The star quarterbacks of the 1920s may not have had as rosy and green a future as the 1964 quarterbacks, with the pro scouts beckoning, but by and large they did very well for themselves. Mostly they went into business or finance. They gained little weight in the lean 1930s, but then they made good as executives and by the early 1950s they were dying off at an unnatural and alarming rate from heart attacks.
Today's quarterbacks need face no such attrition in their late 40s and their 50s, and neither need other young Americans, if they will heed the advice now offered with refreshing unanimity by experts in such varied fields as cardiology, physical education and rehabilitation. Exercise, it is now generally agreed, is good not only for the young, healthy heart, to keep it healthy as long as possible, but also for the not-so-young heart in a body growing flabby with fat—and even for the man who has already had a heart attack.
Obviously, different kinds of exercise in varying dosages are prescribed for those three main groups of people. But the consensus of the First International Conference on Preventive Cardiology, held at the University of Vermont late last month is that practically all forms of vigorous exercise, including the more active sports, are very good indeed for one's heart.
Almost 2,500 years ago the desirability of exercise seemed so obvious to Plato that he recommended gymnastics for oldsters. But they must have been the few idle rich. Exercise or the lack of it was not a widespread problem until the steam engine, the gasoline engine, electric appliances and countless other devices were invented to keep civilized man from using his muscles. The telegraph and telephone conspired with rapid transit to add a new sense of time urgency to life's stresses.
September 20, 1964
Soon there developed an epidemic of "arterial degeneration." which has come to a climax in the current wave of deaths from heart attacks. Heart diseases now take a toll of nearly a million Americans every year-250,000 of whom die "prematurely," below age 65.
"In the worry and strain of modern life, arterial degeneration is not only very common but develops often at a relatively early age. For this I believe that the high pressure at which men live and the habit of working the machine to its maximum capacity are responsible," said Sir William Osier, the famed Canadian physician, in 1897. The experts who walked briskly (few of them rode) to the meetings on Vermont's maple-shaded campus in Burlington attach more importance than Osier did to excesses in eating and drinking—and especially smoking. But they believe that man's physical machine should be worked at something much closer to its maximum capacity than it frequently is today, while his mental and emotional equipment should not be pushed so hard.
In research on exercise and the heart most of the emphasis has up to now been on what physiologists think of as the plumbing: the big pump, which is the heart iself, and all those pipes, which are the arteries. The size of the heart has won a lot of attention. So has the condition of the arteries—whether their internal diameter, or bore, is reduced by atheromatous plaques of fatty material ("rust in the pipes"). Millions of dollars are now being spent in nationwide and international studies to find out whether changes in the typically over-rich Western diet will lower the level of fats circulating in the blood; if so, whether these will reduce the numbers of those fatty plaques and, finally, whether the changes will help people to live longer without heart attacks.
The conferees in Burlington started where the plumbing-and-diet fraternity stops. They conceded the importance of a good pump and clean pipes—in fact, they took it for granted. But under the inspiration of Dr. Wilhelm Raab, Vermont's emeritus professor of experimental medicine, who planned and guided the conference, they insisted that plumbing and diet are only half the story. And perhaps not the more important half, at that.
Many things other than physical exercise make the heart beat faster. For a girl it may be the sight of a handsome lifeguard; for an investor, a coldly coded message on the tape, "IBM 435, off 14." Such things affect the heart through highly complex pathways. The light rays from the bronzed torso and the digital quotation are fed into that most versatile of computers, the human brain. There they are processed and set off a chain of reactions through the nervous system and the hormone-secreting glands. Finally, through the body's elaborate and exquisitely sensitive electrochemical servomechanisms, those signals reach the heart in a simple form: "Go faster." And the heart does. Dr. Raab and like-minded investigators, some on the Vermont campus and many in foreign countries, have found that the heart is able to deliver more blood, more efficiently, on demand, when it is "in training" than when it has been allowed to deteriorate by years of under-exercise. Dr. Hans Kraus, famous as co-originator of the Kraus-Weber physical fitness ratings, calls this underexercise "hypokinetic disease." Hypokinetic means slow-motion or, for a majority of today's sedentary workers, no-motion living. As Dr. Kraus and most of the other conference participants saw it, the problem has two heads: 1) the more civilized man becomes, the more he lets his muscles go flabby, to the point of actual atrophy, from simple disuse, and 2) the more civilized he becomes, the more he finds himself obliged to behave rationally and impassively—and usually while remaining immobile—in stress situations that Stone Age man would have resolved simply and instinctively by fight or flight.
The athlete's heart is a trained heart, though it may differ little from that of millions of men living simple lives all around the world who stay in training by doing what comes naturally. It is, said Dr. Raab and others at the conference, the same size as anybody else's heart or only a trifle bigger. The athletic heart at rest beats more slowly than the average man's, at the rate of about 60 per minute. The slow beat is good because it leaves plenty of time for the right ventricle to fill with blood to be forced to the lungs, and for the left ventricle to force out a strong stream of oxygenated blood to the aorta.
This slow beat is also the most efficient, because the heart is then taking a minimum of blood for its own nourishment through its coronary arteries. And when the trained heart speeds up, as it must on demand for a burst of physical activity, it still accelerates more slowly than the "loafer's heart" and never attains as high a rate for the same work load.
The trained heart gets that way by being lodged in a youngster who stays highly active into the years when formal athletic training takes over. If this young man does not start smoking he will have little to worry about through his college years. Heart and arteries will remain almost completely healthy, though a few little fatty plaques may develop. Even the American diet, overrich in both fats and starches, will do him little detectable harm up to this point, because he will burn up the calories. The trouble for his heart begins after he takes a sedentary job. He is likely to become a steady smoker, and nicotine has a direct stimulating effect on the heart.
The maturing man spends more time on his rump and less on his feet. He stands in elevators instead of running upstairs—and exercise involving the legs is one of the most important factors in preserving heart health, according to bicycle fan Paul Dudley White. (The value of walking was dramatized recently by President Johnson—a recovered cardiac patient—when he walked 4½ miles around the White House grounds while underexercised newsmen—who called it a "death march"—dropped.) The maturing man is likely to accept weekend golf as his only exercise, but it takes more vigorous action every two or three days to stay in trim. Worst of all, the maturing man is likely to go in for more and more very, very dry martinis and marbled steaks with French fries, and he will probably go right on eating sweet, creamy desserts that he loved as a Little Leaguer. The Burlington conference did not bother itself with the question of whether it is cholesterol in the blood, coming from animal fat, that is mainly responsible for coronary disease and early heart attacks or whether it is some other kind of fatty biochemical compound or something derived from starches. The diet-heart experts have not resolved those questions yet. And for present purposes precise answers are unimportant: too much food, most of it too rich, leads to overweight and a lot of other things that are bad enough for the "loafer's heart."
Then there is the matter of breathing. Professor Vincenzo Lapiccirella of Florence, Italy asserted that a major cause of heart degeneration is the fact that civilized man has abandoned deep, abdominal or "diaphragmatic" breathing in favor of shallow chest breathing. Nobody else at the Vermont conference would go that far, but Dr. Thomas R. Dawber, reporting on a long-term study of heart disease in Framingham, Mass., did suggest that "vital capacity" seems to be an index of heart health. This vital capacity he defined as simply "the largest volume of air you can blow out after taking the deepest breath you can take." It takes no medical detective to see that a man slumped behind an office desk or the wheel of a car is doing little diaphragmatic breathing or anything else to maintain his vital capacity.
Advocates of exercise for the heart had been challenged to prove their case with two sets of matched subjects for comparison. Dr. Daniel Brunner of Tel Aviv University offered convincing proof obtained from the study of 5,300 men and 5,200 women in Israel's collective farm communities, or kibbutzim. These people are ethnically alike, and within each kibbutz they all eat food prepared in a single kitchen. There are no choice cuts for executives. The only differences among these people are in how much they choose to eat and the kind of work they do. The results are clear and striking: heart attacks are two to four times as common among the sedentary managerial and clerical workers as they are among the men and women (carefully matched by age groups) who go out and work in the fields.
Today's sedentary man also takes on a more and more "civilized" pattern of behavior that is foreign to his biological nature as it has evolved down through the ages. When primitive man made his choice between fight and flight, either would serve equally well to work off the adrenaline that his body had just mobilized, in response to signals from his midbrain, as a stimulant for his heart. Civilized man must not display feistiness or fear, so he sits still and takes it. Until the Burlington conference there was no neatly assembled body of evidence to show that just "taking it" in frustrating situations, day after day, may do permanent damage to the heart. Most of the evidence came from laboratory experiments on a menagerie of animals, but it was significant.
If a cat's brain is electrically stimulated often enough to simulate the effects of stress and cause an outpouring of adrenaline, its heart will suffer damage resembling that from reduced blood flow in a man's heart. Some of the cats in this experiment, reported McGill University's Dr. Kenneth I. Melville, died from a clearly defined heart attack.
Dr. Marshall E. Groover Jr., noted for his earlier work with aging Air Force officers, had been puzzled by streaks of dead tissue in the heart muscles of Kenya baboons. Then it was realized that the heart damage was related to the date the animal was trapped. Being trapped subjected the savage simian to an emotional storm for which he had no outlet. Transfer from the trap to a handling cage brought another storm. This, said Dr. Groover, may be "related to the mechanisms in the young executive who is caught in an emotional trap and cannot balance his nervous system by physical activity such as running or fighting."
Modern stress seems to be increasingly damaging, suggested Western Australia's Dr. Salek Mine, because it is more likely to be rational and intellectual rather than emotional. He compared a doctor, called out in the middle of the night to see a patient, and a mother awakened at the same hour by the cry of a sick child. The doctor knows what he has to do, because it is his duty, but this is a rational decision without emotional backing. The mother, on the other hand, feels what she must do, and she does it unthinkingly. Her stress is greater, but when she responds in the only way possible she relieves it. The doctor's less severe stress has no such self-liquidating feature.
Underlying all of civilized man's problems in both keeping fit and reacting to the stresses that he has devised for himself is the fact that nature endowed him with two types of muscles and two types of nerves. In each case, one set is under voluntary, conscious control. A signal from the brain through the voluntary nervous system makes a voluntary muscle contract at will, whether to play arpeggios on the piano or to pitch a ball. The involuntary or automatic ("autonomic" to medical men) nervous system sends signals, by instinctive or reflexive action, to many organs and hormone-producing glands. And it is the automatic nervous system, beyond conscious control, that regulates the heart, a muscle beyond conscious control, as are the muscle linings of the arteries. You cannot direct your heart to beat slower or faster. The intricacies of these automatic control systems are forbiddingly complex and their technicalities took up much of the time at the Burlington conference. But of down-to-earth, practical value is what the reports said can be done to avert, minimize or even to repair the damaging effects on the heart and arteries from neglect (meaning underexercise) and abuse (meaning exposure to unmanageable stress).
For the young the prescription is clear, and it was unanimous: keep on exercising steadily all through life, avoid overeating, don't smoke, and try to keep out of stress situations of the type that are only frustrating and cannot end in the satisfaction of a challenge met and something accomplished. This last sounds like the advice, "Don't worry!" but actually it is not quite so fatuous. Several of the authorities in Burlington reported that the healthy, well-exercised man is not only more apt to be outwardly placid but that his inward (and involuntary) system is capable of reacting to stress much more equably than can the man with the loafer's heart.
For those who have subjected their hearts to long years of underexercise neglect, the prescription was also unanimous: get back into training by a graduated program of exercise. Walking is not bad; it simply is not enough. The University of Illinois' Dr. Thomas K. Cureton laid down the maxim that for an exercise program to do the aging male any good it must make him burn from 300 to 500 calories a day. Dr. Cureton scoffed at catchphrases such as "A few seconds a day of isometrics keeps unfitness away." (Isometric contraction got short shrift in Burlington, perhaps partly because its effects are concerned primarily with the voluntary muscles, and it does not provide a complete metabolic cycle even for these.) The days when men recovering from heart attacks were condemned to such utter inactivity that they soon died of inanition are gone, but most doctors have remained cautious indeed about how much exercise they prescribe, and how soon. Dr. Herman K. Hellerstein of Western Reserve used to be as cautious and skeptical as any. Now he is an ardent advocate of the testing of more radical rehabilitation methods. What converted Dr. Hellerstein was the discovery that one of his patients was also enrolled in a "continuous movement" program, following the Cureton doctrine, at Cleveland's Central YMCA. and was suffering no ill effects. Dr. Hellerstein was so impressed by what he saw at the Y that he started a reconditioning program of his own at a Cleveland Jewish community center. Recovered patients who still have 50% to 75% of their coronary artery flow shut off can be restored to near-normal function, he has found. One man who had a massive heart attack is now swimming a quarter of a mile a day.
Dr. Hellerstein feels that the physical educator should derive as much satisfaction from getting a handicapped heart patient to perform at near-normal levels as he would from training a normal subject to perform at championship levels. "This, for the subnormal, is the same as being an Olympic champion," he declared. "The idea that athletic facilities are only for competitive sports and winning trophies should be modified. The use of these facilities should be extended for the general improvement of health, for the also-rans as well as the star performers."
The unquestioned star of the Burlington show was Dr. Cureton, Dr. Physical Fitness himself. At 63, he has gained weight amidships but shows few other signs of aging. First he set forth his dogma: "The greatest need is to train the heart and breathing mechanisms by rhythmical endurance exercises done progressively longer and harder until the desired level of stamina is reached. The best type, short of advocating the overthrow of American recreations, is more walking of the strenuous hiking or racing-walk type. Also the loafer's jog for distance, and the interval training procedure carried out for half an hour to an hour each day, progressing from low to middle to high gear."
Then Dr. Cureton demonstrated what he meant. He began, on his "warmup principle," with deep breathing to get more blood flowing. He walked, then did walking calisthenics, pumping and windmilling and swinging his arms, all the time breathing loudly, as he wants an exerciser's breathing to be heard. Next he began jogging. He did loose kicks and shakes, and walking with stretching, and the heel-toe racing walk. Dr. Cureton was still warming up with the "old man's marathon pace" and had been going 17 minutes before the first drop of sweat appeared. Then, amazingly, he went on with running sidesteps, two-step kicks, knee-to-chest hops and through a whole calisthenic repertoire for a solid hour. Dr. Cureton left every spectator exhausted by his virtuosity.
For the average man, this would be no more possible than it is for the average woman to dance The Dying Swan with the ripples of a Plisetskaya. And every man has to be pretty much his own doctor (until he gets sick). He must prescribe his own exercises, with running, swimming, jog-trotting and bicycling most likely to be effective. Even doctors do not know enough about the interactions of exercise and the heart to be able to give sound advice, and most of them set bad examples themselves. Physical education teachers, too, need to know more about the workings of the heart.
The most hopeful note from the Vermont conference was that at last some of the old jealousies are breaking down. Physicians and physiologists, sports medicine specialists and physiotherapists, rehabilitation experts and psychologists, biochemists and nutritionists, are getting together to seek ways to check the plague of premature heart disease that has been sweeping the Western world for half a century.