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 assume 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 glasses 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 interstitial 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.