence to suggest that it will abate spontaneously. There can be no marked improvement in health for adults and no major further advance in life expectancy in these countries without control of this epidemic. On the other hand, success in combating the coronary epidemic can be expected to produce an increase in life expectancy for adults. The changes in national dietary and living habits being recommended are reasonable, feasible and safe and there is every reason to proceed now with concer- ted efforts to curb the epidemic of coronary heart disease. ■ 31 rehabilitation return to living by Dr E. Helander* Modern medicine has now slashed the death rates of many diseases. Sometimes, however, the price for survival may be a permanent handicap of some important function. This is particularly true for patients with myocardial infarction and cerebral thrombosis. In a cardiac or brain accident stroke—a block in the flow of the artery causes a sudden drop in the oxygen supply to a part of some organ. If this condition lasts more than a few minutes, the cells will disintegrate and die; there will be some permanent damage and a scar tissue will be formed replacing the damaged cells. Consequently, if a patient survives a vascular disease which has caused damage to a part of his heart or brain, there may be such after- effects as disturbances in the rhythm of the heart, paralysis of the limbs or speech disorders. Since patients often continue to live long after acquiring such handicaps, something must be done to help them find their place in society; this is the role of rehabilitation which aims at restoring the patient as much as possible and enabling him to live a normal life, physically, psychologically, socially and vocationally. Besides routine medical care, many methods are used in rehabilitation : physio- therapy, occupational therapy, psycho- logical tests and psychotherapy, social and vocational investigations and counselling, vocational assessment, work training and re-schooling. These methods are integrated meaning that not one person but a team of qualified persons take care of and advise the patients. Organization of rehabilitation differs according to the community in which it is practised. In some instances, the cardiologists and neurologists are in charge. In others, a variety of rehabilita- tion departments have been set up. Many countries prefer to have vocational rehabil- itation organized separately outside the immediate medical framework. Generally speaking, rehabilitation falls into four stages: Each member of the team makes his own examination of the patient, after which, as a group, they convene and analyze the findings in order to propose the most appropriate treatment and set practical goals for rehabilitation. The treatment itself involves the whole team, the physician, the psycho- logist, the physiotherapist, the occupa- tional therapist, the bandagist, the social worker, the vocational counsellor and the nurse. Re-integrating the patient into the community outside the hospital, which may mean finding him a place to live, if possible a suitable job, and perhaps pro- viding means for transportation if his handicap makes this necessary. Follow-up—the patient will often benefit from repeated periods of treatment and counsel. If these are neglected, how- ever, the original good results may be jeopardized. To give a clear idea of what this means in practice, the following are rehabilitation procedures for the most important cardio- vascular diseases—myocardial infarction and cerebral thrombosis. After myocardial infarction Most patients are hospitalized after myocardial infarction; in many hospitals, the patient will be taken to an intensive care unit during the first few days. At the end of a week or so after the acute attack, he will be moved to an ordinary ward where, in uncomplicated cases, he will remain for another two or three weeks. During this phase, rehabilitation may be started in the form of early mobilization. Physiotherapy is provided: active and pas- sive movements and breathing exercises to prevent pneumonia and leg thrombosis. The activity slowly increases. Soon, the patient is allowed to sit in a chair, to walk and take care of his private needs and, finally, to go up and down a flight of stairs. All this activity is carefully super- vised by a physiotherapist or a nurse and the reactions to each stage are noted. Sometimes, occupational therapy may be- gin during the last few days of this first phase. The phase is concluded when the patient is able to leave the hospital to go home or to a convalescent sanatorium. During the next phase of convalescence, the patient may either be living at home and visiting the rehabilitation centre as an out-patient, or following the treatment in a convalescent home. The team at the centre makes an exam- ination that enables them later to design 32 * Professor, Arbetstraningsinstitut, Sollentuna, Sweden. Patients learning to climb stairs again.

an individual plan of treatment. One important test is that of working capacity, which may be assessed by using a bicycle ergometer (stationary bicycle with instru- ments to measure effort expended). After exercising for two or three months under the supervision of a doctor, progress is evaluated by ergometer. Modern methods such as telemetering the electro- cardiogram are also very helpful. Occupational therapy becomes increas- ingly important in this phase. Here, long- term training with a suitable physical and psychological load will enable the occu- pational therapist to decide whether or not the patient will be able to return to his previous job. In some cases, the patient must be discouraged from returning to his earlier occupation. Social and vocational coun- selling may thus be vital. The following questions must be answered. What other jobs are available? Does the patient have the physical and psychological capacities necessary for these jobs? To help answer these questions, the psychologist uses intelligence and aptitude tests. In countries like Sweden, the handicapped patient may enter a vocational school and train free of charge if the rehabilitation team finds he cannot go back to his previous job but can be trained for another. Psychotherapy and family are also im- portant. Negative attitudes of the patient or his family must be dealt with since they may interfere with rehabilitation. In some cases, a new dwelling or transporta- tion between home and job may help solve the situation. In others, however, only sheltered employment or work at home may be suitable. Even after the second phase has been completed, most patients should continue with some kind of training programme. In several countries, group training or Using a mirror helps rehabilitation and gives the convalescent confidence since he can assess his improvement. 1 Exercise in the water is recommended because taking the weight off the muscles makes movement easier. A metal worker learns how to use his hands again so that he may return to his work. Making the arms stretch and work. 3 "infarction clubs" have been organized. In any case, there should be 30 minutes to an hour's exercise two or three times a week in order to keep up the physical capacity gained during the reconditioning programme in phase two. After cerebral thrombosis Patients are generally advised to keep in touch with their rehabilitation teams. Check-ups, including the bicycle ergometer test, should be made at least once a year. Moreover, a change in profession or re- schooling for different jobs should be discussed whenever necessary. In the first phase of cerebral thrombosis the patient is usually at the hospital where he is taken after the onset of the disease. Rehabilitation may start as soon as he has regained consciousness and the most alarming symptoms have disappeared. At first, the patient is given physiotherapy —breathing exercices, passive and active leg and arm movements—for about three or four weeks to prevent the occurrence of pneumonia, contractures and thrombosis in the veins or legs. These exercises are gradually increased. Some patients can sit up in a chair a few days after the stroke but, at this stage of the disease, it is still too early to say whether the patient will recover totally or be left with a permanent disability. There are, generally speaking, three pos- sibilities : (1) he will recover spontaneously, with little or no trace of the disease; he will be left with a severe handi- cap such as partial paralysis, permanent aphasia, dementia or similar symptoms; he will recover but remain in a condition intermediate between the first two. Although rehabilitation may help in the first and second cases, it is of primary importance in the third. The ergometric bicycle not only gives the legs good exercise but allows progress to be measured. Doing exercises while seated makes it easier to keep one's balance and helps blood circulation. At the start of the second phase the patient should be re-examined by the rehabilitation team. They will determine the extent of his handicap : how much active or passive movement the patient is capable of; how much strength he has retained in his muscles, both those that are paralyzed and those that remain normal; it is important to see whether or not the patient's manual dexterity has been affect- ed since, in the case of a watchmaker for example, the loss of dexterity may mean an entire change in the patient's way of life. Tests will be given to see whether eyesight or sensitivity is impaired and to deter- mine the extent of spastic contractions. Psychological tests will be given to see if there has been damage to any of the intellectual functions such as memory, verbal, numerical and logical ability, as well as the ability to gauge space. Any speech disorders will have to be analyzed, in addition to the patient's ability to perform the normal activities of daily living which few of us are aware of until something makes it difficult to perform them, for example, can the patient dress himself? take care of washing? prepare his food? The degree to which he can walk must be determined with exactitude. Some patients can manage walking on level surfaces but are unable to climb stairs. Others, because of a loss in ability, are afraid to go outdoors. Whether the patient can drive a car must be determined as well. Sometimes the patient may suffer from other related diseases such as ischaemic heart disease, hypertension, diabetes, any of which may also cause handicaps. The patient's social and vocational cir- cumstances must be analyzed. This may involve contacts with the patient's family, visits to his home, or discussions with his employer; it should now be possible to make a preliminary prognosis to estimate when the patient will be able to go back to his family, his dwelling or former occupa- tion. All of this information can then serve as background when treatment is pre- 37 scribed: it also enables the therapeutic team to follow the patient's progress and to evaluate the results of treatment. In addition to standard medical care this treatment includes: (a) physiother- apy: exercises of skeletal muscles (includ- ing those paralyzed), retraining and co- ordination of a variety of muscle functions and of physical capacity; (b) occupa- tional therapy, training of daily life functions and vocational abilities; (c) prescription of technical aids, etc. which facilitate certain diminished functions; (d) training of speech disorders; (e) psycho- therapy and training of diminished psycho- logical abilities; (f) social counselling: family contacts, economic aid, changes in the dwelling, arrangement of transporta- tion; (g) vocational functions: coun- selling, vocational assessment, work train- ing, and re-schooling for a suitable job, in school or on the job. After the conclusion of rehabilitation in phase two, the patient should remain in close contact with his rehabilitation team, which advises on the type of training needed to maintain the physical ability at the level just gained. In fact, a "brushing- up" period each year is very valuable. In addition, any change of work should be discussed when necessary. Rehabilitation in medicine is a compa- ratively new discipline but no doubt can achieve a lot. As it is generally agreed that rehabilitation is good for patients and that there are rarely unwanted side effects, most physicians feel it would be unethical to deprive a patient of a chance to parti- cipate in rehabilitation. Therefore, few patients are available for control groups in those places where systematic rehabili- tation is carried out. However, it is hoped that a multi-national study will be made under the auspices of WHO in the coming years. This study will compare the methods of rehabilitation in myocardial infarctions in different countries as well as their results. ■ On the road to recovery. 'I the future the broad approach by Dr Z. Fejfar * and Professor J. N. Morris ** The heart has always been considered the most important organ of the body— the store and the outlet of emotions—and since the beginning of history, it seems, people have died of cardiovascular dis- eases. Here we review what is happening in mortality and morbidity from heart diseases, and consider the possibilities for prevention and control. We attempt also a picture of how the community will face its troubles with heart and arteries in the decade ahead. Many people would now accept that cardiovascular diseases are not simply a phenomenon of old age about which there is little to be done, a notion that might have some substance if only old people died of them. Death rates over the past decade in many countries show clearly the increase of ischaemic heart disease in the age-group 35-45 years. A hundred years ago, of course, the man over 50 was considered old, and this attitude often still prevails in many developing countries. Death rates show a positive correlation of ischaemic heart disease with national income, i.e. with economic progress; in poor countries, moreover, it is an affliction of the rich. This appears to be the situation regardless of ethnic group, and we can postulate that environment is here more important than heredity. Ischaemic heart disease is indeed a disease of affluence; and with further economic growth we foresee more of it. Dangerous factors It is, however, not easy to define pre- cisely what are the dangerous factors in our environment and ways of life. It is even more difficult to prescribe a health- promoting environment although in the future this will surely be the way to prevent the further spread of cardiovascular dis- eases. Cardiovascular mortality is higher in populations consuming large amounts of saturated fat and of "simple purified sugars" (carbohydrates); it is also higher in areas where the drinking water is soft. Possibly some "protective" substances are absent in soft waters, or in purified sugars, or some toxic substances may be added in the process of making flour and sugar taste better. Several minerals contained in minute amounts (trace elements) have been studied, chromium and cadmium being of particular interest. The chromium level in human tissues decreases with age in populations with atherosclerosis. In experimental animals, lack of chromium induces atherosclerosis, and adding it to their diet reduces blood cholesterol. Cad- mium promotes the development of arte- rial hypertension, and this effect may be prevented with zinc. Alteration in fat, carbohydrate and protein metabolism marked by increase of cholesterol and other lipids in the blood, impaired sugar tolerance or frank diabetes and high levels of uric acid, so ominous in "advanced" countries, do not have the same prognostic significance in other countries. Thus, the high-density popula- tions in South Pacific atolls, whose staple fat is saturated coconut-oil, apparently do not suffer from ischaemic heart disease. Diabetes is common among Yemenite Jews and East Africans but they rarely suffer from ischaemic heart disease. Atherosclerosis and hypertension as we understand them today are the two main conditions which contribute to the devel- opment of ischaemic heart and cerebro- vascular disease. Arterial hypertension is widely prevalent, but, in countries where atherosclerosis is infrequent, strokes and the like are the predominant complication, * Chief, Cardiovascular Diseases Unit, World Health Organization, Geneva. 39 ** Professor at the London School of Hygiene and Tropical Medicine. and not ischaemic heart disease. This is so in Japan and many other countries of Asia, Africa, the Caribbean and the American continent as well as in some countries of Europe. Studies with rats have shown that popu- lation pressure leads to tension and fight- ing, and the losers suffer from disturbances of blood pressure. Whether the new com- puterized society will be more humane than the old, which was intolerant of dissent and riven by social discrimination, remains to be seen. Before industrialization, societies lived more or less on local resources and people were obliged to use their muscles consid- erably more than nowadays. Poverty, ignorance, religious habits and the diffi- culties of food transportation kept the nutrition of the mass of the population at a lower level than ours, and only a few in the affluent strata lived in abundance. In the modern, highly populated, techni- cally advanced society, there is a decreas- ing percentage of manual workers, and a gradual disappearance of the difference between "physical" and "mental" work. That men in this century have drastically reduced their exercise while, if anything, eating more makes no sort of physiological sense. There is ample evidence of the noxious effect of cigarette-smoking in precipitating heart attacks and some evidence of its effect on the development of athero- sclerosis. The role of women in modern society is changing remarkably, and we must wonder to what extent this will be reflected in the pattern of disease. This applies particularly to ischaemic heart disease, which up till now has been far less common in women of child-bearing and middle age than in men. Women in most advanced societies are becoming economically more inde- pendent and socially equal, engaging in "men's jobs". They are smoking more and many are taking the "pill" ; both of these habits increase the chances of intravascular clot formation (thrombosis). In the USA, UK and Sweden, for example, venous 40 Women are attaining equal footing with men. As a result all sorts of new occupations are opening up to them. Left page : Indian women at work in a steel plant. Left: a Yugoslav woman welding in a shipyard in Split. Photo below: women checking production in a factory for electrical cables in Permj, Soviet Union. thrombosis is occurring more often among women who are regular "pill"-takers. A far-reaching experiment is under way which may throw new light on the patho- genesis of ischaemic heart disease. Will the changes in women's lives result in an increased frequency of ischaemic heart disease? Will women become equal to men in this respect also? So far, no such evidence exists. The technological society has greatly facilitated advances in medicine. The control of most infectious diseases is now feasible; malnutrition from calorie and protein lack, and the gross deficiency diseases, such as beri-beri or pellagra, have disappeared from many countries. But the problems of water and air pollu- tion, of motor accidents, of social malad- justments in the cities and of malnutrition from caloric over-nutrition are yet to be solved. There are the new problems, too, of the extended survival of the weak, disabled and sick—a situation which recalls the traditional loss of the healthiest and youngest of the adult population in wars while the old remained alive. The survival to old age of increasing numbers of people contrasts with the forced retire- ment of many active workers at pro- gressively younger ages. The paradox in many parts of the world is that society is prepared to carry a heavy burden of medical and surgical care of the chronic sick who have little hope of complete recovery, while the same societies are reluctant to allocate adequate resources for community programmes aimed at prevention of sickness or to support the necessary research that could be a boon to the whole of mankind. Most congenital malformations of the heart and blood vessels are amenable to surgery but their prevention and early diagnosis are only beginning to be possible. Rheumatic fever and rheumatic heart disease have ceased to be the dominant problem in economically advanced socie- ties, but in the less privileged they still remain a fearful burden. Priorities may be confused so that the solution is often sought in highly expensive operations on cardiac invalids instead of in community programmes for adequate treatment of 41

streptococcal infection and long-term pro- phylaxis for children with rheumatic fever. Successful control of severe disturbances of the cardiac rhythm and conduction defects in heart attacks has led to the development of "coronary care" units in hospitals. But programmes for care in the community at large lag far behind. The pilot programmes of Registers of Heart Attacks promoted by wHo, now under way in several cities, are defining the extent of local problems, the need for hospital beds, for acute care, and for the services required for rehabilitation. They should also lead to studies of the diagnosis of the condition in its earliest phase, of how to administer first aid at the place where the attack occurs, and of public attitudes towards the disease. It is also hoped that these pilot schemes will produce a model adapt- able to the local needs of many areas suffering from the ischaemic heart disease epidemic. Heart attacks do not, after all, differ from other medical or surgical emer- gencies, where the responsibility of the community has long been accepted. We expect that similar programmes will soon be established for acute cerebral stroke, which requires even more care to prevent irreversible brain damage, and well plann- ed rehabilitation for speedy recovery. It is not too fanciful to foresee that surveillance and monitoring of subjects with suspect ischaemic heart disease, and of those who have recovered from an attack and are liable to recurrence of dangerous disorders of the cardiac rhythm, can be done by remote electronic control. This will not provoke anxiety if the whole population is made aware, as it should be, of the manifestations and significance of the disease. Voluntary health organizations (the Red Cross, for example) and mass media will become increasingly important in such general health education. The people's health The key question is to what extent the two culprits, arterial hypertension and atherosclerosis, can be recognized early, treated and controlled. As the earlier articles in this issue have shown, the answer has two main aspects. Possibilities exist for the efficient control and treatment of high blood pressure, either by removing the cause or by pressure-reducing drugs. This knowledge has to be widely disseminated and applied to all in need. At present, many opport- unities are missed. Atherosclerosis is a generalized process, scattered lesions developing at varying rates in the arteries of various organs. Localization of the lesions will more often be made in subjects with cardiac or brain symptoms and the occlusive lesions re- paired. But the main hope surely lies in efforts to clarify the causes of athero- sclerosis; these efforts must continue and grow. Experimental, clinical and epide- miological research has identified several factors which appear to be involved, singly and together. International co- operation will be more and more sought for investigation of situations where atherosclerosis is common though not in the coronary arteries (Jamaica), where both are rare (Oceania), and where hyper- tension is frequent but ischaemic heart disease rare (Japan, China). Through such studies, the relative strength of factors for the development of atherosclerosis can be tested and evaluated for the benefit of all. Scarcity and abundance: different social situations present different health problems. In areas with highly endemic athero- sclerosis, nearly half of the middle-aged men have severe lesions in the coronary vessels or ischaemic lesions in the heart; meanwhile there is no generally applicable means of preventing the clinical disease. Atherosclerosis and blood lipid abnormali- ties are known to develop gradually from childhood, while complicated lesions of the coronary arteries occur in young adults. In aiming at the prevention of athero- sclerosis, therefore, it will be necessary to introduce changes in the way of life at a very early age. Even very rich countries have not yet faced up to the situation and are unwilling to begin preventive studies in time; their reluctance is understandable as a great number of subjects would have to be followed up for many years. Many aspects of atherosclerosis and and hypertension have to be studied in men living in different physical and social environments. These studies, integrated into a meaningful pattern, obviously require international co-operation. wHo has accepted this responsibility. Scenario for the future The contributory factors of today's major cardiovascular diseases are already present in young people. The prevention of these diseases in adults will be achieved by promoting optimum development of the growing child and adolescent. Em- phasis will increasingly be placed on nutrition and life-habits in childhood. The burden of cardiovascular disease cannot be lifted until the ecol- ogical balance of society is restored and a more sensible adaptation of man to his environment achieved. Doctors and other health workers will make more systematic efforts to teach the public how to live in healthier ways. Education must be in harmony with practical, possibilities and cigarettes are, today, a case in point. Society's policies against cigarettes are too contradictory to be quickly effective, so a safe cigarette must urgently be sought. Similarly, it is wrong to advise a particular diet if the required foods are difficult to obtain or too expensive. In the city, where facilities are scarce, regular exercise should still be encouraged, since it can be done even in a room. The paradox of excellent individual medical care which prolongs life and a social pattern that often forces men to retire prematurely will have to be re- Preventing heart disease can sometimes begin before birth. On the left, an unborn child of a woman subject to heart disease is undergoing examinations which may allow steps to be taken in time. Photo right: boy in Singapore undergoing a periodic heart examination. considered. It is essential for those who retire to keep mentally and physically active. Community control programmes for the major cardiovascular diseases will be incorporated into general health services— for patients and for subjects at special risk. The barriers between clinical med- icine and public health are breaking down; in all fields of health and social care there is an increasing concern with the prevention of disease. Technology is opening up possibilities at all stages, from preventing atherosclerosis at its earliest stages to suppressing lethal arrhythmias (disorders of cardiac rhythm) in the already damaged heart. Simple methods will identify those likely to suffer clinical forms of ischaemic heart disease. Acceptable approaches are becoming available for controlling par- ticular risk factors like high blood pressure or cholesterol by drugs, and other specific means such as electrical control of irreg- ular heart-beats by pacemakers. Electro- cardiographic screening for arrhythmias, conduction defects and the development of left or right ventricular hypertrophy may become a useful simple procedure in preventive care for adults. Such screening will be a complement to the general hygienic measures that should be taken by everyone. Community programmes for the care of cardiovascular emergencies—heart at- tacks and stroke in particular—are already an urgent need in areas of high prevalence, as both may occur suddenly without recognizable warning. There may yet have to be another sub-division of me- dicine, with hospital departments for these acute medical emergencies providing maximum care in all affected commu- nities. Surgical repair of the damaged heart and reopening or replacing the occluded artery will be more commonly applied in chronic and acute cardiac or brain in- farction. Temporary assistance to the circulation with artificial pumps seems likely to be a practical solution in a variety of clinical conditions. Indications for the transplantation of the total heart, however, will remain very limited. Prevention and control of cardio- vascular diseases will depend on more active co-operation between physicians and scientists in national institutes. Such institutes in turn, through wHo, will strengthen international co-operation, put available resources to better use and thus speed the effective control of this 20th- century epidemic. ■ Apr In Ceylon, general health conditions have greatly improved over the last decade. 46 The reader is invited to follow the author along "a trail of suffering" which runs from WHO regional headquarters in New Delhi to Borneo, Thailand, the Philippines and other places in South East Asia. He shares the daily life of the leprosy patients of Luzon, sits in the councils of the Borneo Dyaks, sees the life draining out of cholera-stricken patients in Manila, and discovers death riding on snails in the rivers of Leyte. In simple and graphic language, the book describes the magnitude of the task facing local health authorities and wHo: 700 million people need medical care, most of them living in poverty and ignorance, pursued by the "four horsemen of the Apocalypse—Death, War, Hunger and Plague". Paying tribute to the many wHo experts who shared their knowledge and experi- ence with him, the author records the hard-won victories achieved in the last twenty years and offers a guarded prog- nosis for the future. Like many others, Mr Wolanowski is concerned about the fact that the decline in mortality and the rapidly expanding population act as a brake on economic development. He seems to doubt, in fact, that the economic take-off is possible. However, although the battle is far from won, man has new cards to play in his game against misery and death, as is shown for example by the "agricultural revolution" now taking place in India. The great merit of this book is that it highlights the enormous health needs of South East Asia and shows how they condition economic development. Petit guide de la sante, Dr Leon Coriat et G. Erlich, Hachette, Paris, 1969 The authors of this book try to let the reader know just how important or in- significant are all the little bumps, pains and other ills flesh is heir to, so that he can know if feeling slightly unwell is serious or just something that a good night's sleep will cure. The book is thus practical in nature and will replace, the authors hope, surreptitious consultations of med- ical dictionaries by worried laymen who may be "dangerously misled by the highly technical explanations" they are likely to find there. The tone of the work is optimistic and reassuring. We are told, for example, that wrinkles and lines in the face,believe it or not, can be "good or bad, there are lines in the face that are touching, winning and friendly just as there are others which are bad, hard and wicked". The authors give the following advice : "Try to keep a smooth face when emotional. Don't knit your brow when thinking or frown when you are annoyed. But don't limit your laughter; laughter is a healthy reflex and the lines it produces on the face are the most beautiful you can have !" What should the reader do about a sore throat? "After a good gargle, go to bed, cover yourself up, have someone tuck you in, carefully, tenderly, or lovingly, depend- ing upon who is taking care of you. Swallow some aspirin or drink a herb tea. Try to forget your discomfort by reading either a detective novel or an Introduction to Philosophy, according to your reading tastes, and try to get some sleep. The next day you should be on your feet again." An alphabetical index will allow the reader to find his way through the maze of diseases. Will it actually help and reassure him or else start him worrying about ills he never dreamed of? This will depend upon the personality of the reader. None are so deaf as those who will not hear, nor as gullible as those who want to believe. Life on Man, Theodor Rosebury, Secker and Warburg, London, 1969 The title is the story. The author, an American bacteriologist, turns a cool eye and a powerful microscope on man, and shows him to be crawling with indigenous life, covering his body with something like a veil, and sharing his ups and downs in an essential, symbiotic relationship. Upal i Goraczka by Lucian Wolanowski, Iskry, Warsaw 1970. This book, written in Polish in a vivid style, is intended for a wide reading public. Technicalities are kept to a strict mini- mum, since the author considers that "the more technical details there are, the fewer the readers". The result is a pot-pourri of anthropology, sociology, folklore and anecdotes. There is, for example, the story of a young Thai girl vainly trying to hold back her tears as the wno physician probes the suspicious-looking patch on her shoul- der with a needle. The doctor tries to console her: "But if it hurts you that's a good sign—it means you are healthy and haven't got leprosy." Numerous colour and black-and-white photographs taken by the author illustrate the text. Order form Please complete, detach and mail this order form to the agent for WHO publications in your country. Please enter my subscription to World Health: I year: 2 years * 3 years I enclose cheque/postal order in the amount of Name : Street : City • Country • * Subscriptions are entered for the calendar year This book is full of comfort for the reluctant bathers, the non-users of mouth- wash, the anti-antiseptic boys, not to mention the drop-outs from the "wash- ing out the mouth with soap" school. Dr Rosebury's thesis is simple: we make far too much fuss about the dirt that is man's true element, and about the words that best describe it; a theme he develops with wit and learning. He is for plain speaking: sweat instead of perspiration; mouth instead of buccal cavity; vulgarity in its original sense; scatology; and the separation of the word "obscenity" from all healthy human acts and functions. Eschewing no honest way of making the point, he entertains with colourful examples from history, sociology, litera- ture and folklore, tracing the origins of our aversions and prejudices. There are a few purple passages, particularly at the outset, probably stemming from a desire to strike a popular note. The effort is completely unnecessary and he quickly abandons it for the clear expository sen- tence that carries its burden lightly. Having discarded the Puritan ethic, Dr Rosebury inevitably reveals himself as a serious moralist with a purpose, an advocate of the not entirely original idea that the experiment should be tried of bringing up children without any hypo- crisy at all. His innovation would be to introduce not only the biology of sex at an early age into education, but also the microbiology of the body parts and func- tion, confident that "at worst, we won't be doing any more damage with the truth than are doing now with our lies." ■ Photo credits P. ALMASY, Back cover, pp. 13, 14/15, 16, 25, 31, 45; ©, pp. 6, 7, 24, 30 WHO, pp. 2, 46 WHO/E. MANDELMANN, pp. 4, 10, 33, 34/35, 36/37, 38 WHO/ROYAL VICTORIA HOSPITAL BELFAST, p. 9 WHO/M. JACOT, pp. 19, 26, 28 J. MOHR ©, pp. 20/21 iLo/wHo, pp. 23, 40, 41 WHO/B. ZEPPILLI, p. 27 WHO/NOVOSTI, p. 41 LEN SIRMAN ©, p. 42 GATT/WHO, p. 43 WHO/T. FARKAS, p. 44 World Health where to subscribe Afghanistan: See India, WHO Regional Office. Argentina: Editorial Sudamerica S.A., Humberto I° 545, Buenos Aires. Australia: Hunter Publications, 23 McKillop Street, Melbourne C. 1; United Nations Association of Australia, Victoria Division, 364 Lonsdale Street, Melbourne, Victoria 3000. Austria: Gerold & Co., I. 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