is directly referable to the lesion itself, although the existence of
the trouble is compatible with long life and active occupation. The
duration of life and the amount of suffering caused by stenosis both
depend upon the amount of obstruction in the aorta and the efficiency
of the collateral circulation.
In 49 cases death occurred in the following manner:
Rupture of the aorta 10 times.
Rupture of the heart 3 "
Sudden pulmonary oedema 4 "
Cardiac failure 8 "
Apoplexy 4 "
Pneumonia 8 "
Capillary bronchitis 4 "
Paralysis 2 "
Pleurisy 1 time.
No cause assigned 5 times.
--
49 times.
TREATMENT.--Obviously, no treatment for the lesion itself is possible.
If recognized, the existence of the sufferer may be prolonged by
adopting moderation in all things as the maxim of his life. Subjective
symptoms of discomfort must be combated on general principles as they
arise.
{828}
DISEASES OF THE CORONARY, PULMONARY, SUPERIOR MESENTERIC, INFERIOR
MESENTERIC, AND HEPATIC ARTERIES, AND OF THE COELIAC AXIS.
BY E. G. CUTLER, M.D.
DISEASES OF THE CORONARY ARTERY.
Chronic Endarteritis (Arterio-sclerosis; Atheroma).
This is the most important inflammatory disease of the coronary artery
which has been observed. It resembles chronic endarteritis elsewhere,
and frequently accompanies the same affection of the aorta, though it
may occur alone. The disease may be general, affecting both coronary
arteries equally, or one may be more involved than the other, or the
disease may be confined to one vessel or to even a small branch.
ETIOLOGY.--Chronic endarteritis of the coronary arteries is especially
a disease of middle and advanced life. It occurs most frequently in the
male sex. The coronary artery stands fifth in the order of frequency in
which the vessels are attacked. The disease is attributed to the misuse
of alcoholic drinks, syphilis, chronic lead-poisoning, gout, and
chronic kidney disease, by encouraging an early senescence of the
tissues, and hence favoring the occurrence of the arterial change.
SYMPTOMS.--There are no symptoms which are peculiar to the disease,
those which exist being due to the consecutive changes in the substance
of the heart. We may divide cases for convenience of description into
those with an acute course and rapid death; those pursuing a subacute
course; and, finally, those having a chronic one. In the first
instance, sudden death either occurs in a person apparently in perfect
health after the manner of a syncope, as in one getting out of bed or
standing on the street, while straining at stool, or under sudden
emotional excitement. Death may not follow on the instant, but occurs
in the course of a longer or shorter time. The attack begins with
pressure in the cardiac region, anxiety, restlessness, streaming pain.
The complaints and anxiety increase; the breath becomes short and
troublesome, the pulse small, frequent, and intermittent; finally,
collapse occurs, with oedema of the lung. Death takes place with either
a clear mind or slight delirium. Such a fatal ending may cover a day or
two or only a few hours. Almost always careful subsequent inquiry
elicits the fact that for some time past respiratory or cardiac
difficulties have existed, which appeared and disappeared and were not
regarded as serious or suspicious. Sudden death may also occur in cases
of protracted chronic heart disease following arterio-sclerosis, with
an old history of the symptoms of angina pectoris, under the appearance
of a fainting fit or of a severe attack of angina or oedema of the lung
lasting several days. In such a case rupture of the heart may be found,
with bloody infiltration of the cardiac {829} muscle and effusion of
blood into the pericardium. In other cases there may be small
hemorrhages, often with pronounced infarct formation and softening. In
still other cases neither hemorrhage nor infarction is found, but fatty
degeneration of the muscle or beginning softening. The sclerosis in
such cases is usually very distinct, and affects the trunk and anterior
descending branches of the left coronary artery. Sometimes it is hard
to find the diseased spot, as it may be circumscribed or on a side
branch. In the last-mentioned cases, where sudden death occurs in a
chronic process, no post-mortem signs of acute disease are usually
found. A chronic fibroid process, with atrophy, exists, which has run a
tolerably latent course and leads to death under the appearance of
sudden cardiac weakness.
PATHOLOGY.--There are two stages of chronic endarteritis: 1. The stage
of simple thickening of the intima; 2. The stage of ulceration and the
accompanying further changes.
At first, the normal smooth, shining inner surface of the intima is
interrupted here and there or in long stretches by flat rounded
elevations, which gradually merge into the healthy surrounding tissues,
and are characterized by a paler, more transparent character, and at
the same time softer but elastic consistence. The surface of these
thickenings, which are frequently located at the point where branches
are given off, is either perfectly smooth or slightly wrinkled. Besides
these translucent spots there are similar ones which are opaque,
whitish or yellowish in color, and have a somewhat rougher surface.
Lastly, there are very pronounced thickenings with a yellow color. In
the slighter degrees these spots occur singly. In the more pronounced
cases they may take up the greater part of the surface; the wall of the
vessel is thickened, the inner surface is uneven, and the vessel itself
more or less dilated. In the beginning the intima retains its shining
surface: after the disease has lasted a long time this is changed, and
the second stage appears. Roughnesses, erosions, and ulcerations
appear, or more commonly calcification of the wall. This latter appears
at first as little thin layers, and finally in large shield-like plates
of lime salts, which may occupy the whole circumference of the artery
and change it into a stiff, bony tube. It is found where ulceration has
occurred, and often without the appearance of the latter. Together with
the rigidity of the wall there occurs a slight tortuousness of the
vessel. At first the superficial layers of the intima are soft; next
they become more sclerosed, and their tissue denser and finally
striated; or disintegration, commencing deep in, may reach as far as
the surface and lead to an atheromatous ulcer. A more or less abundant
deposit of lime salts follows in the sclerosed layers of the intima,
leading to the formation of homogeneous plates as hard as bone.
The result of the process at first is diminution of the calibre of the
vessel, next diminution of the elasticity and contractility of the
artery: it loses its resistance and suffers dilatation in consequence
of the blood-pressure, and may attain aneurism. Or if calcification
occurs early the diminution of the lumen remains, or perhaps even
increases, and may reach an almost complete occlusion of the vessel.
The effects on the heart which follow this form of disease of the
coronary artery, though described in another place, had best be
enumerated here: 1. The flow of blood not being sufficiently interfered
with to cause disease, the heart may remain unchanged. 2. Hemorrhagic
infarction may result, accompanied by simple fatty degeneration or
softening, which is the most frequent cause of rupture of the heart. 3.
Fibrous degeneration or myocarditis may occur, leading perhaps to
aneurism of the heart. 4. There may be a combination of these two--a
greater or less marked fibrous degeneration, to which a fresh
hemorrhagic softening is added.
DIAGNOSIS.--There are no pathognomonic symptoms of this disease, and
{830} it is doubtful if a diagnosis can be arrived at. When the
conditions spoken of under Etiology pertain, and certain of the
symptoms mentioned in connection with the disease are present, a
suspicion of chronic endarteritis of the coronary artery may be
entertained with some degree of probability.
PROGNOSIS.--This must necessarily be unfavorable where the suspicion of
the disease is entertained.
TREATMENT.--Little is to be expected in the way of treatment beyond
mere palliation. In the rapid cases death occurs so soon that the
medical attendant barely has time to reach the patient. In those cases
which last longer the treatment must bear special reference to the
symptoms. Pain and spasm may be allayed by opiates or by the inhalation
of some anæsthetic cautiously administered, as ether or nitrate of
amyl, or by the cautious use of nitro-glycerin and the application of
counter-irritants, as mustard, over the cardiac region. Digitalis is to
be used with the greatest caution, if at all, as its action may be
positively harmful. The same is true of the bromides.
Obliterating Endarteritis.
Besides the preceding, another form of endarteritis has been met with
in the coronary artery--namely, the obliterating endarteritis, more
especially found in cases of syphilis and occurring in the smallest
branches. It is characterized by a gradually increasing thickening of
the intima through the formation of a connective tissue rich in cells,
and which leads to a narrowing, or even complete closure, of the lumen
of the artery. This thickening may involve one side of the artery or
its whole circumference. The inner surface of the intima on microscopic
examination is found to be covered by a layer of intact endothelium
where occlusion is not complete. There is deposit of neither fat nor
lime salts in the thickened intima. The outer coats of the artery show
little change.
The disease is accompanied by indurating myocarditis. Its symptoms are
those seen in this disease--namely, weakened cardiac activity, cardiac
dilatation and irregularity, possibly cardiac murmurs, an accentuated
pulmonary second sound, a pulse of moderate frequency, weak and
non-rhythmical, dyspnoea, cough.
DIAGNOSIS.--Impossible.
TREATMENT.--Purely symptomatic.
Aneurism.
Aneurism of the coronary artery is of rare occurrence. There is no
place of election for the disease, all parts and each artery being
alike liable to be affected.
ETIOLOGY.--The most common cause of the affection is chronic
endarteritis, where, through disease of the intima, the resistance to
the blood-pressure is diminished. Embolism is another though far less
frequent cause of the disease, several such cases having been reported;
and other highly suggestive cases are on record in which embolism of
the artery had occurred, with the production of considerable dilatation
for a short distance above the obstruction.
PATHOLOGY.--This does not differ from aneurism in other vessels. The
number may be from one to many, usually not more than two or three. The
size is generally that of a pea, often it is smaller, and sometimes it
is as large as a large nut. The termination is usually rupture with
fatal hemorrhage, and in far the majority of cases this occurs into the
pericardium.
{831} SYMPTOMS.--In most all of the cases I have found recorded there
were no symptoms till rupture of the sac occurred, giving rise to death
from hemorrhage. Then those symptoms which might be expected
occurred--namely, great præcordial pain, dyspnoea, suffocation,
tumultuous heart, irregular and intermittent pulse, and sudden death.
DIAGNOSIS, PROGNOSIS, and TREATMENT need not be considered, as the
disease is not recognizable.
Occlusion of the Coronary Artery.
Occlusion, more or less complete, of one or both of the orifices of the
coronary artery has been met with in connection with chronic
endarteritis of the root of the aorta. The accompanying sclerosis may
draw the orifices up like the strings of a purse, or a calcific plate
may extend from one side, or perhaps, detached, may lie simply applied
to the orifice. In rare cases the chief disease may be in the artery
itself, one of the main trunks or a branch being affected.
The PATHOLOGY is the same as that already described under Endarteritis,
stenosis being an early consequence of the process, and persisting, or
even increasing, to the last.
The SYMPTOMS observed in such cases are neither peculiar nor
diagnostic. They consist of those depending on the concurrent
affections, as of the cardiac valves, muscular tissue, or aortic
arterio-sclerosis. Prominent among them are dyspnoea, palpitation,
sudden cardiac distress, painful pressure in the region of the heart,
great anxiety; at last pallor of the skin, feeble cardiac impulse,
indistinctness of the cardiac sounds, the right ventricle continuing to
contract forcibly till the end. There is oedema of the lungs at last,
and on post-mortem examination fatty degeneration of the heart-walls is
found as a secondary consequence of the occlusion.
Embolism and Thrombosis.
Although these conditions are rarely found, yet a sufficient number of
cases is already on record to enable us to form a tolerably good idea
of the symptoms which accompany them. These latter in embolism
remarkably resemble those observed in the lower animals on ligation of
the coronary arteries. In the animals experimented on a rapid
enfeeblement of the heart's action ensued. The phenomena occurred in
the following order: First, there was retardation of the rhythmical
cardiac contractions, the left ventricle being primarily affected. At
first, the right ventricle beat faster, and then gradually became slow.
The beats became slower and slower till they ceased, the left ventricle
ceasing to contract a little before the right. The second result was a
gradual loss of power of the cardiac contraction. The third result was
the gradual distension of the left auricle when the left coronary
artery was compressed. The auricle swelled up more and more, became
bright red, and the rhythmical contractions changed to oscillatory
movements, which ultimately ceased entirely. The right ventricle and
auricle continued to contract powerfully, and the left ventricle
feebly.
EMBOLISM.
ETIOLOGY.--Rheumatism with its attendant complications--that is,
disease of the valves, and especially of the aortic valve, atheroma of
the coronary artery and possibly cardiac or other thrombosis--forms the
chief cause of {832} embolism, a small fragment of tissue being borne
away by the current of blood.
SYMPTOMS.--These are acute paralysis of the heart's movements, pain,
feeling of impending annihilation, retained consciousness, and regular
respiration. Nausea and vomiting have been observed. The lips are
livid, extremities cold and covered with a clammy sweat. In one case
there was inability to lie down. No pulse could be felt in any of the
accessible arteries, and neither apex-beat nor heart-sounds could be
detected. The ear applied to the cardiac region could hear only a kind
of cardiac tremor, which was very like the sound of a vibrating steel
plate. There was no loss of consciousness. The respiration was regular
and rhythmical, not exceeding eighteen or twenty in the minute. The
patient died twenty hours after the first symptoms.
DIAGNOSIS.--Although a positive diagnosis is impossible, the negative
pulmonary physical signs, the regular and rhythmic character of the
respiration, and the enfeeblement of the heart's action may lead to a
very strong suspicion of embolism of the coronary artery.
PATHOLOGY.--A small coagulum may stop up the main branch, usually the
left anterior, of one artery, or both arteries may be occluded by a
larger coagulum. In one instance an atheromatous softened patch
ruptured into the anterior portion of the left coronary artery, and
filled up the lumen with a soft putty-like mass (the sculptor
Thorwaldsen). A fatal issue is likely to occur in a very short time, as
the anastomosis cannot be sufficient for the sudden demand.
PROGNOSIS and TREATMENT need hardly be considered, as the affection is
necessarily fatal in cases which can be made out.
THROMBOSIS.
The same causes which give rise to thrombosis elsewhere are operative
in this case. They are chiefly arterio-sclerosis and rheumatism.
SYMPTOMS.--There have been observed slight tightness in the cardiac
region, lasting a few days, or a sense of oppression or constraint at
the back of the sternum. The pulse has been quickened, but is usually
very much slowed and very feeble; it has been observed as low as eight
beats in the minute. There is a sense of great lassitude and feebleness
of all the limbs. The respiration is normal in rhythm and frequency.
Auscultation reveals nothing but ordinary respiration till near a fatal
issue, when moist râles indicative of oedema of the lungs are heard.
Percussion gives at all times a normal resonance. There is no dyspnoea.
The heart-tones are clear, though weak, if occlusion is not complete or
anastomosis is perfect. (West was able to inject the arterial system of
the heart completely from one coronary artery, the other having been
tied.) If there is complete obstruction, we may expect to hear a
fremitus such as is produced by muscular spasm instead of normal
heart-sounds (observed in two cases). The skin of the body and face is
cool, pallid, and covered with sweat. The visible mucous membranes are
anæmic and pale. The mind is clear.
DIAGNOSIS.--The cardiac feebleness and progressive slowness, together
with the absence of symptoms connected with the lungs, might lead one
to suspect the presence of thrombus.
PROGNOSIS.--If a large branch of the artery is affected a fatal
termination is probable. If, on the other hand, the affection occurs in
a small branch, there is reason to believe that the circulation is
sometimes re-established through anastomosis.
TREATMENT must be purely symptomatic.
{833} Rupture of the Coronary Artery.
This may occur independent of aneurism. There are no premonitory
symptoms in some cases, death taking place suddenly. In other cases
vague and irregular symptoms lead the patient to understand that he is
not in perfect health. The symptoms of the disease are not
characteristic. Those which have been recorded are a difficulty of
breathing, a sense of constriction across the chest, or a pain and
feeling of anxiety in the præcordia; a frequent, feeble, and perhaps
very irregular pulse; epigastric pain and tenderness. The extremities
are cold. The mind remains clear. The physical signs are increased area
of flatness in the cardiac region, due to the escape of blood into the
pericardium, and scarcely audible cardiac sounds. The symptoms may
extend over a period varying from a few moments to several days.
Usually, some of the changes indicative of arterio-sclerosis are found
in the artery.
DISEASES OF THE PULMONARY ARTERY.
Acute inflammation of the coats of the pulmonary artery has only been
found associated with the pyæmic process as circumscribed abscesses of
the wall.
Chronic Endarteritis (Atheroma; Arterio-sclerosis).
Endarteritis of the pulmonary artery, though quite rare, is
occasionally met with in persons the subject of rheumatism, gout,
syphilis, or alcoholism. It is seen only when the pressure is
abnormally increased in the pulmonary vessels, especially in diseases
of the mitral valve. It is usually accompanied by a more pronounced
disease of the aorta, but is occasionally seen alone. The extent of
disease is hardly ever so great as that found in the other large
vessels, and at most amounts to the presence of prominent hard yellow
or gray patches in the intima, with perhaps ulcerated surfaces, and
rarely containing a deposit of lime salts. Complete rigidity has been
observed extending far into the lung. The wall of the vessel may be
irregularly dilated and its elasticity diminished. Usually, the disease
is in a much milder form, presenting perhaps a small amount of fatty
degeneration of the intima, and is not infrequently associated with
mitral stenosis or insufficiency (notably the former), pulmonary
fibrosis or emphysema, with accompanying hypertrophy of the right
ventricle. No symptoms have thus far been found to be distinctly
referable to atheroma of this artery.
Dilatation and Aneurism.
Dilatation of the pulmonary artery from primary disease of its walls is
of so rare occurrence that it may be merely mentioned. It depends on
chronic endarteritis, just spoken of. Where, on the other hand, there
is great pressure in the pulmonary circulation, as in marked mitral
stenosis, or insufficiency, collapse, or emphysema of the lung, with
great hypertrophy of the right ventricle, general dilatation of the
pulmonary artery may take place. The artery has been found to be six
and a half inches in circumference in a case of emphysema, the normal
average being three and a half inches; the semilunar valves were
insufficient, and the walls of the artery very much diminished in
thickness. From this as a maximum all degrees of dilatation have {834}
been recorded, with sometimes thickening and degeneration of the coats,
at others thinning with or without degeneration.
A systolic murmur has been observed over the artery when the dilatation
was considerable. The second pulmonary sound is usually strengthened
(unless the elasticity of the pulmonary artery is very much diminished
or the blood-pressure lowered in the right ventricle by changes of its
walls, or the pulsation is very quick and irregular). A circumscribed
dulness on percussion has been found in a few cases at the left edge of
the sternum, when the position of the heart was normal, between the
second and third cartilages. Sometimes there is a double impulse, a
systolic thrill, or more often a systolic pulsation, felt in this
position without any perceptible dulness, the edge of the lung being
retracted and the dilated artery taking its place. It is to be borne in
mind, however, that this sign (impulse, thrill, or pulsation) may be
present without any dilatation of the pulmonary artery or hypertrophy
of the ventricle, when inflammatory contraction of the lung has
occurred or the respiration is superficial, as may happen in phthisical
subjects, women, feeble and anæmic individuals, pregnant women,
convalescents, and persons afflicted with acute rheumatism. In such
persons the pulmonary second sound frequently seems to be unusually
loud when compared with the aortic second sound, without any evidence
of hypertrophy of the right ventricle being present. The determination
of the position of the lung establishes the diagnosis in such cases. On
the other hand, a lung dilated by emphysema may interpose and
completely cover the heart and pulmonary artery, which, though dilated,
may thus be masked.
Aneurism of the trunk or primary branches of the pulmonary artery, on
the other hand, is an exceedingly rare disease. But few cases are on
record. Aneurisms may be spindle-shaped or sacculated, of moderate
size, and are usually situated on the trunk. Lividity of the face,
dyspnoea, cough, dysphagia, headache, pain in the chest and
epigastrium, are the principal symptoms; and a systolic pulsation
(sometimes also diastolic) between the second and third left ribs near
the sternum, more or less prominence here, a superficial rough systolic
murmur propagated to the left and upward, a purring thrill, and
flatness on percussion in the same region and a little above it, are
the principal physical signs which have been recorded.