Chapter XV: Practical Suggestions

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 arteriosclerotic changes 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, ounce I; sodium bicarbonate, ounce II; sodium sulphate, ounce 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 a hot 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.

INDEX

A

Abdominal symptoms, 201

Aconite in treatment, 242

Acquired arteriosclerosis, 159

Adami, effect of syphilis in aorta, 45

Adventitia, 28

Age in arteriosclerosis, 161

Albuminuria, 221

Albutt's classification of arteriosclerosis, 186

Alcohol, 166, 228, 235

Anatomy, 25

Angina abdominalis, 201, 216
pectoris, 197, 216
pseudo, 216

Angiosclerosis, 26, 64

Aorta, 27
anatomical lesions in, 33
Aschoff on, 35
normal, 41
syphilis in, 44
thoracic, 29
thoracic and abdominal, arteriosclerosis of, 39
velocity of blood in, 66

Aortic incompetence, 61, 258
stenosis, 60

Aortitis, acute, 165

Arcus senilis, 191

Arrhythmia, tonal, 92, 102

Arterial pressure, 85
symptoms, 189

Arteries, 29
examination of, 172, 177
general structure of, 27
large, 30
adventitia of, 30
palpable, 189
pulmonary, arteriosclerosis of, 63

Arteriocapillary fibrosis, 26

Arteriosclerotic endocarditis, 60, 219

Artery, coronary, cross-section of, 36
pulmonary, 209
radial, 29

Aschoff on aorta, 35

Atheroma, simple, 32

Atheromatous abscess, 38

Auricular fibrillation, 133
flutter, 131

Auscultation, 176

Auscultatory blood pressure phenomenon, 90
method of taking blood pressure, 83
percussion, 175

B

Balneotherapy, 233

Basch's blood pressure instrument, 70

Blood, circulation of, 65
velocity of, 65
in animals, 66
in aorta, 66
in capillaries, 66
viscosity of, 68

Blood pressure, 68
auscultatory method of taking, 83
clinical applications of, 147
diurnal variations of, 102
drugs influencing, 120
estimation of, 179
in cancer, 118
in collapse, 118
in exercise, 105
in head injuries, 148
in hemorrhages, 105, 118, 148
in infectious diseases, 153
in kidney diseases, 155
in meningitis, 118
in obstetrics, 152
in pulmonary tuberculosis, 119
in shock, 105, 148
in surgery, 147
in typhoid fever, 118, 154
in valvular heart disease, 155
increase of, 55
instruments, 70
Brown's, 74
Cook's, 71
Erlanger's, 72
Faught's, 75, 80
Hill and Barnard's, 70
Hirschfelder's, 73
K. Vierordt's, 70
Marcy's, 70
Potain's, 70
Riva Rocci's, 70
Roger's, 77
Sanborn's, 80
Stanton's, 72
technique of, 80
"Tycos," 77
v. Basch's, 70
v. Recklinghausen's, 76
mechanism of, 55
normal variations of, 88
phenomenon, auscultatory, 90
precautions when estimating, 181
value of, 181

Bowman's capsules, sclerosis of, 62

Brain, changes in, 62

Brown atrophy, 60, 118, 201

C

Calcification of media, 43, 59

Cancer, blood pressure in, 118

Capillaries, anatomy of, 27, 31

Capillary pulse, 67

Cardiac dullness, 172
irregularities in arteriosclerosis, 131
symptoms, 195

Cerebral symptoms, 203

Circulation of blood, 65
physiology of, 65

Cirrhosis of liver, 64, 216

Classification of arteriosclerosis, 32, 37
Allbutt's, 186

Collapse, blood pressure in, 118

Congenital arteriosclerosis, 157

Cook's blood pressure instrument, 71

Cor bovinum, 116

Coronary artery, cross section of, 36

Corpus luteum, 241

D

Definition of arteriosclerosis, 26

Diabetes mellitus, 216

Diagnosis, 210
differential, 215
early, 210
ophthalmic examination in, 214

Diastolic pressure, 69, 83, 85, 94
importance of, 97

Dicrotic pulse, 123

Dietetic treatment, 235

Differential diagnosis, 166, 215

Diffuse arteriosclerosis, 32, 37, 38, 57

Digitalis in treatment, 246, 259

Diuretin in treatment, 246

Drug intoxications, 166

Drugs influencing blood pressure, 105, 120

Ductless glands, 171

Dullness, cardiac, 172

Dyspeptic symptoms, 184

Dyspnea, 184
treatment of, 248

E

Electrocardiogram, 126

Embolism, 59

Endarteritis deformans, 47
obliterans, 46

Endocarditis, arteriosclerotic, 60, 219

Endothelial lining, 27
tubes, 31

Epistaxis, 184, 221

Erlanger's blood pressure instrument, 72

Erythromelalgia, 192, 208

Estimation of blood pressure, 179

Etiology, 157

Examination of arteries, 172, 177
of heart, 172
of urine, 257

Exercise, blood pressure in, 105
in prophylaxis, 225
in treatment, 230

Experimental arteriosclerosis, 50

Extrasystole, 138

F

Faught's blood pressure instrument, 75, 80

Fibrillation, auricular, 133
ventricular, 138

Fibrolysin in treatment, 243

Fingernail palpation, 178

Finger tip palpation, 179

Flutter, auricular, 131

Food poisons in arteriosclerosis, 163

G

Gibson's law, 154

H

"H" wave, 126

Habits, personal, 234

Head injuries, blood pressure in, 148

Headache, 184
treatment of, 248

Heart block, 140
boundaries, 172
examination of, 172
hypertrophy of, 60
physical examination of, 172
stimulants, 243, 246, 259
symptoms, 188

Hemorrhages, blood pressure in, 118

Henle, membrane of, 29

Hill and Barnard's blood pressure instrument, 70

Hirschfelder's blood pressure instrument, 73

His, bundle of, 141, 197

Hygienic treatment, 230

Hyperpietic arteriosclerosis, 186

Hypertension, 60, 106, 169, 185, 249
cause of arteriosclerosis, 159
classification of cases, 112

Hypertrophy of left ventricle, 58

Hypotension, 117

I

Incompetence, aortic, 61, 258

Indicanuria, 167

Infants, arteriosclerosis in, 158

Infectious diseases in arteriosclerosis, 163
blood pressure in, 153

Insomnia, treatment of, 248

Intermittent claudication, 192, 208
treatment of, 247

Intoxications, chronic drug, 166

Intracranial tension, 105

Involutionary arteriosclerosis, 187

Iodides in treatment, 238, 247, 259

K

Kidney diseases, blood pressure in, 155

Kidneys, sclerosis of, 61, 170

L

Life insurance, relation to, 249

Light percussion, 174
touch palpation, 175

Liver, cirrhosis, 64, 216

Local symptoms, 207

M

Marey's blood pressure instrument, 70

Maximum pressure, 85, 94

Mean pressure, 85

Media, calcification of, 43, 59

Medicinal treatment, 238

Meningitis, blood pressure in, 118

Mental strain, 168

Mesaortitis, 45, 47, 49, 165

Mesentery, cross-section of small artery in, 56

Milk diet, 237

Minimum pressure, 86, 94

Moenckeberg type of arteriosclerosis, 43

Morphine in treatment, 243

Mosenthal test meal, 221

Muscular overwork, 169

N

Nervous symptoms, 191

Nitrites in treatment, 240

Nitroglycerin in treatment, 241

Nodular arteriosclerosis, 32, 37

Normal blood pressure variation, 88

O

Obstetrics, blood pressure in, 152

Occupation in arteriosclerosis, 162

Ocular symptoms, 190

Ophthalmic examination, importance in early diagnosis, 214, 256

Orthodiagraph, 173

Overeating, 167, 212, 225, 235

Overwork, muscular, 169

P

"P" wave, 129

"P-R" interval, 130

Palpable arteries, 189

Palpation, 174, 180
fingernail, 178
finger tip, 179
light touch, 175

Pathology, 32

Percussion, 174
auscultatory, 175
light, 174

Peripheral symptoms, 207

Personal habits, 234

Phlebosclerosis, 64

Phthalein test, 221

Physical signs, 183

Physiology of the circulation, 65

Potain's blood pressure instrument, 70

Practical suggestions, 256

Pressure, arterial, 85
ausculatory method of determining, 83
diastolic, 83, 94
estimation of, 179
in surgery, 147
maximum, 85, 94
normal variations, 88
pulse, 83, 85, 87, 100
systolic, 82, 85
technique, 80
venous, 120

Prognosis, 218

Prophylaxis, 224
exercise in, 225

Pseudo angina pectoris, 216

Pulmonary artery, 209
arteriosclerosis of, 63
tuberculosis, blood pressure in, 119

Pulse, 123
capillary, 67
deficit, 135
dicrotic, 123
in arteriosclerosis, 123
pressure, 69, 83, 85, 87, 100
rate, 69
venous, 123

Purgatives in treatment, 244, 259

Pyrosis, 184

Q

"Q R S" complex, 129

R

Rabbits, lesions produced experimentally in, 50

Race in arteriosclerosis, 161

Radial artery, 29

Radials, sclerosis of, 43

Raynaud's disease, 192, 207

Recklinghausen's blood pressure instrument, 76

Renal disease, 169
symptoms, 199

Rest in treatment, 242

Riva-Rocci's blood pressure instrument, 70

Rogers' blood pressure instrument, 77

S

Sanborn's blood pressure instrument, 80

Scaphoid scapula, 158

Schwellungsperkussion, 174

Sclerosis of veins, 64

Senile arteriosclerosis, 32, 37, 43, 59

Sex in arteriosclerosis, 161

Shock, blood pressure in, 105, 148

Spinal symptoms, 205

Spirochaeta pallida, 45

Stanton's blood pressure instrument, 72

Stenosis, aortic, 60

Stokes-Adams syndrome, 197

Stomach, ulcer of, 216

Strain hypertrophy, 47, 54, 55

Surgery, blood pressure in, 147

Symptomatic treatment, 245

Symptoms, 183
abdominal, 201
arterial, 189
cardiac, 195
cerebral, 203
dyspeptic, 184
dyspnea, 184
general, 183
headache, 184
heart, 188
local, 207
nervous, 191
ocular, 190
peripheral, 207
pyrosis, 184
renal, 199
special, 194
spinal, 205
vertigo, 184
visceral, 201

Syphilis, 165
in aorta, 44

Syphilitic arteriosclerosis, 37

Systolic pressure, 69, 82, 85, 94
importance of, 97

T

"T" wave, 130

Technique of blood pressure instruments, 80

Thayer and Fabyan, 34

Theocin, 247

Thoma on arteriosclerosis, 33

Thoracic aorta, 29

Thyroid extract in treatment, 239

Tobacco, 167, 212, 234

Tonal arrhythmia, 92, 102

Toxic arteriosclerosis, 186

Treatment, 229
aconite in, 242
balneotherapy in, 233
corpus luteum, 241
dietetic, 235
digitalis in, 246, 259
diuretin in, 246
exercise in, 230
fibrolysin in, 243
heart stimulants in, 243
hygienic, 230
iodides in, 238, 247, 259
medicinal, 238
morphine in, 243
nitrites in, 240
nitroglycerin in, 241
of dyspnea, 248
of headache, 248
of insomnia, 248
of intermittent claudication, 247
personal habits in, 234
purgatives in, 244, 259
rest in, 242
symptomatic, 245
theocin in, 247
thyroid extract in, 239
Trunecek's serum in, 243
venesection in, 242
veratrum viride in, 242

Trunecek's serum in treatment, 243

Tuberculosis, blood pressure in, 119

Tunica intima, 28
media, 28

"Tycos" blood pressure instrument, 77

Typhoid fever as cause of arteriosclerosis, 164
blood pressure in, 118

U

Ulcer of stomach, 216

Urine, examination of, 257
suppression of, 259

V

Valvular heart disease, blood pressure in, 155

Vasa vasorum, 29

Veins, anatomy of, 30
sclerosis of, 64

Velocity of blood in animals, 66
of blood in aorta, 66

Venesection in treatment, 242

Venous pressure, 120
pulse, 123

Ventricle, left, hypertrophy of, 58

Ventricular fibrillation, 138

Veratrum viride in treatment, 242

Vertigo, 184

* * * * *

Transcriber's Notes: Irregular hyphenation has been preserved, as in blood pressure and blood-pressure. Both "Hg" and "Hg." appear.

Minor typographical errors and inconsistencies have been silently normalized.

The original printed list of illustrations shows the original locations; they have been moved closer to their discussion area in the text to not interrupt the flow of reading.

Page 244 Prescription symbol is replaced with R_{x}

Page 259 Apothecaries ounce symbol replaced with "ounce"

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