3. Sclerosis and atheroma of the vessels form the most danger ous complications in respect to mechanical treatment ; affections of the coronary artery and its branches and of the arteries of the brain are the most serious. Where the development of a sclerosis is to be dreaded, possibly on account of hereditary disposition, a uric-acid, atheromatous, or gouty diathesis, we must try to counteract these affections as early as possible. Besides the ordering of a suitable diet and limiting the use of alcohol, we have in walking and climbing exer cise a powerful remedy to stimulate the nutrition of the vessels, and the elasticity and contractility of their muscular elements. This consti tutes, as it were, a gymnastic exercise of the blood-vessels.
After walking for a certain period, especially climbing mountain paths, the arteries dilate, become distended, while the increased blood-pressure removes all existing stasis, a condition which may re main not only for the few hours during the exercise but also for ten to twelve hours and more after it has been accomplished. Consequently in such cases as do not yet clearly show arterial changes, paths of the first, second, and third order according to the rules and cau tious laid down, may be advised, always taking into account the state of nutrition and the power of the heart action. If, however, sclerotic changes of the arteries have already become established, if sclerosis can be demonstrated or is probably present, the walking exercise and climbing must undergo further restrictions, in which case the rules given under 2 have to be modified so that in the beginning especially, every marked increase of the blood pressure is avoided, so that only paths of the first and second order are used, and so that exercise is limited to rarely more than two to four units of distance. Later on if the heart force has improved, and there is no palpable increase in the sclerotic condition, paths of the third order may be resorted to and exercise may advance to several units, especially on level paths or those of slight incline. If atheroma of the blood-vessels has developed, the walking and climbing exercises must be regulated more cau tiously and limited to paths of the first and second order and to a small number of distance units. In no case, however, should exer
cise be altogether dispensed with.
The minutest precaution is indicated in sclerosis of the coronary arteries, whether this affection is only supposed to be present. or whether stenocardic attacks have already occurred. In regard 'to exercise in these cases the smallest amount, taken on almost exclu sively level paths, is to be advised, but it is to be altogether for bidden only in exceptional cases where there are frequently recurring attacks, since with absolute rest, disturbances of nutrition and cir culation, those of the heart included, will soon grow worse and induce a .condition of weakness; this is not the case if the muscular apparatus is kept active. If myocarclitis, a pronounced albumi»uria, and general cedema have already appeared, while the insufficiency of the heart muscle has gained headway through sclerotic changes, rest and medi cinal treatment alone are capable of preserving the patient's life for some time. Likewise if symptoms from the side of the brain have shown themselves along with sclerosis and atheroma, congestive con ditions, dizziness, if apoplexy is threatening or a cerebral thrombosis or hemorrhage has already occurred, a strictly mechanical treat ment by walking and climbing exercise is best dispensed with. The treatment will then aim at stimulation of nutrition and circula tion by ordering short walks on the level which, under these condi tions, will in nowise endanger the patient.
The presence of diabetes mellitus does not modify the rules of mechanical treatment (see below).
Finally as regards the time of day at which the cure-walks are to be undertaken, the morning and late afternoon hours are those best adapted to the purpose, because the stomach is least filled at these times and digestion has already progressed to a certain extent. Im mediately after a hearty meal a walk must never be undertaken, nor must the patient perform any other kind of bodily exercise. After the noonday meal he must rest for an hour, including, possibly, a quarter to a half hour's nap.