Arteriosclerosis and Hypertension, with Chapters on Blood Pressure / 3rd Edition.

by Louis M. Warfield

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 illustration 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 albuminuria is difficult to determine. The kidneys secrete albumin under so many conditions that the mere presence of albumin in the urine may have but little prognostic value. Many cases are seen where there is no demonstrable albumin, 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 albumin 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.

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]

One might say that the appearance of albumin 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 Allbutt (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.