Louis M. Warfield

“ 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. ”

“ Such cooperation on the part of patient and doctor would save the patient years of active life and make of the doctor, what his position entitles him to be, the benefactor to the community. Too often careless work on the physician's part lulls the patient into a false sense of security and he wakes up too late to find that he has wasted months or years of life. ”

“ Yet how often does it happen that individuals, apparently in the best of health, suddenly succumb to an asthmatic or uremic attack, an apoplexy, cessation of the heart beat, or a rupture of the heart due to arteriosclerosis!
In order to arrive at an intelligent opinion in regard to prognosis certain factors must be taken into consideration, chief of which are: the seat of the sclerosis; the probable stage; the existing complications; and, last and most important, the patient himself. The whole man must be studied and even then our prognosis must be most guarded. ”

“ All the conflict during the past few years over the subject of blood pressure has revolved around this much overworked word. Hypertension means high pressure, and yet it carries with it a suggestion of high pressure which is harmful to the individual. As a matter of fact hypertension is a compensatory process, it is often a saving process in spite of the fact that it carries possibilities of harm in its possessor. ”

“ Arteriosclerosis is essentially a chronic progressive disease, and the secret of success in the management of it is not to treat the disease or the stage of the disease, but to treat the patient who has the disease. ”

“ 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. ”

“ First and foremost is exercise. It has seemed to us that the revival of out-of-door sports is one of the best signs of promise of the preservation of a virile, hardy race. That women, as well as men, indulge in the lighter forms of out-of-door exercise should bring it about that the coming generation will start in life under the most advantageous conditions of bodily resistance. ”

“ Scarcely any of us lead strictly temperate lives. If we do not abuse our bodies by excessive eating and drinking and so wear out our splanchnic vessels and cause general sclerosis by the high tension thereby induced, we abuse our bodies by excessive brain work and worry with all their multitudinous evils. The prophylaxis of arteriosclerosis might well be labeled, "The plea for a more rational mode of life." Moderation in all things is the keynote to health, and to grow old gracefully is an art that admits of cultivation. ”

“ 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. ”

“ Our conception of arteriosclerosis as a degenerative process affecting the vascular tree rather than a disease, removes the possibility of discussing special symptoms. As a matter of fact, we know of very few organs where even profound pathologic changes in the vascular system produced during life any symptoms which could be laid to these arterial changes. Kind nature has given to us such an excess of organs of every kind that the destruction of large portions of any organ seems to affect the function but little. ”

“ It is evident from what has been said that an accurate prognosis in arteriosclerosis is no easy matter. Were arteriosclerosis a simple disease of an acute character there might be grounds for giving a more or less definite prognosis. The most that can be said is that arteriosclerosis is always a serious disease from the time that symptoms begin to make themselves known. The gravity depends altogether on the seat of the greatest arterial changes, and is necessarily greater when the seat is in the brain than when it is in the legs or arms. ”

“ In a disease that presents as many vagaries as arteriosclerosis, it is not possible to give a certain prognosis. Unfortunately we do not as a rule see the arteriosclerotic until the disease is well advanced, or even after some of the more serious complications have taken place. By that time the condition is progressive, and while the prognosis is grave the individual may live a number of years. ”

“ Our generation assuredly is a ruddy, clean-bodied one. What the actual results of this out-door life and frequent bathing will be for the race remains to be seen, but one can not but feel that it must build up a stronger, more resistant race of people, who not only enjoy better health than did their forefathers, but enjoy it longer. ”

“ No one can dogmatically deny the part which the ductless glands may play in the production of arteriosclerosis, but it hardly seems that there is enough actual experimental evidence to show that they take such an important part as Sajous believes. Until further and more convincing evidence is offered by competent investigators, I prefer to look with some skepticism upon the ductless gland theory of the causation of arteriosclerosis. The field lends itself too easily to speculation and imagery. ”

“ It is after all in the arterioles and smaller arteries that the lesions of arteriosclerosis do the most damage. A point to be emphasized is that the whole arterial system is rarely, if ever, attacked uniformly. That is, there may be a marked degree of sclerosis in the aorta and coronary arteries with very little, if any, change in the radials. On the contrary, a few peripheral arteries only may be the seat of disease. A case in point was seen at autopsy in which the aorta in its entirety and all the large peripheral branches were absolutely smooth. ”

“ Psychic activity, especially when it is accompanied by worry, is a potent factor in the production of the increased blood pressure which is the chief factor in producing arterial disease. It has been suggested that sexual continence in high-strung men produces changes in the nervous system which can conceivably lead to the production of high tension and further to arteriosclerosis. This, however, I can not think has any foundation in fact except in so far as such men are prone to live at high speed and wear themselves out sooner than the normal person. ”

“ In no two persons is the initial velocity at the heart the same, nor in the same person is it the same at all times of day. The size of the heart, the actual strength of the muscle, the amount of blood ejected at every beat, and the size and elasticity of the aorta are some of the factors which determine the velocity of blood at the aortic orifice. When to these factors are added the differences in arterial tissue, the activity or resting stage of the various organs, etc., the question becomes exceedingly complicated. ”

“ Blood pressure is a valuable aid in diagnosis and of material help in many cases in prognosis, but it is not infallible neither can it be used alone to diagnose a case. Blood pressure is only one of many links in a chain of evidence leading to diagnosis. ”

“ No two persons have the same resisting power toward poisons that circulate in the blood. Some go through life exposed to all the infectious diseases without ever becoming infected, while others fall easy victims to every disease that comes, no matter how careful they may be, and it is quite the same in regard to the resistance of the arterial tissues. If the tubing is of first class quality and the individual does not place too much strain on it, he may live to the biblical three-score years and ten, and possess arteries which have undergone such slight changes that they are not palpable. ”

“ It can not be too strongly emphasized that it is the whole patient that we must consider and not any one system that at the time happens to be the seat of greatest trouble, and by its group of symptoms dominates the picture. ”

“ In the cases of the first group, hyperpiesis is often more marked, although not appearing so to the examining finger, than in the second class. In view of the difficulty of estimating by touch alone the amount of hyperpiesis in a contracted hard artery, it is often overlooked until a ruptured vessel in the brain startles us to a realization of our mistake. The "narrow" artery is more dangerous than the tortuous one, for with every change in pressure the passive vessels of the brain must receive blood that under normal conditions would go to other parts of the circulation. ”

“ Karl Marx in his famous Socialistic platform said: "No rights without duties; no duties without rights." So we may paraphrase this and say: "No brain work without moderate physical exercise in the open air; no physical exercise without moderate brain work." ”

“ No applicant who has palpable arteries or hypertension can be considered a first class risk. It can not be denied that men with arteriosclerosis live to an advanced age and may even outlive those who have apparently normal arteries, but the average life expectancy at any age for an arteriosclerotic is less than that for a normal person. The apparently healthy applicant who learns for the first time when examined for life insurance that he has the early or moderately advanced signs of arterial disease, should thank the agent and examiner for showing him the danger signals ahead. ”

“ We can not live without the heart beat and the prophylaxis of arteriosclerosis consists in the adjustment of our lives to our environment, so that we may get the maximum amount of work accomplished with the minimum amount of wear and tear on the blood vessels.
The struggle for existence is keen. Competition in every profession or trade is exceedingly acute, so much so that to rise to the head in any branch of human activity requires [225] exceptional powers of mind. Among those who are entered in this keen competition, the fittest only can survive for any period of time. ”

“ 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. ”

“ First and foremost we wish by percussion to learn the actual size of the heart, in other words what is ordinarily called the relative cardiac dullness. With the absolute dullness we are not concerned. That irregular area represents, as has been said, actually the limits of lung resonance. The heart may or may not be covered with lung; there may or may not be the incisura cardiaca. What I wish to insist upon is that the size of the area of absolute dullness can give us no data in regard to the size of the heart. ”

“ Not always are these persons addicted to drug or liquor habit. Many are rather abstemious in their habits. It is not so often that we see as a victim of arteriosclerosis, the carefree person who laughs his way through life without worrying about the morrow. He is not so prone to arteriosclerosis. Worry is a far more potent cause of breakdown than actual manual work. It is the rule to find thickened arteries among neurasthenics. This may be only part of a generalized degeneration of all tissue in the body. The blood pressure in such persons is usually low. ”

“ Arteriosclerosis comes to almost every one who lives out his allotted time of life. As has been noted within, many diseases and many habits of life are conducive to the early appearance of arterial degeneration. Decay and degeneration of the tissues are necessary concomitants of advancing years and none of us can escape growing old. From the period of adolescence certain of the tissues are commencing a retrograde metamorphosis, and hand in hand with this goes the deposit of fibrous tissue which later may become calcified. ”

“ To infer the stage of the disease from the feeling of the sclerosed artery, may lead to serious mistakes. Persons with calcified arteries may be perfectly comfortable, while those with only moderate thickening may have many severe symptoms. The keynote is individualization. It is manifestly absurd to treat the laboring man with his arteriosclerosis as one would treat the successful financier. The habits, mode of life, every detail, should be studied in every patient if we expect to gain the greatest measure of success in the treatment. ”

“ It must not be thought that because the localization of the arteriosclerosis in the peripheral arteries is usually the most favorable condition that it is therefore devoid of ill effects. On the contrary, very serious, even fatal, results may be brought about by interference with the circulation with resultant extensive gangrene of the part supplied by the diseased arteries. The amputation of a portion of a leg, for instance, may relieve, to some extent, an overburdened heart and prove life-saving to the patient, but the neuritic pains are not necessarily relieved. ”

“ A warning should be sounded, however, against over exercise. This leads naturally to hypertrophy with all its disastrous possibilities. Men who have been athletes when young should guard against overeating and lack of exercise as they grow older. Many of the factors which favor the development of arteriosclerosis are already there, and a sedentary, ordinary life, such as office all day, club in afternoon, a few drinks and much rich food, will inevitably lead to well-advanced arterial disease. ”

“ The general condition of the patient, his build, physical strength, powers of recuperation, etc., must be taken into account in giving a prognosis. The more powerful the individual, the more favorable, as a rule, is the prognosis, with this reservation always in mind, that the greater the body development, the greater is the heart hypertrophy, and the accidents from high tension must not be overlooked. Many puny individuals with stiff, calcified arteries go about with more ease than a robust man with thickened arteries only. ”

“ Arteriosclerosis is not an acute process. In its very nature, it is of months' or years' standing, the specific changes are of slow growth, and more in the nature of degeneration. It would seem that a very careful study of the histories of those with arteriosclerosis and a final examination upon the actual tissue might eventually give us data for the etiology.
The most frequent site of disease in these experimental lesions is the thoracic aorta, and it is there also that the most severe changes are seen. ”

“ More and more does one become impressed with the fact that patients with arteriosclerosis are very often those who take life too seriously and either from ambition or from an exalted sense of duty lead especially strenuous lives. ”

“ The retrogressive changes of advancing years can not be rightly termed disease, yet it becomes necessary to regard them as such, for the senile changes, as we shall see, may be but the advanced stages of true arteriosclerosis. Much depends on the nature of the arterial tissue and much [33] on the factors at work tending to injure the tissue. A man of forty years may therefore have the calcified, pipe stem arteries of a man of eighty. Our parents determine, to great extent, the kind of tissue with which we start life. The arteries are elastic tubes capable of much stretching and abuse. ”

“ That is what every man who reaches adult life should aim at. Hobbies are sometimes the salvation of men. They may be ridden hard, but even then they are helpful in bearing one completely away from daily cares and worries. The man who can keep the balance between his mental and physical work is the man who will, other things being equal, live the longest and enjoy the best health. ”

“ The pulse pressure is subject to wide fluctuations but as a rule for any one normal heart it remains fairly constant as the rate varies. In a rapidly beating heart the diastole is short and the diastolic pressure rises. If the systolic pressure does not also rise, as in a normal heart following exercise, we will say, the pulse pressure falls. We know that when the pulse rate is constant, vasodilatation causes a fall in diastolic pressure and a rise in pulse pressure. On the contrary, vasoconstriction causes a rise in diastolic pressure and a fall in pulse pressure. ”