Arterial tension is as a rule increased.

Prognosis most unfavorable.

In differentiating between ulcer of the stomach and angina abdominalis the following points may be of service:

=Ulcer=.

Occurs as a rule in young persons, more often females.

Pain of boring character increased by food and by certain positions with food in stomach. Felt through to left of spine.

Occult blood found in stools.

Considerable anemia apt to be present.

Arterial tension usually low.

=Angina abdominalis=.

Only occurs in adults over forty who have been heavy eaters and drinkers, mostly males.

Pain cramp-like, diffuse, although more localized in epigastrium.

Not necessarily any connection with food.

No occult blood in stools.

Anemia more often absent.

Arterial tension high. (Splanchnic sclerosis.)

=Diseases in Which Arteriosclerosis Is Commonly Found=

There are certain more or less chronic diseases in which arteriosclerosis is found either as a separate disease or as a result of the chronic disease itself, or the sclerosis may be the cause of the disease. As examples of the first cla.s.s are diabetes mellitus and cirrhosis of the liver. As examples of the second cla.s.s are chronic nephritis, gout, syphilis, and lead poisoning. Examples of the third cla.s.s have already been fully described. Then certain rare diseases that have been briefly described in this chapter, viz.: Raynaud's disease and erythromelalgia are frequently a.s.sociated with demonstrable arteriosclerosis.

CHAPTER XI

PROGNOSIS

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.

It is fortunate for the arteriosclerotic that mild grades of the disease are compatible with a fairly active life. The disease in this stage may become arrested and the patient may live many years. Not only in the mild grades is this possible. Even patients with advanced sclerosis may enjoy good health provided the organs have not been so damaged as to render them unfit to perform their functions. The frequency with which we see advanced arteriosclerosis at the postmortem table as an accidental discovery, attests the truth of the foregoing statement. Yet how often does it happen that individuals, apparently in the best of health, suddenly succ.u.mb 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.

It is much more dangerous for the patient when the process is in the ascending portion of the arch of the aorta than when it has attacked the peripheral arteries. Here, at the root of the aorta, are the openings of the coronary arteries and the arteries supplying the brain are close by. The coronary arteries here control the situation. When loud murmurs are heard at the aortic orifice and the heart is evidently diseased, it is useful to divide the endocarditis into two types, the arteriosclerotic and the endocarditic. The etiology of the former is sclerosis and the prognosis is grave because of the liability, nay the probability, that the orifices of the coronary arteries will become narrowed. The etiology of the second type is in most cases rheumatic fever or some other infectious disease, and the prognosis is far better than in the first type. True, the two may be combined. In such a case, the prognosis is entirely dependent upon the course of the arteriosclerosis.

The involvement of the arteries in the kidneys is of considerable importance, for it is usually bilateral and widespread. As a rule, the disease makes but slow progress provided that the general condition of the patient is good, but at any time from a slight indiscretion or for no a.s.signable cause, symptoms of renal insufficiency may appear and may rapidly prove fatal.

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. The torture from these pains may be excruciating.

No stage of the disease is exempt from its particular danger. In the early stages of the disease before the artery or arteries have had time to become strengthened by proliferation of the connective tissue, there is the danger of aneurysm. Later, the very same protective mechanism leads to stiffening and narrowing of the arteries and hence to increased work on the part of the heart with all of its consequences.

Thrombosis is favored, and where atheromatous ulcers are formed, embolism is to be feared.

As the complications and results of arteriosclerosis come to the front every one must be considered by itself and as if it were the true disease. There may be a slight apoplectic attack from which the patient fully recovers, but the prognosis is now of a grave character, as the chances are that another attack may supervene and carry off the subject.

Yet, after an apoplectic attack, patients have lived for many years.

Probably the most noted ill.u.s.tration of this is the life of Pasteur. He had at forty-six hemiplegia with gradual onset. He recovered with a resulting slight limp, did some of his best work after the stroke, and lived to be seventy-three years old. Yet the exception but proves the rule and the prognosis after one apoplectic stroke should always be guarded.

The first attack of cardiac asthma is to be looked upon as the beginning of the end. The end may be postponed for some time, but it comes nearer with every subsequent attack. One may recover from what appears to be a fatal attack of cardiac asthma accompanied by edema of the lungs and irregular, intermittent, laboring heart, but the recovery is slow and the chances that the next attack will be the fatal one are increased.

The significance of alb.u.minuria is difficult to determine. The kidneys secrete alb.u.min under so many conditions that the mere presence of alb.u.min in the urine may have but little prognostic value. Many cases are seen where there is no demonstrable alb.u.min, and yet the patient may suddenly have a cerebral hemorrhage. As a general rule the urine should be carefully examined, but not too much stress should be laid on the discovery of alb.u.min and casts. It is not always possible to determine the extent of the kidney lesion by the urinary examination, yet at any time a uremic attack may appear and prove fatal.

After all the most important fact for the patient is not what the pathologist finds in his kidneys after he is dead, but what the living functional capacity of the kidneys is. This can now be determined in a variety of ways as the result of extensive work carried out in quite recent years. The simplest method of determining the functional capacity of the kidneys is by the injection into the muscles of the back of a solution containing 6 mg. of the drug phenolsulphonephthalein in one c.c. of fluid. This comes already prepared in ampules, with full directions for its employment.[16] Some clinicians use indigo-carmine in place of phthalein. The general consensus of opinion is in favor of phthalein.

[16] I have found the small colorimeter made by Hynson, Westcott and Dunning, Baltimore, Mo., costing $5.00, a very practical instrument.

The nephritic test meal carefully worked out by Mosenthal[17] gives much valuable information. The determination of the nonprotein nitrogen or the creatinin in the blood also reveals the functional capacity of the kidneys.[18]

[17] Mosenthal, H. O.: Arch. Int. Med., 1915, xvi, 733.

[18] Myers and Lough: Arch. Int. Med., 1915, xvi, 536.

One might say that the appearance of alb.u.min in the urine of an arteriosclerotic where it had not been before, is a bad sign, and in making a prognosis this must be taken into consideration.

Bleeding from the nose is not infrequently seen in those who have arteriosclerosis. It can hardly be called a dangerous symptom as it can always be controlled by tampons. There are times when epistaxis is decidedly beneficial as it relieves headache, dizziness, and may avert the danger of a hemorrhage into the brain substance. It is rare to have nose bleed except in cases of high tension in plethoric individuals. My experience has been that it has saved me the trouble of bleeding the patient. It is always of serious import in that it indicates a high degree of tension, but there is scarcely ever any immediate danger from the nose bleed itself.

Intestinal hemorrhage is always a grave sign. As has been shown, arteriosclerosis of the splanchnic vessels not infrequently occurs, and an embolus or thrombus may completely occlude the superior mesenteric artery. The chances of the establishment of a collateral circulation are small, as the arteries of the intestines are end arteries. Necrosis of the part follows, blood is found in the stools, and perforation or gangrene, or both, are apt to follow. There may be blocking of small branches only, leading to ulceration of the intestine. Under all conditions the prognosis is serious.

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. The differentiation as pointed out by Allb.u.t.t (page 186), is well to keep in mind in giving a prognosis. 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.

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.

The att.i.tude of the patient himself also determines to a great extent the prognosis. Some men, especially those who have always enjoyed good health, turn a deaf ear to warnings and instead of ordering their lives according to the advice of the physician, persist in going their own way in the hope that the luck that has always been with them will continue to stand at their elbows. Neither firmness nor pleadings avail with some men. The only salve for the conscience of the physician is that he has done his best to steer the patient away from the shoals and breakers. In others who realize their condition and take advantage of the advice given as to the regulation of their lives, the prognosis is generally favorable.

To sum up the chapter in a few words, I should say: Always remember that the patient is a human being; study his habits and character and mode of life; look at him as a whole; take everything into consideration, and give always a guarded prognosis.

CHAPTER XII

PROPHYLAXIS