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 succumb 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 assignable 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 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.
[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 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.
The attitude 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.