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 quantitative 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
When the arteriosclerosis in the peripheral arteries reaches a stage where endarteritis obliterans supervenes, there is usually no chance for a compensatory or collateral circulation to be established. The area supplied by the vessel undergoes dry gangrene. A portion of a toe or finger or a whole foot or hand may shrivel up. It is more common to see the spontaneous amputation take place in the lower extremities. The same effect may be produced by the plugging of a vessel with a thrombus. There may be much pain connected with the sudden blocking, whereas the gradual obliteration of the blood supply of a toe or foot is not as a rule at all painful. The condition is at times revealed more or less accidentally when a patient injures his toe or foot and discovers that there is no sensation in the part and that the wound instead of healing is inclined to grow larger.
Other interesting vasomotor phenomena are frequently connected with arteriosclerosis. Such a one is the curious condition known as Raynaud's disease, a vascular disorder which is divided into three grades of intensity: (1) local syncope, (2) local asphyxia, (3) local or symmetrical gangrene. This is not the place to describe this condition except to say that the condition called "dead fingers" is the most characteristic feature of the first stage. Chilblains represent the mildest grade of the second stage. The parts are intensely congested and there may be excruciating pain. Any one who has ever had chilblains knows how painful they can be. The general health is not impaired as a rule, although the attacks are apt to come on when the person is run down. The third stage may vary from a very mild grade, with only small necrotic areas at the tips of the fingers, to extensive multiple gangrene.
Another and very rare condition in which chronic endarteritis was the only constant finding is the disease described by S. Weir Mitchell and called by him erythromelalgia (red neuralgia). This is "A chronic disease in which a part or parts—usually one or more extremities—suffer with pain, flushing, and local fever, made far worse if the parts hang down." (Weir Mitchell.)
Probably the most frequently seen result of arteriosclerosis in the leg arteries is the remarkable condition, first described by Charcot, known as intermittent claudication. Persons the subject of this disease are able to walk if they go slowly. If, however, any attempt be made to hurry the step, there results total disability accompanied at times by considerable cramp-like pain. The condition is much more prone to occur in men than in women, and Hebrews seem more frequently affected. The cause is most probably to be sought in the anemia which results from the narrowing of the channels through which the blood reaches the part. The stiff, much narrowed arteries allow sufficient blood to pass along for the nutrition of the part at rest or in quiet motion. Just as soon as more violent exercise is taken, calling for more blood, an ischemia of the part supervenes, for the stiff vessels can not accommodate themselves to changes in the necessary vascularity of the part. A rest brings about a gradual return of blood and the function of the part is restored. Pulsation may be totally absent in the dorsal arteries of the feet and when the legs are allowed to hang down there is apt to be deep congestion.
In this connection a curious case reported by Parkes Weber will not be out of place. The patient, a male, aged 42 years, complained of cramp-like pains in the sole of the left foot and calf of the leg occurring after walking for a few minutes and obliging him to rest frequently. When the legs were allowed to hang over the side of the bed, the distal portion of the left foot became red and congested looking. No pulsation could be felt in the dorsal artery of the left foot or in the posterior tibial artery. There was no evidence of cardiovascular or other disease. An ulcer on the little toe had slowly healed, but cramp-like muscular pains still occurred on walking. The disease had lasted about five years without the appearance of gangrene.