[Ill.u.s.tration: Fig. 59.--Aneurysm of the heart wall. (Milwaukee County Hospital.)]

A very rare complication of the fibroid degeneration of the heart muscle is aneurysm of the heart wall. (Fig. 59.) The apex of the left ventricle is most commonly the site of the aneurysm and rupture occasionally occurs. Such an accident is rapidly fatal. In the arteriosclerotic process which occurs at the root of the aorta, the coronary arteries become involved both at the openings and along the courses of the vessels. A branch or branches or even one artery may become blocked as a result of obliterating endarteritis. The arteries of the heart are not terminal vessels but as a rule blocking of a large branch leads to anemic infarct. These areas become replaced by fibrous tissue which in the gross specimen appears as streaks of whitish or yellowish color in the musculature. Anemic infarcts may not occur. In such cases the anastomosis between branches of the coronary arteries is unusually free. Through arteriosclerosis of the coronary vessels extensive fibrous changes may occur that lead to a myocardial insufficiency with its attending symptoms--dyspnea, irregular and intermittent heart, gallop rhythm, edema, etc. One of the most distressing and dangerous results of sclerosis of the coronary arteries and of the root of the aorta is angina pectoris. While in almost every case of angina pectoris there is disease of the coronary arteries, the contrary does not hold true, for most extensive disease, even embolism, of the arteries is frequently found in persons who never suffered any attacks of pain. This symptom group is more common in males than in females and as a rule occurs only in adult life. "In men under thirty-five syphilitic aort.i.tis is an important factor." (Osler.)

Since the valuable experiments of Erlanger on heart block, considerable attention has been paid to lesions of the Y-shaped bundle of fibers, a bundle arising at the auriculoventricular node and extending to the two ventricles, known also as the auriculoventricular bundle of His.

Interference with the transmission of impulses through this bundle gives rise to the symptom group known as the Stokes-Adams syndrome, which is characterized by: (a) slow pulse, (b) cerebral attacks--vertigo, syncope, transient apoplectiform and epileptiform seizures, (c) visible auricular impulses in the veins of the neck. Many of the cases which occur are in elderly people the subjects of arteriosclerosis.

[Ill.u.s.tration: Fig. 60.--Large aneurysm of the aorta eroding the sternum. Death from rupture through the skin preceded by frequent small hemorrhages. (Milwaukee County Hospital.)]

So far as we now know all cases of the Stokes-Adams syndrome are caused by heart block which is only another name for disease in the auriculoventricular bundle. Of interest here is the fact that besides gummata, ulcers, and other lesions of the bundle, definite arteriosclerotic changes have been found.

"The investigation of a typical case of Stokes-Adams disease has shown that the symptoms of this case are caused by some lesion in the heart which gives rise to the condition now generally termed heart block.

Practically all degrees of heart block have been observed, namely, complete heart block and partial block with 4:1, 3:1, and 2:1 rhythm, and occasionally ventricular silences. These stages occurred during recovery.

"Experiments testing the reaction of the heart to various extrinsic influences demonstrate that when the block is complete the ventricles do not respond to influences presumably of vagus origin, although the auricles still respond normally to such influences, that effects exerted upon the heart presumably through the accelerators still influence the rate of the ventricles as well as that of the auricles.

"When the block is partial the rate of the ventricular contraction varies proportionally with the rate of the auricular contractions but only within certain limits. When these limits are exceeded the block becomes more complete, i. e., a 2:1 rhythm may be changed into a 3:1 rhythm, this into a 4:1 rhythm, and this into complete block, and vice versa.

"The syncopal attacks are, in all probability, directly dependent upon a marked reduction of the ventricular rate. Such reductions of the ventricular rate are always a.s.sociated with an increase of the auricular rate, and it is believed that the latter is the cause of the former."

(Erlanger.)

The epileptiform seizures of the syndrome may be caused by the anemia of the brain resulting from failure of the heart to supply a sufficient quant.i.ty of blood.

The apoplectiform attacks are most probably caused by venous congestion when the slowing of the ventricular contractions is not sufficient to cause convulsions, but will just cause complete unconsciousness.

=Renal=

Chronic nephritis, hypertension, arteriosclerosis form a most important trinity. Some stoutly affirm that in all cases of high tension there is chronic renal disease. Certainly the very highest blood pressures which we see occur in the chronic interst.i.tial forms of kidney disease. The cause is most probably to be sought in some poison which is elaborated in the kidney, is absorbed into the circulation and acts powerfully either on the vasoconstrictor center as a stimulus, or directly on the musculature of the small arteries all over the body. Usually hypertension is progressive but it may be temporary.

A man, 43 years old, entered the Milwaukee County Hospital in uremic coma. The systolic blood pressure was 280-290 mm. Hg, the diastolic pressure 220 mm. (Janeway instrument). Under treatment his blood pressure gradually became lower, at the same period the alb.u.min and casts gradually disappeared from the urine. In two weeks from admission he seemed perfectly well, there were no alb.u.min or casts found in the urine, and the systolic blood pressure was 136 mm., not a high figure for a muscular man of the laboring cla.s.s. It must be admitted, however, that such cases are the exception, not the rule.

Patients suffering from the a.s.sociation of chronic nephritis with hypertension die slowly, usually. There is gradual development of anasarca. Headache is frequent and severe. Pains all over the body may occur. The sight may suddenly become dim or may even be lost. Dizziness may be complained of and dyspnea is usually marked. Cyanosis comes on, the pulse becomes weak, irregular or intermittent, heart failure sets in, and the patient dies with edema of the lungs.

Another cla.s.s of renal arteriosclerosis is characterized by a small granular kidney in which fibrous changes of a patchy character have taken place. These scattered areas are the result of obliterating endarteritis of renal arteries here and there with consequent anemia, death of cells, and replacement by fibrous tissue. It occurs as part of a generalized arteriosclerosis in which the whole arterial system is the seat of diffuse (senile) sclerosis. The palpable arteries are usually beaded or even encircled with calcareous deposits and the aorta is the seat of an extensive nodular and ulcerating sclerosis. The heart is usually small, shows extensive fibrous and fatty changes and possibly the condition known as "brown atrophy;" the blood pressure is low. Such cases do not show any special symptoms. They are anemic, short of breath on exertion, have the appearance and show the signs of senility.

In the first group it is, at times, difficult to say whether the kidney disease or the arterial disease is the most important. From a clinical standpoint the decision is not essential as the end results are much the same in both. However, when actual uremic symptoms dominate the picture, it becomes evident that the disease of the kidney is the chief feature in the causation of the symptoms.

=Abdominal or Visceral=

There is an important group of cases to which but little attention has been paid until quite recently. This is the abdominal or visceral type of arteriosclerosis. It has been stated that arteriosclerosis of the splanchnic vessels almost invariably causes high tension. Among others, Janeway has shown that general arteriosclerosis without marked disease of the splanchnic vessels does not cause as a rule increase of blood pressure.

There are cases in which the brunt of the lesion falls upon the abdominal vessels. Such cases have been called "angina abdominalis." It has been suggested (Harlow Brooks) that this type of arteriosclerosis may be determined by constant overloading of the stomach with food, especially rich and spiced food. This causes overwork of the special arteries connected with digestion and so leads to sclerosis of the vessels of the stomach, pancreas, and intestines. Personal habits probably influence to great extent the production of this more or less =localized= condition.

The organs supplied by the diseased arteries suffer from changes a.n.a.logous to those occurring in general or local malnutrition, such as starvation, old age, or local anemias. These changes are atrophy with hemachromatosis (brown atrophy) or fatty infiltration and degeneration.

Following the degenerative changes there result connective tissue growth and further limitation of the functionating power of the affected organs.

Pain is a more or less constant symptom of visceral sclerosis. In the early stages there may be only a sense of oppression, of weight, or of actual pressure in the abdomen or pit of the stomach. There may be only recurring attacks of violent abdominal pain accompanied by vomiting. In some cases symptoms of tenderness in the epigastrium, pains in the stomach after eating, vomiting and backache may suggest gastric ulcer.

There may be dyspnea and a sense of anguish accompanied with a rapid and feeble pulse. Hematemesis may make the symptom group even more like ulcer of the stomach, and only the course of the disease with the failure of rigid ulcer treatment and the subst.i.tution of treatment directed toward relief of the arterial spasm with resulting betterment, enables one to make a diagnosis. The condition may be present for years and the symptoms only epigastric tenderness with dizziness and sweating on lying down after dinner, as in one of Perutz's patients. The attacks are probably due to spasmodic contraction of the sclerosed intestinal vessels with a resulting local rise in blood pressure. The pains are most probably due to the spasm of the intestinal muscles, and some think they are located in the sympathetic and mesenteric plexuses.

This result of arteriosclerosis is not so uncommon, and by keeping this cause of obscure abdominal pain in mind we are now and then enabled to save a patient from operation.

An autopsy on a case which for many years had attacks of abdominal pain and cramp-like attacks, with high blood pressure and heart hypertrophy, showed extensive sclerosis of the abdominal aorta, superior mesenteric and iliacs. These vessels were calcified. Hypertrophy of the left ventricle was found. The kidneys were microscopically normal. There were no changes in the ascending aorta but in the descending portion there were scattered nodules and small calcified plaques.

The attacks of pain from which this patient suffered for many years, the hypertrophy of the left ventricle and the increased blood pressure were thought to be directly due to the sclerosis of the abdominal vessels.

=Cerebral=

It has been stated that arteriosclerosis is a general disease, yet certain systems of vessels may be affected far more than others, and indeed there may be marked sclerosis at one part of the body and none demonstrable at another part.

In advanced sclerosis there may be one or more of a series of accidents due to embolism, thrombosis, or rupture of the vessels. Such conditions as transient hemiplegia, monoplegia or aphasia may occur. The attacks may come on suddenly and be over in a few minutes; what Allb.u.t.t calls "Larval apoplexies." They may last from a few hours up to a day, and are very characteristic. A patient aged 64 years with pipe stem radials and tortuous hard temporals would be lying quietly in bed when suddenly he would stiffen, the eyes would become fixed and the breathing cease. In a few seconds consciousness returned, the patient would shake himself, pa.s.s his hand over his brow and ask, "Where am I? Oh, yes, that's all right." He had as many as thirty of these attacks in twenty-four hours, none of them lasting over one minute. To just what such attacks are due, it is hard to say. Some have attributed them to spasm of the smaller blood vessels of the brain, but there have never been demonstrated in the vessels any constrictor fibers.

There is a well recognized form of dementia caused by arteriosclerosis.

In general paralysis of the insane and in senile dementia the blood vessels are always diseased. Milder grades of psychic disturbances are accompanied by such symptoms as mental fatigue, persistent headaches, vertigo, memory weakness and fainting. Aphasia, periods of excitement and mental confusion occur in some. Later stages are at times accompanied by inclination to fabulate, loss of judgment, disorientation, narrowing of the external interests, episodes of confusion and hallucinatory delirium.

The hemiplegias, monoplegias and paraplegias may occur again and again and last for one or two days. Unless there has been rupture of the vessels, there is complete recovery as a rule.

In persons who have arteriosclerosis with high tension attacks of melancholia are seen. There are at the same time fits of depression, insomnia, irritability, fretfulness, and a generally marked change in disposition. When the tension is reduced by appropriate treatment these symptoms disappear, to recur when the tension again becomes high. On the contrary, attacks of mania are accompanied by low blood pressure. The dizziness and vertigo in cerebral arteriosclerosis are probably due to the stiffness of the vessels which prevents them from following closely the variations of pressure produced by position, and thus, at times, the brain is deprived of blood and a transient anemia occurs.

Arteriosclerosis of the cerebral vessels is always a serious condition.

The greatest danger is from rupture of a blood vessel. Another of the dangers is gradual occlusion of the arteries bringing about necrosis with softening of the brain substance. The latter is more apt to be a.s.sociated with psychic changes, dementia, etc.; the former, with hemiplegia. It is curious that a small branch of the Sylvian artery, the lenticulo-striate, which supplies the corpus striatum, should be the one which most frequently ruptures. Where the motor fibers from the whole cortex are gathered together in one compact bundle, a very small hemorrhage may and does cause very serious effects. A comparatively large hemorrhage in the silent area of the brain may cause few or no symptoms.

=Spinal=

It is conceivable that arteriosclerosis of the vessels of the spinal cord might cause symptoms which would be referred to the areas of the cord where the process was most advanced. The lesions would be scattered and consequently the symptoms might be protean in character.

True epileptic convulsions dependent on arteriosclerotic changes are also seen and are not so uncommon.

This is on the whole a rare condition, much less common than arteriosclerosis of the cerebral vessels. Collins and Zabriskie report the following typical case:

"H., a fireman, fifty-one years old, was in ordinary good health until toward the end of 1902. At that time he noticed that his legs were growing weak and that they tired easily. Later he complained of a jerking sensation in different parts of the lower extremities and at times of sharp pain, which might last from several minutes to two or three hours. The legs were the seat of a heavy, unwieldy sensation, but there was no numbness or other paresthesia. About the same time he began to have difficulty in holding the urine, a symptom which steadily increased in severity. These symptoms continued until March, 1903, i. e., for three months, then he awakened one morning to find that he was unable to stand or walk, and the sphincters of the bowels and bladder relaxed. There was no complaint of pain in the back or legs, no difficulty in moving the arms, in swallowing or in speaking. He says he was able to tell when his lower extremities were touched and he could feel the bed and clothes. He was admitted to the City Hospital three weeks later and the following record was made on April 21, 1903.

"The patient was a frail, emaciated man of medium height, who had the appearance of being 55-60 years of age. He was unable to stand or walk. When he was lying, he could flex the thigh and the legs slowly and feebly. There was slight atrophy of the anterior and inner muscles, more of the left than of the right side. The knee jerks and ankle jerks were absent. Irritation of the soles caused quite a typical Babinski phenomenon. The patient had fair strength in the upper extremities, but the arms tired very soon, he said. The grip was moderate and alike in each hand. The motility of the face, head, and neck was not noticeably impaired. There was no difficulty in swallowing, and articulation was not defective. Tactile sensibility was slightly disordered in the lower extremities, although he could feel contact of the finger, the point of a pin, and the like. Sensibility was not so acute as normal; there was a quant.i.tative diminution. Sensory perception was not delayed. There was a distinct zone of slight hyperesthesia about as wide as the hand above the femoral trochanters. Above that, sensibility was normal. There was no discernible impairment of thermal sensibility.

No part of the body was particularly tender on pressure. A bedsore existed over the sacrum, and there was excoriation of the genitals from constant dribbling of urine.

"Examination of the chest showed shallow respiratory movements. The heart was regular, weak, there were no murmurs, the second sound was accentuated. Examination of the abdomen showed that the liver and spleen were palpable, but were not enlarged. The abdominal reflexes, both upper and lower, were sluggish. The patient was slow of speech, likewise apparently of thought. He did not seem to show an adequate interest in his condition, still he was fully oriented and seemed to have a fair memory. His mental reflex was slow. There were indications in the peripheral blood vessels and heart of a moderate degree of general arteriosclerosis. The peripheral vessels such as the radial, were palpable, the walls thickened, the blood pressure increased.

"The patient did not complain of pain while he was in the hospital, a period of four weeks, nor was there any particular change in the patient's symptoms, subjective and objective, during this time. His mental state remained clear until forty-eight hours before death, when he became sleepy, stuporous, and comatose, dying apparently of cardiac weakness, which had set in simultaneously with the clouding of consciousness."

At autopsy, except for a few small hemorrhages in the posterior horns of the lower dorsal segments on the right side and a similar condition of the left anterior horns, there was nothing noticed. On microscopic examination, there was found widespread sclerosis of the vessels of the cord to a marked degree with only slight thickening of the vessels of the brain. There were secondary degenerations of ascending and descending type particularly marked at the ninth dorsal segment. They included portions of all the tracts, the pyramidal tract as well. The symptoms in brief were: (1) weakness and easily induced fatigue of the legs; (2) peculiar sensations in the lower extremities, described as jerky, numbness, heaviness, and occasionally sharp pain; (3) progressive incontinence of urine; (4) progressive paraplegia.

Since one of the chief manifestations of syphilis is sclerosis of the arteries, neurologic cases characterized by irregular symptoms and signs which can not be placed in any of the definite system disease groups, are possibly due to irregularly scattered areas of sclerosis throughout the spinal cord caused by obliterating arteritis. Such cases are not so very uncommon. Several have come under my observation. Further studies of the spinal cords of these cases at autopsy are necessary before a final opinion can be given as to their dependence on arteriosclerosis of the spinal vessels.

=Local or Peripheral=