PAUL A. DEOGNY, M.D., MILFORD, NEB.
The frequency of arterial disease, the widespread changes which it produces in other organs, and the serious complications that so often supervene in the course of such disease, make the subject one of unusual importance to every practitioner. There is such a diversity of opinion among recent writers on arteriosclerosis relative to the etiology, the pathogenesis and symptomatology that it makes a study of this disease more than confusing. Our difficulty will be lessened if we get a conception of arteriosclerosis as a condition, not the result of a single causative factor, but as one with a multiple variety of causes, a varied pathology, depending on the size of the vessels involved, and with a variety of clinical symptoms in different individuals and in the same person at different times.
Etiology.—Arteriosclerosis attacks all ages. Fremont-Smith, in an excellent paper, collected 144 cases of juvenile arteriosclerosis. We can assume that arterial changes take place in all individuals after thirty-five years of age. Heredity, improper and indiscreet eating and drinking, excessive social activities, the worry and nervous tension of modern business, and prolonged muscular exertion, determine how rapidly these changes will progress. For these reasons men are more subject to arteriosclerosis than women, Americans more than Europeans. Warfield states that arteriosclerosis is more frequent and of earlier onset in the American negro than in the white race, attributed largely to the prevalence of syphilis and hard manual labor in that race. Jews are especially prone to senile sclerosis. Among the other causes may be mentioned excessive adrenal activity, intoxications as occur in chronic nephritis, gout, diabetes, obesity, and acute infectious diseases. Pierson claims that high blood pressure is far and away the most important cause of arteriosclerosis, especially of middle life. Persistent high blood pressure results from two main causes: (1) Chronic renal disease; (2) primary disturbance of the vessels themselves, probably a result of arteriolar spasm. This latter condition is known as essential hypertension, and is a persistent elevation of systolic and diastolic blood pressures for which there is no discoverable cause. It must be clearly understood that high arterial tension and arteriosclerosis are not synonymous. They can and do exist frequently entirely independent of each other. It is the belief of some that arteriosclerosis is the cause of hypertension. but it is not supported by clinical or experimental observations. For instance, how explain the great senile group of arteriosclerotics with rigid pipe-stem vessels and normal or sub-normal blood pressures? All available evidence seems to indicate that the converse is true, and that at least certain forms of arteriosclerosis are the result of persistent high blood pressure.
Morbid Anatomy.—Four varieties of arteriosclerosis may be recognized—the nodular, the senile, the diffuse, and the syphilitic.
The nodular form: This affects chiefly the aorta and larger arteries. In early stages opaque gelatinous plaques present on the inner surface of the vessel walls, later becoming cartilaginous. When old they become calcined and brittle or degenerate by necrosis. Thrombi and the so-called "atheromatous ulcer" result.
The senile form: This may affect any part of the arterial tree, but, as a rule, it affects the radial and other middle-sized arteries. The vessel walls become thinned, distended, tortuous and rigid. Microscopically, the muscle cells and elastic fibers of the media show fatty degeneration, atrophy, fibrosis and calcification. The connective tissue and elastic fibers of the intima show hyperplasia and fatty degeneration.
The diffuse form: This corresponds to the arterio-capillary fibrosis of Gull and Sutton. It is observed most frequently in association with chronic nephritis and essential hypertension. Affects especially the smaller vessels, causing thickening of their walls and contraction of their lumina. Microscopically, resembles the senile form with the hyperplasia predominating.
The syphilitic form: Affects any arteries, although it has a strong predilection for the ascending aorta and arch. Opaque, nodular, gummatous swellings line the vessels. These undergo cicatrization and form depressed radiating scars, in contrast to the atheromatous and calcareous changes in the nodular form.
Associations and Sequels.—Chronic nephritis is frequently associated with arteriosclerosis. Hypertrophy of the heart is constantly present in the diffuse form. Hemorrhage is one of the most serious consequences, cerebral and retinal being most frequent. Aortic aneurysm, in the majority of cases, is the result of syphilitic mesarteritis. Thrombi and emboli are found in the nodular form. The most frequent sequels are cirrhosis of the viscera, softening of the brain, and gangrene of the extremities.
Symptoms.—The early symptoms are a gradual deterioration of the general health, pallor or tissue-paper skin, prickling and numbness of the fingers, pulse with a distinct interval between beats, and "intermittent limp," as described by Mackenzie.
The symptoms vary, depending on the type, degree and localization of the disease. When the arteries of the brain are affected we get symptoms of diminished blood supply, as giddiness, especially when standing up quickly from a lying position or on violent exertion; loss of memory, particularly for recent events; sleeplessness, headache, tinnitus aurium and mental irritability or depression. The changes in the coronary arteries lead to a diminished supply of blood to the heart muscle, and their presence calls forth symptoms of distress, dyspnea and pain.
Treatment.—The treatment of arteriosclerosis must of necessity in some cases be general, and in others directed to the organs involved. Early treatment is quite successful, but no treatment has been much more than palliative in the fully-developed cases of arteriosclerosis. Excesses, as mentioned in the etiology, must be avoided. Bowel regulation is essential.
The diet should be largely vegetable, but the big thing is to always avoid over-loading. The question of rest and exercise is one of importance. Walking in the open air, deep breathing and eight or nine hours' sleep are necessary. Such organs as the heart, brain and legs are accustomed to be exercised to the limit of their endurance. Enough quiet must be enforced to avoid over-exertion of these organs. Baths should be warm, at night, and never cold. Focal infections in the teeth, tonsils, sinuses, ears, gall-bladder, appendix, genito-urinary tract and lower bowel must be removed, as also chronic -intoxications by alcohol, lead and intestinal stasis. Anti-syphilitic remedies, when indicated, have been disappointing. Remedies that I have proven useful are veratrum, kali phos., baryta mur., sodium nitrite, calcium iodide (salol coated) and sumbul.
Ergot in threatened gangrene of the extremities is a very superior remedy. Body infra-red, followed by auto-condensation, have given considerable relief. Courses of baths at the various springs have been helpful. Animasa, used in thirty-eight cases satisfactorily by Witt, of New York, reduced blood pressure in all cases, regardless of its origin. Animasa abounds in protein substances, and is an organic preparation from the intima and media of young cattle, fetal extract and by-products of erythrocytes.
The following types of hypertension respond to treatment:
Nephritic type: If treated early, this type may be considerably relieved by sigmoid treatments, diathermy to the kidneys and cat. phos. and kali mur. internally.
Adrenal type: Pancreas substance, crataegus or digitalis internally. X-ray treatment to the side of the vertebrae between the eleventh dorsal and upper margin of third lumbar. Failing myocardium type is best treated by diathermy to the heart as recommended by Nagleschmidt. Body ultra-violet radiations. Digitalis, macrotys, crataegus, cal. fluor. and iron internally as indicated.
Liver type: Diathermy to the liver, auto-condensation. Liver substance internally. Results will be had with chelidonium or chionanthus, as indicated.
Climacteric type: Ultra-violet locally with general body radiations. Pancreas substance, with veratrum, macrotys and belladonna, are most often indicated.
Works of Reference.
- Pierson, George Morris: Diseases of Middle Life.
- Warfield, Louis M.: Arteriosclerosis and Hypertension, Third Ed., 1920. p. 159.
- Fremont-Smith: Am. Jour. Med. Sci., cxxxv, No. 2, February, 1908, p. 199.
- Jones: Definite Medication, p. 36.
- Sajous: Analytic Cyclpoedia of Practical Medicine, Vols. x, xi, xii.
- Girdwood, R. L., and Mackenzie: Oxford Medicine, Vol. ii, p. 493.
- Grover: High Frequency Practice, p. 137.
- Stevens: The Practice of Medicine, p. 709.
- Harrower: Pluriglandular Therapy, p. 174.
- Witt, S. E.: Medical Interpreter, Vol. viii, p. 12.