Louis Marshall Warfield.

Arteriosclerosis and hypertension : with chapters on blood pressure online

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ERRATUM


Page 75, Figure shown is not the Brown sphygmomanometer described in the
text, but the Baumanometer manufactured by W. A. Baum Co., Inc., New
York. It is claimed that the Baumanometer is made with particular care
and hence the readings are said to be more accurate than other mercury
instruments. It is apparently a good instrument. The author has had no
personal experience with it.




ARTERIOSCLEROSIS

AND

HYPERTENSION

With Chapters on Blood Pressure

BY

LOUIS M. WARFIELD, A.B., M.D., (Johns Hopkins),
F.A.C.P.

FORMERLY PROFESSOR OF CLINICAL MEDICINE, MARQUETTE UNIVERSITY MEDICAL
SCHOOL; CHIEF PHYSICIAN TO MILWAUKEE COUNTY HOSPITAL; ASSOCIATE
MEMBER ASSOCIATION AMERICAN PHYSICIANS; MEMBER AMERICAN
ASSOCIATION PATHOLOGISTS AND BACTERIOLOGISTS;
AMERICAN MEDICAL ASSOCIATION, ETC., FELLOW
AMERICAN COLLEGE OF PHYSICIANS

_THIRD EDITION_

ST. LOUIS

C. V. MOSBY COMPANY

1920

COPYRIGHT, 1912, 1920, BY C. V. MOSBY COMPANY


_Press of
C. V. Mosby Company
St. Louis_


TO

MY MOTHER

THIS VOLUME IS AFFECTIONATELY

DEDICATED




PREFACE TO THIRD EDITION


Several years have elapsed since the appearance of the second edition of
this book. During this time there has been considerable experimentation
and much writing on arteriosclerosis. The total of all work has not been
to add very much to our knowledge of the etiology of arterial
degeneration. Points of view and opinions change from time to time. It
is so with arteriosclerosis. In this edition arteriosclerosis is not
regarded as a disease with a definite etiologic factor. Rather it is
looked upon as a degenerative process affecting the arteries following a
variety of causes more or less ill defined. It is not considered a true
disease. Possibly syphilitic arteritis may be viewed as an entity, the
cause is known and the lesions are characteristic.

Much new material and many new figures have been added to this edition.
Some rearranging has been done. The chapter on Blood Pressure has been
much expanded and some original observations have been included. The
literature has been selected rather than indiscriminately quoted. Much
that is written on the subject is of little value.

It has always seemed to the author that there is not enough of the
personal element in medical writings. At the risk of being severely
criticized, he has attempted to make this book represent largely his own
ideas, only here and there quoting from the literature.

New chapters on Cardiac Irregularities Associated with Arteriosclerosis,
and Blood Pressure in Its Clinical Application have been added.

The fact that the book has passed through two editions is very
gratifying and seems to show that it has met with favor. The author
takes this opportunity of thanking those who have loaned him
illustrations. Wherever figures are borrowed due credit is given.

It is hoped that the kind of reception accorded to the first and second
editions will also not be withheld from this present edition.

LOUIS M. WARFIELD.

Milwaukee, Wisc.




PREFACE TO THE SECOND EDITION


In this second edition so many changes and additions have been made that
the book is practically a new one. All the chapters which were in the
previous edition have been carefully revised. Two chapters, "Pathology"
and "Physiology," have been completely rewritten and brought up to date.
It was thought best to add some references for those who had interest
enough to pursue the subject further. These references have been
selected on account of the readiness with which they may be procured in
any library, public or private. Two new chapters have been added - one on
"The Physical Examination of the Heart and Arteries," the other on
"Arteriosclerosis in Its Relation to Life Insurance," and it is hoped
that these will add to the practical value of the book.

Arteriosclerosis can scarcely be considered apart from blood pressure,
and in the view expressed within, with which some may not concur, high
tension is considered to be a large factor in the production of
arteriosclerosis. As the data on blood pressure have increased, the
importance of it has become more evident. The chapter on "Blood
Pressure" has been wholly rewritten, expanded so as to give a
comprehensive grasp of the essential features, and several illustrations
have been added in order to elucidate the text more fully. The chief
objects in view were to make clear to the physician the technique and
the necessity for estimating both systolic and diastolic pressures.

The author is grateful for the kindly reception accorded the first
edition. No one is more keenly aware of the imperfections than he. The
necessity for a second edition is taken to mean that the book has found
a place for itself and has been of use to some.

The author hopes that this new edition will fulfill adequately the
purpose for which he prepared the book - namely, as a practical guide to
the knowledge and appreciation of a most important and exceedingly
common disease.

LOUIS M. WARFIELD.

Milwaukee, May, 1912.




PREFACE TO THE FIRST EDITION


It is hoped that this small volume may fill a want in the already
crowded field of medical monographs. The author has endeavored to give
to the general practitioner a readable, authoritative essay on a disease
which is especially an outcome of modern civilization. To that end all
the available literature has been freely consulted, and the newest
results of experimental research and the recent ideas of leading
clinicians have been summarized. The author has supplemented these with
results from his own experience, but has thought it best not to burden
the contents with case histories.

The stress and strain of our daily life has, as one of its consequences,
early arterial degeneration. There can be no doubt that arterial disease
in the comparatively young is more frequent than it was twenty-five
years ago, and that the mortality from diseases directly dependent on
arteriosclerotic changes is increasing. Fortunately, the almost
universal habit of getting out of doors whenever possible, and the
revival of interest in athletics for persons of all ages, have to some
extent counteracted the tendency to early decay. Nevertheless, the
actual average prolongation of life is more probably due to the very
great reduction in infant mortality and in deaths from infectious and
communicable diseases.

The wear and tear on the human organism in our modern way of living is
excessive. Hard work, worry, and high living all predispose to
degenerative changes in the arteries, and so bring on premature old age.
The author has tried to emphasize this by laying stress on the
prevention of arteriosclerosis rather than on the treatment of the fully
developed disease.

No bibliography is given, as this is not intended as a reference book,
but rather as a guide to a better appreciation and understanding of a
most important subject. It has been difficult to keep from wandering off
into full discussions of conditions incident to and accompanied by
arteriosclerosis, but, in order to be clear in his statements and
complete in his descriptions, the author has to invade the fields of
heart disease, kidney disease, brain disease, etc. It is hoped, however,
that these excursions will serve to show how intimately disease of the
arteries is bound up with diseases of all the organs and tissues of the
body.

Some authors have been named when their opinions have been given. Thanks
are extended also to many others to whom the writer is indebted, but of
whom no individual mention has been made.

The author also takes this opportunity of expressing his appreciation of
the kindness of Dr. D. L. Harris, who took the microphotographs, and to
the publishers for their unfailing courtesy and consideration.

LOUIS M. WARFIELD.

St. Louis, August, 1908.




CONTENTS


PAGE

CHAPTER I

ANATOMY 25

Introduction, 25; Definition, 26; General Structure of
the Arteries, 27; Arteries, 29; Veins, 30; Capillaries, 31.

CHAPTER II

PATHOLOGY 32

Syphilitic Aortitis, 44; Experimental Arteriosclerosis, 50;
Arteriosclerosis of the Pulmonary Arteries, 63; Sclerosis
of the Veins, 64.

CHAPTER III

PHYSIOLOGY OF THE CIRCULATION 65

Blood Pressure, 68; Blood Pressure Instruments, 70; Technic,
80; Arterial Pressure, 85; Normal Pressure Variations, 88;
The Auscultatory Blood Pressure Phenomenon, 90; The Maximum
and Minimum Pressures, 94; Relative Importance of the
Systolic and Diastolic Pressures, 97; Pulse Pressure, 100;
Blood Pressure Variations, 102; Hypertension, 106;
Hypotension, 117; The Pulse, 123; The Venous Pulse, 123;
The Electrocardiogram, 126.

CHAPTER IV

IMPORTANT CARDIAC IRREGULARITIES ASSOCIATED WITH
ARTERIOSCLEROSIS 131

Auricular Flutter, 131; Auricular Fibrillation, 133;
Ventricular Fibrillation, 138; Extrasystole, 138;
Heart Block, 140.

CHAPTER V

BLOOD PRESSURE IN ITS CLINICAL APPLICATIONS 147

Blood Pressure in Surgery, 147; Head Injuries, 148; Shock
and Hemorrhage, 148; Blood Pressure in Obstetrics, 152;
Infectious Diseases, 153; Valvular Heart Disease, 155;
Kidney Disease, 155; Other Diseases, Liver, Spleen,
Abdomen, etc., 156.

CHAPTER VI

ETIOLOGY 157

Congenital Form, 157; Acquired Form, 159; Hypertension,
159; Age, Sex, Race, 161; Occupation, 162; Food Poisons,
163; Infectious Diseases, 163; Syphilis, 165; Chronic
Drug Intoxications, 166; Overeating, 167; Mental Strain,
168; Muscular Overwork, 169; Renal Disease, 169; Ductless
Glands, 171.

CHAPTER VII

THE PHYSICAL EXAMINATION OF THE HEART AND ARTERIES 172

Heart Boundaries, 172; Percussion, 174; Auscultation,
176; The Examination of the Arteries, 177; Estimation
of Blood Pressure, 179; Palpation, 180; Precautions When
Estimating Blood Pressure, 181; The Value of Blood
Pressure, 181.

CHAPTER VIII

SYMPTOMS AND PHYSICAL SIGNS 183

General, 183; Hypertension, 185; The Heart, 188; Palpable
Arteries, 189; Ocular Signs and Symptoms, 190; Nervous
Symptoms, 191.

CHAPTER IX

SYMPTOMS AND PHYSICAL SIGNS 194

Special, 194; Cardiac, 195; Renal, 199; Abdominal or
Visceral, 201; Cerebral, 203; Spinal, 205; Local or
Peripheral, 207; Pulmonary Artery, 209.

CHAPTER X

DIAGNOSIS 210

Early Diagnosis, 210; Differential Diagnosis, 215;
Diseases in Which Arteriosclerosis is Commonly Found, 216.

CHAPTER XI

PROGNOSIS 218

CHAPTER XII

PROPHYLAXIS 224

CHAPTER XIII

TREATMENT 229

Hygienic Treatment, 230; Balneotherapy, 233; Personal
Habits, 234; Dietetic Treatment, 235; Medicinal, 238;
Symptomatic Treatment, 245.

CHAPTER XIV

ARTERIOSCLEROSIS IN ITS RELATION TO LIFE INSURANCE 249

CHAPTER XV

PRACTICAL SUGGESTIONS 256




ILLUSTRATIONS


FIG. PAGE

1. Cross section of a large artery 28

2. Cross section of a coronary artery 36

3. Arteriosclerosis of the thoracic and abdominal aorta 39

4. Arteriosclerosis of the arch of the aorta 40

5. Normal aorta 41

6. Radiogram showing calcification of both radial and ulnar
arteries 42

7. Syphilitic aortitis of long standing 44

8. Diagrammatic representation of strain hypertrophy 48

9. Strain hypertrophy 49

10. Cross section of small artery in the mesentery 56

11. Enormous hypertrophy of left ventricle 58

12. Aortic incompetence with hypertrophy and dilatation of
left ventricle 61

13. Cook's modification of Riva-Rocci's blood pressure
instrument 72

14. Stanton's sphygmomanometer 73

15. The Erlanger sphygmomanometer with the Hirschfelder
attachments 74

16. Desk model Baumanometer 75

17. Faught blood pressure instrument 76

18. Rogers' "Tycos" dial sphygmomanometer 77

19. Detail of the dial in the "Tycos" instrument 78

20. Faught dial instrument 79

21. Detail of the dial of the Faught instrument 79

22. The Sanborn instrument 80

23. Method of taking blood pressure with a patient in sitting
position 81

24. Method of taking blood pressure with patient lying down 82

25. Observation by the auscultatory method and a mercury
instrument 84

26. Observation by the auscultatory method and a dial instrument 85

27. Schema to illustrate decrease in pressure 86

28. Chart showing the normal limits of variation in systolic
blood pressure 89

29. Tracing of auscultatory phenomena 94

30. Tracing of auscultatory phenomena 95

31. Clinical determination of diastolic pressure, fast drum 96

32. Clinical determination of diastolic pressure, slow drum 96

33. Venous blood pressure instrument 121

34. New venous pressure instrument 122

35. Events in the cardiac cycle 124

36. Simultaneous tracings of the jugular and carotid pulses 125

37. Jugular and carotid tracings 125

38. Right side of the heart showing distribution of the
two vagus nerves 127

39. Normal electrocardiogram 128

40. Auricular flutter 132

41. Auricular fibrillation 134

42. Auricular fibrillation 134

43. Pulse deficit 135

44. Ventricular fibrillation 137

45. Auricular extrasystoles 139

46. Ventricular extrasystole 139

47. Delayed conduction 141

48. Partial heart block 141

49. Complete heart block 142

50. Alternating periods of sinus rhythm and
auriculoventricular rhythm 144

51. Auriculoventricular or "nodal" rhythm 144

52. Influence of mechanical pressure on the right vagus nerve 144

53. Schematic distribution of right and left vagus 145

54. Blood pressure record from a normal reaction to ether 149

55. Chart showing the method of recording blood pressure
during an operation 150

56. Method of using blood pressure instrument during operation 151

57. Finger-tip palpation of the radial artery 178

58. Finger-tip palpation of the radial artery 178

59. Aneurysm of the heart wall 196

60. Large aneurysm of the aorta eroding the sternum 198




ARTERIOSCLEROSIS AND HYPERTENSION




CHAPTER I

ANATOMY


With the increased complexity of our modern life comes increased wear
and tear on the human organism. "A man is as old as his arteries" is an
old dictum, and, like many proverbs, the application to mankind today
is, if anything, more pertinent than it was when the saying was first
uttered. Notwithstanding the fact that the average age of mankind at
death has been materially lengthened - the increase in years amounting to
fourteen in the past one hundred years of history - clinicians and
pathologists are agreed that the arterial degeneration known as
arteriosclerosis is present to an alarming extent in persons over forty
years of age. Figures in all vital statistics have shown us that all
affections of the circulatory and renal systems are definitely on the
increase. "Arterial diseases of various kinds, atheroma, aneurysm, etc.,
caused 15,685 deaths in 1915, or 23.3 per 100,000. This rate, although
somewhat lower than the corresponding ones for 1912 and 1913, is higher
than that for 1914, and is very much higher than that for 1900, which
was 6.1."

The great group of cases of which cardiac incompetence, aneurysm,
cerebral apoplexy, chronic nephritis, emphysema, and chronic bronchitis
are the most frequent and important appear as terminal events in which
arteriosclerosis has probably played an important part.

Thus, in the sense in which we speak of tuberculosis or pneumonia as a
distinct disease, we can not so designate the diseased condition of the
arteries.

Arteriosclerosis is not a disease =sui generis=. It is best viewed as a
degeneration of the coats of the arteries, both large and small
resulting in several different more or less distinct types.

These types blend one into the other and in the same patient all types
may be found. Thus the sclerosis of the arteries is the result of a
variety of causes, none of which is definitely known in the sense of a
bacterial disease. As we shall see later, one type of arteriosclerosis
has a special pathology and etiology, the syphilitic arterial changes.

Bearing in mind that arteriosclerosis (called by some "arteriocapillary
fibrosis," by others "atherosclerosis") is not a true disease, it may,
for convenience be defined as a chronic disease of the arteries and
arterioles, characterized anatomically by increase or decrease of the
thickness of the walls of the blood vessels, the initial lesion being a
weakening of the middle layer caused by various toxic or mechanical
agencies. This weakness of the media leads to secondary effects, which
include hypertrophy or atrophy of the inner layer - and not infrequently
hypertrophy of the outer layer - connective tissue formation and
calcification in the vessels, and the formation of minute aneurysms
along them. The term arteriocapillary fibrosis has a broader meaning,
but is a cumbersome phrase, and conveys the idea that the capillary
changes are an essential feature of the process, whereas these are for
the most part secondary to the changes in the arteries. The veins do not
always escape in the general morbid process, and when these are affected
the whole condition is sometimes called vascular sclerosis or
angiosclerosis.

Upon the anatomical structure of the arteries depends, as a rule, the
character and extent of the arteriosclerotic lesions. For the clear
comprehension of the process, it is necessary to keep in mind the
essential histological differences between the aorta and the larger and
smaller branches of the arterial tree.

The vascular system is often likened to a central pump, from which
emanates a closed system of tubes, beginning with one large
distributing pipe, which gives rise to a series of tubes, whose number
is constantly increasing at the same time that their caliber is
decreasing in size. From the smallest of these tubes, larger and larger
vessels collect the flowing blood, until, at the pump, two large trunks
of approximately the same area as the one large distributing trunk empty
the blood into the heart, thus completing the circle. This is but a
rough illustration, and, while possibly useful, takes into account none
of the vital forces which are constantly controlling every part of the
distributing system.


General Structure of the Arteries

The aorta and its branches are highly elastic tubes, having a smooth,
glistening inner surface. When the arteries are cut open, they present a
yellowish appearance, due to the large quantity of elastic tissue
contained in the walls. The elasticity is practically perfect, being
both longitudinal and transverse. The essential portion of any blood
vessel is the endothelial tube, composed of flat cells cemented together
by intercellular substance and having no stomata between the cells. This
tube is reinforced in different ways by connective tissue, smooth muscle
fibers, and fibroelastic tissue. Although the gradations from the larger
to the smaller arteries and from these to the capillaries and veins are
almost insensible, yet particular arteries present structural characters
sufficiently marked to admit of histological differentiation.

The whole vascular system, including the heart, has an endothelial
lining, which may constitute a distinct inner coat, the tunica intima,
or may be without coverings, as in the case of the capillaries. The
intima (Fig. 1) consists typically of endothelium, reinforced by a
variable amount of fibroelastic tissue, in which the elastic fibers
predominate. The tunica media is composed of intermingled bundles of
elastic tissue, smooth muscle fibers, and some fibrous tissue. The
adventitia or outer coat is exceedingly tough. It is usually thinner
than the media, and is composed of fibroelastic tissue. This division
into three coats is, however, somewhat arbitrary, as in the larger
arteries particularly it is difficult to discover any distinct
separation into layers.

[Illustration: Fig. 1. - Cross section of a large artery showing the
division into the three coats; intima, media, adventitia. The intima is
a thin line composed of endothelial cells. The wavy elastic lamina is
well seen. The thick middle coat is composed of muscle fibers and
fibroelastic tissue. The loose tissue on the outer (lower portion of
cut) side of the media is the adventitia. (Microphotograph, highly
magnified.)]

The muscular layer varies from single scattered cells, in the
arterioles, to bands of fibers making up the body of the vessel in the
medium-sized arteries and veins.

There is elastic tissue in all but the smallest arteries, and it is also
found in some veins. It varies in amount from a loose network to dense
membranes. In the intima of the larger arteries the elastic tissue
occurs as sheets, which under the microscope appear perforated and
pitted, the so-called fenestrated membrane of Henle.

The nutrient vessels of the arteries and veins, the vasa vasorum, are
present in all the vessels except those less than one millimeter in
diameter. The vasa vasorum course in the external coat and send
capillaries into the media, supplying the outer portion of the coat and
the externa with nutritive material. The nutrition of the intima and


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Online LibraryLouis Marshall WarfieldArteriosclerosis and hypertension : with chapters on blood pressure → online text (page 1 of 18)