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 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 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.
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 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.
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 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.
But the physical signs and symptoms above enumerated are not all present in each case, nor are they when present distinctive of pulmonary aneurism. Dysphagia is mentioned in but a single case, dyspnoea is not constant, and cyanosis was at times absent. Also, the physical signs were not constant. Even if all were present they might be produced, as has been the case, by aneurism of the left wall of the aorta, infiltrated lung-tissue, or by a solid tumor lying over the vessels. The locality of the cardiac hypertrophy and dilatation aids in establishing the diagnosis. If it is on the left side of the heart, aneurism of the aorta is indicated; if it is on the right side, pulmonary aneurism. These aneurisms tend to rupture into the pericardium sooner or later.
Dissecting aneurism of the pulmonary artery has been observed once. It was of small extent.1
1 Bul. de la Soc. Anat. de Paris, 1881, pp. 589–591.
Stenosis of the Trunk or Main Branches of the Pulmonary Artery.
Narrowing of the trunk or of one of the main branches of the pulmonary artery is of very rare occurrence. It may follow compression by an aneurism of the ascending or transverse portion of the aorta, compression by tumors in the mediastinum, as from new growths or enlarged glands; it may be caused by cicatricial contraction following mediastinitis, inflammation of a portion of lung or of the bronchial glands, or it may follow disease of the coats of the artery (endarteritis).
The phenomena produced by stenosis of the trunk of the pulmonary artery are similar to those found in stenosis at the orifice, which are treated of in another place. They are anæmia of both lungs, accompanied by persistent dyspnoea with occasional exacerbations (the patient assumes a horizontal position either habitually or during the paroxysm—a fact of true diagnostic importance [Chevers], as in all other forms of disease of the heart and great vessels the patient breathes easier when the shoulders are raised. But in this the dyspnoea results from insufficiency of the supply of blood to the lungs and system generally, and hence the recumbent posture affords relief by removing the impediment of gravity, and thus promotes the supply of blood to the brain), congestion, dilatation and hypertrophy of the right side of the heart, cardiac palpitation, and finally general venous congestion. Hypertrophy of the right ventricle is shown by increase in the transverse measurement of the cardiac area of flatness and increase in the force of the cardiac impulse. The artery up to the point of constriction is dilated; the second sound is abnormally loud and accentuated. Pulsation may be felt and a systolic murmur heard in the second left intercostal space (observed in the right once), propagated upward to the neck at the left of the sternum, or heard in the interscapular space close to the spinal column.
PROGNOSIS is unfavorable.
There is nothing to be gained by treatment.
Rupture of the Pulmonary Artery.
Violent effort and great excitement have been followed by rupture of the trunk or a main branch of the pulmonary artery. In the majority of cases the coats were degenerated, though this was not always the case (Chevers). Death is often instantaneous, but sometimes is delayed some hours. In one case observed by Ollivier the duration was twenty-seven hours.
Thrombosis and Embolism.
The pulmonary artery, from its position, is especially prone to become plugged, either by substances coming from other parts of the body or by coagula originating in the vessel itself. Pieces of disintegrated coagula from the systemic veins, the contents of echinococcus cysts ruptured into the venous current, fragments of new growths, are carried to the heart and pass into the pulmonary artery, or large thrombi may be detached from their position in a vein and lodge in the trunk or main branches of the pulmonary artery.
Primary thrombosis of the pulmonary artery is very uncommon. In certain septic conditions, in parturient women, in typhoid fever, and in extreme anæmia thrombosis of the pulmonary artery may occur. It commences perhaps in the right ventricle or at the pulmonary valves, though it is also seen farther up.
SYMPTOMS.—The severity of the symptoms depends on the completeness of the obstruction. There is dyspnoea, more or less marked according to the size of the thrombus or embolus, pain in the præcordia, great distress, anxiety, faintness, sense of suffocation, tightness in the chest, palpitation, lividity and extreme pallor, cold sweats, an almost imperceptible pulse, great restlessness, and occasionally convulsions. The mind remains clear. The symptoms develop gradually or rapidly—in the former case depending on the slow increase of a small thrombus—and remissions are often seen; in the latter case depending on the sudden lodgment of an embolus of large size. Sometimes the symptoms are extremely marked, and death takes place in a few minutes. The appearances are not those of asphyxia, and death is usually attributed to want of arterial blood-supply to the brain and medulla oblongata, and not to suffocation or paralysis of the heart.
Percussion shows a normally resonant chest. Auscultation gives normal breath sounds with free inspiration and expiration. There is very likely a basic systolic murmur conducted along the course of the pulmonary artery, but this is not constant. The cardiac second sound and impulse are increased. At the post-mortem examination the heart is found in diastole, the left cavities and pulmonary veins empty, the right cavities filled with blood, and the cardiac veins strongly distended.
DIAGNOSIS.—The diagnosis is often uncertain. When not developing with extreme rapidity the symptoms are very similar to those caused by stenosis of the pulmonary artery, and in the suddenly fatal cases they are almost identical with rupture of the heart or rupture of a thoracic aneurism, or even angina pectoris. The history of an antecedent thrombus or of a disease of the heart which is likely to be accompanied by thrombus, together with the absence of physical signs, render a diagnosis many times probable.
PROGNOSIS.—To be regarded as of the gravest character.
TREATMENT.—In the rapid cases death occurs before anything can be attempted. In the less severe cases absolute rest must be enjoined, and free stimulation with brandy, ammonia, and ether attempted. It might be worth while to place the patient with the head lower than the body, to favor the flow of blood to the brain.
DISEASES OF THE SUPERIOR MESENTERIC ARTERY.
Aneurism.
Aneurism of both the superior and the inferior mesenteric arteries occurs. The former is the more frequent, though still a rare disease.
The symptoms are pain in the epigastric and lumbar regions, a globular pulsating tumor in the median line, the pulsation being accompanied by a bellows murmur. The tumor has been seen in at least one instance to be so large as to press on the renal arteries. Rupture is apt to take place with the signs of internal hemorrhage. The cause of the disease is the same as of aneurism elsewhere. Embolism is said to be a not infrequent precedent. The aneurism is seldom larger than a hen's egg, and is usually globular.
A positive DIAGNOSIS of the locality of the aneurism is not possible.
The TREATMENT must follow individual indications. Compression has been successful in a few instances.
Embolism.
Several cases where the superior mesenteric artery was found at autopsy to be completely occluded by coagulated fibrin were mentioned by Tiedemann in a work published in 1843. Virchow first described the characteristic post-mortem appearances which follow this lesion in his Gesammelte Abhandlungen, and since then records of cases have been numerous.
CLINICAL HISTORY.—In by far the majority of cases there is an evident source for an embolus. Pain in the abdomen is the first symptom, and usually remains one of the most prominent throughout. At first it may be a dull aching just below the borders of the ribs, but soon there is superadded paroxysmal pain resembling colic, and which may at times even be relieved by pressure. The occurrence of this colic in cases where embolism might happen ought to put the physician on his guard for other symptoms; for, though insufficient in itself to establish a diagnosis of embolism, the presence of a colic resisting treatment in the course of cardiac disease justifies the suspicion that this may be the case. The pain is usually located near or above the umbilicus.
Intestinal hemorrhage occurs in nearly every case; death may take place before any change in color of the stools is observed or any blood appears at the anus, but on post-mortem examination blood is found in the intestine. The cause of this hemorrhage is the infarction of the intestine analogous to that which takes place in other organs supplied by end arteries, the superior mesenteric having been proved experimentally to be functionally such an artery, owing to its great length, the extent of tissue supplied by it, and the comparative smallness of the vessels with which it anastomoses on the borders of its territory. The collateral circulation is thus so long in being established that ample time is allowed for those disturbances of nutrition in the walls of the vessel which render them permeable and allow the blood to escape. In view of the hemorrhage certain other symptoms are readily accounted for, as, for example, pallor of the face and surface of the body, the considerable and rapid fall of the temperature, syncope, hæmatemesis, diarrhoea, and melæna. These two latter symptoms are important though inconstant. There is reason to believe that the first effect of the embolism is to paralyze the bowel and prevent peristaltic action. Diarrhoea is of frequent occurrence, and may be profuse, the stools remaining of their natural color; or fresh blood may be passed at first from the rectum, followed by the continuous passage of tar-like masses; or the stools may be of pulpy consistence, mixed with blood, or consisting of tarry blood. Lastly, profuse hemorrhage may take place in which the stools resemble tar-water. The character of the blood does not give any kind of clue to the locality of the lesion.
Vomiting is a frequent symptom, and may consist of altered blood of variable consistency. A fall in temperature can often be determined by the thermometer, especially after severe hemorrhage. Not rarely the temperature is normal or may be even increased, especially if secondary inflammation has set in.
Tension and tympanitic swelling of the abdomen may occur or fluid may be detected late in the case, these being evidence of peritonitis.
PATHOLOGY.—Before proceeding to consider the pathological changes occurring in embolism, a few words on the blood-supply of the intestine might perhaps render what follows clearer. The superior mesenteric artery supplies the whole of the small intestine except the first part of the duodenum; it also supplies the cæcum and the ascending and transverse colon. The inferior mesenteric supplies the descending and sigmoid flexure of the colon and the greater part of the rectum. The anastomoses are as follows: The pancreatico-duodenalis, a very small artery and a branch of the hepatic, anastomoses with the first branch of the superior mesenteric, also a very small artery and given off under cover of the pancreas. The middle colic artery anastomoses with a branch of the inferior mesenteric. Both these arteries are given off from the main trunks of the arteries.
The experiments of Litten in 1875 show that the superior mesenteric artery, though not so anatomically, is functionally a terminal artery, the anastomosis not being developed with sufficient rapidity in case of extensive embolism to ensure the integrity of the circulation.
1. The result of sudden total closure by embolism of the trunk of this artery, therefore, is precisely like that of ligature of this artery in animals, and is first to produce sudden abdominal pain, attacks of colic, vomiting, uncontrollable intestinal hemorrhage, death. The intestine from the lower transverse portion of the duodenum to the middle of the transverse colon is found to be suffused, brown-red, blackish, or grayish. All the layers are swollen; innumerable capillary extravasations of small and great extent are seen, with venous hyperæmia and oedematous infiltration. In other words, there occurs necrosis with oedema and hemorrhage in all those portions of the intestines which are supplied by this artery.
2. Closure of large branches by embolism gives rise to infarction of the portion of intestine concerned, followed by death. The symptoms differ only in intensity, if at all, from the preceding. A case has been seen where there was every reason to believe that embolism had occurred, and yet the patient recovered. (The patient, suffering from acute rheumatism complicated with peri- and endocarditis, suddenly developed profuse intestinal hemorrhage of tar-like color, which was repeated twice. Colic pains, tympanites, depression of the temperature of the body, followed. At the same time symptoms of embolism of various other arteries were present. Recovery took place after eight weeks.) This result of course depended on the subsequent perfection of the collateral circulation.
3. Closure of the smallest branches may produce the same kind of symptoms as the above, though less in degree. Limited portions of intestine have been found to be in a gangrenous condition from embolism of very minute branches, more especially when the embolus extended well into the artery. In place of gangrene of the intestine ulcers of the mucous membrane have been seen independent of typhoid fever or tuberculosis. Considerable stenosis has followed such ulcers.
The affected portion of intestine in embolism is found to contain a variable amount of blood mixed with the other contents of the gut. Peritonitis, dry and limited or general and accompanied by effusion, is the rule. The mesenteric glands are found enlarged and succulent, with perhaps here and there necrosed spots. Thrombosis of the corresponding veins is not uncommon. Large collections of blood under the peritoneum and in the mesentery have been observed. The color of the mucous membrane has been slaty, and a diphtheritic appearance has been observed.
DIAGNOSIS.—The following are the most important points in forming a diagnosis: 1. A source exists from which an embolus might be derived. 2. Profuse and even exhaustive intestinal hemorrhage sets in, which can neither be explained by primary disease of the intestinal walls nor by hindrance to the portal circulation. 3. There is a rapid and considerable fall of the temperature. 4. Pain in the abdomen comes on, which may resemble colic and be very severe. 5. Finally, tension and tympanitic swelling of the abdomen occur, and there may be fluid in the abdominal cavity. 6. Evidence of embolism of other arteries may have been obtained before the symptoms of embolism of the superior mesenteric artery come on, or such evidence may appear at the same time as the latter. 7. Palpation may reveal the presence of collections of blood between the folds of the mesentery.
PROGNOSIS.—The prognosis in embolism of the superior mesenteric artery, though not absolutely bad, is exceedingly grave. It must be borne in mind that the symptoms of occlusion of one of the large branches are similar to those where the main stem is involved, while the probabilities of recovery in the former are much greater, as already explained, from the shorter extent of the anastomosis. There is evidence that recovery from the immediate effects of embolism may take place even where subsequent ulceration has been so great as to cause complete closure of the intestine through cicatrization. (A case is related by Parenski where the patient was operated on for stricture of the bowel, and only at the autopsy was it discovered that the stricture was due to cicatrization from ulceration caused by embolism of one of the branches of the superior mesenteric.) There are at least three cases of recovery on record where occlusion of the main stem was supposed to have taken place; but inasmuch as the situation of the embolus cannot be determined with certainty if the patient recovers, these cases are open to the suspicion that one or more of the larger branches only were occluded. The profuseness of the hemorrhage, though it may imperil the life of the patient from exhaustion, bears no constant relation to the gravity of the case. Copious and repeated hemorrhages per anum took place in cases of recovery, while in other fatal cases this symptom was entirely absent. Extreme fetor of the stools must be regarded as of evil omen, as it may be the evidence that gangrene of the bowel has taken place.
TREATMENT.—One of the first symptoms calling for relief is the colic, which is best met by morphia given subcutaneously or by suppository. For the hemorrhage ergot by the mouth and alum enemata have proved serviceable, or the application of ice to the abdomen. The lowering of the heart's action by sedatives is to be avoided when we remember that their use would lower the blood-pressure, and thus tend to retard the establishment of the collateral circulation.
Thrombosis.
The symptoms of thrombosis have not been determined apart from embolism, and it is doubtful if the affection proves fatal unless the extent of artery involved is very considerable or the formation of the thrombus is very rapid, for the anastomosis is gradually made compensatory. In either of the latter cases the symptoms are identical with embolism, and the pathological appearances are the same. With regard to treatment, general indications must be pursued.
Endarteritis.
This disease is met with, but it is usually slight and unaccompanied by symptoms.
DISEASES OF THE INFERIOR MESENTERIC ARTERY.
Aneurism.
Aneurism of this artery has been seen after death. The diagnosis could not be made, in all probability, during life. Pain might be a prominent symptom, though not necessarily, as many of the aneurisms of the abdomen are unattended by any symptoms. Rupture is not unlikely as a termination.
Embolism.
Embolism has been observed. Sudden pain in the abdomen comes on, followed by vomiting and diarrhoea. The patient looks miserably; the belly is drawn in and painful on pressure almost exclusively in the left iliac region. Severe spontaneous colic-like pains continue, with occasional vomiting and diarrhoea. At first the stools are feculent and pap-like; then they begin to smell bad, and even stink. Red blood is passed. Soon there is a mixture of blood and slimy masses. Finally, the stools are slimy, blackish, almost tar-like, and have a terrible odor, and are passed with griping and tenesmus. Occasional vomiting still continues. The pulse becomes smaller and more frequent, and gradually irregular and intermittent. Soon collapse and death follow.
The predisposing and exciting causes are the same as in embolism of the superior mesenteric artery.
The duration is usually short, lasting from a few hours to three or four days. The termination is ordinarily fatal, though doubtless cases of recovery have occurred, as stated under Embolism of the Superior Mesenteric Artery, the size and position of the embolus not precluding the possibility of the establishment of collateral circulation.
Complications are varying degrees of peritonitis, evinced by tympanites, pain, and tenderness, either localized or diffused, and later by the occurrence of effusion. Sequelæ, when the disease is not immediately or rapidly fatal, are ulceration of the colon with subsequent cicatrization and contraction.
PATHOLOGY.—The mucous membrane of the descending colon, sigmoid flexure, and rectum is somewhat swollen, strongly reddened, and contains ecchymoses and extensive suffusions of blood; or the color may be blackish or slaty and the surface sloughy.
DIAGNOSIS.—The diagnosis can only be made by exclusion. The same points are to be carefully verified as in embolism of the superior mesenteric artery, only the pain and symptoms are in a different place, and the secondary peritonitis also begins on the left.
PROGNOSIS.—The prognosis is very grave, but recovery may take place, contractions or constrictions being left behind.
TREATMENT.—The treatment combines perfect rest, the exhibition of wine, opium, vegetable astringents, and the subcutaneous injection of morphia.
ANEURISM OF THE HEPATIC ARTERY.
The tumor varies in size from a hazelnut to a child's head, and is egg-shaped. Pain in the epigastrium and right hypochondrium or upper abdominal region is a characteristic symptom. At first the pain is not severe, and is occasional, recurring after a pause of several months' duration; later it becomes very severe and lasting. The abdomen is not tender to the touch or on pressure during the remissions from the attacks of pain, but after rupture of the aneurism, whether temporary or lasting, it is very severe. The abdomen is sometimes distended, at others not. The tumor, owing to its position, cannot be felt, nor can pulsation be detected, as the wall of the aneurism consists of connective tissue and blood-clot, and the stream of blood coming from a small artery is slow. In but a single case has increase in size of the spleen and liver been observed. The functions of the stomach and intestines remain normal in spite of the pain. The locality of aneurism of the hepatic artery is such as to readily cause temporary or lasting icterus—a phenomenon which occurs in perhaps two-thirds of the cases. Rupture, with the ordinary signs of internal hemorrhage, seems to be the usual termination. Inflammatory processes or fever does not follow hemorrhage into the abdomen. If perforation occurs into the gall-bladder, a gall-duct, or the intestine, the hemorrhage may appear to be moderate. In such instances repeated discharges of blood may occur from the intestine, or at the same time may be thrown off from the stomach.
There is no means of determining how long aneurism of the hepatic artery may exist without giving any kind of sign of its presence. Judging from analogy, it is very probable that a considerable time may elapse before the disease is observed. Since pain in the abdomen is the first pathological indication, and rupture the last, we may measure the probable duration of the disease by these phenomena and also by the clinical course. This was not over ten days in two cases, and in three cases it was three to four months. Since aneurisms of the hepatic artery, even when they have reached their greatest dimensions, are not palpable, the pains which appear with them have in themselves no diagnostic worth. The same is true of the icterus which appears sooner or later. It is only after rupture has occurred that all the chances are so placed that a comprehensive estimate of them may be made and a diagnosis arrived at by exclusion. The fact that the function of the stomach remains unchanged in spite of rupture (hemorrhage), and the totally unchanged character of the blood-clots vomited, enable us to locate the situation of the hemorrhage as outside the stomach. If at the same time there is an alternate relation between the occurrence and disappearance of the icterus and the hemorrhage, the inference is admissible that the latter is located in the immediate vicinity of the gall-ducts. Other peculiarities of the blood-clots passed at stool are perhaps the imprints of the valvulæ conniventes of the jejunum.
The DIAGNOSIS of aneurism of the hepatic artery is usually impossible.
Aneurisms of the splenic, renal, and other abdominal arteries are recorded, but not in sufficient numbers to warrant a detailed description of them.
DISEASES OF THE COELIAC AXIS.
Aneurism.
Aneurism of the coeliac axis, when the tumor is large, is accompanied by very much the same symptoms as aneurism of the abdominal aorta. The disease is rather uncommon.
ETIOLOGY.—Syphilis, rheumatism, and advanced age play important parts in the etiology of this disease as predisposing causes of arterial degeneration. Many persons affected have been immoderate spirit-drinkers, which of itself does not directly tend to the disease, but does so indirectly, in that it encourages an early senescence of the tissues. In the same way any debilitating conditions may act as predisposing causes. Chronic endarteritis is most frequently found at the seat of the aneurism. Secondary or exciting causes are peculiarities of occupation, as those which are laborious and require much physical exertion and entail exposure to inclemencies of the weather.
SYMPTOMS.—Pulsation is usually the first symptom observed. It is felt in the epigastrium about two and a half inches below the ensiform cartilage, or even higher, and a little to the left of the median line; or it may be midway between the ensiform cartilage and the umbilicus, on the left. It is not unfrequently of a distensile character, and is unaffected by changes in the position of the patient. It is not synchronous with the cardiac systole, but follows in rapid succession to, and terminates with, the ventricular diastole. A tumor, usually globular, is felt in the region of the pulsation. It is of variable size, from that of a hen's egg to a cricket-ball, or in case of false aneurism even much larger. The tumor is slightly tender; it moves with the diaphragm, and sometimes when it presses upon the pancreas ptyalism has been observed, which in one instance was increased by external pressure on the aneurism with the hands.
Another constant symptom is pain in the left side, extending from well up in the chest to the region of the hip, or located in the lower part of the chest alone, or perhaps in the epigastrium. This pain is either constant or excited by exertion, and paroxysmal in character.
Flatness on percussion over the tumor of varying extent is observed in many cases, and a systolic bruit, perhaps of a whistling character, is heard.
The usual termination of aneurism of the coeliac axis is rupture with internal hemorrhage. The symptoms of this accident do not differ from those of the same occurrence in abdominal and thoracic aneurism, and are likewise usually fatal.
PATHOLOGY.—Strain doubtless forms an important factor in the production of this aneurism in an artery previously weakened by disease of its coats. The tumor is frequently a false aneurism, and has for walls connective tissue and the neighboring organs. When it is of large size, on account of its position it sometimes presses upon the pancreas or vertebræ, and produces absorption with consecutive symptoms. In the former case ptyalism has been observed, which perhaps may have been due to reflex action through the coeliac plexus and pneumogastric nerve, the reflex centre being the medulla oblongata with the facial origin. The wall of the aneurism is usually thin, and in some cases it has given way, leading to the formation of so-called false aneurism. Not infrequently the wall is atheromatous. The size of the aneurism varies greatly, though it is never larger than the two fists.
DIAGNOSIS.—This aneurism is apt to be confounded with aortic aneurism, and can only at times be distinguished from it by its locality and small size.
PROGNOSIS.—This must be grave if a diagnosis is made, for the ultimate result is usually rupture and hemorrhage.
TREATMENT.—The general principles recommended in treating abdominal aneurism should be followed out. It is but rarely the case that compression is admissible, and then the distal pressure is to be used. Rest and diet form the most reliable means of treatment at our command.