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FIG. 50.-Female. Aged fifty-four. Post-uremic. Arteriosclerosis and contracted kidney. Albuminuric retinitis first
called attention to this condition three or four years ago. Chief complaint nervousness, depressive dreams, and hallu-
cinations of oppression and fear. Is inclined to weep and looks upon the dark side of things. Complains of poor vision
with buzzing and roaring in ears, physical weakness and occasional attacks of nausea, pain in the head, nocturia
and occasional dyspnea.

Examination shows elongated and fibrous arteries, slight cyanosis, large liver, heart enlarged 1 in. to the right and an
accentuated-aortic second sound with weak muscle sounds. Urinalysis shows albumen and occasional hyaline, granular
and fatty casts. Blood cells are continuously present.

The high systolic pressure and the very large pulse pressure indicating a marked arteriosclerotic involvement.

Treatment in this case was almost wholly dietetic and hygienic with routine hot-vapor baths. Small doses of iodides
in various form were tried but on account of increase in heat flashes and head symptoms were discontinued. The vapor
baths in this case averaged three a week, sweating began in three minutes and was continued for ten. There was no after
exhaustion or any untoward results. The head relief was marked. The phthalein test made 3-24-'15 showed 50 per
cent. first hour, 25 per cent. second hour, total 75 per cent.

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Cardiac lesions...

High pressure and arteriosclerosis (kidney normal).
Pure hypertension..

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Janeway has been led to believe that, in cases of generalized arteriosclerosis which show high blood-pressure (Fig. 50) this pressure is largely due to a kidney condition as most cases of generalized arteriosclerosis without kidney involvement are unassociated with high pressure (about 50 per cent.).

This observer was fortunate in being able to follow many of his cases to necropsy, thereby being able to compare the clinical and pathologic diagnosis. His study brought out the marked imperfections in our present methods of diagnosis, by demonstrating that a large percentage of clinical diagnoses were either incorrect or incomplete when checked by the pathologic report.

SUMMARY

Considering all the evidence, a few important facts stand out clearly, namely, (a) that well-developed generalized arteriosclerosis affects blood-pressure chiefly when the arteries of the general arterial tree are involved, without which blood-pressure may not be altered even by marked local arteriosclerosis. (b) That thickening and degenerative changes in the intima result wholly or in part through the irritating effect of abnormal metabolites or other irritating substances circulating in the blood, and that these substances may operate through the agency of the nervous

system through stimulation and congestion of the adrenals or directly by local irritation upon the vessel lining. (c) The origin of these substances is diverse, probably in the majority of cases of gastro-intestinal or liver origin, although toxic substances of an infectious nature are also of great importance. (d) The majority of cases of arteriosclerosis are preceded by a period of slightly elevated blood-pressure due to a narrowing or hypertension of the arterial walls; and this change is at first transitory, but by being constantly repeated the arterial system is subjected to an intermittent trauma, which is productive of a permanent alteration of a degenerative character in the fibrous coats of the arteries. (e) This change is largely a protective effort on the part of nature to strengthen the artery in order to withstand the added strain. In order to overcome the resistance offered by the hypertension (f) the heart hypertrophies, while disturbance in renal circulation interferes with proper elimination, thus throwing additional irritating substances into the circulation, thereby establishing a vicious circle, which gradually increases as the pressure mounts higher and higher, unless relief comes from a break at some point.

PATHOLOGY

The term arteriosclerosis is too loosely employed by the average physician. This has led to great confusion in the reporting of cases and in the compilation of statistics. It is often impossible to learn precisely what condition an author is discussing, so that the benefits of careful research are often lost to the reader. The two conditions usually confused are, atheroma and diffuse generalized arterio

sclerosis, and less often the condition of pure hypertension, as found before any permanent change has occurred in the vessel wall (see page 244).

The pathologist has more than once pointed out clearly these different conditions and has correlated them with the physical signs. Among them Russell has made most careful studies of the condition of the vessels, and their relation to chronic disease of the heart, kidneys, cerebral system, and to blood-pressure. According to Russell,1 atheroma is a local or patchy affection of the arteries characterized by a local thickening and degeneration of the intima. This soon undergoes a form of fatty degeneration which is termed, atheroma. Later these patches become the seat of a calcareous deposit while in the larger arteries atheromatous cysts and ulcers may be formed with local sacculations. These changes may be so extensive, especially in the aortic arch that a local bulging occurs to which the name aneurysmal bulging has been applied.

Atheromatous changes are quite common in the cerebral and coronary arteries but comparatively rare in the radials. When present in the radials, they give rise to local thickenings, which give an irregular nodular feel to the vessel. They are never symmetric. Russell believes that the character of these changes is very suggestive of a lowgrade infection, and assigns a primary micro-organismal implantation as their origin.

Arteriosclerosis, on the other hand, may be roughly defined as a thickening of the arterial wall with a diminution in the size of its lumen. The changes which have led

1 Wm. Russell, "Arterial Hypertension, Sclerosis and Blood-pressure," J. B. Lippincott Co., 1910.

to this when examined in detail are seen to consist of (1) a marked thickening of the intima, due to hypertrophy of the muscle fibers; (2) a thickening of the intima without atheromatous degeneration; (3) and in some cases a fibrous thickening of the adventitia. The muscular coat may show some degeneration but the prevailing notion that in such thickened vessels the muscle coat is replaced by fibrous tissue (fibrous degeneration) is erroneous (Russell) (Thayer and Brush).

These changes are not confined to limited areas of the vessel wall as in atheroma, but affect uniformly a large portion of the vascular system and are usually distributed throughout the body, for instance, in the coronary and renal arteries.

Cases are encountered where both processes are met in combination. Usually these occur late in life, the atheromatous changes generally being confined to the large vessels and aorta.

The clinical study of blood-pressure and its relation to visceral involvement would seem to bear witness to the accuracy of Russell's deductions and conclusions, for it will be recognized that were this change one of pure fibrous degeneration with destruction of the muscular tissue in the vessel walls, then measures directed toward relieving hypertension (contraction of the muscular wall) would be useless. As proof of this and of the value of such measures, we have only to review the evidence found in every-day practice, where such measures effect a reduction in a large majority of cases.

CLINICAL MANIFESTATIONS

Clinically the elevation of pressure in arteriosclerosis affords a method of distinguishing between this disease

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