DIAGNOSIS
=Early Diagnosis=
Arteriosclerosis is essentially a disease of middle life and old age. It
is not unusual, however, to find evidences of the disease in persons in
the third decade and even in the second decade. Hereditary influences
play a most important role, syphilis and the abuse of alcohol in the
family history are particularly momentous. The recognition of the early
changes in the arteries among young persons depends largely upon how
carefully these changes are looked for. The difference in the point of
view of one man who finds many cases in the comparatively young, and
another man who rarely finds such changes early in life, at times,
depends upon the acuity of perception and observation and not upon the
fact that one man has had a series of unusually young arteriosclerotic
subjects. The diagnosis of arteriosclerosis may be so easily made that
the tyro could not fail to make it. It is, however, the purpose of this
volume to lay stress on the earliest possible diagnosis and, if
possible, to point out how the diagnosis may be arrived at. It is
obviously much to the advantage of the patient to know that certain
changes are beginning in his arteries, which, if allowed to go on, will
inevitably lead to one or more of the symptom groups described in the
preceding chapters.
The combination of (1) hypertrophied heart, (2) increased blood
pressure, (3) palpable arteries, and (4) ringing, accentuated second
sound at the aortic cartilage is, in reality, the picture of advanced
arteriosclerosis. If the individual is in good condition much may be
done by judicious advice and treatment to ward off complications and
prolong life with a considerable degree of comfort. But we should not
wait until such signs are found before making a diagnosis and
instituting treatment. As in all forms of chronic disease the early
diagnosis is all important.
The history of the case is the first essential. Often a careful inquiry
into the personal habits of a patient, with the record of all the
preceding infectious diseases will give us valuable information and may
be the means of directing the attention at once to the possible true
condition. Particularly must we inquire into the family history of gout
and rheumatism. An individual who comes of gouty stock is certainly more
prone to arterial degeneration than one who can show a healthy heredity.
Alcoholism in the family also is of importance because of the fact that
the children of alcoholics start in life with a poor quality of tissue,
and conditions that would not affect a man from healthy stock might
cause early degeneration of arterial tissue in one of bad ancestry.
What infectious diseases has the patient had? Even the exanthemata may
cause degenerations in the arteries, but, as has been shown, such
lesions probably heal completely with no resulting damage to the vessel.
Should the patient have passed through a long siege of typhoid fever the
problem is quite different. Here (vide supra) (Thayer), the palpable
arteries do appear to be sclerosed permanently. Probably the length of
time that the toxin has had a chance to act determines the permanent
damage to the vessel wall. More potent than all other diseases to cause
early arteriosclerosis is syphilis, and hence very careful inquiry
should be made in regard to the possibility of infection with this
virus. Not only the fact of actual infection but the duration and
thoroughness of treatment are important matters for the physician to
know.
What is the patient's occupation? Has he been an athlete, particularly
an oarsman? Has he been under any severe, prolonged, mental strain? Is
he a laborer? If so, in what form of manual labor is he engaged? Such
questions as these should never be overlooked, as they form the
foundation stones of an accurate diagnosis, and early, accurate
diagnosis, we repeat, is essential to successful therapy.
We have called attention to the factor of sustained high pressure in the
production of arteriosclerosis. Constant overstretching of the vessels
leads to efforts of the body to increase the strength of the part or
parts. The material which is used to strengthen the weakened walls has a
higher elastic resistance than muscle and elastic tissue, but a lower
limit of elasticity, and is none other than the familiar connective
tissue. In athletes, laborers, brain workers who are under constant
mental strain, and in those whose calling brings them into contact with
such poisons as lead, there is every factor necessary for the production
of high tension and consequently of arteriosclerosis.
Another question in regard to personal habits is how much tobacco does
the patient use and in what form does he use it? Our experience is that
the cigar smoker is more prone to present the symptoms of
arteriosclerosis than the cigarette smoker, the pipe smoker, or the one
who chews the tobacco. A very irritable heart results not infrequently
from cigarette smoking but such is almost always found in young men in
whom the lesions of arteriosclerosis are exceedingly rare. The
probabilities are that the arteriosclerosis in cigar smoking results
from the slowly acting poison which causes a rapid heart rate with an
increase of pressure.
Last but not least, and perhaps the most important question is, has the
patient been a heavy eater? This I believe to be a potent cause of
splanchnic arteriosclerosis with the resulting indigestion, cramp-like
attacks, high blood pressure, etc. In a joking manner we are accustomed
to remark, "Overeating is the curse of the American people." There is,
however, much truth in that sentence. Osler, than whom there is no
keener observer, states that he is more and more impressed with the fact
that overloading the stomach with rich or heavy or spiced foods is today
one of the first causes of arterial degeneration. It stands to reason
that this is true. We know that organs exposed constantly to hard work
undergo hypertrophy, and that the blood tension in those organs is high.
Blood tension is, after all, dependent on capillary resistance, and if
the capillaries are distended with blood, the resistance is great. The
digestive organs can be no exception to this rule. Increased work means
an increase of blood. This inevitably causes distension of the
capillaries with stretching of the arteries and consequent damage to the
walls. Once arteriosclerosis is present a vicious circle is established.
A man about forty-five consults us and says that he has noticed recently
that he gets out of breath easily; in tying his shoes he experiences
some dizziness. He finds that he has palpitation of the heart and
possibly pain over the precordial region now and then. He notices also
that he is irritable, that is, his family tell him he is, and he notices
that things that formerly did not annoy him, now are almost hateful to
him. On examination, one finds a palpable radial, a somewhat
hypertrophied heart and slightly accentuated second aortic sound. The
blood pressure may be high. The urine may or may not reveal any
abnormalities. Not infrequently, although no albumin may be found, there
are hyaline casts. Such a case of arteriosclerosis is evidently not to
be regarded as early. Then the question arises, How are we to recognize
early arteriosclerosis? I do not believe that the solution of this
problem lies entirely in the hands of the physician. Some men are
fortunate enough to come up for an examination for life insurance before
an observant doctor who recognizes the palpable artery, makes out the
beginning heart hypertrophy and the slightly accentuated second aortic
sound. The patient will tell you that he never felt better in his life.
He gets up at seven, works all day, plays golf, drinks his three to six
whiskies, and is proud of his physical development. But the great mass
of people are not fortunate from this standpoint. They do not seek the
advice of the physician until they are stretched out in bed. They boast
of the fact that for twenty years they have never had a doctor. One may
well say that it is a problem how to reach such persons. It seems to me
that there can be but one way to do this. The people must be taught that
the duty of a physician is just as much to keep them in health as it is
to bring them back to health when they are ill. To that end people
should be taught that at least twice a year they should be carefully
examined. I do not mean that the patient should present himself to the
doctor and, after a few questions the doctor say cheerfully, "You are
all right." The patient should be systematically examined. That means a
removal of the clothing and examination on the bare skin. 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. Early diagnosis of arteriosclerosis is only possible in
exceptional cases unless people present themselves to the physician with
the thought in mind that he is the guardian of health as well as the
healer.
There are patients who go to the ophthalmologist for failing vision.
Physically they feel quite well. They have been heavy eaters, hard
workers, men and women who have been under great mental strain. On
examination of the fundus of the eye there is found slight tortuosity of
the vessels with possibly areas of degeneration in the retina. A careful
physical examination will usually reveal the signs of arteriosclerosis
elsewhere. We have mentioned frequently high tension as an early sign.
This must be taken with somewhat of a reservation, for this reason: not
infrequently a persistent high tension is the earliest sign of chronic
nephritis. The arteries may be pipe stem in character and the heart
small and flabby. However, if one watches for the palpably thickened
superficial arteries (always bearing in mind the normal palpability as
age advances) and the high tension, he can not go far wrong in his
treatment whether the case is one of chronic nephritis or of
arteriosclerosis.
There is also this to bear in mind. Arteriosclerosis may be marked in
some vessels and so slight in the peripheral vessels that it can not
with certainty be made out. But when the radials are sclerosed, it is
usually the case that similar changes exist in other parts. Then too,
there may be marked changes at the root of the aorta leading to
sclerosis of the coronary vessels alone, and the first intimation that
the patient or any one else has that there is disease, may be an attack
of angina pectoris. Except for symptoms on the part of the heart there
is no way to make the diagnosis of sclerosis of the coronary arteries.
=Differential Diagnosis=
In arriving at a diagnosis, when the question is whether or not
arteriosclerosis is the main etiologic factor, the most important fact
to know is the age of the patient. Other points that have been dwelt on
fully must of necessity also be borne in mind.
Possibly the chief conditions that may be confused with some of the
results of arteriosclerosis are pseudo angina pectoris which may be
mistaken for true angina pectoris, and ulcer of the stomach,
appendicitis (?) or other inflammatory abdominal condition which may be
mistaken for angina abdominalis.
Differential tables are sometimes of value in fixing the chief points of
difference graphically.
=Pseudo angina pectoris=.
Etiology rather certain; hysteria, neurasthenia, toxic agents, and
reflex irritations.
No age is exempt. Usually in young people, chiefly females.
Paroxysms of pain occur spontaneously, are periodic and often
nocturnal.
Pain, while severe, is diffuse and sensation is of distension of
heart. No sense of real anguish.
Duration may be an hour or more.
Restlessness and emotional symptoms of causative conditions are
prominent.
Usually no increase in arterial tension.
Prognosis favorable.
=True angina pectoris=.
Etiology not certain but almost always associated with
arteriosclerosis of the coronary arteries and also aortic
regurgitation.
Age is important factor. Rare before forty, and males usually
affected.
Paroxysms brought on by overexertions or excessive mental emotion.
Rarely periodic.
Intense pain, radiating down arm; heart felt as in a vise. Sense of
anguish and impending dissolution.
Duration from few seconds to several minutes.
Silent and fixed attitude, rigidity rather than restlessness.
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 class are diabetes mellitus and
cirrhosis of the liver. As examples of the second class are chronic
nephritis, gout, syphilis, and lead poisoning. Examples of the third
class 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 associated with demonstrable
arteriosclerosis.