DISEASES

THE

OF

ARTERIES

INCLUDING

ANGINA

PECTORIS

MACMILLAN

CO.,

AND

LONDON

BOMBAY

LIMITED

CALCUTTA

"

"

MELBOURNE

THE

MACMILLAN

NEW

COMPANY

YORK

BOSTON

CHICAGO

"

DALLAS

"

SAN

FRANCISCO

"

THE

MACMILLAN

CO.

TORONTO

OF

CANADA,

LTD.

DISEASES

THE

OF

ARTERIES
INCLUDING

PECTORIS

ANGINA

,-

BY
5

SiR^CLIFFORD
M.A.,
REGIUS

M.D.,

F.R.C.P., F.R.S., HON.

PROFESSOR

OF

FELLOW
HON.

OF
FELLOW

IN

PHYSIC

IN

AND
YORK

NEW

TWO

MACMILLAN
MARTIN'S

M.D., LL.D., D.Sc.,

UNIVERSITY

THE

GONVILLE

CAIUS
ACAD.

OF

CAMBRIDGE

COLLEGE

MED.,

ETC.

VOLUMES

VOL.

ST.

K.C.B.

ALLBUTT,

AND

CO., LIMITED

STREET,
1915

LONDON

ETC.

TO,

SiSaKra
fji"v

fJLavOdviD,

8'
TO.

COPYRIGHT

"vpera

PEEFACE

THOSE

the

author,

subject,

done.

hour
"

while

tide.

If
his

and
of

out

or

that

he

deal

with
for

not

But,
to

all,

fancy

possessed

him
if I

to

may

by

cranny

is

haunts
the

work

like
of

outlines
the

the

all

author

The

Of
the

of

to

answer

the

course

detailed

is still obscure

pretend
him

enable

to

of

out
through-

reasonably

enough

away

out

composer

much

on

matter

new

swings

subject

every

far

is done.

author

drifting

for
he

the

temptation

streaming

and

all

the

now

footnote

from

"

the

seems

even

at

to

himself
is

stopped

when

can

of

or

anything

but

far

old

the

nothing

that

is

thought

provisionally

this

to

question

give.
for

speak
the

building
outwork

swift

imperfection

fuller

done

his

of

by

published

it

part

interpretation

facts

withstand

attempt,

the

sight

the

shed

work

nor

beset

comprehensible

it is keenest

yet

of

of
there

of

know

cannot

that

his

sense

work,

structure

the

this

of

is

more

Then

becomes

flow

repentances

new

we

the

No

beyond.

"

if

than

better

however

published,

are

intimacy

is

book,

author

its

none

the

be

to

his

ride."

maun

end

in
He

remains

be

but

years

when

must

sudden

many

of

quality

himself,

to

more

as

impulse

the

shortcomings.

comes

Tarn

"

ebb

or

time

suicidal

make

the

long

perfection,
when

the

spent
its

so

Still

relative

has

know

that

proverb

to

who

can

than

others

to

lie in

which

book

apparent

more

is

of

faults

craving
up

myself,
for

to

put

done

my

semblance

avoid

to

by

superstructures,
a

less
neverthe-

best

of symmetry;

show

conjectural

nature,"

have

of

"

order

the

letting
and

must

as

help

to

colour here and

to

construct

than

pages

data

and

to
biology,

error

derived

unbalanced.

Immature

of the truth

biology at

the

the

of external

factors

said
cleverly

that the

been

incident forces.
No
far
but

effectual

In

remains

symmetrical scheme
principleof

proceeds from
nature

of the

our

of

lack of

even

of

scrappy

in

In

space.

and

be
existing
pre-

biology
tially
essen-

the

complex

determining the

hence

evolution.

livingorganism is a diagram

our

sphere

not

of

the

of

understand

; for in

of

at

The

attained

Ethics

(iii.
4)

that this indefiniteness

not
so

from

far

thingsthemselves

as

arbitrary

any

there

were

they would

any
not

be

all."

flatter ourselves

thoughts we
for

experienceis

passage

are

this book

that

with

puttingon

the vestures, of science ; far from

suicide, than
literary

is

is possibleuntil
interpretation

thingsthemselves

may

with

tangentialinfluences

knowledge, and

fit subjectsfor deliberation

outline and

the

must

we

uncertaintyattachingto
Albeit,we

attractive,
un-

may

deal

to

not

delicate

well-known

"

true, that

"

leaves Hegel for Darwin.

word, the biologist

largerconsummation
the

form

being inessential,enter

more

more

It has

scientific

logical
systems

on

in time and

of

The

process.

has

rate

any

balance, the
potency

"

philosophies.Whatever

scholastic

circumstances, instead

into

still tentative, of

meanings

entities unfolded
potential
external

little

readable,"

more

of

ride in search

from

of them,

true

ground
back-

difficult

not
"

taking,far

more

the

cold in colour.

very

In

"

in the

ugly duckling,is plain in feature, in

like the

truth,

be left

hindrance

there, it is

little shadow

of outlines still vague,

and

into

up

high relief,by paintinga

into

far

argument

an

still insecure

facts

an

progress." By leavingsome
throwing a

things

said of Galen,

Payne

may

work

yet should

as

rather

system

bringingothers

and

which

to

or

be

completenessof

formal

J. F.

suggestions.As

or

guesses

than

notions

and systems
categories

artful

scattered

yet be fragmentary and

as

of

in the nature

inference which

data and

completionupon

AKTEBJES

THE

OF

DISEASES

vi

to

it.

vagueness

the features, or

Better

increase

of

the

for

me

volume

that
of

vii

PREFACE

gossip,in

clinical
into

combinations.

new

tests
not

to

have

; and

I may

not

speak,in

the

tracks

functions

uniform

of

blend,

observation

and

rhythms
illustrated

would

be

and

mobility,by

of reflex

cycles,by activityand inhibition,by

and

so

on

of

kind

steamship the myriad

or

powders

as

on

string. Thus,
the processes

to

vibrations
take

drum

tone

as
sorting,

blend

of

organiclife

in

into

under

form

we

the

members

the

factors,

railwaytrain
sound

track

of

or

harp-

and

out

does

Man

patterns.

Happily,

rhythmicalburden,

can

treacle,

Mendelian

sleeperin

lines of summation

on

as

forms, static and

in

themselves

and

blind.

very

by

we

as

that, poor

of water

dynamic

as

facts

lost ourselves, so

we

for instance

sort

thoughts,

my

such

to

own

my

false coin.

on

as

by

formulas

co-efficients
analysingbiological

If in
to

for rich

pass

adapt

to

of current

the values

to assay

so

tried

older concepts, but

language and

our

I am,

others, I have

of

the tests

or

whether

or
not,
Successfully

fro

and

sortingold phrases to

dailyround

its

chart

fall ill

not

anyhow.
Justlythen
characters

yet
and
own

and

of

small

as

we

attribute the

may

books

our

voice

to

the works

shelves,I have

given less

their

to

I must

authors

I believe that

is honest

work

labour, and

trust

tree, if a littlewithered, may

it may

have

On
The

another

various

aspect

whole

ought to

; in

of

some

such

not
difficulties,

the

than

the

the
a

be unsound

to

being a

some

on

my

withstandin
Not-

put into this

fruitageof

; that with

offer also

the

have

some

an

old

fading

apology.

all been

substance, again and

these, and

remodellinghowever

least

of age.

I have

blended

fault

many

they deserve,

the labour

that the winter

in

knowledge,

preliminaryapology.

the present volumes

them,

to

attention

whole

mellowness

have
a

not

of form

chaptersof

before,

Perhaps

of the

some

of others, even

offer
on

of

nevertheless

us

negligence. To

inconclusive

of contemporary

states

admonishes

unequal and

further

recast

there

the
were

loss of time,

lished
pubagain.

work

as

obvious

already

great.

too

written

at

the

various

times

and

in

this

might

therefore,

sections

repeated

passages

but

to

of

than

dissertations

some

reference

cross

save

; these

indulgence. Furthermore, by
been

libertyto

at

paths of

which

ways

knowledge, and

common

less

are

personalopinionsto
To

engagements

where

the articles
I have

thank

to

the

whole

number

and

many

I have

"

Cardiac

ago, with

such

at

features

no

to

letter to
"

not

few

Dr.

ences
referTo

Wolf.

checked

have
small
trust

error.

effective

of which

methods

platesare

there

not

are

me

I think

dated
it very

Long

Nicolls of Peterhouse,

not

carry

us

far.

therefore,both
any

in

as

called for.

were

of Dr. William

made, but they did

he says,

the passages

earlier sections of this book,

some

attachingto

Nicolls' work

much

show

value and for the interest

a

I have

contain

George Darwin

quote (from

journals. I

manuscript would

hazard

reflections of the late Sir

to

determined

in accessible books.

the able assistance

were

public

at

and

Harvey

definitely
forgone;

Physics,"mathematical

attempts

many

and

applicable. For

not

may

that in

seem

had

correct, I
rindingthese practically

good examples

It may

many

which

amid

footnotes

use

references in my

Illustrations I have

costly,and

to

Dr. Henwood

percentage of them, and

that

I have

avoid,

on

books

to

access

are

heavy undertaking;

reader's

the

unsystematic,and

been

of

quoted

pretence

no

therefore

verifyin proofall the

been

make

and

thought it better

have

re-

of time

accidents

by

emphasis, and

express.

readinghas

my

away,

greater length in

at

matters

on

pruned

to

even

write

to

familiar,or

bibliographyI

or

the

many

of dissertation

this freedom

cursorilyover,

run

string of

I ask

redundancies

for

life and

were

for

serve

may

modelled,
re-

Amongst

been

have

these

of

some

yet remain

see

of

the form

together, there

first put

been

lost

remodelling have
rather

chapters,

have

must

orderly monograph.

an

as

occasions,

has

book

the

Thus

variety.

of the

construction

styleand

Moreover

and

ARTERIES

THE

OF

DISEASES

viii

words

May

Some

for their

of his,I venture

31, 1896). Of

praiseworthy."

He

Dr.
says

ix

PREFACE

(and he) had

further that "Larmor

But
"

mathematical

problem." So,
To

to

doing I might

so

other

Master

(Dr. Hugh

again, and

Library,I

have

been

to

to

in

Except

we

arise
interpretation
few

lines of

by

the

"

the

Last,
to

which

from

the
"

the

"

but

least,I
add

of

have

I should

which

theses not

upon

Departmental

our

Norgate, to

whom

profitablecustomer
and

ends

unknown

pamphlets.
a

secondary

instance,

how

of papers,

or

points

many
"

are

not

are

of

errors

practiceof glancingonly at

at the

the

at

the

excerpts
omitted

quite consistent

article itself.

of the

I may

; and

perused,a practicefrom

for

Conclusions

contents
not

Dr.

friends, for

indicated

been

summaries

From

scissors.

have

things;

Conclusions

indeed
occasionally
with

quoted
many

Langley,

Mines, and

and

books

I have

which

the

thank

Professors

"
a

sending

in

in

notes

learn

may

I would

those
authors, especially

many

kindness

all the papers

source,

which

those

than

troublesome

thank

their

for

me,

Williams

Messrs.

thank
a

to

responsibilities

own

colleaguesand

without
inspiration

if

"

that

it not

Fletcher, for particularaids

UniversityLibrary, or

more

likewise I have

of my

some

child

deep obligations
;

hunting up pamphlets and

For

of the

shelves

am

the

matical
mathe-

the

in

were
particularly

Anderson),

other

and

that

last."

express

Hopkins, Dixon,

many

indeed.

been poor

to

debts

Walter

Dr.

and

that soluble

ensure

general terms,

Caius

Head

I have

in

But,

personalinstruction
the

stick to my

shift

to

seem

Sherrington,Woodhead,
these

"

shoulders.
of

Henry

mathematics

acknowledge my

to

included

in
to

follows

as

careful control

accordinglya

are

case

friends I have

kind

many

gladlywould
in

decided

I have

that,

as

is

in mind

is necessary

of the

leading characteristics

even

that

observation

by experiment and

heed.

taken

I have

these

certain

only rough representationsof

afford

problems

problems,and
biological

actual

of

probably does, bear

must, and

author

The

the important paragraph

biologists

all

to

"

criticisms

and

marginal notes

and made

looked it over

those

have

of my

to

express

readers

my

obligations,

own

also, to

my

colleague

index.

compilingthe

these

as

corrected

publicationfor
the

has

time

while ;

nine months

less than

seem

have
foreignperiodicals

is

little work

of which

countries, most

have

indeed

place in

the

materials

own

additions

no

however, with

"

named

series

essentielle
crucial

to

seems

necropsy,

Hyperpiesia,"
"

Hypertonien

I venture

importance that

but

made.

I. p.

313)

drag it in

to

for

these

One

case

alleged

be

to

the

admitted

of the

War

in the first month

I returned
three

such

routine

to

ward

One

cases.

such

here.

"

outbreak

Die

"

of

of
repeated the current opinion that cases
pure
in
occur
However,
practice.
rarely
hospital
pressure

blood

My

purs,"

Hypertendus

I have

on

of neutral

in respect of the

(see Vol.

last

July ; probably

be

now

me
"

the

Few, if any,

even

somewhat
can

pages

more

militarystress.

some

grown

pone
post-

opinion

during

since last

under

are

to

and

more

laboratories

the

in

is

finally

their

feared.

have

hand

to

done

being

might

one

come

delay

upon

were

me

in

accumulated

materials

Happily, the

difficult.

further

when

come

1914,

however

now

burst

advised

publishersthen

My

for press.

of

earlysummer

in the

pages,

great War

The

(March 20, 1915)."

POSTSCRIPT
us

skill in

and

kindness

his

for

Wright

Aldren

Dr.

friend

and

ARTERIES

THE

OF

DISEASES

"

high
when

duties, I

of them

of

was

beyond middle life,with a systolicpressure of 230, thick

tortuous
vessels,big heart, and paroxysmal dyspnea. The urine contained
less albumin, but, though repeatedlyand carefully
more
or
The specific
gravity was good, and lithates
spun, presented no casts.
often deposited. She had no nausea,
were
headache, drowsiness, nor
a

woman

neuroretinitis.

The

dyspnea

of dilated

with

autopsy it

the

brought

into

second
heart.

was

similar

The

third

of almost

was

Addenbrooke's

previous historylittlewas

head

and

brawny,

face,
with

vesicles and

thighs

and

was

legs,and

large curtain

of

stasis and
the skin.

on

the

oedema

on

very

legs were

multitudes
Extensive

lower

caused
back

ordinary

This

case

man

was

grievous condition, but

His whole

the

orthopnea,
the

the

instructive

singularinterest.

known.

oedematous

lymph
nodules

was

Hospital in

of his

it,but with

to

of

body, except
huge,
clusters

excoriations
him

dense
of

the
and

lymph

under

great misery.

showed

high

the
A

pressure

PKEFACE

also

in the

but

vena

the

accessible

and

the
the

at

arteries

life.

mitral

A
but

The

urine,

lateritious.

occasional

thickened

which

whole

scanty,

Casts

Under

dropsy gave way a little ;

morphia subcutaneously that
obtained.

A fifth of

and

palliatedthe

restful.

became

in

kidneys.
However,

rare.

from

time
No

time, but,

to

sign of

now

it

was

considerable

any

and

cardiac

postponed

its

obtained

was

forth,

so

amendment

was

all the symptoms,

distress

that

morphia

was

his

my
because, in such

use

an

I administered

until

not

save

syphilis.

relief

caffein, digitalis,and

"

subcutaneous

Although

conspicuous
audible

nights
own
a

case

of 29, 1 could

man

young

been

appeared competent.
good specificgravity and

of

of his life some

but

oedema

tortuous,

dilated, displayed

little less

grain every evening assuaged

states, I had

for such

remedy

rather

had

found.

diuretics

valves

sought

were

the

far

been

was

these three last months

medicines.

so

had

the

hyaline cylinder,not

During

and

ineffectual

right pleura gave

ranged about
220,

and

regurgitantmurmur

post-mortem
the

on

systolicpressures

were

autopsy

then,

the

heart, hypertrophied

enormous

and

by

The

dimensions

during

often

litre of fluid from

relief.

temporary

some

of salt seemed

Deprivation

azygos.
of a

withdrawal

the

xi

of primary connot but fear the presence

tracted
"
Pure
be very
hyperpiesiaat such an age must
such it proved to be.
The patient died suddenly :
"

after death

the heart

appeared such as I have described ; the aorta in

its whole
not largely
length was conspicuouslyatheromatous
; it was
mark
of
and
The
arteries
dilated,
presented no
syphilis.
were
larger
thickened
of
the
radial
excised.
universally
was
right
; a portion
of
soaked
in
the
oedema.
The
body was
Every part
kidneys seemed
thus rather large,wet, flabby,and rather pale. The
capsule swam
off like wet

tissue paper,
they seemed

On

section

of cortex
other

for

normal

medulla.

and

Thin

few

very

in structure
sections

small
and

of the

points of adhesion.
in the proportions

kidney showed,

parts, the generalthickeningof the arteries,large and

of the

many

save

Malpighian

bodies

were

thus

obliterated.

in

as

small

This

fessor
Pro-

Woodhead

and
were

his
to

standing
reported,in the kidney and elsewhere, as the outand primary disease ; the lumina
of the tubules were
open,
for the most
in situ,but in places cells
part the epitheliumwas
breaking down, one or two in a section of a tubule, which in
opinionpointedto a quiterecent catarrhal affection belongingonly

the

later stage of the

general oedema
arteries

had

presented

of atherosclerosis

section, was
of fibrosis.

malady.
My personal opinion was
produce this tubular change.

that

sufficed to

fibrosis of the

some

of the

normal,

or

intima.

betrayed

The
here

media, and

the

myocardium,
and

there

The

usual

the

small

patches

on

microscopic

very

early stage

CONTENTS

PART

ARTERIOSCLEROSIS

CHAPTER

INTRODUCTORY
......

CHAPTER

PHYSICS

OF

THE

II

19

CIRCULATION
......

HI

CHAPTER

THE

VISCOSITY

OF

THE

104

BLOOD
......

IV

CHAPTER

CAUSES

154

ARTERIOSCLEROSIS

OF

......

CHAPTER

ARTERIOSCLEROSIS

AND

THE

309

KIDNEYS
.....

CHAPTER

SYMPTOMS

OF

VI

374

ARTERIOSCLEROSIS
.

ANATOMY

OF

VII

CHAPTER

MORBID

455

ARTERIOSCLEROSIS

Xlll

PAET

ARTERIOSCLEROSIS

VOL.

DISEASES

there

all the

OF

THE

AKTERIES

PART

of them

instruments,
needing no new
for their perception; but the mind's eye was
new
faculties,
no
in focus for them.
Thus
it was
until Harvey's revolution
not
not
in physiologythat the importance of the arteries as instruments
of nutrition
was
comprehended ; before Harvey men
than
were
thinkingrather of the inward gambols of the pneuma
in which
it expatiated. From
of the channels
of
the time
the state of the arterial
Morgagni and Haller onwards however
wall was
more
commonly, if not very closely or diligently,
Laennec
and
Trousseau,
regarded. Unfortunately, before
cadaveric stainingof the great vessels was
taken for an arteritis,
as
by Peter Frank and Broussais, and even
by Bouillaud ; thus
observation
wasted
much
it
was
by a false pathology. And
until the dynamics of the circulation began to receive
not
was
the attention awakened
by the generalprogress of physics,that
studied, or
by Hales (in 1727) and others blood pressures were
indeed
the arterial blood presapprehended.1 Hales measured
sure
in a glasstube ; Poiseuille,
about
hundred
later,
one
years
the mercury
column
added
Ludwig the kymographic pen
;
and
drum.
As
regards the tunics, Clifton Winteringham of
York
Parts
(1689-1748), in his Experimental Enquiry on Some
his tests of the arteries in
Structure, described
of the Animal
animals
of these
by forcing air into lengths and branches
vessels ; and he drew up a table of
Comparative Tenacities."
We
recognisenow, all of us, that in the lapse of man's years
one
long reckoningof his mortalityis,and from all known
ages
time,

many

"

has

been, written

that

on

the

walls of his vessels.

We

may

suppose

in

primitiveman,
by external conditions if not by innate
of comparatively brief duration.
Domestic
capacity,life was
animals seem,
as
a
rule,not to live long enough to use up their
not
to live ill enough to abuse
them ; and amongst
or
arteries,
these creatures
has not
been
atheroma, though not unknown,
1

of

Puschmann

On
is

says (Hist. ii. p. 27) that Eustacchi

blood
he does
; but
pressures

abnormally high
a

recognised the importance

give chapter and verse.

not

find such a passage

under artery or vein ; but there
cursory search I cannot
ed. 1563, p. 108) an interesting
speculationon arterial facultyof motion,
far cardiac and how
far peculiar
but this is the difficulty
of the primum

(Venet.

how

"

which

Harvey marvelled, as
prohibeat," says Harvey,
quominus
atque constringat."
movens

at

"

did
eadem

Aristotle
facultas

before

him.

"

Nihilque

illas (arterias) dilatet

CHAP,

INTRODUCTORY

commonly

observed.1

reasonably conjecturethat as
life became
protractedthe arteries got

We

may

in stable societies human

time

to

out.

wear

Now

when

lightupon

we

of

escaped the notice

perceivedby them,
one

at

or

period of

of

return

recession.

of disease
had

or

which

been

proclaim the

to

apt

are
as

form

ancestors,

our

we

rate

any

but

disease

vagrant

some

had

either

obscurely
as

malady

new

after

Thus

thenia,
diphtheria,typhoid fever,neurasand many
another malady has been regarded in its turn
But for the most
as
a newcomer.
thing is not the
part the new
morbid
series itself but our
recognitionof it ; not the order of
but the enlargement and sharpeningof our
clinical wits.
nature
In Egypt as we
know, in Chaldea
as
we
may
guess, regions
of life were
protected by desert,marsh, or sea, the circumstances
equable and favourable ; intervals of domestic peace at home
a

were

far secured

so

enabled

were

bodies

to

of the

that

of the wealthier

men,

their bodies

carry

to

classes at any

ripe maturity.

rate,
In

the

always of very old persons, Ruffer

and Elliott Smith
found the aorta
commonly presentingatheromatous
patches,"ulcers," and calcined plates;and other arteries
thickened, beaded, and as brittle as pipes,so as hardly to bear
baldat his death
a
handling. Meneptha, they tell us,2 was
with calcareous arteries.
headed, decrepitold man
Without
pretending,then, to enter upon a historyof vascular
deterioration,or rather of our perceptionsof it,suffice it to say
it was,
arterial disease (atheroma) has
that, long overlooked
as
been recognised,
for many
anatomicallyif not clinically,
tions.
generaIt was
recognisedby Riolan the younger
(1577-1657)
and
of his contemporarieswho, like certain eminent
some
pathofound
satisfaction
in
final
nearer
our
own
logists
causes
day,
;
they argued, for instance,that, as in the ripeningof years the
heart

fail,the

must

channels

Egyptians, not

might

Such

be

kept

has

been

the

diseases, from

whom

domestic
that

animals

it has

also

arteries

"

open

"

confident
have

decay

were

made
is

escaped attention.
aortique chez les animaux

more

hardened

in order

in arteriis natura

that

their

ossicula collo-

with
their
conversant
opinion of persons
it
that
But
in
seems
enquiries.
likely
and
frequent than is generally supposed,

than
one
Parisot, in more
; e.g.
paper
and
(both domestic
wild), read at the First
Congress of Comparative Pathology at Paris, Oct. 1912 (see p. 215).
2
Cairo Sclent. Journ., Jan.
1910.
L'Ather.

See

DISEASES

cavit,ubi opus

erat

ut

AKTEKIES

THE

OF

PART

And, in brief summary,

aperta manerent."

recognisedby Lancisi (1654-1720),

Boerhaave
(1668-1738), Winteringham, as I have said, Senac
Morgagni (in1764),Bichat(c.1795),
(1693-1770),Haller (in1757),2

arterial

who

degenerationswere

arterial disease in

found

of 60, Meckel

age

(1781-1833),Scarpa,

"

"

flavus

or

"

"

ten

men

the

over

arteries

steatomatous

"

Hodgson (1810).3 Haller's description of

luteolus
succus
interesting
; of the
very

(1748-1832), and
arterial disease

of every

out

seven

"

"

is

the muscular

between

coming
the internal coat," be-

and

degrees softer or pultaceous,

drier ; the intima
in parts becoming
quasi erosa," or
or
that
It
is remarkable
Morgagni says
quite ulcerated.4
little or nothing about
general arteriosclerosis,
as, for instance,
and
in the limbs ; he describes it in the aorta
largevessels
chiefly,but also in the cerebral and in the coronary ; of
these he said in one
reduced
that they were
to
case
bony
canals.
Matthew
Baillie mentions
atheroma
only.
coronary
the
have
recent
Among
physicians and
histologistswho
carried this investigation
of Rokitansky,
forward, the names
de
Virchow, Gueneau
Mussy, Johnson, Lobstein, Hodgson,
hard

first,but

at

all

in

"

Kirkes,5 Wilks,

Letulle,Mahomed,
Cornil

and

visart6
The

be

may

described

memoir

may

diSuser

lesion,as contrasted

Par6

of it, so

is

syphilisas
2
3

as

(Lib. vii. 32).

aneurysm
attain

occasionallyquoted
I can
find, only

far

Even

broader

For

the
with

as

fuller sketch

of the

describing arterial disease,

in connection

with, and

Lancisi, who

to

I include

him.

of others
had
that

name

Baillie
as

did

not

his

Physiology

to

the

Med.

added

associated
much

gratitude.
7
Lobstein, Traite

Times

history of

this

and

his
6

own.

work

some

I find

atheroma
of

he

speaks
of,

consequence

the

forerunner

but

importance

of

(vide iii. 32), failed to

of it.

nothing

Obs.

but

of 1865.

with

chronic
has

I have
Here

renal
other

usually credited

is

followed

he

the

reference

supports Bright, who

disease
and

for

lix.

in this direction

Qaz.

He

Aitchison, Thesis

subject see

but

ampler

Corvisart, Essai sur les mal. du

pathol, Paris, 1833, t. ii.

d'anat.

v.

as

In

already
he

Kirkes'

as

fully realised

M.D., Oxford, Arch. Path. Inst. Lond. Hosp., 1908.

4
Haller, Elem. Phys. xlvi. 4; and Opusc. Path.
5

classical

Lobstein, whose

opening of the study of the

He rightly
patchy atheroma.7

aneurysm,
view of arterial disease
vol.

pioneers. Corpulmonary artery.

the

to

which

Haller, Opusc. Path.

and

of

as

of

owe

as

of

cause

to the

we

accepted

Sutton, Debove

mentioned

arteriosclerosis

arteriosclerosis
be

and

Ewald, Broadbent, Peter, Potain,

Traube,

Ranvier

name

Gull

Lancereaux,

cceur,

I do

claims
ii. 428.

not
on

see
our

CHAP,

INTRODUCTORY

considered

it

degenerative rather than inflammatory, and

thus may
be regarded as the forerunner
of Gull and
Button,
and
Debove
and
service it was
to
Letulle, whose
enlarge the
Then
arose
conceptionof arterial disease as a generalprocess.
Professor von
Basch
of Vienna
the clinical side, by
who, on
tions
acute, sagacious,and comparatively precise clinical observain a large field of experience,checked
continuallyby
experimentsupon animals, laid the foundations of the systematic
day.
knowledge of arteriosclerosis which as physicianswe possess toAnd if indeed in the progress
of knowledge we
have found
that von
Basch's
was
imperfect,and if in his
pressure
gauge
doctrines we have found something to add to, something to dissent
from, and
something to correct
by a truer analysis, as we
as

of the correlation

mechanical

of excessive

arteriosclerosis,
nevertheless, in its main

pressures and
features von
Basch's

work

the clinical

suppose,

always hold

must

classical

placein

historyof

arterial disease.

dynamic side, work of no less distinction

and
moment
was
being published by Marey, Ludwig, Ringer,
ship
Oliver,Cohnheim, and his brilliant disciple
Roy, to whose friendfrom the earliest days of my interest in these subjectsI owe
than I can
tell ; many
of Roy's pupils,
such as Adami
and
more
midst.
Then
the
Rolleston, are
happily still working in our
highly analyticalmind of the physicistwas
brought to bear on
our
so
problems, but the doctrines of these pioneersare now
intimatelyincorporated with current
knowledge, and in the
of this essay must
be so frequentlycited, that I need not
course
butions
give any further sketch of their services. Marey's early contriMeanwhile,

to

on

the

the measurement

littleremembered.
the
as

hand,
we

their

to which

made

he attached

shall see, he took

minimum
The

He

of blood

the

however

are

pressures

too

for
plethysmographicreceptacle
tambour

; with

largestoscillations

this instrument,
of
significant

as

pressure.

clinical

of
interpretation

consequences

called

"

"

"arterial

excessive
tensions"

in arterial disease, as

blood

pressures

they

as

opposed

and

to

erases"
such
"blood
as
speculative causes
"deposits" and
"blastemas," Traube,1 Ewald,
1

Traube, Gesammelte

Beitrdge, Bd.

iii.ss.

164

and

were

and

advisedly
in-

semi-occult
with
and

235, etc.

their
Potain

OF

DISEASES

ARTERIES

THE

PART

Riegell followed in their steps.

Sir Lauder
also was
Brunton
investigatingblood pressures
tions
demonstraTraube's
in 1871
and previously. But
clinically,
chronic
of
made
rather
cases
were
narrowly upon
he
explained
Bright's disease ; and the rise in pressure
the

by
an

first to

the

were

of

assumption
small

too

area

Ewald

pressure.

due

as

Mahomed,2
with

unfold

the

to

in

vasoconstriction
itself felt

make

and
to

and

argued for

Potain
toxin

as

to

or

renal

the

generalblood
tension,"
general hyper-

rise of

"

more

reflex from

renal irritation.

Guy's Hospital,became impressed more

importance of rising blood pressures ;

and

of

that, obscure

as

were

their

causes,

as

area,

indeed

he

more

taught

still

they are,
far-reaching.

their

was
significance
profound, and their effects
and
His view of these changes, as I well remember, was
larger,
knowledge, than appears
approached more
nearly to modern
in the
refer. Mahomed
I now
urged
literally
paper to which
of pressure,
and more
the significance
of these increments
more
and the gravity of this factor in clinical interpretation
and
he
as
prognosis; 3 a salutary warning, whether
they were,
of renal disease.
not always significant
supposed,or were
initiation in this field of research was
due to Burdon
My own
Sanderson
who, under Marey's influence, had begun to work at
the sphygmograph ; and it was
tion
into associathus that we
came
with the young
Guy's physicianonly too soon to be taken
from us.
So during the earlyseventies of last century, Sanderson
and Mahomed
and I were
working togetherat this subject,chiefly
at the form of the pulse; but by means
of the sphygmograph we
were
tryingalso, as Vierordt was trying,with weights or vernier

to

screws,

I will say

get
no

notion

some

than

more

of arterial pressures.

that, to

be

our

For

the present,

disappointment,this proved
Frey observed, a sphygmo-

impracticable(p.59). As von
is one
of which
known.
the ordinates
not
graphic curve
are
Masing tried to supply them by affixinga R.-R. sphygmometer
simultaneouslyon the upper arm ; when he observed the
curves
good and equal on both sides of an obliterating
pressure.
The systolicheight of the sphygmograph began to fall at 120",

to

Riegel, Berlin,

kl

Wochenschr., 1882, No. 23.

Mahomed,
Guy's Reports, 1879.
See also Dr. Graham
Steell,The Sphygmograph in Medicine.
2

CHAP,

INTRODUCTORY

disappeared. This is a difficult experiment ; and

in our
earlydays no external sphygmometer had been devised.
was
applicableonly to experiment
Ludwig's kymographic method
and

150"

at

animals.

upon

Von

Basch's

instrument

known

made

was

in 1876.
Mahomed

at

this time

introduced

phrase which, with

disuse : namely,

the
"

the
has
fallen into
opinion it signified,
formulated
He
an
pre-albuminuricstage of Bright'sdisease."
itself,there
hypothesisthat, before Bright'sdisease manifested
was
a
period,longer or shorter, of augmented blood pressure ;
the encroachment
of the disease could
a
period during which
be foretold,and perhaps forestalled.
Riegelagreed, in 1882.
At this time, and at this stage of the enquiry,we
suffered the
distinguished
colleagueby a premature death.
great loss of our
of these
For, as time went on, I began to rind that many
prealbuminurics
into
did not
disease
that
on
Bright's
;
pass
the contrary not a few of them
recovered
completely: results
which rather shook one's notions on the
pre-albuminuricstage
of Bright'sdisease."
It was
not
however
until I had watched
and many
another for shorter
a certain patientfor eighteenyears,
ject.
periods,that I felt at libertyto publishan opinionupon the subThat lady,who was
the first to come
under my own
private
and
continuous
observation
fell
a
as
pre-albuminuric,"never
victim to Bright'sdisease, but survived
for eighteen years.
a
During this long period she went
through a series of morbid
with high blood pressure
which I shall describe
changes attended
later ; and ultimatelywith a largeand dilated heart she died of
ary
an
seizure,but without Bright'sdisease in any customapoplectic
"

"

"

"

clinical

use

of the term.

alone, I received

my

later,when

ing
work-

was

much

and assistance
encouragement
old friend Dr. George Oliver, then of Harrogate,whose

past and
to

Somewhat

need

my

Some
duties of
I found

to

the

subjectare

too

tributions,
con-

well known

commendation.
later I left Leeds

suddenly to take up the

Lunacy Commissioner
asylums,
; then, on visiting
many
of persons
from all degrees of
largenumber
suffering

years
a

present,

from

rather

arterial disease ; yet most

of these,

without
surprise,
Thus
graduallyI

convinced

any

as

I found

somewhat

apparent aggravationsof blood

became

that

cases,

such

to my

pressure.
as

we

are

DISEASES

10

in another

I shall consider
which

class to

chapter (p.307)

malady in which at or towards

a
malady having
excessively,
the

of

name

class of arterial
rise of blood
does

all persons

in the

engaged
his

work

extension,
never

or

series of which

same

that

and

own

ing
deserv-

the blood

sent

to

Journal

(Nov. 4, 1893).

place in

the

almost

symptoms,
convenient

Huchard

in 1893

This

work,

in the
then

was

also

he

was

published

reissue

and

which

I have

British

Medical

previous papers

Huchard

professionwhich

M.

and

for review

M.

with

toxic arteriosclerosis.

the Heart.

me

common

other

pressure
to

To these I added

line of research

of

rise

pressures

the course,

this time

at

believe, of certain
was

seen,

indeed

scarcelyexceeds, the rise

Diseases

on

of its

class in which

well known

now

secondly,into the
name
Hyperpiesis,a
;

life blood

course

different.
altogether
heterogeneousclass of

are

if somewhat
It is

middle

which

"

disease ; and

in later life ;

issues

and

PART

thirdly,into at least one

degeneration,one not typicallyassociated
a

pressure,

exceed,

not

the

I gave

afterwards

soon

ARTERIES

divided, first,into Bright'sdisease

be

must
considering,

THE

OF

of

an

age

and

in criticising
me
hope justified
his book without reserve,
on
grounds both physicaland clinical.
At a later date these dissents would
have
been
expressed,if
with no
less decision, yet with more
deference.
The perusalof
the book, however, determined
to publish my
tions,
observame
own
and

I summed

them

up

in

which,

paper

of the Hunterian

; but

read

1895.

to

the

written in 1894
Society,was
Societytillits January meeting in

preparingfor

this paper

the request

at

it

not

was

It

was

in

that I found

in important
myselfdiffering
Basch also,as I shall explainhereafter.
With
respects from von
both these authors however
I agreed on the whole, though with
certain discriminations,in recognisingthe disease which
then
I named
Arterial Plethora or Hyperpiesis; * but I differed from
them

in

another
distinguishing

mode

of arteriosclerosis

prevalent,a series independent of arterial high pressure,

to and
of other
I venture
And
significant
causes.
that

if my
which

distinctions had
has

obscured, and

of arteriosclerosis would
1

and

then

have

been

adopted much
is stillobscuring,
the
been

avoided.

Lately I have preferred the etymology

hyperpiesisfor the haemodynamic aspect

of

and

due

think

to

of the

fusion
con-

clinical side

Moreover, in

hyperpiesia

of it.

less

no

for

the

my

malady,

of

heavy

she

arterial pressures,

final stage of cardiac

defeat

ARTERIES

THE

OF

DISEASES

12

maintained
the

her

ground

of her

moment

PART

until the

death

being

cerebral

haemorrhage.
while I was
Now
observingthis case of Mrs. P., at Dr. John
comparing, for the Medico-Chirurgical
Ogle's request I was
with that of
Review, the pathologicalwork of George Johnson
I was
led to believe that Johnson's
Gull and Sutton, when
tion
allegadetermined

by

true, and to
hypertrophy in the arterioles was
suspect that it might be true not for Bright'sdisease only,but also
for certain other modes
of arterial high pressure which, whether
allied to chronic Bright's
disease or not, are yet not identical with
of muscular

it (see pp. 313 and

no
was
470). In Mrs. P.'s case
necropsy
obtained ; but I may
repeat that around her long story, as on a
string,I collected the shorter parts of similar stories of other
periences
necropsies; and that graduallyby these exstrengthenedthat,beside chronic
my growingopinionwas
renal disease,there were
resemblance
to it in
cases
bearingsome
the eminent
feature of rising
arterial pressures and hypertrophied
but in their clinical
heart, and perhaps of hypertrophiedarterioles,
and
issues differing
from
it widely,perhaps essentially.
course
At this opinion,in enlargement of that of Traube, von
Basch,

patients,
many

with

Potain, Huchard, and

will be discussed
To

others

had

in its proper

collect and

compare

arrived

it

independently
; and

place.

cases

with

plete
long and cominterpretthe suggestions

records

as

possible; to note, to correct, and to

of the sphygmograph ; at a later date to take
Basch's
up von
for its capricious
allowances
sphygmometer and to make
ways
as

to

follow

the

experimental work

of the

the

and
physiologists

pathologicalevents of the deadhouse, and all this in the midst

of other professional
slow and
a
protracted
engagements, was
business ; but during the three
1889-92, when I held the
years
office of Commissioner
more

leisure.

And

in
as

in

while

Lunacy, I found with new opportunities

the asylums I was
and for a
surprised,
that,althougharteriosclerosis abounded,

to find
disconcerted,
and hypertrophyof the heart
yet high arterial pressures
neither frequent nor
conspicuous,the new
opinion grew

matured

in my

the antecedent
and

mind

that, although excessive

phase of
apparentlyin them

certain class of

a
a

chief

cause

cases

of the

blood

were

and

pressure

is

of arteriosclerosis,

sclerosis,
yet that

CHAP,

without

or

any,

which

maxim

any

commonly
of
considerable, previous excess

was

not

is

and

by Grodel,

13

might arise, and

arteriosclerosis

an

INTRODUCTORY

corroborated

till some

ten

gathered material enough to justifyme

conclusions on arterial disease which
the provisional
in the paper for the Hunterian
Societyof London to
referred,and

two

later

years

(1896) in

years

in

later,
It

was

publishing

I embodied

which

Lectures

Lane

my

arise,

pressures

yet imperfectlyapprehended.

even

that I

thus

does

very

I have
at

San

subsequent papers, and in this treatise, I

then laid down.
have not had to depart from the principles
had been chieflyclinical ; but meanwhile
work
on
My own
from
Virchow
side of arteriosclerosis,
the pathological
onwards,
In the first volume
of his
valuable work was
much
being done.
Archives
this distinguishedman
celebrated
placed the whole
In

Francisco.

my

arteriosclerosis

pathology of

that the author

true

yet, on

the

too

much

on

an

histological
phenomena

of the

comparing

dwelt

them

to

inflammatoryinterpretation

which

of the

inflammations

if it be

basis,1 and

its modern

on

he

demonstrated,
of

or

cornea,

cartilage,

hand, by the cellular pathology were

other

banished

"

"

depositsfrom the blood in dyscrasias

cating
(the Auflagerungen of Rokitansky),and so forth ; thus vindithe conceptionsof Haller, Scarpa,and Lobstein, and later
Cohnheim
of Cohnheim.
acceptedVirchow's view of the change
as
inflammatory, a view of it which has had to submit to
much
Langhaas 2 proposed a distinction between
qualification.
diffuse and a focal ("knotenformigen")form of arteriosclerosis,
a
the morbid
and
demonstrated
changes in the tunica intima.
that the work
of Marey and Ludwig on cardiac
And
thus it was
to the
physics,especiallythe applicationof graphic methods
of pressure
record
and
elucidation
phenomena in animals and

the

cruder

notions

of

"

"

valuable

many

if less

accurate

measurements

on

man,

linked

and clinical work.

togetherphysiological,
pathological,
Much
view ofarteriosclerosis
misconceptionis due to the prevalent
as
a disease,"a view
againstwhich I contended in the Toronto
Discussion
in 1906
(pp. 374 and 455). .Too often it is regarded
"

as

1
2

more

disease, and
Virchow,

Langhaas,
attention

Uber

acute

Virchow's
than

subdivided

then

Entzundung
Arch.

it has

classes.

"

The

man's

der Arterien.

vol. xxxvi.,

received.

into

remarkable

paper

which

deserves

real disease
"

Arteriosclerosis,"says

was

"

is but

physician.

"

has

its

own

"

symptoms,
have

called

its nature

giving the malady son cachet ; he might as

dropsy a disease and occupied loose columns

and

its

obese ; but

shall

we

should

or

mean,

disease,"

left
the

that the lesion of arteriosclerosis is found

see

cardiac

often without

as

with

of the
hypertrophiedheart, especially
on,2and confuses this again with the heart of

so

we

well

guished
distin-

"

of

symptoms

ventricle,and

did.

ancestors

our

calls arteriosclerosis

friend of mine

German
with

indeed

as

course,

lesion,"says

Huchard,1

Arteriosclerosis,"
says

seer.

PART

eminent

one

is the disease, atheroma

Arteriosclerosis

another

ARTERIES

THE

OF

DISEASES

14

hypertrophy as

by a disease
positiveand

series of symptoms,

mean,

with it. Now

fair

uniformity; in the antecedents of

such uniformity,and
the formal
arteriosclerosis there is no
sub-classes contain processes disparateand alien. To call arteriosclerosis
"a disease"
is not pathology but necrology,and
the
error
penetrates into and confuses all the therapeuticsof the
subject. I am glad to have the categorical
support of Dr. James
Mackenzie
in this respect, who
(Diseasesof Heart, p.
says
235) that I have
rightly protested against arteriosclerosis
disease."
Gull and
a
Sutton, Letulle, and
being considered
Lancereaux
this notion
fostered
of
similar
a
histological
result of many
diseases as
a
disease," as a general malady
which
differs case
by case only in the points of its attack.
Thus chronic Bright'sdisease is said to be but arteriosclerosis
in the
renal
arteriosclerosis of the
area
; hyperpiesis but
heart -block
but
"arteriosclerosis
of
splanchnic area;
a
cardiobulbar
(Huchard), and so on : so that without
type
much
trouble we
have
a
ready key to differential diagnosis.
Local lesions are
but episodes. Once
admitted
these terms,
on
negative,recurringwith

"

"

"

the
As

use

of the titular disease

Dieulafoyironically
says,

"

"

cardiopathies

old friend
in

les affections

toutes

presque

von

and

Nothnagel)in
See

Bourguignan, one
nn
Brightique

corame

Huchard,

summed

the forms

up

for the

of Huchard's
.

viscerales

"

such

un

Medical

devoted

la

limits.

no

pathogenic de
govern

system.

nervous

pathology(inhis
:

Press

the cerebral
of June

pupils,writes

cardio-arteriel

has

it would

of arteriosclerosis

specialreport
est

Elle resumerait

diseases of the

most

Schrotter

of Arteriosclerosis
"

"

meconnu

My

article

form,

2, 1909.
"

all

Etre

(!).

considere

CHAP,

the

INTKODUCTOEY

form, the renal form,

heart

these

In

form.

which

etc. ; to

Ortner

added

hypotheses Huchard, the

Kupert of medicine, with his dashing physics,his magnificent
phrases,and audacious assumptions,has been a leadingspirit.He
of us with much
used to credit some
ignorancebecause we panted
in vain after his systems ; I indeed
was
painfullyconscious
beside his quick one.
But we
of a slow mind
are
learningthat
cardiopathiesarterielles," cardiosclerose,"
phrases such as
dyspnee toxialimentaire," aortisme hereditaire," periode
et pondus
mitroarterielle," etat meiopragique," etc. etc.
the

intestinal

15

vast

"

"

"

"

"

"

"

"

et

Him

ipsa Hue

hollow

over

us

is not

placesor

been

have

an

told.

that

Ideas

he wrote
delicate

are

of execution.

tisme,"

"

"

we
Brightisme
pulmonism do but create

It is

none.

by spade
a

Wilkite,"

calls

labour.

it

so

"

Huchard's

Broussais

love

has

carried

of system

Huchard

did

medicine

which

for

us

to

was

of

some

of

said of

was

could

and

"

arthri-

carried what

was
von

Schilderung
to exclaim

Bouillaud,

stimulate

an

"

to

plore
ex-

"

"

us

or

there

granted than
Wilkes

of such

men

be

not

reside in virtuosities

nevrosisme,"

Jack

schematisierende

in his criticism

It

always

all for

as

pupilswho

market-place,and tempted

giftedobservers

pretence of knowledge where

of

well talk of dermatism

as

However,

his

was

clinics has

and

less

either waft

"

the truth

as

easier to take

much

so

"

platitudes.It

rhetoric.

"

terms

might

"

"

is

that

do not

things,and
Such

of

pathogeny

style in which

trahit

for the decoration

serve

but it is true
neglected,
unsympathetic distrust of

late years

Michelet

volumina

immensa

the arterial side of

that

true

had

vinclorum

never

Romberg
into

the

with

Dieulafoy,

See

where

distinction."
interest

in

the
What

side of

had

scarcelypenetrated into generalpractice,

and
discomfiture
meek
about
the admiring family
to
cast
a
doctor ; this his wondrous
neologisms,his French lucidityand
logic,his categoriesand vue d'ensemble achieved
delightfully
for readers who were
Comment
faitesnot tempted to murmur,
"

vous

done, Monsieur,

French

School

pour

etre

si

sur

de

ces

choses-la ?

"

of

The

to-day perceivesthe frailness of these logical

fabrics.
the arteriothe wane
of
sclerosis
over
Tripierx openly rejoices
legend." With
justicehe complains that by facile
of generalterms, assumptions for reasons,
diagnosis,
use
vague
"

Tripier,fitudesanat.

din.

Cosur, vaisseaux, etc., Paris, 1909.

OF

DISEASES

16

and

ARTERIES

THE

these rhetoricians
classifications,

paper

anything.

As

Vaquez

ready to explain
our
ignorance is

were

tickets

such

by

says,

PART

concealed.

then, as

At the outset

of arteriosclerosis

in

one

and the

shall see, these elaborate

we

vitiated

were

pressures with that of

the arteries,the other

alien
by merging thingsessentially

; e.g. the arteriosclerosis of moderate

category

same

subdivisions

hyperpiesis
;

the

For

secondary.

primary as regards
part, perhaps,in this

one

my

oppositeextreme, into an extreme

distrust of categories
own
point of view, or indeed
; from
my
under all pointsof view, perhaps I ought to have divided these
essay

into the

receded

I have

from the other ; but I feel the time has

several processes the one
much
for radical separations,
not
or
system-building.
yet come
than once, but they
manuscript I tried logicalschemes more
and the loss of many
led to repetitions,
current
a
qualifications,
There
is yet too much
haze on the horizons ;
point of contrast.
in movement
truth is in the making, ideas are
; we
may
envy
of
certainties
the
but we
cannot
the
theologian; our
yet enjoy
facts are
stilldivided and scattered,they cannot
yet be packed
into their universals ; they lack attraction therefore,their grouping
is loose.
As Leo X. put it,when
compared with doctrines
nacle,
digestedinto order and formula, and built into a logicaltaberWith
its Latin tradition,
vagi et ancipitesvideantur."
theologycan providecompletenessfor its pupils; the pathologist
be pontifical,
for a long time
cannot
not
He
is
to
or
come.
embarrassed
Much
du vrai."
then depends upon
by Pillogique
the precise
which
I have
on
use
of words and names, a matter

In

"

"

often

dwelt

in other

papers

reallyreckless. What
colleaguewho told us
asthma

the

are

Mr. A., his

think

day
!

of

that

as

medical
a

authors

clever

and

far

as

to

indicate

admit, lest

rather

should

his cousin

the

were

same

the

deliberatelyinconsistent

in

atherosclerosis

myself of

the

"

in

certain

value
specific

person

disposedto adopt

am

ordinarydegenerativelesion
mislead

eminent

migraine,epilepsyand
to say that
though one were

present subjectI
the

are

"

in place of arteriosclerosis,
at
atherosclerosis,

name

"

"

disease

same

our

to

we

the other

grandfatherand

In respect of

are

for herein

any

rate

the
so

of arteries.

reader, that

have

been

this

have

used

passages
of the newer

usage

where
name,

I wished
but

to

avail

otherwise

INTRODUCTORY

CHAP,

have

not

cared

yet

disturb

to

17

the

use.1

common

The

of

name

widely, for the

hypertonus for high blood pressure or, more
introduced
by German
malady of arterial plethora,a name
writers and adopted at home
by Dr. Russell, although it draws
mode
of the malady with which one
attention to the mechanism
of arteriosclerosis is associated,yet seems
to me
hardlya clinical
for so speciala use.
word, and to have too wide an application
in largeror smaller
Arterial hypertonicity,
in a
occurs
areas,
multitude

of

disorders.

Hyperpiesis,in

have

admit

to

that

of

name

my

its literal sense,

than
one
applies to more
for instance, to both
arterial plethora and
chronic
Bright's
disease
that
it has
is
without
and
not
so
name
ambiguity ;
my
also the fault of emphasising one
a
leadingone, it
symptom
is true
above the rest ; but so do the names
of hydrophobia,
measles, whooping-cough,and the like. It is difficultto persuade
insist on
chaining up a word to its derivation,
persons who
is to connote, not
that this name
the high arterial pressure
only,but the whole morbid series,not chronic renal disease,of
which high arterial pressure
is one
term.
However, I shall use
this name,
rather hyperpiesia
or
(p.313 n.),for lack of a better.
"

"

"

"

For the other

chief series,
arteriosclerosis
or process, in which
is salient,I proposed the name
of Involutionary,
to which
some
of my

brethren

mode

is often found

age

objected.

Sir John

Jores'

heredity,toxins, strains, etc.

"

is open to the same

observed
the Latin verb

objection. In

of

years
such

as

sclerosis
arterio-

"senile

name

this

urged that

in persons of not more

than 55
that it seems
to exclude
other causes,

; moreover,

had

Broadbent

Haller's

works

in its several conjugadecrescere,

tions,

the decline I wanted

to signify
to indicate ;3
frequently
to
and, more
closelystill,Haller used the word decrementum
From
him
therefore I
signifysenile involutionaryprocesses.
sclerosis
adopted the adjectivedecrescent to signifythis senile arterioused

"

or
1

The

word

and I think it will

atherosclerosis,
atheroma

3) it

(iv. 527.

d\evpov," which

is

has

serve.

connotations.
In
interesting
an
Egyptian
H^wa

derived

from

probably

carries

"

the Schol.

"

us

back

to

the

"

Alexandrian

e/c

Oribasius

irvpivov \evicov
before

surgery

Christ.
2

Broadbent, John, Brit. Med. Journ., 1906.

solida ad
elementa
E.g. Corpus animale
:
undique decrescebat
intervalla coibant, vasa
increscebat
terrae
excaecabantur,
portio
in addensando
causae
sect. 3.
corpore aniinali valebunt," Lib. xxx.
3

"

VOL.

minora
.

eae

Subnormal
have

fixed

arterial
for

this

Plebosclerosis
this

lesion

but

abundantly,
course

in

again

the

omitted,

have
vein

where

it

little
it

have

yet

with

less

certainly

clinical
is

within

fall

not

study

little

know

may

portal

this

have

ARTERIES

do

pressures

essay

also

THE

OF

DISEASES

18

pretty

to

the

excuse.

exists,

known.

limits

begin.

significance,
well

PART

But

of

probably
unless

of

PHYSICS

20

CIRCULATION

THE

OF

PART

recorded
complicatedsubject,
observations
(1909-10)upon 250 patientsof 60 years and upwards
at
in an
Strassburg. After excluding
asylum for old persons
in which failing
heart, chronic renal disease,or other malady
cases
after careful consideration

of

very

might vitiate the results,he found the rule to be true that

systolicpressures slowly augment with the later years of life.
But for diastolic pressures the rule is not quiteparallel.Generally
speaking,it

is true, the

but not

to the same

diastolic pressure
amount

enlarged,even
rarelymuch
in younger
aortic regurgitation
not

observations

these
Now

in

so

rise

what,
some-

pulseamplitude is enlarged,
to resemble
the pulse of
as

I think we
shall accept
persons.
with
accordance
clinical experience.
this kind

pulsewith a dilated
in Wildt's
aorta
and
probably atheromatous
experience
; and
correctly.He goes so far indeed as to postulate(in such cases)
direct relation between
a
pulse amplitude and sagging of the
in degenerateaortas
That in stiffer tubes, as
with
aorta.
even
but little peripheralarteriosclerosis,
pulsatile
amplitude enlarges
is a well-known
physicallaw. But in peripheralarteriosclerosis,
far advanced, the aorta may
be but moderately deteriorated.
even
These figures
of Wildt seem
discordant with those of Moutier,1 but
Wildt's results were
with
to accord
carefullyobtained and seem
would be that as the aorta
comment
generalexperience. My own
adapts itself best to output at medium
diameter, if distended
is needed, and to get the
beyond this,in health, more
energy
output taken up systolic
pressure rises ; for instance,on making
a muscular
effort,as the aorta is distended by the rise of pressure,
the work of the heart,alreadycalled upon for the effort,is multiplied,
but as the periphery opens
the aorta
its
out
recovers
advantage. Such readjustmentsare far more
rapid and effectual
in trained persons.
On diastole this high stretch of the aorta is no
longercalled for ; the pressure falls smartly to the rest standard
of the individual; the heart need
not
hypertrophy. Thus
the sum
of cycle pressure in elderlypersons
be no
more,
may
if in its phases the curve
be more
labile. Statically,
the senile
rise is representedin the artery by a gradual growth of the
we

fibrous
of

should

as

also does

naturallyconnect

strands

childhood
1

of
are

the

tunica

probably

Moutier, C. rendus

due

de VAcad.

intima.
to

the

of

The

lower

relative

pressures

proportions

des Sci. cxlii. 10, 1907.

CHAP,

PRESSURE

ii

at

that

of

the

of heart

age

later
of

the

probably some

21

arterial tree ; the

increasingpressures
of life may
be due in part to failing
ence
resiliyears
of friction,
arteries,and small increments
though
katabolic factors,as yet obscurelyknown
to us,
in this alteration.

concerned

are

and

PERIODS

generalthat

At

any

rate

the

rule is

so

in an
systolicpressure of 120-110
elderlyman
arouse
some
suspicionof cardiac fatigue.
may
We
are
as
of pressures
yet far from possessinga normal curve
lations
for the dailyperiod; under bodily and mental impulses oscilnormal
incessant, and so large,that perhaps no
are
so
be formulated.
It is a point of no
little interest,
curve
can
for example, to determine
the arterial pressures
during sleep;
but the obvious
difficulties of taking records upon
in
a
person
it have hitherto prevented
sleepwithout lighteningor dispelling
conclusive results. It is usuallyassumed
that during sleep
any
arterial pressures
rise,and the comparativelypassive cerebral
arteries may
then be distended
by afflux of blood during the
anabolic
waste
activityof the cells in restoringthe nervous
of the day. The
not
of apoplexy and
infrequent occurrence
thus
angina pectoris in sleep has been
explained. But
and
Brooks
the
Carroll,1 on
a
on
long series of observations
phases of blood pressure in 68 normal persons, say that during
of normal
the first hours
sleep pressure fell,but rose as sleep
continued, up to waking. Soon after awaking in the morning
fall of 24 mm.
the readings showed
an
average
; three hours
later the average
and from
this
depressionwas
only 12 mm.,
positionpressure slowly rose until the later afternoon, when it
gradually fell to its lowest day position. These fluctuations
least in normal
in high pressure
were
or low pressure
cases, most
in which
the preliminarydrop
after sleep was
cases
cases,
rapid. In six high pressure cases
(average 204 mm.) the night
sleep,during first sleep,reduced the pressure by average of 44*8
but the waking pressure
was
mm.,
only 22 '8 under the day figure.
The drop seems
to be due to the sleepof night,as in persons
not
fall took placethan posture and
permittedthen to sleepno more
rest would
for.
account
Occasional
day sleeps had no effect
of reduction
of pressures,
that the attempts to turn
so
sleep
a

"

"

"

Brooks

Epit. B.M.J.

and
See

Carroll, Arch,
also

Hobhouse's

of

Int. Med.,
case,

August

p. 658.

15, 1912

"

fullyquoted

PHYSICS

22

meals

of

influence

interferences
of

hunger

under

for instance

as

the
local and

the cardiac

of constriction.

areas

immediate

arterial muscle

muscular
blood

and

or

(videp. 50),yet the arterial system

to the blood
"

capillaryarea

of

"

dilute solution

and

pressure,

as

Drs.

effects

Gaskell,

is not

stant
con-

balance
counter-

may

the

postulateof

reflex between

is still in controversy

whole

and

areas

neuro-muscular
within

mining
deter-

by

physiologists. I

Although

pressure

this

energy

in other

nerve,

influence,

may

of

other

long

sensory

mechanism

many

reflex dilatation

; moreover

and

researches

Hill, and

influence,"because

may

markedly

and

well-known

the

Leonard

"

say

meals

had

we

sciatic,influences,or

fluctuations,with

vasomotor

in

the

promptly

arterial pressures

Langley,

the

tion.
informa-

more

by experiment, what
practice,that irritation of

in clinical

described

obtained

have

we

decided

have

We

such

of

before

fallingpressure

habit, a

directions

other

some

observed

tions
sensa-

surpriseme.

not

In

our

periodicaldilatations

to

The
other

by

I believe

little

fall.

the

overridden

As

rule.

to

due

are

vessels
splanchnic
would

reducible

be

to

had

pressures

much

be too

to

seems

PART

increase

did not

sedatives

Sleep under

success.

arterial

of

moderation

to
therapeutically

CIRCULATION

THE

OF

is

sensitive
directly

to chemical

reacts, as
of silver

The
changes in the blood.
into a vein
tested by the injections
nitrate,or simply of an alkali.1 To

these

enquirieswe shall have to return later ; at present, in order

to keep before us the complexity of these blood
pressure reactions,
I will emphasise the experiments of Elliott and others on the
influence of stimulation
of the splanchnicnerves
in causing,not
only vasoconstriction
by direct action on the vessels, but also
in causing the adrenals to secrete more
The
action of
adrenin.
drugs,so Professor Mines tells me, is thus dual.
many
Atmospheric pressures,
according to Crile, affect arterial
effect
directly. My own
experienceis to the same
pressures
but
as
more
regards not absolute barometrical
or
pressures
less sudden

falls

(Vol.II.

p.

102). Cold and

heat,

as

we

know,

affect them
The
1

See

believe

directly.
of posture
effect
Heger; Ludwig's

uncontradieted.

on

blood pressures

1887.
Festschrift,

has

been

little ancient

empirically
in

date, but

PRESSURES

CHAP,

ii

noted

of

faint ; and

have
devoted
time and experiment
physiologists
enter
is not the place to
a
to this problem. This
upon
descriptionof their results as a chapter in physiology,but

of late years

full

many

cull

I may
let

in

fell down

since the first woman

course

23

POSTURE

AND

few

facts

for clinical service.

reiterate the admonition, which

me

At
Basch

von

the
so

same

time

continually

urged, that only by submitting again and again to the control

divest ourselves of engrained habits of
of experiment can
we
dogma and rough and ready empiricism,and, in respect of our
the general idea of the circulatory
present subject,maintain
whole.
as
a
mechanism, central and peripheral,
Life, like a fountain, consists in a continual ascendancy over
gravitation
;
bow

down

with

careful

of

as

and

life fails heart

their mother

earth.

physiciansat

certain

to

advantage

circulation

in the

vessels,like back
It has
moments

long been

limbs,

customary
the balance

test

to

and

surging forces of
example,by testing

between

the

drag of gravity; as, for

These methods
the pulsein various postures of body and limb.
of fallingpressures,
used chieflyfor the detection
been
have
and even
be revealed in abnormal
which
alarming degrees.
may
in an otherwise vigorous
In one
of great physicalexhaustion
case
had gained
undergraduate,a patientof Mr. Wingate, gravitation
hand
the upper
a
so
enormously that to raise him towards
tion,
sittingposture in bed brought the pulse at the wrist to extincto put his life in instant jeopardy. In another
and seemed
of less degree,a pulse of 114 as the patientstood up fell
case,
Plesch
to 80.
his recumbency, after few transient vacillations,
on
when
20
about
that
more
use
upright we
per cent
says
For the normal
relation of gravity
than at absolute rest.
oxygen
Professor L. Hill has given us some
now
to cardio-arterial energy

lifeand

the earthward

well-known

which

standards

accuratelythan we
only the downward

enable

wont

were

in disorder to detect, more

us

empiricalmethods,

the older

on

not

normal
pressures, but also abwhen arterial pressures
degreesof resistance to gravitation

are

at too

arterial

be

high a
pressures

more

and

Thus

to

more

count

positionand

to

fluctuations

In these last cas.es the differences between

range.
in the

standing and

abated, almost
the

of low

pulsein

compare

the

the

to

recumbent

postures may

abolition.

upright and

numbers,

in the

difference

recumbent
in

healthy

PHYSICS

24

of

persons
from

Marey's
blood

the
When

and

the

pressures

nervous

be

may

they

may

heart

is

amount

rate
on

of

on

when

medical

recent

recumbent, both
became

wave

the output

more

became

in

balance

some

rate

the rate

and
more

work

emptied.

not

standing

I have

; or, as

Congress,stated
the crest

be altered.

may

initial effort the

lower, but the trough sank

of

course

augmented

the recumbent
when

be

may

depends in part
peripheralresistance ; the

its normal
much

paribus,

close relation between

very

increased,and the left ventricle

were

wave

as

be very

coincide,as

persons,

that the

in part

far

slower than

Kissingen,at
curve

caeteris

; and

of the difference.

this device

(p.399).1 Pulse

pressure

even

the

assume

governance,

If the blood

the

not

it only as
affecting

wall

supposed that,

hand

is at

must

we

been

inverselyas

instrument

service ; but

on

is

pressure

no

rates

it has

time

PART

old clinical device

beats, is an

to sixteen

ten

some

CIRCULATION

THE

OF

that

said,
of the

Hesse

of

in

healthy
trough of the

the
than

the

crest,

so

ampler, the pressure being unaltered but

the uprightpositionthe order was
reversed,

smaller.

Quantities of output, other conditions

beingstable,may thus be guessedat. But, in all pulserecording,

the multiplicity
and shiftiness of conditions,such, for instance,
the automatic
vascular tone of largeareas, room
as
temperature,
and emotional
be forgotten; for the reflexes
never
phases,must
which
signal all these fluctuations,constrictions,dilatations,
ordained.
outputs, and so on, are exquisitely
In this context
I take the libertywith Dr. M'Curdy 2 of
adoptingthe followinguseful table drawn up for growing children,
table which
be compared with Wildt's records for the
a
may
elderly.
"

See, e.g., Tigerstedt, Phys. d. Kreislaufes,p.

experimenters
2
M'Curdy,

agree.
J. H., School

355,

with

whom

other

Hygiene, 1912.

[TABLE

CHAP.

PRESSURES

II

For

children

1. The

heart

M'Curdy

rate

serves

2. A

high heart

rate

3. A

heart

with

and

rate

concludes
as

indicates
wide

weak

blood

peripheralresistance,or

5. A

fall in pressure

on

these

Symptoms,
The
range

points

variations

pressures

shall

between

of

poor vascular
100) indicate a

lack of

horizontal

adjustment.
weak

heart,

splanchnicadjustment.
a

horizontal

lack of cardio- vascular

return

the

again

under

to

stand-

adjustment.
the

head

of

p. 399, etc.

pressures
over

of condition.

condition.

changing from

positionprobably means
To

poor

(below

pressures

25

fair indication

standingpositionis indicative
4. Low

Dr.

POSTURE

AND

the
in the

of

and postpubescents
prepubescents,
pubescents,
same
general field,with a tendency to lowest
prepubescents,highest in the pubescents,and

OF

PHYSICS

26

CIRCULATION

THE

PART

greatest range of
postpubescents. The
is in the prepubescents.
variability
at
The
periods short enough
experiments should be made
time there is a rapid rise ; and, if
whether
at any
to determine
relation to pubescence. It should
in what
rise occur,
such
a
be related to growth in height,weight, and muscular
strength.
the same
A series of examinations
on
boys, fall and spring,
for a period of years
during the change from immaturity to
in

intermediate

the

maturity,would
Mental
effect
later

bodily

as

is said

exertion

conditions.

fulfilthese

to

seem

(Gibson) to
This

exertion.

have

the

kind

same

coefficient will be

of

considered

(p.70).

Pressure
of
efficiency

Gradients

correlations

defy analysis. In my
fear, to be not only dull

to

For

all and

every

these

"

circulation

the

coefficients and

Velocity.In

and

are

so

artery

many

these

hands
but

said

be

may

to

the

functions

consist ; but

their

and

complex as almost
paragraphs will prove, I

obscure.
to

which

gauges

can

be

appliedthe

of internal surface systolicand diastolic

speaking,equal (Dawson) ; but below these
are, practically
magnitudes the gradient,by increase of friction,falls rapidly;

blood pressures

unit

per

"

"

and

here lies the

five-sixths of it. The

or
resistance,

the heart being constant,

resistance,

are

of tubes, diameter, ramification, tone

many

and

and

factors

subtle ;

consistence

of

length

of walls,

temperature, viscosity,
permeation of leucocytes,tissue work,
and

so

forth.

narrowing,the

In

areas

of

vasoconstriction,or

of

structural

heart's action

being constant, this fall of gradient

is of course
are
so
steeper ; but these areas
independent of aortic
and velocityas to be beyond calculation.
Hence
one
pressures
chief difficulty
in the discrimination
of heart values.
Pressure
gradientsin the arterioles are estimated to fall to about 60-70
35-45 ; in the
mm.
to
pressible
commore
capillaries
; in medium
veins
to 15-20 ; in the finer superficial
capillaryareas
about the same,
in the fine venous
or
more
(p.55).
plexuses5 mm.
l
Dr. Oliver
has endeavoured
this law to account
to turn
by
the
with
those
at the radial or brachial artery
comparing
pressures
in the phalangealvessels.
Caeteris paribus,as peripheralresist1

Oliver, G., Lancet, July 22, 1905

Journ., 1900, vol. ii.

cf. also

Dr. Waller's

paper,

Brit.

Med.

PHYSICS

28

be

CIRCULATION

that of the left ventricle ; but

rate

any

THE

OF

constricted

so

to be almost

as

PART

less
neverthe-

the radial may

empty, and

stream

pressure

researches seem
to indicate
imperceptible
; although,as recent
to instrumental
(W. Russell),
compressionthe stiffened muscularis
resistance rivalling
offer a
the central blood
may
pressures.
Thus
that the amount
see
we
of Hood carried to the periphery
be largelyindependent of the blood pressure ; other factors
may
are
guide to cardiac energy :
engaged ; stillwe may find thus some
the whole, the better the heart the better the velocity.1
on
Again,
in illness we
have to deal with largervariables,such as peripheral
resistance and heart values ; yet possibly,
as
we
anticipate,
may
the same
with
readings. In the state supposed, of
pressure
that
know
arteries,we
peripheral constriction with normal
double

to

radius

the

of the

radial

artery would, if the heart

ready for it, multiply its stream

activitysixteen times ;
the bed is,per se, to lower resistance,
to widen
though of course
if large additions
and plus velocity,
made
the
to
even
were
a
quantity of the blood, would mean
fallinglateral pressure on
To expand the stream
the arterial wall.
bed is of course
so far to
slacken the linear velocity the velocity,
ming
for instance, of a swimmean
corpuscle; but increased area does not necessarily
retardation
Dehio,
(Gaskell,Heidenhain, Bayliss,Volkmann,
etc.); the work of the circulation in the district may be largely
the fall of resistance ahead
enhanced, and
quicken the run
behind.
As it is difficult to apply abstract
physical laws to
these biological
Stromproblems, the term stream
activity
were

"

"

"

"

intensitat
instead
if

of

German

authors

"

be

may

used

in this context

of

as
velocity,
givingus for local phases of high activity,
little loosely,
the generalconceptionwe
If the sympawant.
thetic

be
that

cut

in the

neck

the

of the

temperature

district rises,

if velocitybe lessened

blood
by the dilatation,more
be passingthrough,an increase probably due to the opening
must
of a rich collateral circulation ; especially
if it be true that in
arterioles and venules.
placesfine cross vessels connect
Velocity
then in any district depends upon
the attitude of its own
vessels,

so

On

this subject

It is to
his

even

be

regretted

arteriosclerosis

degrees
"

"

see

moderate,

into

Deutsche

Hensen,

that

in this

origins

medium,

paper
instead

and

Arch.
the
of.

extreme."

f. klin. Med.,

lamented
or

as

well

author
as,

1900, vol. Ixvii.

did
into

not

divide

columns

of

CHAP,

and

the cardiac

on

increase

demand

"

that

as

was

calculated.

pressure

be the

to

So Hill and

cause

certain

and

the

not

then

pressure

also.2

Flack

the

damage

other

vessels under

relaxed

upon

the other

On

blood

the

to

no

the carotid,

activity

stream

long arteries

than

more

was

This

similar

in

are

"

Stromstarke

"

of the

precociousthickeningof
but

"

fall the

of the limbs

conditions,such

as

temporalsin migrainoussubjects

if this result be verified.3 We

"

"

found, I think by Hiirthle,on

began

labourers,and

the

intensity we shall
to the filling
of the
its cardiosystolic

centimetres

Stromstarke

direct relation ; it was

of

observation

cubic

in

volume

of

elsewhere.

may

under

"

stream

relation

in

energy

"

by

29

stream
makes
Speaking generally,
activityin an area
the heart ; it is provided for by correlative conon
striction

pressure.
no

; and

energy

signifythe mechanical
portions of the vessel
local

ACTIVITY

STREAM

ii

shall

arteries that

hand, in spite of

that it is not

see

internal

tell.

pressures

constricted

stricted
con-

upon

vessels, within

limits, the

peripheralcirculation may be even

abundant
more
conversely through dilated vessels the
; as
supply may not be increased. Heidenhain's experimentsillustrate
how
in narrowing arterial areas
velocitymay be augmented, and
0. Miiller (of Tubingen) 4 found
velocityin cutaneous
areas
increased
by cool baths ; that is during degrees of vasoconstriction. Dr. Harry Campbell 5 demurs
in some
to an
measure
narrow

of Sir James

argument
arteries

is

lessened

enquires "if
contraction

"

Hill and
in

spiteof largerand

side the
ished
3

contracted

force.
See

Gowers

(Paper
water

warm

and

other
at

the
4
6

seem

to

the

mean

the

other

in cold, that

on

current, the systolic

pressure

arteries
was

authors

conducted
a

wall

wave,

the

systolic wave

and

would

the

same.

immersing

on

heat-relaxed

fell,while
with

be better

and

on

almost

side,

the other
undimin-

conducted.)

Rolleston's

Sir William
System of Med. vol. iv. p. 617.
of a lady, set. 50, a life-long
sufferer from severe
the righttemporal
right side of her head, in whom

has published the case

frequent migraine of the
sclerosed.
Thoma
described
(only)was
sided supra-orbital neuralgia,in which
In persons
subject to migraine on both
This local arterial change stands
in no

and

generalisedarteriolar

Royal Soc., April 10, 1913) found,

and

swifter

(But this

Allbutt

of

Well, for this calculation the heart's energy

Christen, loc. cit. ; and

elbow

lateral pressure in contracted

converted
into velocity,"and

partly
propositionbe true

Flack

"

that

and

one

in

this

Barr

the

similar

of leftcondition, in a case
sclerosed.
(only) was

left temporal

sides, both
relation

general blood pressures.

0. Muller, Kong, innere Med., 1907.
Campbell, H., Brit. Med. Journ., January

to

be affected.
may
arteriosclerosis
to
general
or

temporals

28, 1905.

PHYSICS

30

OF

resistances would

terminal

must

therefore

modify

and

of
velocity,

cardiac

and

vascular

tone

mm.

The

sec.

ascertain; in

the

in

circulation

velocity in

circuit of

Still,in

take

the generalarterial pressures

the elder

rest

23

widths

just the
The

whole

sec.

there is much

and those in

Cohnheim, Roy, and

sumably
Pre-

sec.

p.

at

424

at

difficult to

ever-changingneeds.

conversation

current

at

mm.

themselves

set

and

particlemay

the aorta

perhaps J-J

smallest

the momentary

serve

(seeFellner, p. 103).

vessels is still more

smaller

the vessels in health

to

and

largely the factors of pressure

propulsion and peripheralresistance ;
be the most
to
important of
prove

mean

rate

physiological
myogenic,

very

may

puts the

These

arterial, vasomotor

the coefficients of the normal

Plesch

PART

to be determined.

have

and

tides, cardiac

CIRCULATION

THE

others

confusion

areas
particular

elucidated

these

between

although
problems

long ago. To raise pressure experimentallyin the carotid and

the heart,
not
react
to double
it,may
even
on
axillaryarteries,
the general blood pressure
nor
on
; neither hsemo-dynamically
reflex. But if in any
an
nor
area
by nerve
artery of supply is
in which
constricted,a case
ordinarilythere is a corresponding
dilatation
the

elsewhere, the
constriction

blood

within

pressures

the

yond
be-

area

paribus,tend not to rise

but to fall ; any increase of velocitybeing negligible.In other
words, unless of course, as by collaterals and cardiac augmentation,
be
increased
reinforcement
which,
velocity
accordingly,a
of reciprocal
dilatations and of the largersectional
account
on
of the finer vessels,does not ordinarily
take place,a periarea
pheral
area
of constriction,or beyond constriction,is an area
the blood is
not of high but of low pressures (p.218). Ordinarily,
from
the constricted
to
more
areas
simply diverted
;
open
and
obtains the general or
so
long as this accommodation
central blood

pressures

must,

cceteris

unaffected.

are

But

force
the blood
constrictingareas
may
in
probably no infrequentevent, especially
thus an intense splanchnicconstriction may
or

renal

even

coronary,
the whole

tubular

pressures

may,

constrictions

In

into

continuallydo,

correlative

areas,

so

rise in

that,

the
;
areas

as

we

areas

conditions

force open

health

powerful

weaker

instable

system is kept fairlyuniform

and
in

arteries.

largeand

cerebral,

capacity of
and although
because
have

of

seen,

CHAP,

ii

dilatation

BLOOD

PRESSURE

AND

of vessels in active

If however,

does

areas

of current, yet the

retardation

SCLEROSIS

not

heart's work

31

necessarily
imply
remains
ordinarily

of constriction
supposing,areas
if the splanchnic or musculoare
large,and particularly
very
be so included
that equallylargereadjustments
cutaneous
area
take
elsewhere
cannot
in spite
place, peripheral pressures,
of cardiac hypertrophy and some
increments
of velocity,
even
tend
the pressures
in the largertrunks
to fall,and
rise ;
to
and
them
see
rise,even
we
enormously ; though how far in a
is extending inwards, is another
constriction
given case
very
interestingand important question (vide p. 298). Clinical
of arterial spasm
the
experiencetells us that in severe
cases
brachial arteries may
be constricted to something like half their
constant.

mean

diameter; and,

as

as

we

are

it is estimated

that the amount

of cardiac

expended upon friction is nearly two hundred times that

standing
directlyavailable for stream
that, notwithvelocity,we
see
velocityis as the square of the impulsive force, to
the vessels over
narrow
areas
largeenough to raise aortic and
energy

intraventricular

pressures,

and

to

diminish

the output per

beat,

is with

difficulty
compensated, even
by the heart's wonderful
capacity for hypertrophy ; thus the lateral pressures upon the
walls of the largervessels must
be increased.
These observations
I make
partlyto point out that in respect
be any
of blood pressures sclerosis of the largerarteries cannot
great matter (pp. 185-188),for it is beyond them, in the assumed
areas

does

of

that
constriction,

matter, and

what

the

heart's

chief work

lies.

What

happen, is a fall of stream

velocity.
little
exerts
than
more
Velocity
a
negligibleinfluence upon
levels,as Hensen, on Tigerstedt's
calculations,proved
pressure
againstSahli and Riva Rocci.
Nevertheless,as stream
velocity,
viscositybeing constant, is inverselyas cross section total sectional
of the vessels in a part, and as velocity,
area
peripheral
may

"

"

and
resistance,

other two,

blood

pressure

are

each

of them

function

of the

lation
correperceivethat changes of pressure have some
with changes of velocity,
and mean
bear
must
pressure
some
proportionto mean
velocity. The total pressure head is the
lateral pressure
plus the velocityhead.
But, during the cardiac
cycle, these relations are modified by reflected inertia waves
which
raise pressure
but arrest
velocity; so that, as Hiirthle
we

PHYSICS

32

THE

OF

CIRCULATION

PART

only be directlyproportionateto pressure

at
when
are
high levels. Pressure
gradients then
pressures
ance
give us little help for velocity. Within ordinary limits resisteffect on
has
more
velocitythan pressure ; for instance,
in convalescence
velocityrises before pressure, and before other
of the pulse attain stability.But as yet we
cannot
conditions
velocities in convalescence, or for periodsof age ; these
compare
of
methods
accurate
calculations
imply far more
measuring
than (in man) we
The
and diastolic pressures
systolic
possess.
showed, velocitycan

should

total blood

It is said

that, positionand

velocityis higher in
that activity
of
seen
starke

"

the circuit in about

make

the

"

authors

of German

limbs

the upper
stream

other

"

must

"

velocityin spite of the dilatation

for instance during mastication
as
the stream
velocityin the carotid

30

sec.

conditions

than

the lower.

We

"

Stromintensitat
be

being equal,
"

Strom-

or

largelyconcerned

of the

local blood

have

with

vessels ;

and

salivaryactivitywhen
is multipliedthree or
four
of dilatation the velocityrises high during
In areas
times.
systole,but during diastole falls precipitately.So also after
of an
anaemiation
as
by compression,the blood returns
area,
of velocity. The
with
an
biologicalrelations of
excess
to
perplexed; by a vasomotor
velocity then are
pressure
breeze

mechanical

calculations

may

at

be

once

disconcerted

the peripheralvessels shrink in calibre

fall and
pressures
increase.
this
resistance (friction)
must
By Hiirthle's stromuhr
as

inconstancyof

velocityrelations is demonstrable
;
to rise
but on the whole, viscosity
being constant, velocityseems
than pressure.
more
readilyor sooner
Generally,as we
pass
from the heart, velocityfalls more
quicklythan pressure.
away
This is due to arterial elasticity,
and
of
might be a measure
it. Velocitymay
improve with sundry patterns of pulse.
From
tell in manifold
peripheryto centre variations in velocity
that rear
ranks
often much
ordered
disare
degrees. Soldiers know
by littlechanges of speed in the van which, there passing
the ranks in ever
plying
multialmost unnoticed, are propagated down
ranks are
oscillations so that the rear
fatiguedby the
A classical instance may
alternations of check and doublingup.
be
few

taken
men

pressure

from
at

the

the

and

Peninsular

head

of

War

column

when,

jumped

it is recorded,

so
a

ditch, whereby,

CHAP,

WALL

ii

in the
this

successive

and

so
irregularity,

did not

detachment

form

may

time

much

and

33

the march

of the

blood

conceptionof

largearteries,the consequent abnormal

walls, and the harassingvacillations of the
It has often

occurred

to

stream

we

the

stresses

vessels

be

must

no

felt
their

upon

demands

the

carry

to the blood

upon

that, in such checks

me

losses of the inertia of the blood

if

through

in the

heart.

Now

checks

upon

lost that

were

energy

tillafter dark.

camp

clearer

some

VELOCITY

multiplyingvacillations consequent

reach

this illustration into

we

WAVE

the

speed,
negligible
to

used to perceivein the streets when

one
principle
if not
the horses, even
stopped but only slackened for half a
rate.1
minute, had to pullan omnibus
up again to the mean
Arterial Wall
and Wave
Velocity.An elastic body offers
kinds of changes caused
resistance to two
by the incidence of
and
forces,namely to change of volume
change of shape. In
factor.

This

"

aortic system

our

of elastic tubes

each

cardiac

systoleloses

it passes each point in the more

elastic kind
in the aorta ; but this is not friction,
of course

fraction of itself as
of artery, most

paid out again on cardiac diastole,

that in the fine network
of the peripherya mean
so
only
pressure
In rigidtubes on
diastole
remains, and the flow is continuous.
of the pump
the flow might almost stop.2 The optimum travel
of the wave
in a healthy artery is about the level of the normal
In higher pressures,
if we
maximum
regard physical
pressure.
less and less a hyperbolic
laws only,the mobilityshould become
to be proportionate
Extensions
to loads.
curve.
cease
Nicolai,
and Herringham and Wills,found the wave
rate to rise as elasticity
became
impaired; but we shall see that this axiom also is much
On the whole, too,
cut into by contingencies,
as
by innervation.
the wave
would be slower in low pressures, as in a
pulse."
vagus
If the arteries of the greater magnitudes,either by the hardening
of disease or by stretching
to the full,become
nonpractically
extensile tubes, the systolic
impulse is not thus taken up ; so
far stream
accelerated,and
velocityis reduced, but the wall wave
not

or

waste

; the

is

energy

"

"

For

further

velocity,vascular

illustration

tone, etc.,

of
see

researches
G.

N.

on-

Stewart's

nervous

many

calibre,

influences,
papers,

and

Gushing,

LaboratoryPapers, vol. ii.,1912-13.

2
It is generally supposed
that

blood
than
a
a
rhythmical passes more
this
articles
Gerlach
in
and
but
doubt
of
statement
stream
see
by
;
Hiirthle in Pfluger,vol. cxlvii.,
1912.
Also Hiirthle, Berl. klin. Wochenschr., 1912.
continuous

VOL.

PHYSICS

34

without
into

bellows,

is wasted

of

are

the

and

the

in unit

passes

heart

usuallydoes

notches

more

whole

If then

tree.

constant, the heart

must

flow

the

the

work

vessels

is

due

quantity per

to

In

crescent
de-

are

full,
over-

tinuous
longer con-

no

is forwarded

the vibration

minute

harder, or the bed

Increasinglengthagain modifies some

the stiffened walls respond

harder

in value,

grow

less blood

the down-stroke

on

not

works

time.

of

if the

velocityfalls. Or,
rise,and

of bagspasmodic screams
pipes
jarring propulsionsof fluid

peripherybut jerky,and

in the
there

the

PART

that, unless the heart

so

diastolic pressures

the

the

to

widen, less fluid

sclerosis,as
energy

CIRCULATION

to

or

rigidpipes;

vessels

the

or

THE

approximate

the movements

pumped

OF

is to

be

enlarge.

must

of the

widening,and everywhere
less sensitively,
in
especially
friction ; so
of intermittent
that the large jumpy
the areas
those of aortic regurgitation.Moreover, in the
arteries simulate
of radius
largevessels,while less potentialis stored, inequalities
Such
a
cause
a
tendency to vortices,which arrest the stream.
pulse we see in dilated aortas, as in the syphilitic
pulse
; the
amplitude increases so as to simulate that of aortic regurgitation,
though not with the range of a hypertrophiedheart ; the mean
be changed. And
not
the aorta
can
no
longer
may
pressure
various
in
itself
to
outputs, though
adapt
young
persons, if the
peripheralvessels be still active, the aortic default is largely
Thus here again the readjustive capacities
compensated by them.
of the animal
body are marvellous ; if the peripheralvessels
of it,as often they do even
retain their quality,or much
when
is much
the aorta
damaged, yet, as Stadler says, (within limits)
still present normal
features.
the sphygmogram
So with
may
arterial

spasm

becomes

so

follows

that

wasted, and

before

rigidtube

far

within
the

the

tissues

sclerosis

any
;

and, from

section
are

less and

less

that

constricted

what

friction is

pressures of course
effective.1
most
of the arteries are
It is at medium

the

has

been

artery
said, it

increased,energy

is

nourished.
efficiently

the resilient

properties

these

and
Hill read
written, Wells
paragraphs were
an
strating
interestingpaper to the Royal Society (Proc. Roy. Soc., March 6, 1913),demonthese
fully; but as their results fortifyand illustrate
points more
for alteringmy
these remarks
I find no
reason
text.
Professor
Hill's demonstrations
1

Some

time

that
important, but I cannot
agree
very
taken
into account."
not been
had hitherto

are

wall

wave

after

the

"

factor

of

the

PHYSICS

36

him,

with

difference

no

CIRCULATION

THE

remarkable

the

or

OF

PART

that, whatever

rule

normal

the

the
(seep. 75),in aortic regurgitation

difference

patientis much
that in the arm.
Professor Hill regards this difference
above
and due
to
a
more
as
pathognomonic of aortic regurgitation,
In aortic regurgitation,
besides
rapidpropagationof wall wave.
the femoral artery is probably thickened.
impaired resiliency,
in

arterial pressure

In

this contrast

condensation

by

vibration

the

leg in

of wall

the

recumbent

and

wave

then, if,whether

stream

wall
distension,the wall be tight,the systolic

or

travel

should

strated
along it so much the faster. Hill demontion,
observathis by using means
of relaxingthe artery under
when
the wave
retarded accordingly. Again, as in the
was
the veins

cuff arrangements
for

velocityare
of

an

This

arrest.

venous

instant

obstructed, the

are

checked

is

stream

and

wave

moments
they encounter
cuff
disadvantage of continuous
as

of this and such interferences I have not

compression. Because
able entirelyto trust
Mackenzie's
been
interestingnotes on
the first few
some
palpable differences perceptiblebetween
touched
waves
as
by the fingeron relaxation of cuff pressure ;
these in my
tions
experienceare often due, not necessarilyto varia-

in heart's
of

but

energy,

to

other, or

or

one

to

than

more

these

to
emotion, or
secondary interferences,or
each factor small perhaps ; but small interferences
respiration,
in the nervous
are
up.1 The variables,especially
apt to sum
in
system, are largeand indefinite. Sclerosis presumably would
of the wall to respond to the nervous
its degree lessen the power
of pulseinfluences,but careful experiments show that a group
waves
givesbut a glimpse of the degree of vascular constriction
sclerosis ; for instance,deep respirations
or
so
modify the wave
one,

rate

that, if we

discriminate

are

between

to guess

degenerationof

by speed,amplitude,and
to

the

measure

wave

at the health

minimum

rate

wall and

pressure

always

tone

or

in the

"

same

of the wall

abnormal
we

must

"

to

tension
be careful

positionof

the

which
is far from
respiration,
Again, if the wall be
easy.
be, often would
rigid,the cardiac energy may
be,
indefinitely
less ; and of cardiac energy
have no index.
The
we
indefinitely
of pressor and depressornerves
irritability
probably varies a good
deal with

times
1

See

and
also

states, even
Mann,

in the

same

individual.

Guy's Hosp. Eepts., Jan.

25, 1908.

Gottlieb

CHAP,

FRICTION

INTERNAL

ii

37

"

"

slowed the
wave
pulsedigitalis
; but,
acts
variouslyon various
as
they clearly point out, digitalis
vascular regions: if it constricts the splanchnicvessels,expansion
and

Magnus

in

occur

may

found

that

other

parts,

e.g. in

skin

kidneys ; atropinalso interferes with

disturb

conditions

the

be

muscle,

again vital

rate, but

wave

the

in

or

We
that if a
have seen
physicalaxiom.
water
the pulse-wave will be retarded,

placed in warm
although,as tested on the
limb

and

other limb, the blood

is constant.

pressure

rates
spiteof risingpressure wave
may
oscillations of
slacken ; vascular tension varies, probably under
and so forth; or againwith constant
nerve
centres, of respiration,

It

certain

seems

blood

it

rates

wave

pressure

Thus

in

that

may

certain that blood

seems

of

determinant

during the recordingof blood

other hand, or
in the patient's
apparent

pressure

opinionis due

my

instrument

of

observed

limb

rise

may
as

much

by

or

(p. 76) than

factors are
at work
again many
;
of
The frictionat the sides, even

layer of blood

immobile

if any.

Kries

Von

thinks

of the

to rise of aortic

here

an

invests
the

mm.

to the immediate

more

sympathetic tension

some

close

to

40-50

some

means

no

; but

this in

effect

on

the

of

the

However

pressure.

for instance.

vessels, if

atheromatous

the inner

the
fist,

the

muscles

attention

deviation

chief

easilyobserve if
place a small weight

ask him

even

even

by

may

we

pressure

influences.

nervous

is

pressure

know, and

We

rate.

wave

under

vary

walls, is but

of the

axial

little,
stream

of atheroma
but
the
incidence
negligible
;
intercostal
at the forks, e.g. at the originof the cervical and
branches, points to the contrary. Eddies probably arise in the
relatively
largespaces of the heart and great arteries,and possibly
It is said that, at blood speed and
at
forks, bends, or kinks.
blood viscosity,
eddies do not form in tubes of magnitudes less
in smaller tubes
than the aorta ; that
even
or
asperities,
jections,
prodo not
but
act
eddies,
cause
only as diminishingthe
ever
radius ; an
important point in arteriosclerotic physics. Howthis may
be, the frictionis mainly within the blood itself.
the walls
It has always been
that the .blood wetted
assumed
of the vessels, so
that the outermost
cylinder of the blood
at

the

stream

is

forks

was

immobile.

looking down,
rabbit

concave

on

cross

Moreover

it has

been

stated

section, into the half-full

meniscus

is to

be

seen,

the

aorta

blood

that
of

on

the

adhering

38

PHYSICS

to

the sides around.

I consulted

John

Dr.

OF

THE

But,

not

Tait, who

of the

and

ox,

endothelium

probably

found

material
it to

Suffice

mean

these

wall

it to

10

to

me

tions
observa-

of which

that

here

say

I shall mention

Poiseuille's

law

later

(p. 109). The endothelium, even

it does

as

in the blood

of atheromatous
is

stream,

(p. 429).
wet

supposes

importance here, and again

point of some
of the arguments
and
some
discussingviscosity,

in

lining

Vascular

cent.

per

the

aortic

afterwards

full

the circulation,some

on

"

point,

estimated

in the

lipoid

"

be

Hewitt

the

of

Thoma

vessels,living

stable.

remarkably

Furthermore, Schade, of the Kiel Klinik,

Resiliency.21
and proved by experimentalwork, that
pointed out clearly,

has

"

elastic reactions

of the

circulation

that

tissue.3 Moreover

pointed

infiltrated

out

to

cushions

cushions,
"

are

finds

that

disease.
the

he

has

they

vary

The

chemical

taken
much

maintenance
of the

state

records

of

as

areas,
"

blood

these

nective
con-

George
they are

and

describes

arterio-

part of

most

the

vascular

the

hydrodynamic

incompressible but tidal

juices. Schade, in this interestingpaper,
which

about

or

with

with

than

more

consist for the

these
me,

far

are

the

they depend largelyupon

capillarybed, which cushions
Darwin

and
adhesion
would
lipoid membrane,
clotting.Dr. Tait's letter,and his published
interesting
subjects,open out many
problems

is then

on

papers

and

clotting,he

of ether- soluble

PART

feelingclear about
most
kindly sent
Startingfrom some

the adhesion.

reply.1 He doubts
by Lister on
amount

CIRCULATION

other
a

gauge
elasticities ; he

under

change of conditions, as in
resiliencydepends much
upon

of

colloid structures

; and

he

that

notes

slightand temporary deviations from the normal, such as

remarkably.
slightdegreesof oedema, lessen this cushion resiliency
Thus
shall see how
we
quickly a slightand invisible but
retention may
age.
widespread aqueous
put the heart at a disadvanteven

He

oedema, in
1

wall
blood
2

good
3

Private
be

also that

argues
so

far

as

they

unwholesome
muffle

letter dated

verified, the

February 6, 1912.
validity of Poiseuille's

will be still further

In

reasons

the

discussion

at

preferred

of
elasticity
If this
law

the

not

this universal

slipbetween

for

states,

and

stream

circulation

of

the

See

impaired.
p. 430.
the Royal Society in 1913

to

relaxed

or

elasticityor

Schade, H., Zeitschr. f.

exp.

Med.

"

u.

the

term

"

"

lability

resiliency."
Therap. Bd. xi., 1912.

was

for

CHAP,

EESILIENCY

ii

cushion, will have

39

like effect.

unless

Thus,

heart

the

be

will
equal to a correspondinglyincreased effort,stream
energy
will tend to fall into a pulsatile
be impaired,the peripheral
stream
rhythm, elastic storage in the parts will be reduced, and the
and
residual blood : the
more
peripheralbed will hold more
loses way,

stream

as

loses way

boat

when

the

get less

oarsmen

thinks
With
his gauge
he is able to
Schade
quickly forward.
detect incipient
degreesof this muffling.
We
have
regarded the elastic coefficient of the wall as the
the stream
chief factor of the pulse-wave
not
velocity,nor
The wall wave
be compared to
again the blood pressure.
may
"

vibrations

the

No

its stem.
stand

for

the

of

of

old

an

is

man

lifetime

blood.

or

sound,

so

under

tree

young

artery

no

so

unchanged against the

Professor

MacWilliam's

blow

upon

perennial,as to
incessant
beating
into

researches

the

need
to
of the aging aorta are too well known
failingelasticity
emphasis. Drs. Herringham and Wills, at a meeting of the
Medico -ChirurgicalSociety on
May 31, 1904, demonstrated
128

on

strengthwith
the

in

aortas

limits

reached

of

reduced,

age

up
the

that

man

up

to

40

vessel

when,

years

in

grows

it is

long as

so

size

and

healthy,

ordinaryenlargements,within a small fraction,are

to this age then
should not be seriously
resiliency
tube after dilatation should return
promptly to its

resting diameter.

Now

even

distended, resists deformation

diminishes

this

and

the wall-

normal

and

more

vessel, as
more

; its

it becomes

extensibility

it is
And
so
velocityincreases.
with a morbid
rigidity. Thus, early in chronic renal disease,
the
walls of the vessels are
as
velocity
tightened,the wave
But
rises ; later, as
they stiffen,the effect is permanent.
tell us this ; it must
be calculated otherwise.1
palpationcannot

As

age

advances,

and

wave

the

inferior connective

tissue may

be

comes
displacingor succeedingelastic fibres,the arterial diameter bepermanently enlarged,and resilience fails. This enlargement
cannot
sense.

that, as

at any

rate

not

in Thoma's

it may
be, in the sense
Compensatory, or rather palliative,
with age distensibility
the vessel is permanently
wanes,

capacious,and

more

and

be called compensatory,

See again

Hill,paper

the

accumulation

Friberger,Deutsche
read

at

Royal

Arch.

Soc., Feb.

f. klin.

of
Med.

residual

blood

vol. cvii.,1912

6, 1913, after

this text

was

in the
also Wells

printed.

OF

PHYSICS

40

of the heart, is

heart, or overwork

cardiac

probably is that
both

diminish

and

volume

for

fluid of

prevent these

or

work

diameter

of

little. One

more

stream

favour

however

vortices, to

be

expended
rarelythe case.

must

energy

is

"

that

is if the

If

To assume
steeper one
goes slower.
grows
rise of pressure
arteries lose elasticity
must
a

the
is

that

road

to

that

assume

function,

output,

effect

velocity
comparatively low

and

would

done, which

be

PARTI

postponed a

contraction
as,

viscosity,enlargement
overcome

CIRCULATION

THE

as

follow

velocity and
be still fairly

stream

If the heart
capacity are constants.
little
retain no
normal, the subjects of arteriosclerosis may
compass.1 A slower
activity,but it lies within a narrower
oxidation.
As Dr. Auld
slower
stream
means
a
pointed out
deteriorate,a change
long ago, the elastic fibres themselves
which has since been more
fullydemonstrated
by Jores and others.
contains not only
But this is not the whole matter
; the aorta
elastic fibres sufficient for its physicalreactions, but muscular

cardiac

fibres also which

it with

endow

the

adjustment. However,
of tone

obedience

in

stiffer the

vessel the

becomes

but

but

more

also

more

less

or

oscillations

disregarded. A

be

moment

to

and

tone

few

of self-

authors
a

(reflex?)

independent movements

of pressure

elastic,in

consists
elasticity
in quick recovery

power

have

for

the

that

the

may

urged

mathematical

sense,

it

deformation
only in resisting
after compression; in this

not

qualitythe diseased vessel,stiffer as it may be, deteriorates.

The
pulse-wave depends then, mechanicallyspeaking,upon
elasticity,
gravity,thickness of wall and viscosity; then comes
in the

system,

nervous

and

vasomotor

central, to

govern

the

mechanism.
The

Heart

and

Blood

Pressure.

"

We

have

glanced

at

the

carriageof the blood as conditioned

by arterial and venous
by velocity,by the state of its channels, by tissue
pressures,
and so forth ; let us turn now
to the
by blood viscosity,
activity,
which depends the maintenance
heart itself,
of all pressures.
upon
of cardiac
be a relatively
Can there by way
inefficiency
high
peripheralresistance without excessive blood pressures, or with
inconsiderable excess
Broadbent
?
was
perhapsthe firstphysician
1

See Auld,

f. klin.

Med.

Herringham

Bd.

xci., 1907.

and

Wills

(loc.cit.),and

Strasburger, Deutsche

Arch,

CHAP,

to

BLOOD

ii

PRESSUKES
such

perceivethat
blood

excessive

when,

if I may

; and

to this

phase he

so

far

Many

years

this, that the so-called

as

in the

"

the

the

gave

41

later

so,

say

I ventured

ago

HEAET

about

comes

pressures

disheartened
tension."

state

THE

AND

period of
heart

comes
be-

"virtual

name

qualify his opinion

to

virtual

"

tension

often,

was

perhapsgenerallyin the cases under contemplation,stillpositively

have justbeen discussing,
we
high. Although, on the principles
with the yieldingheart the circulation is slowing down, and the
falling,
yet, until the final stage of exhaustion, figures
pressures
such as 170 to 180, or even
higher,may stillbe read on the scale.
it did, the resistance to it is obThe
stinate,
heart is not doing what
yet it is working still at supernormal although no longer
If in some
instances, although
rare
compensating pressures.
into action,the heart yet fails to
of hyperpiesiscome
causes
rise to

the

beginning sink,

and

such

Mr.

conditions

D.,

sound.

set.

There

cardiac

and

rhythm

rather
been

for

heart's

heart

time, and

other

had

been

but

Even
becomes

in

loud

other

or

who

years
last twelve
far

impulse, so

in

case

aortic

second

but

murmur,

pressure
arteries to

His

140.

to

some

the

one

systolicarterial

farmer

recall

had
he

drunk

had

been

the

as

fat

rather

the

freely,

chest

had

would
A

extended.

have

course,

was

fat and

his breath

months

and

beer

the

preceded

this

of his age, the interval of

facts in his historyI conjecturedthat a flabby heart

health

the

out

one

of

have
"

"

virtual tension,"
"

to

may

consider

of balance

with

each

"

virtual
been

have

if the

self-strained system

diligentheart impairs the

that ab initio

readjustment required,and

diastolic pressures

we

ultimatelya

parts get

tainty
cer-

full consideration

on

equal to
malady was
patient's
(The unrecorded
never

with

their

can

and

diffuse

phase

the

mitral

appreciateit, was
of
period
high pressure might, of

neutral

the

was

existed

130

as

For

and

man,

cannot
at

cases

worse.

the

to

me

latent

dates,
He

no

and

uneven,

various

The

dilated

large eater.

pursy
short.

allow

on

was

have

his visit

normal.

were
was

51, had
was

registered,at
touch

the

may

from

beginning.
arteries themselves
might escape
but in all other respects the diagnosis

injury,it is true ;
prognosiswould be far

mechanical

which

such

thus

may

maintained,

catch

to

conditions

these

Under

pressures

be

fail to

or

it is hard

say

and

emergency,

piesis.
hyper-

raised

cardio-arterial

; if the

ing
reciprocat-

other ; if in time

resilience of the

?)

elastic

the

spring upon

42

OF

PHYSICS

which

it operates, and

springis

the

system.

tend

oscillate

"

ease."

at

as

I think

who

of fibres

round

without

slender

crossinga

on

of

such

his

and
"

shown,

arterial tree.
coronaries

be

may
If

the

themselves

the

in the

may

slow

enough,

rigid,or

turn

be

change
grow

shows
have

as

decaying

the

even

to

large

heart

of

limb

soundest

disciples,

arterio-cardio-

common

pathy." Hearts decay, as all organs decay ; but,

the
we
are
now
considering,
majority of the cases
little independence of arterial disease
and,
no
often

tant
impor-

as

Cardiosclerosis,

under

do M. Huchard

the arterial tree in

it and

of step, and

out

so

troops

reason

impulse is

of

As I shall show

mass.

like

to do

the

distributes

axis

For

balance

better of the heart than

involve

ideal

ordered

machine

the

periods.

bridge are

In such

balance

elastic

throughout the cardiowould

these fibres straightthe machine
Were
in one
two
or
only of its axial
periodically
unequally.
phases would strain the machine

planes,and such
But
a
spiralmovement
stresses, almost

PART

it is itself operated. The

spiralarrangement

arterial
to

which

by

CIKCULATION

THE

very

silt

coral, or

incapable muscle
nourished
from some
hidden source,
bravely
yet be fighting
may
aortic
of driving through a narrow
along, still capable even
orifice the slenderest of streams
at a velocityhigh enough to
maintain
old man
at the chimney corner.
an
or
woman
of cardiac originis often attributed
Fall of blood pressure
to
faultyproportionsof extrinsic constituents such as the potash or

up

at

their mouths,

lime salts ;

within

or

while

the heart, with

no

of choline-like bodies which

but

lower

pressures ;

fallingpressures, except in contrast

pertainto my subject. In respect of the

with

of the arterial,
we

risingand falling
phases,

have

to

deal, in both

increments,

cardiac

function

do

not

also,as

with

highlycomplex, indeterminate, and often erratic variables ;

of the five qualities
of the heart
excitability,
tonicity,
any one
conductivity,
contractility,
rhythm may vary alone,or in mutable
"

"

combination

with

the rest.

Professor
certain
and

experiments on

lime.

To

quickly than

cut

off

Contraction

the

dynamic

calcium

Journ.

results of

salts reduces

Hemmeter,

illustrated the relation of vagus

E.g. Mines,

conduction

vary

dependent
in-

Mines, in his interesting

papers,1reports

conduction.

and

changes

contraction

of Johns

inhibition to the

in

lipoids
more

Hopkins, has
inorganicsalts of

of Physiol. vol. xlvi., 1913.

PHYSICS

44

best

unit

in

outputs

OF

THE

time

and

fall of

febrile infections
than

the
the

and

dilatation

of the

of the current

may

other

if there

hand,

arterial
systolic
pulse in most

first instance

less to

are

pressures

output adequate and

accelerated

in the

is due

PART

blood

best

raise

may,

with

pressures

the

On

ordinary pulse rates.

sufficient peripheraltone,
a higher pulse rate
will,or
at

The

CIRCULATION

be

equal,

pressure.

of
the

the

heart

peripheralvessels,presumably busy
in meeting the excessive tissue and immunity operations.
When
with the ordinarysphygmometer we
the fingerto
use
ascertain the phases of pressure,
take either the arrest
we
may
the return
of the wave
or
as
our
guide ; the opening (return),
It is probably more
which
is slightly
lower, is generallyused.
accurate, but in any case we should observe uniformityof practice.
The
of arrest
about
3 mm.
at
wave
runs
higher, but the
to

volume
not

correspondswith
double

of the

that arrest

assume

inconsiderable.

be not

It is said that

artery suddenly collapsesunder

the

of

this,and it does

has

arm

; this may

been

inflated

not

to

of the

arrest

on

this pressure,
seem

must

we

the radial

fingeron

closure of the brachial stream

the pressure.

evidence

to the

wave
pulse-

For

but

probable.

the obliteration

of

require
have

we

After
the

the

wave

cuff

no
on

pulse-wave

finger. This is no
of Koranyi's clinic
Tatsache," as a member
calls it,1 but an
illustration of a hydrostaticlaw.
The
pulseis
before
the
the
is stopped, or
stream
wave
damped
pressure
much
reduced ; and
of course, caeleris paribus, diminution
of
calibre goes for little. However, I take this point here because
Gartner's
"

still shows

gauge
iiberraschende

the writer had

in

got hold of

the
efficiency

less and

colour

in

useful notion

difference between

the

"

that

the two

as

the heart fails

obliterations

be

may

less ; and

in a responsivecase,
by the use of digitalis,
the difference might increase daily,even
up to the normal.
Blood Mass.
It is so well known
to physiologists
that, within
the total mass
limits which concern
the clinical physician,
of the
"

blood
were

has
it not

blood
not
vera,

have
p.

direct

no

or

continuous

that many
mass

dwelt

255).
1

authors

among

the

relation to blood

in
persist

of consideration
causes

pressures

of pressure

that,

ating
enumer-

variation,I need

Plethora
this factor (vide e.g. section on
upon
in
The heart's work, the systolesbeing uniform

See

Deutsche

med.

Wochemchr.,

June

2, 1910.

CHAP,

BLOOD

ii

MASS

time, is a function, not

"

that

is, of the

CAPILLAEY

AREA

of the total blood

the

lifted,and

mass

mass,

45

but of the output

peripheralresistance.

the abdomen,
physical effort, which usually also compresses
few
increase the output by 50 per
or
a
deep inspirations,
may
without
cent
The
blood
alteringthe blood pressure.
sure
presin the horse does not differ very
widely from that in the
rabbit,yet the heart of the horse, throwing a vastlylargerquantity
of blood
certain

into the circulation,does

of

cases

bulky watery blood,

be doubled

may

than

more

or

work.

vastly more

the resistance

If,as in

falls,the

doubled, without

put
out-

rise of

any

the heart is doing more

work, but
again of course
in these cases
the pressure
in the coronaries is
as
unfortunately,
it is not fed in due proportion,
either by pressure
not rising,
or
by
of
blood.
It
from
the
increased
seems
quality
probable,
pressures
seen
temporarilyin a few cases of plethora,and of normal pressure
in others, that while the heart readilyadapts itself to a larger
of blood the vessels are slower than the heart in doing this.
mass
Thus at the beginningof strong exercise the heart seems
at once
to supply the energy
and
capacity needed, but two or three
minutes, accordingto the trainingof the individual,may
elapse
before the periphery opens
wind
out
second
("
"). Again, if
fluids of a little higher or a little lower viscositybe injected
into an
animal, although the heart quickly adapts itself,the
systemicpressures temporarilyrise,with fall of arteriolar velocity.
The capacity of rapid readaptationto variations in blood mass
; here

pressure

suggests that such

is used

to

fluctuations

are

and

common,

that the

them.

Obliteration

of CapillaryFields. Balfour regarded the

obliteration of peripheralvascular
with
areas,

of

the

"

tissues,as
in

pressures

very

or
Involutionary

is no

remarkable

pressure
error,

to

in the

or

considerable
This

most

part

Decrescent

in the
"

senile

subjectsof

of vascular

But

surelyto

areas

is but

it to increase
guise,of attributing

mended
com-

tracts

is

Granular

yet in whom
"

Senile

Arteriosclerosis,in

rise of pressures.

ing
shrink-

hypothesis never

not

are

sclerotic
athero-

ing
increas-

of

cause

subjectsof Hyperpiesiaor

high, but

obliteration

in another

chief

for this senile obliteration of vascular

notable,not
especially
Kidney, who for the
rule

elderlypersons.

itselfto me,

pressures

system

whom

"

my

"

there

attribute rise of
the

well-worn

of blood

mass

46

PHYSICS

small

forgottenthat

often
a

whole,

but

system there

In

of blood.

old

see

and

in them

the

of

blood

contraction

cardiac

probably reduced.
jugular pulsation is rare
the opinion that in old age
And

reduced.
the blood

body

mass

in all

this

now
alternately

serve

observe

that
bulk

and

side,

venous

velocity
that

which

supports

of the

blood

in nature's
to

as

we

ones,

observes

volume

but
activity,

area

quantity

stream

persons,

total

simultaneous

and

and

as

vascular

any

the

Mackenzie

normally of such

is not

in universal

the

we

men

old

system

chillyyoung

towards

Dr.

in

almost

stricted
re-

blood, it is

the whole

in

volume

Moreover

are

to

in certain

and

men,

of

system

hypothesis of

the vascular

are

inclination

an

may

the vascular

total volume

not
discussing
the arterial tree only ; now
is room
enough to accommodate
we

PART

Balfour's

of increased

in that

as

In

its content.

for

area,

CIRCULATION

THE

propositions
being that

of both

the argument
is too

OF

economy

the whole

keep
is only sufficient

that, in obedience

now

is

to

much
periodicactivities ; moreover,
less
of the blood, if not the same
or
parcelsof it,may he more
continuallyoutside the working circulation,as in the abdominal
Huchard's
Therefore
and other reservoirs.
opinion that blood
factor in persistently
was
a
mass
augmented arterial pressure
for senile arteriosclerosis.
be admitted
cannot
even
Output may
and

partialdeterminations

be

doubled

without

rise in

any

foreignauthor, describingrises
effect of
"

this

are

an

arteriosclerosis,
goes

atresia
capillary
aggravationof

defaults

is related

the decrescent

to

renal

and

the
the

and
series,

pressure.

Yet

of pressure,

and

to

that

on

say

atrophy

high pressures.
high pressure

neither of them

"

able

its cumulative
the

results

of

(not Bright'sdisease)
But

recent

they

neither
both

of these

belong

to

raises arterial pressures

perceptibly(videremarks on Arteriosclerotic Kidney, p. 334).

Resistance.
It remains for us now
to
The Heart and Peripheral
of vascular
consider the effect of increasingresistance,whether
"

tonus

or

of

other

friction ; for, if the

heart

is thwarted

in

the bodilyfunctions must

velocity,
perhaps the first to speak of the
begin to flag. Senac was
arterial heart," and Ludwig the first experimenterto show the
circulation,of which resistance is but
importance of the peripheral
one
Empire the centre
aspect. As in the historyof the Roman
The higher
the circumference.
had at times to be sought on

its efforts to maintain

due

"

"

CHAP,

pressure

RESISTANCE

PERIPHERAL

ii

mainly due

is, of

resistance

One

is

pulmonary

function
of

of normal
little

use

peripheryis relaxingwidely ;
the other hand
peripheralconstriction in a limb only,say in
on
one
leg,would have little effect on the systemicblood pressure ;
if constriction of the splanchnicsystem,
indeed
it is doubtful
without
some
plus tone elsewhere, would suffice to keep up the
normal
systemic pressure.
As resistance increases the need for intra-ventricular capacity
to force

cardiac

up

in

valvular

in

volume

energy

with

comparable

healthy

the

disease, when
Thus,

life.

the

for

likewise,and

increase

must

when

the

stability. It is

increase

to

course,

of

that

resistance.
peripheral

this

to

above

aortic system

of the

47

heart

the

functional

than

fluctuations

undergoes

resistance

as

increase

permanent

more

tides

of

day
every-

increases, higher and

quantitiesof cardiac function are established,

higher mean
in aortic stenosis ;
as
grade over grade. The systolelengthens,1
individual fibre takes longerto reach its degree of relative
every
the
this
But
abbreviation, and
optimum load is altered.
of
stressingof the systole,and increasingcontraction volume
the left ventricle,cannot
compete with a steady rise of resistance ;
output will diminish

soon

very

ventricle; and,

le

The

jtablished.
ms

be

favourable

under

each

at

blood

conditions

blood

contrary factors be

readjustment

(ifit have

suction

the

some

in the

abate.

lag

over-exertion
are
1

met
Vide

the value
will

out

moderate
;

chain

of

as

heart,

the

disease,

stores

Luderitz, Zeitschr. f. klin. Med.

approximate

fall,ventricular

coronary

circulation

is of graver
or

of the
Bd.

xx.

in

import than
of bodily
stress

which, within

accommodations

ordinary

even

assignedto it)will slacken,

exchanges are thus
oxygen

events

valvular

; if the

system be fretted,

will

pressures

commonly
of the

temporary

of the

favourable

work, then

at

fill,
and,

substance

Such
in

short

come

system

venous

reduced
will

will

dimen-

defended
perhaps at the unstill lag behind ; yet,
may
output and velocitygrows

equal pulse rates, the quotientof

If the conditions are
not
largerthan normal.
ifthe nervous
blood be infected or impoverished,
if other

in

do, become

in all structural

not

may

at

or

accumulate

contraction, as

residual

some

residual

extraordinarystress,hypertrophy

readjustment

complete ;
space,

this

to meet

id dilatation must, and

and

heart.

S. 374

and

limits,

Contrariwise
other

authors.

48

PHYSICS

it is said,on

some

atony

cause

may

CIRCULATION

PART

clinical evidence, that within

hypertrophy of

the arteries rilled.

instance

THE

OF

Still we

the heart

do not

know

limits

peripheral
by its labour to keep

all the conditions

for

the

possiblevascular call for adrenin.

much
to be said,
so
Viscosity.Under this head there was
which is not common
knowledge, that this section grew into the
chapter which follows (videp. 104).
in Physiology. From
Laws
what
has
Validityof Mechanical
the physicalarguaccurate
ment,
gone before we perceivethat, however
in these problems there is more
than a physicalquality.
shall see, in the chapter on
that in the neuroWe
Viscosity,
be subjectto interferences
vascular system Poiseuille's law may
"

"

so

for

and

many

so

considerable
the

livingstructures

as

to

lose its abstract

mathematical

laws

values

of

or

elasticity
may
than a subordinate
have more
not
validity.1Inconstancy of the
be a largefactor in the regulationof speed ;
bed of an area
must
diminish
the channel
to
abstractedly,
by one-half is to reduce
speed sixteen times ; but the critical velocity the relation of
be so intricated with other conditions
to diameter
viscosity
may
difficult to disentangleand to value.
to be very
it
as
Poiseuille,
is true, did experiment upon
livinganimals,2 and concluded that
his law held good for the circulation of the blood ; that of the four
factors
tested
viscosity(?;),
pressure (p),radius (r),length (1),
constant
by varying any one while the other three were
pressure
varied directlyas the fourth power
of the radius, and inversely
cannot
as
length and viscosity. Still,in life,we
analyse a
of exclusion.
Even
compound effect by the method
physically
aids
for
law
the
us
so
scarcely
complex a system of tubes of very
various diameter
; or it holds only for vessels of the calibre where
and
the arteriole passes into the capillary,
where
velocitymay
be directly
And, so far,all attempts to calculate the
as
pressure.
dependence of current on p and rj have failed. In a glasstube
effect on
to alter 77, the others being constant, has a consistent
other factor is at
velocity,but in the artery it is not so ; some
section.
work, in part the inconstancyof cross
(See also p. 38.)
Moreover, the length is not constant
; as well as a diametrical,
there is a longitudinal
tone, the loss of which is plainlyto be noted,
"

"

"

"

Volkmann,

Preface.
Hdmodynamik,
p. 53, and
my
la force du cceur, Paris, 1828.
sur

See

Poiseuille,Recherches

CHAP,

MECHANICS

ii

that
varied

relation

the

with

the

49

of neurasthenics.

for instance, in the aorta

moreover

PHYSIOLOGY

IN

between
We

area.

Volkmann

can

no

universallythe simple physical formula

inverse proportion to the
of the
square

velocity and
sure
presthen
assume
longer
that velocity is in
diameter

central

controls,secretory and hormonic

tensions, the effects of
form,
calcium, barium, or potassiumsalts,or chloroas
ingredients

nervous

such

be

may

diameter,
blood

of

and

than

of more,

often

or

importance than

perceivethat livingvessels

we

dead

much,

as

in any

Indeed

ones.

shown,1velocitymust

has

found

may

more

pass

elastic vessels,as

Hiirthle

fall more

rapidlyas pressures decline,

for instance in a
as
pulse."
vagus
Vasomotor
System. Thus, as regards the elastic tissues,to
which physicalprinciples
these in the
simplicity,
apply with more
and
livingbody are in co-operationwith muscular
irritability
Tension
of wall is no longer,
in passively
nervous
as
government.
distensible tubes, directly
proportionateto a pulsatinginternal
fluid pressure ; there
is a large,if unmeasured,
factor
of
"

"

resistance

tension

to

surroundingparts and over

to be taken
by no means
radial

arteries

variable ; but
And

half-turn

of

but

supplied;
of events

;
or

an

an

the

is not

choke

sets

or

up,

areas,

and

accommodation

pressures

resistance

In

content

which

in

narrow,

be

placeat

of the

cuff

or

others

the

same.

throttle valve.

aroused

area

of lateral

up, another

set

be

the

series

in

bouring
neigh-

by anastomosis

for

animal,

an

may

is

patientsthe

some

may

mere

may

active vasodilatation

artery of

variable

in

pressures

stopcock directlylowers pressures in

when
the pipe is an artery the increase

dilatation is said to take

into

the

on

pressure

correlated

due

uniform.2

constriction

above

pressure

than

the

large areas,
as

and

tone

habituallylarge,in others

are

vasomotor

of

variations

in

the

blood

more
compass
arrested.
Such

the site of insertion of

even

in the brachial

cannula

artery under

(Mac William).

u.
Hiirthle, Druck
Geschwindigkeit,"PflugersArch., 1912, and Berl kl.
He
used optical records
Woch., April 22, 1912.
of the stromuhr
and a very
number.
lightmanometer
lever, as described in a previous article in the same
He gives diagrams of the methods.
2
Some
on
interestingremarks
reciprocatingand independent, or discordant,

vascular

"

areas,

article

with

their

by Miiller,Arch.
Weber, ibid.,1906.
VOL.

hydrodynamic coefficients, are

f. anat. et physiol.,1904 ; and,

to
as

be
to

found
the

in

an

brain, by

PHYSICS

50

CIRCULATION

Bayliss,1in arguing

Professor
when

THE

OF

cleared

of

that

matter, tend

nervous

PART

arteries,even

muscular
constrict

to

as

pressures
section
a

also that such

they fall,showed
be independent of any
of tone
nervous
arc, or of balance
may
be simply
between
sympathetic and autonomic
systems ; it may
myogenic," the sudden stretch of an artery by a rise of pressure
being of itself an after-spasmof the unstriped muscle, which
this excitability
that by muscle alone the
to possess
seems
; so
normal
vessels may
tone,2 and may
a
respond to local
preserve

rise,and

to

relax

as

"

anaemias

cachsemias.

or

remains

tone

fibres

in

about

or

divided

are

It

some

the walls of arteries after

cardiac

and

certain that

seems

influence

removed

local vascular

post-ganglionic
for after

to heat or cold,or
temporary drop the tone, in response
before.
This is true
as
irritants,3returns
pretty much

after

splanchnicarea

the
I say

"

in

or

"

about

in the walls is a very

the

problem.

factor

or

another

end

of

even

more

centres

than

be
depressornerve
excited of course
a fall of blood
ensues
; but if strychnine
pressure
rise
to the animal
the same
be administered
a
experiment causes
of pressure.
And, conversely,
by strychninethe rise of pressure
which
normally follows the stimulation of a sensory nerve
may
into a vasodilatation.
Chloroform
be converted
has an opposite
action in these respects ; so that we
how
see
complex are the
have
with which
conditions
to deal, and
how
we
secretlyone
intercurrent

the central

he showed

But

certain

connections.

nervous

walls,as the existence of minute

obscure

this ; if in the rabbit

of all

severance

may

of the

drive

system of functions

to be
opposition. And active vasodilatation is of course
from passive (atony), especially
in the splanchnic
distinguished
and in the opening out of vascular areas
in corresponding
area,
stimulation
of motor
muscles
on
nerves
(Gaskelland others).

into

familiar

with

We

are

but

if the vessels of

nerve

they return

such

an

to the

area

series of events
be dilated

normal,

or

in

embolism

by section of
very nearly,in a

also ;

vasomotor

few

days.

Bayliss,Physiol.Congress,Wiesbaden, 1907.
these
MacWilliam
After
and
Kesson's
printed 1 saw
paragraphs were
important paper on the dilatingeffect of repeated recompressions of an artery
in Journ.
Anrep's paper
Physiol.,January 1913, in which
(see p. 75) ; and von
reaction
local
of
the
arteries
he attributes
to a gush of adrenin
from
Bayliss's
local
thinks
reaction
has
be
a
its glands,and
proved.
yet to
8
1887.
See Heger, Ludwig's Festschrift,
1

52

PHYSICS

OF

THE

CIRCULATION

improbable,neurovascular

reagents

tissues

tissues

or

not

may

affinities,
govern
How

; the

the molecular

PART

be

acceptable to the
themselves, by their specific
may

attachments

and

transits.

far in arteriosclerosis all these

propertiesand coefficients
It is currentlysaid
are
abated, or reinforced, is unknown.
that in this state the carotid-radial interval is prolonged,but is
stream
wave
or
velocityintended ? We know that in a thickened,
or in a tightly
distended,artery wave
velocityshould be increased,
but stream
velocitymight be reduced (p.33).
In

order

ascertain

only but also the

tried to record the splanchnicwaves
inward, Weber
by inserting
inflatable bladders into the rectum
or
vagina. He found that by
this method
due to diaphragmaticrespiration
could easily
waves
be distinguished.Briefly,
Weber
found that in normal
subjects
the abdominal
varied inverselyas those of the arm,
curves
so
far an interesting
verification of theory ; thus a normal
plethyscurve
mographic arm
might signifya normal splanchnictonus.
Klemperer further proposed to diagnose splanchnic sclerosis,
not
only by the flatter curve, but also by the deviation from
a

uniform
In

to

alternation

chronic
more

of

spasm

course

we

the

from

pass

continent

reactions

arm.

the

to mass,

influence

an

with

Bright'sdisease,when
than the splanchnicarea

adaptationof
Thus,

surface

not

vascular

is concerned.
function
to

away

of other

constriction

and

of

In vascular

tone, the

mean

normal

or

often remote

is perennial,

abnormal

distribution,
re-

correlations.

between
distinguish
positiveand negative
vasoconstriction, between
an
adaptation of the vascular system
to imperfectlyfilled vessels,and
an
insurrection,of whatever
Is
origin,
againsta good heart and a normal blood distribution.
it not then
better to keep the word
tonus
accuratelyfor the
automatic
term
adaptation,and to discard the German
hypertonus
due to toxic or
altogether
; for arterial constriction,
other
extraordinarycauses, is scarcely tone," but rather a

repeat, we

must

"

"

"

morbid

spasm
There
is

muscle

be

is

in the

no

evidence,

as

have

said, that the

arterial

readilysubjectto fatigue; dermatographic lines

obtainable
has

in articulo

for its function

mortis.

As

the maintenance

largearteries,fatiguein

the

of the blood

the vessels would

may

ism
mechan-

vasomotor

be

pressures

perilous:

CHAP,

VASOMOTOR

ii

the vasomotor

centres

COEFFICIENTS

may

coefficients stillmore
venture

(see

so

well-known
Sherrington's
muscle.

exhaustible,and

to
application

some

upon

be

476).

p.

the

their

But

bral
highercereperhaps
may

of Professor

unstripedfibre

observations

of

the tonus

on

voluntary

"

arterial muscle

The

53

common
a
scarcelybe called
there
is little competition for it ; its
path," it is true, because
is quite, or almost, singlein kind and
stimulus
origin; but
nevertheless
common
Sherrington'sprincipleof the
path
being always held in possessionas tonus, the resultant of
all peripheralimpressions,positiveand
not
negative, seems
I repeat that
inapplicable. And
apply
presumably we
may
can

"

"

with

still

principlethat
if in our
fatigue,
of the

reflex.

"

the

common

case

any,

path

lowlier
does

not

lies in the afferent

chief seat

The

this

to

assurance

more

the

agency

tire," and
factor

in

"

farther
that

the

waning

of

fatigueis said to be at synapses

fails. But here again
where, in extraordinaryactivity,
oxygen
in our
continues
the muscle
to
simple and lowly mechanism
if blindly,to internal pressures,
whether
the
respond directly,1
wider and more
central reflexes and inhibitions be waning or not.
be compared
Fatigue of a muscle, or other animal fibre,cannot
with
it means
molecular
fatigue of a metal ; in this case
"

"

dislocation, in that

(within limits, of course) only a temporary

The
limits of tone
however
in
abeyance.
vary,

functional
unknown

degrees,with

molecular

dislocation

is

age, and

no

in full vigour of life a stream

maintains

tension

curve

curve

in

lying well

steady
within

from
concert

the

old

tissues

If I may

quote

in

graduallyestablished.

myself,2
"

doubt

the

all

centres

nervous

with

the

other

elastic limits

of

efficients,
co-

the

tissue."
particular
How
functions upon
cerebral
largelydependent are vasomotor
is illustrated in an interesting
of Illinois
article by Bonser
causes
made
a
University.3 Bonser
long series of experiments upon
twelve students of his university. Amongst his observations
it
is pertinenthere to say only that intellectual fatiguewas
panied
accomto emotional
by diminished vasomotor
changes ;
response

Bayliss, Journ.

of Physiol., 1902,

and

other

papers.

But

see

note

p. 51.
2

Allbutt, C., Proc. It. Med. Soc. vol. i. sect. 2, p. 209.

Bonser, Psycholog. Rev., March
1903, quoted Lancet, April 13, 1903.

2,

54

PHYSICS

and

from

recovery

OF

them

CIRCULATION

THE

(as in the dermatography of

slower

was

PART

blood
meningitis).But the psychic influences on
pressures,
and how
by disease of the vessels these normal reactions may be
modified and prevented,I have yet to consider (p.68).
The

vasomotor

cortex,

with

be connected

or

in the
re-represented

be

must

system

it.

In the upper

cerebral
centres

vasomotor

represented,severallyand together; so
issue now
that a general stimulant, or depressant,may
upon
the
this area, now
that
the
cutaneous,
splanchnic,or
e.g.
upon
and so on
before others, and the splanchnicmechanism
being,
suffer fatigue,as
in upright man,
of recent
organisation,
may
I remember
ing
observneurasthenics.
perhaps is the case in some
with Roy that in dogs it was
comparativelydifficult to produce
accidents
chloroform
shock
in
them
are
splanchnic
; and
all districts must

be

"

"

The
the

; I cannot

rare

very

remarkable

circulation

pressure

Of

recollect any

and,

to

it is true

that

the

capacity of
blood
of viscosity
on
Viscosity.

effects

in the section

capillarydynamics

effectual

it appears,

as

counteract

I shall consider

incident.

such

we

have

on

but

little

knowledge, yet

If,
longest circulation time.
Broadbent
to
wont
as
was
argue, peripheralresistance lay in
this field,
it could scarcelybe on hydraulicprinciples
; indeed he
himself attributed it to some
of tissue exchanges.
or sluggishness
clogging,
Of the immense
but stillobscure operations
of physical
coefficients in this peripheralfield coefficients such as osmosis,
forth
I make
diffusion, surface tension, absorption,and so
tentative appreciations
in the section on Viscosity. The
some
which these energies dialysis,
for example
enormous
pressures
reduce even
can
gravity to a negligible
bring into play may
of measuring capillary
quantity! We have no exact method
here

lies the

"

"

"

pressure, we
vessels and

can

but

guess

at

take
that

systematic estimate
method.

He

glycerineor
become
and

visible.

pressures

of the

in afferent

intermediate

capillarypressures

area.

by

are

and

efferent

The

most

Lombard's

with
skin,say the thin skin of the finger,

transparent oil,so that under

fluctuations

found

the

smears
a

of

the pressure

"

The

circulation

under

pressures

is

now

recorded

in the small arteries 60-70

lens the fine vessels

arrested

intermittently,
He
by opticalmeans.
mm.

; in small

surface

CAPILLAKY

CHAP,

ii

veins

15-20

and

mm.,

the

DYNAMICS

55

40

mean
capillary

These

mm.

figures

high. Von Kries estimated the blood pressure in the

at ^-f of the aortic pressure
Hg.),and his
(20-38 mm.
capillaries
estimate, though it seems
accepted.
high,has been provisionally
of the larger
This estimate is probably taken from the pressure
rise farther
it would
and
as
they enlarged into
capillaries,
the mean
Others
fine arterioles.
(on the finger)have made
In
the smallest
capillaries
capillarypressure only 7 mm.
beyond the arterioles the pressure, peripheralto their tone, can
than 10-20 mm.
depends
scarcelybe more
; but here again much
the
this local tone, the hydrodynamic cushion, and
upon
Dr. Harry Campbell x reminds
us
that, in an
generalpressure.
seem

too

area

remote

arterial pressures,

from

about

10

mm.

of pressure

network
of the liver. We
capillary
may
resistance as negligible
capillary
perhaps consider mere
; although
Roy and Brown
(loc.cit. p. 57), and Strieker
ago
many
years
that the capillaries
can
also, showed
contract, probably by the
to respond
cells of the walls, which
clasp the channel and seem
which
to the sympathetic nerves
Baylissand
; a demonstration
Langley have verified. The sizes of corpusclesin proportion
however
to
are
negligible
by no means
capillarydiameter
;
the current, and so reduce mean
stem
velocityin the
they must
2-0 or
0-5.
finest channels
to
1*0, or even
Presumably also
occur
some
delay must
during their emigrations.
such delaysin the finer vascular web,
If then we suppose
some
for vasodilatation
would
to rise
and thereupon pressures
ably
proband the blood stream
equalisethingsbut for the moment
thereby to be permanently retarded, the heart would work harder
to regain velocity; and
thus, at the cost of cardio- arterial
the less muscular
hypertrophy, and of a heavier stress upon
not
like, but
vessels, velocity might be regained. Such
Rosenbach's
the same,
was
hypothesis: that by the action
to

seems

suffice for the

"

"

of

the

some

toxin

tissues,and

irritation
more

blood

excessive

an
was

poured

metabolism
in ;

that

arose

thereby

in
the

in size,
increased, the left ventricle grew
systolicoutput was
and
secondarilythe rightheart also and the lungs (whence an
emphysema). This explanation is clearly out of place for
of which
is not
decrescent
the character
arteriosclerosis,
high
1

Campbell, H.,

Brit. Med.

Journ., Jan.

28, 1905,

PHYSICS

56

central

OF

CIRCULATION

THE

PART

but

peripheralatrophy ; as an explanationof
of its consequential
it might
so
arteriosclerosis,
emphysema is generallyfound, not with the

pressures

Hyperpiesia,and
be urged ; but
but with the decrescent disease, and is due in my
hyperpietic,
opinionto decay of the bronchial arteries.
Longitudinallyit is true that in detail the systemiccapillaries
traversed
and, at ordinaryvelocity,
measure
are
only about 5 mm.
in about half a second ; but if ingravescentcauses
of retardation
be found there,and superactiveconstriction in middle areas
does
is largeenough to
not
of the capillary
area
intervene,the sum
make
it a considerable factor in the peripheral
friction. It is also
that a considerable
time may
so
elapsebefore a change
roomy
of arterial pressure
is felt throughout the area, as for example
And
the applicationof a cuff.
it is true that to purge the
on
reduce
At
to
venous
high arterial pressures.
system seems
this point of view Dr. George Oliver's well-known
observations
into consideration
cannot
on
come
we
lymph pressures
; and
forgetthe marvellous ascent of sap to the tops of the tallest trees,
the resistance being overcome
not
by capillaryattraction only,
but also by cell dynamics. Leucocytic diapedesislies nearly
altogetherin the capillaryarea, and is favoured
by dilatation,
with
blood afflux and access
and by warmth
of oxygen,
; and
rises of pressure
in the capillaries
dispose to unloading by
exudation.
Volkmann
argued that in secretion and excretion
constituents of the blood flowed at various rates through hypothetical
the blood stream
stomata, so that in active areas
might
and velocity
be accelerated by a sort of aspiration,
thus increased
behind, while
Sir James

in

of rest

areas

Barr,

Dr.

Haig,

capillary
problems,and

at

the

does

current, but

depend

pressures

indeed

to

; but

in

Barr

the

the

and

rate

others

would

have

be retarded.

worked

at

these

the effect of lime and

not

favour

the

other salts upon

opinion that high

is tempted
One
capillaryobstruction.
that a reduction
of protoplasmic activity

upon

suppose

might permit

the stream

blood

rarityof

to

traverse

atheroma

in the

its

area

with

less occupation

pulmonary vessels,except

equivalent states, suggests that, in this

less efficacious in
cycle at any rate, tissue activityis infinitely
forwardingthe blood than cardiac propulsion. Again unquestionably
the nitrites,as
vasodilators, do, by reducing resistance,
mitral

stenosis

or

CHAP,

CAPILLARY

ii

favour
the

blood

nitrites do

The
to

the

blanch

field

the

the

directlyinfluence
of it ; this

constriction

is wide

57

lower

of vasoconstriction, as

area

reflux

and

current

not

first effect

DYNAMICS

the
we

pressure,

yet

capillaryactivities.
see

may

in

fear, is

small
relatively
a
enough to cause
persistent

holds
and

arterial

until in

and

plethora,and with this rise of venous

pressure
the capillaries
fillreadilyenough, so long, that is,as the
see
we
If vasoconstriction
generalarterial pressure is constant.
persist
that the capacityof the system is diminished,
over
a largearea
so
venous

pressures

would

rise also

condition

all the

on

the

side ; and in this arteriolar

venous

side.
the venous
are
on
correspondingcapillaries
As to allegedcapillary
reflexes,the observations made, save
of the plethysmographic,seem
worthless : the
perhaps some
other local conditions ; on
must
depend also on many
responses
cold and warmth, on
on
phases of vasomotor
viscosity
position,
of the blood, on
metabolic
activityin the area, and so forth.
Here
lie some
of the disadvantagesof gauges
the principle
on
of Gartner, and of the time records of blanchingafter the pressure
of a pad or button.
If the capillaries
contractile l (p.55)
are
the movement,
so
long as the vessels are sound and the blood
in the frog'scapillaries
healthy, is negligible.The flickering
in the arteriolar tone
is due to waves
being slower,
; the stream
individual
be watched
better
and the currents
corpusclescan
perceived.
Venous
is negligible,
laterals
in the portalsystem ; and coltonus
even
too abundant
to permit of local constrictive anaemias.
are

Instruments.

Before

proceeding to the clinical features

of the circulation,I must
something of the mechanical
say
of registering
the phases of arterial pressures.
Until
means
introduced
in 1887, my
Basch
sphygmometer was
by von
work

wn

of

"

and

"

others

"

in respect of
done

was

another

blood

pressures,

kind
1

See

we

of instrument
Roy

and

the

same

is true

of

entirelywith

cardiograph. Invaluable as
"graph in revealingthe form
after many
attempts to adapt
of

I believe

man

Brown,

had

Marey's sphygmograph
the records of the sphyg-

were

rhythm

and

it to
to

would
Journ.

even

of

the

pulse, yet,

approximate

ing
record-

this purpose
be required; and about this
admit

that

for

Physiol. vol. ii. p.

32.

PRESSURE

58

GAUGES

PART

time

Ludwig's epoch-making kymographic apparatus

fields of
methods
and
researches
were
opening out new
of

and

record.

However,

who

one

no

has

used

and
covery
disthe

sphygmograph carefullyand habitually will have failed to

and instruction it can
recognisethe value of the information
with the instrument, such
of the earlier workers
give. Some
I mention
few
a
Sanderson, Mahomed,
as
Riegel,Galabin, Roy
into my mind
as
publishedexcellent
names
they happen to come
French
and papers, especially
curves
; then unfortunatelybooks
furnished with tracings,
and English,which had some
vogue, were
of them
some
hackneyed cliches,not a few of which
new,
many
showed
unskilful merely as tracings
more
a want
were
; while many
of the sphygmograph
of the limits and capacities
of appreciation
itself. Too often the observer had taken pains to read into its
records what the instrument
was
incapableof describing; or had
features due only to its mishandling,
as
physiological,
interpreted
"

"

its defaults,or

I will venture

its inertia.

to

repeat with

some

breviatio
ab-

than
by myself more
l
of the publishedsphygmograms.
twenty years ago
many
upon
without
the realityof precision
is a dangerous
The semblance
led to write up
to many
are
tracings
temptation. Thus we
tions
which are either bad in themselves, or deformed
by inertia vibraThere is no such thing
or
shortcomingsin the instrument.
the normal
as
pulsetracing ; a good tracingimpliesnot only
sensitive make
of instrument, but also a sensitive manipulator.
a
strument
Many an amorphous tracingbetrays to the reader that the ina

paragraph from

review

written

"

'

'

had

followed

not

the artery ;

some

of its finer

waves

ment
beyond the capacityof the instrument used, or of any instrutreated to
are
; or againbeyond the user's dexterity. So we
when under
of comparativelystructureless bumps, especially
rows
shift or reflex stimulus the pulsehad receded from the pad,
some
or
re-engagedwith it ; so unsteady is the personalequation in
In applying the sphygmograph we
with
meet
these researches.
and inequalities
four main difficulties : the quantities,
properties,
of the limb containingthe artery ; the unequal
of the structures
and unstable
applicationof the pad along the vessel ; the lie
the whole underlying wrist ;
of the instrument
and pressure
on

were

the calibre of the artery.

1

For instance, anacrotic

Brit. Med.

Journ., Dec.

31, 1892.

waves

are

often

PEESSURE

60

of

the

pad

or

fall.1 The

in

no

with

the

on

GAUGES

Thus

artery.

amplitude of

the

direct ratio either with

the

heightof

only ratio
which

are

Dr.

is to

artery under

has

shown

in

rise

systole,or

observation

; the

of pressure,

arterial walls.

of the

(Marey) is

wave

local vacillations

magnitude of
inverselyas the tension

will

notch

of blood

the volume

the

T. Lewis

dicrotic

the

sphygmographic

in the

pressure

PART

how, unless in each

over
More-

special
attention be directed to the conditions
of instrumental
tion,
adaptathe diastolic or statical phase of the curve
is liable,
especially
under low diastolic pressures, to suffer degreesof defalcation and
suppression,or on the other hand of exaggeration,far beyond
what
was
generallysuspected. Curves taken before and after
venesection,

before

or

amyl nitrite,well

and

after

case

administration

the

of

m.

of

illustrate this

and the delicacyof its

lability
conditions.
Dr. Lewis
that although the
finds, by the way,
comites affect a tracingonly when the venous
venae
are
pressures
fulness of the limb affects it by
excessively
high,yet the venous
interference
with the fallinglimb
of the curve.
Another
of
Lewis' many
the
observations
is upon
the effects on
interesting
of degreesof compression of the brachial artery, whereby,
curves
other things,he thinks
the important factor of blood
among
velocitymay be guessed at.
However, in the hands of James
Mackenzie, Lewis, Starling,
Bayliss,and others at home, and of Wenkebach, Engelmann,
and

others

of the

limitations
the

deserves
the

all of

abroad,

well

as

of

means

sphygmographic

Lewis,

with

those

been

of

of

capacitiesof

restored

research.

curves

well

expert observers

of the

as

has

sphygmograph
as

them

Any
Dr.

to

the

who

one

Mackenzie

the

aware

ment,
instru-

positionit

will compare
of Dr.
and

Riegel, but with

those of most
other authors
of twenty years ago, will perceive
the difference between
skilful handling and true comprehension
of the capacities,
and
accidents of the instrument,
incapacities
and the lack of these accomplishments. The observer must
not
to the work, but he should, if
only himself be well accustomed
1

These

not

conditions

and

were

recentlythey, or some
again by Dr. Hawthorne,
2

Practitioner,Feb.

Galabin, Roy,

pointed
of them,
Studies

1907, and

on

out

have

long
been

Clinical

Journal

or

by Roy in his admirable

way
adequately and lucidlydiscussed

ago

Med., 1912.

of Anat.

and

Phys.

vol. xli.

CHAP,

FINGER

THE

ii

the

always

use
possible,

61

instrument

same

thus

the

variations

be neutralised,may
patients,which cannot
allowed for. No littleadroitness is required
be half instinctively
to keep the instrument
steady and exactly on the artery. We
the sensitive fingerto lose perfectadjusthow
know
ment
apt is even
of the
the slightest
or rockingalters our
sense
side-slip
; how
wrists of the

in the

it may

pulse,even,
But

proceed

to

in

that

said

have

sphygmograph
methods

on

the measurement

back

namely

Basch

in 1876, another

much

information

of

to

the accumulated

us

So

as

Journal

rebuked

has

by
pauperiseour

pressures

the
all

"

old

at

those

acumen

and

help of von
By the finger

the

be

obtained, and

pulse brings home

fruitful method.

writer

the

British

for

in

attempting

means.

weaken

Thus,

to

says

clinical

estimate
the

acuity."

Medical
arterial

writer,
So

"

we

eminent

Professor

Lindsay also has chidden us

finger,"he has said, "is sufficient

"The

in the estimation

of blood

greeted the

for
for

pressure." But

invention

of

every

into clinical medicine.

precisionyet introduced
the jokesof old-fashioned physicians
enough to remember
faddists who
thought to make up for lack of clinical
and
experienceby the pretensionof the stethoscope;

little later
"

us

is to

on

the

and

leader

stillleast dispensable

made.

was

animals, we

of

instrument
am

arteries in

manometric

of this ancient

protests have

such

and

these

as

vanity1:
practical
purposes
same

opened

of Broadbent

and

senses

clinical observer

Ludwig's

as

qualitativekind

other

any

for

and

the finger,
until,with

values

that

is this

true

of

step forwards
a

that

such

beat.

the readiest,and
the first,

upon

ofpulsegauges,

work

only

evasive

an

I
arterial pressures
:
represent these pressures
by the

defeated

were

available

driven

were

to

seeking to

we

were

the loss of

be,

of the

thermometer.

Then

likewise

we

were

and impair your own

natural
pauperiseyour senses
short cuts to diagnosis?
enc
by the use of mechanical
is that instruments
of precision,
Th e truth however
far from
so
clinical perceptions,
of fever let us say, have
pauperisingour
them.
the contrary enriched, enlarged,and corrected
Let
on
of Leech
of Manchester
rather recall the wise foresight
who
me
said that
changes in arterial tension are not often so indicated
and
direction can
be
by clinical phenomena that their extent

asked,

Why

"

;lowments
"

Lindsay,

Brit. Med.

Journ., July 1, 1905.

GAUGES

PKESSUKE

62

PART

"

Gibson
said that
a
graphic methods."
long trainingof his fingerbeside the sphygmometer had taught
fallacious the fingermust
him how
Krehl, whose
always be."
will not be questioned,declares
judgment on such a matter
that in palpation of the pulse for pressure the best observers
cating
Dr. Byrom
often deceived.
Bramwell, while justlyvindiare
where
of the finger,points out
it fails
the function
us.1 Dr. Batty Shaw 2 says :
Continuously maintained
high
without

measured

"

pressure has not received

simply because our methods

blood

the clinical attention

it deserves,

measuring it have been quite

Mere
digitalexamination
inadequate and untrustworthy.
of the radial pulse will fail again and
again to show that the
Cook
and Briggs,of Johns Hopkins,
blood pressure is raised."
have
write that all physicians who
practisedsphygmometry
of the finger;that "in many
conditions
admit the deceptiveness
of the circulation the fingeris the most
deceptive and grossly
In illustration of his arguof all sphygmometers."
inaccurate
ment,
the
A
the
Dr. Cook
published
followingcase :
woman,
under
anaesthetic for operation when
an
subject of cancer, was
shock
for this reason
of
set in, and
the operation
symptoms
Dr. Cook
had been observing the blood
then abandoned.
was
shock
on
came
pressure throughout,and he noted that as the
the blood pressure jumped up to 160, and the heart dilated ;
but stillthe blood pressure rose, to 180 mm.Hg, and so continued
diffused and
while the cardiac impulse was
widely apparent
the
beyond the nipple. He asked himself indeed, whether
of sodium
nitrite might not paradoxicallyhave
administration
and
enabled
the operator to proceed ? As combeen beneficial,
pared
and

of

"

"

"

"

pressure gauge, he declared that in such

the pulse receives but a tardy and uncertain

with

fingeron
It

57,

but

was

other

the

largeeater,

that

day

consulted

"

me

"

dyspepsia," oppressionround
The

forth.

heart

was

the aortic second

was

soft.

astonished
1

sound

pulse seemed

The
to

not

was

find that

Bramwell,
2

warning.
of
big high-colouredman

for thick
the

heart

acid urine,"
after

much
too

accented, and

"

to

the

with

any

so
ear

the radial wall

sustained, it is true, but

not

gouty

meals," and

obviously enlarged nor

I could

B., "Address

Shaw,

the

cases

patiencemake

on
Medicine," Lancet, July 29, 1911.
B., Clin. Journ., March
27, 1907.

was

the

CHAP,

THE

ii

FINGER

63

200.
under
Now
these cases
of hypersystolicpressure much
if caught early,are
often quite curable, yet by the finger
piesia,
they are continuallyoverlooked, or misjudged, till the time for
ciation
is past. At the Toronto
cure
meeting of the British Medical Assohe frequentlyfound
said
himself
(1906) Dr. MThedran
in his estimate of the pulse,
when broughtto the test of the
in error
2
mine) Dr. 0. K. Williamson,1 and Hopke
sphygmometer (italics
of thoracic
also,comparing the two radial pulsesin certain cases
"

' '

found

aneurysm,

which

fingerhad

the
in

Indeed

that

than

more

the instrument

failed to detect, and

half

his

in
digitalexamination
misleading. Dr. Mackenzie,

of

an

instance

of

in

it,

"

revealed

differences

stillfailed to

of this kind

cases

this

the

says

often

appreciate.
(32 in number)

respect proved useless,if

remarks

some

This

on

variation

not

pulsusalternans,3
was
imperceptible

minded
tracingit became apparent. Hensen rein countingthe pulse,if we control the record
that even
us
of the fingerby that of the watch, we
have to make
a large
may
correction.
I have
with no
met
physician who has patiently
compared his ringer impressions with the indications of the
sphygmometer, who has not confessed that his fingerhad much

to the

to

finger,"
yet

learn

and

on

unlearn

to

the

of

even
fallibility

his

systolic pressure
For

that

and

;
most

erudite

only but
example,

diastolic
in

part of the

lesson

is the

touch, especiallyif
also

be

taken

into

not
sideration.
con-

experience the high blood

in the later stages of a prolonged constill maintained
dition
pressure
of hyperpiesia,
the heart is relatively
a
stage when
failing
Broadbent's
virtual tension
it
be to
perceptibleas
may
the
tactus
eruditus," is rarelyappreciated; yet by the manometer
the systolic
be proved to run
in these phases
pressure
may
The
is true of the cases
of mitral
as
same
high as 170 or 180.
disease in which, as demonstrated
by Dr. H. J. Starlingand Dr.
H. C. Mann, pressure,
in failingcompensation, is often
even
still high. And
full artery with
stiffish walls may
as
a
give
false
of
a
impression
high pressure, so in incipienthyperpiesia
my

"

"

"

"

"

substantial

rise of pressure,

artery still soft and

1

Mackenzie,

0.

Hopke,

to

180,

K., Lancet, Nov.

see

Jas., Brit. Med.

ref. p.

101

lurk

may

still quiet. For

heart

Williamson,
2

say

further

under

criticism

30, 1907.
n.

Journ., Oct. 20, 1906,

p.

an

1007.

64

PKESSUEE

of this kind

I may

may

Now

PART

refer to Sahli who, in his well-known

explainsclearlywhere
fail

GAUGES

and

how

the

fingeras

Lehrbuch,

pressure

gauge

us.

the

of this

fallacyof the fingeris not difficult to

perceive. The fingergivesus no oncographic information, it is
in largeslow pulses,
apt to take amplitude for pressure, especially
whereas
in high pressure
the arterial excursions
less. It
are
perceivesthe total stroke, not the pressure per square unit ; yet
radial may
be largeand dilated under low pressure,
under
a
or
be small (" feeble "). In cases
of plethora
very high pressure
may
vera
(see Vaquez' disease, p. 256) the choke-full radial gives a
of high pressure,
sense
usually false. Let the doubter put a
of a thin person,
aorta
or
finger upon the abdominal
upon
the

iliac artery, then

and

he

vessels
stated
at

reason

will find it hard

the pressure

while

the

"

an

low

when

pressures

Dr. W.

have

Russell

seemed

said,
heart

the

pressures

stage of
no

in the radial artery may

brachial,

"

atonic

in fact

remarks, of

goes

was

him

to

much

"

the
a

case

small

by

dilated, but

reach

the normal

scarcelyfeel the vessel at

and compressiblepulsemay
pressures
in which

record
small,that the systolic

pulse

the

upon

to

fingercan

that in fevers

very

radial, then

persuade himself that in all these

the pressures
It has been
are
practicallythe same.
by von
Frey, Hensen, and others again and again that

times

even

the

upon

the

and

of 170

simulate

of normal

the radial

and

values.

artery felt

"impossible"; the
feeble," for the finger,as I

size of

over

are

all ;

and

was

vessel.

over

It is true

again

I have

that
found

higher than this with dilated heart, as in the later

hyperpiesia(without contracted radial)
falling,
; pressures

doubt, but

artificial

not

balance

reduced

to

that normal

would

be

perilous. Accustomed

abscissa

which
as

for

so

I have

comparisons,I find that I cannot be sure of degrees

150 and
of systolic
180 ; howbeit
such
even
pressure between
little importance in diagnosis. When
be of no
differences may
in ambiguous cases
I test my
I consider
fingerby the instrument
the
it a good guess to come
by
fingerwithin 20 to 30 mm.
of the measured
either way
in any case
systolic
; and
pressure
at the more
idle.
important diastolic pressure even
guesses seem
I do my
of one
best to guess by keeping the fingers
hand upon
the
radial artery, while with the other I manipulate the brachial,
been

to these

CHAP,

FINGER

THE

ii

it so
compressingand releasing

fall,and duration
One
the

of

M.D.

our

pulses of

arteries

were

five

very

that, being

of the

man

notion

some

small,

"

was

trained

The

of the

rise,

waves.

occasion

patientsin dysentery in

sphygmometer, when
the systolic
pressures,
standard.

get

candidates, having had

normal

to

as

65

so

struck

in all five of
ringer

deceived

note

radial

their feebleness

with

his amazement

to

the

whom

scientific method,

on

to

he

procured

he discovered

that

them, ranged about

him

by

"

the

this confusion

with unit pressures, as if one

of total pressures
to mistake
were
the total steam
per
pressure of a large boiler for its pressure
inch
of
be
in
boilers
which,
a pressure
equal
course,
square
may
"

To illustrate the oppositefallacy,

unequal dimensions.
such as pertainsto enlargement of the artery, let us suppose
that to a patientin pneumonia a dose of alcohol is administered,
the radial artery enlargesand
afterwards
and that very soon
the artery
blood flows through this vessel ; now
to the finger
more
thus enlargedmay
give the impressionof a rise of pressure, or
of no
fall ; although,in the essential and crucial
at any
rate
have
respect of unit estimate, both pressure and velocitymay
fallen considerably,
diastolic reading would
as
a
probably
show.
Thus the largerelaxed leatheryartery of elderly
persons
is frequentlydescribed
of
whereas
the
as
one
high pressure,
be no more
than is quasi-normalfor the patient's
pressure
may
low ; such a pulse may
be
even
age, and the diastolic pressure
in an
old man's
influenza.
Under
as
preliminaryof asystole,
chloroform,as Professor Gushing has demonstrated, fluctuations
in arterial diameter
often be misleadingto the finger,
may
and fraught with guilefor the unwary.
He
fore
therewarns
us
that during anaesthesia a blood pressure
recorder, if not
In July 1902
continuouslyin use, should always be at hand.
I saw
with Mr. Arthur Cooke in Cambridge a lady of middle age
whose blood contained
ten million red corpuscles
over
(p. 260).
Her complexion was
ruddy almost to a mahogany tint,and her
radial artery full as if to bursting,
vasodilatation being extreme.
To both of us the arterial pressure on a fingerestimate felt as if
the state of the
How
very high,yet it proved to be but 120.
of very

arterial wall
and

may

interfere with

digitalestimation
VOL.

is

an

both

oncometer

important point to

measurement

which

I shall
F

PKESSUKE

66

Now

return

(p. 79).

person,

often within

at

time

one

than

it to dilate
it

GAUGING

the

radial

the limits of

another, and

varies

wall

consultation

PART

fingeringthe

in

the

same

; it feels thicker

vessel

incite

may

(MacWilliam) (p. 75).

consideringblood
pressures only ; it is in this estimate only that the sphygmometer
pretends to compete with the erudite finger. Even
with instrumental
aid we
as
are
yet far from being enabled to
a highlycomplex function
analyse the factors of the circulation,
indeterminate
of many
variables ; of pressures rising,
falling,
and fluctuating
in distribution ; of phasesvarying with the many
and contingencies
of energy
in the nervous,
sources
secretory,
and other storing,
and controlling
directing,
systems of the body.
Let

Moreover

be

we

remembered

have

to

that

contend

with

of which, unless it be

none

apparatus, is

am

now

defects

many

of

ments,
instru-

our

of the oncometric

one

ing
record-

yet in close and

followingtouch with the

vessel, or capable of recordingconstantlyand definitely
systolic
and diastolic pressures.
The fingerthen can
tell us many
things
which the sphygmometer cannot
tell ; so sensitive is it that in my
own
pulseoften, and stillbetter in certain abnormal pulsesof the
sick,the ordinaryrespiratory
phases may be detected.
By the
fingeragain in accessible parts we can appreciatethe state and
the characters

as

of the arterial walls ;

we

learn how

can

far the

pletion
re-

of the vessel is

mation
or
persistent
fluctuating,1
preciousinfornot
yet so well obtainable by the sphygmometer ; the
sphygmograph helps us better here : by the fingeralso we can
get a fair notion of kinds and degrees of arrhythmia,although
for their ultimate analysis
are
complete graphiccurves
necessary.
It is to these analysesthat the electrocardiograph
also is bringing
its aids.

Besides, as

Professor

Sahli says,

we

have

little

"

sure
pres-

in our
memory"; we cannot
fingertips,
carry a standard
for diastolic pressure.
not
especially
Unfortunately,instruments
total pressure
to record
cyclesare too ponderous for ordinary
them
uses
we
can
hardly hope to analyse and to
; yet without
solve the many
and
urgent problems of the circulation itself,
of the conditions which modify and control it.
It is remarkable
that the champions of
fingeronly do not
"

Dr.

comites

Leonard
may

Hill

mislead

thinks

the

that

fingera

in

cases

of

venous

little in this observation.

"

retardation

full

venso

GAUGING

PKESSUEE

68

PART

registerand for evidence

by hour, for our own
in published work
to present to pupils or
or
colleagues,
; for
be compassed, records far more
such purposes, if only they can
individual
definite and
perceptions
permanent than subjective,
and
of arterial pressures are
memories
required.
fail to keep a hand and an eye upon
In so far as we
everyday
the uses
in current
of clinical tact, to assert
methods
practice
of appreciatingthe subject
of empirical qualitativemodes
of the medical
matter
art, and to uphold such expert impressions
which
have
of the
more
against imperfect methods
the protests
seeming than of the realityof scientific precision,
I have
of which
and
rebukes
spoken have no little justification.
or

hour

even

For

that

admit

we

the

instrumental

methods

at

our

yet in themselves

far
so
imperfect and, even
ware
as
they go, imperfectlyinterpreted. Nevertheless, let us bein the face of history,we
lest once
set ourselves
more,
against a main principleof all scientific progress ; that is to
of quantitativeappreciation,
in defect of
say, againstmethods
of knowledge have ever
substantial foundations
been
which
no
of modern
physiology
permanently laid. The great advances
service

have
to

as

are

Research

measurement.

long as clinical
empirical wisdom

so

medicine

continue

clinical

sphere the

time

some

to

come

person

of progress
Emotion

of emotion,

from

taken

the

has

kind

of

one

was

to

put

is

without

the

of

long
calling.In
so

Instrumental

I insert
of

our

us,

to

on

Records.

attention,on

by

curve,

Dr.

one

"

the

Martin, by

of many

such,

laboratoryassistants,a
our

before

ways,

he

and

reclined

to
on

minimum

in ten

The

the arterial

our

cool

ments.
instru-

the

began just as he had taken his place. By the

that although his pulse rate had settled
will seem

to the
practically

will

quickening.

demonstrated

the record
it

the

compass,

miss

of keen

been

others.

arm

cufi

doubt, but

drift,under

measurements,

on

even

or

well accustomed
The

hit and

to

operations

progress of sphygmometry is slow, and for

be tentative ; but no
little has been
must
rate

systolicpressures
myself,and many

exact

of its

pedantriesno

is contented

of

be

Influenceof

influence

its

adepts, without

to

achieved, and the

The

of

the submission
has

medicine

control

and

information

with

in hand

hand

gone

couch,
line
timedown

minutes, yet his blood pressure

CHAP.

INTERFEEENCES

II

69

and did not reach its minimum

(systolic
maxima) was stillfalling,
tillafter the lapseof about fifty-five
It then remained
minutes.
perfectlylevel for the followingtwenty-fiveminutes, when the
Gibson
stration,
found
that, after a clinical demonexperiment ended.
his own
ately
blood pressure, if he recorded it immedisystolic
35-40
above the ordinarylevel.
after,had risen some
mm.
This interference is often embarrassing in singleconsultations,
when

excess

pressure

be

may

either

temporary

as

or,

in

systolicrises due
to nervous
cerned.
excitement
can
usually with a little pains be disFor
instance, these emotional
augmentations, as in
Klemperer'swill impulses(p.238),are commonly systolic
only,the
diastolic pressure
is more
steady ; by the pulse rate and rhythm
earlygranular kidney, persistent.However

2-1O

again

2-15

form

2-2O

2-25

2-3O

2-35

2-4O

opinion as

J""45

2-5O

2-55

3-5

3-1O

3-15

the

degree of nervous
The
excitement
attention.
or
usually runs
higher at
pressure
the first than on subsequent sittings,
and at the beginning than
at the end of a consoling
visit. In some
the cardiac and
persons
one

vasomotor

whole

may

centres

seem

some

to

be

very

to

labile.

Women

are

on

the

to these fluctuations,but ill-health and

susceptible
of us unmoved
apprehensionleave none
; so that the quickerand
be better, even
if a little less accurate.
simpler methods
may
Some
Kymographic methods
are
only for the habituated.
patients are disturbed by the tighteningof the cuff ; if so, the
suffice.
The
fingerand the stethoscopemust
pressure
gauge
should not be brought out till near
of the interview,
the conclusion
after some
quietexplanation,when the patientwill be told
to expect the grip of the cuff ; if then the full pressure
be brief,
and the colour of the hand watched, generally
speakingthere will
more

70

PRESSURE

be little nervousness

GAUGING

PART

applicationin winter
of a chilly
rubber cuff to the arm
of a sensitive patient,of either
thin
be appliedover
cuff may
sex, should be avoided
; a warm
ing
soft underclothingwithout mechanical
disadvantage. In watchthe instrument
the dial the patient is apt to hold his
or
Tell the patient,both
breath, and thus to disturb the record.
and muscular
as regardsmental
tension, to be as easy as possible,
to turn
his eyes elsewhere, and to try to regard the matter
as
indifferent. Still,
in an average person calm
after all precautions,
is not

reached

discomfort.

or

for

ten

some

The

fifteen minutes

or

of rest.

It is better

sitting
; the discomposure
be increased,the muscles may
tighten,and venous
may
tion
congesbe
in
In
abnormal
more.
high pressure
states, say
may
cases, rest in bed alone will often reduce pressures by 20-40 mm.,
that in such cases
be deferred.
the record should, if possible,
so
The
the vasoPsycho-physical effects of emotion
upon
not

repeat the

to

test

during the

"

"

system, and

motor

same

so

the

upon

pressure, offer a curious

researches
have
been
such

blood

and
sphere of study.1 These
obtain
to
as
generally on
plethysmographic methods, so
This method
shows how sensitive
comparative records in areas.
these curves
that
to
are
so
psychicalimpressions,so much
Neurasthenics
be trusted.
only continuallyuniform curves
can
are
peculiarlysensitive to these impressions; in such patients,
after all preliminaryprecautions,even
the tape may
to start
arouse
reaction,so that before acceptingthe record a short run
be given away.
must
Still such
be noted
as
a
a
liability
may
subordinate
sign of the malady. It is said by house physicians
that all pressure records rule higheron days of leavingthe hospital.
As a voluntary movement
of one
will send up pressure in
arm
the

other,so

or

the

any

like, may

are

habit spasm,
vitiate

larger in

the

as

facial twitch, a torticollis,

curve.

Although

in
subjects,

nervous

difficult to tell beforehand

such

which

amongst

these

unknown
them

tions
fluctua-

persons
may

prove

it is
thus

susceptible.On one such patientSchrumpf noted that apprehension

drove up the pressure, which after a quiet
of the diagnosis
and reassuringchat fell on a second and a third observation
by
studies ; Citron, Verein
f. inn.
Klemperer's well-known
Med., Berlin, July 17, 1911 ; Schrumpf of Strassburg,Deutsche med. Wochenschr.,
1

Dec.

See

Weber's

22, 1910

and

Zabel, Munch,

med.

Wochenschr., 1910, No.

44.

CHAP,

33

INTERFERENCES

ii

per

; then

cent

and

worries,such

again by

rose

emotional

25

The

pressure curves
this malady.2

on

per

I have

cent.

of pressures

paper
in neurasthenia

For,

interferences

had

later

likewise

have

may

been

that

already
l

Schmidt
in

an

essay

(Vol.II. p. 61), the

hyperpiesiaand

these

as

believe

to

reason

toms
symp-

the pressure

be greater when

may

I shall show

as

vexatious

by Stursberg and
I hope to discuss

recent

diagnosticdistinction between
often ignored. Fatigue curves
for comparison.
Such

of the most

some

etc.,when
sleeplessness,

the

as

enhancement

ruling high.
on

he recalled

71

neurasthenia
thus

be

verified

is

obtained

in

persons
heart and

only indisposed,as well as in those sufferingfrom

arterial disease.
Speaking generally,although these psychical
factors influence systolic
yet in arteriosclerosis
pressure chiefly,
rule
in this
this
is not
fully available, because
change
diastolic pressure
also
be
somewhat
the
augmented
may
(Schrumpf). In the heat and cold tests on the skin it must be
remembered
that not only the local reflexes but cortical influence
also
as
pleasureor pain may enter into the result.
What
the effect of concentrated
to note
Klemperer did was
from the manipulationsand the
attention, or of any annoyance
like ; he and Citron,0. Miiller,
and v. Romberg pursued these researches
into the sphereof ideas,and accordingly
of "suggestion,"
and they found the effect of cortical excitement
upon these vasoreactions to be remarkable
motor
; by suggestionthe pressure
instead of rising
curves
were
reversible,the pressure falling
; and
and abnormal
reaction curves
thus
were
conversely. Normal
The limits of my
obtained.
subjectwill not allow me to illustrate
"

"

such

mental

fluctuations

reflected in the

as

behaviour

of

the

blood vessels,but in

passingI may demur to too ready an acceptance

of such fugitive
phenomena. Psychicalstimuli are indefinite
in qualityand quantity,and too much
intermingledwith other
widespread reactions and influences to be standardised ; presumably
also the cortical outflow, on
its way
through the
to
or
spina-sympathetic
system, is liable to absorptionresistance,
shunt ; and so likewise for the ingoingsensations.
1
2

Stursberg and
See

new

Schmidt,

edition

(2nd edit.)System

Deutsche

of my
essay
of Medicine.

on

Arch.

f. Id.

Neurasthenia

Med.

Bd.

xc.

in Allbutt

and

Rolleston's

PRESSURE

72

GAUGING

PART

As

attitude during the observation,the conditions

regardsthe patient's
be as uniform
should
then
as
possible. This in the
largemajorityof instances is easy, as in the hospitalor consultingfurniture is at hand, and needs only some
the same
room
change
for tall and

of cushions

In outside

short persons.

consultations

venient.
patientis usuallyin bed, and this positionalso is quite conand by keeping as far as possible
By these precautions,
relative uniformity amid
one's
the same
instrument, some
results can
be maintained.
The
foregoingconsiderations

the

to
own
warn

if blood

that

us

scientific accuracy,

to

pretence

be

to

are

pressures

be taken
they must
two
quietlyrecumbent.

patienthas been for an hour or

As regards the hour of observation,
I
as
have but little accurate
we
guidance on the
arterial

of

worked

at

enough for the comparison of

in privatepracticehave been
of ten

hours
In

Dr.

Gibson,
pressures.
the subject,but our

and

yet delicate

not

observations

My
nearly always

the

between

o'clock.

one

conclusion,we

arterial pressure

have

others

small variations.
made

the

(p. 21),
dailycurve

normal

are

when

said

have

Oliver, and

methods

much

with

taken

may

pressure

about

200,

or

be about
over

impressionas

an

The

that,

say

on

whole,

the

if the

walls

are,

count

for

of

much

of the circulation,our

uniformity on
and

and

about

or

150,

or

of his diastolic pressure

Pressures

which

and

over

about
I get

175,
as

usually,but

200

or

good
by no

the Pressure

Gauge. It will be obvious

the vessels,widely variable as their states
in proportion to the dynamic elements
records
we

resilience,which

in health
pressure

and

due

renal disease.

Arterial Wall

that

with

normal,

can.

always,mean

means

taken

to

precautionsin patients
at rest are
fairlyconsistent,and uniform enough for practical
if not for close comparisons. For my
own
part for
purposes
satisfied to ascertain if a patient's
practical
systolic
purposes I am
blood

records

be content

have
our

must

"

lose much

presumed.

or

The

instrumental

all of the fair

arterial expansion

curves

factors ; upon
what
two
upon
vascular tone.
If the system

express,

I may
were

call

pend
de-

piston

the
inelastic,

of pressure would express itself directly

as
pistonvelocity;
is essentially
indeed
elastic system the curve
in an
dependent

curve

on

it, but

with

interferences.

Now

the

vascular

walls,

CHAP,

as

COEFFICIENT

ii

know,

we

homogeneous,

not

are

WALL

ARTERIAL

OF

of the several tunics.

discussed

lucidlytwo

the muscular

own

in.

come

He

this function

upon

my

three

or

bell
Harry Campago.1 He argued that
then the
of the systole,

years

of the media

with

compared
impressionis also

exclusive

laid too

have

may

the form
of
upon
of the momentary

factors Dr.

fibres bear the first stretch

elastic fibres

as

These

in

phasis
em-

an

lateral
resisting

pressures,
distribution,but

in blood

its function

in indirect

therefore

and

the effect of the wall

(external)
manometry
the curve
of activityis an
algebraicsum
attitudes

TS

for littlein this

that the elastica counts

has
languageof physics,this membrane
little of the elastic property of resisting
deformation, but is very
resilient. Hence, near
the main trunks where the pulsations
are
felt and are
most
taken up as potential,
the elastica is large;
towards
and it thins out
thins out
to selvage ends
even
the periphery,
where pulsationis almost spent. The adventitia,

phase of resistance;in

the

"

"

"

"

if

in

one

elastic, is far

more

sense

resilient ; it is chiefly
a

the media

the

more

elastic and

the

more

the relaxation

elastic and

the

vessel

The

tighterthe

of this coat

"

to

promote, let us

into the blacksmith's

as

vasa

of

tone

the less extensile it is ; the less

extensile the looser its tone.

blood inactive work

of

forth.

so

and

the vehicle of

sheath,and
protective

lymph channels,and

vasorum,

distensible

less

resisted;the safeguard of

Thus

say,

arm

"

the

more

rapidafflux

of

the less is strain

is reduced, and

tonus

impaired. In the
ultimatelythe unresistingvessel becomes
is most
the distensibility
at first ; but
passiveartery of course
of pressure
the vessel contracts
the first yieldingto increments
as
becomes
more
gradual,and before the adventitia has to carry
the stretch,
much
of the stress, or the elastica is put fullyon
the central pressure
be very
must
high. Dr. Campbell says
that the maximum
lies about
100
which,
distensibility
mm.,
if so, is at a point a little higherthan the maximum
oscillation,
after

limit

which
of

reflected in
from
What
and

the
a

it diminishes.

main

correspondingresistance

without

is

to

now

the effects then

are

condensation
1

to

opponent

of

upon

the

Campbell, H., Lancet,

to

instrumental

arterial wall
1, and

traction
con-

within

is

sion
compres-

attention.

manometry

Jan.

stronger

from

pressure

our

occupy

this

far

How

ness,
of the tone, thickitself ?

subseq.

1910.

Von

Basch

PRESSURE

74:

satisfied himself

that

GAUGING

PART

in the

these
readings of the manometer
variable factors of the wall lay within limits so small
about
5 mm.
Hg for a sclerosed artery as to be negligible.Dr.
C. J. Martin
conclusion ; namely, that the
to the same
came
7 mm.
wall of a thickened
Hg.
artery might interfere by some
and
Dr. Oliver
the same
have
held
Dr. Janeway
opinion,
and
the
fair
of
records, has
generalexperience,by.
uniformity
"

"

seemed
with

confirm

to

certain

these

conclusions.

Professor

MacWilliam,

be mentioned

stillthinks that
presently,
is inconsiderable,if not negligible.Ordinary
to

reserves

the factor of the wall

tone, in the brachial

artery for instance, seems

appreciableresistance

face of great eccentricities in pressure records some

well be
in 1907
suspected, and
may
Russell

raised

the arterial
scheme

As

he

of

fallacy.

to

the

of the

form

has

direct

no

that in the
such

William

Dr.
the

ference
inter-

factor

of

by a certain
infrequentlya copious

not

pulse,it

Strauss

no

it,as demonstrated

exhibited, to be

observers,by Professor
form

important question of

declared

wall, and

which

source

the

anew

offer

to

me

Still I admit

compression.

to

to

has

been

of Berlin for

dependence

by

many

example,1that pulse

blood

on

shown

wall

that

pressure,

and pulserate count

for more
elasticity
(p.59). As I have said,
the clock rate, the tracingfrom a sclerotic artery
by accelerating
be approximated in form
vessel.
to that from
normal
a
may

repeat also that Sanderson

I may

pluspressure
combined
has

seemed

with

not

latelyreinforced

this

of

relation, in form

Mahomed

I found

and

of itselfto flatten the curve,

certain

and

of

rate

and
principle,
between

curve,

shown

but sclerosis

that

outflow, and

that

Lewis

Dr.

the lack of direct

arteriosclerosis

blood

and

I have alluded also to the questionof the compression

pressure.
it may
set up
itself,whether
dilatation,or contraction, of the

subject

vessel ?
has

MacWilliam

artery

Herringham and
since proved, that on

relax, the

may

by Luciani
sphygmometry the

are

and

told

relaxation

of

furthermore
1

See

the

heart's

insertion

of

artery, and

that to compress
also

other

Roy's

paper,

Womack

suggested,what
recompressionsthe
many
We
being constant.
energy
that in internal
physiologists
the

of its

cannula

one

area

of Pkysiol, 1879-80,

causes

principalbranches

largeartery in

Journ.

often

may

vol. ii.

and

cause

76

PRESSURE

adopted by
carotid,seems,

and

channels.

the observations
of the

use

and

about

various

till the

have

may

been

breadth

same

as

ambiguous

of cuff for

buted
Kries attri-

; von

Hiirthle said
or

later,2

Before

leg.

in

as

erroneous,

and

arm

the

pretation
correct, their inter-

were

of recoil ; or,

wave

reaches

stress

nouncing
pro-

these difficult physicalproblems very great caution

on
observations
Van Bogaert of Antwerp has
needed.
are

many

made

to be improbitself,
able,

contingentfactors

upon

with

crural

compared

pressure

If the observations

the difference to

the

blood

tell much

not

might depend

PART

others, who

regardsthe

as

friction does

as

smaller

Hurthle

GAUGING

800

comparisons of

breadths

of cuff in each

states

of

other

habitual

and

arm

leg,experimentingwith

limb; also

on

in various

persons

and with due regardto meals and

health,in all positions,
conditions

he

concluded

in

that

and

arm

leg

the pressures, systolic

and diastolic,
were
practically
equal. He
used both the K.-R. and the Pachon
instruments.
In external
it must

manometry

be very

difficult to

between
distinguish

blood

thick walls
of the
degrees of arterial constriction,
as
vessels of the legswhich
have
resist gravitation,
to
and
tone
of surrounding muscles.
My impression is that the tone
and volume
of the voluntary muscles
; Ludwig
goes for much
pressures,

"

Frank,3 who
flaccid

tested

the

brachial

in

pressures

palsied and
repeatedly

and
against the other (normal) arm,
found
the reading on
the palsiedside lower, came
to the same
conclusion.
lies one
Herein
arm
objectionto the use of the forefor manometry,
that the unequal resistance of the two bones,
and of the fascia,likewise prevent a quasi-fluid
behaviour
of the
arm

circumambient

parts.

Volkmann
that

in various

heart

These
view

than

was

of

See

than a systolic
difference ;
leg more
pulseamplitude varied for the same
larger(" erheblich grosser") in the

in the

much
carotid

all the

Hasebroek

But

(p. 51).

in

these

Hurthle, PflugersArch.
2
3

Hurthle

in

largerarterial

takes

peristaltic
forwarding of

however

artery. Dawson,

equal in

diastolic pressures
local fluctuations

arteries
1

in the

arteries the

beat, and

crural
found

found

branches.

favourable

as

the blood

arguments

(loc.cit.)

by

the

to

muscular

insufficient

atten-

vol. xlvii. ; but also cxlvii.,1912,

p. 593.
Pfluger,vol. ex., 1905.

Frank, L., Zeitschr. f. exp. Path,

und

Ther.

Bd.

ix.

his

CHAP,

FACTOK

ii

AETEEIAL

THE

OF

WALL

77

paid to the distinction between fluid pressure within the

from the heart's shock along
artery and propagation of a wave
active as the vascular
its walls (p. 33), a propagation the more
because
of its denser structure
wall is more
or
rigid,whether
of a tenser state of it under
The femoral
a high blood
pressure.
artery, which has to resist gravity,is a stiff vessel ; so that we
should expect it to transmit
a
quicker and higher wave.
But,
I said in a discussion in 1913
at the E-oyalSociety,although
as
stiffer walled artery would
a
propagate a quicker wave,
yet a
distended
thinner
(elastic)
fullyby a high blood
artery, when
shall
pressure, might have a similar conductivity.1However, we
see
presentlythat these differences between one limb and another
striction
depend, in part at least,upon degrees of arterial tone, of conthat
by frequent (20 to 30) recompressions
; and
(MacWilliam) the higher record can often, if not always, be
brought level with the lower.
If, as occasionally
reported,compression of one considerable
tion is

artery raises the

pressure

another

must

limb, we

has

put

out

of order.

out

let

But

us

Russell's reassertion
external

schema

which

did not
not

were

tubes

seem

the

of blood
fitted with
to

of unit but

me

in

of the

the

heart

side,or in

in the

interval

mechanism
circulatory

examination

of

Dr.

is

William

factor of the arterial wall in

In his first demonstration

pressures.

indiarubber

tubing was

pari material

of total pressures.

other

in any

No

exhibited

case,

scheme

its records

with

rubber

than tentative and suggestive.

regarded as more
Dr. Herringham and I sketched
out
another
testinggauge, on
oncometrical
in which
principles,
lengths of arteries might be
used.
With
the help of Mr. Womack,
Dr. Herringham constructed
a
experiments upon portions
many
gauge, and made
1

the

It

could

to

the

of the inconstant

measurements
a

that

or

come

now

that

suppose

work,

more

in its fellow

after

was

paper

at

surmised, that
hot water
be

be

and

this manuscript had gone

and
Hill read
to press that Wells
Royal Society to which I have alluded.
They proved, what I
by immersing a limb (arm or leg),pn Klemperer's method, in
thus relaxingthe arteries,marked
alterations
of pressure
records

the

the interference
of vasomotor
tides and
of output
Also
produced.
make
difficult.
the
cold
and
water
test prowarm
experiment
Klemperer by
duced
differences
12
and
of
of the two
sides ranging between
rise
fall of
a
a
6 cm.
of water.
See also Hill and Rowland,
Heart, vol. iii.No. 2 ; and Rolleston,
Heart, vol. iv. p. 82, 1912, who are also unconvinced
of the differences.
can

PRESSURE

78

of vessels in various

GAUGING

PABT

obtained

amazingly inconsistent
I had
results.1
In clinical work
attention
never
paid much
10-15
I regarded our
methods
to differences under
as
mm.,
too rough for differences so fine ; but Dr. Herringham exhibited
of 20-30 mm.
Indeed he agreedwith Dr. Williamson
irregularities
of pressures of 200 mm.
and upwards the legpressure
that in cases
In
by 30-40 mm.
(in recumbency) might exceed those of arm
son,
one
high pressure case, observed both by himself and Dr. Williamdifference between
the rightarm
and leg of 72
there was
a
the left limbs of 36 mm.
! After death, portions
mm.
; between
tested in the oncometer, when
arteries were
from the respective
found between
difference was
60 mm.
artery from the rightarm
but smaller difference between
and the leg,and a considerable
so
bewildering,
segments from the left limbs. These results were
inordinate

5, 4, 6, 12, 15,

our

22
to

instruments,

more

been

My

had
respectively,

extreme

so

other

namely, 8, 14,

vagarieswhich in my clinical custom

but as, with
regard not indeed as negligible,
less inevitable.

or

observations,

own

not

were

In

mm.,

used

I have

fallacies somewhere.

suggest grave

differences

the

cases

to

as

states, and

satisfied

Martin, Janeway, and

pressure and decrescent

that the opinion of von

high

on
me

others, that

many

walls of the arteries altered the pressure

atherosclerosis

records

so

cases

Basch,
of the

little (say 5-10

was
negligible
justified.Time after time with my
the pressure in such arteries
mind on this problem I had measured
both with the R.-R. and
other
at ordinary systemic pressures,
had obtained
fairlyconsistent records. I have, I
gauges, and
admit, tested the leg rarely. It is difficult in ordinarypractice

mm.)

to be

as

for

allow

to

which

factor

observers.
the
a

of

arm

of

the

tone

may

not

have

thus

may

strong

muscles

Hensen

be

Herringham
Hensen,

f. kl Hed.,

driven

says,2and

"

strong muscles

been

anticipatea high

equalityof
hydrostatic
of the

the

and

as

Beitrage

1900, p. 436.

z.

muscles

do

not

other
from
offer

resistance.

tion
Any tendency to contraccloselywatched, as the readings

be

up

by 25
Frey

Womack,

limb,

wholly got rid of by

irregularrecord even

whose

man,

must

von

or

of the

Proc.

PhysioL

und

mm.

had

and

said

more.

It is true,

before, that

the

Roy. Soc. Med.t May 1909.

Path.
d. Blutdrucks," Deutsche

as

mere

Arch,

CHAP,

FACTOK

ii

OF

of muscle

thickness

however, which
made
results which
arterial coats

is apt to

but

or

79

little ; not

the

so

tone

in both

concerned, that
often

legswere

disease

the

scarcelysuppose

even

vary

far

so

were

measurements

oncometrical

their

matter,

no

WALL

during an experiment.
L. Hill, at the Royal Society discussion
and afterwards,1
some
important criticisms upon these erratic results,
need much
sifting.He asked how it was, if the

Professor

In

is

ARTERIAL

THE

in the

in

identical,for
femorals

two

Herringham

gauge

arteriosclerosis the

and

be

to

could

we

equal ?

Womack

tested

specimens of excised arteries,stillwith eccentric results,

precautionson which Macpartly I think because the many
has insisted were
not
William
always observed ; and the same
at least of Dr. Russell's experiments
criticism appliesto some
sections of arteries. Again,
with dead, half-dead, or surviving,
other

of

the diameter

forgotten;

it is fair to add

However,
upon

his

them

all

external
and

Drs.

rather
that

must

we

; it

morbid

with
1

muscular

also in

William's

regards
from

the

reversely.
that, generallyspeaking,
raise the resistance

may

the

vessel would

internal.

also

RusseU,

Williamson,

As

Med.

Brit.

0.

published
and

are

Dr.

to

oppose

Williamson,

of

our
on

Journ.,

in

many

Mackie,

own

without

laboratories have

excised

Journ., Jan.
1908, ii. p.

K., Lancet, May

be solved

cannot

conditions

Flack, Brit. Med.

MacWilliam

is derived

contracted

problems

observations

some

and

Park

and

Russell

artery

it opposes

as

these

as

all of Mac
Hill

Dr.

likelythat

seems

experiment,we

make

to

evidence

stress

great

assistance.

much

However,
direct

lays no

opinionthat it is spasm
sclerosis which contributes to high resistance ; 3 and
defects of elasticity,
or
thickeningsand stiffenings,
little. In this distinction the trained fingershould

than

give us

with

agree

of

pressures
Jane way

for very

go

Russell

the wall contracted, and

as

contraction
the gauge

the radial to the brachial.

and
before
after the exhibition
of
pressures
he found 2 that resistance to the compression of

rose

I think

best

be

not

of

nitrites,when
gauge

Dr.

must

portions of arteries,and

His

fallible.

as

e.g., from

that

experiments with

comparisons
the

reckon,

cannot

we

the limits of its spasm

vessel and

endeavoured

arteries ; and

we

is,as

satisfied

that

more

believe
to

the

30, 1909.
1076.

25, p. 1409.

e.g. Royal Society,

papers,
Brit. Med.
Journ., Nov.
14,

Nov.

1908,

21, 1901
p.

1477.

and
His

PRESSUKE

80

after death, the kind

time
mode

forth.

so

series for M.D.

refer to two

PART

of disease of which

preparation,and

of

GAUGING

theses

Dixon's

the

died,the

owner

Of these

experiments I will
: the first by Dr. Stevenson, in
second by Dr. Cow, now
Beit
a

the
laboratory,
student, in the same
laboratory. Dr. Stevenson's researches,1
by
similar to those of Herringham and Womack,
methods
showed

Professor

arteries of the muscular

with

were

was

in that
in

the

constriction,
on

contrary, had
and

the compression;
resisting
from

rose

by running
Of

chloroform

were

he felt unable

more

contractions

effect

as

were

sures
pres-

excited

solution

through the sections.

tested,side by side. Stevenson

decide

to

arterial wall counts

of the

and

more

The

considerable

of internal pressure the resistance

1-3.
Such were
the figures;but

about

the whole

on

10 millimetres

constriction

on

barium

or

controls

that for every

rose

this

17-8 to 22 per cent.

many

course

found

Basch, Janeway, and

von

rightin saying that in arteriosclerosis the state of the

practically
negligible
; but they agreed with Dr. Russell's

others
wall

type that

than

more

for

at

more

this

"

high

that resistance
than

at

low

He
that this inconstant
found, moreover,
factor of
pressures.
tells more
in arteries like the brachial, to which
constriction

usuallywe apply our tests one in which the wall bears a large
than, e.g., in the carotid or subclavian,
proportionto the channel
is relativelylarger. He
the channel
in which
did not
note
excised or in life,
under recomsignsof dilatation of the arteries,
but in many
an
pressions,
artery noted by the fingeras thick
and hard the record proved to be low, while others taken
by
offered high resistances.
be normal
the touch
to
In four
sclerotic specimens (brachial)
of Stevenson's
contraction
was
still good, though three were
taken from subjectsover
50 years
Dr. Harry Campbell pertinently
of age.
asks why it is assumed
discern between
that the fingercan
resistance of coats and resistance
of high pressure if the gauge
?
cannot
Does
the
not
"

"

important
these

pages.
majority of

constriction
should
he

thinks,
1

and

be

of 1913, quoted in a previous note, appeared too late

that on
the whole, and
Fortunately, he concludes
in
the
clinical
but
liable
readings are consistent,
cases,

paper

of
used
raise

the
to

artery under

relax

the

the

vessel.

obliteration

Thesis
for M.D., 1910Ireland, 1910,

observation

Keeping

sets

up

in.

Then

continuous

to inform

the
to

vast
err

if

recompressions
pressure

may,

record.

Paper

read

again,

Pathol.

Soc.

Great

Britain

CHAP,

THE

OF

FACTOR

ii

WALL

ARTERIAL

in the

interference of the wall, if it vitiates observation

vitiate it

less in the

no

other ?

Dr.

Cow

81

one

way,

arteries from

took

amputations,and, over and

at a uniform
Mac William's
above
instructions,he kept them
in oxydised saline. As in
temperature, and suspended them
the previous experiments,portions of approximately equal
were
compared. The least
magnitudes but from several areas
used throughout,and these were
possiblemanipulationswere
made
as
equal as possiblefor all the specimens. The drum
of known
in 42 sec.
revolved
After excludingthe cases
1 cm.
201 experiments remained
for comparison.
or
possiblefallacy,
Cow showed
that portionsexcised from peripheraland visceral
wise
contrariand even
branches respectively
often acted differently,
constriction in the one
:
might correspondto dilatation in
the other.
This observation
reconcile many
contradictory
may
records of such experiments under
adrenin, and the
pituitin,
like ; that constriction in certain peripheralareas
is,or may
is
be, accompanied by dilatation in certain visceral areas
of these contrasts
clearlyknown ; but some
depend on
may
the degree in which
withstand
rise of
weaker
a
a
artery can
animals

systemic pressure
I think
Russell

the

from

be

must

from

resistances

enormous

experimentswith

erroneous

during life ?

for what

Mac William's

of formalin

use

and

(sheepand oxen)

excised
range

rules
I

as

seems,

of wall

have

arteries,e.g.

does

said, to introduce

experiments on vessels tested

immediatelyafter death, as by Janeway

reactions.

by the inconstancies

Their

careful

research

70-150

mm.,

for pressures
mentioned,2and the

variable ; but

often vitiated

without

of survival
indicates

another
vatives
preser-

and

Park,3

and

vital
quasithat

however

nil ; in later life,even

youth wall resistance is practically
reach
10 mm.,
atheroma, it may
or, if calcined, 15 mm.
; but

most

this is in

the

Russell,Herringham, and
be raised, even

may

M.D.

For

March
3

Thesis
other

mean

others

by

30

position: they
that by spasm
the

VOL.

are

in

in
at

admit

with

wall

ance
resist-

mm.

in 1910.

possible fallacies of

these

experiments

see

L.

Hill, Lancet,

27, 1909.

Janeway

Dr.

by

it leave

not

are

reckoned

and

Park, Arch.

int. Med., Nov.

1910.
G

PRESSURE

82

We

told that

are

GAUGING

sclerosis must

arterial wall ; this may

or

not

may

artery would

an

the resistance of the

be true,

so

It does

not

the weakest

sections under

for

constrainingus

factor of wall ; for the

his

opinion also,
the

of constriction
coincides.1

view

of the

; a

But

not

regardsthe

as

I believe

resistance

sclerosis but

to

with

matter

which

reinforced

distal

wall

is

Oliver's

Dr.

by

for the most

rise

in

yet it

high pressures
(p. 30), or
of appreciUnfortunatelythe difficulty
ating

of them.

diastolic pressures, and the scantiness of diastolic

in obscurity.
a largepart of this argument

The

siderable
con-

degrees

to

of low pressure

area

to

for the stories of local

account

keep

for

on

debt

opinion,and

the

constriction,not
makes

atherous

an

owe

data

our

own

my

where

is due

generalpressure,
may

to revise

resistance

applied
of higher
or decay.

strongest but

perplexities,
we

present

is that

the

on

sclerosis
athero-

the cuff.

the issue of these

Dr. Russell

tracts

compressionof

gives records, not

Whatever

but

spots,spots of relaxation

artery tells,and
cross

about

at or

to be realised that

seem

far

hydrostaticpressure

close it not

resistance but at the weakest

increase

is unequallydistributed,
and
to such

PART

few

observations

blood

on

pressure

records,

the central side of

on

of them
the thicker vessels of the leg,
amputations, some
on
do not
point to considerable differences between external and
internal gauging (p. 91).
However
Uskoff, comparing the
records
the

of

results

much

external

gauges

so
conflicting,

and

internal

much

so

in

his

the

to

artery, found

opinionas

to

throw

doubt

estimates
of pressure, whether
systolicor
upon
diastolic ; but the diastolic results were
to uniformity.
nearer
As in clinical work
continue
so

to do

so

the

calculated

Hensen

only

must

remember

mm.

more

because

the brachial

artery, and ought

walls

of

(seealso

other

p.

vessels

76),we
the

to

that the wall of the brachial

resistance

that each

of data

this vessel is rather less

fluctuations

radial to vasomotor
of

all use

in order that the accumulation

far uniform, and

resistance

we

than

regionof

that
the

of the

body

may

to

be

subjectthan
leave the

may

physiologists.

offers

(ccet.
par.),

radial.2

has its

And

we

build of

own

Oliver, G., Clin. Journ., Sept. 16, 1908.

(in Dehio's Laboratory), Blutdr. d. jungen
Arch. f. kl. Med., 1902, voL Ixxiv. p. 254.
Menschen," Deutsche
2

See also Masing

"

u.

d.

bejahrten

84

PKESSUKE

instruments
evidences

of
of

aortic

of

Gartner

increased
are

between

"

kind.

pressure

stress

individuals

And

be

may

PART

in

the

equivocal;

of

the

and

man

insisted

already
more
quickly than

wave

heart

may

notably in bulk, while audible signs

in
but
much
impressions, and
vary

arterial wall

have

other

early case

an

for

woman

instance,

of the great vessels to the chest wall.

nearness

high

yet have

not

the

GAUGING

that

"

slack

stiff vessel
one

and

the undulation

On

with

contrasted

as

stream

wall

the

or

pressure

propagates

doubtless

often

we

have arrested the current

when
have only damped
we
we
presume
the excursions of the wall (p.33). As Dr. Jane way says, we
must
be careful to record, not the obliterating
only,which in
pressure
constriction he agrees may
after obliteration.
But

vasomotor

of return

systolic
pressure
The

but the point

fallacious,

be

all this of

only,a partialrecord.

differential arterial and

venous

in the

pressures

Hill,Moritz, Tabora),an

enquiry,have
interesting
sufficiently
investigated.
Pressure

Recorders.

discard

concerns

course

the bulk

After

"

hesitation

some

not

I have

arm

(L.

yet been

determined

I
manuscript on these instruments.
that in so doing I am
am
only too well aware
throwing doubt
the methods
of my
of my
and the sources
own
experience,
upon
has
with these methods
own
opinions; still,
as
familiarity
my
to their
increased,so far from attaininga better assurance
as
I have found but a growing mistrust.
For many
capacities
years
indeed
I
have
discountenanced
past
preciserecords of pressure in
in my
of accuracy
as
giving a false appearance
man,
; when
to

I enter

notes

own

them

but

as

Although

of my

the

shown
on
precisefigures
rough approximations,or short
without

bent

the gauge

regard

memoranda.

mechanics

and

ready to
manometric
instruments
as
try all external
they appeared
the market, yet I have never
had the leisure carefully
on
to test
and compare
I began my
clinical
them, or to improve them.
observations

not

with

these, before
their
1

1908.

the instruments

reading
I had
incapacities,

The

first of these

literature of the

some

to

of

von

Basch

conclusive
Tigerstedt's
discarded

on

instruments, introduced

subject will be

found

by

0.

the

and

demonstration

productionof

in 1887.

Potain

of

Hill and

full account

Miiller,Ergebnisse d. inn.

of the

Med.,

CHAP,

PRESSURE

ii

Barnard's

apparatus,

arm

1896-97, and

meeting

constructed

in action

exhibited

of the

for many

RECORDERS

subsequentlyfound

width, the brachial cuff of the

child ; but

depends not
axial

on

on

This

be used

as

on

largerdimension
for the

for the

thighof a
artery,that velocity
the lengthof a tube,

regardsthe

only but also

radial length. I

I used

definite rule

no

of

Cambridge

instrument

the

to

is

may

as

in the winter

that date at

the diameter

well

as

man

remember,

must

we

about

There

necessary.

them

by

PhysiologicalSociety.
after altering
the cuff

years,

85

on

have

had

little trouble

with Hill's

in fact but the need of a comparison

largergauge, none
and readjustment from time to time with a mercurial
column,
and sometimes
the
I
makers.
think I was
fortunate
a refitting
by
in my
instrument, as, generallyspeaking,aneroids are very
own
liable to fall out

of value.

And

like all external

it is

manometers,

give too

The
dial
high a record for systolicpressures.
is convenient, and
though the phase of large oscillation is
needle inertia,
its
inconvenientlyextensive,and there is some
suggestionsof diastolic pressure do tolerablywell for an observer
to

apt

accustomed

little later

of the Riva-Rocci

vogue

other forms

and

it.

to

became

and

"

I had
its

see

while I used

tube

nearly said blatant

and

Then

rate.
a

into

our

light short
closed

frequently;
to

this

at

which

hands

For

mercurial

by

the

enough

came

I wanted

is

unaided

by

soon

it is

ous,
conspicu-

eye

one

eliminated

or

variation

in

may

tracted
sub-

pulse

Oliver's later gauge, the drive

column
of air in a
a
glass

end.

convenient
for

column

be

cannot

diastolic pressures

against

farther

it is very

accurate

me

the

of these ; but

one

inertia is disturbed

index

captured by the
Martin's adaptation

in regard to what
it,especially

inertia of

overridingwaves,
;

of

The

absurd.

in

as

"

most, namely the diastolic pressures.

almost

all

were

instruments

for

dissatisfied with

we

This
for

the

ordinaryuse

gauge
eye,

but

and

have
it

it will not

used
seems

bear

Its indications of diastolic pressures,

if not so
carryingabout.
perceptibleas in the oscillometer of Pachon
(of which I shall
of von
of Hill and
speak presently),
Recklinghausen,or even
Barnard, are better than by the mercurial column ; if they do not
of minimum
which a graphic
givethe precisemoment
oscillation,
method
inertia interfree from
only can
give,they are more
"

Sahli

therefore

prefersa

fine tube

with

petroleum

column.

GAUGING

PRESSURE

86

only

of all the

but

parts of these instruments,

vitiate their indications

methods

section

Without

has its

of

how

better

artery

an

allow

to

has

means

no

discovered

been

curve

of

of
the

fallacy.

approximations.
is to get an
approximatereckoning of
difficulty

chief

The

sonal
per-

with

be content

must

to

"

defects.

for their

the
givingus accurate pressure records all through
sources
interveningconditions bring in too many
We

tend

and

better

learn

needles

scientific standpointexternal
strictly
fear, all radicallyinadequate; though we

seem,

or

which

instrument

that each

so

equation." From
shall

backlash, not of columns

It is the inertia and

ferences.

PART

diastolic pressures, for these are

minimum
pressure which shows

the

most

how

the

important. It is the
blood is gettingaway.

Moreover, resistance being equal,a fall of diastolic pressure

first

probably the
both

diastolic and
low

; but

sign of heart failure.

systolicpressures is
pressures

outside

are

It is said that
an

my

vary

the diastolic

stable.

more

are

and

oscillations

maximum

oscillation

elasticity
thought that
the

mean

of the vessel ?
flattening
and Dr. Davenport Windle
(loc.
cit.),

imply some

oscillation
elastic

as

Howell
2

and

Brush,1 Masing

regard the point of

mum
maxi-

diastolic pressure ; the wall is then in

Gibson
regarded the point of diastolic

the

equilibrium.
that

pressure ; Sahli takes

must
diastolic pressure, but his method

the
signified

as

external

the vessels stiffen the diastolic

As

inverselyas
pressures, which, caeteris paribus,are
fall proportionately.Marey
of the system, must
maximum

fall in

culosis
early sign in tubersubject. We have
high-pressurecases,

in
systolicpressures, especially
incidents,internal
greatly,obeying many

that

seen

is

which

the

largeoscillations suddenly begin to

diminish.
With
his oscillometer,
von
Recklinghausen3 (with
the point
Erlanger) notes as the approximate maximum
pressure
where the vibrations,
after a small augmentation, become
denly
sudwhere
larger; as the minimum
or
diastolic,
they become
pressure

1
1
8

Howell

at

and

Brush, Boston Med. and

Windle, D., Lancet, Nov. 18, 1911.
Von

Surg. Journ., 1901,

p. 146.

Blutdruck
b. Menschen,"
Recklinghausen's last paper,
in Beihefte
med. Klinik, aus
z.
dem Lab. f. exp. Pharm.
zu
Strassburgi. E., 1910, Heft 8,
contains
a full description
of his instrument
and much
besides.
matter
interesting
His oscillator does not depend exactly
an
elastic
aneroid
but
an
upon
upon
metal
which
capsule (Bourdon
of
from
-Rohre),
the point of view
however,
to me
to come
seems
to much
stability,
the same
thing.
"

CHAP,

PRESSURES

DIASTOLIC

ii

87

by the
suddenly smaller ; the diastolic pressure being signified
needle
lowest of the largeoscillations ; though with an unarmed
less definite. The signsthen of these periodic
this phase is made
with a graphic
somewhat
oscillations are
arbitrary,and, even
record

before

are

us,

not

particularinstruments
Dr. Janeway accepts

of

so

to

easy

would

determine

have

us

as

the advocates

believe.
of the excursions

the first diminution

Sahli take the

the diastolic pressure, and Strasburgerand
the beginning of the
instrument
Pachon's
With
moment.
diastolic

as

same

large

To

take,
phase is taken as
oscillating
pressure.
with
von
Recklinghausen, the first enlarging oscillations on
considerable
the opening side makes
a
difference,and others
(Janowski) take the middle swing. But surelyas the excursions
As regards tone, we
be tightening?
diminish the wall must
have
no
compared the sphygmographical
guide. Dr. Windle
with the sphygmomanometrical curve
by affixingMackenzie's
of a tambour, and then
polygraph to the radial artery by means
oscillation slowlypumping up the
from the point of maximum
pressure.
In UskofTs

instrument,

as

in others of this kind,

read the pressures where the firstdefinite

the tracingis a
which
of course
after arrest
on
to

are

we

beginto

"

directed

wave

appears
straightline.

enlargementat the beginning

visible jiggingis so gradualthat there is a variable
of the scarcely
;
play, and with it accordinglya fallacyup to, say, 10 mm.
in
constructional
defects.
Dr.
besides certain
Oliver, emphasising
But

in many

the

importance

cases

suggests that
with
and

"

the

in all
"

of diastolic pressures,

we

may

Marey, and Roy

as

not

take the maximum

and

not

"

pad,

small

assures

we

us

or
systole,

will suffice for

need

not

the rest of the

and

nervous

pad

In Graves's

other

step farther

bother

cycle.

incidental

depend
it); then, if
on

ourselves

he

the

mean

pressure,
capacityof the

this be

overmuch

This alternative would

exaltations

disease,for instance, the

oscillation first (which,

Adami, he regardsas the

does

this measurement

goes

normal, he
about
avoid

the
the

of

systolicpressures.
systolicpressures may rise

apt
considerably
; but, complicationsapart, the diastolic are
rather to fall ; the pulseamplitude is larger.
Dr. Malcolm
One of our juniorgraduates,
Donaldson,1 carefully
1

Donaldson,

M., Thesis

for

degree M.B., Cantab., July

1912.

PART

and

Pachon's

them
sphygmometers, among
latter offered the tempting advantage

tested

Uskoff's,

some

which
of

GAUGING

PKESSUKE

88

he

not
figureswere
Uskoff's apparatus

the absolute
To

uniform.

tracings
parallel

if
gave a fair report ;
fairly
correct, their relations were
in
there is a preliminary
objection
l

Pachon's

Of

pulse and pressures.

of

before it falls

defacingof the smoked paper while on the roll,

the essential defect lies with
under the styles. But

the

expansion

line of

The

introduces

but

is necessary

of

or

strain.

from

protectsthe tambour

bulb which

rubber

capacityfor

Such

tection
pro-

error.

enormous

is not

balloon

the

recoil of

india-

the

impulses will tell variously

the radial phases of the bag. Furthermore, to
surrounded
by a stringnet,
protect this bag in its turn, it is
inextensible ; what
happens when the rubber bulb
practically
expands,as it does, to the diameter of the net it is impossibleto
but

straightline
according to

Brugsch's

Of

guess.

For

of

to

error

use

own

my

know

instrument

who
Margulis,2

reported by
Uskoff's.3

that

so

curve,

prefers it, on
have
thought
I

stick to the instrument

than

more

no

the

whole,

to

for uniformity

it better

accustomed

was

is

to.

shall not

forget that
and minimum
have ascertained maximum
when we
positionswe
records we
have
but a part of the manometrical
require for
If it be possibleby any external indirect gauging
clinical use.
of the
total
to
phases of the
get kymographic records
undulations
of arterial pressures, it may
be only by means
of
those of von
such large and costlyinstruments
as
Keckling4
of
hausen
and
Erlanger; instruments which have been tested
and somewhat
simplified
by the late Dr. Gibson, whose valuable
When

dealingwith

are

we

in this field is well known.5

work

for clinical use,

still out

the

hospital;

wards

of

On

Margulis,Zur

An

Pachon's

exp.
Vc,n

Von

machines

are,

however,

reach, unless it be occasionallyin

and

Gibson

told

me,

few

months

Halls Dally, Brit. Med.

see
Journ., Oct. 11,
Sphygmotonographie, Diss. Berlin, Aug. 14, 1911.
of

account

instrumental

methods

will

"

Path.

Pharm.

u.

Bd.

Recklinghausen's
of 1913,

tiiiL'uiahed from

See,

These

be

found

recentlypublished Studies on Clinical Medicine.

Recklinghausen, t)ber Blutdruckmessung beim Menschen,"

Wochenschr.

of

we

instrument,

interesting

Hawthorne's
4

phases

e.g.,

his

xlvi. p. 105, contains

useful
a
latest instrument
is described
in

Nos.

15-16.

His

oscillometer

Gibson, G. A., Quart. Journ.

Med., Oct.

1907.

in

Dr.

Arch.

f.
bibliographicallist.
the

Munch,

(tonometer)

kymographic apparatus.

1913.

is to

med.
be

dis-

CHAP,

up

he

standard

the

to

89

death, that he had

his lamented

before

INSTRUMENTS

VARIOUS

ii

not

strument
yet brought his in-

desired, and

could

not

unconditionally. Dr. Singer1 has made

in Gibson's
promise to
apparatus which

yet

it

recommend
modifications

he

service, but

ready for
If then

tells

that

me

his instrument

likewise

some

be

is not

of

yet

the market.
we

for

wish

pulseappreciationwe
fairlysatisfactory

perceive,infer, and record the pressures as best we can,

and then take a sphygmographic tracing(Mackenzie's
polygraph);
but, whatever
pains we may thus be able to take in a few cases for
cannot
research, we cannot, or we
yet, bring all these engines
in ordinary work ; not
mention
to
to
bear
frighteningour
must

"

patientsinto extravagant
We must
not forgetthat
insinuation
wall wave,

and

wall wave,

is not

the first wave

under

of the stream
or

tensions."

the cuff, but

stream

exactlythe first
the impact of the

it ; this increases

upon

as

the

beginsto unfold,and depends chiefly,

blood pressure, but upon
not on
pulseamplitude ; in other words,
the tapping on the cuff varies in recoil with the depth of diastolic
descent.
This rule appliesto tracingsfrom all cuff instruments.
Hensen
used to say that he could detect the returningwave
by
record as
we
palpationat 3 mm.
get a cuff and tambour
; can
this ? or must
near
as
palpation,or auscultation,be added ? If
have reason
the pulseamplitude to be large,and
to suppose
we
that the lever moves
much
before the entry of the returning
the line of returningstream
note
adding itself
stream, we
may
to that of the cuff impact ; thus
be
the descending line may
carried below the abscissa, a dip which, as the stream
finds its
through,dwindles out in four or five waves.
way
It is true that instrumental
fallacies touch rather the systolic
enclosed

than

parcelof

the diastolic pressures

be better
are

be

the artery

able to

we

most

slow ; in the

slow

chance, the lever has

the

doubled

below

the

index

of
1

cardiac

more

But

want, and

pulse the
time

but

we

to

know

these

should

we

diastolic pressures
get least,unless the pulse
these

has

instrument
descend

for

better

instance, in

fall even
extrasystoleit may
be an
If the height of the pulse wave
may
capacity,in diagnosisand prognosis,as we

pause

line.

could

interpretthose.

what
precisely
very

Singer, Lancet,

after

Feb.

an

5, 1910, and

Quart. Journ.

of Med.,

1911.

shall

later, diastolic pressures

see

the

of

the

between

vessel

Another

chief indications.
diastolic rather than

the apex of the triangle.The

under middle age to lie about
On

90 it is abnormal.

if over

50

to

mm.

subnormal.

Let

us

of these

measurements

are

we

is in

systolicpressure
or

and

"

is that the

"

normal
80-90

mean

the minimal

nearer

mm.

to

pressure,
phase than

it down

the

low,

very

continuallyobserving that

excess

know

hand, in health,a slow

carry

may

the

were

diastolic pressure seems

of 125
to a systolic

the other

relaxation

pulsewith largearterial
even

mine)
(italics
desire
why we

ness
ful-

the

and

pressure

beats

systolic
pressure

important condition, lies

very

As
significant.

more

are

reason

PART

again,1the

and

again

said

Broadbent

GAUGING

PRESSURE

90

while

be normal
may
to
further consideration

diastolic

then

give some
diastolic phases so

neglectedin

much

our

practice.
I have

said that if by external

methods

we

can

make

any

sure

approximationto these,it is by a well balanced oscillometer ; yet

here again we have no constants
C02 content,
: tone, elasticities,
of the body and of the diaphragm
to which
cannot
we
as
position
mental
always have our own
anxiety,these and other such
way,
variables,added to the defects of our instruments, hamper our
search
after true
criterions.
Mr.
Mummery
(in 1908) was
about the records of diastolic pressures,
the pressure,
sceptical
that is,immediatelyprecedingventricular systole,
but he used, I
think,mercurial gauges only,and perhaps was tempted to ask for
than the instrument
able to give. Indeed
Professor
more
was
Mac William thinks oscillation figures
untrustworthy,and apt to
too
high (p. 96). Moreover, it is in diastolic pressures
range
that the peripheralvenous
especially
congestion and inertia,
"

which

I have

mentioned

due to the cuff

(p.60),tell againstthe
with Hill and
Still,
a
long familiarity
Barnard's instrument
in guessingdiastolic
some
facility
gave me
from it ; and oscillometers have since been
pressures
improved
by von Recklinghausenand Pachon of Bordeaux.
ment
In the instruas

of the record.
precision

of
more

Pachon,

net, and
Muller

now

I think

and
1

Blauel

on

its

the periods are

trial,

there is less instrumental

2

and

three

French

E.g. Discussion,Med.-chir. Soc., Jan.

Blauel, Deutsche Arch. /. klin. Med,

Muller and

shorter

and

inertia.

physicians, one
1903.
vol. xci,,1907.

GAUGING

PRESSUKE

92

PART

and

of

capacity(Vol. II. p. 31) ; the conditions of heart's energy

If we had the product of output
the peripheryare big variables.
stillbetter, if with this we could
pressure, and,
calculations
make
could
some
velocityalso, we

blood

and
the

heat

doubt

no

work,

this internal work

the double

but

the external

as

then

even

heart's internal

of the

measure

(p. 98). But

done

external work

be

is

at
slackening,

have

passing into
only as great

not

Dr.

least in rate.

begins to fall,the

Jane way

experienceof us all that, as the walls of

the systolic
their elasticity,
pressure mounts
the

the

of which

most

be

exceeded.

the

diastolic

and
systolic

105-210
rate

In

mm.

of

aortic

In

the

forward, but

goes

Thus, with

the

difference

It is in

case

between
much

of my

between

the

as

at

own,

180, the diastolic

was

not

may

pressure

the difference
regurgitation
as
figuresmay be enormous,

32, the systolic

pressure

systolic,

its tion
proporless energy,

above

mean

certain Adams-Stokes

in

the great vessels lose

absorbs

falls ; the aorta

which
diastolic,

that

says

arteriosclerosis the diastolic pressure alters less than the

agreeingin this with Israel ; but in which mode of it ?

to

no

treble of it.

If, caeteris paribus,the diastolic pressure

heart

the

of

it

of

some

may

even

or

should

we

measure

90

mm.

diastolic

systolicand

the blood
waxing as the resilience wanes,
pressure
and
thus
racks
and
more
suddenly
largely,
bangs more,
machinery. The greater vasomotor
labilityin youth has

pressures
moves

the
a

like effect,but

the vessels

then

are

is stored ; moreover
energy
often confined to limited areas,

these
in

as

much

resilient and

more

peripheralrelaxations

blushingand

the like.

are

In

an

earlyhyperpietic,
or
nephriticsubject,the systolicexorbitancy
be
inconsiderable,
or
may
variable,while the diastolic is steadily
in

As

excess.

upwards;
a

of

Wildt

80-75
found

an

the

French

"

of 160
In

systolicpressures

rising"a sign,he
important maxim.

pressures

amplitude increases

(Wildt).

pressures

be

the

systolicpressure

diastolic

age advances

says,

In

may

cases

probably due to the enormous

hypertension diastolique
obstacle
par
were

authors"
1

for Dr. H.

Mann,

C. Mann

says

Guy's Hospital Gazette,Feb.

with

senile

pneumonias
the diastolic

failure.
the

and

80

associated

unpromising
and
falling,

of heart

those

be

to

This

may

risingdiastolic
venous

veineuse

inertia
"

that, as compensa22, 1908.

of

CHAP,

AND

DIFFICULTIES

ii

FALLACIES

93

diastolic pressure

begins to fall,and the systolic

we
are
irregular.When
observing the blood
readings become
in diastole the
heart, by the aortic valve, is cut off
pressure
tion fails,
the

from

with

distended

would

pressure

might mean,
capillaryareas
as

in many

or

to

fine holes in it,so

with

bag
not necessarily
mean
often does mean,

and
;

faster the fall.

But

the arterial tree

the arterial system, and

and, if
Such

another

the

so,

weak

be

due

take into consideration

we

dynamic

when

the

remember

we

all these

heart ; it

is,dilated
head

pressure

in

the

pneumonia,

toxic

to

influences ;

defective

exhaustion, or
simple atony, nervous
infinite.
here again the variables seem

When

that

"

of the stomata

may

compared
rapid fall of

weak

stomata

stronger the

relaxation

malady,

that

or
failing

be

may

nutrition.

conditions,static and

volume

of the

wave,

the

density of the walls, the thready pulse

big pulse with low pressure, meals and
they affect the splanchnicsystem, the
of trainingof the individual, the viscosity
state
or
velocityof
his hormones, his mental stability
his blood, his lung capacity,
inward
to which
factors, all modifying or overridingeach
many
and
pressure, the tone
with high pressure, the
the hour of the day as

"

to be

other, are

the tricks of the machine

added

; all these

tricks

and the consequent complexity of

fallacy,
to forbid all hope of scientific accuracy,
that
so
reckoning,seem
able experimentersdoubt the diastolic values of all or any
some
How
then out of this tangleare we
to pick out what
we
gauge.
?
cardiac capacity,
want
diastolic,and mean
systolic,
pressures,
and so forth.
Well, some
splanchnicconditions, tissue activities,
and

these

sources

of

"

of these

coefficients

still out

are

notwithstanding,I would
observers are
fairlyagreed. We
arterial pressure of a healthy man
constant, about
few

over

and

(male)

under

the

120

some,

morbid

compared

with

such

of

our

reach

plead that
are
agreed
of the age

yet, these

;
on

the

diastolic pressure

as

clinical data.
ranges

about

systolic

of 25 is very

athletes, are
young
conditions
the tests must
be
the

points

many

that

In

normal

80-90

fusions
con-

fairly
under,
plied,
multiadult

in children

Again, the arithmetical mean

(in
pressure
the aorta) is about equal to the diastolic pressure in the brachial,
varies
plus-Jrdof the pulsepressure there. The geometricmean
it

about

75-80.

with the form

of the

runs

curve

of descent, which

is not

simplelinear

GAUGING

PKESSURE

94
but
declivity,

PART

velocities.

of differential pressures and

indicate fairlywell, not indeed

complex

heart

do,

can

the

what

approximations

These

what, with gravityadded, it is doing.1 On

but

the

and
mental,
instruthen, consideringall the fallacies personal
comforting,to find the
it is remarkable, and in practice

whole

in fair

agreement.
of wave-arrest
by touch
appreciations
for age,

figures,
age
But

yieldingplace,at
Will this

method.

sight are
the present, to the auscultatory
Ehret's phenome?
non
assurance
"

better

giveus

is this,that at

"

for

rate

any

certain

the fingeron
slowlyfalling,
for the purpose) perceivesa

It has

in this artery.

throb

sudden

throb, within

this

that

stated

been

the pressure in the

the brachial (the radial is too

point,while

cuff is
small

and

few

millimetres,

is so perceptibleto the
diastolic pressure, and
patientthat his subjectivesensation might be taken as the mark

indicates

the

of the recovery

of the

this is

However

wave.

and
curiosity,

scarcelytrustworthyfor scientific methods ; what is of more

importance is that such pulsesare audible,as sudden alterations
of tension ; and it seems
probablethat their sounds may be taken
of the

marks

as

several

palpatory signs.

This

Korotkoff,4 whose

more

auscultatorymethod

methods

tried

rather

than

accuracy

initiated

was

by
verify

clumsily to

stethoscope.Dr. Oliver,5who did us the service

England of describingthis method, improved it by the application
of a phonendoscope,a broad flat surface which
exerts

with
in

with

moments

wooden

concentrated

no

In

pressure.

tambour
air-tight
and adopted by

Mac

the

this furniture

field.

cyclecan

With

to

be followed

maximum
the
1
2
"

cannot

the

instrument, which

and

fitted
has

we

are

to

Amer.

the

not
distinguish,

Journ.

approved

Physiol

in

workers

manometric

its minimum,

its relative intensities.

sensitive

been

other

it is said that

appreciatedin

by Percy Dawson,

Armstrong, H.
be depended

Oliver

William, Janeway, and

phases,which
qualityof tone, as by
See able paper
Ehret, Munch,

1911

mean,
so

much

and

by

Many observers,
vol. xv.,

1905-1906.

med.

Wochenschr., 1909, No. 12.

G., Brit. Med.
Journ., Sept. 21, 1912.

This

sensation

in nervous
excitable persons.
or
upon
4 In
a
read at Petersb. Mil. Med.
paper
Acad., Oct. 20, 1905, and again in
1906, and quoted in many
journals. Fellner discovered
method
the
same
independentlyabout the same
time (DeutscheArch.f. kl. Med.
Bd. 84).
6
Two
Oliver,G.
new
methods, etc., Roy. Soc. Med., 1910, Clin. Section,
pp. 8 and 207, and Quart. Journ.
1911.
exp. Physiol.vol. iv. No. 1, March

CHAP,

AUSCULTATORY

ii

METHOD

95

to the value of this method,1

are
testifying
foreign,
of
which
is of chief importance, for indications
especially,
diastolic pressure.
Schrumpf2 extolls the auscultatory as
of
are
superiorto any other method, and Oliver and MacWilliam
the same
opinion. At the Freiburgdiscussion,Moritz,on physical
grounds which he gave at length,argued that the auscultatory
method
indicates too high a pressure amplitude ; but Oliver says
that, being more
delicate,it gives a systolicpressure of 10-15
lower than the palpatory. Lang and
Manswetowa
made
mm.
and animals between
careful comparisons on man
the oscillatory
the auscultatorymethods, and, comparing the auditory
and
method
with the graphic curves
of von
ment,
Eecklinghausen'sinstru-

both home

and

found

them

may

information

also that

from

it

to the

capacityof the heart ;

this I cannot
careful
deny, as I have not myself made
any
comparisons of the method, but the arguments allegedfor it
far from conclusive.
Between
are
contrary opinionstime must
decide.
On the whole, Ettinger thinks that minus
and
tone
a
mean
plus murmur
failingheart ; this opinion at first
sight does not seem
probable, for, if the murmur
signifies
of
the
the
strait
critical
an
vessel, its loudness must
eddy at
the heart's energy.
With
depend somewhat
stiffening
upon
of the walls
all these
intensified.
On
the
phenomena are
we

derive

It is asserted

concordant.

some

"

as

"

and often erratic,variables in these estimates I have

intricate,
much

said

them

Ettingeremphasisesthe temporary
diameter
of the vessel, the degree of elasticity,
the size of the
the rate and viscosity
of the blood, and the heart's energy :
wave,
to these I may
add the degree of venous
congestionof the part.
already;

The

among

method

slowlylet

out

is thus

of the armlet, and

brachial artery,
1

See

Goodman

throb

and

find

in

med.

Wochenschr., 1909,

Arch.

f.klin. Med.

this

described

method

Ho well, American

approximation
med.
Wochenschr., 1910 (quoted in
Clinic),
Zeitschr.f.
exp. Path. u. Ther. Bd.

Moritz, and
German

see

valuable
2

from

beginsto

wave

silence.
Journ.

arrest, the

The

traverse

air is
the

transition,at

Med.

Sci., Sept. 1911, who

burg
Peters; Hoffman,
other journals) ; Bickel
(of the Bonn
Hit. 3, Jan. 1909 ; Fischer, Deutsche
v.
to

dynamic

values

article ;

Deutsche
Lang and Manswetowa,
Bd. xciv. Hfte. 5-6 (controls by animal
experiment); Schrumpf,
others, Protokoll, Naturf. Gesellsch. Freiburg i. Br., Juni 9, 1909,
journals of the time ; and Ettinger,Wiener kl. Wochenschr., 1907, a

contribution

Schrumpf

14, 1909.

the
the

breaks

an

; as,

and

important

an

MacWilliam

Zabel,

"

Auscult.

and pupils, many

important articles.
med. Wochenschr.,No.
Blutdruck.," Munch,

GAUGING

PRESSUKE

96
60-90

about

20

phase is maintained for some

but ceases
sharply. Thus
wanes,

this

and

laid down

are

the
signifying
four

both

"

"

then

(5th)silence.

absent.

murmur

The

vigour of

the

third

in its full

phase

it

ally
gradulimit

minus
the

1 mm.,

is

lower

dulness

inconstant, often

directlyas the
1
descriptionof the qualityof
Sterzing's

heart.

to

be

Oliver, and

he

said

feature

is the

agrees with

the sounds

plus and

then

sense),loudness, and

murmurish

The

is intensified,

Ettinger and Oliver formulate

faint pistolshot),murmurish-

phases: sharpness(clickor
(not

it is said, to

sharp, so

diastolic pressure.

ness

mm.

fairly

arterial pressures.

the

the throb

cuff pressure

increasingthe

On

quitesharp and

fallingwith

risingor

in all persons,

unifortn

is

silence to throb

from

mm.,

PART

that

of

us

warns

wise
like-

by the contact
2
a
phonendoscope. Dehio
of a
uses
says
indicates the complete collapseof the artery in
the loud tone
by
overcome,
diastole,first obtained, and the minimum
pressure
of the
the note
This he regards as
external
cuff pressure.
of the waning of the sound
diastolic pressure ; as the moment
he also regards the auscultatory
the systolic.Thus
betokens
method
the best for diastolic record (beginningof phase 4),
as
and Professor Mac William 3 is of the same
opinion. In disease
by differences,especiallydiastolic,as yet unexplained, the
4
Dr. Windle
auditory and the oscillatory
signsare discordant.
swish to dup ; dup rises to a
as
puts the sounds phonetically
maximum
and dies out as the air-escapes.On releasing
external
the sounds
take the inverse order.
On
the precise
pressure
of these sounds
observers
not
interpretation
are
yet agreed;
differ
somewhat
with
the magnitude of the
probably they
vessel under
the ear.
The
beginning of the fourth phase
to be
the diastolic moment.
seems
Von
Recklinghausen is
he
less sure
the
;
auditory with the palpatory
compares
method, to the disadvantageof the auditory,which, he says,
is at best not more
accurate.
The precision
of its data he has
phenomena
stethoscope; he also
that

the

may

altered

be much

Warfield,
.

Interstate

Med.

Journ.

xix.

Windle, D., Lancet, Dec.

1912, Nov.
9, 1911.

10, and

.,

Arch.

"

____.

Int.

Med.

x.,

Sept.

CHAP,

INSTRUMENTS

VARIOUS

ii

97

kymograpliicrecord, when he found it often

quitefallacious ("versagt nicht selten ganz");1 he regardsthe
(" labil und
auditorycharacters as rather unsteadyand capricious
launisch "),and says that a littlechange in the congestionof the
To avoid this, for diastolic pressures,
arm
modify them.
may
raises the pressure slowlyfrom zero
tillthe diastolic
MacWilliam
beside the

tested

other experts, among

Some
whom
was
appears.
part, I think more
agree with these criticisms ; for my
but
on
phases of vascular tone than is fullyrealised,

Gibson,

note

that in this method

have

we

the most

useful

depends
I hope

index, by indirect

and diastolic,
systolic
yet available.
invaluable
in the interpretation
of
Electro -cardiography,
of rhythm, gives us
cardiac function, especially
as
yet little
assistance in the study of pressures or of sclerosis.
Of small and handy machines for ordinarypurposes many skilful
and Gossage,speak well of
observers, such as 0. K. Williamson
Professor
I carry it in my
Hill's little gauge.
bag, and find it
in a
Its index is unstable
subjective sense.
decidedlyhelpful,
under
manipulation,so that it is difficult to exhibit a record
to
a
bystander not used to its little ways ; as a handy
using.
rough test however for one's own
eye it is quite worth
Herz
has produced an instrument, simple,handy,
of Vienna
and
Neimark,2
cheap," which I have not seen ; unfortunately,
it wanting : when
has tested
who
it, found
pared
carefullycomwith the R.-R. instrument, or with von
Recklinghausen's
inconstant.
Like an apparatus
graphicmachine, it proved to be
suggestedby Dr. Oliver,in order to avoid the discomforts
recently
of pressures

measurement,

"

"

"

ordinary cuff,it consists in part of

of the

so
only partlyfilled,

hand

of

the

from

moves

to

zero

the

folded round
less

observer

Oliver has

purpose

that its
;

higherpressures
the

as

arm,

which

take

does

that the

degreesslipup

hand,

indeed
1

the

and

Neimark,

better

seems

the

squeezed

down

the

Herz

than

the

with

every

by

For
can

the

this
be
and

narrow

Neimark
;

he

says

vacillation of the

small Hill instrument.

cit. (Beihefte, p. 226).

Diss., Berlin, Dec.

is

index

the

instrument.

hand-pressuremethod

Recklinghausen, loc.
2

VOL.

to

they do in

Von

effected

pointof pulsearrest or return.

provideda small sack bandage which

however

as

is

are

which

the

adaptable cuff figuredin

not

armlet

armlet

an

8, 1911.
H

from

the

fingerwithout

ranging

errors

; its fallacies were

use

adjustment of

careful

be got
and, if this initial difficulty

inconstant, the

PART

it is difficultto obtain

cold weather

glaring.In

and

of

has fallen out

Gartner's gauge

OUTPUT

OF

MEASURE

98

20

per

bath

water

warm-

stillvery

are

and

cent

many

pulsation

any

its records

over,

to

upwards

need
regards those diastolic pressures which we
The
most.
gradientof fall from the forearm to the fingerends
is very rapid.1 Fleischer of Berlin,in Strauss' Poliklinik,devised
colour tests, but on
which he relied,not on fleeting
a
gauge in
reactions in the whole
finger.2The finger,
plethysmographic
as
especially

warming, is passed into a stall of rubber

of mercury
volume
a regulated
; as the pulses
selves
they repeat thempropagatedto the mercury,

after any
necessary
around which flows

fingerare

of the

on

procured

merits, but

certain

have

vessel.

of the

instrument, which

the

I could

not

large mass
workmanship

metal

the

finger. As

was

in certain respects defective,I

of

Measurements

also,as I have

whatsoever

the Work

done.

of maximum

approximate notion
obtain

the

moreover

that

agree

surface

seemed

of

the

chilled

instrument

put it aside.
"

and

said,a notion

If

we

can

obtain

fairly

minimum

pressures we may
of the work which the heart,

is actually
its capacity,
performing(p.92). The

product is

to

inertia of

the

of metal

the

indifferent,and

the

was

the upper

from
springing

graduatedcolumn

tude-frequ
ampli-

said to be

equal to volume per second

divided by the arterial diameter.
Or by Haldane
and Smith's,
learn the relations of quantity per
Plesch's,method
or
we
may
beat and per minute.
It is said that during the pulsecyclethe
resistance may
be taken as constant
peripheral
; within ordinary
limits of diastolic phase this may
be true.
Yet the estimates of
work are widely apart ; those of Volkmann, Hiirthle,von
Frey,
Magnus, Hensen, so vary, from ^-thto Jrd of the minimum
figure,
that it is not

worth

while

quote them

textually. Hensen's
in man,
attempts to measure
output by the ordinary methods
careful as they were, issued in very divergent,
if not contradictory
results.
Gumprecht, working with Mosso, calculated the pulse
amplitudeat 30-60 mm., presumablyunder different conditions. In
the

rare
1

to

instances of direct measurement

See

Miiller
1

u.

Breuer, Deutsche

Fleischer,Berl

Idin.

of the output

Arch. f. kl Med.
Wochenschr., 1908,

on

the open

Bd.

xci., 1907.

No.

4.

what

clinicalobservers

as

of the heart's work

attempts

we

in the circulation,or
Sahli that

The

of this kind.

PART

anxiouslydesire,a

It is to Professor

per beat.

OUTPUT

OF

MEASURE

100

direct measurement

at

any

we

owe

instruments

rate

ous
assidu-

the most
have

we

put
of the out-

cussed
alreadydisforces

of the

resultant

than the
many
give us no more
able to analysethese in such
engaged in the cycle; but if we were
the several values of the factors concerned,
to give us
as
a way
we

be

should

enabled

to

with

provideourselves

others

and

importance. Hopke (see p. 101 n.)

giveus
instruments
(Hopke used Christen's)
but
so,

if

value

the

of

the

repeatedon

function

whole

great
these

think

only such details,

do
(output ?). They may

individual

same

of

data

not

at

the

hour.

same

In

of
previouspapers l I have pointed out how little our methods
in a particular
to know
do for the enquirerwho wants
investigation
what
qualityof heart muscle he has to deal with (Vol.II.
case
that by any instrument
I am
not persuaded
yet designed
p. 25),and
such analysis.Hopke however, following
enabled to make
are
we
; and typicalnormal
Christen, givesresults in gram-centimetres
the child's like

curves

(1)adult, (2)child

heart

(weaker periphery?).

characteristic curve,

He

says

an

that

crossingthe

the energy

adult's with

weaker

hypertony gives
resistance

curve.

He

cachectic states the pressure

pointsout truly that when in some
the poverty
to the fingernot
bad, by this energy
curve
seems
also with
out energy
of the pulseis betrayed. He worked
curves
and cooled, and under
the forearm warmed
adrenalin, digitalis,
etc. ; but I cannot
pursue this part of the subjectany farther.
of
the name
In
Sahli 2 introduced, under
1907
Sphygmothe "vital force"
bolometer," an instrument which was to register
of
and thereby a measure
(" lebendigeKraft ") of the pulsation,
of the volume, of the systoleof the
the work, and indirectly
"

heart
record

3
"

say 60

gram-metres

per

stroke of left ventricle.

the energy

It is to

it
effectively
given out, the cardiac potential
cannot
give; it may givethe Leistung,"but not the
Leistungsas
fahigkeit."The method seems
inadequate,for what we want
clinicians is this potential,
the cardiac capacity,
could be
which
tested only by tasks of work
done
under
the operationof the
"

E.g. Brit. Med.

Sahli, Deutsche

Sahli, Klin.

"

Journ., March
23, 1912.
Wochenschr., 1907.
Methoden, 5te AufL
1908.
med.

CHAP,

ENEKGOMETERS

ii

Sahli

But

instrument.

is

101

of this limitation.

quite aware

he assures
private conversation
he does not pretend to test the
have
should
thought that for

that

us
reserve

his

with

energy

his

In

instrument

of the heart.

plethysmographic
A pad exerts
would
methods
have been better ?
only a partial
the artery and can
hardly be kept plumb upon it
upon
pressure
without
slipping. Sahli suggests that a weight lifted by the
might be a cardiac test (p. 61); but such an
unoccupied arm
effort would, I fear, be difficult to arrange
without
vitiating
Sahli has listened to
In a trulyscientific spirit
the observation.
2
criticisms on his instrument, urged especially
by Christen
many
who
matics
brought to bear upon it a battery of physicsand mathe; and

reconstructed

has

his

purpose

apparatus four

or

five times.

and applications
of the mass
of a measure
and
principles
thrown into the system, the reader
energy of the blood effectually
of Sahli's instrument,
be referred to the scheme
and description
must
which
he showed
at the London
Congress of 1913.
for this purpose,
Christen has himself designedan instrument
it to me
In no carpingspirit
and kindlydemonstrated
in Bern.
I trust, I may
confess to an
abiding prejudice that, as I
have repeated again and again in this work, the hsemodynamic
For

the

conditions

are

radial artery

subtle, and

so

difficulties to

analysis.

under

conditions

normal

still to

inconstant,as

so

The

the diameter

offer almost

large variations

very

the

not

are

and

many,

so

least of the

of the

insuperable
of

output

difficulties.

Mathematics, freely used

serve
by Sahli and Christen, may
and
then to test principles
now
(Preface); but experience of
mathematics
in biology shows
that
its methods, admirable
far too
for interpretative
abstract
as
structive
conchecks, are
or
be obtained
applications
only
; definite results can
of the intimate
factors which
to
by eliminatingmany
go
make
the sum
in this
of the physiological
And
up
process.
1

Sahli, loc. cit. vol. i. p. 187;

also

Correspondenzbl.Schw.

Arzte,No.

16,

1911.
2

Med.

Christen,
Bd.

1910, Bd.

vi. and

(On

my

Methoden

neuen

Ixxiii. Hfte.

paper, considers
Exper. u. klin.
1913.

Die

"

1 and

2 ;

Also

Ed.

vii.

the state

reprint
in

Med.

d.

dyn.

Zeitschr.

no
an

Zeitschr. f. Id.
Pulsdiagnostik,"

f. exp.

Journ., Oct.

of the arterial wall.

Path,
1912.

und

Ther., 1909 and

Christen, hi the first

Hopke (of von Bergmann'sKlinik),

Kreislaufdiagnostikmit dem Energometer,
has since (1914) pubof journal.) Christen
name
lished
interesting book with ingenious charts.

Untersuchungen

his researches

and

ilber

submitted

I have

here, the

friends

mathematician.

PART

by Cambridge mathematicians.
Christen's designand argument to two of my
the other
a
one
physicistand physiologist,
both of opinion that there is no
They were
(" sphygmobolometrical (Sahli)or
curves
reinforced

been

have

opinion I

OUTPUT

OF

MEASURE

102

"

these

that

proof

bear
energometrical(Christen))
"

"

relation to the

constant

any

energy-output of the heart, the conditions being,as I have said,

too
complex. For instance, in the apparatus the compression
of the air of the
not

compressionis

the

so

cuff is assumed

but

mathematical

of the

this is

it is adiabatic, a

rapid that

so

upsets the whole

which

be isothermal

to

dition
con-

reasoning.

of
proved therefore, as a measure
be
cardiac energy, to be physically
accurate, though there may
margin enough for clinical approximations. The only way of
instrument
would
conditions such an
under
what
ascertaining
The

instrument

work

would

be, instead of the heart, to attach it

whose

pump,

is not

and

vasomotor

relation to the
has

be

could

energy

phases of

that

with

arteriosclerosis this instrument

but

Sahli's

the

of

Miinzer

energy.

artificial

an

bear

conditions, etc., should

pressure

publishedobservations

kraft

that

measured

so

to

constant

Prague,1who

remember

must

indicates that the throw

that,on

that in

instrument, says

(" Wurf-

") of the pulse-waveis considerably

raised; this may

we

of the loss of

account

of

curve

be true,

resilience,

far less of the heart's

energy is taken up en route by the large
elastic vessels,
and in each
a
quantitywhich is quite indefinite,
individual
of these
as

yet

those

we

of

method

variable.

Admiring

for the reasons

experimenters,
can
placetheir records in no
other and simpler manometers.
is

one

It must
Christen

unknown

an

of

be

seek to

promise for

understood
measure

the

that

is not

I do

as

I have

the

mentioned

work
I fear

effective

more

Still I

lightthan
hope that the

future.
the

the

"

volume

which

Sahli

pulsepressure,"with

and

which

I have dealt

already,but the exerted mechanical energy related to

the filling
of the portionof the vessel observed; the
volume
systolic
to
increases
(according them)
in cubic centimetres
measurable
the
of
volume
by
air displacedin the instrument.
This energy
I suspect in the same
individual and
For instance,
in fever filling
be
may
1

Miinzer,Wiener

kl.

in health

fair,but

Wochenschr.,1910,

No.

is very
at

38, and

inconstant.

low energy
other

papers.

; in

CHAP,

both

cachexia
in

be

scale

each

of

volume

the

the

of

arrest

(plethysmographic),he
so

arm

to

as

did, by the

way

time

on

when,

with

"

stream-clock

to

the

lie between

mm.

2-400

per

into

frictions,its

muscular,

and

near

to

influences

have

uniform

data

adjustment,

same

I had

observer, and,
1

these
2

am

sorry

wall

of hormones,

clinical agreement.

Christen

The
must

we

the

's book

we

has

med.

the

Hiirthle

he notes

the

returns

controlled

the brachial

to

his
1000

artery

quotient of

the

run

reached

we

and

the

the

to

part

say,

me

too

Wochenschr.,

Feb.

and

find

of

limb, the

same

for any

4, 1909.

so

wish

we

instrument,

the

late

ferences
inter-

subtle

surprised to

same

fat, lean,

of it all is that if
to

sider
con-

manometry

arterial walls, the

be

and

on

indirect

or

wave,

outcome

keep

that, when

paragraphs.
Fellner, B., Deutsche

as

"

faults, the

may

limb

same

almost

volume

calculates,on

I reiterate

changing

and

energy

He

that

(see p. 31).

the

arms,

affirms

compresses

; then

is equal
elasticity

difficulties of external

bony

venous

He

inertias,its mechanical

of stream
various

of

By dividing the output by

the vessels and, according to

second.

pulse rate

the fallacies and

its

their

He

velocityin

of

of all this discussion

sum

3rd

value

energy

compression, colour

the calibre of

reckons

Kecklinghausen,
In the

of

lengthening

rate, and

bandage

animals.

on

the variations

pulse pressure

the

to

fingertips.

observations, that

von

effort ;

arterial and

of the

release

method

velocityhe

claims

of his

shortening

cardiac

Esmarch's

an

method)

the

may

independent

energy

alluded

it of blood

empty

gradual

the

out

pressure,

pulsepressure, stream
separate velocity.

can

(on the Gartner

by

mean

computations, Fellner

energy

the three components,

whole

of

pulse

put

energy

palpable wave.

In respect of these
from

wiry

"

low

displaced air.

I have

stroke.

powerful

of

record

a feeble
auscultatoryphase signifies

of it

the

(p. 96) is of opinion that

Warfield

the

percentage of

direct

of the

and
elasticity

in

plus ;

"

be

may

provides a logarithmic differential

the

beat

instrument

manifested

is small,
filling

Christen,1who

giving to
his

be

may

the

disease, while

enormous.

for

both

103

the energy

and
filling

the

disease

aortic

renal

COMPONENT

VELOCITY

ii

the

same

patient !
modification

of

III

CHAPTER

in

occupied

and

demonstration

to

foundation

this

before

they

methods

chemistry

and

had,

understood.

The

calculated

by

muscular

confederacies

Basch,
forth

and
;

the

on

Ehrlich

subtlest

and

others

of

evanescence

patience

and

analysed

and

calculated
1

April

This

section,
voL

iv.

No.

of

such

of

many

re-edited,

in

On

was

other

104

and

the

several

of

such
the

on

von

the

these
that

as

hormones

as

those

we

admire

Quart.

and

have
and

has
Journ.

munity.
im-

the

departments

the

of

of

counterplay,

perseverance
in

researches

fleeting phenomena,

lines

so

Einthoven

work

by

the

on

few

activities,

published

15.

being

are

pressures

problems

their

fluids

Ludwig,

but

swiftness,

which

and

Arrhenius,

processes

an

principles

solids

Marey,

Starling

in

motion

Sherrington

arterial

dynamic

motions.

now

of

of

body

physics by

the

these

recorded

their

1911,

respect

assiduity

of

mention

to

and

realise

we

those

Waller,

biological
in

human

the

said,

penetrating

are

living

but

vanish

and

mechanical

the

chemical

secretions,"

When
the

the

of

the

on

"

of

upon
;

have

laws

Hales,

Sanderson,

on

the

on

of

physics

again,

internal

"

on

as

followers

Pfeffer,

of

methods

molecular

pioneers

and

such

their

of

knowledge

mechanics

physicist

properties

day

conditions

as

the

living

description

own

our

been

the

to

diagrams,

our

Without

the

nor

of

dynamic

modern

comprehensive

be

cannot

the

of
medicine.

and

accurate

the

Nevertheless,

seen.

analytical

of

task

the

flux, elude

continual

are

is

discover

to

in

being

these,

it

conditions

themselves

lend

which

conditions

organism,

statical

the

of

discovery

have

investigators

modern

Vesalius

of

time

the

FROM

BLOOD

THE

OF

VISCOSITY

THE

found
of

Med.,

CHAP,

less reward.

OF

VISCOSITY

THE

in

BLOOD

THE

105

if
instance, in the physics of the circulation,

For

have
done, yet for the most
part, as we
alreadyin the pages of this book, these dynamical currents are
been

has

much

slippingthrough
indeed

that

in the delineations

even

is stillmuch
sides of

to

siderable,
Conhost

there

electrical
of the

outlines

bodilyjuicesand surfaces, and have

to practice.However,
applicable
principles

activities of the

attained

as

it is

of the conditions

one

yet

in

essayed

but

to few

of advance

respect of the

time

from

that

in the

and

position;

our

survey

humble

definite

even

and

still

have

we

mechanics

the chemical

on

lack

we

been, yet

of its massive

be desired ; while

haemodynamics

molecular

should

have

into the tides of the blood

of observers
seen

escapingour reckonings.
of a
the investigations
as
successful,
signally
and

snares

our

seen

time

to

followingarticle

viscosityof

the

blood

we

I have

such

some

task.

necessary

of a fluid,
degree of cohesion of the particles
of the circulation of the blood and
factor in the efficiency
as
a
lymph, although not without recognitionin Germany x and
France, has received little attention among
English observers.
In America, by the work
of Russell Burton-Opitz2 and others,
this factor is well recognised; yet nevertheless I read last year,
in a useful little treatise on
American
arteriosclerosis by an
The
physician,this astonishingsentence
:
viscosityof the
blood, as such, probably has very little effect on the resistance to
or
Viscosity,

the

"

the flow."
"

such

"

as
runs

this sentence

Can

And

bantered

what

it be that

freelyalong its

as

In

does

the author

channels

have

of Poiseuille ; and

any

due

would

I will admit
prepossessions,

another

to many

e.g., Senator's

1907.
Gegenwart, Marz
2
Burton-Opitz, Journ.
other

what

and

do,

hol
alco-

or

"

me

to the conservation
gravitation,
to our
applicable
present subjector

See,

mean

believes that the blood

water

as

"

on

British critic of my
studies on the arteries lately
3
for that I
stillclingto viscosity."
Well, if a man

of science may
to

"

"

article

of

on

Amer.

the

of energy

"

cling

also,and, whether

not. likewise to the law

theory which

treatment

Med.

that I

laws

or

has survived

by

'of arteriosclerosis,Ther.

Assoc., July 29, 1911, and

dt

many

papers.

Sir Lauder

regard
of May
10,

to

Brunton

of a
gives the weight of his authority to the need
gives some
interestingillustrations in the Lancet

this factor, and

1913.

universal

And

consent.

multiplywith

must

when

friction in

that

fluid

with every increase,

viscosity,
of the fluid,and when
we
particles

of the

nearly200 times
overcoming friction

also that

remember

PART

increase in

every

that is,of the cohesion

know

we

BLOOD

THE

OF

VISCOSITY

THE

106

of the heart's energy

more

than in direct transference

expended in
shall scrutinise most
to the stream,
of velocity
we
carefullyany
fluid ;
small,in the stickiness of the circulating
degrees,however
times
for these, calibres being constant, will be multipliedmany
in the degree of internal friction
And
in frictional resistance.
is reduced, although in
the velocityof the stream
(viscosity)
livingblood vessels,contrasted with straightinorganicpipes of
remain
uniform
bore, the pressure may
unchanged. It is true
fluids viscosity
be so
notwithstandingthat in the circulating
may
balanced
to be virtually
constant
be aca
as
cepted
; and, if so, may
both sides of our equationsand currently
as
on
disregarded
;
and if it be said that in comparison with a widespreadarea
of vasoconstriction viscosity
motor
would become
a vanishingfactor,we
be ready to agree.
It is true that this other chief factor
may
is

in

the dimensions
resistance,

under

the influence

of the

of the

tubes, is far from

within large limits.

That
the
continually
shifting
pulsatingstream, Hiirthle says, is no great matter.
On
to

the whole, relative

and,

measure,

physicallaws

are
degreesof viscosity

if

even

measurable,

vital fluids and

to

the

organism as to maintain
is the case with
as
stability,
in

more

study

less

or

of the

and
and
the

output
heart's

if

; or

It is most
1

vital

Thoma,

The

arterial pressures,

be
may
heart may

fall and
viscosity

increased.
the

Deutsche

Arch. /. kl

or

may

pressures

If blood

in

able

an

about

come

not
are

be sent

other

maintain

constant,

through,

be normal
pressure
nevertheless
be
may

ascertain
Med.

but also

excessive,or

blood would

capillary
system

difficult to

condition,

of
protectiveharmonies
is said, not only in relative

work

constant, more

work

velocitythrough

abnormal.

heart

accumulate.

vessel diameters
the

the

difficult

is still beset

subject,
said,1this compensation may

divergences
may
same

the normal

it,as

application of

our

abidingequilibrium. Still,
as
Thoma,

in different ways

the

it,so it

of

arterial is

most

their continents

with fallacies ; however, the standard

is so
incessantly
readjusted by the

otherwise,it is

and

system

nervous

constancy

at

once

vol. xcix., 1910.

both

the

Of methods it would
knowledge to speak ;
importance,and those

the

as

seem

the

difficulties and

of my
been

own

of

been

have

witnessed

I have

which

to

me

PART

experiments have

own

my

What

few.

become

not

BLOOD

THE

OF

VISCOSITY

THE

108

no

paratively
com-

fallacies of the

presently: difficultieswith venesection

(inman), with the coagulationof the blood, with its gas content,
with changing temperatures, and indeed with the very application
shall see, there
As we
conditions.
of physicallaws to living
the principleof comkinds of viscometers ; one
on
paring
two
are
research

shall

we

are

see

sample with that of water, the other of the

Hiirthle's method,
rate of transit of a body moving in the fluid.
Hirsch
valuable as are his results,is applicable
only to animals.
and
is frequentlyused
in Europe,
Beck's
viscometer, which
requiresnot inconsiderable quantitiesof blood, and takes it in
the venous
state, a state in which, as we shall see, it is of higher
the blood
the left
we
as
viscosity
prefer to know
; whereas
ventricle lifts it. The
earlier viscometers
did not
provide for
the flow of the

constancy of temperature

but

in his last model

Determann,

to
by jacketingthe tubes, aims at this constancy, and moreover
provide blood enough for the estimations by a simple puncture
of ear or finger
0-2 grm. is sufficient. Walter
; in his instrument
l

Hess
and

in his

together,enables

near

the blood

under

ready and

can

be

cleansed

probably sin

less

on

with

or

this instrument

quickly,and
the whole

been

field.

It is said that the

observers

the best ;

closelyaccurate,

he who

with
comparison of glasscapillaries
the safetyof the inference from the one

course

hitherto

seems

The
and

the
two) of ascertaining

if not

than

the rate of
compare
flow of water.
As a

to

that of

(in a minute

the bedside

glasscapillaries
parallel

the observer

examination

quick way

at
viscosity

it

instrument, by fixingtwo

will

it.

uses

the fine blood

to the

vessels,

other,have

of

thoroughlydiscussed by all experimentersin this

techniquemay be trusted, for certain

have

stated

that the

blood

column

in the

aorta

of

Hess (Walter, of Zurich),Deutsche Arch.

f. klin. Med., 1903-4, Ixxix. 128 ;
(on instruments)M iinch. med. Wochenschr.,1907, liv. 2, 1590
; in collaborawith Determann,
"""n
"Die
Viskositat des Blutes
bei Gesunden,"
Deutsche
rcA./.khn. Med., 1908, xciv. ; see also Traupp,
Etudes sur la viscometrie,"
quoted Jahreab. /. Kinderheilk. vol. xxxiii.
also
116

and

"

suppls. (See

L.g. Hirsch

in

Heubner, Arch.f.

1906

and

exp. Path.

Beck, loc. cit.

u.

Pharm.

Bd.

But

to

the

liii.p. 149.

p.

contrary

see

n.)
Wolfgang

CHAP,

METHODS

in

freshlykilled animals, by
wall, forms
of

adhesion

of

109

the

blood

around

meniscus, that the blood does

concave

it does

that

artery, and

an

ESTIMATION

OF

not

slip;

or

the

the

wet

if it does

wall

the

that

in the peripheral
vessels
And
negligible.1
oscillation is merging
be neglected,as in them
The
is not
into
continuous
flow.
term
a
capillarytube
signifyidentityof diameter with the
physiological
; it does not
of the circulation,but tubes of small if not constant
capillaries
in which
otherwise
than
in large or
fluids behave
diameter

slipis occasional
pulsationmay

and

"

"

Of

channels.

middle-sized

of fluid and

surfaces

in

course

full tubes

this attraction

attraction," as
capillary

"

air, or

is

no

lies between

contiguous
different qualities.

fluids of

of two

there

fallacyof tube diameters, Determann

in his estimations
has frequentlyused in the same
experiment
tubes of three calibres ; namely, tubes traversed
by water in
7-6 sec., 12-3 sec., and 58 sec.
respectively.He found however
However,

eliminate

to

these limits the calibre of the tubes

that within
2

Tigerstedt

with

agrees

Poiseuille's law
to

any

Hiirthle

said, with

be

may

and

Hirsch

was

unimportant.

and

Beck

slightmargin

very

that

of error,

hydrodynamic processes in the circulation (but

p. 38), but other experimentersdo not hesitate to bring
into serious doubt ; they are
far from sure
methods
that
the

express

comp.
lese

'oiseuille's law, which

is true

for

solutions,holds

also

for

for suspensionsin which the floating

especially
icles are, relatively
speaking, large,and also various in
ize.
the mode
of motion
May not such corpusclestransform
and of friction from
cylinderwithin cylinderinto that of one
in all parts of the transverse
rate
cylinderof the same
tion
sec?
If so, the
This questionis asked also by Rothmann.3
result cannot
be accepted until the tube diameters
in relation
to the size and
number
of the corpuscles
are
known, a complex
function not to be settled by simple application
of Poiseuille's
law.
leave
This problem I must
to
those competent
to deal

isions,and

As

such

is still the

leave this as
current
opinion,I must now
Quarterly Journal
of Medicine, and previously in
Dr.
but
this
doubted.
See
14, 1903;
opinion is now

1911, for the

Feb.

observations

on

page

38

; the

question

Tigerstedt,quoted by Krone,

Rothmann,

Rothmann
Juni

"

thinks

2, 1913.

1st

at any
Rothmann

das

Deutsche

the wall

is Assistant

the

it in

Lancet,

John

present in suspense.
Wochenschr., 1910, xxxvi.

Tait's

is for the

Poiseuille'sche

rate

I wrote

med.
Gesetz

is wetted.

in the

1438.
"

Suspensionen gultig?
Berl. kl Wochenschr., No. 22,
fur

Breslau

PhysiologicalInstitute.

if it be true,

it ; but

with

does

blood

hold

will not

of

blood

for these channels"

the

vessel, Poiseuille's law

awkward

an

PART

experiments,that

in Tait's

as

the wall

wet

not

BLOOD

THE

OF

VISCOSITY

THE

110

dilemma

son,
Our
graduate Dr. W. L. JohnViscosity."
in his thesis for M.B.
Cambridge, 1912, described what is
not exactlya viscometer, but a very simplecoagulometer;
really
here.
Glass
be worthy of mention
it seems
to act well,and may
and
Coagulability

tubing drawn
into lengthsof

closed in flame.
boiled

are

in

After

tube.

and

2 cm.,

about

and

1-23

between

to

1-37

end

one

of each

Very small shot, picked out

shot
One
spiritand dried.
is introduced

blood

the

calibre,is

mm.

the

cut

pieceis partially

as

is

about

placed

ends

are

10

mgr.,

in

each

placed

jaws of a dressingforceps,on each of which a little

has been placed,and thus the tube is dipped in water
plasticine
kept at 35-8" C. by an electric lamp plunged in it,which serves
the

between

also

illuminate

to

the shot
In each

rolls to

the
and

three

case

or

The

tube.

fro, and
four

constancy for his method.1

tube

the time

readingsare
Dr.

Welsh

is

now

so

rotated

that

of its passage
is noted.
made.
Johnson
claims

however, in nine various

patients,found no direct relations between

coagulation time
(Addis method) and viscosity
; but Mayesima, like Dr. Turner
(p. 150),is of opinionthat the shorter the coagulationtime the
higherthe viscosity.In a preliminaryessay Holmgren 3 discusses
the relations of viscosity
to coagulationtime.
Having shown
the considerable
influence of the polymorphs
viscosity,
upon
and of viscosity
coagulation,he proposed to try whether
upon
like relation exists between
no
a
or
leucocyte form (" Leucocytenbild") and viscosity
(p.125). Up to the present his result is
that viscosity
depends largelyupon the polymorph : lymphocyte
quotient. If this be verified,
scattered facts may
be pulled
many
either
as
together;
baths (p.147),
reagents,such as glycerine,
or
as
excitants of
actingrespectively
as
minants
deterpolynucleosis,"
or
as
"

of the
rule may

See

of

find support in

effect of gases

areas

also

in the

"

on

polymorphicdistribution. Holmgren's
the low viscosity
of typhoid blood.
The

of C02,
blood, especially
may

Coagulometry," Dale

and

Laidlaw,

Journ.

vol. xvi., 1912.

1
3

Welsh, Heart, vol. iii.No. 1, 1911.

Holmgren, I., Deutsche med. Wochenschr.,Jan.

30, 1913.

be

Path,

by
and

some

Bact.

CHAP,

mediation

such

of

optimum

an

when

with

surely depend

also

so

the presence

on

of any

not

To

amount.

111

blood

But

pressures.

on
specifically

of calcium

amount

these

add

in defect

is not

calcium

COAGULATION

likewise

and

coagulation must
content,

AND

VISCOSITY

in

probably

salts

salts,but
the

by

would

calcium

have

mouth
effect

no

experiment a neutral salt,if concentrated,

prevents coagulation.
As regardsthe interference by the coagulationof the blood
that during the first moments
of venesection
observed, it seems
blood
alteration ;
the
does
not
still
undergo substantial
at

all.

arterial

In

careful

"

may

of Determann
conditions
records
each

has

be

to

work.

made

too

"

instance, Determann's

; for

therefore

are

however

relative

observation

Denbrinismg agents such as oxalic

alter its qualitiesconsiderably. The
instruments
identical in their physical
and
Hess
not
are

rapidlyfor
acid

the

condition

this

under

values.

Determann

wider

are

directly comparable :

not

consistent

are

tubes

within

those

themselves

hirudin

uses

their
of

and

give
quantity,

in minute

this agent may

interfere with the
suspectedthat even
normal
propertiesof the blood ; certainlyit must facilitate the
of the corpuscles.Dr. Welsh, in a case
of haemophilia
precipitation
in which
that
slow, found
coagulationtime was
very
hirudin
did not
with and
modify the viscosity
; the viscosity
it is

but

without

hirudin

the

In

6-108.

was

seems
anaesthetic,
morphia especially,

effect ; in chloroform
to rise.

Scarpa x

discussed

and

narcosis
Luziani

and

forms

the

case

have

to

of

animals

modifying

some

the
2

viscosityof the blood is said

have analysedviscosity
problems,

of viscometers

with

solutions

of pyrocate-

chine,hydrochinone,etc., with the aid of mathematical

with

which

seem

to

I
to

me

Professor

am

come

not
to

Wenkebach

That

conversant.

much

an

was

told me,

these

probably my

methods
did

papers

not

fault.

in 1911, that two

of his
"

pupils,
"

ideal
an
physicistand a chemist, claimed to have made
for temand constant
perature.
viscometer,avoiding all known
fallacies,
It was
to be, and
is, described in
presumably now
thinks that
Cheinisse3
Dutch, a language out of my reach.

Scarpa,

"

Lo

Sperimentale

sulla

viscosimetria

et path., Nov.
sangue," Arch, de la biol. norm,
2
1910.
Luziani, ibid. fasc. May and June
3
Cheinisse, L., Sem. med., Dec. 21, 1910.

1911.

tensione

superficiale del

improved

the

with

BLOOD

THE

OF

VISCOSITY

THE

112

studies

instruments

on

PART

issuing
largely

viscosityare

practicallife. He notes how

observers
are
agreed in comparisons of age, sex, diurnal
shall see
It is true, as we
presently,that these
etc.
curves,
in refraction, in
kindred
qualitiesoffer to us in electrolysis,
osmotic pressures, and in chemistry,alternative and controlling
from

of measurement.

methods

experimentersare

However,

yet

as

satisfied with

from

far

hitherto

viscometers

various

the

of

one

any

into

academic

an

invented

and

laboratoryof W. His of Gottingen,whose work in

vancing
field givesweight to his opinion,thinks that instead of adis usual in instrumental
to greater simplification,
as
in the

Adam,1
this

viscometer, if it is

the

progress,

in the

inherent
contingencies
elaborate

more

instruments

be

may

points our

some

delicate.

too

various

many

of the research, must

nature

although on

even

the

meet

to

For

we

come
be-

imperfect
baffled

are

of the
delicacy of the mechanics
matter,
by the infinite complexity of this
yet more,
problems in their physical,chemical, and vital

the

not

only by

but

also, and

and

the kindred

potencies.
with

For

the mind's

let

eye

endeavour

us

to

obtain

vision,

various modes
of
glimpse,of these myriad and infinitely
of space throughout
streaming forth in all dimensions
energy,
the animal
body ; forces so fleetingand yet so perennial,so
or

intricate and

yet

subtle

specific,

harmonious,

so

elusive yet

and

universal

so

and

yet

so

nicely

in
mighty.
swift,so quickening,
; in their spring so
implicitwith the cadences in which they are to vanish
yet ever
when
the symphony is over.
With
a
pertinacitywhich indeed
is born of them
microscopes,our manometers,
our
we, with our
so

the

balance

We

so

live but

of them

viscometers, our

electrometers,our

polarimeters,year
plottingout
mazes,

scheming diagrams of their

centres, their rings,and their chains,threadingthem
now
and
here
and
then,
there at some
aiming
exact
measures
are

year

their

features ;

streamlines

chemic, and, what

salts

we

permeating and

them

by
1

are

Adam,

Zeitschr.

their
and
of

tensive, diffusive,osmotic, ionic,

fain still to

the
spinning

evanescent

after

more

phases from

call,vital
static

dynamic

and
colloids,

suspensionto

f. klin. Med., Berlin, 1909,

the

ing
pass-

solution and

Ixviii. 177.

CHAP,

CONCERT

THE

in

oxidation.1

Nay,

purpose
indeed
Vain

nature."

them, without

world,

"

"

to

paintthese

solar system,

of

such

endeavour

some

113

strength,animation,
great Chime and Symphony

the

are

cell

every

prismaticfountain

immeasurable

and
of

molecule

organism

every

LAWS

vain it is to try with, words

how

influences ; every

PHYSICAL

OF

to

words, and

yet without

this vast

express

tudinous
multi-

and

and
symphonic dance, we might
rhythm, this mazy
isolate one
by one diffusion,osmosis, ionic stresses, gaseous
tensions,and so forth,as we might pin out upon a board the
several items of the body
its bones, its tendons, its nerves,
and yet form no vivid conceptionof its functions as a whole.
And
if we
do attain to any vision of this unity in complexity,
first marvel
of the poise of these bewilderingrhythms, in our
of harmonious
at this infinite concert
energiesmay we not recoil,
in his amaze
Darwin
at the beauty of the human
as
eye recoiled,
in momentary
from his own
incredulity
theory ?
A certain effect,or expression
rather,of this concord of infinite
velocities and exchanges is that we
seize no
of
moments
can
arrest
can
during which by our machinery static measurements
be made.
infinite mind, we halt
Not having the cosmic eye, nor
between
arbitrary classification and functional jumble. If
from phase to phase fluctuations must
be, or may
be, large,
held up again ; stillunless,on account
they are consentaneously
of the fragmentary outlook
mind
of the human
and of other
limits of its faculties,
after some
catch
can
we
arbitrarymanner
them
flying,and get some
kinetographicrecords of exposure,
must
we
give up the hope of attainingto a scientific knowledge
"

)f the

functions

become

demand

of the

circulation.

If the

viscometer

clinical instrument, yet the

handy

cannot

clinician must

approximate calculations
of the potent if not
factor of viscosity.If, like the
dominant
hydrogen ions, in health always,and commonly in disease,it
be so incessantly
to be virtually
a
constant, so
as
equilibrated
much

from

the

some
physiologist

the easier for

this constancy

at

"

us

any

; but
rate

shall not

we

laboratory
experiments convince
approximation
1

For

an

to

us

states

of

either of

to assume

disorder

until

"

uniformityor

of

it.

interestingsurvey of these
Roy. Soc., Aug. 12,

Schryver, S. B., Proc.

VOL.

in

not

fresatisfied

intimate

physico-chemical laws

1910.
I

see

that

the

blood

the

suggested

relations of blood
arterial pressure the space
lating
altered, and therewith the density of the circu-

are

fluid.
also to

have

high

under

lymph

and

PART

of Dr. Oliver

observations

well-known

Certain

BLOOD

THE

OF

VISCOSITY

THE

114

Erb,1
younger
that with
conclusion
The

concentrates

(p. 118), came

see

rise of arterial pressures

the

contains

"

shall

we

as

solids ;

more

and

that

as

dilute ; though this reaction is

more
pressures fall it becomes
this point of
From
the previous concentration.
slower than
Mr. Mallock
(Nov.
papers read to the Royal Societyby
24, 1910) are of interest ; in these, by inorganicapparatus, he

view

two

that in

demonstrated

"

viscous

flow the character

of the stream

decreasing or
accordingto whether the flow is towards
think
subsequent observers
increasingpressure." However
that in the animal
body such changes are not due, or are not
exudation
and
of lymph from
the
return
notablydue, to mere
differs

blood
in

vessels,and

that the ebbs

and

distribution

lymph nitration. Besides,

such and so free are
the molecular
amid
all the
reciprocations
that in these respects the lymph, which
is actually
bodilyfluids,
the medium
of the cells,
be taken as the equivalentof the
may
blood ; indeed
Botazzi 2 and his pupils seem
have
to
proved
this upon
animals ; so that little or nothing is to be gained by
separatingblood from lymph as one of our necessary if arbitrary
divisions of the subject. To Botazzi's work I shall make
some
predominate over

areas

reference later

those

flows of blood

of

(p. 118).

What

analyticdivisions then can we conveniently make ?

In the first place our
experimentsare restricted to capillary,
or
virtuallycapillary,
tubes, concerningthe physics of which, by
the labours

of Poiseuille and

and

such

within

frictions
and
As

are

within

tubes

most

the

others,we

in the

tenacious.

viscera,are

body
The

affected

are

instructed

it is that
currents

by

in

other

approach the peripheral

find the
areas
we
rapidly. And in the blood it is of importance to
we

already;
the circulatory
larger vessels,

conditions
resistance

also.

rising
watch
not only
its behaviour
as
a
whole, but also,as we shall see, dividingthe
corpuscularelements from the plasma, to calculate the viscosity
of the plasma and the blood
severally.By the corpusclesthem1

Erb, Deutsche Arch. f. klin. Med., 1907.

Botazzi, Biochem.
Zeitschr.,1908, vii.,quoted by Determann

BLOOD

THE

OF

VISCOSITY

THE

116

PART

high in athletes (5,800,000

variations lie in varying
to 6,000,000). Probably the irregular
percentages of red corpusclesand haemoglobin. Besides, the
must
themselves, as requiringshoves in narrowest
corpuscles
vessels,exercise a mechanicallyretardinginfluence,so that in
1-0 or
fall to
maximum
channels
such
even
velocity may
has indeed

Welsh

the red count

Nevertheless,

0-5.

to

found

if

even

77

be

within

limits

of

the

possiblenormal, and indeed if the haemoglobin figurealso be

not positively
abnormal, yet, accordingto Hess, if the quotient
outside

be

i"rr-

limits

the

17-21, the

of

condition

is

haemoglobin
There

In

the

within

difficulties also in

other

are

normal.

haemoglobinfactor

the

To

abnormal.

for

woman,

normal

the climacteric,and

to

shall return.

definingthe

instance, is pregnancy,

In

we

woman

fall after

in pregnancy
a
in the latter time
blood, especially
found

is

limits

of the

menstruation,

to rise before
viscosityseems
it. Ribaudi,1using Hess's instrument,2
fall of viscosityof the whole
of it,until justbefore parturition,

if the birth were

hard one, or
a
especially
in eclampsia to fall immediately after delivery. The viscosity
of the blood is higherin the foetus than in the mother.
During
blood
does not
rise.
suckling the viscosityof the maternal
a
Similarlythere is, he says, a premenstrual rise of viscosity,
fall during menstruation,and a rise to normal
immediately after
it. Again, idiosyncrasy
plays its part, perhaps a considerable
various speciesof animals
Hiirthle found
such
one
; between
differences : dog'sblood he found about 4-7 ; cat's blood about
when

it

rose

"

"

rabbit's blood

4-2 ;

3-3.3

about

fluctuations

during the day

nervous
diet,

and

and

so

see,

their

forth.

the

Then

again

effects of

there

are

certain

meal-hours,exercise,

temperamental influences (especially

vasomotor),
Climate
and altitude likewise have, as we
shall

effects

on

the

in Arch,

viscosity.I
des mal.

shall

not

quote

many

quoted
coeur, 1909, 256.
Kagan and others have shown that this instrument is liable to some
fallacies.
See Kagan, G., Deutsche
Arch. f. klin. Med.
Bd. 102, Hefte
1 u. 2, 1911.
It
is too simple for the complexity of the requirements
(p.112), and sedimentation
of the red corpusclesalso vitiates the readings. Determann
Hess
and
have
combined
since made
a
instrument, avoiding the faults of either.
See also
Miinzer and Bloch, Zeitschr. f. exp. Path. u. Therap. ii. 2, 1912.
Hess, in the
Berlin, klin. Wochenschr.
of 1912, discusses instrumental
fluence
capacity and the inof pressures on the coefficients of blood viscosity.
8
Hiirthle,PflugersArch. f. ges. Physiol.,Bonn, 1900, Ixxxii. 438.
8

Ribaudi,

du

CHAP,

LIMITS

in

figuresin

these

OF

for
enquiries,

NORMAL

THE

yet, such

as

117
the discordances

are

have

little firm

the

food-stuffs,may

ground for generalisation

if some
them.
from
Concerning diet and blood viscosity,
could be formulated
definite conclusions
they would be very
helpfulto the physician; but the reports are discordant. Hiirthle,
and Burton-Opitz,upon
animals, inferred that changes of diet
in variations
reflected largelyin the viscosity
even
were
curve,
Determann, on the contrary (in man),
so
largeas 20 per cent.
comparing vegetarian and animal diets, strictlyobserved for
became
some
days,failed to convince himself that these extremes
1
likewise
of viscosity
Bence
perceptible in terms
; Julius
failed to find any
loss of viscosityon
a
vegetarian dietary.
that the blood, in gathering and selecting
its
It seems
to me
of various

own

observers, we

materials

out

of

of supplies,at
irregularities
are

to

be

got

out

of

any

either

rate

for

diet,

well

days

some

and

neutralise

extremer

teins
pro-

tions
varia-

in

effectual.
electrolytes,
probably more
e.g. salts, are
In our
everyday work much must depend on such adaptations;
though over much longerperiods a year or a decade of years
alterations
established.
We
more
might become
permanent
shall see that in plethorics
with high blood pressures Determann
himself has noted a higherviscosity,
and it is said that in animal
experiments large feeds of flesh raise the viscosity.However,
in this respect may
be
comparisons between carnivora and man
invalid.
It seems
likelythat, in dogs for instance,the viscosity
of the blood would
fluctuate more
violentlyon conversion to
in omnivorous
I fear the pig would
a vegetablediet than
man.
In the careful and
parallelwith ourselves.
present a nearer
repeatedexperiments of Burton-Opitz on dogs the most definite
results seemed
to be that pining (presumably water
was
given
to them) reduced
and
full flesh-diet increased it ; in
viscosity,
with the watery constituent
rabbits,that viscosityvaried more
of the food.
It would
that feedingand fastingshould offer
seem
crucial differences,though it is not
determine
more
to
easy
the optimum moment
of cell satiety. It seems
certain that
the meals
determine
fluctuations
of viscosity
some
; these
to be largerin the morning than in the evening ; the daily
seem
excursions reachingeven
In experimentalestimates
12 per cent.
"

Bence, Julius, Deutsche

"

med.

Wochenschr., 1905

VISCOSITY

THE

118

daily waves

normal

these

results
conflicting

or

more

to

seems

good

THE

not

be

BLOOD

forgotten. Hitherto

is rather

observers

PAET

the

baffling.

opinion that viscosityvaries as blood

inversely; but the evidence in this respect

referred to Erb's

I have
pressure

of

must

OF

as

me

less

too

yet

slender

to

be

It may

trusted.

be

that

expels the watery part of the blood and so raises

and so the viscosity. As
the apparent percentage of corpuscles,
rises,so rise,it is said, cell content, haemoglobin value,
pressure
high

pressure

gravity;and converselyas pressure falls. But these

specific
internal reciprocities
phases are subjectto great interference and many
of the
(p. 144). And overridingall is the governance
the reservoirs of lymph
relations between
the running blood and
formed
and
elements, which, if in considerable
part physical,
also in no
small part be subject to the nervous
must
system.
It is stated, for instance, that if viscosity
be raised with gelatin,
the cord divided below the bulb, and the vagi resected so that
take place,osmosis
and
surface
nervous
readjustment cannot
tension have free play,and pressure
and viscosity
rise together.1
that the injection
of gelatin(within
Japelliverifies the statement
limits,of course), although in arterioles and capillaries
it raises
for a moment
(probably an arrest of velocitybefore a
pressures
On the
peripheraldilatation ?),does not raise aortic pressure.
and
degrees of independence of pressure
viscosity,Kubino
givestwo examples of febrile conditions : in the first case, with
of 5-23 the blood
a viscosity
was
130; in the second, with
pressure
of 4'08 the pressure
a viscosity
150.
But
this is familiar
was
ground to us all,as seen eminently in polyglobuly.
and

Pressure
of

may

vary

pressure

between

as

may

vessels

viscosityat a critical phase

be rapidly compensated by
and

tissues.

Erb, junior,2as

at
this question, but
Marburg, worked
although it is of great importance by methods

at

at

get

the

yet, if the

underlyingrelations
phase

be at all

animal

the

by

pulmonary

the

Rubmo
"

prolonged,in
machinery dominates

nervous

Japelli (in

between

coeflicient.

Botazzi's

Erb

laboratory,Arch.

(loc.cit. p. 119 n.).

Erb, "Blutdruck
u.
Konzentration

tested

an

change
inter-

also Hess

concluded

that

of exclusion

viscosityand
the livingand
the

tions
fluctua-

to

pressure,

complete
balances, perhaps

the concentration

d. fisiol.
vol.

d. Blutes," Munch,

iv., 1907;
med.

and
quoted

Wochenschr.,

CHAP,

PKESSUEE

BLOOD

in

pressure relation in rabbits

of the blood
concentration

agent

The

truth

the effect of

gauge

to

the

as

vary

is,to repeat what

viscosityon

conditions, and

simultaneous

119

adrenalin,and
by injecting

merely mechanically,or

act

may

EXEECISE

AND

also

as

I have

pressure

these, if

pressure

not

we

found

the

but

this

chemical

stance.
sub-

already said, to
must

know

are
infinite,

all the

yet

fold
mani-

and

complex.1 (See Martinet and others, p. 143 et seq.)

Concerning work and exercise the evidence is less conflicting.
Sweating, it is agreed, raises viscosityby about 1*25. Apart
from this factor, Blunschy 2 found from his own
and from other
reduces
experimentsthat prolongedexertion, such as ski-running,
while short forced efforts raise it. Notwithstandin
viscosityconsiderably,
it was
found that by derivation from the tissues a
reduction towards the normal
was
soon
brought about (Lommel,3
discussion,4
Hess, etc.). Bohme
(Kiel),speaking in a physiological
said
the

that

by

to

exertion

severe

the albuminous

serum,

it returned
the

brief

normal

in about

trated
(on the ergostat)concen-

content

rising7'8-8'5

five minutes.

higher osmotic

This

he

per

cent

explained

in the muscle

during work, the

water
An important feature of these,
and of some
other careful experiments,is that relatively
large
that there is room
for some
so
are
figures
registered,
experimental
For instance,on long marches
1346
error.
as
as much
per cent
of difference has been recorded ; an
estimate
which
ought to
leave
in

an

pressure
passinginto the muscle.

result of, say,

interestingdiscussion

remarked
Associations,5
1

secure

See Eubino,

or

at

that in

8 per
one

of

And

cent.

the

Hasebroek,

German

estimatingblood

pressures

Medical

during

"

C., II Coefficiente di viscosita sui valori di pressione,"Gaz. d.

ospedali e di clinica,Feb. 2, 1908, an
interestingarticle based on competent
into far more
detail than
enters
knowledge and personal experience. Rubino
I can
find room
for; see also Gouget, Quelques travaux
la
recents
sur
viscosite,"
Presse med., juilletler, 1911.
"

Zurich
dissertation
of 1908 of which
a
I have
Blunschy's paper was
seen
of normal
only extracts in year-books,and other quotations. His curves
daily
fluctuations, etc., are republished in Determann's
For many
of
book, p. 66.
his observations
he seems
to have
used hospitalpatients more
less indifferently,
or
of them
probably out of health ? In any case, Vaquez accepts his
many
conclusions
with doubt
and reserve,
especiallyin respect of alcohol.
3
Deutsche
Arch. f. klin. Med., 1904, Ixxx. 308 (quoted by Krone,
Lommel,
vide No. 2) ; and
Munch,
med. Wochenschr., 1908, No. 6 (quoted by Determann,
loc. cit.).
4

Reported

Hasebroek,

in

Deutsche

med.

Wochenschr.,

reported in Deutsche

med.

May

5, 1910.

Wochenschr.,

1909,

xxxv.

1414.

in

correction

to his

occasion,referred

own

estimate

to

"

noted

he had

during bodily exertion

that

added

Deneke

which

PAET

viscosityalso a
agreed. Blunschy also, on this
experiments(mentionedabove),and
had

fallacyhe

exertion, to avoid

BLOOD

THE

OF

VISCOSITY

THE

120

of

movements

clinical
for us
and
;
viscosityto be parallel
value,
physiciansthe important factors,with blood of constant
its speed and the heart work
expended on it. Hasebroek
are
methods
indeed expressedthe opinionthat Oertel's therapeutical
and

pressure

owe

itself. He

heart

in

reduction

to

more

long

the

run,

than
viscosity

also, as
trained

in

found

have

we

by

men,

reinforcement

to

in

of the

England, that

exercise

the

arterial

reduced.

are

pressures

found

of

largeand vague a condition to detain us long

at present.
Mayesima (p.149) finds as a rule the viscosity
of
lower in the Japanese than in the European ; the number
his red corpusclesis fewer ; and Matsuo,1 another
Japanese
makes
the
with
like
same
physiologist,
results,but
comparison
be due to the vegetarian
suggests that the lower figuremay
Climate

diet.
one

In

is too

altitude

for which

others

have

we

have

we

have

found

definite

more

definite data.

some

that

factor, and

Determann

and

high altitudes viscosityincreases

rate in part, to the
substantially
; this is probably due, at any
well-known
increase of red corpuscles
find the same
we
; and
rule in cyanosis,in which
these
abound.
corpuscles more
It is well

ascertained

at

that

the

blood

of normal

residents

in

such as St. Moritz, is richer in red corpuscles

high altitudes,
;
have
they
probably a more
capaciousblood-making apparatus
and
lung capacity. It is in these persons
that Determann
finds a corresponding
of viscosity
excess
(by 174 per cent) ; and
has
found
von
that this excess
Kordnyi
be reduced
can
by the
inhalation
that

as

of oxygen.
coefficients of

It is not

always

remembered

however

have
to estimate,not
we
viscosity
also the haemoglobin.

the

corpusclesonly,but
The density
and volume of the several secretions and excretions
of the body, difficultas they are to
follow,are yet much concerned
in the problem before us
; for presumably by their fluctuations
the

equilibriumof the corporealfluids is largely

provided. When,

for

example
1

under

Mateuo, Deutsche

sweat, the

of
viscosity

Arch. f. klin. Med.

Bd.

the blood

cvi. Hefte

5 and

rises,and
6, 1912.

CHAP,

is

SPECIFIC

CLIMATE.

in

compensated by

derivation

reservoirs

of the

system

element

and

some

in

GKAVITY

from

will

the

give

up

the

measure

121

tissues,the

canals

and

of their

some

aqueous
elements
also
electrolytic

and I believe
experience,
readjusted. It has been my own
that during long climbs one
does
that of mountaineers
generally,
indeed after coming home
is it wise
desire much
food ; nor
not
for the secretions of the parts of digestoo soon,
to eat largely
or
tion
of
have rendered
up their juicesto prevent concentration
will be

the arterial blood, and

scantiness

The

of the

prolonged exercise
So

therewith

the

dryness

familiar to every

are

sketched

far I have

and

urine

the

out

labour

increased

of the

of the

heart.

mouth

in

exerted

by

one.

of influence

sort

viscosityof the blood ; I may now

in pursuing this train of thought
ask the reader to follow me
and
into the motions, qualities,
exchanges within the blood
itself. This part of the inquiryis traversed by certain important
at any
rate by handy
but indeterminable
factors,indeterminable
Two
of these factors, not
methods.
easilyto be appreciated
currentlyduringexperimentalwork, are the velocityof the blood
outward

conditions

and

stream

the output of the left ventricle.

be reckoned

can

the

upon

in,our

observations

them.

Meanwhile

about

stillhave

however

we

ventional
somethingcon-

make

may

little

which

not

theyhave some
dependence.
that viscosity
And
is
this seems
to be the place to point out
specific
gravity,an assumption not infrequentlymade, even

by

eminent

progress

with other conditions

must

Until these moments

writers

the circulation ; there is not,

on

direct relation between

a

The

strong salts

"

and

inconsistent

not

the

"

of the blood

chloride,have

as

such

iodide,or the

as

sodium

Sodium

formate,

the two

classes.

blood

May

as

we

oxygen

its

as

expect, lies

even

viscosity.

equal doses.
sodium

on

Of

and

the

calcium

the limits between

shall see, 'the gas

we

viscosity; by

it is reduced.

Grawitz, Zeitschr. f. klin. Med.,

18, 1907.

such

low

or

differ widely in molecular

the effect of
some,

A normal

with

"

indeed, any

viscositya positiveeffect ; others,

and organicsalts,
acetates
a negative.

should

Again, as

largelyaffects

increased,
by
1

concerns

salts

weak

weight,and accordinglyin
solid constituents

coefficients.

these two

high specificgravityis
"

on

1893

carbonic

acid

Furthermore, Grawitz
;

quoted Saundby,

of the

content

Brit. Med.

this

is

showed
Journ.,

BLOOD

THE

OF

VISCOSITY

THE

122

PART

specific
to point out
May I digressfor a moment
gravityof the blood.
a
negligiblefactor ?
that the specific
gravity is by no means
A long series of observations
by Roy, Lloyd Jones, and myself
the specific
gravityis maintained
proved that in the normal man
that stimulation

of the vasomotor

fairlyconstant, being 1058-60;

If in
in males.
fall,1
especially

but
the

the

increases

nerves

of 40

after the age

elderlyit

should

tends

to

rise,the rise

rise of arterial pressure also, in which

be preventcerebral haemorrhage is to be feared, and
able.
may

is often coincident
case

In

with

I have
hyperpiesia

never

this variable

found

normal,
be sub-

to

if pressures abate the specific

gravity falls likewise.
Conversely,if in a case of suspicionof cerebral haemorrhage the
and

gravitybe low,
specific

the

diagnosis
"

as

in

respect of embolic

(Lloyd Jones and

myself). In this case the arteriosclerosis will probably be of the
kind which I have called involutionaryor decrescent, as opposed
At the same
time,
to that ensuingupon
prolongedhigh pressures.
or
high arterial pressure,
although in a case of arteriosclerosis,
and haemorrhage be feared,
the specific
gravitybe high,or rising,
specific
gravitymay not be propitious; for if not
yet a falling
cerebral haemorrhage it may
consistent
with
signifyfailing
reactions.
For
to
instance, to return
viscosity,Hirsch and
Beck
(loc.cit.)have shown, contrary to the presumption of
Ewald, that if in the earliest stage of granular kidney the
disease above all in which peripheral
resistance is high viscosity
or

thrombotic

alternatives

"

should

be revised

"

"

rise, it

may

may

soon

fall,the

fall, beinglprobably due

to

the

hydraemia; or in part to anaemia, as it is often said

that the specific
gravity of the blood runs
parallelwith the
haemoglobin content of its red cells. But the whole question
of molecular

concentration

in the

sundry kinds of renal disease

yet to be dealt with.
Generallyspeaking,in later life falling
arterial pressures
attended
with
are
fallingspecificgravity.
then
is no guide to viscosity
Specific
gravity
the relation
; indeed
of the two
factors often moves
factor
that each
inversely,2
so
be measured
must
separately.

has

see
2

and

For the percentages of water

in the blood
Lust, F., Jahrbuchf. Kinderheilk. Hefte

in infants
1 and

and

in certain

Burton-Opitz, Stud. Rockefeller

Inst. Ned.
Research, vi.
Arch. f. klin. Med., 1900-1, Ixix. 503.

Beck, Deutsche

disorders

2, 1911.
190 ;

and

Hirsch

VISCOSITY

THE

124

of the

tubes

radii of the

limits,have
clear that

be

to

OF

friction takes

as

also.

with

reckoned

it

But

of wide

quite

seems

percentage of the

enormous

an

up

PART

lengths,variables

their

and

BLOOD

THE

again friction varies as the fourth power

of the radius, a very
slightincrease of radius will make a very
largefall in resistance. Again, we are assuming the motion to be
which
rectilinear,
probably,at any rate in the middle and small
vessels,it is ; but there is a certain "critical velocity,"
depending
the
the
ratio
of
kinematic
of the fluid to the diameter
on
viscosity
of a pipe, at or about
which
the transition takes place from
heart's energy,

linear to

then

as

turbulent

motion,

of coloured

means

is endowed

value
and

rises
To

143).

viscometer

new

the flow be

as

meet
J

with

this

turbulence,an

which, he

says,

of

tubes

obscure

much
factor

falls,and

has

However,

those

must

and

that

cosity
vis118
a

pressures

law

Miinzer-Bloch

turbulence

is

of viscometers.

forget, namely,

not

thinks

the Poiseuillle

Hess

I suggest that

largerthan
we

the

rise

on

constructed

inconstant

interference) with
in

in

conversely(videpp.

variable,Determann

happen

may

set

Determann

designedto prevent high or

settingup

instruments.

turbulence

retarded.

arises

paradoxicallythe

adaptive capacity so

an

pressure

Keynolds by

If turbulence

with, and

readilywill

more

and
pressure-head,

Osborne

by

in the stream.

is interfered

the fluid the

the system

shown

as

filaments

Poiseuille's law

thinner
of

and

But
that

factor

another
it

is in

the

that
the
capillaries
work
is done;
there
the
physiological
take
exchanges
the
place between
nutritive
juices
and
the cells ('Gewebsgefuhl
which
be
out
with'),
can
scarcely
effect in speeding or
some
This
delaying the blood.
effect Broadbent
believed,in some
morbid
conditions, to be
a

considerable

factor

in

delay

of the

blood

in the

capillaries.
the gas content
see
also is a large factor of
the velocityof the stream,
or at any
rate of its viscosity.Whatsoever
these coefficients,
Miiller,
Brodie,and du Bois Reymond2
studied that of the
carefully
in the stream
viscosity
through the
capillarysystem (on Brodie's method) in cats.
Quantitative
And

we

shall

that

,?e^r?rn'
If^f*

med-

Gesellsch. Sitzung 30. Mai, 1911

G" Br0die" and
Del 907T'

dU

Woche"fo;
;

and

B"iS

Report of
f. klin.

also Zeitschr

Reymond'

Disc-

*%"*"

Freiburger
Med.

Bd

Med.

73, Hefte

Gesellsch. Berlin,

CHAP,

BLOOD

in

apart, Poiseuille's theory

differences
for the

HOMOGENEOUS

NOT

Within
systemic capillaries.

fluctuations

whole

the

on

viscera

the

for accurate

variable

too

were

125

held

the

good

vasomotor

appreciations.

Thus
far the blood has
Homogeneous Fluid.
water
been taken as if it were
a
homogeneous fluid,as it were
less with glycerin. But
well know
thickened
that
we
more
or
such is not its condition ; that in the plasma colloids and saline
matters
are
mingled, and that in the plasma are suspended a
red and white.
Now
if we
of corpuscles,
largenumber
suppose
these bodies to be equallydistributed throughout the fluid,and
such
to be of constant
a
diameter, would
compound stream
if homogeneous ?
In making the comparison the
behave
as
blood
the corpuscles
us
clottingembarrasses
; in defibrinised
be completed, and the addition
sink before the observation
can
of chemical
agents to delay clottingpresumably interferes with
Determann's
the reaction of the blood thus treated ; even
monious
parsiThe

Blood

not

"

of hirudin

use

Professor

Mott

is said to be open to this demur

(p. 111).
has suggestedthat nucleo-protein,
which
has so

rapid a coagulativeaction

the

blood,

have

"

viscosing
effect on the blood
Bodington,in his Cambridge
; and Dr. Arthur
M.D. thesis for 1903, expresseda similar opinion. In this place
of the several methods
a
description
by which these difficulties
have
been
be
surmounted,
reduced, would
or
superfluous;
on

may

' '

suffice it to say

Hiirthle, and
Poiseuille's

that expert observers, such

of

are
Tigerstedt,3

law

the blood

opinion

be

may

Beck

as

that

considered

and
in

to

Hirsch,2

respect of

behave

as

homogeneous fluid within small limits of error.

Notwithstanding
this approximation,it is of some
in
our
importance
analyses,as
shall see, to reckon
we
severallythe part played by the plasma
and
Burton- Opitz says, as we
should
by the whole blood.
that in the normal
condition the viscosity
of the serum
suppose,
is without

influence

viscosity
may

serum

would

1
2

be called

be felt the

presently.
The
plasma
Mott,

the blood

on

more.

consists

Phil.

pressure

constant

Of

if in health

the effect of

lakingthe

of colloids

Trans., London,

; but

blood

we

the

tion
fluctua-

will

speak

suspended, and merging by

1899, Ser. B, cxci. 211.

Beck
and Hirsch, Arch. f. exper. Path, und PharmakoL,
1906, liv.
Tigerstedt,quoted by Krone, Deutsche med. Wochenschr., 1910, xxxvi.

54.
1438.

OF

VISCOSITY

THE

126

solution,in the

degreestowards

BLOOD

THE

this consists of

serum

PART

tion
solu-

proteins,on which its propertiesdepend.

of much
lower
the corpusclesis of course
The plasma without
said as 2 : 3 ; l the
than the whole blood, it is generally
viscosity
viscosityof the blood depends not on the corpusclesonly, but
of salines and

plasma

the

upon

also ;

content

which have
upon the salts,
in
chloride may
Calcium
"

"

"

"

than,

stronger

say,

acetates

colloids

than

effects upon

different

be

viscosity.
osmoticallymuch

both

of

(see pp.

121

chloride, and
the

the

upon

solutions

some

sodium

than

stronger

very

more

far

course

and

132).

viscosityof the whole blood is higher than that of a

of the corpusclesin the same
mixture
proportion with salt
It is not
and
water.
proved that free calcium ions affect
but rather the fixed lime salts,for whose
tion
estimathe viscosity,
Barr2 and others).
have
no
we
(SirJames
ready method
Barr is of opinion that although the fixed lime
(albuminates
in the viscosityof the blood, free
of calcium) is concerned
The

ions

calcium

drive

ions

cause

may

the

contraction

of

the

arterioles.

osmotic

pressure ; and although Ca is

is essential to such
viscositynegative,yet its presence

The
as

to

other

There is no evidence of
rhythmical contraction.
a
higherviscosityin the blood of residents on limestone soils.
of hydrogen ions viscosityis presumably increased.
By excess
Again, if the corpusclesare not uniformly diffused,viscosity
will vary
in areas,
risingin those in which the corpuscular
is denser, and falling
content
in those in which
it is scantier.
in asphyxia the rise of viscosity
Thus
be due to the more
may
to variations
in their size ; but here,
numerous
or
corpuscles,
co-

efficients

as

we

as

shall see, the effect of carbon

leucocytosisor
obvious
6-0 ;

dioxide

erythrocytosisviscositymust

inference ;

as

matter

in.

comes

of observation

rise

That

seems

it may

in
an

rise

over

and

although total blood-volume

be increased,this
may
increase,in a profusionof reds, is in less relative proportion. In
two
cases
publishedby Dr. Parkes Weber3 in which the red cells
attained 8-8J and over
10 millions respectively,
and the hsemo200
globin
per cent, although the blood pressure
(fullsystolic
?)
1

See
!

"

case.

Lisbourne

et

Margaret, quoted

Arch,

des mal

du

cceur,

etc., mai

1913.

Barr, Sir Jas., Brit. Med.

Weber,
Parkes

Journ., Sept. 24, 1910.

Parkes, the first case, Lancet, London, 1905, i. 1254
Weber
and Dorner, Lancet, 1911.

the

second

CHAP,

BLOOD-VESSELS

in

was

only

160

(157

mm.

on

[a rough

VISCOSITY

AND

between

mean

observations)and

two

127

Haldane's

Weber's

Kiva-Rocci

Hill and

Barnard

such that the heart, in spiteof this

was
viscosity
at the age of 29, under
moderate
systemicpressure, was failing,
the aggravated friction thus engendered, and the considerable
of
75 cm.
body weight) excess
(in the second case
per 100 grm.
and
Hutchinson
in a
to be driven.
total blood- volume
Miller,1

(165 mm.)],

the

high degreeof fibrosis of the vessels,which

they reasonablyattributed to the high frictional resistance of 7f-8
which favours the assumption that
million reds ; an observation
of arteriosclerosis ; Dr. Craig's
viscosityis at least a vera causa
Cambridge M.D. thesis on excessive arterial pressures in a certain

similar case, recorded

kind

is well known

of melancholia

Bruce

now

and

Alexander,2

of

insanity,say that these

mm.) are associated with a leucocytosis.
pressures (of 140-180
that in the high viscosities of polycythaemia
to me
It occurred
the heart should be enlargedon both sides ; but, in such notes
I can
of the few necropsies
lay my hands upon, the heart is spoken
of in generalterms
a
only,as hypertrophiedor dilated. When
rise of arterial pressure
is due preponderantlyto largeareas
of
on

the

high

pressures

vasoconstriction

the stress,as

left ventricle

the

resistance be due
on

cases

in chronic

carefullynoted

disease,falls upon

corresponding degree; if
increased viscosity
the stress

to

of the several

the state

renal

in

sides of the circulation alike.

both

future

in such

on

in such

chambers

Miiller's method.

however
should

It is to be desired

of the

heart

It is also

to

the
be felt
that in

should
be

be

desired

the

corpusclesare reduced in number,

for instance under
as
methods, that the effect on
therapeutical
blood pressure, and, if possible,
should be accurately
on
velocity,
that in granular kidney,unless in the
noted.
We
have seen
of the blood is not much
earliest stage of it,the viscosity
increased,
if at all,3a notable point when
consider the polyuriaof the
we
disease ; now
it is in granular kidney that hypertrophy is
developed often wholly,always very preponderantly,in the left
It may
if the corpuscles
ventricle.
at first sight,
seem
surprising
be so largea factor in viscosity,
of heavy polythat in the cases
that

when

Hutchinson

Bruce

Beck

and
and

cases

and

1906, i. 744.
Miller, Lancet, London,
Alexander, Journ. Mental
Sci., London,
1890, xlvi. 725.
Hirsch,

Arch.

f. exper.

Path,

und

Pharmakol,

1906, liv. 54.

THE

OF

VISCOSITY

THE

128

BLOOD

PART

cythsemiato which I have referred the arterial pressures

rise enormously; certain compensatory adaptationsseem
stress, and

the

them

among

small

wide

if such

areas

cubic

yet

increase

annulled

be

increases

even

how

pointed out
increase

to meet

must

largemust

be the effect

take

arterial radius, if

of

dilatation

do not

dilatation

vasomotor

principal
part. I have
produced by quite a

do

yield more

of space, the extra

burden
of the heart
thereby.1 How
perilous,how mortal,

over

than

not

may
enormous

corpuscles,or relative increases,may

be, is
diseases,such as
phases of certain colliquative

of the

illustrated in

cholera ; conditions

in which

the

marvellous

effects of intravenous

of saline water
in reducing the viscosity
injections
are
likewise conspicuous; now
these cases
ent
are
probably but eminexamples of an injuriousprocess which, in many
diseases,
in certain fevers for example, may
constitute a considerable
if
occult cause
of danger to life.
I have alreadyhinted that in the viscosity
of the corpuscles
there

is

bodies.
of

than

more

We

this

the

mutual

mere

friction of multitudinous

forget in the discussion,not only

question,but also of associated physical
to

apt

are

mechanical

questions,that the surfaces of the corpusclesbeing bathed in

the plasma, and wet
with the colloid fluid in which
they are
suspended,partakeso far of its qualities.But there is a simple
method
of ascertaining
mechanical
by elimination the mere
ditions
conof these

have

this is by takingthe blood

solids,

; in laked

blood

what effects,
opportunityof observing
other than by
mechanical
suspension,the corpuscularelements may
have
on
the physical
reactions of the blood ; by their stroma, for
instance,
their haemoglobin,their
Detercontent, and so forth.
gaseous
we

mann,2
blood
blood
a

Adam,3

these

to

an

Hess,

Blunschy,4have

functions,which

proves

to

be

substance

more

less,but

not

; for this reason,

that the

viscous

than

while

within, is prevented from

Qea.

Zurich, 1906.

"Viskositatd.
in

j Determann,
3

Adam,

ZefecAr.

be after this

to

seem

Blutes

und

given especialattention

more,

viscous

than

corpusclescontain
the

Laked

manner.

plasma, which

normal

within

them

substance,

this property
exercising

to

the

Herzarbeit," Vierteljahrsschr.
d. Naturf.-

/. klin. Med., Berlin,1909, bcviii. 177,

loc. cit.,Berlin, 1909, Ixviii. 177.

Blunschy,quoted by Krone and by Determann.

and

73 (3-4).

EFFECTS

CHAP,

in

full.

Thus

it falls out

OF

CARBON

that

when

DIOXIDE
laked

the

129

molecular

friction

relativelyhomogeneous fluid is higher than between

the serum
the corpusclesand
stroma, segregatinginto
; the
friction than
do the bodies of
granules(Adam), sets up more
the intact corpuscles
themselves.
On removing these suspended
Adam
found the friction reduced.
granulesby the centrifuge
But this is not all ; by another series of experimentsthese
industrious observers
after
that, even
proceeded to demonstrate
in

the

removal

the

of the

stroma, there

was

still a

notable

excess

of

traced to the compound coefficient

viscosity
; and this they have
of haemoglobin and
Oxygen or carbon dioxide,
gas content.
produce no effect of viscosity
plasma deprived
upon
gases which
of corpuscles,
affect its viscosity
instantlywhen to it are added
then
that in laked
see
crystalsof pure haemoglobin. We
into full activity,
and
blood this compound factor comes
how
important it is in these comparisons to take heed, when testing
that the blood be taken from a standard area
viscosity,
; venous,
arterial.
or
capillary,
into view
most
Here
a
comes
important principlein
of disease of the lungsor heart ; namely, that
disease,especially
of carbon dioxide l means
of viscosity.This may
excess
excess
the same
be quicklydemonstrated
on
by comparing the
person
from
blood
a
simple finger puncture with another specimen
taken
after producing local cyanosis; but observers of cyanotic
blood do not, or often do not, remember
to compare
the specimens
know
in respect of cell content
that C02 alters the
now
we
:

number, the form, and the surface of the

red cells.

However, this

in vitro where
the number
of
viscosityis demonstrable
It seems
is constant.
fairlycertain that in defective
corpuscles
for instance,at the moment
oxidation,in mitral insufficiency
when
the velocityof the blood should receive a compensatory
the burden
of the
acceleration, its viscosityis rising
; thus
in a
vicious
circle.2 In
heart
increases
cyanosis it is a
familiar experiencewith me, as I doubt
with my
not
brethren,
rise of

Determann, Die Viskositdt des menschlichen

Blutes,Wiesbaden, 1910 ; and
med. Wochenschr., 1907.
of various bloods was
Hess, Munch,
(The gas content
estimated
Barcroft's
on
method.) Burton-Opitz, Visk. d. Blutes," Pfliigers
"

Arch.
2

Bd.
See

cxix. Hefte

6-8.

Bence, Julius, Deutsche

med.

Wochenschr., 1905

careful

series of

experiments.
VOL.

BLOOD

THE

OF

VISCOSITY

THE

130

PART

tion
pulmonary respiranot
it may
always be easy to explain the beneficial
the patient
instances
inhalation, yet in many
action of oxygen
with desperation.
clingsto his oxygen-pipewith affection,or even
although

that

Now

know

we

the

on

of

mechanics

mere

that in suffocation,as in

narcosis,tracheal stenosis,

is extremely high ; if,therefore,

viscosity
of the
of the viscidity
attenuation
favours an

the like,the blood

and

of oxygen
blood, it should
access

dioxide

of carbon

; ifaccumulation

forward

and

the heart

thereby ease

the

for

makes

an

stream
blood-

increase

current, the comfortingeffect of oxygen

sluggish
be demonstrated
inhalation becomes
intelligible.The principlecan
readilyas follows: Some blood is drawn from a vein and,
little hirudin is added, and the
to prevent coagulation,
a
very
in air,to oxidise it,and the
It is then shaken
tested.
viscosity
siderably.
againmeasured, when it will be found to have fallen conviscosity
And, besides this relief by oxidation, we may presume
in the
further fall in friction by a diminution
in the body some
of red corpuscles
number
multiply,
; for these in defect of oxygen
of

viscidityand

"

in abundance

Koranyi
and

has

of it

reduced

are

shown

by

in number.

blood-counts

that

rise of tension of the gas in the blood

in the number

of reds.

Strobell's

disease

In heart
inhalations
are

von

of oxygen

followed

by

fall

experiments indicate that

in chronic tracheal stenosis the heart becomes
hypertrophied.
It would
indeed that of all factors of viscosity
carbon
seem
dioxide is the chief,for the changes in viscosity
by these gases
less of the plasma than of the corpuscles
are
; so that in diseases
of the heart and
lungs,as Determann
says, a vicious circle is
established of plus viscosity,
plus resistance,plus C02, and so
round
to plusviscosity
again a gyration which the heart may
be unable, by increasingthe pressure
head, to break through.2
Furthermore, as tissues are declining
to hydration and acidification,
"

at their surf

To

this

of

other

C02,a

albumin

weak

This

of
alkalinity

factor

the blood

d.
Strobell,Zeitechr.f.

On

Win.

isionised and

acid, contributes

acids its tension

its removal.
the

aces

rises there
must

tell

is reduced

friction thus increased.

; and

in the presence
is less alkali to spare
for
as

heavily in
; stillmore

fevers
in

"

in which

acidosis

"

vol. i.,1913 (quoted Zentralbl. H. u. 0.).

gea. exp. Med.
this aspect of the matter, see also Bence, " Visk. d.
Blutes," Zeitschr. f.
Med., 1906, vol. Iviii.

lie within

BLOOD

THE

OF

VISCOSITY

THE

132

PART

be

limits,yet their quotient may

normal

abnormal

if
alreadyquoted, that even
lie within
haemoglobin and viscositytaken separately may
divided give a figurewhich
normal
extremes, yet if these figures
does not fall within 17-21, the blood is of abnormal
composition.
Bachmann,1 working with Hess and Eichhorst at Zurich, gives

by Hess's statement,

illustrated

as

the

observers

at

concur

ought

to

v^c

normal

blood

and
present in statingthat viscosity

globin
haemo-

formula

followingnormal

"

In

that

parallel
; but

almost

run

in disease

this

relation is often disturbed.

In

the

next

the blood, which

discuss

place we

may

leads

another

to

set

the saline constituents

of

of conditions, conditions

and plasma ; namely diffusion,osmosis,

both corpuscles
affecting
of the blood
and the calculation of the crystalloids
electrolysis,
to certain laws,that is,of chemical
physics.2It is by the disaggregating
of salts in solution on the proteinsthat the activity
energy
of life is maintained
being less
; and the inorganicsalt solutions,
the organic their diffusion rate from
viscous than
a
limiting
surface
more
disaggregating capacity;
being higher, have
of this viscosityand
their action is a function
of the surface
tensions.
The higher the surface tension and the viscosity
the
the
weaker, of course,
disaggregatingaction. Salts have, of
other disaggregatingcapacities
of them
have,
course,
; some
for instance, varying measures
of solvent action on globulins.3
And the well-known
rise of blood-pressure
obtained
by injection
of normal
salt solution is said to be accompanied by an increase
of corpuscles
(20-30 per cent),apparent or real.
be that of
Again, a very important condition of life must
adsorptionof salts,as for example of chlorides,the greater as
"

"

the surface tension

molecules

storage of

; which

of the solution is

property by

"

lower, on

sterical inhibition

It prevents the chemical

energy.

surfaces
"

of colloid
makes

interactions

for

of the

largecolloid molecules, and prevents, or moderates, condensation

and precipitation.
The reactions of toxins and antitoxins
may
1

Bachmann,

observations
2

on

See

exper.,
3
See

Deutsche
400

Roger,
Sept. 1908.
"

various

Arch.

f. klin. Med., Oct.

1908

careful

paper

with

cases.

Introd.

papers

1'etude

by Hardy

de

and

la

viscosite

Mellanby.

du

sang," Arch,

de

med.

CHAP,

CONSTITUENTS

SALINE

in

less

or
depend more
interchangesof

133

adsorptionphases.1

on

chemical

action

mass

the

Thus

ordinary

inhibited,and the time

are

closelyoccupying
the attention of chemists, every reaction probably having its own
time rate, depending on concentration, temperature, cataclysts,
rates

more

or

less retarded

; these

rates

are

now

probablethat these time rates are of the inner secrets

of biology; for instance, ordinarymass
action may
depend upon
the
optimum times and quantitiesof fresh supplies,and on
several
Thus
by
specificreaction velocities,as of ferments.
subtle measurements
we
might obtain a modulus for carbohydrate,
of
and in the presence
protein,and fat changes respectively,
each, as of proteinchange in the presence of carbohydrate; and
The
obtain some
service.
sort of rules for practical
so
primary
It is

etc.

factor of osmosis

is

that, of

of different substances

number

in

solutions of

equal percentage strength,the solution of substances

of small
than those
molecules
molecular
weight contain more
of
which
contain
substances
weight. In
heavy molecular
the normal
body the salts, in their quantity relation to the
other
remarkable
a
ingredients,
equilibrium. Besides
preserve
Ringer'sproofthat calcium was necessary for rhythmicalmotion,
know
also that it is necessary
for the buildingup of protein
we
complexes in cell-nuclei ; substances, therefore,which precipitate
calcium
from these cells are poisons.2 An excess
of calcium ions
which, by their electric charges and mobilities,fortifies systole,
of the heart in systole. Sir
to the arrest
pushes up tone, even
James
Barr sent to me,
on
February 6, 1911, the two following
notes

:"

in J.

B., after the calcium

raised,the vise, was

index

0-5 ; urine

7-06 ; cap.

velocity4

the vast

extent

channels

and

hear

that

I may
observations
sterile
2

and
recesses

surface
here

note

mm.

been

or

; cap.

in

; calcium

1|^sec.

of lime.

index

in vain

When

0*8 ; urine

try

we

to

realise

diversityof surfaces throughout the infinite

of the body, we
shall not be surprisedto
osmotic
tension has been regarded as the

in

passing

Griinbaum

by

had

in f sec. ; calcium
velocity4 mm.
of lime : in P. H., vise.
normal, slightexcess
645

acid, slightexcess

1010

of the blood

content

and

the

very

Coplans

curious
at

but

Leeds

on

yet incomplete

as

filtration

through

asbestos.

As

bearing

Sir

James

for

April 12,

in

Barr's

1913.

an

interesting way

lecture

on

Rheumatoid

on

these

Arthritis

in

I may
Brit. Med.

laws

chemical
the

refer to
Journ.

is not

comparablewith
in

rather

differential surface

If, by bathing

in isotonic

between

reactions
saline

more

sists
con-

sarcoplasm.

solution, the salts of the fluid

sugar

reduced

is

muscle

the

extracted

parts be

the

and

colloid contractile elements

the

osmotic

or

activity

engine,but

internal combustion

an

animal.

muscular

opinion is prevalentthat

instance, the

For

PART

organism, plant,or

the

in

of energy

overrulingmode

BLOOD

THE

OF

VISCOSITY

THE

134

inactivity;by

to

readilybe restored.1 Thus,

or
while the vast stream
system of energy is working between the
forces justindicated are
and the outward, the molecular
inward
returningits

salts its

activitycan

as

within,and with confederate intensities almost

striving
What
play in these animated
may
part filtration
and
at

universal.

processes

of relative local mechanical

data

the

for

uncertain,

as

is

pressures,

reach, at any rate

of the distribution of gases, are out of our
in the
present. We recognisenitration in certain areas, as

renal

though
glomeruli,

mere

filtration ; and

is not

glomerular function

the

be

it may

inconsiderable

no

of

one

where
else-

factor

and osmosis
universal, and govern the
are
diffusion
brings
balances of viscosity.The enormous
pressures osmosis
almost reduce even
quantity.
into play may
gravityto a negligible
If evaporationfrom the leaves of a tree keeps up a negative
;

but

such

; and

sap

is the potency of osmosis

Thus

the nutrition

heart

and

these

as

secretions

of the cells and

no

the

And

Such

intense

work

components

the

I may

mechanical

of the

ease

and

of the
their

remark

here

there

the peeps

are

we

may

get

immeasurable

blood

that

are

lymph, but also in the blood

between
its plasma and its corpuscular

reciprocationsof these
healthy body.
ordinarymethod, although it gives
as

and

to

the

lymph,

physicalattractions

balance
physiological

the tissues

and

here and

coefficients in the
biological
Chemical
analysison the
us
indispensableinformation

lightupon

simpleranimals.

these reactions with

blood

to

at
incessantly

elements.
into

in the

favoured

are

confined

means

itself are

the

of the

in the ascent

and isotony,
by isoviscosity
in their turn
are
regulatedby the bywash of the
fluences
inand
excretions, and are
probably under some
circulation

of innervation.

by

aid osmosis

it does but

(ascending)
pressure,

"

normal

at which

the

saline
red

ultimate

"

is

mediate

independent
and gives
repulsions,

throws

and

and

no

usually a

corpuscles remain

little too
unaltered

dilute
is 0-9.

CHAP,

FKEEZING

in

BOILING

AND

POINTS

135

insightinto the physical and electric vibrations which

For instance, many
constitute the dynamics of these fluids.

little

which

enzymes,

colloidal,elude

be

may

and

measurement

even

separation.We shall see however that we are not without some

have a
of measuring these activities,for in electrolysis
we
way
of ascertaining
means
approximately the rate of osmosis, and
indirectlyof molecular friction. Hampered as we are by the
imperfection,or alleged imperfection,of viscometers, it is
electric
of the
well to attack
these problems also by way
resistance of the blood.
Dr. Dawson
Turner, of Edinburgh,1
the time occupied
made
number
of experiments to ascertain
a
by

sodium

15'6" C.

at

93'5.

chloride to reach

In

five

being 550
the

cases

taking 30 grainsof
The
resistance

was

at

taken
15'4

for the

first

minutes, and
of Ann

before

measured

was

five minutes'

J. Edmunds,

Dr.

ance
resist-

normal

mean

resistance
(Turner),the specific

blood-resistance

time

average

minutes.

ohms

the salt,and

of the blood

effect 21*4

the blood, the

intervals afterwards.

lowering of

for the

the

maximum

Arbor, also told

by interposinga length of the

femoral
with positiveand
hooks
connected
two
artery between
negativepoles,and recordingthe variations of conductivityof
me

(in September, 1907) that

the

blood,

very

he

was

brief,between

enabled
his

to

observe

a
injecting

the intervals,which

saline solution into the

were

jugular

conductivityof the blood.

The tests of freezing
and boiling
points,as we shall see (p.141),
have proved disappointing
For instance,
in practical
medicine.
of the cow
have
the milk and the serum
the same
freezing-points,
but the electric conductivity
tively
of the milk, because it contains relaall
more
Besides, not even
organicmolecules, is lower.
the inorganicparticles
in these fluids are in full electric activity,
for some,
in combination
with proteid substances
(Loeb's ionand
less electromotive
exert
osmotic
even
or
proteids),
energy
their
of ions but their rapidity,
It is not
the number
none.
drivingpower againstthe indifferent colloids,which is of working
importance. And here we observe again the irrelevance in these
of the specific
measurements
gravity(p.121). Speaking generally,
colloids are of low electric conductivity,
salts of high conductivity
;
but salts,as we
have seen, are far from being of equal effect on
vein and

the consequent

Turner, Dawson,

rise in the

Nature,

London,

1902, Ixvi. 127.

VISCOSITY

THE

136

BLOOD

THE

OF

PAKT

have
seen
viscosity,or conductivity,or freezing-point.We
far from
ionic effects of the various salts are
that the specific
raise viscosity,
identical ; some
others, such as the iodides,reduce
it.

So that

and

in blood

concentrations

the

be taken

urine must

incessantlybombarding and
penetratingthe colloids thereby promote the various dynamic
Thus
activities in the fluid, from
diffusion onwards.
viscosity
falls ; and
at temperatures
higher than the atmosphere, but
under
that of incipient
coagulation,these operationsare more
constituent.1

of

each

and

more

active.

in weak

saline ;

neutral

albuminous

small

salts

Globulin, insoluble
and

increments

did not

The

becomes

soluble

Pauli,2 obtaining by careful dialysisa

solution,found on adding to it gradually

of

rise,but

in water,

salt

fell.

(sodium chloride)that the viscosity

He

explainsthis paradoxical reduction

of inner friction on
the addition
of solids by supposing that
of salt, attachingthemselves
to the albuminous
cule,
moleparticles
form a more
combination.
slipperyalbumin-salt-ion
Yet,
shall see, in practicethe viscometer
as
we
fails to registerany
definite fall in the blood of patientsunder
treatment
with the
ordinary doses of iodide of potassium. We cannot, it is true,
identical with that in the finer
regard the flow in glass-tubes
as
arteries,but

approximation is supposed

it may

the

the

fluids and

be that

the

cells,and

rapidlycompensatory

so

And

if under

has

yet been

in the

iodide

the

that

of

body

the

vasomotor

fail to

we

potassium

no

be

fairlyrepresentative
exchanges between
readaptations,are
to

catch

fall of

the

oscillations.

arterial pressure

proved, the belief of clinical observers, for what

it may
be worth, that by the administration
of this salt
circulation is eased, is
notwithstanding
very prevalent.
the
Diffusion,
contrasted

with

passage

osmosis, which

interstitial spaces
which

of

A.

are

V.

Hill, in Barcroft's

Pauli
'.mtsche

Kolloidchemische
Zettschr. Bd.

qi?
iQe,eny
1910
;

Determann,

et

fluid spaces,

passage

through

the circumstances

as

the
of

universal

factor ; and in colloid fluids is

thick fluids of differential densities lend

recent

Studien

iii. (I have
688ayS

is selective

solid,is,under

porous

speaking,a
for
particularly
efficient,
we

through intermolecular

the

and

loc. cit.,etc.)

work.
an

not

Eiweias, Dresden,
seen

handbo"ks

either
J

of these

e.g.

1908
papers,

and

Kolloid-

but

they

are

Philip,Physical Chemistry,

CHAP.

DIFFUSION

Ill

themselves
the

less

diffusion

slower

readilyto
depends on

the reaction.

It is

137

mingling. Other
more
viscosity
; the
by diffusion only that

things equal,

mere

the

viscous
the

stationary

cylinderof blood which wets the wall of the vessel

of
is continuallybeing changed.
that colloids are
It is true
fusion
low
but
diffusibility,
by the disaggregatingsalts their diffinds that, in
is promoted, and
the physical chemist
in solution behave
substances
as
respect of diffusibility,
gases.
Thus by variations in kind and quantity of saline content, some
others
salts being positivein respect of viscosity,
negative,
continual
activityin the blood is provoked ; the proteid or
colloid particles
are
alonglines of least frictional
continually
sliding
resistance and, as it were
at their thin edges,passingfractionally
outermost

from

stream

in that

To

attempt

"

the

of

process
energy

lation
of the circu-

particulararea

course

velocityof

the

on

the

area.

to

pursue

the

researches

lines of these

several

chemical

mechanical, the electrical,the

beyond

would

"

carry

us

accepted that in the

of
of biological
analysisthe separation of the modes
repaired,
by which the tissues of the body are woven,
present

our

purposes

and

demolished, and

each

is an
severally,

and

In

suspensioninto solution.
diffusion depends also

indeed

are

the

it must

be

concentration

arbitraryconvention

enabled

more

or

less,to

of

attention

our

which

by
apprehend

we

upon

endeavour,
ate
discrimin-

and

the lines and

ings
degreesof energy ; yet in these partialreckonnot to forgetthe whole, not to lose comprehension of
we
are
the blend of these various aspects, the merging of these functions
the one
into the other, the unity in complexity. Thus, in
passingon from the mode of energy which we have called diffusion,
the steps by which
advance
to osmosis
we
are
imperceptible;
and

again in the discussion of osmosis

from
fluids,as
absorption by membranes
filtration through hypotheticalpores
soon
we
onward

"

contrasted

"

involved
as

the

must

under

in certain

their several

receive

certain other

velocity,and
molecular

refractive

and

with

certain

expressionand

atomic

other

ourselves

find

as

resistance

under

pressure

propertiesalso, such

weight, and

with

analysis
again
recognition
; so

coefficients which

conditions, such

tive
selec-

aspects of function, such

other functions, or

or
electrolytic

i.e. the

so

forth, we

are

as

head
volume

dealing in

VISCOSITY

THE

138

BLOOD

THE

OF

PART

modes
of
ubiquitousand protean but harmonious
transformingthemselves the one into the other.
energy, incessantly
often interpretone
Thus
it is that we
by the other, as osmosis
thus, as I have
; and
by refraction,or by electro-conductivity
obtain one
more
hinted already,by electrolysis
sorelyneeded
we
and osmosis being
method
of measurement,
electro-conductivity
of similar significance
either mutually convertible, or
terms
;
of

forms

many

friction.

-conductivityof a
Although some
years

observers

later, showed

the

fluid

electro

that

being

Professor

ago

colloids have,

of

inner

and
Starling,

other

index

an

or

have,

may

some

conductors,
slightelectro-conductivity,
yet, generallyspeaking,they are nonand their inner friction is high ; without the impulses
of saline ingredients
they have no osmotic pressure, or nearly

by this virtue of its colloids it is that the blood

againstthe continual fluctuations in the densities

; and

none

saline constituents.
lower
electrolytes

Now,

to

for between

we
itself,

the

have

fluids,as

there

shown,

is

word,

we

of

rate

functions

of the

internal

the

incessant

whereby

structure

they

Eeid,

play of
in specific

differences
exercise

the

body

Waymouth

the differences

present vital

some

consider

cells,differences which, for lack of

call for

may

an

while

cells of the

Professors

of its

raise it.
to

come

fluid to the multiform

specific
alternating
phases,accordingto
endowment

that

moreover

seen

the blood

complex

others

have

viscosityof colloids,others

these and

and

Loeb,

the
from

pass

relations of this

We

is protected

better
at

any

selective

nice that

of
only certain kinds of reciprocation,
or
take place in each area
physiological
can
permeability,1
; thus
the kidneys select some
the pancreas
ingredients,
others, the
so

gastro-intestinal

canal

example of these
impermeability,for

"

of the

bladder

in

others, and

vital

"

obvious

situ ;

an

forth.

so

remarkable

is the acquired osmotic

peculiarities
of the healthyepithelium
purposes,
adiabatic

state

which

fails when

the

is

injuredor deteriorated.2 When

salts are held againstthe
of
apparent disposition osmosis, this attitude may
be maintained
by surface tension. To remove
the living epithelium from

coat

Vide

loc. cit., 1908,

Boruttau,
specifischerVermittlung," etc.
2

Upon

molecules
on

these

the

function

I have

points.

not

of

touched

lipoidsas
;

experts

p.

106,

investments
are

not

as

"Die

of,

einzelnen

or

as

clews

yet in substantial

Zellarten

amid,

the

agreement

that

much

content

seen

the

from

varies

blood

the whole

gas

VISCOSITY

THE

140

viscositydepends

the

of

addition

into the

chloride is

plasma. We have
haemoglobin and

chlor-ions

penetrate
content

of the

active

most

PART

that their water

concentration

of the

one

on

the

C02

so
corpuscles,

increases,and the molecular

Sodium

that of the

of the
on

plasma

than

more

BLOOD

THE

OF

plasma increases.
ionizingand osmotic

in the

electro-conductive,
plasma. The plasma is more
the corpusclesare
colloid ; and, as
more
already stated, are
At present
salts,not permeable to others.
permeable to some
it would
that by some
endowment
seem
physicalor biological
of the corpuscularedge, or
the inorganic conmembrane,"
stituents
of the cells and the plasma stand various and unequal ;
the corpusclebeing rich in potassium and phosphate,the plasma
and
in sodium
chloride.2
It is at this boundary, in its origin
agents

"

almost

ideal,that

note

we

character

the initiation of inhibition,that fundamental

of

organisedlife,of survival by an economic

and
facultypreventing dissipationof energy,
storing it for
further and largerends.
For this auto-limitation, viscosity
and
friction and,

have

adsorption,putting the brake

And
it
physico-chemicalprocesses, give the conditions.3
upon
is here that for a moment
of
we
glance again at one
may
the most
practicalproblems of the clinical physician,at the
of the body, its reserves
resources
or
potential. In advancing
we
less permeable ;
years
suspect that the tissues become
osmosis
is less active,less free : for to
equalisethe rises and
falls of viscosity,
osmotic
or
be readily
tension,the cells must
For example, in laboratoryexperimentswith
perviousto water.
as

we

yeast the cells must

cells of the
It has
and

day

been

excretions

be

before

fresh, hatched

their

"

"

for

hour

an

the

WiysioL, Jan.
oxygen
For

from
an

d Law

subject.

; of these

agenciesthe

The

observations

of

Barcroft

and

Orbeli

1911) on the effect of lactic acid also in

sweeping
tissues,are very interesting.

out

and

other

(Journ. of
low-tension

the

able
of

study

of

these

phases

and

"

Garrison,
Physiology and the
Journ., Sept. 25, 1900; and
by Hopkins, published after my text was
printed.

Thermo-dynamics,"

by Barcroft

system

nervous

Physical Chemistry, 1910,

this

on

two

or

Adam, Zeitschr. f. klin. Med., Berlin,1909, Ixviii. 177.

Boruttau, Med. Physik, 1908 ; Philip,

uthors

or

dischargethe secretions
or
fluidity
viscidity
play a large part in
reserve

equalisingviscosity,
balances in which
must
play a largebut incalculable part
1

within

far less sensitive.

are

said that

by

seen,

N.

see

York

Med.

CHAP,

urine

function

of the

with

respirationthe

the

be

must

141

important, sharing indeed

very

chief part ;

to

the

much

given,and

been

has

little attention

EXCRETIONS

AND

SECRETIONS

in

urine

therefore

help was anticipated,

in estimatingthese

Koranyi and others, from cryoscopy

by von
Bradford,1 Sir
exchanges. Unfortunately, Sir John
Barr
Sahli,2 Winternitz,3 and other
(inprivateletter),
its indications, which

found

observers, have

no

of

James
careful

fluctuate

course

largelyin health, unavailable, at any rate in this respect ;

likewise
those of electro-conductivity
(p. 321). It tells us
than

more

concentration

the

substances,

To

gravity.

get

we

weigh the
computation

it than

from

ashes

of

moment

of

out

more

no

the

at

the

out

locomotive

as
no

dissolved
of

specific

does

not

efficiency.For instance, if
off the waste
the kidneys fail to carry
products the molecular
of the
concentration
blood, and therefore its freezing-point,
fall ; but other variables
should rise,and its electro-conductivity
in renal default this is not regularly
the case
such that even
are
;
of the urine, and converselyof the blood, fail to
and cryoscopy
tell whether
after operationon
one
kidney the other is healthy
in

far

go

Now

not.

or

to

test

the
indirectly

renal

of

and

20

cm.

falls of

exclude

the

of

its

concentration

by
efficiency,
it

then

even

concentration

of the
needs

cryoscopy
to

seems

due

blood, and

to

me

so

venesection

impossible to

variations

of

cardiac

If electrorisingvenous
pressures.
it
conductivityshould fall independently of the freezing-point
A little proteid,
would suggest a retention of organicmolecules.
however
toxic, would
scarcely alter the freezing-point.The
of the whole blood and of the plasma are practically
freezing-points
make
difference ; quartz dust,
identical ; suspended particles
no
difference ;
for instance,suspended in a similar solution makes
no
the contrary, of the whole
blood is but
but the conductivity,
on
from
which the corpuscles,
which obstruct
half that of the serum

energy,

other

or

conduction, have
Of

the

effect

reallyknow
Allbutt

Sahli, Klin.

methods
3

as

been
of

nothing.

and

of

causes

removed.

glands
On

the

and

hormones

sum

of such

Rolleston, System of Medicine,

Methoden,

edit. 5, 1909, ii.748.

data

as

these which

edit. 2, iv. pt. i. 535.

Sahli criticises von
Koranyi's

fallacious.

Winternitz, in Krause's

viscositywe

upon

Lehrbuch, 1909, 259-60

BLOOD

THE

OF

VISCOSITY

THE

142

PART

l formed
consideringDu Pre Denning and Watson
be not
to
an
the provisional
opinion that viscosityseemed
dominant
in
not
independent but a dependent variable ; one
the circulation,but by its adaptive changes contributoryto
of its consistency and efficiency.At present
the maintenance
has gone
before that in pathowhat
logical
indeed it is not clear from

been

have

we

always beneficial ; but with so

we
in the evidence that is obscure, or even
contradictory,
much
From
for the present hold our
must
judgment in suspense.
still speculativenotions, vitally
and
data
these inconclusive
important as the facts may be, and enlargingas these concepts
its fluctuations

states

to

are

vision, it
physiological

our

stickier blood

that

few

for

applicationto practical
says,2(other things being equal)

Hess

the

increase

must

admitted

be

must

formulated

as
can
yet be
principles
medicine.
Although, as
a

are

of the

burden

heart

both

on

this variable

qualitymay be met
by
If a
readjustments as to be virtuallya constant.
so
many
will soon
thicker blood flow more
slowly water
gather in the
rapidly
body ; if a thinner and less valuable blood flow more
be increased, and
the normal
the urinary effluent will soon
viscosityrestored. Yet a thinner blood, if, as is probable,it
and if,as less nutritious per unit, it be run
be in largermass,
at
be the
greater speed,and with equal aortic pressure this would
be no less burdened
; though not necessarily
case, the heart would
still disposed to think
under any rise of blood-pressure.I am
be concerned
in some
that a superviscousblood may
modes
of
sides,yet it is

that

true

arterial stress.
the

Upon

difficult to
another
certain

influence

say

sections

the

than

more

chapter I

of

have

of the

system

nervous

that

it must

referred

to

spinalcord

be

on

viscosityit

is

considerable.

In

experiments showing

that

have

remarkable

effect in

of cells in the blood.

To
determining the apparent number
stimulate
the cord
the capillaries
with
high up
may
gorge
red corpuscles
to stimulate
the vasomotor
; and
system directly
increases the viscosity,
mechanism.
probably by the same
"

"

However, further research

1

78,

Du

Pre

Denning

and

Watson,

on

Proc.

this

subjectwill surelylead

Royal Soc., Oct. 24,

1906.
2

Hess, Deutsche

Arch.

f. klin. Med., 1908,

xciv.

404.

1900

and

to

No.

CHAP,

AND

VISCOSITY

in

BLOOD

PRESSURE

143

therapeuticalresults. For there is evidence

in health so ready,in
states these readjustments,
that in abnormal
for instance, that in the state of
disorder may
lag ; it is alleged,
excessive
blood-pressuredescribed independently by Huchard
and
of arteriosclerosis,
and
by myself in 1893-94 as precursory
named
Presclerosis,the viscosity
by me Hyperpiesis,by Huchard
of the blood is,or may
be, raised ; the observations on this point
however
as
are
yet too few, and too lacking in authority,to
establish a rule (p. 118). But since this chapter first appeared
love of symmetry
Martinet,1 in an able treatise,by the French
and logical
completenessmade a littletoo plausibleand trim, has
and many
clever diagrams,
further researches
published some
and Hood-pressure. He
used
the relations between
on
viscosity
of Hess.
He concluded
that the physiological
the instrument
clinical and

some

is within

variation

very

limits

narrow

say,

"

limits
(3*8to 4'5),but that the pathological
within

individual, and

one

0*3
are

to

0*4, at

wider

by

few

days, he recorded
pathologicallimits

far

in

rise from

1'9 and
were
experiencethe
7*8.
Martinet
stress
lays much
watery dilution of the
upon
the efficiency
of renal filtration and
blood, and accordinglyon
the degrees of dilution of the proteids
pulmonary exhalation
In chronic
renal
by refractometric methods.
being determined
disease therefore some
cases
present a plus, others a minus,
Beck,2
viscosity points already brought out by Hirsch and

5 to

his

most

In

7*8.

"

"

and

Lommel,3

(loc.tit.),but

Determann

which

all the

are

clearer for this verification,

as

they bear closelyupon our clinical

of excessive blood-pressure,
problems. For instance, of 22 cases
renal or
whether
hyperpietic,four had a normal
viscosity
of the
and seven
a
plus viscosity(an addition to the burden
be overlooked). Ambard's
heart which
cannot
overlaboured
in the urine and the blood respectively
researches on the urates
these
bear closelyon
postulates(p. 321). In
plethoriques
and the pressure
both in excess,
were
simples"againthe viscosity
and these cases
offer a favourable
prognosis; if the viscositybe
"

Martinet,

Hirsch

Med.
3

Bd.

1908, No.

Beck,

"

Studien

d. Viskositat," etc., Deutsche

Arch.

Arch. f. exp. Path. u. Ther. Bd. liv., 1905.

; and
Deutsche
Arch. f. klin. Med., 1904, Ixxx. 308 (quoted

f.

klin.

Ixix., 1901

Lommel,

in Deutsche

arterielles et viscosite sanguine, 1912.

Pressions

and

med.
6.

Wochenschr., 1910, xxxvi.

1438)

and

Munch,

med.

by Krone,
Wochenschr.,

low

have

we

reduced

was

blood

Yet

it.

lower

admit

we

viscositydo

and

in

cell elements

not

that

falls
pressure
rise together as
"

but

rise in

must

also

come

C02

accumulates,

in, when

into

the

of

until

of

by

time

exhalation

pulmonary
balance
thrown

past, has laid great

be

must

more

or

ing.
reckon-

under

will rise,
of

C02,
"

the coefficient of

upon

pulmonary disease of
less gravelydisturbed,and
All observers

cosity
vis-

and

the

in

renal filtration.

on

stress

the

kidneys
and plus
pressure
venosity. Hess,

water

he says, minus
Briefly,
complicated sum.
and
pulmonary insufficiency
viscositymean
some

sures
pres-

say

"

arterial pressures

escape

the

would

of

the

signs

for

arterial pressure

distribution

the

cosity
vis-

valvular,say

respect of respiratoryexhalation

in

respect

In

of

curves

refractometric

set

may

the

the

As

digitalisdiuresis
fall
and viscosity

retained

were

wet.

were

parallel
;

run

blood

the

water

the

seven

systoleis in default and venous

while hydrsemia l
raise viscosity,

as

would

rise, C02

and

tissues

the

diluted, and

was

mitral, disease,

in

chlorides

PARTI

In

default.

renal

with

do

to

BLOOD

THE

OF

VISCOSITY

THE

144

that

agree

this

course,

work

more

hydrogogue

while, caeteris paribus,both maximum

purgativesraise viscosity,
and minimum
fall (unless tissues water-logged). In
pressure
of Martinet's
one
patients,in a mitral asystolicphase, under
three days' diuresis set in, and
the cedema
a
appeared
disdigitalis
; the

of
viscosity
6*0.

and

PR.

and-

+ PR.

and-

The

fell then

the blood

Martinet
PR.

"f

urine

thus

ran

up,

obtains

to

the

for three
three

normal

days,

formulas

quantity and
to

5 '8 and

even

the
to

Viscosity plethora sanguinis (hyperglobulyor glyksemia).

Viscosity hypoglobuly (anaemia).
Viscosity hydrsemia (renal insufficiency).

iodides,he

says,

also,but bad
viscosity

are

useful

if pressures

when

high
low.
viscosity

and

hydration, which

has,

pressures

be

are

In
high but
the former cases
free dilution is required,
but not in the latter ;
for therapeutics. Martinet
good points,if duly verified,
opines
that in cases
commonly called plethoric(my hyperpiesia)
the plus
is
due
to
red
viscosity
plus
corpuscles"say 6 to 8,000,000 (p.260) ;
but of any special
relation of polymorphsto
or
viscosity
tion
coagulatime, or of Austrian's observation (loc.cit.)that although
1

be confused
Hydraemia must
not, of course,
with
probably, but a slightinfluence on viscosity,if any.

CHAP,

EFFECTS

in

OF

IODIDES

145

of the blood may

fall (hydrsemia),
the viscosity
nephritis
yet in uraemia that of the plasma rises (due to retention products?
Holmgren, p. 110), a clinical point of much interest,he says
nothing (seeremarks on Giesbock's cases (pp.256-60). Austrian
coefficient at least normal
in thirteen renal
found the viscosity
he had
out of twenty-two ; and in some
cases
cases
high-pressure

in chronic

"

it

seen

minus.

even

For

Martinet

the chief determinants

then

He
gives an
viscosityare pulmonary and renal efficiency.
with weak
sketch of the cyanotichabit, of persons
interesting
hearts
livid extremities ; torpid,shivery, and
and
blue
or
rules high.
: in these he says
venous
viscosity
The difficulty
of attaining
to exact
knowledge in this subject
is illustrated by the uncertaintywhich
in these respects still
surrounds
the arterial
the effects
of iodide of potassium upon
circulation.
in spite of the
noted
how
We
have
tenaciously,
lack of definite evidence
of this virtue, medical
practitioners
arteriosclerosis
of this salt in
clingto the prescription
; and
this in justifiable
able,
disregardof pharmacologicalopinions justifi-

of

"

"

"

that

is, if it

in
decisively
and

men

appears

its favour.

animals

has gone,

doses of iodide of
has

been

obtained.

and

Beck's

vessels,but

moreover,

in stream

upon

far

so

the

clinical effects

observation

as

of

Miiller

and

the blood

whose

Inada,1

searches
re-

Romberg's supervision(Hirsch

under

that

the iodide

2
not
arteriosclerosis,"

the blood

normal

ate
of the effect of moder-

littleevidence

Ottfried

by

any

which
viscosity,

had

"

able
favour-

effect upon

in 9 out

of 11

the
men

in

"

"

found

of 20-30
has
1

and

Miiller (Ottfried) and

Ther.

Inada, Deutsche, med.

d. Gegenwart, 1906, 360-361

Med., Wiesbaden,

Romberg,

iodide

of

see

Wochenschr.,

1731

xxx.

Kongr.

Lehrbuch

d. Herzkrankheiten

who

upon

this

ground

recommends

sclerosis.

177.
L

f. inn.

1909.

in

1904,

also the reports of the

potassium
coronary
Adam, Zeitschr. f. klin. Med., Berlin, 1909, Ixviii.

VOL.

are

They stated,
degreesfrom 1'7 to 8'3 per cent.
that they had demonstrated
a
gain of four seconds
ministered
velocity. But on the other hand Adam,3 who adpotassium iodide in full doses i.e.45 grainsa day
reduction of viscosity
in only 6 of 30, and that doses
wise
likeDetermann
difference at all.
no
grains made
under
been unable to detect any reduction of viscosity

reduced

was

Yet,

instrument),found

effect upon

that

them

of
potassiumin reducingviscosity

carried out

were

to

salt.1

the

He

BLOOD

THE

OF

VISCOSITY

THE

146

PART

that, if the iodides be useful in high blood

says

In vitro
be sought elsewhere.
must
pressure, the explanation
viscosityin
that iodide of potassiumreduces
it is well known

those

have

would

reduction
to

He

months

for

lest iodine

must

be avoided

The

observations

This

conflict of evidence

be

effect of

have

This

into

taken

been

consideration.

of Altona

said that in his wards

reductions

iodides,not
Boveri
"

administered

whole

the

tested

In

20, 30, 40 days.

from
and

10

(in my

examination
there

at
not

are

to

seems

the

some

blood, and

the

eightof

source

be

alleged

an

the

any

cases

to

twelve

there

of cases,
of

the

the

time.
with

persons

intervals

of 10,

fall of

of the

viscosity
not
large,
day on each

whole

Boveri

was

differences

the

the

arteriosclerosis,

at

serum,

On

at

long periods of

parallelismbetween

kind

long series

administration

rate) the hours

mentioned.

to

referred,Umber

without

The

not

discussion

I have
a

may

ing
vein, of constrict-

the

Jorns, in

and

downwards.

cent

per

which

to

viscosityon

with

hypertension,"some

and

of

In

large doses but over

iodine compounds

in very

iodides

property, if it exist, appears

Congress (1909)

noted

the

possiblyto

or

injectedinto

Wiesbaden

had

just quoted (p. 144).

effect of

difference ;

potassium salts,when
arterioles.

the

have

the

to

as

time

upset the stomach.

free and

be set

Martinet

of

in part to

due

five

to

"

He

month.

every

I., three

gr. of P.

an

say

"

response

reaffirmed

of soda,
equal quantity of bicarbonate
but with
eight to ten days' pause
a
year
the iodide ingestionfood
that near
us
warns

with

day,

and

experiments

4-6

about

in
Miiller,
2

to his

gave

blood.

whole

the

on

criticisms,returned

his conclusions.
times

which

recognisedthe large effect

have

we

plasma ; and
relativelysmall

in blood

and

watery solutions of serum-albumin,

are

arteriosclerosis
"

says
sumably
pre-

"

"

and
hypertension
consequent upon
the viscosity
of the blood, and
(contrariwise)iodine ingestion.
But

it is to be observed

that these falls were

"

"

in the whole

blood,

Blutviskositat
bei loddarreichung," Deutsche
Determann,
med.
Wochenschr.t 14. Mai, 1908, p. 871 ; Lommel,
Deutsche
Arch.
f. klin. Med., 1904,
Ixxx. 308 (quoted by Krone, vide No. 2) ; and Munch,
med. Wochenschr., 1908,
No. 6 (quoted by Determann,
loc. cit.).
2
Muller, Fartach. d. deutsch. Klinik, 1910, p. 358.
"
Viscosite du sang et iode," La Presse med., 1908 ; extracted
Boveri,
in
"

Arch,

des mal.

du

caeur,

1909, 265.

in dogs
viscosity

increase

lower

for

is said

to

118).

p.

viscosityin disease

Of

PART

usuallyremains

however

plasma

(Vol.II.

weeks

some

of the

that

again ;

BLOOD

THE

OF

VISCOSITY

THE

148

little.

know

we

the

In

rabbits.1

and

Hunger

cussion
dis-

Wiesbaden

high viscosity(8'27) had

six months
of a patientin whom
been found in the diabetic coma
viscosityhad been
in spite of acidosis, the blood
previously,
?
nearly normal
found
(5'61). But is this
nearly normal
Martinet, etc.)that in glycsemia
Most
authors agree (Austrian,
that

stated

Umber

very

"

"

is high (letus
viscosity

the

diabetes

urine

of the

also,

enormous.

of the

blood

the

from

as,

is

8'27

?) ;

electrical resistance

mellitus the

is that

as

5'61

say

In

is

high,
conductivity

low

containinguric acid is said

have
alteration of viscosity.In anaemias, as we
to present no
caeteris paribus,
the viscosity,
in respect of polycythaemias,
seen
in the area
from which the
of corpuscles
will vary as the number
In simpleanaemias it falls a little. Matsuo
blood is drawn.2
(loc.
remark
that in anaemia
the interesting
viscosity
cit.)makes
readingsrun proportionalto bruit de diable,which begins at and
In menorrhagia, in Grave's
2'8.
under
acidosis,"
disease,in
which need not be a fulminatingmalady, and no doubt in other
be excessive,and viscosity
duced.
reaffections,the calcium loss may
of sugar,

we

should

expect. Blood

"

Albumin

then

may

leukaemias,in spite of
them, increased

low

is
viscosity

total increase

in

appear

(Barr). In

urine

the

in

haemoglobin content

often noted

and

this pretty

of

surely

be noted
corpuscles for it may
here that the white corpusclescount
for viscosityat least as
much
the red, some
think for more.
In splenicleukaemia
as
Determann
found that the white corpuscles
in their proconduced
portion
to the viscosity
than did the reds.3
more
Usuallyin these
to inhale oxygen
does reduce
much
cases
the viscosity
; but
of the reds, and
the haemoglobin
depends on the number
on
of haemoglobinuriastudied
values.
In a case
by Determann
the liberation,
during the attacks, of viscous substances from

depends

the

reds

on

enhanced

the

of

some

blood

restored, regularlyfell

were

"

Bussk.
Krotkow,
Wochenschr., 1912.
8

The

viscosityvalue

Wratch,"

which, as
viscosity,
again. Here at any
No.

"

of the

"

See

42,

1912,

extr.

these

bodies

rate

clinical

in

also Austrian, loc. cit.

plateletsis

unknown.

Deutsche

med.

CHAP,

EFFECTS

in

observation
laked

blood

resistance

of the

while

resistance

the

strikingfact

ohms,

raised

urine

plasma,

of whole

exosmotic

drive

88

to

of

"

which

Mayesima (loc.cit.)found

the

"

that

showed

remarkable

the

effect

place in
astonishing,and

in

after all

iodide

salt and
Some
raises
on

authors

and

that

Turner,

Bd.
3

Med.

Zuntz

H.
and

as

in

in these

Dawson,

Proc.

of the

of

be

must

ated
associ-

tures,
(p.142),as after frac-

stasis,and
Cohnheim

and
of the

on

also

spinal cord

local

rise of

cells.
in

in
cosity
vis-

Viscosity

anaemia

and

Martinet,

see

malignant growths.
falls

tion
extirpa-

infusion

It rises
of

p.
on

common

bromide) of potassium.

that

rise of

hydrogen

ions

in the

blood

and
gout, uraemia,acetonaemia, fatigue,
states

under

of alkalies

the administration

Royal Soc. Edin., 1891-92, vol. xix.

so

p.

20, quoted by

1902, Ixvi. 127.

J., "Viskositat

Mayesima,
xxiv.

not

say

viscosity;

himself, Nature,
2

(but

tions
varia-

electrolyticchanges.
operationswhich irritate

of sections

injectionof gelatineor diuretin,but

not

and

soft parts,
operations on
chronic
but
nephritis(Cheinisse,

145), in liver cirrhosis,and

with

45)

of salt content,

extensive

leukaemia, in

300

to

definite

most

determining local afflux of red cells and so

being gorged with blood
; the capillaries
falls in

down

he

corpuscles. The
tion
dropsy on elimina-

peritoneum, or affect the spinalmarrow

acute
purulent inflammations, venous
of the spleen,viscosityrises. Zuntz

the

kidneys

size of

and

viscous, osmotic,

wide

salts the

the

reckon

to

take

dietaryis

the

if

"

blood

protein content,

may

few

too

the

pernicious anaemia

have

content

gas

hence

"

(instead of the normal

that
viscositydoes
says

shall

we

(about one-half),

as

the

of

blood, of number

of salt from
with

case

Mayesima2

far obtained

so

of

the electrical

found

contained

amount,"

resistance

haemoglobin and

of
results

In

doubled

was

urine

the

in all diseases

But

with

experiments

ohms

300

urine

the

another

beriberi

In

fall.

the

Turner

to

abnormal

an

the

and

ohms.

of

electrical

the

found

fallen

while

that

fault."

at

were

Dr. Dawson

blood

contained

blood

149

(p. 128).

perniciousanaemia

In

with

correspond

to

seems

DISEASE

OF

d. Blutes," Mitt.

a.

d. Grenzgeb. d. Med.

u.

Chir.

3.

Cohnheim,

Journ., May

18, 1907.

Berl. klin.

Wochenschr., 1886, quoted Saundby

Brit.

; but

modified

as

yet

our

viscositycoefficient

The

cyanosis,if any.
Dr. John
In epilepsy

the

time

is

time

is much

attributes

he

having

in

Turner,1 who

the

blood
to

the

small
at
mere

that

considers

that

the

more

more

the

retard

the

same

upon.

coagulation
coagulation
frequent
coagulation
found

he

pressure

often

in

were
epileptics
He
heart.
ill-developed

pressures

reason

depends chieflyupon

blood

coagulationand

variously

be

to

scanty

disease

heart

bromides

arrived

fevers

In

too

are

thinks

The

relation.

data

this the

Between

rate.

of the reds may

shortened, and
He

PART

adhesion

viscosity(p. 110), says

of

measure

seizures.

the

as

mutual

The

falls.
viscosity

BLOOD

THE

OF

VISCOSITY

THE

150

no

low, this
2

Besta

quotes

conclusions.

rise of

temperature

is attended

with

viscidity(see p. 147) ; 3 but if the fever be prolonged

this
contrariwise
will act
the
evaporation of water
;
may
falls
in
that
denial
fevers, and
viscosity
explain Mayesima's
rise of viscosity
the divergentresults of Biegel,who
a
registered
in fevers.
Venesection, as
already remarked, by reduction
in number
in some,
but not
reduces viscosity
of the corpuscles
in close,proportionto its amount,
possiblyup to 12 per cent,
and accelerates the stream
velocity; an effect which, as regards
the plasma, continues
for a considerable
time, the corpuscles
under
made
ordinary circumstances
being soon
again.
up
fall of

"

"

Welsh

observed

disease, renal
abide

for

the

result in seventeen

various

disease, eclampsia, etc.

some

considerable

The

cases

effect

; mitral
to

seems

period.

In

4 found
in spite
a fall of viscosity,
typhoidfever Bachmann
of some
of C02 ; but in pneumonia a rise,
not
excess
due, in his
either to blood-pressure
to leucocytosis,
and apparently
opinion,
or
not
to excess
of C02, as the rise was
noted
also in mild cases.

He

considers that this difference may

be regarded as a diagnostic
rises in epidemicmeningitisand very
point. Also that viscosity
much

in cerebral

that

in

haemorrhage. There
diphtheriathe viscosityof

Turner,

J., Journ.

Mental

Sci., Oct.

is some
the
1907,

of evidence

consent

plasma
a

paper

is increased,
in

many

ways

interesting.
3

Amer.
4

Besta, Rev. sperim. de freniat.voL xxxii., abstr. J. M. Sc., April

Burton-Opitz, Stud. Rockefeller
Inst. Med.
Res., 1907, vi. 190, and
Med.
Assoc., July 29, 1911.
Bachmann, Deutsche Arch. f. klin. Med., 1908, xciv. 409.

1907.

Journ.

CHAP,

151

DISEASE

OF

EFFECTS

in

body we know that the peptonisinginfluence

fluids less
albuminous
of bacteria,as
of trypsin,is to make
to increase
free ions (e.g.amino-acids),
viscid,and, by releasing
of bacterial
conductivityalso. Would not further investigations
these lines to a
lead on
actions, and comparison with venoms,
better knowledge of catalytic
poisoning?
Torday,1 in a paper which deserves more
Czepai and von

though

outside the

it has

than

attention

in 118

and
specified,
of disease

kinds

of

mixture

that

"

liver

old

ccm.

0'9 per

57 of various

and

4'0 in

quotientover
viscosity

is in

alcohol

absolute

with

serum

fully
care-

"

tuberculin

severe

serum

tuberculous

1 '8-2-5

it

cases

alcohol

absolute

ccm.

in mild

serum

health, i.e. from

in

0'2

But, if we

solution.

NaCl

cent

Laub,2 the

of

of

value

tuberculinised

61 of tubercle

"

methods

on

experiences absolutelya specific sign of tuberculosis ;

of the foetal
alcoholic extract
of syphilisan
few cases
is 0'2
much
a
higher quotient still. The admixture
gave

But

cases

"

their
in

received, conclude,

is much

(method of Czepai and

from

higher

runs

"

viscosityis of favourable
guinea-pigsthe reaction

of

as

in

Torday).
upwards. A fall

3'0

von

On

omen.

ccm.

Eisler and

relyupon

may

of tuberculosis

cases

O'l

proved

whole

the

much

be

to

in
the

same.

In respect of
of the

method
but

drugs other than the iodides (p.145),the accurate

pharmacologistsshould give us definite results,
is not

yet there

as

much

M'Caskey,3and Determann,

build

to

found

it.

Burton-

to

the

alcohol, in varying degrees of dilution, into animals

the

facial vein,

blood

in all

viz. from
in 5-10

(6)into

cases

4'95

minutes,

is
Digitalis

Czepai

Eisler

and

persistedfor

and

M'Caskey,

caffein

maximal
minutes

30-35

effect upon

slightlyand

(a) into

"

found

"

method

viscosity
; strophanto raise it,
transiently

the

1911.

"

W ien. Idin.

20.
Amer.

Med.

Assoc., Chicago, 1908, li. 1653

(quoted by

Krone).
4

(6);

(see p. 247).

Torday, Deutsche med. Wochenschr., Aug. 10,

Laub,
Viskositatsbestimmung bei Tuberculose,"
Journ.

the

effect arrived

von

Wochenschr., 1912, No.

3

no

duodenum

under
especially

(at 87" C.). The

said to have

and

or

5'71

thus, adrenalin, and

1

stomach

viscous ; but

more

to

the

alcohol,

viscosity,
Opitz,4injecting

that it increased

that alcohol reduced

but Bachmann

As

upon.

Burton-Opitz, Journ.

Physiol., Cambridge, U.S.A.,

1905, xxxii.

8.

BLOOD

THE

OF

VISCOSITY

THE

152

PART

is made
that
statement
interesting
the nitrites temporarilyreduce viscosity.1
the point of practical
of this review, from
conclusion
The
of viscosity,
estimation
if the
be that
to
medicine, seems

camphor

unless

to

The

it.

reduce

content, be

respect of calcium

in

yet of little clinical

as

academic

service,it is desirable notwithstanding that

tions
observa-

subject should still be pursued, seeing that it

stitution,
conis a study of those
dynamical problems of molecular
and chemical
osmotic
electro-conductivity,
pressures,
the
principlesof life. Moreover, while
physics which are
continue
the
to
to
penetrate to the arcana
patientlywe
and
ultimate nature
and genesis of the materials
intimate
we
obtain meanwhile
have to study and to handle, we
some
may
useful tools for rough and immediate
reckonings. And if in the
of evolution the periodsand fluctuations of these forces
course
have become
so
rapidlyadjustableas to elude us, our methods
of research must
be refined to a correspondingnicety. That
the

on

"

influences

these secret
and

forces of the

have

effect upon

enormous

circulation,
upon

its distributions
but

an

and

its pressure

its issues is

tenance,
heads, its mainmatter

no

the stresses

of

tion
specula-

of verified

and definite data.

The difficulties
principles
in the present problems lie not so much
in the principles
in
as
the complexity of their common
sphere of operation. So far as
research

enables

to

us

pry

into the

future

it

seems

out
if,with-

as

"

vital
these physico-chemical
postulatingany
agency,
with their time relations,will
principles,
much
of the
compass
of
life.
interpretation
"

This

review

made

was

in

order

to

learn, if possible,the

degrees of dependence of cardio- arterial integrityupon

the
qualitiesof the fluid these vessels contain and drive. Subtle
changes in the content, actingover
long periodsof time, would
induce

corresponding modifications
the causes,

largeand
more

viscous fluid,as

in the

I refrain

experiments

in

And

from

they

long
giving

are

if it be true

soever
continent; what-

run

the

far from

which

that to accommodate

polycythaemiafor

capacityin the

place,yet

the

the arteries do suffer modifications

conspicuous.

of vascular

in

many

secondary adjustments
references

conclusive,and

instance,adjustments

whole, or in very largeareas,

no

are

to

need

these

and

extensive

do take
can

be

other
many
verifications.

CHAP,

CONCLUSIONS

in

153

If the vessels be so dilated

equivalentto the normal balance.
that the blood-pressure
is littlealtered,yet the frictional pressures
be driving the systoleand diastole to act within much
must
limits of vascular elasticity,
and in time to strain the
narrower
has
first publishedDr. Welsh
arteries. Since these words
were
be no questionbut that blood of high
said (loc.
There can
:
cit.)
to force it through the
viscosityrequiresmore
driving power
of lower
than
does blood
viscosity,and that the
capillaries
dilatingor contractingof the arterioles does not alter this fact
?),although it may
partlycompensate it." We know
(postulate
"

that

in

and

the

as

man,

arterial
the

present

may

of solids and

coats

thicken

ventricle

Osmotic

of

traces

some

blood

the

areas

reduction

far

of the

rise

degrade ;

while

small

on

taneously
simul-

degrees

exhibit

the urine may

so

little,

less active ; the

become

and

albumin,

radius

take

may

pressures

that

the

watchful

of salt intake.

If

finer vessels be

of

shins

poverty

physician

by

sclerosis

diminished

the

viscous ; if also the

relativelymore
endothelium
would
be favoured.
were
unhealthy thrombosis
And
alongsidethese senile changes the peripheralvascular areas
be shrinking,
but therewith,and perhaps in indirect propormay
tion,
the total volume
of the blood falling
Such
is the
(p. 46).
intricacyof the mechanical
system which we have to interpret.
Finally; as of the conclusions of these studies on viscosity
which
better established,one
is the increase of viscosity
seem
on

would

and

changes

slightoedema,

prescribesome

may

in

go

left

hypertrophy.

blood

on,

years

so

increments

of

be

carbon

vicious circle

inhalation
as

so

in many

diseases

is the

minus
plusviscosity,
increasing viscosity. Hence
"

to

dioxide,

the

of

in

oxygen

fine vessels

of

the

velocity,
plusC02, and round
one
advantage set up, of
of inadequate aeration.
Now,
cases
lungs are comparatively of constant

radius, excessive

internal

friction must

This effect

little able to

tell

sooner

on

them.

but in practice
directly,
of graduallyencroachingcyanosis,
meet
due
we
dailywith cases
for instance
to
bronchial, emphysematous, or more
general
which
lead to or are
associated with enlargement of the
causes,
rightside of the heart. It seems
probable that in these cases,
in other multiplesof cyanosis,increments
of viscositymay
as
play no inconsiderable part in the adversity.
we

are

measure

IV

CHAPTER

IT

is when

study the

to

come

we

ARTERIOSCLEROSIS

OF

CAUSES

of diseases that

causes

we

are

by the breadth and depth of our ignorance;

with guesses, presumpit is here that our
path is most cumbered
tions,
the untimely and sterile fruitageof minds
and conjectures,
bear to wait for the facts, and are ready to forget
which cannot
of hypothesis lies not in the display of ingenuity
that the use
but in the labour of verification.
Again and again the data
disconcerted

most

requiredare
so

far

as

before

not

have

we

fullybefore us ; indeed, even

be impossible to track them

not

or

us,

them, it

may

of
severallythrough the perplexities
we

have

anatomical
far

two
"

or

main

more

divisions ; such
"

of

should

several

separate

directions

ultimatelyto

the

the

areas

the

not

that ;

of

universal

then

processes,

bottom

at

prove

"

if the

or,
to

be

various

features

one

and

the

process,

determinations

In

to

shall

we

it

may

have

at

or

the

to

rate

any

of

some

paths which lead

Again, in respect of

of the

other.

is

arteriosclerosis

that

see

in

prevailsnow

which

and

discussingthe
to
keep an

processes

akin,

ing
includ-

name

hyperpietic

shall

and

body,

the

as

we

"

"

decrescent,"kinds.

arteriosclerosis

these

to

them

"

again how
unity within

omnibus

an

an

and

processes

is

Moreover,

disease," but

not
signifies

concept, but

involutionary,"
or

causes

eye

uniform

"

lives.

"

is not

morbid

arteriosclerosis

name

itself,not

the

result of several
"

the

arteriosclerosis

that

seen

individual

throw

this

area,

some

in

now

light

upon

causation.
The

Many

Correlation
years

of Arteriosclerosis
elapsed before my main,
154

and
and

Blood
I

venture

Pressure."
to

think

ARTERIOSCLEROSIS

OF

CAUSES

156

PAET

explainedby the suppositionof an enfeebled heart, and likewise

regarded these contrasted states as but phases of one process.
ence,
while confirmingthe differSo again Dr. Coley of Philadelphia,
this,I believe,is
; and
explainedit by cardiac insufficiency
stillDr. Herringham's interpretation.Thus for all these authors
of accident and degree,and lies
the character of pressure is one
in

profferthe

however
did
Jane way
process.
explanationof Hasenfeld and Hirsch, that
of

difference

radical

no

alternative

rise in proportion to the degree of

pressures
in the splanchnicor
supradiaphragmaticareas.

as

Romberg2

von

extensive

says,

(" sehr selten ") ; it is

rare

(p. 188), is

elsewhere

considered

This

thesis,
hypo-

abandoned

now

splanchnicarteriosclerosis
ascertained

now

arteriosclerosis

indeed

that

is

even

splanchnic and thoracic arteriosclerosis do

themselves
not
recognisablehypertrophy
give rise to any clinically
should
he
it
ventricle.
of the left
If,
truly added,
not
of the heart, this would
increase
the work
necessarily
imply
which
That the attacks of high pressure
rise of pressures.
any
transient and curable
arise occasionally
in elderlypersons
are
of

high degrees

(p.452) indicates that the

In

arterial alteration.
it
arteriosclerosis,

these
be of

cases

cannot

notable
The

effect upon

next

lie in any

it supervenes

upon

conspicuous degree

however, neither before the intervention

which
any

may

of these

cause

and

nor

static
senile

ubiquity,

after

it,had

the arterial pressures.

observation

I will

quote

upon

this

part of the

subject is by Dr. Cautley,3who emphasised the absence of

high blood pressure, and of cardiac hypertrophy, in syphilitic
arterial disease ; he brought forward
of this disease in a
a
case
in whom,
aged 40 (primary infection fifteen years before),
man,
although the arteries were
extensivelydiseased, there had
been
arterial tension and no
cardiac hypertrophy." The
no
abdominal
aorta
transformed
into a thick
was
rigid tube.
Although the patientwas
scarcelymiddle aged, the case reads
like one
of original
arterial disease merging into
senile"
syphilitic
"

"

arteriosclerosis

(videp. 296). Such

this

demonstration

emphatic
1
2

See, e.g., Marchand,

Discussion

much

was

Verhandl.

abound, yet nevertheless

needed.

Kong. f. innere Med., 1904.

Budapest Congress, in 1909.
Cautley, Lancet, April 6, 1901.

Arteriosclerosis

on

cases

at

CHAP,

it

But

arteriosclerosis

after my

these
of

the appearance

by

PRESSURE

of

clinical characters

less than

no

157

opinionon the
were
compelled

clinical observers

between

distinction

the

to

HIGH

(ten years

published)that

first

listen

until 1904

not

was

point was
to

WITHOUT

SCLEROSIS

iv

three

important
distinction,by

directed to this fundamental

especially
of Nauheim,1
GroedePs
Groedel
by Dunin,2 and by Sawada.3
attention
than
announcement
at the Congress attracted
more

papers,

the

other

made

two

observations

1000

constant

no

and

increase

With

pressure.

known.

the

the blood

found

arteriosclerotic

than

Of 380

high.

in 80 normal,

pressures

found

moderate

years

low

and

arteriosclerosis

in his younger

often rather

were

pressures

of

advance

Dunin

But

arteriosclerotic cases,

is normal, but

of pressure

patientsthe
he
patients,

440

on

well

now

approximate proportionbetween

or

blood

is

and

papers,

somewhat

or

raised : a proportionof high

remaining 300 it was
by the way, much largerthan later observations
cases,
pressure
established ; probably the sum
contained
renal
have
many
less ; in the

Dunin, with

cases.

caution, made

proper

deductions

no

for

gradual quasi-normal rise with age say to 140 or 150.

of arterio206 cases
sclerosis
Sawada, from this point of view, examined
122
uncomplicated cases
only 12'3 per cent
; in
Of the rest 75 were
proved to be associated with high pressures.
complicated with cardiac or with renal disease, or both ; and
the high pressure
number
the whole
30' 6 per
cases
were
upon
there
cent, a far lower proportionthan Dunin's ; but of course
the

"

"

is

much

threw
a

"

in

chance

the

series of

pressure

during

From

the

of these

date

At the British Medical

3
*

but

then

quoted

disease of the aorta

there had

his article

was

been

no

written

and

high
for

papers

medical

Association

in 1905

opinionbegan

to

veer.

"

Dreschfeld,5 divided

Groedel, Verhandl
Kongr. f. innere Med., 1904.
Dunin, Zeitschr. /. klin. Med., 1904.
med.
12, 1904.
Sawada, Deutsche
Wochenschr., Nov.
In the

sentence

another
6

life ;

Krehl

scale,and

same

found, yet in which

was

lists.

different purpose.

somewhat

of such

weight of his opinioninto the

necropsiesin which extensive

visceral arteries
blood

collection

the

edition

new

(p. 31) that

that

the

Dreschfeld,

cause

of

in

his book

high

lies in

Brit. Med.

(1912) Krehl

pressures
"

is not

atherosclerosis

hypertonie."

Journ., August

1905.

lucid.
accounts

He

says

in

for much;

one

in

ARTERIOSCLEROSIS

OF

CAUSES

158

PART

high tension and those

Dr. Herringham, in accepting
with low
; but at that meeting
the difference, attributed it,as I have said, to degrees of myothat among
elderlypeople
cardial degeneration; and assumed
in
to an
those live longerin whom,
allegedincrease of
response
the heart is hyperperipheralresistance due to arteriosclerosis,
Dr. Herringham for his
to
all indebted
are
trophied. We
but here I cannot
follow
important researches on these subjects,
shall see presentlythat arterial decay does not itself
him.
We
with

of arteriosclerosisinto those

cases

"

cardiac

set up

is

heart

the

disease, the
blood

hypertrophy; furthermore
cases
are
hypertrophied
arteriosclerosis

being

of

in which

cases

hyperpiesiaor
the

not

These

effect.

pressures but their

the whole much
on

that the

of

cause

the

die not

persons

of renal

high

later but

of cardiac defeat
ordinarily
this time Dr. Henry Campbell accepted
of apoplexy. About
or
this should
of the matter, and argued that
not
statement
my
surpriseus, seeingthat thickeningof vessels need not necessarily
increase the resistance which
they oppose to the blood flowso
long as a generalisedarteriolar hypotonus (or a tone not
that by the stiffening
higherthan normal ?) prevails To assume
of the tubes and loss of their elasticity
the heart is hypertrophied
l is
not justifiable
unless we
also that
or
assume
injured
the circulation is kept as efficient as before, of which
there may
sooner

sooner

"

"

"

be

no

evidence,

much

or

to

the

The

contrary.

first effect is

is round
probably a retarded blood stream; the curve
topped,
and
the pulseamplitude increased (vide p. 31). Dr. Rolleston
that
of fact, the
often, as a matter
agreed with me
very
when
obstructive
general blood pressure is not raised, even
"

arteriosclerosis

unabated."
energy
I
in 1907,
me,

Dr.

"

of

the

your

view

Again, in

Chalmers
been

as

to

the

and

severe,

Watson

examining

As

by

many

my

authors,

Address

see,

e.g.,

39-40.
Private

letter,January 1907.

the

kindly

the

blood

there is
at

no

obvious

Wien.

med.

informed
pressure
than half
I

fully

class

of

rise of pressure."

Toronto, in 1906, I

Grossmann,

heart's

...

necessityof recognisinga

of arteriosclerosis in which

cases

have

and

patient with thick arteries,but not more

every
number
had
raised blood
distinctly
pressure.

share

Nos.

extensive

seems

set

forth

Wochenschr., 1910,

CHAP,

SCLEROSIS

iv

WITHOUT

HIGH

discussed

these differences,and

them

and
colleagues,
agreed that in many

with

stated

of well-marked

cases

159

Dr. Rudolf

Rudolf

Dr.

in 1908

of his

PRESSURE

and

that

some

he

now

arteriosclerosis the

augmented ; but he stillseemed disposed,

with
Senator, Janeway, and
Herringham, to attribute this
realise my
not
to
was
stabilityto cardiac defect, which
blood

view

is not

pressure

of the

and

pressor

different series.

yet later article by

much

was

Rudolf

Dr.

classification in full.
than

arteriosclerosis
non-pressor
interested therefore to read

the

He

had

found

half of his arterial cases,

difference

due

not

was

to

that he had

heart

high

pressures

in most

and

failure.

adopted

At

of

as

in

original

my

in not

of the rest

more

that

the

the British Medical

"

half
Meeting in 1908, Dr. Newton Pitt admitted that
his cases
not associated with hypertrophy
were
(ofarteriosclerosis)
of the heart," 3 and in the same
of
year Dr. George Oliver, in one
able contributions
of his many
the not least interesting
to this
that in
of arterial
wrote
a largepercentage of his cases
subject,4
thickeningthe blood pressure is not only not at all raised but
Association

"

may

be

sub-normal

somewhat

is consistent

with

low

blood

very

and
pressures,"

extensive

atheroma

refers these

to

cases

Involutionary(orDecrescent)class,as set forth by me at the

Hunterian
Societyin 1894 (Trans. 1895) and in the Lane Lectures
Dr. Oliver proposed yet another
But
of 1896.
class,in which
arteriosclerosis for some
time precedes a rise in pressure
which
In these cases
nevertheless may ensue
he alleges
a
quitedefinitely.
generalfibroid change all over the body and all vessels,arteries,
and veins,
capillaries
includingthe kidneys." He identifies it
of Thoma,
and distinguishes
with the angio-sclerosis
it by the
of such
vessels to the action of the nitrites
insusceptibility
the increase of friction being of mechanical
rather than vasoI have
motor
origin; static rather than dynamic. These cases
The
arteriosclerotic kidney of
not
been able to discriminate.
and
Lorrain
Smith
myself,and J. F. Gaskell (p. 334)
Ziegler,
is not
associated
with
exorbitantlyhigh pressures ; genuine
Granular kidney is so associated,but from the very outset.
Dr.
my

"

"

"

"

"

Oliver's

cases

may
1

been

of the kind

which

I have

Journ.
Med.
Sci., Sept. 1908.
Rudolf, Amer.
Rudolf, Brit. Med. Journ., Nov. 26, 1910.
Pitt, N., Brit. Med. Journ. and Lancet, Aug. 8, 1908.
4
Oliver, G., Clinical Journ., Sept. 16, 1908.
2

have

described

episodesof high

as

ARTERIOSCLEROSIS

OF

CAUSES

160

in the

pressure

PAKT

of decrescent

course

(involu-

such
on
tionary)arteriosclerosis (p.452) ; but these episodes,

ment
treat-

lastingfor
employ, would be transitory,
weeks only. But to proceed : in Osier and M'Crae's System
a few
sclerosis
Osier accepts my
Sir William
originalthree classes of arterioarteriosclerosis (Hyperpiesis
and
; namely, High pressure
chronic renal disease); Involutionaryor Decrescent
(" Senile ") ;
Oliver would

Dr.

as

Infectious

and

I must

content

now

submitted

who
cit.),
(loc.

arteriosclerosis

augmentation
in

to

of blood

"

the

proved
quoted

have

He

and

avoided

the

vicious

prove

pressures

still go

in which

maze

this

Male,

No

No

nor

respect

that

arteriosclerosis proves
medical
writers have

but gouty,
syphilis,

Gradual

case

in view
to

circle of argument

I have

high
high
gone

and

quote the following

Dr.

Guthrie

Rankin.1

free liver.

in

Keen

Pulse

development

arteries."

Then

of

exceedinglyhigh tension.

of moderate,

but

able
unmistakbut

slightalbuminuria,

no

epithelium.

quote this

venture,

whom

Mental
scanty and lithatic. No albumin.
ability
tongue, sleeplessness,
headache, lassitude, irrit-

tortuosity of the
renal

authors

I would
distinction,

etc.
dizziness,

murmur.

casts

in 64
pressures
that many
of these

adds

other

many

chapter

Urine

of temper,
"

in another

uses

blood

from
point of interpretation,

body and mind.

depression,furred

yieldsby

testimonydisposesalso of the remnant

decrescent cases
began as augmentations

all these

set. 37.

heart

cases,

Their

astray.

of pressure.
In illustration of the
on

the

arteriosclerosis and

hypothesisthat

case,

he

renal.

be

to

pressures

and

enhanced

but
of arteriosclerotics,

cent

per

1). Israel found

p.

no

For such default he

ensue.

cardiosclerosis,"to be discussed

name

(vol.ii.

might

was

in these

course

kinds, if the

various

intrinsic default dilatation

of

that

there

Druckerhohung "), and

tion
einzigesMai eine Dilata-

(" ohne

added

(my "decrescent")
these

in

analysis;

enlarged(" kein

of

others

in many

of "senile"

cases

pressure

"). He

verzeichnet
as

16

minute

the heart

was

none

diabetes, lead, etc.).

(typhoid,syphilis,
reference,to Israel
myself with one more

Toxic

or

of

typicalcase

of

the

distinction

as

questionDr. Rankin's
1

Rankin,

and
hyperpiesia,

am

making,

opinion that

G., Practitioner,
May

this

1904.

case

with
was

would

great
one

CHAP.

SPASM

VASCULAR

IV

161

"

decrescent kind).
tubing (i.e.
my
In these cases
the
the cardiac hypertrophy does not
ensue
upon
first and the
loss of arterial elasticity the high pressures
come
arterial changes are consequential.
"

of

material

bad

for the

used

"

"

"

Vascular

that
principle

the

endowed

with

these

with

its reactions

the

blood

first described

which

"

nerves,1perhaps
bridles

as

foundly
pro-

variable

pressures,

these

one

and

reins

sanguineousvessels,either by strainingor pulling

retard, sometimes
incite, the
together,sometimes
the blood accordingto the needs of the viscera."
Now

of

that in disease the

it is asserted

observers

some

upon

the

themselves

by

dwelt

endowment

an

assistance,regarded them

Lower's

course

to

have

inorganictube, but

an

mechanism,

Willis,who

are.

which

by

artery is not

an

We

"

nervous

modifies
as

Arteriosclerosis.

in

Spasm

arteries

are

influence.
There is
to the nervous
susceptible
that in arteriosclerosis the vessels,
indeed an impressionabroad
territories of them, if lamed
or
more
by the disease,are even
less but

not

more

than

liable to spasm
and

433).2

tion

than

have

We

of

health, and

in

hear

this
Sir

vasodilatation.

little direct

very

in

more

less under

evidence

(pp. 216

respect of vasoconstric-

W.
of

control

Osier

admits

that

incidental

these

we

visceral

angiospasms,but the formula is very handy for an explanation

of all sorts
of problems. Hence
come
Nothnagel'saudacious
vascular
the
vascular
crises,"
colic," and
phrase of
abdominal
formulas
by which
pains, vomitings, cerebral
another
seizures (pp. 416 and 445), and many
disorder,
periodical
of the
are
explainableoffhand, as by the "strictum and laxum"
"

Methodists.
the

That, in

stimulation

postulate than
be

so

it is diseased

more

such

to

"

argued

intermediate

that

its

far

the

is, on

as

more

the

advocates

if the

the muscular

coat

is concerned,

readilyor touchilyit responds

face

of it,

seem

to

more

realise.

anomalous
It

might
parcels,

damaged in
be brought into degrees of morbid
frailer parcelsmore
centrallysituated

muscular

coat

be

parcelsmay
but if so. the
irritability,
of the
elements
would be imperilled.I admit that the muscular
believed ;
arteries are more
than is generally
peripheral
persistent
and the nerve-endings
these vessels,being placed externally,
on
1

Willis,Anatomy of Brain, ch. xxvii. p. 138, quoted Ferrier, Harv. Or., 1902.
See, e.g., Osier, Luml. Lect., Lancet, March
26, 1910, pp. 842-843.

VOL.

for

may

while

some

and

nerve

capriciousphenomena, and
constriction or expansion, may

for

However

in health.

than

both

these

capableof
whether

gone,

PART

beginning from

the sclerosis

escape

is far

demolition

Until

AKTERIOSCLEROSIS

OF

CAUSES

162

such

effect ; indeed

have

we

evidence

as

of tone,
unstable

more

evidence

is to

have

we

be

may

the balance

direct

no

within.

muscle

be

the

this

to

contrary.

in

the

arm
arteriosclerosis,
Plethysmographicexperiments upon
skilful investigator
than
one
experiments carried out by more
(von Romberg,1 0. Miiller,2Thayer, and others), indicate so

far that

the

muscle

to

"

response

of the vasomotor

mechanism

stimulation, as, for example, by the touch

in the normal

and

nerve

"

of

piece
scale by
a

bring down the

is in arterio4 cm., or, on
the contrary, by a warm
sclerosis
application,
but diminished
not enhanced
; although the reflex path is
presumably open, there is in sclerosis so progressivea diminution
of the arm
that declining
of the volume
in response
sponse
degreesof remight be taken as proportionateto advancing degreesof
of ice,which

sclerosis,and

as

the limb

person

for them.

test

may

So

in

of

cases

severe

sclerosis
arterio-

tested
conrespond at all. As Curschmann
these results,they were
carefullyrepeated and verified ;
be difficult.
psychicalconditions being excluded, which must
of the ice,in proportionto the degree of the
On the application
arteriosclerosis (gewohnlichund
flattened
gradatim) the curve
sclerosis it became
until in extreme
almost a straightline. This
maxim, that thus arteriosclerosis of a limb and its degrees may
be appreciated,
Klemperer felt able to formulate (at the Kongr.

ciY.).3

may

MThedran4

Dr.

mobility,watching the
that

when

promptly

the
and

in

Von

See

pressure
are

nitrites

when

indefinite.

arteriosclerosis

respond to

decided

as

under

curves

healthy

definitely
; but

of the artery to
1

used

coats

these salts is slow and

found

not

the

W.

blood
the

Cook

found

falls

pressure

impressionof

likewise

loss of

vasodilator

arterial

their use, and

sclerosed
H.

of

test

abilityon
drugs.

(loc.
Qit.}
the

part

Romberg, 21ter Kongr. f. inner. Med., 1904, and Deutsche

med.
Wochenschr., Oct. 28, 1909.
2
Muller, 0., Deutsche med. Wochenschr.,1906, Nos. 38 and 39 ; also Deutsche
Klinik, 1910, and Zeitschr. f. klin. Med. vol. Ixxv.
also

observations

of

Klemperer, Citron, Simon,

and

session, July 17, 1911.

same
4

Reported

at

the

Toronto

Meeting,Brit.

Med.

Ass., 1906.

others

at

the

and

case,

of sclerosis
is

that in later life there

admitted

peripheraladaptation,that
extremely ;
quickly.

pressures rise too

easilyand tire more

an

the

(p.178). It is generally

increasinglack
the

exertion

on

PART

activelyto respond are

fail

the vessels which

Monckeberg's mode

of

seat

that

ARTERIOSCLEROSIS

OF

CAUSES

164

of

quick

central

thus

elderlypersons

And

I have

blood

chill

remarked

more

the

that

fingers" of old persons are the effect not of arterial

In their
and atrophied arterioles.
but of tardy stream
spasm
phenomena are not easily
dermatographic
legs and feet
pressure be
produced,but if,by the tip or length of the finger,
"dead

"

"

made
the

the skin for

upon
skin very
blanched

second

or

two, the
for

slowly. However,

tint returns
the

to

armchair

expansions are so
this ready
doubt
on
that it is heartless to throw
convenient
to verification.
is safe in its inaccessibility
resource
; and as yet he
far from
I am
of course
denying that such vascular phases
as
in arteriosclerosisas we
ought to be from assuming them ;
occur
vascular
speculator,peripheral

are

we

One
cannot

sufficient data

without

there

demur

well hold,

et

either way.

is, moreover,
some

and

of the muscularis
486

as

and

cramps

which

seems

we

to the irritable spasms

writers do, both

the initial medial

inevitable

sagging of

Thoma

(pp.

seq.).

Heredity.

"

At the very

outset

then

of

discussion

of

causes

necessityof distinguishingthe several

of arteriosclerosis. In respect of hereditary influences
kinds
been divided into
for instance, the family histories have
never
and those of premature
arterial
those of high blood
pressure
this primary discrimination
these
decay ; and yet without
worthless.
histories are
Surely there is all the distinction in
between
the world
a
family disposed to arterial pressures so
excessive that by it the vessels are
damaged consequentially,
and
a
family disposed to primary and essential arterial decay,
such
in our
without
high pressures ? J And
experience we
this difference every day. We are acquainted,if we
will but
see
think of it,with the familiesin which, generation aftergeneration,
individual lives are
ended by cerebral hcemorrhagewithout
of renal
the
disease ; and
with
those
ordinary symptoms
were

we

met

by

the

In this respect I think

"Set.,1905,

ia indecisive.

Dr.

Stengel'sinterestingarticle

in Amer.

Journ.

Med.

CHAP,

HEREDITY

iv

165

by stroke, it is
not
by the haemorrhage of high pressures but by the
of arterial twigs not
occlusion
subjected to excessive blood
but already in decay. Dr. Mott, extending his data
pressure
edition of Allbutt and Rolleston's System, says
in the second
still more
confidently(p. 595), The relative infrequency of
intracerebral
haemorrhage in the insane with atheromatous
arteries is probably due to the fact that they have not been the
by the
subjectsof prolonged high arterial pressure, as shown
of a pauper
absence
of cardiac
hypertrophy." The inmates
not
are
usually full-blooded persons ; a
asylum or workhouse
on

the

which, if death

in

contrary

come

"

renal

suggest chronic

would

in them

rise of pressures

disease.

prevalenceof sanguineous
plethoric families ; this hereditaryproneapoplexy in certain
and recognised,
to apoplexy has long been known
even
ness
by the
insisted on
heredity
explicitly
public (vide p. 412). Broadbent
and
in high blood
on
hereditary hypertension
pressure,
certain
the
of apoplexy. In
a
family, some
as
precursor
to illustrate the

It is scarcely
necessary
"

"

"

"

of

whom

friends
lifelong
carried

were

of

stroke.

keen
table

under

came

of

about

They
the

not

cellar ; the

generationafter generation,
age (65-70) by this kind

men,

the

same

big

were

and

sportsmen,
and

mine, the

off

observation, all of them

clinical

my

from

averse

two

muscular

florid

whom

the
I

countrymen,

pleasures

examined

of

had

the

large

leathery arteries under

high and sustained
very
pressures.
Among themselves this mode of death, and about such an age,
disease, as
was
recognised,and calmly anticipated. Renal
With
such
them.
understood, did not appear among
ordinarily
I am
examples however
appealing to an experienceso familiar
that I need

not

that Dr. James

of

high
family;

labour

the argument.

Mackenzie

Some

publishedin

while ago I remember

of the journalsa note

one

Professor

Raymond1
and

high pressures
ruddy but some
to

calamitous

again was
apoplexy as

convinced
a

familyfate,some

spare and sallow, and

story : The patient,a man

arterial tension

"

and

an

Raymond,

aortic

of

systolicmurmur

Prog, mid.,

mars

30, 1907.

individuals
the

following
43, had
high
; his grand-

narrated
set.

"

"

ruddy-faced
of apoplexy.
this disposition

of a
sisters,members
pressures in two
the
patients'father and uncle died

"

CAUSES

166

died

early of

died

father

of the

cerebral

stroke

same

ARTERIOSCLEROSIS

OF

his father's

haemorrhage ;

aet. 57

at

PARTI

his father's brother

sister

suffered

at set. 59 ;
haemorrhage at aet. 52, and a second (fatal)
had had an attack ; of five cousins three had
sister (living)
his own
and the other two had cerebral haemorrhagesat
died of the same,
57 respectively.A gentleman, aet. 60, who
the ages of 52 and
about a skin affection,proved to have a very high
called on me

cerebral

cautious

to some
pressure ; in answer
frankly said that his family had

blood

head

"

; for three

generationshis

of mine

remark

tendency

to

immediate

"

blood

ancestors

to
on

he
the
the

knowledge, died of cerebral

paternal side had, to his own
that every
haemorrhage (see also p. 412). I have assumed
of experience
is well aware
of this common
hereditary
practitioner
desire to insist is that in
peril; but the point on which I now
these families the proclivity
is not in the first place to arterial
disease
to arteriosclerosis
but to the prevalenceof high arterial
as
damaging these
hyperpiesiaor as renal disease
pressures
of them.
vessels,and ultimatelyrupturing one
or
more
Nay,
under such pressures
take place without
tion
degenerarupture may
apparent to the microscope. Dr. Savill gave me a section,
in our
now
collection,in which the media, healthy
pathological
far as histological
methods
could detect,was
so
giving way at
one
pointin its circumference where the coat, suddenly thinning,
pouted with the adventitia outwards ; but complete rupture
had
taken
not
place. I see that von
Recklinghausen has
expressed the same
opinion.1
But with the involutionary
decrescent kind of arteriosclerosis
or
it is otherwise ; this proclivity
but
also seems
to be hereditary,
"

"

"

"

not

with

justtaken
tortuous

certain

the

bent

towards

the maximum

excessive

pressure

in

blood
man

pressures
aet. 80 with

I have

extremely

and

calcified vessels ; it ran

125-30.
The arteries of
families may
be made
of less durable
stuff. In the Jews

it is said that the decrescent

arteriosclerosis is frequentand

rather

precocious. Or againa disposition

to certain katabolic perversities
in families.

Yet,

people,liable as
indeed they are
to obsolescence
of the decaying vessels, in the
brain as elsewhere,and to a general
atrophy resultingfrom the
of the degraded vessels and slacker stream
increasing
inability
may

run

Von

Recklinghausen,F.

as

Handb.

we

shall see, these

allgem. Pathol

des

Kreislaufs,1883,

p. 84.

167

AGE

iv

CHAP,

liable
of blood and lymph, are
not
sufficiency
very
with
it is in these subjects,
even
to cerebral haemorrhage. Now
vessels
exasperatedby bony scales," that, as I urged again
not
and again in 1894 and in 1896, the arterial pressures
orbitant
exare
later,when Groedel repeated the
; but until ten years
presses
observation, I could get no hearing. Dr. H. D. Rolleston 1 exa recent
opinionwhen he says the belief
change of common
is
of high arterial pressures
that arteriosclerosis is the cause
in which, with general
contradicted
cases
by the innumerable
to

convey

"

and

atheroma

failure,the blood

heart

to

the normal

reach

not

widespread

be discussed

arterial

though,

he

as

toxins

some
later),

but little raised,or

are

pressures

without

degeneration yet

(a suspicion

justly adds
act

may

both

as

do

even

stimulants

to

arterial tunics.

Dr.

I
opinion,founded on an unusuallylargeexperience,
alreadyquoted, and shall have to quote again.

have

and

rise of pressure

as

corrosives

of

the

Mott's

respect of

In

arteriosclerosis

transmission, the direct

hereditary
which

form

I have

apparentlyeither
of the

the

named
in

other

such

form

which

peculiarities,
may
I have

named

and

there

are

modes

two

the indirect ; the

of

direct,that

Decrescent, or primary, which

sists
con-

original
frailty
or toxic susceptibility
which, like
frailtyor susceptibility

an

arterial structure,

then

run

in families ; the indirect,that

the

Hyperpietic,a secondary event,

which
apparently depends not upon an originalarterial frailty
ill-understood poisoningor perverbut upon
to some
a proclivity
sion
making for high blood pressures ; and to these high pressures
arterial structures, thus subjected to
it is that the soundest
preternaturalstresses, will succumb.
Age.

"

Marvellous

of parts and

as

the

harmony
that the stealthy hours
no
quantitiesof energy.

in the human

frame

the symmetry

are

of function, yet it cannot

carry

supposed

qualitiesof tissue,

no

away

be

the
old
men
Although in many
soft and straightenough, and in a few
accessible arteries are
to the naked
detriment, yet
cases
even
necropsy,
eye, betrays no
arterial resilience is inverselyas
the whole
the years of its
on
duration.

few

days before

these

lines

me
gentleman, aged 78, called upon
suggestive,at least, of aural
symptoms,

for

old

Rolleston, H.

D., din.

Journ.,

written,

were

brisk

slightMeniere's

sclerosis ;

June

21, 1905.

yet all his

ARTERIOSCLEROSIS

OF

CAUSES

168

PART

in the legs; and the

perfectlysoft,even
invisible.
The
radial pulsein a thin wrist in full daylight was
test of effort. Again,
heart seemed perfectly
normal, even
some
on

accessible arteries

were

an

intercurrent

malady,

cardiac valve

and

of necropsy

instance

I remember

in his 83rd

in

whose

year,

to the naked

cusps

who

man

eye

and

aorta

seemed

died, of

an

arteries

intact ; to the

been
fibrosis would
have
revealed ;
microscope probably some
and doubtless, as von
molecular
Recklinghausen says (loc.cit.),
I would
in the
add the waning of autolyticcapacities
or
fatigue,
cells,may
coming within microscopicken ; for,
go far without
accidents apart, it is by cellular and molecular
fatiguethat we
number
of Mildenhall
took
our
days. The late Dr. Hudson
once
to see
me
a
man
aged 100 years, who was
gratulations
receiving the conof his friends on that birthday. He
allowed
to
us
note
that his arteries were
barely perceptibleto the touch, and
that his heart was
all physical examination
to
normal.
The
blood pressure
to the fingerseemed
rather under
than over
the
normal.
Dr. Hudson, who
had brought him through an attack
of pneumonia eighteenmonths
before,said that his health and
faculties,includinghis memory
for recent
events, were
good.
He ate well, and sleptwell.
He

had

As

white

as

ever

are

many
in whose

cases

head

and

fresh

produced by youth

were

Engendering
There

in the

blood

record

on

and

of hale

of

cheek

age

fourscore.

of

persons

90

years

and

bodies on
upwards
the largervessels presented
necropsy
no
signs of arteriosclerosis,
at
rate
the eye.
to
none
any
Morgagni,1in a woman
probably about set. 90, was surprisedto
find little signof arterial disease,
white spots in the
except slight

descendingaorta

and

the first to

in the

exhibit

sites which,
iliacs,

as

we

know,

are

those

signsof decay. Charcot, of a

in the Salpetriere,
woman
aged 103, reportedcomplete integrity
of the structures
of the heart and arteries.
Sir George Stokes's
accessible arteries at the
soft and straight; his
age of 83 were
among

maximum

Nevertheless
rise of

135, his minimum

pressure

20-30

about

during advancing
is the

mm.

1
1

DeS.

rule.

etC.

Schell, Virchow's

years

gradual systolic

Schell,2 who

M., Ep. Ixvii.

Arch.

100.

Bd.

measured

11.

cxci.

H.

i.

the

AGE

iv

CHAP,

169

various
bodies
that
at
larger arteries in many
ages, found
decreased
that these vessels had
had
with
so
age resiliency
This he attributed to the prolonged
longerand broader.
grown
blood.
It is not quitetrue then that,
of the circulating
stresses
in the

acceptance of

common

arteries."

It is true,

in advanced

common

the

used

Koy

as

to

life ; yet many

fair

"

words,

say,
a

old

his

man

is

that

old age is most

man

as

grows

as

old while

and

a
converselymany
man,
with
and
distorted
labourer or
arteries,
grotesquely
not,
rough
at any
rate in the limbs, lives activelyand
cheerfullyto a ripe
antiquity. Jores has pointed out that in arteriosclerosis many of
and commonly do, remain unaltered ;
the finer vascular webs may,
and
for instance in a myocardium whose
stems
even
coronary
be decayed. Broadly,but not universally,
it is true
branches may
follow
that arterial degenerationis a senile change ; yet I cannot
Jores and others in a formal adoption of "Senile Arteriosclerosis"
It predominates or arises in the period of senectus,
name.
as
a
not of senium
appeared in the earlier it will not
; if it has not
in the later. Lancereaux
declared emphatically
to much
come

his arteries

that

keep

arteriosclerosis

usuallyappears, if it
Here
again however

aspect

is not
is to
I

disease

pressure

vascular

strain,in hyperpiesiaor

average

at

age

somewhat

called.

If

extremer

age,

at
60 and
all,between
appear
have
to
distinguishbetween

arteriosclerosis and

an

of

the decrescent

form

; the form

kidney disease,occurs

younger

than

the

"

but
65.

high

due to
on

the

tinctivel
senile," dis-

pathologicaleffect in both may be

the same,
the kind due to Hyperpiesisor to
Granular
Kidney
much
is not
infrequentin
; though it is true
younger
persons
that in these younger
and less vulnerable
subjectsthe strain of
its mark
on
high pressures takes a much
longer time to make
the arteries. Although the "senile
form is naturallyan affection
of more
advanced
by the inroads
years, yet it is often antedated
so

the

"

"

"

of infectious disease.

High

pressure

that

of the

not "senile"; it
certainly
earlier periodof life,
at an
occurs
we
might say roughly a decade
earlier ; though, as resistance to strain may
then delay it by
perhaps five years, the age periodof high pressure arteriosclerosis,

and

overlap. And

the

arteriosclerosis then is

decrescent

form, if they

longersurvival

do

not

of the decrescent

coincide,may
arteriosclerotics

separates the

ARTERIOSCLEROSIS

OF

CAUSES

170

Probably, if

still farther.

incidence

age

PART

leave

we

to be discussed
exceptionally
cases,
young
the age period of my
Hyperpiesia(Huchard's Preseverally,
lie over
Sclerosis ") would
an
Basch's
Latent
sclerosis
; von
out

sides the

both

on

"

"

"

age

periodof,say, 45-60, with

years

form

over

"

of my

that

perhaps with

an

Arteriosclerosis

Decrescent

For

indefinite duration.

while

"

the

"

to fifteen
"

Senile

of 55,

commonly
and with an
the costal cartilages,
Hyperpiesia,if uncontrolled by
the

period beginning about

the ossification of

of ten

duration

average

age

by accident, is a mortal disease,one of

end by failure
which
the unimpeded progress brings life to an
however
life
in which
of the heart to keep up the fight,
one
crescent
is often cut
short incidentally
by sanguineous apoplexy, demedicine

and

unbroken

arteriosclerosis

on

the other hand, whether

in inward

or

old age.
extreme
incompatiblewith even
In this age-comparison chronic
omitted ;
renal diseases are
these maladies have their own
cycle. Moreover, in respect of its
bearingson our present subject,I shall consider renal disease in
another chapter (see Renal
chapter,p. 309). If here again we
not a few, the age
are
disregardthe young cases, which however
incidence of Granular Kidney would be about that of Hyperpiesia.
In a later section I shall deal fullywith
the arteriosclerosis
of infectious
origin,the chief of which is syphilis. Before me
the notes of a case
of syphilis
in which the primary infection
are
in outward

trunks, is not

incurred

was

at the age

of 17, and

after this

arterial affection

an

For such kinds of

appeared within the year.
influenzal,
syphilitic,
typhoidal,etc. (seep. 281)
"

age

averages.

Lancereaux's

arteriosclerosis has

not

remark

there

if in any

be

no

individual

the age of 60-65, it will not

must
be taken to apply to mere
take

painfulnote

arterial

thickeningin the limbs, which

true.
great matter, it is so far fairly
Hyperpiesia,as
afterwards,may

can

"

appeared by

appear at all,is a reflection which

senile arteriosclerosis. If we
do not

degreesof

that

arteriosclerosis

at

age ; it is

of
may

slighter
be

no

I shall show

tingent
infrequent conelderlypeople,when, if detected in good time,
usuallyreadilycurable ; if not, however
transient, it is a

appear

any

no

disorder in

it is

serious

to decadent

disposed to think
that if an individual
have a proclivity
to hyperpiesiaso strong
to defy treatment, he will have it
as
comparativelyearlyin life,
menace

structures.

am

172

of

them,

OF

any

knowledge

nor

youngest
of

has

arteries

the
heart

come

He

abnormal

conditions

all.

In

besides

and
or

thickeningof
systolicmurmur

that

in

these

more

the

it not

later

had

appeared

at

the

vascular

material

been

the

probablethat

work

at

when

Other

but

of

was

in these

authors

in

heart

rhythm,

Fahr

apex.

cases

not

of the

failed in

the

suffered

largemajority of

had

as

had

notes

wholly vanished ;
less enlargement

or

least

at

dates

thickened, and

the heart had

arteries,

cases

quality. Is

had

number

from

as

in the

however

examined

since those

that

then

His

nature.

Since

years

noted

who

found

the

some,

some

before

been

illness.

no

of their anatomical

of

hypertrophied,and

as

from

had

PART

of 12.
age
in. Fahr1

intervals

after

persons

the

at

was

case

information

some

ARTEKIOSCLEROSIS

CAUSES

infers
inferior

cases

some

have

reported
of this kind
juvenile cases
(Frankel, Baumler, Thayer and
Councilman, Marchand, 0. Miiller,Oppenheim) and have generally
causes

attributed
Seitz

Halm

own

cases

older
a

by

the aorta

in

case

an

friend

of

quotes

14), Fischl Martin

Chiari

and

read, in

In

of his

one

atheromatous.

Hodgson's

from

cases

(age 9), Filatou

(age 13).

child,aged 5, was

have

0. Miiller

Diseases

Among
of Arteries,

infant

to
aged 15 months, communicated
George Young; and Scarpa3 and Portal4

records

boy

6, illof

set.

and

(age 12), Sonne

writers,I

his

infections.

to

of 12, 13

(at ages

and

of

them

similar

Hirschf elder

case.

records

the

case

him
each
of

nephritisand

acute

pneumonia followinga
and
B. coli cystitis,
in whom
a
the arterial pressures were
continuouslylow throughout,yet the
accessible arteries became
tortuous
and thick.
The boy made
a
complete recovery, and the arterial affection passed clean away.
But there is more
than this to be said : these last were
probably
B. coli abscess

infectious

an

of the buttocks

in which

cases

children,yet with

these

the
not

blood

were'

pressures

infrequent
cases

as

usual

in

it is my
present
known
historyof

others in which there is no

purpose to compare
infection but the blood
is temporarilyraised and the
pressure
radial thick.
In this observation 0. Miiller
he has noted
agrees

Fahr, Deutsche Arch. /. Idin. Med., 1911.

2
Miiller,0., Deutsche Klinik, 1910.
3
4

In

his work

Portal, Cours
6

d'an.

on

Aneurysm.

med.

vol. iii. p. 133.

Hirschfelder,loc. cit.,p. 345,

2nd

ed.

CHAP,

AGE

iv

173

under
in young
persons,
of them
of 25 ; and in some

palpable arteries
the age

about

puberty, and again

heaving heart-beat,

hypertrophy of the left ventricle,and a reinforced second

bilious ; the tongue is heavily
These patients
aortic sound.
are
sive
the stools offentumid, the bowels irregular,
coated, the abdomen
and
pasty-faced. Under
; and the child or youth is languid
the whole
gentle mercurial and other appropriate treatment
definite

"

trouble

the arteries after

and

clears up,

"

while

some

their

recover

quality(p.618). In these cases I think the vessels are

merely temporarilyhypertrophied. Broadbent, in the discussion
in January 1903,
on
Society,
my
paper at the Medical Chirurgical
The condition
agreed with me concerningthese cases ; he said :
high systolicpressure and fulnessbetween the beats (italics
in the child,and the schoolboy;
recognisable
mine) is sometimes
natural

"

and

often in

againunder
present.
shall

the head

of

to

appear

these

As

will be considered

cases

be held

Symptoms they may

for the

over

however, as

we

in children is perhapsmore
infrequent

very

in adolescents.

Dr. Mott

is common

of the aorta

atheroma

30."

arteriosclerosis of certain infections

The

if not
presently,

see

prone

under

men

that

says

"

the post-mortem

on

in

asylums

table,even

comparativelyyoung people." It is not usuallyattended with

fibrous than atheromatous
is more
in its
high pressures, and
nature."
These are probablyof infectious origin
; processes which
in a later part of this chapter (see p. 281).
will be considered
for these paragraphs on
As
I was
collectingnotes
age, a
gentleman, aged 30, presented himself for insurance with an
excellent
one
personal and family history. With
exception,
I could
favourable.
all tests which
bring to bear on him were
healthy,yet his accessible
Certainlyhis heart and kidneys were
arteries were
thickened, and the emptied vessels felt
definitely
not
like tape.
But the pulse was
sustained,and the systolic

in

"

blood

about

was

pressure

of arteriosclerosis in decades
but

he

and

the

did

not, of

course,

hyperpieticforms.

remark,

which

is

true

worth

remembering,

active

the

process.
1

that

Lancereaux,

between

recorded

his

30-40, 40-50, and

cases

50-60

distinguishbetween

the

decrescent

however

the

interesting

added

He

of

think
the

Of such

Lancereaux

120.

the

the

younger

are

Paris

the
Med.

decrescent

two

form, and

patient the

cases

Soc., 1908.

which

more

follow

with

J.,seen

Mr.

ARTERIOSCLEROSIS

OF

CAUSES

174

Mb.

1904.

Wingate, May

Mr.

business

easy

cords.

"

Pressures

of infectious

The

No

anxieties

pulse at

as

"

(Wingate). No history
visit extremely weak
and

always extremely low

disease.

No

nature.

traceable, very
Arteries,
and
lower
leg thick, non-pulsating
far

so

feet

of the

those

degenerate ;

"

sufficient.

and

and

Weakly

43.

dyspeptic; often pains of neuralgic or of uncertain

of syphilis.Habits
quietand temperate.
probability
"

PART

my

compressible.
of us in hospital. No history
many
with little energy.
A weakly person
of typhoid or other infection.
Blood
accessible.
at various
Arteries
thick, wherever
pressures,

Young

dates,

I had

time
fits of

under

infection.

Both

to be amenable

finger. Systolicpressure

any

infection.

Yet

in

middle

life

come

the too
Andral

281

et seq.
to

now

in
cases,

certain

and

Marchand,

at

month
22

and

not high presinfants,

sure
Brault,in 1897, contested

that arteriosclerosis
at the ages

was

unknown

an

infant born

(Soc.Anat., 1899) ; Gee,

and

in

of 15 months, 7,18,and

Durante, in

27 ;

of arteriosclerosis

in

even

often with calcification.

axiom
positive
publishedcases

the seventh

manifestations

extremer

youths and children,and

H. Martin, at the age of 9 ;

at

case,

elderlypersons also the degenerationis rapid.

thickeningwhich we find not infrequentlyin early
is generallya
mark
of some
past infection,as

explainedpp.
We

syphilisor other
thicklyunder
No
120.
history of
Female
aet. 29, p. 187.)
rolled

some

arterial

The

Longworth's

Habits,

No

above

never

same

occasional

treatment.

conspicuous,and

were

also

to

careful.

very

the

(See

the

undergraduate subject to

an

malady,

radials

About

below.

usually rather

seemed

his

of

care

my

which
epilepsy,

account

on

by

seen

normal

above

never

26,

aet.

man,

many

other

at

such

youth.

24 years.

prematurely
the age

of 7 ;

instances

are

record

by Filatou, Chiari, Simnitzki, etc., the majority

Chiari's infant was
and
died
probablybeingsyphilitic.
syphilitic
The
same
aged 15 months.
congenitalinfection was
present
in three cases, aged 10, 11, and 12, publishedin his M.D.
thesis
(Camb., 1901) by Dr. Graham
Forbes; in these the cerebral
on

arteries and

brain

were

precociouscases

very

indeed

some

causes

much
are

attributed

cases

; but

with
1

See

diseased.1

this is not
syphilitic,
to syphilis
arise from

these
also

If not

"

congenital or

Bury, Brain, April

1883.

few

of these
of all ;

true

able
respect-

more

infantile

"

cases

CHAP,

AGE

iv

To

reallylittle concern.
I reportedsome

have

175

onwards

pass

years

and

ago,

showed

to

escence,
adol-

pupilsand

my

girlsand boys in their teens

be considerablythickened
the accessible arteries may
(p. 279) ;
the pressure is usuallyfar from
in these cases
now
high. The
In
nodular.
graduate
underan
artery is uniformly thickened, not
friends,that in

of diabetes

and

youth

to

cases

consulted

who
the

heart,

as

tone.

His

pulse

in

Under

treatment

weeks

he

I had

well ; but

definite

no

hearts

Ainslie

Dr.

in

the

of

In

120.

due

to

instructive

boy

set.

fourteen
tunics

though the
him
again
these

found

such

11, who

died

there

infection.
sclerosis
arterio-

on

papers

blood

overdone

passing

some

indebted,
a

in

his radial

"

infection, but

much

aorta

on

tuby

"

under

whose

all

are

football, I

at

wanting in
standing up 120.

that

noted

any

commonly

Hollis, to

we

patches

story of

most

are

well

"

abated, and

the vessel

decidedlythick, and
was
(systolic)
pressure

strain

80 ;

was

symptoms

were

was

heart

stomach, dilated, and

recumbency

these

was

"

for

me

also the

found

in

elevated
his

under

atheromatous
aorta
an
appendicitis.1 He found
of the aorta
in a girlaged 2J ; a similar condition
in a girl,
of pneumonia ; another
died
set. 17, who
again in a girl,
died ten days after a burn : 12 out of a series of 52
set. 18, who
care

from

cases

of

arteriosclerosis

instances, if looked
would

be

to

prove

for

attention
Infections,

the young,
to attribute

least

at

or

not

has

to

transient
of

some

infection,noted

medial

have

with

raised

blood

just been

unnoted,

or

of thick

cases

Such

23.

were

not

arteries in

he is

me

hypertrophy,were

them, with

probably the examples

some

Certain

Dr. West,2 which

reportedby

set.

by observers intent upon the point,

under
shall see
infrequent. As we
been fixed too exclusively,
if still insufficie

the heart.

upon

death, under

at

were,

disposed

associated,

consideringas
associated

but

pressures

due

with

to

high

Simnitzky's paper on this subject is well known.

This author, who
unfortunatelyincluded no clinical notes in
his article,rested his argument
necropsiesonly,and his
upon

pressures.

1
2

The

reprint

West,

in

my

hands

S., Lancet, Feb.

bears

no

date

nor

reference.

11, 1899.

Simnitzky (Prague Institute, a pupil of Chiari), Zeitschr. f. Heilkunde,

A.s.schen
Veranderungen d. jugend. Individuen."
April 1903. "Haufigkeit von
3

researches

ARTERIOSCLEROSIS

OF

CAUSES

176

chieflydirected

were

the

to

PARTI

He

aorta.

ranging from 2
autopsieson children.

27 '5 per cent

part there
the

the

For the most

of the arterial disease.

direct clinical symptoms

no

were

In all of them

in 18

of his series of

kind, and

of the atherosclerotic

changes were

history of infection

definite,and belonged to

was

is

25 ; that

to

of altered arteries,at ages

cases

reported 37

one

rheumatic
fever, diphtheria,
followingkinds:
culosis
tuberscarlet fever, measles, smallpox,typhoid, pneumococcus,
infection had occurred.
an
Syphilis
; in all but seven
his series.
from
excluded
Simnitzky calculates that in
was
set. 25 some
of necropsiesin persons under
signs
27 per cent
or

of the

other

of arterial affection
that

and

Fraentzel
not

few

these

men

"

at

least of

these

for

the

writes

that

in the
with

men
young
succumbed

to

most

the

aorta

part

due

are

Franco-German

thickened

he

war

others

found,

infections.

to

observed

further

arteries ; and

fatigue while

be

to

are

"

of

no

that

more

parent
ap-

well.
but with normal
vessels,got through fairly
strength,
the vasa
In two
vasorum
were
only of Simnitzky's cases
to suggest that the
affected in such a degree and manner
as
them.
In cases
sclerosis might have
depended primarilyupon
from
of recovery
infection,he also thinks that probably for the
most
part the arterial lesions clear up entirely. Josue, in his
book on Arteriosclerosis (1903),and Oppenheimer,1testified to the
similar effect,except that Oppenheimer regarded the
or
same
of the kind
of primary medial
degeneration
change as more
with atrophy of elastic fibre. Certain
authors, Saltykow for
far as
declare that
to
instance,2 push these observations
so
in its germination,is not a disease of age ; that
arteriosclerosis,
its beginnings,as some
opine concerning tuberculosis,are to
be sought in adolescence, and even
in childhood, though it may
itself tillyears
manifest
likewise begin to tell. Saltykow,
not
views

whose
clinical
and

the

be

taken

rather

from

relies too

much

on

chemical

than

causes,

repudiates

poisons,such

as

"

"

Oppenheimer, Vir chow's Arch., 1905.

Saltykow, Korr.-Bl. /. schw. Arzte, 1911.

wear

alcohol.

these young
scarcelybe said then that
cases
because in them
hereditarynature of arteriosclerosis,
factors can
be found
recognisedetiological
; none
can

from
"

experience,slightsmechanical

tear," and
It

the

may

attest
none

of

of the

CHAP,

AGE

iv

conventional
to

grant

than

much

have

we

of

case

causes

Bryant

INFECTION

AND

177

be found, it is true, but

may

causes
largerfield to infectious
to do (p. 281).
been wont

Hale

and

White

*"

shall have

we

in arteriosclerosis
In

the

well-known

months), the

(an infant of

congenitalphimosis with retention of

urine, dilatation of the ureters, double
hydronephrosis,and
in the
no
syphilis
atrophy of the kidneys. Probably there was
of
All the arteries of the body were
affected,and many
case.
child had

suffered

smaller

the

from

obliterated.

ones

In

collection

of

in his

cases

graduationthesis (Camb. 1901) on cirrhosis of the liver in children,

Dr. Bull of Ashbourne
reportedof a child (Case XIX.) aged 5,
cirrhosis and

with

ascites and

anasarca,

the

that

arteries

were

reported (at St.

although the heart and kidneys were
The parents had givenbrandy to
Bartholomew's)to be normal.
the child
for a long time."
Perhaps the most
important
this part of the subjectis by Wiesel of Vienna,2 who,
on
paper
300 necropsies,
from this point of view, investigated
and reported
of them
children
minutely on 80 of young, many
very
young,
had
who
succumbed
to
diphtheria,scarlet fever, and other
infections ; the clinical kind of the infection is of less pathological
for the characters of the morbid
histologyare
moment,
much
the same
in all (p.287). Such difference in form as there
the stage of the disease.
the
be depends chiefly
About
may
upon
end of the firstweek changesbecome
in the aorta, carotids,
visible,
and coronaries,etc., as minute yellowish
patches,some
presenting
calcareous points. Under
the microscopethese changes are found
widespread throughout the arterial tree ; indeed they predominate
in the peripheralvessels.
The
first change is an
infiltration of the media
and vacuolation
of the muscular
layer;
hard

"

then

the

elastic fibres break

necrosis.
is involved
As

The

only

in

endothelium
a

small

and

the muscular

survives

minority of

death

increase of fibrous

from

other causes,

goes
tunic under-

longer,and
the

regards later stages of this lesion,as

after
necropsies
some

up,

the intima

cases.

revealed

the result of

tissue,
probablynot

very

by

few

healing is

harmful.

Even

if

high-pressurethickeningin comparativelyyoung persons be

not
muscular
mere
lesion, in early life
hypertrophy but some
1

At

the
2

VOL.

Meeting of the Royal Med.-Ch.

Soc., Jan. 12, 1903.
Zeitschr.
Heilkunde,
Wiesel,
1906, Bd. xlvii.
f.
N

considerable

probablyhave

the arteries
Elastic

ARTERIOSCLEROSIS

OF

CAUSES

178

elements

muscular

and

restored, as

regeneration.
experiments
; if

demonstrated

have

animals

of

powers

be

can

PARTI

and

on
surgicaloperations

and

artery be laid bare from its external supports,

ditions
thickens, on the restoration of its normal conconsequently

perimentally
ex-

an

to its proper

it returns

in three

measure

weeks.

four

or

then corroborative of those of

are
investigations
form the process
Flexner and Thayer in typhoid. In its acute
speaking, Monckeberg's rather than Jores'
suggests,clinically
testify
arteriosclerosis. Ortner, von Romberg, Marchand, Baumler
similar effect,and I need not multiplyinstances ;
to the same
or
Wiesel's

"

"

but

refer to

I may

on
fully,

of his

11

but

In

The
vascular
not

collected,of arterial disease

typhoid

had

also

fevers

fibrous

the bane

was
syphilis

cases

aorta

regarded as not abnormal

and
sequelof small cell infiltration,

their

be

may

vessel

hyperplasiais the
or
congested vasa
Von Romberg
the age

his

of infection

cases

the

and

majority of

scarlet, and

rheumatic,

victims.

34

cases

writes

who
by Levy-Frankel,1

paper
and

own

In the

in children.

good

looked
over-

yet

this

of blocked

vasorum.

calculated

of 15 arteriosclerosis

necropsiesof

of

that

plateswhich form
development in foetal life are
fulland

to Fremont-Smith's

cent.

per

curiosities

other instances

under

spots of imperfect

about

calcareous

dwell ; and for many

in 5*88

found

was

children

I need

which

on

references I may

and

One

accessible paper.
In
to quote :

of his

refer

examples

1890," he writes, I
tempted
with sclerotic and
attended
man
a
aged thirty-two,
arteries. He
beaded
a
historyof luetic infection in his
gave
attention was
drawn
to his son, a boy
eighteenthyear
my
aged twelve years, who by his pinched and haggard appearance,
by his complexion,figureand carriage,
suggestedthe witheringof
however

"

am

...

age

rather

than

the freshness

of

youth.

sclerosis in all palpablearteries,with

in his parent ; the

"

beadingcould

calcification

have

as

been further

advanced

as

exaggerated

kidney disease, and the

author's diagnosiswas
congenitalsyphilis.Whether
syphilitic
and
cerebral
arteriosclerosis are not rarelyfound
or not, coronary
in young
atheroma
is even
frequentin young
; coronary
persons

at

any

stage of life."

not

revealed

Examination

Levy-Frankel,

There

Arch,

was

dea mal.

no

du

cceur,

oct.

1, 1912.

in

been

have

ARTERIOSCLEROSIS

OF

CAUSES

180

we

women

are
contingencies

the

continuityof observation, and

enjoy more

of

in the circumstances

; because

women

PART

fewer.

we

and
little,

know

of subordinate

most

regionof

earth

the

age

these

importance. Estimates
of that depend much
or

of

the United

for

but

this little suggests that

bias of the observer.

and
opportunities,

frequentin

respect of arteriosclerosis

in

Country, and Climate

Of Race,

time

some

It is said
there

past the Americans

have

to

at

are

frequencyin this
the diligence,
on

appear

States, and

factors

be

to
at

earlier

an

been

more

closely
England

frequent in
be,
the English are
because
; they may
large meat-eaters
serves
at cosmopolitan hotel tables obbut surelythe traveller who
of his continental
the customs
neighbours will not be
It is said

their arteries.

watching

be

to

"

"

that

convinced

guests ;

nor

Englishman

the

do I think

that the

is the

of the

voracious

most

histories of spas, of Marienthat

this testimony. It seems

case

would

give
of arteriosclerosis prevails
in all countries the plethoricform
the wealthier
the high feeders, that is, among
rather among
in the colder regions where
a
more
plentiful
classes,especially
form
that the decrescent
and
richer feeding is required,and
impressionof hospital
prevailsrather among the poor. My own
received
from
practiceis to this effect. The impression one
Watson
that sanguineous apoplexy, a
and
Abercrombie
was
the
common
frequentresult of high pressures, was more
among
the working classes.
be
Occupation cannot
gentry than among
In
hot
the
countries, where
forgotten in this connection.
the
decrescent
of arteriosclerosis
foods are
form
simpler and lighter,
will be relatively
to
more
frequent,and this seems
the case
with the ancient
have
been
Egyptians, with whom
neither a rich meat
diet,nor
alcohol,nor tobacco, nor syphilis,
modern
had much
nor
gout, nor
place; yet we have
worry
bad

for

example,

"

seen

(p. 5) that

in

often extensive,1and
that

in Bohemia,

"

their
not

where

bodies

very

the

arteriosclerosis

late in life.

disease,is, generallyspeaking,not
Of
1

the
See

of
liability
Journ.

of

Path,

Professor

Pick

hospitalpatientscome

unless it be
class,the arteriosclerosis,

pressure.

is common,

the
and

Bact.

poor

part of chronic

attended
Jews

of

says

to

with

Bright's
high blood

decrescent

vol. xv.,

1911.

sclerosis

CHAP,

have

Medical

spoken.

CLIMATE

COUNTRY,

RACE,

iv

who

men

have

report that, although in these

countries

181

practised in

low, arteriosclerosis is frequent enough

rule

earlier in life

comes

does

so

is

it is of the senile

and

more

senility
Physicians
as

Calcutta, tell

of

the

among

us

natives

variety.

and

Their

haemoglobin

sclerosis
that arterio-

Camac

say

appears earlier in the black

Warfield
adds that, beside

and

common,

Caucasian

in the

than

Warfield

less.

is also 25 per cent

is

pressures

Europe (90-105),yet that their arteriosclerosis

in Western

precocious;

and

senile arteriosclerosis.

in India, such as Professor M'Cay

practising
rule lower
that arterial systolic
pressures
than

blood

climates

hot

but

races

their

and aneurysm
are
physicallabour, syphilis
very prevalentamong
The
General
them.
Hospital
Reports of the Massachusetts
(Oct. 1908) do not bear out the greater proclivityof the negro
I gather from
these reports, though the rein the States.
porters
do
kinds

arterial

of the
which

with

observe

not

they

the

Lambert3

John

it is the

concerned.

blood

phalangeal

observed

in

pressure

that

vessels

But

defective.
attributes

citylife ;
kinds, and
has

become

subjecthas
On
found

the

for

data

on

decrescent

form

made

parative
com-

these

brachial

was

bright days,

factors

ran

rise.

with

of causation
on

artery
Dr.

high
of well-being,
naturallyrather

sense

Stengel,basing his conclusion

Dr.

main

the

there

with
a
rose,
pressures
in persons
with whom
especially
pressures
low.

two

Oliver

Dr.

blood

barometer,

the

in hot and
cold weather
pressures
satisfied himself
that, on the whole, in continuously

weather

in

between

of blood

and
respectively,

fell,while

disease, that

mostly

are

estimates

hot

distinction

my

are

as

yet

certain statistics,

apparently rapid increase of arteriosclerosis to a

he does not distinguish
between
the two
chief clinical
I think, that in recent
forgets,
citypracticediagnosis
far more
the
of late years
searching; moreover,
an

far

attracted
Peak

Pike's

pulseand

attention.

more

(14,109 ft.)Dr. Haldane

blood

pressures

Warfield,

change in

no

below

Arteriosclerosis,St. Louis, 1908.

Camac,

Lambert,

Amer.

Journ.

Thesis

Med.

for M.D.,

Set., 1905.
Cambridge,

companions

Kronecker, after

littleaffected.

ascendingto the Jungfraujochby rail,found

pressure, though a littlebother at the station
1

his

and

1908.

had

blood

raised it

to

but

PART

the

to

come

healthy men,

disturbs

feet

4000

to

for

be true

This may

has

Brunton

Sir Lander

160.

AKTERIOSCLEROSIS

OF

CAUSES

182

pressure (Vol.II., p. 102).

said, by Eumpf
It has been

level of 3000

subjects of high

already the

persons

conclusion.

same

sure

am

for instance, that

calcareous

largemilk consumption, promotes calcification of the

If the degenerativ
arteries.
remarks,1
But, as Dr. Percy Lewis
lime there is plenty to be had, both
process wants
in the food, without
in the body and
callingon chalk in the
district of Cambridge the drinking
In my
water, and so forth."
water,

or

"

I have

hard, but

is

water

found

not

difference

any

in the prevalence

this district and

severityof arteriosclerosis between
the manufacturing districts of West
land
Biding, where the moorknows
well a
is of the softest.
water
Gouget, who
district in Champagne, around
the Aube,
certain calcareous
or

is hard

the water

where

to

even

arteriosclerosis

milkiness, says

The fact is,calcification

prevalentthere than elsewhere.
is a secondary and ultimate
not the
event, the coffin,
of decay. Indeed, as we
shall see later (p. 505), calcification
cause
be rather a good than an evil ; it may
give some
may
substance
vessel.
to a perishing

is not

more

Mechanical

Causes.

undertake

we

discuss

to

approach

the centre,

with

causes

the

When,

"

we

or

the

mechanics

exclude

cannot

causes

discrimination
or

the

subsection

instance,are

from

of this

and

truth

therefore

aetiologica,

we
arteriosclerosis,

subject.

our

In

consideration

affection,and

effect.

mechanical

effects,depends the
This

For

of

of

centre, of

one

allegedmechanical consequences
of cause
some
reciprocations
on

the momenta

among

Not

dealing
certain

may

only so,

conditions,whether
of

must

my

version

run

to

some

cover
disbut
as

of arteriosclerosis.

length.

certain

manifestations
of excessive arterial
arteriosclerosis ?
Or do these
pressure dependenton a pre-existing
rises of pressure
and possiblyproduce it ?
precede the affection,
In the beginning of this chapter I argued that arteriosclerosis,
with high pressures
and
without
incidental
not
them, were
variations of
the
as

one

general process but

followingparagraphs I

convenient,to find
1

Lewis,

out

shall

what

P., Brit. Med.

were

two

proceed, with

may

several kinds.
as

little repetition

be the mechanical

Journ., July 22,

In

1911.

conditions

CHAP,

CAUSES

MECHANICAL

iv

blood

correlations of arterial disease and

and

that

seen

and

Basch

von

We have
pressures.
majority of authors down to the

the

arteriosclerosis

opined that the

established so impedes the

present day have

when

and

therewith

increases, and

the

have itthat

high arterial pressure

that, sclerosis

further

in the

and

Basch, always would

established,these

reaction

deformative

larger trunks

the result of sclerosis ;

was

once

first,

comes

that resistance

stream

likewise,followingvon

Potain

exert

blood

pressures

onwards.

he admitted

183

would

stresses

weakened

the

upon

though
tube

peripheralareas, in which normally the

in
the contrary Huchard
pressure gradientsfall quickly. Then to
wards
1893, 1 myself independentlyin 1894, Edgren 2 in 1898, and afterThoma
other authors,urged that the high presand many
sures,
but
the result
however
not
cause
a
brought about, were

so

far at any

rate

H.

of arteriosclerosis.

and

bent

the

as

of his

end

observed

Edgren, and

in France

as

in all my

have
that
any

this

nervous

reiterated, and

must

arteriosclerosis may

preliminaryphase

ordinary
way,

middle

pressures,

of

life onwards
as

past phases

under
of

very

in almost

it home

being

pressures,

morbidly high

and

first I

(see

p.

155)

in time, under

that

arteries

the

rare

arteriosclerosis becomes
excessive

(1894),

the

oftendoes arise, without

all persons,

age

indirect.

and

From

content.

high pressures
old

for

though Edgren

first paper

own

drive

to

arise, and

exceptions in

the

ordinary

and

try

the

to

So likewise

subordinate

in my
not

was

tension
hyper-

previousphase,
a
phase perhaps

pressures

as

singlecategory
I

essential.

blood

causes

later papers,

of

"

Lancereaux, Chantemesse, all

Hayem,

exorbitant

toxic and
with

for

Broad-

1904

Huchard

For

pressures,

implied and

always

arteriosclerosis meant

But

of arteriosclerosis.

effect

view

the

opposing

unobserved, of excessive

or

admitted

in

life,arteriosclerosis signified
always

past, but

of the

(loc.
cit.)
says that in

Cook

W.

still alone

were

"

the

as

;
as

present

so

that

give
from

frequentunder
or

past.

persistent pressures

For
leave

is it then that
plainand indelible records upon the heart. How
that high pressures
without
sclerosis,
saw
occur
although Traube
and sclerosis without
high pressures, and although Hope in 1832 3
1

Potain,

treatise.
Arteriosklerose,1898 ; a valuable
Edgren,
of the Heart, 1832.
of the Diseases
Hope, James, Treatment

La
Die

Pression

arterielle,Paris, 1902.

AKTERIOSCLEROSIS

OF

CAUSES

184

PARTI

depraved condition of the blood

that overand replied, It appears to me
vessels into activity?
distension of the arteries by the force of the circulation is what,
at least,producesthis effect,"
yet to this day authors,
principally
the clinical and pathological
sides, fail to clear their
both
on
minds of this confusion, and continually
speak of arteriosclerosis
"

asked,

is it that calls this

What

"

the

as

after essay,

essay

than

rather

cause

"

the effect of blood

as

the most

even

In
pressures ?
stillread of
alterations
"

recent,

we

the
leading to high pressure,"and meet
assumption that arteriosclerosis and high pressures are but the
the same
and
static and dynamic aspects of one
malady."
vessels

the

in

"

For

British
"

at

the

Toronto

Professor

of

Clinical

example,

arterial tension
the

never

of it

"

and

opinion in

is still the

what

Medicine

eminent

an

that

declared

roundly

be the result of arteriosclerosis but

might

cause

discussion, in 1906,

thus

did
It

vogue.

was

but

roundly
express
is but the other day
"

the
leadingarticle of a medical journalI read that
arteriosclerosis may
existence of generalised
be inferred with a
fair degree of certaintyfrom
blood
measurements."
pressure
Indeed the great authorityof Dr. Mott seems
to incline to these
opinions; he speaks of arteriosclerosis coming first,then a rise
of pressures, and, thirdly, a multipleeffect of both ; so that the
arterial lesion may
be both cause
and effect of high pressures."
that

in

"

"

In most

of thickened

trophiedheart
in which
How

the
do

an

; but

kidneys

in his

years

it hypertrophies,
and
work

not

some

does

no

few

tion
combina-

it is not
and

in

under

years

more

is

now

heart

has

of

included

work

more

pressures rise. But why ?

than make
up the loss.
vancing
arguing that as with ad-

senile arteriosclerosis

high pressures

"

is concerned
elasticity

Lancet, Sept. 15, 1906,

p.

729.

an

increased

heart

trophies.
hyper-

that the heart

the heart

indeed, before arteriosclerosis

probable that loss

hyper-

Well, in the old story

elasticity,
they offer
stream, and consequentlythe
"

are

the arteries lose

hypertrophies;

suspicion.

the
elasticity

Englishauthor

But

for

under

were

resistance to the blood

time,

find

we

not

cases

arise ?
prepossessions

heart

eminent

of

sum

the arteries lose

to do ; therefore

if the added

of arteriosclerosis

says,

arteries,a high-pressurepulse,and

"

these

that because

Thus

"

cases,"he

waxes

sets

some

in.

It is

in the moderate

CHAP,

MECHANICAL

iv

CAUSES

185

quasi-normalrise of pressures which is the rule in middle and later

it may
the stream.
slow
life, but by dissipationof energy
Even
Gouget,1who has had to admit at last that high pressure
of arteriosclerosis,
could no longerbe regardedas the sole cause
still declares that this degeneration,if spread over
a
large
of vessels, must

number

1905,2when
arguments

if it should

it less effectual

In

disease.
the

decayed

"),

be

under

to

substitute

pressure.
of the
sensibility

impaired, and

as

pressure ;
; but makes

work
we

shall

in Graves'

or

tubing of

elastic

that

argue

arch

as

pressures

so

far

the

it in

see

emotion,

rigidfor

reduces

the

may

jerky ; 5

stream

raise blood

heart

more

healthy persons

mechanics,

aorta

tambour

the

of

calibre

same

make

not

and

carotids

relaxed

pour

arterielle

ellememe

increase heart work, cannot

does
elasticity

loss of

("a

"), then by hypertrophy of

This view prevailedat an
important discussion in
however
the late Dr. Foxwell
brought forward good
to the contrary.3 As von
Romberg says,4sclerosis,

heart.

even

tension

la tension

exagerationde

obligeeune
consequence
at first by itself (" par
the

arterial

augment

in

blood-pressure
be

less well

governed.
In

the Paris

1910

"

untruly that
medical
the

before

had

men

far

pioneerand

Huchard's

"

(in this
accurate

more

the Lancet,6 after

discoveries

directed

been

orifices

cardiac

correspondentof

the

said that

entirelyto
respect ignoring all von

lesions

researches,the work

Potain, of

(Huchard) belongsthe merit

of heart

cases

many

the

to him

disease

circulation, which

of which
(italics
mine). My own

arteriosclerosis

that
the

best Huchard's

at

of

cases

were

pressure

he

many

; to

Gouget, Arteriosclerose,1907.
See
Same

I think

As

Med.

p.

others),

showing

functional

that

disorder

this subject

24, 1910.

of

arterial

without

substantial

this class I then

gave

increase

the

name

1028.

in his article in Deutsche

Lancet, Dec.

many

Basch's

Journ., Oct. 21, 1905.

journal,

bearing on

to

of

of

of

hypertension,and to
this hypertension
is only the firststage"
observations
(publishedin 1894, showed
view was
but a partialone, and that

Brit.

due

called

are

arteriosclerosis
as

of

attention

almost

Sanderson, of Oliver, of Broadbent, of Brunton, and

"

stating

see

med.
Wochenschr., Oct. 28, 1909.
Josue, Arch, des mal. du cceur, avril, 1909.

of

ARTERIOSCLEROSIS

OF

CAUSES

186

"

Involutionary,"but afterwards,

"

Decrescent."

that
"

thus

cannot

we

and

dispositionto

accept

divides

hyperpiesiaseems
correspond with my

to

admits

that

distinguishthe
"

my

which

by

"

Atheroma,"

atheroma

"

criticisms,

some

do

pressures
of each.
But
the therapeutics

well contrasts

He

rise.

"-

he

to

and
arteriosclerosis,

of

which

in

form

decrescent

see

"

intended, and

be

to

in response

some

kinds

Arteriosclerosis

"

into

them

several

the

of

views

Teissier shows

PARTI

processes
Ortner1 has

(p.510).

shall

we

sclerosis
arterio-

"

as

admit

to

now

not

uncomplicated arteriosclerosis may produce neither cardiac

hypertrophy nor high pressures ; but in another place he still
the leadingsymptom
of established
calls 2 high blood pressure
"even
in far advanced
arteriosclerosis." Jores3 says
categorically
arteriosclerosis hypertrophy of the heart may
be absent
sclerosis
or
very slight." I repeat then that for the assertion that arterioof pressures
is itself a cause
abnormally high for the
have no evidence whatever.
When
time after
patient's
age we
time cases
are
pointed out of high arterial pressures without
that

"

disease at
of the

of this

cure

admitted

indeed

"

"

them

of any

rate

any

accessible

condition,which
he narrated

arteries,and
Basch

von

such

many

pseudo-arteriosclerosisit

as

"

nevertheless
inaccessible

that the rise is due

sight

and

to

himself
but

cases,

"

and

was,

furthermore,

candidly
dismissed

still is, argued

but of vessels
arteriosclerosis,

example, in the
mesenteric
and aortic areas
(Hasenfeld and Hirsch),or in wide
ramifications
in peripheral areas
(Balfour). Broadbent,4 in
testified
discussingmy view eight years after its publication,
to

touch,

of arteriosclerosis

cases

"

for

as,

in which

the

blood

pressure

was

had been."
high,and never
Masing also supported my
decisively,
sayingthat the blood pressures bear no definite
5

not

view

relation

to

sclerotischen
des

to

arteriosclerosis
Prozesses

Blutdruckes."

with well-marked
whose

blood

ist

He

"

das

I think

des

fur die Hohe

an

gave

did not

his art. in Deutsche

W.

Entwickelung

keineswegsentscheidend

exceed

Ortner, Fortschr. d. D. Klinik, Bd.

Id., Jahreakr. Feb. 1911.
In

der

example of a man,
aged 68,
(" ausgesprochenem ") rigidand snaky arteries,

pressure

Broadbent,

Mass

Arch.

in

One

Deutsche

may

see

dozens

i. 1910.

f. klin. Med., Sept.

H., Lancet, Feb.

in his
paper

120.

1908.

7, 1903.
Arch.

f. klin. Med.,

vol. Ixxiv., 1902.

if arteriosclerosis

that

with

attended

be

not

that, in

They urged, moreover,

if in

even

have

fair

seeming, yet,

Hasenfeld's
bore

paper,

his

out

that, although

Hirsch's

and

Hasenfeld

their conclusions

fifteen

paper
been

have

on

areas.

of

pursued

were

these

tions
ramifica-

its

publication,I read
cases
by no means

it

is sufficient

own

However,

than

did

arterial pressure,
mesenteric
trunks
might

his

thought

more

suing
en-

high

sclerosis

When,

conclusions.

mesenteric

microscopic search

if

revealed.

be

would

of

the

finer network, extensive

their

to

aortic and

cases

the eye

to

cases

some

with

pressure,

heart, yet that this consequence

occupiedthe

the disease

when

rise of

substantial

paper,1 alleged
branches
might

peripheralarterial

in

of the

hypertrophy
follow

PART

Hirsch, in their well-known

and

Hasenfeld

ARTERIOSCLEROSIS

OF

CAUSES

188

to

say

have

elapsed since
was
published,years during which
reasserted
and
built upon
again
years

been verified in the author's

again, yet they have never
namely, that high pressures and cardiac hypertrophy
sense;
arteriosclerosis in the mesenteric
in
and
depend upon
area,
this area, or the thoracic aortic,only or mainly.
careful
No
comparison of degrees of arteriosclerosis of
the several
of the
areas
body with the coincident
ranges
of blood
life
has
been
Hasenfeld
during
published.
pressure
and

and

Hirsch

splanchnic

admit
and

that

pressure

and

necropticobservation
without
mesenteric

contrariwise
to

prove

notable

is

arteries

have

sclerosis is not

that

learn

We

rare.

the

vessels

from

there

pressure

at

and

any
we

other

rate

shall

than

the

influence

no

is

of

frequent,in

ample
cases

the
in
see

store

on

of

of arteriosclerosis
aortic
their

and
main

that, while

their finer ramifications

it

pathologists,
including Jores,

many

finer ramifications

have

in many

been,
;

"

that

rise

trunks, extensivelysclerosed
in these

in

supradiaphragmatic
"

blood

sclerosis

of

the

mesenteric

branches

are

generallyintact. Again, if disease began in this area, what

about
the explanation of high pressures
of the
by spasm
?
Mesenteric
splanchnic system
in so far as
arteriosclerosis,
it may
impair the supporting mechanism, would tend to a fall
1

Hasenfeld

and

Hasenfeld

has

problem.

It is

since
now

Hirsch,
admitted
too

Deutsche

Arch.

(1913) that

late to alter my

his
text.

Bd.
lix., 1897.
f. klin. Med.
explanation does not solve the

CHAP,

MECHANICAL

iv

of arterial pressures
were

to

set

an

up

other

the

on

CAUSES

hand, if

the

order

place in

of

; sclerosis

whether
of arteriosclerosis,

excessive

with

without.

or

Thus

disease, and

to
liability

all extents

pressures

contrary.

would

being in this
The aorta
comes
early in
generallytakes a large

be the effective factor in rise of pressure

not

arterial irritant

an

the constriction
constriction,

extensive

respect superfluousif

189

later

observers

are

compelled

to

admit

lack

of

and
the
the courses
of arterial pressure
parallelismbetween
degreesof mesenteric arteriosclerosis ; also that pressures may
has progressed
reach high levels before sclerosis in this area
I
conversely. The late Dr. Savill, with whom
very far ; and
in this matter, whose
field of
had
frequent communications
practiceand necropsy was
large,
experiencein workhouse
very
and
who
whose
indefatigable,
diligencewas
compared arterial
was
ramifications, magnitude by magnitude, in many
areas,
such
such
unable
to discover
or
parallel,
guide to
any
any
levels. Thayer and Fabian
concluded
that on
tit.)
(loc.
pressure
the whole radial sclerosis runs
to the visceral and
fairlyparallel
that high pressure
aortic. Von Romberg, who has fullyadmitted
precede all sclerotic change, has himself produced postmortem
may
evidence

Arterien

(" Unterleibs
*

Marchand
mesenteric

in

that

is

") often

quite clear
cceliac

that

the

cases

show

no

rise of

abdominal

vessels

correlative

pressure

is not

and
arteriosclerosis,

disease.
due

to

proceeds to say that

cardiac hypertrophy is common
arteriosclerosis without
; indeed
he doubts
the heart is primarilydegenerate,
that, as in some
cases
the alleged
effects of arteriosclerosis (" sehr fraglich
high-pressure
ist,wieviel da von
Rechnung der Arteriosklerose zu setzen ist ").
t is true
that, as the mesenteric
postulatebecame less and less
nable, von
Romberg and Hirsch began to lay more
emphasis on
the aortic side of the explanation; but everyday experiencetells
that even
in enormous
aortic deformation, as in the Hodgson's
us
known
cardiac hypertrophy,unless
aorta
to be syphilitic,
now
of the
atheroma
by some
complication,does not arise. When
is associated with hypertrophy of the heart the story is the
aorta
other way
:
high pressures first,cardiac increase second, aortic
the
injury third. It is surely common
experience,whatever
1

and

such

Marchand,

art.

"

Arteriosclerosis

"

in

Eulenburg,

4th

ed.

state

the

PART

of the mesentery, that the aorta, the orifices of the carotids,

all be extensivelydiseased without
subclavians, etc., may

Marchand

blood

history of high

hypertrophy,or

cardiac

any

ARTERIOSCLEROSIS

OF

CAUSES

190

pressures.

the hypertrophy is
(loc.cit.)
agrees that in such cases
be attributed to the sclerosis ;
constant,"and cannot
means

"by no
although in

of them

some

concomitant

with

emphysema

right ventricle proves that, had there

it, the heart was
capable of hypertrophy.
quite truly,that cardiac hypertrophy cannot

of the
call for

also, and

affect

but

which

raise the minima,

clinical

At

arteriosclerosis.

of

areas
upon
vessels could

are

systolicmaxima
;
more
importance.

the
of

(p. 445) x

high
In my

view,
due

of blood

range

as

to

it does

time and

high

been

any

He

says

depend
the large

it could

to

abdominal

that any
appear
is registered.

not

pressure

experiencehave increased, the

pressures

has

taken

not

In the recent

attributed

of colickysymptoms
descriptions

arteriosclerosis

sclerosis of

most,

trophy
hyper-

spicuously
con-

sclerosis
arterio-

less rather

than

50 per cent
of Groedel's
More
than
cases
largercompass.
Vessels which
showed
no
signs of excessive blood pressures.
but
cannot
are
incessantlysubjected to hydrostatic stresses
as
betray their effects ; and these the more
by one co-operating
be less fit to withstand
another
their coats may
them
or
frailty
;
but by arteriosclerosis of high pressure, properly so called, we
mean
surely lesions primarily and mainly thus produced in
vessels previouslysound.
find in highIf, as frequentlywe
the arterial integrityis not otherwise
impaired,
pressure cases,
it takes a longer and severer
persistenceof excessive pressures
than is generallysupposed.
to damage them
In a young
adult
45
under
sufferingfrom
person
say,
Bright'sdisease with inordinate arterial pressures, the aorta and
vessels may,
for a couple of years or more,
as
proved again and
again by post-mortem examination, show no visible injury,and
the heart itself no
more
change than a sound hypertrophy ; so
largeare the cardiac capacities.Now if the rise of pressure does
not follow but precedesthe vascular
strain,all the busy speculation
a

"

as

to

is thrown
1

1903.

the way

in which

"

arteriosclerosis

causes

high

pressures

away.

E.g. Ortner,

Klin.

Vortrdge,N.F.,

Nr.

347

Innere

Med.

Nr.

102, Jan.,

CHAP,

In

pressures
the aorta was

fairlynormal.

observation

my

before

191

set.

of blood
but

KINDS

39, with no renal disease,but a very high range

during life,the heart after death weighed 42 oz.,

shopman,

SEVERAL

ITS

iv

He

Addenbrooke's

in the

tillhe

working

was

three

Hospital,only

made

as

serve

Dr. Aldren

by

before.

from

also

case,

Hospital,may

the

set. about

and

granular
Kidneys small, scarcely any

Addenbrooke's

the

illustration.

Male

Wright.

of

mortuary

converse

Albuminuria

years
unknown.

The

autopsy

Lead

55.
casts.

but

19

and

normal

inner

Aorta

surface

somewhat,

yellow,but

darker

collapsed
fingercould

these

their

parts and

something

to

return

the

upon

patient.

On

well-marked

age,

low
The

modes

the

constitution,and

"

that
the

high

identical
histologically
clinical series

multiple in form,

is not

"

"

the

malady,
pends
de-

course

habits

of

the

aortic pressures,

low

least

at

and
pressure
different
or
"

the

clinical

two

decrescent
the

that

different,and

therefore

are

in 1906,

Toronto

have

we

of

again and again

peripheral arteries with

is,with scanty output,

of arterial lesion

at

much

goes,

observe

may

sclerosis of

wave.
systolic
corollaryhowever

reiterated

we

the

of

cure

on

may,

integrity
; but

hand,

some

patches.
degeneration
degree of

clinical observation

as

like

extreme

or

whether

"

functions

the other

aortic stenosis ; that

and

far

so
incipienthyperpiesia,

to

was

cusps

much, dilated,

not

heart

long-standingearly proneness of the

There
presumably had spared the aorta.
arterial
peripheral
thickening(toxic?).
a

In

mitral

atheromatous

no

pressures

The

cortex.

was

fairlytranslucent.

was

colic twelve

Blood

degenerate; the
weighed
oz.,
very
be thrust easilythrough the ventricular wall. Aortic and

heart

Here

weeks

his death.

Another

and

under

came

sponding
corre-

that,

as

be it singleor
arteriosclerosis,"

disease

but

sequence
pathologicalconof several diseases," is not
Although
yet realised.
doubts
are
expressed by Monckeberg, Adami, and others as
after
to its pathological
unity,a problem which we will consider here(p.483), in current medical writingthe unity of the process,
as

clinical series,is still assumed.

in the
of

causes

form

of the

play
reckoning

course

the

; the

large part,

much

difference

in

the

in the

It is needless

form

decrescent

mechanical
which

stresses
same

way

decrescent

as

form

may
in

to

say

stresses

be
the

taken

that
must

into

hyperpietic

being not

so

much

ARTERIOSCLEROSIS

OF

CAUSES

192

PART

qualityof the
of other
vascular structure, and in the presumptive co-operation
dental
metabolic
coefficients of decay, such
perversionsand incias
In this place
poisons,of which I shall speak hereafter.
of high blood
I am
not
dealing with the causes
pressure
as
known, will be considered
they
these, so far as they are
strains

of the

incidence

in the

lower

in the

as

"

arise, but
"

in this way

140-150

dissent

rise of blood

(See also

mm.

That

high

normal

critical

at

and

morbid,

or

leading

manifestations

distortion

the

points and

stress, whether

stenosis

at

the

hither side,and

site of

and

is normal.

in valves
the

the carotids

Here

central

toxin

no

any

above

say,

it in

the

alteration

of

dilatations

with

elongation.

In

and

botalli

cerebral
the

on

In

the

of

far

tell

on

the

extremely

side

How

narrows

points and
congenital

arteries,
are

is concerned.

the

change

aorta,

farther

up
I

its earliest

are

arteries.

or

set
; and

bifurcations,at

at

ductus

to

Adami

and

lines of atheroma

while
(atherosclerosis),

diseased

us

that,

of

cause

competent

are

by Roy

proof of
points,as
again at

to

lines of

of rises,let

friction

and

familiar

adduced

arterial wall

itself is

462.)

clearlyshown

was

far then

prevalentdoctrine

the

from

pressure,

p.

pressures

atherosclerosis

wave

my

in that, arteriosclerosis

or

considerable

have

causes

So

arteriosclerosis.

of

the

maintain

but

do

with

the

tree

along the
beyond

that is in areas
peripherally,
the critical fall of pressure
This knowledge
gradient,is unknown.
need.
Much
must
we
depend upon the habitual attitudes
of tone in the several districts of the body.
If then, besides ordinarywear
and tear, there are many
other
tree

of

pressures

atherosclerosis,
we

can
forgetthat in none
the mechanical
coefficient be absent, or even
negligible.If so
be that in this way
or
that, by toxic agencies,as Krehl insists,
defective quality,
or
the consistence and resistance
by originally
causes

of the arterial coats

stresses

of

that

the

are

co-operate with

of

by

the

blood

is

directlyeffected

mean

whatsoever

multiplyits effects ;

not

reduced, it is nevertheless

undoing

stress, whether

must

of

or

toxic

labantem.
impellit

enquiry,if atherosclerosis
pressures

or

or

stresses, and

does

so

by

mechanical

every

increment

must
systolic pressure,
morbid
and
proclivity,

But
much

accelerate

we

are

itself to
its

own

still faced

aggravate
career

CHAP,

MECHANICAL

iv

CAUSES

Now, in estimatingthe mechanical

system,

forgetthat

shall not

we

If the term

of life.

condition

inthecardio-arterial

stresses

its motions, if

nevertheless

of dissolution,are

elements

193

themselves

of their

contain

they

the form

duration

own

the
and

is implicit

they are coefficients of work and

on
which, like the weaver's shuttle,
pulsations,

them, yet meanwhile

within

The

development.

of the arterial coats

the molecules

diastole of the

systoleand
nourished.

By

vasa

travel to and

by which the coats are

doing work they also,as

vasorum

action,while
reciprocal

fro,promote the

feed.
And this
open and close the valves of their own
mechanical
coefficients
illustrative instance is but one of the many
it were,

of

perfectcirculation.

oscillations the
limits
both

efferent,and

(p.209). It is for the

of the

several

and
regurgitation,
vessels

less

are

areas

mechanism, by increase
;

as

of the

well

to determine

as

system.

As

efforts of

elastic,
high maximum

pressures

diastole

the

"

are

normal

expel all juices,

may

in the muscular

systoleand

between

but

oscillations lead to strain

extreme

vasomotor

these excursions

to moderate

exchanges ;

protracteddistension

afferent and

limits,the largerthe

certain

the nutritive

more

narrow

are

Within

apt

we

the

tions
irriga-

in aortic

see

whose

elderlymen
"

wider differences

strain the

to

of tone,

vessel ; and

arterial
largermean
Such a
be distinguished
diameter.
must
be low and output large.
from high pressure, as resistance may
rind during active muscular
exercise ; on sitting
Such a state we

usuallythis

down

rest

to

means

the musculo-cutaneous

maximum

the

condition

mean
falls,

of

maximum

be, rather

may

largeroutput and
high upstroke however
a

arteries contract

and, while

actually rise. That

largeaffluxof blood it

may
pressure
oscillation and

of pressures, which
range
arteries of labourers (videp. 205). Marchand

than

high

mean

damages the limb

of arterial
laysgreat stress not only on high pressures as a cause
on
large oscillations of pressure (" haufige
decay but especially
starke Schwankung "). Agreed, but let us be clear ; this rule
We
have
that oscillation is a
seen
scarcelystand alone.
coefficient of nutrition,that high pressures through all phases of
the cycle militate against nutrition,and this tension, though
narrow

as

is for the arteries

oscillation,

the circulation.

Marchand,

protected
by tone, and

artery is
VOL.

What

and

that if

an
we

over

adverse

condition

of

all,mean

is that

the

long periodstone
o

is in

that

excise

to

kidney in

one

activitymay

in size and

that

so

the

ingly
correspond-

concurrentlyadrenin be injectedthis renal artery soon

stresses
impaired.1 Within limits then, mechanical

short ?
becomes
a

are

efficient
co-

limits ;

Within

lies death.

in their default

grows

too

If

of life,and

is true

other

the time

is not

; but

artery

the

produce sclerosis of

not

renal

voluminous

animal

an

PART

it
Experimentally,

arteries get battered.

the

abeyance

AKTEKIOSCLEKOSIS

OF

CAUSES

194

regard the
as
directions : in the height of the systolic
in two
wave,
excess
in resistance to arterial systole; that
in aortic regurgitation,
or
tension ; or of
is,in an excessive amplitude,or in a high mean
in a co-operationof both factors, as in certain phases of
course
limits is

in these

what

but

In

Bright'sdisease.

chronic

outwards

is driven

molecule

if not

near,

material.

breaking limit ; and

liable,in this place and
own

altered

by

lie

may

fail to

the

stress

be

adhesion

set, and

new

molecular

set

We

have

and
may

failed to

focal detriments.

cohesion
between

consequent

are

preciselyto

return

which

groups

explanationof

some

some

course,

hence

is strained

the

At

there

is

glidingsurfaces

bias of function.

But, if the

mitigated,perhaps some

place,or resolution
by dissipationof
molecule

its

to

result ;

expense

in that, to

normal

spots where

may

molecules

separation the

this

herein, in molecular

that

still,of

its

to

dangerously

take
a
new
may
group
sizes of particles
would
stresses.2
create
new

back,

the

other, and

of each

the

outward

the

on

the

seats, when

presume
come

conditions

of the
limits of the cohesion
upon, the extreme
is far within
of all materials
The limit of elasticity

the

their

driven

be

may

may

of its attraction

the verge

to

we

these

first of

the

neighbours; all the molecules

curve
dangerouslyout of touch

Well,

excess

in

of the

mean

the energy

place,a

own

the

or

lower

take
recovery of pattern may
In this way
direction.
perhaps,
which
should
restored
each
have

lower

fibre

if

more

static kind

surviving may

increase

of fibre
at

the

higher.

See

Frugoni, Sem.

We

cannot

of

med.

No.

9, 1913.

that even
of functioning
suppose
normally the molecules
all
return
their
to
parts
it so
absolutely
place before the action ; were
life would
be not a development and
oscillation.
involution, but a
course

stationary

But
of

we

conceive

development

back

towards

of these
or

their

of
own

movements

strain.

Tissue

places, incident

as

having

memory
forces

their critical
tends

to

to

carry
deflect them.

phases, whether
the

molecules

the

that

so
piesia,

release,while,
from
which

tunics

ARTERIOSCLEROSIS

OF

CAUSES

196

wall of the
still

worse

vessel

expanding

to

deliver

they have

to

feed.

loses its

now

perhaps, the

their

vaso-systolic

vasorum

vasa

tale of

Thus

PART

high

are

blood

vented
pre-

the

to

levels of diastolic

increments
mischievous
to the arteries than
more
pressures are
of cardio-systolic
systolic)
pressures with normal diastolic (arterial
rest

then

repletion.As

and

exorbitant, so molecular
it is called

strain

blood

mean
"

in many

fatigue,"as

"

become

pressures

materials

shearingstrains,and

tensile and

"

the

probably a ripping
muscular
fibres, conspire
to
poverish
damage and im-

spiralthread of the
with the squeezing out of vasa
vasorum
the media
and
intima.
over,
Morethe coats, especially
it may
be that, when
high parietaltension occludes the
also undergo an occlusive
these vessels themselves
vasa
vasorum,
such as we see in experimentalresearches
process of degeneration,
the ligature
of vessels (see also pp. 460-2).
on
to be with high pressures
in arteries otherwise
So then it seems
sound
Dr. John
and well nourished.
Cowan, in an interesting
the historyand evidences of arteriosclerosis,1
essay on
says that
action

the

on

excessive

blood

whether

pressure,

the vessels ;

always damages

sooner

for arteries less sound, and

stillmore

are

themselves

may

the

we

which,

be

I have

as

urged again

elderlypersons,

much

narrower,

under

stresses

as

the

not

are

in them
vessels

And

so

far

And

as

tions,
reflec-

nourished,
the vessels
will arise

this is,in

fact,

mode
arteriosclerosis,
a

and

again from
implied. In the

the

disorder,

these

of stress

quicker.

1894

"

have

cognate mode

Time

that

and

in
1896

arteriosclerosis

elastic limits

fall into

extraordinary.

not

renal

less well

constitutions,in

decrescent

or

onwards, high pressures

of

later.

or

for persons

strain be the

in senile

see

without

or

frail,the evil consequences

and
readily,

more

what

; in such

apt

with

gave

become
of

decay

doth

now

his

giftconfound."
The
play of external
those of
especially
upon
but

contingent forces

the limbs, may

this factor will be considered
later.

Up

to

not

the arteries,
upon
be inconsiderable
;

this

agreed that
albuminuric

point then the argument seems

under
rises of pressure,
persistent
Stage
1

"

Cowan,

of

Mahomed,

the

"

clear ;
as

Latent

John, Practitioner,August 1905.

in the

we
"

Sclerosis

are

Pre"

of

CHAP,

MECHANICAL

iv

CAUSES

of

Hyperpiesia,and
the
that is, when
again in chronic Bright'sdisease, especially,
lifted up, yet also in very high systolic
diastolic pressures
expansions
are
sclerosis
arteriowith
ampler diastole,as in aortic regurgitation,
results sooner
or
later,and takes after the ordinary,the
vessels may
intimal and subintimal, pattern. Young and sound
about
resist this degeneration for years, but surelyit comes
in them.
even
Speaking generallythen, a thickened
artery
means
plus stress or minus elastic value, or an algebraicsum
of both in various proportions.
In a later paragraph, under
and
the easy phrase of
wear
Basch,

von

"Presclerosis"

197

the

Huchard,

my

"

tear," I shall discuss

the

infinite accessory

factors which, besides

directlymechanical, impair the arteries ; but here I must

that
sure
tarry a little to interposethat we are not by any means
have
We may
are
we
dealingalways with anatomical constants.
four histological
modes
of arterial alteration : atherosclerosis,
to recognise
described
as
by Langhaas and Jores ; the strain of
Monckethe media in the vessels of the limbs, called by Adami
I accept for present convenience
berg's sclerosis," a name
(p. 482) ; the simple intimal connective hyperplasia found in
healthy elders, which is liable,however, in spots to slow fatty
tissue hyperplasia
degeneration,and the syphilitic.Connective
the

"

does

always

not

which

begins even

anatomical
for

lie within

forms

in childhood
than

more

of disease ; it is

the terms

(p.489). One
the

process

other of these

or

rest, connective

hyperplasia

of mere
mechanical
stress;
significant
to engender atherosclerosis
some
auxiliarycauses, toxic perhaps
in nature, may,
operation.
as
urged by Dr. Mitchell Bruce, be in coIt is generally to this complexity of causation
that
German
Abnutzung."
our
colleaguesapply the term
these ambiguitieswe
shall endeavour
But
to appreciatein the
later paragraphs.
conditions of mechanical
As regards the vascular
stress : the

instance,

be

may

"

intima, in its inclusive

media
in
the

and

the

adventitia

this respect the

media

media

subordinate

being
does

is efficient but

the adventitia, a tunic

channels

is the

sense,

blood-vessel

of blood

the

investingsupports ; and
chief work, for so long as

its

the

little of the

which

proper,

tensile stress

serves

rather

and

lymph,

as

and

as

reaches

carrier of the
a

bond

with

AKTERIOSCLEROSIS

OF

CAUSES

198

PART

the media
however
yields,these
surrounding parts. When
have
be
channels
in a squeezed adventitia
as
we
seen,
may,
relations
straitened or stopped. And, while upon these outward
of the vessels,we

remark

may

of the branches

with

that these vary

the distributions

vessels,like the descending aorta,

some

surrounding structures
; others, if not
in
embedded
the surrounding parts, are
so
in muscle
them
fat for example, as to be none
the less well
or
supported or packed ; others again,like the cerebral, temporal
and coronary
stand free
but loosely,
branches, are attached
or
from packing ; so loose or so free as to be almost
unsupported.
It is easy to perceivein the earlythickeningand tortuosityof
in persons wholly free from general
unsupported branches, even
how
arteriosclerosis,
important for the integrityof the vessels
closelyattached
closelyattached to

to

are

"

these external relations must

which

well

be.1

Thusthe
and

embedded,

basal cerebral arteries,

possessedbut
of feeble muscular
tone, suffer comparatively early; and their
tion
twigs,when impaired in quality and unprotectedby constricof their
affluents,are
peculiarlyliable under
rising
to give way.
As an
pressures
artery yieldslengthwiseit must
be thrown
into secondary curves
between
of its points
two
any
are

not

of closer attachment

and,

as

each

on

friction is thus

who

of its bed

vortices

and

possiblyformed,
defect,like all defects,would multiply

should

has also made

moreover

oscillation it rises out

increased

suppose that the

itself; and such is Albrecht's
we

are

conclusion.

Oberndorfer

however,

careful

comparison of arteries in supported,

unsupported (e.g. temporal and
immobile
coronary), and
positions,
disagreeswith Albrecht in supposing that the vessels,
or

parts of vessels,most
If it does

he reminds

of the

us

e.g. the trunk

its limb

of the
to

the

in

heart
rate

of

such
which

he

temporal,
givesmany;

rigidand calcareous
comparatively,unaffected.

that

be supple to
they may
generallypassive to distension,in

oxidation
See

in

cardiac

again

Albrecht, Deutsche

Schade

Arch.

excitement
(p. 38).

f. klin. Med.,

supported.
un-

the

as

supported and, althoughmuscular,

1
2

for some,

the

are

is often

wholly,or

order

and

arteriosclerosis

of
negativeinstances,

are

not

are

innervated

true

seem

of the iliac,
which

branches

coronaries

liable to

1911.

are

the

while
The

feebly
paces

obedience

(Barcroft,loc.

CHAP,

VASCULAR

iv

cit.),and

on

CONDITIONS

of

access

any

the

instantlyto

199

blood

high

heart's

pressures

need

may

if
respond
; a
response
opposed by the constrictions so often assumed,1 might be
The
impeded.
dependent arteries, those of the legs for
another
example, have to withstand
stress, that of gravitation
long as this does not exceed the normal, we
; and, so

find

no

but

if
"

than

more

in

as

dorsalis

relative

veins

varicose

which,

thickness

of the

of

leg

these

branches,
rise in

pressures

"

the

posteriortibial this thickening palpably

increases,if still perhaps within limits of healthy hypertrophy.
If in a
comparatively young
subject the varicose veins are
cured by operation the arterial thickeningwill subside ; 2 but
if the venous
disease continues
the co-operatingarteries fall
into

irremediable

an

sclerosis.

repeat that

I may
any

and

pedis

that

to assume,

rate

have

we

no

produce medial
as

of the vessel to

in exposure
In

the

of the

extent

may

obvious

variable
the

is

apt

more

to

(p. 48 et seq.); but,

make
a
largedifference
and

constriction

constriction

constriction

magnitudes, are very

tightlyconstricted, but

in tone

at

none

another

tone

which

to

or

suppose,

lateral pressures

with

high-pressure
cases,

arteries,the diameters
and

than

hypertrophy
heart, plus or minus

in the

diameter

one

any

to

reason

inwards

in many

tensile strain.
of the

confine

may

towards
cases

palpable

the

the

them,

larger

radials

are

brachials

apparently not so ; in
others both brachials and carotids feel narrow
and tight. The
capacity of the carotids for inordinate changes of diameter
is conspicuous in their expansion in Graves'
disease ; and
itself in pseudo-aneurysmal throbbing of its
that of the aorta
abdominal
tion
portion. In other patientsagain,whatever constricthere
be, if any, in the outward
periphery,or in
may
visceral areas,
be
of ordinary
the radials themselves
may
and
stretched
radials
the
diameter, or even
leathery. When
constricted
the protection against strain of their own
are
of fact in
be enormous
coats
must
(p. 218) ; and as a matter
these cases,
for a long part of their 'course
at any
rate, the
constricted

of low

walls

present

tone, such

as

1
2

See

the
See

an

texture

even

cerebral
Essay

Vignolo, Societa

on

and

Angina
Editrice

the

to

the

touch.

coronary,

Pectoris.
Libr.

Milano, 1900.

Arteries

which

work

to

nearer

ARTERIOSCLEROSIS

OF

CAUSES

200

their elastic limits,are

the

PART

liable,as

more

experience

in time at ordinary pressures.

proves, to suffer injury,even
be played by cellular and capilThe obscure part which may
lary
arteriosclerosis I shall consider

functionin

again presently;

disposed to find in these areas

chief part in peripheralaugmentations of blood
a
pressure.
that
I
here
such
considerations, may
Brieflyto anticipate
say
Thoma,
fortifyinghis position by quantitativereckonings,
the parenchymatous
relation between
postulated a constant
blood current
through its
weight of an organ and the mean
capillaries
; that the weight of the kidney, for example, is in
and

Thoma

relation

to

Broadbent

constant

were

the

of its vessels.

bed

mean

the

Thus

provincesmay be said to determine, or to express, the

capillary
mean
quantityof blood passingin time-unit through the terminal
coefficients as
and
arterioles ; though probably,in such
rate
individual differences.
Now
there are
this,says
viscosity,
upon
Thoma, if velocityrises then tonus
falls,whereupon the artery
in his view of the matter,
enlarges; and conversely. Tonus really,
a rise
depends on velocities. Other thingsbeing equal,of course
in a somewhat
wider area, must
increase
of pistonpressure, even
and
tides,muscular
even
velocity; but vasomotor
movements,
also
in it (vide p. 27). Sir James
concerned
posture are
Barr * says that by lowering a limb capillary
velocitymay be
doubled.
He adds that the extra- vascular pressure
in capillary
amounts
to about
areas
a quarter of the
capillary
pressure from
which

it is derived.

tissue needs
the demands

"

Broadbent's

The

arterioles contract

of the tissues ;

arteriosclerosis

are

attention

drawn

was

relax in obedience

or

therefore,the
ultimately,

in the relation of blood

to

more

of

causes

tissues."

and

to

This he

illustrated

with fall of pressure,

by the behaviour of the arterioles,
pyrexia,an activitydue to the cellular insurrection against

in

the toxin.
the

flow

Chauveau

reckon

to

also

read, but

to

of

demand

on

are

lime

with

demonstrated
may

hormonic

engaged
and

be

in the

other

and appreciatethese
register
1

Barr, Jas., Brit. Med.

Lancet, Feb. 7, 1903.

salts

that, into muscular

increased

fivefold.

influences,which
sum

of

events.

something

tissue

Journ., August

may

areas,

We

have

are

hard

tions
By calculabe

done

to

Blair Bell and

as
activities,
25,

1906;

Broadbent,

W.

H.,

MECHANICAL

CHAP,

iv

Barr

are

do;

to

wont

CAUSES

also

as

201

other

tests

indicated

the

by

metabolic

of

processes.

At

innervation

vasomotor

modifying

inwards

proofsof

the

the

the

as

of

pressure

effects

To

varicose

of

be,

may

mechanical

arteries.

the

the

on

effects of the

texture

of

stress

return

by

stress

e.g. that

"

upon

upon

critical observers, such

by

adolescence

growth

intima

into

Fuchs

incidents

arteries

attributes
I

known,

as

the

confines

the

elastic limits grow

as

such

in

which
who

Jores
as

the

return

may

any

rate

to

have
indeed

carotids.

another

in

observations,

areas

stresses.
longitudinal

to

of

the

of

some

of

growing

the closure of the ductus

spoken already,observations

I have

"

consequent

of the

alteration

these

already alluded (p. 199) ;

find
into
the sphere of
disease, we
may
in healthy arteries,or
evidence
at
want
we
Of Thoma's
arteries barely entered into disease.
the fibroid increase

the

to

proofs, that
the
posteriortibial
but, before travelling

of

one

veins

I may

factor

artery, I have

also, on

the

of

part

activityin preventing or
arterial coats, enormously

tissue

and

mechanical

increased

the

having

however,

present

been

botalli
verified
it in

traces

This

fibrous

Taking
character

these
upon

namely, the buttressingof the channels

At these
at pointsof bifurcation.
at pointsof stress, especially
of the divergentchannels
fortified by
are
junctionsthe mouths
tissue,a firmer weldingdeveloped
a small angularpad of additional
in response
to heavier impact, and perhaps,in largervessels,
to
This provisionis best seen
vortices.
from
at the bifurcations
the aorta ; especially
where, as at the intercostal openings,the
branches
diverge at large angles. And further, it is at such
pointsas these that the earliest signsof strain begin to appear.
By infinite degrees normal and conservative fibrous buttressing
into hyperplasia and degenerativeaccumulation
over
;
passes
in

of health,

advancing life (afterthe

becomes

manifest

fibre,and
elastic and
1

is

smaller, and

The

more

I cannot

muscular

mutual

sooner

exceeded.

And

retrogradecharacter
nective
fallingproportion of elastic to conpenetrationof this fibre between the

in the
in

fortieth

are

the

year)

elements.1

development

fullydescribed, and
give more
space to

in

and
a

them

retrogressionof
way,
very interesting
here.

of constituents
this group
by Aschoff (loc.cit.),but

almost

the

crucial.

current

is the

may

far

to

as

be

great, and

Thus, under

indeed

is
the

on

which

stresses

arily
ordin-

exorbitant, the

extremer

monary
pul-

of pressure

cases

hypertrophy of the rightventricle,as for

instance
in advanced
degrees of mitral stenosis,emphysema,
chronic bronchitis,or congenitalmalformations, the pulmonary
artery suffers strain and injury more
commonly than is usually
supposed, for Torhorst,1 by closer research, demonstrated
internal proliferation
in many
in which, at first sight,it
cases
Good
not
was
specimens of this arteriosclerosis may
apparent.
be seen
in any largepathologicalmuseum.2
Again, while the
on

main

rightside

reservoirs

the

times

at

in
artery suffers little. Still,
the

which

strain,one

the

of

indeed

be.

velocitymay

may

capacity of

another

to

turn

us

lungs also, that vast

be heaped up there without
stemming
harmful
raise the systemic pressure,

heart, and

blood

let

PARTI

effects of mechanical

Such

the

so

loss of

as

"

of the

right side of
quantitiesof

Here

Arteriosclerosis.

Pulmonary
manifestation

ARTERIOSCLEROSIS

OF

CAUSES

202

trunk

with

normal,

seem

may

patches of

sclerosis may
instance
I may

and

its two

even

be obvious

beyond them.
quote Langdon Brown

branches,
For

and

an

trative
illus-

Durno,3

who

of patent ductus
arteriosus in which
published a case
the pulmonary artery and its two
main
branches
dilated
were
The
uniformly,the walls showing largeplaques of atheroma."
rightventricle was very largelyhypertrophied |ths inch thick
as
of
33 years
againstJ inch of the left. The patient was
Dr. Brown
calculated
that in his case
the pulmonary
age.
"

"

artery
Dr.

was

submitted

David

Lees

pressure

than

more

published a case
child,aged 9, with

unaffected.

much

has

artery in
was

to

Kitamura5

enlarged on

both

of atheroma

the

normal.

of the

monary
pul-

mitral stenosis ; the aorta

describes

right and

double

it in

left sides.

"beer
There

heart"
was

no

Torhorst, Ziegler'sBeilrage,Bd. Ixxvii. p. 380, 1904.

A good drawing of atherosclerosis of this vessel is given
by Letulle, p. 165.
Syphilis of this vessel (see Rogers, L., Quart. Journ. Med., vol. ii.,1908) is of
-

excluded

course
3
*

in

Rolleston's

System

Foxwell, Brit. Med.

des

mal
6

this

place.

Brown, Langdon, and Durno, Lancet, June

13, 1908.
Lees, D., Clinical
Oct.
Journal,
1901
9,
Mott,
;

du

coeur,

Kitamura,

of Med.

vol. iv. p. 587, who

quote
Journ., Oct. 21, 1905, p. 1028.

aoiH

1913, and

Zeitschr.

f. klin.

Frugoni,
Med.

Arterioskl.

vol. Ixv., 1908.

and
F. ; Allbutt
from
two
cases
Romberg ;
See also Avrilaga, Arch,

pulm., Milano, 1912.

the lesion

have

described
carefully

very

threw

an

of work

excess

of the other side.3

The

atheromatous.
F.

right

lung

one

"

trophy
rightlung and hyperand
branch
normal
Right pulmonary
fibrosis of

ventricle.

"
both nodular
atherosclerotic
strain ; left branch
excluded.
diffuse,"all through its ramifications.
Syphiliswas

and
The

"

characters
were
histological
aorta.
(By the way, on

the

in the

current

increase

right branch

of the intima

Thoma's

hypothesisthe slowing of

damage

be

can

and

bacterial toxic
declines

well

as

to

the

normal

seen

mechanical

"

inflammatory ; but neither

The rate of the pulse,that is

the walls of the arteries in unit of

compensatory

branch.)

thinks

Simmonds
are

herein concerned,
"

atherosclerosis, for it is

as

is atherosclerosis
the

an

portalvein in
dropsy.4 The intima

causes

accept the change

of

in the

deteriorated.

media
as

caused

have

of cirrhosis of the liver with

cases

is thickened

and

with

should

thos6

matous
athero-

identical

of this nevertheless

mechanical
parallel

many

not

followingmay

of

pulmonary artery
strained branch only became
be given as an
example :

signsof

without

the

cases

can

of the

the branch

Pleuropulmonary

eet. 39.

of

In such

illustration

closure

in which

cases

upon

The

Steell,Ehlers,2
(loc.cit.),

Torhorst

crucial,and

PABT

stenosis.1

mitral

pertainingto

as

stillmore

be made

ARTERIOSCLEROSIS

OF

CAUSES

204

number

mere

inflammatory.
of blows

time, apart from

upon

their energy,

is

probably, within the limits of life,negligible. Generally

speaking,the quicker the pulse the lighterthe several blows.
There
is less time, it is true, when
the pulse is rapid,for the
molecules
to
to their former
return
that in this
so
positions,
to give them
better chance ;
respect a slow pulse would seem
a
and they do not
get that comparativelylong rest in which, as
observe in the edge of a razor, materials
we
tend to
familiarly
at any
regain their elasticity,
or
rate their original
positions.
mechanical
Again, as Dr. Rolleston has shown, the mere
effect of
1

In

stress

certain

cases

on

vascular

supposed

the

to

hypertrophy of the right

Bengal Quart. Journ. Med., Oct.
8

Ehlers, Virchow's

good

account

will be
4

found

structures
be

witnessed

not

Dr. Leonard
syphilitic,
Rogers regarded
as
consequential. Rogers, Cases in

1908.

178, H.

of the arteriosclerosis
Arch,

Pylophlebosclerosis. See
ccvii.,1912 (seven cases), and

be

ventricle

Arch., 1904, Bd.

in the

may

des mal

Simmonds
other

3.

of the

papers.

pulmonary artery, with

du

cceur,

of

Hamburg,

graphy,
biblio-

1910, p. 218.
Virchow's

Arch.

vol.

CHAP,

MUSCULAK

iv

in the valves

205

also in the

only, but

arteries

and

LABOUR

effect of mitral

liningof the left auricle.

In thus considering
fatigueof the arteries by the incessant
their walls,we
beat of the blood upon
naturallyturn to observe
in persons
than
the effect
effort,
exposed to more
of muscular
Artificial stimulation
of the
of this kind.
ordinary stresses
cerebral motor
a
general rise of blood pressure ;
causes
area
increase
the
time
the same
at
plethysmograph exhibits an
of all four limbs, while the splanchnic vessels are
of volume
the

stenosis upon

Moreover
the same
effect in kind is
correspondinglyreduced.1
suggestionof the effort. One of the first
produced by the mere
this side of the
to publish definite observations
on
pathologists
exertion on
the
problem, on the effects of prolonged muscular
The importance
arteries,was
Tschigajew,in a paper entitled
in the production of arteriosclerosis." 2
work
It
of muscular
is to this effect : that in Russian
peasants, during the heavy
"

thicken

walls

only

the

of

labours

vessels

the

other

certain

this

; but

thickening of

to

when

and

summer

harvest

thickening
media

the

their

to

return

however,

labourers

in hard

work

dwindles

"

vascular

due
pseudosclerosis

"

"

the

seasons,
"

in

the

winter,

ordinary consistency;

such

iron -workers,

as

in

men

continuously,a genuine
arteriosclerosis
is prematurely established.
and
permanent
this is, we
cannot
as
Yet, interesting
forgetthat iron-workers
other
are
injuriousconditions of
probably exposed to many
life ; unwholesome
and so
workshops, habits of drink, syphilis,
need facts for a comparison of outdoor
labour with
we
on
; and
who

occupied

are

indoor,

in warehousemen

as

of the

wage-earners

is

and
class not

same

how

imperfectlyknown

far

more

inside
so

this

porters, and

again with

heavilylaboured.
labourers'

Also

it

arteriosclerosis

into the various

regionsof the body ; whether the strain

of muscular
effort falls simply or mainly upon
the arteries of
the limbs, a comparatively small matter, or sets up likewise a
general arteriosclerosis extending to the inward parts ? Even
then the still deeper problem remains, Whether
this degeneraextends

Weber,

Tschigajew, Wratsch,
this

I find

Internal

paper,

notice

but

Physiol. Congr., Heidelberg, 1907.

Dr.

1894,
Mott

p.

353.

kindly

of it also in Virchow's

I
sent

must
to

Jahresbericht

not
me

pretend

certain
for 1895.

to

extracts

have
from

sulted
con-

it ;

of blood

derivation

I wonder
cannot
not

of

parts in

to

of

accumulation

the

to

mechanical

directlyto

tion be due

PART

or
stress-strain,

the

ampler
or
extraordinaryactivity,
again

These

perhaps be left out of reckoning.

far as
mere
curiosity
; for in so

blood

Contusive

radials ?

thick

to

in tissues and

metabolites

more

had

Hawkeye

if

ARTERIOSCLEROSIS

OF

CAUSES

206

the

friction

questionscome

sclerosis may

be

predominant tissue
calls in any part,so far we
concerningthe heart,
anticipate
may
the brain likewise,in persons whose
occupationsmake large
or
that such
and incessant demands
energies,
upon these respective
local tides may
imperilthe integrityof the respectivevessels,
and so of the more
preciousorgans which they supply.
Again,at the Diisseldorf Congressin 1912,1 Dr. Remy of Paris
due

drew

to

blood

increased

attention

labourers

at

addicted

to

and

"

alcohol
And

in response

many

years

effects of muscular

in the

of arteriosclerosis in

the age of 35,

; he mentioned

when

to

occurrence

common

about

factor.
interested

the

to

flow

"

if they
especially
syphilisalso as an
ago

in Leeds

exertion

surprisedin hospitaland dispensarypracticeto

labouring men
frequency of arteriosclerosis among
without
other signs of ailment, unless
any
or
some
perhaps in some
aspect of premature senility,
was

of tardiness

lack of endurance.

and

less in

This

evidence

find

portant
imfirst

was

the

upon

were

heart
a

high

sclerosis
arterio-

it

were

in

disability

however

pressed
im-

largecity,where other noxious influences,

such as drink and syphilis,
since it has done
at work, than
are
where the country labourer is less exposed to
in Cambridgeshire,
me

these ill influences,and

Counties

I found

the

works

in the fresh air.

In

the Eastern

ing
frequencyof arteriosclerosis in the labourless ; perhaps in these half-fed labourers
no

populationwas
it is even
higher. Moreover, I soon learnt that I was not alone
in this impression. Mr. Wilkin
of Wickhambrook
practisesin a
district of which a largepart of the soil is a damp clay,the other
of
part is a lightdry upland (around Newmarket). The contrast
these different
us,

and

is not

In

the

damp

"

rheumatism

"

chronic

areas

has often been

without

some

subjectof discussion between

bearing on the present subject.
a

clay part of his district Mr. Wilkin

in large proportion,
fever
both rheumatic

"

rheumatism."
1

See

Rheumatic

fever

marks

report in the Lancet, August 1912.

its way

finds
and

by

MUSCULAR

iv

CHAP,

LABOUR

207

the chronic rheumatic

signpostsof heart disease ; among
patientshe seldom finds valvular lesions,but in their accessible
arteries of these he does find a largeproportionof arteriosclerosis,

the

of
signsor symptoms
at Hesse
practises
among

who

Romberg,
in a hillycountry,
it

women

the

of

defective

and

believes

concerned.

are

to

that

aside
his

among

these

of

40-49

one-third.

In

appeared usually
a very
largeproportion

neurosis

other

renal

and

factors

disease, he
"

pressures

were

difference

not

are

toil
posed
dis-

was

arteries
main

one

thenia,
neuras-

besides

also

patients thickened

the blood

cases

in renal disease

much

rheumatism

"

of

in them

in his folk

that

chronic

with
that

being in

hearts, and

one-seventh

also found

he

(p. 289).

that

30-49

ages

But

arms.

Putting

say

associated

between

prevalent,and

less

was

legsbefore

in the

found

disease

hard-labouringpeople

and between
arteriosclerosis,

his list showed

the

cardiac

definite

without

excessive,

they rule high. The chronic

and arteriosclerosis he is disposed to put down
rheumatism
in
(poor feeding too much
carbohydrate
part to malnutrition
but chieflyto
constant
material, too little nitrogenous),
posure
exwith the Irish labourer
whose
to
damp
; as
cottage
to a
wild duck."
In
was
damp enough to give rheumatism
whereas

course

"

"

"

"

as

(loc.cit.)labour

lists

Hertz's
cause

observed

of

and
arteriosclerosis,

that

doubt

no

were

and

of temperature
left out

of the

returned

was

of

external

reckoning.

toil is not
be

of itself

the

in

the

first

place

the

large majority of cases

labouring class ; but extremes

frictions and

Professor

contusions

Leonard

sufficient cause,

Hill
but

that

cannot

thinks

be

indeed

the vascular

"

toxic
to
generate.
depredisposed by some
agency
Thayer and Brush 2 (after a study of the toxic
conclude
that palpable radial arteries
of arteriosclerosis)
causes
are
frequent in persons
occupied with heavy physical
very
labour ; but, they add, such
are
commonly given to
persons
drink.
So perhaps neither in citynor
country may the causation
of arteriosclerosis be attributable to manual
labour merely ; the
to be more
problem seems
complicated. On the other hand, as
member
of a Committee
of the Home
a
Office, I have lately
visited certain large works
in the cities of the north, where

wall

must

'

Hill,L., Allbutt
2

Rolleston, System, Art.

Thayer and Brush, Journ. Amer.
and

"

Path.

Med.

Cereb.

Ass.,

Circ."

1904.

p. 263.

again

much

was

heavier

and

departments

of

of sober

without

thickeningof

proportionof
l

Bruce

the

radial

thicker

was
case

of the

lame

leg the

his

in

mainly

us

one

considerable

with

the

adds

righthand

Marchand

that in

the

right

mentions

markable
re-

aged 35,who (from infantile palsy)was

left leg had to do all the work.
In this

woman,

the

artery showed

femoral

for

not

was

; and

labourers

left.

the

than

rightleg;

there

the

emphysematous. Dr. Mitchell

sclerosis
hospitalexperience,reports arteriomanual

worked

who

about

selected

guide

my

sclerosis
arterio-

occupied in

age,

also

prevalentamong

of these

some

of

years

of

called up

we

the radial arteries;and

were

men

likewise,from
as

prevalence

habits ; yet in these

healthy men
some

50

forge,and

PART

In Sheffield

labourers.
40

between

men,

the

impressed by

in the heavier

twenty

ARTERIOSCLEROSIS

OF

CAUSES

208

medial

extreme

the
calcification,

of the arteries of the

rest

body, includingthe other leg,being

have testified to untimelyarteriosclerosis

healthy. Other observers

in the legs of postmen.

Boveri2

also, in

effect,stated that arteriosclerosis

same

limbs

labour,and thus

of heaviest

was

to

argument

an

to

prone

occupy

the

the

conspicuouson one side,

than on another, accordingto the relative incidence
limb, more
or
Dr. Harry Campbell 3 has observed
exertion.
of the muscular
the
arterial thickeningin the arteries of the limbs of peasants,
same
and attributes it to a continual hypotonus of these vessels during
the afflux of blood to the active limbs, an
explanation to be
considered presently. Friedrich,in 1384 labourers under the age
of

40, found

arteriosclerosis
that

(loc.cit.)states
stevedores, whose

summing
in

labourers

he

especiallythose
tortuous,
the

work

Bruce,

Boveri,

and

limbs

labour

has
of

found
the

the

of 1000.4

appears

is very

investigationof

this

arteries

more

used

distributed, being

Warfield

early ages in
heavy. Baumler,5
subject, says that
at

of

chiefly used,

arm

calcified ; the

is thus

in the

arteriosclerosis

muscular

his

up

was

arm,

the
to

in

arms,

be
cases

more
strikingly

and

widened,
where
affected

M., Lancet, July 15, 1911.

Riform. med., No. 30-31, 190?, quoted Deutsche med. Wochenschr.,

was
unfortunately omitted.
year
Med.
Brit.
Journ., Feb. 3, 1906, and Lancet, Feb. 19 and
Campbell, H.,
April 2, 1910.
where

the

*
6

med.
Friedrich, Munch,
Wochenschr., 1909, p. 2080.
Baumler, Berl. klin. Wochenschr., 1905.

CHAP,

the other.

than

collected

He

in them

found

and

LABOUR

MUSCULAR

iv

side

this

that

number

was

209

of left-handed

workmen,

decidedlymore

affected

heavy weight lifters he found the aorta

He supports the opinion that in
also to be gravelydamaged.
sclerosis of this originthe patches arise at pointsof givingway
At the same
time he argues that
(" Nachgeben ") of the media.
other area, in the brain for instance
excessive activity
in some
by work or worry, in the stomach, in the kidney,may also be a
other.

the

than

But

in

of the limb

factor in the deterioration

or

ingredientspresent themselves again as

in
in it ; for at first sightexcessive activity
to imply vasodilatation,and so far a fall of

possiblyconcerned
would

area

any

seem

the sclerosis of the arteries of

Klotz,1on

pressure.

"

they

arm,

says

but

he does

suffer under

We

have

demonstrated

that

in the

rapid afflux

vasodilatation

vessels

work

the

has

stresses."

"

but

the lax

It is said that

It will need
such

close,as

must

areas

effect in

more

the

injuringthe
evidence

more

"

"

Strom-Intensitat

small

would

pressure

constricted

high tension."

in

peripheralto

other

some

it is not
"

;
pressure
local
systemicor

mean

(p. 28) the

"

blood

abundant
they mean
of velocity.Claude Bernard,

(caeteris
paribus)the aortic

from

he

blacksmith's

afflux with

authors, by which
increase

and

increased

Does

discussed

probablysome
pressure

the

explainhow.

not

pressure ?
of German

If so, katabolites

baneful

such

other

vessels.

as

know,

we

raises blood

area

dilatation, but
fall.
no

To

effect this

doubt

they

vessel which

periodicand

arteries than

that

do ;

suffers

intermittent

more

continued

than has yet been

produced

postulate.My own
opinionis,as I have said,
that in the working limbs the arteries suffer from a largeswift
them
while in a state
of relaxation, and
output telling
upon
that this in the long arteries of the limb may
produce Monckeberg's form of sclerosis (p.482) which, while deforming these
vessels,need not signifydisease in the vessels of other parts,
I
where
indeed
be proportionately
relieved.
pressures
may
to

prove

"

"

look back

great
and

so

upon

and

energy

or

of

arteries became

life. And

labourers,as
1

temperate habits, of
activity,
ridinghard, rowing hard,

three sportsmen

muscular

forth, whose

before middle

VOL.

two

of

very

thick

repeat that in these

in

Klotz, 0., Science, N.S.

like class

(in the limbs)

cases

of arteriosclerosis

of senile cases,

vol. xxxiii.,June

1911.
P

the

but,

at

others say

and

Dr.

Elliott Dickson

long

series of very

primary

in December

good

At

perusal.

miners

point of view, 500

consecutively.A
of

of

19

personalhabits
In

work.

these

indicative

symptom

the

tables,and

of

character

250

miners

variation

of

there

observed

at

random,"

of

their method
Besides

as

the

noted

were

its sounds

also

of

conditions

was

no

the normal

from

this

also the full notes

me

alcohol, meat, tobacco, and

to

as

of

200

and

heart

size of the

the

from

miners, were

points of specialobservation.
radials,pulse rate and blood pressures,

of the

state

to

pretty much

of their

material

specimens of the
of recording the

of the

state

also, other than

enclosed

chosen

cases,

the

on

they had examined,

completed cases were

cases

Dickson
"

the

; 250

few control

brothers

The

added.

time

that

Lochgelly,Fife, made

pressures in coal miners ; and

enough to forward their manuscript

the blood

for my

decay.

observations

careful

were

medial

his brother, of

and

accessible arteries and

1907

only,as Orth, Monckeberg,

exactlyor mainly atherosclerosis

; not

in part,

rate

any

PART

of the limbs

be

arterial disease may

Marchand,

ARTERIOSCLEROSIS

OF

CAUSES

210

sign

nor

the

dition
con-

save

of the radials ; in the

of

in whom

the

ordinary

systolic
pressure

155 ; and

was

"

the

pressures were
radials were
entered

cases

normal."

had

who

plumber

various cases, such as

minoritywere
worked
with lead-piping
for three years,

The

so

In the 200

on.

always well within

as

A, B, and

the

C ; that

is,

healthy artery (impalpable); B, easilyflattened,but then

To
feelinglike thick tape ; C, thick, rough, and tortuous.
these letters a plus or minus
signwas frequentlyadded.
Only
18
entered
A.
191
As to
cases
were
were
plainlyas
age,
12 only had
set. 20, and of these
normal
radials.
over
They
A,

found

relation

no

between

(broad cuff R.-R.) and

instance, in
was

case

with

150

the

arteries A

indications

state

of

full notes

the
see

(set.35) ; while in
112.

was

Case

of

radial
the

For

wall.

systolicpressure
2

case

74, with

instrument

the

(set.65) with
of 155,

pressure

queried,but no other abnormal signwas found, and this was

with so high a pressure
only case (inthe short complete list)

the average
cases

the

3 of the

arteries C, this pressure

was

the

of

"

run

was

Allbutt's

from

from

; the

110-135
"

Hyperpiesis

this category.

Of

the

were

19

mean

about

observed, but
full reports I

cluded
ex-

were
see

Some

120.

men

CAUSES

212

heart.1
particular

of the

increase

must

waste

cleansingwork
of

the

and

area,

circulation,not

the

to

vast

capacity
development again

muscular

Enormous

PART

the functional

graphicdata

over

on

fouler blood

from

ascertain

to

attempts

ARTEKIOSCLEROSIS

OF

to

throw

thus

the

mention

more

delivery

itself.

myocardium

huge muscular
generallysupposed to be unhealthy ; the
development, are
muscular
a parasite
system becoming as it were
upon the frame :
they stand disease badly,so it is said,and become senile early. In
so-called

The

this context

"

strong men," worked

of

some

us

recall

may

to

up

well-known

in
passage
habit of body

Republic(403 E) : "I am afraid,I said,that a

such as our
ordinaryathletes have is but a sleepysort of thing,
Do
observe that these
and rather perilousto health.
not
you
their lives,and if they departin ever
athletes sleepaway
so
slight
a
degree from their customary regimen are subject to most
This is remarkable
direct testimony
as
dangerous illnesses ?
these
from
observer earlyin the fourth century B.C., when
an
athletes were
held in high esteem
for their prowess,
and when
of metabolic
unknown.
our
suspicions
perversionswere
The

"

the other

On

hand,

not

few coefficients are,

and

Zuntz

as

pupils have proved, working wonderfully for conservative

of course
in periodsbefore the advent of old age.
ends, especially
If an active effort of short duration causes
rises of pulserate and
of maximal
and minimal
whereby the heart is urged,
pressures,

his

in

continuance

and
systolic
intervals
discussed

of
as

toxins
than

to

Acid.

"

if

Oswald

not

vessels

sink towards
it.

them
upon
has recorded

Loeb

in

bodies

such

and

Fantus

klin. Med.
Ztschr.f.
1912
2

and

have

here.
certain
of

matter

alcohol,nicotin,etc.

as

time

he obtained

my

Staehelin

Bd.

article

Loeb, O., Deutsche

"

(Berlin),

Ixx. He.
"

on

Heart

med.

5 und

6 ;

Strain

"

With

sclerotic effects

yet, as he remarks, it is impossibleto

See

this

points I

these

dwell

verified,seem,

long periodsof
1

But

the
out, and
open
the normal ; in the

ments
experi-

causation,

stances
importance. After trying the effects of various subvessel poisons,he found, generallyspeaking,bacterial
be far more
frequentlydestructive to these tissues

other

over

the

probably below

elsewhere, I will

which,
be

exercise

diastolic pressures

of rest

Lactic

to

of

say that in such

Blutdruck

Otis, Amer.
in A. and

wahrend
Journ.
R.'s

Med.

cholesterin

(seep. 252),
periodsthe
Muskelarbeit,"
Sci. vol. cxliii.,

System of Medicine.

Wochenschr., Sept. 18, 1913.

LACTIC

CHAP,

iv

hutch

rabbit may
with

discovered

BKAIN

WOEK

213

fallinto this disease of itself. But

not

of these

bodies
the

with

and

kinds,

in

menting
experi-

alcohols, etc., he

aldehyds of the aliphaticclass only were

followed by this degenerationwith a high degree of certainty.
It began to
that in so far as ordinary alcohol had any
appear
effect on the arteries it was
by its aldehyd. He suggests that in
and
diabetes, by oxydation of sugar, glycerin-aldehyd,
acetobe of the offendingagents.
aldehyd and glycol-aldehydmay
And
the amido-acids
aldehyds arise from fatty acids,especially
Now
from leucin,etc.
of these series lactic acid, arisingout of
and
is in his opinion one
acetoof the most
glycol-aldehyd,
injurious.By the mouth, lactic acid,at the rate of 1 g. per kilo
of animal, constantlyproduced multiple degenerativepatches
in the

that

ACID"

"

aorta, while

although these
animals

other

controls

"

often

became

reason

that

in the

indeed

he finds that, the normal

100

g. of

to

150

mg.

school).

and

the muscular

and
limb
the

Loeb

the lactic

pointsout

being

exertion

the

increase

same

with

abound

about

15-20

content

may

follows

mg.

rise

defective

(Hoppe Seyler and

districts of the body, as

also in

Whatsoever

his
in

the coefficient of

vessels,a surplusof lactic acid in indolence,or

of

lactic-laden

blood

in

heavy labour, may

be

in the result.

concerned

more

while

effect ;

liver affections

accumulate

of the

such

no

lactic acid must

content

system of labourers.

large affluxes
To

The

certain

Now

of labourers

more.

It may

overwork

limbs

blood, after hard

oxydation, and

cachectic

in fair condition.

continued

to

controls, had

acids,on

turn

to other

areas

of effort ; that

diseased in brain workers

Klemperer
arteries

labour

urge

that

no

bodilywork

(and it is these of which

be

of

vexatious

In the labourer's

besides,

I have

kind

the cerebral
evidence.

arteries

are

Von

Romberg
is more
apt to injurethe
we
are
now
speaking)if
sclerosis."
a
psychogenic arterio"

"

life there is

more

beer than

worry

asthenia
interpretthe early stages of hyperpiesisas neuris no
of diagnosis. Judges, who
very infrequenterror
rule live long,seem
to have
sclerosis
a
as
no
more
tendency to arterioin the cerebral area
than other people. Cynics may
say
that with years they become
too ingenious. Apoplexy and
even
sclerotic occlusion in the cerebral vessels are at least as frequent
1

to

Romberg

and

Klemperer,

Verhandl.

Kongr. inn. Med., 1904.

idle

thoughtlesspersons,

in

ARTERIOSCLEROSIS

OF

CAUSES

214

PART

professional
men,
is disposedto think

in

laborious, as

or

Dr. Mott
sedentary as their habits often are.
conducive
to cerebral arteriosclerosis
that a sedentary life is more

physicallabour,

than

such

but

impressionsdepend very much

of individual physicians. During

of observation
upon the spheres
active intellectual work the blood

by

of cardiac

way

other

reinforcement

of

instance, Bickel

For

large areas.

pressure is said to rise a little,

constriction in
and vasomotor

methods,
plethysmographic

that

pressures

Bonn

reports, on

rise in intellectual

as

is
An augmentation of heart work
they do in emotional work.
But
partlyconcerned in the rise,as well as arterial constriction.
in

the

states
pathological

work

mental

in health

to

lessens in the

volume

brain work

engaged in

While

of the outward

the volume

it rises,the blood

bowels

and

cool skin and

to

is other

curve

cold

in the normal

than

and

arm

feet.

while

ear,

So far

as

of

we

correlated

those

accidents
From

in this

live

to

apart, seems

of

observation

of
interpretation

the

with

muscular

tendency

know, these
narrower

The

scholar,

long.

animals

we

help in
As Haller pointed out
extended
are
scarcely

get

arteriosclerosis.

lives of wild

respect,the

efforts.

in brain

the brain.

to

cerebral affluxes oscillate within small limits,limits much

than

in

districts increases ; whereas

being thus diverted

am
always conscious

legsand

animals

very

little

their
period of fullest activity; and in confinement
conditions.
For domestic animals
lives are shortened by unnatural
and
reared for food life is brief ; and even
draught animals, oxen
live more
than twenty years.
horses,rarely
Elephants and parrots
he excepted. Birds are said to have the longestlives of all animals,
data are
to think
that
but our
scanty.2 Haller, who seemed
longevitywas inverselyas sexual expenditure,stated that doves
vivunt
in justo matrimonio
live long. He noted, however,
cum
of the arteries in old horses (" petrifactio
induration
an
this lesion is rare
scutellata aortse "). Hodgson says
in the
in those so long lived as the elephantand the eagle;
brutes, even
but he gives no
grounds for his assertion. On enquiry at the
I
ZoologicalGardens of London, and at veterinaryinstitutions,

beyond

the

"

"

Bickel, "Kreislauf

On

London,

"Longevity
1911.

NeuroL
u.psychischeVorgange,"
in

Mammals

and

Birds," C.

Zentmlbl, Nov. 2, 1914.

Mitchell, Proc. Zool
Soc.,

AKTEKIOSCLEROSIS

CHAP,

iv

have

found

disease

that

is to

what

we

paper

I have

ANIMALS

215

little information

concerning arterial
be had ; it is reported as rare
or
insignificant,
been published on
the subject. We
do not
see
look
for.
Dr.
Hans
not
Lyding,1 to whose

little has

and

IN

do

very

been

referred, says

the

on

contrary that sclerous

more
changes in the arteries of cattle are much
frequent than
is generallysupposed,2especiallyin stall-fed cattle ; he
gests
sugtoxic origin. Lyding had no opportunities
of investigata
ing
the matter
in draught-oxen. An old bear which died at the
Of 100
more.
age of 23 had a singlepatch in his aorta, and no
of atheroma
in cattle Lyding found
it to be considerable
cases
in 35 ; but in all the disease was
confined to the settingon
of
the aortic valve, the concavityof the arch
about the
especially
"

of the ductus

scar

botalli,the

of the intercostal
that

says

atheromatous

in animals, both
such

wild

old rabbits

as

and

considerable.

and

The

after the kind

lumbar

by

are

domestic

Parisot

no

Nancy

uncommon

in

more

which

disease

of

means

rather

hares, among

spontaneous

of that

arteries.

arteries
and

tions
the bifurca-

descendens, and

aorta

the

herbivora,

percentage is

in rabbits

is,he

produced by compression,or

by

says,

adrenin.

The

has been
fault.
at
probabilityis then that observation
4 finds
that, omittingparasitic
Zuiserling
disease,which, he says,
tion
Lyding failed to do, horses are subjectto necrosis and calcificaof the media
of the arteries with vasomotor
decay, after
the manner
of the Monckeberg variety in the limbs of man.
this kind of arterial disease in horses,but Zuiserling
Faber
notes
in them
that
the precise atherosclerosis
of man
does
says
5
has
though more
rarely. Again, in old horses Kitt
occur,
described

sclerosis

in

the

valves, sinuses, and

patches presenting to

aorta,

the

naked

eye

arch

much

of

the

the

same

in them
in man
Charcot
demonstrated
as
; that
appearances
atheroma
of the abdominal
and of the vessels of the legs
aorta

is

old

an

Lyding

story.

in

Lyding, H.,

I find

He

says
3
4
6

much

Faber,

it is

Thoma

largernumber

Zeitschr.
who

in 17

f. Tiermedicin,

has

same

Bd.

xi. He.

atheroma
Hutch

as

many
the human

same

form.

de Pathol.
Congr. Internat.
Comp., Paris, Oct. 1912.
W. D., Virchoufs
Arch., Bd. ccxiii.,Juli 16, 1913.
Zuiserling,
d. Hausthiere, Bd. ii.
Kitt, Lehrbuch
path. Anal.
Premier

once

rabbits

4-5, 1907.

animals, is of the

examined

the
histologically

dogs found
only twice.

opinion.

said in laboratories

are

ARTERIOSCLEROSIS

OF

CAUSES

216

present about

to

is

so

But

animals

these

in

Steinbiss says,

of aortic

cent

per

atheroma

that

experiments on
be made
must
on
largernumbers.
in Cambridge, that, if kept under
atheroma,

PART

as

find

we

conditions, atheroma

natural

in them.

rare

it would

Thus
and

(we have

them)

as

hard

kinds

of

muscular

the

but

if real, is of

vascular

decay

on

lence
life of indo-

promote cardio-aortic

effectual to

as

work

go, that

animals

as

observations

no

change,

that

says

be

highfeedingmay

atheroma

far

so

seem,

generalarteriosclerosis
here

is of the

of the

the distinction
In

interest.

much

so-called

in

Ball

cows

Monckeberg's

variety(vide p. 482), that it is much disposedto calcification,

and
consists primarily in a yielding of the media, the vasa
vasorum
being fairlynormal ; but that in the draught-horse
it is of the sub-intimal hyperplastic
kind, as elucidated by Jores.
In respect of the
in the horse
found

the

occluded

cerebral

these

left

by

arteries,we

fall into

may

sylvian and

have

some

sclerosis.

In

evidence

that

horse

Ball

one

arteries

posteriorcerebral

almost

the disease.

Vasoconstriction

in

such
largeterritory,

the

as

mesenteric,

extensive
the musculo- cutaneous,
be
perhaps, without
enough by itself to raise systemicarterial pressures (videp. 218).
Professor
Hill translates the splanchniccapacityinto terms
of
about
of
50 mm.
as
Hg. ; and the vascular network
pressure
the skin is said to have
a
capacityof from one-half to twomay

thirds
breaks

of the

blood

Thus

mass.

rack

to

drive

the

coach

with

the

the

machinery. Splanchnic,musculocutaneous, and cerebral tone should mutually balance each other ;
that constriction in the splanchnicor musculo-cutaneous
so
area
alone ought not to drive up pressures
high, nor maintain
very
them
perpetually. These observations,with their bearingson
and
physiologicalbalances
on
pathologicalhigh pressures,
familiar
made
all long ago
were
to
and
us
by Cohnheim
sclerosed vessels anywhere have
morbid
Roy. Whether
a
clivity
proon

to

another

must

constriction

is

notion

which

have

discussed

on

(161); this notion has rested hitherto chieflyon

speculative grounds, and probably is over-rated.
It is popular
because of its convenience
in guesswork. Hypera
as
resource
trophy
of the left ventricle alone, without
rise of peripheral
page

CHAP,

VASOCONSTKICTION

-EXTENSIVE

iv

217

keep up a high pressure ; and the evidence

and diastolic
elevations of systolic
at present is that persistent
pressures, with narrowing amplitude,are due to extensive regions
in arterioles presumably healthywhich cannot
of vasoconstriction
be, or are not, compensated by dilatation elsewhere, and must
stresses, establish a
therefore,by raisingleft intraventricular
Krehl
has
correspondinggrowth of this part of the heart.
of vascular
been quoted to the effect that so persistent
a
spasm
1
turn
districts is a prioriunlikely; but if we
to his context
we
shall see that he is referringnot
to systemic arterial pressures
resistance,will

but

not

of pressure in areas,
it is remarkable
that the only too
to

allegedrises

or

local anaemias.

To

digestionsof big
should
be compatible with widespread splanchnic coneaters
striction.
Professor
Langley suggests that the depressor
enfeebled or rusty; and Mr. Mummery2
mechanism
become
may
has pointed out
that in old persons slightfalls of pressure,
e.g.
to 90-100, produce shock.
waves
be,
Paroxysmal and capriciousas vasomotor
may
districts at any rate,
healthy vessels do seem
capable,in some
of permanent, even
Two remarkable
tions
observaperennialspasm.
on
as
convincingas if experiments on animals, were
man,
In these cases, both in men,
published by Gibson.3
dislodged
vasoconstriction
kidney had set up a permanent
simulating
Eaynaud's disease ; by fixation of the kidney in both cases
release was
obtained.
a
Gushing, in his brainpermanent
experiments,showed vividlyhow on compressionof the
pressure
brain the arterial pressure
while the splanchnic vessels
rose,
visiblycontracted, to dilate again as the compressionwas relaxed
and
the pressures
fell. Roy and
similar
I carried out
some
experiments with similar results. Von Basch vividlydescribes,
irritation of the splanchnicnerve, the crimping up of the small
on
and smallest arteries,and the collapseof the small veins passing
from emptied capillaries
he
the
as
;
part behaving,
says,
like a squeezed sponge." Thus
all tl^e viscera, except the
accumulates
in
The
blood
extruded
kidneys, are blanched.
the heart and large vessels and
in the lungs and extravisceral
me

able

"

2
3

Physiol p. 3, 4th ed.

L., Lancet, March
25, 1905.

Krehl, Path.

Mummery,

Gibson, Geo.

A., West

Canada

Med.

Journ.,

April

19.

CAUSES

218

PARTI

Von
Basch,
pressure.
visible or invisible,to be at
arteriosclerosis,

augmenting arterial

areas,

he

'

AKTERIOSCLEKOSIS

OF

did

of every

of

case

by

persistenthigh

pressure,
the potency of vasoconstrictions,though he
its

importance.
practical
alone,

cutaneous

aortic pressure.
effective
;

be

in

vasoconstriction

that

the

added, it is,of
on

animals

; in animals

positiondemands

muscular

this rise is

But

if to the

and

the

course,

the

do

prove

not

no

means

is the seat

that such

calculated
in

or

prompt

so

Jores

has

But
state

perhaps it could not be, for in man

from the splanchnicmechanism

Dr. William

demonstrated
Kussell

to

be the

(who adopts from

of

and

of constriction
these

ments
experi-

be permanent

can

the
a

upright
capacityof

constrictions would
and such permanent
save
permanence,
arterioles from
the stress of high systemic blood pressures,
indeed

the

of the constriction

area

stubborn.

more

overlook

enduring rise

an

further

forgot

to

alone,

area

as

bottom

means

apt

was

cause

by

splanchnicarea
splanchnicsome

the

experiments he

own

sufficient to

were

when

as

In his

no

assuming

its
as

case.

the German

the term

the constricted
vessels which
hypertonus)argues as if it were
but, so far as our evidence goes, vasoconstriction
undergo sclerosis,
does not provoke arterial disease in the districts so affected as
ligaturedoes, and within the district suppliedpressures of course
rise but fall (p.30). I have
must
not
stricted
long urged that a conartery is protectedfrom strain,and Dr. Harry Campbell
has agreed with me
the trunks servingit
or
no
(p.199). Whether
become
strained depends upon
the extent
of the constriction ;
if the trunk or trunks
of supply are
included
in the sweep
of
far protected; if outside its limits,
the constriction they are
so
and the constriction be wide enough to raise systemic pressure,
they will suffer with the rest of the high-pressureareas
; and
vessels of low contractile capacity,
such as the coronary
and the
cerebral,will suffer,as these do, disproportionately
(p.477). As
of estimatingdirectly
the blood pressure
yet we have no means
in the aorta and arteries of the greater magnitudes
; the records
which our instruments
giveus are taken rather towards the sphere
of peripheralpressures.
We
have
of
seen
(p. 44) that increase of the total volume
the blood, regarded by Huchard
of increase of blood
a
as
cause
1

Russell, W., Arterial

Hypertonus

and

Sclerosis,1907.

CAUSES

220

ARTERIOSCLEROSIS

OF

notwithstandinghypertrophy

left ventricle.

of the

disease in these finer vessels

PART

pheral
peri-

be due to the

scarcelythen

can

This

high pressures, unless we suppose them to be far more

it is not
than the largervessels ; moreover,
easy
choose
and
should
pick
systemichigh pressures
among

vulnerable
to

why

see

the vessels

of the several viscera,unless it be that in the liver the finer vessels

or

portal network.
sclerosis certainly
does, as we all
and large vessels,are there then

saved

be

may

strain

the aorta
disease
then

of arteriosclerosis at

kinds

two

the

by

categoriesof

two

And

toxic lesion in others ?

and

findingsof
piesia,without

the

morbid

anatomy,

renal

symptomSj

sclerosis is concerned,
data

this side of the

bearingon

farther
renal

other

high pressure
anywhere wholly to mechanical
or

I must

be

It is

state, I

to

but
singly,

which
the

mechanical

between

alone

problem

some

areas

attribute

strain.

This

solve

cannot

little

whether

in

arteriosclerosis
however

problem

it.

made

external

as

experimental

hesitate

one

to

cases

Some

far

so

will be mentioned

make

observers
the

kind,

one

causes,

are

These

if

lesion in

discussing,either in
experimentsof Lewin and Larkin
we

attention.

anastomosis

or,

difficult to test in animals

obviouslyvery

conditions

some

content

duplicitybe supposed on
that in hyperwe
assume

can

considerations

These

on.

mechanical

if this

work

at

are

then

agree, in time affect

in chronic
Bright's

work

; mechanical

causes

If

the mechanical
combination
l

attracted

arterio

an

carotid

have

and

or

the

venous

external

jugularvessels,to see if the highercarotid pressure would set up

of the
hypertrophicor sclerotic changes in the vein. In some
animals (dogs)the arterial pressure
was
aggravated by injections
of adrenalin.
The dogs lived for periods of 60-100
days one
lived for 120 days but the results were
negative. This,I think,
we
might have anticipated.Probably the local rise of pressure
of which
no
measures
are
given was very transient ; and in
case
an
operationso considerable,conditions so unnatural,
any
"

"

"

"

and

the differences between

abundant

for

room

Adrenalin

and

have
the

been

of
vulnerability
1

Lewin

arterial and

offer

structure

venous

fallacy.
Arteriosclerosis.
made
the
and

with

"

drugs

and
arteries,
Larkin, Journ.

large
and

with

number

other
none

Exp. Med.,

agents

more

1911.

of
to

periments
ex-

test

frequently

CHAP,

adrenalin

with

than

which,

as

(Josue, and

active

an

SCLEROSIS

AND

ADEENALIN

iv

later

numerous

substance,

pressor

221

to

appears

verifications),
be especially

I
and
Lion
Gilbert and
Josue
were,
apt for this purpose.
think, the first to publish definite results. Their researches

of adrenalin into animals,

injection
shorter periods of time.
at intervals, for longer or
By this
means
conspicuouschanges were
produced in the aorta, of which
3
and
Stanton
verified their
I shall speak presently. Pearce
made

were

results

the intravenous

by

in respect of

that

nearly all

seem

in them

to have

that

hutch
is

But

the

rabbits
low

confined

of

percentage
is taken

at

it is

been
to

the
renal

like effect in the

estimate, and

about

per

must

Manouelian

aorta

Institute

animals

these
The
;

effects

Erb

though

arteries.
aortic

We

have

disease

in

probably this
higher than this.4

cent, but

the

of the Pasteur

on

made.

spontaneous

runs
liability
discuss these figures,
not
for,as
the feeding and
depend upon

I will

much

been

indeed

have

researches

such

(junior)reported a
seen

rabbits,and

found

Handelsmann

says,

housing. And, as
his positiveexperimental

(loc.cit.)to be 84'9 per cent, and in his most

decisive experimentsstill higher,there is a largemargin for any
in the form
of fallacy. The firsteffects are
spontaneous sources
of minute
necrotic areas
of granulardegenerationin the muscular
The
intima is not much
coat.
affected, but oppositethe foci in
the media some
littleproliferation
be seen, and occasionally
may
advanced
some
tendency to form fibre. In more
stages the
of degeneration are
areas
larger,or continuous, but are still
confined to
the media.
The
adventitia
and vasa
practically
A very remarkable
unaffected.
vasorum
are
part of the changes
in these aortas is the rapid advance
to calcification.
If,without
defeatingthe experimentaldesignby too sudden an injury,the
effects of the injections
be carried
certain degree
to
can
a
rather
be found
rapidly, the media
degenerated over
may
considerable
calcification ; but this does not
lengths without
usuallyhappen ; usuallywithin these brief experimentalperiods
calcification sets in, not
as
a
tardy and incidental but as an
results

Josue,

Gilbert

and

Pearce

and

Weinberg,

La

Presse

Biologie, dec. 3,

medicale, 1903.
"

experimental, Arch, de
Stanton, Laboratory Studies, Albany, 1905.
Lion,

"

"

Atherome

Atherome
1908.

spont. chez

le

lapin," C.

med.

rendus

exper.,

de

1904.

la Soc.

de

CAUSES

222

ARTERIOSCLEROSIS

OF

essential effect.

earlyand

in such

discovered

Moreover
true

tracts

PART

not

bone

with

few

observers

have

osteoblasts,Haversian

The
elastica breaks up
rudimentary marrow.
into granular relics. There
and
becomes
even
disintegrated,
then that laboratoryanimals, chiefly
rabbits x it is
is no
doubt
under longeror shorter
for fallacy,
true, after all due deductions
of adrenalin,have
with fair uniformity exhibited
courses
very
definite degreesof arterial disease ; though almost
exclusively
of the aorta.
But here again my
appears.
problem, or a part of it, re-

canals, and

even

For
doubt

it remained

while

whether
still,

these

effects of the agent or,

of

in doubt, indeed

more

or

less,to

Warsaw,2 after experimentingwith

concluded

due

changes were

it is in

some

the pressor
toxic influence.
C. Otto

simply to

drugs on

many

this method,

as
they acted, if at all, in the same
way
pressor substances, producing their lesions just mechanically.
He agreed with other experimentersthat the media
suffers first,
then the intima ; finally
show
the adventitia may
tion.
signsof irrita-

In

that

the

"

media

elastic fibres break

and
of

the
up,

degenerates. Ludwig
adrenalin

because
of

on

they
amyl

the

were

not

nitrite.

muscular
and

ultimately the

Braun

arteries

fibres suffer first,then

concluded

prevented by
Dr.

Rickett

amyl nitrite does not prevent an

rise
by the adrenalin injections,
a

that

mechanical

not

were

intima

simultaneous

however

the

thickens
the
but

effects

toxic,

tion
administra-

demonstrated

that

forcingof pressure
which
in spiteof nitrites will
endure for five minutes.
It has been argued that thickeningof
the arteries in Addison's
in young
disease,even
subjects,occurs
too
coincidence ; but the lesions provoked
frequentlyfor mere
attended
with
by experimental adrenism
are
plus pressures ;
in Addison's
disease adrenin
is lacking and pressures
low.
are
But
I have
been
unable
to verify the
clinical facts alleged.
Mr. Markham,
in a thesis for our
M.B.
degree,reported the
arterial pressures in ten cases
of Addison's
disease as ranging
between
74-85 mm.
of his cases
In one
of adrenalin
an
injection
forced up the pressure
only from 84 to 112.
1

Pearce

Stanton

(Lab. Stud., Albany, 1905) failed to produce these

of Bonn
Leersum
likewise, Deut. med. Woch., 1906.
dogs;
Rasser
Ph.
June
u.
Th.,
support Harvey (p.223) (Z.f. exp.
1914).
2
Arch.
Bd. cciii. H. 3.
Otto, C., Virchow's
8
Zur Frage d. Art.-scler.,"Munch,
med.
Braun, L.,
1905.
Wochemchr.,

results
u.

and

enormous

in

F. Fischer

"

CHAP,

ARTERIOSCLEROSIS

EXPERIMENTAL

iv

This

doubt

mechanical

between

and

toxic

223

seemed

causes

by further experiments which, by bringingto

bear stresses
merely mechanical, still produced lesions of the
I
with those caused
identical in character
aorta
by adrenalin.
research of Dr.
refer to the long and assiduous
especially
may
of
laboratories,1who, extending the method
Harvey in our
aortic compression of Roy and
Adami, by periodicalcompression
the
lesions
in
set
aorta
of the abdominal
rabbits)
(in
up
The
and the
the upper
vasa
vasorum
portion of the vessel.
unaffected.
adventitia were
(See also Adami, p. 229.)
of these cases
is that in none
A graver
difficulty
(my own
been
made
observations
have
not
entirelyon Harvey's preparations)
have the lesions,similar as they are among
themselves,
of man
If in
resembled
the arteriosclerosis (atherosclerosis)
certain respects they show
some
some
analogy,or even
deeper
resemblance, to medial
degeneration (" Monckeberg's ") with
being demolished
rapid and extensive calcification,the media
and
sharp strains such indeed as in life do not
by sudden
instance
in no
to
knowledge have the intimal and
occur,
my
sub-intimal
changes of arteriosclerosis proper (atherosclerosis)
been
produced mechanically, unless it be in Manouelian's
Dr. Rickett,2 in our
laboratories,produced these
monkeys.
be

to

set

at

rest

lesions,that is a deterioration

aortic

of the muscular

fibres of the

barium
quicklyby calcification,
by nicotine,squill,
chloride,and adrenalin ; but no reactive signsappeared,no connective
the fatty stain reaction
tissue proliferation,
not
even
demonstrated
of the kind
by Jores ; nor any manifolding of
the elastic layer,which
merely loses its wrinkles and breaks
In this layer the earliest changes (I quote from
Adami,
up.
Rickett, Harvey, and Drummond)
are
stretchingand interruption
fibrillation of them
of elastic fibres, then
with
granular
fibres likewise degenerate,and
disintegration. The muscular
is depositedoutside the elastica,enteringinto
calcareous matter
The literature of this subject is very large; I am
the media.

aorta, followed

Harvey,

results and
Wien.

Lubarsch,

Rickett,

Journ.

Arch.

Bd.

of Biedl

klin. Wochenschr.

cogent.
1907.

Virchow's

inferences

No.

on

the

Pathol.

and

cxcvi.

20, 1909.
other
and

H.

Braun,

2.

"Zur

See 'also similar

Path.

Dr. Andrewes

d. exp.

and

confirmatory

Arteriosklerose,"

regardsHarvey's

results

as

hand, has said that he failed to verifythem.

Bact., Oct. 1907 ; and Thesis for M.D., Camb.,

indebted

Dr.

to

AKTEEIOSCLEROSIS

OF

CAUSES

224

in references, and

for assistance

Harvey

PART

find

general agreement that experimental arterial disease is of the

medial
type," the process being apparently too brusque for
But
observers,1
some
a
gradual thickening of the intima.
in which
the strain was
made
in cases
as
gradual as possible,
Dr. Mott also
record a preliminaryhypertrophy of the media.
medial
these experimental effects to the
type of
compares
"

"

(vide p. 482). There

retarding the
method
vessels
"

form

one

of connective
be

side, may

on

the

other

of

Jores) ; but

these

Bickett, comparing the

extremities

the

evidence, obtained

some

in

current

increase

an

is however

blood

in

described

arteriosclerosis," as

human

by

only, that by a slower

tissue, as compared with the
obtained
(the regenerative
limb

"

records

need

adrenalin

confirmation.

experiments

with

Dr.

others,

purelymechanical; as did likewise Pearce,2

Baldauf.
I have
Stanton
and
as
Experimental work seems,
said, to be too brusque to produce ordinary arteriosclerosis ;
but Councilman,
Sajous,3and others, have suggested that if
adrenalin
in some
were
excess
insensiblydiffused through the
arterial tree over
long periodsof time, it might set up arterial
lesions, and
perhaps arteriosclerosis of the typical intimal
lesions

regardedthe

as

(atherous)kind.

This

evidence

for

is not
the

wholly upon
while

it.

the recorded
indicates

the

the

mischief.

It

rabbit's

has

to

be the

rather

must

be

results

regarded by

them

in

aneurysm

media

case

Gilbert's

and

were

tendency

not

may

Lion

media, but

disease
of

or

may

than

the

also
as

bore

toxic ;

experimental

the intima

remembered

yet the

as

as

however

the
that

seat

the

the

complete intima of man, and is little

than a layerof epithelium; it is lackingin the elastic and
more
musculo-connective
sclerosis.
arteriolayerwhich plays its part in human
Thus
the aorta
of the laboratory animal
is differently
aorta

constructed

from

different,and

are

Victor

Pearce

not

that

certain

of

man

the

animals, the rabbit

time

conditions

seem
especially,

Ball, These de Lyon, 1907 ; Papadia, Arch. gen. de med., aout 1906.
and
others, "Exper. Art.-scler.,"Journ. of Exp. Med., 1906, continued
in Proc. RockefellerInstit. vol. vi., 1907.
See also to same
similar
or
effect Nowicki
Virchow's
Hornowski,
u.
Arch., May 7, 1908, and Drummond,
Journ.

of PhysioL, 1904,

torn, and
8

the

media

Sajous, Med.

thus

Assoc.

vol.

xxxi.

exposed
of New

Drummond
first to the

York,

1906.

thinks
brunt

of the

that

the

stress.

elastica

is

CHAP,

ADRENALIN

iv

to
peculiarly
susceptible
to produce such lesions

the

on

would
for

and

SCLEROSIS

these strains.
in the

horse

Ball

225

to have

seems

double

the

normal

in

dog,though

or

of adrenalin
injection

with

horse

rise to

minute

AND

; there

failed

ments
experi-

the blood
it would

sure
pres-

remain

half,and then gradually(in five minutes) fall

tressed
disDuring the experiment the animal was
and respiration
much
were
disturbed,and
; the heart
broke
the body.
sweat
out over
there are no signsto suggest that
As I have hinted in passing,
the vasa
invasion, have any part in the
or
a leucocytic
vasorum,
initiation of these changes.
As to the extent
of the experimentalarterial lesions,
whether
they are confined to the aorta or are more
generallydisposed
throughout the arterial tree, I have said that observers differ.
1
Handelsman
reportedthe smaller vessels sound ; in them were
back

normal.

to

necrosis

no

point

of

of the

keeping

no

calcification.

all his rabbits

free

and

He
well

made

great
nourished, for
a

to exhibit necrotic foci in

certainly
prone
the aortic media.
Erb (junior)
at first thought the changes were
later to change his
more
widelydistributed,but he found reason
mind, and reportedtheir seat as almost exclusively
aortic,or at

cachectic

rabbits

media,

aortic and

most

are

renal.

ventricle of the heart

All observers
becomes

however

that the

agree

left

much

enlargedand dilated,and
that venous
be found
in
hypersemia and haemorrhages may
the lungs and
Stewart
has shown,
as
kidneys. Histologically,
this cardiac enlargement is not, or is in part only, a genuine
muscular
hypertrophy.
In my
chapter on Arteriosclerosis and the Kidneys (p. 309)
I shall discuss the hypothesiswhich
maintains
that in Bright'
s
disease the high arterial pressures
due to irritation of the
are
adrenal bodies, with profusionof adrenalin
shall express
; and
the opinionthat as yet we
have little evidence that such is the
nexus,

and

I think, the

not

little to the

first to
of

attribute

arteriosclerosis to

much

of this argument

on

a useful
Handelsman, Inaug. Diss., Berlin, Dec. 4, 1906
essay
Also Elliott,T. R., Q. J. Med., Oct. 1914; appeared too
"

Nov.
Josue, Soc. d. Biologic,

VOL.

change,

some

irritative kind, in the 'adrenal bodies

an
presumably
From
point of view,
my

Josue, in 1903,2 was,

contrary.

(p.221).

both

sides

with

graphy.
biblio-

late for

14, 1903.
Q

me.

due

most

enlarged capacity, and

of

stimulus

or

occurred

in the

M.D.

at

adrenal

of

the

found

the

in them

with

but

are

such

of

not

medulla.

normal

mean

course

have

moreover

abiding

any

state

which

the

blood

of the arteries,had

been

noted

state

of correlation

evidence

any

Frank

vessels.

of the

in

adenoma

that

of

excess

thesis for
number

pressures,
; in none

the adenoma

between

found

often

Increase

Dr.

least

at

was

constant

no

Green, in his
Hodge of Woodford
Cambridge, brought togetherno inconsiderable

cases

or

with

cortex

(adenoma) need

of function.

of

that

baseless.

in other maladies
likewise ;
indifferently
prone to occur
of
of degradation rather than
of the nature
of them
are

are

size

be

may

ever,
How-

is associated

adrenals

the

there

alterations

it ; whatsoever
as

of

alteration

sclerosis
arterio-

be

surmise

lump, it will appear

in the

Taking arteriosclerosis
characteristic

adrenal

less if the

the

this matters

the

between

of decrescence.

that

and

PART

distinction

by neglectof the
to high pressures

is confused

or

AKTEKIOSCLEROSIS

OF

CAUSES

226

in many

and

cases

of

not
concerned, nor
high blood pressure, the adrenal bodies were
system ; and Miinzer is
probably any part of the chromamn
opinion.2 Miinzer says that a middledecisivelyof the same
aged friend of his took adrenalin, subcutaneously,for asthma,
continuallyfor eighteenmonths, but that neither in heart nor

vessels

did

alteration

any

diphtheria,the
Dr.

Mott,

the

adrenals

Handelsman

weighed
those
failed

adrenal

the

control
find

to

any

themselves

are

scarcelymake
1

Arch.
-

Frank,

"

f. klin.
Munzer,

are

adrenal

bodies, and

in

blood

series of

from

for

the

of intimal

profusionof
v.

Bd.

ciii. p.

194

Zentralbl.

f. Herz-

u.

and
I

he
have

vessels

cases,

urged

further

stated

above.

of the

adrenals

sclerosis,a change which

their

chron.

weights with

non-atheromatous

correspondences;
those
substantially

the seat

of atheroma,

cases

and, comparing the

taken

Chromaffinsystem
Med.

the

of arteriosclerosis

cases

many

bodies

bodies

objectionswhich
In

one

in
(loc.cit.),

also

of

of

infections, as

some

perils of convalescence.
in some
high-pressure
carefully weighed
cases,
and found
to attribute the perversion
no
reason
often proved to be wasted.
Indeed
these bodies

them.

to

injures the

toxin

falls, making

pressure

In

appear.

specific
product. Nowicki
Hypertonie

des

(1911).

Gefdsskr.,Nov.

1, 1913.

Menschen,"

can

and

Deutsche

opinion Janeway
with
further
Hodges

this

to

than

more

as

serve

and

M'Clure

Addison's

disease, and

removing

even

of them

one

bodies

adrenal

the

good

are

in

stuff.

any

Some

of

or

recent

lower

think

we

of

guinea pig) of
the

values

hyperpiesa,on

If however

in these

concerned,

way

system,

underrate

heart

big

it too

adrenin

(in the

cannot

we

bodies

secrete

emergencies.

ill effects

agrees

adrenal

vascular

we

the
cases
call
re-

may

of
opinion of Sajous that their secretion is a means
exchange, and is partly identified with the albuminous
of the red corpuscle; if so, it may
doubt
no
play a

the
oxygen
molecule

all tissue

in

part

with

the

of these observers

none

more,

metabolism.

in connection

point again
once

the

whole

for

of the

And
organs.
of
hand, is made

direct

of the

reserve

these

the

that

Janeway

are

arterial

other

; and

agree

peculiarproduct, and

tone
a

PART

assertingthat very minute doses of

Still,when
by vasodilatation.
pressure

observers

of

Park

the

maintain

slowly to

and

little of their

too

secrete

ARTERIOSCLEROSIS

OF

CAUSES

228

shall

touch

specificinfections.

has

taken

this

on

But,

into consideration

abundantly verified,that many

originalpostulate,now
of arteriosclerosis are not attended
cases
at any
probably most
periodwith arterial pressures excessive for the age of the patient.
my

"

"

while

It is worth
of

the stresses
arterial

areas

strained

are

clinical side.

constricted
uterus

in
in

; not

vasomotor

series for
the

the order

note

in which, under

loaded

Under

us.

skin, stomach

adrenalin

the

vessels

are

and

bowels, mesentery, and

the brain, heart, lung, nor
in which
liver,areas
is weaker

tone

become

to

injectedadrenalin and cognate substances, certain

undergo constriction,while others not so held up
and
damaged, a question asked already on the
Gaskell, Cushny, Dixon, Harvey and others have

such

described

however

with

blood

these

; and

areas

in

some

therefore
of

are

liable to

them, if the heart's

augmented, which, subjectto uncertain vagus restraints,

it usuallyis,the vessels,or at any rate the aorta, become
strained.
energy

But

be

the

efferent

outflows

"

cranial, thoracico-lumbar, sacral

"

of these
Janeway, Amer. Journ. Med. Sci., May 1913" a full discussion
similar
and
for
H.
a
see
Rolleston,
D., Lancet, Sept. 28,
problems ;
survey
1907;
Langendorf, Zentralbl. f. Physiol., 1907, and
Moller, S., "Beitrage
z.
Therap. Monatsheft, Dec. 1905, and
Wirkung d. Nebennieren-Extractes,"
1

Jan. -Feb.
2

1906.

Sajous, Journ.

Moller's
Med.

papers

I have

Assoc., New

not

York,

seen.

1906.

CHAP,

uniform

not

are

INTERNAL

OTHER

iv

is best

and

Dixon),

curious, if

adrenalin
must

we

distribution

activityvaries

the

SECRETIONS

in the

marked

not

In
positionof the animal.
rabbits were
suspended head down
130
the thinning of
days, when
calcareous
deposit,after the manner
observed

and

about
set

up

genous.
of

for three
the

media

experiment
extent,

described

the

by

on

laboratory
a
day for

minutes
of

is

ever
How-

coat.

Adami's

the cervical and

and

how
The

by
If

some
so

things,in
high pressure

extensive

then

case

any
cause,

Why

; in them

Professor

This

aorta

Dr.

with

Harvey

cranial vessels

notably affected.

were

In

thoracico-lumbar.

directlyon the muscular

forget that in mechanical
is dependent, at least to some

the

also

(Gaskell,Cushny,

areas

acts

of lesion

(p.223), was

in

229

constriction
have

antecedents

the

is it that

these

to

is
be

only the proximate

sought beyond.

widespread constrictions

come

is
is that
the constriction
conjecturalanswer
poison in the system, autogenous or hetero-

it be,
the

we

have

remarkable

instance

of the

irony

abundant

generationfor evil of an agent of

of which, for good in a therapeutical
we
sense,
need.
for fallingperipheral
often in sore
Our
remedies
are
in collapse,are
fallible ;
as
few, difficult, and
pressures,
and
the
strychnine and
fugitive adrenalin
pituitin being
perhaps our only available pharmaceuticalvasoconstrictors.
teresting
Concerning the 'pituitary
body and other hormones, so indiscussed
on
speculativegrounds by the late Dr.
in the address on
Gibson
Medicine
at Liverpoolin 1912, I have
than
to say
no
more
concerning the adrenals ; but in chronic
disease of the pituitarybody cardiac hyperplasia(letme
repeat
not
be enora
mous.1
genuine hypertrophy) and atherosclerosis may
Secretin seems
to cause
a fall of pressure
; for although
it constricts many
it dilates other large ones, such as, it
areas
is said, the splanchnic. As Gouget says,2 we
cannot
arrange
I have argued that
our
glandsinto pressor and depressorranks.
these inward
glands are not to be regarded as quite separate
1

Vide L. Humphry's case, etc. (p 27 1) For a study of Hypophysitic Extracts

Lewis, Miller, and Matthews, Arch, of Intern. Med., June
15, 1911
(quoted
B.
Med.
active
in
Epit.
more
Journal). Dr. Blair Bell thinks this extract
.

see

pathologicalthan in normal
mid.
Gouget, Journ.
1912.
Gefdsskr.,March
2

states.

Fr.

ii. 52,

1912,

quoted

Zentralblatt

/.

Herz-

u.

CAUSES

230

and

peculiar.
not, is

useless,

Whether

accident.

an

harmful,

or

of

Weber, Lorand
Williams

and

its waste

product

manufacture

To

is

the

wards
discharged out-

be

can

utilised

product, useful,

some

of

all

H.

D.

Rolleston, Leonard

suggested that
precocious may be due

when
especially

property

Carlsbad, Ewald,

others

PART

shall be

secretion

inwards, whether

or
or

ARTERIOSCLEROSIS

OF

have

cells.

Parkes

senile arteriosclerosis

thyroiddeficiency
We have as yet no evidence of this,indeed Sir Victor Horsley and
other competent observers deny any such relation.
They have
reminded
however
that in elderlypersons
the thyroid often
us
involution,and that these senile changes may be
undergoes some
with degreesof myxoedema ; or, again,
comparable in a measure
Rolleston puts it,1the suprarenalsmay
as Dr.
get too big a pull
In my
infection.
a
own
thyroidinjuredby some
elderly
upon
body five grainsa day of thyroid extract taken experimentally
for about
five days in one
of a
week, instead
perennial
set
and
spring,
tachycardia,fine tremor,
petulance,when
up
I was
fain to stop the experiment,and
therewith
venture
my
for carnal immortality. I have
tried the same
drug on a few
arteriosclerotics of the decrescent
I supposed to be
kind, whom
rather more
torpidthan myself,but with no signsof advantage.
Atropine of course
palsiesthe autonomic
system, but choline
"

stimulates

it.

but

not

Ovarian

it in the

The

chromaffin

the

; at

period the balance of

in elderlypeople the

and

these

lower

have
rate

blood

been
it

2
*

the

thetic
sympa-

pressure,

and

rises of

rule is,not

attributed

poverty of

to

probable that at
glands is deranged.3

hormonic

suggested that

pressure

that

the

is maintained

arterial pressures,

normal

by

balance

the

See

this
But
in

as

or

normal.

The

pressure.

Fearnsides, E. G., Lancet, July 4, 1914.

arterial

action of
antagonistic

arteriosclerotic
one

of

other

states

of the

Rolleston, H. D., Clin. Med. Journ., June 21, 1905.

See Kinneir
Wilson, Brit. Med. Journ., June 14, 1913, p. 1261.
According to some
the blood
authors, in myxcedema
pressure

according to others it is depressed or

the determining factor in the blood
6

influence

seems

several internal secretions ; so

that
arise, for instance, from defect of
1

decline,4but rise rather.

It is often
health

any

to

system.2

is said to

climacteric

system

myxoedema,

substances

the autonomic

extract

at

pressure

"

myxoedema

is

may

inward

Ibid.

is raised,

probably

not

CHAP,

BAKIUM

iv

glands
such

231

chromaffin

the

ovaries

thyroid,of the adrenals and

the
carotid body, the pituitary,

and

menopause,
"

so

under

slow

Some

CHLOKIDES

SODIUM

of the

as

tarism

AND

In

on.

thyroid

Fearnsides'

Dr.

extract

of arteriosclerosis with

cases

of

pressures

after the

of

case

bodies,

dyspitui-

"

fell to

180

120.

attributed
glycosuria,
connective
hyperplasia,

chronic

with
atrophy of the pancreas
originatein a precedingsclerosis of its finer vessels.
may
of high
chloride acts simply as a mechanical
Barium
cause
It seems
of a widespread vasoconstriction.
by means
pressure,
to act
directlyon the arterial muscle, and with a vigour proportionate
to

the

to

in the

of muscle

amount

branches.

several

injectedintravenouslyinto rabbits it thus raises pressure,

like
and
rather
more
provokes changes in the aorta
than
the effects of adrenalin ; namely, intimal disease
atheroma
for the
far makes
of the elastica,a result which
with splitting
so
opinion that these changes are not toxic but merely mechanical.
When

of certain other

virtues

The

force up

arterial pressures,

complex

for

in any

sclerotic ; *

salt.

arterial pressure

The

research.

be

tested

discussed

The

oedema

for

Javal

The

normal

estimate

it

upon

cit.). I have
persons

There
1

Arch.

for
are

is 0-562
than

matter

again

found

with

abnormal

in

Chloride

later

that to cut

out

Exp. Path,
1904.

and

Pharm.,

has

organ
of

chiefly
yet

to

Widal

it.

is

metabolism

suppose,

but

we

salt from

the

July

1907.

diet of

far

shall

chapters (vide Bickett,

days produces no changes of

certain syntheticsubstances
which

de med.,

is

more

by electro-conductivity.

usually

we

far

needs

retentions

serum

grm.

some

each

to

large and

is too

salt retention

few

Bayer, Journ.
gen.

is

credited

been

economy

system, but

it in the blood

content

complex

touch

correlated

and

normal

has

and
incidentally,

here

musculo-cutaneous

and

more

; caffeine

adrenalin

meals

after

part of salt in the

be

to

the

too
are
digitalis,
particulardirection,and

as

salt is said to
of common
most
readilyin subjectsalready arterioquickly subsides on free excretion of it.

rise which

rise of

in

may

squilland

retention

ingestion or

raise arterial pressures,

various

such

agents which

known

still.

Excessive

the

better

experimentalwork in this
they are less energeticthan

case

less active

The

and

loc.

healthy

pressure.
credited with
are

Ambard

and

Beaujard,

OF

CAUSES

232

virtue, certain

pressor

ARTERIOSCLEKOSIS

affected the aorta

adrenalin, but

and

been

used

pressor

corresponding
in experiment;
the

of

manner

sufficiently
convincing

not

are

substance,is said

vessels,after

other

far the results

so

the

amines, ketones, and

secondaryalcohols. Some of these have

which, by the way, is not a
pyrocatechin,
to have

PART

argument.1 Of the effects of lactic acid,

in the muscular
it maybe generatedduring a suboxidation
as
field,
I have
spoken already(p.212). Here again the arterial lesions
attributed
it in experiment on
animals
do not constitute
to
into the present

to enter

the .arteriosclerosis of human

with

calcification

(p. 482) ;

"

disease, but

kind

of

"

the

medial

necrosis

change which, as we have

seem
capableof producing,

hypotensive substances
of the rabbit (videp. 234).
at any
rate in the elementary aorta
shall now
We
Toxic
Causes.
farious
proceed to discuss the multiagents which, under the general conception of animal
toxins," enteringthe body from without or enpoisonsand
gendered
within it, impair and disintegrate,
it is supposed,
so
some

seen,

"

"

the coats

of the vessels.
the marches

steps across
unnumbered

And
of

illsof obscure

to these

"

by psychic causes,
may
and may
be directlyrelated
under

that in many

middle

of them

issue at
to

it

as
"

cases

with

tear,"marches

some
origin,

which

shall remember

and

wear

advance

we

uncertain

haunted

by

engendered even

length in arteriosclerosis,
and

cause

effect.

But

we

apparentlytoxic," in

persons
strain of the

in renal disease,the
especially
shows
aorta
itself as a sequel at a comparatively late date (see
of high pressures.
p. 498) after a long continuance
But when
to enquire into the influence
we
come
of poisons,
knoivn or suspected,
the
coats
of the arteries,we are arrested
upon
at the outset
difficulties. For instance, arteries do
by many
age,

all behave

not

in the

same

way

to

the

agent, and

same

animals

differ much

in their

Thus

adrenalin,while all the other arteries contract, the

under

weaker

coronary

and

several

reactions

cerebral arteries

artery, before its entry into the

the

intrapulmonary twigs remain

1

For

papers
Strauss
Bd.

drugs

dilated.

a
experiments I may make
general reference
Dixon,
Dale,
Cushny,
Barger, Laidlaw, Widal,

and

Cow,

He.

others.
3 and

Douglas,

Also

to

Scholz

and

and

The

Hinkel, Deutsche

to

for M.D.,

Cambridge,

Dec.

the

well-known

Vaquez, Achard,
f. klin. Med.

Arch.

4.

Thesis

secretions.

pulmonary
lungs,is constricted by it,but
unaffected, or dilate.2 Again,
are

these
of

cxii.
2

to

23, 1910.

CHAP,

TOXIC

iv

have

muscular

the

reaction

nervo-muscular

or

to

reaction

direct

the

that
arteriosclerosis,
in

may

be

nature

if any,

blood

than

51

n.),
I

kinds

we

local

again

or

insisted

have

originsof

and

known

this

by

If, after

one

if it be

And

pressures.

agents

directlyfrom

be

or

(p.

arterial disease

more

such

under

difficulty,
concerningmixed

another

upon

lateral

to

arteries

mechanism,

the

irritant in

an

233

the response,

whether

discover

to

of the

behaviour

observingthe

in

CAUSES

name

wont,

our

we

kind
of poison to act directlyupon
the walls of
one
suppose
to be the case
the vessels,corrodingor inflamingthem, as seems

with

"

of the

some

infections," and

peripheralmechanism,
such

to

as

force up

strain,it would
two

kinds

at

main

the

least,or

at

any

class of strained

into the

; and

at

we

with

rate

to

act

to

should

two

no

point of

the

to do with

have

of arterial

processes,

poison or

the

upon

constriction

field of

pressures

cases

these cases,

wide

blood

that in these

seem

reaction

and

lesion

settingup

another

fall

poison,would

tion
wall, those into the class of deteriora-

first sightwe

should

that
anticipate

the

histological

dioxide
differ also.
Carbon
phenomena would in the two cases
authors as the poison associated with high
is regarded by some
with consequent
; asphyxia of the medullary centres
pressures
intense

vasoconstriction, therefore

and

on.

so

I do

but

mention

experience has

clinical

two

when

Thus
in

we

output,

hypothesis,which

little to

however

recommend.

Edgren

cause

to

come

of

causation

the

of

this

less cardiac

only, (1) the toxic, and (2) the

but often
nervous
; the toxic being autogenous or heterogenous,
mechanisms.
Lubarsch
emphasises
actingthrough the nervous
side
in
the toxic
causation
almost exclusively.

admitted

kinds

done

less and

consider

arteriosclerosis

the part of toxic substances

find ourselves

we

if poor

in

strictlyas
knowledge yet rich in conjecture. We
regard more
are
poisons substances, such as lead or strychnine,which
measurable
in virulence, and
theoretically
by dose, constant
from

recoverable
selection.

zymotic
and

toxin

"

energy,
of
to

excretions

regard as

of the

rather

"

We

the

toxins

and

those

the

whose

tissues

their

of

propertiespartake

in respect of
of livingmatter
protean qualities
tion,
of transformaof incubation, of multiplication,

relative
bacterial

imponderability.
be
products may

To
too

restrict the
narrow

we

term
are

CAUSES

234

OF

ARTERIOSCLEROSIS

PART

decomposition of food itself,simply in the course

two
of oxydation, may
not
pass through toxic phases. These
dealt
classes of poison are
with
each
by its appropriate
on
analyticmethod ; or, in the case of substances which move
that

not

sure

the

borders

kakobolites

or

"

between

amine

classes,such

for the

as

xanthine

or

these

moment

order, by

we

call them

may

of

combination

katabolites

certain

as

of the

"

chemical

and

methods.
biological
While

then

bear

to

series

such

in mind
the

thirdly the
modes.

the

high

the differences

are

differences

convenient

When

largelyoverlapping class
fathomed
the depths of these

of

but

have

we

and

mode,

decrescent

the

also

have

we

arteriosclerotic

several

of the

mode,

pressure

of agents,

toxic

reactions

shall

probably be enabled in great part to redistribute our

provisionalclass of toxic arteriosclerosis,and to remit the
of them, such
poisons of some
perhaps as certain recognised
substances
of the adrenic, ergotic,
amine
or
series,to the high
of a more
class,and others of them, some
gradual and
pressure
mise,
surstealthynature, to the decrescent class. For it is a common
strengthenedon the one hand by the occasional precocity
we

of decrescent
a

few

old

mere

be concerned
with

simply

who

men

than

more

and
arteriosclerosis,
have
and

wear

lived
tear

"

than

more

(p. 236).

adrenalin, whether

this

or

pressor

and

rate

detrition

mere

in its establishment

pressor,

The
be

body

also

those

in

may

"

ments
experi-

recent

the

on

aorta

toxic agent, have

of toxic agency,
as

its absence

by

life,that something

sheltered

no

perpetuated discussion
of toxic bodies,such
investigation
any

the other

on

and

led to

of the amino-N.

at

the

order

(Dale, Barger, Dixon,

Laidlaw), and of other perverters of

and
be
metabolism, pressor
depressor.1 Yet, if this advance
made, it seems
probable that specifickinds of arterial disease,
kinds such as the syphilitic,
for instance,or the plumbic, will
remain, for which

regards

as

classes,and
a

the

further

produce arterial
1

He.

See,

e.g.,

5-6;

Bain's

toxic

class must

arteriosclerosis

be maintained.
of

the

first

papers

und

Deutsche

Thorspecken,

(loc.cit.),and

so

on.

med.

second

and

various

contributory toxins, we
difference ;
namely, between
lesion directly,
and those which,

Hirsch

more,
Further-

shall
those
as

causes

Wochenschr.,

ceive
perwhich
of
1912,

OF

CAUSES

236

relations of oxygen
the many

how

ways

noxious

that, carried

and

lactic

acid, and

PART

to be alive
forth.,

so

in which

by fatiguemetabolism
may
in the blood
metabolites,circulating
perhaps by way of the vasa
vasorum,

arterial tunics.

the

ARTERIOSCLEROSIS

Dr.

be

to

perverted;

in this way

or

corrode

may

Gaskell, in his well-known

paper

in

the Journal

of Physiology,suggestedthat acid metabolites, due

the activityof an
to
organ, might play a part in relaxing
the muscles
arteries
of the small
supplying the organ
by
altering the composition of the lymph bathing such arteries
This

(p. 51 n.).

all,would

at

however
such

tend

that

far

far

so

as

as

it would

experiment
I

affect blood

its relaxation.

towards

hitherto

lead, seem,

as

so

agency,

know,

to

sure
pres-

It is remarkable

with

have

poisons, even
failed to produce

definite arterial disease.

If

and

(" Abnutzung ") is to mean

strictly
fatigue
of the coats by frictional and oscillatory
stresses, it should have
been contained
wholly in the previoussection ; it is in this sense
that in former papers I have used the phrase. But Dr. Mitchell
Bruce

wear

tear

extend

to

proposes

the

term,

from

the

mechanical

already considered,into a more

comprehensive sense,
to
not
a
sense
cover
only psychical pressor (p. 70) as well
obvious
series of
as
physicalstrain, but also an incalculable
small, insidious,
mostly unperceivedactions upon the circulation,
causes

"

of

an

unfavourable

character," influences

allegedperversionsof
attribute

"

my

wholesome

decrescent
From

or

to

which, with

katabolism, he would

involutionaryform

"

(of

their

chiefly
sclerosis)
arterio-

this

point of view in another passage

Dr. Bruce
discusses more
and
fully worry
anxiety as a
of
I
cause
arteriosclerosis,
being herein, observe, a discipleof
The
Sophocles: ritcrovcn, yap
rot,
KOI
SvcrOvjjiiai,"
voaovs
belief is prevalentthat mental
anxiety,worry, care, distress,
this vascular deterioration
actingover longperiodsof time will cause
was
as
Huchard
eloquent about neuroses
as
; Lancereaux
about
toxins ; but this impressionis aggravated more
less
or
in diagnosis,
that is by the mistaking of some
by an error
cases
of hyperpiesiain its earlier stages for neurasthenia.
It is also
asserted that vascular instability
under
is very
psychic storms
tryingto the coats of the vessels,but I am not yet prepared to
(p.532).

"

"

"

Bruce, M.,

"

Lumleian

Lect.," July 8, 1911

Lancet,

p.

71.

CHAP,

WEAR

iv

admit

excitable, emotional

that

yet convinced
I

am

that

production of
inclined

TEAR

persons

237

are

subject to

more

I am
of equable temper.
not
persons
of this kind take a leadingplace in
causes

than

arteriosclerosis

the

AND

"

my

rather

to

"

Decrescent

expect

mode
them

from

of arteriosclerosis ;
effect of

some

hyper-

perhaps ultimatelyof the sclerosis consequent

of ancient
this. The life of a wealthy inhabitant
Egypt
upon
does not at first sightsuggest to us
the excitements, the haste,
harass
of the Stock
and
the mental
Exchange ; yet in the
Decrescent
Egyptians arteriosclerosis,apparently of my
II. himself,who
however
in Rameses
kind, was
prevalent,even
unrest."
We
too
have been worried
are
by Hittite
apt
may
back for a Golden
to look wistfully
Age in which passionswere
and
calm
occupations tranquil. But the tyrannous passions
and
internecine raids of savage
peoplescan scarcelyhave made
for emotional
and secretory equilibrium;
peace, or for circulatory
and we
do not know
that the conditions of life among
such peoples
and
piesis,

if

so

"

"

"

were

or

wholesome

more

are

than

our

And

own.

repeat that

comparatively golden, of Egypt,1 and probably of

and Assyria woke
Chaldsea, before Edom
up," appears to have
made
if it
rather conspicuouslyfor decrescent
arteriosclerosis,
were
only by the prolongationof life ; as does the quiet boudoir
of the rector's wife, or the cloistered life and peacefuloccupations
of the philosopher. Thirty-sevenyears ago 2 I publishedcertain
the

age,

"

evidence

in favour

of emotional

harass

as

cause

of

"

Granular

then with
much
met
opinion which
acceptance,
3
and
since again at the hands
it
of Sir James
Goodhart
; now
be that Granular
toxin, as yet
Kidney is set up by some
may
unknown, upon which pressor effects would immediately follow ;
harass
metabolism
be so
or
possiblyby emotional
may
verted
perof endogenous
to engender either corrosive
metabolites
as
formation
which
attack the coats
of the vessels directly,
or
a
toxin
damaging them indirectlyby strain. We know
pressor
how
in incipientdiabetes
or
a
sleeplessnight may
worry
throw
into the
urine.
Speculative as this argument
sugar
is, yet in its context
some
interestingstatements"
very

Kidney,"

an

See

Brit. Med.

Ruffer, Journ. Path, and Bact. vol. xv.

10, 1877.
Journ., Feb.
Oration, 1912.
Goodhart, Sir J., Harveian

CAUSES

238

at

1907,

may

and

the

even

in

Wiesbaden

the

made

statement

It

hypnotic trance,

excite

to

of

part

any

in

April

"

the

the

Medicine

of Berlin,
by Weber
by Klemperer, that,
idea, the psychical

impression of

motor

"), without

stated

was

PART

Inner

corroborated

was

mental

of

Congress

mentioned.

be

factors, the
Arbeit

ARTERIOSCLEROSIS

OF

an

effort"

(" einer

effort itself,raises arterial

be that incessantly
agitating
pressure (videp. 69). Thus it may
ideas, with oscillations of the blood pressure no less incessant,
in time

may

tell upon

the

coats

of the

vessels,or

affect them

of

It is
imperfectlyeliminated waste.
physiciansthat the blood pressure rises in convalescents
of
the
the
But
Dr. Bruce
on
day
leaving
hospital.
himself
with
remembers,
some
perplexity,that death from
cerebral haemorrhage is greater per million in the country than
in London
must
not
forget that nowadays many
; though we
citizens and publicmen
reside in the country.
Moreover, apoplexy

indirectlyby
said by House

connotes

with

excesses

decrescent

not

Dr.

that

Bruce

damage the
opinionthat

worry,

hard

intellectual work

circulation

"

wear
.

suspense,
of failure
of

comes

coats

hereunto

no

remember

soldiers

doubt

is of

'

arrears,

the

without
a

after
evil

many

of itself

anticipation,
ment,
disappointthe
hunted
failinghealth,

only

system." Age
in

however

(vide p. 213). He

and

not

Frantzel, it is true, noticed

arterial

of

or

cardiovascular

"

I agree
does not

anxious

overwork
out

sclerosis.

pressor

"

"

but

of

organs

consciousness

feelingthat
despair

"

regret,
but

nervous

years.

'

It

sorrow,

also
be

may

the
so

large proportion
palpable
and
but
long war
exposure,
factors conspire. Yet
I
when
of

the

of cases
of arteriosclerosis,
both
large number
decrescent
and
such
no
hyperpietic,in which
history was
of cases
without
cardioarterial
apparent, and the largenumber
in which
such misery had abounded, one
is disposed
consequences
demur
that Dr.
to
Bruce's
more
experience is drawn
f
rom
certain
classes
of
especially
society.
Before
genous
weighing the evidence, clinical and other, of autotoxins which may
poison the arteries,let us set out from

what

Diet.
as

know

we

"

more

diet, in the

That

scheme
of

of certain

or

decrescent

selection of

obvious

agencies.
ordinary acceptationof
food, has

part in the

any

arteriosclerosis I have

this word

no

tion
genera-

knowledge.

It

is

CHAP,

DIET

iv

in the Hall.

and

wealthy and

in the

frequent both

239

that

But

in the

poor

of the kinds

one

; in the

Hospital

of arteriosclerosis is

and
excessive, feedingwith meat
relatively
wine, and that this kind is caused by a persistenceof high
Basch's opinion that the
arterial pressures, as opposed to von

due

excessive, or

to

high

pressures

been

my

the consequence

were

of the

opinion from the first,an

independentlyin 1893-94

I stated

said, that

I have

he

has
arteriosclerosis,

opinion which

Huchard

difference from

; my

and

Huchard

this

explanation of high
I applied it to one
whereas
mode
pressures to all arteriosclerosis,
only, and this a secondary mode ; the event seen
ultimatelyin
in kidney diseases,and perthe malady I have called Hyperpiesia,
haps
being, as

in other

morbid

with

processes

who
(loc.cit.),

Cohnheim

marshal

excessive

then

had

we

arterial pressures.

blood

recognisedhigh

big heart in gluttons, said

was
one
interpretation.Traube
times,

gave

pressure

data

no

for

and

its

of the first physicians,

in recent

clinical evidence

luxus

consumption, and
the questionon scientific lines. He argued,and in this
to argue
Frantzel
followed
him, that with gluttony arose
an
overcharge
which
of the veins and a fall of centrifugal
velocity,
propagated
backwards
and
rise of pressure
to the capillaries
a
arteries,a
to

which

condition

he treated
When

These

pipes

With

And

that

to

blood

pass

arteries

of

endowment

"

without

and

it

in

calcification,so

change, when
Vide

Rossle,

blood

our

feeding.
then

the

were

efforts

of

the

multiplied. On
hypertrophy, and

absent

arteries

no

well

is

elsewhere

"

u.

medial

and

marked,

tJber Hypertrophie
Wochenschr., 1908, No. 8.
1

of

conveyances

circulation

this
so

followed
The

on.

the
most
are
alimentary tract
among
body, and have a very complex nervous
and
mingled vasoconstrictor, vasodilator

the

supply ;

vagus

stuffed

these

arteriolar

the

laxatives

pressed the familiar argument

was
excretory superficies
inadequate

renal

through

in

muscular

and

and

demand,

Johnson's

George

This

the

as

have

followers

increased

the

to

wine

his

and

he

we

with

on

in

the

even

hypertrophy,
so
palpable.

system,1

may

Organkorrelation," Munch,

be
med.

ARTERIOSCLEROSIS

OF

CAUSES

240

PART

overfeeding
Stengel2 emphasises as causes
and
that
and
regulation of
hereditary predisposition,
says
alleviate the
diet and
habits, if they cannot
cure,
may
in its more
advanced
stages. Sir Lauder
malady, even
Dr.

here.1

found

Brunton,

Dr.

opinion.

"

this

even

great

Man

common

all

that

say

Russell,

W.

ist,was

others

many

opinion with
hyperpieticsare, or

some

have
and

men

of

are

Still I think

isst."

er

of them, both

many

and

the

hold

must

we

same

We
cannot
qualification.
been, gluttons,though

women,

have

or

are,

been

opinion, too scepticalof overfeeding

of arterial disease.
cause
as
a
Overfeeding is a relative
be injurious
not
question: what is overfeedingfor one
may
person
be superfluity,
for another.
overfeeding,
though it may
Human
men
engines vary much in consumption of fuel ; some
do long and active work on very littlefood ; others, especially
can
liberal table, and give way
without
it.
big men, need a somewhat
and

Vaquez

work

can

well

reasonably

and

rich

persons,
inactive

is, in

my

half the food

on

which

other

active

by experience to require. In
even
enormous
even
overfeeding,

or

in

habits

muscular

has

sense,

been

men

notable

some

with

seem

somewhat

consistent

with

obese ;
are
energeticlife. And not all such persons
find a mansion
in the case
of a treble
some
are, others might
hautboy." Many heavy feeders, friends and patients,have I

long

and

"

who, with

known,

pretty

always
other

then

sure

direct

in normal

In the

moderate,

pressures

proverbs
digging one's
that

may

is not

The

Journal
crowd

is

What

for Feb.

of them

absorbed, and

then

is the factor

8, 1913, is

which

warn

has

remarkable

fore
there-

of evil ?

collection

against gluttony, against

with
one's teeth, is in all times and
all peoples innumerable,
grave
the illsof overfeeding have
been manifest
to all shrewd
observers.

From

Theognis

these

saws,

such

and

Hippocrates,through Latin, medieval, and modern

Europe,
Non
cecidere gula," and so on, have
plures gladio quam
du
her large experience of hospitality,
Deffand, from
"

as

Madame

abounded.

all the food

destroyed.

Medical

of diet.

of

to a good old age.

We
living,
mere
surplusageof nutriment

cause

or

British

of

so

that

persons

be used

to

wrote

blood

of arteriosclerosis of any kind ; there are

coefficients. Physiologists
of opinion
are
intercessory

and

that

soft and

lived,or happilystillare

have
be

arteries

feeding

"

C'est

un

des

quatre

fins

de

l'homme

j'ai oublie

trois autres."
2
3

Med., Jan. 2, 1904.

Stengel,Amer.
to the Physicotherapeutic Congress
Vaquez, Address

at

Berlin

in 1913.

les

CHAP,

DIET

iv

241

overwork
in katabolism, or the
plethora,mere
generationof toxic by-products? I have said that we, as
other engines,differ widely amongst ourselves not only in the
quantitiesof food we need for given work, but also in our
for dealing with it economically. As men
in their
capacities
capacityfor disposingof sugar in the system vary widely,so no
for other metabolisms.
doubt they vary widelyin their capacities
Is

it

true

small

eater

not

across

became

bad

few moderate

metaboliser

small eaters

or

subjectsof hyperpiesia
;
exercise,could

ample outdoor
impunity. To
the

yet be

may

of

head

and

I have

come

who, notwithstanding,

not

few

who, in spiteof

indulgetheir appetiteswith
questionwe shall return under

not

this side of the

(p. 273). Meanwhile

Gout

; and

I would

that, if

urge

gluttonouswith impunity,and another on a

moderate
diet becomes
nevertheless
the average
plethoric,"
who
man
indulgeshis appetitefor food and drink, especially
if his habits be sedentary,runs
little risk of high arterial
no
the integrity
and of imperilling
of his arteries. As
pressures,
of his
Fanny Burney neatly put it, Thrale's miscalculation
ended in an
then
digestive
apoplexy. Let us remember
powers
in The
the well-known
And
do you
not
Republic:
passage
hold it disgraceful
to require medical
aid, unless it be for a
man

one

be

can

"

"

wound
to

"

requireit, I

lead, and
like

call

owing

mean,

get ourselves

to

so

to

health

than

bad

of butcher's

to

more

be
when

doctor

stuffed

with

"

*"

of

sons

and

Asclepiusto

good cook,

when

one

wind,

is in

as

some

perfect

is ill !

Concerning the part

making for high pressures,

in
particular
I shall speak presentlyunder
the head of autogenous toxins.
To
the experiments of Professor Chittenden
I need
do no
than refer,so well known
more
are
they ; and Dr. William
Russell and others have emphasised their importance in clinical

medicine.
excessive
Professor
who
1

is

meat

was

proteinfeedingled in
Saundby says that

by

"

Russell

Dr.

no

means

Plato, Rep. 405

VOL.

in

and

of the year
the life we

humours

clever

feared
one

the time

to

laziness

our

quagmires, as to compel the

diseases by new-fanglednames
observed, is

one

of illness incidental

attack

an

or

'at the

the individual
the

idler,is

an

D.

amazed

as

Russell, W.,

diet

to

the

of

follows
Brit. Med.

that

statement
no

bad

results."

Trappist monk,

Journ., Sept. 3, 1911.

E

CAUSES

242

Bread,

17^

oz.

beer, \1\

vegetables,6
That

is

ARTERIOSCLEROSIS

OF

oz.

vegetable

PART

pint ;

soups,

green

oz.

Protein
.

62

grms.

254

10

grms.

93

450

grms.

Fat
.

Carbohydrates

heat

units.

1845
"

2192

Mr. Fletcher's diet in

Chittenden's
Fletcher's
which

is

(he is
diet

120
50

man)

of

grms.

least up

to

Saundby says that

of protein,is a sufficient diet
life ; and this he
or
professional

grms.

business

units.

for 6

Mr.

days only,

Chittenden's

Professor

grins.

heat

1700

proteina day,

47-55

it at

usuallyconsume

heat units. Professor

1606

Professor

his eye, consumed

while under
athletes

of

grms.

of endurance.

test

no

lightspare

40

was

laboratories

our

athletes,

protein; university

the Voit

cal.,containing

2000

for

of

standard

140-lb.

in

man

illustrates thus

75 cal. ; toast, 3 oz.

207 cal. ; butter, \ oz.
egg
cal. ; milk, J pint 90 cal. ; tea
30 cal.
Rice
Lunch
cal.
6
500
168 cal. ;
:
pudding, oz.
; cheese, 1 J oz.
40 cal.
138 cal. ; fruit
bread, 2 oz.

Breakfast :

120

Dinner

Clear

oz.

56

soup, \ pint (say30

cal. ; potato, 4 oz.

cal. ;

pudding, 4
pint lightwine
=

The

whole

three

Chittenden's

in my

for

danger
case

cal. ; savoury,

the

of

of

diem.

to

equal

little

in

full exercise

cal. ; half-

70

cals. ;

2000

over

consumed,

I fear this looks

in

or

awkward

in

for

all,under

some

of us,
serve

under

Moreover, in restricted diets there is

stresses.

omitting or reducing some

of the skin of the

rice,which

subtle

element,

as

in

the

is essential to health.
"

with high feedingand culture

Gray1 said of plantsthat
It is stated that in
to disease."
vastlyincreased liability
milk and vegetablediet arterial pressures
on
a
healthy man

fall,but
In

oz.

20

vegetable

cal.

Asa
comes

cal. ; meat,

56

cal. ; green

90

oz.

experiencethose tightreckonings,if they may

months
or
a
perpetuallysuffice
year, do not

few

all kinds

50

320

meals

athletes

cals. per

but

oz.

cal.); fish,2

carbohydr. 286, protein50, fat 26.

grammes

3000

find

no

discussingthe
1

note

of

effects of

any

accurate

work

overfeedingupon

Gray, Asa, Darwiniana,

pp.

338, etc.

on

this

point.

arteriosclerosis

CAUSES

244

be, often
as

ARTERIOSCLEROSIS

OF

quite moderate

are,

and

eaters

phrase,with

contrasted, in Wiseman's

PART

in drink,

temperate
"

bodies

of gross

men

rather
In them
the defect is qualitative
habits."
disorderly
in the liver or elsewhere,
than
quantitative
; in them, whether
its
flaw whereby the food, and especially
be some
there must
and

nitrogenouselements,
of katabolism,

one

self-engendered
;

or

or

some

way

The

wrong.

go

glandularincapacity,and

of

be

it may

individuals

machinations

whose

in

the
may

be

innate

so

microbe

some

be

may

or

to

peculiarly
susceptible
; or
of

element

be due to some
again,it may
which disagreeswith individuals.

of

work

error

our

diet

common

probable then that

health and
of sound
in a person
some
vigorous metabolism
if not continuous
;
overfeedingmay do no great harm, especially
in
whether
of
lower
visceral
that
but
qualityor capacity,
persons
such as the liver,
by fatiguingcertain departments of digestion,
antidotal
substances, or by
or
or
antilytic
by defect of some
imperfect oxydation of katabolites, or again by co-operation
of them
other
of imperfect combustion,
with
causes
some
and
putrefaction
possiblyemotional, or finallyby accumulation
in the bowel
ever
of waste
with resorptionof toxic products whatthe explanationmay
to be
overfeeding,or liberal
prove
and
meat
on
alcohol, or indeed feedingnot,
feeding,especially
excessive for particular
custom
as
goes, excessive,but relatively
individuals, sets up and maintains
high arterial pressures, and
It

seems

"

"

this the

if the

more

muscular

exercise be insufficient.

This may

about

in large areas,
which
by excitingvasoconstriction
of
the coats
pressures, if long continued, inflict injuriesupon
the intima.
other vessels,and especially
on

come

I make

attempt

no

now

of

to

fasten

katabolites

exclusive

attention

upon

as
particulargroup
knowledge of these bodies is scarcelybegun.
; for our
group
In my
and
his school,
opinion then, as in that of Huchard
arteriosclerosis thus
the
not
produced is the consequence
of high pressures, and is probably of purely mechanical
the cause
little,or not much, to a corrosion by toxins ;
origin,and owes

any

but

I did
the

covers

not, and
whole

kind

or

kinds

high

pressures

of
"

I do

not, agree

"

with

such

Huchard

field of arteriosclerosis ; there

at least
arteriosclerosis,

pressures

of any

as

xanthine

the

that this view

is, I repeat,
in which

numerous,

considerable

height
"

are

not

CHAP,

DIET

iv

concerned,

whether

production of
obvious

no

as

this kind

part

by adversityand

disease, is caused

particularlyof

the

Either

mode

in the

clergy,in

and

decrescent,
in

occur

may

yet in such

privation,
by Woods
from
kidney

the

persons

privation,if true, is true

of the hyperpieticmode.

not

abstinent, or
is

vegetarians. Privation

stated

as

ascetic persons,

even

ladies of slender

maiden

with

with

even

others,1 arteriosclerosis,apart

and

the

overfeedingplays

contrary, although consistent

life,it is not inconsistent

self-indulgent
itself an
atrophy. That,
being indeed
Hutchinson

is in

It

or

consequence.
of arteriosclerosis that

the

on

cause

245

as

in teetotallers

means,

guarantee againsthyperpiesia,

no

decrescent

is far and

malady

more

away

Thus
hyperpieticis rare.
hyperpieticcardioarterial disease, frequentenough in privatepractice,
is sparsely
in which field decrescent arteriosclerosis
found in hospital
practice,

frequent, the

abounds.

overfeeding,apart from a toxaemia, can raise

if by a parenchymatous surfeit, is a
as
pressure,

Whether

mere

blood

the

question which, as we have

Dr. H. T. Starling
of Norwich
an

In

answer.2

observations

which

livingunder

the

for

Dr.

few

had

years

control observations
climatic and

same

other

but

something towards

Starlingmade
eighteen patients submitted

; simultaneous

vogue

yet unanswered

as

has contributed

sanatorium

upon

stuffingsystem

is

seen,

so

manometrical
gross

extravagant

made

were

that

to

upon

generalconditions.

nurses

The

of the

29.
The results
30, of the nurses
patientswas
indicated
that in the patientson the stuffing
system the systolic
and ranging
rose
notably,averaging about 140 mm.,
pressures
the whole
10 degrees above
those of the nurses.
And
on
we
that
in
shall not forget
commonly
phthisisthe arterial pressures
mean

range

age

rather under

that

this

been

under

than

the average.
arterial pressures

over

It

also remarked

was

occurred, wholly or
heightening of
chiefly,
during the periodsof regainingweight,while presumably
the nutritive system was
ill-balanced ; when
such patientshad
their

brought
receded

weights

also to the
1

for

treatment

Hutchinson,
2

up

some

to

time, had
the

done

well,

level, the

normal

normal.
Woods,

Brit. Med.

Journ.,

Sept. 23,

Starling,H. T., Lancet, Sept. 29,

1906.

191L

and

had

pressures

It is convenient
free

which

it, such

alcohol

as

cause

and

of diet, and

as

mingle

with

tobacco.

if such

Now,

it

cause

be,

arteriosclerosis ;

i.e. decrescent
it

substance,

arterial walls

this

questionit
the

experiment on
the

conditions

we

are

met

factors.

was

pressor
tensions.

pressure ?
Much

of administration
in animal

Moreover

questionit is almost

the

machine, measured
hours'

directly

impracticableto imitate
Here
of sottish habits in man.
again however
continuallyby the fallacyof accepting systolic
this

man,
pressures only. Experiments on
Now
record diastolic pressures.
Raff,1

two

the mode

again upon

of other

concurrence

give a plain answer.

to

easy

the dose, much

depends upon
and

is not

as

blood

of alcohol upon

then is the influence,if any,

What

if, acting

or

consequentially
by high

them

damages

shall ask if it acts

we

depravinginfluence,slowlysapping the

To

dietetic data

our

gliblyassumed

is

of this lesion.

"

writers to be a definite
by many
of us everything
of arteriosclerosis ; but reallyfor some
good enough, or bad enough, to be a cause
anything seems

Alcohol

as

and

set

confines

the

on

to

PART

interferences,to discuss certain

incidental

lie

substances

order

in

now,

possiblefrom

as

ARTERIOSCLEROSIS

OF

CAUSES

246

littledisturbed.

And

when

most

by

von

them, fail

of

to

Recklinghausen's

of alcohol

effect of doses

himself

assured
carefully

rest, and

or

on

the

that

drunkards

on

after

man,

tion
circula-

admission

to

deprived of alcohol, the systolicpressure rose for

the firstfew days,and then slowlyreturned to its former position,
the diastolic pressure
being unchanged throughout. Aubertin
reportedthat by keeping certain animals under the continuous
influence of alcohol over
long periods,such as two years, arterial
degenerationensued ; but Fahr, who repeated the experiments,
failed to verifythis sequence.
However, experiment has thrown
the
the
immediate
effects of alcohol
on
some
light upon
circulation ; and
a
comparison of the testimony of expert

hospitalwere

indicates

observers
at

all,the

towards
upon

rise is transient

lower

the dose

and

the mode
a

rise of

persons

Raff, Deutsche

Arch.

that

The

pressures.

given by the mouth

in
especially
once,
1

that, if doses of alcohol raise blood

not

in

the

main

initial rise

the

of administration.

f. klin.

Med.

Bd.

to

effect is

depend

If alcohol

systolic
pressures
accustomed

to

seems

pressure

usuallyoccurs
its

cxii. He.

The

use.

3 and

4.

be
at

rise

CHAP,

is

ALCOHOL

iv

usually 5-15

variable

fall may

the

"

but

mm.

50

per

arterial pressure
does

nerve

(10 mm.)
raise

not

when

moment

while

at

The

it.

rule

the alcohol reaches

minutes

of 5-30

keep up the pressures

of
largedose (say 50 cm.

and

once,

is

may

alcoholic solution,Kochmann)

cent

Its duration

mm.

after intervals

in

thirtyminutes,

or

30

of small doses

for instance, a succession

for twenty

reach

may

set

247

stimulation
be

to

seems

the blood

of

sensory

from

that

current

the

down

send

may

the
fall;

pressures

of alcohol are followed promptly by fall

injections
without preliminaryrise (see p. 151). The transitory

thus intravenous
of pressure,

rise of pressure
striction in the

then

be but

may

splanchnicarea

usual

the

by
by

the afferent

stimulation

this retardation
succeeds
and

it.

In

and

like

to such

heart

The

the

heart

transient,and

gives way

soon

areas,

is

the
at

the

manner

an

extent

constriction
persisting

as

but

pressure

as

any

in

rate

override

and

quickly

is transient,

vasoconstriction

to mask

that

first is retarded

of acceleration

vasodilatation, at

to

fibres of

also to be stimulated

seems

phase

vasocon-

afferent

protectionagainst high

vagus

reflex

momentary

through

gastro- intestinal surface.

the

peripheral

any

areas

of

low

systemic pressures prevail.

and
:
although pressures
velocities are in inconstant relations yet, the widening of channels
heart
less by an
accelerated
or
beat,
being compensated more
1
and
this is the
blood
rule during
velocity is promoted ;
the first stage of the
cordial," till by the drug the heart is
and
enfeebled
sink.
Thus, although perfusion of a
pressures
On

the

whole

then

so

resistance

falls

"

heart

with

if the

doses

seem

therefore

fractional
are

parts of

increased

that

the

alcohol

heart

if alcohol

is

is
a

the

accelerates

soon
cause

poisoned.

It would

arteriosclerosis

of

this is not
careful
And

find

no

Mitchell
1

by way of excessive arterial tension. Lancer

experiments also were
negative.
if we
turn
to the clinical side of the enquiry we
stronger evidence
Bruce

to connect

James
(loc.cit.),

alcohol with

Barr,2 and

flow,

eaux's

shall

arteriosclerosis.

Cabot

agree

with

other
others,
experimental facts see, among
Dennig and
papers,
Blutdk.," Deutsche Arch. f.klin. Med. Bd. xcvi. He. 1 and 2; Kochmann,
Deutsche
med. Wochenschr., 1905,No.
"Alcohol
and Blood
24 ; Brooks,
Pressure,"
Journ. Amer.
Penn.
Bull,
xviii. 70.
and
Univ.
Assoc., July 30, 1910 ; Wood
Hoyt,
2
Barr, Sir J., Brit. Med.
Journ., July 1, 1905.
8
Journ.
Med.
Cabot, Amer.
Sci., 1904, vol. xliii. p. 774.
For

"Alc.u.

CAUSES

248

under

drunkards

abuse

drunkards

pointed out
cirrhosis

that

of the

one-third.

frequentfeature
out

their

per

will be

822

allowance

liver

in the

of

more

than

normal.

arteriosclerosis

in

Brault
of

cases

conspicuous. In topers of all

thickeningof the radial artery only in
opinion is that arteriosclerosis is not a
and
alcoholic cases
of generalhospitals,

was

found

no

not

Herz
of Vienna
agrees with him (loc.cit.). Max
circular to
Austro-Hungarian physiciansinviting

opinionas

received

select

we

cent;

incidence

Mott's

Dr.

Andrewes

the

Bruce

Dr.

sent

negativeopinion. Cabot,

arterial deterioration

of age,

of arteriosclerosis to be

incidence

Dr.

years

the
taking all drunkards
50 per cent : and
conversely,in well-marked
notable
arteriosclerosis
found
he
no
prevalence
Fahr
of alcohol.
(loc.tit.),in 309 necropsieson
the
in the harbour
Hospital at Hamburg, found

of

ages

50

about

only in
prevalence was

found

cases

in

PART

statistical tables, reports that, if

his valuable

from

ARTERIOSCLEROSIS

other clinical observers

Crile and

of

OF

certain

allegedcauses
replies.In such a

to

useful

has to be made

of arteriosclerosis
crowd

of witnesses

he

great

for the various

and
spheresof practice,
impressions; but some
pointsseem

for

personalprejudicesand
to come
out
saliently.Alcohol ranked in the third column, not
high. The vineyard folk, who drink heavily, and the
very
much
for even
the children drink
spirit,
peasantry, who consume
brandy, proved not to be especiallyliable to arteriosclerosis.
low ; but the mass
of the people cannot
out
Gluttony too came
attain to gluttony,and the returns
did indicate a prevalenceof
arteriosclerosis in the trading classes.
I have
For many
years
of
finds in cases
pointed out to students how commonly one
alcoholic
cirrhosis
even
potatores (as Wepfer says) qui
gurgites et voragines de poculorum magnitudine
tanquam
that the accessible arteries are
certent
quite soft, and the
blood pressures
by no means
high. And after death, as many
also testify,
other observers
little is to be found
of lesion in
the main
arteries but
trifling
superficial
patches
spots and
of
Aubertin's
fatty degeneration. Therefore
explanation
that alcohol causes
arterial disease indirectlyby excitingthe
"

"

"

"

1
"

Bruce, M., Lancet, March

23, 1901.
Atiol. d. Arteriensklerose," Wiener
Herz, Max,
"

44, 1911.

klin.

Wochenschr.

No.

CHAP,

ALCOHOL

iv

wanted.

is not

adrenals

before,

gators
Egyptians and Orientals,as we learn from investithese lands (Elliott
Smith, Buffer, and others),peoples
been for ages sparingboth in the use
to have
suppose

in
whom

we

of animal

of alcohol

and

liable

extensive

to

arterial disease
observe

assertion

by settingup constriction
of copious bibbers, can
increase

of blood

arterial

pressures

is

rather

associated

alcohol

that

p.

venous

then

is not

potent allyof

any

cause

other

persons

who

Huchard

in

arteries ; nor,
him

and

if

and,

poison which

respect

Traube

that

be, raises

may

the

plethora

drunkenness

veins

lose

domain

in eminent

"

them

arterial disease

alcoholism

side ;

in

follow

injuriousit
In

44).

in

causes

with

agree
however

found

then

cannot

sedentary habits, the

voluntary muscular machine.

Alcohol
a

We

He

early as

as

with

the

motor,

lives."

we

(see
the

.on

their

of the smaller

mass,

very

"

abstinence.

confident

still are,

sclerosis.
arterioprecocious decrescent
pilgrimage,Dr. Buffer made
who
certainly had
persons

even

in

Orientals

as

were,

frequent and

as

such

no

his

and

alcohol

touched

never

food,

During a Mussulman
800
necropsies on

than

more

is

remarked

I have

Conversely,as

ancient

the

in

249

be

their

"

main

but

it

be in co-operation

may

Vaquez thinks that alcohol conspireswith other

and vessels of heavy beer drinkers.
to injurethe heart
causes
The beer drinker, again,suffers from doses of arsenical poisoning
which through the healthy man
would
pass nearly or altogether
harmlessly; the whisky drinker suffers from traces of lead in
he
the tap water
which
adds
his glass,but
which
leave
to
with

other

it.

and

Thayer
effects

of

decrescent
limbs.

limb

or

observed

that

rich meat

alcoholic

under

alcoholic drink,

diet

are

than

gormandising teetotallers

gross

feeders

So

likewise

habits

the

physicallabour, and again,more

typhoid fever, were
greatly multiplied. This is
and
of
it may
be chieflymedial
or
arteriosclerosis,
that
the facts of experience,I think
And, on

other

virtuallyor

unscathed.

water

same

arteries of

greedy feeders,if to
wine

the

Brush

the

on

widely,
the

of

consumers

have
even

Thayer

turned

to

they

more

add

liable to

indeed

an
"

high tension

in recent

strict abstainers.
and

Brush,

Amer.

Journ.

years

in alcohol, some

moderation

Med.

of

abundance

Sci., 1904.

many
are

"

CAUSES

250

OF

ARTERIOSCLEROSIS

PART

of
gliblyas alcohol,is declared to be a cause
and
his school, who
have
arteriosclerosis,
especially
by Huchard
into a serious and
erected
Tabagism
polyphasic malady ;
Cohnheim
disbelieved in the
though on a slender foundation.
In
allegedsclerosingeffects of either tobacco or alcohol.1
the first witness
have
been
to
seems
Germany Traube, who
Schrotter,and Klemagainsttobacco, and after him Erb, von

Tobacco,

as

"

"

looked

have

perer

of arterial detobacco
generatio
cause
as
a
upon
thinks it injures
the abdominal
preferentially

Ortner
vessels.

No

affected

with

arteriosclerosis ;

coincidence

arteriosclerosis in
so

facile

must

of

it be much

of

are

arteriosclerotics

as

be

profoundly
especially

many,

also

are

the

But

largeone.
and

effect.

the

many,

frequency of

is sufficient to make

cause

poison,is a

smokers

many

smokers

elderlywomen

connection

with

meet

we

circles ; and,

in German

normal

doubt

Moreover

us

pause

in

tobacco, if

slow

poison,at any rate to most

ditions
persons ; so that its effects,being mingled with the other conof senility,
almost impossibleof discrimination.
The
are
late Dr. Dixon
Mann,2 a careful and thoughtfulobserver whose
death we are now
lamenting,collected many
opinionsto the effect
that

the

not

less

was

of

of tobacco

use

very

resulted

in arteriosclerosis ; but

he

was

difficult. Edgren
ready to admit that proof was
very
opinion that tobacco had no permanent effect on the

vessels.

Dr. Mitchell

the

heart,

Bruce

that, apt

says

as

is tobacco

to

order
dis-

"

gravely, it does not, in my experience,

produce either enlargement of the heart (i.e.no abiding high
C. A.) or thickeningof the arteries."
Renon
holds
pressures"
the same
opinion,but less decisively. Dr. George Oliver 4 is
unable
that
to
arteriosclerosis is
more
frequent in
say
even

"

habitual
smokers

smokers

(he)had

Lancereaux5
alcohol
The
indicate

and

than

in

non-smokers

failed to discover

(p. 247) excluded

any

and

in

the

great

of this disease."

evidence

from

some

list of

causes

both

tobacco.

researches
that

the
1

nicotine

by Professor Langley and his pupils

and
rises of
drug produces vasoconstriction

on

Cohnheim,

Syd.

Soc.

Edn., vol. i. p. 67.

Journ., Dec. 5, 1908.

Mann,

D., Brit. Med.

Bruce,

M., loc. cit. Luml.

Oliver, Clin. Journ., Sept. 16, 1908.

Lancereaux, Mid. Soc., Paris, June

Lect.

1908.

CAUSES

252

AKTEEIOSCLEROSIS

OF

PART

extraordinaryprevalenceof arteriosclerosis. Dr.

not
obliterative arteritis,"
Parkes
Weber,1 it is true, speaks of
of them
in poor Russian
Jews, many
as
syphilitic,
prone to occur
ad libitum.
cigarettes
engaged in tobacco factories,who smoke
The ancient Egyptians (p. 249) presumably did not smoke.
although
Obesityand high pressure have little in common,
in the
in diabetes a low pressure
arteriosclerosis is frequent,even
have their origin
As both hyperpiesiaand obesitymay
young.
in gluttony,so they are apt to meet
in the same
person ; on the
manifested

no

"

other
old

hand,

have

persons

like the

rest

observed

Basch

von

as

quite soft

of their

Marienbad,

at

arteries and

muscles, tend

pulses;

rather

to

fat

many

their hearts,

want

of tone, to

hypertrophy. There is
of two
inconstant
variable.
and unknown
Fat people are
some
main
kinds : the hereditary,often flabby and rather anaemic,
tired ; and the big
soon
malmsey-nosed feeders, who have
abundant
blood and often,if not hampered by fat,great energy
;
flaccidityand

deterioration, than

to

"

"

the blood

normal.
above
pressures of these persons do often run
Chokstercemia.
The presence of doubly refracting
(anisotropic)
"

fats in the

products of atheroma has long been well known ; but

recentlyit has been suggested that cholesterin is no accidental
element
is
cholesterin
in the process.
It is suggested that
concerned
with the fatty streaks and
essentially
spots in the
vessels after certain infections,
after typhoid fever for instance ;
and it is asked
It is said
if these are
?
atheromatous
strictly
that they have
the connective
not
hyperplasiaof atheroma
;
and
that
in
but
not
swollen
again,
they present
persons
young
Some
that the relations
degeneratedcells of the intima.
suppose
of cholesterin
is
is

to

the vessel walls is altered

depositedpassivelyin
a

chronic

more

again take

atheromatous, and

are

not

to

Wacker

wear

and

and
Hueck

the arterial tissue,while

disorder

the broader

of

view

cholesterin

that the

that these and

tear

and

gave

that this substance

so

Others

metabolism.

fattyspots of the
ordinaryatheroma

strain, but

pure

arteriosclerosis

to

cholesterin

the
to

infections
are

due

cholestersemia.2

rabbits

"

15

grms.

Weber, Parkes, Lancet, Jan. 18, 1908.

Path.
See, for instance, Wacker
of the Munich
Hueck,
u.
Inst., in Munch,
rncd. Wochenschr., Sept. 23, 1913 ; also Zinserling,Zeitschr. f. Pathol. Bd. xxiv.
H.
14, quoted Deutsche
med.
Wochenschr.,
1913, pp. 1695-6.
2

CHAP,

OBESITY.

iv

cholesterin
obtained

in

3000

CHOLESTER^EMIA

of oatmeal

grms.

in

atherosclerosis

true

253

and

"

these

that

say

animals

thus

they

also that

two

whom
they quote, obtained it independently
physicians,
in the same
certain
experimentalway.
They also administered
and
in five months
toxins whereby they obtained
cholesteraemia,
Besides free cholesterin in the blood they found much
atheroma.
Russian

The

adrenals
;

in the serum,

esters

as

more

that

in

; and

the

that

injuryof

of

that

dyspnea
However

whether

its
and

of these

in cholesterin
of

excess

ficiency
de-

organs

the

is

stress.

They

did not

find any
disease ;

of pressures

excess

present in the blood

or

from

absent,
one

case

or

to

with

in

reaction

still,to

say

cholestersemia.
relation between

constant

that

in

arteriosclerosis,

not, cholesterin
that

and

farther

go

connective

to

as

of

matter

association

arterial

and

metabolism, and,

degree

without

Cantieri

great fluctuations

be

always rich
adrenin
produce

to

excision

cholesterin

is not

with

of the liver.

sympathetic (chromaffinsystem ?)
cholesteatosis.
They think that muscular

time

cholestersemia

cholesteatosis

injectionsof

blood, and

produces a local
activityinfluences
hyperplasia, that
durations

as

said, in the cortex,

are

moreover

cholesterin

and

in the

another, or

there

serum

in the

even

be

might

are

same

in the whole or the sick,depending on

quantities,
In nephritishowever
he found cholestersemia usual, even
diet.
if without
high pressures ; and otherwise that there was
no
cholesterin.
relation between
and
On
feeding man
pressures
with cholesterin no rise of pressure
appeared.
Saltykow,2 still later in date, published an elaborate paper
based on experiment on rabbits.
He began by statingthat the
rabbit's aorta
is capable of true
of a very
atheroma, by way
tenuous
layerof connective tissue under the endothelium, which
undergo hyperplasia,and show sudanophile granules and
may
largerfatty particles.Saltykow found that to obtain definite
results fat must
be fed to the rabbits with proteid; he used milk,
the

person

which

contains

cholesterin

; this he

doubly refracting
lipoids") by the vasa
The
cholesterin
is then
deposited,and
secondary reactive process takes place.
1

Cantieri, Wien.

Saltykow, Ziegler'sBeitrage, Bd.

klin.

Wochenschr.

is carried

thinks

vasorum

about

to

the

the

vol. xxvi.

aorta.

deposit

remarkable

In

Ivii. H.

(" fats and

p. 42, 1913.
3, Jan. 20, 1914.

consent

CAUSES

254

yolk of

fed with

of rabbits

in the aorta

PART

and

egg

brain

substance,
"

of the
produced is not
type," but is morphologicallyand microchemically
atherosclerosis.
with human
Saltykow however admits

affirms that the aortic lesion thus

and

adrenalin
identical

factors
co-operative

that many

that in

and

man

but

enormous,

forced

small

that

arteriosclerosis

simply

observers, and

be

pressure

Steinbiss,regard

of

disturbance

as

suffice to

not

suffice if the blood

doses

Kussian

The

up.

would

given in experiment are

the doses

says

in arteriosclerosis,

concerned

are

diet rich in cholesterin

Anitschkow

produce it.
also

also reports identical results

Anitschkow

observers

other

with

ARTERIOSCLEROSIS

OF

and

metabolism,

phase ; for my part, I

variable
think in arteriosclerosis it is impossibleto overlook
a
but often decisive connective
periments
hyperplasia. In Saltykow's exless.
the media
more
or
always participated
Faber

that

seems

there

16-17

to

up

"

contain

should

aorta

it

vessel

normal

the

artery contains much

atheromatous

The

reactive

of any

convinced

is not

only about

more

parts

per

thousand.

large accumulations
of haemolysis
?).

of it may
Cholesterin

and salt have.

the escape into the tissues which urea
thinks that if cholesterin,
soluble,is
being slightly
"

and

plaques d'atherome,"

try

to

dissolve

In

the

blood

in the
the

it away
the

several

normal

not

direct relation between

cholesterin

of

when
defective

in the

excretion.4

cholesterin

metabolism

Anitschkow,
Wochenschr., Jun.
2

Lemoine,

Bull, de la Soc.
3

See

cholesterin
blood

rise of

blood,

the relation

is various.

content

more

Med.

to

In

(p. 505).

old

small ;
persons

There

less.3
and

pressure

be not

des prat., Sept. 1, 1913,

des Hop., 1912, No. 28.

Linossier, Arch,

should

is

no

the amount

ease,
said, in renal dis-

high pressure but of

The liver,not the suprarenals,
regulates
(Aschoff,reportedto me by Dr. M'Nee).
seems

N., Ziegkr's Beitrdge,Bd.

11, 1914.

Gaz.

but

I have

as

save,

depositedas

is very

content

Lemoine

of calcification

say

cholesterin

tissues the

contains

blood

some

as

occur

has not

we
arteriosclerosis,

causes

But

hyperpiesisis

in

nor

normal

the

in the blood, unless the

cholesterin

of

proved excess
when
kidneys are failing,
(with,I suppose, an excess
any

two

arteriosclerosis

in

neither

cent

per

cholesterine than

more

des

Quoted Arch, des maladies du

4
Cantieri,C., loc. cit. The

maladies
cceur,

oct.

de

of

Ivi., 1913;

quoted

Deutsche

med.

journals.

Also

and

in other

Fapparat digestif,etc., mai

1912.

1913.

followingpapers

also, among

many

others, may

PLETHORA

iv

CHAP,

bolism
appreciateperversionsof metaand
enquire if there be
consequent toxic issues,we must
and an abiding
condition as a true plethora,a considerable

Plethora.

such

But, before

255

"

of blood

excess

we

can

(p. 44) ; and,

mass

if so, whether

or

no

mere

In my
mechanicallystrain its vascular continent.
that
the subjectl I assumed, a little carelessly,
first papers
on
such a condition might grow, and by distention might strain the

repletioncan

cardio-arterial

tree.

But

afterwards

I remembered

that

Cohn-

"

plethoravera," save as a transient

be, or cannot
modulation, cannot
persist; that any such excess,
as, for instance, in experimentalhydrsemia,is promptly shed off
contested
both this opinion and
by the urine. Krehl however
the validityof the experiments,good up to a certain point only,
heim

and

which

on

Roy had said that

it

based.

was

There

is

some

evidence

that

when

bulky hydrsemic blood all the tissues are saturated, and

in the urine,
the kidneys are torpid,so that albumin
may
appear
if alreadyhigh,may
blood pressures, even
be forced up.
Anaemia
and cyanosisalike irritate the vasomotor
centre, but in ansemia
vascular
friction is less. This point is considered
also in my
that the
chapter on Viscosity(p. 148). And we must remember
capacity of the whole vascular system is very great, perhaps
25 per cent
volume.
As the bulk of the
largerthan its mean
blood increases the veins fill; and conversely. On injection,
say
with

blood, the rise

of defibrinated

but the

is transient

is continued;
long as the injection
that if the heart keep up, the velocitymust
increase.
As the
so
of fluid the peripheral
the excess
vessels expand to
receive
resistance falls. Bellingerand
his disciplesurged that fluid
surfeit was
not only possible,
but, as in beer drinkers,not rarely
reached
to tax
the heart and vessels beyond
as
so
high a mass
their capacity. In these patients however, by lowering the
and
tone
quality of the myocardium, the alcohol co-operates.
Vaquez, in his descriptionof Polycythsemia rubra, emphasised
the impression of the clinical observers
(e.g.of Bollingerand
The
established.
become
others)that a
plethoravera
may
venous

pressure

"

rises

of arterial pressure

so

"

Ellis,Fraser, Gardner, Proc. Eoy. Soc., various

papers,
1908-12
J. W., good summary,
Quart. Journ. Med., April 1914, and
; M'Nee,
Oct. 1914, pp. 72
letters to me,
July 1914 ; Elliott, T. R., Adr. Cortex (ibid.,
and
83). Grigant, many
chieflychemical, C. rendus Soc. biol.,1913.
papers,
1
Hunterian
Lectures, 1896.
Soc., 1894, and Lane

be

indicated

Doree,

Senator,1who

late Professor
at

opened

plethysmographic and the

plethoravera does happen ;

PART

discussion

Congress in 1909,

Buda-Pest

the

ARTERIOSCLEROSIS

OF

CAUSES

256

Smith

this

subject
himself,by the
on

convinced

Haldane-

methods,2 that

only in Polycythaemiarubra
I may
indicate here
which
Geisbock's disease
and in
briefly
P. rubra without
as
enlargement of the spleen but also with
and hypertrophy of the left ventricle.
blood pressures
enhanced
it does not concern
as
Lymphoid metaplasiaof the marrow,
my
and

not

"

"

"

"

table of

in which

cases,

eight millions

six to

indeed,
cells may

that in

know

we

; yet in many

volume

though usuallyregular,prone

blood

normal

about

pressure

Geisbock

cases

own

the

excessive,and

Lucas
extra-systoles.

to

in

is raised

pressure

his

of

did, in fact,find the arterial pressures

blood

regularparallel

no

corpusclesand the blood pressures ;

the red
the Vaquez-Osler (splenic)
cases

stillwith
millions,

ten

over

run

heart

of

found

He

more.

or

number

the

between

and

18

3 contains
ing
a
very interestpaper
the red corpusclesranged from

Geisbock's

I omit.

argument,

the

says

the

of

one-third

pulse,
of

cases

erythraemia. In 50 per cent (ofall the cases) traces of albumin,

It is scarcelyout of place to
less slight,
noted.
more
or
were
class of
how
like to my
to point out
digressfor a moment
of the cases
Geisbock's list. Take this,
on
Hyperpiesiaare some
for instance
Male

On

headache.

and

days

later it

120.

Red

grew

worse

Red

54.

aet.

faced.

pressure

Dizziness

200-210.

pressure fell to 156, and two

Nitrites reduced
it still farther,ultimatelyto
blood

venesection

150.

was

Blood

after

bleeding,still ten million ;

Urine
normal.
whites
The
9680.
including rise of
symptoms,
bleeding,and this from the radial
; but a second
pressures, returned
artery, relieved the condition greatly,and for ten days the blood
But again they rose, and the patient
120.
pressures ranged about
pressures

cells however,

for

continued,
artery
1
2

C02

was

method

that

the

120

improvement

much

returned

man

its coats

diarrhoaa

when

months,

to

opened

is

They

weight
3

so

days

seemed

to

work.

but

to

trustworthy,as
find that

body

blood

the results
volume

in,

set

on

then
When

the

are

is

inconsistent

are

not

; and

f. klin.
vol.

x.

and
radial

sure

normally proportionate

not

vol. Ixxxiii. (1905) p. 396.

Quoted Janeway.
p. 567, 1912.
Med.

that

they give

surface.

Arch.
Geisbock, Deutsche
Lucas, Arch, of int. Med.

which

followed

normal.

Senator, Polyzythamie und Plethora, Berlin, 1911.

(Dept. Path., Oxford, 1913)
Dreyer, Ray and Walker

reasons.

three

moderated

ten

to

the

other

body

CHAP,

PLETHORA

iv

In Dr. Hale

which

remarkable

was

be

to

three

times

whites

the

and

White's

257

"

the blood pressures were

normal,"
the volume
of the blood (said
considering
cases

the normal, the red

also

in

pressures

were

over

200.

the normal,
the

Stahelin,2 under

excess.

Polycythaemiahypertonica records
blood

cells double

In

seven
none

cases

of these

title of

in which
the

was

the

spleen

more
enlarged. Geisbock's varietyof the disease seems
prone
I
i
n
have
to high pressures
made
unfortunately
Hyperpiesia
;
no
(See however p. 308 note).
corpuscularcounts.
let me
In the next place,
report certain evidence which Hart 3
The author says
produces from the side of morbid anatomy.
that in the corpses of certain persons, at an age of full vigour,he
finds an obese condition, but powerful muscles therewith, and a
There is oedema, but the body is charged
strong bony frame.
the arteries also, with an
overflowingdark
throughout, even
violet blood.
Both
right and left ventricles are enlarged in
condition for which no ordinarycause
muscle and in capacity,
a
be found.
The kidneys likewise,though structurally
normal,
may
are
hypertrophied. The spleen is full of blood and somewhat
tough,but not otherwise altered. The systemicarteries,beyond
increased
an
capacity,present little or no change ; but the
pulmonary artery up to its finest ramifications is affected with
In
atherosclerosis.
the pulmonary artery and
its
one
case
not
atheromatous.
The
branches, though much
dilated,were
of the longbones presents a lymphoid hyperplasia. Hart
marrow
the great capacityof the systemicarterial
pertinently
compares
system, whereby it can adapt itself to variations of blood mass,
with the pulmonary arterial system, which
is not endowed
with
the same
vasomotor
capacity,so compensation of excessive
friction can
be met
only by the capacityof the lungs. He also
emphasises,what other observers have recentlyshown, the wide
limits of distensibility
But, says
possessedby the normal aorta.

Hart,
the

the aortic side the increased

on

the vessel
1

2
3

is

it seems
to be
resiliency,
not
only enlargedin lumen,

but

is not
true

obtained

for age,

still,
age

The blood volumes

were
Hale, Lancet, Jan. 6, 1912.
method.
Smith's
Haldane
and
on
Douglas
Stahelin, Berl klin. Wochenschr., Jan. 16, 1911.
Wochenschr.
med.
No.
Hart, Deutsche
17, April 25, 1912.

indebted
VOL.

at

development ;

measured

White, W.

Dr.

by

of

expense

diameter

Gordon

to
I

Hart's

much

am

paper.
S

OF

CAUSES

258

than

AKTERIOSCLEROSIS

PART

its

from
the
ordinary elasticity
; and
be made
to
aorta
as
a
a
cognate development in
guess may
the whole tree, or at any rate in the vessels of greater magnitudes.
of a morbid
These independent observations
anatomist
in the presence
of great interest in explaining how
of
are
high blood pressure and cardiac hypertrophy the aorta may
be
free from
disease, an
apparent anomaly which, in the
subjectsof chronic Bright'sdisease has often arrested
younger
less

no

possesses

attention

my

the

on

table ; and

post-mortem

this I

to

think

all observant

pathologistscan bear witness.

Strasburgerl also
has recentlydescribed this quasi-normalhypertrophy of the aorta
and
under
such
similar conditions.
In one
of Strasburger
's
a
weighing 26J stones, the aorta, when
huge man
cases,
submitted
of Hg pressure, showed
to 40-240
mm.
a distensibility
of

86-0

that,

for

age

limits than
blood

of 80-160

pressure

minute- volume

of

Walker

no

have

shown

in

ten

mm.

of
activity

body

since that

increase

the bone

of

cases

itself as

marrow

which

it entails.

the ultimate

by

In advanced

and

failure of

several

increase of blood

volume

his

reasons

drunk

are

the

is that
and

diabetes

in diabetes

got rid of

with

June

the

excessive

the

the
to

thus

can

in

as

thirst

reference, but

of Physiol,

as

bosis
throm-

as

this limit of cardio-

reasons

the

Ainley

by the state of the

the circulatory
system
Like

here,

Hart

suggests that the

physiologists
that

assume

persist
;

insipiduslargevolumes

probably precedes

without
by Hart
conclusive
paragraphs.
2
Dreyer and Walker, Journ.

Quoted

and

varies

area

course,

sooner.

but

the less.

Dreyer

Hart

much

so

the

man,

that, accidents such

capacity is reached the

however
he is indisposedfor
aqueous

but

in

mean

the size of the aorta

correlated

of
life,

renal

mere

much

text

our

be

may

in

tensile

narrower

than

its sectional

apart, life is imperillednot

blood

lower

output being so
the

than

accordinglythe

woman

direct relation between

In the

vascular

has

woman

; and

weight or height of

bodily surface.
blood

man

wider

cent

per

28*5

was

Strasburgerdemonstrated

of

aorta

its diameter

74-78

were

like manner,

averages
of cardiac

that there is
the

In

the

age,

that

pressure

adds

man

average

and

that is,its tensile limits

c.cm.,

the

At

c.cm.

of

diabetes
and

probably

12, 1912.

one

of

water

mellitus,

imbibition.

with

all

the

CAUSES

260

"

amputations

abundant
these

"

OF

conditions

if

that

and

should

so

an

be

more

of

accumulation

the arterial pressure.

might aggravate
it stated

seen

PART

by vasoconstriction,and

in pressor

I have

ARTERIOSCLEROSIS

that

in

the
polycythaemia

dicrotic

wave

wholly suppressed; if this prove to be true it will be very

is exaggeratedafter
this wave
all know
how
we
as
interesting,
right,some
haemorrhage. There are on record, if I remember
that waves
the
on
experiments by von
Frey which showed
descending limb of the sphygmogram vary inverselyas the
fluid. Guinea-pigsare
said
specific
gravity of the circulating
is

to

show

dicrotic

no

I have

hesitated

not

Hart

in

this way

coordination

fault

by

at

length upon this part of the

some
important lightmay

regrets the lack of clinical data,

clinical data
I confess

to dwell

I think

subject,because
come.

wave.

of my

with

the

The

own.

or

at

pathological
;
which

cases

rate

any

and

of those,

"

have

confess to the omission

to

find in them

of blood

of red

counts.

here

called

I have

kind as those, or some

Hyperpiesiamay be of the same
described by Geisbock, cases, that is, of
plethoravera
polycythsemia,hypertrophiedheart, and high arterial
but without the splenicenlargement of the Vaquez cases

of

"

with

pressure,
; and I

If hereafter

we

cells,my

hyperpiesiacases
may
rank with those of Geisbock
(but see note, p. 308). Polycythsemia
in
rubra
which
the spleen is enlarged,but in which
the heart
is not
falls into another
disease, and
enlarged, is a rarer
As
I write (in July 1912), a woman
of about
category.
50 with
an
enlarged spleen and eleven million reds is under
the

care

her

skin

an

excess

of

Arthur

Mr.

Cooke

of

Cambridge

although

is

deeply and universallyreddened, and her very

large,slightlythickened, curved radial (and other accessible)
arteries stand out visibly,
chokeful of blood, yet I cannot
satisfy
myself that her heart is hypertrophied,and her blood pressure
about
120.
at
Here
the ringer estimate
ceptive,
deruns
was
very
for

high.

to

Monro

the

and

touch

Teacher

the
l

blood

pressure

have

seemed

very

publishedan interesting
paper
based on
three cases.
In one, a mixed
with enlargement
case
of the spleen,the pressures
and the
ranged from 180-200 mm.,
radials were
thick.
The kidneys were
smooth
the surface ;
on
1

Monro

and

Teacher, Lancet, April 12, 1913.

CHAP,

INTESTINAL

iv

and

the cortex

POISONS

diminished, but

glomeruliwere

healthy kidney intact, and

261

the reduction

there

attributed

by the
negative.

was

No

occlusion.

much

was

R.
: Wa.
syphilis
Let us now
proceed to consider certain
AutogeneticToxins.
toxic substances
supposed to be generated within the body by
metabolism.1
In one
some
perversion or defect of its own
have
heard, especiallyin France, a little too much
sense
we
of them, for their very existence is as yet largelyhypothetical
;
in making use of them, in explanation
not as yet justified
are
we
and in therapeutical
doctrine, as if the processes
were
definite,

authors

vascular

to

"

and
page

the

substances

of such

rise to
of

familiar.

guesswork as

"

Yet

due

"

auto-intoxication

"

to

we
a

page
metabolism
faulty

sentence

with

meet

which

in the

kind

is

after

giving

present

of talk which

mere
knowledge
verbiage,or a
bears no scrutiny. Moreover, all these speculations
confused,
are
if not vitiated, by the lack of discrimination
between
the two
modes
of arteriosclerosis
with high pressures,
and
the mode
consequentialupon them, and the primary mode, without high
We
shall do well to start from
principlessuch as
pressures.
firm ground beyond.
to seek for some
these, and then tentatively
One eminent
sclerosis
author, beginning with the notion that all arteriomeans
high pressures, attributes these primarily to
the action
of a toxin or
the tissues,
toxins which, irritating
provoke a wasteful metabolism, and thereupon a call for larger
suppliesof blood, so that the capacityof the heart is increased ;
and so on.
Others argue about bacterial decomposition in the
bowels with production or disengagement of poisonous or toxic
substances hence, continually
absorbed
into the body.
or
fitfully,
Others again believe that the fault lies with some
organ, such as
the liver,which
fails to purify the products, or
prevent the
metabolism.
perversion,of normal
In respect of overfeeding,
it is said that the chemical affinities
of the tissue cells are strongest for proteins,
less for carbohydrates,
least for fats ; and
it is suggested accordinglythat order in
the issues of proteins,
whether
or
as
concerns
excess
perversion,
is more
hydrates
of carboimportant to the body than in the issues
in
and
fat.
It is therefore
the field of protein

state

our

"

See

historical

Dr.

Cowan's

notes

and

careful

article

Simnitzky,

in

the

Zeitschr.

Practitioner

f. Heilk.

for

vol. xxiv.

Aug. 1905,

with

OF

CAUSES

262

ARTERIOSCLEROSIS

PARTI

physiologychieflythat observers have engaged in the search for

to arterial
bodies, hypertensiveor poisonous,apt to be injurious
of the research is that the bodily
tissues. The great difficulty
fluids

tissues and
and

the

on

hand,

one

the other the excretions,such

on

as

for instance

as

the urine and

the

serum,

faeces,
are,

experiment ; and of their constituents

at any
virulent, are so
some
rate, and these perhaps the more
The
tests.
unstable
elude
to
as
precise separation and
blood serum,
at first sight a promising field for search, is so
subtly constituted as to be almost beyond the reach of physical
chemistry.1 No pressor substances have been found as yet in the
fluids of apoplecticand other high pressure
cases.
cerebrospinal
of the intestine is capable
Metchnikoff
has stated that the mucosa
of absorbing the toxins produced by three chief putrefactive
in the human
and other
intestine ; but agglutination
anaerobes
far proved
tests for the influence of B. coli in the blood have
so
has laid upon
the
negative.2 The emphasis which Metchnikoff
colon as the probable seat of diffusible toxins is well known, but
still on very uncertain ground. Probably the lower end
we
are
of the ileum is more
to be suspected. Roger and
Gamier,3 in
been
have
to
seem
carefullyplanned,
experiments which
as

wholes,

made

too

extracts

complex

for

of the intestinal contents

at

several

they injected intravenouslyinto dogs

Extracts
from
unless it were
the large intestine,
the caecum,
less injurious
proved much
; those
extracts

levels
but

did

virulent.

more

neutralise

not

lung

also

dose

of the extracts

moderated

that of the extracts

milk

it ; to

diet

pass

reduced

them

levels ; these
and

those
from

their

through

rabbits.

the

their

from

higher
toxicity,
liver

much
that the
so
so
activity,
three
injectedinto the portal was
The
injectedinto a peripheralvein.

or

lethal
times
toxins

But
in these
apparently albuminoid, and very unstable.
mainly biochemical experiments the factor of arterial pressures
dealt with.
Lubarsch
not
was
reportedthat feedingrabbits for
aortic degeneraliver produced the well-known
time on
some
tion
Some
later
of these animals, as under high arterial pressure.
observers, as von
Leersum, have failed to verifythese vascular
were

1
2
3

Manwaring, RockefellerInst. Rpts., 1907.

Goodall, Lancet, Sept. 30, 1911.
Roger and Gamier, Rev. de med., Aug. 10, 1906.
Vide

CHAP,

changes,

but

of

course

blood

POISONS

INTESTINAL

iv

Leersum

von

this

and

prolonged

very

powdered liver)raises

he

(p. 235) ,l and

pressure

that

agrees

(e.g.dried

food

263

found

heart

the

in

the

these

hypertrophied. Stuckey,2 by a rich animal

he produced in rabbits an
diet
flesh juice,milk, eggs
says
of the aorta
with but slightchanges in the
intimal
atheroma
much

rabbits

"

"

media,

identical

form

(an authority
had

he

this

on

rabbits

fed

with

the

subject
animal

human.
has

Fahr
3

reported

diet, and

of

Mannheim

likewise

that

found

consequential
subsequently a
degenerative changes in the intima ; and
degenerativeenlargement, not a hypertrophy, of the adrenal
arteries
and
adrenals
bodies, both
deterioratingtogether.
He
attributed
the degeneration in the aorta
both
to
causes
mechanical.
Steinbiss of Diisseldorf,reports4 that
toxic and
in such
rabbits as can
be kept alive, say for three months, on
albuminous
food, with as littlefat as possible("Eiweissnahrung")
this diet causes
glycosuriaand disease of the aorta, and peripheral
of
effects
identical
with
the
adrenin
arteries,
injection
;
and this the more
surelythe longer the survival.
Many died,
survived ; one
121
but some
to
days. The finer peripheral
the renal (see p. 351), but
vessels also were
sclerosed,especially
those of intermediate
not
so
magnitudes. A very small addition
and the aortic changes
of vegetablefood prolongslife indefinitely,
come
on
gradually,as yellow spots and streaks, resembling
with the
contrasted
more
as
closelythe intimal type in man,
adrenin

acute

wholly alien

type of the
to

such

However
that

these

diet is

so

experiments

crucial.

as

Still,that the daily use

of bacteria

rabbit.

the rabbit's constitution

scarcely be taken

can

on

of

animal

flesh favours

in the

the

growth
Repeated

largebowel is generallyadmitted.
bacteriological
analysesof the faeces,as carried out at the Battle
Creek
that on a change from a flesh to a nonSanatorium, show
flesh diet the number
of intestinal bacteria are
markedly
very
diminished,
1

See

the benefits of this

Leersum,

von

Ther.

und

and

Bd.

Stuckey,

"Alimentare

xi. H.

3, p. 409,

article

quoted

in

change

are

speedilyreflected

Blutdrucksteigerung,"Zeitschr.f.
exp.
Centralbl.

f.

Herz-

u.

Dec.
GefdssJcrankheiten,

1912, p. 399.
3
4

Path,

1912.

Fahr, Deutsche path. Gesellsch. zu Strassburg, April 1912.

Arch. Bd. ccxii. Heft
Steinbiss, Virchow's
1, 1913.

OF

CAUSES

264

ARTERIOSCLEROSIS

PART

and progress of the patient. Spa physiciansof

feelings
experiencewill probably admit that a largepart of their success
disorders is due, not only
in dealingwith gouty and rheumatic

in the

the

to

great

electrical and

baths, massage,
also to

measure

animal

quantitiesof
animal

Now

substantial

the

other

methods, but

diminution

in the

in

daily

food.

extracts

as

class

of
(unless,

course,

taken

from

peculiarparts, such as certain of the inward working glands)are

vaso-dilatin in the mucosa
of the
hypotensive (cf.Popielski's
ments
experialimentarycanal. Stewart1 however, who made
many
with

sufferingunder
dogs, concluded

men

into

occurred

but,

than

more

as

apparentlynot
adrenalin

that

Dale

and

of

and

men

from

he injected
pressures, which
that in some
of them
pressor substances
I have said,faeces are
much
too complex for

as

blood

high

such
appreciations. Moreover
pressor
thus
have
were
betrayed themselves
may
in any degree comparable
not
very potent, were
for

amine

an

normal

from

rough

constituents

with

both

faeces,taken

of intestinal
intense

causes

the

instance.

the

hand,

other

it is true

putrefactionseparated by Barger

bronchial

These

uterus.

effects of this amine,

On

spasm,

authors

and

aptly

strong

tions
contrac-

reflect that

such

poison rather than a toxin, may depend

side chain action, but on
not
on
physicalor physico-chemical
reactions ; on
on
on
solubility,
quality of cell membrane,
to responsivecell constituents,
on
degree of access
adsorption,
and

forth ; but

so

pressure.

is of

course

small

doses

in

minute

it dilates the arterioles and

Barger

differential action

on

thinks

this is

blood

reduces

Popielski'svasodilatin,

the histidine base

factor

so

is very

curious.

This

Dosage

of

importance ; for certain agents, in

stimulant,are in largerdoses depressive. Possibly
doses all protoplasmic poisons may
be primarily
a

stimulant.
observations
Bacteriological
Some

of disorder, such

states

marked

locallyby gas in
haemolysis,are associated
1
2
3

the
with

seem

as

yet

no

less in the haze.3

butyric fermentation, states

bowels, and constitutionally
by
B. aerogenes
capsulatus rather
as

Stewart, G. N., Journ. Exp. Med., 1911.

Barger and Dale, Journ. of PhysioL, 1910.
Biol. Chem., Aug. 1906.
Vide Harter, Journ.

CHAP,

INTESTINAL

iv

coli ; in other

B.

with

than

organisms, while
products, as of

indol

the

intestinal disorder there

vasoconstrictive

265

of disorder
series.
to be

seems

the

are
streptococci

cases

kind

third

POISONS

action, and

In

prevailing

three

these

its

kinds

of

of extensive

great likelihood

no

by

is indicated

therewith

of

high

pressures ;
of a kind to

of them, engender toxins

though they may, some
organisedtissues,such as the arterial tunics. This
upon
prey
evil attribute, as
shall see
we
presently,not a few specific
infections possess.
But
the
less specifickinds, if they do
the
interfere with
arteries,are
operate
more
likelyinsidiouslyto coin the sum
kind of
of effects leading to the decrescent
arteriosclerosis ; for this
"

senile,"for thus it
Work

age.

yet

Medical

Association
"

and
various
by many
specific
origin,in much
Such

toxins

to

"

but

At

the

are

or

and

earlier life.1
we

the

presume

but

do

we

physiciansare

suspect

that

determined

specific

more

whether

know

not

the

of

toxic

in

becoming

certain

kinds

by

diseases

become

and

same

with

of these

the age

are
speculations

Hitherto

then

arteriosclerosis of
attended

with
1

Vide,

to

Thus
of

most

mental

the
as

the

patient.

vessels

elements

find

ourselves

the

decrescent

abnormally high

than

pressures

that

and

may

be due

distributed

form
;

rather

not

but,

to

to

ordinarily
return

med.
Vide, e.g., Saltykow, Deutsche
Wochenschr., 1911.
Robertson, Brit. Med. Journ., Oct. 26, 1906, and later papers.

e.g.,

to

guesswork.
back

carried

form,

influence

all,or nearly all,

However

yet little more

we

ends.

prognosisgrows

the

cases

result

this

blood

in these

abated

more

autogenous

part

Osier's

disposed to
disease, if remotely

more

permanent

done

damage

to

the

the parts concerned.2

the

compass

bodies, for

such

part

worse

of

to

of the nervous
peculiarsusceptibility
the
individual, depend immediately upon

of

when

alone

competent

Alienist

Swiss

perennialcorrosion
initiated,especiallyif of

toxins, often

possess

not

are

as

sclerosis
Senile arterio-

stresses
ordinary mechanical
acting, in Sir William
phrase,upon
originallybad tubing,or upon tubing of

tone,

old

before

is in progress,

published.

obscure

an

the insidious effects

are

infective

to

been

called it

not

occur,

St. Gall in 1911,

Meeting at

attributed

was

have

have

often does

the intestinal anaerobes

upon

definite conclusions

no

and

occur,

may

it is that

reason

to

OF

CAUSES

266

ARTERIOSCLEROSIS

PART

in sayingthat there is no evidence

justified
generationof pressor toxins apt to damage
not
the arteriesindirectly,
by corrosion but by tensile strain ; l
or
perhaps by exertinga twofold influence,both directlybaneful
tissue and
to the vascular
provocative of high pressure ? a
pressor bodies, are we
in overfeedingof any

"

twofold

mischief

with

observers,

Many

which

as

have

we

has been

adrenalin

credited.

seen,2attribute

considerable

neutralising
capacity to the liver. For
instance, rises in blood pressure have been vaguely attributed to
of the blood, and
certainlythe liver seems
fallingalkalinity
able to destroy sarcolactic acid ; on
the other hand, Bayliss
and
from
the intestinal wall
Starlingextracted a substance
which, on intravenous
injection,lowered the blood pressure,
I remember
and this substance
also the liver neutralised.
Roger
and Josue, I forgetwhere
reported,injectedintestinal extract
into a branch
of the portal vein with no effect on
the arterial
of this kind

measure

and

pressures,
obstinate

of

that the liver protects the system.

concluded

In

constipationand in dilated colon the arterial pressures

do not rise.
The patientis usuallymeagre
and sallow, the eyeballs
and
the
orbits
yellow,
hyperpietics
darkly ringed; some
of spare
and
sallow habit, but the majority are
are
plump and
ruddy complexioned. Choline does not raise pressure but lowers
it ; partly by reducing cardiac energy,
partly by dilatingthe
peripheral vessels ; if atropin be previously administered,
by plus output per minute and splanchnicconstriction,the fall is
converted
then
that
to
an
assume
augmentation. We
may
the liver,and
active muscle
stances,
likewise, can
destroy pressor subadrenalin
for instance ; and, by destroyingthem
or
Adrenalin
for regulationof pressures.
sparing them, make
indeed is used up rapidlyin the act of vasoconstriction.3
And,
it seems
as
probable that the liver is susceptibleto nervous
influences,if it be
we
arteriosclerosis,

function
the

1908,

of the

passage
Abelous,
and

may

and

liver may

See

Elliott,Journ.

Abelous
papers

that
guess

of destructors

various
also

true

and

between

emotional
that

in

causes

part,

at

may

promote

any

rate, the

be the seat

of

of vascular

integrity.Thus,

Bardier, Journ.
1906

and

disorder

some

de

allowing
whether

physiol.et path. vol.

1909.

Delaunay, Gaz. hebd. des sci. med., July 21,

of Physiol 1904-5-6.

1907.

x.,

CAUSES

268

ARTERIOSCLEROSIS

OF

PART

pressor
iodothyrin have a deaction.
centre,
Viperinepoisonsparalysethe vasomotor
that the splanchnic vessels are
so
vividly to dilate ; a
seen
fall of pressure which may
be arrested by dividingthe cervical
however
the heart can
still respond to adrenalin.
cord,1 when
Colubrine
poisons affect the respiratorycentre, but much
reinforces vasoconstriction
depends on the dose. Cobra venom
and cardiac tone, but has also a cardio-inhibitory
action, factors
is

supposed

which

obscure

relaxation.
the end,

do ; while

to

each

others

other ;

largedoses

until the heart

2

Eichler

Similar observations

are

to carry

apt

raises blood

over

pressure

into
till

(videchap. Viscosity,
p. 129).
in the serum
of nephritics,
and of

vasoconstrictor

substance

like adrenalin.

publishedby Schlayer; 3 and

Behring, found a poison in the serum
have

Esh,4 working with

v.

of

which

eclampticwomen
Tyrosin, when
tyramine, a pressor

"

fails

(seep. 359) found

nephrotomised animals,

e.g.

is well known,

Asphyxia, as

or

"

been

he identified with

inoculated

with

that of the urine.

faeces,is converted

into

substance

version
nearly akin to adrenalin, a conwhich may
tion
prove to be an important link in the causaof high arterial pressures due to intestinal poisons. Harvey,
has with this toxin proby injectionsinto animals (rabbits),
duced
various
characteristic
from
of
renal
disease,
degrees
thickened
arterioles to general parenchymatous degeneration.
In 15 of them
definite aortic damage was
Some
also found.
of these rabbits were
kept alive for periods from eighty days
to over
of the rabbits was
Out
a
immune.
Only one
year.
of 33, 20 betrayed definite renal disease ; 25 aortic lesions ; 10
cardiac
hypertrophy ; 13 were
negative. The chronic renal

deterioration
which

may

Gaskell.5

seemed
accord

But

due

arteriosclerosis of the renal vessels,

to

with

the observations

the order of events

of Jores, Aschoff, and

differed from

Granular

first,injured aorta, secondly,sclerosis of the

reaction
thirdly,epithelial

general

arteriosclerosis

distended

in the

with

glomeruli,thickened
1
2

renal

11, 1907.

Schlayer, Deutsche

med.

Esh, Munch,

See

Wochenschr., Feb. 19, 1912.

the renal factor, pp. 339 and

my

chapter

on

arteries ;

kidney, and, fourthly,more

further
renal change, such
as
Bowman's
capsule, etc., and

Rogers, L., Proc. Roy. Soc., 1903.

Eichler, Berl klin. WocJienschr., Nov.
med.

kidney :

Wochenschr., Nov.

14, 1907.
351.

INTESTINAL

iv

CHAP,

cell

detritus,round

consequent

POISONS

269

and
infiltration,

connective

new

supplantingthe glandularparts destroyed.

have
not
But
we
yet quite done with the alternative of
toxi-albumins.
Handowsky and Pick,1 of the Pharmacological
tissue

of

Laboratory

Vienna, found

stronglyvasoconstrictive, and
This

after

serum,

All

while

ox

as

proceeded

to

(5-6 days)

became

influence

bacterial

others

serum,

was

have
horse

test

also

done,
serum.

constrictive.
stronglyvaso-

excluded.

The

con-

strictive substance, which

they compared to adrenalin,did not

not
a
globulin. The authors
parchment filter. It was
pass
but due
to
a
disaggregationof
regarded it not as crystalloid
A Petrograd
colloid complex, a change of physical state.
a
2
the same
in serum
(?) substance
which,
physiologist found
it free, applied to the rabbit's
after coagulationwhich
sets
constricted

ear

the

vessels.

The

adrenals

had

been

previously

had

effect. As it was
not
no
extirpated. The fresh plasma
to be
destroyed by boiling,this observer took the substance
perhaps derived from the blood cells.
crystalloid,
of Metchnikoff
and his pupilsseem
The publications
then to
have

done

if with
little,
but

elaborate

great respect
fabric

slender

I may

so, to reinforce

say

of

toxi-alimentary
hypothesis,
clinicians. Huchard's
constructed
chieflyby the French
matic
dogin
cardiac dyspnea for example, to forbid
assertion that,
and meat
all meat
extracts, and to substitute a milk diet, brings
to such foods
relief,and that to return, however
sure
sparingly,
if his rule be verified by further experirecalls the distress,even
ence,
of too many
admits
allow
to
to accept
us
interpretations
the
and so extensively
toxi-alimentary doctrine so confidently
this
it. For
built upon
toxi-alimentary dogma in particular
no
experimentalproof was produced ; not even
analyses
of the urine before and after these prescriptions
analyses
; and
of bowel
dischargesbefore and after colectomies in England
hitherto been perfunctory,and practically
and
elsewhere have
the

"

"

"

worthless.

is but

concerned

looked

with

Society
1

Vaquez,

of

Handowsky

the

interest
Medicine
u.
2

for

instance, declares

quantity
to

of

the

that

ingestedsalt.

discussion,now

a
"

on

"

past,

alimentary toxins

"

Many

factor
of

us

the

Royal
but, ably as

at

Bd.
Ixxi., Dec.
Pick, Arch. f. exp. Path. u. Pharm.
Extract, Zentralbl /. Physiol, 1913, No. 11.

24, 1912,

CAUSES

270

the

OF

ARTERIOSCLEROSIS

PART

introduced
by Dr. Hale White, and profuse
subject was
that the publicationof the
the speeches,so
were
posium
symthe Society"235, yet the gleaning was
cost
scanty.
of various
the behaviour
looked
for experiments on
paratively
comsubstances,not beyond
simple and even crystallisable
"

as

"

We

from
the several areas
of the
separation,derived
canal ; for experimentson their absorption,
physicalor selective
know
nothing); for comparisons of
(of colon absorption we
that of the vena
of the portal vein with
the content
cava,
whereby the function of the liver and the passage of such
substances
from stage to stage in the body might be elucidated ;
chemical

and

so

But

on.

slender

our

array

of

facts

received

little

had
few, of clinical gossip a surfeit.
proofs we
it
is
Dr. E. Mellanby,
substantial
us
true, gave
some
help. The indoxyl group, the treacherous auxiliaries of many
he
threw overboard," as relatively
and laborious speculations,
and directed attention to the amines
innocuous
or
insignificant,
produced by certain speciesof intestinal bacteria by splitting
amino-acids.
With
off C02 from the proteolytic
the jettison
of
the indoxyl series the ordinary conform- organisms,which
have
so
long held our attention,fade into comparative neglect: the
old vague
that tryptophane,
suggestionslose their footing,save
of Hopkins and Cole produced by B. coli,
the indol amino-acid
has a somewhat
remarkable, if slight,
toxicity.
The
products of ordinary septicorganisms being then, so
far as
in noncommon
experience goes, all depressor,even
febrile phases, let us
the hypertensive amine, or
return
to
Now
these amines
amines.
are
perilouslynear, the
near,
of nutrition, and
amino-acids
bring us back to the difficult
and
abnormal
intestinal absorption and
problem of normal
to be the key of the position,1
selection,which seems
but of which
know
we
really nothing. Those
bodies, some
more
pressor,
ingredientsof the intestinal processes,
depressor,are normal
increment

of

"

and

under

some

unknown

conditions

may

in the
intestinal area
body. Vasoconstriction
opposed to absorption. Dogs' urine normally
1

May

Since

this

3, 1913.
See

was

He

written, Dr. Mellanby has made

suggests that

also Mutch,

specificintestinal

Quart. Journ.

the

same

secretions

Med., July 1914.

into

pass

would

seem

contains

comment

may

be

the

the

de-

Lancet,
minants.
deter-

CHAP,

INTESTINAL

iv

POISONS

271

substance, precipitable
by alcohol, which

pressor

in

artificial

point of view of hyperof chief importance; decrescent

are
be in part a result of slow and long absorparteriosclerosis may
tion
of
from
the bowel
depraving substances, neither pressor
nor
depressor; but of such processes we have much conjecture
The
and
evidence.
supposed lactic acid control of certain
no
cannot
escape.1 It
nephritis
piesisthat pressor substances

the

of the intestine has made

bacterial conditions

morbid

is from

which

then

substances

no

way.

activelydepressor
arterial poisons. For the present
as
have, as yet, no recognition
know
ing
we
only one or two intestinal substances capable of affectthe blood pressure, e.g. the ergot-like
body alreadymentioned.
Those

This

basic

substance

must

be

studied

with

are

the

chromamn

secretion

be apt to break
loose from
pituitary,which
may
of the circulation.
In
proper control and perturb the balance
disease of the hypophysis (posterior
lobe) a pressor substance,
which as yet I think has not been analysed, is found abundantly
in
the urine ; and
in these
the
cases
heightened arterial
and
enlarged heart simulate Hyperpiesia. In Dr.
pressure
2
Professor
Dixon
found
10
that
cases
cc.
Humphry's two
of the urines injectedinto a cat drove
the
blood
up
pressure
70-80
Now
similar injection
of normal
urine drops the
a
mm.
It is true
that the big heart of pituitarydisease,as
pressure.
of
adrenalin, is not hypertrophied in proportion to its often
increase of bulk, which consists in largepart of degradenormous
ing
of the increase must
tissues ; but some
be genuine,for the
is usuallyincreased,if
systemic blood pressure in these cases
not
greatly. In Dr. Humphry's first case, though at death the
heart weighed 2 flb.13 oz., the systolic
blood pressure
was
only
160 (Male set. 39). There was
generalthickeningof the arteries.
I have spoken elsewhere
But of the effects of pituitin
(p. 225).
Professor
Hopkins and Mr. Sidney Cole have kindly drawn
attention
to
Slyke and Meyer,3 in which
by van
my
papers
it is stated
that, in protein digestion,free amino-acids, not
into
incompletelybroken down
complexes, are absorbed
any
and

the

the

blood
1
2
3

(see

p.

322).

Their

method

consists

Pearce, Journ.

Exp. Med., 1910, vol. xii.

Humphry, L.,
Van
Slyke and

Brit. Med.

Meyer,

Journ.

Journ.

p,

in

an

128.

vol. ii.,1910, p. 1047.

vols. xii. and

Biol. Chem.

estimate

xvi.

CAUSES

272

(by a specialapparatus
in ike blood and
to

meal

40-50

and

accurate

120

is not

In

nitrogen.

to

mgms.

100

per

This

of meat.

rises to 10-11

cc., and
nor

urea

liver the

the

uric acid

mgms.

nitrogen,
rises from

amount

quently
thereabouts, the high figuresubse-

or

mgms.

PART

technique)of ammo-nitrogen
nitrogenis present in the blood

Such

tissues.

amino-acid

but

ARTERIOSCLEROSIS

of 3-5 mgms.

the extent

after

OF

metabolised
in the liver.
are
fallingas the ammo-acids
Van
Slyke offers proof,from quantitativeconsiderations,that
absorb all of the total non-proteidN ; but part of this will
we
be in acids ; not therefore representing
waste
products. Thus
N can
be carried out.
his estimation
giving us this amino-acid
Deducting this from the total, the rest will be N in the form
and uric acid, which
of urea, ammonia
togetherwould vary as
colorimetric
renal efficiency.Then, if by Folin's new
method
will be urea
and
estimate, thirdly,uric acid, the remainder
we
Thus
when
in high protein feeding N is retained
ammonia.
in the tissues it is not as stored digestionproducts but as body
Slyke'sresearch,not
protein. I have given this sketch of van
is practicable
because his method
in clinical work, but because
it opens
in

horizon

our

and

indicates

clinical method

line of work.

If

succeed

we

of

detecting retention products

in the blood, and of watching the descent of these simplifying
bodies
towards
the
shall have
outwards, we
kidneys and
and its correlations.
something like a key to renal efficiency
Constant," p. 322.)
(See Ambard's
inventinga

"

The

of this part of the argument

sum

is concerned, that
to
to

Abelous
show

others

and

that

offer

by

the

basic

from

one

Another, that

of the active

exercises

coli group,

an

affect the blood

be

pressor

action.

as

One

pressure.

converted,

acid, into

of

them

"

that

tyrosin is chemically related to

powerful, yet produces potent pressor
"

derived

constituents

ecbolic

owe

and

can

substance

the

and, if less

adrenalin
effects.

with

we

clearness

some

protein(e.g.histidin)
may
organisms which deprive them of carbonic

substances

derived

with

which

of

amino-acids

Certain

evidence

sclerosis
arterio-

as

separable crystalline
protein by bacteria, especiallyby a

from

products produced
bacillus of the
specific

is,so far

observations

definite

two,

or

one,

certain

then

weD

as

from

histidin,turns

of ergot
a

pressor

(Dixon
action.

and

out

to

be

others),and

How

far these

GOUT

iv

CHAP,

bodies

their effects,if any,

be

to

of

are

determined.

how

conditions,and

that

these

bases

far

remains

quantitative
importance yet

is true

It

what

under

absorbed, and

are

273

present

are

quantityin the intestinal wall ; but of their absorption,

of the permeabilityof the gut, in health, in disease,in
or
lesion necessary
for their
advancing age, or again of some
know
we
nothing; nor again do we know how far,if
passage,
in small

absorbed, the
lets them

normal

liver modifies

them,

the

or

abnormal

they pass unmodified, the tyrosinderivative

must
especially
aggravate blood pressures by actinglocallyon
the vessels,
lie the secret of the malady of Hyperand herein may
not
piesia. Such poisons,moreover,
only crimp up the
may
but also do some
direct injuryto their walls.
arterioles,
2 rather
Gout.
All these hypothesesLancereaux
scornfully
put
If

pass.

"

away,

evil

and

denied

but

his

less in the

that any

modification

scepticismcarried

influence

him

of diet would

referred the solution of the

disease,and

far ; he disbelieved

too

of infections,even

reduce

the
no

of

in arterial
syphilis,
whole problem in vague

disorder.
I think before his lamented
trophic nerve
death
fallen a
little out
our
distinguishedcolleague had
of touch
with
the subject, work
work
recent
which,
on
incomplete as it is, points at present in other directions.
It is fair however
add
that Lancereaux
to
regarded gout
of trophic nerve
a
as
cause
changes, and herein we
may
find some
The
belief
is
common
prevalent that
ground.
with
arteriosclerosis ; moreover
gout is intimatelyconcerned
Gout is to the
Huchard, in his rhetorical way, propounded that
terms

to

"

arteries what
on

which

are

baffled

rheumatism

to

by

base
the

There

is to the heart."
such

any

confusion

an

which

axiom

and

consists

are

here

no

statistics

again

in the lack

we

of discriminatio

between

hyperpieticand decrescent arteriosclerosis,

and in the obscurityof the nature
of gout itself. Professor
Elliott Smith, in all his experience of ancient
in
anatomy
in
Egypt, met with one
case
only of gout, and this was
the earlyChristian period; though arteriosclerosis,
have
as
we
the
and in all periods. From
seen, was
present abundantly,now
1

Mellanby and Twort,

is probably true

of histidin
2

Lancereaux,

VOL.

Journ.

of Physiol.vol.

xlv.

p. 53.

What

is true

of others.

Paris, Acad.

Med., June

2, 1908.
T

of

days
one

Sydenham

gout

in this disease

occurrence

uric acid in the blood.

of

in

arteriosclerosis
have

we

pressure

seen

its causes,
so
among
successive
generations,

in

individual, or

the

of

kind

common

is this habit

but

arteriosclerosis there

gout and

Between

learned

have

we

namely, from Alfred Garrod,

relatively
large quantitiesof

ground ; as in the
consequent upon persistenthigh blood
to accept overfeeding as
one
reason
is this

PART

present time

the

to

about
principle

new

the

ARTERIOSCLEROSIS

OF

CAUSES

274

presumed to engender gout.

confidentlyand almost universally,
And, broadly speaking, both hyperpiesisand gout are wont
manifest

to

themselves

at

middle

about

or

of muscular

energiesof digestionand assimilation,and

become

urinaryside
has

one

less efficient.

less and

elsewhere, may

or

notion.

any

By

what

But

and

the

exercise,

whence,

peccant bias

be the

Garrod's

life,when

this

on

poison no
discoverysuspicionsof uric
or

deepened almost into conviction, but this relict is

be that
to the quack ; although it may
now
generallyabandoned
to
as
a
as
by-product of gout uric acid is so far significant
is that the specific
of it. The notion current
be some
measure
of gout is of the kind of xanthine bodies,and other purins;
cause
acid

were

that

is, some

antecedent

or

associate

acid.

Both

for uric acid it is true

endogenous purinsand
capacity of dealing with them
and

exogenous

of uric

for
that

(" urikolytischeKraft ")

varies much
in different individuals, and probably at different
other
somehow
of life ; and presumably is connected
or
ages
in certain areas
and the same,
with the oxygenating activity
:
of
or
something like it,may be true for hyperpiesia. Injections

the

xanthine

bodies have

they

or

; however

At

present

we

do

not

found

far been

at
transiently
experiments in this

but

so

more

have

so

no

direct evidence

to

raise arterial pressures,

the moment
direction

of harm

of operation
wanted.

are

done

by,

or

of

Uric acid, notwithstanding

purin retention.
from the body
to be excreted
its frequentinsolubility,
seems

clinical effects due

as

readily as

if toxic
itself,

enough
are

no

in

at

all,one

considerable

See

substances

of the

many

We
papers

cause

may

purins; as
then, if they may

of arterial disease, and

perhaps go

by Hopkins,

Walker

so

far

is indeed

order, and

same

of the less toxic

leucocythaemia.1Urates

in the coats.
1

other

to,

as

are

is manifest
be
not

sign,

found

this, that, if purin

Hall, Langdon

Brown,

etc.

OF

CAUSES

276

which

is apt to follow

blood

and

extent, would

here

to two

cases

under

now

active

already ten attacks

perfectlynormal, and his

Has

of

had

butler

in

for

uratic

deposits.

many

at his
quitecommon
fingerthe pulse is not

pressures

It must

tense

times

at various

be conceded

not

commonly

asserted

arteriosclerosis
as

then

arteries

quite soft.
aet.

feet, olecranon,

at

most

akin.

regardsregulargout, is
at any

ears,

to

have

rate

not

free

than

more

To

the gauge
the
exceeded
never

and

liver.

etc., full of

visible.

even

nor

sustained

that, whatever

editions of his Lehrbuch

51

slightlythickened,
tortuous

allude

yet his arterial pressure

that

somehow

are

I may

regulargout
associated.
incidentally

than

more

nor

and

48, of gouty parentage.

Hospital;

very

age ; not

set.

man,

accessible

Hands,

years.
Radials

observation

podagra

Addenbrooke's

Gouty

to

systemic pressures.
my

settingfree of
cloying,unless of very

such

But

affect

not

PART

is due

treatment

B., a temperate and

Mr.

are

bath

lymph exchanges.

wide

is

ARTERIOSCLEROSIS

high

the

systolic
140.

pressures

However

it

is

the
Yet

pressures, gout and

this vague
even
hension,
appre-

doubtful.

Orth, in the early

cluded
(my copy is dated 1887),con-

spiteof a prolonged and suspiciousscrutinyhe

could not perceivethat gout played any part in arteriosclerosis.
The
writer on
gout in Eulenburg (4th ed.) says the same
thing ; and Ebstein J on the whole is disposedto agree. For
with high preswhether
part I think that arteriosclerosis,
my
sures
is
no
or
a frequent,
means
an
though by
not,
obligatory,
of gout, especially
of irregular
concomitant
first
gout. In my
the subjectof high pressure arteriosclerosis (in 1894),
on
paper
I noted this association of irregular
or
suspectedgout with high
that

in

unable to connect
arterial pressures, but was
the two
processes.
I thought that in this respect podagrous gout differed from the
"

"

Dr. Mitchell Bruce, whose

careful notes
suppressed modes.
the
and digestsof privatepractice
put one to shame, has found
in irregular
than in regulargout
radial pulse more
tense
; in
the arterial pressures
raised in more
than
his irregular
were
cases
in the majority the arteries were
50 per cent, and
thickened.
intermittent
These
patients (men) suffered from irregularfluttering
of them
from anginal and precordial
hearts, and some
faintnesses."
suffered also from
It would
pain ; the women
"

"

"

Ebstein, Gickt, Wiesbaden,

1906.

CHAP,

GOUT

iv

then

seem

much

so

gout

In

vulgar notion

if the

as

as

true, that

were

podagra is,not

relief of gout.

arterial disease

of

respect

277

Dr.

pointed

Bruce

out1

the

frequency in gouty subjectsof degenerationin the aortic area ;

audible in 12 of 29 of them. Aortic
aortic systolic
was
an
murmur
of atheroma.
of course
is rarelya consequence
regurgitation
Gueneau
chronic rheumatism
de Mussy
Under
the head of
"

"

noted
have
the

followed

be,
On

or

itself

gout

course,

equivocal;

but

and

others
and

one,

vague

of such

many

cases

of gouty nature.

are,

then, it
be very

not

may

is, of

name

less

no

doubtless

the whole

forms

The

him.

condition

may

Kosenbach

and
frequency of arteriosclerosis,

yet that

as

appears

conducive

if in

its

regular

arteriosclerosis,
yet that

to

perversionwhich we must for the present be

content
to call irregular,
or
suppressed,gout, are apt to promote
arterial disease, sometimes
by settingup high blood pressures
with consequentialstrains, sometimes
perhaps by endogenous
modes
of decay ; the two
the
toxins, decrescent
processes,
judge by their
regular and the irregular"gout, if we
may
several
issues, not
being identical. In irregulargout the
drive
blood
with
without
or
perversion may
up
pressure,
of the arterial tunics ; in the regular
independent detriment
form
the poison or
attack
these
deranged metabolism
may
tunics directly,
that, independently of any
so
they
pressure,
yield; for we have noted that Mitchell Bruce found the
may
radial pulse more
in the subjectsof irregular
often tense
than
of regular gout." The
facts point to some
vice of
pressor
metabolism
defect of antilysins
rather than to a mere
(Hort),
of
which
stimulins
to growth and repair; conditions
or
might
the kind

or

kinds

of

"

"

"

"

however
mediation
In

for

account

of excessive

rather

in

in the

followingcase

big man,
in very
1

correlation

A.,

set.

blood

than

and

"

pressure.

to

and
be

arterial pressure

high

and

cause

L. Lect,"

Dr. Norman

the

seem

probably

effect,as

large affairs,and

Bruce, M.,

arteriosclerosis without

patient of Dr. Hay ward

and vivacity. He was
energy

68,

full of

decrescent

then, gout

cases

many

Mr.

saw

much

Lancet, March

Moore

have

given

company.
23, 1901.
like

of Wimbledon,

fine

incessantlyengaged
He

did not

Murchison,

testimony.

Sir

hesitate

Dyce

worth,
Duck-

admit

to

that

time

pressures

past

more

headaches,

no

inherited

He

he
lived
regards food, wine, and tobacco
few
Dr.
his
some
Hayward had found
years
about
and
for
shorter
200,
some
ranging (systolic)
as

less of

or

He

sugar.

any

PART

For

generously.
blood

AKTEKIOSCLEKOSIS

OF

CAUSES

278

had

cloud

shown

never

of albumin
any

vomiting,no
gout definitely.His own
nausea

or

in the

urine.

signof

uraemia

retinal

affection,
no

first attack

Never

oedema,

; no

no

drowsiness.

(podagra)was

at

and feet had recurred from time

of 35 ; and attacks in hands
b
I found the systoliclood pressures above
since.
200 mm.,
Heart
and
diastolic near
180.
to
large,
dilate,but myobeginning
cardium
Arteries
thick.
rather
Second
aortic
probably healthy.
the age
to time

sound

ringing at
pulmonary base.
long search failed
uric acid

base

and

There

was

discover

to

apex.

few

ring of

crepitationsat

albumin

casts

any

fine

in the

renal

or

left

urine, but

epithelium.

Some

cells

?),and a shred or two

(leucocytes
of vesicle epitheliumconstituted
all the deposit in drops on many
slides.
This urine had stood in a conical glassfor an
hour
or
two,
and the drops were
taken by pipettefrom the bottom.
If

crystals,one

now

have

of both

with

this

poisoning,the symptoms
least

definite story ;

we

gout,
more

at

or

high pressures and

that
Desplanches

says

first

as

based

of exposure
arterial system

case

the whole

thickeningis

and

to

of which

remarkable

thickening.

drew

attention

necropsies,in
found.

was

lead

affected.

from

semblance
re-

find the rule to

of arterial

four
upon
atheroma
disease, extensive

(loc.cit.)
gives a
The

lead

arterial

result,

renal

set. 34:

find

it,we

Lancereaux1
to

two

kinship with

some

one

to

turn

we

to

be

or

Bureau
Death

set. 15.

There

was

which,

no

gout.

early a phenomenon that

it to be not
must
one
assume
merely the result of strain ;
toxic influence,plumbic directlyor indirectly,
also
some
must
conspireto the result. It is said that in cases
caught earlyand
cured the thickeningdisappearsas if,at any rate at first,
it were
due
only to medial hypermyotrophy, a condition in marked
with the high brief systoleand low diastole of alcohol.
contrast
of watching cases
of lead poisonGibson, who had opportunities
ing
from
renal disease
beginning to end, says that whether
be apparent or not, the arterial pressures
are
high throughout.
the less equivocalas lead poisoningwith
These observations
are
these symptoms
often occurs,
like syphilis,
early in life,un1

so

constant

Lancereaux,

Diet.

so

Encycl. art.

"

Arterite."

CHAP,

LEAD

iv

POISONING

279

complicated by senile degradations. I have recent notes of

the blood pressures
were
plumbism in a man, set. 41, in whom
and thick far beyond
excessive and the radial arteries tortuous
hypertrophy.

mere

the

heart

becomes

will fall of

arterial pressure

The

In

weary.

degree

recent

if

course

examination

painter,aet. 51, presentedextremely diseased arteries,not only

thickened
but also beset with granulesof calcification. We, as
had

examiners,

his blood

describe
not

alone

the

by

pressure

task ; however

easy

very

whether

decide

to

difficult to

be

it would

we

the

candidates

should

fingeras high or moderate,

all agreed that by the finger
that

say

the

was

pressure

mented
aug-

in his urine.

casts
granularand epithelial
found to be largelydilated,
on
examining the heart it was
in impulse ; his legs were
puffy, and crepitations
poor
audible at the bases of his lungs. No record of the blood

yet he had

Now
but
were

call

used

to

high

pressure

also

in the

found

was

pressure

"

the

of

defeat

the

heart.

and

Bigart, states that

indirectly
by excitingthe adrenals.
It has been suggested that minute
Bernard

concerned

in many
originof which

the

therefore

reputed health,

of

the

of

cases

is obscure

These
A

persons

few

must

years

examined

and

ago

Broadbent

the

detected
have

notion

was

of lead

we

in

lead

of

very

abroad

be

of the

in wine, beer,
bread.

in

even

17

may

reminded

are

of

vessels

arteriosclerosis

premature

urines

lead

lived in

injuresthe

traces

and

Aubertin, quoting

lead

Reports on Foods, which reveal traces

cider, syphons, etc., in groceries,and
Putnam

what

was

tension," the lapsingof long periods of

virtual

by

This

notes.

Dr.

in
persons
of them.
cent

100

per

adulterated

market.

diabetes

that

was

have
The
notion seems
to
high arterial pressures.
with Potain, but, if so, this master
of clinical medicine
originated
altered his opinion. His own
not a trustworthy
soon
was
gauge
and
probably at first he happened to try it on some
one,
is not
of glycosuriawith granular kidney. Diabetes
cases
a
disease of high pressure,
though glycosuriais no countercheck
to such
rises if under
conditions
concomitant
some
they may
disease

be

of

generated ; and

diabetes
power

to

the

meat

some

diet.

authors
In

so

attribute
far

of the heart it is a disease of low

as

arteriosclerosis in

diabetes

pressures

may

sap

the

; the occasional

CAUSES

280
of

records

the arteries thickened

is due

of

to

that

sure

toxic

some

complicated

cases

simple diabetes

be pretty

may

high tension, but

to

not

we

PART

are

in

therefore

When

disease.

heart

of the

hypertrophy

renal

with

ARTERIOSCLEROSIS

OF

find

we

the sclerosis
of

not

causes,

observers
have
declared
recent
pressor kind (p. 450). Some
in young
that arteriosclerosis does not occur
diabetics,but, as
a

is
testify,this statement
wide of the truth.
Many years ago I pointed out the occurrence
of the youngest being
of thick arteries in young
diabetics, one
a
hospital,aged 14. I have notes
girlin the Addenbrooke's

pupils of

my

of

can

arteries in children

of such

instances

many

past

years

many

in young

and

adults

sufferingfrom the malady.

I think that in diabetic patientssome
thickeningis the rule ;
is familiar knowledge.
their consequent liability
to
gangrene
comparatively young

and

I may

select this

from

case

notes

my

No
aged 25, a diabetic.
sign or probabilityof syphilis.
Sugar on ordinary diet abundant, and not wholly removable
by
did badly ; his knee jerksdisappeared,
diet.
The man
the strictest
A

man

his

and

measured
under

extension

foot

arterial

the heart

sustained, and

never

the

over

becoming

few

more

calcined

never

longer,for

in

at

pressure

especiallyas

normal,

cyanotic,and

weakened.
any
the

suffered

years
and
more

he

had

time

there

was

became

was

emaciated

in its nutrition.

very

rise

no

often, indeed, it

patient

more

always

was

But

The

of

well
and

pulse was

ing,
Notwithstand-

compressible.
arteries slowlythickened,

to live the

tapy

to

the

presumably they would

diabetics grittyvessels are

touch.
have

In

him

done

the
had

he

vessels
lived

enough.

common

In

the incidence of arteriosclerosis

elderlypersons of course
and
of glycosuriarespectively
is high enough to make
their
coincidence
so
frequent that neither could be regarded as the
of the other.
Such
cause
glycosuriais often of the milder
senile type ; the sugar
often
slight and intermittent, and
A more
accompanied with a littlealbumin.
plausible
suggestion
is that
the glycosuriamay
be a result of arteriosclerosis in
particularareas, as, for example, in the pancreas (Naunyn), a
of us
in past
suggestion which occurred no doubt to many
times before we
had
had
the opportunity of witnessing the
gradual advance of the vascular changes as a sequelof diabetes
in young
cases

of

persons.

mild

That

such

may

be

the

glycosuriain elderlypersons

causation
is

of

some

possibleenough.

CHAP,

DIABETES

iv

have

verified

been

that

diabetes

is of the
found

relations

of the

views

These

has

by

of diabetes

them

among

examination

of 29

of arterial pressure,

ranges

many

Elliott

agrees

raisingblood pressures.1Janeway

opinion. Severie,2after

same

arteriosclerosis

to

observers.

recent

more

effect in

no

281

diabetics,
even

up

figuresurely indicative of the renal disease which

of diabetes.3
Thus many
frequentlyappears in the later course
old gouty glycosuricspresent a
cases
high blood pressure
which often end in apoplexy or angina pectoris
; it is the young
diabetics who, as a rule, are
disposed rather to low pressures,
of them the arteries
if prone
to phthisis
especially
; yet in many
be the direct agent in this
obviously deteriorate. What
may
tell at present ; perhaps an
detriment
cannot
to the vessels we
of rapid
under-alkaline
In those
blood.
too
frequent cases
in young
diabetes
which
occur
subjects arterial degeneration
fail,only because in them survival is too brief to include
may
few cases
of longerduration
it. Nevertheless, I have seen
not
a
in which it never
appeared.
We
are
hearing something now, from Neubauer, Weiland,
and
blood
and
others, of
high arterial pressures.
sugar
these hypotheses4
Port, of Gottingen,has recently reviewed
240,

to

"

"

shows

and
Thus

the association

injectionof

several
there

was

no

diseases,e.g.

cases

of

many

the

of

seed

Elliott, Journ.

Severie, Sem.

sugar

"

may

appear

do.

in the urine.

is due

large

to

Hospital physicians see

too

of

been

back, and
of

sources

As

bring them

have

farther

individual.
shoots

cause.

processes

"

farther and

common

some

the poor to accept this notion.

of late years our
views of natural

among

Infections.As
have enlarged,we

tumours

will not

consumption

many

to

arteriosclerosis in diabetes

that

argument

meat

will

adrenin

is due

together. He quotes
in which
of a very high blood pressure
(non-renal)
hyperglycsemia,
except in apoplexy : we know that

cases

in brain

The

that

"

in

some

in

Amer.

Med.

to

or

adult

trace

chains

causes

bygone history
perversionsof the adult

discover

to

defects
cases

sown

enabled

in his

tuberculosis

infancyor childhood,

so

may

be

the

it is surmised

Assoc., July 1907.

mid., juillet31, 1907.

3
See discussion
Aron, Israel, and others, Berlin. Med.
1913, reported in the German
journals about that date.
4
med.
Port, Deutsche
Wochenschr., Jan. 9, 1913.

Gesellsch., Feb.

19,

CAUSES

282

after

toxic

some

influence

arterial tissues ; the slow

which

in

accumulation

and

tellingon vessels whose tone

sapped in infancy or childhood by some
this

for

that

I have

reason

because
arteriosclerosis,"

to

and

impaired
"

the

wear

and

had
elasticity

been

"

infection.
Jores'

eschewed

it seems

life

of stresses

"

under

on

creep

early

"

tear

PART

likewise

arteriosclerosis may

in adults

that

ARTERIOSCLEROSIS

OF

I have
of

name

ignorethese

"

said
Senile

precocious,

more

specificcoefficients,and to throw the effect

Until our
ledge
knowentirelyupon simple and inveterate stresses.
for certain
is riperwe shall do well to keep the door open
become
which may
obvious tillafter
detriments
not
co-operative
decade.
the lapse of many
a
infections of children have
fallen
One
by one the common
and the harm
under suspicion,
they do, both acute and chronic,
That
has been demonstrated, especially
by the French School.
the arteries is confirmed
the infectious fevers attack
by Dr.
writes (Rpt. L.G.B.
in
Andrewes, who
1913) that it is rare
of such young
patients to miss local spots of fatty
necropsy
of
the aorta
and
larger branches.
change in the intima
be tracked along the
Occasionallyin infections the lesion may
These changes he illustrates by excellent plates.
vasa
vasorum.

latent, and

often

Lesions, both
media

focal and

lesion of the

and

diffuse,such

necrotic

as

intima, have

spots in the

been

to
brought home
fever, influenza,small-pox,malaria,
typhoid fever, rheumatic
scarlet fever,diphtheria
; and to such ubiquitousmischief-makers
as
streptococci,
staphylococci,and the colon bacillus (p. 528).
The diphtheriatoxin especially
in experimental tests, to
seems,
attack the vessels with some
The
stances
constancy.
poisonous subsecreted or excreted
by these bacteria are so subtle as

hitherto
not

are

to

have

eluded

alien from

all attempts

plant and

animal

to

isolate them

venoms,

and

; but

they
probably

are

perversionsor developments of normal secretions,each one

affinities in the cellular world.
its own
specific
However,
not

task

my

to

jeopardisethe

discuss

these

bodies

except in

so

far

as

with
it is

they

arterial tunics.

focal inroads upon the larger

trunks, and especially
of the French
aorta, I shall report the observations

Of the acuter
upon
and
so

the

other
that

in
pathologists

my

chapteron

here I will deal rather with

the

Aortitis
more

(Vol.II. p. 189) ;

diffuse

or

universal

CAUSES

284

others, although the arteries

In many
the

arterial pressures were

such has been
my

and

published I

was

in these
I

have

chance

thicker

Since

not

across

but

all, or

blood
Aldren

not

Wright, Mr.

obtained, but

was

was

pressure

normal,

Thayer's paper
of unduly
cases

few

than

little increased

Dr.

historyof typhoid

the
Dr.

at

PART

were

experience.

cases

recently,with

saw

not

come

arteries in which

thick

ARTERIOSCLEROSIS

OF

M.

augmented.

set.

20, in the

ently,
typhoid fever. We noticed, independthat even
tapelikewhen
already the radial arteries were
empty, and rolled roundly under the fingerwhen full ; but the
rather under
dicrotic,and systolicblood pressure
pulse was
arterial
than
In the active undergraduate normal
95.
over
of Thayer's cases
low.1
In some
valvular
were
run
pressures
of which
I need
the doubtful
not
lesions, on
interpretation
dwell.
the arterial pressures
run
on
During the fever of course
second

the

week

lower

of definite

side

90-95

say

"

; whatever

the

temperature

doubt
pulse rates, the pulse is usually no
the pressures
return
to
During convalescence
take

occasion

the acute

partly
because

to

in

say,

respect of blood

infections,that pressures

because

of

reduction

some

in

the

relativelyslow.
normal.

pressure

rule low

and

rather

cardiac

I may

in most

of

than

high ;
values, partly

of

The rises of pressure recorded

peripheralrelaxation.
in the earlier or later historyof sufferers from
typhoid fever
need further study and discrimination.
The opinion of Thayer
and Brush
that the thickeningof the vessels in or after typhoid
fever is due
to
overstrain
of the vascular
walls from
high
tension, however
caused," is not on the face of it very probable.
I suspect that in typhoid fever, as in the class of infections
the injuryto these tissues is due more
generally,
directlyto the
in typhoid
seen
poisonitself. The mental symptoms occasionally
"

convalescents,such

slightdementia,
on

the

loss of

as

be due

may

vessels, and

not

to

incoherence, and

memory,

effects of the

directlyupon

even

poison mediately

the

cerebral

tissue

itself.
For

these infective vascular

are
aortitis)

should
1

often

hesitate
See

art.

on

changes the terms arteritis (and

used, especially
by French writers ; but we

to

use

Heart
2

these

terms

Dr.

Stress, Allbutt and Rolleston's

Andrewes, F. W., loc. cit.

Andrewes
System, 2nd

thinks
ed.

CHAP,

INFECTIONS

iv

285

is in part at

disease

least

inflammatory, but
for the most
the reparative
part the process is degenerative,
reaction, if any, being in typhoid of the slightest
(p. 522).
I find in Brouardel's
On turningfrom the diffuse to local lesions,
by MM. Landouzy
System that typhoid aortitis was demonstrated
and Sireday,but no reference is given ; I have made
brief
some
about the probable dates
search for this source
say 1885-87"
and I have not pursued it because our debt
but without
success,
arterial

the

that

"

herein to the French

Louis

and

Laennec

the

upon

in

discussed

will be

Cavendish

my

recognisedthe

heart ; and

has

dates

(Vol.

evil influence

of

from

recentlyverified

Infectious

Lecture

closer

our

disease in the infections

Barie

is of earlier date.

School

these

aortitis

II. p.

148).

typhoid fever

knowledge of cardio-arterial
Hayem's well-known
paper.1
observations.
the
Clinically

of arteries,
such as the femoral or tibial,
to acute
obHteraliability
and
in France
tive lesion in typhoid is freelyadmitted
England,
in Germany (e.g.
to be doubted
by Komberg and
though it seems
of typhoid
The
thrombosis
the late Professor
Curschmann).
fever
be due to focal patches of
of other infections
as
may
arteritis. In a previouspaper I have attributed the sites of circulatory
and legs,at any rate in part, to a
disorders of the arms
and thus explainedthe relative date of their
mechanical
cause,
As
the patient emerges
from his prostration,
and
appearance.
he is apt to throw
of movement,
one
regains some
leg
power
the other, or turning a little sideways to lie upon
limb.
over
a
"

"

asked, before

be

it may
Still,

arterial lesion caused

is it

kind,

or

some

allusion

has

lesions
and

478) ; and
act

the

been
are

Dr.

go

farther,of what

kind

is the

these infections ; is it of the subintimal

by

attack

an

we

the media

upon

made

medial,
is

Cowan

similarly.It seems
alongthe
vasorum,

or

In

(necroticfoci),to which

syphilisof

medial

and

disposed to
agreed that

the

course

adventitial

think

the

acteristic
char-

(pp. 296

other

tions
infec-

the infections enter

tracks of which

by

exudations
leucocytic
that preferentially
be observed; and
they attack the arch
may
of the aorta, a thick wall richlysupplied
by these minor vessels.
On the other hand, he notes
how
frequentlyafter acute infections
atheroma
arise,in which
fresh, often translucent, patches of
be detected
sometimes
bacteria may
(and thence might set up
vasa

"

"

Hayem,

Arch,

de physiol. norm,

et

path., 1870.

OF

CAUSES

286

will admit

subject he

is clear that

draw

cannot

we

endarterite sclereuse and

that

though

more

of the nature

that

it

definite distinction
so
calcifiante

do not

of

these

between
attribute

to

lead, gout,

that

the media

have

agents

tend

inflammation, and

says

attack

as

this to

effects of

the

reactions

and

the like toxins

and

I think
(atherosclerosis).

the

hyperplasia. Klotz

connective

is

mesarterite

it is true

etc. ;

of

of arterial disease

cognate substances,and

and

toxins

to

study

recent

more

this mode

that

subintimal

kind

often in site and

PART

probably in

endocarditis). But

infective
the

ARTERIOSCLEROSIS

to

diphtheria,typhoid
but

the

intima, and

with doubt,
however
assents
Saltykow 2 agrees with him; Adami
stop the imbibition
remarking that, if so, the change would soon
and
to the inner media
of nourishment
implicateit also in a
rather in rabbit experivicious circle. In animal experiments,
or
ments,
the media seems
to be the primary seat of the reaction and
from that
lesion,but, again,the rabbit's aorta differs too much
from the one
to
of man
to permit us readilyto apply conclusions
In monkey experiments,at the Pasteur
-the other.
Institute,
with
streptococcaland staphylococcalemulsions, Manouelian
3
and Metchnikoff
closelylike
cit.)
(loc.
produced lesions far more
of
of man,
the aortic atheroma
by repeated injections
especially
less virulence ; but in the rabbit (86 of them were
infected)the

rudimentary
elastic fibres

had

aorta

but

and the muscular

calcification,
"

of 6

out

absent

was

evident.

that

soon

are

the seat

follow.

the morbid

rabbits

in

this,as

commented
direct

effects

2
3
*

infected

of the

In the

first

monkey

were

not

small

with

microbes

No

uniform.

Duval

states

of
glanders proliferation

vessels occurs,

but

Adami

the

comments

experiments of the kind, as I have

experimental arterial lesions in rabbits,that
upon
comparison can be made between such arterial lesions
one

in these animals
1

of the

internal,and calcification
more
change was
relativelyslight,hyaline change being more

or

endothelium

no

fibres

and

detected, I believe,in the parts examined.

were

on

up,

The

of response.

mode

one

if its

as

the

"

But

this

first to break

seem

strains ;

those of the mechanical

effects in 73 resembled

may

and

on

all

arteriosclerosis in man,

and

that the results

Journ.
Med.
Sci., Oct.
Klotz, quoted Adami, Amer.
xlii.
vol.
Saltykow, Ziegler'sBeitr., 1908,
p. 187.
Oct.
1910.
Metchnikoff, Ann. de VInst. Pasteur,
Duval, Journ. Exp. Med., 1907, ix. p. 241.

1909.

INFECTIONS

iv

CHAP,

in apes

distinction

call

Infectious

the

attacked,
in

yet

as

in infections

the

foci of atheroma

chronic

or

have

lesions

fever, typhoid fever.

scarlet

the

rate

for the

lesions

in

all the

scarlet fever in
the

media,

had

yielded in

the

of

those

are

been

been

found

places,but

of

examinations

Vienna,

of the

(about 300) of mortal

cases

blood
of

surmise
of the

affected.
no

were

typhoid fever;
subject which have

at

necropsy
lesions were
found

fever will be described

Wiesel2

vessel

perhaps

reports

was

there

fever,

of distribution

19 ; extensive

also

this

may

mode

to

this

on

staphylococcic

In

we

Kiinne

adventitia

many

return

researches

is the

arteries.

aortitis of rheumatic
to

such

girlaged

but

focal, and

are

present that

But

has

rheumatic
(Manouelian), anthrax, erysipelas,

smallpox,
any

all, is

at

aorta

tubercle, pneumococcic, streptococcicand

affections

whether

focal,or

arteriosclerosis

radical

scarcelyprepared to answer.
ception
septic foci is the prevalent con-

When

process.

acute

there is any

no

are

we

around

arteritis

of

infections

these

question which

or

diffuse arteriosclerosis and

between

should

we

Whether

homologous.

more

are

287

The

(Vol.II.
the

among

who

made

vessels

The

my

minute

in

typhoid fever,

150).

p.

most

fallen under

in

media

aneurysms.

later

on

exact

notice

mortem
post-

large number
scarlet

fever,

under
of age.
24 years
diphtheria,and other infections in cases
To take
typhoid first,and omitting the cardiac pathology, in
selected young
he found well-marked
lesions in the
cases
carefully
and pulmonary artery, and in the coronary,
aorta
radial, iliac,
femoral, tibial,hepaticand superiormesenteric
vessels,especially
in the intestinal branches, the pulmonary, and
the anterior

(as also in their veins); the cerebral vessels

coronary

affected.

Sometimes

arteries,but
thinks

the lesion had

in the coronary,

not

as

advanced
to close

so

least

were

far in smaller

the channel.

Wiesel

typhoid is universal
and
constant, being thus of higher frequency than the wellknown
there is nevertheless
cardiac changes ; though ordinarily
a
quick and complete restitutio ad integrum ; so that ill
he obtained
instances
are
rare.
Ultimatelyin some
consequences
1

und

indeed

Kiinne, Frank/

Oefdsskr.,Jan.
2

that

this arterial

Zeitschr.
.

f. Pathol.

effect of

Bd.

v.

H.

Zentralblatt

1, extr.

f.

Herz-

1911.

Wiesel, Zeitschr. f. Heilkunde, Feb.

1905

and

July

1906.

(See also

p. 477.)

necropsieson
one

found

close

of recovery

cases

from

"

occurred
he

ARTERIOSCLEROSIS

OF

CAUSES

288

more

or

the vessels to

here
investigation
tissue had

connective

spots, where

all

and

seeming

there

the intima

other

been

had

sound

the

which

death

had

; in these

causes

again ; although on

spots could

supplanted

"

typhoid in

later,"from

years

PART

be

detected

muscular

; and

where

in

attacked, signswere

some

observed

"

change (videp. 522-3).

regenerative (proliferative)
Now
also thinks that the name
to these changes Wiesel
of
of atherosclerosis
arteriosclerosis
at any
rate
or
ought not to
not
be applied. They are
primarily affections of the intima,
of Jores'

"

but

of

"

and

media

Simnitzky,1 in

his

intima.

large

said
calcification,

some

calcification to be
The

minuter

; but

remember
cases,

Wiesel

that

found

did not

in
find

cases.
specific

histologyis thus

iliac,femoral, and radial arteries.

of such

medial

of these

feature

morbid

collection
be

to

Moreover,

He

described

found

by

Wiesel

on

the elastica broken

that in

placesthe fibres,imbibing
vanished
little stain, or none,
reduced
to a
or
were
altogether,
Thus far, especially
when
seated in the medial
granularstate.
portionof the aorta, the changes,which are in agreement with
of Manouelian
of the Pasteur
the description
Institute (loc.
cit.),
differ from
the manifolding of the elastica in atherosclerosis.
muscularis
The
it is largely supplanted by
wastes, but, as
connective
hyperplasia (" eine starkere Ausbildung des intramuskularen
Fasernetzes
"), he did not hesitate to use the suffix
mesarteritis
which
seemed
"-itis,"and to speak of a
to run
parallelin time and degree with the myocarditis. I have said
that Dr. Andrewes
also is disposed to regard the process
as
inflammatory. Curschmann, on the other hand, denied that
this change was
endarteritis and, from
the nature
of the
an
patches on the aorta, was
disposed to accept the process as
atherosclerotic.
But if so, the rapid and complete restitutio ad
remarkable.
integrum is the more
Thayer thinks that in the typhoidand rheumatic fevers arterial
lesions are
most
at least of his patients
frequent; but in many
hard labour, or irregular
habits,or both, were
conspicuous. As
while I have gatheredno littleevidence
rheumatic fever,
concerns
up

by

degenerativechange,so

"

of arteritic and

atherosclerotic
1

"

lesion of the thoracic

Simnitzky,

loc. cit.

aorta

in this

CHAP,

INFECTIONS

iv

littleof the diffuser forms

disease,I have
as

of arteriosclerosis

For the aortic lesions I would

refer to

(Vol.II.,p. 152),and Angina Pectoris (Vol.II.,p. 422) ;

Aortitis

interstitial arteritis of the

for

and

lightedupon
sequelof it.

289

myocardium to Dr. Carey

Coombs'
preparations.Concerninggeneralarteriosclerosis as a
sequelof this infection,I have only this case to offer :
the Addenbrooke's

patientin

disease

and

heart, attributable

dilated

of 14, and

fever at the age

also thick and
accessible

We
a

vessels). There

are

no

"

gouty.

referred

attack

severe

since for hard

ever

mitral
of rheumatic

work, presented

Still the

(radials,
brachials,and other
signsof aortic valvular disease,

that

moderate.

were

pressures

chronic

for scientific use, and

term

are

were

the blood

that

agreed

unfit

to

with

leathery arteries

of renal disease,and

nor

Hospital,aged 35,

"

rheumatism

is too

of the

some

cases

vague
called

so

chronic

malady to which I have already

cold and damp, whatsoever
its nature,

dependent upon
attended
with arteriosclerosis,
first
as
cases
probably in some
and
pointedout by Gueneau de Mussy, and verified by Rosenbach
others.
On another page (206) I have spoken of the experience
whose practice
is divided between
of Mr. Wilkin of Wickhambrook,
the other
the Newmarket
side
two
districts,
one
a heavy clay,
On the clayside,where he has to deal with large
a dry upland.
as

is

"

"

of

numbers

cases

"

chronic

arteries

thickened

cases

of

are

frequent,but without
in his practice,
and
rare

is very
Syphilis
Renal
unknown.
practically
comparisons. This so-called
pressure.

heart
of

disease.

Professor

rheumatism," he finds that in these

disease

was

found

lead

poisoning

excluded

from

is not

followed

rheumatism

Stockman

rise of blood

in

an

excised

these

by
portion

"

jointthus affected, that the small blood vessels showed

connective
distinct peri- and
with marked
endarteritis,
very
tissue proliferation."
Dr. Aikman
of Guernsey1
Diphtheria. Concerningdiphtheria,
has
In cases
published the following curious observations.
he had
insufficient to
in which
injecteddoses of an ti-serum
control the attack in a few
days a perceptiblethickeningof
the accessible arteries set in. In the elderlyof course
the change
masked
was
by senile decay, and under set. 3 the artery in a
but in youths and persons
fat arm
not
was
easy to appreciate,
a

"

VOL.

Aikman,
I

Brit. Med.

Journ., April 21, 1906

an

letter,
interesting
U

middle

under

renal

age

the

be

enough.

discovered

in these

thickeningusuallydisappearedin
on

the other

control

to

He

hand, in which
the attack

PART

evident

change was

could

disorder

ARTERIOSCLEROSIS

OF

CAUSES

290

he
the

No

ing
correspond-

persons.

few weeks.

This

In those cases,

injectedanti- serum
arterial thickeningnever
had

cient
suffiin.

set

change in the arteries after influenza

typhoid fever, but usuallyin them also it disappeared in
rather suddenly,
The thickening appears
weeks."
ten
or
of diphtheritic
aortitis
disappearsvery slowly. Many cases
observed

had

similar

"

and
nine
but

(videAortitis,Vol. II., p. 164).

Here again,Wiesel's laborious researches,which have not been
assistance.
He examined
to our
confined to typhoid fever, come
infections other than typhoid,again selecting
of acute
200
cases
normal
and otherwise
subjects,and followingup his
young
examination
through arteries of all magnitudes to the capillaries.
and 80 were
of scarlet fever.
In
of diphtheria,
Of these 80 were
become
diphtheria,says Wiesel, small opaque grey spots may
the aorta
visible on
even
by the sixth or seventh day (but at
is
this date rarelybeyond the aorta) ; indeed, so far as the aorta
was
concerned, this observation
applicableto all the infections.
Moreover, in diphtheria,
by the microscope,a degenerativeprocess
almost always revealed in the coronaries (this never
was
wholly
failed"). At the very beginning,before either intima or media is
the media is soaked in serum
("Durchtrankung"),
disintegrated,
fibres are forced apart,
and by it the elastic lamels and muscular
ing
juiceis a homogeneous badly stainor squeezedtogether. This
substance, with a leucocytehere and there in it. In aspect,
somewhat
though not in nature, these changes vary of course
vessel
with the magnitude or structural varietyof the particular
with the relations of the tunics). Then the elastic
examined
(i.e.
fibres begin to refuse the stain, and by the eighteenthday these
are

on

record

"

the muscular

and

fibres break

patches of damage
homogeneous matter in which

up,

and

fall into necrosis.

in

the

media, patches of almost

These

of elastic fibre may

be

does

run

few casual nuclei and

in size about
but

also

mm.

some

scraps
In the

begins to swell
adventitia
is usually intact.
Such
towards
the lumen
; the
found in about 40 per cent of the diphtheriacases,
patches were
and
were
frequent in scarlet fever, influenza,septicdiseases,
severer

foci the intima

seen,

not

escape,

OF

ARTERIOSCLEROSIS

usual

loss of distal

CAUSES

292

follow

this may

the

and

certain

associated

until, with
Tubercle,as

shall

we

is but

Tubercle

all of us, and

could

be

of

although
evidence

course

tubercle

that

Of the effects of

much, and

and

this

be content

with

so

much

to

test

involved
is

in

definite

no

know

we

Morbid

Anatomy

that in this context

Hasenfeld

in 188

nature

sclerosis.2
general arterio-

on

say,

brief summary.

used the Wasserman

Budapest

tuberculous

the arterial structures

the section

the

observed

contingentin

produce

to

on
syphilis
subject,in

Aortitis,I shall have

on

I may

on

is apt

rarity.

never

arteritis).There

(a true

as

arteries of the
than

more

gressed
pro-

sclerosis.
generalarterio-

arterial district is often

an

inflammation

tuberculous

in the

changes
regarded as

I have

part

own

which

experiencein

an

common

for my

such

clinicallyany
which

too

appeared,

rather

in the aorta

occurs

that

says

ensued.

with the effect of

occasionally

Its toxin is credited

practiceof

see,

death

causes,

pulse with dangers of

patientDr. Mitchell Bruce

of influenza a systolicapex
murmur
physicalsignsof dilatation of the aortic arch,

Of
gangrene.
attack
after an

so

PART

old

and

Szili of

(" hochbetagten ")

with

not
general arteriosclerosis,
clinically
distinguishable
from
the ordinary form, and
found
it positivein 20. 3
The
results of such examinations
depend a good deal upon the kind of
of that
populationinvestigated
significant
; stillsuch reports are
of alien toxins with
which so often
and tear
wear
co-operation
men

"

itselfupon
is an
that syphilis
of cerebral

attention

our

presses

(p.236).

underlyingfactor

arteriosclerosis in persons

of 45 and

55 who

"

in

Dr. Mott

is

"

convinced

largeproportionof

of both

cases

between

sexes

the

have

in earlier life." If in
acquiredsyphilis
such vessels a recent
arteritis may
be distinctive,
some
syphilitic
from ordinary
ultimatelythe changes may be indistinguishable
arteriosclerosis (p.480). We
not surprised
to read again and
are
in its juvenile
again that in General Paralysisof the Insane, even
ages

1
2

Bruce, M., Luml.

L., Lect. III.
book
Faber, whose
(Die Arteriosklerose,1912) did

manuscript

arteriosclerosis
do

no

more

made

was

than

is

quite

up

for

press,
in

common

refer to this able

Hasenfeld

Mott, F., Allbutt

and

Szili,Deutsche
and

tuberculosis, and

to
comes

essay.
med.
Wochenschr., Oct.

Rolleston's

System of

Med.

reach

not

states, somewhat

me

until

this

surprise,that
my
now
early. I can

28, 1909, p. 1903.

vol. iv. p. 613.

CHAP,

SYPHILIS

iv

293

"

"

is very
of the aorta
(as in one patientset. 18), atheroma
frequent(Vol.II.,p. 181). Dr. Mitchell Bruce (Lettsom. Lect.,
form

1901) stated that

9

in 28

of

cases

presentedaortic disease,and

sounds

the

over

had

Vol.

In

II.,p. 424).
He

(p. 295).

myself,that

these

occurred

(vide Essay

two-thirds

ringingsecond
cases
pain of an

are

processes

"A.

on

the radial artery

Mott, and, if

Dr.

with

agrees

all the others had

(p. 389). In half the

aorta

anginal character

cardiac symptoms

with
syphilis

Pectoris,"

was

I may

say

sclerosed
so,

with

still imperfectlyunderstood.

arteriosclerosis usually
experiencegoes, syphilitic
in two
the primary inoculation ;
from
to three years
appears
in other
it is delayed,
it seems
sometimes
cases
precocious,
Darier
and
or
apparently delayed. Marchand
quotes from
Nonne
well -authenticated
instances of syphilitic
arterial lesion
eighteen months, nine months, eight months, and five months
after primary infection.
Benda, quoted in Aschoff's
respectively
So far

as

my

Lehrbuch, reports such

But

must

we

delay

to

case

confuse

year

delay of

and

obvious

half

after infection.

arterial

changes with

of clinical consequences
within the arteries themselves
; even
and latently. Moreover
these changes often progress
silently

the
one

not

historyof

who

confesses

conceal

its date

this
to

infection
specific
infection

the

and

occasion

may

; and

is often very

slippery:
still have
good reason
middle-aged sinners are

tempted to push back the date of the scourge to the reckless

days of youth. Not only so, but other poisons,as of influenza
of typhoid, or again the deteriorations of alcohol, may
have
or
intervened.

it is true"

Still I suppose

have

some

evidence

arteriosclerosis may
signsof generalsyphilitic
for twenty years.
In hereditarysyphilis,
the
be delayed even
on
sclerosis
other hand, as we
have
the invasion
of general arterioseen,
be very
precocious. (See under
Age," p. 174.)
may
aortitis
With
syphilitic
schwieligeAortensklerose," the
of
Mesoaortitis productiva of Chiari,the
miliarygumma
I shall deal under the head of Aortitis (Vol.II.,p. 167) ;
Letulle
in the
here I am
lesion only as it occurs
consideringthe specific
vessels of smaller magnitudes. Syphilis
of the largevessels,as we
shall see, was
by Pare, and by Bianchi (quoted
recognisedeven
This
of course
well known.
by Morgagni) ; to Morgagni it was
disease
also to have
seems
perceivedsyphilitic
great pathologist
to

suggest it
"

that

"

"

"

"

"

"

"

"

CAUSES

294

vessels,1but

smaller

of the

appeared
syphiliswas

ARTERIOSCLEROSIS

OF

it

of his

first volume

(in the

Virchow's

Archives)that
followed

clearlyrecognised.2 Then

in 1863, of visceral and

until

not

was

PART

paper

small-vessel

Wilks's

descriptions,
tested
syphilis,
stubbornly con-

vascular

by his contemporaries. Wilks wrote, in his Lectures on

in aU
arteries are
The
probability
(1859) :"
Pathology
influence ; that is, a deposit,atherosusceptibleof the same
of an analogous kind, forms within the coats, leading
matous
or
"

"

"

to various

;
consequences
softeningof the brain from

thus, in

cases

some

of aneurysm

and

of

has been the

vessels,syphilis

diseased

"

"

And in his Guy's Lectures on

Syphilis
probablecause."
(Lancet,Feb. 9, 1867), after speaking of syphilitic
meningitis,
the blood vessels by a
also
otherwise
etc., he points out how
of the
fibroid thickeningof their walls, as in other structures
body (bringabout a) ramollissement of the cerebral substance."
enabled
Two
to
later (St.George'sReports, 1869) I was
years
from the brain of a soldier who
give the histological
description,
cerebral
presentedample evidences of lues and died of specific
Heubner's
in this area
disease.
fuller account
of syphilis
appeared
most

"

in 1874.3

The
the

questionwhich
lesion be singleor

not

of this tunic

modes

us

various

at the outset

As

is whether

syphilismay

that but of the whole

vessel,and

be
as

in nature
a

disease

its kinds,

incidence,bear

it
directlyupon clinical diagnosis,
is desirable,in order
to
this question,to anticipate
answer
considerable
some
part of the histologyof vascular lues. In the
chapter on Morbid Anatomy (p.478) the division of the subject
into lesions of the several coats respectively
to
is less applicable
which is prone to attack them all. In the earlier years of
syphilis,
of syphilitic
observation
vascular
disease it so happened that
my
I found, or thoughtI found, universally,
in the younger
even
cases,
morbid
less
a
or
change, apparently fibrous (p. 480), more
throughout the accessible arteries ; for it so fellout that amongst
which
under
a
came
cases
long series of advanced
syphilitic
notice a sclerosis of these arteries was
so
frequent as to
my
or

1
2

Comp. Proksch, Arch. f. Derm.,

Steinberg's retrospect, which

See

1861, Bd.
3

of

or

meets

Die

1878.
I know

only

from

Canstatt's

iv. S. 328.
luetischen

ErTcr. in d. Hirnarterien,

Leipzig, 1874.

Jahrbericht,

CHAP,

tempt

to

me

occurred

cases

be

This however
generalfeature.
of experienceanother run
the case
; in the turn
in which, althoughfor example the aorta might
it to

suppose

to be

proved not
of

be

touch

unaffected.

under

the age

thickened
I

in
syphilis

of

in two-thirds

the

persons

of all the cases,

more

all accessible

clanging second
dated

soft

of

years
cases

enough.

only ; but of course, while

periphery the cerebral
"

recall many

such

cases

before.

are

The

palpablearteries

of

exempt, other arteries of the

instance
in

one

tion
infec-

The

were
pressures
the peripheral
of aortic syphilis

these
for

characteristic

audible.

speaking here

am

the

thick, and

were

aorta
syphilitic

few

in many

But

are

arteries

sound

from

moderate.
vessels

notes

to

were

features, the arteries of the limbs were

specific
tion.
evenly to the touch, not presentingpalpablecalcificawith Col. Kilkelly,in
3Bt. 43, at Osborne
saw
a
man,

the

whom

45, says that

or

arteries

accessible

Bruce, in his

Dr.

of 40

the

manifestlydiseased, yet

besides

295

SYPHILIS

iv

be

may

"

medical

infected

man,

affected.

in the

of his

whose
pointedunmistakably
profession,
symptoms
of the basilar
infection
to cerebral syphilis,
and apparentlyto an
to the touch normal.
artery ; yet in him every palpableartery was
time another
patient,near the same
Conversely,about the same
but in this case
every
age, presentedsimilar cerebral symptoms,
course

accessible artery
three
area."

first

My
under

recovery

the

medical

patient,the

earliest

symptoms

were

no

limitation

made

man,

inunction, and

well ; in the second

Osier describes

Professor

thickened.

diffuse sclerotic type with

mercurial

stilllivingand
means

"

of the

cases
x

much

was

after many

of

complete
years

was

although by the same

wholly and permanently

case,

sterni and
the manubrium
dulness appeared under
dissipated,
of Hodgson
extended
to the right; the dilated anfractuous
aorta
was
was
diagnosed,and at death some
years later this diagnosis
that as, in the
I may
state by the way
fullyverified by necropsy.
last few

signs of
to

months
the

of life,two

or

three years

after

disease, this distinctive

aortic

its wont, extended

visiblyto

the innominate

the

process,

for aneurysm
1

!
Osier, Sir W., Luml.

according

artery, an

of no
distressed the
little note
surgeon
opinionthat this vessel ought long before to have

upon

first definite

Lect., April 9, 1910.

prising
enter-

patientby the
been operated

CAUSES

296
in

Why

ARTERIOSCLEROSIS

PAUTI

is thus

disease

arterial
syphilitic

cases

some

universal, why

or

OF

it is limited, and

in others

by

general

apparent

no

rule,to this, that, or the other district of the arterial tree,

why again it

instance,to the ascending aorta, and

for

as,

appears
diffuse

shapes as a focal lesion,as a more

in placeswith intimal lesion not unlike atherosclerosis
fibrosis,
or
are
questionsas yet beyond our comprehension; but as regards
of syphilitic
the generalised
rate as regardscases
cases, or at any
in

least two

at

"

"

sclerosis of the

vessels of the

that

this distribution

Such

is the

determined

be

may

have

impressionI

sport in hard
And

forms
in

of this

shape

diffused

more

the

fibrosis rather

supposed by
than

cerebral

then

us

well-known

This

try

as

to

and often-described

in areas,

disease

business

ask

be

pathologiststo

lesions of the types

the

learn

as,

or

in its

to, in the limbs,

alluded

other

and
arteries,

and

nature

if in kind

questionwe

I have

some

extended

in the

or

Let

several.

or

such
distribution,

is

change

the aorta,

one

own

my

engaged by

men

enquiry concerningthe

the

to

arterial
syphilitic

it be

under

cases

stress.

exercise.

muscular

to return

now

aorta, I think

functional

by

from

received

observation,for this has happened in

or

of the

and

limbs

diffuse

recognised in
tricts.
particulardisof the

essential nature

arterial disease,whether
syphilitic

it be

sclerosis,
singleor multiform, whether distinct in nature from atherobut a variety of this.
in later
In some
or
cases,
and
atherosclerosis may,
stages, and in elderlypersons in whom
the specific
lesion of the vessels,
usually does, supervene
upon
it may
be difficult in a particular
specimen,even with a fat stain,
clear distinctions between
and
to draw
atherosclerotic
syphilitic
in disease of old standing; so
if we
to
are
lesions,especially
form
distinctions
a
judgment upon real or allegedhistological
must

we

If

we

examine

turn

Dr. Mott1
with

to
or

fibrosis of the

Mott, F. W.,

Disease," p.

567.

Adami,

of mark

on

the

and

our
compare
shall find that, whether
there

long

attacked

different in form

author

recent

Professor

theirs,we

commonly

the lesions in their earlier and

from
Allbutt

arteries
in

way

not, the

or

which, if

the invasion
and

subject,such
own

be

inward

not

of the aorta

Rolleston's

clearer stages.

observations
also

diffuse

arteries

in nature, may
and

System of Med.,

as

are

be

largervessels.
art.

"

Arterial

CHAP,

It is

SYPHILIS

iv

generallytrue

the renal

that

arteries and

so

the

297

cerebral,the

on,

furthermore

and

the

coronary,

hepatic,

the veins

also,are

invaded

with
primarilyfrom the outer side, and, in contrast
is not from
the beginning
atherosclerosis,by a process which
virtually
degenerativebut is inflammatory or sub-inflammatory,
the result of an
irritant ; so that, logically
speaking,syphilitic
arteritis is not atherosclerosis,and has no
proper place in this
never
category. Atherosclerosis,being degenerative,
propagates
itselfto contiguoustissues. In syphilis
the adventitia is attacked,
it seems,
irritant passing in the periarterial
as
lymph
by some
in the brain
channels, channels
especiallynotable of course
where
arachnitis involving the vessel, and thence
a
we
an
see
of proliferation,
with
the inflammatory features
periarteritis
infiltration,
vasorum
being
diapedesisand so forth ; the vasa
in the process.
It is true
manifestly in active participation
nevertheless
is inflammatory, the
that, although this process
inflammation
from
the beginning verges
degeneration,
upon
and may
be merged in it,and that then the intima becomes
soon
involved
also.
Yet if this first inflammatory stage be promptly
met
from clinical evidence
seem
by specific
treatment, it would
that the drift to degenerationmay
be prevented,or at any rate
effected ; a cure
which
in the earliest phases
arrested, and cure
be practically
without
a
scar
complete,possiblyeven
(local
may
fibrosis).On the other hand, if the mischief be not arrested, it
may
so

advance

in

as
destructively

hard, fibrous,not

to

closelylike atherosclerosis,but

not

manner

reduce

the

arterial branch

thin

and

cord (arteritis
A typical
calcified,
obliterans).

and

read by
carefullydescribed case was
before the PathologicalSociety so long
exhibited

to

the

adventitia

with

increased

as

the

seat

of

an

Buzzard
ago

as

active

and
1877.1

Sankey
They

filtrati
small-cell in-

or
new
activityof the vasa
vasorum,
newly visible twigs of which penetrated into the intima; the
fibres
media
and the muscular
presented a similar proliferation,
had
no
passed into granulardegeneration. In the intima were
fibrous hyperplasia. In a girl set. 19,
plasma cells but some
2
subject of congenitalsyphilis,Biermann
reported arteritis
both legs were
The posteriortibials on
(apparently)universal.
,

Soc., Report of Meeting in Lancet, Feb. 10, 1877.

Biermann, Deutsche med, Wochenschr., 1911, No. 25.

Pathol.
2

CAUSES

298

OF

thus obliterated,and
Yet
the

the left radial

then, if the anatomy

even

parcelof

the vessel above

efficient collateral
of the part, may

Now, if
in

ARTERIOSCLEROSIS

we

much

was

of

the block

less

or

supplies

be established.

thence

cerebral

suppose

vessel

be

caught quite
described
by
appeared ; otherwise
depend primarily,as
to

intima

form

be, in the
the

described, the

we

first inroads

succumbs

first,the

the lumen

may

poison,as

of

The

practicallyintact.

artery

more

circulation,
accordingto the vascular

early stage, the changes in the

Heubner
and
myself will not yet have
do appear
they soon
they may
; and
in
Baumgarten argued, upon
processes
whether
vasa
by a propagationof
vasorum,
or
merely by interference with nutrition.

be

in calibre.

permits, as

dilates,a

the

before

reduced

circulation

the

PART

intima

yet, white

be, it contains

lime.

this may
of

falling

in the aorta, may

or

to

and

irritation
specific

instead

the

even

intima,

direct occlusion

as

such

In

these

cord -like

adventitia

However

it does

adventitia,

no

the

media,

swellingeven

and

the

basal
the

cases

of

cerebral
intima

be

lously
greatly thickened, and breaking through the marvelcombine
with thrombosis
to stop
enduring endothelium
ulcerative
up the channel ; or a patch may
present itselfin an
form very like an
ulcer.1
atheromatous
have been
Spirochaetes
found in such lesions in early cases.
In the largervessels the occurrence
of independent luetic
may

"

"

foci in
I

the

intima,

which

to

repeat, when

such

have

alluded, is

rare.

ever,
How-

intimal

established,
changes are
it may
become
difficult or
impossible,especiallyin elderly
and in some
between
to discriminate
arteries,
syphilitic
persons,
and atherosclerotic disease.
The rule,originally
own,2 that,
my
unless mingled with atheroma
in elderlypersons,
the specific
is much
less subject,in itself indeed is not subject,to
process
fatty and calcareous deposit,but is more
disposed to fibrous
thrombotic
and
occlusion, has been
generally accepted. A
aid in the distinction
scrutinyof the perivasculartracts also may
extension
of gummous
a
perivascularfibrosis,or an
;
material,may have penetratedfar into these,and have obliterated
1

coloured

illustration

is given in Griinbaum's
2

See

of

Morbid

Fagge's Textbook,

3rd

syphiliticcerebral
Histology,p. 106.

ed., vol. i. p. 551.

artery, from

chimpanzee,

OF

CAUSES

300

AKTEKIOSCLEKOSIS

PART

frequent,and to the microscope conspicuous,in the

media ; granulomatous patches quiteindependent of adventitia
intima.
But around
or
them, and in other places,plasma cells
in groups and layers,
and a fibrosis pushing inwards
be seen
may
disease

from

outwards

and

adventitia

being usuallyinvolved

more

intima

and

less from

or

activities of the adventitia.1

morbid

the

the

I have

media

outer

beginning in
said that

the

in these

changesproduced in Mott's and

in Sumikawa's
experiments of paintingthe outside of a vessel
irritant. On this primary luetic disease of the outer
with some
this coat, ensue
those
elastica and media, injuringand enfeebling
or
warpings and bulgingsof the vessel which give rise to more
extrusions
less sacculated
of the wall, to
rhages,
dissecting haemorWhen
patches of
or, in the finer twigs,to thrombosis.
fat or lime are seen, they suggest, or even
blend of
a
announce,
wellatherosclerotic
with
a
disease, as also would
syphilitic
marked
of the elastica (p.520), a layerwhich in syphilis
splitting
is more
prone to decay than to multiplication.
respects the process resembles

the

"

Is this medial

disease gumma

said to me,

Well,

as

"

Dr.

Andrewes

once

macroscopicalthan
cellIn histologythe ordinary minute
a
in the arterial coats
nests
in nature
are
homologous with more
is, in vascularityof
conspicuous gummatous
swellings
; that
granulationtissue,abundant
plasma cells,earlynecrosis,
young
over
Moreand
(inthe artery) obliterative inflammatory processes.
there is a largerproportion,
of fibrotic
than in atherosclerosis,
there is
(productive)to degenerativeproducts. Histologically
exudate.
more
activityin the stellate and spindlecells,more
be uniformlyor crescentically
The lumen
narrowed, or if the
may
intima be deeply engaged, even
closed ; and often it is actively
vascularised,though at the same
time, e.g. in the brain,it blends
is rather

"gumma"
pathologicalterm.

with

the

adherent

the

of

media

clinical and

this with

and

the

which

adventitia

pia mater, and this again to the

Probably the lymph sheath is always an
to

the

infection.
his

Thus

Jores

also

"

cerebral
active

luetic

compares

be

may

stance.
subarea

arterial

"

regenerative (" Bindegewebswucherung ")

of
endarteritis
of ligature,
form, comparing it with the
impression
pulmonary cavities,and of meningitis. My own
disease

with

"

coloured

illustration

is

given

in Letulle

"

for reference

see

p. 202

n.

CHAP,

SYPHILIS

iv

in the

distinction

the

is that

301

smaller

vessels

between

sclerosis
athero-

sclerosis is a true
but is
syphilitic
one,
by coincident atherosclerosis or, except
apt to be obscured
To quote
in its fresher stages, to lose its peculiarcharacters.
Dr. Andrewes
again (loc.cit. p. 226) although he thinks that
fibrous all through the wall,
the specific
thickening is more
of
the lumen
and
narrowed, he regardsthis as a matter
more
kind.
Moreover, such a
degree rather than of histological
but may
be seen
in cerebral
change is not confined to syphilis,
These, we repeat, are
meningitis,in tuberculosis, and so on.
arteritis,not atherous
degeneration; they are inflammatory,
However
Stein 1
and often begin from the adventitia as such.
in which disease of the common
of syphilis
has reported a case
iliac artery presentedthe features of ordinaryatherosclerosis and
The elastic fibres were
of aortic medial disease.
not
multiplied
the ordinaryswellingof fattydecay. The
and in the intima was
and

diffuse

"

media

the adventitia

fibrosed and

was

artery there

no

was

criterion.
specific

discrimination
histological

vessels,hard

for minor

is

may

as

it may

be to

the

fattynecrosis
that

in fresh

and
cases

inflammation

depositin

vasa

also admits

be very

the media.

also ; that

vasorum

detected, and
It is true

difficult.

Still,

contrast, that

other

often

that

some

the

proneness

all,is far less

at

small-cell infiltration and

be

that the

fuse
dif-

of fibre ; that the adventitia

if it exist
calcification,

may

the

identifyparticularcases,

the broad

may

involved, and

Josue

at times

to make
perhaps venture
sclerosis consists more
syphilitic

we

thickened, but about

foci

to

; and

evidences

of

of

of these

syphilitic
changes are

of interference
with
nutrition
particularways
tissue change ; still,
than to specific
however
engendered,they
of our
into the sum
data.
enter
interpretative
wellbesides the now
Summarily then, whether in syphilis,
known
irritative process of a granulomatous character, attacking
most
frequentlyand commonly in the first place the adventitia,
also frequently,
the outer media, but
or
early,and independently,
rarely,in a primary and independent sense, the intima, seats in
been
has often
which, in the aorta, the spirochseta
detected,

due

rather

to

whether, besides

this

in which

the

another

now

well-known

sclerosis is

Stein, Virchow's

Arch.

process,

general and

Bd.

ccxi.,1913, H.

there

may

be

diffuse,possibly
1.

CAUSES

302

AKTERIOSCLEROSIS

OF

"

of a fibrous rather
parasyphilitic,"
the
especially
nature, and falling
upon
whether

furthermore

there

be

may

an

PART

than

atheromatous

an

vessels of the limbs, and

endarterial

form

in which

sclerosis,
something of the order and semblance of atherostartingin the intima only or chiefly a mode which
has been detected (Teacher,p. 479) ; whether
certainly
syphilitic
arteritis be thus multiform
broadly speaking,twofold,
or, more
after the first two
than
the
modes, the third being no more
blend in later life of ordinary senile fibrotic or atherosclerotic
common
lesion,we are not yet
changes with a foregoingsyphilitic
in a position
Yet after all,disease certainly
to decide.
syphilitic,
advanced
and syphilitic
the
only, is,in its more
stages when
the process

takes

"

vessel

whole
area

often

"

be

hard

admit

must

is involved

the

in

say

"

coronary

or

cerebral

from atherosclerosis ; indeed we

distinguish
the distinction may
histologically
occasionally

to

that

impossible.
In

respect of

into that associated

clinical division

main

my

with

and

high pressures

of Arteriosclerosis

that not

associated,

so

I wish here to

impressupon the reader that grievousand extensive

arterial disease may
in many
as
be, salient,
syphilitic
cases, as a
great deformity of the thoracic aorta, with or without a general
peripheral
thickening,
yet, unless complicatedby renal or by other
incidents,in
have

no

chanced

normal.

And

effect have

of these

one

to

in not

been

find
few

confirmed

the

recorded, I do

blood

of my

own

we

see

of

scores

them,

ranging above
pressure
observations
to this
cases

by expert colleagues.

cases
Upon the remarkable
of
cases
congenitalsyphilis,

in

and

cases,

of universal
which

no

arterial

degradation

inconsiderable

number

these arterial
histologically
ruins are
for interpretative
too far gone
data, and their interest
is other than histological
(p. 174). On the systematic morbid
aortitis and arteriosclerosis I offer some
anatomy of syphilitic
further remarks
in later chapter (p. 478).x
other microbes upon
Of the poisonouseffect of some
the blood
in
vessels,the followingcase, quoted from Dr. Andrewes'
essay
Officer for 1913
the Report of the Medical
(Infectious
Origin),
is a remarkable
example :
are

now

on

For

Arterial

fuller discussion
Disease

not

of

in Allbutt

return

this
and

subject
Rolleston's

I would

refer to Dr.

System of

Medicine.

Mott's

article

CHAP,

CANCER"

iv

NEURITIS

303

duration
girl,aged 17, died after an illness of four months'
due
There
to B. coli.
was
no
a
suggestion of
pyelo-nephritis
fatty streaks along the
syphilis.Apart from a few superficial
limited to the transverse
arch and
descendingaorta, the lesions were
Here were
of the great vessels of the neck.
to the origins
large projecting
intimal plaques up to half an inch in diameter, firm in consistency,
A

"

covered

and
the

by

ordinary plaques
purely

were

endothelium.

resembled

They
arteriosclerosis,
except

contained

and

fibrous

intact

an

of nodular

elastic elements.

no

that

they

Fatty

and

present in the

deeper parts of the

demonstrable
in the intimal plaques ;
thickenings. No bacteria were
but in the adventitia, and
extending a little way along the vasa
of inflammatory ininto the media, were
filtratio
vasorum
scanty areas
calcareous

even

changes

and

were

situations

in these

stain.

negativeto Gram's
specimens had been
originalpaper.) See

I found

Cultures
into

put
Vol.

staphylococcan toxins
(of cats). Foreign serums

said, on

are

is

Edgren,

probably

whole

advanced

to

this

impressed by

for

vague

This
disease
of

fortuitous

seems

bane,
other

to

both

diseased

Eichhorst,

Bd.

from

Lawen
i. H.

maladies

swine

"

by

pertain

then

and

now

on

is much

one

marked

consider

In

one

the

much

gout.

to

the

nervous

cause

strands

u.

Paralysis,

and

neuritis

of both.

play

in

But

the

determining

arteries has

Virchow,

Vulpian, Lobstein, Nothnagel,

might

add

clinical and

Dittler

may

consequence

General

degenerations

common

of arterial

cases

associated

in

been

much

Marchand,

discussed

A.

Chantemesse,

and
Brown-Sequard,
by Bernard
the experimentalpoint of view ; but

result than

more

1, 1913.

certain

Tabes,

Frankel, Martin, Bervoet, Bechterew,

the

degrees,and we
cytolytictoxins,or upon degenerative
both ; but such speculations
too
are

infections, arterial

instance, by

without

sheep, ox,

neuritis, itself probably the

in

as

sclerosis of the

both

constrict

to

noted
arteriosclerosis,

in very

fitting
place to

attributed

part which
for

said

e.g. of

"

Still

life.

association

be attributable

may

in

present consideration.

some

and

the

as

(Illustrationsgiven

are

with

cancer

speculateupon
to
common
proclivities

out,

like effect.1

be led to

may

have
of

association

The

the

to

cats,

bacilli,

160.

Filtered
arteries

of

groups
be carried

not

formalin.

II.,p.

few

could

the

collection of many

Bering's (Leipzig)laboratory,Zeitschr. f.

curious
exp,

Med.,

CAUSES

304

cases

OF

ARTERIOSCLEROSIS

PART

such, for instance,as that of Chantemesse

brachial

the

injury to

arteriosclerosis of the

plexus
wounded

followed

was

by

in which

an

well-marked

only, the other arm, both

and vessels,remainingquitenormal.
Similar results
to nerves
as
have
been described
as
dependent upon injuriesof the sciatic,
and
the tibial nerves,
and
of others no
the peroneal,
doubt ;
arm

but it is often difficult to say in what

vascular

lesions stood towards

Hansemann,2
cases

concomitant

he

was

results

were

arteriosclerosis from

frank

enough to
negative. Israel

add

when

the vessels dilate and

in

that

thinks

influences

under

nervous

be the

change might

nervous

that

alteration

of arteries in

the sciatic is not

tooth

slower

his

cases

suffer

might add,
stretching.Aschoff

atonic

in which

he had

so

do

I ; however

Frankel's
cut

such

alleged
a

nerve

convincing; but in all such experiments

bring temporary lesions into line with the

very

difficult to

it is very

areas

to

primary lesion

the vessels thus

explanationvery dubious, and

the point elsewhere.
considered

I have

leaned

similar

19

Israel's

thinks

and

rise ; or, I

pressures

undergo

the

Oguro, working under

preparationsof

when

as

each other.

and

nervous

affection of the local nerves,

the belief that the

but

in

detected

relation the

of time.

Most

writers follow Bechterew.3

Frankel

followed by
reportedthat after section or irritation of the sciatic,
effects,morbid
livelyvasomotor
changes eventually,but after
a
long time, appeared in the smaller arteries. They began in
the adventitia,then the unstriped fibres became
and
opaque
granular,and as new vessels appeared connective tissue increased,
both in media and intima.
The same
changes are said to follow
in the veins and
pathologicalneuritis. Similar changes occur
of cervical rib with trophic
lymphatics. Dr. Todd,4 in a case
palsy of the sympathetic fibres,found disease of the intima of
the arteries leadingto thrombosis.
He pointsout however
from
Schafer's Physiology(Langley,and others),
that the sympathetic
does

not

pass

Read

Hansemann,

the

Bechterew,
544

pp.

at

down
Paris

the
Medical

Virchow's
Die

Funkt.

main

vessel

Association

Arch.
d.

Bd.

in

but

February

cxcviii. H.

Nervencentra,

in

"

this instance

"

1908.

3.

trans.

Weinburg,

H.

1, 1908,

et seq.

Todd, W., Journ. Anal,

See
Lancet, May 17, 1913.

and

Physiol. vol.

xxvii.
Photograph by Hirsch,
Bruce, A. N., Arch. Exp. Path, and Pharm.
No.
63, 1910 ; and Frankel
yql, ix.,
(quoted Todd), Wien. Tclin. Wochenschr.
1896 ; "ee
also Todd, Joy,rn. Nerv. and Mental
Dis" vol. xl, July 1913.
also

CHAP,

NEUKITIS

iv

anterior

sciatic and

the

by

305

crural

More

nerves.

definite

are

experimentalresults, obtained by Manouelian, of the

He
Institute.1
Pasteur
a
nerve
sought to erase
supplying an
artery directlyand, after other endeavours, stripped off the
the
passing to the abdominal
aorta, near
sympathetic nerve
originof the left renal artery, and to the pulmonary artery
in dogs. The dissections were
most
made,
carefully
respectively,
certain

so

of

the

form

of

of the

disturbance
seemed

muscular

and

elastic

calcification

the

and

The

parts.

constant,

fibres

scarcely occurred

effects

degeneration

were

but
atherosclerosis,

parts took

on

hyaline

promised to pursue these researches.

describes a painfulneuritis (sciatic,
of Breslau
brachial,
more
rarelytrigeminal)due to sclerosis of the vasa
from senile neuritis,in which
which he distinguishes
author

The

decay.

Foerster

etc., and
nervorum,

the

other

any

sclerotic foci," which

"

in

avoid

to

as

is

nerve

perhaps

not

tender

more

so

to

pressure

His

obvious.

point

and

the

of view

arteriosclerosis

of
is, conversely,

arteriosclerosis. The
article
followingupon
losses of reflex,
does not admit of abridgment. There were
no
until muscular
nor
atrophy also set in. Such inferences
palsies,
Klotz
(loc.cit.)contradicts, saying that the sclerosis due to
lesions is septic,
the nerve
a
gradual infectious arteritis,
going
disease

to

on

of

nerve

chronic

fibrosis.

And

microbes

many

take

neural routes.

largervessels there may be a mesarteritis with conspicuous

hypervascularity.Or under the intimal changes there may be
due to preventionof nutrition from the
medial degeneration,
a
Gowers
lumen.
Sir William
atheromatous
speaks of an
neuritis
an
atrophicinflammation, or fibroid reaction.
Of
thrombo-angitis"(Raynaud'sdisease,certain obliterative
I say little.
arterial diseases,chronic and acute, and so forth),
In the

"

"

"

"

These

are

not

constricted

or

arteriosclerosis,
nor
vessels.

Some

thrombosis

other

of

factors,probably including

destruction, are concerned in these

epithelial
grievousand painfullesions.3 Syphilismay
few

some

1
2

; and

other

infections

in

obscure
be
some

See
VOL.

Jan.

concerned

others.

Wien.

25, 1913.

Buerger, Amer.
I

often

and

xxvii., 1913.
Manouelian, Ann. de VInstitut Pasteur, tome
in
Deutsche
med.
discussion
of
Wochenschr.,
1912, and
Report

Wochenschr.,
3

of them

merely sclerosed

Journ.

Med.

Sci. vol. cxxxvi., 1908.

X

in
To

med.

CAUSES

306
witness

few

one

middle-aged

as

as

true

accidents

or

of acute

of such

values

of evidence

local

invasion

are

of this

at

which

influences ;

nervous

malady

system

more

need

some

of this

nervous

kind, we

of

record

on

of

one

arm

to

Neurasthenia."

Traumatic

as

left

guess
outbreak.

of arteriosclerosis

concurrent

whole,

of the

an

generaland

obliterative

thinking of

compelled

affectingthe

"

in

arteries

be

cause

cases

early and

an

shocks

the

as

the confines between

on

such

is to

"

remarkable

Some
stand

woman,

in the

PART

"

attack

infection

virulent

agonizingprogress
it occasionally,I am

sees
an

cases,

ARTERIOSCLEROSIS

and

active

the

as
arteritis,

my

OF

To

after

or

ascertain
data

more

than

less
the
we

usuallyget. Rivalta has publisheda strikingsuggestionof such

had never
set. 29, who
a
sequence.1 The patient,a young man
and was
suffered from syphilis,
not addicted
to alcohol or tobacco,
fell from

his saddle

for ten

days,

month

after

arteries

His

increased

lay

What

arteries

friends

was

the
and

vomited, and

bed

the

twenty-fivedays. A
noticed
that his temporal
was
dimensions
of a goose
quill.

very

I will not

vanished
dwell

The

tortuous.

change

thickened
in the

stranger is that six months

even

insensible

was

for

also much

were

noticed

arterial lesion had

But

it

to

thickened

were

He
in

got about

accessible

other

his head.

remained

and

he

were

walls

The

on

radials
and

"

and

tense."

temporal arteries.
later all sign of the

points of no great importance to my

of the cases
subject,as in many
uniformityof data and testimony
stillwanting. In
all see a
are
nervous
we
subjects,of whom
looked for signsof precociousarterial
good many, I have carefully
.decay,but have not been impressed hitherto by their undue
not
frequency; I am
yet prepared therefore to agree with
Mitchell Bruce and Israel,if they lay much
emphasis on causes
on

"

of this kind.

"

"

Neurotics," it

into old age

to

seems

me,

often

nurse

selves
them-

without

of
presentingundue manifestations
Aschoff thinks Israel's postulatesdubious, and
arterial disease.
indeed
Dr. Bruce, in asking if disease of the cerebral arteries
in

women

flushingsand
1

can

med.

be

may

attributed

false

refer

Wochenschr.,

to
21.

the
Mai

1907

their

precordialoppressions,
other
judiciouslythat
many
"

angina," says

Rivalta, II Polidinico, March

only

"

to

Epitome, Brit.
Arterioskl.
by Rumpf,
1914, which
appeared too late

article

Med.

"

u.

Journ., 1907.
Unfall," Deutsche

for this book.

OF

CAUSES

308

is

pressure

opinion

this

as

under

130

over

the

on

close

whole.

and

heart

labouring

discussion

adequate
the

of

papers
In

this

with

Note,

to

informs
in

drawn

it.

of

man

190-200.
in

48,

both

but

an

little

heart
and

in

one

clinical

other
in

the

other

1020

under

elderly,

six

pleura,

in

sertation
dis-

ask

malady

what

"

And

Hochhaus

Professor

he

Now

in
the

in

no

orbital

nor

the

the

man

five

woman

subconjunctival

that

had

had

have

been

on

in

one

tests

specific

red

corpuscle
a

range

of

oedema.

dropsy

the

gravity
count

which

high.

unexpectedly
large

of

pressures

The

millions,
was

man

had

sedulous

most

and

Hospital,

Both

whatever.

woman

The

enormous.

and

surely

hyperpiesia,

50.

over

variably,
any

over.

of

been

pressure

disease),
would

cases

casts

blood

Addenbrooke's

in
two

woman

reveal

renal

have

counts

high

attention

found

1914,
a

of

his

anaemic-looking
was

but

hand,

August

millions,
and

cases

evidence

appeared
to

and

worn

both

would

blood

routine

(i.e. persistent

abnormality

albumin

at

to

certain

We

with

hospital

hyperpiesia

failed

cases

both

in

ranged

legs

wards

Though

urine

The

the

of

about

reader

effect.

conversation

of

course

my

any

On

charge

and

cause

In

12.

without

presented

to

taking

both

an

Arteriosclerosis

this

on

for

"

of

cases

counts

1.

3,
the

in

hypertrophy

these

is

par

that

many

cardiac

for

260,

p.

me

made

was

element

failing

every

bring

not

pulse

mentioned.

reading
"

quential
conse-

But
the

far

so

slow

refer

of

exclaimed,

do

that

have

after

in

signs.

Causes

who,

which

are

the

on

disease,

and

must

names

reviewer

conditions

whose

that

promote

diagnostic
I

corroborated
is

may

subject

chapter

another

on

chief

this

authors

the

revising

sympathise

the

of

further

no

the

are

it

disease

but

have

impression

own

renal

arteriosclerosis,

PARTI

supervision,

My

cause

may

pregnancy

ARTERIOSCLEROSIS

of

the

CHAPTER

ARTERIOSCLEROSIS

AND

KIDNEYS1

THE

to consider
problem which we have now
of the most
in pathology
is one
alluringand the most baffling
think to
we
alluring,
perhaps,by its very subtlety. Whether
approach it by the way of clinical observation, or of the exacter
of chemistry and
methods
of clinical research
the methods
pirical
physics,or, again,by way of experimentsin animals or of em-

INTRODUCTION.

The

"

"

"

tests

These

in man,

find ourselves

we

side disconcerted.

every

conjecturesand speculations
before the early spring of a working
witheringuntimely even
indeed
has
hypothesis. At the bedside the physician,who
made
of the task than his comrades
of the laboratory,
more
justly
ence
believinghimself to have delineated certain broad lines of differbetween
kinds of kidney disease, when
he has followed his
"

are

ways

into

cases

tubular

strewed

on

the

with

dead-house, is disconcerted

"

being

cases,

"

also

hear

to

his

that

his interstitial

and
interstitial,"

will have none

of his
being likewise tubular,the pathologist
divisions. Moreover, he is informed
that, althougha certain group
of these diseases may
be more
lated
obviouslyand extensivelycorrewith cardio-arterial disease,
of chronic Bright's
yet few cases
disease fail to reveal to the pathologist at least within the relics
cases

"

This
of

Journal,

April

an

abstract

of

Meeting in 1912.
in repetition of
after
If

chapter
labours

Metropolitan
and

15
a

1911

the

address

an

Counties
;

same

delivered

Branch

and

in

in

this

effect read

1911.

journal for Aug.

at

the

Brit.

I have

is the
the

decided
way

of

for the

perusal less tedious

increased

by frequent

cross

309

part

most

conviction

in

if, for

any

to

Med.

Medical

10, 1912
Assoc.

is

Ann.

find many
paragraphs
Arteriosclerosis
; but
leave

case

parts of the

reference,

Kensington

British

See

the chapter for this book I

re-editing
similarly dealt with already under

In

the

before

matters

will find
not

22,
to

paper

reiteration

are

of

extension

an

hesitation

some

true,

is

essay
the

Division

them
reader

in

place.

of

this

argument,

his

ARTERIOSCLEROSIS

310

of the

kidney

KIDNEYS

of arterial disease.

measure

some

"

THE

AND

PARTI

The

physicist
freezing-points

studying in Bright'sdisease the

of the urine or of the blood, told
and the electro-conductivity
but yesterdaythat evidence of retained katabolic products of
us
non-conductive
was
a
quality and therefore of organicnature
secured ; to-day we
are
told, on authority as good, that had
tests
to the
these investigators
thought of applying the same
the chemist,

and

"

normal

they would

man

have

consistent

received

much

the variables

that, in either case,

and

"

the
too

are

same

response
to

many

issue in

results.

Again, but yesterday we

in renal disease the

told that

were

of

body to
especiallyfood

waste
nitrogenouswaste
remaining
poison it ; to-day we hear that, other things,
values, being equal, the total urine in renal

disease

in extremis, often

urine

indicated

in the

Once

is,save

to

were

we

more,

lack

"

well

as

found

have

loaded

as

standard

some

in health.
of renal

such
dischargeof conspicuous bodies
these tests likewise
potassium iodide, now
said to have failed in constancy ; the kidney,it seems,
are
work hard on one
set of bodies,and either neglectothers or,
may
more
probably, refuse to take notice of them until properly
chloride and iodide excretion depend
presentedto it. Moreover
in the rates
efficiency
as
methylene blue or

obscure

upon

movements

tissue affinities.
of the

some
an

internal

of

"

"

of the

and
circulation,

turn

rumours
us

almost

surmising that
occult influences of renal function might be due to
secretion, perhaps of a pressor quality; and there
of a hypothetical renin
; later investigators

back
any

variable

were
Finally,the physiologists

"

were

upon

with

"

that

the announcement

other

organic extract,

momentarily, yet the main

if renal
raise

may

effect is

extract, like

blood

pressure

Well
depressoror
Professor Adami
say, in his Principlesof Pathology,that
may
arterio-renal problems are
the most
complicated and
among
obscure in the whole of pathology.
But

from

these

diversions

we

must

neutral.

the part of the

turn

to

the

present discourse

of
subject which is to be the matter
namely, the relations of arteriosclerosis

to

the

kidney, sick

;
or

sound.

Historical.

"

generationago,

when

"

high arterial

tension

"

CHAP,

HISTORY

OF

SUBJECT

311

the interest of physicians,

this condition
was
began to awaken
disease of the kidneys.
to
regarded as belonging essentially
view of it ; such were
Such
Traube's
was
George Johnson's,1

Burdon-Sanderson's, Mahomed's
that

first

the

8)
Mahomed,

who

of renal disease

pertainedto
but

had

the

none

We

shiftingof this attitude

proved
rarelyto

not

were

likewise.

that

become

less, that

fruitful life Mahomed

one

kind

did not

or

symptoms

still Mahomed

of tension
another.

to

arterial pressures

in whom

manifest

this increase

renal disease in

was,

in persons

(p.

seen

in part, due

excessive
persistently

be found

not

have

posed,
sup-

essentially
In his brief

get beyond the doctrine

that

latent
high arterial pressures constituted an initiatory,
foreboding of renal disease,2 a stage which he denoted as the
prealbuminuricstage ; not very happily as it proved, for,
much
albuminuria
is by no
more
as
see
we
now
means
clearly,
decisive symptom
of Bright'sdisease.
Not only so,
a peculiar
or
and I argued fifteen years later,albumen
but as Huchard
and
when
taken together,are not by any
high-bloodpressures, even
decisive of a diagnosisof chronic renal disease in the
means
of the term.
ordinaryclinical sense
another
dislocation of opinion,when
Soon
afterwards
arose
these

"

"

Gull

Lancereaux,

and

Sutton, and

Debove

and

Letulle

tested
con-

allegedarterial hypertrophy, and in so doing

lifted the whole problem of cardio-arterial disease,and especially
from the narrower
of the granularkidney proper,
notion
of a
stitutional
kidney disease into the larger conception of a general conthe kidney disease and
the
distemper, of which
Johnson's

vascular

disease

but

were

coefficients.

On

the other

hand, in

larger view they lost sight of such distinctions as the

Granular
kidney,the Secondary Contracted (" senile white ")
and the Senile.
sclerosis
arterioMoreover, unfortunately,
they named
arterio- capillaryfibrosis,which
it is not, or only
an
in some
part. Besides, the exaggerated notions of the effects
of vasoconstriction
blood pressure
preted
in the kidneys,as interon
shaken1 by Cohnheim's
by Traube, were
especially
proofs
is quite
that arterial constriction confined to the renal areas

their

"

"

R.

Johnson's

Med.

Chir.

originalpapers
Soc., 1872

and

Researches

in the

Med.-Chir.

Trans., 1872,

were

in the

Brit. Med.

our

n.,

1867, and

Trans.

1877.

period 1875-1881,

vide

Trans.

Intern.

Med.

Cong., 1881,

inadequate to produce even

pressures.
inconstant

Chauffard, in
correlation

changes, perceived

THE

AND

ARTERIOSCLEROSIS

312

renal

that

the

rise of

temporary
diseases
relation

with
was

PART

generalarterial

of the variable

survey

of

KIDNEYS

and

somewhat

cardio-vascular
thus

not

merely

mechanical.
Gull

and

Sutton

were

methods,
histological
Johnson, who

misled

by the imperfectionsof their

of glycerine.
especiallyby their use

in Chauflard's

words,

the opener of the histological

positivein his assertions

was

too
period of renal disease,was
obsolete
and interpretation
(p.470). While preparingfor a now
Review (p.
article in the British and Foreign Medico-Chirurgical
prealbuminuric stage
12), certain suspicionsthat Mahomed's
speaking,we
(p.11) did not always issue in what, clinically
other kind of Bright'sdisease
as
one
or
classify
suspicionsI
lamented
discussed
with
friend
had
shortly before his
our
death
took definite form
in my
mind.
and
By the
grew
of this enquiry,however, a long periodof time had necesnature
sarily
to elapsebefore it was
possibleby experienceto be assured
"

"

that

excessive

blood

clinical series ; and

pressure
a

may

enter

into

stilllongerinterval before

more

than

I could

one

hope

to

morbid
series so
persuasionto others. To compare
protracted as these was, generallyspeaking,possibleonly in
privatepractice; yet in privatepracticeat the end of such a
clinical series to obtain a necropsy
was
a
very infrequentopportunity.
On the other hand, in hospitalpracticesuch patients
and went
for long and continuous
too irregularly
tions.
observacame
I have explained that sphygmographic curves,
however
suggestiveto a practisedoperator, give no record of pressures.
We had no pressure
even
; and
yet the graphicrecord of
gauges
continuous
of blood pressures
course
on
depends too much
any
the occasional zeal of a house-physician.At any rate no trustworthy
and continuous
series of such records,such as they are for
instance in the courses
of pyrexia,were
then,if they be now, open
to the enquirer. Still in time, by observinga few privatecases
throughout,by watching,as I have said, one case in particular
of hyperpiesiswithout
which
Bright'sdisease a thread upon
much
of my
material
was
through its period of
strung
eighteenyears, by selectingand patching longer and shorter
of other cases
terms
the invenon
and, latterly,
seen
piecemeal,
carry

this

"

"

CHAP,

HISTORY

tion of pressure

apply

to

myself that

chronic

as

another

and

initiation,inter-

the

the clinical

physician
its forms ; but is significant
of
series,though one
ultimately

of

clinical

to

arteries in like manner,

the heart and

damaging

known

the events

different

comparison, and to satisfy

by excessive arterial pressures

marked

disease in any

renal

of

does, arise without

often

sequelof

or

currence,

standards

some

313

tions,
enabled, by approximate verifica-

was

certain process

and

may,

gauges,

SUBJECT

OF

and

clinical series I named

This alternative

Plethora,"1 but, the malady being not

less irreparably.

no

at first

"

Senile

of

I suggested
senility,
the alternative name
of "Hyperpiesis."2 Unfortunately,many
in detachingthis name
too literalauthors persist
from the malady,
total morbid
or
series,thereby indicated,to confine it to the
mere
phenomenon of high blood pressure under whatsoever
circumstances.
German
authors now
between
die
distinguish
essentielle Hypertonien
with
die nephritischen
as contrasted
mitted
adour
terms, I think it is now
Hypertonien." But, whatever
kinds or
that, although in Bright'sdisease, or in most
of it,persistent
modes
of arterial pressures
is an obligate
excess
condition,a like persistent
nevertheless,in obedience
excess
may
to some
deed
causes
as
yet unknown, arise independently,and inbe engaged in another morbid
series.
was
During the years of which I have spoken Huchard
occupied in similar observations, and also in discriminating
this alternative
clinical series,not
Bright's disease, though
correlated with high pressures.
He attached
to it the name
of
less happy than mine, as it seemed
a
name
even
Presclerosis,"
that the
to signify,
intended
and, indeed, was
by him to signify,
disease,when fullymanifest, would be that of Arteriosclerosis.
To this issue I shall return
presently.
renal disease and
to
from
Now, to digressfor a moment
one

"

"

"

"

return

Professor
arteriosclerosis,

to

The

plethora

of

the

ancients, with

vertigo, epistaxis, etc., and

"

Granular
2

In

Society,
in

which

"

kidney
my

year

"

Lane

Lectures

in

1894

from

"

was

process,

the

subject,

years,

name.

correct

an

collected

materials

as

contain

from
an

It has
form

address

occurred

for the

to

to

Hunterian

the

and

1870

between

private

great part

Hyperpiesia.

also

alternative

in

doubt

no

was

the

as

pulse, headache,

characteristic

its

venesection

this

on

introduced

I preferred this
the

by

class would

I passed, for three

hyperpiesia

hyperpiesisis

the

first publication

written

term

but

relief

far back

Osier, so

1889

asylum practice
"

In

name.

to

malady

me

is

"

the

1896, in my

since

that

while

hyperpiesia.

AKTEKIOSCLEKOSIS

314

of his

edition

third

THE

AND

text-book, New

York,

concluded
speaking of arteriosclerosis,
There

KIDNEYS

PART

(p. 771), when

1898

certainlytwo groups of cases,

the first change, and the other

in which

one

are

sclerosis
the arterio-

it appears
to be
secondary to a primary affection of the kidneys. The former occurs,
I believe,with much
greater frequency than has been supposed.
is

Samuel

Dr.

in

West,

his

in which

Lectures

Lettsomian

for

1899,

the
problem under discussion no less definitely
spoke on
;
his
I
I
shall
cannot
quite accept
presently,
although, as
say
he separated from
views
the whole.
on
However,
Bright's
disease,as I had done, the deteriorated kidneys connected with
atheromatous

advanced
"

"

So-called

often

senile

are

the clinical

run

gouty

or

interstitial

markedly

granular, and

disease, or

the

"

kidneys "...
they need

because, although

Moreover,
large."..."
ofgranularkidney."

the

often

course

I italicise this

sentence

as

necessarilybe

not

it coincided

very

need

cases

nearly

not

with

To
previous discrimination.
judge by the context, Dr.
West
red granularkidney
to
clearlyintended by the name
not
a
mere
signify,
aspect of the kidney in the literal meaning
of the adjectives,
but something more
specific
lar
; namely, a particumy

"

series of clinical events

That

Dr.

West

my

further

distinction

to

excessive

pressures

then

not

record

"

had

certain

arterial

pressures

or

process

ease."
dis-

accepted
degenerationsecondary
at

the decrescent

arterial

"

morbid

not, in 1899

between
and

any

"

any

form
"

made

"

rate,

indeed, he did
his

testimony

peculiarlyvaluable by its clear separationof the group of renal

and of the "Granular"
patientsfrom other arteriosclerotics,
proper
from other rough or deformed
that Dr.
kidneys. I must assume
of non-nephriticarteriosclerotics was
West's
contrasted
group
I had
mixture
of the cases
a
distinguishedas decrescent (or
involutionary)and hyperpietic respectively. At that time
indeed he may
have regarded all high-pressure
renal.
cases
as
decide
pathologistsmay
Again, whatever
concerning the
late Dr. SavilFs testimonyto Johnson's arterial hypermyotrophy,1
I may
at least quote his seventh
proposition: 2 That arterio1

Jores

Paper

15, 1897.

is

disposed to

read

before

admit
the

stage of medial

Royal Medical

and

hypermyotrophy (videp. 471).

ChirurgicalSociety,January

ARTERIOSCLEROSIS

316

of

high

need

not

those

and

pressure,
concern

us

Dr. Graham

THE

AND

of toxic and

KIDNEYS

of

PARTI

inyolutionaryorigin,

now.

Steell

writes of

of sustained

cases

pulseof high

tension, with

hypertrophy of the left ventricle and loud second

aortic sound, leadingto dyspnoea and mitral regurgitation,
which,
notwithstanding,are not Bright'sdisease.
And, further, at Toronto, in 1906, Dr. Stengel reiterated
what
Huchard
and I had pointed out many
before, that
years
albuminuria

in

evidence

of

of arteriosclerosis must

cases

be taken

not

alone

a
as
Bright'sdisease,nor necessarily
foreboding
of it. Dr. Stengelargues that the appearance
of albumin
in the
urine in arteriosclerosis may
be independent of renal disease,and

as

that

in such

If, now
the

renal

cases

then

and

disease

in terminal

be

may

and

is absent.

often

stages, convulsions

they

occur,

are

result

the
simply of failingcirculation.2 Senator makes
is a late symptom,
same
admission, pointingout that albumin
and even
then transitory
in
Granular
kidney,"
; it is not, as
3
Dr. Tyson of Folkstone
brought out by meals or exercise.
"

the

to

effect relates

same

later middle
other

and

elderlylife

of

at

albuminuria
One

heavily loaded

of

experience

own

of renal disease.

symptoms

for insurance

his

such

in

cases

without

casts

or

patienthe accepted

premium,

and

it turned

out

safe transaction.
Dr.

Heitz

me

any

to

it does

things stand
longer possible always to

hypertension to
chromamn

"

that,

says

as

renal

lesion."

He

ascribe

not

seem

persistent

falls back
5

the
upon
Sir John
Rose

(seep. 220). And in 1907

Bradford, while giving the same
warning againstthe fallibility
of a diagnosis
of renal disease merely on the result of one examination
system

of the
to

diagnoseacute

albumen.
"

urine, said that

He

Steell,G., Med.

Stengel,Amer.

3
*

cosur,
8

on

in

depend

is

common

more

than

nephritismerely on the presence of

phrase which I would emphasise,that

on

Chron., Dec.
Journ.

arteriosclerosis

mistake

chronic

argues,

diagnosismust

article

or

no

and

Med.
the

clinical examination."

1902.
Sci. vol.

cxxxv.

p.

196, 1908

an

interesting

system.

nervous

Clin. Journ., July 11, 1906.

Heitz, Jean, Journ. med. fran$ais,Feb.

Tyson,
mai

15, 1912

quoted

Arch,

1912.

Bradford, Sir J. R., British

Medical

Journal, March

31, 1907.

de mal. du

CHAP,

KIDNEYS

BLOOD

AND

PRESSURE

317

Janeway (loc.cit.)says, and Dr. Tyson of Philadelphia

however, there are fairly
Excluding nephritis,
agrees with him :
and
with high arterial pressure
numerous
cases
hypertrophied
"in
the
arteriosclerosis."
hearts," and
beginning without
1 is
others in the United
States, Dr. Riesman
one
Among many
Dr.

"

of

the

Osier's

most

witnesses

recent

the

to

effect.

same

Sir

W.

quoted already(p. 314). Dr. Leonard

2
of
Williams
that high arterial tension is,in the minds
says
with renal disease that
far too many,
connected
so
indissolubly
of the urine and otherwise, they persuade
if,by examination
themselves
not
that the kidneys are
affected, they are unable
to realise that the excessive
be doing any harm.
pressure can
Frankel
is of Krehl's opinion; he says :
testimony I

have

general arteriosclerosis can be the result of renal disease

is seen
in the young
Nephritikern,"but that high-pressurecases
exist independentlyof it (of renal disease)is seen
in many
in
cases
That

"

which
and

the

urine, if it may

specific
gravity,with
granular

no

but

few

little albumen,

casts

of any

which

seem

is of full colour

kind, and

practically

casts.

Geigel,in
the

jtween

contain

reflections

some

arteriosclerosis

due

in

not

the

main

to

distinguish

to

exorbitant

other causes,
that due
to
that the
says
pressures and
of
relation
renal
to
disease
is not
high arterial pressure
understood, for the arteriosclerosis may be an independent event.
blood

Fiessinger3reported
were

renal ; 44

such

cases

"

were

that

out

of

160

high-pressure

arteriosclerosis without

cases

renal disease."

he

84

Of

emphasised the curability

(inearlystages); 30 of
these patientswere
less obese.
Faber
of Copenhagen 4
more
or
writes :
of chronic
Unquestionably,however, there are cases
Bluthigh-bloodpressure without renal lesion
(" chronischer
drucksteigerungohne Nierenleiden "). See also Loeb, p. 357.
The
that high blood pressures always signify
great assertor
renal disease is Strauss.
But, as Vaquez remarks, surelywhen
from
first to last no
clinical sign of renal affection appears,
such a postulateis
analyse on the latest methods
as
you
may,
"

"

1
2

Journ,
Med.
Riesman, Amer.
Sci,, April 1913.
din.
Williams, L.,
Journ., 1907.

Fiessinger,Bull

Faber, A., Die Arteriensklerose,Jena, 1912, p. 13.

de VAcad.

de Med.,

April 18,

1912.

THE

AND

318

ARTERIOSCLEROSIS

at least

premature, and from the pointof view of clinical medicine

KIDNEYS

PART

Constant," pp. 272 and 322). Von

(see "Ambard's
cases
Romberg, who, with Strauss,had regarded all high-pressure
of cases
latent Bright'sdisease,collected notes
of plus presas
sures
baseless

without
obtained

evidences

disease.

of renal
found

and

In

of

one

these

he

the

normal,
kidneys practically
both to the eye and to the microscope; but he cynically
objected
these cases
to
being regarded as the arteriosclerosis of high
physiciansshould be
pressure, lest by this view of the matter
induced
this symptom
! Surely if we
to treat
to discover
are
a

necropsy,

and

causes

between

to

the

neutralise
several

prevent them,

or

series of

phenomena
In the pathologicallaboratoryreports of
I see
that cases
of high arterial pressure
divided

into the two

Nephritis,"which

betrays the

arteriosclerosis is the
rather

than

division
other

in

"

does

cases

one

of

cause

of its kinds

well

as

Berlin

"

Arteriosclerosis

similar,and

as

we

can.

City Hospital
recentlybeen

have

"

and

Chronic

still

prevalent assumption that

excessive
persistently
pressures
the effect of it ;

"

provisionallyto segregate

serve

of

"

classes of

discriminate

must

we

often

less

no

yet still the

the

renal

from

exorbitant, arterial

pressures.

But

it may

be

Well, necropsieson

said, where

The

are

hyperpiesiaare
few, they do not

entered

previoushistoryis unknown,

"

as

evidence

post-mortem

of

cases

hospitalthese patientsare
breakdown, and then

is your

hard
appear

to

get.

?
In

tillthe final

heart disease," or

apoplexy.

consequentialarteriosclerosis
is found in many
districts of the body, includingthe renal,the
kidneys are not scrutinised from our present point of view, and
are
we
phrases,such as
put off with common
kidneys slightly
granular,"and so forth. Hyperpiesiaas a clinical series belongs
and in privatepractice
chieflyto privatepractice,
necropsiesare
But not long
rarelyto be had ; by consultants almost never.
in a man
set. 37.
Historyimperfect.
ago I did obtain a necropsy
of
A
drinker.
Died
High blood pressures.
an
apoplexy.
Heart
to
naked
hypertrophied. Kidneys
normal, except
eye
renal artery stiff and
the renal vessels
Microscopically,
open.
thickened, but the parenchyma of the organs was unaffected.
were
a

"

The

arterial disease

Dr.

Herringham

was

most

severe

and

(kc. cit.)reported

extensive

that

in

in the brain.

high-pressure

CLINICAL

CHAP,

of

out

cases

without

he

26

319
cardiac

found

of the renal arteries.

disease

any

of

series

CRITERIONS

Such

brief,or in early stages before

on

disease, and

renal
clinically

were

confirmation
renal

; in

disease, 7 proved

of lesion."

discriminate

of

some

these

random,
but

were

post-mortem

these

spots

last

cases

he

does

nor

"

cardiac

of

few

carefully

renal disease.
"

reported

of these, 28

showed

"

compare

of the

quential
conse-

clinical evidence

no

and
not

at

kinds

the

between

that

clear

does

taken
necropsies,

control

with

writer

the

But

was

be renal

to

the

was

paratively
com-

of
1

pressure

such

there

14, in which

are

of Nauheim

blood

high
persistent

42 necropsiesof

cases

inroads

the

stages Fischer

In later

sclerosis.

hypertrophy

It
"

seems

mitral

or

"

kidney (" Stauungsniere").

Clinical

Criterions.

On

"

I have

obtained

from

albumen

in the urine is of itself no

consulted

by

other

authors

medical

of chronic

renal disease.

He

slightoedema

in the

urine, which

the

on

however

of
was

ject
to be the sub-

largeheart,a

data

on

the presence
1878 I
About

criterion.

had

and

that

stated

friend,who believed himself

pulse of high resistance,some

little albumen

testimony

own

my

sustained

shins,and

good colour
and specific
tions
gravity,and often lateritious. On repeatedexaminabut a few casts were
found, and these hyaline. As my
experiencethen stood, I was unable to give a definite diagnosis;
of renal
but, in the absence of the ordinary clinical symptoms
was

of

disease,in the absence,for instance,of characteristic headache, of

nausea,

anaemia, of retinal lesion,and

of

speak encouragingly. My patientwas

lived well

well.

man

forth,I ventured
of

means

to

had

and

dietary,some
rest, and
laxative drugs,his life was
of alterative and
courses
spared for
of renal disease appeared, and he
symptoms
many
years ; no
reached old age before at last his labouringheart was
defeated.
of the early signalson
This case
was
one
path; and, as
my
too

"

I discovered

more

and

On

so

restricted

cases

more

of

with

similar kind, I ceased

arterial

regard albuminuria,
indicative
necessarily

pressure,
of Bright'sdisease' in the clinical sense

the

of

term.

friend

even

disease,publisheda while

mine,

high

well-known

followingcase of
Bright'sdisease," essentiallya wrong diagnosis:
1

Fischer, Deutsche

ago

the

student

Arch.

f. Bin

Med.

"

very

vol. cix.,1913.

of

to
as

of

heart

chronic

Male, set. 45.

from

time

to

without

blood

The

of

of ailment.

pressure

for ten

years,

he

when

urine

This

was

went

seized

was

in his urine

The

high.

was

PART

observed

been

had

sense

any

inconvenience

any

attack

severe

without

time

normal.

otherwise

of albumen

trace

KIDNEYS

THE

AND

ARTERIOSCLEROSIS

320

on

with

angina.

frequentenough,and end either cataclysmically

in apoplexy or angina,or decline by the more
gradual defeat
be found
few
In the urinary deposit may
of the heart.
a
cells and hyaline casts, but few or no
leucocyticor epithelial
numbers,
granularcasts, which, if found repeatedlyand in some
of chronic Bright's
and
of grave
are
probably significant
omen,
of deposit
I speak here of ordinary slide examinations
disease.
old-fashioned
in a conical glass,after our
Hyaline casts
way.
in many
know
conditions, e.g. hard
occur
fairlynormal
we
Such

are

cases

Lestock

Dr.

But

exercise,oxaluria,etc.

of Exmouth

Thornton

spinnerswe shall
probably with truth, that with modern
not
discover
definitelyrenal,
more
granular casts in cases
in old people,than we
wont
to expect.1
are
especially
The
mean
kidney again
age of the subjects of Granular
is somewhat
lower, not than that of early gatheringpressures
in hyperpiesia,
but than that of the later and graver consequences
the last stage, which too often is
of their long-continuedstress
the first to be submitted
to the physician,
to be detected
or
by
urges,

"

him.

One

in 261

cases

of

candidates

M.B.

of my

Granular

"

found

kidney

"

the

mean

age

of death

selected from

cases
(definite

hospitaland post-mortem records) to be 56. This age however

is too
probably include, besides the true
high ; the cases
arteriosclerotic kidneys."
kidney, many
primary contracted
"

"

Contracted

incidence.

white
In

"

forms

have

hyperpiesiathe
far

accomplished,so

as

can

of

course

ultimate
reckon

still lower

defeat
or

guess,

of

the

about

mean

age
is

heart
a

mean

higher. The arteriosclerotic

higherin age than the primary
kidney runs a decade more
(senile)
contracted
kidney ("Granular" proper).
refined methods
of appreciatingrenal
As regards the more
with some
meet
values we
difficulty.The researches of Sk John
five

age

of

Rose

Bradford, of Passler,of Heineke,2 of

some

1
2

to

ten

years

von

Noorden, of Ritter,

Thornton,
L., Lancet, June
7, 1913.
Heineke, Virchow's Arch. vol. cxcvi.

CHAP,

others have

and

TESTS

OF

shown

that

secretion

may,

as

RENAL

VALUES

321

genous
although in damaged kidneysnitrohave

we

said, be

to

up

the normal

in

periods,yet it is prone to drop suddenly,or to

into periodsof inefficiency.
Such periods
shade off gradually,
be due to the variable relations of cystalloids
and colloids
may
in nephrotomies that urine
in the blood.
It is remarkable
from
a
grievouslymutilated kidney,
dischargedby the wound
be of quitegood chemical value. Dr. Thomson
Walker,1 after
may
to animals,
examining urines by the methods of cryoscopy,toxicity
of fallacy.
electric resistance,and so forth, discussed this source
and methylene blue tests were, on
He decided that the phloridzin
method
is
the whole, the most
trustworthy; but, as the phloridzin
somewhat
delicate,he regardedthat by methylene blue as better
Moreover
it is perhaps safer than phloridzin.
for ordinaryuse.
charts of the behaviour
Dr. Walker
interesting
publishedsome
To the methylene blue test I have already
of these substances.
for short

amount

alluded, and

I have

said also that

of the

cryoscopy
friends who
have

blood

or

by
practisedit,has
of
proved an untrustworthy test, at any rate as a measure
Dr. Lydiard Wilson, in his M.D. thesis,Camb.,
renal affections.
for blood and urine obtained
1910, in testingcryoscopicmethods
I

urine, as

results.

inconsistent

had
from

careful

be

to

it."

informed

am

The

so

Sir James
far

not

Barr

I think

me

decisive

any

of the
electro-conductivity
is discarded, but

present purpose

draw

to

to

wrote

urine

that

"I

have

inferences

also for

our

the whole

on

Krause
looks
good sodium chloride excretion is favourable.
of testing
all methods
He
renal values.
sceptically
says,
upon
form
of
the
of
the
if we desire to
an
opinion
efficiency
kidneysby
urinaryanalysis,we may take into consideration togetherspecific
concentration
a fall of molecular
(by cryoscopy),a fall in
gravity,
and
injection,
nitrogenousexcretion,a fall in sugar on phloridzin
a fainter colour discharge
on
indigo-carmine
injection
; and, when
all is done,
A

we

may

of the urine

Walker,

See

much

heed

small

differences.

to be in the
seems
investigation
tion
Ambard
content.
compared the uric eliminafor a definite period,and compared it with the
1907.

these
3

to

of

16,
Thomson, Lancet, March
where
chapter on Viscosity, p. 141,

length.
VOL.

too

line
profitable

more

direction of blood

at

pay

questionsare

Krause,

discussed

Lehrbuch, ed. 1909.

Y

more

AKTERIOSCLEROSIS

322

by
or

the

of

quotient

the

for the

blood

the

of

content

same

square root of the

lyingbetween 0-063 and
1-20

constant"

urea

Folin

Congress1Professor
with

made

be reduced

can

to

them, and

than

per

kept

at

litre of urine

the

blood

was

stated

; and

such

London

the

blood,

torpor, anaemia,

nausea,

"

without

pressure

albuminuria,

0-076-0-090

normal),
(i.e.

purs,"

over

even

this

With

can

200

conclusion

contributes

or

Carrion

in which, without

cases

arterial pressures

ruled

albumin, but

casts, yet with

no

also

declare

has
that

renal function,
Widal

indeed

and

uraemic

In

etc.

"

the

Ambard

be

now

simple high
with traces
only, it stands at
indicates that in
hypertendus
renal function is not reduced.
and
Nitesco 5
Vaquez agree.

which

mm.,

urea,

by diet these products

the kidneys can
adequately
levels. Higher concentrations
abnormal.

are

of

that

Parvu3
and
testimony. Aubertin
disturbance of
reveals the slightest
this urea
curve
this notably in renal cases
and
(0-12-0-14).
finds a parallelbetween
a
risingblood content

symptoms

0-07,

as

International

similar

given

divided

determinations

that

level at which

deal with
25

the

at

stated

of blood

c.cm.

constant,

"

non-coagulable nitrogen in

total

and

The

it might
insufficiency
Opinionsconcerning Ambard' s

varied, but

have

time.

same

PART

; in renal

0-08

2-0, possiblymore.

or

KIDNEYS

nitrogen of
urinary output,

urea

the

reach

THE

AND

"

high,with

any

renal

bruit de

excessive

symptoms,

galop

urea

"

and

the

little
If so,

content.

after all to be a kind of renal disorder.

hyperpiesiamight seem
But I would
point out that,at the stage reported,cases of hyperpiesia
of
and
the
cardiac
are
cases
fatiguedheart,
kidneys
cardiac
(Stauungsniere).If in
kidney," as perhaps in all
decliningcases, the urea content of the blood be indeed in excess,
this phase among
do not count
the kidney diseases proper.
we
He
is well known.6
Maragliano'scontradiction of Ambard
"

"

"

See

also Folin

Quoted

Aubertin

from
et

Denis, Journ.

and
the

Soc.

Chem.

journals.

de Biologie, Dec.

Zentralbl.

fur

vol. xiv., 1913.

Herz-

21, 1912, and

Tribune

mid.,

June
15, 1913
Gefdsskrankheiten,
and, a later verification, Berlin Intern. Congr. Physiotherapie,March
1913, and
1913.
Arch, des mal. du coeur, mai
Vaquez took part in this discussion.

January

1913

quoted

in various

Spanish

Parvu,

Biol.

Soc. med.

Ambard,

Nitesco,

Maragliano,

C. rendus
Gazz.

u.

des hop., dec. 5, 1913.

de la Soc. de Biol., juillet4, 1913.
dei

osped., Oct.
See

7, 1909, reported in Epit. Brit. Med.

also Virchow's

date.
Journ., about same
1903) and contemporary
journals; and

Lewis

Jahresbericht
and

for 1902

others, Heart, vol.

(published
v.

i. 1913.

ARTERIOSCLEROSIS

324

KIDNEYS

THE

AND

excretion

PART

of the

kidneys,and the
of kidney and heart respectively,
I cannot
and potentials
states
The
enter.
experiments are complicated and the results
now
The
as
quantitiesand values of urine are said
yet indecisive.
with the
to vary
pulse-pressure."Caeteris paribus,this may
far too complex and inconstant
for
be ; but the coefficients are
hydraulic capacity and

the

"

clinical maxim.

such

any

Morbid
confused
do

Anatomy.
heap of cases

find

we

huddled

death

after

respect of the kidneys, what, in the

In

"

under
find

We

the title of
in

Arteriosclerosis,

of them

some

kidneys

little deteriorated, as

to
so
or
irreproachable,
find
cardiac
be acceptableas
we
fairlyhealthy ; in many
kidney ; in not a few genuine Granular kidney ; and in
from slightor moderate
another largeclass an atrophicfibrosis,
less
or
degrees to extensive layers,streaks or bands with more
conspicuousdeformation.
into the histologyof renal disease, there
enter
But, as we
of a preliminarykind which
certain conditions
to
we
are
are
remember
that the parts of organisms
bear in mind.
We
must
have
themselves
so
highly differentiated as the mammalia
in structure
to stamp
become
acter
as
a
so
specialised
peculiarcharfunctions but also upon
their normal
their
not only upon
of an
defects.
As the more
peculiarthe structure
organ, the
more
peculiarits business, and the wider its differentiation from
the forms and
the functions of co-operatingparts, so with its
faults and
impairments ; these likewise,especiallyin initial
features and their limits.
Thus, in
stages, will have their special

which

either

are

"

"

"

"

the

kidney,

of function
the

"

we

and

should

of structure

liver,the heart

rightand

expect the
to

again,the

each after its own

wrong

it is true, of

nervous

features
much

derangements

of their

centres, and

fashion.

vessels, secretory cells, and

all

of

The

own

the

as

;
rest

go

kidney consists,

connective

fibre

"

the

body obey certain general laws of

growth and decay ; yet notwithstanding,because in the kidney
relations and functions,so their
they have specialdispositions,
of growth and decay in the kidney proceed on lines conmodes
gruous
elements

which

have

"

among

organs.

And

over

themselves
within

but

the structure

differential in respect of other

itself the

reciprocal
changes of

ANATOMY

MORBID

CHAP,

than in quality.
quantitatively
features,features not those
histological

the tissues will prove

to vary

Renal

own

disease has its

of disease

more

substance, of the

of heart

325

structures,

nervous

of the

of renal disease
and so on ; to the observation
gastro-intestinal,
then we
must
bring certain views, views obtained from a consent
of experts, views not precisely
those deriving from observation
of disease

in

other

For

organs.

instance,

if the

arteries distributed

kidney are terminal arteries,an interference with

will partake of the form
of an
isolated infarction.
of them
one
Also, as by their tufts in the glomeruli and in their relation to
their affections
so
capsularand connective tissues they are peculiar,
and
will have
features concordant
and differential,
play
within a narrower
Furthermore, the canaliculi,as they
range.
the
take originfrom the tufts,depend in a peculiarmanner
upon
in the

functions
diseases

and
of the

peculiarand
so

far

as

narrow

are

they present

features which

of other parts, will among

present certain and

the

features

all of

this

them

we

mark
and

themselves

characters
other part.

kidney, in

the

them

off from

amid

their

diseases

particulars

resemblances, resemblances

considerable

which

of

diseases

several

the

so,

kidney, have

of diseases of any

those

not

it is that

Thus

sources.

it is

kidney, because

if this be

Now,

of these

disorders

the

from

separate them

shall expect to observe

in
In

elsewhere.

diseases

characters, and

common

shortcoming or injury; for,

in so far as failure or injurymay
have proceeded,these structures
will have descended
from peculiarto more
generalcharacters :
returninginto the common
paths of dissolution of all living
of tissue
forms
tissues,they will be melting into the common
decay. Thus it is that in the earlier stages of impairment we
shall expect to discern the characters specific
of the renal diseases
the earlier stages of

in
especially

but alien from

the diseases of other parts ; in the later stages

shall expect to find these characters

of wreck.

But

initial stage of
ultimate
in

which

as

chancy

defect, but

issue,so
the

it is

we

are

to

catch
to

easy

an

universal

internal viscus

too

of

of

the

kind
in

it in

upon

much

characteristic

metamorphoses

lay hands

make

to

apt

into
drifting

the

organ

we

an

the

ruins
have

vanished.
To

stages

press
"

these

considerations

the stages of initiation

"

a
we

little closer.
find in the

In

the

early
kidney, according

ARTERIOSCLEROSIS

326

to

its several

arterial

yet within

THE

AND

KIDNEYS

PART

units,a lobular arrangement

tions,
of its affec-

dependence of disordered
constituents ; we shall scarcely
that disease will express
anticipate
itself in singletissues,such as the connective
the parenchyor
matous

or

each

mutual

the vascular, because

arterial unit live

of all.
much

area

For

life

common

instance,the blood
1

of

leavinga

on

is the disorder

one

tuft has

lost

yet relieved of the corresponding

is not

happen to be abnormal,
if it contain some
toxic ingredient,
the efferent
or, still worse,
vessels and
the tubes, however
considerable
their capacity of
repair,must undergo at least temporary disturbance.
Probably
the tufts themselves
their capsulesmust
and
suffer also ; no
ideal limits can
be set to the implication
of the whole functional
unit.
That
nevertheless
in the kidney substance
the visible
effects are
generallyscattered and focal is curious ; but this
it is not a peculiarity
of the kidney, nor
of
as
inconsistency,
terminal

waste

if then

in the terminal

the disorder

"

of its water, but

quantity of

elements

these

I do
arterioles,

not

this waste

stay

the affections of most, if not

for

instance, and

obscure

all,organs

depend

may

of

"

vascular

on

all dimensions

over

reason,

of

consider

to

now

of

; it is notable

in

myocardial lesions
For

areas.

some

there is not
organ
than
vulnerable

an

sections seem
to be more
equivalence; some
others (p.528). Especiallyas regardsthe kidney then, we
are
for disease of vessels,now
not
to look now
for hyperplasiaof
for degeneration of the secretingcells,but, if in
fibre,now
some
irregular
proportionsof incidence,for a group lesion. So
tells us
that, strictly
investigation
speaking,there is no such
contrasted
as
exclusively
process as an acute interstitial nephritis,
2
with a parenchymatous or with an arterial nephritis
if at
or
;
the

outset

there

blurred, and

any

blurred

of renal disease

and

be

such
and

more

confounded

are

difference,this will
in

Talamon, in their well-known

Bright's disease
1

It is true

to have

that

in

the

the

tufts

1888

are

until the

more

specialfeatures

generaldissolution.
treatise

edition

supposed

to

of
be

on

become

soon

Lecorche

Albuminuria

Brouardel's
little

more

than

and

System,
filters
"

these reflections,
to invalidate
as
excretory virtue, but not so much
in principleby Adami
and Nichols
also.
which, I find, are made
2
See especiallyLohlein, who
endeavoured
clinical with pathoto combine
logical
research
d.
die entziindlichen
d. Glomeruli
("Uber
Veranderungen
mensch.
d. Path. Inst. Leipzig Heft 4, 1906).
Nieren," Arb. aus
some

CHAP,

ANATOMY

MOKBID

327

when

principle.Yet it is with these ultimate stages,

that pathologists
features are waning or obliterated,
specific

have

for the

insisted

this

on

most

to

be

For

content.

such

the

reasons

Nephritis is misleading and indeed

originalperversionis,to say the least,as much in

name

Chronic

wrong

the

part

Interstitial

the blood-vessels.
It is understood

then

of different nature

yet when

we

the ultimate

to

usuallyto be content, we
of whatsoever
inscriptions
erased ;

earlystages,we
peculiarstructure

must

sundry kinds,
affect the kidneys,

may

states, with

examining
disease

expect,

of

become

obtain
from

even

access

have

we

in which

documents

have

we

which

blurred, if

the
not

specimens

to

the outset, that

the

be
kidney will by its very peculiarity
can
expression; its manifestations
only

of the

in its range

be in its

are

that,if indeed

moreover

in

limited

although disease

clinical course,

and

come

that

of

vernacular.

own

study such kidneys as we can get, and as

their morbid
anatomy in its earlystages is peculiarin mode, and
in its later,
that is to say in most
of our
back
specimens,is falling
into chaos, we
shall be the more
persuaded of the importance of
shall deprecate
controllingnecropsiesby clinical records. We
the seclusion of pathology from
clinical medicine, each in its
should
shall regret that laborious
solitaryoffice ; we
papers
who
be written on the morbid
often
are
anatomy by pathologists
from
which
their
ignorant of the clinical history of the cases
materials were
detached, or inexpert in co-ordinatingthe two
lines of study. In terminal states for instance,the two shrunken
kidneys,both correlated with high pressures and hypertrophied
heart, which in this country we have been accustomed
fairlyto
distinguishas the small white and the granular,may, alien as
they are in nature, be so far reduced by decay to a common
denominator
that microscopic analysisno
longer marks
any
signaldifferences. Let us grant then that a classification of
Now,

renal
at

as

we

have

to

diseases cannot

any

rate

the clinical

not

be founded

in obsolete

on

anatomical

basis,or

must
-diagnosis

include

history.

features
provincial

diseases

mere

The

stages.

It is in the earlier stages that

the

on

which

the

of its tissue

we

shall seek what

I may

call

changes,the stages of kidney

conditions
specific

inherent

in the

organ

ARTERIOSCLEROSIS

328

itself stamp
in them

each

each

KIDNEYS

different,with

kind, however

all,while

THE

AND

retains its

PART

its

own

seal ;

pression
quality,the range of exwill be limited by the renal styleof organicreaction.
If these thoughts seem
tedious, I must
plead again that
they are too often forgotten. Thus, in Germany rather than in
our
own
diligentresearches
country it is true, we
peruse
into obsolete
deavours
Schrumpfniere (shrunken kidneys),painful enstill to decipher in these relics the characters
of the
several
If in shrivelled kidneys
modes
of Bright's disease.

of differential character

remnants

seals

are

broken

renal devices
the

own

are

at

may

this stage

obsolescent

can

we

"

stage in which

"

stillbe detected, yet the

hardly expect

the
to

peculiar
decipher

of

series. If in these blurred characters

foregone specific
to read anything, I reiterate that we
have
must
we
are
with us continually
the whole morbid
series the clinical story.
When
at length the old amyloid kidneys,small whites,terminal
whites, granulars,are merged in a common
degradation,what
scrutinythen can discern the originalrelations of time, place,
or
qualitybetween
parenchymatous, arterial and fibrotic perversions
?
A skilled pathologist
may
guess, or indeed
may
nounce
prowith some
the
but
he
can
no
confidence,upon
kind,
longer
notes

"

read
The

in the organ the series of its morbid

in the past.
processes
mutual
of function and
interdependenceand the integration
in the

kidney being such as we have seen, we shall not

be surprisedif,ultimately,
clear divisions betwixt
no
parenchyIn the
disease
be
made.
or
matous, interstitial,
can
glomerular
of this vitiated tissue or that we
find variations
proclivities
may
in the relative rates
or
quantitiesof change, but iipon them
all we
shall find the seal of renal idiosyncrasy
shall, I
; we
and more
convinced
that it is
repeat with emphasis, be more
of clinical with pathological
investigations
only by a close combination

structure

that
diseases

"

we

can

frame

any

classification based

fruitful classification of renal

not

upon

but
superficial

upon

profounder affinities.
Jores, Prym, and Roth, in their minute histological
tions
descripof the shrunken
or, rather,in his latest and
kidney,admit
maturest
dissections
that, invaluable
as
essay,1Jores admits
"

"

may

be, yet the anatomist, without

1

Jores, Virchow's

the clinical histories of the

Archiv, 1909.

CHAP,

ANATOMY

MORBID

329

interpretthe various diseases by

author on the
When
which the kidneys had been damaged.
an
subjectso eminent as Professor Saundby hesitates to follow the
English1 dualistic conceptionof chronic parenchymatous and
interstitial nephritis
for convenience),
(Iuse these equivocalnames
cannot

cases,

"

because

"

the

on

shown

between

of his

the
is

aside other clinical

intermediate

forms

be

can

largewhite and the small kidney,the validity

not
setting
convincing. For instance, even
what

considerations,
upon

of tissue

or

table

post-mortem

argument

aspect

far to

very

go

change

in ultimate

notes

of anatomical

shrunken

kidneys can we
of high pressures and
their uncertaintyand

explain the correlation from the outset

cardiac hypertrophy in some
of them, and
All classifications are
of
in others (e.g.p. 367) ?
irregularity
but the separationof the largecongested or
course
arbitrary,
white
often
and
(inflammatory?) kidney, primarilyepithelial
healed, from the primary shrinking kidney, primarilyarterial
and never
to me
on
healing,seems
grounds both clinical and
anatomical
dualists ;
Gull and Button were
to be fullyjustified.
in their broadest
distinction
"

the

view

and

of renal disease

about

the

time

same

nephrite d'originearterielle"

Lecorche
could

not

With
disease

and

Talamon

be

the end

in

may

bear

of the

on

not

overlook

this

distinguished

Lancereaux

observers, with

all these

1888, insisted that the granularkidney

these reflections let

as

they did

largewhite kidney.
to consider

turn

us

so

arteriosclerosis ; for such

of renal

much

the limits of

are

assistance of Professor
subject. What, with the indispensable
Lorrain
Smith, I argued before the Association of Physicians
at Liverpoolin the summer
of 1910, and by myself,as well as
my

I could, before the

Royal Medico-Chirurgical
Societyon

13, 1903, I would

consider

now,
a

for the

little more

sake

of

the

January

of

study

sclerosis,
arterio-

fully.

In

of
of

coming to close quarters with the pathologicalanatomy

the kidney,I would note that one
broad result of the researches
Jores and his pupilsis,that in shrunken
kidney, whether small
"

white

or

renal

arterioles

granular,"the arteriosclerosis,
even
alone, is arteriosclerosis

speak of it as English because

divisions
and
Grainger Stewart, whose

though
forms

it is true

that Virchow

separated the amyloid.

also

was

we

owe

the

if restricted to the

proper

phrase

subdivisions

"dualist," and

have
from

is, sub-

that

"

to

Johnson

held

their

the two

"

and

to

ground;
"

Brightic

ARTERIOSCLEROSIS

330

intimal
This

THE

AND

the

of
hyperplasiawith splitting
arterial disease

renal

then

KIDNEYS

does

internal

kind to the

arteries is atherosclerosis.
of

kinds

There

in them

change

disease

of the

at least two

other

however

discrimination

need

"

and the hypertrophyof the media

obliterans,
by Johnson, Ewald, Savill,and later writers.

former, endarteritis obliterans,is incidental

caught

in

inflamed
The
no

focus

inflammation, which

of

but, in unmixed

distinctions to the

fattygranulesare

involved, there

does

cases,

thus

namely,
alleged

to

twig

itself

becomes

fattynor

turn

not

calcify.

that the elastica is intact ;

microscopeare

seen

without

peculiarin

endarteritis

The

in atherosclerosis,all the coats

as

renal disease the state

are

which

layer.1

atherosclerosis

arterial disease

no

generallyin

and

kidney ;

is

elastic

differ,except in

not

peculiarseverityin the Granular

kidney, from
elsewhere, as generallyrecognised. If renal
arterial disease is rare, yet there

PART

are

and
more
persistent
proliferation,
fibrosis ; so that the vessel tends directly
occlusion
of lumen,
to
with consequent atrophy of the area
of its supply (canaliculus).
Excellent

fourth

is

cell

more

illustrations

edition

Endarteritis

of

obliterans

is then

The
pure

local

seen

Pathology,pp. 347-49.
incident,with secondary

the contrary,
on
arteriosclerosis,
tend so directlyto closure,it is less
of its unit.

kind, hypertrophy of the media, that is

other

not
hypertrophy,

(p. 470). One

is prima facie
fibrosis,

to

say,

improbable event

no

that, under the

presume
affirm itself. Jores is
would

is

tempted indeed
of high tension, it

lateral pressures

in the

as

the nutrition

to

menace

be

to

are

process
Practical

of Woodhead's

Forasmuch
consequences.
thrombosis
apart, does not
of

this

to

indisposedto grant that the assertions to this effect of certain

truth in
English observers,accepted by Ewald, may have some
them ; although (as I and others have pointed out before, and
I ventured
his own
himself upon
to Johnson
to point out
as

not

some
specimens),

(p.470).
1

to

be

In

the

clear

logistsare
the

But,

text,

atheroma

coming

discussion
as

now
a

to

the

were

I have

said

on

paper

my

precisemeaning

of

use,

in nature

will

identical

Marchand's

probably

and
be

intimal

the

sclerotic

elsewhere, for these

at

Kensington

of the

quite precisein applying it

process
that
so

into

as

of them

with

to

the

that

AschofFs

dimensions

speakers seemed

some
"

name

arteriosclerosis."

definite
which

in
"

name

adopted generally.

type

process

not

Patho-

mentioned

large vessels

in

is called

atherosclerosis," now

ARTERIOSCLEROSIS

332

explained,by
notion

the

Kanthack

and

Hasenfeld1

of

AND

THE

myself.

We

that

KIDNEYS

discarded

have

increase

arterial

of

PART

(p.188)
pressures

vessels, an
implication of the mesenteric
depended upon
opinion still surviving here and there ; arteriosclerosis arises
in the vessels of the alimentary canal, but in those
first not
of the
spleen and pancreas ; and this is so uniformly the
that, in order to avoid the toil of searchingthrough the
case
it
for cursory
body for evidences of arteriosclerosis,
purposes
is sufficient to record the state
of the vessels of the spleen;
in order after them
next
(p.456) atherosclerosis usuallyattacks
of the bowels

those

not

or

liver but those

of the heart

and

of the

brain.
is the characteristic

atherosclerosis

In the renal vessels then

systemic atherosclerosis an essential part of all

the renal affections of which we
are
speaking ? Apparently not,
though it is rarelyquite absent ; if assiduouslysought for it is
of Jores,has described 2
Roth, a disciple
commonly to be found.
six cases
all of one
of diseased kidney, apparently not
kind,
without
generalarterial disease ; 3 Lohlein * 3 cases ; and Jores
himself 1 case
at least,as follows (Case III. in his 1904
paper) :
; but

change

is

"

and

streaks

Uraemic

aet. 45.

Female,
wholly

of

left

in thoracic

Heart

coma.

ventricle.

few

much

not

enlarged

spots and
opaque
All other vessels
iliacs.

yellow

aorta, coronaries, and

Renal
arteries mostly free
(includingsplenicand cerebral)normal.
medulla
from
and
the cortex
disease, but twigs running between
intimal change.
showed
of hyperplastic
a good deal

Indeed
is not

Jores says

found

the heart

have

2
3

are

be

In

should

only one was

changes

of them
4

young

have

Still these

cases

Heineke5
persons.
of the clinical records
lost

much

of

are

although
few, and

regrets,
such

their value.

as

tions
observa-

Prym

Arch. f. klin. Med.

vol. lix.
Hasenfeld, Deutsche
Archiv, 1907, vol. clxxxviii.
Roth, Virchow's

retinal

Some

scarlet fever nephritis),

even
(e.g.

done; that for lack

these

sclerosis of the smaller arteries

hypertrophied.

in

them

as
1

in all cases

may

of

most

plainlythat

In

blood

noted
as
pressure
None
mortal
was

probably "small whites."

laboratory report which I have
various
periodicals.

being very high ; in only one

by apoplexy, all by uraemia.

were

local

fullyquoted

the

mentioned.

in

Heineke,

Prym,

Virchow's

Virchow's

Archiv, Bd.

Archiv, 1909.

cxcvi.

not

seen,

but

which

has

been

CHANGES

CHAP,

the other hand, that in

reports,on

of age the intima

after 40 years

the
in

or
arteriosclerosis,

to

limits, he

considers

which

point

of the fine and

to this statement.

Aschoff

and

Except

in the

of

Gaskell

would,

occasional

cases

the main

persons,

the aorta

renal

also,pretty

degeneration. Crossingthese

limits, the

arteriosclerosis

so

kidneys may

be obvious

part of

in the

of disease

evidences

as

arteriosclerosis elsewhere

in young

in this form

surelylikewise present

arteries of

verification.

indeed

artery, and

medium

not
kidney may
trespass beyond physiological
for middle
aged persons ; a

even

primary contractingkidney

333

of seventy persons

out
sixty-six

normal

as

needs

think, demur

of

VESSELS

kidneys is thickened, often without

the body. This change, which
even

amount

RENAL

IN

present in diseased

commonly

the
generalarteriosclerosis,

standing open and stiff ; or, on the other

be so slightand intimate as to be overlooked
hand, may
by the
the intravisceral
pathologistwho does not minutely examine
the vasa
afferentia.
twigs,and especially
main

renal

arteries

unable

However,
data

the

to sort

the kinds

heap

each

of

kidneys
For

we

instance,

morbid
specific

researches
amyloid,though in some
More
assume
confidentlywe
may
exceptionalspecimens referred to
have

"

been

small

surely right

in

assuming

arterial

present

whites."

lesions

"

afferent arteries of affected

in those

specimens,even

else in the organ

afferentia

of

spleen and

pancreas,

is that
between
necropsy,

made.
afferens

lobules

small

it

and

begins

white

in

one

serious

to attach

to

which

it

distribute

error.

of them

two

or

be

to

expresslyexcluded.

are

if not

many,

without

as

try

may

these

all, of the

arteriosclerosis to

English dualists are pretty

the genuine
granulars all

least

at

units.

or

and

"

that

secured

if nowhere

the

Our

we

without

suspect

may

of clinical

clinical series to

that

or

of the records
we

absence

kidneys examined,

this character

some

in the

be

may

of obsolete

the

to

belonged,yet by
the

as

in

in

the

Jores

"

interlobular

states

that

and

in all his

earlystages, arteriosclerosis,

outside

affected ;

it,was

in

these

viscera

the

brain.
;

but

The
the

vasa

the

tion
presump-

distinction

granularkidney, whether
restingon
clinical history,or on
both sets of data, was
on
not
In
of the vas
one
specimen the arteriosclerosis was
from
the interlobulare.
only} sharp at its offshoot
"

and

in the

pretty surely in

also

often

found

"

THE

AND

ARTERIOSCLEROSIS

334

KIDNEYS

PART

apparentlynot, or not yet, an

although this kidney was
for it was
pale yellow,smooth, and unordinary granular
stands alone,and
in cortex
diminished
yet, as it by no means
arterial disease peculiarto the granularkidney,
there is no
as
the site of the initiation of the arterial affection is significant.
of the granular
it for the present that
take
We
may
kidney arteriosclerosis of a peculiarseverityis a primary and
tions
invariable feature, and begins in the intimate vascular ramificaepiphenomenon, due to prolonged high
; although,as an
arteriosclerosis of the largervessels may
tension, an
appear,
add that in many
of
a
but later. I would
especially
necropsy,
disease of no
subacute
long duration in comparativelyyoung
but a nominal
or
arteriosclerosis,
degree of it, is
persons, no
in the vessels of the largermagnitudes.
to be found
is whether
the
Granular
the chief question for us
But
essential part of general arteriosclerosis
is, or is not, an
kidney
?
In other words, Is it,as we commonly read, especially
in French
writings,a general arteriosclerosis invading the
makes
the proper
Granular
In
renal artery which
kidney ?
fibrous proliferaGranular
kidney the patches of nephritic
tion
found
in
close
be
connection
with
the
are
generallyto
Now,

"

"

"

"

"

"

"

"

This

arterioles.

mischief, under

the

along the lymphatics also,as

influence

it does

of

toxins, may

in tubular

nephritis,
with
nuclear
and
tion,
it is associated
lymphocytic infiltraand
assumes
larger proportions (Woodhead, Mott).
I
will begin by citing again, from
this dilemma
On
our
at
of Dr.
Lorrain
Liverpool/ the conclusions
joint paper
the fibrosis of the parenchymatous and
Smith.
Passing over
interstitial forms
of nephritis,he says :
The
of the acute
interstitial nephritisoccurs
fibrosis of so-called chronic
in
limited areas, alternative areas
being free from fibrosis. In the
fibrous patch the glomerulusis converted
graduallyinto a mass
to
of hyaline fibrous tissue ; the tubules
are
a
large extent
alone remaining. So far, the
destroyed,atrophied rudiments
disappears; but the unit next to it artery
secretingmechanism
creep
when

"

"

tube
be

and

interstitial tissue

hypertrophied.
1

of the

Our

paper

was

Now

read

and

Physicians'Association

"

may

from

normal, unless

this state, he

specimens
in 1910.

be

exhibited

at

adds, the
the

indeed
'

it

arterio-

Liverpool Meeting

GKANULAB

THE

CHAP,

sclerotic

'

kidney

arteriosclerosis

deprived by the
by a small amount
This,

area."

unaffected

normal,
tubules,

concludes,

is not

in areas, that

affected, may
are

Although both forms present

I have
already alluded as not
toxins

here

and

elsewhere,

the

are

consist in

to

seems

such

form.

any

vessels may

discernment

be

the

focal

distribution

inconsistent

we

with

call the

may

with

the

which

urged

the

effects of

Arteriosclerotic

Granular

instance, from
Male,
record

as

that,even
have

inconsiderable

no

"

73.

aet.

latent

given);

Constituents

1025-31.

found

granular cast

These

in 1903, but

arguments
without

indicated

necropsies,
fest
always mani-

is not

and

author

concentration

I take

little over

blood

this

"

latent

chronic
For

case.

hypertension

(no

albumin.

capacity

rarely. (Simply

term

the

an

arteriosclerosis ;
of
nephritis." Traces

but

Huchard

the

in the reports of

Senile

nephritis unjustifiable.The
a

kind, which

triple confusion, often under the head of

this senile kidney, hyperpiesia,
between
and
nephritis,"
primary renal disease if not universal,is far too common.

which

to

In

fairly
still be pervious the glomeruli,
in the
same
degree normal.

irritative process.

to think

I venture

Now

infarcted

an

pathologicalcorroboration.

valuable

same

slow

those

as

same

nephritisin

is,in which

contrasted

witheringkidney, as

resembles

"

interstitium

and

tissue,and

of fibrous

"

if

or,

kidney,that is,which partakesin a general

unit
differs considerably. In this disease
a
sclerosis of its free supply of blood is replaced

he

areas

335

the

"

"

KIDNEY

senile

Sp. gr.
undisturbed.

kidney, and the

probably ranged

pressures

normal.)

the
senile
and
distinguishedbetween
Granular
the
kidney. Dr. Stengel recognised the senile
form
clinical grounds, and
on
pointed out that in this form
little albumin
in the urine is negligible
a
(p. 316). With these
of posta wilderness
problems in view I have run my eye over
mortem
never
"

"

reports which
loose

for

the

most

"

part put

us

"

off with

such

kidneys granular," kidneys slightlygranular,"

and so on ; much
little granularity being reported
or
not with a specific
a
even
or
precisemeaning, but on superficial
and
accordingto the generalnotions and personal
appearances,
vocabulary of the reporter. If in superficial
aspect a kidney
be described
well
as
granulated."the adjectivemay
may
phrases

as

"

"

"

AKTERIOSCLEROSIS

336

THE

AND

KIDNEYS

PART

"

earlyinterstitial degeneraonly a subordinate fact ; and

tion
clerks often,and, I venture
is meaningless. Post-mortem
anatomists
to think, professedmorbid
sometimes, forgetthat as
technical term
a
merely an
granular kidney does not mean
rough and deformed, shrunken, fibrous, or senile,but a
organ
series of clinical phenomena.
certain disease, a fairlyuniform
in nosology, Granular
So, as a name
kidney is to be attached,
not
to
kidney whose
capsule is rough, shrivelled, or
any
wrinkled, and the substance fibrous, but is to signifya certain,
events, positiveand negative,
usually long, series of morbid
recurringin clinical experiencewith fairlyuniform symptoms,
alterations of character;
and in morbid
anatomy with fairlyuniform
Even
in the kidneys,the arteries,
and the heart.
especially
Ortner l in his diligent
not to perceivethis difference
study seems
the primary contractingkidney and the decrescent
between
or
renal
arteriosclerotic kidney ; or
that in hyperpiesiawithout
the kidney at death may
be the terminal kidney,the
symptoms
admits
that the
cardiac kidney," of failingcirculation.
He
inconstancyof these phenomena puzzlehim, and that he finds the
ment
of big heart and high pressures to be hard to trace, a senticauses
which I humbly share ; yet I think Ortner would find some
sclerosis
arteriohe to realise that decrescent
pointsbecome clearer were
labour
raise pressures,
and senile kidney do not
nor
Granular
the heart, as we
in
observe
Kidney." Lancereaux
likewise confused
the arteriosclerotic and
the granular kidney
together,includingboth as "an actual nephritisof arthritic
origin ; and confusion of arteriosclerotic renal atrophy with
the
Granular
is still too common.
nephritis of
Kidney
the term
Indeed
nephritisis not appropriateto either of them.
is to give hostages
To propose
explanatorydivisions of my own
convey

"

"

"

"

"

"

"

"

to

fortune

thus
cases

"

"

"

I to

were

"

do

so

it would

be

(" granularkidney ") ; (3) atrophiccases

invasion,
substitute

may

in

as

for

"

atrophy,when the
by obsolescences
1

as
an
specifically
Dupuytren's contraction,"

appear

"

Ortner,

division,

(" tubular nephritis

") ; (2)arteriolytic

cases
(1) cytolytic

Fibrosis

threefold

"

nobler

tissue ;

for

blood

supply has

been

in the

vascular

tree.

Fortschr.

d. deutschen

(senilekidney).
active

strangling
or
as
a
cheaper
instance, as a phase of
very graduallycurtailed
As specific
tissue dis-

Klinik, Bd.

i.,1910.

CHAP,

secretlyin

The

connective

the

contrasted

tissue,as

chronicity
;

it wants

elements.

with

337

proliferation
appears

more

increase

For

necrosis,there

arteriosclerotic

of
be

must

or
nective
consome

in

such

patients,
teristically
body, charac1881, virtuallyagreed

process,

also in the other parts of the

Zieglerdemonstrated
the

KIDNEY

time.

decrescent

in

fibrillar

and

nuclear

appears,

less

ARTERIOSCLEROTIC

THE

Ewald,

pancreas.

in

and
that in arteriosclerosis
Ziegler,
pointed out moreover
the vascular
be
change and its fibrotic consequences
may
found in many
while the kidneys are but little affected,
organs,
unaffected.
that Dr. West,
This interpretation
it was
or
even
in the Lettsomian
Lectures alreadyquoted,rightly
accepted and
excluded
from the category of Granular
pursued. He
kidney
certain
in advanced
atheromatdegeneratedkidneys
ous
disease,and in the chronic gout of elderlypersons
kidneysoften marked by interstitial change,and often not small,
of Granular kidney."
but large; and not runningthe clinical course
Thus Dr. West emphasisedthe axiom that in the name
Granular
the adjectivedoes not mean
the superficial
Kidney
glance of
morbid
a
anatomist, but a certain disease regarded in its processes
and
whole.
as
a
conditions,clinical and pathological,
at random
Contrariwise,of the fibrous kidneys thus reckoned
as
granular,"Dr. Rolleston says : 1

with

"

...

"

"

"

They
from
of

in the

are

blood

diminished

the

renal

great majority of

tubules

and

tissue takes

supply, depending

arteries

where
.

glomeruliare
its

the

cases

this

result

upon

is most

of

atrophy

arteriosclerosis

marked

there

the

most

atrophied

and

the

hardier

fibrous

place.

cally
Recently,again,Sir John Rose Bradford writes2 emphatithat in spiteof occasional transition forms, and of some
obscurities of pathogeny, the true
Granular
kidney is to be
distinguishedfrom the arteriosclerotic kidney ; he also relies
on

the clinical course.

unfortunatelyno
et seq., that
1

In

January
2

the

Senator, to whose

there is

subject index, admits, .on pp. 117 and 291

contracted
kidney of irritative originis to be

of mine
at the Medico
of a paper
vol.
Trans,
Med.-Chir.
Ixxxvi.).
(vide

discussion

1903

excellent book

Bradford, Sir J. R., Allbutt

and

Rolleston's

-ChirurgicalSociety,

System of Medicine, second

edition.
VOL.

ARTERIOSCLEKOSIS

338

from

discriminated

and Nichols

Adami

arteriosclerotic

the
1

KIDNEYS

THE

AND

PART

(" Nierensklerose

the arteriosclerotic

likewise consider

").

kidney
"

different from the

Granular
and clinically
etiologically
;
althoughon the post-mortem table the difference may not always,
Of shrunken
far as the kidneysgo, be easy to exhibit.
so
kidneys,
of
small
the
forms
four kinds
two
white, the
they distinguish
granular form, and the arteriosclerotic. In the arteriosclerotic
they agree that an atrophic,scarcelytoxic,process is concerned.
"

as

"

Eichhorst, in the sixth edition of his text-book, is rather confused

the many

among

kidneys,but

shrunken

of the Granular

and

tion
that the distinc-

agrees

the arteriosclerotic forms

history. Although Senator 2 felt obligedto

he urged that transition cases
were
distinction,
common,
Smith's
experience and mine.
contrary to Lorrain
clinical

admit

cannot

that

arteriosclerotic

and

upon
admit

the

which

is

Moreover

the

Granular

degrees of one
that the
the other hand
Primary contracting
process, or on
is an
local manifestation, of general
incident, a
kidney
senile arteriosclerosis. In the simple sclerotic kidney the heart
is not enlarged,or but very
and the blood
slightly,
pressures
for the time of life are
excessive ; in Granular
not
kidney
it is always very
much
enlarged,and the blood pressures
3
has written
this contrast
of
on
high. Wildt
range
very
He works in a hospitalfor old persons,
and there he
pressures.
examined
the kidneys after death of 250 old folk among
whom
renal atrophy,kidneysoften scarred and very rough,was
common
;
kidney

if

the

the

rests

proper,

they

blend,

may

but

are

"

"

yet arterial

pressures

of these

contrast

is very
Wildt's

definite.

above

with
I

have

the normal

his

of

cases

quoted

Dr.

were

very

primary
Mott

to

unusual.

contracted
the

same

The

kidney
effect.

remarkable
he seems
testimony is the more
as
disposed
all rises of pressure in terms
to interpret
of renal disease.
Ribbert
resemblance."
emphasisesthis "deep difference under a superficial
Ebstein

says,

by Wagner,

in his Handbuch,
and

he

that

this distinction

was

this effect from

drawn

Wagner's article
in Ziemmsen, vol. xii. The Leipzigschool
Dr. Stengel's
agrees.
and his disregardof a littlealbumin
emphasis on the difference,
in the urine, I have quoted.
1
2

quotes

to

Nichols, Systemic Pathology,1910, p. 721,

Senator, Erkr. d. Nieren, 2nd ed., 1902, p. 306.
Feb.
Wildt, Zentralblatt /. Herz- und Gefdsskrankheiten,
Adami

and

etc.

1912.

AND

ARTERIOSCLEROSIS

340

sclerosis of the retinal vessels ; the

beingthat

KIDNEYS

assumption here also

order,"senile for example,
"

to the retinal arteries the result is "albuminuric

extends

in the listsof

PART

erroneous

arteriosclerosis of any

when

THE

retinitis"

publishedby himself,Prym,
clinical point of
and Roth, the reader perceivesthat from
a
view
a
more
discriminatingcollection might have been made.
of
Roth
admits
that all his 6 cases
Schrumpfniere without
call
small whites."
The kidneys
what we
arteriosclerosis were
(see p. 434). And

cases

"

"

"

of Case

II. had

smooth

and

smooth

The

same

of

others parts

some

be

may

said of the

(9 out of
paper
renal arteries without

Herringham's able
disease

was

surface, and

parts warty.

cited in Dr.
there

hearts ; that
Jores' Case

of the

(in his 1904

kidney only,as

follows

cases

126), in which

hypertrophied

primary renal disease

of
evidentlyone
paper) was

is, senile kidney, not

IV.

were

at

all.

senile

Male, set. 78. Capsule easilydetached (" loslich "),some

(" ziemlich ") increase of interstitial tissue. Very little change in epithelium.
Renal, splenic,
pancreatic,and cerebral arteries sclerosed.
I trust

that

I have

work

on

made

gratitudeto

our

arteriosclerosis too manifest

Jores

for his

plished
accom-

to be misunderstood

side of the

subjecton which he does not,

I believe,professto be an expert. The difficulty
of disentangling
these
states
on
only is admitted ; especiallyin
necropsy
Granular
kidney proper arisingin persons of middle lifein whom
some
independent progress.
general arteriosclerosis had made
Here the cyanotic(" cardiac ") kidney lends us some
tion.
interpretafirst
the
round
hyperplasia,
Prolonged congestioncauses
the tubules ; then appears
a
glomerules,then between
slight
contraction and roughness of the surface : but with all this the
of the parenchyma may
destruction
be relatively
little.
if I enter

caveat

Furthermore,
"

on

as

have

said, the

age

incidence

of

"

primary contracting kidney is at least ten years

that of the arteriosclerotic (decrescent)
than
kidney
younger
senile
(J. F. Gaskell,and Lorrain Smith and myself). Many
kidneys are taken from aged persons, nearly all from patients
Granular

"

"

"

over

50

When

rough

of age.
therefore morbid

"

years

fibrosed

anatomists

kidneys they must

use

have
an

speak of these
adjectiveless equivocal
to

CHAP,

THE

ARTERIOSCLEROTIC

KIDNEY

341

in the
granular,"one not already earmarked, or current
The
by him much misused.
sphere of the physician,and even
Granular
in the
Granular
not
name
Kidney
Kidneys
unfortunate
invention
concrete
plural an
signifyingonly
of many
surface resemblance
a
kidneys diverse in nature, is
It has at any
bonnet.
bee in the pathological
rate the
now
a
ing
advantage of not committing us to any frail hypothesisconcernless equivocalname
Still some
the nature
of the disease.1
desired ;
is much
to be
Primary contracted
kidney
may
is cumbrous, and
for the present, but here again the name
serve
the adjective primary
beg a question.
may
be reasonably argued that, if many
Nevertheless, it may
than

"

"

"

"

"

"

"

"

"

units

destruction
Yet
we

"

be

due

makes

to

endarteritis

that

seen

arteriosclerosis.

It

the senile
suffer

or

to

well

as

arteriosclerotic
This

more.

behind

we

the nature

Granular

and

kidney,

little whether

matters
to

chronic

this

inflammation.

are
qualifications

necessary

irritative process,
occlusion than does

obliterans, an

me

as

vascular
that

in the

kidney ;

so

that the

seen

incidence
whether

kidney

thicker

than

parenchyma

in the cerebral

find ourselves

and

Granular

far

others, are

difference is well

Besides,it is here that

questionof

or

complete

seems

arteries,renal

the

for

surely

more

occlusion

I think that certain

of this demur
have

function, it

in

obsolete

are

"

of

in

may

arteries.

faced
a

by the farther
hypotheticaltoxin

such

toxin

confines

itself to

tissue
raiding the vessels, or attacks the connective
I have
and
the parenchyma also ?
always suspected that
in the foci of the primary granular organ
the parenchyma
suffers directly,
and by some
corrosive than mere
more
process
the same
withering; and Dr. Tyson expresses
opinion (loc.cit.
the plumbous kidney, which
into the
smoulders
p. 342). Thus
Granular
kidney, if caught in an early stage presents so Sir
Thomas
Oliver informs us
a universal
parenchymatous affection,
first in cloudy swellingof the epithelium,then in granular
seen
tissue with invasion
degenerationand increase of connective
from the capsule; and the whole organ shrinks.
It seems
to me
then
such original
that, although in a state of ultimate wreck
"

"

differences
1

For

Croonian

of

process

differentiation

Lecture, 1904

may
of

and

be

erased, yet

syphilitic renal fibrosis,

Path.
York
Loomis, New

that
see

J.

Soc.

the
Rose
Trans.

Granular
Bradford,
1880.

ARTERIOSCLEROSIS

342

THE

AND

KIDNEYS

PAET

virulent than
more
an
kidney is the result of some
process
atrophy. Notwithstanding, as fractional parts of healthy
the focal distribution of its virulence does
kidney suffice for life,
enable the kidneys to keep at work for longperiodswithout serious
breakdown
It is

; thus

that in Granular

allegedindeed

the intact
In

it is that for years

areas

may

this is very
We

and
up

lie latent.

may

arteriosclerotic

for the defective

(p.334).a

tage,
disadvanorgan is presumably at some
doubtful ; I have never
seen
trophy.
any such hyperbe careful not

must

to mistake

extension

for

growth.
happen in

likelyto
againstit,it would be more
arteriosclerotic (senile)
kidney where the atrophy is a

Were

not

the

kidney

the whole

where

cases

to make

grow

the disease

age

kind

of

ablation.

Of the amyloid disease

BrigMs Disease and High Pressures.
high arterial pressure is not a feature ; but in acute parenchymatous
nephritisand in acute interstitial nephritis,
although in
these maladies, and even
in cases
ending in recovery, the arterial
inconsiderable
rise suddenly to no
heights and
pressures
may
burden
the heart severely,
what
yet in them high pressures are someand inconstant in their occurrence.
I have spoken
irregular
of the
in America,
dualists
in England and
the physicians
"

"

who

"

from

the

of

time

Johnson

and

Wilks

have

divided

chronic

Bright'sdisease into Chronic Parenchymatous Nephritis

and Granular
Kidney ; a distinction still recognisedby Tyson 2
3 in
in Philadelphiaand Rose
Bradford
London.
All biological
classifications are of course
and divided by no hard and
arbitrary,
fast lines ; but, broadly speaking,this
dualism
corresponds
with clinical experience. In most
the contrast
of symptoms
cases
suffices to determine
a
diagnosisbetween the two kinds ; and
in cases
the hesitation of differential diagnosis
of doubt
even
often
in the data, or
probably lies more
opportunitiesof
"

observation,than in

exact

Whether

in

few

cases

not, Granular

or

are,

of

each

E.g. see
2

of the main

Chronic

Kidney
them, a fairlyconsistent
Zeitschr.

his valuable
3

morbid

the differential features

and

Kawashima,
In

blend

"

work

processes.

be

conspicuous
Parenchymatous Nephritis
clinical series throughout.

f. exp. Path. u. Ther. Bd. viii. H. 3,

Bright's Disease and Diabetes.

on

Bradford, Sir J. R., loc. cit.

1911.

CHAP,

THE

"

the

In

KIDNEY

Chronic

"

series

clinical

invariable.

not

are

343

PRESSURE

Parenchymatous

if common,

pressures,

BLOOD

AND

this

In

high

disease,

high pressures, the heart, whether by

both sides, if
dilatation or hypertrophy, is usuallyenlarged on
the same
to
not
degrees; in some
necropsiesno very great
in the granulardisease the arterial
But
enlargement is notable.
stress, risingearly and enormously, tells primarilyand in the
the left ventricle,
main
on
though not so exclusivelyas often
alleged. Unless perhaps in an early stage, the right ventricle
in the increase ; though considerable
measure
partakes in some
enlargement of the rightside is a secondary event, and a signalof
in which
systemicfailure. Roy's experiment will not be forgotten,
in both
raised pressure
aorta
acute
compressionof the abdominal
left and rightventricles.
Dropsy in Granular
kidney is rather
its correlative

under

and

Once

more

have

renal

I must

we

high

disease.
tread

Still,keeping

with

variables
have

may

yet unmeasured.

as

or

with

even

parenchymatous
with
comparatively
so
conversely
none,

arterial pressures without

any
But in this important part of
I

close

as

we

chronic

pressure,

early cases

warily,as
as

In respect of arterial pressures

arterial

high

in mild

little excess,
may

as

nephritiswith

of

renal.

in these diseases to do

have

we

than

in nature

cardiac

manifestation
my

argument

enteringinto contested positions.

possibleto accepted hypotheses,it is
am

Basch,
von
generallyadmitted, I think, that Mahomed,
in declaringthat
Potain, Huchard, and myself were
justified
and
often do arise without
renal
high arterial pressures may
that is,without
disease in any accepted clinical sense
Bright's
We
arteriosclerosis
have seen
disease.
that Huchard, regarding
now

"

not

as

anatomical

an
a

disease

result of several

diseases but

as

itself constituting

(p. 14), interpretedhigh arterial pressure

as

the first stage of it,and

this stage Presclerosis ;

accordinglynamed
it as an introductorystage of Bright's
Mahomed,
as
interpreting
it Prealbuminuria.
disease, named
plained
My position I have ex(pp. 10-15) : that in the first place arteriosclerosis is
disease
in the clinical sense
no
unity,is not a
; and in the
second
place that, although it is often associated with high
"

pressures, these
for some
which
Groedel

"

are

no

ten

years

verified

necessary
I

stood

arteriosclerosis

condition

of

it
"

doctrine

in

unsupported (p.183). Then

without
high pressures, an

ARTERIOSCLEROSIS

344

THE

AND

seems
independence which now
admitted.
Had
Dieulafoy

to be

KIDNEYS

PAET

if rather tacitly,
generally,
the

discerned

different

relations

and in
kidney, in hyperpiesis,
vascular involution without
high pressures, he would have been
between
the arterial
less puzzled by the inconstancyof parallel
under the exorbitant pressures
and the renal changes. For, even
of Granular
be
kidney, whatever minor
spots and streaks may
visible in vessels of the largermagnitudes,1deterioration of the
outside specific
be long resisted ; a degree
arteries,
areas,
may
in the muscular
vessels I have
of immunity which
attributed
in part to the protectionafforded by peripheralspasm.
Even
arteriosclerosis

of

the
of

thoracic

Granular

in

aorta

for

seems

protectivemuscular

thesis

for

M.B.

the

intima, there is

intimal

time, if there
not

The

first to

die

of

suffer

put

Dr.

blood

on

some

measure

J. T. Macnab,
a

case

in his

of Granular

high. In
arteries were
altered ; in August
not
his arteries were
thickened.
definitely
be some
generalfibrous increase of
may
of the elastica, no
subyet splitting

hyperplasia. Indeed,

the

to

in 1907, described

kidney in a boy aged 11.

August 1902 his accessible
1904
he reappeared,when
some

while

hypertrophy.

Camb.

For

as

the cerebral

(p.333), the victim

while

his

pressures

were

arteries

of Granular

large arterial

are

among

kidney

may

trunks,
apoplexy
stillin fair preservation.
are
elasticity,
Let me
In my
Hunrepeat myself again,for a moment.
terian paper of 1894, and again in the Lane Lectures of 1896, 1
stated that a certain disease
that is to say, a fairlyuniform
series and
correlation
of symptoms
recurrent
positive and
negative is to be recognisedand delineated,which, although
from the outset
marked
by a rise of arterial pressures, does not
follow the clinical course
of Bright'sdisease in any of its modes,
but manifests itself by symptoms
which
I have
described
where
elsean

whatever

their loss of

"

"

in this book.

Nor

does

it,as

Senator

"

supposed, if
Granular
to
neglected go on
kidney ; usually it is
neglected." Furthermore, that it is not an expression of
but generallyspeaking,if recognisedin time, is
arteriosclerosis,
curable ; and if recurrent, as frequentlyit is,yet even
after two
"

"

"

"

Recent

pressures
8

do

transplantationexperiments
not

in animals

to
injure the vessels seem
d. Nieren, 2nd

Senator, Erkrankungen

me

to

be

that high blood

prove
very fallacious.

to

ed., p. 306, 1902.

CHAP,

HYPERPIESIA

three recurrences,

or

the

such

strain

as

is not

diseases ; is not

contrary, from
or

disease, but

this

but

of which

this rise is but

the

have

questionwe

here

of the

consider

to
"

but

the

on

of Senile Plethora, or

name

simply

series taken

one

several

of

is

I gave

certain morbid

sclerosis
arterio-

Thus

arterial pressures,

Hyperpiesia,meaning by Hyperpiesia not

pressure,

arteries undergo

result

or

is

quiteconsistent with ordinary

disease it was, in originindependent

beginningto end,
To

event

an

often

too

as

arteriosclerosis.

of excessive

cause

that
arteriosclerosis,

of

in

issue

to

low pressures.

even

vigilantprecautions,it

good. If however,
the
treatment, or is neglected,

it defies

case,

other

and

for

banished

usuallybe

may

diet

by

345

as

character

whole

series

"

The

principalcharacters.
is whether

of

this disease

be

Kidney," or with any chronic

close kinship,I deny,
form of Bright'sdisease.
This identity,
or
for reasons,
chieflyclinical,alreadygiven. If it be urged that
the renal function
in
is nevertheless
fundamentally concerned
the disorder, this guess I neither gainsay nor
confirm.
It may
identical in nature

be so,
come

or

to

Dr.

that, of
no

it may
a

with

We

not.

Granular

have

as

yet

evidence

no

Janeway,1 after settingaside all

130 patientswith blood pressures

later paper

he says,

which

to

either way.

conclusion

clinical evidence

on

of renal

disorder

doubtful
about

could

200

in 17

mm.,

detected.

In
"

hyperpietics, the
I
renal defects, if any, may
kind."
be of the most
insignificant
add that the hyperpietics,
in some
with nephritics,
contrast
may
bear venesection
well, and are much benefited by it. Josue and
the patient
Block,2 of a certain high-pressure
case, write that
presented an instance of one of the most definite ('des plus nets ')
of clinical types, namely, ^hypertensionpur ; without
presenting
ing
imputable to a renal lesion," yet maintainany disorder directly
a
high tension.
(See Preface, P.S. p. x.)
very
Of HyperpiesiaI have never
offered an explanation,
or nothing
than conjecture; I have been content
it,as a
more
to distinguish
clinical series,
disease. I am
from the recognisedforms of Bright's
far from denying that in this disease of hyperpiesiathe kidneys
have
the
renal
some
concern
may
(p. 322). Passing over
on

necropsy

of the

be

found

cases,

pure

"

"

1
8

Janeway,

Josue

et

Amer.

Journ.

Block, Arch,

ScL, May

Med.

des mal

du

coeur,

mars

1906.
1908.

ARTERIOSCLEROSIS

346

THE

AND

KIDNEYS

PART

inadequacy" of Clark, adopted by Huchard, as either renal

here the argument
I may
mention
or
a vague
speculation,
in his Goulstonian

Batty Shaw,

Lectures

of 1906,

disease
of Dr.

argument

an

fullylater (p.357). He argues

putting
aside problematicalinstances in which
changes usuallytending
subdued
to high arterial pressures are
by intercurrent conditions,
it is agreedthat
such as cardiac insufficiency
or
competing toxins
which

I will discuss

more

"

"

the
more

Huchard

names

the

dependent

upon

nevertheless

kidney will be
origin,and is

Mahomed

Bright'sdisease under
Prealbuminuria, Presclerosis,or Hyperpiesis,do
of disease of the kidney ; yet
course
common
insidious kind they are
renal disorder of an

as

follow

Allbutt, and before them

and

separated from

less,have

or

such
not

which

cases

furthermore,
found.
due

The

to

dissolution

an

on

frank

fatal

issue,some

defect

in the

is of renal
pressor element in particular
escape of renal substance, or products

of

nephrolysis,to use a current word

into the blood.
Now
Dr. Shaw's explanationmay
not be
or
may
is to point out again that the distinction lies
true ; my
concern
between
Bright'sdisease and another malady which, if caught in
time, is,if not always, yet usuallycurable, and when incurable
cardiac defeat or apoplexy,and does not at any stage,
abuts upon
of renal

even

of

"

fatal career,

"

present ursemic

anaemia, headache,

symptoms

not, that

is

sion,
convullethargy,retinitis,
When
Huchard
states that cerebral haemorrhage
or
coma.
occurs
only in arteriosclerosis combined with interstitial nephritis,
he fails in this distinction, as he fails to distinguishbetween
hyperpiesiaand involutionaryatherosclerosis not due to high
of Nauheim,
Catalogues, like those of Fischer1
pressures.
which
in
give us large percentages of high pressure
cases
which the kidneys proved to be more
less affected,are useless
or
unless accompanied by controls ; i.e. by an
equallylong series
and equally careful scrutinyof kidneys,during life and
after
death, in persons of and beyond middle life in whom
pressures
raised. Again, what does Fischer mean
not
were
by "nephritis"?
In many
of his high pressure
the renal defects were
cases
very
slight; small spots of fatty degeneration,""punctate areas
of degeneration,"and
All
cardiac kidneys
should
so
on.

to

say,

nausea,

"

"

be

excluded,
1

as

final stages.

Fischer, Deutsche

Arch.

And
f. klin.

"

distinction
Med.

must

vol. cix., 1913.

be

made

AND

THE

that

in such

ARTEKIOSCLEROSIS

348

Hensen

But

still to learn

had

is not

factor.

necessary

KIDNEYS

Whether

sclerosis
arterio-

even

cases

in

then

PART

of

essence

respectivediseases the fairlyuniform

series of symptoms, negativeand positive are widely different in
is
I shall argue
And
care
course.
again that in necropsy
the
between
taken
to distinguish
not
cardiac," the atrophic
Granular
and
the
kidney technically
or
arteriosclerotic,
renal

originor not,

the

"

"

"

"

"

fessor
by Professor Lorrain Smith, Prodistinguished
other
Aschoff
(in 1903), Dr. John Gaskell, and some
believe the arteriosclerotic kidney
besides myself who
authors
limits still fairlycapable,but regard the Granular
to be within
kidney as corrupt, if not activelyvicious,from the beginning.
The
slight or variable degrees,or the absence, of high
of disease of
and cardiac enlargement in many
cases
pressures
been
have
their structure
the kidneys, when
impaired
may
been
for a long time
to
a
even
puzzle to
extremes, have
If the heart be enlarged to any
clinical observers.
great
renal
besides
the
disease,
that,
extent, certain physiciansassume
correlated disorder of a systemic kind, vaguely indicated
some
so

called,kinds

as

"

"

cachexia

the renal

be

(Passler,1Senator), must

disease,a condition,by the

way,

with

associated

scarcelyfavourable

to

myocardial growth. Others, with doubtful success, look for the

determiningfactor of the high arterial pressures in the differences
of the renal elements
of the glomerulifor example,
concerned
as
which I will consider presently; or in epithelial
decay ; or in the
quantity of renal substance abolished ; or, again,in absorption
renal substance
of disintegrating
(Dr.B. Shaw). On one clinical
distinction at any rate we are all agreed: namely, that the form of
renal disease in which
find the arterial pressures
we
constantly
and regularly
exorbitant,and the heart from the outset notably
Granular," which form is in this respect
hypertrophied,is the
from other diseases ending in shrunken
also to be distinguished
small white," 2 terminal or original.In
kidneys,such as the
"

"

"

it is true,

these other processes,

1

99

Passler
u.
Heineke,
(and reported in German
2

Professor

indicating
and

Roth's

of this kind.

its

Verhandl

Rose

Bradford

often

latent

cases,

under

the

some

d.

journals of

arterial tension

path.
that

Geselhch.

zu

and

Meran,

cardiac

1905,

accepts the primarily contracting white

course

bundle

in
name

young
of

ix.

year).
adults.

Some

of

Schrumpfniere, seem

Jores,

kidney,
Prym,

to have

been

CHAP,

THE

AND

KIDNEY

BLOOD

PRESSUEE

349

enlargement are usuallyfound, but not so early,so constantly,

red granular
form.
nor
so
enormously as in the
of renal structure
As regardsthe amount
; that the cardioof its
arterial stress is not, directlyat any
rate, as the sum
detrition is apparent on comparison of
Granular
with
cases
of shrunken
cases
or
damaged kidneys of other kinds in which the
"

"

"

"

obsolescence

of renal substance

of renal disease,such

certain kinds

renal elements

proper

obliterated,the heart

definite relation

rise of arterial pressures

pressures
has become

local disease

"

"

much

demolition
heart

; the

the blood

large,and
urine

"

the

between

In

the

as

the arterial pressures raised.

And, when
find
kidney proper, we
closelyat the Granular

more

the

less.

no

all,nor

at

look

not

may

be

sum

amyloid,in which the

universallyimpaired,and some
in the amyloid is not
be
larged
en-

be

must

in the

may

in

of the
these

kidney

cases

and

often

we
no

the

grows

high,in incipient
stages before
manifest, or importunate, or the

run

attenuated.

Renal

angio-spasm

"

is

hypothesisex machina.
We
have seen
that Hasenfeld's
hypothesis,which attributed
the high pressures and enlargedheart to the geographical
tion
distribuof the arteriosclerosis,
namely, in the mesenteric area, had it
for ordinary cardio-arterial hypertrophiesand
been valid even
is quiteinadequateto explainthe enormous
cardiodegenerations,
arterial changes of Granular
kidney ; and it has been disproved
researches
observers,as for instance,by the well-known
by many
of

Marchand.

I have

said

also

that

Jores, in

many

cases

of

Granular

kidney with largeheart and high arterial pressures, had

demonstrated
the slightness
virtual absence of arteriosclerosis
or
in the mesenteric
indeed
area
that, speaking generally,
; and
the pancreatic,splenic,and
cerebral
arteries are, as a rule,
diseased

more

In

than

those

of the bowels.

thus

little lantern
the correlations
turning our
upon
between
renal affections,
and
arteriosclerosis,
high pressures,
crucial point,although no
instantia crucis ; we
we
see
meet
a
another
baffled inquirer,
each perhaps with his own
many
guess,
of
the
but
What
or
are
information,
no
signpost.
scrap
scraps ?

Well,

as

we

disease, and

have
in

kidney,pressures

that

seen,

of

many
do

not

in

cases

some

tuberculous,

or

of chronic

calculous, or

rise at all ; that in others

the

renal

surgical
rise is not

ARTERIOSCLEROSIS

350

does

predominant, and
heart

inconsistencies

"

affect

not

ventricles,after the

both

THE

AND

in

mainly

because

with

strong contrast

PART

the left ventricle

often

of, and

way

KIDNEYS

but

of, failing

the definite

class,

the name
with the disease to which
of Granular
especially
Kidney is given, in which from the first high pressures predominate,
and consequently the left ventricle,in the manner
concentric
of the so-called
hypertrophy," is affected chiefly,
enormously,and often until the stage of cardiac fatigue,alone.1
Still,if not eminently characteristic of them, yet it is true
in
that in other chronic renal diseases,even
surgicalkidney,"
and

"

"

arterial pressures ; so we
that in renal disease there is a something which
presume
provokes
in the Granular
this excess
kidney
; something which
there

is

is

inclination

an

in

constant,

engendered in,

the

rise of

others

of, the

or

Aufrecht, which

to

while

variable.

kidney

Is

itself ?

this
In

something

the

view

inconsiderable
no
ago found
of this pressure-provoking
means

the

of

favour,

the
conspicuousexample
Granular
the
kidney is but a local expressionof arteriosclerosis,
renal implications
of which colour the whole malady. But, like
also regarded arteriosclerosis as necessarily
Huchard, Aufrecht
I had proved
associated with high pressures, although in 1894"96
that very frequentlyit is not ; and, in particular,
that even
an
arteriosclerotic kidney may
be, and often is,associated,from life
"

"

death, with arterial pressures normal

to

In

222

cases

of arteriosclerosis Dr.

kidneys somehow

affected in 141

for the age of the

Mott

(82 male

found
and

the

patient.

heart

and

female),but in
30 male cases
and 55 female neither heart nor kidney was
altered.
A short time ago he kindly discussed with me
300
necropsies
in
in his Department,
which he had noted that if,as it commonly
happened in cases of atheroma, includingthe cerebral arteries
themselves, the renal fibrosis

not

was

that

59

of Granular

kidney,

cerebral

haemorrhage was relatively

infrequent. This result of a
large comparison agrees with the impressions which on this
in Lunacy.
subjectI received when I was a Commissioner
Now,
1

take

this

accepted ; I may add that Jores in his last (Deutsche

carefullyrecorded the cardiac condition, on Miiller's method,
of shrunken
kidney, and found definite hypertrophy by no

as

Arch., 1909) paper

unsorted

in

of
"

cases

But

Jores,

Smith

and

constant.

means

what

Lorrain

arteriosclerotic

"
"

my

as

I have

I, and

decrescent,

in an
uncertain
number
said, mixed
and
have
Gaskell,
separated as

Aschoff
"

or

"

involutionary

"

kidney.

CHAP,

as

THE

Mott

Dr.

selection
of the

of

AND

KIDNEY

BLOOD

PRESSURE

himself

observed, in pauper

cases

among

the

of arterial disease

cases

insane

asylums there is some

largeproportion
very

those

not

are

351

associated

large cardiac
pressures and
non-renal origin; they are of

encroaching arterial
whether

of renal

or

softeningin

cerebral

nature, with

the other hand, it is

named
the

well

that in the

ill,Granular

or

On

areas.

disease
specific
lesion begins in

Kidney, the arterial

kidney with certain associated

in the

kidney, or

hypertrophy,
degenerative

the atheromatous

ascertained

now

with

distal

areas

central arteriosclerosis
etc.),and that a more
(spleen,
pancreas,
is not
compassed until in other districts the strain of a
systemic high blood pressure has begun to tell. Yet it seems
improbable that, as under the renal disorder pressures begin to

increase,the strain would

In

twigs.

renal

the

on

indeed, where

area

the

visceral

remoter

afferentia

vasa

off from

branch
and

the

tell first

in the

both

by

High

tension

friction and

later in the

twigsare

the interlobular,the pressure gradientis falling,

must
tufts, which are affected earlyand severely,

by

would, and
and

aorta

among

extension

fall very
itself manifest

of

does, make

great vessels

the first to be

bed

but

damaged, to
playingon

if the

quickly.
sooner

or

finer visceral

initiate it must

there

periphery? * In
of true
of Roth's cases, one
Granular
one
kidney in a man
aged 30, with blood pressures of 185-215 (death comparatively
early,
presumably from intercurrent causes),althoughthe kidneys
were
typical,but little alteration of the largervessels had appeared
be

not

some

insidious

humour

the

"

; and

that

mentioned

I have

constriction

in the

renal

"

such

instances.

area

would

Traube's

suffice to

notion
enhance

ligationof both
renal arteries does not do it. If a peripheralarteriosclerosis
almost
universal,it is possiblethat pressures
quicklybecame
might rise ; but in Granular
kidney such extensions come
in thirty
about
of it, even
later, although, at the outset
to forty days, arterial stresses
reached
have
high
very
may
is not
degrees. Certainly the high pressure
engendered, as
have supposed,of mere
some
chronicity.
2
The Glomeruli.
Weigert adopts the opinion,and it is one
generalpressures

was

erroneous

even

sudden

"

1
2

See

Steinbiss, p.

263.

Weigert, Die brightsche Nierenkrankheit, Berlin, 1906,

Sammlung, Nos. 162, 163.

and

Volkmann's

AND

ARTERIOSCLEROSIS

352

KIDNEYS

THE

PART

independentlyinclined,that the secret of

lies in destruction, or
increase
suppression,of the
pressure
renal parenchyma ; Passler and
Heineke's
conjecturesalso, to
be widely different.
which I have alluded, may
not
Weigert's
opinion is strongly supported by pathological evidence.
Aubertin,1 in a case of abuse of absinthe during the ten months
before death, found
a
nephrite purement epitheliale; but
the heart nevertheless
was
largelyhypertrophied. There was
aortic nor other arterial lesion anywhere in the body. In the
no
do a like damage
discussion E. Gley said that certain snake serums
to the kidney epitheliumwith consequent cardiac hypertrophy.
November
Aubertin
followed up the enquiry,and in the following
produced a large array of experimental facts,experiments by
and
bacterial agents. When
the
slow poisoningwith chemical
and necrosis)
effects were
purely epithelial
(cloudy tumefaction
from
the very
outset
enlargement of the heart ensued, even
when
the epithelial
barely perceptibleto the
changes were
that the
microscope. Passler and Heineke's view is (loc.cit.)
correspondencewith the cardiac enlargement lies not merely in
the glomerularbut in the total renal defect ; and Sir John Rose
to which

had

own

my

"

"

Bradford

it

would

Hensen

15, in which

later,as
kind

in

case

blood

the

inference

aged

to

rose

pressure

in,fell to

set

recovery

similar

from

ablation

certain

at

seem,

quoted

degreespressures begin to rise ;

from
lessening the eliminatingsurface.
of transient acute
nephritisin a girlaged

which

experiments,in
as

make

to

seems

180, and

120.

I remember

28

30.

two
case

weeks
of this

She

presented acute
cytes,
leucourine thick with albumin, epithelium,
dropsicalnephritis,
In a few days her heart became
and casts.
enlargedand
loud.
She did well,the physical
the aortic second sound painfully
she went
to service and
out
signsreceded, and in three months
I lost sight of her.
was
reportedwell for a year or so, when
conclusion
that high pressures
However, Passler and Heineke's
definite cardiac
of renal
and
hypertrophy arise on removal
tissue

young

to

woman,

certain

correlated

or

amount

think, a little more

confidentlythan

More

verification

is

doubt

it, or

regard
1

wanted
the

as

indeed

variations

as

is

relied

upon,

yet is quitejustifiable.
some

experimenters

slightand

Aubertin, Soc. de Biol, juli27, 1907.

inconstant.

CHAP,

GLOMERULI

THE

Jores,for his part, was

353

to formulate

unable

direct

any

proportion

high pressures with cardiac increase, which often is

great in comparativelyearlycases, and microscopicalevidence
of parenchymatous destruction of the kidney. That the blood
of both kidneys,or on the
does not rise on extirpation
pressure
occlusion of the renal arterial tree by the injection
of paraffin
into both renal arteries,1may
be attributable
to the severity
of the operation; and
in calculous
anuria
the same
lack of
reaction time and capacity may
be a valid explanation. In
Aubertin's
stated that the adrenals were
it was
cases
enlarged,
between

and

the

that

renal

cardiac

lesion,but

to

profusionof

have

however

increases

shown

been

have

may

adrenin.

due

to

not

Certain recent

the

tions
observa-

that, although by adrenalin

great

ment
enlargement of the heart can be brought about, yet this enlargeis not good muscle, but something of a degenerative
accumulation
(videp. 225).

duringlifewere

recorded.

In

raised,and the adrenal

not

were

not

Aubertin's

In

Gley'ssnake

cases

bodies

not

were

contrary opinion prevails,that

The

blood

the

cases

in

pressures
the pressures
mentioned.

glomerular lesion

high pressure in renal disease, as was

Meeting of the Deutsch. Path. Gesellsch.
apparent at the Meran
in 1905.2
Ziegler3 regarded glomerularlesion as the essential
factor of high pressure, and thought that, if the vessels were
itself. Ziegler's
clear,the impaired epitheliumshould recover
lies the

views

secret

of

attention,but

command

to

are

me

inconclusive

because

he

granular,the arterioshall see is not quite the same

and
what we
sclerotic,
thing
the mere
senile atrophickidney,two forms in which the glomeruli
he was, so far
to suffer passively;
a curious
as
seem
inconsistency,
arteriosclerotic
I know, the first pathologist
the
to recognise
as
renal arteriosclerotic atrophy
shrivelled kidney
(p.337) : a
..."
due primarily
form of contraction of the organ
a special
to sclerosis of the renal arteries with, usuallybut not necessarily,
In
of areas
of the intimate renal ramifications also.
participation
Granular
kidney, although it is true that lesion of the finer
arteries of the organs
to be an
seems
obligatecondition,these
always discriminate

did not

the

between

"

"

"

"

"

"

"

Senator, H., Zeitschr. f. klin. Med.

Verhdl.

loc. cit. p. 112;

Ziegler,Deutsche Arch.

VOL.

Bd.

F. Miiller and

f.

klin. Med.

Ixxii., 1912.

Volhard, Monckeberg and

Bd.

others.

xxv.

ARTERIOSCLEROSIS

354

THE

AND

KIDNEYS

PART

with others of similar magnitudes in several other regions

vessels,
of the

body,

substance, of
the whole

rather

may

be the gate of entry of

some

perniciousagent corroding unit

some

histolytic
by unit

gland.

surprised to find that lesion of

large in this enquiry. As centres
glomeruli has loomed
with
arterial disease
also
quasi infarctive effects, and
have
fibrous hyperplasia,these structures
caught the eye
shall

We

be

not

the
of
of

observers

always

means

any

than

more

times

:
parallel

run

do

not,

the

hyperplasiamay
conversely. The

arterial disease, and

the

capillarysystem
advantage to an
twenty

however

the processes

would

be

to

seem

Jores

as

rather

admits, by

obstacle

an

of

be

far

double
than

an

through its system ten to

passes
organ which
blood
than
almost
other.
Professor
more
any

Starlingsays the glomerularfunction needs a pressure of some

30 mm.
Hg., a pressure which must fall below its needs when the
vessels are narrowed, whereupon the glomerulusmust
shrink and
while the
ultimatelydegenerate. The longerafferents suffer first,
shorter are
still normal
met
are
(J. F. Gaskell). Here we
by
the interesting
argument of Professor Brodie, and of Jacobi of
Tubingen,1in which they suggest that the glomerulus,within the
firm and inextensible
capsule of the kidney, so far from being
an
obstacle,is a small hydraulicram
propulsor is Brodie's
term
that the
reinforcingthe heart's impulse ; 2 moreover
that
glomerulus is not a water-springfor the tubules,nor a filter,
the water
reaches the tubules by their own
epithelium(Woods
such aspiratingcapacity
Smyth). Tigerstedtattributed some
"

"

"

"

whole

to

the

he

said,in spiteof the

without

organ

as

increase

(Virchow's Schwamm
and

narrow

of diameter

contorted
rise of

or

that,

?), so
vascular

pressure,

as

channels,

the

stream

filtration
quickened. That the aqueous dischargeis not mere
is now
concentramovements,
generallyaccepted.3The aqueous
tive and eliminative, depend upon
the tissue colloids,
variables
however
which
influence,are
usually,probably under nervous
was

Jacobi, Munch,

Dr.

W.

Woods

med.

Smyth

Wochenschr., 1911, No.

of

Maidstone

wrote

against Brodie

Sept. 23, 1911, to claim, as

1911) the priorityof this suggestionfor
to the American
Encycl. of Biography.
3

See

Hober, Physik. Chem.

v.

Med.

36.
the

to

Brit. Med.

Journal

(Croonian Lect., Roy. Soc., June

his brother
The
Bd.

A.

W.

hypothesis
i., 1907.

Smyth

is far from

on

15,

he referred
verified.

ARTERIOSCLEROSIS

356

of
Bahr

arterial

and

heart

the

and

he

because

AND

others

selection

THE

KIDNEYS

pressures.
find that

However

PART

various

quote

toxins

have

vaso-tropism,as Ehrlich might put

to
it. The
injury to the glomeruliand afferent vessels seems
be due to the filtering
through them of the morbific substance,
in distribution,
and in degree,even
depends on the dose.
In estimatingglomerular
reduction,the personalequation of
instances account
for some
reckoningand the selection of striking
vascular

various

"

inconsistency of results.

Differential

counts

are

tedious

so

dominant
moreover
personal equation becomes
;
in
in
the
amount
glomerulus disintegrationdiffers much
several parts of the same
kidney ; but most recent observers
heart enlargeJores, for example find no
parallelbetween
ment
and suppression of glomeruli. As however
Loeb,1 and
the

that

"

"

the rise of pressures

and
of the left ventricle to be in direct proportionto the

growth

the

Krehl

Passler,and

also, still assume

to test this statement

Jores injected
glomeruli,
of shrunken
with
kidneys ; in many of those unattended
a number
cardiac hypertrophy he found the glomerulardestruction to be no
whatever
less ; moreover,
damaged (" verodeten ") glomeruli,
many

of the

destruction

of functional

their remnant

arterioles

; much-thickened

are

often stillpervious. Lohlein

also,in the present respect,have

J. F. Gaskell

and

at least still permeable

value, were

attached

little

importance to glomerulardisease,and on experimentaland clinical

the
data look to tubular and diffuse nephritis,
as
or
nephrolysis,
It is a point in Rautenberg's experidisturber of pressures.
ments,
that although rise of pressure
to be mentioned
presently,
intact.
and cardiac hypertrophy set in, the glomeruliwere
On
the other hand, in the amyloid kidney without
rise of pressures,
cardiac increase,glomerular obliteration
but little,
and
or
no,
for

retain their form

in

pressures

rise but
of

earlycases
area

are

while

far

Quoted

of
by

remarkably long time

cases

renal
Dr.

in

which

is of

to

course

mere

influence

of cardio-arterial
disease

Janeway.

can

be

again

the

; and

well

that

and
on

Krehl, Path.

in

in the renal

general blood

demonstrated

obsolete,

aware

obliterations

pressure

glomeruli

repeat that

glomeruli are

many

the

pressure

limited

too

stoppages

little. Loeb

high

in other

evidence

ureteral

kidney,

senile

the

In

great.

very

seems

pressure,

strain
necropsy
Phys.

p. 3.

no

CHAP,

STUFF

KIDNEY

AS

PRESSOK

357

wider reflexes,operatingespecially
whereupon he postulatedsome
an
through the brain
argument in which he became
speculative,
if not vague.
let
tinguishe
claim that this disHowever, here again
me
pathologistalso admits the not infrequentoccurrence
of high pressure
without
renal disease.
cases
Charcot
argued that glomerulardefect entails defect of the
whole
unit, but this apparently
secretory (glomerulo-tubular)
*
reasonable
uncertain.
Bainbridge and Beddard
guess is very
of the
showed
that
after complete occlusion
glomeruli the
maintain
their
tubules, if adequately supplied with oxygen,
and
From
normal
urine.
secrete
histological
appearance,
may
of
cases
Rautenberg'sexperiments,as in some
surgical
kidney,"
it would
that without
active glomerular disease the mere
seem
annullingof renal substance, if largeenough, provokes a rise of
arterial pressures
the glomeruliin
were
(p. 352). Histologically,
sclerosis
Bright'sdisease,say in "Granular kidney,"the seat not of arteriobut of arteritis obliterans,we
might have a criterion
of an irritative againstan atrophiclesion of these elements ; but
"

"

take

must

we

Gaskell

that

it for the
the

present from

Jores

primary arterial change

is

and

Aschoff

and

arteriosclerotic,
as

recognisedin subintimal hyperplasiawith splitelastica,and in

its disposition
to fattydegeneration,
kind of decay to which
a
idarteritis obliterans

is less prone.

I have alluded to Dr. Batty Shaw's2

Kidney Stuffas Pressor.
assumption of a positiveeffect,as a hypertensive poison, of
ibsorptionof the gland into the system ; a curious construing
of Johnson's
of the
presumption that the
stopcock action
vessels served
from a previouslytainted
to
protect the organ
Dr. Shaw's
blood.
conjectureis that kidney stuff of its own
nature
acts
hypertensively; and that not in Bright'sdisease
and myself,
only,but also in the hyperpieticmalady of Huchard
"

"

"

the

kidneys are

into the blood

and

current, with

order

of

the

of
consecutively

evidence
histological
the

kind

undergoing some

events

of solution

effect of

be

is contrariwise.

But

produced.
Dr.

Shaw

Shaw,

B., Goulstonian

Lectures,

1906.

striction,
con-

surely some
Prima

facie

supposes

the

Journ., 1906, vol. i. p. 255.

Bainbridge and Beddard, Biochem.
Paper read April 24.
Bainbridge and others, Proc. E. Soc., 1913.
1

diffusion

general arterial

arteriosclerosis.

of this should

and

See

also

ARTERIOSCLEROSIS

358

only

differences

diffusion
not

so

the

more

of

not

are

to

familiar
as

issue in

train

have

we

concentrated,

so

seen,

always
laysgreat

Dr. Shaw

we

symptoms
1

this

PART

solution

and

virulent,or

perhaps
as
recogniseclinically
of
Bright's disease.

rise of pressure with

renal disease, whether
with uraemia or
declares

arteriosclerosis is
not.

of

so

or

what

KIDNEYS

that

be

Hyperpiesia to

as
specific,

Ortner,

THE

AND

stress

that

experimentsof Tigerstedt
of renal
injectionof extract
the

on

and

Bergman to the effect that

cortex, prepared by their method, drives up blood pressures
to degrees unapproached by any
other such organic extracts,
except the pituitary.Maragliano also injectedkidney pulp of
after tying the ureters,
dogs into rabbits,or the blood serum
and
inferred the presence
of a nephrolysincausing nephritic
He 2 made
series of experiments in this way
two
symptoms.
;
he injectedkidney pulp of dogs into rabbits, producing so
I gather from
the records
little rise of pressures, but a general
in which
the kidney was
cytolysis,
implicated. But do not
these injections
from one
to the
speciesinto another seem
open
of animal
objection of violation of the idiosyncrasies
species
Nuttall (and others)?
Parisot's researches, in a book published
"

"

(in

interne,

far

so

not

arguments

differ.

they
pressor

Dr.

after

1908

Shaw's),

as

they

dealt

with

Parisot

effect is due

diffusion

not

by
so

the

to

are

leans

Pression

on

to

much

the
to

effect, contain

same

Shaw

Dr.

arterielle et secretion

though in some
current
opinion, that

an

inward

no

facts

the

renal secretion

or

imperfectelimination of pressor substances in the

blood, and helps out his case
by lookingto adrenal hyperplasia
(p. 225). He notes the hypotensive effect of blocked ureters,
and
of very sudden
and
acute
nephritis.By the way, he, as
others have done, experimented with the liver also, and found
to

as

that, in this respect, the substance

had

little or

effect.

no

later

conclusion
experiments fail to support Tigerstedt's
contradictoryor inconclusive.
Bingel and
; they are
of
Glaus,3 on
injectioninto animals
expressed juices from

However,

Ortner,

Two

Wien.

references

degli osped., October

have

not

Rpts. vol.
3

the

seen

v.,

Bingel

klin. Wochenschr.,
:

1902.

(1) Virchow's
7, 1909

Jahrb., 1903, vol. ii. p. 244 ; and (2) Oaz.

Journal,
1909); I
(Epitome, British Medical

original papers.

See

also

Bender

in The

Bender

Lab.

1908.
und

Claus, Deutsche

Arch.

f.

klin. Med.

Bd.

100.

He.

u.

4.

healthy

of

any

effect

PRESSOR

359

the effects

be

or
scarcely,
Pearce
again,on Bingel'smethod, injected
from
both
healthy and diseased organs

to

"

"

indecisive

animals, with

into
as

kidney

AS

kidneys, found

diseased

or

transiently,
pressor.
extract

STUFF

KIDNEY

CHAP,

arterial

on

results ;

pressures

the

on

whole,

far

so

it
perceptible,

was

was

followed
Also
he
transient, and
by a fall.
slight and
from
some
dogs in which
large portions
injected serum
of the kidneys had
been excised, and from
others in which
an
the
artificial nephritishad been induced, and at periodswhen
urine was
free from
depressor substance ; but the evidence of
was
a
slight. He concluded,
very
pressor substance, if any,
likewise, that the kidney did not contain a pressor substance
We
have
masked
powerful depressor constituent.
by a more
found depressorrather than
that Josue and Block (loc.
seen
cit.)
of high-pressure
of the serum
subjects
pressor effects on injection
it is true, but
into rabbits.
The experiments were
not
many,
laboratories the researches of
definite enough. In our
they were
Professor
and his colleagues
Dixon
and pupilshave led to similar
doubts
and
however
objections. We have seen
(p. 268) that
of not
Eichler did find the serum
only nephriticbut also of
nephrotomisedanimals to contain a vaso-constrictive substance like
If these results
adrenalin ; and that Schlayer2 agreed with him.
indicate that a pressor
substance
be verified,they would
may
absence
of the kidney.
the kidney but from the
ippear not from
latent renal
a
However, if with Dr. Shaw
we
might assume
distemper sufficient to taint the blood but not gross enough
to amount
to Bright'sdisease,we
might find a solution of the
problem of hyperpiesia. Dr. Shaw does not forget that renal
,

cortex

is not

inexhaustible,and that,under

the morbid

conditions

be very ready; but with

its reproduction
could scarcely
postulated,
thus labile,stores would
presumably in no great interval
organs
of time be expended, and even
before that periodrather reduced
described by
than multiplied. Now
the course
of Hyperpiesia,
as
into
would draw
and myself the disease which Dr. Shaw
Huchard
and frequentlydoes,
the net of primary renal causation
may,
"

"

continue

before

for

years

upon

its final events,

1
2

Pearce,

years

not

of

Jmtrn.

Schlayer, Deutscfo

med.

"

from

fifteen years

to

ten

cardiac

uraemia, but

of

of Exper. Med.,

1909.

Wockenschr., Nov.

14, 1907

defeat

"

or

ARTERIOSCLEROSIS

360

AND

THE

KIDNEYS

PARTI

cerebral

I think Dr. Shaw

And
does
haemorrhage,appear.
not
of
give weight enough to the experience that our cases
if detected
in good time, are
curable, and curable
hyperpiesia,
repeatedly; unless perchance he supposes that our remedies act
influence on the kidneys not directly
favourablyby virtue of some
intended
or
recognisedby us.
Again, should we not find that
other kinds of disturbance
of a kidney, as by a calculus or by a
of tubercle,
for instance, by vexing the renal tissue and by
mass
of the cortex
and diffusing
promoting the assumed
disintegration
of

"

"

it into the

rule,

blood, would
incidental

such

renal tissue around

arteries

run

lesions,however
them, do

heart.

arterial pressures

up

And

they

raise pressure,

not

after

solvent

nor

Yet,

as

be

may

deform

of
the

Batty Shaw's hypothesis

it
would
to prove true,
tions
distincnot
set aside the practical
the series of clinical events
between
long familiar to physicians
under the name
of
Granular
and
the
different
Kidney
series distinguished
and by myself as Presclerosis
by Huchard
or
Hyperpiesia.
describe Rautenberg'sexperimentsdefinitely.1
Let me
now
in Lichtheim's
Rautenberg works
laboratory at Konigsberg,
and his report of two
to prove
long series of experiments seems
that he is an expert investigator.At first he lost many
animals
or

Dr.

all,were

"

but
(rabbits),
about

half

he became

as

of

"

them

in

dexterous

more

survived.

His

tyingthe
by experience.

left ureter

bladder, and

right kidney

lived
a

for nine

year

two

the

and

years

connection

months,
half, one

and

half.

nine months, and

in the controls.
; in the

Then

were

The

for three

was

for

two

for

and

more

successful,

sisted
improved operation conweeks, a perioddetermined
was

made

anew

with

extirpated. Some
year

and

animals

quarter,

year

and

it

rose

(from 110-122) to

160-170.

On

in all these cases

arterial disease was
found.
necropsy,
heart was
in like degreesenlargedup to 2 or 3 grams
; but
these animals
the organ
is inconstant
in size,well-marked

Kautenberg,
2

for

one

for
one
three-quarters,
The blood pressures rose distinctly
in about
then systematically
measured
in them and
rise proved to be proportionate
to the duration
a

longersurvivors

only were

the

accepted. Alvens,2for
Deutsche

Alvens, Deutsche

med.
Arch.

the

same

as

in
largements
en-

purpose,

Wochenschr., March
24, 1910.
klin. Med., Dez. 3, 1909.

f.

The

CHAP,

EXPEEIMENTS

RAUTENBERG'S

361

gradual compression to the kidneys of animals, and found

blood
rose
parallelwith the degrees of compression.
pressures
Similar compression of the spleen,or
other viscera, did not
control experiments the nervous
produce this effect. In some
used

connections

cut,

were

eliminate

to

as

so

afferent

stimulation,

wise,
Furthermore, contrariplace just the same.
relaxed the blood pressures pan
the compressionswere
as
passu fell ; and this in Alvens's opinionproved that the rises were
from
As
the kidney into the blood.
not due to squeezingof juices
in Dr. Harvey's experimentsin our
the arterial
own
laboratories,1
disease of these experiments could not be called atherosclerosis,
but a calcifying
necrosis rather (p.223). That the rise of pressures
but

the rise took

arterial disease

could

not

those

animals

when

the lesions of the vessels had

have

been
which

the

due

to

died

in the

evident

was

in

earlier stages of

high pressure,
beyond pinpoint

advanced

not

pinhead spots ; a stage at which they could not have had

the arterial
that if directly
any such effect. Rautenberg admits
of risingpressures, yet some
ning
forerundamage be a consequence
to
toxic condition may
make
the arteries more
susceptible
the abnormal
stress.2 Harvey's researches however, by experiments
that
in which
used, demonstrated
compression only was
mechanical
stress
was
amply sufficient to establish this arterial
under
his
ion ; and Rautenberg thinks that, in the animals
at any
stress
rate, the chief cause.
operation,mechanical
was,
visceral arterioles
But in Granular
kidney,so far as the peripheral
and

concerned,

are

result

primary atherosclerosis.
Rautenberg's experiments was

of

lapse of

nine

to

months

could

pressures

determined

be

dilutions

Harvey, A.,

It

of renal

of 1 in 20, dilated

by

structure

reaction

Virchow's

is remarkable

lesions

the

"

even

in

this

uniformly acting

remarkable

even

of

these

pupil of the
suggestingthat

high

animals,

enucleated
this

serum

cxcvi.

process,

cause,

the

before

static effects of

the

Archiv, 1909, Bd.

that
a

that

serum

3),thus

cannot

stresses

Another

before, that is,any

"

frog'seye (Ehrmann's

of the

excessive

that

seen

for their

account

even

have

we

of

after

experimental

death

focal

abolition

distribution

noted.

was

Arch. f. exp. Pathol

und
1905, Bd. liii. S. 97 ; and see
Pharm.,
Ehrmann,
blood
that normal
It is said however
Arch. f. ges. Physiol. Bd. cxxix., 1909.
Wiesel
and
(Wien. klin.
Schur
less of Ehrmann's
reaction.
or
gives more
3

Wochenschr.,
muscular

work

1907

and

1908) attribute

calls forth

secretion

it to chromaffin

of adrenin

into

tissue, and
the

serum.

argue

that

ARTERIOSCLEROSIS

362

contain

may

pressor

AND

THE

substance.1

KIDNEYS

PART

Thevenot,2 after referring

venously
Kathery's researches, injectedrabbits intraof nephritic
(8-12c.cm.),with the blood serum
patients
four times a day. He came
to the following
(cases described),
conclusions : (1) That
of those
the nephrotoxins of the blood
sufferingfrom nephritisare in accord with the gravity of the
clinical phenomena ; (2) that they are
in inverse ratio to the
of permeability of the kidney estimated
state
according to
the method
in
of Claude
and
Balthazard
; (3) that they are
in the serum
direct relationship
with the albumins
; (4)that they
in the
of urea
to present no
parallelwith the amount
appear
It seems
serum.
probable therefore that the nephrotoxins
of chronic nephritisbelong, at
in the course
developed in man
least in part, to the albuminoids.
that by RautenIt is possible
the kidneys were
not
berg'smethod
merely suppressedbut were
into
and so made
to dischargea hypothetical renin
irritated,
the blood ; still,
the whole, they point to renal negation,
on
rather than
of accumulation
of
the cause
to renal poison,as
It is to be hoped that steps will
pressor influences in the blood.
be taken to verifyRautenberg'sexperiments.

Castaigne and

to

"

"

if there be but

Now,
this must

one

pressor

"

concerned, either

substance

always by fault of the kidney or there must

be alternative conditions to giverise to its formation, retention,or
The kidney is understood
but
to be not an
excess.
elaborating,
Unless
it be, as Dr. Shaw
an
eliminatingorgan.
supposes, by
sacrifice of its own
but cannot
body, it may fail to remove,
manufacture, a pressor or any other poison. A failure to eliminate
it is true, depend sometimes
times
on
transitorydisorder, somemay.
incurable disease ; or possiblythe strain of excreting
on
such
drive the kidney into disease, though, at
a
poison may
rate

any
a
we

accumulate

at

first,or

in milder

would

one

cases,

look

for

rather

hypertrophy ; a state however of which, in these circumstances,

have no
on
experience. In the lightof recent researches
"

gout for instance

kidney
1

In

to

excrete

this

the

"

fault

normal

connection

Wellcome

I must

Sympathomimetic
PhysiologicalResearch

reprint (1910?)].
2
Thevenot, Prov.

lie not

in

failure of the

waste, but of the antecedent

"

on

to

seems

Med., May

mention
Amines

again
"
"

for

the

example,

Laboratories

7, 1913, quoted

searches
interestingre-

various
of

[recent, but

reductive

Barger and
no

Epit. Brit. Med.

date

Dale,
on

Journal.

my

ARTERIOSCLEROSIS

364

THE

AND

KIDNEYS

PART

they fail to be excreted ; but not by default of

hyperpiesis
chloride prothe kidney, as the harder work of excretingsodium
ceeds
undisturbed.
But surelythe release or retention of sodium
chloride is not a mere
renal function ; with kidneys presumably
diseases
in pneumonia, for
normal
the salt is retained in many
instance, and in certain dropsies. Salt retention is,in largepart
gout

or

"

at

least,a

of the heart

matter

and

circulation

(p. 231),and

the

of circulating
fluids. Abelous'
probably
body was
isotonicity
Barger'spara-hydroxyl-phenylethylaminea pressor substance.
by
Harvey x has experimented on rabbits with it ; on some
In 20 rabbits the kidneys
on
some
injection,
by the mouth.
became
diseased,in degreesfrom arteriolar thickeningonly to
extensive and universal change (Aschoff,Gaskell,Lorrain Smith,
and
others); in 13 the results were
negative. In 25 the
had
aorta
enlarged. The
degenerated,in 10 the heart was
of life in the renal positiveswas
80 days to
duration
from
of these
over
a
days ; but one
year, in the negatives 30-70
lived for 141 days. The
urine produced vascular disease, first
in the aorta, secondly in the renal arteries ; at first without
alteration of the parenchyma.
Then
the epithelium became
impaired, the glomerulidilated, their capsulesthickened, and
here and there were
cell infiltrations. The quality
round
some
of the urine and the degreesof renal lesion did not run
parallel,
still these
results seem
be of considerable
to
importance.
Crofton2
that certain xanthine
found
bodies, if pressedin full
doses, caused at first granular and fatty deterioration of the
the
renal epithelium; in animals
which
survived
six months
blood pressures
and intertubular proliferation
of the connecrose
tive
elements
Professor Walker
ensued.
Hall has made
ments
experi"

of

similar kind

Bodies, 1903). But

difficult.
to obtain

these

similar results

problems are

instance,in

litre of urine.

in

Dixon

urine,

the

solvents.
1

He

they

regardsthem

Harvey,
2

whence

traced

Journ.

Crofton, Amer.

Path,

not

and

Journ.

were
as

Bact.
Med.

(see his Purin

obscure

very

Dixon

and

the pressor

; thence

and

Harvey,

appreciablequantity,had

putrescence in the alimentarycanal

into

yet

as

laboratories

our

their putrescent toxin

evaporate
to

For

with

and

to

substances

to find their way

separated by appropriate
toxins but
as
crystallisable
vol. xvi. No.

Sci. vol.

cxx.

1, July

1911.

p. 592, 1900.

INFECTIONS

RENAL

CHAP,

substances, such

chemical

caution

that in any

turn

now

may

"

Meanwhile

we

animal

shall

dying

toxic.

become

Infections.We

Renal

isoamylamine.

as

Schafer's

forgetProfessor
slowly the blood may

not

365

familiar kinds

to

note

the

effects of

in

those of
particular,
of scarlet fever, of diphtheria,and
the infective diseases
so
The focal distribution of lesion might lead us to postulate
forth.
that these distempersaffected the renal meshes rather by bacteria
have seen
how
the simplest
it not that we
than by toxins, were
and

of other

toxins

more

"

lesions

in

the

tissues

discontinuityis
probably always of

focal
is

to

play a

much

less apparent
toxic

largerpart

scattered.
in

than

Ribbert

this

observes, the

renal diseases toxins

the bacteria.

lesions of the infective diseases

However

which
nephritis,

acute

origin. As

is that in the various

of evidence

trend

thus

be

may

However

seem

this may

disposedto attack the

if directly
renal epithelium,
as
by an acute cytolyticprocess ; but
if
in the puerperalkidney this corrodingnecrobiosis may,
as
time be given,associate itself with irritative overgrowth of the
tively
not distincconnective elements, so that an interstitial nephritis,
Grancher
and Sargent,1
glomerularin distribution,appears.
noted
the epithelial
in toxic nephritis,
(and glomerular)seat of the
disease,and the secondarynature of the interstitial changes. The
the cells
epithelium,
primary lesion they observed in the secreting
swollen and fattily
of which, if not destroyed,were
degenerated.

be,

the

are

"

"

Many tubules had vanished

others

again

thickened

; others

and

shrunken

were

Such

abraded.

or

moniliform

lesions Welsh

and

diphtheriaalso, and opined that they

might be due to bacilli plus their soluble products, or to the toxic
alone ; or, again,that a mixed infection might occur, the
principle
diphtheriabacillus or toxin combining, for example, with a
From
such merely tubular
streptococcus, for multiplemischief.
it is not
take place,indeed
attacks recovery
infrequent;
may

Flexner

but,

as

demonstrated

in scarlet

in

fever,there is a

fear of

second

stage, in which

perivascularcell infiltration sets in, and a diffuse nephritis,

by implicationof all
largewhite or secondary shrunken, marked
and fibrous.
To add
the renal constituents,glomerular,
cellular,
and
to this perplexity,
the putrescent toxin of Dixon
Harvey

Grancher

and

Sargent,

Rev.

de med., 1901.

ARTERIOSCLEROSIS

366

THE

AND

KIDNEYS

PART

although a hypertensivepoison,is correlated,not with Granular

kidney, but primarilywith a tubular nephritisand a dropsy of
in dropsicaldistension of the
the tissues,strikingly
manifested
glomerular cavities. Toxins apart, if the renal artery be tied
to
(in animals), the epithelium begins at once
degenerate
a
degradation due, it would
merely to deprivation of
seem,
"

if the

oxygen

animal

survives

for

least

at

"

six months,

an

"

Granular
lished.
atrophicfibrous,but not a
kidney proper, is estabwell aware
In practicewe
that we
cannot
are
keep too
the integrityof the renal epithelium,as
vigilanta guard over
evidenced by integrity
of its own
and the cardio-arterial functions.
For many
months
after apparent convalescence
this vigilance,
if less incessant, should
at due intervals be no
less searching.
stantial
Happily, as ablation experiments suggest, so long as a subfraction
elimination

can

of

renal

meanwhile.

on

go

remains

structure

The

intact, much

patches of nephritisin

kidneys of children,consequent upon bacterial infections of

the urinary tract
with
not
attended
(e.g.B. coli),are
high
arterial pressures,
is
the
heart
nor
enlarged; there are no
ursemic symptoms,
and hemorrhages, if any, are
not
especially
the

in the

brain, but also submucous

in

Now

discerned
affected

chronic

and

nevertheless

the

Riegel,1in

the

Kalb

likewise.

Cases
not

This

are

XV.,

without

not

well

necessarily

XVI.,

XVII.,

of the child

aged 5, in
hypertrophiedand

somewhat

was

be

may

in the scarlet fever

even

case

scarlatinal

arterial pressure
2

arteries

acute) ;

heart

the like.

diseases,as

in Jores's

demonstrated

rise of

and

renal

subjects,the
young
(see Jores's first paper,

kidney, as
dilated.

infective

in

XVIII., both
which

these

and

kidney,
any

has

renal

demonstrated

arteriosclerosis,

is very

puzzling. The explanation

scarlatinal kidney, in whatsoever

probably is that the

never
becomes, the true
stage of shrinkage, is not, and
contracted
primary or Granular
kidney ; but, at worst, is a
secondary contracted
kidney, the result of a glomerulosuch a kidney is followed at
tubular
nephritis. But clinically
length by the systemic arteriosclerosis of high blood pressures.
Dr. J. D. Rolleston 3 reports that in the majority of cases
of
"

"

Biegel,Zeitechr. f. klin.
3

Med.

Bd.

vii.

Rolleston, J. D., Journal

Kalb, Munch,

of Childr.

Dis.

med. Wochenschr., 1903.

vol. ix., 1912.

CHAP,

RENAL

scarlatinal

nephritisthe

pressures

the

Of

under

are

INFECTIONS

norm.

often indeed

the

cases

were

pressures
persistedonly in 3. The

in 12

excessive

in excess,

not

are

such

33

367

renal
only,and excess
arteries in scarlatinal kidney if often, are
not
always affected ;
in one
of Jores's cases
not.
Such cases
in children are
they were
The toxic inflammation
resembles
largelytubular (epithelial).

cantharides, absinthe

of

that

(see p. 352), mercury,

and

other

renal

poisons,which may issue in interstitial overgrowth, but only

in chronic cases.
Such cases
these mark
at length,
off the toxin
as
of infective nephritis,without
intimate
renal arteriosclerosis,
for cardio-arterial strain,from
measure
although making in some
the poison if such there be
lying behind granularkidney, in
"

"

the

which

intimate

cardio-arterial

strain

such

In

events.

renal

essential,and

are

case

arteriosclerosis

as

that

in

of acute

and

some

the

enormous

correlated,

way

dropsicalnephritisin

sclerosis
aged 29, publishedby Heineke, without visceral arteriofor example, normal
mined
spleen,pancreas, etc., as deterin which, on
after death
the lapse of ten
twelve
or
months, arteriosclerosis appeared in the largeand small arteries
of the extremities,one
is tempted to guess that the dropsical
' .uid itself might have contained
an
arteriolytic
poison ?

man,

"

"

Sir John

Bradford

kidney is
syphilitic

(Croonian Lecture, 1904) tells

Romberg, and others doubt

"

than

commoner

we

this,and

Stadler,

suppose.

suspect that

that

us

"

some

von

cardiac

in

heart disease have

But
been included.
syphilitic
in one
clinic I think in Leipzig?
five
Schrumpfniere were
found in fifty-twoautopsieswith syphilitic
In syphilitic
aorta.
arteritis affecting
the district of the pancreas
is
a
periarteritis

kidneys

"

"

"

"

the
The
was

extend

to

seen

and

penetrate into the substance

marked

being
by a
followingcase, homologous
published by Dr. Loomis.1

process

twelve
when

months
the

which

before

patientwas

occurred

to

chicken-pox. Twelve
pneumonia) albumin
and

the

left ventricle
1

Loomis,

the birth
six years
the

and
of
New

profusion of

old.

York

Path

its

and

was

Soc.

(by lobular

death

found

were

heart

infections

whooping-cough

were

casts

only other

The

before

the

organ,

lymphoid cells.
with
the syphilitic
pancreas,
The
father contracted
syphilis
and
died of it
of the patient,

child

months

of the

in

its

urine,

hypertrophied.

Trans.,

1889.

The

ARTERIOSCLEROSIS

368

AND

about
one-third
kidneys were
rough, the capsule thick and
of almost
arteritis,
connective

cortical tissue

the

and

placesit
cells

was

not

were

was

the senile arteriosclerotic

Factors.

Nervous

chronic

intertubular

unevenly distributed,
diminished
not
regularly,in some
at all. Apparently the secreting
universallydiseased,and we may
was

very

mischievous

more

than

kidney.

Hitherto

"

was

arteries,and much

of renal disease be

kind

PART

size,the surface

There

adherent.

fibrosis

hardly narrowed
primarilynor

if such

doubt

The

KIDNEYS

normal

of the

all the smaller

tissue.

THE

I have

said little of any

nervous

problems ; they are baffling

enough as it is,and
is unwillingto seek the obscure
one
by way of the obscurer.
1
has pointedout how stimulation of one
Sir John Bradford
Briefly,
afferent nerves
of many
produces generalconstriction of visceral
blood-vessels, includingthose of the kidney, with consequent

factor in these

rise of arterial pressure

the renal circulation are
of

ends

the

; and

that

other

produced by
depressors,or, again, of

great fluctuations

excitation
the

in

of the central

central

ends

of

the

posteriorroots of certain lower dorsal and upper lumbar

ments,
segthe
often
association
assumed
of
renal engorgewhereby
ment
with generalvaso-constriction,
be
the
in pueras
case
may
peral
is
obtained.
But
from
this
as
eclampsia, manifestly
yet
have received littlelight,
side of the problem we
although we may
speculatewhether our hypotheticaltoxin or toxins raise arterial
the peripheralneuro-muscular
pressures directlyby acting on
renal proby the middle term of some
machinery, or indirectly
duct
?
such
Of
this
least
at
be sure,
an
we
operation
having
may
that the intimate renal arteriosclerosis of Granular
kidney is no
effect of vasomotor
tides ; that this primary and
incidental
essential effect is brought about by some
virus,whether, renally
vaso-constriction,
speaking, autogenous or exotic. Extensive
great rise of

with

mean

course

low

very

The
1

may

concur

Adrenals.

"

in the

main

arterial pressure

Thus,

peripheralareas.
pressures

pressure

contrary

with

I must

very

not

Bradford, Sir J. R., Goulstonian

to

arterial trunks, may

of
in the renal and
other

current

opinion,very

high

deficient flow of urine.

omit

to

allude

to

Lecture, 1898, and

the

hypothesis

later papers.

CHAP,

THE

best

known

that

the

the

to

rise of pressures

kidney

chromaffin

the

Schur, favoured
diseases

accidental

(" erhohte

in Granular

excess

had been

of this mode

or

made.

variable

the

of

chromaffinen

der

independentlyof them,

The

constancy

kidney might be explainedby

of

to

otherwise

or

by Josue,
attributable

due

Funktion

"). Before Wiesel and Schur,

guess

is not

event

contiguous adrenals

system

this reasonable

of pressure

specialproclivity
in
itself
their
direction
propagate

to
nephritis

community of miscarriagein the organs

again by some
pairs. The hypothesishas called forth a multitude of papers
which only a few can
be noticed here.1
Eichler 2 agrees with
;

as

of

or

Wiesel

and

Schur, and

Falter and
the age
"

369

and

in renal

all,but is an

at

implicationof
Gewebe

of Wiesel

that

as

ADEENALS

of
Priestley

so
von

in great
Noorden's

clinic.4

of 50 increase of the adrenals

almost

or
constantly,"

with

do

measure

is found

Tacher,3 and

Pearce

after

says

with renal disease,

with both.
or
arteriosclerosis,

He

regards it as compensatory, as does Pribram 5 in another way.

Schlayer6 on the contrary, with Meyer'sdelicate method of testing
and Bittorf got negative results,and
by arterial contractility,
Meyer'smethod is said to be more
trustworthy. Many observers
remarks
questionWiesel and Schur's tests. Frank of Wiesbaden
the absence of hyperglycsemiain chronic renal disease.7
upon
The adrenal hypothesisis contested, and I think conclusively,
the grounds both of morbid
on
anatomy and of biochemistry.
Lubarsch
failed to verifya true
hyperplasia,and stated that
and
the ceil conditions described by Wiesel
Schur
found
are
read
in normal
We
adrenals.
much
too
plasia,"
hypervaguely of
of
hypertrophy,"and the like. Landau,8 in 15 cases
the
found
arteriosclerosis,"
no
changes in the adrenals save
"

"

"

sclerosis of their

"

Aubertin,
Hyperplasie surrenale
hypertensives,"Butt. Soc. Med. des Hop. de Paris, 1905; and
1

See

Ambard
2

the

in

Bender

klin. Wochschr., Nov.

Deutsche

Lab.

Pribram,

vol.

Munch,

Schlayer, Deutsche
Frank,
Landau,
VOL.

Arch.

nephrites

des

Aubertin

and

11, 1907.

f. klin. Med.

Berl.
Priestley,

and

Falter

and

the

previous year.

Eichler, Berl
Tacher,

Stud

Vaquez

e.g.

of

Pearce, by estimation

vessels.

own

klin.

Bd.

Wochschr.,

xcviL, 1909.
1911, No.

v., 1908.
med. Wochenschr., Juli 25, 1911, No.

med.

E., Berl. klin.

Wochschr., Nov.
Wochschr., No.

Zeitschr. f. klin. Med.,

14, 1907.

47

see

also Pearce,

30.

See also Nos.

45

14, 1912.

1907.

and

51.

adrenals

healthy

in 12

tried

by accident,

died

standard

without

KIDNEYS

50
a

with

standard, and
*

Stewart

pressures.
them
submitted
to

had

who

in arteriosclerosis ; but

adrenals

PART

of age

years

of blood

notes

for adrenin

tests

over
persons
establish
to

163

to compare

THE

AND

ARTERIOSCLEROSIS

370

this

tunately
unfor-

took

the

up

rigorouscriticism and
of serum
from a case
injection
in
pressure into dogs caused

and

experiment. He had found that

with very high blood
of nephritis
one
experiment a slightfall of pressure ; in the second a rise of
Serum
saline.
of normal
but so did a control injection
pressure,
caused in a
of non-renal high pressure (Hyperpiesia)
from a case
fall of pressure ; and after cuttingthe vagi,no
third a transitory
effect at all. He found the test by the enucleated
frog'seyeball
enough
discriminating

not
a

test

the uterus, but,

of adrenin.

Erwin

close survey

of

the medulla
found

an

; for

40

But

the

were

kidneys

unable

was

in ways

to

consistent

other.
or
renal,cardio-arterial,

In conclusion, what

often

found
or

in

he found

controls.

that either cortex

any

of these

or

morbid

of this discussion

arteriosclerosis and

simple

affected

more

(See also Elliott,p.

issues out

of

he

largement
en-

same

cases
no

than

kidney

the

that in

affected

normal
relatively

with

evidence

no

of shrunken

intact ;

discover

stimulant

the

oftener

cases

he

in

and

specimens,concluded

medulla

The

renal diseases than

word, he

behaved

instance, in

atherosclerosis.

in chronic

mydriaticeffect.

after
laboratory,2

is much

cortex

enlarged cortex.
where

non-renal

of

isotonic,and

blood, he got

of Marchand's

Thomas,
adrenal

the

renal disease

in normal

even

largenumber

is far from

produces the same

test on
inhibiting
gut,

the
preferred

on

urine

chloride

solution of sodium

Stewart

; the

255

to

In

medulla
series ;

n.)
elucidate

the

kidney ?
May we not go this far ? That arteriosclerosis being almost
in which
the only terms
an
artery, apart from implicationin
should expect
we
surrounding tissues,can respond to irritation,
influences.
to various untoward
it to give this peculiarresponse
timate
In Granular
by atherosclerosis of its inkidney it respondsfirstly
not
intra visceral twigs ; secondly,at a later period,when
these or such vessels but the systemictrunks begin to suffer under

the relations between

"

1
2

Thomas

Stewart,

G. N., Experim.

Erwin, Ziegler'sBeitr.

z.

Med.
Anal.

vol. xiv., 1911.

vol. xlix.,December

1910.

ARTERIOSCLEROSIS

372

renal

normal

AND

sufficient for

tissue

KIDNEYS

THE

life,a feature

narrower

PART

by

Granular
it with the true
disposed to contrast
But so sharp a
kidney," which I had regarded as necrobiotic.
cannot
contrast
kidney
quite be maintained
; in the Granular
islands of apparently normal
also there are
tissue, and the
which

"

was

essential difference

kidney, but

the

seems

as

"

we

as

have

yet

to

lie,not

surmised

"

within
in

the

compass

poison

some

at

of
the

ever
Howkidney and elsewhere.
this may
be, the two kinds of kidney, often not unlike in
in nature
different
are
radically
aspect, at any rate superficially,
in an
effete organ, yet by
difference which, if less obvious
a
it belongs is,in uncomplicated cases,
the clinical series to which
citations have proved,
in this distinction,
decisive.
And
as
my
l
For instance, Dr. Andrewes
I am
far from standingalone.
says,
This form (the Granular
kidney ") is associated with great
senile
left ventricular
the
hypertrophy, whereas
type of
granular kidney scarcely raises the heart weight." Then
should we
discard the title
Granular
not
altogether?
Transitional
forms, if they exist,are so infrequentas to be
negligible.2
Accordingly,Professor Lorrain Smith's conclusion, in our
jointpaper, was that the arteriosclerotic kidney is a local phase
of generalarterial disease,producing in the kidney justthe alterations
which it produces in other organs of the body
alterations
which
need not amount
to anything very
grievous,as they are
compatiblewith many, if sere and yellow,years of life ; but that
form of progressive
Granular
kidney,on the other hand, is some
essential to its function
lesion of the gland as such, the structures
in
In this mortal disease arteriosclerosis appears
being attacked.
in the fine arterioles of the
two
primarilyand essentially
ways
itself ; secondarily
and later in the systemic arteries,the
organ

back

disease in the

of the vascular

"

"

"

"

"

"

"

strain

effect of
Granular

stage of
I

am

under

the

excessive

blood

pressures

in which

The arteriosclerotic
kidney is always and regularlyinvolved.
kidney, on the other hand, if it may arise in the later
which personally
strained arterial systems in hyperpiesia,

ready

not

form

decrescent
1

admit,

is most

found

commonly

of arteriosclerosis.

Andrewes,
z

to

Herein

F. W.,
I

St. Bartholomew

disagreewith

Reports, vol.

Senator, loc. cit. p.

xlviii.

344.

in

the

CHAP,

CONCLUSIONS

I to

Were

might

follows

as

run

formulate

to

try

373

these

"

Chronic

in

Bright'sDisease!
A

CLASS

(i.)Primary intimate

high

inconstant.

high
A

as

pressures

(" small

white

in

renal

as

"

whether

other

mixed

disease

long prevalence

of

in

on

be

may

very

"

(ii.)Less

)rimary
kinds

of
"

pressures

blood

kidney

"

toxin

any

but

not

am

alteration

an

of the

pressures

kind

decrescent

kidney

;
;

by the
(as

considered

be

may

Bright's disease

The
(iii.)

fibrosis may
The

diseases

to

of

implied
without

(ii.)
as

commonly
(ii.)

arterio-

consecutive

).

(i.) obligate with

with

associated

other

(iii.)
independent of Bright's disease

Hyperpiesia ").

(e.g.
B

not

frequently, entailed

Granular

due

"

Granular

"

or

atrophic condition.

jlerosis of excessive

High

[It is suggested by

form.

arteriosclerotic

An

pressures.

general arteriosclerosis,

modified

general arteriosclerosis,usually
h

kidney

branches.

pressures.] I

CLASS

(i.)The

on

Bright'sDisease.

Not

contracted

arterial

high

kinds

other

consequent

primary contracted,

the

to

organs.

Decrescent."

or

called,

so

opinion, unless

"

"

due

not

originallyBright's disease

not

cases,

supervening

Hyperpietic

kidney, properly

main

in

secondary

in

visible

pathologiststhat

some

constant

some

in

also

seen

More

").

A few
(iii.)

such

this

kidney

likewise

Found

arteriosclerosis

(ii.)Secondary, systemic, arteriosclerosis

to

intrarenal

Granular

in

pressures

they

Arteriosclerosis

provisionalconclusions

term

of

the

be

merely
more

Bright's
kidney.

starved

evident
disease

kidney

than
is used

of old

persons

in

which

arteriosclerosis.
to

cover

the

two

or

more

primary

VI

CHAPTER

SYMPTOMS

IF

arteriosclerosis

or

many

have

be

different

ARTERIOSCLEROSIS

OF

not

disease

but

diseases, it is evident

incidental

symptoms

of its

own

probable hypothesisof a
the hypothesis of Virchow
process,

says

writer

recent

who

two

more

may

less

or

uniform

series of
not

very

who, still influenced

in

saw

of

accept the

unless,indeed, we

of

that, if it

consequences
consequences,
order, it can
scarcelyhave any

mechanical

result

arteriosclerosis

that this arterial

change is a

by

flammator
in-

an

substantial

attended
with a subtle
malady having a characteristic course
periodicfever. If the febrile stages of the change escape us, it
is,in his opinion,because of our lack of vigilance
; for the change
in the arteries advances
advance
or
by phases of activity
may
and remission.
That under the influences of various poisons,
arteriosclerosis does often progress in this fluctuating
we
way
have
far

seen

and

damaged

effects,or

as

it is obvious
to

be

impaired in

symptoms,

the direct
perversions,
regarded as symptoms
Arteriosclerosis then,
and

does

not

shall

and

Thus

see

so

rather

it is that, in

to

to

of arteriosclerosis in

by-product

is

further)we

meddle

separate them

so

not

track

yet

them

374

self-consistent,
in its morbid

indeed,even

beginning the

to

questionto which,
a

sense.

disease, is not,

single or

Whether

have

immediate

an

of many

undertakingto
with a heap
as

are

secondary
arise ; but
various
consequential
may
effects of the infection,
can
scarcelybe

series.

it is uniform

I am
Arteriosclerosis,
or

later the vessels

their functions, then

itself represent, any

specific
symptomatic
anatomy,

that when

as

definite

have

we

seen,

answer.

Symptoms of
entangledskein,

chapter of

unravel

an

of skeins, and
out

to

attempt

singly. Fortunately

CLASSIFICATION

vi

CHAP,

skeins, by the united

of these

many

modern, have

and

combed

been

with

still confused, but

are

BY

the

375

of observers

of them

one

various

I must

modes

make

have

Many

"

seems

be the

kind

built upon

to

consider

place to

the local incidence

certain

of

for illustration of

these

hypotheses I

of M.

trust

my

Teissier,1I

The

also

"1'envie
which

de

faire

is apt

and

symmetry,

and

physics are

be

teaching
be regarded as a
eminent
colleague.

may

scheme
not

of

upon

"

M.

both

author

to

and

has
"

Forms

drawn

reader

of

up

the

to

plexity
com-

of which

process,

Teissier.

it to be, may

The

one

concentrate

attractive

very

based

arteriosclerosis,forms

diversityof nature but on local

is treated throughout, after the

M.

it

but

of

school

arteries hard
be admitted

process, one
itself here

sclerosis
Arterio-

distribution.

of Huchard,
"

chief marks

the

hypertension,a large heart, and

Such a uniformitycannot
now

ship
author-

"

Teissier

Clinical

uniform

one

medical

A
logic
biologicalphenomena.
which
in the simpler sciences of mathematics
in the biological
sciences
an
inspiration,
may

seduction.

des

elusiveness

and

if

And

"

blind

to

this

depends
for system
talent
and
hypothesis
of
the
sentences,"
logical ardour

brilliant

upon

school.

the

reflect upon

the

to

of

hypotheses of

representativeviews of an
attraction
and
persuasivenessof French
a
quick clinical insight;
depends upon

tribute

been

some

arterial disease.

criticisms

of arteriosclerotic

their several series of conseqiiences

and
;
processes
the most
ambitious
of these schemes
to the French
we
owe
This

ancient

order ; others

some

Arteriosclerosis.

the

discern

to

attempts

labours

alreadyinto

some

beginning.
Local
Manifestationsof

LOCALITY

are

and
; but

in nature
or

vascular

often
let
as

there, and

as

ous."
tortu-

listen

us

he

ceives
con-

by this

the
Thus
diversityof effects.
in elaborate
author
series of types, lucidlyset out
creates
a
cardiac type," the
tables, such as the
aphasic type," the
renal type," and so forth ; the
gastro-intestinal
type," the
clinical events
varying with the changes of the incidence of

diversityof

distribution

set

up

"

"

"

"

the

arterial

disorder

abdominal, and
1

The

so

latest paper

sclerose," LeQons

forth
I have

prof,mai

cerebral

now

"

in

type,

now

cardiac, now

territorial arteriosclerosis.

before

me

is

"

1908, Rep. Journ.

Les

Formes

mid.

cliniques de 1'arterio-

Franc.,

1908, pp.

629-638.

SYMPTOMS

376

When
what

"

is

what

mechanism

the

there

ask

we

happens

Teissier records
20

in the

cm.

in the

Williamson's

method

the

in several

cases

observations,

temporal area,

by moving Potain's instrument from

full of fallacy
instrument
no
; indeed

measure

such

be

assuredlyit

true,

The

local differences.

but

is true, that

the pressure

(see 0. K.

numbers

were

place to place,a
can

be trusted

illusive.

are

to

It may

sclerosis is

cidence,
unequal in its inprinciplesof haemodynamics

the

it is contrary to

data

in the radial,

radial

these

Now

75).

department

or

or

?
satisfactory
cm.

on

answer

the tibial,the

answer

of 22

pressures

p.

in the

affected ?

prompt

tension

and
so
temporal,or the tibial,
was
higher than in temporal

tibial

obtained

district thus

(videp. 30). But is this

rest

PART

receive

we

of vascular

concerned," i.e. in
functionally
radial,and the

in each

be ?

may

elevation

an

ARTERIOSCLEROSIS

OF

primarilylocal variations of wall or diameter

could heap up local gradientsof pressure.
That
alterations of
the wall of a vessel modify the wall wave
know, and they
we
bring with them also other alterations of resistance ; but
may
blood pressures
thus vary
from place to place. Yet it
cannot
is continually reasserted
that each part of the body may
have
its own
ask about
the mechanism
are
we
we
gradient. When
not
Let
us
enquire a little further.
put off with words ?
to

that

suppose

We

told

are

is raised ;

for

in

pressure

If

190.

such

district the

instance, in the

the

within, is said
to

in

that

"

type

temporal artery, and

rise, say

to

demur

we

to

that

250

unless

local blood

pressure

"

aphasique the blood

in branches
inferentially
in the

radial

this rise be

and

confined

tibial
to

the

particulardistrict,if the temporal district does but share in

a
general rise of pressure, wherein lies the peculiarityof the
^
The
rejoinderis that the rise of pressure is local,
type
that such a local rise of presnot
general. But we have seen
sure,
in inches Hg (" 12 cm."), is, save
measurable
ary
momentas
"

"

fluctuation,inconceivable

by

dilatation

or

might of
signifya rise of
blood

would

parts, and
resistance.
we

need

not

; it would

derivation

elsewhere.

be

course

(See remarks
dwell

on

much

less consistent

no

An

but
persistent,

lateral pressure
be

be neutralised

"

on

this

excessive
this

above
with

instantly

afflux

would

scarcely
the surrounding
fall of peripheral

Stromintensitat," p. 28.)

point because

the

of

author

"

whom

But
I

TONE

vi

CHAP,

taking

am

the

that

is not

the

377

opinions

current

of intense

one

describes

he

TENSION

representativeof

as

state

contrary

AND

state

afflux of blood

as

"

of

one

plainly

says

"

of the

but

localised

spasm,"

caused by toxin, emotion,

as
questionis asked whether
the hypertension provokes or
overwork, etc.
betrays the
of partialischsemia leading to supthe source
localised spasm,
pression
the

and

"

"

"

What

small hard

constriction

as

ansemiated

an

area.

"

is the

area,

A vessel,or

cord."

"tense,"

be

cannot

injury by stretching. Nor

the

observe

to

"

"

is

raised

but

then

hypertension ?
A distinguished
stretched ?
The
physician writes :
small, hard and thready, and of extremely high
very
The
brachial artery could be rolled under
the finger

tension.
a

vessels
the

invited

not

are

dilated

where, within

so,

pulse was
as

We

and

large output

But, if

"

function

of

stilladmit

it may

which

of

vessels,while under
stretched,

within

pressure

except

pressure,

more

less

or

suffer

or

be
far

so

high systemic

Dr.
L. Hill
explicitlyexcluded.
corroborates
the generalprinciple
when
he says that to bandage
the hand
difference to the pressure
no
tightlymakes
readings
of brachial or radial artery. Even
anterior
the
to
stricted
conjust
pressure,

area

if

however

blood

of low

one

vein

the

of

be

cannot

can

be

must

area

group

the vessels cannot

contraction

on

be

reflex

of

be tense.

vessels

It may

be

that

true

of

the
supply to a large area
head
is reinforced, by plus velocitythe blood supply
maintained
have
no
knowledge of any local
; but we

pressure
may

is

mechanism

other

or

to

such

compass

result

in

paratively
com-

Baylissand Professor MacWilliam

have
that compressionsof an
shown
give rise to
artery may
vascular
dilatation in the part supplied,but compression is not
constriction ; compression may
affect the (supposed) nerve-end
fields.

narrow

organs

of

Indeed

to

the

arterial

raise

constriction would
The

investment,

universal
be

as

only adequate reflex

for vascular

Dr.

dilatation

pressure

as

to

uneconomical
we

can

think

an

embolus

get
as

over

it would

of would

to

seems
a

small

do.

field of

be ineffectual.
be

tissue call

in its field.

happen to arteries in areas where vaso-constriction

had
local
long been approximately complete, as in so-called
syncopes,"is a more
complex problem ; and it is a problem not
of physicsbut of biology. From
know
of the effects of
what
we
What

would

"

SYMPTOMS

378

ARTERIOSCLEROSIS

OF

PART

imperfectly,of Raynaud's Disease and

ligatureand, however
ergotism,constriction to the degree of closure results in, or more
probably is correlated with, a kind of arterial lesion (Endarteritis
obliterans)to which I shall make a passingreference under the
In these diseases there

head

of morbid

work

of

mere

sclerotic constriction.
I

anatomy.

virulence,and

more

local disorder

profound,than
be syphilitic.
of the cases
may
of diseases by
French
scheme

Some

afraid,therefore,that the

am

territorial arteriosclerosis will not

It is

surprisinghow

more

close examination.

bear

authors, such

many

factors at

are

Pal

as

even

and

general,attribute arteriosclerosis
to constriction,which, I repeat, must
surely be a protection
at
rate
against strain of the wall. An experiment of
any
Hirsch and Thorspecken neatlyproved the converse
; namely,
that if equal doses of adrenalin be injectedinto two equal rabbits
the depressorhas been cut and in the other not,
of which in one
the aorta
with the intact depressorsuffers far less injury.1 I
constriction
be a
of damage under
must
the notion
suppose
the
griping of the tissues ? But it is not easy to understand
?
tension
notion,for if the damage be by squeezing,then why
the tension is produced by
When
Yet
Pal definitely
says :
vascular
contraction in a definite
area
(!) then follow peculiar
pain," etc. etc.2 My mind's eye loses sightof him.
In this,as in previouschapters,I shall observe first the two
Gouget, if not

in

authors

indeed

"

"

"

"

main

of arteriosclerosis

distinctions

the

kind

consecutive

to

primary or decrescent kind.

I propose
then, omitting here renal diseases recognisable
some
as
such, to begin summarily, though I fear not without
the symptoms
and
with
signs of high pressures
repetitions,
correlated with arteriosclerosis
as
Hyperpiesis (pp. 346-7) so
out.
far as they have been made
the

and
hyperpiesis,

"

"

Hyperpiesis." We

high pressures

to

and

converse

was

nearer

Hirsch

and

cvii.,He. 5 und
2
Quotation

that

seen

be the consequence

Von

Basch

assumed

of the vascular

were

the

truth

that, when

associated,the lesion

Thorspecken

of

Gottingen,

was

Deutsche

6.
from

Osier, lancet, March

26, 1901.

the

lesions,but

pointed out independently,in 1893-94,

Huchard

high pressures

have

that

the

arteriosclerosis and

usuallythe result of
Arch.

f.

Id. Med.,

Bd.

SYMPTOMS

380

ARTERIOSCLEROSIS

OF

PARTI

series. If it
aspects of one
pressures and sclerosis as two
this confusion
is of the past, I would
replied that now

blood
be

the confusion

urge that

is

perpetual;

it not

were

wearisome

to

illustrative quotations. Just

more
give many
recent
more
(loc.cit.),
example I will offer : Martinet
one
after showing very
definitelythat high blood pressure
may
other
exist independently of known
lesion
kidney or
organic
his own
categoriesare
high pressure with and without lesion
in the same
of arteriosclerosis
article,
proceeds to argue continually,
as
high blood pressure with high viscosity,and to
it with
nephrosclerosis as high pressure with low
compare
ception
viscosity. Yet from the beginningI had affirmed that the conof high pressures must
be detached
from its secondaryand
inevitable implication
of arteriosclerosis ; that these
by no means
be regarded as significant
of a certain malady
must
pressures
originally
independent of arterial lesion,but bringing this evil
do

so,

could

"

"

"

"

"

in

its wake

be broken

should

thus

and

"

up,

and

that

the

the

of

concept

arteriosclerosis

lesion distributed

several

among

diseases.
Can

then, under

the

of

Hyperpiesia,or of any other

appellationwhich hereafter may well be preferredto it,describe
Disease ; that is to say, a fairly
uniform
association and suca
cession
of symptoms,
This
I will
positive and negative?
endeavour
to
do, but the disease is often latent and stealthy,
whereby indeed it has happened that the malady has not
we,

received

the

visitation
Whether
accessible

attention

requires.
the high

name

which

blood

they
at

now

may

to

describe

be the same,
let

rate

any

in
frequently

the

in the
or

which, when

the

more

an

vehement,

that

the

have

the

our

we

adult.

doubt
must

In

still riper,
man

discover

notice, has
the
One

symptoms

body

as

that

as

too
to

could

wish

were

more

the
a

we

in nature
:

assume

adult,

most

though

woman,

state

which

not

the
or

in

encountered

to

open

mortal

so

thickeningof

malady

same

life,we

ascendancy in
amelioration,yet beyond cure.
such

the

akin, but this

begin with
middle-aged,or

it falls under

we

adult, is

us

in earlier adult

sometimes

obtained

and

arteries in children, which

often

and

grave

pressures

previouschapter (p. 171), is

have

so

of disorder

often

be if not

furtively

beyond

its assaults
clamant.

were

We

CHAP,

HYPERPIESIA

vi

"

of

often read

exertion

on

the fifth act.

late,very

are

physicianis

the
the

long
patientto

may

discomforts

which

I must

seek

in

are

we

to the

of

state

he awakes

too

secretly,a stage
certain

However,

one.

timely advice,

more

indicate ;

to

try

driven

not

then

its last stage

be

cannot

book).

the true

to

cardia
steno-

or

recent

late,symptoms

dyspnea, but

reached

has

the
instigate

discomforts

well-known

awakened

not

of

occurrence

thenceforth

which

(I quote from

slightdyspnea

often,it is true, the patientis

Too

disease

late ; the

as

! these

Early symptoms
physician,or
things,until

such

earlysymptoms
"

381

by

or

chance,

some

of
the erudite sense
applicationfor life assurance,
detect hyperpiesisin an
the physicianmay
early phase, in a
period in which it may be completely curable, yet when, as I
have
said before, the patientmay
himself to be in good
suppose
Dr. Christian
With
health.
Mr. R., set. 56, in
Simpson, I saw
whom
Dr. Simpson had
perchance discovered that the systolic
I verified this by two
strument
inblood pressures
ranged about 200.
such

as

an

of

heart's

The
much

own

my

if

prolonged,as

were

eddies

even

at

it

it

the

[uitewell

The

to

outward

second

very

arterial coats

be about
the

first sound

little thickened,

were

stop the pulse of the brachial.

felt the heart's

action

but

to

170.

there
(possibly
loud and clanging

murmur

doing plenty of work,

was

had

he

seemed

into

arch) ; the

apex.

and

inch

an

seethingon

difficult to

was

bed

the

in

diastolic

half

was

apex

the

be

felt

He

when
occasionally
labouring,and so

"ught advice.
It may
"me

be, though here

middle

under

hear

the

come

pressures

appearance
would

cases

thus

the

to

apprehend

to avoid

alarms,

vigorous

high, and

and

man,

all

that

must

them

be

in

in which

"

while, yet in

and

continue, there
and

themselves

it in

I shall be

under
persons

for
at

interested

in this respect.

readers

of

doubt, that

is normal, pressures,

160-170.

my

some

"

in much

pressure
to

up

experienceof

range

higher for

even

age,

across

discovered

speak

highish blood

persons

Often

physicianswho had
systolicand diastolic

who

still

little excitement
nevertheless

to

all

practicalends are in good health. One

in advancing years, if the high pressures
danger of an apoplexy. We are anxious

fusses,and
often

the

to

more

say

nothing

to turn

energeticfor

the

cheerful

ample

tide

SYMPTOMS

382

of blood
time

to his

brain,into

prognosis and
falsified by an apoplexy or
of those

years

of age,

who

invalid ; but
introspective
pede perhaps, or more
quickly,an

economical

most

PART

anxious

an

time, claudo

after

ARTERIOSCLEROSIS

OF

indecisive

an
a

Of such

heart defeat.

in the midst

have

treatment

been

least

at

are

of

energeticand rubicund health

struck down
are
by the awful calamity of a hemiplegia.
It is convenient, if a little illogical,
to describe firstan
advanced
conspicuous,
stage of Hyperpiesia,as being the most
and thence to trace the spoor
backwards.
A patient of 55-70
sometimes

or

hills he has found

stillyounger,

himself

will tell us

pulledup by

ing
that in ascend-

shortness

of breath

His countenance
by a substernal constriction.
be healthy,or may
be too florid,or may
show
a sallowish
may
ground tint with a splashof ruddiness upon the malar eminences,
tints apt to turn
bluish on
exertion.
The general nutrition is
to fatness ; though
usuallygood, often indeed with a disposition

perhaps

some

also

of these sufferers

are

and

meagre,

their cheeks

sallow

more

than

drive the belated

to
ruddy. Or the symptom
patient
have
been
to the physician may
sudden
hitch in his talk,
a
or
a
vertigo,or a passingparesisof a hand or arm.
Probably
of
shall be told that, if naturally
we
energetictemperament, he
had of late lost his elasticity,
had become
fretful,
more
sluggish,
and despondent, especially
early in the day ; he would
pout
the morning," cheeringup a littletowards
evening. Or the
upon
mental
have
been
more
and,
perversion may
distressing,
"

even

in earlier and

obsession.

If he

appetite,but
himself with
to this

eggs,

When

had

so

pressed to

story is often

anxious

forth,

may

and

but scarcelyknew
ailing,

amounted

liberal table, he may

more

and

more

not

to

grave

have

tempted

to

lost
rouse

glassof sherryin the forenoon ; and

wife, by drams, meat
extracts, whipped
have
ministered
only too assiduously.

describe

vague

become

wine, to desire
an

have

stages, may

kept

will have

excess

and

curable

the

recent

course

hesitating
;
how.

He

he

had

has

of

his health, the

been

conscious

of

sleptso well, and

of my
records
he had been sensible during
I find in many
as
when
the night of his heart's action, especially
lying on the left
side ; he may
complain also of a fulness of the head or dull
headache, of an
aching about the heart ; perhaps of
uneasy
tinnitus ; or again of some
or
even
vertigoand some
pursiness,
"

not

"

HYPEKPIESIA

vi

CHAP,

pantingon exertion, or
a significant
symptom
with

attacks

"

had

drowsiness, and

of

bleeding.

nose

he may

or

of unaccountable

"

have

this he may
and

after meals

383

difficult to discriminate

and

speak
"

"bronchial

colds

this is
"

; and

with lassitude,peevishbiliousness,"
ness,

perhaps
In

one

or

at

women

unaccountable

more

the climacteric

it is very

between

perturbationsdue to the period

of life and
those perhaps due to hyperpiesia. The urine may
be lateritious,
or
certain,
alternatively
profuse; the bowels may be unsometimes
loose ; piles may
have
costive, sometimes
thinks he is gouty, and talks of wandering
protruded. Or a man
and of more
fixed painsin the side
pains about the loins or joints,
or

to

back.
"

These

overwork

and
"

"

or

Kichard

such

symptoms

brainfag,"and

Cceur

de

Lion

have

may
in

who,

been

some

cases

when

not

attributed
not

without

fighting,
was,
I fear, a
a
drunkard, and a bad subject for the
septicwound of which he died,1 was probably a subjectof hyperpiesia.
After death, his heart, when
in
the
placed
gold casket,
described as
and reverwas
praestans" (Gervase),
grossitudine
ently
of his strength.
admired
the fountain
as
Now all these complaintsare, as symptoms, too vague to dictate
disorder of a
a
a
diagnosis; they are consistent with many
far, Israel a pupil of Krehl
temporary nature
; thus
may
demur
that
the
is
characteristic
not
plausibly
symptom
; it
group
for many
than what
been
a generationhas
signifyno more
may
liver."
And
it may
well be that this
spoken of summarily as
secret
vast, manifold, and
gland has no little to do with these
and
of them
but
cloyed passages
corrupted humours, some
heading away into a pertemporary disorders, others however
manent
looked
for this
derangement. Or it may be, had we but
the
under
of the states formerly confused
feature, that in some
reason.

glutton and

"

"

"

"

"

name

biliousness,"we

should

have

found

the

blood

pressures

such
temporarilyaugmented ; but in transitoryindispositions
research
A few doses of calomel clears
is not thought necessary.
medicine
the system ; and, as we
shall see, in hyperpiesiano
biliousness
is so effectual as calomel
blue pill. If the
or
troublesome
and
becomes
stubborn, and the wary
physician
looks a little deeper,he may
find in the pulse the crucial sign
and sustained ;
be large,thrusting,
which he is seeking; it may
"

See

Ramsay,

Angevin

Kings,

p.

365.

"

SYMPTOMS

384

or

small, tight,and

to

the

less wary
behind

ARTERIOSCLEROSIS

OF

small

wiry, so

observer

it,and

due

the

perhaps

sense

of

PART

as

the

scarcelyto give
often

enormous

equivocalas the narrow

artery
still present to palpation a wall fairlyor even
quite free
may
from
sclerosis. Every now
and
then, or more
frequently,as
Dr. Mackenzie
intervene,
extrasystole
says (videp. 390), an
may
in slow
an
interruptionmore
pulses. Caeteris
apt to occur
ever
paribus,these pulses tend to retardation ; other things howoften unequal.
are
The
A fuller light will be thrown
Circulatory System.
the case
by the state of the heart. The heart usually
upon
presents quite decisivelythe features of hypertrophy,or at
of enlargement,especiallyof the leftventricle,with
rate
any
pressure

more

"

aortic second

resonant

sound

features

well known

too

in this

to

need

place. At a stilllater stage for it is surprising

how
far this malady may
to
advance, even
an
surreptitiously
apoplexy,without compelling attention, or at any rate without
the hypertrophywill have givenway
arousingadequateattention
to a largedilatation ; a mitral murmur
be coming and going,
may
and the accessible arteries,
if not protectedby constriction (p.377),
and
will have
become
thickened
tortuous, at each pulsation
liftingvisiblyfrom their beds. If thus the heart be yielding,
such pulses to the finger will feel less
virtual
tense," the
tension
of Broadbent
the patient be at the
; though, unless
last stage of his malady, the pressure gauge will still indicate a
than by the ringerwe
had supposed. The larger
highernumber
recount

"

"

"

"

"

veins, as

subcutaneous

swollen, with
of the blood

oedema

on

the backs

tumiditywhich

pressures.

And

of the

hands,

are

now

is apt to fluctuate with the

close

inspection
may

detect

often

periods
a slight

the shins ;

perhaps also a trace of albumin in a urine

of normal
tale
free,from tellspecific
gravity,and free,or practically
at the pulmonary bases, if not
deposits. The respiration
be harsh and prolonged; and the percussion
crepitating,
may
there a little muffled.1
For this state
sounds
of things,the
heart, which has gallantly
fought a long and losingfight,has to
failure."
He is suffering,
of
carry the blame
says the physician,
from
he is,but why ?
heart failure
Whose
fault
; of course
on

"

"

"

Amer.

For

Journ.

study
Med.

of

arteriosclerosis

Sci., January

1907.

and

pulmonary

oadema,

see

Riesman,

CHAP,

CIRCULATORY

vi

is that ?

Certainlythe

SYSTEM

heart

it be the fault of the

Whether

the

not

was

385

kidneys I

primary

have

offender.
in the

considered

previouschapter.
Krehl
of objection,
that the
says, apparentlyin the sense
cardiac hypertrophy is not to be regarded as
disease because it
is compensatory, a strange demur
; surelya disease consists in
its symptoms,
of which is hypertrophy,not in our
one
tions
explanaof them.
The

time

followingcase,

with

Mrs.

Mr.

X.,

younger,
called on

Day
lady

of

over

saw

Baldock, is

of about

moderate

which

60
and

eater

typicalone

years
total

of age,

18, 1894,
Day on November
noticed
that her pulsewas
Day

Her

flushed

for

periodof

but

looking rather

abstainer, of

Mr.
Mr.

considerable

some

active

habits,
order.
temporary dis-

hard, and

too

and

Her

her to

sent

brother

died
complexionwas
dusky.
of apoplexy. Radial pulsevisible,
but vessel not hard nor
tortuous,
and to the finger,
if small, was
not very obviouslytight; but as the
rate
not very easilyguessed at.
was
124, the pressure was
By the
full
the
systolicpressure proved to be
sphygmometer, however,
240 mm.
evident
and
Heart
and action exover
a largearea,
(H
cessive,
B).
outward.
As her complaintwas
but apex not definitely
chiefly
of attacks, on the least excitement, of painfulflushing
of the face and
coldness of the feet (which warmed
again as the attack passed off),
I hoped that the high pressure register
might be largely nervous,"
me.

had

"

and

vasomotor

urine

The

temporary.

free from

was

albumin

and

of good specific
gravity. The
phasesof polyuria,
second
aortic sound
altered in
was
slapping,but not definitely
quality. However, Mrs. X. did not improve ; though she was sometimes
free for a few days,the
would return in all weathers,
attacks
of cards.
little an
excitement
even
so
as
on
a
Passing over
game
of continuouslyhigh pressures on later visits,
wards
notes
two
years afterfollows : Systolicpressures, taken
note
runs
as
quietly,
my
with hands
and feet warm,
200 mm.
The artery
at about
persisted
and
under
the
the
was
constricted,rolling
pulse sustained.
finger,
The apex of the heart was
well outside the nippleline,and the
now
To an
action thrusting
still ruled above
the normal.
; the rate

casts, and, unless in

"

eliminant

and

strict

dietetic

"

treatment

we

now

added

nitrites,

of
on
January
good
the head, depression, and
so
inabilityto exert
with
severelythat, in accordance
previous agreement, Mr. Day bled
She spontaneously
her to 16 oz.
with remarkably good results.
clear
had
she
not felt so
wrote
letter
of
a
me
gratitude,saying
and

with

some

effect.

21, 1907, fulness

herself returned

But

"

in her brain"
VOL.

for years, and

was

now

active

again and

in

good spirits.
2

SYMPTOMS

386

She

went

seekingadvice

well, not

on

illness in the
with

and

anxiety

keeping
slippingback
as

she

this

as

but
on

was
on

usually

the

way,

April

29th

she

her, both

pulse was

1907

"

instrument

still with

decided

Day

she

was

room

were

own

home

bleed

to

her

report (by the

very good
returned
not
a

registered 180

since

the

first

(systolic),and

enhancement.

nervous

some

had

in my
at her

taken

when

with

called

attacks

vasomotor

taken

systolicpressures

higher than

mm.

the

bleeding). My
doubt,

in

fortunately,
un-

the

Notwithstanding, Mr.

Mr.

"

The

20

Day.
by
and
on
again,

when,

at 200 ;
systolicpressure now
for a good record, I thought,
nervously anxious
former
be deducted
from
visits,something should

the systolicrecord.
about

I found

weeks

a heavy call upon

reportedthat the

; still Mr. Day

But
less sustained.

little.

PAKTI

for many

made

house

work
and

softer

ARTERIOSCLEROSIS

OF

But

the

now

no

vessel

manifestlythickened,
slightlytortuous ; a change
to relaxation
by bleeding and nitrites. On November
if she might be bled both springand autumn.
25 she called to know
If not at the moment
quite at her recent best, she had felt better
since the first bleeding; her complexion also had been fresher
ever
and
diastolic pressure were
and clearer.
But the systolic
still too
thick
and
tortuous, and the pulse
high ; the radial wall was very
walls

and

were

possiblydue

had

become

albumin

and

casts

sustained.

and

had

Gibbon

proved

also intractable

arteries

Radial

thick

which

such

symptom,

headache,

as

for many
years
Stiff of Bury St.

saw

Dr.

life.

and

Pulse

leathery,

vessels

the

still free from

was

with

Dr.

Edmunds,

lady passing middle

urine

appeared.

followingcase, which
with
and (afterwards)

The

The

ursemic

no

neuro-retinitis

or

nausea,

and

large

thrusting and

but

not

attained

sustained.

contracted,

the

dition
con-

1889 to
during
years
Complained
sleeps,
apprehensionsand
and
false worries.
Pain, fulness, numbness
oppressionsin the
and
at times
some
head, depressions,
panting. Accuses herself of
fancies," and self-regarding
preoccupations. These attacks come
of
arterial
with
for some
on
higher
phases
pressures, and
years
mercurials
with
of
other
were
fairlyreadily dispelledby
course
to

from

shorter
of restlessness,

1905.

"

"

such

means,

but

as

heart

the

increased.

soften ; sometimes
as

The
and
more

for

regards
heart
the

pressure,
also would

action

severe

There

diet,etc.

calm
and

few

was

the

weeks

it would

and

for

while

any sign of renal disease,

attacks
the pulse would

Between

thick

down.

never

As

tortuous

she

recede

become

frequent. Finallycame

the

as

within

got older

almost

the
on

vessels

narrower

attacks

normal
were.

limit
became

slight transient

SYMPTOMS

388

had

the

missed, and

been

ARTERIOSCLEROSIS

OF

heart, after

PART

long

and

brave

fight,

defeated.
These

few

from

cases,

typicalexamples of
spiteof remedies, in

as

In

large collection of the kind, I offer

Hyperpiesia,proving intractable.
pure
the first case, the pressures seem
likely
a

continue,and it is to be feared she

to

brother.

The

neurotic

element

in the case,

would, without

attacks

suffer the fate of her

may

and

the well-marked

the

sphygmometer, have been

might be
very misleading; I admit that at first I hoped the case
of mere
and too readilyI promised
vasomotor
one
instability,
Other pointsof interest were
the frequencyof the pulse
a cure.
vasomotor

"

which

often
the
and
are

far

however

is not
in

recorded

follow up
subclavians
may

thus

sound

or

is

closer to

the

with

as

also altered

normal

and

of the

aorta

the

and

dilated,the

and

area,

at

as

the

the

on

only

not

or

the

on

of

vessel

the base,

depend

second

end

the

be

and

is

more

noisier,

degree of

it.

of the
carefullycompared the conductions
abnormal
ringof the cardiac sounds down the course
After

aortic second

spine of

the

very

the

sound

audible

column
and

age of 50, he
descends
from
the third dorsal

scapulato

left side of the vertebral

it becomes

stress

may

parts about

If

surface,and

also may

apex

the aorta

behind.

of the

sound

noisy at the
in clang,which

sclerosis of the valve

Friedmann

its sectional
the

sternum;

widely audible,

the

towards

louder, for the

becomes

"

dilated.

be much

not

may

thorax

cylinder increases

from

of

cases

of the circulation

the symptoms

rises in the

aorta

experimental

and

cases,

and
high pressure
observation
of the hypertrophy of the heart
advent
under
Cases caught early
the thickening of the radial artery.
usuallycurable, but a persistentconstriction extending so
inward
the radial arteries is an unfavourable
as
sign.
To

but

in these

uncommon

very

; and

says,
the

to

bility
audi-

line drawn

spine,down

if there be much

clear,down

the

the

atheroma

line drawn

from

scapula to the seventh dorsal spine. For this

the state of the vessel,
extension of sound he givesfive reasons
of the
variations
surrounding parts, the position of the
Friedmann
does not
to
heart, and so on.
pretend however
the

spine of

the

"

discriminate
1

alterations
Friedmann,

of sound

Wien.

Klin.

due

Wochenschr.

to

atheroma
No.

25, 1900.

from

those

CHAP,

SIGNS

vi

due to

mere

be

may

less

or

Huchard

HYPEKPIESIA

of aortic pressures,

excess

more

OF

loud

second

appreciationof high tension, and

I remember

in

taken
base

of the heart

such

to

about

at

parts

from
but

normal

atheroma

settle

Mere

is

an

with

persons

In

well

high
far

the

reinforcement,
ventricular
a

morbid

sound

may

of the second

even

as

very

due

not

changes in

marked

and

distinctive

contrasts

and

faced

not

atheroma

of the cardiac

state

sound

and
be

by

chambers,

cases

distinct below

coexist.

tinny,or, if
in mere
high

tabourka."

But,

even

distinctions into words.

a

"

clack

smart

and

so

nervous

approach

sound

clang.

at

even

"

in

of

cases

be

may

the

If however

driven

at the apex,

of

do

of

either

muffled
"

in

timbre, be
in

often

wall, the second

to be remarkable

significance
; and

of timbre

are

the

at

distinguish

we

pressure

we

altered somewhat
altered

or

wall

be

by
have

could

sound

there

untrustworthy sign; in women

atonic vessels, and
again in

and

same.

part of the interpretation

; and

of the great vessels to the chest

reinforced

can

Is

and

accentuation

the apex,

but

high pressure may

The
change of clang in atheroma
may
the parts be cushioned
by atheroma,
In syphilis
it is
it is a thump.
pressure
if they be real,it is not easy to put such
course

alteration

atherosclerotic

to

or

forth, will

the

an

suddenly attacked

alteration

an

pressure

dilemma, for the manometer,

so

fancy

for

enough

much

says

was

impressive;

most

syphiliticclang ?
difference of clang between
mere
is appreciable; fortunatelyso
and

is

vessel,the stamping second

aortic pressure

the

sclerotic

or

Edgren
structural

any

sound

second

heavy

enhanced

was

before

sound

who

woman,

young

that
nephritis,
placein valve

acute

difference which

perceptible.

that

says

389

through

it may

high

pressure

the heart

level.

the

well have

the second
Much

must

depend on the state of the conducting structures

; for instance,
two
the pulmonary second sound, although aortic pressures are
three times higherthan the pulmonary, is nevertheless usually
or
be quite accounted
cannot
rather the louder, a difference which
for by the relative positionof the pulmonary artery ; it must
depend also upon different vibrations of its wall. By experienced
physiciansthese discriminations are well recognised; what is not
recognisedis the
defeat,by high

difference

pressures,

between
interpretation
of a capable heart, and

of

the ultimate
the

gradual

SYMPTOMS

390

encroachment

of

ARTERIOSCLEROSIS

OF

decrescent

atheroma

PART

heart

upon

and

vessels

rise of pressures.
(See Vol. II., pp. 5-6.)
of the first moveIn high pressures
the audible characters
ment
here.
of the heart are
to need description
too well known

without

notable

any

point only I will refer ; namely, the extraordinarysense

discussed this with Dr. James
of a prolonged systole. I have
Mackenzie, who in a few cases had recogniseda distinct lengthening
of the systole,
but not to any well-marked
degree. The point
is one
which might easilybe settled on sphygmographic tracings.
the proThe impressionon
the ear might lead one
to interpret
longation
rather
of the
as
prosphygmic period." Anspannungszeit but such a variation is not otherwise very probable.
has
On
Dr. Mackenzie
the extrasystoles
of high pressure
written important notes in more
than one
place.1 He finds that
these extrasystoles
are
usually of ventricular origin(when due
these
arise in the auricle). Now
to myocardial disease they may
ventricular
alternate beat,
intrude at every
extrasystoles
may
in which case
from pulsus
they are to be carefullydistinguished
in case
alternans ; in the high-pressurecases
not, of course,
of pulsus alternans
the arterial pressure
to reduce
by
proper
nitrite
a
regularises the pulse; and as the effect of the drug
Dr. Mackenzie's
tracings
passes off the extrasystolereturns.
show
after
some
regain of steadiness under the nitrite even
long years of stress and irregularity,
although the contractile
be failing
atheroma
of course,
as
; and
power
coronary
may
increases and the myocardium is starved, a true pulsus alternans
begin to complicatethe record.2 But he pointsout also that
may
under high pressures
as, short of disease,fatigueof contractility
To

one

"

"

"

"

"

"

"

beats
appear, and the weaker
do not arrive through the cuff. To reduce the pressures, e.g. by
or
amyl nitrite,
not, then abolish the pulsusalternans,
may,
may
sets

in, true pulsus alternans

or

after

He

adds

that, under
other

Among
Journ.

Med.

vol.

papers;
well-known
2

For

Handbook

papers

Oct.

xciv.

Dr.

(by
Wardrop

studies
this and
on

an

Griffith's
and

other

Diseases

this subject I

on

author

an

there may

high pressure,

20, 1906

many

may

Schorstein

others,

pulse symptoms
of the Heart, 1906

name

at
see

be

refer

interestingarticle
whose

be obtained.

this relief may

little waiting at rest

some

Med.

may

have

to

in

Dr.
with

and
Graham

good

stringof

Mackenzie,

Deutsche

Arch.

forgotten);
Dr.

Lecture, 1912;
home

J., Brit.

f. klin.
Lewis'

Dr.

Graham

pre-

Steell's

abroad.
Steell's excellent
curves.

little

CHAP,

EXTRASYSTOLES

vi

mature

rhythms

ventricle,or

of the

knot

abnormal

pulse
"

; and

391

reduction

on

irritations of

of the

auricle,
normal

to

pressures

the

He
however
that a
warns
us
regularrhythm may return.
true
pulsus alternans may be latent to the finger,
although an
make
it palpable. We
effort,such as walking upstairs,
may
may
observe
also, under
high arterial pressures, geminal, triplet,
and
I suggest that
other
curiosities of rhythm.
in highthe extrasystole
is induced
by the higher intrapressure cases
cardial pressure
which keeps the myocardium
more
tense, and
under
this loading within limits
irritable ; always at full
more
cock, less under
inhibitorycontrol, so that a slighterstimulus
fires it off. In this case
the
extrasystoleis presumably of
ventricular,though it might be of auricular,origin. Other causes
in the muscle itself,
ventricular
however, such as some
instability
"

auricular,may

or

"

lead to similar

premature detonations.

If the

starts
from the ventricle,or even
from the auricle,
extrasystole
there will be a lengthenedpause
but not if it is from the sinus
be mixed
with pulsus
(H. E. Hering).1 If these extrasystoles
alternans the confusion may
be disconcerting
then a
; still even
careful graphic analysis will usually serve
to
disentangleit.
Professor
careful
Mines
has made
a
study of such complex
that arrhythmia,especially rhythrhythms.2 Huchard
says
"

"

JLJJ.

mi ic

arrhythmia," is

due

cardiosclerosis

to

"

an:
analyse the rhythms, he does not define
Chap. VIII.), he attempts no proof. Dr.

himself

of

the

"

term

pulsus alternans, and

A

he

the

systoleinto the so-called

he

does

Mackenzie
a

state

also

"

not

(see

avails

signified
by

fails to define it.

gallop rhythm is often audible

renal disease,
a severance
(Hyperpiesia,
etc.),
"

but

cardiosclerosis

cardiosclerosis,"as

likewise

in

high-pressurecases
of the constituents

of
"

and deuterosystolic
protosystolic
sounds, without
duplicationof the arterial pulse,as explained
This
is due
not
to the
by Potain.
splitting
many
years
ago
absolute
degree of systolicpressure but to an aortic pressure

H. E. (Prag)
Herzalternans," etc., Zeitschr. f. exp. Path. u. Ther.
and
has been discussed
i.,1912 ; a very interesting article,which
in part accepted by others.
however
cli.
H.
A
rch.,
1913)
(Pfliiger's
Fredericq,
that
of Dr. Gaskell
denies Bering's explanation.
He
from a conclusion
argues,
bundles
in several
of
alternation
is attributable
to inequality of refractoriness
the myocardium,
in
and
base
that the apex
be
opposition.
may
2
Mines, G. R., Proc. Roy. Soc., 1912 (paper read Oct. 28
1912).
1

Bd.

Hering,

X.

Hft.

"

SYMPTOMS

392

ARTERIOSCLEROSIS

OF

PART

ductivity
conrelativelyhigh for the available myocardial energy
minus
that the systole
so
or
relatively
contractility
be due
the second
is slightly telescopedout
tap may
; or
fails to reach the wrist.
IE
to a supplementary systolewhich
high tension the aortic pressure may be rather too much for the
for the
heart ; in myocardial infections the heart too weak
aortic pressure.1 The
auricular action is said to be in excess.
be something of a
Although then this gallop rhythm may
"

"

"

"

of prescorroborative
evidence
as
curiosity,
yet it often serves
sures
Yet
relativelyhigh, for that heart at that moment.
this rhythm may
be casual ; not
long ago I noticed it in a
with irreproachcandidate
for life insurance, a fine young
man
able
mality.
family history. His organs presented no other abnorThe
presumably due to some
momentary
gallop was
cardiac and aortic pressures, perhaps of nervous
discord between
it was
not heard
again.
origin. On subsequent examinations
the walls of the aorta

When

and, such
with

as

other

it

is,is not,

as

the output varies more,

taut

in the normal,

Under

coefficients.

are

such

engaged

conditions

or

more

even

less

digitalis

where
the vagus
might produce pulsus alternans ; or, in cases
dominates
the position,atropin might dispel it. However,
in glancing over
tops more
graphic records, I find uneven
nans
often in those of aortic regurgitation,
a
pseudo-pulsus altercontinuous
the regularlyand
not
alternatingrhythm,
an
inequalityprobably not dependent on myocardial capacity.
experiment,2 says,
Strubell, in a careful essay
resting upon
that it is false to say that pulsusalternans
somewhat
incidentally,
be a speciesof
is necessarily
equivalentto asystole. It
may
be
usually is." The difference may
trigeminy," or indeed,
authors
discernible by the test of bodily effort. Some
say that
be produced by certain drugs, chloral
pulsus alternans may
"

"

"

of them.

being one

high blood
the heart becomes
irregular not merely by extrapressures
systole yet without oedema, we may suspect that it is suffering
As in all complex motions,
toxic influence.
from some
directly
If in

case

of

cardiac

strain consequent

upon

"

"

Pawinski, Zeilschr. f. klin. Med., 1907, Bd. Ixiv.

Strubell, published as an
originalarticle in Centralbl. f. HerzSee also Windle, D., Heart, ii. p. 95, etc.
1912.
skrankh., March
1

See

u.

Gefas-

CHAP,

so

MITRAL

vi

DEFECTS

and

in the circulation,many
summation

393

variable

are

factors which

the

work
in rhythm.
out
reciprocation
another
On
(Chap. VIII.),I shall protest againstthe
page
senile myocarck'ta's,"
cardioor
frequentmisuse of the name
ill-nourished
to
sclerosis,"names
decaying
given sometimes
hearts with broken
to
rates, sometimes
rhythms and irregular
hearts naturally sound
but embarrassed
strained by high
or
blood pressures,
sometimes
the
to myocardial fibrosis. Hence
puzzlesin text-books about the inconstancyof hypertrophy,an
inconstancy which, with due distinction,is explicableenough.
More
less fugitive
mitral murmurs
of course
to be expected
or
are
In
in the later stages of hyperpiesiaor decrescence.
these chief modes
of arteriosclerosis mitral defects are respectively
of two
kinds : the one
due to distension of the hypertrophied
then
ventricle by high arterial pressures,
the left first and
the right,with forcing of the valve ; the other to sclerotic
of its aortic
degenerationof the valve and its parts, especially

by

or

"

In the former
cusp.
like the liningof the

case,

"

under

strain,the cusps,

the abnormal
have

auricle,may

undergone

fibrosis,

some

perhaps atheroma
present
; in the latter the heart does not
often show little or no
hypertrophy nor dilatation ; the chambers
alteration in volume.
The
right ventricle is affected in no
nstant
proportionto the overwrought left ; it slowlybacks up
and is more
less affected the longeror the shorter the
e left,
or
uration of the burden
It is not
of the peripheralresistance.
obscure
to
the co-operationof some
cause
assume
necessary
actingdirectlyon the myocardium.
and mitral
As under
perennialhigh pressures the heart yields,
regurgitation
perchancesets in, the blood pressures abate to some
degree,say to 160-170, but rarelyto the level of the normal pulse.
or

fall to

the

normal

under

these

signifygrave dilapidation.Even in primary mitral

Hubert
Dr. H. C. Mann,2 and others have
Starling,1
fall of pressures
might forebode
any considerable
the
and

circulation,whatever
as

of fact in

matter

emphysema,

the

during

pressures
1
2

Mann,

cases

resistances,
of
the

must

disease Dr.
shown

that

dissolution ;

be

carried

on

ordinary mitral disease, or

grip

Starling,H., Lancet,
H.

would

artificial conditions

on

life may

1906.

C., Guy's Hosp. Rep. vol. Ixii.

be

even

of

SYMPTOMS

394

exalted,

OF

fall in the

to

As

ARTERIOSCLEROSIS

relief,in the other

with

case

one

PARTI

case,

fails the
falls,and
despair.
all pressures approach the mean
more
systolic,
; pressure becomes
occupiesa smaller part of the cardiac cycle,and is inconstant ; 1
Thus
the diastolic pressure being meanwhile
in decline.
doxically,
parabut quiteintelligibly,
if venesection
or
brings
digitalis
about
an
improvement, both systolicand diastolic pressures
fall. On the other hand strychninemay
work up pressures
may
in both phases.
arterial
As an example of the gradual declension of systolic
with

pressures
to

the

as

certain

Jones

and

the

heart

disease
for

case

velocityrate

(Hyperpiesia)made

some

the

under

years

way,
care

I may

allude

of Dr.

Lloyd

myself.

who
had lived well, and in later
elderlyman
sedentary life. As a rule, his radial pulse was
years with a more
of the largeleatheryand thrustingsort, the sort of pulse an
elderly
in the midst
The
of his complaints is often proud of.
case
man
of
with
never
a sign
throughout was one
uncomplicated hyperpiesia,
he
such
renal.
to regardas
wont
or
as we
are
Latterly had
symptom
become
subjectto occasional attacks of paroxysmal dyspnea, not in
its severest
degree ; and with these seizures for a day or two the
of
become
small
and wiry. During the main
course
pulse would
his disease
the systolicblood
ranged very high (220) :
pressures
in the penultimate stage they fell to about
180 ; the diastolic
recorded
ultimate
not
were
stage the systolic
; in the
pressures
reached
160.
pressures rarely
The

patientwas

case

but this

on
was

admission

which
a

the

at

renal

case

With

the

untrustworthy, or
some

in

190, and

apex,
of
appreciations the

In

lectured,in 1908,
a

cases,

showed

late stage.

systolicpressure

to
rose
pressures
ameliorated.
much

louder

an

170

was

therewith

altered

in

of

second

the

timbre.

In

indeed

or
hyperpietic,

without
moreover
1

Dr.

in aortic

evidence
there

of
be

some

an

atony
dulness

has demonstrated
Batty Shaw
regurgitation. See also p. 392.

of
on

this

the
the

be

us,

was

became

sound

these
of

many

atherosclerosis,the aorta
syphilitic,
may
in
the
notch
or
palpable
episternal

or

the

by rest and treatment

the patient'scondition

finger,as applied by
even
deceptive.
whether

On

three weeks.

the amendment

and

contrary movement;

Anasarca

phases
were

most

of decrescent,

abnormally

; if it be

manubrium,
of

parent
ap-

apparent

great arteries,and

inconstancy

the

it

if

signi-

systolicpressures

SYMPTOMS

396
back.

the

ARTERIOSCLEROSIS

OF

Riesman

that

says

PART

flatulent stomach

be

may

an

of

hyperpiesia.
To a more
tion
permanent ambiguity I have alluded,to the elongawithout
of a yieldingaorta
the swinging heart
; thus
hypertrophy the heart may present its apex considerably
any
beyond its normal site. To turn the patientfrom side to side

earlysymptom

"

"

"

will in this

alter the

case

of dulness.

area

It

pretty certain

seems

tion
that before the appearance
of atheroma, indeed before any alteraof the aorta visible even
by the microscope,the vessel yields
and

twists

if its fibres had

little,
as

quality;

with

thus

slowly widens and lengthens.

Schul,2who has latelyrestudied this problem, attributes these
in my opinion,too exclusively
of blood pressure.
to excess
effects,
A widelyshifting
heart depends upon
conditions to have
too many
than a corroborative
value (Vol.II.,p. 199). If the right
more
subclavian
variable phenobe raised above
the bone
a
menon,
very
far be
have
we
so
as
elongated -vessels may
seen,
indicated.
be given to
Again, very careful attention must
or

age

deterioration

lost

the

vessel

"

Professor

Wenkebach's

relations in space

Professor

and

of heart

Keith's

studies

of

the

and

diaphragm.
The fallacies of percussiondiagrams,especially
as
paraded by
certain bath doctors, are
thanks
to Dr. James
especially
now,
Mackenzie's
animadversions, becoming better realised. Long
Basch
pointed out the fallacies of percussivediagrams
ago von
of cardiac
dimensions
small
have
a
a
big heart may
; how
of dulness

area

"

castigated

and

though records
cases
incipient

of

discussion

by X-ray
has

The

He

methods

excessive

area

also lie open

Riesman

Schul, Virch.

and

gently

to like fallacies.

of the size of the heart

may

by experts many
precautionshave
diaphragmatic and respiratoryexcursions must
even

; and

In

ing
dyspnea we may generallynote that an interestwith the physicianwill reduce it,and a return
the symptom
Even
will bringback its urgency.
Franz
Grodel of Nauheim3
as
(orthodiagraphy),

shown, estimates
that

so

of

an

in der
Virtuosenthum
diagrams,"and
watched
the respiration
narrowly ;
very

of this function

conversation
a

heart

"

decorative

Percussionskunst."

to

normal

be fallacious ;
to

be
be

taken.
allowed

Journ.
Med.
others, Amer.
Sci., April 1913.
Arch., Jan. 1908 ; see also Fuchs, Zur Physiol.d. Blutgefass3
systems, Jena, 1902.
Grodel, R, Arch. Rdnt. Rays, Nos. 88-89.

CHAP,

CIRCULATORY

vi

in small

for, and

the

chests

broad

and

wide

one

SYMPTOMS
heart

397

is less apparent

it diminishes

also

than

in

during starvation,as

by rigiddiet, or in sickness. Franz Grodel thinks that in age

the heart enlargesa little. For my
own
part I would emphasise
the variability
of the cardiac dimensions
in high-pressure
cases
line ; how
in a few
outwardly beyond the midclavicular
even
recede
under
treatment.
As
days or less the outline may
we
physiologists,

know

heart

how

vary

may

the

how

it may

contraction

increase

volume

and
prodigiously,

of

the

yet be

the arterial
discharged on systole; under such circumstances
than
50 per cent,
systolicpressures may vary even
by more
variations
presumably governed in part by reflex expansion
fluctuations
of the periphery. Such
signify however
good
and
and
vessels,a good
heart,
bolism.
fairlyyoung
good generalmetaStill I have
seen
changes of this kind in temporary
of high arterial pressure, as during their episodical
states
occurrence
in elderlypersons (p.452). I have the impression,
derived
from athletic men
in Cambridge, that under very active exertion
of

kind

temporary

muscles

the

wall

of

the

left

ventricle,like the

of the

thigh,may enlargeby turgescence ; a turgescence

which
circumstances
of
usually recedes quickly, but under
ntinuous
be perpetuated as
stress
a
hypertrophy. In
may
of these cases
the left ventricle has certainly
seemed
some
to

increase,and after
And

when

to

short time to return

these
such

variables
as

we

emphysema,

add

to its normal

the

ossified

percussionsounds, and in women

manipulation,we may well scrutinise

many

dimensions.

incidental

barrassments,
em-

ribs,or fat walls which

big breasts botheringour

muffle

some

very

confident

clinical

reports.
Puke.
to

"

abbreviate

ventricular
of

It has

been

said that

high

diastolic pressures

seem

prosphygmic interval, the aortic and intrabeing more

nearly equal at the beginning
pressures
the

systole (p.390).

I have

made

no

time

measurements,

but

times
prolongationof systole,
apparent or real,someI think
is more
which
or
an
extraordinaryprotraction,
less prosphygmic. Anacroty, a phenomenon of like character,
is generallyrecognised as
a
no
infrequent feature of sphygof high pressure.
Dicroty is an insignificant
mographic curves
high
symptom, standing in no direct relation to arteriosclerosis,

have

alluded

to

SYMPTOMS

398

ARTERIOSCLEROSIS

OF

PARTI

compensation, length of systole,or arteriosclerosis.

more
frequentand distinct in relaxed vessels is true,
but that dicrotyis wholly inconsistent with high pressures is a
maxim
open to no little exception.
thick corrugated and contorted
The
radials,which suggest
observer
to the unwary
a
high resistance, if consistent with
characteristic
of it, but
not
hyperpiesisare
suggest rather
pressures,
That it is

arteriosclerosis.

decrescent

in

in such

order

blood

the

often

test

confirm

and

pressure
its independence

emphasise
For
instance, in one
patient,a
arteries were
man
grotesquely deformed, and
aged 50, whose
whose
pulsesuggestedto the fingerhigh blood pressure, but who
trivial
complained of little ailment, and sought advice for some
I may
add, in whom
a
no
yieldingof the heart
man,
cause,
occurred
then or since, in him I found the full systolic
pressure
I
90.
120
about
above
the
maximum
oscillation
lay
barely
;
persons
of arteriosclerosis.

also reiterate

may

to

notable

artery, that

arteriosclerosis

accessible vessels is found

this vascular

in which

in the

somewhere

Certainlyit

disease

the brachial

difficult to

are
proportions

been

have

peripheralconstriction

may

reach

may

to

and

other

of the

two-thirds

about

proves

radials

the

cases

in existence

tree.

far inwards

How

only in

in

the radial

from

here, in respect of inference

artery

appreciate. I

extend

But
have

these

(p.31) 'I
vascular

said that

when,

happens, there is no pressure gauge at hand I find some

advantage in the manipulation of the brachial artery with one
hand while keeping the other on the radial,pressingand releasing
the vessel so as to obtain
notion
of the effort requiredto
a
as

often

the

arrest

brachial

Thus

beat.

; and

if

attention

my

estimate

we

is often

the main

arteries

turned

roughly by

the

in which

the

size of the

limb

brachial

in diameter
decidedlyto be narrowed
;
but not always chronic renal
the radials

cases

seems

often

"

we

may

find

not

few

cases

the

to

"

in these
are

very

wiry.
In respect also of its walls the brachial
sulcus
may
cases,

is

feel

artery in the bicipital

point of observation ; in hyperpiesisthe wall

tough and incompressiblebut uniform ; in decrescent

useful

while the skilled ringer may

degenerated vessel

may

leap to

note

no

the eye.

great tension,a
The

tortuous

temporal artery,

dorsalis

the

or

CIRCULATORY

vi

CHAP,

radial and

hard

brachial

have

We

are

discussed

than

more

399

almost

cords ; and

no

this in

in which

cases

leatheryand

if not

which,

and
obliteration,

to

(p. 24) the relations

arterial pressures,

and

thicken

pedis,may

twigs become

thin

SYMPTOMS

littletortuous.

between

constant

so

of

shorn

of

much

their

apt observations, but

series of

it is

However,

augmentor

nerve

the

and

which

demonstrated

been

sciatic.

cut

of area,

expanse

whole

slow rate

slower

Again, a
if it

save

for retardation.

lack

of

summary.
relations are
too

these

considerablyquickened.
the output even
against

be accelerated
in animals

by

pulse diminishes

an

If then

Marey's

interference

irritation of

friction,and

friction,may

some

In

is

pulse
increase

may
a

that

Core

once

urged
of pulse rates
published a long

He

some

was

variables,for clinical maxims.

risingpressures,
has

with

generallyagreed

complex, contain too many

some
high-pressurecases
The

usefulness.

pulse rate
as

supposed, are yet not without importance. Dr.

charts without curves
forciblythat blood-pressure
are

the

make

on

rule of inverse

the
an

the
portion
pro-

between

pulse rate and blood pressure has a certain

fundamental
it;is so often overridden
validity,
by other factors
be a governing principle. In practice,
that it cannot
under
accelerated
an
pulse is not at all infrequent,
pressures
have

many

)bserver
normal

reported it
persons

of

note

for

this
me

in

the difference

contrast

40

out

in rate

and

of
of

140

trustworthy

of such

pulsebetween

and

cases,

stand-

lying is usually about ten beats ; the heart, as Dr.

of Philadelphiaremarks, endeavours, as resistance falls,
in quite healthy persons
But
even
keep up the pressure.
be imperceptible
far as watches
and
adjustment may
; so
tell us, with a rising
pulse,as for instance in nervous
luges can
remain
luctuations,the pressures
unchanged ; or with
may
the pulse rate
not
risingpressures
change perceptibly
may
nice problems, and
(Josue and others). However, these are
often involve psychicalfactors ; for the present they are
not of
mch
important side of the
practicalimportance : a more
itter is the
allegedperversion,in high arterial pressures, of
of sittingand
the pulse rates
relation between
ie
common
laid much
emphasis.
iding,a perversionon which Huchard
1

Core, M.D.

thesis, Manchester

Univ., 1910.

SYMPTOMS

400

AKTEBIOSCLEKOSIS

OF

PART

be
degree of perversionmight even
For instance,
used as a rough gauge of such high blood pressures.
the
he stated that with risingpressures
parallelismbetween
these and pulse rate failed ; the pressures might rise while the
rate was
comparativelystable,or indeed in cases of high pressure
the rate
on
recumbency might increase, and the recumbent
exceed that of the standingposition. Some
confusion
rate even
and
his pupils continually
hung about this positionbecause Huchard
assumed
the direct correlation of high blood pressures
this alleged
and arteriosclerosis. However, by other observers
diagnosticdifference is denied ; Vaquez in France and Leonard
been unable
in England have
Williams
on
repetitionof these
which
rule, unless in measures
experiments to verifyHuchard's
I have not myself
variations.
under baffling
or
are
insignificant,
the point,but my
pressions
immade
on
systematic observations
any
that a gradual waning of the posturaldifference,
are
incidental observation,has not
formity
unihowever
as
an
interesting
as
a
measure
enough to be used as a criterion,or even
declared

Huchard

that

the

of symptoms.
As

reiterate

injure the

than
see

persons,
chronic renal

of

characters

the well-known
;

of the

touch

regardsthe

pulse,I need not lay stress

the pulse of high arterial

vasoconstriction

that

arterial branches
in

even

radial

disease,whose

protect

pressure
rather

concerned.

life,the

later

must

upon

Continually we
subjects of hyperpiesiaor

and
arteries,

other

vessels

of

condensed
and whatever
magnitudes, however
by constriction,
the impulsion of the blood
stream
within, still present
still compelled to urge that
coats
supple to the finger. I am
of
call such
is to toy with
to
a
high tension
pulse one

like

"

words

narrow

the vessels

more

pressure,

central

caution

Another

pulse may

constricted

sink

on

almost

if reduced,

to

"

artery is not
it may

the touch

be

tension, though

(p. 377).

of the

extinction

to

under

pulse is

while

in the

is

fairlymaintained.
the lung or stomach

that

For

the

radial

brachial

the

instance, in

the radial pulse

haemorrhage say from
shrink until it becomes
its waning content
impalpable,
may
upon
and
a wrist gauge
quite useless,while in the brachial a pressure
of 100-110
still be registered.
for a while at any rate
may
On the other hand, in peripheralvasomotor
slackeninga wide
"

"

"

"

CHAP,

RESPIRATORY

vi

SYMPTOMS

401

often find in the

as
give to the finger,
we
acute
infections,quitea false impressionof stability.1
I may
Here
repeat that Traube's
pulsus alternans
(see
in the
Angina Pectoris, Vol. II.,pp. 334 and 372) may occur
the heart is yielding
the
stage of Hyperpiesiawhen
; as under
conditions we
same
recogniseit in chronic renal disease.
radial artery may

"

If calcification appears,
after prolonged strain of
arteries
and

be

may

mode

time

time.

to

I have

than

is

subtler

in

suppose

coronary

No

for such

than

"

Jut I have

had

"uch and

two

mflict of

mtly

of

cry

out, sprang

conflict made

to

to
an

individual
that

suppose

ordinary
from
as

"

Dyspnea."

man

with

witnessed

e.g. cerebral

decay

is

possible
;
forth.

so

As

enter

upon

of life the

paroxysm
in a hospitalward,

almost

this

desperate

of suffocation

and

or

accessible.

habits, and

vividness

livid to wrestle

the fell enemy

are

quently
fre-

more

particular
artery, e.g.
be fairly
normal
the
to
obviouslysclerotic.

become

the

degradation.

elderlyperson

seized
patient,

up

which

of arterial

the rate

later have

us

The

[animation.

of those

again with

strong

some

"

System."

see

touch,

witnessed

themselves

visceral arteries

causes,

years

Respiratory

iragraphI

certain

as

for

in

twofold

suspicionssuggest

reason

radial,may

the

decrescent

"

in the touch

generalrule
depends upon

much

le

of

states

accessible

question,whether

progress in some
disease,and the vessels thus suffer under

grounds

of

common

degenerationI have
is

set in and

The

in lax vessels

case

arteriosclerosis may
renal
or
independence of hyperpiesia

to

reason

some

of

there

But

the

the coats
hyperpiesis,
to
gritty,or nodular

tortuous

more

hyperpiesia. This

is sometimes

as

uneven,

vessels

the

"

which

during

an

throttled before he could

with

death.

visible to

us.

The

desperate

Now

this way,

fightfrom the edge of it,to sink

back in utter exhaustion, but only to rise againpanting,with the
the battle, the
sweat
streamingfrom him, desperatelyto renew
to the bystandersas to the victim.
almost as distressing
scene
was
thoracic agony it was
Some
exclaimed
one
Angina Pectoris !
indeed, but dyspnea is not a character of angina pectoris.
Uraemic
then suggested,but asthma, a totally
asthma
was
different malady, it certainlywas
not, and ursemic in the ordinary
that, springingup in bed

now

to

"

"

"

"

"

See

also Passler

VOL.

and

Roily, Munch,

med.

Wochenschr.,

Oct.

1902, p. 1737.

SYMPTOMS

402

proved

it

sense

be

to

not

attack, akin

The

AKTERIOSCLEROSIS

OF

such

as

the

patientwas

attacks

"

not

be

may

PART

the

to

nephritic."
paroxysmal

in this case, as
indeed
it
Bright'sdisease,was
of high-pressure
in Bright's disease, a
be
paroxysm
may
labouring and hypertrophied, the
dyspnea. His heart was
arteries thick and the arterial pressures very high. The agony
alleviated by nitroglycerine,
and under
was
repeated doses of
in this kind of dyspnea,
As is common
the drug it subsided.
to lividity.
not cyanoticbut pallid
the face was
The
subject of paroxysmal dyspnea has been brilliantly
handled
by Pal ; but a far greater advance in our knowledge
made
has latelybeen
by Lewis, Barcroft, Wolf,1 and others.
These
experimenters find that this dyspnea is not a cyanosis
acid intoxication ; and the same
but an
explanationmay hold
Chloride
for the dyspnea of high altitudes.
retention has no
divide dyspnea by its mechanism
part in |this dyspnea. We may
whether
nervous
(bulbar),pulmonary, circulatory,or
tumour
as
by pressure of some
coarselymechanical
again
; or
by its seat or origin whether arisingfrom pulmonary, cardiac,
forth.
cerebro- spinal disease ; and
or
so
Amblard,2 after
formulates
three
describing some
cases,
phases of these
seizures : (1) the preliminaryphase ; (2) the main
attack ;
During the preliminary phase the pressures
(3) the wane.
of

dyspnea

"

"

least 210

at

to

run

and

max.

upwards, with
Secondly,during the attack
of

250,

sign

little and

but

maximum

of

from

180

In

does

not

160.

Thirdly,unless
; but

more

the maximum

height

before

same.

If the

set

to

to

of

fall ;

heavily
"

minimum.

190,

the

maximum

minimum.

usuallythe

that
In

influence

the

in,systolicpressure
recover

in this

same

kind

place to

divide

copious,

falls

pressure.
and
more

itself (though not

will

case

fell only

blood

attack),the minimum
remaining
between
patientbe closelywatched

It is convenient

one

minimum

the

tides of the

ominous

venesection, even

cases

may

attacks,smaller

to

about
the

the
the

grave

usuallybe detected.

dyspnea

into the cardio-

Lewis, Barcroft, and others, Heart, vol. v. No. 1, Oct. 1913.

Amblard, Presse medicale, April 12, 1911, quoted Martinet
(loc.cit.).
1

230

these

reaction

often

may

maximum

decisivelyto

seem

curves

fallingtowards
fell from

to

both

the

while the maximum

proportionate rise

or

minimum

min.

190

SYMPTOMS

404

Glasgow

found

and

above

normal.

to

only

Nor

blood

but

lives

for

his radials
have

we

no

fifteen

arterial pressure

of

long (because

attack
this

with

the

asthma

the arteries of the asthmatic

are

?). During the

emptied ;

which

PABT

in

pressure

in

20

; usually he

thicken

habits
or

the

recorded

years,

AETEEIOSCLEROSIS

OF

abstinent

constricted,

be

may

prone

very

his

was

concern.

high blood pressure dyspnea is that due

directlyto cardiac hamper to intraventricular pressure, either
less
This dyspnea, if more
excessive.
or
or
relatively
positively
furious
on
so
during rest, is never
paroxysmal, or apt to come
central nervous
the
form, or as the two acute pulmonary
as
kind

Another

of

"

"

"

forms

and

inf arct

"

clot in the

oedema

acute

heart.

often

Too

such

but

;
a

it

cardiac

simulate

may

attack

is called

Angina Pectoris,because it is prone to attack the patient for

of a hill,while hastening to a
the first time during the ascent
train, or walking against the wind ; indeed a dull oppressive
with it. Von Basch well contrasted
submammary ache may come
this cardiac dyspnea, often associated with falling
pressures, with
form.
After his scientific habit he
cerebral paroxysmal
the
made
appropriateexperimentsupon animals, and concluded that
"

"

by C02
add

before

that

ventricle

and

ventricle distends,

an

attack

"

is irritated

pulmonary artery.
viscous (p.129). Then, as

vasoconstriction

and

to

may

the

and

pressure

to

two

or

the left

rises in the

pulmonary artery,

be distended

I may

the

right

three times

of the left."

the content
I have

is more

back

so

centre

rises in the

pressure

cyanoticblood
is opposed by

left auricle

the vasomotor

rises because

the aortic pressure

said

that

latent

high pressure may be

dyspnea during a tripto the mountains.

of

revealed
One

by

of my

of great energy
and
business
capacity, on
patients,a man
5000
feet,was
so
arrivingat a Swiss Hotel at a height of some
gravelyattacked by nocturnal dyspnea that, although on descent
his return
he
home
to a lower level the dyspnea passed off, on
We then found a very obstinate state of
sought medical advice.
and a largeheart; a
systolic)
Hyperpiesia(rangingabout 200 mm.
become
which
at this period had
state
susceptibleof relief but

hardly of
symptoms

The

cure.

of
1

urine

ursemic

Adam,

in every respect was

normal, and no
kind appeared. As in nearly all cases

Jas., Brit. Med.

Journ., Jan.

13, 1912.

CHAP,

RESPIRATORY

vi

of the

"

kind,

heart

SYMPTOMS

failure

"

405

diagnosed; and,

was

usual,

as

effort had long been

unlucky member, which by supreme
successfully keeping things together,fell into
silentlyand
disgrace.
In my
experiencethe paroxysmal dyspnea of central origin,
this

in its

which

violent forms,

more

in chronic

even

renal disease,is

is rare.
The
frequent,in Hyperpiesia(without renal disease)
cardiac dyspnea, characteristic of the later phases of hyperpiesia,
chronic affair,and is not so apt
harassingas it may be, is a more
with stupor and
the Cheyne-Stokes phenomenon.
to alternate
Dyspnea is seen, as Dr. Bruce says, in the stout, free-living
man,
justpassingthe meridian of life,whose heart is largeand weak
;
heart
in the third stage of hyperpiesia,
but
not
a
weakening
of
At the end
a
long and arduous campaign
naturallyweak.
it is jaded and spent, though often game
to the last.
central
Seizures of paroxysmal
dyspnea may springup in
a
period of his malady, and at a later stage
patient at one
I saw
in
give way to ordinary cardiac dyspnea. Such a case
The notes
are
briefly
January 1910 with Mr. Nash of Bedford.
not

"

"

"

follows

as

officer,
aged 60, temperate hi all thingsbut tobacco, some

Indian

An

"

subjectof hyperpiesia. No symptoms of

hronic renal disease had ever
appeared. The heart was much hypertrophied,and the blood pressures ranged high. The first event
in
to the high blood pressure was
to call attention
a severe
epistaxis
In
August 1905 ; and a smaller haemorrhage had occurred in 1906.
seized by the first attack of paroxysmal dyspnea,
March
1907 he was
before

become

had

the

There

not

very severe.
this attack was
of

more

and

blue

and

even

of great

less

or

severity

His
on

his

visit

feet,and

of the

"

and
severity,

In

panting

the

attacks

ordinary
to
begun now
largely dilated

was

run

were

correlation

thereafter

prone
for
much
relief,

lawn.
"

strict diet,salines,

"

got fewer
of

and

"

breath

and

(his own

place
words).

high pressures,
had appeared in

the

also

their

aspect.

The

and
the

arterial pressures

normal.

paroxysmal dyspnea with reduction

blood
by Lewis and Barcroft is most

of this

attacks

time ; he could walk abroad

of 1908
the paroxysms
winter

still ranging well above

alkalinityof the

while

1907

oedema

off in condition

for

From

dilate under
;

tillOctober

recurrence

to recur.

shortness

had

he had

however

The

the

by

big heart
my

obtained

mow

returned, but
was

notable

no

were

pillhe

taken

was

SYMPTOMS

406

ARTERIOSCLEROSIS

OF

PART

in the value
both
of the knowledge and
as
an
interesting,
example of genuine clinical research as contrasted with arbitrary
and logical
categoriesbuilt up of phrases.
postulates,
with or without
of dyspnea which
Another
occur
cause
may
arteriosclerosis is emphysema (not Asthma, see
p. 403). Many
often emphysema
how
accompanies
years ago I pointed out
I suspect
of the decrescent mode, when
arteriosclerosis,
especially
arteries.1 Josue
it to be due to degenerationof the bronchial
has noticed the same
no
proffers
frequency,but being a wiser man
For this emphysema a careful
explanationof the concomitance.
scrutinyshould be made, for in elderlypeople,whose chests are
be obvious, although sufficient to conceal
not
rigid,it may
be the cause,
dilatation ; or
to
cardiac
or
auxiliary,of a
a
gets
dyspnea otherwise interpreted. Such a patient however
short-winded, and subject to a dry cough ; a little crepitation
The accessible
both pulmonary bases.
is prone to stick at one
or
arteries may

be

thick

tortuous, but the

and

much

in excess,

if at all.

Dr.

this

coincidence

for me,

found

decrescent

arteriosclerotics

blood

Gregory,2who
that

collected

than

more

50

emphysematous.
precede the dyspnea
for

observed
both

the

cases

of

cases

of

cent

per

How

were

risingarterial stresses may

which
Basch
von
by two cases
twelve
respectively. In
years

not

pressure

long

is illustrated

four

years

and
were

pressures

before

respiratorysymptoms
The
author
set in.3
gives very careful descriptionsof the
of the lungs in high-pressure
morbid
cases.
anatomy
be remembered
that
In consideringthese problems it must
of itself raises the blood
simple asphyxia
e.g. laryngeal
by medullary reflex,or increase of viscosity,
pressure, whether
the
other
both
or
together (see Viscosity,p. 129). On
carries more
to the
hand, if a higher arterial pressure
oxygen
itself excite
the
this does
the
not
medulla
respiration
;
bulb, susceptibleas it is to the smallest trace of C02, seems

found

to

have

risen

30-35

mm.

"

indifferent

to

"

oxygen

output lags behind

the

Barcroft

as

intake.

and
But

little,and are
so
dyspneas" we know
discuss them
guess-work,that I cannot
1
8

Report Brit.
Gregory, M.D.

Med.

Assoc.

Dixon

of the nature

hampered
further

meeting, July 28, 1910,

thesis,Camb.,

1911.

put it, the C02

Von

and

to

of
so

any

"

toxic

much

by
profit.

previous allusions.

Basch, loc. cit. p. 285.

CHAP,

RESPIRATORY

vi

SYMPTOMS

407

is well known
not
Cheyne-Stokesrespiration
as
infrequent
in the extremer, though not necessarily
the ultimate, phases of
hyperpiesia. In the dyspneic phase the pressure rises,in the
rise so
to
apneic it falls. Pressures may
high as to seem
be

the

direct

of semicomatose

phases, often with tidal

phases appeared again and again in a lady

cause

respiration. Such
with Mr. Wallis of
whom, nearly twenty years ago, I often saw
Cambridge. During the attacks the arterial pressures, systolic
and
diastolic,always excessive, ran
enormously, and she
up
would
fall into a stupor, sometimes
with stertorous
breathing.
There were
All these attacks
never
any signsof renal disease.
she survived
to
die of a defeated
and
heart
dropsy. In
a

to

case

with

Mr.

which

have

alluded

Teale, complete

another

on

page,

as

seen

place in spite of
high pressures, paroxysmal dyspnea, Cheyne-Stokes breathing,
The patientwas
a very
stupors, and delirium.
vigorousmiddleaged man, a free liver,and occupied in largefinancial concerns.
Bronchitis,or at any rate troublesome
cough,is no infrequent
than a tiresome
companion of hyperpiesia; often it is no more
hawking and clearing; but also often a true winter (bronchial)
of these patients
cough with free expectoration. In some
bronchitis
the case
is the way
of death ; such
recently was
with an
old friend of my
in whom
own
high arterial pressures
had persistedfor many
The discoveryof such pressures
years.
will indicate

the

line of

took

recovery

which

treatment,

is often

calomel

proof of the diagnosis; for dietetic reform, with

"

other

so-called

the bronchial

anti-gouty

"

means,

irritation without
have

Hcemoptysis I

hyperpiesis
; never
arteriosclerosis.

In

"

or

the
and

alleviate

delay.

referred

I think

banish

may

also

to

as

unless in

lady,whom

occasional

an

specks

mere

"

of decrescent

in consultation, a

once

saw

result of

of, no
betrayed a hyperpiesis
common.
doubt, some
long standing. Epistaxisis more
The
Nervous
Cerebral,Seizures." For years
System.1
past observers of arterial disease have been occupied with the
which occur
paretic,
symptoms, convulsive or pareticbut chiefly

haemoptysisof

or

ounces

first

"

in
the

the

later

first to

stage of

arteriosclerosis.

discriminate
1

See

Stengel, Amer.

between
Journ.

the
Med.

In

1871

was

hsemorrhagic and
Sci., Feb.

1908.

not

the

SYMPTOMS

408

"

"

obstructive

this distinction
and
a

ARTERIOSCLEROSIS

OF

apoplexies; and, in respect of

between
the apoplexiesof high

those of arterial obsolescence

in which

distinction

PART

the

palsies,

arterial pressure
thrombosis, or of embolism,

and

chief kinds

two

cerebral

of Arteriosclerosis

be

severallyrecognised,is essential.
As regards the lesser manifestations
of disorder about
the
brain
head
in hyperpieticand
decrescent
arteriosclerosis
or
mention
I may
and tinnitus ; they
headache,vertigo,
respectively,
may

are

and

they
the

in routine

down

set

do

are

not

often
is not

ear

Meniere

may

fashion

gainsay
overrated

importance.

; but

supervene

far

these

arteriosclerosis,

Notwithstanding,

misconstrued.

or

In

that

infrequentlyaffected, so

importance only so
Headache
again is

arteriosclerosis

the

incidental

patientmay be
capriciousand ill-defined symptom,

either,or of

form

any,

of

symptoms

phenomena
harassed
by

the

as

characteristic of
In

their

of

symptoms

as

of

are

them.

not

pecially
es-

of arteriosclerosis.

experiencehowever
subjects of migraine have seemed
to hyperpiesis
of them
the migraine passed in
; in some
prone
middle
life into hyperpiesia
others drifted into chronic
; some
renal disease (" Granular
kidney ").
High tension headache
is said to be occipital,
and aggravated not by opticalerrors, but
that in my
or
by mental
bodily effort. I cannot
ence
experisay
such
which
is
in
worried
a
common
headache,
enough
or
overwrought patients,has been a specialor characteristic
feature either of the hyperpietic
the decrescent mode.
aches
Heador
my

"

arise in all persons

chronic

renal

disease

from
it is

"

trivial and

incidental

Of

causes.

In a few
grievous symptom.
however
been
I have
cases
impressed by the insistence of a
patient,afterwards attacked by an apoplexy, on a vexing pain
the side of the head oppositeto his subsequent hemiplegia.
on
It does not
seem
probable that arterial lesions in the brain,
intracranial

apart from
membranes,

producing ;

be

can

in

sudden

pressure

themselves,

embolism

high

so
or

as

their

distend

to

the

reactions, pain-

might be, but

of its effects pain would
be the least distressing
and
significant
of a night,is of
headache, usuallyworse
part. The syphilitic
course

symptom,

not

specificinflammation
Ambrose

Pare

mentions

of
about
the

or

cerebral
the

thrombosis

arterial disease, but

skull

nocturnal

and
headache

its

of

of the

membranes.

syphilisi

CHAP,

NERVOUS

vi

often associated
or

usuallyto
of

one

the

abate

the laboured

heart.

it

effect, by
the

renal

but
only relieves present suffering,
rallyand to take food ; while to
do no
harm
to
malady it seems
ease

part,

moderate

of

What

in

convulsion

disease, it is true, the

in

rate

to

pain, an

To

renal

any

confutations

many

symptoms."

treat

at

; for

pressure

assuage

the

be,

to

blood

In

potence ").

seems

excessive

409

with, deafness, twistingof the mouth,

palsies(" Vie

headache

SYMPTOMS

the

enables

"

is

not

to

nitrite not

the

patientto
of the

general course

whatever.

the

which

way,

by

of

nitrite is

maxim

headache
also

by

the

absurd

result

Indeed

it may

hyperpiesiapatientsoften

do

complain of is oppressivefulness or confusion in the head.

Vertigois likewise a symptom of indefinite meaning : it may
mean
anything from the little swim of atonic cephalicvessels
neurasthenics
to which
are
subject on stooping,or the passing
giddinessof a dyspepsia,up to labyrinthinedisease, or a small
apoplexy. Stomach vertigowas something of a fad of Trousseau;
of his cases
were
probably many
labyrinthine. It is often a nice
whether
in a particularcase
the
to decide
diagnosticdilemma
know
that labyrinthine
vertigobe central or peripheral,
e.g. aural ; we
attended with
vertigo,though usually,is not necessarily
In
of acute
with
tinnitus.
case
deafness, nor
a
even
vertigo
with Mr. Nash
of Bedford, we
diagnosed
B.) which I saw
had a slightbut unsmall apoplexy, partly because
he had
mistakable
a
His diastolic
before.
apoplecticseizure 12 months
.

was

pressure

In

of the

cases

some

There

165-170.

unequal. One
enough that in

vertigoof

such

case

haemorrhage the pupilsare

It seems
remember.
likely

small

well

the

vertiginousattacks ; and,
other phenomena.
brain, without

has

been

which

is said to have

which

is

has

been

more

to
no

likelyto

foisted,and

if in

"

silent

"

Arteriosclerotic

sclerosis of the internal

On

anastomoses.

cidents
ac-

tinyhaemorrhages,

cases
high-pressure

cause

attributed

thrombotic

arterial disease minute

decrescent

in littletwigs,as in

would

of renal disease.

indications

no

were

parts of

vertigo

auditory artery,

allegedcondition,
mode, high pressure

this

be of the decrescent

decay of the twig has

been

confused

with

cerebral
high-pressurevertigo of cerebral origin. In syphilitic
is frequent,and might
arterial disease vertigo,almost to swoon,
almost

be called characteristic.

In

this kind

of disease, of

the

SYMPTOMS

410

ARTERIOSCLEROSIS

OF

PART

especially,
vertigomay be very severe, but it rarely
and swooning,but
lasts very long : the patientfeels bewildered
keeps his wits so far as to sit down, and usuallyin a short time
fathers
foreOur
the later consequences.
is steady again ; whatever
between
wont
to distinguish
vertigotenebrosa and
were
vertigocaduca (syncope). Syphiliticdisease of the cerebellum
severe
vertigo. Labyrinthine vertigo
might, I suppose, cause
basilar artery

its

has

own

arteriosclerotic

most

of

aural ; I

have

said

characters

and

course

vertigos are

so-called

the

it may

that

deafness.
I saw
latelya medical friend suffering
appear without
after influenza ; there was
from vertigo,clearly
no
labyrinthine,
deafness

and

Tinnitus

hisses

of the carotid
set

may

the

not, arises in the

ear

great bother
occasional

It is often

for

tinkle

few weeks.
or

that

assumed

chirp

to

sclerosis

through its bony canal,

is that
but my
experienceof such cases
deafness
with vertigo and
associated
or
itself. It is rarelyin rhythm with the
it passes

artery, where

tinnitus,whether

was
an

hums.

or

tinnitus ;

up

from

vary

may

maddening

It

tinnitus.

no

pulse,and in elderlypersons too

Meniere's
grievous affliction of
"

often

Disease."

part

as

appears

of

the

Sometimes, it is

disappear again,
then I suspect they
whatever
the blood
pressures ; still even
aural.
are
When, on the other hand, in aortic regurgitation,
without
obvious arteriosclerosis,
slightdegreesof it appear,
even
the sound
does synchronisewith the arterial pulsations. What
take in setting
direct part arteriosclerosis may
up the ear troubles
leave to the aurists
of Meniere's disease in elderlypersons I must
in puttingto
to say ; but again and again I find myself justified
true, these

symptoms

the account

of the

ear

quickly

appear,

symptoms

to

had

which

been

attributed

to

arteriosclerosis.

cerebral

Epilepsy,"as an allegedsymptom of arteriosclerosis,

tion.
quickly dismiss ; Stengeland others accept the associa-

Senile

"

I may

I have

little to

say

about

it
"

no

more

indeed

than

to

convulsive
agree with the ordinary opinion that in old persons
not
attacks resemblingepilepsyare
they
infrequent. Whether
are,

speaking,epilepsyor
strictly

which

I have

presence
may

not

been

be

made.

At

I cannot

say

in

cases

in

happened in my
by the convulsion alone the diagnosis
of epilepsy
the simulation
rate
any

concerned

besides, even

not

no

seizure

has

SYMPTOMS

412

embarrassed, haltingfor
and

ARTERIOSCLEROSIS

OF

few

PART

hours, or but for

few

minutes,

then

It has been
concert.
returning to the normal
my
experiencethat in chronic renal disease the strokes generally
fall heavily,maiming or
killingthe patient; those of Hyperoften than in renal
piesia,
heavy as likewise they may be, more
disease are
kind, but of a
preluded by assaults of the same
lighteror skirmishingorder, forebodingrather than compassing
the maiming or mortal attack which, however
tardily,is pretty
to follow.
chronic renal disease,which,
sure
Omitting however
if not alien from our
subjectis beside it,let us dwell more
ally
especithe strokes and palsies
of
Arteriosclerosis."
on
And
here again I must
tion,
continuallyurge my cardinal distinc"

the fundamental
take

little

whether

heed, between

of

decrescent
both

distinction

renal

of

or

forms, whether

due

factors

books

arteriosclerosis

the

disease

of which

and

of

toxins, to

still

high

pressures,
that of the

Hyperpiesia,and

to

papers

detrition,or

mere

together; I must
they belong fairlydefinitelyto

to

class ;
is in

cases,

accordance

Excluding then
us
begin with
decrescent

distribution

renal

disease

the

cases

with

cerebral

speak severallyof cases, as

the decrescent
the high pressure
or
which, in spite of a few mixed
of nature.
the ordinary courses
in its ordinary clinical forms, let
of Hyperpiesia; the
symptoms

will consider

we

afterwards.

The

which usually
hereditary
tendencyto cerebral hcemorrhage,
of renal
means
a
tendency to high arterial pressures, whether
originor not, has long been recognisedby the laity (p. 165).
I have
At my
said already,I look back
family
age, as
upon
after family in which
this fate seemed
inexorable.
Sir William
of this bent ;
Gowers, all neurologistsindeed, are well aware
Gowers
has said truly that
causes
apoplexy depends upon
the
that take their heredity far away
from
the brain in which
lesion occurs
heredityis active is
; yet the frequency in which
"

most

notable."

people :
gouty,

"

My

and

75.

father
for

apoplexy, or
68 and

Sir Hermann
died

several

apoplexy ;
generations the cause

had

of the

all lived

of his

reports thus

of cerebral

allied affection

They

Weber

his

family was

of

death

brain, between

freelywith

regard

Weber,

H.,

set.

38, Brit. Med.

Journ., Nov.

was

ages of
and
to wine
the

food."
1

own

21, 1912.

CEREBRAL

vi

CHAP,

HAEMORRHAGE

413

Catastrophesin disease are sudden to him only who is blind

to their approaches ; so it is with
apoplexy in the Latin tongue
the springing of a mine
is no
sideratio,planet-stricken.But
"

wonder

the

to

who

sapper

laid it,nor

him

to

who

touched

the

whose
blood
known
example, one
or
pressures,
have
been
unknown,
waxing for years, and whose arteries,in
and elsewhere,have been strained, but who
the encephalicarea
have had littlesense
of ailment,rinds himself
notwithstanding,
may,
in speech. The embarrassment
hindered
is not a stutter, or
usuallyit is not ; it lies deeper. He does not laugh it off ; he
of some
is startled, as by a sense
profounder lapse. Indeed if
For

button.

be also

there
at

few

suspect it

to

once

numbness

some

minutes

or

or

"

be

to

slackness

of

stroke."

limb

Often

seconds, the embarrassment

he is

ready

however, in
off.

passes

One

patient,a clergyman, while preaching,hesitated,felt confused,

looked anxiouslyabout him, called up his will and pulledhimself
together,hoping the congregationmight not have noticed it ;
if noticed

in

it were,

few

minutes

the incident

forgotten

was

congregation,but not by the preacher,who wended

his physician with
in his
of some
his way
to
arrest
sense
a
the physicianfinds an hypertrophiedheart,
life. In such an one
a
high blood pressure, and a radial artery constricted and wiry,
the area
of constriction may
be. Another
as
or
largeand leathery,
patient,in the midst of conversation, found himself at a loss for
until the faculty returned ;
speech, and quietlyleft the room
back and resumed
his family,he went
his talk
then, to reassure
but himself being the wiser.
Both
these men
without
one
any
later by largeapoplexies. Such cases
stricken down
were
may
Now
it is true
that like omens
be given by the score.
may
by

the

manifest
the
or

themselves

phenomenon
slackness
confusion

of
;

in other

be,

may
a

limb
but

or

as

districts of the
I have

cerebral

centres

said, a transitorynumbness

again merely

it is remarkable,

at

or
vertigo,

any

rate

ing
bewilderit has

so

experience,that in hyperpiesiathis kind of omen

I use
in a
most
frequentlyin speech,a word which
appears
and
finelybetween motor
distinguishing
generalsense, not now
these menaces
psychicalspheres; often indeed in their fugitiveness
mittent
interthese
closer analysis. Now
to what
are
a
escape
of the paresis?
claudications
due, what is the nature
been

in

my

"

"

SYMPTOMS

414

one

mine

PART

haltingof speech was often repeated:

of aphasia; and once
he had several brushes
by chance found
himself
all of
agraphic without aphasia. Probably however
of the same
not
these aphasic manifestations
were
nature, for
In

patientof

ARTERIOSCLEROSIS

OF

"

(he

too

come

"

was

on

the

parson) often

towards

the

halt without

of

end

prayer

confusion

any

short

or

would

reading (he

had

when it may
have been due
againstlongerservices),
centre
a
atrophiedor damaged by a previoussmall

been warned

fatigueof
haemorrhage or thrombosis
But to this patient I am
to

"

"

true

intermittent
but

claudication."

criminati
passing and disnot
of hyperpiesiabut
one
allusion,for his case
was
in which
kind
these simpler
of decrescent
a
arteriosclerosis;
apraxiesof atrophiccentres are frequent.
These
transient pareticattacks,in their various
shapes, are
for me
well known
to tarry now
too
longer in descriptionof
of Beccles Matthew
Paris records
them.
Of the knight Alan
the Abbey, gluttonouslyeating many
he raided
that, when
should
eat," suddenly his speech
dainties, eating as none
failed him.
Unluckily for Alan, this preliminarypalsy had its
him
that a full
later consequences
was
; the judgment upon
now

making

"

seizure should
he

and

follow
smitten

was

this

according to

and

so

with

it followed

apoplexy."

an

chronicler,seems

to

"his

veins

Adam

have

burst,

Fitzwilliam,
had

similar

Apoplexy was recognisedin the time of Hippocrates,

in
habit and,
who describes the plethoric
the attack, the
and unrhythmical breathing. But in old days cerebral
stertorous
of course
confused, as was
inevitable,with
haemorrhage was
with
alien conditions ; even
(" paralysisuniversalis ").
syncope
this dramatic
became
event
By our later forefathers however
transient

better

attack.

and

better

being that

best

the time
attributed

alia,"

of

cerebral

of

of Matthew
"

understood, and

Wepfer

1
"

Paris,

were
so

many

devoted
in the

treatises
to the

17th -18th

"

one

of

subject.

the

As in

century it

was

"

(" inter
intemperantiain victu et vita sedentaria
had
in view
chieflythe
course). These descriptions
haemorrhages of high arterial pressure, for these are
to

book
(1620-95), in whose
physician of Schaffhausen
ago
many
years
of
of
much
a
pioneer
neuropathology, an opinion
interestingmatter, as
of Halle
in which
(1666Wepfer, as Hoffmann
Payne
agreed with me.
cerebral hsemorrhage as a cause
of apoplexy.
1742) after him, demonstrated
1

I found

CEREBRAL

vi

CHAP,

most

was

then

415

in their

dramatic

the

HAEMORRHAGE

inevitable,the

explosions; though of course,

as
hemiplegiasand other palsiesof cerebral

atrophy and thrombosis in decrescent arteriosclerosis were classed

chapter,half distinguished
by them under the same
perhaps as
in which
the cases
again and again they had observed bleeding
be harmful.

to

In

recent

larval forms
Dr.

our

have

of stroke
Weber1

Parkes

with

years,

intimate

more

attracted

records, of

and

more

diagnosis,the
attention.

more

patient(M. set. 51) suffering

from
high arterial pressures, that he had eight attacks of
with hemiparesison
the rightside,one
with the
aphasia; seven
the left. Dr. Pruen,2 in an interesting
same
on
survey of these
and
such cases, opines that
than three-fourths
of the
more
classical strokes have these lightermenaces
as
a
prelude once
oftener repeated; he quotes from
Gee's Aphorisms to the
or
effect. In my
same
stress
opinion Dr. Pruen lays too much
a

"

upon

mental
I

what
does

conditions
for

may

the

as

immediate

call, the

moment

insist

compared with,

as

causes,

mechanical

and

he

doing, divide the high-pressure

from
the
cases
atrophic (decrescent). By nature
distinct,
be
symptomatically indistinguishable
occasionallythey may
;
but

not,

in

as

I must

"

Dr. Pruen's

on

associated

of

summary

symptoms

I think

the
aggravated. In hospitalpracticeof course
prelusivephenomena are apt to pass unrecorded.
attention on
Now, while still concentratingour
hyperpiesia,
?
in what
do these preludes consist pathologically
What
are
they due to ? Omitting conjectureson local redemas, local
discuss the two
molecular
and the like, we
more
fatigues,
may
that of local vasoconstriction,so forcibly
important explanations,
advocated
by Pal,3 and that of small local haemorrhage; for
small
embolisms
thromboses, maladaptations of stiffened
or
vessels,and local atrophicsolutions of continuitybelong rather
the
arteriosclerosis.
For the contemplativeman
to decrescent
hypothesisof vasoconstriction is very seductive ; without moving
this confusion

is

of his armchair

out
1
2
3

can

order

it about

Weber, Parkes, Proc. Roy. Soc. Med., Feb.

Pruen, Lancet, Oct. 28, 1911.
Pal, Gefdsskrisen,Leipzig, 1905

large superstructure
may

he

be said of the

rests

shorter

in

"

great part

discussion

very
upon

of the

'and

turn

it to many

1912.

attractive
unverified

subject

in

treatise, although its

hypothesis.
Meyer

and

The

Gottlieb.

same

SYMPTOMS

416

As

uses.

cloud

formula

ARTERIOSCLEROSIS

OF

the

over

sea

the

so

anemone,

eclipseexplains this functional

machina.
closure or that, as occasion requires; an argumentum
ex
to constrictive
The vessels of the brain are
probably susceptible
influence in some
vasomotor
degrees,though in degreeswhich are
discernible only to very sensitive methods
slightare they
; so
indeed that for many
years by skilful observers this susceptibility

handy

denied

was

be

of

closes the

sun

PART

The

them.

to

slender

so

vasomotor

take

only

as

to

in

high-pressure

function, and

considerable

resist any

endowment

be

to

cases

constriction

to

place in cerebral
quite incapable to
elsewhere.

Cow, in verification of Barcroft's

laboratories,Dr.

therefore

seem

subordinate

of

areas

would

In

our

results,found

that adrenalin, while

constricting
largeareas, dilated the cerebral
vessels, as it does the pulmonary (Brodie,Dixon,
coronary
Elliott). Gaskell and Barcroft think that the dilating

and
and

effect is due

under

metabolites

indirect,that

but

direct

to

these

I suggest that
weaker

eminence, well

aware

doubt

no

this guess on
in small areas

adopt
constriction

the
of

vasomotor

However

high systemic pressure.

the

this effect is not

yield

areas

certain

authors

of

of the

spellsof seductive hypotheses,

lighterapoplexiesby vasomotor
the

brain.

Osier,1

Sir William

discussingthe brief pareses, confusions, and sensory disorders

attributes
them
of arterioto
of high-pressurecases,
spasms
sclerotic vessels,assuming that in the sclerotic state arteries are
I
to vasomotor
not
less,but more
susceptible
; a notion
cramps
have

discussed

alleged

such
very

and

rare

elsewhere
cramps

(p. 161).

in

dubious

branches

And
of

observations

to

he
the

"

could

sclerosed,and

were

not

"

Dr.

and
1
2

defends

of them

arteries,

will return

patient,with
were

whose

such

excessive, but

sclerosed ;

and

to

(accessible
?)

palsiesso transient
be organic! Well, do not
let us speak too confidently.
Russell,2likewise accepts the vasomotor
hypothesis,
fervour ; although he adds that slips
it with some
says

that

Med.
Ass. Journ., Oct. 1911.
Osier, Sir W., Canad.
Russell, W., Brit. Med. Journ., June 4, 1904, and other

this inference.

of

us

retinal

which

refers to a certain
presently. Sir William
whose
arterial pressures
transient palsies,
arteries (those accessible ?) were
whose
not
a
second, likewise under
high pressures,
vessels

reminds

essays

concerning

CHAP,

CEREBRAL

vi

of the heart

surely in
action

of

areas

would
the

also may

HAEMORRHAGE

play

constriction
He

of the internal

area

lesion the size of

part in their

some

be indifferent.

admits

of

that in

an

Dr. Russell

is not

which

one

cerebral

vessels

of such
be

be

distinction.

"

condition

change might conduce

artery constriction is unlikely.
are

but

brain,
these,

to
can

tract,
con-

all respect,the distinction

in these terms

not

tides in vasomotor

"

Sclerotic

this

there

on

; in the

the

hypermyotrophic,a

and

accepted,or

cases

ible,
process of atherosclerosis is not thus divisthe author give us post-mortem evidence in support

does

nor

can

quent
fre-

goes

sclerotic arteries in the

With

cannot.

cardiac

of his

one

the susceptibility
to vasomotor
influences
attributing
and denying it to those ; a sclerotic artery, he says,
atheromatous

Yet

that the symptoms

discovered.
from

causation.

confined, tides

so

and
capsule,

was

pea
to distinguish
atheromatous

417

cerebral arteries

which
to

Dr.

spasm

Dr.

Russell
in

Russell

activities

"

indeed

we

might

accepts,
fibrosed

that

argues
know

there

this

Nor
does
the
principlescarcelyassists us.
appeal to migrainehelp us ; the allegedvasomotor
contraction,
afferent
dilatation,in this neuralgiais secondaryto a peculiar
or
often in the eye (eye strain); it belongsto the hither
irritation,
side of middle
life,to healthy arteries. In later life,when
arteries deteriorate,
migrainegenerallypasses away.
are

Furthermore, vasodilators,which
arrest, or

even

If in the

us.

cerebral
mitigate,
high-pressure
cases,

have

pareses
as

been well tried,do not

of the kind

for the most

before

now

part these

are,

the

vessels could concerebral or coronary

tract
feeblyinnervated
which
against a systemic pressure of 170-200 or more,
is unlikely,
vasodilator
should promptly release the cramp.1
a
fine that
In the pia mater
network
the vessels form
so
a
of blood
it is not
arrest
an
easy to imagine in a small area
minals
not
supplemented by collaterals ; partialeclipsesin the terof
but

cramp

for

the

but
1

so

anterior

and

strong and

middle

cerebral

persistentin,a

are

circle

conceivable,
so

narrow,

does
not
seem
paresisis often of small compass,
probable; if probable,it would surely be not stedfast,
capricious,
creeping hither and thither, and setting up

very

Bd.

the

Arch. f. exp. Path, und

generallyagreed ; but see Wiechowski,
ibid. Bd. li.,1903.
Loeb,
1902 ; and as regards coronaries,
xlviii.,

Pharm.

As

VOL.

SYMPTOMS

418

about

blow

breezes

functional

of

dissolvingviews

ARTERIOSCLEROSIS

OF

the

PART

squalls. And
normal

and

common

do

why

not

such

brain, playing with

indeed
are
quoted
continually? Transient epileptic
pareses
That
causation ; incertum per incertius.
in proof of vasomotor
is itself
in cerebral vasoconstriction
epilepsyconsists essentially
cannot
mere
a
carry any corollaries.
guess (p.411),and certainly
are
phenomena. So
merely exhaustion
Post-epileptic
pareses
be it true or false,rests
far then this vasomotor
interpretation,
data ; indeed
some
plethysmographic and other
as
yet on no

us

experiments go rather to the contrary.

these paretic
of Bristol has written
Dr. George Parker
on
history of the subject,and adding five
cases,1 giving some
I am
Dr. Parker
is as sceptical
about the
of his own.
as
cases
conjecture; he leans to the hypothesisof a local
vasoconstrictory
oedema.
If it had

been

found

in these
in

themselves

manifested

death,

to

reasons

anatomical

or

sclerosis
arteriothat

some

suppose

substratum

area

and

the

gives little or no
hypothesis. Very rarelyindeed, so far
support to the vasomotor
I know
in one
as
only (Peabody's case),is it true that
necropsy
negative as to focal lesion has been
a
negative condition
of high pressure
paresis. In a few other
proved in these cases
apoplectiform phenomena

but

cerebral

lesion, in this

some

this

between

link

functional

have

should

we

other

fleetingpalsieshad

the

proportion to

discovered, without
after

that

cases

necropsy

"

"

at
necropsies,

that

asserted
lesions

escape

or

faded

in

the

not

in colour,

might

with

for
the

have

been

no

focal

not

And

even
interpretation,

vastly greater
have

are

overlooked.

functional

number

at

best
were

of like instances

plainly demonstrated.
in medicine
for our M.B.
1913 the examiners
In December
degree
St. Bartholomew's
mentary.
set a certain case, from
Hospital,for comA part of the historywas
a
hemiplegiaof two years'
The brain
standing,with degenerationof the pyramidal tract.
closelyscrutinised,very carefullysliced in thin layers
was
very

in

correlative

which

lesions

brain

preciseenough
in degree
lesion,minute

focal

some

attacks,it has been

of the

these records

; but

that

faced

after such

correspondingareas

demur

the

they give little hold

they

intervals

discovered

were

to

various

Parker, G., Bristol Med.

Chir.

been

Journ., March

1899.

I remember

that

he reeled,and

one

for

morning, on

risingfrom

minutes

was

much

which

had

some

this attack, like others

length he died
good chance we
mortal

case

almost

prayers,
few

days

In the brain, besides the

sixteen
; most

away

standing.

old

haemorrhages:
of them yellow
for

Now

me

this

facts,but also in itself an

of curious

record

morning

confused; in

less than

no

faded

evidentlyof

only a

not

of

PART

At
preceded it,passed over.
unmistakable
apoplexy ; and by

autopsy.

an

traces

tiny,some

was

and

grave

found

brownish, and

or

obtained

clot,were
were

some

of

ARTERIOSCLEROSIS

OF

SYMPTOMS

420

clinical and pathological.

significance,
Among other lessons,it taught me that tiny stains,littleclumps
of haematoidin
or
crystals,
pigment, or tiny thromboses
(p.426)
easilybe overlooked, even
by a responsibleanatomist, and
may
the brain reportedas
negative."
?
Was
it
teach too much
But, it may be urged, did this case
aberrant and too imposing an instance ? If,
not a crucial but an
I have
been led to attribute
like experiences,
by this,and some
education.

It

full of

was

"

transient

of

pareses

the

kind

under

discussion

i.e. for

"

the

too
generallyto
high-blood pressures
haemorrhage,what has been the experienceof others, and what
later experience?
own
Well, apart from certain exceptionsto
my
be noted presently,
the weight of evidence in favour of multiple

part those

most

under

"

focal lesion in these

cases

in full would

largea

few

be too

remains

considerable.

task ; I must

content

marshal

myself with

it
a

witnesses.

Senator,1writingof cerebral haemorrhage on

"

To

Also at times

throughout the
after

diffuse punctate
whole

death, has

brain."

often

haemorrhagesare

Marchand,

observed

the whole, said

found

scattered

in such brains examined

"

numerous

old
(zahlreichen)

reportedcases in his 1904

a
high-pressurecase with largeheart
says of the first
paper,
and
atrophic kidneys," that, with a general arteriosclerosis,
includingthe vessels of the brain, a fresh haemorrhage was found
in the right temporal lobe ; and
there were
also multipleold
of renal
foci (italicsmine) : in the second, a case
apoplectic
disease with
hypertrophied left ventricle,a similar group of
in
discovered.
Of another
case
multiple haemorrhages were
the same
died of cerebral haemorrhage,
male, who
a
paper
apoplecticfoci."

Jores, in

two

of the

"

"

"

"

Senator, Erkrankungen d. Nervensyst.2nd

ed., 1902,

s.

313.

HEMORRHAGE

CEKEBKAL

vi

CHAP,

421

read:
tached
case
we
"kidneys,capsule easilydehigh-pressure
of interstitial excess,
fair amount
but very
a
(loslich),
little change in epithelium." Besides the final rupture
multiple
found.
old haemorrhagicfoci
Kaufmann
in
were
indeed, his last
edition, goes so far as to divide cerebral haemorrhagesinto two
classes
the Punctate
Hcemorrhages and the LargerHcemorrhages.
The
as
multiple and sharply defined.
punctate he describes
A careful article,touching this subject,by Pick1
has fallen
notice.
under my
Pick, by a macerating method, separatedthe

also

"

"

"

"

we

the

from

substance

brain

he
considering,

arterial tree

found

thus, in

such

cases

as

that

apoplexieswhich were mortal

miliary aneurysms.
ruptures larger than

are

from
always came
The
miliaryruptures
"

in circumvascular

"

he divided

into

(1) blood

clots confined

of small

strated),
twigs (as Kolliker first demonthat is, false dissecting
to be distinguished
aneurysms,
from
Charcot's
:
miliary aneurysms
; (2) dissecting
aneurysms
had
of these in his specimens many
ruptured, and clinically
of death
Pick conhad
caused
transient
siders
palsies. As causes
the
that
importance of these small haemorrhages has
been

spaces

overrated.

and, in the

after

says,

of

brains

the

in

months

or

often

are

Out

origin.

with

attention

an

distinction made

no

another, he
scattered
cases,

to

describes

in

says

between

kind

one

of

haemorrhages. Vaquez,4
these vertigo and
repeated
"

Dr.

characteristic."

as

the

cause

of

John
of

death,

on

course) small

high-pressure
rhages
haemor-

Gaskell,5 from

another

with

man,

in which,

cerebral

fresh

primary

tracted
con-

atherosclerosis,

extensive

and

I will

of arteriosclerosis and

lesions

other

(among

the case
point of view, mentions
kidney, a large heart,

whom,

by Naunyn

interesting
paper

seen

probably

testimonies

cerebral

are

in

such

more

be

to

of

of many

minute

years

explained,are
quite satisfactorily

vascular

walls.

tiny sclerotic patch ;

insane, islets

with

sacs

which, although not

direct

contained

representedonly by

be

haemorrhagesmay

never

are

Robertson2

Forbes

Dr.

They

haemorrhage

was

Pick, Berl. klin. Wochnschr., Feb. 21 and 28, 1910.

Dis. p. 335.
F., Path, of Mental
Samml.
Ser. xix. Heft i.,1905.
Naunyn, Volkmann's
Robertson,

avril 1913.
des mal. du cosur,
Vaquez, Arch,
Gaskell, J. F., Thesis for M.D., 1912 ; see
1911 (case No. 39).

also

Journ.

Path,

and

BacL,

SYMPTOMS

422

evident

"

but

gangliaand

ARTERIOSCLEROSIS

OF

old

many

found

haemorrhageswere

ovale."

centrum

PART

And

in the basal
other

here he alludes to four

(ofhis own) of death by apoplexy : in the second

cases

found

were

haemorrhage)signsof multiple
old haemorrhages in the basal ganglia; in the third such signs
in the rightlenticular nucleus, and an old
apoplectic nodule
in the putamen
; in the fourth, old haemorrhages in the pons,
(besidesin all the

the fresh

cases

"

ovale,and

centrum

apoplecticnodule
remember

we

in

not

these

cases

with

concern

any

nucleus

same

are

the

cited

present

in

strikinglist
another

old
when

argument

question.

About

ten

of my
one
pupils kindly looked up the subject
ago
in the records of the Manchester
Royal Infirmary (but

years

for

that

the

in the fifth,an

; and

lenticular nucleus
in

"

me

forgot to sign his report, now

on

10

of the

out

multipleold haemorrhages;
found in the pons in 5 cases
they were
; in the basal gangliain
3 ; in the cerebellum
in 1, and in the occipital
lobes and
bellum
ceremention
in 1 case.
Other
observers
a
proclivityto
cortiny haemorrhages in the pons, accidents which find some
71

collected he found

cases

roboration

in

is the evidence

mention

file)
; in

my

clinical histories.

our

of morbid

of

Now

May

anatomy.

such, and
not

we

much
then

more,
assume,

of
that in the vast majority of cases
any rate provisionally,
this high-pressurekind, cases
of hyperpiesiaor chronic
renal
at

disease,transient
Let

us

of all of
prove

by

turn
us

signifysmall haemorrhages?
clinical experience: is it not the experience
transitorypareses, aphasicand otherwise,

pareses

back

to

that these

their issues to be

oscillation of molecules

no

within

mere

swerves

of

function,no

limits of tissue

mere

consistency,nor

maladaptations of stiffened vessels, but to be premonitions

of mortal apoplexy. Unless overborne
the
at
heart,
incidental event, do not these patients,
cut off by some
or
practically
all of them, die later of a largerhaemorrhage,a haemorrhage
?
of which
attacks were
the slighter
forerunners
Dr. Pruen, in
summing up his paper (loc.cit.),
slightstrokes are always
says,
followed by ordinaryones"; meaning, no doubt, other accidents
complete in which
apart. Thus no case of the kind is clinically
the later historyis not given.
In comparing the hemiplegicwiththe unaffected side,Huchard,
often much
who in haemodynamics was
the
to seek,said that on
even

mere

"

CHAP,

CEREBRAL

vi

affected side the pressure

other

HEMORRHAGE

falls to

423

"hypotension";

while

on

the

the

This condition
he
originalhigh pressure continues.
names
hemihypertension." Such partialstates are of course
could extend
impossible; no such contrasts
beyond a vasomotor
change of diameter in the radial of either side, a change
by which the systemic pressures would be quite unaffected.
I have
remarked
that these transitorypareses
often
are
other forms.
In one
aphasic,or alalic ; stillthey appear in many
of well-established
case
hyperpiesia I detected several small
visible haemorrhages under
the skin
no
rare
discovery
very
and on examining the retina I saw
minute
a
haemorrhage there
had
also. There
been no
complaint of vision in this case, and
there was
renal complication; the singlesmall haemorrhage
no
the only visible eye lesion.
wella
was
Epistaxisis of course
known
signalof high blood pressure (p.442). In an extract from a
French journalx it is stated that in the course
of repeatedlumbar
of some
of high blood
to relieve the headache
cases
puncture
evidences
frequent
inof
not
meningeal haemorrhage are
pressure
fluid is stained
with
blood, and haemoglobin
; the
of older
red corpusclesmay
be found
in it,the
remnants
or
haemorrhages." To discover red corpuscles,or haemoglobin,
20-25
cc.
are
required; but in high-pressurecases the cerebrospinalfluid often jetsforth in relatively
largequantities.Dr.
Riesman,2 in discussingthese haemorrhagictendencies, thinks
that mere
high pressure with arterial disease is insufficient to
produce them, and bringsin a hypothetichaemolytictoxin as an
opinion; but
auxiliary. Some other observers are of the same
"

"

"

"

"

"

Riesman's

was

of cerebral

cases

many

the

attention

cerebral

concentrated

upon

renal

cases.

haemorrhagein hyperpiesiait

arteries,
even

near

the rupture, shew

is true

no

In
that

signs of

necrosis

(p.429, Charcot).
One other critical point there is,a pointupon which Gushing
dare
not
that
of Baltimore
laid much
we
emphasis, one
of an
forget,although at the moment
apoplexy the recollection
of it may
be somewhat
embarrassing; this is,that under the
compression of a haemorrhage the generalarterial pressure may
rise from
1

La

an

average

Tribune
2

level

med., Nov.
Riesman,

Amer.

enormously (even to 250-300), in order

24, 1906
Journ.

quoted
Med.

Med.

Sci., Nov.

Rev., Feb.
1907.

1907.

SYMPTOMS

424

OF

ARTERIOSCLEROSIS

for life'ssake, to force blood

into the bulb

PART

blanchingunder

pression.
com-

The

this inordinate
be, whether
embarrassingdilemma
may
rise of pressure
is such a purelyconservative
feature of
the moment,
is the obstinate continuance
of a long period of
or
The form of the heart may
gnosis,
high pressures.
help us in this diaand to decide whether
Stillthe problem
to bleed or not ?
is often more
difficult. For instance, in a severe
of apoplexy
case
in a man,
with Mr. Grellet of Kitchen
I saw
an
aged 64, whom
attack which
visit was
of eight days' duration, and so
on
my
still torpidsevere
that, besides a left hemiplegia,the man
was
Mr. Grellet said that on
the first day of the seizure the pufee
"

"

was

one

of the hardest

he had

ever

felt."

Now

this

was

not

merely compensatory, for this state of the pulsehad been recognised

for
time
and observed
little
before.
some
by Mr. Grellet
So with
this knowledge venesection
might well have seemed
this patient was
called for. However
not
even
or
justifiable,
bled ;

and

second

day

consultation

was

of the attack, Mr.

called because, after the first

Grellet found

the

or

pulsesoftening,
and this so much
his apprehensions. We
to arouse
as
judged
by the touch and by the stethoscope(we had no gauge at hand)
that the blood
had
fallen decidedly; the pulse had
pressure
softened, the aortic second sound thinner, and the impulse of the
The
heart more
diffuse.
heart was
dilating. Had the patient
been bled, this change might have been attributed to the operation
indeed
in
this
venesection
have
been
harmful.
case
might
;
Whether
at length the heart was
under
or
failingintrinsically,
the cerebral oppressionindirectly,
it was
not
to say.
(I
easy
have no note
of the issue.) Celsus shrewdly remarked
that in
these reflections
apoplexy to bleed cured or killed. However
somewhat
are
digressive.
the
of
On
cerebral
pathological modes
haemorrhage,
why cerebral haemorrhage is very frequent, while coronary
the
on
haemorrhage is very
rare,
part miliary aneurysms
in the event, again on
the allegedseasonal
take
prevalence
of apoplexy, and
than
is
to say
so
forth, I have no
more
and
recorded
in the books
the disposalof all of
at
essays
I may
allude again
us.
But, in respect of blood pressures,
to the comparative frequency of seizures during the night,a
of angina pectoris,to a
tendency attributed,as in the case

CHAP,

PNEUMONIA

vi

I know,

as

it may

Or

we

have

be

due

and

Janeway

rise of

nocturnal

supposed

liable than

other

observation

which

ranged

about

verification
the third

200.

trial the
:

Pneumonia,

hyperpiesia;

critical

to

with

tide.

more

pressure

an

of all unstable

published a

60, with

Pal,

few

years

arteriosclerosis and

nephritis. Her systolicpressures ordinarily

One day she complained of severe
headache,
read at 250, even
little higher. For
a
was

I have

taken

was

three

times

being read she

haemorrhage.

was

fatal cerebral

the

far

so

such

of

know

we

was

set.

woman,

record

as

of

excesses

what

case

pressure
the observation

unconscious

R. F.

evidence

); but,

recumbent

remarkable

interstitial

the

have

of

21

position. As
pointed out, hyperpieticsare

accords

chronic

when

the

persons

equilibriums. A
ago, by Jackson,1

(see p.

pressure

definite

no

to

others

425

said, is

no

is

followingcase

of many

business

the

instances

on

floor

intervention

uncommon

one

on

while

in

:
"

man
good trencherof whisky a
Four
five ozs.
and
or
day.
Went
Sent
to
of Harrogate.
to
Harrogate
me
by Dr. Roberts
for eczema.
his pressures over
170.
Dr. R. found
High frequency
little service.
and
other spa treatment
current
During following
winter
No
in
muddled
tinnitus, no deafness.
feeling head, dizzy.

C.,aet. 61. Obese.

heavy smoker.

keen

fell

man.

200,
insecurityin walking. Systolicpressure in my room
careful
but with care
sustained.
Most
Pulse
180.
down
to
brought
for renal disorder, but urine
examination
had been repeatedlymade
No
1015-1030
albumin, no
tion.
constipaalways between
sugar.
; no
Afterwards
for age.
Heart
rather big,but arteries not bad
Sense

of

I heard

from

Dr.

R.

that

later

year

he

had

had

slight stroke

hemiplegia; from this he recovered so far as to return

to a mild
of golf,but, after again a year'sinterval, he was
game
attacked by acute pneumonia and died.
with

transient

For

convenience

symptoms
The
need
us

symptoms
no
over

much

of

the

of

contrast

nervous

of decrescent

system

in

now

bring forward

Decrescent

the

Arteriosclerosis.

taken
arteriosclerosis,

as

whole,

it would
because
carry
long description
; fortunately,
It
is
not
function.
whole
the
sphere of bodily
is well recognised and
the condition
needed
because

Jackson, J. M., quoted Lancet, March

Sura. Journ., Feb. 26, 1903.
1

I will

28, 1903, from

the Boston

Med.

and

SYMPTOMS

426

OF

ARTERIOSCLEROSIS

PART

familiar ; and

again because in character its symptoms are for

the greater part negative,and consist in a drought of the body ;
in failing
of organs such as the cardiac, the renal,the
irrigation
the gastro-intestinal,
the
and the rest : we
note
cerebro-spinal,
withered
skin, the shrunken
limbs, the shufflinggait,and so
forth.
Or in the more
rapid cases, often rather premature in
consist in a kind
of progressivecachexia, with
age, it may
pallorand emaciation, the arteries presentinguniversal rather
than local degeneration.
An eminent
physicianwrites, Granular
kidney, up to the
(ofapoplexy) pretty equallywith
age of 60, divides the honours
?
atheroma."
What
cent
atheroma
Certainlynot with the decresmode.
Let us then consider brieflythe cerebral palsiesof
"

decrescent

the
arteriosclerosis,
pressures,

and

mode

not

them

contrast

with

with

correlated
of

those

high

ordinate
in-

blood

Broadly speaking, the plain distinction is that

the palsiesof this mode
not
are
hsemorrhagic but atrophic.1
it is usuallyinto a patch
When, rarely,haemorrhage does occur
previously softened by arterial decay, and is not a primary
it is not
of palsy or dementia
accident
cause
as
an
; indeed
had been
for usuallythe vascular supply to such an area
common,
already obstructed or cut off. The finer twigs are very readily
blocked
or
by tumefactions
shiftingparticlesof decay. Stiff
pressures.

the

as

slow

artery in such
and

small ;

cases

often

be, the blood

may

the

does

heart

is often

stream

exceed

not

10-12

weight. In high pressure cases, on the contrary, in

of ordinarycerebral haemorrhage in the Manchester
the 64 cases
Infirmary,which I have quoted as obtained for me by an old
pupil (p.422), the heart was
hypertrophied,with or without
in the rest
It was
dilated simply in 5, and
dilatation,in 52.
Of the 64 cases, the kidneys were
normal.
called
granular in
"normal."
40; in 24 they were
inmates
The great proportion of arterial disease among
Dr. Mott,
asylums is not associated with high pressures.
in

ounces

"

"

"

Prior

et

perpetua
excaecari, tanta

si negas
simos
coloratos
.

ita

ad

myriades enim
Phil
Trans.,

(says Haller)
eorum

vasorum

liquoresnegent admittere.

arteriolas
vasorum

n.

"

306.

minimas
nunc

minus
caecae."

"

excaecatio

est

arctitudo
.

humoris

ut

vasorum

aut

"

injectos etiam

Angustia

et duritas

venit, et
Haller, loc. cit. He

vi

tenuis

arteriarui

debiliori.

refers to

his Art.,

SYMPTOMS

428

OF

ARTERIOSCLEROSIS

PART

constipation,yet Dr. Mott finds in asylum practicethat

on
sanguineous apoplexy is marvellouslyinfrequent,abundant
of atrophicpalsies
the other hand as are the cases
due to arterial
males the
degeneration. In his 160 necropsieson atheromatous
moderate
heart reached
a
hypertrophy only in a few, and a
marked
the
hypertrophy in two only ; and in 140 female cases
much
the same.
results were
Although high-pressurecases
of a class which
drifts towards
the pauper
not
are
asylum, yet
the theatre people,the Covent
at Charing Cross Hospital,
among
Garden
porters, persons engaged in the liquor traffic and so
forth,where the hyperpieticform of disease is more
common,
Dr. Mott
found
frequent. Of 60 such cases of
apoplexy more
after death, only about
one-half, in his
apoplexy examined
opinion,presentedrenal disease.
Marie,1 in an interesting
study of the morbid anatomy of the
kind of cases
classed by me
decrescent, while agreeing that
as
in them haemorrhageis not the cause
of hemiplegia,demonstrates
of its causes,
in a lacunar process : irregular
its cause,
or
one
cavities are
formed
of atrophicsoftening,
of sizes from
by areas
to

millet

seed

to

often be
may
arteriosclerosis.
To
dozen

or two
up to a
pea ; one
in the central ganglia,always with

detected

atrophieshe attributes especiallythe smaller palsiesor

in such
is it not
parsesthesias
subjects. And
possiblethat,
solution of continuity,swoony
without
sensations
and passing
be due to a loss of the adaptive capacity of
apraxias may
and
of taking up
the cerebral arteries, a capacity in health
balance
with surrounding vascular
restoringenergy in mutual
We
all of us, I think, disposedto suspect more
than
are
areas.
arterial decay in
softeningof the brain
; something more

these

"

"

"

universal

and

"

intimate; but decrescent, or in

arteriosclerosis

marks
the

arterial disease

pressure cases
but stream
velocityalso
2

of

large part
is better

the

is not

some

cases

process.

only

maintained.

toxic,

In

high-

less obliterative

Likewise, Dr.

argued, if a twig is plugged,its neighbours

ansemiate
be overcharged and by pressure
for the moment
may
No
uniform
surrounding tissues,causing transient symptoms.
George

tautness

Parker

has

of the vessels of
1
2

Marie,

part would
Rev.

have

this action.

de mid., 1901.

Parker, G., Bristol Med.-Chir.

Eeview, March

1909.

H. W.

CHAP,

DECRESCENT

vi

Cook1

PALSIES

429

truly of the cerebral disorders

sclerotics without
Such
high pressures,
an
at
the
frequentlypersistsfor years, even
with an unenlargedheart, or perhaps with some

of

says

"

without

albuminuria, and

frequent in

is not

these

with

fair

these

arterial alteration
of

ages

cardiac

general health.

which

arterio-

65

or

70,

atrophy,
Apoplexy

typicallyrepresented
and
women
overwork
tobacco, alcohol,syphilis
by
do not
often complicate the picture." He
adds
that though
brittle enough to break in the fingers,
the vessels may
the
prove
135-160
systolicarterial pressure is usuallybetween
; in some
These cases
Cook contrasts
"with the apoplexies
cases
only 120.
cardiac dilatations of big eaters," a contrast
which I have
or
on
Indeed
said my
Cook
virtuallyaccepts my clinical and
say.
Charcot, in his chapter on
pathologicaldistinctions of 1894.
had said that these are
miliarycerebral aneurysms,
infrequent
in senile brain
with
obsolescent
sclerotic arteries,
softening
in which
He
added
cases
sanguineous apoplexy also is rare.
that it is in high pressure
that miliary aneurysms
be
cases
may
obvious
cerebral
found, and result in an
apoplexy without
arteriosclerosis
i.e.,high systemic pressures tell hardly even
fairlygood vessels so slender as the cerebral (p. 423).
cases,

are

in whom

old

"

When

transient

pareses

in decrescent

occur

arteriosclerosis,

less complete obstruction,in part

or
they are usuallydue to more
by thickened intima, and not attended by pressure symptoms.
be simulated
effort,with
They may
by lack of concentrated
slowness

of utterance
2

or

other

class,Dr.

Russell

heart and

feeble circulation

aphasia
climb

the

at

he

(p.417).
after

Grimsel, when
himself

found

I have

attributed

response.
transient

unable

already referred

to

to

the

Of
a

ask
kind

Thus

in

case

of this

to weak
speechlessness
this kind was
Tyndall's
fatiguingand perilous

for his supper.

instruction

given to

me

Edinburgh (see p. 38), researches on which

to throw
more
seem
lighton the siltingup of the peripheral
vessels in decrescent arteriosclerosis. Lister perceivedthat blood,
tion
of some
its issue from the body, clots because
physicalrelaon
by

Dr. John

between
in contact.

Tait

of

it and
Freund

external

of Vienna

surfaces
first showed

with

which

that

Med.
Assoc., Jan.
W., Journ. Amer.
15, 1912.
See Russell, H., Lancet, Nov.
H.

Cook,

the

the
1905.

it

comes

blood

of

SYMPTOMS

430

ARTERIOSCLEROSIS

OF

venesection

be
may
is not
vaseline, which

kept

fluid

by smearing
by the blood.

wetted

PART

the

basin

Dr.

Tait

with
made

experiments on the adhesion of defibrinated blood to

the cells of
liningof the blood vessels ; as also between
blood
and
organic and inorganic surfaces and particles.

many

the
the

and

Tait

Hewitt

material

estimated

then

in the

the

of the

liningmembrane

to the
came
briefly,
lipoid-membrane
"

; while

of

aorta

vascular

that

and

Campbell

the ox,

and,

endothelium

Tait found

is

the

same

with
cavities,contact
lining of the serous
which
does not bring about coagulationof the blood.
(So far,
at
concerned, Tait thinks it improbrate, as rabbits are
able
any
meniscus
would
be formed
that a concave
by the blood in
to

the
of

be

of

conclusion
"

of ether-soluble

amount

true

half -filled

the

aorta.) The

to
platelets,

blood

"amoeboid"

so-called

which

movement

the initiation of

clotting
sible,
a
phenomenon, being irreverlike the spreadingof a raindrop over
a
stone, and due to
adhesion
between
the plateletand, say, the
greater molecular
surface of a glassslide than between
plasma and the same
glass
does not take place on lipoidsurfaces,
surface ; such movement
must

be referred,is

because

there

fashion
Now

Tait

if

we

the
adhesion

Naunyn)

simple contact

sufficient molecular

no

adhesion.

In

similar

partlyexplainsphagocytosis,and even
diapedesis.
that
in
of
the
vascular
thelium
endodegeneration
suppose
lipoidqualityis removed, impoverished,or altered,
thrombosis

and

Authors

is

structures

would

diseases of the

on

have

follow.
nervous

of late drawn

system (Gowers,Dejerine,
attention

enfeeblement
of
weakness
patientcomplainsof increasing
and insecurity
of gait not due to neuritis (Erb's Dysbasia
of parsesthesias.This
often
angiosclerotica)
shuffling
; and
and
face
or
totteringoften accompany
precede the vacuous
and other signsof senile dementia, but it may
be well marked
the

legsin old persons.

in

persons

cases

who

more

The

retain

their

mental

effects of disease of the arteries of the

doubtful

due

to

cases

and

vacuoles
1

See

faculties.

be difficult clearly
to discriminate

it may

atrophy

to

is

similar
one

of

no

cause

legsand
however

some

between

the

such

the local

the effects of

spinal

distinction

in

great practicalimportance. Both

tinyhaemorrhages(consequentupon
also article

In

by myself

in 1st ed. of my

arteriosclerosis)

System of Med.

CHAP,

DECKESCENT

vi

found

been

have

in the brain and

of advanced
well known.
of the limb
after branch
or

other

here.
description

Such

are

then

between

the

chronic

renal

in which

local symptoms

vessels of the

cramps,

"

and

These

the mischief

their

in the vessels,causing

aching,darting,and

causes

tingling.

familiar

too

are

need

to

nearlyalways of my decrescent
attended
with high systemic blood pressure.
not
is the contrast, as regardsthe effects upon
the brain,
arteriosclerosis of high pressures
(hyperpiesiaor
cases

are

disease)and the decrescent

the

far I

How

with

miseries

symptoms

class,and

The

legs are
If a largeartery is suddenly blocked pain and palsy
intolerable suffering
if branch
cause
may
; especially
be occluded
and perhaps inflamed,and an ischsemia

pains and
such

But

431

spinalcord.

arteriosclerosis of the

neuritis associated

PALSIES

generalarterial pressure
have failed to impress this
is only too manifest.
For

great eminence,

whose

one

hold in respect,wrote

mastery

mode

of arteriosclerosis

is not

notably in

distinction

upon

excess.
temporaries
con-

my

instance, a physician of

of clinical medicine

all

we

long ago, concerninga certain patient,

follows :
The
70 years
old, presents the
as
patient,now
old age
arteries of extreme
not only atheromatous
but calcareous
and nearlyrigid,
and his radials are sigmoid and tortuous
;
indeed they are fragile
mineral tubes
condition
a precarious
of these
arteries may
one
causing
rupture to-morrow
has gone
Now
from what
before it will
apoplexy and death."
be seen
to be
that, supposing the case
as
one
probably it was
arteriosclerosis without
of decrescent
high-blood pressures and
in him
not
a
hypertrophied heart, cerebral haemorrhage was
Such
have seen
as
we
likelybut an unlikelyevent.
persons
often survive to long ages in health,
e'-x/roz/re?
7%"a? avtovvpov
But
and even
what
with fair mental
happen to
energy.
may
not

"

"

...

"

"

"

"

"

the many

of

enough ;
decay and

but

this class who

are

less fortunate

Palsies

rarely by sanguineous apoplexy.

choke

or

detached

bits of them

are

Their

often
vessels

swept forwards

and more,
and
velocityfalls more
of
is eroded, many
the endothelium
loses its lipoidelement
or
In
these
the smaller
channels
are
occupied by thromboses.
of functional failures,
degradationsand atrophieslie the causes
accumulative
or
definite,partialor general,sudden
or
;
vague
and of disordered sensory
failures of mental
and bodily energy
as

emboli

or

infarcts; and,

as

SYMPTOMS

432

and

functions.1

motor

ARTERIOSCLEROSIS

OF

And

haemorrhages,if any,
already in decay ;

in these

consecutive

processes

small and

are

PART

sporadic,and

their effects,if attended

bral
cere-

break

into

with

vertigo
and transient confusions, rarelyissue in the deeper degrees of
In age
collateral circulation is not ready ; new
vessels
coma.
hardlydevelop as in youth ; and except in a few places,such as
the circle of Willis or the palmar arch, the arterial system is
The followingis an example of the mode
not rich in collaterals.
of hemiplegia in decrescent
atherosclerosis :
areas

"

F. set. 79.
This

Seen

failed

arm

blurred
as

17, 1907, for palsy of the rightarm.

gradually,she
halting,but

and
words

her

December

dropped things;

not

so

and

fit of any kind, but had paraesthetic

sensations
in other parts. Rather
lachrymose at times, and

in the

came
be-

speech

to prevent all
as
lost consciousness

Never

correct.

were

far

tion,
conversanor

had

limb,

and

attention

tinuous.
discon-

contracted a little and refailing.Right arm

flexes
and leg colder than left limbs ; no
exaggerated. Both arm
palpable pulse in smaller vessels on either side. Radials, tibials,

Memory

thick

etc., very

and

heart

apparently

On

few

could

be found

That

less.

the media
one

occurs

only

was

is prone
to
known, but of the

arteritis
Syphilitic
obliterative

and

of

130,

pressures

about

1020;

albumin

noted

ranged
trace

blood

no

sugar.
no

casts

time.

at any

is well

obstructive

in

Urine

normal.

haemorrhage

disease
know

occasions

Brachial

tortuous.

in

occur

of its

manner

of the

cerebral

cerebral

effects rather

diseased

process.
rather in vascular

arteries.
syphilitic
Ophthalmic Signs.
much.
Light-stop may

Thus

it is that

gumma

than

The

as

in
a

occurrence

we

vessels tends

than

alone, of these thin vessels all three

syphilitic

to

coats

necrosis
are

to

of

involved

syphilis
haemorrhage
direct outbreak

from

of the

pupilsdoes not help us

indicate
in
a
syphiliticsource
; but
is not surprisedto see the pupilsmore
atherosclerosis one
less
or
contracted ; they often are
so
during Cheyne-Stokes breathing;
reactions are sluggish. There seems
the pupillary
to be some
or
"

relation

pressure, by
the iris,
may
may
1

See

blood

between

dilate

state

and

pressure

size of

and lengtheningthe
straightening
the pupil ; as converselya
narrow
it

good study

(Waller). Even
of

subject by Cramer,

in

aneurysm

Deutsche

med.

pupil; rises
spiralvessels

of
of

fall of pressure

it is not

always

Wochenschr., Sept. 1909.

CHAP,

OPHTHALMIC

vi

to

easy

the

express
the

on

pressure
I have

been

the

to

pupils in

assertion

to

seen

that this is the

and

variable

433

of

terms

mechanical

sympathetic.

alluded

vessels have

SIGNS

contract

datum

one

hypothesis. It

is therefore

the observation

may

have

that

for

atherosclerotic

while in spasm
(p.416),
for the cerebral vascular spasm
a

precious. In

been

retinal

true

; but

bear

must

we

instances

rare

very

in mind

that

arteries are
impressionsfrom highlyrefractory
apt to be
deceptive. How is it that spasmodic capricesof vision are not
of only one
based upon
direct
more
case
frequent? I know
evidence, and adequately described, viz. Wagenmann's case,1
relied upon
In a patient
by Pal to carry a very heavy burden.
with arteriosclerosis (including
the retinal branches)these vessels
shrank away,
so
we
told, into fine shiny yellowishpulseless
are
threads ; and the veins also emptied. The attacks, during one
of which
this was
produced blindness which lasted for
seen,

about

minutes, then the vessels filled

ten

before.

as

But

the

subsequenthistoryis not given. Now in other cases, of similar

later stages proved that the refilling
of the vessel was
history,
but temporary, and a complete and soon
afterwards
permanent
occlusion
certain

of

established.2

was

from

cases

wrote

his

of mine, most

own

"In

Fisher,to corroborate

kindlysent me records
spondence
note-books, and in a subsequentcorregeneralterms I do not think that we

publishedremarks

some

Herbert

Mr.

constricted and
sclerotic artery
a
a
distinguishbetween
unless in blockagecomplete or partial." Mr. Fisher went
to say that
on
a
recurringattacks of
historyof transiently
in cases
which subsequently
amaurosis
is not uncommon
present
themselves
obstructed
with
all the features of an
artery."
can

"

..."

big

The

sclerotic

of blood

stream

tunics, its lumen

silver wire

or

before

as

not

may

be

artery
the

sclerotic

carry

may

changes

I do

constricted.

as

in its
think

not

Thromliable to spasm." ..."

especially
bosed branches
(showing)white lines with -a threadlike red line
in their centre, are
quite different,and easily distinguished,

that such

from

are

sclerotic arteries." ..."

See

Wagenmann's

Grdfe'sArch.
2

arteries

See
VOL.

in
Circulationstorungen

xliv.,1897, p. 219.
James, Discussion of the

dem

would

not

Netzhautgefasse,"

Bd.

Taylor
I

"

paper,

Ophthalmicsurgeons

Ophthalm. Soc., April 24,

1913.

SYMPTOMS

434

with

agree
'

the

OF

of

renal

described

arterial spasm
and
Elschnigl

poisoning,in

which

fibres of the

vessels

events

same

'

opinion that

pathognomonic
;

ARTERIOSCLEROSIS

lead

retinal

I have

reports spasmodic

disease

he

the

in

the

by

brain.

in

the

that

know

we

lead

muscular

poison,and
But

are

the reference

not

that

have

to

amauroses

suggests

irritated

are

arteries

is said

Benson

in the retina, but

happen

may

'

silver wire

disease.'5

PART

that

the
in

early,and I think it is very easy

to
over
a
gleaming lightupon silveryvessels. Moredo not hear definitely
of complete vision, and
of return
we
it is at least as
likelythat these amaurotic
phases are results
of variably deteriorating
accidents
branches, with thrombotic
Indeed
complete and incomplete. These accidents are not rare.
the allegedcases
tinguishe
of embolism
of the retinal artery also,2as dispoisoningthe
be deceived
by

from

local obliterative and

accepted with
At

vessels suffer

thrombotic

states, must

be

caution.

of atherosclerotic
ophthalmologists,
sclerosis
later an obliterating
or
subjectspresent sooner
in the retinal branches.3
The arteries change in size, have
a
double outline and compress
the veins at the crossings
; greyishwhite opacities
and streaks of exudation
and possiblyhsemorrhage
from the vessels may
be seen.4
Probably retinal signsare especially
the
in
which
disease
falls
in
those
to occur
cases
early
prone
and mainly upon
have seen
the cerebral system of arteries. We
how
be ; that usually it is not
partialatherosclerosis may
tion
disease invading extensive
and uniform
of the circulaa
areas
be
in quick succession ; the arteries of the limbs
may
least 40

knotted

and

intact

are

twisted

of

nearly

we

are

say

suffer

soon

while

For

so.

of

as

the

extremes

unable

cerebral,

supplieddo not

so

to

or

distribution
cases

cent,

per

to

these

offer

an

of

the

brain

caprices of
explanation. In many
apparent

atherosclerosis

coronary,

and

those

the

obviouslyif the morbid

parts
process

be slow.
1

Lead
2
3

Poisoning,
See

in

arteries
4

(2 cases),Practr., June
Med.

Marple,
System of

decrescent
may

Kober,

be

Wochenschr., 1898

quoted by Legge

and

Goadby,

p. 76, 1912.

Hawthorne

Vide

Rolleston's
that

med.

Elschnig, Wien.

Record,

March

1907.

16, 1907

vol. iv. p. 621, 1910.

atherosclerosis, not of renal

seen

Verschluss

Med.

sooner

or

later in most

and

Mott,

My
vague
origin,disease
own

cases.

der Netzhautzentratarterit,

Leipzig, 1913.

in

Allbutt

and

impression is
of the

retinal

SYMPTOMS

436

terminal

of the

away
and

mainly by the variations

separate nephritisfrom

can

we

tension,and from the senile form

form
is

the oedema

changes are
probably mainly due to
is

in these

arteriosclerosis

things that
with
high

of arteriosclerosis.

In this last

but little seen,

deficient

be marked

to

apt

more

their tissue connections,

is

It

"

arterioles from

PART

the veins.

on

pressure

ARTERIOSCLEROSIS

OF

the

and

degeneration
tion
degenera-

nutrition ; and

the macula

at

four

than

in other

parts

of the retina.
"

almost

but Holmes
treatise,

Your

interests

question concerning
greatly. I have seen

me

retinal

of the
spasm
also seen
have

retinal
as

to

Mental

but

disease

to

the eye

stroke, does

"

his

with

or

arteriosclerosis ;

and

in such

to

the

suspect,
is due,

cases

where
beginning some-

434).

The

childish
may

do.

hyperpiesiaor
well

I have

the

part of the brain

or

vacuous

The

mind

said

as

slow

not

of chronic

before

disturbed

for

us

the

after

renal disease.
dwell

(p. 382), dark

by irascible or
apprehensions or glooms ;

tion
dissolu-

characteristic

characteristic

to

we

decrescent

inexorable

oil-drylamp,

known

heart

or

hyperpietic,unless

atherosclerosis,is

is too

as
hyperpiesia,

the

on

contrasts.

cerebral

disease

over

of

experience,spasm

in the vessels

161

faculties,the

atherosclerosis of

brood

due

Cerebral

become

not

mental

decrescent

renal

in

(see pp.

arteriosclerotic does,
of

arteries

standing
haemorrhage then is the outand of chronic
of the atherosclerosis of hyperpiesia
kind, cerebral atrophy. As
; of the decrescent

further

some

retinal

amaurosis

temporary

obstructions

regards other symptoms

find

the

of

spasm

in

is associated

Symptoms.
event

renal

said

said, that the ebb of the blood

spasm,
behind

require
something about

retinal arteriosclerosis."

implies that,

arteries

I have

not

where

with

Paton

Dr.

would

early arteriosclerosis ; but I

attacks of a migrainous character

arteries

cases

associated

were

I have

and

forms

two

referred to.

I have

it in the paper
"

the other

between
distinguish

To

of

of the
Chronic

it ; in
upon
shadows
may

despondent

clouds which
by ceaseless
evening.
gather especiallyof a forenoon, and lift towards
melancholia
These disorders may
a
engender obsessions,or even
amounting to insanity,but not in my experiencethe delusions

moods,

or

MENTAL

vi

CHAP,

SYMPTOMS

437

and

peculiarfeatures of paranoia. Some years ago, Dr.

Craig,beginning from the side of insanity,in his M.D.
of very
careful
Cambridge, published a large number
which
which

may

which

and

Dr.

done

much

main

he agrees

careful work

of melancholia

name

disease

Wakefield

of the

Melton

mania,

the

tells me

pressures,

of

normal

Asylum, in his
Dr. Craig'sconclusions
Asylum, who has

corroborated

blood

on

below

or

Craig and Bodington.1 The

serve
high pressures
may

with

"

that in the

followingcase
as

instance

an

point :
Seen

After

with

Dr.

well

remorseful

herself

(not

of

Campbell

temporary

some

looked

and
to

of the

Longworth

with

about

the whole

on

tions,
observa-

in this respect differed from

Bodington, then

thesis in 1903,

M.D.

was

"

thesis at

"

melancholia

convenience

present
and

that

usually ruled

pressures

Dr.

mean.

in

for

pass

indicate

to

arterial pressure,

high
in

seemed

"

Maurice

and

ailment

Then

all sorts
fixed

nor

made

fat.

rather

feelings;
voices

Cambridge.
slow

Mrs.

W.

recovery

(set.42?).
gained flesh

became

of evil

delusions).

and
sleepless
suggestions spoken
Much

in

worse

prey
within

morning,

better after tea.

Physical examination, etc.,negative,except a very

radial artery ; by laying the length of the
wiry
fingeralong it,it was hardly to be arrested,it forced its way beneath.
Heart
two
fingersoutward, beating heavily ; second aortic sound
hard

contracted

loud

and

No

thumping.
specific
gravity.

very

Other

observers

this rule

be

high

that

of

some

the

prevailare but
they should show

pressures

if so,

deobstruent
other
too

and

often

are

profound,
medication

such

decrescent

stages which

met

we

without
is

themselves

of

by

high

measures
cases

often

melancholia

the

is not

of

which

with

less,to

or

the

of littleavail.

prove

of melancholia,

pressures,
Some
little service.

It

high
hyperpiesia;

more

in contrast

ciated
asso-

universal.
in

amenable,

good

accept

is often

malady

blood

to
arteriosclerosis,

in

terms

of

cannot

we

of melancholia

cases

dietetic treatment,

in which

cases

that

the correlation

pressures

; urine

casts

nor

shown

have

qualification
; if

without

with
may

however

albumin

even

in

which

of

these

acute

many

Only
and

alterative

belong

to

early stages of senile dementia,

precede imbecilityby

Longworth, private letter, Feb.

some

years.

26, 1909.

In

these

SYMPTOMS

438

obsession, of

than

more

and

the

curable

more

discerned

be

delusion

While

sin.

imaginary

some

generallynoted

I have

patientshowever

ARTERIOSCLEROSIS

OF

of

melancholies, and

only too

indelible type.

or

melancholies,

some

with

attended

whether

many,

not,

or

of

are

rather

condition

melancholic

the

voices,

are

some
more

hipped than
phase than an

obsessions, is usually more

well-marked
and

The

something

and
graver
though he may
depressedhyperpietic,

of arterial pressure

excess

hyperpietic,a state to
therapeuticaltests, yet other

them,

clinical and

by

for instance

I think

then

of

characters

as

PART

have

insane

abiding

have
to
in all such cases
we
derangement. But no doubt
deal, and largelyto deal, not only with the proximate causes,
also with

but

mental

inherited

the

of the

bias

individual

so

asylums hyperpiesishad issued in

hyperpietic
depressiveinsanity. Generally speaking however
call for
to
far deranged as
not
so
patients,if moody, are
off insensiblyinto
shade
seclusionjthough one
variety may
in

that

inmates

some

of

the other.
In
the

very

whether

by

anatomical

in

from

may

in the

arterial disease

The

condition,

former

of distribution,of intimacy,or
peculiarity

some

form,

to

seems

less conducive

and

self-control,
a condition

emerge, and usuallydoes emerge, uninjured,

from the mental
different matter
decay of decrescent

the mind

arteriosclerosis.

the

and

of

besetment

hyperpiesia,this clouding or

mind, and loss of calmness

which
is

in

case,

any

be

thrombosis

to

of endothelium

conservative

more

obsolescence

and

of

; moreover,

ever
high pressure itself maintains a better blood supply. Whatthese morbid
the explanation,
tempers apart, I repeat that
occasional, and
intermittent,
hyperpiesia insanity,if an
in

term

the

series,is

not

Indeed,

feature.

common

very

alternatingperhaps
with periods of fretfulness or depression,
yet frequentlyproduces
increased
of energy,
for a while a sense
even
an
activity.
when
he is becoming puffy on
In later stages, even
exertion,
with
the renal patient is
the hyperpietic here in contrast

as

said,the higher blood

I have

pressure,

"

"

often

and

and

still

capable of

work

and

; too

often

no

exercise
he

drinking.

tend

keeps up

This

little endurance

is not

to

his
at

; he

is not

anaemic,

tion
peripheralcirculawith liberal eating
fitfully,
spirits,
open

out

all the

his

story of the

decrescent

CHAP,

MENTAL

vi

of the disease under

form

irresolute,without
story.

The

defeat,

as

SYMPTOMS
which

mental

the

case

the other

impairment,

be, with

may

hand,

attain

arteries

for his

are

moistened

to

heart

otherwise

he

dieth

decrescent

in

sclerosis
arterio-

notable

loss of memory,

have

various

"

own

marrow."

without

age

notable
we

with

subjectsof
old

green

of

or

faculties

plethora

his

up

deal with

mental
it would

arterial

lesions

in

degree,in the brain or in the

In one
brain.
patient,while the energies
unabated, thick distorted and grittyarteries

are

conspicuous in

are

mental

But

many

persons

distributed
partially
body apart from the
mind

as

without

even

that in these

of the

aimlesslyabout,

moons

enough to make
hyperpieticpatientsdie, of apoplexy

also

seem

man

intention

substantially
unimpaired.
full strength,and his bones
On

the

439

in fair

or

the

limbs

in

another, whose

accessible

good condition,the gradualwaning of one

mental
faculty after another betrays no less conspicuouslya
of cerebral
starvingof the brain,perhaps a common
disintegration
vessel

are

or

cerebral

and

substance.

This

is

cloud,

no

miasma

no

to be

but a creepingmode
of death by inches.
dispelled,
of cerebral
disintegration
spoken purposely of a common
and

cerebral

substance,

in not

because

few

cases

I have

vessel
cannot

one

atrophy is something of a reciprocal

process,
does
united
of
so
organicdecay,
differently
singleor
process
it work
from
the secondary atherosclerosis of hyperpiesis.
out
[n hyperpiesisthe vascular injury,
though grave enough to end
an
apoplexy, is not penetratingenough to sap the organ
but surmise

mind.

that this

In

without

the decrescent

rises of blood

form,

the contrary,

on

hypertrophy,

cardiac

without

pressure,

witness,

we

the
only, in respect of the brain, the lapse of memory,
and
the slow
"rpid apprehension, the blank countenance,
ich, but also the feeble gait and slurringfoot, which suggest

lot

extensive

more

)gether. Finally,I
persons

dnd

; in

Dr.
Mt.

Health

include

two

the first case

perhaps

Brought

and

as

much

hard

up

beer

always good.

Most

fed

as

he
of

of the

limbs

introduced
on

coarse

could

decrescent

days

out

only.

this

old

Always

of doors.

to

man

bread, swedes,
get.

centres

nerve

apparently healthy

of

cases

and

arteriosclerosis of the

extensive

Smith, late of Newport,

86.

pork,

with

decay of vessels

combined

and

little fat

good

Eight

me.

eater.

children.

SYMPTOMS

440

OF

ARTERIOSCLEROSIS

PART

Placid
Voice, hearing,sight all good. Good head of gray hair.
and
intellectual
fairly
(Dr. Smith)
temperament
Sleep? "Yes,
could
hours
of
a
sleep on a clothes-line,
eight
night." Pulse 68.
Radials
like
vessels
Heart
extremely atheromatous,
rough tendons.
trifle
but
No
a
outward,
perhaps
lungs probably atrophied.
sign of
"

"

Sounds

high pressure.
of radials in him

normal.

at least

Dr.

Smith

had

twenty years before

; and

has very cordy arteries (seep. 206)

Inherits
side.
Never
had chilblains,
troubled
with
nor

of
compatibility
long life,the followingcase

Female,
died
found
and

extensive
is

Recorded

set. 100.

maternal

internal atherosclerosis

Savill.1

by

brother,set. 70,

cold extremities.

example

one

his

this condition

longevityon

Of the

found

with

"

healthy old woman

;
of no
obvious
disease,but a few spots of bronchopneumonia
Widespread arteriosclerosis in larger,middle,
post-mortem.

small

arteries in all
The

lumen

; in the

areas

brain

"

to the finest ramifications.

even

everywhere large,in some

districts,
e.g.
diameter.
Heart
rather
common
iliac,to 2J times
small,
The arteries showed
not dilated,structure
the usual
fairlynormal.
intimal thickening,but the muscularis
showed
no
more
degradation
than where
in the dilated vessels it was
correspondinglydiminished

in

was

the

in thickness.

Now

if all this be true, and

their
modes

two

such

of

not

experience,if

arterial

clinical contrasts
are

so,

clinical

own

many

I would

disease
in

essays

ask

this contrast

is here

again

practicalmedicine
on

the

readers

my

cerebral

to

tion
ques-

between
valid

as

as

the
any

be, if this be

can

of

symptoms

sclerosis
arterio-

obscured
it is true,
does

some

contrast

abnormal
cases

? Here and there,

by a lack of this discernment
2
L. W. Weber
deeper insightis to be noted.
the cases
of depression,even
amounting to an
of sin, or some
but not to insanity,
ineptitude,

sense

by

no

But

he does

even

different nature
the

modes

pressures

Dr.

irremediable,with

means

of
and

Alexander

of the

not
two

carry

big heart,

processes

of Aberdeen

the

of senile

the distinction

the
arteriosclerosis,
a

those

one

other

however

nor

does

marked
in these
has

made

back

tude.
decrepiinto the

he

distinguish
by high blood
points negative.
an
interesting

Savill, Lancet, Sept. 24, 1904.

L.
Arteriosklerotische
W.,
Weber,
med.
Wochenschr., 1909.
2

"

Verstimruungszustande,

Munch,

CHAP,

MENTAL

vi

contribution
in

1894, the rises of

salines, the

fall in

which

consists

bursts

These

and

of

he

cases

in

bed, fluid diet, calomel,

reduced,

are

Overfeeding aggravates
with

subject.1 He describes,as I did

with the attacks of depression,
pressure
urea
excretion, and
sluggishbowels.

blood

pressures

mischievous.

441

this side of the

to

together with
By treatment,

SYMPTOMS

and

prolongs

the

subside.

them.

with

contrasts

attacks

and

Hypnotics are
agitatedmelancholia

excitement, which

requirea different treatment,

not
pest
excluding a judicioususe of opium. Yet when at BudaInternational
discussed
Congress,in 1909, the subjectwas
indefmiteness
of outlines prevailed. One
at length,the
same
thenia
speakerindeed did not avoid the confusion of mixing up neuras(vide Diag. Vol. II.,p. 61) with these arterial cases
; an
avoided by Professor
contribution
the
error
Cramer, whose
was
based
most
he, in his argument
a
important ; but even
upon
fusion
previous article of his own,2 did not avoid the prevalentconarteriosclerosis
of taking
as
one
disease, and heaping
collection of cerebral
a 'heterogeneous
togetherunder this name
series and the senile series
effects. Between
the high pressure
he made
to remark, without
distinction,save
no
followingit up,
that in certain of the cases
the heart is enlarged to the left,
difference ?
and the pulsetense ; surelya remarkable
Throughthe separate but tangled
"ut his description
indeed
traces
one
threads of the two
different processes
mingled
indiscriminately
"

together. Another
the high pressure

"

instance
the

and

different in nature, but

of this confusion
senile

is in

paretic attacks,

yet confused

in

one

respect

of

attacks

so

story.

It

is well

perhaps here to utter the warning, which Dr. Stengel3 has

occurring,perchance,in
emphasised, that not all disturbances
of the
arteriosclerotic subjectsare
to be accepted as characters
in arteriosclerosis,
arterial lesions ; a caution specially
necessary
a
malady of elderlypersons who might, as Falstaff said, have
diseases than

more

they

knew

for.

and
See also Alexander
Alexander, H. de M., Lancet, July 5, 1902.
Lancet, Aug. 24, 1901.
2
med. Wochenschr., Nov.
21, 1907 ; the Buda-Pest
Deutsche
Cramer,
1

is

published

paper

have

contemporary
3

in

the

before

same
me

of

journal for September 16, 1909.

only
the Congress speech I have

reports.

Stengel,A.,

Amer.

Journ.

Med.

Sci., Feb.

1908.

The
the

Bruce,

speech
earlier

(fairlyfull)

SYMPTOMS

442

I think
of this
The

I need

ARTERIOSCLEROSIS

OF

not

subjectinto

the time of the reader with

occupy

the

recognised,and

well

so

described,

pursuit

of cerebral arterial disease.

kind
syphilitic

of focal lesions of this

symptoms

PART

speciesare
have

as

well

alreadyso

been

also the

more

diffuse luetic lesions of

and tabes, as to dispense

generalparalysis
with
formal
sclerosis
a
recapitulation.Nor on the effects of arterioof the limbs, as productiveof pareticand parsesthetic
need
I dwell : it is generallyeasy to discriminate
symptoms,
those of central origin. The
these local effects from
alleged
interdependenceof arteriosclerosis and neuritis in the limbs,
in the legs,
I have discussed in another
paragraph (p.
especially
coincidence

304). The

careful observations

is

obscure

an

one

but

have

we

few

it,and probably the association is one

upon

than of wide significance.

pathological
curiosity
Reflexes. Dr. Moncorge of Mt. Dore x says that the knee-jerk
is,within limits,inverselyas the arterial pressure, risingas pressure
falls,and in high pressure cases
diminishing. I have made
this point,and have not read of any other
few observations
on
series than this ; Dr. Moncorge himself confessed he had not data
enough to speak confidently. If his postulate prove correct
it would
in distinguishing
give us one
point more
hyperpiesia
from
neurasthenia
with its heightened reflexes.
I am
under
the impressionthat the knee-jerkmay
increase in the decrescent
of

more

"

of atherosclerosis.

form

when
it occurs
Epistaxis,
early,is a very important symptom ;
often the first suggestionto the physician of the hyperpiesis
It is not uncommon,
but occurs
in
(renalor other) at work.
It may
indicate
the
the
minority of cases.
propriety of

venesection, then

or

at

later date.

In such

cases

carefullyexamined.
and tearfulness
On such early signsas garrulity
of repetition
of
higher controls,as under alcohol

should

"

due

to

retina

due

to loss

be

"

of

the

and

loss of memory,
and

familiarlyknown,

so

forth,I need

signifythe

not

decrescent

dwell

old

stories,

they

are

of arterial

mode

disorder.
and torpor is well
Sleeplessness
of

"

arteriosclerosis
Moncorge,

date, but I think

Rev.

"

known

in all its modes.

med.

I received

de Mt.
them

Dore.
in 1902

The

(?)

as

Whether
pages

symptom

common

by

forwarded

overpressure
to

me

bore

no

SYMPTOMS

444

OF

renal disease in which

such

periods of

with

attacks

PAET

complete (p.407) ; in another

Cheyne-Stokes respiration,
repeated

was

recovery

also with

case,

ARTERIOSCLEROSIS

these symptoms

witnessed

were

again and

of
again,until the patientat last died of apoplexy. In none
the preceding attacks did any
tions
paresisappear, and the indicabe of haemorrhages but
seemed
not
to
of phases of
excessive blood pressure
lastinga few hours at a time.
and
Certain
discomforts
of arteriosclerosis,
paraesthetic
symptoms
more
especiallyof the decrescent kind, have been
attributed
but

not

to sclerosis of the

Abdominal

System.
and

few

kinds

of

viscera ; and

in

in

all

nervorum

The

"

abdominal

be at least
to
appear
In gross feeders
arteriosclerosis.

of

ribs and

the

in

bred

not

only

encroach

pot is
the

upon

abdominal

Huchard,

one,
or

granular
be, and

may
on
are

the

the other
not
"

of them

this

in

when

that

the formation

up

of fat about

and

an

The

fat

may

health,

be
"

plethora

no

loss of

the abdomen

an

weight
is often

of the trouser-

habit, independently of
emaciate, the sign is an unfavourable

be

kept

of
of

on

that

quitefree from
hand, many
subjectsof
may

if

the looseness

repeat

may

efficient treatment

girthof

to

must

eye

in

pupil of

gross

often are,

obese, and

originally

races

cardio-arterial strain.

under

by

seen

patient of
end, begins

decrescent

slacken, aggravatingthe condition, and

be

may

casts.

abdominal

pursy,

as

this

to

hyper-

againstthe empty pot

become
superfluity
may

suggest

may

desired, the

even

if

But

reservoir

patientimproves

reduced,

treatment

heaping

perilousnuisance.

heart,or

observed

has

observed, or

band.

observe

may

the

in

respiration.Bourguignan, of Evian,

arteriosclerotic

much

we

empty

never

muscles

the

hampering

is

to be

nuisance, but

of

symptoms

observable
buttocks, especially

the

when

of course,

guess

troublesome

as

which, with

hardship,seems

but

The

"

window

bow-

equivocal. Flatulencyis a frequentsymptom

dyspepsia, or of venous
congestion of the
of gluttonyit is not wanting. Still it
cases

would

"

unlikelyone.

an

piesiaare

vasa

the
while

urine,for sugar
obese

of blood

excess

excessive

blood

persons

pressures,
pressure

Thus
while in
spare build.
the older physicians,in the

puffy condition of persons addicted

some
rubicund, the bowels
pallid,

high living,some
windy
get sluggish,

to

CHAP,

ABDOMINAL

vi

and
with

SYMPTOMS

445

the ascendingand
about
especially
colicky,
pains around the navel, and while in some

rather

is fullish and

tender,

and

the rectum

transverse
of them

hot

colon,
the

liver

and

subject to
in others we
a mere
see
piles,
insufficiency
; poor nutrition,
failing
But
and
these
digestion.
strength
patientsalso are subjectto
and, like the
glycosuria,
irregular
podgier subjectsmay also
in the
complain of weak heart," insomnia, weariness,tinglings
In some
and so on.
of these cases, as we
limbs, fidgets,
shall
the stomach
bowels may
or
without
see, haemorrhagesfrom
occur,
hepaticcirrhosis.
"

"

"

If

have

we

heard

various

much

of

splendour,
sclerotica" for example
prave
that, in entering upon
names

writers,mostly continental,of

curiosities,
phenomena

clinical

certain

from

"

Dyspragia

"

'orts

"

the most

with

shall meet

those

with

is seized

malady

of tabes,

disease.

we

"

angiopate
antici-

may

arteriosclerosis,
we
the direst,manifestations

victim

crises

require

to

as

intermittens

indeed

if not

The

abdominal

of mesenteric

or

"

abdominal

dramatic,

sphere of

of all this

curious

so

of this

magnificent
comparable only with

thrombosis.

He

cries out

of

burning pain and cramp in his belly,of distension,belchingsand

than one of these cases
an
dyspnea, such that in more
exploratory
Deration has been performed. Usually there is obstinate conpation,but sometimes the patientis torn by a watery diarrhoea,
an
example of the milder varietyof the disorder,I may quote
recorded
school as
the followingcase
Preby one of Huchard's
sclerose gastro-intestinale
:
"

"

M.,
orse

two

te in

hard,

or

enough

loss of

and

on

up

death

have

contributed

even

distress may

investments

the

about

of

to

the

epigastriumand abdomen,

eructations

and

of these

adonis

vernalis,and

and

All

the great vessels, with

of

tension

(see Angina Pectoris,pp. 462-3). However,

the

in them
may
and

discomfort
disease
of

it is likely

and

cceliac axis

Certainly

of extension

thick,

valerian

often discovered

aorta

discomfort.

bad

Pulse

arteries

equivocalcases

disease

case

("hypersclerosis
").

abdominal

arise in

nausea

insomnia.

Accessible

intermittent.

atheromatous

the

theobromine,

publishessome
that

in

appetite; vertigoand

intensified

sound

cleared

symptoms
Barie

after meals

occasionally

aortic

tenderness

and

hours

three

mouth,

and

second

after

Pain

set. 35-40.

to

these

although for

the

parts
some

SYMPTOMS

446

OF

ARTERIOSCLEROSIS

PART

with arterio-sclerotic
conversant
fortyyears I have been specially
of such persons
almost
seen
patients,and the number
day by
day by English physiciansis very great, yet I fail to recognise
consistent or uniform
malady answering to these descriptions.
any
the
in
which
the English
Perhaps it is not
way
behaves
abdomen
itself,but is it not as likelythat many
of these cases,
?
surely multiform, have been misinterpreted
of the neglectof the
Constipationand wind are consequences
colon which are common
enough in elderlypersons, and no doubt
nutrition
the activityand
of the bowel
become
as
impaired
these disturbances
are
more
prone to arise. Dr. Stengel admits
of these patients was
that one
cured
by a dose of calomel.
the

On

other

hand, I have
in

seen,

which

all have

we

seen,

and

many

degeneration of the
the gastricand
and
mesenteric
axis, and
descending aorta
trunks had resulted in no such extravagances.
My experience
of advanced
arteriosclerosis of the gastricvessels is that it is
usuallyattended with the negativesymptoms of loss of appetite
and
which
flesh, debility,and
hypochlorhydria; symptoms
not
to
infrequentlylead to suspicion or even
diagnosisof
a

many

necropsy

extreme

carcinoma.

However, Ortner's papers

this

on

subject1have

received

not

the

and discursive,and,
they deserve for, if overlaboured
he honestlyadmits, not very conclusive,he has spared no pains
as
in the settingforth.
The author is naturallyinfluenced by the
Pal.
Dr. Stengel,
vasospasmodichypothesesof his able colleague,
at the Toronto
Meeting of the British medical Association,drew
attention

attention
I have

to

25

only

and

paper,

cases,

that

aware

vessel is often to be
much

so

have

so,
not

to

as

suggest

observed

in

these

of his

he

N.F.
*

Ortner,
No.

N.,

"

347, 1903

Quoted

Angiosklerose
;

and

W ien.

by Stengel from

d.

Max

own.

included

of the
may

be tender

; this is not
cases

the

kind

Darmarterien,"

kl. Wochenschr.

vol.

to the

"

of

some

Volkmanri's
xv.

Progressive Medicine, Dec.

p. 45.

1905.

We
aorta

uncommon

by

Buch

instances

abdominal

crises,"with grave and agonisingpainsrecorded

1

Buch's, which

rightlydiscarded.

palpated,and
tumour

of Max

paper
cases

Ortner

of atheroma

cases

in these

and

Angina abdominalis, which

in

to

reportedalso

He

seen.2

not

collected

Ortner's

of
are

this

touch
; but

abdominal
authors.
Sammlung,

CHAP,

ABDOMINAL

vi

If

"

abdominalis
of

closures

as
(!),

chapter
pain depends on
thesis

of

or

maintained
further

for

inflamed
and

pains
intense

distal

that
in

that

the

certain

the

for the

the

^visceral

stance
mesentery, for inIn

able

an

Abdominal

vessels,

Trotter

explanationof
pains due to

cases,

that

of the liver.
of

is the

angio-

mere

shall urge

degree in 1912, Dr.

such

spasmodic

engender violent pains.

of

Thrombosis

congestionof

assume

may

tension

on

capsule,as

M.D.

our

evidence
observed

We

tension,

angiosclerotica

be due to

evidence

no

anywhere else,can
Angina Pectoris I

on

an

intermittens

or

Embolism

on

have

vessels,we

the

447

pareticcondition,may

spasticanaemia, here
In

Claudicatio

"

assume

we

SYMPTOMS

adduced

the

agonising

sudden

and

(seeA. Pectoris,pp. 462-3).

area

present that

of

symptoms

intestinal

atony and

inactivitymay well be attributed to the anaemia of

narrow
or
impervious vessels,but that severe
pain, if vascular
in origin,
is probably due to emboli
thromboses
with their
or
congestivesequences, or enterospasm, pullingon the mesentery.
of colic, belching,distension, insomnia,
Rosengart,1 in cases
not
fatigue and tinglingin the limbs, symptoms
improbably
attributable, at

dilated heart, and

sclerosis of

he has noticed

difference between

pulse,a great
a

in these

that

vessels,adds

in part, to

rate

any

abdominal

fluctuating

very

lyingand standing;
These

murmurs.

even

also

the

and

also

of symptoms

groups

only too frequentin ordinaryvalvular heart

disease,independent of arteriosclerosis ; it is probablethat they
disturbance affecting
characteristic of any kind of circulatory
are
the function of the intestines ; in cardiac disease they ensue
upon
and
lower tract.
venous
Among them
congestionof the stomach
remind

also

of those

us

are

the

cases

the present,

Upon

local

consequences
decay that

that
case,
man

was

few hours.
1

yet
"

ill,which, for

so

visceral

vascular

this mechanical

it is rather

for

the

present attribute

symptoms

to

would

epiploicais

At

the

Rosengart,

will well

pain in

severe

autopsy

Munch,

to

of

some

med.

rent

was

Wochenschr.,

remember,
the

left

found

a
an

the

know

We

alluded.

liable to sclerosis and, in

Barlow

suddenly by

I have

which

gout."

occlusion, grave

and

Sir Thomas

seized

to call

to be content

ensue,

may

the arteria
which

well, and

so

atrophiesensuing upon

exorbitant

more

in

have

we

know

we

certain

elderly

side,and

died

in the stomach

1906, No.

20.

SYMPTOMS

448

junctionof

the

AETERIOSCLEROSIS

OF

PART

cavity with the oesophagus; the tissue

of the part had been atrophiedby advanced
sclerosis of the gastric
sclerosis.
general arteriosystem of arteries,a part of a far advanced
Now
this patienthad suffered,for a year or two before,
the loss of appetite and
from
flesh and
generaldebilitywith
achlorhydriasuggestiveof malignant disease of the stomach
which I have mentioned
(p.446); but no such disease was found.
H"morrhage from the stomach or intestines due to arterial
decay in elderlypersons is not a very frequent event; but
from
record of hsematemesis
are
on
cases
rupture of decayed
arteries.
The
region of the coronary artery
gastriccoronary
is the principal
source
(seep. 457). Dr. Ainslie Hollis published
near

discussed

and

short series of

and

oesophagus
large plaques

in

"

"

thither.

the

which

Hollis

Dr.

such

breaches

orifices of

the

at

of ulceration

cases

however

with

corresponded

arterial

is very

of the stomach

branches

cautious

in

going
ascribing

probably malignant,to the arterial

Still in less equivocal instances
disease.
there
is some
of such cause
Bitot and Papin J describe
evidence
and effect.
of hsematemesis
due to gastric
arteriosclerosis ; in both,
two
cases
the haemorrhage was
as
repeated,an operationwas performed,
In the second case
but nothing else was
discovered.
gastroscopic
these

ulcers,in

examination

Male,

tortuous

small ulcerations

were

Bitot

No

of
and

thrombosed.

recorded

that

ulceration

vascular

which, on later examination,

Mauriac,2 referringto

necropsy

these

Five years later epigastric

set. 30.
Syphilis,
pain
General
arteriosclerosis
(ulcersuspected). P.M.
stomach
and
neighbouring duodenum, which were

The

Oct.

the

near

Marks

Bitot
not

cases

Papin,

looked

up

of

of the

changes,or
et

of

change

rupture

detected

were

atherosclerotic

was

(intimal).

Oaz.
the

haematemesis

membrane

mucous

that blood
hebdom.

in

issue

may

des scL med.

originalpaper

as

it

arteriosclerosis
may

show
the

accompany

from

non-ulcerated

July 21, 1912 ; I

reported in the Lancet,

de Bordeaux,

seems

well

12, 1912.
Bitot

et

in

miliary aneurysms.

ulcer, no

and

vessels,and

set. 36.

places. Histologicallythe

have

sinuous

hsematemesis
vessels

of

and

publisha third, with

cases,

and

dilated

cicatrised.

found

two

cases

revealed

altered vessels
were

some

Mauriac, Gaz. des hop., May

13, 1913.

This

paper

I have

seen.

CHAP,

ABDOMINAL

vi

surface.

In

this state

dilatation ;
recorded

cases

arteriole may

an

again

or

SYMPTOMS

such

no

for the

are

sign

most

449

present
be

may
in

part

died

in whom

well-marked

of

one
cases

in

them

sclerosed coronary
the same
condition.

due

In

and

of the instances

in

of

of the violent

evidence

ordinary

then

course

slender, and

formidable, and
cases

no

means

is remarkable

and

in suspense,

seems

in

I have

referred,
made

to

the

Even

for

that

most

the

is

concept

carry

present it is

remember

be

bowels

the

of

most

arise in

spasms

adequate to
imposing.

the

for

and

and

cramps

so

on

there

was

that

to which

arteriosclerosis

name

few;

are

them

senile

Other

in Barlow's
as
decay, especially,

attacks

that

of

by

found

79, with

set.

man,

of excessive blood pressure

are
suggestions(unverified)
atherosclerosis would
abdominal
yet surelyadvanced
in the senile (decrescent)
form.
common
The

death

(in 1876, but

of this kind

cases

of

miliaryaneurysm

age

district of the lesser curvature

The

It
gastro-epiploica.

a.

the

38, after

by Gallard

Sachs

by

of the

none

liable to this form

the

as

rupture of

to

artery;

cirrhosis of the liver.

case,

of

age

of

case

gastricarteries was
aneurysmal dilatation.

such

quoted ;

are

to be most

small

ulcer
a gastric
ref.),

no

the

at

from

obviously

sclerosis of the

showed

record

on

attack

an

The

apparent.

aged and
reported a

arteriosclerotic persons ; but Hirschfeld

suffered
who
had
from
hsematemesis
man,

18, and

aneurysmal

an

alleged

wise

these

so

hold

to

few

some

flatulent
be found, such
as
probable explanation may
thromboses
or
indigestion,
enterospasm, or small embolisms
such
in the diseased arteries of the brain.
as
commonly occur
Watery diarrhea is consistent with such small pluggings.Besides,
more

enterospasm,
is
to

in

connection

no

with

whatever

arteriosclerosis,

infrequentmalady. Meanwhile, we shall do well not

pilespeculationupon speculationby guessingat vasomotor

no

spasms

affections

or

nothing,and
The

those of

the

addition

of

more

of
and

which
more

know

we

enormous

our

the consequences.
1

VOL.

avoid

the

alreadyloaded categories.
liable to decay than
far more
vessels of the pancreas
are
alive to
the intestine,and we
are
perhaps insufficiently

to

names

to

coeliac axis

of

whitening of

Sachs, Deutsche

med.

the

stools,which

Wochenschr.,

May

float in

may

19, 1892.

SYMPTOMS

450

water,

variable

or

ARTERIOSCLEROSIS

OF

of sugar

traces

decay in this area

and other
peri-arterial

and, with

vascular
of

that

says

in

of the

cause,

these

urine, may

the

betray
incursion

it,probably an

hyperplasia.1Ottfried Miiller
the
the glycosuriais the result,not
failure ; this is not
unlikely,but the

cases

vascular

is often

converse

in

fibrous

also ; in diabetics

true

still young,

not

arteries

any

in arteriosclerosis

that

Cammidge's method,

on

sclerosis of
this

the

respect

these

signsin
absence

course

arteries

is often
of the

with

agrees
one

examination

an

case,

that

Dr.
of the pancreas.
stated, if I remember

states

stools,

point to
experience in

this may

positive;

My
pancreas.
of Dr. Chalmers

have

paper which
he examined

seen

But

necropsy.

the urine does not exclude

Bosanquet,in a
right,that

and

of the urine

apparentlyverified by

of sugar from

in

even

rise of pressures, the accessible

Watson
thicken (p.279). Dr. Chalmers
infrequently

children,without

PART

"cirrhosis

"

mislaid,

I have
100

of

of

cases

proportion found
of glycosuria.
a
symptom
organ without
the relation of the islands of Langerhans to these conditions
have no
definite knowledge.
An
arteriosclerosis of the portal system, beyond the portal

pancreatic disease, and

cirrhotic changes in the
Of
we

vein

is unknown
itself,
reason,

some

subjectto

bathed

sclerosis

in

to

considerable

The

me.

in amino

(Jores and

acids

vessels
as

they

liver,for

of the
may

be,

seem

others),and mechanical

little

stress

in

fee reduced

of the portalminor
by the interposition
circulation.
However
a
portalsclerosis has been described by
to be due
to
Simmonds,3 which does not seem
high arterial
he regards it as independent,
pressure | or liver block ; indeed
or
less,of generalarteriosclerosis. The process is intimal,
more
with ruptures of the elastica,
some
secondary affection of the
attributes
media, and a tendency to calcification. Simmonds

them

may

it to

toxic influence,from

some

lead

to

more

or

in the stomach,
not

to

In
1

same

See

less extensive
and

be confused

the liver

(or bowel ?). It may

to varices
thrombosis, and even

haematemesis.
with

mid., Oct.

25, 1903;

C., Brit. Med. Journ., April 11, 1908.

Virch. Arch., March
1912.
Simmonds,

Watson,

this condition

section of the liver be

year.
2

course

is

syphilis.

if a
generalarteriosclerosis,
Lepine, J., Lyon

Of

quoted

Brit.

carefully

Med.

Journ.,

SYMPTOMS

452

recent

of

"

in

so

contain

may

Genitalia.
have

Of

"

the

due

will dwell for

to

moment;

which
hyperpiesia,

attributed

fears of

to

about

be

pressures
that

140

we

under

has occasionally

one
cases

of his

own

have

Williams

point only I
of tendency

occur

about

the

may

not

years

similar

advantage has
Williams

shown

says

rise of blood

fall after them

The

upper

range

mm.

IN

THE

ELDERLY.

"

intercurrent
transient
upon
than one
set of conditions
more

all, or

are

times

periods,and
beginning during the flow.

remarked

I have

ancient

Uterine

Leonard

these

menstrual

HYPERPIESIA

EPISODIC

itself.

Dr.

about

with

associated

uterus

cancer.

haemorrhagesmay

moderately bleedingpiles. Dr.

the

pressure before
the subsidence
may

be

the

or

of arteriosclerosis

subject.1 On
namely,that in certain
is especially
to
prone

personalobservations

that

to

or

absent

lighter.

arterial disease in the organ

benefit ; from

be without
been

symptoms

loss of blood

free

menopause,

uterine

this part of the

on

are

the urine is rather

decay confined

haemorrhagedue only to
given rise to grave
written

casts

disease

general change,

this

to

vascular

normal

has

renal

the

It is stated that climacteric

littleto say.

be

with

contrasted

little albumin, but

In the decrescent

rare.

separate chapter

specificgravity of the
is normal
urine, except during polyuricperiods,
; in later

stages it

of

standard

diurnal

disease, the
lithatic

suspect degrees

to

cases

important that they are discussed

(Chap. V. p. 309). In hyperpiesia,as

are

PART

in arteriosclerosis
conditions,
negativeand positive,

renal

The

in such

learned

have

years we
acidosis."

ARTERIOSCLEROSIS

OF

many

pressures ; but
occasional phases of

of us,
in

liable to

More

than

once

of

high
probable
periods of

phases
; it is

transient

this

paragraph I wish to insist

hyperpiesiain elderlypersons, and to
upon
emphasisethem, because in these states they may lead to an
in them they are attended
with
unbalanced
prognosis; moreover
I have
little immediate
peril. For many
recognised
no
years
make
allowance
for
these intercurrent
phases, and learned to
them.
An interesting
example of this episodeappeared in a very

excessive

Williams, L., Clinical

Journal, March

3, 1909.

CHAP,

EPISODIC

vi

HYPERPIESIA

453

old

comely

of Newmarket.
lady, a patientof Mr. Maund
Her
right,was about 80 ; and wonderfullyupright
age, if I remember
and
and
comely she was, vigorous in mind
the
body and
animating head of a large family circle. Accustomed
to
a
of
found
living,she had never
to deny
generous
reason
way
herself what
the gods gave
her ; if she desired a glass of
champagne for her lunch it was
Then
there, and so on.
at
found
her with
length she fell out of sorts ; we
coated
a
tongue, depressedin spirits,
unequal to her many
occupations,
and so on.
Her
pulsebetrayed at once an unquestionablyhigh
blood

We

pressure.

have

approached

calomel

and

result that
time

had

200

no

mm.

salines,and
in two

later I heard

that

hand, but

put under

it

must

of

course

stricter

three

or

at

gauge
She was

dietaryenjoined; with the

she was
herself again. Some

weeks

with

caution

in diet

she

had

remained

in

In
this
of
good health.
lady the radial artery was
old lady, a
ordinary amplitude ; in another
patientof my
late friend Mr. Hartley of Stortford, the same
story of recent
rise of pressure
was
given ; but the radial was so constricted
that

I feared

chronic

of treatment
and

the
old

disease.

adapted simply

quick recovery
improvement
But

age.

renal

;
was

we

are

and,

as

to

However,

she
hyperpiesia,

friend of her

on

abiding,and
not
always

made

family,I

that she lived to

fortunate.

so

system

In

good

knew

that

stillriper

third old

I used to see
with Dr. Maiden
of Cambridge, such
lady, whom
the first occasion
set in ; this on
an
episode of high pressure
ever,
Howvanished, as we expected,under appropriatetreatment.
time later another
such
attack
some
supervened, with
high arterial pressures and some
slightanginiform symptoms.
but, before we had time
Again this attack also was
dissipated,
to
forced,
mitigatethe arterial tension, the aortic valve was
It
established.
and
aortic insufficiency
was
a
permanent
to
interesting

ventricle
balance

succumbed

attained.
in
to

fair
a

Such
The

how

quickly and
was

continued

see

at

an

age

fourscore

And

for
and

few

years
until
spirits,
a

heavy weight of
episodesare seen

and
years
in both sexes

of intercurrent

high

the left

that

so
largelyhypertrophied,

health

followingnotes

far from

not

new

more

this

at

length

the

aortic

lady
she

sufficienc
in-

alike.

pressures

was

sent

SYMPTOMS

454

by

to

me

on

episodic

high

R.,

Mrs.

usually

set.

outbreaks

of

would
with

day

that

her

incompressible.
her

After

The

persons

restoration

forced.

alterative
to

her

of

the

absence
of

no

accessible
be

little

present,

anxiety

of

these

arterial

firm

and
made

alcohol

would

pressures

episodical

cardiac

preceding

until
the

the
heart

in

cases

If

are

pressures
or

however

cerebral

elderly
and

enlargement,

arteriosclerosis.

lest

became

self.

normal

is

associated

correspondent

relief

the

to

which

temper,

my
and

prompt

and

subject

were

times

pressure,

course

become

changes

these

her

mine

vivacious,

bad

even

These

in

gave

feature

arteriosclerosis
be

pill

active,

latterly

and

at

rose

distinguishing

infrequently

may

pulse

an

had

days.

of

thin,

she

Now

Blue

worse.

fall, with

three

or

observations

persons

PART

some

sullenness,

somnolency.

found

had

two

old

But

lady.

peevishness,

for

last

read

fourscore,

over

old

had
in

pressures

sweet

who

physician

ARTERIOSCLEROSIS

OF

not

decrescent
abated

there

artery

be

CHAPTER

MORBID

AT

ANATOMY

Toronto, in

Sections both
Sections

and

endeavoured

is not
less common

OF

of

As

prove

to

issue and

uniform,

not

the

in the Medical

detriment

the
the

as

more

or

in the Pathological

(pp. 13 and 374),so

be

in

hearers that Arteriosclerosis

my

expressed a suspicionthat

phenomena might
of the

Pathology.

an

to several diseases

discussed

was

to convince

Disease, but

Section

ARTERIOSCLEROSIS

1906, Arteriosclerosis

of Medicine

I had

VII

pathological
unqualified

commonly implies,but twofold or manifold.

That
each specific
would
its own
to have
cause
specific
prove
mode
of arterial tissue reaction I scarcelysupposed ; it is improbable
be
of it that arterial tissue should
by the structure
capable of much
variety of decay ; an identical or closely
in a
similar deformation
be the
particularstructure
may
issue of several kinds of distemper (videp. 324) ; yet
common
use

name

from

certain

those

in the main

broad

toxic,or "senile"

differences

between

the

those

which

mechanical, and

(decrescent)
"

we

causes

"

between

in the main

might anticipatesome

are

various

if the decay I have

degradation.1 For even
called decrescent,involutionary
or
primary,be indeed due mainly
of mechanical
to long accumulation
stresses, yet it might prove to
results in arterial

have

certain

anatomical

features, or

mode

some

of distribution

correspondingto the slow, intimate, and belated

it either in character or in
causation, to distinguish
incidental,and

earlier,more
And

again,should

more

the decrescent

influences,whether

of autotoxic
1

See

paper

seat

of
from

its
the

high tension.
be engendered

violent strains of
kind

prove

chronic

by myself, Brit. Med.

455

mode

or

to

virulent

more

Journ.,

1911.

and

ANATOMY

456

ARTERIOSCLEROSIS

OF

untimely,it might present certain characters

due simply to excessive tensile strain.
Order

of

Lesion.

Rokitansky, have
rule

of the

Morbid

"

to

orders

or

different from

anatomists, from

endeavoured

order

PART

in

formulate

which

the

those

time

of

principleor

some

arteriosclerosis

invades

the

body, but as yet no principlehas emerged. Its incidence

be curiouslypartial
may
; for instance, the cerebral arteries may
be affected with little or no
The
change elsewhere,and so on.
illustrates unequal distribution of arteriosclerosis :
case
following
I saw,
with
right radial was

medical

friend,
obliterated

almost

thickish,being fairlynormal.
normal.
was

two
some

The

not

The

brachials

did

not

(Martin) were

kind

; not

not

labourer

show

all.

The

unequal.
nor

an

in whom
the

blood

The

notably altered,if at

arms

middle-aged man
by atheroma
;

was
pressure
like difference.

blood
He

was

pressures
a

the

left,though
not

above
heart

The
taken

in the
of

man
professional

athlete.

publishedscales of frequency,in respect of sites,fail

in a generalresemblance.
The order may
not be the same
even
for hyperpiesis,
for granularkidney,for the decrescent forms, and
to tell on the aorta first,
and thence
on.
so
High pressures seem
the arteries of the larger magnitudes, as the stresses tell
on
along the tree ; but we do not know that this is the case ; the
the peripheralvessels must
stresses
vasodepend upon
upon
motor
tides,general and partial. But, as I have said before,
sclerosis of main
between
trunks
and
of peripheralbranches
there is no consistency
conclusion pointingto large
; a remarkable
variables
in causation.
In renal disease, as I have
already
there
to be two
of arteriosclerosis
movements
seem
suggested,
(p. 351) ; the one intimate in the kidney, and pertainingto the
of the disease,the other simply mechanical, a consequence
nature
of the high pressures.
And
under certain other conditions
also
vessels may
be widely affected while the largerare
the peripheral
spared ; often again the stem of the main vessel of a viscus
such as the coronary
stand stiffly
may
open while its radicals
many

"

"

are

still intact.
On

the order of

liability
Rokitansky and Lobstein did agree,
it is true ; and on this order : (1) the ascendingaorta and arch ;
(2) the descendingaorta ; (3) the splenicartery, and the crurals ;
(4)the coronaries

(5) the internal carotids

and

the

vertebrals

CHAP,

OKDEB,

vii

within

the

skull ;

(6) the

spermatic; (9) the

(11)

the

The

Dr.

Mott

and

the

order

of

also

did W.

of

the

Eomberg

von

the

and

stomach

mesenteric

found

457

(7) the brachial

carotids ;

of the

order

LESIONS

uterine ;

common

coronaries

mesenteric.

OF

(10) the

hypogastric;
rarely") ; (12) the

(" very

mesenteric

with
arteries,

is notable

agree,

Eomberg

von

sclerosis in this

(8) the

(p. 188). On

made

vestigat
specialin-

sehr selten

"

area

which

"

as

C.

Hodges (M.D. Thesis, Camb., 1914). (See also

In my
experiencethe gastriccoronaries would come
p. 218.)
higher in the scale of frequency. It is important to remember
that
the
suffer
and
dependen
ingastric arteries may
fairly soon,
of

the

abdominal

(Potain, Teissier, Pal,

aorta

of it,
Hamburger). This event, and the obscure symptoms
such
as
debilitywith defect of hydrochloricacid, and in one
into the pleural
case
perforationof the necrosing stomach
cavity,I have already considered (p.448).
Dr
order
of decay, of all kinds
Mott's
of arteriosclerosis
is :
arteries of limbs, aorta, splenic,iliac,
indiscriminately,
femoral, coronary,
cerebral, uterine, brachial, gastric mesenteric
sclerosis againbeing rare
is,suffer first;
: the limbs, that
of these the lower limbs before the
upper, the anterior tibial being
the first of all arteries to yield. His cases, collected at Claybury,
consist no doubt
arteriosclerosis (p. 351).
of decrescent
chiefly
Comparative maps
of the distribution of decrescent and high"

"

sclerosis

pressure

the

largestpile of
pupil Bergmann

his
ant.

(93

carotid

per

int.

(87

cent),

per

cent), a.

(55

per

toxins,and

Med.
2

"

(94

carotid

per

(68

per

cent),iliac ext.

per

of
per

upon

Thoma,

by

cent),tibial.

(88 per cent),cerebral (87

per

cent),

cent), splenic(82

per

cent),femoral
asc.
(67
cent), aorta

cent), axillary (71

per

(64

is that

ulnaris

founded

(58

per

per

cent),brachial

cent).1

of structure

See

it is this

common

abd.

material

unsorted

order

The

cent), radial (86

per

As determinants

needed.

cent),subclavian

per

cent), popliteal(79

(87

much

are

of work

; different conditions

development,on
finally

also Harlow

Sci., 1906.

Pitt

of site Dr. Newton

Brooks, New

I have

Pitt, N., Brit. Med.

seen

the

Journ.,

York

"

difference

affinitiesof
; selective

the lines of the several aortic

Med.

Journ.,

latter paper
only.
10, 1908.

Oct.

suggests:

1906, and

Amer.

Journ.

ANATOMY

458

In

arches.

syphilisthe

arch, suffer first ;

the sinuses

and

in

at

thoracic

atheroma

the

cerebral

arteries

the root

strain of the

the vessel,a

but

unfortunatelythe incidence
Sometimes
they are affected very
of other

notion

but

cusps

of the
for

important

very

the

part often left unopened,

inferential

is

PART

the ascending
especially
of the aorta just above

aorta,

points of

subdiaphragmatic part of
suffer early. Some
may
the

ARTERIOSCLEROSIS

OF

them

upon

sometimes, while elsewhere

is very
before

even

soon,

the

of
liability
physician,
irregular.

other

vessels

it is

conspicuous,
they
show littleor nothing of the disease.
But as no order of liability
be acceptedwhich
is not verified by microscopical
examinations,
can
the earlier scales are far less trustworthy. A very frequent
of atheroma
is the pelvic,where
the sclerosis is attributed
area
to
the incessant
disturbance
of the vessels by the intestinal
activity. If so, these arteries may be put side by side with the
and those of the arms
and legs. Monckeberg in 130
coronary
found
medial
calcification in the limb arteries (vide
cases
pure
areas

or
p. 482), with
atheroma
without

of the

inference

no

As
I

and

arms

On

atheroma

in

from
Thus
peripheralform.
we
legs,without clinical diagnosis,
the

to the

central

57

the vessels
draw

can

internal vessels.

not

the

disorder
paragraphs on the physics of circulatory
premised, so in respect of these on Morbid
Anatomy,
pretend to occupy the reader with a systematicreport.
clinical side my
opinions are at least first hand, the

fruit of my
I am
more

it the

might

have

upon

well

aware

of

taken

other

the anatomical

on

of others.

that
and

tubes, built

instruction.

coat, in part

twisted

extension

reason

before
Still,

side
ing
enter-

preliminaryreflections upon
vessel may
be permitted. The structure
of the normal
pieceof mechanical efficiency.From
very interesting

makers

coat

and

the work

dependent upon

the normal

arteryis

observation

own

diseases of arteries, some

upon

but

central

in my

have

I do

as

without

spiral;

the metal
fibrous.

"

big gun

and

must

Pure

resist internal

to

not

makers
be

metal

is built like
of all gun

stresses,
an

artery,

barrels

are

homogeneous or uniform,
is too plastic
to resist
"

compound substance, by the internal friction of

its dissimilar particles,
offers increase of resistance, as
sandy
is more
tenacious than so much
mortar
homogeneous lime. Thus
the contemplativebiologist
tubular
admire
this wonderful
may
;

ANATOMY

460

is

OF

ARTERIOSCLEROSIS

PART

rough guide to the position of a vessel in tone, or in

use
hypertrophy. But much
fallacylies in the too common
of the term
fessor
hypertrophy in the loose sense of bigger. ProMac William
found that 20 per cent plus diameter
the
over
empty state flattens out the waviness, but beyond this degree
is guess-work; though an expert eye for its own
measurement
differences due to the
guidance,not forgettingthe remarkable
mode
of death, between, let us say, the healthy arteries of an
amputation for accident,and those from a case of death from
to some
an
come
exhaustingdisease,may
approximate judgment.
But
arteries from
various
individuals
differ a good
deal.
In his well-known
studies of arterial qualities
Mac William l
has demonstrated
how vastlymore
and
is the play of distensibility
elongationin a relaxed than in a constricted artery, the pulsatile
expansionbeing much larger. Thus to affect a contracted artery
the blood pressure must
be very high. This is indeed what
we
should expect, for in a constricted artery the limits of its elasticity
are
perhaps not nearly approached ; in this position,as we
have seen, equal rises of unit pressure are
followed by equal
not
increments
of cubic capacity. Indeed
sion
the differences of distensome

"

values

"

between

vessels in

tone

mean

in contraction

and

are

of all

reckoning. By Dr. Mac William's illustrations we all

observe
we
comprehend how in some
as
directly
cases,
may
in peripheralarteries which
for an
indefinitely
long periodof
time
have
been held tightlyin constriction,these vessels may
out

present little or

although for

no

even

less

central vessels may

to

of renal

cases

lower

of deterioration

had

an

is often

excessive range.

conspicuousin
under

these

largermagnitudes and

injury,while
magnitudes are

(see p. 218) ;

periodthe hydraulicpressures

disease when,

other vessels of the

suffer

have

stresses
injurious

evidence

no

the

constricted

the

in the

Such

more

resistance

radial arteries in

strains,the aorta, and

less muscular

structure,

arteries

muscular

of

the

comparativelysafe. And so likewise in

the
and
accelerators
health, as
play mutually upon
vagus
thoracic
and
is continuously acting as
aorta
heart, tone
the
effects of incessant
a
percussion,
damper to moderate
dilatation,and extension (Vol.II.,p. 290).
1

Proc.

Roy.

Soc.

Mackie, Brit. Med.

vol.

hex., 1902, and

Journ., Nov.

later

papers

14, 1908, p. 1477.

e.g. Mac

William

and

CHAP,

TOETUOSITY

vii

461

Fleming 1 has suggestedthat the elongationof an artery

be a physicalprocess, or not merely such, but a vital
not
may
to meet
a hypertrophy of length; that
demand
the
one,
more
vessel
longer. Experiment showed, he said, that a
grows
Dr.

"

certain

"

india-rubber

tube

submitted

to

internal pressures

to

up

Hg did not elongate. Dr. Harry Campbell leans to

this opinion,which
at least is interesting.
Yet, in so far as
be a sign of elongation,we
observe
that in
tortuositymay
clinical experienceit is not the arteries more
active in tone
or
become
tortuous, but those rather which
vitalitywhich
are
in old age.
If Dr. Fleming in his experiments
as
losingvitality,
will force the circulation through a senile rubber
tube lying
between
relativelyfixed points he will find it begin to sag.
Thus
under
in the younger
arteries
high blood
pressures
much
later than
in the vessels of older
tortuosityappears
400

mm.

persons in whom
in proportion to

the

pressures

have

may

been

excessive

only

the

of the tunics.
failingresiliency
Besides,
this growth explanationdoes not seem
to be applicable
to dilatation
of the aorta.
result of elongation
a
Tortuosityis of course
within
fixed attachments, whether
physicalor biological
; by
severed
much
when
as
as
an
by so much at least
artery contracts

it extend

can

itself normally when

pressure.2 Moreover,

I have

as

has

axes

to

bed

fixed
normal

internal

fluid

(p. 195),if a fairly

limb, be bared, a serpentine

naked

eye.

As

lie nevertheless

tube

losing

between

the

elongationtravel out of its

and if the blood pressure be very high it may
tug on the
points to degreesapproaching or surpassingthe limits of
instructive
resilience. To turn to what is perhaps a more

it must
fixed points,
relatively

same

to

said elsewhere

long and quitehealthyartery, as of

shift of attitude can
be seen
by the
its resilience in both

submitted

on

experiment,I find that metallic wires (which are easier to gauge

than by an
than rubber) by flexion elongatemore
equivalent
in
which
wires
prove
simple traction ; and this follows sooner
to be less homogeneous. And as on arteries lateral
microscopically
constriction of the spiral
than longitudinal,
tell more
pressures
shortens
fibres,so long as these are healthy,by closingthe spiral,
the tube, and prevents tortuosity
(p.196) ; for by so much are the
1

Fleming,

Brit. Med.

Ballance

and

Edmunds

Journ.,
;

see

Feb.
also

17, 1906.

Campbell, H., Lancet,

Jan.

15, 1910.

ANATOMY

462

connective

elastic and

ARTERIOSCLEROSIS

OF

fibres slacker and

smaller the radius the less the

PART

safer.

And

burstingpressure.

of

the

course

So it is that the

itselfagainstthese internal pressures. If tortuosity

tube of considerable diameter
it will aggravate itself

vessel defends
in

occurs

by

the consequent increase of

I have

At any rate, as
that, whatever

and
vortices,

urged in

former

of internal friction.

so

the current

opinion
the attitude of tone, in arteriosclerosis tortuosity
is more
less directly
of systemicpressures is certainly
or
an
excess
this opinion Mitchell
and
incorrect ;
Bruce, James
Barr,
1
and
Harry Campbell have accepted. Dr. Ewart
explicitly
i
s
criterion
of
that
excessive
blood
tortuosity no
agrees
;
pressure
it in hypotensivepersons
he
had often seen
(seep. 192). For
tube normal
subnormal
even
or
a deteriorating
slightly
pressures
e
xcessive
and
become
relatively
;
day we see grotesque
every
papers,

"

"

tortuosities in the

arteries of old

pressures had
of later life.

exceeded

never

these remarks

However

Meanwhile,
the

of

interaction

the blood
persons in whom
the quasi-normalstandards
at most

H.

as

these

W.

are

Cook

incidental

has

conditions,a

and

cipatory.
anti-

put it2 concerning

with

fair arteries
be worse
under a pressure of 200
mm.
off by far than a
may
sclerosed vessels under a pressure
with well-marked
man
of 140.
which
This is a cardinal maxim
I
have
and shall
on
long insisted,

have

to

more

The

later.

say

Arterial

man

Coats.

concerning these severally,

we
must
to any
not carry
sharpness,certainlynot in the aorta,
the three divisions which
we
accept for ordinaryconvenience ;
namely, the tunica intima,the media, and the adventitia.
They
less by the kind than by the directions
be distinguishable
may
of their fibres.
and
from
Developmentally I understand
a valuable
development we receive many
suggestion the artery
Now,

"

"

"

tubes

consists of two

If then

investments.
convenient

the three

make

to

if

we

forgetthat

relations ; moreover,
to the channels

and

stresses,such
1

as

we

vessel proper, and its porting

supfor ordinarydiscussion we
find it
or

we
divisions,

these coats

pass from

shall be led into misconceptions

have

very

the anatomy

close mutual
of the aorta

of the
For

relation.

the intima

"

network, they change in structure

peripheral
ward
outinstance,arteries exposed to flexions,
or
as

those

of the

have
limbs, or the facial,

Ewart, W., Brit. Med. Journ., Feb. 15, 1908.

2
Cook, W. H., American
Medicine, 1905.

an

CHAP,

THE

external

coat

COATS

relativelythicker

than, let

the abdominal

protected

as

the

same

wall of the

upper

The

it.

third

of

point

mutua

"per

is

more

and

have

we

padded

strenuous,

the

on

the floor

of

function.

nexce

"

is

than

Furthermore,
fibres

are

the

between

generallysupposed.

normally

fine muscular

muscular

fibres

inward

more

fibres

the outward

on

may

in

the

interpenetrating

more

carries the muscular

which

of
the

as

in

even

The

connective
is not

"

interstitial network

in

the radial ; facts which

as

"

as

as

is thicker than

scaffolding from adolescence at any rate

Dr. Herringham
endothelial only,but all-pervading.

vessel

tions
bifurca-

at

so

that

seen

less rich in elastic fibre than

comparable size,such

tissue

vessel

in certain of the smaller vessels,such

section,elastic and muscular

same

more

say,

muscular
only more
definitely
lower magnitudes than
in those

and

differences

to

is

aorta, which

muscular

more

others

us

also is not

largestdiameter, but
renal, it is

impact

thoracic

media

arteries of the

some

where

instance,or

463

Moreover,

aorta.

vessel at points of stress

for

of

ARTERIAL

vii

sub-

describes the

cells in

renal

strands

and so
justvisible,1
traced.
Longitudinal

be

aspect Drs. Andrewes

J. F.

and

"

"

intima
means
clearly. Yet
of us fully
than many
that
more
recognise.The intima is strictly
layerwhich lies within the inner elastic layer,as the media is that
the two elastics;but as certain morbid changes
which liesbetween
in the inner elastic layerare of cardinal importancein disease of the
in pathology be considered
intima the inner elastic layersmust
In respect of the vasa
with the intima.
vasorum
again,as we come
and the twigs
vessels disappear,
arteries these subsidiary
to minute
at any
phatic
lymrate, nourished only from the investing
are, partially
demonstrated

have

Gaskell

very

that

fibrosis

arterioles,in the
tissue is

and

Herringham
these

occupies the
intima

undeveloped into
morbid

anatomical

stream.

Thus

fibres nearest

of disease the medial

forms
and

the blood

and

spaces

same

which

of

see

W.

a
clearly

spicuous
con-

are

of disease
interpretation
considerable importance.

of

speaking,it is hard
disease,strictly
capillary
which has
except in respect of damaged epithelium
Herringham,

connective

in the

Of

the

in the elastic layer(Jores,Marchand,

others). And
variations

position. In

little
practically
shall

certain

decay first;

the intima

relative

elastic fibre,we

change seated

in

it is that

P., Path.

Soc., London,

to be

1901.

so

sure,

another

kind

ANATOMY

464

of

That

importance.

arterial branch
of

OF

the

where

in this

spoke of the obliteration

disease
peculiarcapillary
in

that

extensive

some

channels, having
Gull

obliterative

dependent twigs must

obvious, and

course

ARTERIOSCLEROSIS

of

disease

know

we

an

silt up, is

George Balfour
but of primary or

little. Indeed

it is now

asserted

but

are
capillaries

areas

that

was

ing
perforat-

It is well known

structure.

proper

attacks

dwindle, or

capillaryareas

visceral

no

it

sense

PART

that

Sutton

and

alleged an extension of certain fibrillary

or
to the capillaries,
hyalineperversionsand nuclear proliferations
and

few

observers

logicalmethods

with
not

were

hesitation

followed

then

they

what

them

are

but

and

now,

histofor the

In this
by as undecided.
pass the matter
of the circulation the rulinginfluence is the cell activities.
must

present we
Vasa
with

vasorum.

them

In

"

there

ought perhaps

vessels ; that

these

respect of the

arterial

be

to

health

area

largerarteries supplied
good deal to say about

in

must

inconsiderable

no

be

dependent upon these auxiliaries seems

able.
unquestionx
The late HippoliteMartin
laid great, probably too great,
of arterial efficiency,
as
a condition
emphasis upon their integrity
measure

indeed

he

Rindfleisch

attributed

atheroma

again insisted

yet, reasonable

less

no

their

to

their

on

previous disease.
primary importance :

these

the evidence
that
opinionsmay
seem,
they are primarilyconcerned in ordinary arteriosclerosis,
apart
from
and
other
infectious
diseases,is not convincing;
syphilis
is it growing with our
with the subject. Moreover
nor
familiarity
arteriosclerosis not
only extends to ramifications beyond
the region of the vasa
but also often, as in chronic
vasorum,
renal disease,begins peripherally. The nutritive vasa
penetrate
normally about half-way into the media ; but it is said that
coloured
granules injectedinto the lymph channels pass from
as

adventitia

the
under

of

normal

tied

segment

conditions

this

of vessel
be

so,

to

the

the lumen
intima

if

depends

less upon
the
more
or
nutritionally
as
vasa
vasorum,
many
believe
for
instance
that
Marchand,
a
pathologists
high
; so
blood pressure by squeezingthem dry should starve
minimum
the
"

Martin, H.,

"

La

Pathogenic

des lesions atheromateuses,"

Rev.

mid., Paris,

1881.
2

Durant, quoted Sanders, Amer.

II. and

IV.

Journ.

Med.

Sci., Nov.

1911

see

his Cases

CHAP,

VASA

vn

intima

Adami

(p. 193).
if any,
the

from
should

to be

blood

constant

or

and

and
slight,

In my

465

others however
believe the

If

stream.

pine.

not

VASORUM

so,

in

noteworthy coincidence

even

intima

medial

specimensI

own

think this
to be

disease

ence,
depend-

nourished

the

intima

have failed to mark

between

any

atheromatous

patches and distribution of the vasa, odd as the incidence of

be ; indeed
the patches may
that around
note
one
such
may
a
patch,if in an earlystage, the vessels from the adventitia
not
occasion
seem
active
only patent, but on
even
over
in syphilisonly ; or as if participating
not
in a
subinflamor
(vide p. 523). In acute
subreparativeprocess
matory
"

"

"

arterial lesion,as in the infections for instance,the

vasa

vasorum

the propagation of new

to
visiblydistended, even
twigs
into
the
swollen
and
in
penetrating
superepithelial
layer,
demonstrated
that
the
experimental infections Metchnikofl
are

vasa

suffered little,
if at all.1 Moreover, in decalcified

vasorum

atheromatous

in

aortas

he

man,

found

the

vasa

not

vasorum

extended
around
and even
within the
only patent, but more
patches quite good vessels, with normal epitheliumand red
(He appends two
plates.)
corpusclesin their channels.
the
almost
Manouelian
con(loc.cit. p. 305) notes with surprise
in
it absence
of morbid
vasorum
changes in the vasa
of
itheroma
aorta.
of the human
Simnitzky,includingcases
the same.
of infection other than syphilis,
says
ly kinds
Again, Monckeberg and others agree that in arteriosclerosis the
vasorum
are
vasa
generallyfound, unless in far advanced
they
pervious,if not intact ; indeed in active cases
"

be

may

book

without

and

have

said

disease
could
main

elsewhere, that

of

is

vas,

or

even

hardly determine
vessel.

But

it does

seem

systolicand

diastolic,cases

pulsationof

the

vessel

Metchnikoff,

group

of

remember,
of the

network

formation

to

the

we

shall

in

the

see

adventitia

de

VInstilut

reduced
Pasteur,

to
Oct.

narrow

very

1910.

^
VOL.

that

of disease in the
patchy disposition
of highpressure,
that in cases
likely
the diastolic and systolic
in which

itself is thus
Ann.

vasa,

his

vessels

in

we

vascular

the

in

Brault,

occurs

When

vasorum.

vasa

as

sclerosis

freely anastomotic, even

grating around the media,
cylindrical

subadventitia
of

And,

ramification.

in

Arterites,demonstrated,

Des

beyond
as

extended

limit,and
the

to

ARTERIOSCLEROSIS

ANATOMY

OF

their due

oscillation

466

arrested,the free

would

vasorum

vasa

PART

hindered

be

of blood

access

if

the

so

tunics

short both of blood and lymph. And,

they nourish would come
in the brain,do give some
though the lymph spaces, especially
is a tough sheath.
for expansion, the adventitia
An
room
atrophy of a diffuse or fibrous kind might indeed thus come
to excess
about, but fibrous substitution is not brought home
defect in the

or

them.

vasa

endothelium

The

is

does

and

vasorum,

doubt

no

not

nourished

be due

to

seem

to

the

directlyby

in their channels.
passing blood, as are the sponge microbes
and
most
Hence
precious immunity
probably its remarkable
in these diseases.
the

is in

It

to

seems

find

notable

surprisedto find that

be

poison without

hurt

would

farther

back

attacked

of

arterial

of these

way

channels

In any

themselves

case,

"

blood

suffer

less from

cases

of

for

while

poison

although we

integrity
; they

own

the

not

seem

attribute

to

So

escape.

may

the

convey
to

be

ordinary

of its

vessels, subdivided

because

their

if arterioles

be

by

part] played by the

previousdisease or thrombosis
be but to push the questionbut one
should
to the questionwhy the vasa

arterial disease to
vasorum

to

these

of the mischief.

the first seat

the

less of its distribution

or

more

that

cases

is most

vasorum

vasa

toxic

vasa

short

step

themselves
far

rises

as

concerned, these subordinate

are
pressure
and
freelyinterlaced as they are, should

strain

than

the

high pressure the vasa

they are called upon to
which
artery a suffering
"

is

tubes

they

should

vasorum

overfeed
would

nourish.

suffer

the coats
soon

That

end

in

early

of their distressed
in the defeat

without
opinion not indeed
is
probability. All we
can
supporters,
say
that outward
is
permeation of poison from the blood current
not
vasorum
likely; while by way of the vasa
poisoned
very
reach the media
and even
the intima of
blood would
directly,
their

of

own

purpose
without
but
"

an

into their interstices

vessel,penetrating

vasa

may

vasorum

much

the

be

affected

by

the

for the parts

; and
causes

in
of

so

far

as

the

all arterial

they supply,the tissues

would
enjoy the less provisionfor repair.
but not wholly dissimilar,
of
course
Syphilistakes a peculiar,
The questionhas been asked if the well-known
its own.
transdisease

so

worse

ANATOMY

468

OF

ARTERIOSCLEROSIS

PART

in

unfortunate
the
as
syphilis.And this is the more
analogy of the coveringsof other viscera suggests that the aortic
investment
like them, contain afferent nerve
endings; indeed
may,
have
such structures
been found
there by Thoma
(see Angina
Vol.
definite
I
have
to believe
Pectoris,
reason
II.,p. 418).
given
that the ascending arch is endowed
with a peculiarsensibility
blood
to
plays a considerable
part in their
pressures, and
compensation (Vol. II., p. 415). Hirsch and Stadler1 have
brought further evidence to prove that in this area the depressor
balances the stress of every cardiac systole
(every aortic diastole).
On Ludwig's method, they cut the depressor in some
rabbits
into both
and
in others ; they then
not
injectedadrenalin
series,and found that the aorta in those with cut depressors
strain.
An
suffered far more
interestingillustration of this
that
if in aortic
comparison is given. We
may
presume
paired,
in syphilitic
or
aorta, the arch is profoundly imregurgitation,
it would
lose this sensitiveness and adaptability
to pressure
the local disease must
oscillations : in which case
multiply
itself infinitely.
From
the clinical side, I had
long ago formed
the opinion that in many
viscera, if not in all,pain has its

disease,even

in

source

the

investment

outer

its extensions

and

in the

as

"

pleura,in the meninges, in the peritoneum and mesentery, in

the capsuleof the liver,
and in the pericardiumand its extension
the aorta.
Dr. Hugh Anderson, from the side of physiology,
upon
had

arrived

view

viscera ; thus

discussed

under

enquire how

disease

; and

lesion

this

the

This

Angina

skin

point

Pectoris

following the
remain

view

adventitia

probably will
mainly the inner

answer

affects

of

investments

as

will be

in his

in-packing
mode

have

we

is affected in arterial

be that
coats

of

fully

more

(Vol.II.,p. 411) ; here

far the vascular

the

; these

visceral sensations

sensation.

cutaneous

to

similar conclusion

prolongationsof

are

of the

at

as,

of

syphilisapart,
the

aorta

and

vessels,if the adventitia be involved in the process, it

the atheroma
is but occasionally
happens to dip
; that is,when
other

deeply than

more

is usual

if it suffer at

with

all,seems

it.
to

In atherosclerosis
be the

last to

the adventitia,

suffer

little

On this
Stadler, Deutsche Arch. f. klin. Med. Bd. Ixxxi., 1904.
Deutsche
med.
also
Bittorf,
Wochenschr., No. 36, 1910,
complex problem see
Arch. f. klin. Med., 1904, and Munch,
med. Wochenschr.,
and previouslyDeutsche
1907, No. 18. Again, Bruns and Genner, Deutsche med. Wochenschr., 1910, No. 37.
1

Hirsch

and

CHAP,

of connective

excess

tissue,some

that all three coats

know

ADVENTITIA

slightcellular

some

vasorum,
we

TUNICA

THE

vii

469

about
proliferation

infiltration.

In

vasa

syphilishowever

liable to the disease

are

the

(p.301), and

proliferation,
largelyperivascular
(vasa vasorum), is
in the adventitia.
H. Martin
and Dieulafoy,as I have

active
seen

(p. 464),

believed

secondary

that

in atherosclerosis

to this affection of the

largearteries

; but

apart, the

vasa

expected.

We

infections
been

have

might

tends

fibrotic encroachment
first with

all three

what

of it

that

so

was

how,

in chronic

cases,

from

creep

in very

way,

chronic

slow

fibrosingprocess,

in the

later stages of

impossibleto
primary and

it becomes

cases

in the

point to point,at
propagation,or in spots remote

to

liable to

are

cell infiltration ;

small

or

coats

rate

was

for less than

count

know

cell
perivascular
supply ; and in this

vascular

from

lesion

at any

vasorum,

vasorum

slow

intimal

said

expressingthe generalopinionwhen I
first,and indeed that,
thickeningcomes

am

repeat that the intimal

certain

vasa

the

to be

say

where

what

the mischief
The

secondary.

sclerosis,
without

particular
originated,
prosector

of the
dense and stiff the substance
frequentlynote how
under
the knife.
Still,infections
aorta
becomes, cuttinggristly
apart, in ordinary atherosclerosis the lesion is in large part
than
one
mechanical, and, as I have
argued in more
graph
paraHowever
subintimal
layer.
(e.g.p. 513), begins in the
these are
late phenomena and, summarily speaking,it would
that, syphilisapart, the adventitia and its appurtenances
seem
sclerosis.
do not play a primary, nor
important part in atherovery
any
may

said that Dr.

I have

Dr.

J.

is the

F.

fibres in

these

of

muscular
longitudinal

in

disease

in the iliac

as

fibres

yet

we

artery, and
how

demonstrated

Gaskell, in the renal, have

adventitia

behaviour

Andrewes,

; but

know

rich
of the

nothing.

be more
to
would
important in
seem
Longitudinal tone
of the media, in the
But
long vessels like those of the limbs.
next
place,incomplete as our knowledge may be, there is much
"

"

to

more

The

be said.
disease

subject.

my
1

Andrewes,

J. F., loc. cit.

2

Dickson,

Dr.

F.

Periarteritis nodosa

named

CarnegieDickson

W.,

Sections

C., Journ.

Report
shown
Path,

Arterial

on

at

the

and

does

separates these

fall within
cases

Degn., 1913, Plate II. ; and

Congress, 1913.

International

Bact.

not

vol. xii., 1907.

into
Gaskell

ANATOMY

470

classes

two

either

carried

the
syphilitic,

one

ARTERIOSCLEROSIS

OF

the

by

vasa

other due to
or

vasorum

PART

unknown

some

poison

by the lymph sheaths.

Harry Campbell 1 argues

Hypertrophy. Dr.
that more
regard should be given to the relative tensions of
in the various attitudes of an
the investingcoats
artery, that
their relative tensions at any given time or positionare
by no
Media

The

will be

will be

coat

This

is

No

doubt

is

there

change, but

regarded this

no

increase

as

blood

and

alluded

media

thickened

is

in

as

muscular

true

Johnson

stream,

to

as

the

and

sible
pos-

arterial

common

general agreement

observers, such

some

injury.

of

cause

an

tightensthe
too; though this

intima

I have

papers

not, I think,

the media

as

media

between

in former

but

true

the

slackened, and

compressed

positionwhich

of it

same.

discrimination.

unobserved
adventitia

"

the

and

one

means

tion
interpretaSavill, have

hypertrophy ;

others

hyperplasia. The chief functions of the muscular

by Henle in 1840, are distribution of
coat, first demonstrated
in the several regions and, with the elastic fibres,
irrigation
as

fibrotic

resistance

assumed,

lateral

to

attributes to the muscular

coat,

forwarding of
peristaltic

the second
to
a

of these functions

lateral pressures.

certain

normal

mean,

limits,such

within

the

stress

at any

not

who

seems

of

It is however
to

now

pressures
reasonable

in the

would

in the smaller arteries,

stream.

have

If these
it

rate

blood

we

but

mentioned,

have

alleged by Hasebrock,

function, that

third

pressures

ance
speak the resistexceed
persistently
"

to

that,

suppose

muscular

arteries take

But
it is a
as
a
hypertrophy of the media.
shape statically,
dangerous thing in biologyto rest assumptions on probabilities.
of medial hypertrophy was
probably
George Johnson's assurance
which
he
the sections
less just (p. 312) ; but, among
or
more
the
to me,
were
some
ordinary arteriosclerosis,
kindly showed
subintimal
thickeningwhich, in certain of his drawings,we may
discern
had

(p.330). Herein

now

even

advantage,though

some

by Galabin, Lancereaux,
of the

account

was

on

and

other

See

Johnson,

Senator, and

imperfectionat
be

Campbell, H., Lancet,

Jan.

S., Med.

Chir.

Trans,

Sutton's

researches

pioneerwork,2 supported

Johnson's

of research, is to

methods
1

Gull and

others, tentative
that

time

of

as

it

staining

remembered,
gratefully
1, 1910.

vol. li.,1868, and

many

other

papers.

CHAP,

vii

while

we

bear

of

many

our

how

mind

also

still tentative

the

that

how

Mott,

the

sections from

encouragement

32

his many

cases

and

put in doubt, and

At

Dr.

be

Since

that

urged again
"

with much

meet

specimens were

heard

date

tinct
dis-

in this coat

seen

carefullymade

the experts who

among
adherents.

that

rate, when

any

Savill

he did not

"

Herringham,1

hypertrophy,as

demonstrated.

to

media,

convinced

not

of

observers

thickened
Dr.

are

quality

yet

even

far fibrotic.

PathologicalSociety,in 1904,
true
hypertrophicincrease was

declared

for
of

nature

471

specimens genuine muscular

has been
fibrosis,

exhibited

few

the

to

as

and, I think, Dr.

of the
from

the

interpretations
;

agreed

Cowan,

in any

he

MEDIA

far it is muscular,

Dr.

at

TUNICA

own

far from

are

in

THE

him

however

he

found

more

and

of a genuine hypertestimony to the frequentoccurrence

has
been
cases
myotrophy in high pressure
accumulating;
still
unable
seem
although histologists
fullyto rely upon their
of authoritadifferential tests.
tive
Notwithstanding,the number
who
English and foreignpathologists
accept the correlation
of a genuine hypertrophy is increasing,
and in weight is already

more

inconsiderable.

not

The
grow

musculo-elastic

under

layer

increase of stress.

of

also

large arteries

the

may

Klotz, in his last article,

accepts

though after the age of 35

infrequent,3
he doubts
its quality. Jores says that in chronic renal disease
with
the media
increases
unquestionably genuine muscle ;
after
connective tissue increase may
come
although hyperplastic
this,and from the intimal side, forming, as it were, another
it

as

definite and

layerof

not

He

the intima.

insists

on

the careful

use

of differential

of these changes
precise mode
This form
notice in a
homogener derber Eindruck."
escapes
tion.
of connective
overgrowth is little subject to fatty degenerait in the arteries in aortic regurgitaQuincke demonstrated
which

stains, without

the

"

tion where, at

rate

any

in rheumatic

it appears

cases,

to

be

purely mechanical, not a toxic alteration ; an observation which

4 for
example,
has been recentlyconfirmed
by others,by Merklen
who givesan excellent drawing of this alteration,extendingeven
1

Herringham,

Pathol.
2

Klotz, 0., Journ.

of Path,
4

Soc., London,

1901, and

Savill, Lancet, Feb.

and Bact., 1913 ; M'Cordick,

Merklen,

letters

to

myself.

16, 1904.

Lemons,

1908, p. 135

Journ.

Med.

Res., 1914.

ANATOMY

472

the

to

ARTERIOSCLEKOSIS

OF

arteries.

coronary

Jores, on

the

PART

hand, in aortic

other

in young
medial
has demonstrated
true
a
regurgitation
persons,
that it is unstable
arterial hypertrophy. He
thinks however
and
does not long endure.1
We
that from child to adult
know
a
manifolding of the elastica is a part of genuine growth ;

yet under
into

merge

be unstable, and
this process may
that the
Jores agreed however

conditions

other

atherosclerosis.

thickeningcorrespondedin kind to that which he had verified in

earlystages of high arterial pressures in disease. I may remark
that Jores' opinion in this matter
is of weight,seeingthat he,
and
and Thoma
and others,had also observed, and by surgical
experimental ligatureproduced, a thickening of another seat
and nature
regenerative increase of the
; namely, a so-called
fibrous constituent
of the intima,
Bindegewebswucherung
of
a
change which is apt to invade the media, or the room
it. I may
add that in two
Jores took portionsof artery
cases
from
the walls of hypertrophied hearts in young
the
persons
subjects of valvular disease, and demonstrated, besides the
of the elastic lamels, a very considerable increase
multiplication
"

"

"

"

"

"

also of the smooth

muscular

probable then that

hypertrophy of the
indeed

says

that

For
in which

the

it is

all

cases

if transient

true

It is

them.

does

is not

least of

yet much

affected.

fibrous kind, is sure

to be

Some

intimal

present, of senile

universal

should
focal

pressure

with

Marchand
frequentlyoccur.2
three coats
take on a genuine hypertrophy.
may
should
be selected
cases
appreciations,

intima

high

media

accurate

at
thickening,

vessels

in

fibres associated

be

lesions ;

and

but the media, if a hypertrophy,

proclivity,
nodular
nor
uniformly thick, not
presenting
the elastica not
Indeed,
splittingaway.

of the elastica may

be a subordinate
test of the nature
integrity
of the change.3 The
notion that lateral pressure,
strength of
the muscular
pulsation,concerns
coat, while the elastic and
connective
constituents
concerned
with stretch lengthwise,
are

cannot, I think, be confirmed.

1
2

for
so

printing,says
auffallend
8

Bd.

Arch. Ed.
Jores, Virchow's
able book
Faber, whose
was

See

on

"

eine

ist,dass

clxxviii.,1904.

published after
Mediahypertrophie, die

sie als zweifellos

this, Hallenberger, "Skier,

viii. ; and

Aschoff, Beiheftez. med.

this

manuscript

in der

Niere

in

was

made

vielen

up
Fallen

bezeich.net
d. Art.

werden
kann," etc.
rad.," Arch.j. Min. Med,,

Klin., 1908, Hft. i.

1906,

CHAP,

THE

vii

few

it.

It

hypertrophy in

belt of

certain

not

to

renal

so

media," attributable

to

(p. 476).

spasm

Orth

Johnson,

essential

confirmed

side of

central

these authors

and

demonstration,Ewald
the

on

that

473

disease,and

primary

cases

of the

"

of

first

likewise

vessel ;

MEDIA

Johnson's

demonstrable

was

narrowed
in

after

years

verified medial

TUNICA

had

no

any

doubt

working hypertrophy

excessive lateral pressures,

who
often argued on
too

it to arterial spasm
lines, attributed
due
teleological
to
a
of
action
the
muscular
vessels,a defence against
stopcock
the access
of poisonous matter
the organs.
to
Of recent
Dr. Newton
Pitt,2 Professor Adami,3 Dr.
English investigators,
"

"

Andre

wes,4 Dr.

Sir
Campbell,7 and
genuine hypertrophy
Letulle

Josue

and
9

Marchand
chronic

(in

renal

diffidence
I believe

the media

Dr.

Cowan,5
John
in

William

Broadbent,8
of

cases

of

cases

on

that

For

my

in

France,

Ziemssen,

von

10

Friedemann

plus pressures);

disease),and others.11

Harry
accepted a

have

high pressures
in Germany,

accept it,and

all

Russell,6 Dr.

part, with

own

(in
due

questionof histologyin which I am no expert,

in high pressure
cases
a
genuine hypertrophy of

in the muscular

type of

does occur,

vessel

and

that this

perishablethan might be supposed ; but the

proof is difficult,and not only because the muscularis is liable
to fibrotic invasion and to degeneration. To the chief difficulties
muscle

new

is less

of demonstration
diameter
coats

I have

alluded

(p.331)

the want

taperingvessels,the various
to
different vessels,especially
as

amid

in the

intima, the allowances

hard
constriction,

to

be made

of

standard

proportionsof
the thickness

in specimenstaken during
estimate, especially

to

"

in

occur

high pressure

Russell, W., Lancet,

Campbell,

Brit. Med.

Journ., June

15, 1910, p. 195

Lancet, Feb. 20, 1904.

Marchand,
his article in the

Sir John,

Kongr.
4th

Inn.

Med.,

1904, and

Friedemann,

Virchow's

11

E.g. Sanders,

Amer.

Arch.

Journ.

Med.

Chir.

vol. clix.
Med.

Sci., Nov.

4, 1904.

note.

edit, of Eulenburg.

10

dated

trophy
hyper-

(as in the heart)."

cases

1901, and

H., Lancet, Jan.

Broadbent,

of the

degrees of dilatation and

for

Arch. Bd. IxxL, 1877.

Ewald, C. A., Virchow's
Pitt, Newton, Brit. Med. Journ., Oct. 10, 1908.
Adami, Pathology, vol. i. p. 594.
Andrewes, Report to Loc. Govt. Board, 1913.
1906 ; and
private letter to me
Cowan, J., Practitioner, March
I am
March
he says :
quite sure that a true medial
8, 1913, in which
may

the

1911.

Trans., 1907, and

in

ANATOMY

474

ARTERIOSCLEROSIS

OF

long persisting
rigor mortis, or
solutions, the

confusion

which

processes

the freshness

have

or

bathed

in

of subintimal

not

staleness

of

regionsof

normal

medial

thickening,
precisely,

of the

specimens,the various
uncertaintyin our differential

variations

smaller and

are

defect

of the blood

in

stiffening

or

discriminated

preparation,and some
the arteries of women
Speaking generally,
those
than
of men
(Marchand). The
of the

water

with

been

always

PART

modes
stains.
thinner
ledge
know-

our

vessels in different

the

body, and at different ages, again often makes it

indeed impossible,
to decide whether
or
difficult,
a
given vessel is
book
Thus, as A. V. Meigs observes, No texthypertrophiedor not.
contains an accurate
illustration of perfectly
or
description
"

normal

renal

blood

vessels,any

than

more

the other

organs, and therefore any one

the kidney is constantlyconfronted
with
whether

blood vessel
particular
is enhanced
in the case
difficulty
par

different

is thick

"

years

in

the

Likewise

early.

considerable

tissues,but

advancing

adventitia
of

the

as

of

studies

diseases

of

of deciding
difficulty
diseased."

or

This

of the arterial intima, the seat

excellence of arterial disease ; for not

normally present

vessels

who

is normal

of blood

differences

only
in

does

this coat
arteries

the

of

normally it undergoes thickening with

It
wrinkled."
surelyas the face becomes

coronary

arteries,in which

it is often

difficult to

atheroma
decide

appears
whether
the

be

morbidly thickened or not, owing to the difficulty

tive
determining the boundary between it and adjacent connectissue.
Dr.

cases,

in

at
Herringham relies,

upon

estimation

any

rate

of the muscular

in

in

part, and

nuclei ;

these, he

early
says,

the

or
allegedhypertrophy are not increased in number
l
laboratories
Dr.
Gutch
that
had
shown
quality. In our
muscular
rate
in the myocardiumhypertrophy at any
consists rather in an
of
enlargement than in a multiplication
the individual
fibres ; to this Dr. Herringham repliedthat,
knowing Gutch's work, he was stillof opinionthat in the media
of high pressure cases
these fibres are
neither multipliednor
also asserts
that, in four cases, his stains
enlarged. Benda
"

revealed
as

not

Savill
1

so

much

muscular

franklysaid,medial
Thesis

for M.D.

degree.

as

fibrous

increase.

hypertrophy is far
Journ.

of Path,

and

from

However,

being uni-

Bact., 1901.

ANATOMY

476

stances

although, of
and

fibrosis may,
the muscular
If

ARTERIOSCLEROSIS

OF

often

layer

course,

subintimal

does,encroach

upon
thrustingit back.

or

PART

general
media, penetrating

or

the

more

stronglycontracted media be, as seems

probable,that
kind
of arterial thickening which
especiallyresists the cuff
of a vasodilator
manometer
(p. 80), the administration
might
instrumental
slacken
the
and
this
bears
curve
possibility
;
the
question if a long abiding constriction,without
upon
of lateral pressure,
excess
bring about such hypertrophy
may
would
rather
constriction, if persistent,
(Russell)? That mere
be unfavourable
to nutrition,I have
suggested; but is it clear
Dr.
that
tone
effort ?
more
means
more
Hugh Anderson,
of some
in the course
study of the iris,found that abolition
of the tone of the iris for two
atrophy,and he is
years led to no
disposed to think that excessive tone does not result in hypertrophy
a

he

should

"

no

sees

reason

to

suppose

that

one

attitude

of

lead to

than another."
hypertrophy or fatiguemore
I suggest that, although as an
there must
be
artery contracts
transient consumption of energy, yet, the new
some
position
Nor do the nerve
attained, energy is no longerconsumed.
centres
death.
fatigue,till near
Traube-Hering movements
persisteven
in profound shock.
Gray and Parsons,1 it is true, in certain
tone

conditions

in,

of renal

found, when
vasoconstriction,

evidence

of

fatigue,due,

vasodilatation

they suspected,to a
substance ; but they found
in
none
shortage of chromaffin
That
in many
ordinary clinical shock.
regions of the body
certain nerves
out
of action (indefatigable)
know.
are
never
we
Such
is the case
with the vagus
and the depressor,
and many
The
others.
most
probable opinion is that it is an increase
of intermittent
lateral pressure, never
sufficient
or
oscillating
to strain the muscular
active within
coat, but keeping it more
its limits of elasticityas, for example, by pulsatingabove
a
moderate
stenosis
which would
cause
hypertrophy. If this be
of peripheralvascular
so
so, in case
widespread as to
spasm
raise arterial pressures,
should expect to find medial hyperwe
trophy,
much
in
the
not
so
closely constricted
portions
in
where
as
the
more
portions placed
centrally
dilating
stresses
more
come
fullyinto play. In the voluntary system,
set

some

as

"

"

Gray

and

Parsons, Arris

and

Gale

Lect., Brit. Med.

Journ., May

18, 1912.

CHAP,

LESIONS

vii

it is not

in muscles

OF

THE

in permanent

MEDIA

477

that

spasm

find

we

trophy
hyper-

(p. 218).
It is not

trophy as

then

easy

combine

to

result of excessive

the

lateral

over-constriction,
independent of
morbid

stimulant

called

reflex

because
(Russell),

due

these

in action

to some

known
un-

factors,although

constriction
together,

conceive

may

reaction, whereby

or

and

pressures

be
they may alternate,can scarcely
to tension.
We
being antagonistic
vascular

hypothesesof hypermyoand
of
pressures
(Savill)

of

contractile

internal

an

function

is

antagoniseextraordinarytensile stress, though

such a myogenic reaction is disputable(p.50). I have dwelt
this point because, as we
have seen
in my
brief remarks
upon
of the arterial wall, and
sphygmography, condensation
upon
muscular
constriction,may, as Dr. Russell says, interfere
especially
with the readingsof the external
sphygmometer (p.80).
the
media, independentlyof tone, has also its own
Although
is largely,chieflyindeed, one
elasticity,
!of
yet its function
attitudes
be

to

upon

of

tone, and

inverselyas

its moment
"

is the term

erroneous

its deformation
of

arterial

under
Hence

tone.

perceivehow

we

tension,"when

must

pressure

we

arterial

mean

pressures.

The
e

Media

Lesions.

limits of the normal,

discuss its morbid

always results
or

of

many

have

we

them, do
and

seen,

observations

to this

preliminaryremarks upon
quasi-normalmedia, we may proceed

After these

"

or

of

infection.

some

or

kinds

Of these the acuter

states.

attack

may

shall

see

effect,upon

It

that

seems

farther, made

Infections,
interesting

some

and

the coronary

haps
per-

Wiesel,2 as

first.

the media

are

other

arteries,

orders.
typhoid,influenza, diphtheria,scarlet fever, and septicdisIn cases
of this kind in the aorta
necrosingspots are
the size of a pin'shead or of a linseed,beginningat any
seen,
rate in the media, if not confined to it.
Myocarditismay become
in

little later.

apparent

passing

into

Wiesel

in
or

The

which
cases
8

scar

suggests that
few

tissue,

muscles

perhaps

or

in later

apparent exceptions

they virtuallyheal,

convalescence

In

years

such

to this rule have

naturally powerful

were

calcification ;

into

damaged spots
been, in my

probably no

may

spasm.
Klin. Wochenschr., 1906, No.

24.

be

experience,cases

larger than

before

of intermittent

Wiesel, Wiener

but

(See also

p.

287.)

ANATOMY

478

for
starting-points
are

in

ARTERIOSCLEROSIS

OF

senile arterial

diphtheria is concerned,
arteries also ;

but

and

in

Klotz's

degeneration.

with

agreement

PART

he

those
noted

of

Wiesel,

the

so

vations
obserfar

as

change in
streptococcal

same

of

typhoid and
intimal
infections he found
proliferation.Other observers of
arterial infection report hyaline degeneration of the media,
difference.
These
considerable
well
no
depravations cannot
mesarteritis ; they are
mations
inflambe called "mesaortitis"
not
or
but degradations.
The now
well-known
of adrenalin upon the media of
effects
vessels in animals, by some
authors regarded as toxic,
the largest
the evidence
of Harvey and
on
are
now
generallyinterpreted,
results of high blood
others,as mechanical
(p. 223).
pressures
other

effects of

These
because
because

adrenalin,

cases

or

mere

they are identical with

under
the
they illustrate,

tissues break

up.

strain,are

not
interesting,

atherosclerosis
eye,

the

way

man,

but

in which

such

in

First,the nuclei of the muscular

whole

fibre

blur,

degenerates; so that hyaline

and clumps, advancing, in the media, to
and
thickness
and
its whole
circumference,with perishing elastic
fibres and
cells
to tell of vanished
empty spaces, only remain
foci very soon
and tissues. Such
give a lime reaction. Here
and there patchesof increase of connective tissue appear, possibly
in part set up by the lime acting as a foreignbody. If there
intimal changes they are
are
adjacent to the worst medial
any
patches,and due to contiguity. The adventitia and the vasa
few
but
little affected ; and
or
are
vasorum
no
leucocytes
from
in
human
them, though, as
atherosclerosis,
are
wandering
be seen.
few giantphagocytes may
a
But the gravest of these infectious injuriesof the arteries,
and
especiallyof the media, is that of syphilis.Syphilitic
well known
arteritis is now
too
to need much
here,
description
and I have dealt with it more
fullyelsewhere (p. 292). I touch
the media.
it here only so far as concerns
Before my
upon
demonstration
of the histologyof syphiliticdisease
of the
cerebral arteries,
of other internal organs,
as
syphilisof arteries,
had been described,macroscopically,
by Wilks, in 1863 (p.294) ;
but his revelations were
long neglected. And the enormous
which
deformities of the aorta
we
now
recogniseas syphilitic
and

consequentlythe
granular streaks

fibres

CHAP,

LESIONS

vii

OF

THE

MEDIA

479

well described

by Hodgson, and later,as syphilitic,

by Welch
(Vol.II.,p. 167). The pre-eminent part of syphilis
in aneurysm,
recognisedplainlyby Morgagni and Lancisi,has been illustrated
writers, and re-emphasisedby Dr. Drummond.
by many
By
were

these observers

and
especially,

also,though by

by the Kiel school,the initiation

probably gummous," lesion of the
with

and

more

media,

or

or

manifested

by
again,rarely,in

1912),is very
spirochsetahas
other

the

always

not

the

has been
adventitia,
In earlycases
of arterial
progressingfrom the adventitia

isolated

granulomatous foci in the

the intima

observers,in the adventitia.

vessel,

coat,

(asin some
preparations
shown
at the Physicians'
Association at Glasgow
distinct ; and lately
in recent
the specific
cases
been
and
detected, by Benda
after him
by

in

many

whether

process,

Dr. Teacher

by

gumma

of

middle

clearlydemonstrated.

more

syphilisthis
inwards,

evident

ally,
origin-

means

of this disease in
punctate,

"

associated

no

we

see

the

destructive

but
calcification,

As

elsewhere

stage succeeded,

so

not

in

by

by scar.
gradualcorrosion,
point to point,here extinct there smoulderingon,
in time extends to the enormous
deformityof Hodgson (Vol.II.,
on
intenselyand ulceratively
one
p. 168) ; or, if fixed more
spot,
that the media
becomes
the
gives way, a saccular aneurysm
diffuse blisterings
and pouchIternative,
or associate,of the more
the test of Wassermann
In these cases
igs of Hodgson's disease.
of diagnosis.Hasenfeld,
now
givenus one more efficient means
the Buda-Pest
test
Congress in 1909,1 found the Wassermann
dtive in 10 per cent of all cases
of "senile" aortic degeneration,
and
similar results are
being obtained by others. But these
pointsare discussed more
fullyin the section on Aortitis.
In

the aorta

this

creepingfrom

The

lesions in the field about

the orifice of

an

aneurysm

are

atherosclerosis,and

of
less of the nature
or
)mmonly more
aortas
in all old syphilitic
)f secondary causation.
And
blended are
lesions if not intimately
and
atheromatous
specific
associated in close approximation (Vol.II., p. 206).
is syphilitic,
Although in the vast majorityof cases. aneurysm
such as
it springsfrom other toxic causes,
yet in some
cases
rheumatic
then

we

fever
come
1

(see Aortitis,Vol. II., p. 150),and

across

cases

Hasenfeld, Deutsche

of
med.

aneurysm

in which

Wochenschr., Oct. 8, 1908.

now

and

syphilitic

ANATOMY

480

ARTERIOSCLEROSIS

OF

originis incredible,or

PART

of these
impossible; of the causes
know
failures of the media
we
nothing,but as a healthy aorta,
that seems
after death to be healthy,may
one
or
rupture, so
smaller crack might issue in an
a
Aneurysm may
aneurysm.
also
arise
in sepsis,
that obscure disease Periarteritis nodosa ;
or
in which
there is also -a class of rare
cases
myriads of small
in the viscera and

aneurysms,
as

indeed

it would
The

of

appear,

resemblance

in the limbs,
infection

some

unknown.

arterial
of syphilitic

atherosclerosis may
be close, as Heubner
that
cerebral vessels.
It is in the aorta
distinct

most

are

arise,in consequence,

such.

as

disease
I

and
the

disease
Syphilitic

ordinary

to

showed

in the

features
syphilitic
of arteries of lesser

from
and more
that of the aorta, and
magnitudes differs more
not
merely in those incidental modifications which depend upon
size,place,and circumstance
; for instance,in the cerebral it
like atherosclerosis (pp.296-298), and withtakes a form more
out
other data may
be indistinguishable
from it. Again, if we
to syphilisof the common
iliac we
turn
find its
our
eyes
may
like atheroma, though the adventitia is more
state more
thickened,
the media
fibrous.
Or the adventitia may
and
be fairly
more
for secondary effects,while
the media, save
normal, and even
active foci in the intima may
obtrude more
less crescentically
or
the channel.
It seems
also that in syphilitic
on
patientsa more
diffuse kind

change
See

more

of medial

intimal

and

fibrous than

also, since this

sclerosis is prone to occur,

a
of atherosclerosis (vide p. 294.

that
in

print,Gruber, loc. cit. pp. 71-75).

The followingnotes, kindly sent to me
by Dr. Andrewes, show
how difficult it may
be even
to specifythe difference
on
necropsy
between
syphilisand atherosclerosis.
"

of

R.

Gr.,set. 45,

aorta, but

was

drunkard.

far

not

advanced.

Adventitia

but

supple.
mostly open ; a
by arteritis,but
for two- thirds
in the

intima.

the

media

save

certain

media

No

for the

in

degenerate,with

No

muscular

'

spots.

The

patches,the
the

usual

positive. P.M.
calcification.

thickened

junctionwith

media

its

Atheroma

Aorta
vasa

vasorum

obliterated
definitely

visible vessels in the inner

nor

other

was

much

third

degenerationof

of the

encroachment

intima

tough

part activelyvascularised

most

atrophy

thinningby

some

ulcerated

generally and

near

the

No

much

not

few

of its thickness.

nor

'

Wa.R.

intima

near

thickened, both

strip(next media) being widely

the two
three
or
phenomena. About
outer

CHAP,

'

LESIONS

vii

ulcers

'

OF

THE

the

was
vascularity
abundant
stronglymarked ; there were
cells
and
cells
plasma
large giant
(liketubercle),with
nuclei close to the lumen.
Fatty changes diffuse,not to

many

great degree. The renal artery, taken

normal
trace of plus intima, and media
normal.

Renal

arterioles

v.

e.g.

"

control,was

as

normal

; no

; elastica not

split. Kidneys
normal.
afferentia,
My report

abbreviated.
No spirochaeta
found.
necessarilymuch
Probably
of the intima apart from the comparatively
true
tertiarysyphilis

slightmeso-aortitis."

Such

Andrewes

Dr.

tissue

granulation

into

eaten

was

with

is very difficult of determination

that the intimal plaque was
not

case

thought

but
definitelyspecific,
"

481

of

groups

is

MEDIA

cells and

giant

by a perishable kind
plasma cells ; hence

of
the

ulceration."

We

have

disputablematter.
Apart
from the effects which
we
usuallygroup together as infectious
and
included, and independentlyof
septic,syphilisof course
fibrosis,and of atherosclerosis a disease primarilyof the intima
although usuallyencroaching on the media, is there a kind of
arteriosclerosis
primarilyof the media itself
; a degradation
there, having characters of its own, and taking its
originating
?
Some
own
deny any such separate lesion
pathologists
way
Marchand, while
altogether
; others, like Jores, Aschoff, and
in some
not
degradationsof the
denying a certain peculiarity
to

now

"

enter

upon

more

"

arteries of the

limbs,seem

to

pay

brain, heart, and kidneys,they detect

the

but, atherosclerosis
would
cit.),
(loc.
medial
with

mode

others, like

to it elsewhere

littleheed

Dr.

Mott

no

authors,

Pitt

Newton

and independent
accept and describe a particular
which
mode
of arteriosclerosis,
a
they compare
in the
degenerationfound in animals, especially
with experimentalarterial lesion.1 Again, some

French,2

Dr.

as

converted

from

muscular

atherosclerosis but
the media.

does

not

adheres

connective

See

is itself liable to
the

is thus

coat

tissue tube,

process

independentof it,and belongingprimarily

French's

article is not

distinguishhigh pressure cases

to the current
opinion that, when
1

VOL.

Dr.

to

necrosis

medial

distinction from

in

suggest that the muscle

leadingto calcification,
fibrous deterioration,so that
a
non-calcifying

to

Dr.

and

nothing

the arterial

herbivora, and

not

or

more,

; in

clear in
from

so

the

as

he

rest;

he

far

high pressures arise,

Harvey, Virchow's Arch. Bd. cxcvi., 1909.

2
French, H., Lancet, July 13, 1912.

ANATOMY

482

ARTERIOSCLEROSIS

OF

PART

secondary to a foregoingarterial rigidity.That the

of the whole vessel,of all the coats, under
connective
scaffolding
tends to trespassfrom the borders of physiology
stresses
increasing
tissue growing
into pathology,so that in senile vessels connective
they

are

the muscle

between
the

reach

fibres and

contrast

on

French

other fat test.

not

refuses

as

yet

is not

used

the

this

regard

fibre than

but

the other

medial

any

peculiarprocess
is incomplete,
fibrous arterial

disease

(p.530).
III.

Sudan

and in
infinite,

are

hyperplasia absent,

less of
to

states

abound, and

yet demonstrated

as

far he

how

say

Intermediate

contains

more

between

important scale

is connective
media

of any

may

atherosclerosis,the evidence

an

does

the intima

(p.516);

atherosclerosis

sclerosis and
Dr.

know

adventitia,we

in the media, not

and

from

sclerosis
arterio-

no

normally

the

Aschoff

coats.
more

as

or

or

other

indeed to have
varietyof arteriosclerosis. Jores seems
That
high blood
regarded the media as outside his argument.
sequential
pressure is due to a fibrosis of the peripheralvessels with a conbe maintained, as
hypertrophy of the heart, cannot
than

arterial

of this work

sections

in many

between

fibrosis.

is no

twigsthere

and

atheroma

The

fibrous

shown.

have

the

finest

truth is,the old distinction

arteriosclerosis,
or

"

Arterial

hyperplasia in youth

(p. 530). Connective

Cirrhosis,"is dead

In

fibres.
it grow the elastic and muscular
be regenerative,
After the stationaryperiod,if it may
e.g. after
infections,it is generallysubstitutive, and then is associated
is

formative, and

with

atherosclerosis

that

is,with

fattyand

necrotic

changes.
tion
Monckeberg's Sclerosis. However, a distinction and descripof a primary medial
degeneration,peculiar,or almost
peculiar,to the vessels of the limbs, is attributed, as by
Adami, to Monckeberg.1 Monckeberg has the credit of the
full comparison,but, as he himself points out, Orth 2 first drew
attention to it. As laid to the charge of the media, this alleged

with

"

varietybegins in a non-atherous
with
early calcification,even,
conversion
1

und

which

to

Monckeberg,
ihr Verhalten

"

zur

Uber

Adami
die

reine

decay
it may

and
Media

Arteriosklerose,"

his

be, with

coat,

ossification,a

pupils,especiallyKlotz,

verkalkung
Virchow's

muscular

of the

der

Arch.

Extremitatsarterien,
Bd.

clxxi.

s.

141, 1903.

Beitr.
d. Arterien verkalkung,"
also
z.
Hubschmann,
path. Anat.
Ziegler'sBeitrdge, Bd. xxxix., 1906.
2
Orth, Virchow's Arch. Bd. cxci. Hft. 2; and Lehrbuch, 1887.

See

"

ANATOMY

484

ARTERIOSCLEROSIS

OF

In

yet but little thickened.

tone, if pressures are moderate, or even
tortuous, and

slack.

What

indicate

that

and
to

muscularis

In

elastica.

and

in the

observed

be

may

consists in

primary decay

uterine

the

intima,

and

conversion,
gelatiniform
Westphalen tried to obtain
with

no

notion

current

described

as

help in our
twenty-fiveyears

some

vascular

morbid

leucocytes,and

different

scar.3

calcification,and

and

forth,

so

of the

demonstration

; the process

little

but

The

the

fibre

salts.
this

is too

much

give us

to

lightfrom

some

clear result

very

in lime

takes

of

change
dental,
patches being inci-

only in the larger branches :

l
rapidlylapsesinto hyalinedegeneration; the
a

seems

down

melting

this

and

vasomotor

of the uterus

process

such

any

waning

low, the vessels get thin

of the involution

know

we

PART

media

undergoes

Thoma

and

involution,but

little like arteriosclerosis

present problems. The

mesarteritis,"
ago of a
cell activitywith infiltrating
"

closed

was

Marchand's

by

process of necrosis, dissolution,

be taken in this
part which may

of largervessels may
by obliteration of the vasa vasorum
and akin, but is certainly
be auxiliary
secondary and inconstant.
have
The
specimens thus interpretedas of an arteritis may
arterial infection ; but generally
in active
been derived from an
issue

the

cases

exudate

is somewhat

adventitia

may

be

cellular

in the

seen

process which, by the

invade the media
may

Monckeberg, in

concerned,4 and

perivascularlymphatic spaces, a
known
in French as "pacifiqiie"
penetration
almost

130

cases,

to

up

found

the intima.
calcification of the media

changes seemed
associated with intimal change
medial, but in 12 they were
strictly
likewise speaks of
Dr. Mott
the medial
also (atherosclerosis).
I have
arteriosclerosis," mainly in the limbs.
type of human
little objectionto Dr. Mott's terms, but I do not go quite so far
arteries in 55 instances

limb

; of these

of

in 43 the

"

"

"

Monckeberg

as

I think

does

; nor

of

this kind

Faber.

tinct
if a disor
arteriosclerosis,
arterionecrosis,

to the arteries of the muscular

kind it be, pertains
1

See

of Obstet.

Barbour, Journ.

vol. xviii. ; Pearce, Brit. Med.

2
In pregnancies a curious

namely,
3

In

See

of

formation

his article in
however

"

new

vol. vii. ;

Journ., Dec.
and

vessels

Findlay, Trans.

the

old

Eulenburg's Encyclopedia.

Infections," p.

282.

Amer.

Assoc.

Obst.

5, 1908.

perhaps unique
within

rather than

process
ones.

has

been

observed

CHAP,

LESIONS

vii

of the elastic type, and

but,

only ;

guiseassumed
medial

limits may

the

in

no

but

wes

of

worn-out

earlier

vessel."

stages this

shall

elastica intima

when conillusory,
nective
especially
in.
Thus von
Romberg, at
that atheroma,

of

seat

vessels,were

it is in the

arteries

invades

connective

(videp. 524) ;

atherosclerosis,
although
disease

the

at

Dr.

outset,

of the
or

end

in

sub-intima

the

only,

little later, the

very

the depravadisintegrates
tion
; and
and
by atrophic
destroys the media
or
pathologicalcontagion
proliferation,

splitsup,

thence
pressure,

be

may

that

see

In

of

distinction of intimal

in whatsoever
arteriosclerosis,
the

be

may

arisingin long vessels

September 1909, affirmed

that

legs
in
fallacy

"

Andre

we

or

and

arms

by the individual ; rather a premature maxim.

the natural
as
regards Monckeberg's decay

used

most

when

disease

be obscure

; and

same

485

that there is

sure

calcification crowd

atherosclerosis,and
and

as

site under

the Berlin Discussion

one

yet be

atherosclerosis

by

fibre and

MEDIA

"Monckeberg'sarteriosclerosis"

this type ; in such

and

THE

of these to the arteries of the

cannot

we

observations, so

our
a

as

OF

and

which

process

rather

seems

be

to

tion
propaga-

advantage, than
by contiguity,and a
made
an
a
primary vice of the media itself. Sanders (kc. cit.)
(in
important research into these conditions upon 300 cases
of these indicated a gross or visible
Berlin and Munich). None
the beginning of atherosclerosis (a
affection of the media
at
loss of mechanical

which

name

author

the

is established,he says,
and

the disease

test

if

on

which

complete agreement

decay in arteries

of

be scrutinised,

limbs

the

in the muscularis, seem

lesions,originating

clearlyand

severallymade

it.

Hyaline change
sclerosis

little,if
rather

the rabbits' aorta.

In

out

the

to

muscle

me

cell

quality,and turns
ing
and this while the neighbourperhaps always something,

loses
fragmentation,

really has

Monckeberg's
lesions of

scribes
de-

not

fatty,cloudy,hyaline,or chalky
with

indeed

of

swells, undergoes

wrong

in

occur,"

may

he

been

intima

media

relyso much on the fat test, a

is,I think, unduly sceptical.Notwithstanding,

earlycases
have

the intimal disease

Sanders

decay.
almost

intima

of the

Jores, though he does

focal necrotic
to

secondarilymedial

later and

with

"

accepts); but after

hypertrophy of the

is prone

its

to

resembles
other

calcification. Thus
the

chronic

experimental

cases,

of

kind

486

ANATOMY

which

scarcelyamounts
supplanted by common
the media

ARTERIOSCLEROSIS

OF

had

fibre is

disease, the muscular

to

connective

lost

PART

of its tone,

some

In

fibre.

these

in

as

slowly
I presume

cases

of the appearance

case

slowlydilatingmyocardium (Vol.II. p. 9).

It is part of the argument then that this degenerativeprocess
in the media is essentially
independent of the intima ; though, if
subintimal
atherosclerotic
changes set in, it is obvious that
its inner side also ;
of the media
be menaced
must
on
stability
the vessels of
into the subintimal
layeritself,
yet hither,as even
the adventitia may
creep, as part of a feeble quasi-inflammatory
of this fibre in

fibrotic

reaction.
(reparative)

There

remains

however

advocated

one

Thoma,

by

this

particularmedial disease may

yet, on the yielding of the media,
breach

to

or

fill it up,

and
atherosclerosis,
make

up

such

and

throws

that

arteriosclerosis

this
;

sidered,
point of view to be connamely, that, although

other

one

not

lie also in the intima,

the

intima,

the

out

blends

so

fortifythe

to

stuff which

is called

medial

as

with

lesion

to

losingits definition,both

the media

in respect of its several features.

Muscle,

such, is no

as

nuclei may
longerrecognisable
disappear,and the tunic
; its very
This is the
itself may
be bulged and attenuated
to abolition.
with great
advocated
hypothesiswhich, as we shall see, Thoma
We shall
and assiduity,
and from time to time reinforced.1
ability
that it carries us
far beyond the vessels of the extremities
see
where such considerations
especially
apply.
Thoma' s chiefpoint of view is that arteriosclerosis has its origin
in the intima but always in the media, the intimal changes
not
which ensue
being,in his opinion,set up to compensate the medial
defect.
He does not hesitate to speak of compensation in terms
of an interference,as it were
of some
providenceat watch to put
notion
in a stitch or a dab where needed ; indeed this teleological
Most

colours

all his arguments.

in their

changes are beckoned

allyin advance, or even

by an
depend for their survival
adaptation as they may
1

as
a

Thoma's

I know)

are

long reply to

papers
in the

are

long

104th

and

his critics in the

by

such

have

rather

hither

of

power
or

structures

and

thither

of intention, but

stream

tedious

that

not

good

inherited

112th
same

hold

us

for their

upon

and

of

reserve

acquired.
his

vols. of Virchow's

and

re-

Thoma

first papers
(so far
he
published
;

Arch.

journal,vol. 204, April 5,

1911.

CHAP,

vii

supposed that, as
slackened, the
in any

109),does

not

media

would

and

dilatation the stream

the intima

on

"

such

of his argument,

part

to be vague

and

487

tug,"

is,if Dr. Tait be right(pp.37-38

This

occur.

innate

tug

to suppose,

about, it

comes

forces

yieldingof

on

seems

tion

OPINIONS

stream

hard

case

THOMA'S

and guessy.

arise out

must

far

so

If however

and

as

prehensible,
com-

readapta-

of the

of the
algebraicsum
auxiliary,some
inimical,

contingent,some

accordingto which, and in which, the structure lives and moves.

We
must
distinguishbetween fortuitous conditions,advantageous
not, and

or

ought

not

whatever

ought
after

be

to

their

to

this

use

and

this latter

capacities.The

used

word

not

Abramoff
it be

case

diagrams of

the incident and

its milieu.

injurious,some
making up for
are,

the

on

Now

it

it be

if

we

elastica

growth or,
splitting;if in

mechanical

innate forces at work

if these forces

in

and

the

; if favourable

some

"

balance

in the intima

some

if they

"

them, againstlife,the

of

life,it

to

in the structure

actingon the artery

impairing the media,

reparative,some
by, let us say, alterations

whole

part will die

normal,
histologically

whether
a

"

compensation

temporarilyhelpfulit is so but by chance.

that changes of structure
represent moving

well

and

tissues

know

believe,

It has been

said

"

term

capacity. It is doubtful
the multiplication
of the

or

of

do

we

of

save

quantity

maturity, as

Pick

as

innate

will

But

survive.

the

intimal

arise out of the processes

at work
changes must
; each
be called
entail the next, which
cannot
step for good or bad must
by a provision. If we are to call the reaction which
up, as it were,
compensation,"
produces fibrous hyperplasiain an artery a
"

what
it

are

we

to call the

and

scars

maims

thickeningof
so
a

much
beam

; but

when

we

it to understand

that

intention

to the

or

an

valve

the intima

the better, as

reaction,due

same

If

of the heart ?

happens
a

to similar causes,

speak of
end, but

buttress

life may

man's

this end

to

"

be saved

brought about
it was

that

in

media

are

by

defect,

by the

we
compensation,"

was

that

be then

so

when

fall of
not

by

numen,

already impliedin the

moving equilibriumand the conditions under

chance
which
it was
working. That is, we must distinguish
innate
capacities. The action and reaction,
vantages from
two
large bodies
relatively
which
obvious
are
enough between
of
qualities

in

the

collision,
are, if less obvious,

no

less true

for

system of

ANATOMY

488

molecules
of the

if in

; now,

factors

OF

AKTEKIOSCLEROSIS

varies, this variation

system againstit ; but

in

of bodies

system

PART

for the

equilibriumone
has

moment

the

readjustment the action and reaction

be potential
of it as may
constitute a "compensation,"or so much
in the system.
Thus
Adami, who has some
leaning towards
Thoma's
views, ingeniouslyexplains that the intima thickens
because
of, and proportionately
to, the pull on it of the yielding
of a hypertrophy of connective
media.
This might be conceived
than a hyperbut atherosclerosis is far more
a degeneration
tissue,
trophy,
all
or
repair. As physicianswe are too ready to assume
if beneficial to be schematic
or
readaptationto be beneficial,
; we
rid ourselves of Paleyism ; yet Sir Berkeley Moynihan
cannot
recentlyproclaimedDame Nature to be, at any rate, a sad muff in
In so far then as a moving equilibriumis such it may
surgery.
under incident forces rearrange itself ; but this possibility
has its
limits, and
are

incident

on

forces

advantageous.

not

be careful not

to

impute motives
aphorism, In

assume

to

nature

often

set

up

rearrangements

which

then we
shall
interpretations
provisionsfor future advantage, nor to
In

our

shall rather

we

bear

in mind

Kant's

"

organisedproduct of nature all is end and all

is means."
The paths of science are
paved with the broken
of finalist hypotheses.
stones
Now
coming to the facts,with minds free from expectations
the
of the useful and prepared only to discern the useful from
what Thoma
has to report; for in this subject
not useful,let us see
he has done good service in tracingthe connective
and elastic
tissues and their respective
proportionsand distributions through
the vascular

an

system.

To return

then

to his

argument

; this

is,that

yieldingof the media, caused

in its own
either by excessive blood pressures, by an imperfection
or
consistency,
by a fall of stream
velocity; though the author's
that he adopts the
mind
dwells mainly on the vascular frailty,
so
for this incipient
name
phase of Angiomalakia. In the next
place he postulatesa lowered nutrition of the wall, a condition
in the abstract, to detach from the first. Thirdly,
even
difficult,
the wall gives way
substantially,
whereby no doubt we should
the first alteration in the artery is

"

expect

"

to

find

of its nutrition.

but, as

we

have

some

further

interference with

Fourthly,the

lumen

all observed, in

the normal

is widened, not

sources

uniformly,

lengths,in spindlesas

it were,

CHAP,

THOMA'S

vii

often

and

blood

eccentrically;
whereupon

stream, when, Thoma

must

contract,

contract,
To

OPINIONS

be narrowed

or

does

or

this

disease

he

point of
examine

to

to

ensues

retardation

restore

the rate

somehow.

then
insufficiently,

so

lateral pressures
At

says,

argument

certain

which

of the

the vessel

If the muscle

the intima

cannot

thicken.

must

little attention.

pays

the

489

Thoma

structural

leaves the

alterations

of

sphere

of

particular

or
pathological
physiological
according
of their development ; the most
to the circumstances
useful for
this purpose
of these alterations is the physiological
increase

parts,processes

which

follows the closure

which

of the ductus

certain

ensue

the

portion of
the

are

changes
aorta, changes

arterial stream

into the

of the

intima

correlative

of the

with

channel.

new

closure

botalli,a
the

Upon

upon

intervening
direction

the

nature

of

of

these

and Jores alike

changes pathologistsare agreed ; Thoma
admit that they consist mainly in a thickeningof the intima,
but of the layernearer
the lumen ; and this by an increase of the
arteriosclerosis." But
connective tissue
virtually regenerative
sclerosis
it is here also, in the deeper layersof the intima, that atherobegins.
proper
Within
limits then, limits probably of stress and comparative
"

"

health

and

youth

of the

organism,an
its growth up to

in the artery,as from

the

to

dabs

to

elastica,and

where

see

It

youth, a

extreme

always

pate,
antici-

should

appear

may

to

seems

in endo-

connective

often in annulose

or

more

be

in

seen

early

that, in slightand

of
proliferation

some

but

needed

in

impressionsare

My own
it is quitecommon

cases,

rudiments

tissue is

of connective

the intima.1

adult life we

promotes

tissue in its intima.

hyperplasiaof connective
generallyagreed that connective
thelial proliferation,
and, unless
a

less fine stratum

increase of work

overgrowthinternal
the

form

intima,
around

not

in

vessel,

while the muscular

it a little,
seeming concentricallyto narrow
Klotz 2 decides that these changes in
is quite unaffected.
coat
the intima
are
largelyindependent of change in the media ;
in
and
opinion. And so, fortuitously,
Ophuls is of the same
section

one

intimal

an

1
2

See

Klotz

we

boss, or

Adami,
on

degeneratedmedia alone, in another

graduaUy raised patch,without correspondsee

may
a

Pathol

hyperphasia

2nd

ed.

Also

of the intima,

Wingate
in Journ.

Todd

cit.,p. 304).
(Zoc.

Exp. Med., 1910,

vol.

xu.

ANATOMY

490

medial

ing
in

the

change ;

and

ARTERIOSCLEROSIS

various

allocations

individual.

same

if the

even

OF

In

caged animals

PART

of

experiments on

and

decay

repair
wherein,

animals

be in full health, the stresses

acute

are

excessive,this connective

hyperplasiais usuallyoverborne,
prevented by degenerative or even
inflammatory products;
the same
is seen
more
acutely in the infections, and more
of the
when, by years or ill-health,
graduallyin man
redintegration
stressed parts is less efficient : then we
not development,nor
see
even
repair,but mere
degradation. Notwithstanding,the effect
the intima

upon

be of

is that it is thickened

kind

one

another, dilatation is reduced

or

the thickening

and, whether

if the

whereupon,
by

condition

thickeningbe in due placeand proportion a

no
means
guaranteed,the normal rate of the blood stream
may
be
to
far
re-established.
But
how
we
even
so
are
perchance
in short lengths of a vessel subject to
blood
at
rates
guess
variable distal resistances,
vasomotor
influences,and systemic
At this sixth phase of Thoma
then we
must
stop
pressures ?
for some
reflection. In the necrotic long arteries Monckeberg
At
and his school declare that of intimal change there is none.
most
admit, not that the intimal changes,if any, are
we
may
"

established
dilated
old

in order

to

the

restore

parts, for Nature

does

due

put herself

not

alive,but that, if they happen

men

for the stream.

To

rate

to

of
out

the
much

fit,so much

explainthe ignoringof

stream

the media

to

in

keep

the better
in current

pathology,Thoma
suggests that in its attenuation it is
by the bloated intima so far aside as to escape due notice ;
in all,this is true.
specimens,though by no means
of conharmonise
the apparentlyirregular
nective
formation, now

arterial
thrust
in many
To

tissue,now
lime,
that
he

now

estimates

section ;

so

elastic and
pressures
stresses

are

offers the

tissue there is its

the

that

formative
if pressures

for connective
somewhat

these too

arteries,if a

tissue,now

of bone, Thoma

even

for each

of elastic

mean

would

pressure

fell it

less and

might

between

bone

cross
per sq. mm.
be reabsorbed
(?) For
"

the

formative

presumably under
the unstripedmuscle

less ; and
For

For

6-5

in this order

"

atrophy.

be taken

at

debris and

ingeniousexplanation

critical pressure.

own

tissue

of necrotic

contraction

and

lower
of the

relaxation,

the critical pressure

would lie above elastic fibre but considerably
below cartilage.All these calculations and many
others, in the

ANATOMY

492

it yieldsthe blood

when

the intima

waxes,

againsthigh

the

focal

distinction

kind, the

slackens,and

race

to

PART

"

compensate

"

this

waxing being not a hypertrophy directly

Thus he interprets
the primary arteriosclerosis,

pressure.

whether

ARTERIOSCLEROSIS

OF

diffuse ; for these

or

not

are

varieties of

is

recognised,as now
generallyagreed,
said that he had
never
only for broad comparison. Thoma
seen
pathologicalthickeningof the intima due to high pressures,
lateral pressure ; but here he seems
clear
not
to make
a
distinction between
connective
tissue growth, regenerativeor
to

or

senile,and

atherosclerosis

(that of 1911)

paper

wholly
We

of smooth

one

in the

concerned

he

do

tending
admits

calcification ; in his last

to

that

muscle, but

the

that

degenerationis
the

elastic fibres

not
are

failure.
find

then, unless

rarely in slow changes in

tion,
vessels,an intimal fibrosis of this hyperplasticderivayoung
of it with
the alleged medial
nor
areas
correspondences
(Councilman). On the contrary, our specimens show that where,
in the arteries of the limbs, the yieldingof the media
as
distinct and
be more
conspicuous, it is in the more
may
early of these medial bucklings that the intimal proliferation,
if perhaps never
be slight. I have
wholly absent, may
a
section, given to me
by Savill, of a
already mentioned
cerebral arteriole,from
of high pressure
in a man
of
a
case
thickened
in its muscular
56, apparently somewhat
coat, but
otherwise
at one
normal, save
point. Here, although the media
normal
the point of rupture the intima was
on
was
; haemorrhage
the
had been stayed for the moment
adventitia,with probby
ably
remnant

intimal

by
and

not

where

not

of

intima.

hyperplasia,do

in arteries of the

the media'

is forced

Such
occur

limbs

bad

here

spots,

and

there

In

animal

only.

not

buttressed

in the

media,

experiments,

first,while the foci of lesion in it

are

tiny there is no thickeningof the intima ; and all experimenters

agreed
(Erb, Kiilbs, Klotz,1 Harvey, Pearce and Stanton) seem
mischief
and
the
intima
is
involved, there
that, as the
proceeds
close correspondence in its thickened
is no
patches with the
Klotz
(loc.cit.
degenerated parcels of the media.
says
In
own
opinion the primary development of
my
p. 43) :
"

Klotz, 0., Journ.

of Med., 1911.

of Exp.

Med.

vol. xiL, 1910;

Publ.

Univ.

Pittsburgh Sch.

CHAP,

THOMA'S

vii

intimal

OPINIONS

493

sclerosis with

plaque-likethickeningfollowed by
an
atrophy of the media is far more
than a weakening
common
of the media
precedingan intimal sclerosis."
In earlystages
there is no
(exclusiveof syphilis)
evidence of affections of the
an

"

media
And

but

what

the

at

in animals

follows
time

same

advancing

on

it is true

that

be

disease

of the

intima."

experimental arterial lesions

with

arteriosclerosis as known
compared
in
As to the velocity
Thoma
itself,
regarded it as determined
activityof the capillary
area,1 wherein substantially
he

man.

cannot

by the
agreed with

the views

Nevertheless
blood

at

evident

of Broadbent

(p.200).

declared

warm

Thoma

that if

into arteries affected

pressure

the casts

be poured
paraffin

by

sclerosis it becomes

that

bucklings of the media are levelled

of the intima.
The experimentis a
up by the counter-swellings
difficult one, and the changes are such as easily
to lend themselves
to a preconception;
suffice it to say that the subsequentobservers,
Klotz and Strasburger2 for example, who
have repeated these
experiments,have not arrived at the same
conclusions,
they assert
rather that the patchesof arteriosclerosis obey no rule of support
to the
distributed so far at haphazard 3 : by
media, but are
to many
common
haphazard I mean
by local determinations
in the infections,which as yet are unexplained.
lesions,
especially
Strasburgerfound vessels in earlysclerosis to be less dilatable,
if tested with as little disturbance
considers
as
possible
; and
Thoma's
experiment fallacious. Notwithstanding,we have to
into the light,
thank
and in the
Thoma
for bringingthe media
limbs

on

we

In

this not

Thoma's

he

he

velocity. If,
exceeding the critical

stream

vessel
1

Thoma,

Strasburger,Munch,

See Klotz, Trans.

med.

velocities

they

abide

on

argument,

depend upon
continually

are

of

diameter

the
velocity,

mean

or

Arch.

Virchow's

the

says,

increase ; if

should

deterioration

medial

make

would

main

his

considered

have

decay is considerable.

still incompletecommentary

brief but

very

hypothesis

which

by

its part in arterial

that

see

the

it, the diameter

below

vol. 204, p. 72.

April 9, 1907, No. 15

Physns., 1907 ; and Ophuls' Experiments,"

Wochenschr.,

"

Amer.
the

Journ.
media

intima
here
New

the

or

Med.
to

media

Assn.

Amer.

Sci., June

deform
was

Apt

1906.

as

it, Ophuls failed to find

always

or

intimal

that
a

rule that

regularly weakened.
Adami's

given, quite accept Professor

York Med.
Journ., May 15, 1909.

view

in

disease

under

I cannot,

is to
a

for

support of Thoma

invade

diseased
reasons

in the

ANATOMY

494
should

OF

ARTERIOSCLEROSIS

diminish, either by constriction

PART

the

by

allegedmorbid
thickeningof the wall (intima). In his view there is no
slip
and
blood
and
between
wall, but adhesion
pull. But this
tion
argument is not consistent with the physics of the circulaexercise
traction
retarding flow cannot
; a
any
upon
velocities vary
Stream
the intima.
largelyand continually,
and
in the spaces
of the body ; there
both
in the times
or

"

be

may

no

the

between

adhesion

blood

and

the

"

wall

(see

the non-corpuscularplasma
109) ; in any case
pp. 37-38 and
axial and more
skirtingthe wall is less viscous than the more

corpuscularblood.
It

to

seems

and

stress

overstress

analogiesin
at

any

arterial diseases,without

forward

elsewhere

shall

we

arterial tree

in the

but

of

that

their

heart,suffice,

interpretations
the velocityrates

littleevidence

in it

"atheroma"

see

find

with

our

bringingin

which
rest upon
ingenuities
to sin againstthe economy
appear

the aorta

of the

conspicuousstructures

more

associated

which

strain, phenomena

other

and

at

the

or

"

for the present, to carry

rate

of these

that the structural variations

me

and
If

causes.
more

is

we

over
more-

look

than
distinctly
hardy judgment

"

"

value in
large vessel sees any
compensatory
its inner coat, patcheswhich
the diseased patches which disfigure
the blood
have
cannot
save
possiblyto
race,
any effect upon
I have
of vortices.
increase friction by the formation
argued
that stresses within normal
limits,acting upon
healthy tissues
thrust or
those which
such
we
are
as
considering,
pull over
their molecules
justso far only that these can return at once to
this stress
their positionof equilibrium(videp. 194) ; if however
be largely
increased, either by a singleexcessive pullor by a high
of continual
and
pulls,the molecules are
fatiguing mean
to their
to such anglesthat they do not quitereturn
thrust over
positionsof equilibrium; and in this case surelywe are passing
and
of the field of compensation altogether,
out
enteringinto
that of lesion.
For, let me
repeat, if compensation be more
of lesion,not of impaired
not
accident it must
than
come
an
in this

which

"

"

fabric
in

and

nutrition, but

short,it must

Thus

of

come

compensation

of the media, and

in

in
a

of nutritive

not
physiological

abundance
of

or

reserve

means.
pathological
certain cases
is found
in a hypertrophy
primary yieldingof the media a counter

CHAP,

THOMA'S

vii

OPINIONS

495

proliferation
might be anticipatedin the adventitia ; l but in the
intimal changes which
have under consideration
we
all are
now
reaction
is to be detected,
agreed that little sign of proliferative
scarcelya note of an inflammatorykind ; almost entirelythe
of degradation,out
of the womb
of which
change is one
no
be

can

resources

bred.

Indeed

it is in the

in which, under

cases

higherpressures, the media is normal, or genuinelyhypertrophied,

find anything like such a fibrotic reinforcement
that we
of the
intima as the hypothesisrequires.
Now
if my
clinical view of the subject,the view
described
in 1894, emphasised in 1896, and
often since reiterated,had
received

attention, there would

more

have

been

less confusion

the

about

also lumps all

pathology of this subject. For Thoma
arteriosclerosis together,whether
with inordinate
or
pressures
without them, as one
series. Apart from
definite infections,and

from

inflammation

held,

and

with

of

an

artery, which

conviction

more

is

different affair,I

still hold, that

arteriosclerosis

separated into two main kinds at least,or at any rate

and the involuregarded on two clinical aspects the hyperpietic
borderland
Puttingaside for the moment
tionaryor decrescent.
has
of pressures
in which
cases
long-continuedexcess
cases,
of mixed
in decay, and
few
ended
causation, and
a
giving
the
attention to less equivocalexamples, we
our
compare
may
effects of high pressures in a comparativelyyoung
subject as,
in granularkidney, or in
for instance, in aortic regurgitation,
named
I have
the malady which
hyperpiesia with those of
arterial decay in a person, apparentlyhealthy,but advancing
have
We
in years.
long in high pressure
seen
(p. 334) how
in a fairlyyoung
a
hypertrophied heart may
cases
person
drive the arteries at high pressures without
producing obvious
must

be

"

"

"

their

changes

in

in

their

due

if

the

intima,
And

two

elapse

be
in the

or

three

before

And

as

they will, they

time

case
as

coats.

very

slow,

not

will consist
so

physiological
process
years, possiblymore

this

change

changes

these

at

do

arise, as

the

outset,

degenerating
of fibrous hyperplasia.
in young
subjects,
may
much

degenerates

into

in

atherosclerosis,

in the adventitia
growth, or other signs of irritation, seen
with
absorption of depraved matter
arteriosclerosis
are
generally correlated
from
the diseased
intima, not to growth.
1

Round

cell

in

ANATOMY

496

unless

perhaps in

OF

ARTERIOSCLEROSIS

the aorta

of arteries of smaller

itself ;

magnitudes

PART

before,that is,the subintima

will

begin to

show

the

reaction,and before the sections exhibit the accumulated

in these

Now

there is

fatty

debris.

for Thoma's

hypothesis; the
abides,as the finger
media, far from dwindlingor bulging,
duringlife
after death tell us ; strengthening
and the scalpel
iftime peritself,
mit,
either with true muscular
fibre,as on physiological
principles
we

should

cases

expect, or

no

at any

room

rate

with the connective

fibre,which,

is less resilient. Even

in middle life during a long
though stiffer,
continuance
of such a high pressure malady, periodsduring which
the fingertells us that the accessible arteries are
thickened, the
advent of secondary subintimal
decay may be very slow, so slow
its incidence

that

life ;
patient's
heart
But

some
we

senile

with

before

and
the

the shortened

span

of the

largervessels may suffer,or the

arteries generallyare
injured.

wise
dystrophicarteriosclerosis the facts are otherif the first change may
be attended with
; in these cases,
addition to the connective
layers,from the mingling,as
pathologicalspecimens of areas of
may
suppose, in many

not

or

tissue with

connective
and

but the aorta

succumb

may

fall within

not

may

areas

characteristic

of

element

atheroma, it is but
in

the

affection

transient

which,

even

beginning,takes the form of the well-known senile decay,

with its widespread but patchy subintimal
accumulations.
In the next
unable
in respect of the arterial
place,I am
thickeningto separate the effect of the dilatation of a vessel
from that of the blood retardation (seep. 488) ; or were
I to lay
emphasis on one of these coefficients it would be rather on the
what
do we
dilatations.
For
elsewhere
in hypertrophy,
see
in the growth of an animal
tissue or in the stem
whether
of a
that hypertrophy comes
We
of intermittent
stresses.
tree ?
see
By such alternations the nutritive juicesof the part so stressed
are
squeezed out into its meshes, and there, according to the
its
to
degree of favouring circumstances, dispose themselves
A tree grows
nutrition.
by virtue of its flexions this way and
that, the larger stresses, as on the lee-side of it, promoting
largeroutgrowths : a muscle thus grows by its alternate flexions
from

and

the

extensions

the strands,more
an

; and

if,as in the heart,these dilate and compress

juicesexude, and

artery in like case?

In

the part

it also do

hypertrophies.Is not
not
alternatinglateral

CHAP,

EFFECTS

vii

expansionsand
interstices

OF

VARIOUS

STRESSES

retractions contribute

which, within

limits,for harm,
exudation

waste

or

should

for

It is to

the exudations

to

limits,make

497

be

into its

growth,and,

of

out

expected then

that

take

of a bent
place on the inner curve
portionof an artery, buttressing
it,as in the tree more
woody
fibre is thrown
out againstthe flexion ; this increase
being due
the
to
not
bulging the lateral pressure
to the rate
of the
new

"

blood,
that
so

if not

stable
now

of the

in

as

branch

time

lateral pressures
become

correlations

some

of

therewith.

patchesare

to

rest

and

feed

on

for the present

"

and

The

of material
of whom

health ; the

confine

our

we

intermittency

the extruded

we

It is true

not

tree, but the persons

enfeebled.
or
speakingare elderly,
dilatingstresses then is essential to

have

must

without

this inner aspect the swollen

on

are

"

tissues

juices;

when

view to these

"

and tensions become

persistent,
extreme,
then the tissues and their juices,
no
longerenjoyingfull diastolic
stolic
phases,degenerate. It is possiblethat persistenthigh diatension with small pulse amplitudesmay
lead from the
more

more

of arteries ; and

first to attenuation

radials of ill-nourished

and

in the aortas

this I think

I have

and
subjects,

in

seen

some

of

granularkidney (pp.483-484).
be
In one
then the argument of compensation may
sense
increase of oscillating
stress
used ; that a uniform
will,within
limits,increase physiological
growth so long as pulseamplitude
rapid cases

fairlywide, and tension on the hither side of strain ; this

growth is almost entirelyin the form of connective fibre,
constituents : the
muscular
elastic and
possibly with some
is

kind
the

of

perhaps,as

of tissue may

Thoma

says,

of the critical pressures.

quantities
have to bring in
But
here probablywe
I speak elsewhere
which
(p. 513), a

true

artery

"

the

intima, and

its accessory

be determined

the

by

shearingstresses

shear

between

the
; the

investments

with
tubing within a coil,the structure which I have compared
that of a big gun (p. 458). To this shear it is that I would
the
the more
attribute
degenerate kind of 'lesion between
hardlyraised to
intima and media, an exudation (atherosclerosis)
that this stuff is not proved
have seen
the level of repair. We
to

be laid down

bucklingsof

the

to partial
quantityand placecorresponding
of its deposit
media ; and, if my interpretation

in

2
VOL.

498

ANATOMY

be correct, it bears
and

of

knows

OF

no

ARTERIOSCLEROSIS

relation whatever

nothing of it.
deposit,lumps

This

the available

to

is evident

PART

in the many

lumen,
surfaces

which

or
directly,
indirectlyby promoting
thrombosis, instead of improving the channel, narrow
or
occlude it. Indeed this capricious,
and for the most
part injurious
senile
notable in the
form of arteriosclerosis,
silting
up is especially
that form which
most
definitely
suggests a primary or
correlated yieldingof the media.
Again often, when evidence of a yieldingmedia is plain,we
find little of the subintimal
disease ; there is no correspondence
between
these two
changes : they do not correspond spot for
not
tortuous
only but
spot. Many an arterial branch becomes
In the cerebral arteries this independence is
longer and wider.
well manifested
see
we
plainlythat the subintimal and
; in them
the medial
degenerationsare not parallel.The poverty of these
excess

"

"

arteries in
in

process

the lumen.
we

muscle, the difference in structure, alters the morbid

thrusts conspicuouslyinto
; the intima
appearance
Between
of the aorta
this simple form and atheroma

find every

whose

gradation.

tissue reactions

are

It is in the

hyperpieticform,

still sound, that

in persons

the vessels for

no

consider
in-

time

betray littlealteration ; as the stress continues,

static buttressing
visible in the form of increasing
becomes
a true
fibroid hyperplasiaof the intima, and of increase of the media,
probably at first,and in certain vessels,a muscular
trophy.
hyperThus
it is that for five or six years, in hyperpiesia,
in granularkidney of not very virulent degree,no great measure
or
of atherotic degenerationmay
and the accessible vessels
ensue,
though thickish to the fingermay stillbe smooth and fairlysoft.
As time goes on however
atheroma
adds itself to the hyperplasia;
of such high pressures,
but it is only in protractedcases
and very
if they
of calcification may
late in these, that beads
appear,
at all; generallyin a damaged media, or intima.
appear
in these histological
If then much
comparisons remains still
indecisive,
yet much
it appears
whether
to

the

is

only

we

to

me

has been
that

done

while

some

and,

on

the whole

loss of tone

evidence,

in the media,

marked
or
precede the
not, may
histologically
intima
and its degenerativehyperplasia,
yet that
one

cannot

arteriosclerosis,
or
divide

the

limb

atherosclerosis
sclerosis

from

; that

the

hurt

there

in nature

central

form.

ANATOMY

500

of both
in the
the

mind

and

chapter

nutrition

on

it existence

makes

life worth

be starved,
having may
Notwithstanding,in other

to be
prove
of survival.

But

to

legor

consistent

stillnormal

while

even

perchance reveal

may

dissolution,the blur, which

the age

over

persons

detected

to

even

here

as

with

I have

of 50, and

in this vascular

area

or

areas

there

of

effectua
in-

an

and

artery

an

scope
eye, the micro-

that

indicated.

in both

which

happy

many

to the naked

and

seen

persons, degrees
accessible vessels

calcification ; in the muscle

proceed with

arm,

far

so

is curtailed ; then, if

indefinitely
prolonged,that

extreme,

are

of that

of arteriosclerosis which,

useful years

of

and

be

may

remnant.

go,

PART

body. Too often however, as we have

Symptoms, by siltingup of vascular

of this organ

under

of this kind

ARTERIOSCLEROSIS

OF

first stage of

In the bodies

it is often to be

sexes,

in that ; and

of

the age

over

of 65

it has

in

less. Hyaline degeneraor

tion
generallybecome obvious,more
of decay occurs
has little specific
significance
; this kind
in the elastic and connective, and
various tissues,especially

under

conditions

various

besides,it is often

"

artefact.

an

It

"

amyloid by the well-known

distinguishedfrom the
colour test.
By the microscope,in sections treated by von
in
Kossa's
silver process, or by chemical
calcification,
analysis,
minute
dots, specks or clouds, corresponding to tiny points
diffused
lime
of necrosis or
to
more
a
affinityfor failing
is to be

earlier age than we

in its medial
in the aorta ; not
especially

tissue, may

found

be

at

an

wont

are

to

portiononly
but also in the elastic and subintimal
layers. The microscope
the eye, yet chemical
detects the lime long before
analysis
still; as
the nitrogenous content
falls
tells the tale sooner
suppose,

the ash

rises.

ash

The

may

rise six-fold ; and

may

rise

is true

of dried

of the constituents

in
twenty-fold. Still,

that

in

muscular,

the

atheromatous

as

of the

contrasted

with

a
vessels,calcification,
sign of previous muscular

be manifest

in the

media

when

and
change is perceptible,
of
occurs

the

vessel ; this

elastic arteries,as

the media

is the

particularlyin

the

in the

in the

intima

is,as
of

the

affirms,it
the

but

as

elastic

necrosis,may
littlemorbid

he says, the

variety which,
vessels

ash the lime

Klotz

as

cases,

many

aortic substance

we

limbs.

aorta, this fibre is prone

mainstay

have
But
to

seen,

in the
suffer

CHAP,

CALCIFICATION

vii

from

the

indeed
first,

converted
and

occupies.
good deal in
2

Klotz

follows

The

breaks
and

opinion that

simple;

that

or

re-engaged

are

the

lime

atheromatous

The

in the

soluble K

cycle of

tated
precipi-

as

as

patches, cholesterin
their double
dissolved

these
crystallise
out, releasing

or

the

calcification arises

fattyacid compounds are detected by

under
polarisedlight; cholesterin may be
potash,soda,

granules,

irregularly,
increasing

of

speak

to

the

lime.

into

cases.

tissues is too

then

fibre is not

hyalineremnants,

and

acids, and

The

down

varies
lipoid,

medium

in
optically,

"

but

substance

fat,not

some

is of

in the

lime

the cement

salt
a

is often the firstto suffer.1

directlyinto

these,and

501

and

in the

with

disappear,

soaps

changes,but

fatty

combine

to

Na

refraction

the

Ca

soaps,

being insoluble, are

the phate
deposited; then, by interaction,
phosof soda, with a little carbonate, and traces
of phosphate
and
carbonate
of magnesia are
laid down
in the tissue. The
of the cholesterin
platterform is due in part to the structure
in plates,in nodules,
layers. The deposit however, whether
or

diffused, is

more

arteries with

of

the

kind.

same

In

curved

internal

offsets the

circumscribed.
patches are more
But
important and explanatoryas these researches are, they
not include quitethe whole
If they include ionisamay
process.
of calcium
tion, segregationis hardly considered, a segregation
many

intermediation
of

as

"

an

the

dissolution

and

From

may

be

may

follow

book

the

arterioles

cement
"

down

10

others

am

glad

to

around
the

intima

failed,in

I have

not

Faber

is but

quotes

have

calcified

them

tissue

them

Dr. Andrewes

see

elastic fibres.

of the

where

p,

failed,as
n.) I

(p. 499

substance
to

path.

parts such

some

without

that

or

similar

in

an

even

has

salts

lime

decompose

can

possiblethat

work,

at

concerning the calcification

and

it is

Baldaux, who
Faber's

bacteria

Certain

the necessary

biological
processes,

perhaps, more

or

sulphate;

agency

Wells

of soaps

ossification.

even

lecythicbodies,3 without

with oleic and

compounds

said

too

these

found
down

many

to

the

epithelium lying

much
fibres
finest
upon

elastic lamel.

an

Klotz, Journ.

Exp. Med.,

Nov.

1905

Institute,vol.
Repts. Rockefeller

and

For calcification without

Dockray, Thesis for M.D., Viet. Univ., 1898.
26 and
Nos.
27, 1914.
Wochenschr.,
med.
Deutsche
sclerosis see
Maanus-Levy,
~"
Med.
Research,
1906,
Journal
3
Calcification,"
of
See Wells,
Pathology
of Aorta,"
Calcification
and
of
Atheroma
vol. xiv. p. 491 ; Baldauf,
Chemistry
and
Voorhoeve,
1907, p. 68;
Hygienic Laby
ibid. xv.
355; Stud. Benda's
v.,

1906;

"

Berl

klin. Wochenschr,,

1912, No.

36,

ANATOMY

502

at any

cases

rate,

ARTERIOSCLEROSIS

OF

find calcium

to

PART

in the aorta.

soaps

Baldaux

abundantly, and this substance he regarded as

In diabetes calcium is
of the phosphatic element.
the source
carried off in the urine by the fattyacids (Ransom).
has recentlygone
the
Professor Benjamin Moore,1 who
over
ground again,returns to the old opinionthat calcification takes
placein extravascular parts and is due to the hindrance in such
tion,
supply and of lymph flow. This kind of degradaparts of oxygen
in parts
such as fingers
and toes,
he reminds
as
us, appears
lecithin

found

"

circumscribed
cartilage,

extravascular

parasitictissues, extra-uterine
the blood

from

of which

the

stream

vasa

vasorum

calcium

thinks

Moore

facilitated
no

by
that

doubt

the

in

vessels

factor

; but

of connective

plasticmode.
My own

are

precipitated,
of stearates
of

as

that

there

high
of

be

may
seems

reaction, as

in

modes

some

calcification,than

to

under

this respect than

vasorum

well

as

There

closed.

or

may

tissue

connective

thickened

determining

urates,

stearates

stable, less disposed

of

in arteries

first.
Professor
appear
this process
be
in elderly persons
that
may
It is true
a
higher alkalinityof the blood.

though

and

remote

are

assumes

be narrowed

may

of oxalates

as

he

areas

which

"

obsolete

pus,

imperfectlyoxydised products

of

heterogeneous lees

foetus, etc.
such

and

tubercle, old

is

pressure

more

others ;

access

be

difference

some

if between

substitutive

that

stable

more

degenerativemodes.
of nutrition, e.g. by

more

to

in

is

The
vasa

in the modes
and

hyper-

Harvey's 2 experiments in our

laboratories on arterial lesions prevents my
acceptingProfessor
In Harvey's experiwithout
Moore's conclusions
qualification.
ments
(in rabbits),by
(p. 223) strain of the thoracic aorta
portion,led, on
repeated brief compressions of the abdominal
to the
the central limb of it,to very
even
early calcification,
observation

of Dr.

and

prompt
phenomenon of true ossification,a lesion more
for
complete than deprivationof oxygen could well account

and

such

curious

similar results

are

experiments by means
that by sufficient doses
1

in the

of adrenalin.
in the food

thousand

Voorhoeve
the lime

and

one

(loc.cit.)says
charge of the blood

B., Brit. Med. Journ., April 1, 1911.

Harvey, H., Virch. Arch. (loc.cit.).

Moore,
2

recorded

CHAP,

CALCIFICATION

vii

503

be

increased,but Professor Dixon tells me that the results

of our
own
laboratories,
times repeated,are
many
in absolute
with
those
of
disagreement
Voorhoeve,and also of Wright. On
healthy people the administration of lime, as lactate or milk
can

diet,produces

change

no

in the blood

coagulation of the blood.1

of

the

blood

and

It is said that

inhibits the effect of

rabbits is rich in lime.

content, and

And

not

no

pluscalcium

adrenalin,but

under

increased

the

content

blood

of

experimentonly,but also,

rarely,in senile decay, and even

in the precocious
arterial decay of
children (p. 174), due possibly
to syphilis
young
other toxic influence,
or
this curious development of bone
may
pear.2
apin ossifying
Zieglerfound cartilage
arteries. In a case
ported
reby Bunting,3even genuine cellular marrow
was
discovered,
though its originalseat could not be exactly demonstrated.
Happily it does not fall to me now
to try to explainthis strange
development, for a development at some
growing edge it seems
not

be ; I

to

only note
of changes in
fattyatheroma

the series
But

as

suppose

We

find lime
is

occurrence

as

an

occasional

term

of

arteriosclerosis.
is quiteindependentof lime, so

must

we

that

not

there

its

can

is essential for calcification.

fattyaccumulation
deposited in the purest connective tissue,where

within stellate
fattystains ; and even
cells. We
find it often and readilyin the physicalalteration
called hyaline. Any one
of the histological
constituents of an
artery, be it fibre or membrane, is susceptibleof calcification.
It seems
of calcium
albuminate
cases
an
probable that in many
is formed
during necrosis of proteintissues. Calcification again
be found
in particulartracts, as
in the arteries of the
may
limbs, and not in the visceral. To avoid repetition
hereafter,I
calcification conveniently
may
say here that although I have described
under
the head of the tunica media, yet this change
is found

no

response

also

Whatever
active

an

in the

to

atherosclerotic

the

chain

attack

upon

of

degenerationof

processes

the

in

the

intima.

it
calcification,

artery by the

is not

salts ;

lime

it is

of Path, and Bact. vol. xvi., 1912.

precisionare exemplified in his words on this
Morgagni's
naturam
ostendebant
aliquid aut ossei aut ad osseam
point :
(the vessels)
1

See

also Dale

Laidlaw,

and

Journ.

and

caution

"

vergentes."
of

But

Bunting,

case

in

all his

Journal
man,

contemporaries

of Exper. Medicine,

set.

72, with

review

ossification."
spoke of
discussion
An
1906.
interesting
May
of
the
subject.
literature
of the

in

this

"

sense

ANATOMY

504

passive,and

OF

Professor

as

seems,

ARTERIOSCLEROSIS

Moore

position. Klotz

vascular
does

not

Metchnikoff

near

us

that

of lime in old persons

attribute it to an
we

bone, an
vasis

vas

great authorities

hardly persuade

can

transference

and

The

occur.

that

says

in

or

arise wherever

to

says,

is necrosis, signifying,
in tubercle
as

there

PART

extra-

tion
calcifica-

of Virchow

it is due
from

to

and
tion
libera-

attenuating
skeleton ; nor
can
overcharge of lime
in food
blood.
and
Gouget asserts (loc.cit.)that in the
blood
of arteriosclerotics no
qualitative
change of constitution
discovered,whether

be

can

constituent.

other

that

seen

of

aorta

about

animals

We

calcification

in

see

Cholestera3mia,p. 252.) We

can

be induced

attribute

then

arterial

food

the

seeking a
prevent it by withdrawing
which I have
compared to a
a

whom

man

We

we

have

longer attribute

no

or
respect of lime, cholesterin,

have

readilyand

acutelyin the
rabbits ; as however
it occurs
spontaneouslyin
young
of young
captive rabbits, in using these
per cent
for experiment this percentage has to be controlled.

cannot

lime

(But

in

an

calcification

resting-place
;
lime

from

withdrawal

left in
rickets

the

to

of

excess

to

attempt

nor

food,

measure

of

ready-money from
possessionof his cheque-book.1
to a deficiencyof lime in the

Not from
body ; nor are the arteries affected in osteomalakia.2
the attenuatingbones only,there is plenty of lime available if
the parts affected be in a state to attract
it. Decay comes
first,
of the ruins.
then petrifaction
Animals
have been fed again and
of lime without
effect upon
the arteries.
again with excess
any
If calcification of the aorta
be more
frequentin herbivora than
in carnivora, in many
of these at any rate, such
as
dogs, it is
for lack of lime, for this mineral they are continually
not
ing
gnawOne would
from bones.
with
Klotz
in
matter
that,
suppose
calcification
be
chemical
must
dead,
a mere
practically
process,
in no way
able
dependent upon tissue selection. Still it is remarkthat carbonate
and phosphate in the affected parts are
in
the same
balance ;
proportionsas in bone and in the serum
if the correlations were
rather than merely physicoas
biological

and

Aschoff

See
cannot

believe

is, I find since, of the

and Robert, Arch.

Etienne
now

seek,

their paper

was

same

med.

opinion.
experim., Nov.

1911.

I have

mislaid,

corroborating reference to Selig and Ameseder,

in the Zeitachr. f. physiol.Chemie, about
1910.

but

CHAP,

CALCIFICATION

vii

chemical.

However

chemical

may

do

we

505

yet know

not

how

far the

physico-

us.1

carry

It is

obvious, perhaps not probable,that this

by no means
is mischievous ; as some
depositin foci of degeneration
experiments
to
it
seem
to fortify
serve
even
a weak
prove,
may
spot, to
stop

; if so, to

gap

indeed

error,

the finer

silt up.

as

various

withdraw

calibre and

heights,and

found

diminished.

at

is

do

not

be

much

so

rilled calcified and

would

normal

an

rupture
arteries of

to

In

pressure

his

traction, was

or

experiments the

at

vessels

rate

any

broke

never

calcareous

patch. Aschoff also agrees that the calcification

rather protectivein its effects,and
that therapeutical
incidentally
the lime are useless if not injurious.
attempts to dissipate
a

But

to

it should

instead

centres

brain

build

of those

it is

encroaches

thrombic

life."

by

it is

In

the

blood

stream,

of the finer

occlusion

twigs.
that

endothelium, roughening it, so

it.

with

calcify,

organise or

these

As

"

thick

be dissected out

doubt

"About

are

within

curved
minutes

ten

an

than

like

of

not

artery,

resistant

more

18,

"

such

1913

radial

the

as

it

for

lengths of

can

be

tube."

moderately stiff rubber

later these

"

death,
patient's

normal, but

the

says

during
stony rigidity
of the

hour

be

by Professor

MacCordick

considerably modified.

tortuous,

of October

the arteries

bent, squeezed and

.

it is less wanted.

it slackens

Journal

be

generalrule
If

no

sub-

to
if we
are
experimentsand speculations,
article by MacCordick, communicated
remarkable

to

are

example,

arteries of the cerebral

these

to the British Medical

as

reparative

or

is obliterated.

convinced

"

calcification is compensatory,

the base, where

promotes

the

upon

However

Adami,

up

at

layers cohere

the branch

the

nuisance;

the

If compensatory,

error.

thrombosis, and

favours
It

do, that

some

contrary

in purpose,

the

as

argue,

is

the food

of regulated
originwith columns of mercury
that by calcification the resistance of the

arterial wall, whether

not

from

vessels
calcifying

Weil

Ludwig

lime

the

vessel

become
1

But

for the

need

of

verification

of the

facts of calcification

A., Journ. Path, and Bact. vol. xvii., July

Weil, L., quoted Virchoiv's Jahresb., 1906.
experimenter whose
Wochenschr., 1868, by an

H.

notes.

They

possessingpipe-stemcharacters.
absolutelyrigid,
see

Stewart,

1912.
See
name

also
was

paper
not

in

enter

Berl

khr

ANATOMY

506

ARTERIOSCLEROSIS

OF

In a certain
being bent."
of the foot the poplitealartery was
of senile gangrene
case
much
bled freely,
and was
sclerosed,but on severance
ligatured
Lower
the anterior
without
down
and
posterior
difficulty.
this
filled with recent
and
below
arteries were
clot,
they were
hard and brittle ; the knife cut againsthard calcareous deposit
similar to that in the artery exposed to the air : evidently
calcification had
taken
this dense
place before amputation.
of Montreal
MacCordick
who, performing
quotes also Gruner
an
autopsy immediately after death, found the aorta fairlysoft
the specimen presented
and pliable
; within a few hours however
of
hard calcareous
plates with peripheralulceration in areas
atheromatous
degeneration. The author says that the induration
is identical with the settingof mortar, by the absorptionof C02
after death
the reaction of the bodily
from the air. Moreover
acid.
tissues and fluids becomes
It seems
then that during life
the calcareous depositsare "unset
puzzlesare thus
; and many
explained,or an answer
suggested,such as the infrequencyof
traumatic
rupture in largeand tortuous vessels ; during life they
without
bosis
thromulceration
of the aorta
not rigid. Again,
are
crackle

break

PART

compression and

on

on

"

"

be thus understood, if the ulcers

may

; the

before

hard

calcined

the

the
place, when
epitheliumaway
Choksterin
So

"

far

post-mortem
from

then

of

the

contraction

the

soft,but

are

of the

to

seem

media

be

three

becomes

takes

breaks

the

with

ways,

In

diseased.

syphilis
the

later

involved ;
commonly
obscure
especiallyin the limbs, under
reasons,
or, for some
inferior
of wear
and tear, or, because
of an
causes
originally
qualityof tubing,"it may undergo the fragmentation,necrosis,
in
the
second
calcification described
cloudy swelling,and
place; or thirdlyits muscle may be supplanted by a fibrosis
its muscular
strands, and
invading
penetrating between
without ; there
it from
within
and
being apparently some
of

stages

subintimal

lesions

set

p. 252.

see

ductions
pro-

they

vessel

the

Atherosclerosis

there

life

contractingwall
patches.

tension

and

four, in which

during

areas

post-mortem

are

it

is

"

inverseness
fibrosis.
medial

in the

relations

the
Clinically,
degenerationwith

of medial

kind

of

calcification and

arteriosclerosis

calcification is

more

medial

attributed

characteristic

to

of

ANATOMY

508

Thus,
that

I have

as

the

OF

said

difference

prevalenceof one
Finally,it is

ARTERIOSCLEROSIS

PART

(p. 485), in the contrasted

be

may

of

set

stated

only

one

causes

that

the

parts I submit

degree,determined

by

another.

or

of iron

traces

calcified vessels ; I presume

of

accretion

to

be

to

are

be

found

but

in

logical
patho-

curiosity.
Disease

We

of the

Intima.

sclerosis.
Arteriosclerosis,
Aiheroma, Athero-

"

the main

part of

pathology,and here
it is that we
have to satisfy
ourselves concerning
more
especially
the aspect and nature
of the histological
changes. At the head
of this section I have taken three names
as
equivalent,two of
which
and arteriosclerosis
eminent
namely, atheroma
by some
authors are
still regarded as signifying
while
distinct processes,
the third
atherosclerosis
they would confine to the field of the
large vessels, or repudiate altogether. These opinions must,
therefore,be sifted. The considerable authority of Klotz l is
arteriosclerosis to disease of
againstany limitation of the name
enter

now

upon

our

"

"

"

"

the intima

; he would

extend

media

(vide p. 483). We

Klotz

will

disease

the

grant

of

the

it to include

may

name

intima,

as

more

at least diseases of the

if
acquiescewith some
reserve,
atherosclerosis
especiallyfor the
fully described by Langhaas,

others, with

Jores, Mott, Aschoff, Marchand, Andrewes, and

its

course

though, as
of relative

decay

elaborate

more

is confined

adventitia

in the main

its elements
intima

the

the intima

to

partake

reaction,with
But

neighbouring media ;
difference may
be only one
elements.
The largerthe
intima.
In the early stage the

consequentialeffects upon
I have said (p.485), the
degrees of the constituent

artery the

in the

few

new

we

see

are

later the media

less

and

even

the

slightreparative
here and there be perceptible.
pushed back, thinning,and

vessels,may
soon

becoming confused,

its fibres

the

disease, and

the media

of

first

definite,and

even

on

are

the

side

mixed

the

nearer

with

ragged

granulardebris. But when

Klotz would
divide these arterial diseases into the degenerative
follow him ;
and the productive,there, syphilis
apart, I cannot
for my
fully,productive
part, as I shall presentlysay more
it
and
Were
evanescent.
at all,is slight
reaction, if perceptible
ruptured elastic

and

fibrilsand

their

Klotz, 0., "Arteriosclerosis," PittsburghMed.

Sch.

Publ,

N.S., 1911.

CHAP,

DISEASE

vii

inflammatory
All

OF

it should

Klotz,

lores'

descriptionof the
ignoringof the media.
with

measure

limbs

parts.

this

point,1is
that

asserts

between

he

in

various

labouring
is
We

more

Lobstein's

meaning

vague

offhand

think, an
remain

the

the

arteries of

or

anatomical,

; that

it is

must

admit

that

we

which

and

loose

comes

somewhat

on

different in kind

application
;

the
a

but

one

the

early

from

sclerosis,
athero-

work

recent

Letulle, Cornil

others

and

that

general term
of

is now,

and
in

ledge
know-

our

points of

many

of Adami

and

demur

this

in the present state

criticism,one

Pitt, Andrewes,

Lancereaux,

in great

another

infrequentlywith

not

decision,the

for

Hollis, Cowan,
of

or

longer justifiable.Although

no

comparative

arteries of

of arteriosclerosis is itself but

name

with

less different in mode.

or

indeed

meet

seat

one

limbs

much

generativ
de-

Romberg also, if too categorical

when
he roundly
justification

von

(p. 205), if not

men

the

as

regards

as

mainly

agreement

distinction,clinical

no

the

as

far

not

is

with his

expressed my

without

not

neighbouring
parts.

quarrel so

not

so

509

medial,

or

proportions. But

of

INTIMA

disease

Adami

that

knows

arterial disease

of

I have

arteriosclerosis of

disease

in

intimal

though

I think

intimal

think, does

and

concerned

are

other

Klotz

TUNICA

propagate itself to

whether
arteriosclerosis,
But

on

THE

detail

Klotz, Mott,

Great

Britain ;

Ranvier, Martin, Josue

of

Langhaas, Thoma, Monckeberg,

Jores whose
test for the
Marchand, Aschoff, Jores
especially
of the disease is crucial ; of Janeway, Cook,
fatty element
casuallyin
Councilman, Thayer, Stengel in America, to name
sclerosis
arterioeach
country but a few, has separated and defined
categoriescan be defined.
as
preciselyas biological
in

France

in

Germany

"

"

"

On

lesions

the

of

perhaps have
in
inefficiency
conduce

to

diseases

due

some
see

disease

yet
under

Von

have

we

than

one

media

by

that

this coat

decay

; and

seen

mode

of

the

loss

of

that

may
an

protection,may

again that the arterial

have
to
syphilisespecially,
to infections, and
less peculiar
presentlywe shall
or
; and
more
is capable of hypertrophy as well as of
intima

the

the

the

features
that

more

media

decay of the intima

all these
the

Romberg,

processes

general name
Deutsche

med.

may

conveniently

of

Arteriosclerosis.

Wochenschr.,

Oct.

28, 1909.

be

cluded
inThis

ANATOMY

510

the

being

OF

the

ARTERIOSCLEROSIS

PART

Atherosclerosis, introduced

by Marchand, and accepted by others well versed in the subject(Jores,

Baumler, von
Romberg, Aschoff, Benda), has been adopted to
signify the chief of these processes ; namely, ordinary nondecadent
lesion of the intima, whether
seated in the
syphilitic
as
atheroma, or in the smaller,
largervessels,and there known
where

case,

it has

atheroma

I have

papers

I have

sense

But
with

been

but

as

name

called

arteriosclerosis.

Virchow

regarded

farther stage of arteriosclerosis ; and

accepted the

Atherosclerosis

name

in recent

in the

specific

indicated.

it must

be

admitted

that

this

in

have

we

use

not

all

Huchard
to the
pathologists
expert in this matter.
last resented the comprehension of atheroma
and arteriosclerosis
l
under
he urged that atheroma
is one
disease
of
one
name
;
another
of the small arteries
large arteries, arteriosclerosis
and viscera ; insisting
that the symptoms
affections
of the two
different ; so
of any
were
that, in view
clature,
change, in nomenus

"

"

"

"

he would

have

recommended

Arterio-visceral-sclerosis

for the

regarded as distinct. Klotz2

(after Monckeberg's form)
examples of different processes
discussed.

Josue

from
of

other

many

Dr.

Newton

contrasts

with
a

But,

witnesses

Pitt,4 who

sclerosed

difference

not

have

we

artery

aorta,

as

alreadyfully
atheroma

this

point further,
only the authority

to pursue

upon

he

different "entities,"whatever

I will cite farther

looks

radial

between
affinity

as

and

which

atheromatous

an

regardsthem

mean.

may

Atheroma

names

respectiveprocesses,

likewise denies any

and arteriosclerosis,
and
this word

the

"atheroma

and

sclerosis
arterio-

Indeed
of
the balance
quite distinct diseases."
in England and France, is
rate
contemporary opinion,at any
perhaps stillin agreement with these eminent dissenters,though
as

Dr. Mott

to decline

seems

in the

atheroma

instance,and
1

Huchard,

the distinction.5

aorta, subclavian, carotid,

arteriosclerosis in

at

the

I have

French

Congress

limb

admitted

iliac artery for

or

artery, such

for Inner

Medicine,

that

as

Geneva,

the radial

Sept. 3-6,

1908.
2

Klotz, Report

Josue,

Pitt, N., Lancet, August 8, 1908

See

Journ.

also

Lancet, Feb.

of Toronto
Amer.

Med.

Ophiils,Amer.
20, 1904.

Meeting,
Assn.

J.

Med.

Brit. Med.

vol. xlii. No.

;

and

Assoc., 1906.
25.

Brit. Med.

Set., June

1906

Journ., Oct.
;

and

the

10, 1908.

Broadbents,

CHAP,

DEFINITION

vii

anterior

or

tibial

have

they

been

resemblance

be,

be

or

dorsalis

or

called
each

to

other

granted on both
displayed,in the

them

whether

there
notwithstanding
of

Meanwhile, it will be

if identical

process,

kind, is

in

kind, but

one

case

also

the different conditions

by

of space

in the

stress

nature, but

sites. Still,
these are differences not of
respective
positionand pattern ; the comparison of natures

of

depends upon
methods

sclerosis,
as

bear but littlesuperficial

consideration.

in

focal

profounder likeness

sides that

the difference of web, and

and

and

511

vessel of the elastic type, in the

vessel of the muscular
type, would be modified by

upon

pedis" diffuse

; but

further

some

AKTERIOSCLEROSIS

respectively"
may

not, within

question for

other

OF

more

intimate

and
qualities,

penetrating

more

upon

of

investigation.
Other
complain that the word atherosclerosis contains
of blood vessels,but custom
no
settles meansignification
soon
ings.
In discussingthe minute
of arteriosclerosis
anatomy
I will not
however
beg the question by making use of the
atherosclerosis at this stage of the enquiry.
name
We are so much
indebted to Jores for his work on this subject,1
that in any careful descriptions
of it his papers, and those of his
pupils,such as Roth and Prym, must be studied ; but the reader
critics

who

desires to

find in small

in the same
line
distinguished
investigator
he requiresin the essay by Aschoff
what

another

developed by

of research, will find

indicated

in the note.2

pointin

At this
attention

the

to

of

in

Langhaas,
much

of the

in

As

the

also
2

Beihefte
recent

The

Beitr.

on

"

mediz.
norm.

writers

to

of the

Klinik, Urban

the

did

not

author

of the

correctlyor not, Langhaas.

intima

at

in his later essays,

of the Kidney

Disease

various
as
"

ages,

indicated

also

(p.309). See

Aug. 31, 1909.

und
und

path. Anat.
Langhans, I have
u.

the

of

and

Arteriosclerosis

Atherosklerose

z.

name

in

its

of 1903, and

Wochenschr.,

med.

Aschoff,
zur

"

chapter

Wiirzburg3

Archives, which

Virchow's

thickness

in his book

set forth

Munch,

of

time

various

the

of

it fair to recall

publicationthe notice it merited.

a
long and careful personalresearch, anticipated
strated
demonof arteriosclerosis. He
later descriptions

the

at

by Langhaas

paper

I think

however

the discussion

thirty-sixthvolume
receive

and

these results,revised

compass

Co., Wien

d. Arterien.
taken

und
As

volume

Gefasssystems,"

Berlin, 1908.
this paper

pains again

article in the

des

Sklerosen

andere

to

cited

is attributed

verify my
is

by

reference.

plainly,whether

512

ANATOMY

comparing

young

old

ARTERIOSCLEROSIS

PART

and

demonstrating

the

of

He

structures,

fibre in aortas
Jores

stronglyas

as

that

and

connective

excessive
insisted

OF

the media

50

over

years

the subintimal

on

age.

of the lesion,

seat

affected

secondarilyby squeeze, thrust,

and
pressure-atrophy(durch verdrangendDruck)" with very
little fatty change; the thickeningbeing reallyintimal, even
that a film of intima
the diseased
so
might survive between
and

was

"

intima

and

the meqlia.
and

described

He

splittingof

proliferation.In view of
he compared the signs of
but probably in error, that
into

connective,

muscle
As

several

plication,
increase,multi"

(" Zerfaserung
lamels,

not

see

cellular

allegationof an arteritis
such irritation. He
thought also,
fibre might degenerate
the muscular
this lower fibre might originatefrom

that

Virchow's

nuclei.
have

we

would

or

elastica

the

of the

219) and

also loc. cit. p.

also the

presumed

be determined,

then
or

more

that

the

pattern of the

disease

less,by the pattern of the normal

brieflyrecall to mind the varieties of the normal

structure.
Broadly, we divide the arterial tree into, first,the
ary
largearteries,such as the aorta, innominate, carotid or pulmonelastic tissue predominates,but is woven
; vessels in which
web, let

into
web

us

kind

now

of felt with

connected

with

some

the

connective
lamina

and

elastica

muscular
interna

fibres,a

secondly,

magnitudes, such as the radial, in which the

tissue begins to predominate,and, as the longitudinal
muscular
fibres taper out, takes
transverse
a
or
spiral order ; and,
the finest arterioles,
which possess only the endothelium
thirdly,
with its lamina elastica.
On these variations of structure
depend
sclerosis
atherovariations,sometimes
a little confusing. The
pathological
which
in the smaller
arteries begins in the musculoelastic layerof the intima, is seated in the aorta in the media also.
Again, the process may begin in the largestarteries,or in the
smallest ; the larger,
in primary contracted
as
kidney, suffering
These
later.
oppositionsof seat may correspond,as we have
I have alreadysuggested
seen, to profound clinical differences.
call the cell wall of the circulating
blood is
that what
we
may
of
the
intima ; the
media
and
adventitia
being structures
all through the tree is the same
;
support. The endothelium
arteries of middle

but

in the vessels of the first class the intima

consists also of

CH.

WHERE

viz

fibre-elastic
itself

MECHANICAL

layer which,
consists

again

of

transverse, of which

STRESSES

with

fine muscular

layers,the

two

TELL
fibres

513

interwoven,

and
longitudinal

the

the

thins out.
longitudinal
It is in this
atherosclerotic disease begins.
I am
stillof the opinion that the disease which beginshere
due to tensile and shearingstresses,which arise at the
plane
the
intima upon
its supportingand distributing
appositionof

layer that
is
of

coat, the media

have

(pp. 11, 195, and 497). Thus in previouspapers

of the media

spoken

coiled

and suggested that

spring,
the media
and
the intima to
yieldrather to longitudinal,
may
lateral stresses.
However, writers on this subjectlay too much
tubes ; in
emphasis on lateral pressures, as in distended inorganic
life the stresses
are
tangential,shearingrather than bursting.
Disease beginshere because lesion beginshere.
Here the intima
is sometimes

the

shifted upon

or

pulmonary artery
of

side

under

disease, arise
the

that

which

that tissues

by the lymph

is not

by the blood stream,

fed

To

return

to

the normal

the

disease

mechanical.

in the

the

on

again

consequent

The

it lies

postulate

beyond the

examination

nourished,

are

high

seen,

lesions,and

bear

it does, will not

have

lax,

the atherosclerosis of

as

such

merely

and

large vessel, and

suffers first because

intima

vasorum,

in

forks, how
causes

We

stenosis,as

constriction

orifices of

the

at

as

its base.

in mitral

; sometimes

out

tightened media

Causation, by such instances

on

central

stretched

between

squeezed

pressure,

section

folded, sometimes

sometimes
blood

as

vasa

for it is

the intima, if not

and

beyond lymph irrigation.

anatomy

with

similar convenience

again,with Kolliker, regardthe intima as consistingof

active member
corresponding
the endothelial or vitally
two
layers,
cavities. As we
to the same
part of the lymphaticsof the serous
we

may

along the lengthof

pass

other

coats

so

also

the endothelial coat,

in the

intima,

constituent

layers accordingto

in

areas

different

; as, for

the

certain

of

variation

variations

instance, of the

in the

find,as

we

blood

its

of its function

distributions,
bifurcations.

bearings of mechanical stress, as at the

intima
ought to be
Logicallyperhaps the elastic layer of the
of mechanical
regarded with the outer layersas an investment
and consupport.1 Elastic fibre abounds where the expansions
the

or

That

elastic

and

connective

fibre have

not

several

and

independent
2

VOL.

ANATOMY

514

tractions

are

in
as

tapers off

Moreover,

of diameter.

decrease

every
are

rhythmic, and

are

continuous.

more

ARTERIOSCLEROSIS

OF

great, we
then,

in the

even

At

the muscular

see

muscular

and

strong.

elastic
In

for blood

tidal,and

are

the
very

Elastic fibre

with

pulsation;

distribution.

when

we

to

explainthe

the

connective

come

contrast

or

compare

the elastic constituents

arteries,such

animals, where

erect

vessels,is concerned

to

fibre, because

predominant.

the argument,

effect of stresses, and

and

in

more

machinery

point of

intracephalicpressure,

rich

of

with

cerebral arteries,
which

of distribution

fibre

smaller

fibre with

this

and

of content

uniform

becomes

the wall decrease

on

Although the

equally supported by the

rather
thin, yet they are
direct
them
the pulses are
those in the splanchnic area

fluctuations

the flow within

as

stresses

PART

of the tube, it is convenient

to

pare
com-

propertiesof these two tissues. The elastic

be called the resilient or labile
tissue might more
descriptively
elastic power
of resisting
tissue,for it has little of the strictly
the capacityof
deformation, although it has in large measure
Its elastic limits are
then very
recoveringfrom deformation.
several

the

wide

well

pressure,

compared

to

varies

as

constant,
the state

constricted

connective

elastic limits

heart

by

it

nuclear

are

when

inner

elastic resistance

on
more

much

the

armlet

of

section

same

of the

elasticity

artery, but

an

of its circular muscular

elastica

other

of

is thrown

hand

into

differs from

elastic resistance

may

manometer,

Again, the coefficient of

for the

fibres ;

folds.

The

the elastic in

deformation,

to

rebounding capacity,the resiliency.Its

but

take
far

so

that when

so

narrower,

instance, in

For

of the

of contraction

recover,

never

length.

even

less of the

much

it may

stiff cover

vessel the

tissue

possessingindeed
but

the

its excursion.

controls

is not

in

under

wide, is

wall of the vessel,the stiffer adventitia, which

of the

soon

elastic limit, however

breaking point. Moreover,

the
reachinga certain degree,overcomes

usually

be

the

in all materials

and

a
as

permanent
the

overstretched

once

at

set

muscular

greater

fibre of the

fibre,or be supplanted
penetratedby connective
(p. 544), so far the cavity,under excessive tensions, is
be

may

origin,but that connective

of elastin, is

Arch., 1906.

postulate beyond

fibre is converted
my

competence

into elastic

to discuss.

by

Vide

the addition

Fuss, Virch.

ANATOMY

516

in its

impairments

vital substance,

to

seems

rather

react

to recede

if prone

as

ARTERIOSCLEROSIS

OF

PART

as

within the

physicalthan a
sphereof inorganic
a

degenerateas to show effects of stress

beyond its physicallimits. Dr. Harvey,1 testingthe physical
of elastic fibres,found them almost of inorganic
stability
qualities
; not

textures

He

(p.521).
and

found

them

much

so

stretched

to

them, buried

them

for

time, and

remarkablyindestructible;but the

nearer

so
a

on,

tissue

approaches to the physicalthe less its capacityof spontaneous

teriorate
repair. When under excessive increments of tension the fibres deceased
fragmentsand granules,
they split
up into fibrils,
to respond to their normal
stains,and calcified. Notwithstanding,
there

is little doubt

but

that

elastic tissue,and

its cement

stance,
sub-

undergo fattydegeneration(Jores,Andrews, Torhorst),

strain (Harvey) ; and
tissue is
no
especiallyafter mechanical
it may
be by some
vital chemistry.
more
ready for calcification,
do

The

connective

tissue is then

useful

constituent

up

to

quantity ; but to increase beyond this quantity a

signifies
quantity varying with the parts of the branches
have much
strain and tissue compromise, or senility. We
yet
to learn concerningthe behaviour, and
perhaps to discriminate
certain

"

"

concerning the kinds, of connective tissue ; when for instance,

these new
amid
products, it is subject to fatty degeneration,
as
it appears
when
and
not
so
as
a
subject; when
useful
surrogate of waning specificelements,
quiet and
it
when
and
invades, penetrates, and
strangles them ;
far Dr. Bashford's
dependen
glimpses into the functional inalso, how
of tissue, and
of the several kinds
a
sympathy
its
each
with
of
and
kind,
own
a
pation
particithroughout the system
be verified ; if again such movein its fortunes, may
ments
extend
widely by
starting in particular spots can
cyclical,and how far
sympatheticexcitement ; if they are
and
under
cidental
harmonic, inretrogressions
subject to advances
or
experimentalconditions ?
It is of much
importance therefore in this enquiry,if by these
to read some
characters we
are
part of its history,to ascertain
where and in what proportionsconnective tissue fibre is normal to
find much
the vessel (see p. 482). In this research we
help in that
of Thoma
work
by which he estimated the proportionsin which
1

Harvey,

Kenwood,

Journ.

Exp.

Med.

vol. viii.,1906.

CHAP,

CONNECTIVE

vii

AND

of the connective

growth

of the arteries.
results

of

tissue entered

infection,it

is in

then, taking

us

Jores,

and

Adami,

conditions

of the

that

departure from

our

give

little

connective

and

of the elastic fibre,in

requiredto
comparison of

withstand

variations

all

as

more

that
on,

go

the

definite
directed

rather

But

at

portion

lotalli.

In

yet, with

we

abnormal

our

the

inaccurate

as

is

far

aorta

that

Thoma,
would

after the

be

pressure

the

to

closure

of the blood

normal

stream

it

"

as

scarcelyapt

incidental,whereas

on

of the

growth

is not
an

even

have

we

anticipating
more
simple
subjectedto
volume,

and

growth
of the

of

leg,

increased,

the closure

connective

the

ductus

arteries of the

the

in
gravitation

trasted
con-

evident

more

invests

is the intima

said,

as

life,and

cells and

of blood

have

of

livelyvessels

and

was

In
retrogressive.

or

tissue

nective
con-

research

development;

becomes

muscle

present it

in the

in

increase of this tissue

and

substitutive

describe

To

well-directed
which

as

development

foreseen, the elastic layers are

have

definite and

or

In

important

elastic than

consideration.

under

the diversion

also manifest.
if not

more

vessel

stouter

as

arterial

the third decade

connective

the

of

this, as

although,as
a

of

his attention,

central

ive
connect-

pressures.

least

at

of it which

usuallyafter

increase

and

unequivocalin young
and rather rapidincreases

more

duct,

growth

genuine growth

particularlyunder

that

bodilygrowth

degreesin

increase

the elastic fibres.

and

the

artery it spreads amid

more

The

needs of
special
which
essential,resilience,
equalisesthe
is for

of

of this nature, but

old

these

to

less resilience

blood
increasing

sedulous

be of the nature

years

Langhaas, Thoma,

it has with

accordinglythat
conspicuousin the

layers. Some
requiredto discover
with

and

observed, the qualities

find

we

is

young

may

the

of pressure,

resistance ;

have

with

as

connective

elastic tissues.

as

the

see

the virtues of parts which, for the

circulation,are

the

so

increases
resistance,

is

the

far

we

consideration

more

we

ment
develop-

that

coat

the firstsignsof strain.

note

we

517

into the normal

alterations of the

tissue, supplementing,as
elastic

TISSUE

If it is in the middle

elastic tissues of the intima

Let

ELASTIC

of the

tissue is

thickening,"
hypertrophic

for

suggests

the

consists neither

in

this term

the process

adaptation,nor a degradation.By imperceptible

and
this growth proceeds,
steps during youth and adolescence
a

reaction, an

ANATOMY

518

probably

is fulfilled the
tissue

is low, but

"

fibres.

and

third and

wide

as

are

youth
growth

"

describes the
(loc.cit.)

Aschoff

Then,

as

we

elastic elements

fourth

decade

of

shall

the

see,

filaments

become

aorta

nective
con-

but
of

separate elastic laminae

and

increases, the lamels thicken,more

muscular

artery of

strengthenedby the tissue the

which, conversely,has a higher resistance

arteries

elastic limits.

muscle

the

PART

elastic limits very

infancy as presentingwell-defined
and

In

altogetherceases.

never

elastic resistance

narrower

ARTERIOSCLEROSIS

OF

more

healthy life

elastic

branch

slowly

off,and the

implicated. If

in the

the connective

tissue

be almost

life and during old

the turn
of middle
on
stationary,
it begins again to increase, a feature of decliningyears
age
in
this
the
arterial tree ; but
not
to
peculiar of course
no
declension, whether
longer
readaptive or decadent, we can
at
regard the hyperplasia as a feature of growth but one
In a paper
least correlative with deterioration.
by Thayer and
Fabian1
it is shown, especially
the first part of the aorta,
on
and
as
concerning the radials, that in the third and fourth
decades
of life,
in labourers
not
only, but also to a certain
in all persons,
tissue
extent
connective
slowly advances,
in the harder worked
arterial areas.
(See on the Media
especially
pp.
the

496-97).

It

intima, and

delicate

itself into

layers and

the

on

and

within

elastic

filmy fibres

the inside of the elastica interna,

seen

elastic

insinuates

on

layer it penetrates

in the media, and

indeed

between

of it may

its outer

it, splittingits layers. Again

in

the muscular

penetrates the whole

strands

of
be

side also,

the

musculo-

increases
fibrils,
wall ; thus

for

fortifyingits structures, but at the expense of their

resiliency.The stream becomes more
bouncing. In the smallest
connective
districts at any
twigs, in many
rate, there is no
in these fine vessels the tissue
or
as
hyperplasia,
practically
none,
scarcely exists ; in them degenerationbeginsin the elastic fibre.
fied
a
Hallenberger,2
pupil of Aschoffs, in a careful research verithe cause
of
these conclusions, and regarded the process
as
the
Abspaltung of the elastic lamels, normal and abnormal.
flammator
inNow
this fibrosis must
be
clearly distinguishedfrom
tissue
proliferation
; it is a completed connective

while

"

"

Thayer and Fabian, Amer. Journ. Med. ScL, Dec. 1907.

2
Hallenberger, Inaug. Diss., Marburg (date mislaid).

CHAP,

ATHEROSCLEROSIS

vii

mesh, looser
which

hyaline

characters.

active

mode

from

of it may

collaterals

on

of

molecularlyless stable
it
degenerationaround
At

what

as

an

arterial

twig.

than

under

other

academical

irritation ;
to innutrition.
An
to

of

It

more

the
also

several

arteries
within

taken

as

the normal

circumstances.

connective

of

question,and,

In

fibre, are

signs of disease. Such a

subjectduring adolescence

childhood,

the individual
Jores

fat

of
may

under

say

case

with

agrees

it is

necessarilyto

not

and

flat top,

be

may

watched

more

not

or

But
in

appear

suppose

may

in

life.

earlyadult

we

be

less

the age

prolonged

be.

may

(p. 517) and, by

observations

Thoma's

how,

atherosclerosis,

without

precede the decay of

he is disposed
elastic fibres ; but in conspicuousquantities
increase
as
partaking of the nature
regard connective
we
of lesion and
repair. Here
rate
at
disease, or
any
the fibrosis of the tricuspidvalve as a sequel
compare
mitral stenosis

into

tissue may

interstitial connective

strain

sure

becomes

and

when,

as

tissue

connective

elastic, that

change.

On

wall, I have

in
for

stresses, and

the

have

elastic stains, indicates

and

of

be

as

medium-sized

some

process

of 10 ; and

the age

for this tissue to

curve

to

the

decay.

except in the first part of the aorta, fibrosis does

the

be

to

muscular
strands
slightdevelopment of longitudinal
of the elastic lamels,and
elastica,some
multiplication

increase

this

here

seems

than

and

areas

the

some

as

hyperaemiaof

growth into repair,

or

intricate

an

nor

parenchy-

conditions,but

infect it with

degeneration,is

in

seen

area

an

must

granular

not

if due

if due
in

seen

of

it by with
we
practical,
may
pass
reflection that, as we
shall see, splitting
of the elastica is
of stability,
and
which varies
a
one
very uncertain standard

one

in

them,

stage this change lapsesfrom

into

even

branches, as

be well

block

519

presents proliferative
cells,some

vascular

in foci away

again

FIBROSIS

function,but
scavenger
This fibrosis may
be

parts around

matous

but

closer,and

or

have

may

AND

the
more

in the
has

tricuspidit

the

while

a
a

is

is due

(p.195).

thicker vessels, of
to

increase

out

of

insisted,and

We

in

may
the

to
proportion
pathological

of standards of wall, and

difliculty
once

tinued
con-

it merges

elderlypersons,

is passing into
physiological

than

long

; then
protective

contractingscar

begun

to

layers of

this context

the

ANATOMY

520

ARTERIOSCLEROSIS

OF

PART

is multiplied by the variations

of this connective
difficulty
of the vessels,and
in various topographical
element
tracts
parts
of vessels,the tissue being developed in longeror shorter lengths
of stress require,
the habitual incidences
arteries being
as
some
The
much
thicker than others.
earlier investigators,
especially
of the French
school, gave much
weight to this supplantingby
connective tissue.
Debove, Letulle,Duplaix and others followed
de Mussy in supposing it to be a primary and active
Gueneau
la diathese arthritique of this observer, la diaihese
invasion
fibroideof the former authors, a process distantlycomparable,
?
to Dupuytren's contraction
If this conone
ception
may
presume,
partook of the French schematic tendency yet, like the
similar Gull and Sutton
hypothesis,it led physiciansto take a
largerview of the whole subject. Thoma's views of these changes
notions that our gratitude
are
so
stronglytinctured by teleological
"

"

"

is directed
As

to

him

in the next

for his facts rather

place we

the elastic strands, we

the

from

for his arguments.

the connective

shall find, as

we

to

from

progress

consider
the

child

ambiguous boundary between the physiological

and
the pathological. Summarily, as
have
we
seen,
what
happens under experiment is this : the earliest changes
under
stretchingare strain, fibrillation,
splittingand granular
the
associated
muscular
also
generate
deelements
disintegration
;
calcification begins in and
outside the elastica
; then
and
encroaches
the media, the calcified fibres making little
on
lumps. The intima may or may not be thickened already, but
breaks
in the
seems
disposed to this change, especiallynear
of repairmay
few elements
calcified tissues.
be
Finally some
detected.
Jores has studied these changes of the elastic strands
minutely. The singleelastica from early childhood seems
very
lamels ; 1 in the twelve
months'
to grow,
by splittingoff new
to

the

pass

than

man,

same

it is doubled, and

aorta

both

its muscular

and

connective

fibres

though certainly
develop ; yet the hyperplasiaof arteriosclerosis,
the
similar
form ; indeed
to
the
a
regressive,assumes
eye
be more
copious than the originalsheet.
secondary layersmay
in septic
be purely destructive
That
this splitting
we
see
may
1

Lamel

is

Dictionary the
Yonge.

convenient

authorities

and
for it

already
are

Grew

an

and

English
Henry

word.

In

More

and

the

Oxford

later

Miss

CHAP,

THE

vii

conditions,

when

the

prone

to

resistant,is

the layers.1 I have

element

ELASTIC

TISSUE

elastic tissue, on
and
split,

521

the

microbes

whole
be

may

between

seen

said that the elastic fibre is not

(p.516); it does not

relatively

living

very

developmuch, nor
capable of
its multiplication,
and here it is that the
we
repair.
earliest pathological
changesare found, we can hardlyregard these
multiplelamels as physiological.They are unstable, apt to blur,
to lose regularity
of outline,to rupture and break
up into granules.
If

And

examine

between

fibre,take

them

the

whether

other

nuclear

they will break

say

is very

structures, muscular

stain

indeed

badly,and

into vacuoles

this kind

connective

clearlydegraded

are

and fat. It is often difficult.

to

apparent granulesare

fibrils. In

and

such, or

ends

cut

of

multiplied

disintegration,
accordingto Jores, the
disease consists ; thus and otherwise, wherever
it be, betraying
its kinship to
In
normal
atheroma.
growth there are, as
of development ; one
have
modes
of the aorta
we
said, two
vessels
of the parts about
and
of the first magnitudes, and
certain anglesof stress, the other of the vessels of middle and
radial. So also
lesser magnitudes, such
the brachial and
as
the

muscular

disease.

If

have

done)

what

we

that

regard as
homogeneous elastic

from

we

find

much

slower

in twelve

of
Med

that

not

we

as

separates

soon

fibre, will be
;

is

the

growth, but

the aorta, say

in

attained for

ten

delicate muscular

years.

fibres,

the elastic" forming

elastic fibre

and

P.,

Caforio, Rtf. Med.,

Jan.

found,

and

between

of

fine

themselves

this with

we

is not

This

fibres.

compare
identical mode

and

from

stripsdetach

all know,

of connective

1, 1914, vol. xix.

of

large vessel,

the

of

intima

If

lengthwise,
appear

growing
elastic

is

as

Thayer and Fabian

find during infancy, in

elastic

radial

in the

genetic relations

are

characters

the

the definition attained

large artery,

of them

Feb

so

months,

in the

The

similar,if

lateral

lamels

great

so

affect

we

lamel

splitting. Then
homogeneous lamel.

radial

most

the

first
the

not

surrounding muscular

of elastic fibres

Jores'

radial,

with

aorta

high

(as Jores, and

compare

we

is

much

not

may

network

But

does

asserted, and

resist

to

specialelastic

arteries

difference

this

Still

identical ;

not

elastic

the

developed.
often

is

type

in

pressures

in arteries of elastic

of the elastic constituent

arrangement

and

of

by Schaffer

the
the

"^o1^
Jo

I/, 1914.

urn.

exp.

ANATOMY

522

Thoma's

OF

the

phrase

ARTERIOSCLEROSIS

elastic-muscular

of

stress, than

in

muscular, fine connective

the

is seen

structure

lengths of

fibres

its intima.

layer of

the lesser arteries this musculo-elastic

angles

PART

them

rather

In

the

the

of the elastica tapers out ; there we

reduplication
degenerated simply. In youth the manifolding of

elements, under

the

likewise in the

formative
and

aorta

the

nor
identically
pari passu in
speaking,in the smaller the

in the aorta

is, in

three to

stimulation

of

In
at

where, for the

substituted.

are

twigs
see

may

it

elastic

the

stress, progresses

small vessels

but not
respectively,
all the smaller vessels.
Still,
broadly
elastica multiplies
two
to threefold ;

fourfold,a stage which

is the
proliferation
hyperplasticform of Jores, though I repeat that the prefix
hyper is rather suggestiveof a phase in which this process
is beginningto slipfrom the physiological
into the pathological
mode, into phases which, when
morbid, conmore
stitute
definitely
Jores' second
form, called, not very happily,regenerative
Thus
is
(reparative).
physiological
chieflyvisible
growth
"

health,

constant.

is distinct
elastic

so

in the muscularis

certain

this

; at

does

it

begin to

disease, these

this stage it is that

features

first

phase

in transition

is

no

the
more

about

no

less

chieflyin

hitherto
than

the end

at

be

the

stable

of the fourth

decline.

preserve

manifested

should

structure

towards

turn

though degradation is
elastic fibres,and

until

; not

years

the

fibre

in connective

; and

of stress

areas

efficient form

twenty

some

In

only in

In

decade

The

of

resilience and, with them, stability

resistance,
are

best.

the

mode

"

in the elastica,less

for

This

in the third decade

tenuous
a

normal

importance,

an

the

behaviour

connective
increase

of

strands.

would

be ;

mediate
interguided by some
and
Diagnosticdistinctions
however
be made
can
ordinarily
plainenough ; slightdegreesof
of the elastic lamina
be neglected,
so
splitting
long as no
may
Dr.
Cowan
fatty reaction is given to Sudan.
says that the
elastica is peculiarly
to suffer in the infections, such
as
prone
tuberculosis,pneumonia, and typhoid fever, when it blurs, and
loses stain characters (p. 285). Faber also lays much
emphasis
this fragility
of the elastica
of the elastica. When
on
splitting
into layer after layer has evidentlybecome
morbid
a
activity,
find
or
a
dilapidation(Herringham, Jores and others),we soon
or

phases we
suspensory
equivocal combinations.

are

524

ANATOMY

it in view
intima

of

ARTERIOSCLEROSIS

OF

opinion that

own

my

PART

this

hyperplasiaof

the

takes its

originin the lesion of strain,of tension, and of

shear at the plane of appositionof the intima to the coats which
mechanicallysupport it in its functions (p. 513). This process
be seen
in trauma, but also under
not
only,as we presume,
may
other conditions of mere
mechanical
strain ; as, for example, in
the pulmonary vessels in mitral stenosis,first demonstrated, or
illustrated,
by Traube (p.202). But, as a complex organ in the
circumscribed
in
and more
degree of its complexity is more
its forms
of response
to
contingencies(p. 324), reactions, the
those of Jores' second
or
same
or
as
regenerativemode
very
similiar to them,

part

of

internal

in

artery

an

manifested

are

other conditions

under

thrombosis,

beyond

or

in

as

where
ligature,

As
then the
wholly cut off ; and so on.
morbid
various causes
characters under
histological
many
may
be uniform
tell
little
to genesis,
us
as
they may
though they may
indicate a greater or
lesser reparativecapacity. Connective
a
tissue increase in advancing years is a universal process, probably

is

pressure

in

obedience

there

either

irritation

of

mode

not

it may

substitution

kinds

always of the same

signifyan inflammatory

shortcoming, and
instance

several

to

But, in taking

or

denominator

common

or

or

here

of
for

specificactivity,
anywhere.

advantage of Jores' work, I must

beware
lest I commit
Jores does
him to opinionsnot his own.
not
identify his regenerative proliferation of connective
tissue with arteriosclerosis ; in it he had in view only a healing
much

so

"

like that

process,

of

wound,

and

"

the

result

scar,

without

atheromatous
way
in

the
of

out

is

seen

(fatty)proclivity.Perhaps we may
put it this
that Jores' regenerativeconnective
arises
tissue form
innermost
connective
layer of the intima, and increases
proportion to the elastic. The atherosclerotic process
at

least

as

layer between

in the musculo-elastic

soon

elastic fibres and

them ; young
elements, muscular
splitting
connective, which
run
quickly to fatty decay. But the
A mere
often simultaneous.
are
hyperplasiaof
processes

subendothelial
be found
of

is not

and

but

common,

hyperpiesis,and

obliterans

tissue in which

connective

in

may

true

endarteritis

be

no

seen

endarteritis.

proper,

lesions

in

fat response

the
and
two

the
can

the earlier stages

In

thrombangitis

which,

except

as

CHAP,

INFLAMMATION

vii

lie
syphilitic,
at

before

rate

any

have

to

seems

outside

OR

DEGENERATION

subject,the

my

stages

of

and,

response

first in

that if stress
or

that

is

and

the determinant

stress

though

distinction
view

of the

stillurges

that
than

and
proliferation

admit

more

less

or

result rather

Rokitansky
is best

this response

be

Sumikawa

of site,it may

than

Jores,

to

marked

might

at

demur

be the chief,

not

atherosclerosis itself.

of the

cause

all

fall upon

part, if I think infections often

my

intact,

inflammation

the cell

on

we

Kirkes

greater

the intimate,
For

which

of

areas

chronic

relies

from

as

agreed

pathologistsare

this

of 96 cases,

atherosclerosis

that

But

(pp. 518-19).
a

increase

tissue

And

validityagainst Sumikawa's

some

primary degeneration. He

connective

elastica is often

demolition.

process, who, after an examination

atherosclerosis is in nature
rather
a

525

the media, or,

the great
all the coats, yet I also admit
syphilis,
upon
other than stress
poisons,toxins, or
probabilitythat causes
afferwith the vasa
metabolic perversions may, as it would seem
Granular
entia of
Kidney
(p.399), engenderirritative changes
in the intima in which
ordinary stresses and hydraulicpressures
by contingentcauses
take but a subsidiary part. As, whether

in

as

"

"

"

"

defect,

inherent

or

moderate, will the

however
so

enfeebled.

An

on

the foot.

And

old shoe

liferative

that

be

not

seen

enfeebled, mechanical
distort and

sooner

long

wears

few

the

plane of

long

so

certain

cell infiltration,
etc.) is in
about

salientlyin and

its

healthy old persons

very

spoilthe

the shelf,but not

on

junctionwith the
perhaps in the
itself,and still more
arteriolar and lymph passages.

and

stress,
tissues

expert
side my comparativelyinhistological
in mere
repair"sound repair"the prp-

activity(e.g.small

to

cases

the

on

impressionis

is

structure

we

may

media

as

adventitia
I

admit

intima

the

media

in the

its

with

in

that

livened
en-

some

find Jores' regenerative

in the arteries of the

especially
absent ;
atherosclerosisbeing practically
tibial),
leg (e.g.posterior

process

but

then

even

almost

and

in almost

we

at

always,

ruptured,and

It is said

by

sclerosis may

some

pure

may
stress

have

observe

Sumikawa,

that

points,been
undergone

of
pathologists

be detected
i

form,

the

elastic fibres

overstretched, are
some

split

fatty degenerat

consideration that

by the microscope

have

diffuse

in cerebral arte

cxcvi.
Virch. Arch., 1909, vol.

ANATOMY

526

which

the

to

fibrosis also
are

ARTERIOSCLEROSIS

OF

naked
may

be

evidentlyof

very

normal.

seem

eye

discovered
slow

in

Some

such
and

course,

PART

leptomeningeal
These

changes
give rise to

cases.
never

may

symptoms.

regardsthe intimal disease and

again to Thayer and Fabian,

As
turn

radial
But

arteries

only in

not

various

at

the decades
who

examined

from

ages,

branches

coronary

83

to

arteries also

the wall becomes

"

may

morbid

61

days

56

the middle, in the small

the cerebral and

we
of life,

years.

such

"

as

thickened

and

There
tracts
of
are
unequally, patchily,discoloured.
moderate
then a hump.
and
Under
the
thickening,and now
be seen,
sometimes
masses
microscope atheromatous
may
almost
In other tracts of these arteries,
closingthe channel.
"

the

of

or

have

Up

"

renal

and

fallen into
the end

to

labourers

"

of the fourth

connective
such

the

increase

abnormal

the

at

have

may
at

of

age

; it contains

open

separated,and

and
stress

of work

Here

has

again,as

the

in

The

appear.

media

to

yet

elastic strands
vessel

is

22

Still
called

fifth decade
stand

now

connective

more

be

also

of
the

"

media.

may

even

may

the limbs

the

vessel

of

less increase

scarcelybe

can

However,

strand

only

the

to

may

hyaline decay.

was

age

of 30,

stain),which

fibre ; the

muscular

the

the age

intima

from

(van Giessen's

tissue

media

the second

extended

50.

changes
significant

more

and

into

decade, when

for instance, whose

one,

state, abnormal

intima

or
manifoldingof it,and more
be observed, especially
in
may

tissue

in

like, both

atrophy together,or

an

the elastica,and
of connective

the

have

supplanting
multiplied

"

clinically thickened."

begun to tell,at any rate in certain

pathologistshave stated,and
many

The

areas.
as

Jores

at this
by his fat stain has demonstrated, such alterations even
not only so, but are
or
comparativelyearlystage are not diffuse,
Adami's
calcification,
on
hypothesis,
focal and patchy. Indeed
of common
implies a previous fatty stage. It is a matter

observation

that

in

the

smaller

often
focal protrusions,
irregular,
into
the
3000

the

lumen,

cit.; in 24

to

The

arterial

of

closure

cross

crescentic

sections

the
and
as

show

ing
section, thrust-

of it ; foci which

decay of
by Ruffer
ago is described
subjects)as exactlythe same

fat stain.
years

even

arteries

ancient

react

to

Egyptians

Elliott Smith

(loc.

the atherosclerosis

CHAP,

of

PATCHY

vii

In

to-day.

below
and

these

DISTRIBUTION
the earliest

cases

the fenestrated membrane

later fused

If with
and

can,

to

lesser and

by

no

they began at

largertracts.
scalpelwe splitopen

examine

we

changeswere

in

close

or

discrete points

into

small

527

them

lesser
"

magnitudes

uniform

means

stillperceivethe

with

even

"

the foci

as

far

as

lens,as

common

shall find the

we

; smaller

the finer vessels

we

as

pass

thickenings

become, we

shall

patchinessof disease as in the largevessels,

and (on cross- section)the crescentic
humps, which all respond
to the fat stains.
In every cabinet the
specimens are many, even
in very small vessels,of ruptured endothelium, with
tinycraters
of

"

ulceration."

same

if

Or,

back

to

the aorta

allegedfibrotic parcelsof it"" sclerotic

with its
protrusionsof atheroma
succus
ascertain by Jores' method
that there is

in contrast

we

go

"

"

of the

inside

of

fatty decay
differingfrom

is

vessel in the

not

aortic

thickened, that
and
dissolving,

be

to

the
that

depth

elastic

have formed
calcification,

fibres

of

areas

size

no

"

we

pulpy
may

thickening

retrogressive
patches then,

It is in

only, that

have

the

to

with
"

sclerotic

of which

detected.

patches in

luteolus

and

the

broken

up

intima
and

is
are

coagulation necrosis, leadingto

probablyin

the

ing
deep intima encroachthe appositeparts of the media, perhaps forming even
on
within
it ; but this disputed questionI will not reopen
here
(p. 485). My own
opinion is that in atherosclerosis of the
visceral type these changes displaceand
damage the media
but

do

some

Auld's

behave

the

On

other

hand

the

blood, resists these changes with

in the

though
Dr.

arise in it.

not

bathed

"

be

endothelium,

vitality
;
perceived. In
rare

hyper-activityof its cells may

the epithelial
(and connective
words,
"

like any

tissue

other

on

which

an

tissue)cells

inordinate

demand

is made."

Again (see p. 326) we

whether
presenting some
in patches?
not, appear
1

See

Adami

and

for this affinityuses

Klotz,
the

loc.

word

"

may

ask

why

ineffectual
Difficult
cit.,and

as

reparativereactions
the questionis,we

Ribbert's

analogous," but

degenerative
processes,

by

Lehrbuch,
his context

p.

65.

he must

or
see

Ribbert
mean

homologous.
2

As

described

by Russell, Brit. Med. Journ., Oct. 10, 1{

teaching, Aitcheson, Thesis for Med. Oxon. Arch. Path.

for instance

as
reflectingrecent
Hospital, 1908.
Inst., London

and,

ANATOMY

528

OF

ARTERIOSCLEROSIS

PART

in many
and
dispositioncontinually,
parts of the body.
of the discrete
think
of segregation,or
The
physicistmay
or
granulations of metals under
crystallisations,
long persistent
with
and rhythmic stresses, such
mallet.
as
a
beating
l
of
remarks
Dr. Mott
Some
on
foreignbodies in the blood,
here not
irrelevant : he
bacteria for example, seem
such
as
bodies seem
not
to be diffused equallythrough
says that such
Even
in groups.
in the violent
the blood plasma, but to run
strains of experimental arterial
destructive
but uniform
and
dispersionof the consequent lesions is to be
injury, some

this

observed

here

and

we

Hollis's

Dr.

note

may

bombardments,

In

the larger arteries we

presently.
perceive
the
streaks
and
tallow
this partialityfirst in
drops, so
fully described by Ainslie Hollis, and later by Cowan, and
emphasised by Jores and his pupils,Askanazy (1907),Simnitzky,
and Benda
as
(1909) ; spots and streaks regarded by Virchow
believed
be of this nature.
to
not
atheroma, though now
These
clearlyrepresent lines or points of stress ; the segregations
are
by molecular affinities or surface
perhaps determined
tissue increase, if any,
sequent.
tensions ; the connective
being subthat
tissue is of perfectly
We
no
may
presume
uniform
sclerosis
quality throughout. A patchy beginning of atherobe

to

discussed

in

familiar

is very

the

elsewhere, it begins rarely,if

which

begin in

to

seem

exposed

most

Dr.

from

stresses

to

ever,

but
diffusely,
of

first part

the

arteries

coronary

the

where,
in

as

parcels

branch, the

part

the aorta.

tribution
closelyinvestigatedthis familiar streaky disfor such it is,however
of earlyatheroma
superficial
has

Hollis

"

in appearance
largestbranches
"

in various
and

vessels,which

parts of the

forks ;

in
especially

is remarkable

and

aorta

the coronary

in the words

of

of the

some

and

bral
cere-

Morgagni,"linese

albidse maculse."
et
longitudinem directse
in incipient
in young
jects,
subThis character is best observed
cases
when
it is probably due to an
infection,such as typhoid
fever after which
they are very frequent (p. 282). Simnitzky,
bodies of ages from 2 to 25, found them
in a series of necropsies
on
in

subobscurae

in 48 per
soon

cent.

AJ8the

lesion becomes

chronic, their outlines

are

is brief.
blurred, so that the periodof their initial significance
1

Mott, F., Journ.

of Path,

and

BacL, 1894-95.

CHAP,

DISEASE

vii

This

OF

raised
slightly

is to be

"

DESCENDING

linear

"

in well-marked

seen

aorta,

and

AORTA

529

spotty subendothelial atheroma

and instructive forms in the descending

of this

great vessel which, as Dr. Hollis says,

and as Morgagni said before him, we are apt to leave
unopened.
For instance,in two of Hollis's cases
of
(ofone
which he givesan
part

neither
illustration)

itself gave
revealed

the state

notion

any

of the
the

slitting
up

on

atheroma
incipient
than

in the

even

to

ostial

of the

valves

extensive

that of the arch

nor

atheroma

descendinglimb.

in this limb

of the

portion,where

which

Linear

great vessel

are

was

streaks

of

straighter

their

spiralor twisted arrangement,

when
the base transverse, signifies
or
near
the eddies by
which
they are engendered,and of which they are the record.
Posteriorly,
they trend towards the floor of the arch, their long
of the blood.1
diameters
In the
being with the main stream
descendingaorta of long bedridden cases, these streaks are most
in the regionof the second
intercostal artery,and are
abundant
and
the dorsal aspect of the lining,
evident on
most
penetrate
show

One

the media.

that

such

seemed,

case

in Dr. Hollis's

form

streaks may

atheromatous

"

opinion,to

within

few

"

atheromatous
that the
tracery may
days ; and he presumes
week."
The
within
intima
the
be produced on
a
incipient
much
on
changes at the sites of branch openingsbegin, not so
vessel,"
the liningof the aorta, as along the sides of the branch
and are probablydue to vortices. These features,as we have seen
ing
intimate bearan
in the chapter on Causes, have, in my
opinion,
"

"

Hollis's

Dr.

in atheroma

factor

the mechanical

upon

opinion is not,

or

but

merely, that

not

this factor in
of

hydraulic

""detritus
or
by particles
clouds
by
also he speaks of bombardment
cells. Elsewhere
of
and suggests that it is by the stinging
of noxious
particles,"

stresses, but

also

of

"

bombardment

"

be stimulated and maintained,

these that vaso-constriction may
blood
that to the initial disease the farther evils of excessive
so
may

pressures

be
gradually

of the contained

stratum

blood, he

examining

On

added.

finds that in

the

lowest

supinepatients,

with the plasma,

in comparison
lightness
contrary to their specific
there accumulated, instead of floatingupward

leucocytesare
to

ventral

the

they

But

gatheredtowards

had
i

aspect.

See

also Klotz

and

may

we

not

also

the dorsal aspect

Manning, Journ.

Path,

and

as

surmise

phagocytes,in

Bad., Oct. 1911.

2M
VOT.

that

ANATOMY

530

search

AETERIOSCLEROSIS

OF

of toxic matter

detritus ?

PART

Of the

penetrationof the
diseased
patches themselves, and of the walls, by leucocytes,
Dr. Hollis has publishedsome
illustrations.
interesting
Until Jores by the Sudan
III. stain demonstrated
that the fat
with which
the tallow drop or streak is so fullycharged is of
in atherosclerosis,even
universal
in tracts of quite
significance
fibroid appearance
where, until this test was
applied,no fat was
wont
to discriminate
or
even
a
supposed,authors were
perceptible
fibrous

or

arteriosclerosis

fatty reaction
vessel.

lies

It may

atheroma

from

criterion

be that

But

(p. 482).

of atherosclerosis

in

the

in whatsoever

of the

fattyspecks or streaks on
aortas, if quite superficialand
independent, may
young
*
vanish, or leave a small scar ; but, as they are often traced
also signifya deeper,but in youth
to some
infection,they may
remediable, disintegration. It is true
notwithstanding that
not
ment
only the manifoldingof the elastica,but also the encroachof the connective
fibre,precede the fattydecay, and may
considerable
time ; except in the acute
do so by some
infections,
when
fat appears
quickly and abundantly, especiallyin the
But
aorta.
ere
long sharp outlines are blurred, the elastica,
in its older strands, begins to accept the fat stain, and
especially
then
definitely.The cement
points of fatty necrosis appear
in these
doubt
concerned
substance
is no
degradations,but
The
it is not
easy to apportion the shares of each rudiment.
doubt
if elastic fibre could break up into granulardegeneration
is now
quite decided in the affirmative ; and, as the elastica
breaks
apart), yields,
artery (vasomotor conditions
up, the
tortuous.
But I must
reiterate
lengthens,widens, and becomes
the elastic fibres,although
that in a few sound bodies of old men
susceptibleto both fatty and calcareous change, lose their
alteration
slowly; and for a while little or no more
qualitymore
is to

be

than

seen

withstand

increase

to the aid of

which, coming
muscular

an

some

the

better

oscillations and

somewhat

elderly; although,

connective

tissue

less resilient elastic and

on

slower

current, but

more

Adami,

less tonic

beats,

bumping

highersystolicblood pressures of the

the other hand, it gives less help in

recoil.
1

(p. 517)

of the

by narrowing the excursion

coat, may,
even

of

Amer.

Jaurn.

Med.

Sci., Oct.

1909.

ANATOMY

532

of

vasa

tone

disruptionsof
enfeebled,

are

Nuclear

and

small

observed

are

the

and

vasorum,

minute

finer

cell from
the

and

cell

only

ARTERIOSCLEROSIS

OF

repairsthe
and
are
overborne, elasticity
begins to yieldas a whole.

hyperplasiawhich

cell

vessel

activitysoon

if notable

and,

wane,

skirts of the

the

on

PART

at

lesion ; nuclei and

all,

fibres

begin to decline their stains,and become hyalineor put on those

definite fatty specks.
react
as
granular characters which soon
Thus
it is that
early and transient phenomena of repair
into those
of decay, hypertrophy being lost in an
merge
accumulation
often

closed.

nourished

if the

And

by imbibition,as
Such

impeded.
other

Thus

of waste.

in

small

the coat

epithelium,be
is further

in

as

in

observe

degenerations,we
stresses,

is

lumen

alters its nutrition

mechanical

to

the

intima, beyond the

or
fortifications,

parts exposed

arteries

mitral

the

of the
hypertrophied heart ; or at the attachment
insertions ;
chordae
tendineae
the corresponding cardiac
and
Of the leaf of the
or, again,at the insets of the aortic cusps.
valve

of

valve

there

atheroma
the

; and

While
have

at

be

rest, may

"

be

may

such

of elastic fibre,and
spots the splitting

be

said that

part in these

no

yet in ordinary

their

cases

We

artery.1
toxins, autogeneticor
an

arterial

issues, whether

(p. 236), while

unmistakable.2

in

recognisedas

it cannot

its insertion

sclerosis,"but about

pure

part, if

doubt

can

factor

the

appreciab
in-

and

is salient

stress

longerthat

no

elsewhere,

is remote

any,

of

or

foreign,

and

the elastic fibres,

vitality,do
nevertheless undergo physicaland chemical degradation; and on
the other hand
told on
the best authority (Aschoff
we
are
and others) that, after arterial development is complete,they
naturally

be

cannot

stiffened

into

restored.

As

strands

of

they

grow
of the surrogate connective

low

very

old and

lose

resiliency,
proliferation

tissue,as normally observed

in childhood,

capacity
suppliestheir place so long as regenerative
be
I
holds ; though, as
have
said, this descriptionmust
qualified
by the provisothat in the arteries of very vigorousold
not
much
not
exceed, and may
people the alteration may

amount

about
2

to

See

e.g.

more

than, connective

Dewitzky,

thrombus, or on
See Beitzke, Virch.
a

Virch.
the

Arch., 1910;

distal side of

Arch.,

tissue defence.

and

the

complete

1901, vol. clxiii.

same

In

process
obstruction.

these

may

cases

be

seen

CHAP.

ARTERIOSCLEROSIS

vii

the elastica is stretched

and

Auxiliaryconnective

fatty change,

no

tissue
focal

free,being of

diffused,in the arterial

or

minority,even

which

few

of

even

excepted. As it is but

course

of

old

healthy up

men

altogetherabsent, it would
subjects,to be expressive, as I

section

Causes, of little

on

mechanical
that

and

wear

tear

the arteries suffer in

developed a
When

(p. 236).

of such

structure

after these

are

the

identical in

general category
besides

atheroma

of

its

fibrosis,medial,

extensive

connective

that
arising,

is,as

thelium

the

and

in

stellate
elastica

syphilitic
peripheralsclerosis
The

the

former,

subordinate

and

of

in

the

than

prolonged
amazing thingis not
time, but that they have
more

The

and

in essential

even

rather

as

yet

very

are

within

or

if

the

contained,

are

form,

certain
"

in

the

origin,

the endo-

supposed

the

and

intima-medial

furthermore

not

to

form,

that

familiar

more
or

return

arteriosclerosis

diffuse

strated.
demondistinctly

ordinary arteriosclerosis.

fibre cannot

If subordinate

convinced

small

very

could rarelycause
specific
process
any confusion
is
whether
or
regenerative
(readaptive)
atrophic,
feature

the muscular

arteries

present in

hyperplasiabeing intimal
and spindlecells between
and

"

the

supposed

find
justified,
we
ordinary arteriosclerosis

of

and

is

perennialduration.

nature, and

atherosclerosis

extensions
more

have

atherosclerosis be

name

in

histological
descriptions
we

questions (p. 510) whether

not

of

process

coats

young

when

seem,

nothing

or

there

death, that atherosclerosis

to

is

such

533

increasingly
manifest, but

superficial
fattystreaks, from
are

ATHEROMA

(Adami, Marchand, Jores,Herringham)

spoilt; the vessel is thinner, and the

be

parts may

in

AND

We

itselflapseinto connective

luetic forms

be

omitted,

I think

agree

fibre
we

;
a

that

(p.481).
must

be

identityof ordinary arteriosclerosis

forget Professor Adami's warning lest

of the substantial

atheroma.

I do

not

to decisions
be
too aortic,"and lest we
come
investigations
if for the moment
we
disregard
characters.
Still,
superficial
upon
and
observations agree more
the long vessels of the limbs, recent
in
the intima, and
attention upon
in concentratingour
more
showing that sclerosis of the aorta, of its largerbranches, and
"

our

so
so
"

on,

that

of the

coronary,

all such

Atherosclerosis."

vessels

cerebral,and
may

If in the

be

the

included

rest, is atheromatous
under

long straightarteries

the

name

of

of the limbs

ANATOMY

534

least

at

appearances
the media

prove

extensive,

seat

ARTERIOSCLEROSIS

somewhat

are

be

to

of

while

decays

OF

the

otherwise,if in these vessels

first,as

disease,if the

connective

fibre

of

blends
To

while
arteriosclerosis,
the

between
the

kinds

be

who
etymologists

most

fibre suffers and

(Monckeberg, Adami,
be regardedas another

waxes

in

may

certainly the

it is

muscular

this
Marchand, Aschoff and others),
mode

PART

may

certain

transitions

areas

or

seen.

will have

it that the

atheroma

name

shall not be extended

to any
(or atherosclerosis)
process, however
matter
akin, in which pocketsof porridge-like
(aOdp^)are not to
be found,
cut

back

we

to

Sclerosis

shall pay

little heed

their roots,
of

the

; if all

language would
I must

veins

our

come

words
to

an

were

to

be

end.
this

subject
indeed
have
much
definite information, and, clinically
not
we
us.
(On portalsclerosis,
speaking,it does not very nearlyconcern
Vol. I.,p. 450.) Sclerosis of the veins and venules certainly
see
does occur, but it is altogether
minor in degreeand importance to
arterial sclerosis. In them
internal

pressures,

it cannot,

unless

from

over

pass

as

on

rule,be due

local obstruction, such

cirrhosis of the liver,and

forth ;

to excessive
as

rhoids,
haemor-

againunder gravitation,
as
commonly seen in such veins as the femoral, saphenous,
or
popliteal.External frictions and contusions, or compression
certain pointsby the contractions of the voluntary muscles
at
in part for the obviously thick and
account
dilated veins
may
of labouringmen.
in them
of the arms
This thickeningseems
fibrosis of the intima ; hyalineand
to consist in a subepithelial
in the veins
than in
fattychanges are apparentlyless common
arteries. The sclerosis which
arises in the pulmonary arterial
in them
and the rightventricle,as
system under high pressures
in mitral stenosis,is,as we
have seen, homologous with ordinary
than
atherosclerosis ; if less constant
one
might have supposed
it is not
infrequent; probably its minor degrees are often
so

or

overlooked.

END

Printed

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