Thickening of the innermost of the three coats of a blood vessel (sclerosis) in which both the elastic and connective tissue elements are concerned, in Osler’s opinion, is perhaps the most constant feature in all types of arterio-sclerosis (a fibrous overgrowth associated with degenerative changes in the middle coat, causing thickening of the arterial wall with loss of elasticity and contraction. It may be out of all proportion to changes in the middle muscular coat of the artery and may narrow or obliterate the interior space. This is the most important single factor in the disease, responsible for more symptoms than all the others put together. It may be limited to one set of vessels, as of the legs or heart. The cause of this thickening is much discussed but is still in dispute. In lowered vital processes incident to old age and toxic (poisonous) forms, there is a replacement of muscle fibers by connective tissue, fat or lime salts, very much as occurs in larger vessels. The middle coat degeneration seems really as important in the small as in the larger arteries, and in the old age type lime beading’s follow these degenerative changes of the muscle fibers.
There can be no question that in many individuals the rise in blood pressure comes ahead of the appearance of the arterio-sclerosis. The four great factors in the case of the latter are the normal wear and tear of life, the acute infections, the intoxications and those combinations of conditions which keep blood tension high.
The conditions of modern life favor arterio-sclerosis. The best express engine run day by day at maximum speed will not last one-tenth of the time it would if not so pushed. But nowadays with the human engine it is top speed or nothing and we cannot wonder that it early shows signs of hard usage. In the fourth or fifth decade (30 to 50 years of age), even with the best of habits in eating and drinking, the incessant strain and anxiety of business or public life may lead to a de-generation of the blood vessels. The tragedies of life are largely arterial. How often are the best and bravest called away in their primemen whose only fault has been the unselfish abuse of the body machine?’
After 40 it is the exception not to find evidence of degenerationhere and there a small streak of intestinal fatty degeneration and with this the mitral and aortic cusps may have lost a little of their delicate tenuity, (cusp, a little knob at the center of the free margin of a heart valve; aortic, relating to the aortic orifice of the left ventricle of the heart). With advancing age the arteries become thicker and the fatty degeneration of the walls is more marked. As a rule, in the very aged not only the small arteries are thickened, but the aorta (the main trunk of the arterial system, arising from the base of the left ventrical of the heart), and its main branches show extensive changes with calcification (the deposition of insoluble salts of calcium, lime). Occasionally, however, a very old person may have singularly healthy blood vessels. Leading quieter lives women are not so frequently the subjects of arterial changes and in consequence they last longer.
Of 52 post mortems at the Johns Hopkins Hospital in which notes of the condition of the aorta were made, evidence of sclerosis (thickening) were present in 30, and in 21 the changes looked recent. It is remarkable that out of 62 instances in which the condition of the coronary arteries (supplying the heart muscles) was stated, 19 showed sclerotic changes and in 13 these changes were recent. One of the Johns Hopkins house physicians, a very vigorous man of only 25, died in the third week of typhoid fever. There were patches of endarteritis (inflammation of the inner coat of an artery) at the root of,-the aorta, and numerous patches of yellowish sclerosis in both coronary branches.
Of the poisons which have an important influence on the blood vessels, the special poisons from the outside are alcohol, lead and, tobacco, the first named being very generally regarded as a potent influence in causing degeneration of the blood vessels. Tobacco is another poison about which it is very difficult to get conclusive evidence. Experimentally it is easy to produce the most extensive degeneration of the aorta in animals with nicotine. But there are many cases of inveterate consumers of tobacco for long periods who show no trace of vascular change. Nevertheless it rapidly raises tension and may cause spasm of the arteries, which factor may account for the cases of sudden death in young or middle aged men in whom excessive use of tobacco has been the only factor of causation. .Angina pectoris (severe pain in chest from the region of the heart to the left shoulder) is sometimes associated with abuse of tobacco, and the influence may be, as Huchard and others believe, through inducing an arterio-sclerosis of these coronary arteries (of the heart muscles). A form of intermittent limping of the lower limbs has recently been attributed to the abuse of tobacco.
Janeway, who did so much to advance the clinical study of blood pressure, in speaking of preventive treatment, says “tobacco is best sharply restricted” since it has a marked effect on increase of arterial tension.
Our author’s attention was repeatedly called to the frequency of arterio-sclerosis in persons who have been temperate in every respect except at the table. In the United States arterio-sclerosis is very common among the well-to-do classes who, as a rule, are abstemious as far as alcohol is concerned, but exceedingly careless and indulgent in the matter of eating. In our bodies, as in an overstoked engine which is required to carry very much more steam pressure than necessary, damage is certain to follow from the accumulation of waste and a marked disproportion between intake, work and output. We have no positive facts that meat eaters are more prone than others to arterio-sclerosis but Indians (of the Indian dominions of Great Britain) and Japanese, who subsist chiefly on a vegetable diet, are said to be much less affected than Europeans.
There are three great groups of arterio-sclerosis. First, that caused by the ordinary wear and tear of life and which is as natural as gray hair; next, the toxic or acute poison infections; third, causes relating to extremely high blood pressure. Practically in a given case of a man, say, of 55, two or all three factors may be present and it is extremely difficult to assign to each its relative value.
The nature of the changes probably differs in different groups of cases. Slowly advancing, the peripheral (surface) arteries harden, the retinal vessels (of the eyeball) become more tortuous, the blood pressure rises to 150 or 200, the enlargement of the heart becomes more marked, and the urine shows a slight amount of albumin and tube casts. Very many of these patients, particularly those under 40 years, have marked symptoms of nerve weakness causing them to be irritable, sleep-less, emotional. A marked loss of weight is not uncommon.
Stevens says the majority of the victims are persons of apparently robust health and many are overweight. Prolonged mental strain or anxiety, especially if associated with too rich living and deficient muscular exercise, is undoubtedly a potent factor. Alcohol and tobacco may play accessory roles. The symptoms may be for a long time latent, and may be grouped in three classes. In the first they are referable to the heart and consist of shortness of breath on exertion, palpitation and discomfort (in front of the heart) or severe cramp-like pain in the chest. In the second class the earliest manifestations consist of ready fatigue, lassitude, nervous irritability, disturbed sleep, vague pains in the back or limbs and varying combinations of the functional nervous derangements of the stomach. In the third class the first indications consist chiefly of dull headache, vertigo, noises in the ears and perhaps transient attacks of speechlessness, or paralysis of one side of the body. Less frequently the first indication is a slight blur-ring of vision due to small retinal hemorrhages, (eye). Occasionally convulsions related to epilepsy occur, especially at night. In this event the diagnosis is likely to be made of presence of urinary constituents in the blood.
Physical examination frequently reveals besides blood pressure which is often very pronouncedsystolic 200 to 250, diastolic 110 to 140,accentuation of the aortic sound (relating to the aortic orifice of the left ventricle of the heart) and more or less heart enlargement. (The systolic pressure is taken during the contraction, when the heart is in systole, producing the outward flow of blood through the arteries; the diastolic during the rest period while the heart is in diastole,* or filling with blood. The former is the maximum pressure and the latter the minimum pressure in the arteries at any given time. Systolic is the pressure usually referred to. The pulse pressure is the difference between the two.) For years there may be no obvious changes in the accessible arteries. Eventually, however, arterio-sclerosis supervenes, the vessels becoming thickened and tortuous. Except in advanced stages, when secondary changes have occurred in the kidneys as a result of heart insufficiency or of sclerosis (thickening) of the arteries of the kidneys, the urine is usually normal or contains but a trace of albumin and a few hyaline casts (composed of albuminous material). Functional tests indicate inefficiency of the kidneys. Examination of the eyes may reveal nothing abnormal, although in cases of long standing it frequently shows sclerosis (hardening) of the retinal arteries (in the interior coat of the eye which receives the images through the lens), with hemorrhages and inflammation of the retina.
This higher tension of the arteries is a chronic condition, often lasting 5, 10, 15 years or longer. In course of time it is followed by enlarged heart, hardening of the arteries and inflammation of the kidneys. If recognized early before the circulatory system of the blood has undergone any structural changes, it may sometimes be recovered from, and in the majority of cases materially aided .l
The average systolic pressure for women in a series of 200 observations recorded by T. C. Janeway was 10 millimeters (points) less than that of males, owing to less muscular development. The physical fitness and muscular development of the individual slightly affect the blood pressure. Exercise immediately before an examination, even so small as a short walk and a climb of a few steps to the doctor’s offlce, will, if a rest does not intervene, sometimes affect the record as much as an exaggeration of 10 points.
Oliver 2 thinks the best series of normal systolic pressures on record is that afforded by 13,067 normal, accepted risks, by the Northwestern Mutual Life Insurance Co. of the United States (Milwaukee) which does not accept risks above 60 years of age.
It will be seen from this authentic record that the popular notion, frequently heard, that normal blood pressure is represented by the addition of 100 to the age of the individual is very generous. That figure is too high even for the age of 25 to 29. It will be noticed that 100 added to the age of 60 will show an error of 25.54 in excess of the correct average.
Brooks, New York, in an article of notable clarity and authority expresses the opinion that high blood pressure is not a cause but usually a result. It is not a disease though the evidence of it. It is not pathological (indicating the structural and functional changes caused by disease) but is usually if not always physiological (a normal process). It tends more to prolong life than to shorten it. The purport of the discussion is that increased blood pressure is nature’s method of meeting a condition of disease that has arisen in the body and that if the cause cannot be removed the _blood pressure should be left as it is. He cites a case, in illustration, of a young man of 33 who was twice in the hospital first with lobar pneumonia with a systolic blood pressure of 200, that during the course of the disease fell to 150; next under the care of the author at the City Hospital with a history of alcoholic excess and a systolic pressure of 190 to 200. Uremia developed (presence of urinary constituents in the blood) and he died. It was found on postmortem that the blood could not have been forced through the greatly shrunken and sclerosed (hardened) organs without a very high blood pressure; without it death must have taken place months or years before. With it very little real damage had been inflicted on the heart, which remained up to the end perfectly competent.
The only well known author, with a large experience, found who gives a definite method for the treatment of blood pressure is Kellogg. He assigns the same cause to both arterio-sclerosis and high blood pressure by quoting with approval Prof. Henri Huchard, of Paris, to the effect that the former “begins by intoxication, continues by intoxication and ends by intoxication,” and also Huchard’s further remark that the origin of the disease is alimentary, the change vascular (circulation) but the danger is renal (in the kidneys).
The first thing to be done in arranging the regimen for persons suffering from high blood pressure is to change the intestinal flora.
Foods containing uric acid in appreciable amount must be discarded, also tea and coffee. A. cup of coffee contains more than double the percentage of purin (source of uric acid) found in normal urine. Foods rich in oxalic acid, such as sorrel and rhubarb, must be discarded. Eggs must be used sparingly, and then the yolks rather than the whites. Potatoes and other farinaceous roots should be largely used (in place of cereals, breads and breakfast foods) because of the rich supply of organic bases (the element that combines with an acid to form a salt) which they afford and which neutralize the acids arising from tissue wastes always present in excessive quantity in persons subject to arterio-sclerosis or high blood pressure. Fruits should be freely used and greens in sufficient amount to furnish an adequate supply of lime and iron. The charcoal test should be frequently applied to determine how long the food remains in the colon. If more than 24 hours elapse before the black color disappears from the stools further stimulation of intestinal activity is necessary and the amount of bran and paraffin oil (discussed elsewhere) should be increased. In addition an enema should be used at night two or three times a week when a considerable amount of residue is found. It is desirable if bowel movements three times a day can be established. Vigorous measures for changing the intestinal flora should be adopted and continued until putridity disappears. In many cases the colon is so crippled that the regimen for changing the flora must be repeated every few weeks in order to maintain a normal flora. The adoption of an antitoxic and laxative regimen after change of the flora generally results in a pronounced lowering of the blood pressure, within a month. In the case of young persons or older persons who have recently acquired the high blood pressure, the tension can often be brought back to nearly normal. It is not an uncommon experience to note a drop in the pressure from 200 to 150, or even lower, within a few weeks, and then by the proper regimen it may be kept down for years. Dr. M. A. Mortensen 2 has reported thousands of such cases, one where a man past middle age whose blood pressure was reduced from 260 to 160 and still remained at this point after seven years, with the disappearance of other symptoms of ill health.
It is more than probable that colon poisons resulting from the putrefaction of meat residues in the colon are the most active of all causes of arterio-sclerosis. Dale showed that a poison found in decaying meat acts like supra-renal extract and raises the blood pressure at once from 110 to 260. Hence the great importance of, a low protein and fleshless diet in these cases.
The hardening of the arteries and high blood pressure, says Cabot, mean that the tubes through which the blood flows have become smaller and stiffer than they normally are. The heart is therefore called upon for more work. It compensates as we say; that is, gets larger. Thus for years the trouble is compensated so that these people may get along fairly well. In time the load becomes too great. But people with this type of heart trouble may live ten or fifteen years. They are more or less disabled all the time but capable of enjoying life if they do not try to be too strenuous. There is a characteristic trouble that goes with the diseaseangina pectoris. This means a pain in the region of the heart which comes on after emotion or exertion and is relieved by rest. We often see in the street a pathetic figure pretending to look in the shop windows when he does not really want to. Perhaps he has been caught by angina and must stop. After a few moments’ rest he is able to slowly move forward again. There are many causes for angina pectoris but arterio-sclerosis is the commonest. The nights are very bad when compensation begins to fail in any type of heart disease; and the patient with hardening and thickening of the arteries may expect many bad nights. Sleeping in a morris chair is a common practice. One man did it for years and went to business regularly the next morning. He had learned to sleep well sitting up
The rheumatic heart is due to infection. The streptococcus, the micro-organism back of the disease, may show itself in the throat (tonsillitis), or in the brain (chorea, St. Vitus’ dance), in the joints (rheumatism), or in the heart, endocarditis (inflammation of the heart). This last disease begins usually in childhood and rarely after twenty-one, and is almost twice as common in girls as in boys. People can live fifty years with it and then die of something else, but this is frequently not the case, because fresh, virulent crops of the streptococci (micro-organisms of the intestinal tract) get into the heart and extend the old damage. This usually occurs before twenty-one. If mothers can take extra care of their children up to that age, even though the heart seems to be doing pretty poor work, the chances are good that it will settle down and be a useful organ for the rest of life. In such cases the heart strengthens itself, thickens its own muscle, and enlarges its cavities so as to over-come the defects in its valves. Failure of compensation occurs in children mostly when there are acute attacks of fresh poisoning, with fever. When compensation fails, either from this cause or from overexertion we get the symptoms swelled feet, short breath, difficulty in lying down at night, finally general dropsy.
The nephritic type of heart comes as a result of kidney disease. It results in holding back in the blood poisonous waste products which should pass out in the urine. Those poisons as they circulate in the blood stimulate the blood vessels to contract and this spasm produces high blood pressure. The two main causes of high blood pressure are arterio-sclerosis and kidney trouble. In chronic kidney trouble heart failure comes in about eighteen months from the patient’s earliest complaint, making this the worse type of heart disease we have. The treatment of all types of heart disease is rest, plus some measures which empty out the dropsical fluid from the tissues. It is really miraculous what rest can do, without other aid, after compensation has failed. A person who has seemed at death’s door may recover and live for many years provided he can rest with no exercise that produces shortness of breath.
Merely because a person has high blood pressure is no reason to fear a blood vessel will break for in fact it seldom does. High blood pressure does not necessarily mean anything serious, although arterio-sclerosis of the brain is the usual cause of apoplexy or cerebral hemorrhage (a “stroke”). In the brain arteriosclerosis may lead to chronic insanity in a form that may be almost indistinguishable from paresis (incomplete paralysis with dementia). Prognosis of arterio-sclerosis (prediction as to the termination) is very difficult to state. On the whole people usually get too much worried about it. With the syphilitic taint, which with one exception makes the worst prognosis, the diagnosis rests largely on the Wassermann blood test (the standard test for the syphilitic taint).