Up to the present there are no extensive series of life-expectancy tables in which hundreds of thousands of cases are analyzed from the diastolic pressure values. There are many such tables for the systolic pressures alone. In the tabulation of such statistics one must not lose sight of the important fact that the figures are taken by thousands of men of varying capacity and different degrees of intelligence. Such studies to be of any real value must be taken from records made at the home offices by capable men. We shall await these tables with interest. In the meantime we must be permitted to have the impression that the diastolic pressure has been much neglected. This has no doubt been due to the difficulty of measuring it with any degree of accuracy. Now with the auscultatory method and the correct place to read the diastolic pressure the results of blood pressure estimations should begin to have some value for statistical data.
Clinically the diastolic is probably more important than the systolic. Until proof is brought to the contrary we shall believe that in life insurance examinations it has the same importance.
The time spent in obtaining a careful history of a case is time well spent. Often the diagnosis can be made from the history alone, the physical examination merely adding confirmation to the data already obtained.
The younger the patient who has arteriosclerosis, the more probable is it that syphilis is the etiologic factor. A denial of infection should have little weight if the history of possible exposure is present. Miscarriages in a woman should arouse the suspicion of lues in her husband. The complement-fixation reaction will often clear up an apparently obscure diagnosis.
There are various ways of examining a patient but there is only one right way; the examination should be made on the bare skin. However skillful one may be in the art of physical diagnosis, he can gather few accurate data by examining over the clothes even if he use a phonendoscope.
The immoderate eater is laying up for himself a wealth of trouble at the time when he can least afford to bear it. The ounce of advice in time is worth more to him than the pounds of medicine later.
It is a wise maxim never to drive a horse too far. Apply that to the human being and the rule holds equally well.
There may be no symptoms in a case of advanced arteriosclerosis. Do not on that account neglect to advise a patient in whom the disease is accidentally discovered.
Many a man owes a debt of gratitude to the life insurance examiner. He rarely feels grateful.
When a competent ophthalmologist refers a case to a general practitioner with the statement that he believes from the appearance of the fundus of the eye that arterioscleroticchanges are present over the body, the case should be most carefully examined. The earliest diagnoses are not infrequently made by the ophthalmologist.
It is the part of wisdom never to have such a firmly preconceived idea of the diagnosis that facts observed are perverted in order to fit into the diagnosis. Let the facts speak for themselves.
Beware of the snap diagnosis. Even in a case of well-marked arteriosclerosis when the diagnosis seems to be written in large letters all over the patient, go through the routine. Nine times out of ten this may seem needless. The tenth time it saves your conscience and reputation. Always consider that you are examining a tenth case.
Gradual loss of weight in a person over fifty years old should arouse the suspicion of arteriosclerosis.
Do not call the nervous symptoms displayed by a middle-aged man or woman neurasthenia until you have ruled out all organic causes, particularly arteriosclerosis.
When palpating the radial artery, always use both hands according to the method already described. Pay attention to the superficial or deep situation of the artery.
The examination of one specimen of urine does not give much information, especially if it should be found to contain no abnormal elements. Fairly accurate data may be gathered from the mixed night and morning urine; most accurate data from the twenty-four hour specimen. To be of any real value there should be frequent examinations of the day's excretion.
In measuring the day's output a good rule is as follows: begin to collect urine after the first morning's micturition and collect all including the first quantity passed the next morning. It is best to examine the centrifugated urine for casts even though no albumin be present. It is useless to look for casts in an alkaline urine.
Casts are not infrequently found in chemically normal urine from a middle-aged patient. Other things being normal,the finding has no significance. The kidneys must be carefully tested functionally.
Blood pressure readings should always be taken with the patient in the same posture at every estimation. At the first examination it is advisable to take readings from both brachial arteries. Let the patient sit comfortably and relax all muscles.
Differentiate as soon as possible between the uncompensated heart caused by valvular disease and that caused by arteriosclerosis. There is a difference in prognosis. Both give the same symptoms, and are treated similarly until compensation returns; thereafter the management of the two forms is different.
Aortic incompetence that comes on late in life is generally the result of curling of the free margins of the valves caused by syphilitic arteriosclerosis. Prognosis is grave because of the fact that the heart muscle also is the seat of degenerative changes and compensatory hypertrophy is established with difficulty.
When laying down a regime for a patient, consider his disposition, and individualize the treatment. Remember that exercise is an essential feature of the hygiene of the patient's life but do not forget to be explicit about the amount and character of the permissible exercise.
In the prophylaxis of arteriosclerosis, a rational mode of living is the all-important factor. As a rule, the less meat one eats, the less is the liability of arterial degeneration as age advances. The exceptions to this rule are many, and probably depend upon the character of the "vital rubber" with which the individual begins life.
The diet in well-marked cases of arteriosclerosis should be carefully selected with regard to its nutritive and non-irritating character. Animal proteins should be sparingly used. Milk should have an important place in the dietary.
No drug relieves the pain of uncomplicated aneurysm as surely as iodide of potassium.
Iodides frequently upset the stomach. Be cautious in the use of them. The irritable stomach may turn the scales against your patient.
Use cardiac stimulants with care and judgment. If all the valuable ammunition is used up at first, the fight will be lost.
Use digitalis with especial care. Its chief usefulness is in steadying the decompensated heart, improving the conduction of impulses, and increasing the tone of the cardiac muscle.It should never be given to patients with very slow pulses, the subjects of Stokes-Adams syndrome.Digitalis has been found to produce partial to complete heart block when therapeutically administered.
Remember that in the uncompensated heart morphine not only eases the oppressive dyspnea, but also steadies and stimulates the heart.
See to it that the patient has a daily movement of the bowels. In the early stage try the effect of liquid paraffin or of the mineral waters such as Pluto, or Hunyadi Janos, or artificial Carlsbad salts (Sprudel salts). These last can be made as follows: Sodium chloride, ℥I; sodium bicarbonate, ℥II; sodium sulphate, ℥IV. Take two tablespoonsful of this in a glass of hot water before breakfast. Should these not succeed, assist the action of the drugs by the use of enemata. The pill of aloin, strychnine sulphate, and extract of cascara, with the addition of a small quantity of hyoscyamus, is a mild tonic purgative. In cases of constipation with high tension, there is no drug as valuable as calomel or one of the other mercurials given occasionally.
Never give Epsom salts unless copious watery stools are desired to deplete effusion into the serous cavities or into the subcutaneous tissue.
Chronic constipation increases the gravity of the prognosis.
In case of suppression of urine and anasarca, hot air packs may be of value. The patient may be wrapped in ahot wet sheet and covered with blankets. I do not believe in administering pilocarpine to assist the sweating.
Remember to treat the patient and not the disease. The careful hygienic and dietetic treatment, combined with the least amount of drugging, is the best and most rational method of treatment.
AAbdominal symptoms,201Aconite in treatment,242Acquired arteriosclerosis,159Adami, effect of syphilis in aorta,45Adventitia,28Age in arteriosclerosis,161Albuminuria,221Albutt's classification of arteriosclerosis,186Alcohol,166,228,235Anatomy,25Angina abdominalis,201,216pectoris,197,216pseudo,216Angiosclerosis,26,64Aorta,27anatomical lesions in,33Aschoff on,35normal,41syphilis in,44thoracic,29thoracic and abdominal, arteriosclerosis of,39velocity of blood in,66Aortic incompetence,61,258stenosis,60Aortitis, acute,165Arcus senilis,191Arrhythmia, tonal,92,102Arterial pressure,85symptoms,189Arteries,29examination of,172,177general structure of,27large,30adventitia of,30palpable,189pulmonary, arteriosclerosis of,63Arteriocapillary fibrosis,26Arteriosclerotic endocarditis,60,219Artery, coronary, cross-section of,36pulmonary,209radial,29Aschoff on aorta,35Atheroma, simple,32Atheromatous abscess,38Auricular fibrillation,133flutter,131Auscultation,176Auscultatory blood pressure phenomenon,90method of taking blood pressure,83percussion,175BBalneotherapy,233Basch's blood pressure instrument,70Blood, circulation of,65velocity of,65in animals,66in aorta,66in capillaries,66viscosity of,68Blood pressure,68auscultatory method of taking,83clinical applications of,147diurnal variations of,102drugs influencing,120estimation of,179in cancer,118in collapse,118in exercise,105in head injuries,148in hemorrhages,105,118,148in infectious diseases,153in kidney diseases,155in meningitis,118in obstetrics,152in pulmonary tuberculosis,119in shock,105,148in surgery,147in typhoid fever,118,154in valvular heart disease,155increase of,55instruments,70Brown's,74Cook's,71Erlanger's,72Faught's,75,80Hill and Barnard's,70Hirschfelder's,73K. Vierordt's,70Marcy's,70Potain's,70Riva Rocci's,70Roger's,77Sanborn's,80Stanton's,72technique of,80"Tycos,"77v. Basch's,70v. Recklinghausen's,76mechanism of,55normal variations of,88phenomenon, auscultatory,90precautions when estimating,181value of,181Bowman's capsules, sclerosis of,62Brain, changes in,62Brown atrophy,60,118,201CCalcification of media,43,59Cancer, blood pressure in,118Capillaries, anatomy of,27,31Capillary pulse,67Cardiac dullness,172irregularities in arteriosclerosis,131symptoms,195Cerebral symptoms,203Circulation of blood,65physiology of,65Cirrhosis of liver,64,216Classification of arteriosclerosis,32,37Allbutt's,186Collapse, blood pressure in,118Congenital arteriosclerosis,157Cook's blood pressure instrument,71Cor bovinum,116Coronary artery, cross section of,36Corpus luteum,241DDefinition of arteriosclerosis,26Diabetes mellitus,216Diagnosis,210differential,215early,210ophthalmic examination in,214Diastolic pressure,69,83,85,94importance of,97Dicrotic pulse,123Dietetic treatment,235Differential diagnosis,166,215Diffuse arteriosclerosis,32,37,38,57Digitalis in treatment,246,259Diuretin in treatment,246Drug intoxications,166Drugs influencing blood pressure,105,120Ductless glands,171Dullness, cardiac,172Dyspeptic symptoms,184Dyspnea,184treatment of,248EElectrocardiogram,126Embolism,59Endarteritis deformans,47obliterans,46Endocarditis, arteriosclerotic,60,219Endothelial lining,27tubes,31Epistaxis,184,221Erlanger's blood pressure instrument,72Erythromelalgia,192,208Estimation of blood pressure,179Etiology,157Examination of arteries,172,177of heart,172of urine,257Exercise, blood pressure in,105in prophylaxis,225in treatment,230Experimental arteriosclerosis,50Extrasystole,138FFaught's blood pressure instrument,75,80Fibrillation, auricular,133ventricular,138Fibrolysin in treatment,243Fingernail palpation,178Finger tip palpation,179Flutter, auricular,131Food poisons in arteriosclerosis,163GGibson's law,154H"H" wave,126Habits, personal,234Head injuries, blood pressure in,148Headache,184treatment of,248Heart block,140boundaries,172examination of,172hypertrophy of,60physical examination of,172stimulants,243,246,259symptoms,188Hemorrhages, blood pressure in,118Henle, membrane of,29Hill and Barnard's blood pressure instrument,70Hirschfelder's blood pressure instrument,73His, bundle of,141,197Hygienic treatment,230Hyperpietic arteriosclerosis,186Hypertension,60,106,169,185,249cause of arteriosclerosis,159classification of cases,112Hypertrophy of left ventricle,58Hypotension,117IIncompetence, aortic,61,258Indicanuria,167Infants, arteriosclerosis in,158Infectious diseases in arteriosclerosis,163blood pressure in,153Insomnia, treatment of,248Intermittent claudication,192,208treatment of,247Intoxications, chronic drug,166Intracranial tension,105Involutionary arteriosclerosis,187Iodides in treatment,238,247,259KKidney diseases, blood pressure in,155Kidneys, sclerosis of,61,170LLife insurance, relation to,249Light percussion,174touch palpation,175Liver, cirrhosis,64,216Local symptoms,207MMarey's blood pressure instrument,70Maximum pressure,85,94Mean pressure,85Media, calcification of,43,59Medicinal treatment,238Meningitis, blood pressure in,118Mental strain,168Mesaortitis,45,47,49,165Mesentery, cross-section of small artery in,56Milk diet,237Minimum pressure,86,94Moenckeberg type of arteriosclerosis,43Morphine in treatment,243Mosenthal test meal,221Muscular overwork,169NNervous symptoms,191Nitrites in treatment,240Nitroglycerin in treatment,241Nodular arteriosclerosis,32,37Normal blood pressure variation,88OObstetrics, blood pressure in,152Occupation in arteriosclerosis,162Ocular symptoms,190Ophthalmic examination, importance in early diagnosis,214,256Orthodiagraph,173Overeating,167,212,225,235Overwork, muscular,169P"P" wave,129"P-R" interval,130Palpable arteries,189Palpation,174,180fingernail,178finger tip,179light touch,175Pathology,32Percussion,174auscultatory,175light,174Peripheral symptoms,207Personal habits,234Phlebosclerosis,64Phthalein test,221Physical signs,183Physiology of the circulation,65Potain's blood pressure instrument,70Practical suggestions,256Pressure, arterial,85ausculatory method of determining,83diastolic,83,94estimation of,179in surgery,147maximum,85,94normal variations,88pulse,83,85,87,100systolic,82,85technique,80venous,120Prognosis,218Prophylaxis,224exercise in,225Pseudo angina pectoris,216Pulmonary artery,209arteriosclerosis of,63tuberculosis, blood pressure in,119Pulse,123capillary,67deficit,135dicrotic,123in arteriosclerosis,123pressure,69,83,85,87,100rate,69venous,123Purgatives in treatment,244,259Pyrosis,184Q"Q R S" complex,129RRabbits, lesions produced experimentally in,50Race in arteriosclerosis,161Radial artery,29Radials, sclerosis of,43Raynaud's disease,192,207Recklinghausen's blood pressure instrument,76Renal disease,169symptoms,199Rest in treatment,242Riva-Rocci's blood pressure instrument,70Rogers' blood pressure instrument,77SSanborn's blood pressure instrument,80Scaphoid scapula,158Schwellungsperkussion,174Sclerosis of veins,64Senile arteriosclerosis,32,37,43,59Sex in arteriosclerosis,161Shock, blood pressure in,105,148Spinal symptoms,205Spirochaeta pallida,45Stanton's blood pressure instrument,72Stenosis, aortic,60Stokes-Adams syndrome,197Stomach, ulcer of,216Strain hypertrophy,47,54,55Surgery, blood pressure in,147Symptomatic treatment,245Symptoms,183abdominal,201arterial,189cardiac,195cerebral,203dyspeptic,184dyspnea,184general,183headache,184heart,188local,207nervous,191ocular,190peripheral,207pyrosis,184renal,199special,194spinal,205vertigo,184visceral,201Syphilis,165in aorta,44Syphilitic arteriosclerosis,37Systolic pressure,69,82,85,94importance of,97T"T" wave,130Technique of blood pressure instruments,80Thayer and Fabyan,34Theocin,247Thoma on arteriosclerosis,33Thoracic aorta,29Thyroid extract in treatment,239Tobacco,167,212,234Tonal arrhythmia,92,102Toxic arteriosclerosis,186Treatment,229aconite in,242balneotherapy in,233corpus luteum,241dietetic,235digitalis in,246,259diuretin in,246exercise in,230fibrolysin in,243heart stimulants in,243hygienic,230iodides in,238,247,259medicinal,238morphine in,243nitrites in,240nitroglycerin in,241of dyspnea,248of headache,248of insomnia,248of intermittent claudication,247personal habits in,234purgatives in,244,259rest in,242symptomatic,245theocin in,247thyroid extract in,239Trunecek's serum in,243venesection in,242veratrum viride in,242Trunecek's serum in treatment,243Tuberculosis, blood pressure in,119Tunica intima,28media,28"Tycos" blood pressure instrument,77Typhoid fever as cause of arteriosclerosis,164blood pressure in,118UUlcer of stomach,216Urine, examination of,257suppression of,259VValvular heart disease, blood pressure in,155Vasa vasorum,29Veins, anatomy of,30sclerosis of,64Velocity of blood in animals,66of blood in aorta,66Venesection in treatment,242Venous pressure,120pulse,123Ventricle, left, hypertrophy of,58Ventricular fibrillation,138Veratrum viride in treatment,242Vertigo,184