In auscultating the heart I prefer the binaural stethoscope of the Ford pattern. The recent subst.i.tution of an aluminum bell for the hard rubber bell is an improvement. Personally I do not favor the phonendoscope or any of the new patent non-roaring instruments now for sale by urgent instrument makers. The phonendoscope has its uses, for example in auscultating the back when a patient is lying in bed or in listening to the heart sounds when a patient is under an anesthetic; but for differentiating the murmurs and for heart diagnosis, I much prefer the regular bell stethoscope.

In arteriosclerosis the two places over which it is important to listen are the apex and the second right cartilage, the aortic area. Over the former, one gains data in regard to the strength of the heart as indicated by the first sound, over the latter point, one learns of the tension in the aorta by the character of the sound produced when the aortic valves close.

The hypertrophy of the heart in arteriosclerosis is invariably due to the enlargement and thickening of the left ventricle. From the nature of the position which the heart a.s.sumes in the thorax, this enlargement is downward and to the left. The apex beat will therefore be found in the fifth or sixth inters.p.a.ce, and definitely at an increased distance from the midsternal line. As stated above, it is most important that this distance be accurately measured and put down in the notes of the case for future reference. No satisfactory prognosis can be given unless this is done, for the gradual increase or the decrease under treatment in the size of the heart can thus be definitely known, and, knowing the other factors, a prognosis may be given which will be of some value to the patient.

=The Examination of the Arteries=

It is exceedingly difficult at times to affirm definitely that an artery, the radial for example, is actually sclerosed. Much depends on the sensitiveness of the fingers of him who palpates, and much upon the relation of the palpated artery to the surrounding, chiefly underlying, structures. In the examination of arteries it is well to inspect the body for the pulsations caused by them. Frequently an exceedingly tortuous artery, such as the brachial, may be seen throughout its whole extent and yet the radial appear little, if any, thickened by palpation.

Again the artery of a pulse of high tension which is small in size but full between the beats, may not be as sclerosed as one which collapses and feels much softer. It is difficult to obtain accurate data in regard to the tension in an artery by feeling it with the fingers of one hand.

One should use both hands. With the middle finger of the right (left) hand the artery is compressed peripherally, that is, nearest the wrist.

The blood is then pressed out of the artery with the middle finger of the left (right) hand, so as to obliterate completely the pulse wave and the two or three inches between the middle fingers are felt with the index fingers. By holding the finger firmly on the artery near the wrist so as to block any wave that may come through the palmar arch by anastomosis with the ulnar artery and by releasing pressure on the proximal middle finger, some idea may be had of the degree of pulse tension. However, no amount of practice can more than approximate the tension and when one is surest that he can tell how many millimeters of pressure there are, he is apt to be farthest wrong when he checks his guess with the sphygmomanometer.

Much may be learned from carefully palpating the peripheral arteries, and, as a rule, the sclerosis of these arteries means general arteriosclerosis, although there are many exceptions to this.

A more recent method, and one which in the author's hands has been found to be valuable, is that proposed by Wertheim-Salomonson who palpates the artery not with the ball of the finger but with the fingernail. The finger is held so that the nail is perpendicular to the surface of the skin and the artery is felt with the end of the nail. The sensation is perceived at the root and makes use of all the sensitive nerve endings there. In this way it is possible to feel the arterial wall distinctly, and a little practice will enable one to determine whether or not the vessel wall is thickened. It is also possible to determine with a considerable degree of accuracy the diameter of the artery and the size of the wall when the current is cut off by pressure on the proximal side of the artery. It is best to have a firm background when this "fingernail" palpation is used. This may be obtained by palpating the radial artery against the lower end of the radius.

Probably the best method of palpating the arteries, especially the radial, to determine the degree of sclerosis and thickening, is to use the tip of the finger and roll it carefully over the artery. The tip of the finger is exceedingly sensitive and, moreover, it is a firmer palpating surface than the ball, thus enabling one to appreciate degrees of sclerosis which could not be differentiated by palpation with the soft yielding ball. This finger tip palpation is well ill.u.s.trated in the figures here shown. (Figs. 57 and 58.)

[Ill.u.s.tration: Fig. 57.--A method of finger-tip palpation of the radial artery. (Graves.)]

[Ill.u.s.tration: Fig. 58.--Another method of finger-tip palpation of the radial artery. (Graves.)]

=Estimation of Blood Pressure=

It must be borne in mind at the outset that arteriosclerosis and high blood pressure are not always a.s.sociated. As a matter of fact in the severest grades of senile arteriosclerosis the blood pressure is usually below the normal for the individual's years. However, as high tension is a frequent factor in the production of arterial thickening, blood pressure readings are of importance.

The instrument which one uses is of minor importance provided it is properly standardized. The most important feature of the instrument is the cuff. This must be 12 cm. wide and be long enough to wrap around the arm several times so that the pressure is evenly distributed over the whole arm and not over a small portion. One mercury instrument we had in the hospital was reported to be at great variance with a dial instrument. This mercury instrument was provided with a cuff which was short and was tied around the arm by means of a piece of tape. This caused a tight constriction over a small area and rendered the estimation too high. A new, long tailed cuff easily remedied the apparent defect in the instrument.

In taking blood pressures the difference from day to day of 10 or even 15 mm. of systolic pressure has no great significance. Fluctuations of the systolic pressure alone, it is insisted upon, have very little meaning. One must take the whole pressure picture into consideration and determine how the picture changes in order to draw any conclusion in regard to the state of the blood pressure. Failure to pay attention to this evident point has caused much futile work to be written and published.

It is well to emphasize again the point that the blood pressure picture consists of the systolic, the diastolic, the pulse pressure and the pulse rate.

=Palpation=

Hoover has called attention to the direct palpation of the femoral artery just below Poupart's ligament as a more accurate index of the pressure in the aorta than the palpation of the radial artery. Possibly one can obtain a more accurate estimate of the blood pressure in this way. This, however, is open to dispute. To estimate the blood pressure by palpating the radial artery is most deceptive. In about 75 per cent of cases one can tell fairly well whether the pressure is abnormally high or abnormally low. Small variations are impossible to determine.

Unquestionably it is most advantageous to get into the habit of palpating the femoral artery and checking the result with the sphygmomanometer so that the fingers may be trained to appreciate as accurately as possible changes of pressure.

It may be that one day when the instrument is needed it is not at hand.

A well-trained touch then becomes a great a.s.set.

=Precautions When Estimating Blood Pressure=

There are certain precautions which must be strictly observed when deductions are drawn from the manometer readings. The psychic factor must be reckoned with. Any emotion may cause marked variations in the pressure. Excitement and anger are especial sources of error. Even the slight excitement arising from taking the first blood pressure on a nervous patient especially is apt to give false values. Usually the readings must be taken many times at the first sitting and the first few may have to be set aside. Worry is a potent factor in raising the pressure. A walk to the physician's office, especially if rapid, has its effect.

The position of the patient when the blood pressure is taken is important. Usually in the office the pressure is taken when the patient sits in a chair. He should a.s.sume a relaxed, comfortable att.i.tude. The readings should be made at the same time of day and at the same interval between meals. The pressure in both arms should be measured and comparisons should be made only between readings on the same arm. These precautions may seem useless and even somewhat trivial, and the conditions difficult to control. But unless they are carefully observed the readings will be false, no comparisons can be drawn between the readings on different days, and the instrument will most probably be blamed. I have known this to happen so often that I can not emphasize too strongly the importance of controlling all the essential conditions which go to make accurate work.

=The Value of Blood Pressure=

In the past few years there has been a veritable avalanche of blood pressure instrument salesmen who have covered the country, sold instruments, and have made many startling claims for the instrument.

They have emphasized its value out of proportion to what the instrument can do even in the hands of one familiar will all the defects.

Consequently it is not necessary to emphasize the value of blood pressure. It seems best to utter a few words of caution in regard to its interpretation.

The value lies not in the occasional estimation compared with some other one reading, but in the frequent estimation and in the visualization of the blood pressure picture. For the great majority of diseases the blood pressure has no particular value except to show that the circulation is not materially disturbed. The limits of normal are rather wide, so that consideration of the patient's age, s.e.x, build, etc., will give us some idea of a base line, so to speak, for any one person. Wide departures from relatively normal figures are important, but are not diagnostic or, rather, pathognomonic. I can not help but feel that the diastolic pressure is _the_ most important part of the blood pressure picture.

Persistent high diastolic pressure means increased work for the heart, which, if acting for a long time against the high peripheral resistance, must eventually hypertrophy. The arteries become thickened, lose their wonderful elasticity, fibrous tissue is deposited in their walls, and the vicious circle is established which leads to pathologic hypertension.

Blood pressure readings must be intimately mixed with brains in order to be of any great value in diagnosis or prognosis.

CHAPTER VIII

SYMPTOMS AND PHYSICAL SIGNS

=General=

Well developed arteriosclerosis shows four pathognomonic signs: (1) hypertrophy of the heart; (2) accentuation of the aortic second sound; (3) palpable thickening of the arteries; and (4) heightened blood pressure. However, it must not be inferred that these signs must be present in order to diagnose arteriosclerosis. It has already been said that a very marked degree of thickening, with even calcification of the palpable arteries, may occur with absolutely no increase of blood pressure, and at autopsy a small flabby heart may be found.

While arteriosclerosis is usually a disease which is of slow maturation, nevertheless cases are occasionally seen which develop rather rapidly.

The peripheral arteries have been noticed to become stiff and hard in as relatively brief a time as two years from the recognized onset of the disease.

Since involution processes are physiologic, as has been described (vide infra), arteriosclerosis may a.s.sume an advanced grade and run its course devoid of symptoms referable to diseased arteries. It is doubtful whether the sclerosis itself could produce symptoms, except in cases later to be described, were it not that the organs supplied by the diseased arteries suffer from an insufficient blood supply and the symptoms then become a part of the symptom-complex of any or all the affected organs.

There are cases, however, in comparatively young persons where a combination of certain ill-defined symptoms gives a clue to the underlying pathologic processes. These symptoms of early arteriosclerosis are the result of slight and variable disturbances in the circulation of the various organs. Normally there are frequent changes in the blood pressure in the organs, but the vasomotor control of normal elastic vessels is so perfect that no symptoms are noted by the individual. When the arteries are sclerosed, they are less elastic and the blood supply is, therefore, less easily regulated. At times symptoms occur only after effort. The patient may tire more readily than he should for a given amount of mental or bodily exercise; he is weary and depressed, and occasionally there is noted an unusual intolerance of alcohol or tobacco. Vertigo is common, especially on rising in the morning or in suddenly changing from a sitting to a standing position.

Some complain of constant roaring or ringing in the ears. There may be dull headache that the accurate fitting of gla.s.ses does not alleviate.

Unusual irritability or somnolency with a disinclination to commence a new task may be present. Sometimes the effort of concentrating the attention is sufficient to increase the headache. This has been called "the sign of the painful thought." Numbness and tingling in the hands, feet, arms, or legs are also complained of, and neuralgias, not following the course of the nerves but of the arteries, also occur. It is important to remember that the train of symptoms resembling neurasthenia in a person over forty-five years old may be due to incipient arteriosclerosis. This tardy neurasthenia frequently accompanies cancer, tuberculosis, diabetes, and incipient general paralysis, as well as incipient arteriosclerosis.

Bleeding from the nose, epistaxis, taking place frequently in a middle-aged person, sometimes is an early symptom. The bleeding may be profuse, but is rarely so large as to be positively harmful. In fact, it may do much good in relieving tension. Slight edema of the ankles and legs is seen. Dyspnea on slight exertion is not uncommon. Dyspeptic symptoms are not infrequent, pyrosis (heartburn), a feeling of fullness after meals with belching or a feeling of weight in the epigastrium.

The dyspeptic symptoms may be so marked that one might almost speak of a variety of arteriosclerosis, the dyspeptic type. For quite a while before any symptoms that would definitely fix the case as one of undoubted arteriosclerosis, the patient complains that foods which previously were digested with no difficulty now give him gastric distress. The examination of the stomach contents of a patient presenting gastric symptoms reveals usually a subacidity. The total acidity measured after the Ewald test meal may be only 20 and the free HCl may be absent. Attention has been called to an unnatural pallor of the face in early arteriosclerosis. Progressive emaciation is sometimes seen in cases of arteriosclerosis and may be the only symptom of which the patient complains.

=Hypertension=

Not all cases of arteriosclerosis are accompanied by increased arterial tension. As has been stated in a previous chapter, the blood pressure in the arterial system depends chiefly on two factors; viz., the degree of peripheral (capillary) resistance, and the force of the ventricular contraction. The highest arterial pressures recorded with the sphygmomanometer occur not in pure arteriosclerosis but in cases where there is concomitant chronic interst.i.tial disease of the kidneys. When this is found there is always arteriosclerosis more or less marked. In cases where the arteries are so sclerosed that they feel like pipe stems there may be an actual decrease in the blood pressure. Hence the clinical measuring of the pressure in the brachial artery alone is not sufficient for a diagnosis of arteriosclerosis. A persistent high blood pressure even with normal urinary findings is not a sign of arteriosclerosis. The high tension later may lead to the production of sclerosis of the arteries, but in these cases the kidney may be primarily at fault.

The impression must not be gained that hypertension in itself always const.i.tutes a disease or even a symptom of disease. Hypertension itself is practically always a compensatory process. That is to say, it is the attempt on the part of the body to equalize the distribution of blood in the body when there is some poison causing constriction of the small arteries. In this sense hypertension is not only essential, but actually life-saving. A heart which is so diseased that it can not respond to the call for increased action by hypertrophy of its fibers, would shortly wear out. The very fact that the heart becomes enlarged and the tension in the arteries becomes high, indicates that in such a heart there was great reserve power. But while hypertension is largely an effort at adjustment among the various parts of the circulation, it nevertheless tends to increase, provided the cause or causes which produced it act continuously. Moreover, as has been said (Chap. II), the arterioles do not respond to increased work on the part of the heart by expanding, but by contracting. A vicious circle is thus maintained which eventually must lead to serious consequences.

Hypertension is then, if anything, only a symptom which may or may not demand treatment. That hypertension leads to the production of sclerosis of the arteries has been repeatedly affirmed here. In certain cases it is good and should not be experimented with. In other cases it is bad and some treatment to reduce the tension must be tried. The main point is to regard hypertension as one regards a compensated heart lesion.

Prof. T. Clifford Allb.u.t.t divides the causes of arteriosclerosis clinically into three cla.s.ses: (1) The toxic cla.s.s--the results of poisons of the most part of extrinsic origin, chiefly those of certain infections. In some of these diseases, the blood pressures, as for example, in syphilis, are ordinarily unaffected; in others, as in lead poisoning, they are raised. (2) The cla.s.s he calls hyperpietic,[15] in which an arteriosclerosis is the consequence of tensile strength, of excessive arterial blood pressure persisting for some years. A considerable example of this cla.s.s is the arteriosclerosis of granular kidney, but in many cases kidney disease is, clinically speaking, absent. (3) The involutionary cla.s.s, in which the change depends upon a senile, or quasisenile degradation. This may be no more than wear and tear, a disposition of all or of certain tissues to premature failure--partly atrophic, partly mechanical--under ordinary stresses; or it also may be toxic, a slow poisoning by the "faltering rheums of age."

In ordinary cases of this cla.s.s the blood pressures for the age of the patient are not excessive. Although the toxins of the specific fevers, notably typhoid, as stated above, and influenza, have been shown to produce arteriosclerosis, this, under favorable circ.u.mstances he believes tends to disappear. This has been shown by Wiesel.

[15] From pieso to squeeze, oppress or distress. Hyperpiesis, therefore, signifies excessive pressure.