Coronary artery

“ Or if calcification occurs early the diminution of the lumen remains, or perhaps even increases, and may reach an almost complete occlusion of the vessel.
The effects on the heart which follow this form of disease of the coronary artery, though described in another place, had best be enumerated here: 1. The flow of blood not being sufficiently interfered with to cause disease, the heart may remain unchanged. 2. Hemorrhagic infarction may result, accompanied by simple fatty degeneration or softening, which is the most frequent cause of rupture of the heart. ”

“ It is quite true that less frequent beating of the heart, and even irregularities of the pulse, may occur spontaneously, and certainly without ligature of the coronary artery. Any one who has made frequent experiments on dogs in which the pressure of the blood has been noted down during a long period, knows very well that intermittent pulsation, and even greater irregularities, are not unfrequent occurrences in narcotised and bound or curarised animals—irregularities which disappear or re-appear, as the case may be. ”

“ I25.70 Atherosclerosis of coronary artery bypass graft (s) , unspecified, with angina pectoris I25.700 Atherosclerosis of coronary artery bypass graft (s) , unspecified, with unstable angina pectoris Excludes1: unstable angina pectoris without atherosclerosis of coronary artery bypass graft (I20.0) I25. ”

“ The blood leaving the heart passes from the left ventricle through the aortic semi-lunar valve, into the ascending aorta. Here the two [126] coronary arteries come off which go to supply the muscular tissues of the heart. The ascending aorta passes into the arch of the aorta. Here are given off the innominate artery to the right and the common carotid and the subclavian to the left. The innominate is only about an inch or two in length, and divides into the right common carotid and the right subclavian arteries. ”

“ No fewer than nine out of 28 cases, of which I have private notes, were the subjects of double aortic disease; practically all the others had a loud ringing second sound over the aorta, significant of degeneration; pain of anginal type in half the cases was the prominent complaint; and two-thirds of the subjects had sclerosis of the radial artery. When we consider that syphilis does also affect the myocardium primarily; that fibroid disease, chronic aneurysm and fatty degeneration of the heart are all traceable to specific disease of the coronaries in many instances ”

“ The most dreaded of all the ills of the cardiac and vascular systems nowadays seems to be arterio-sclerosis, or hardening of the arteries. It is possible for a man of forty-odd, like Mr. Pitts, to have arteries in a condition which would not be encountered normally in persons under seventy years of age.
"The hard or hardening artery means increased blood pressure, with a consequent increased strain on the heart. ”

“ It is after all in the arterioles and smaller arteries that the lesions of arteriosclerosis do the most damage. A point to be emphasized is that the whole arterial system is rarely, if ever, attacked uniformly. That is, there may be a marked degree of sclerosis in the aorta and coronary arteries with very little, if any, change in the radials. On the contrary, a few peripheral arteries only may be the seat of disease. A case in point was seen at autopsy in which the aorta in its entirety and all the large peripheral branches were absolutely smooth. ”

“ It occurs with greater frequency and with greater severity in men than in women.
Atheromatous degeneration is most common in the large arterial trunks, and the changes are most marked at the arch of the aorta, opposite the flexures of joints, at the mouths of large branches, and at parts where the vessel lies in contact with bone. The presence of diseased patches in the wall of an artery diminishes its elasticity and favours aneurysmal dilatation. Such a vessel also is liable to be ruptured by external violence and so give rise to traumatic aneurysm. ”

“ The blood pressure may be sufficient, or even increased if arteriosclerosis is present, although the rise of the sphygmograph tracing is not so high as normal. If the pressure in the aorta is sufficient from the amount of blood forced into it, the coronary arteries receive enough blood to keep up the nutrition of the heart muscle. Sooner or later, however, the left ventricle will become weakened, especially when there is arteriosclerosis or other hypertension, and chronic endocarditis and fatty degeneration result. ”

“ When there is a sudden rise in the blood-pressure in the arteries, due to vasomotor spasm of the peripheral systemic arterioles, and the heart-walls are strong and well nourished, palpitation is evoked; when the coronary branches are involved in the vasomotor spasm then angina is produced, and the heart-walls, acutely distended with blood, can scarcely contract in the face of the opposition presented to their contraction by the high arterial tension. ”

“ In arterial hæmorrhage the blood is bright red in colour, and escapes from the cardiac end of the divided vessel in pulsating jets synchronously with the systole of the heart. In vascular parts—for example the face—both ends of a divided artery bleed freely. The blood flowing from an artery may be dark in colour if the respiration is impeded. When the heart's action is weak and the blood tension low the flow may appear to be continuous and not in jets. The blood from a divided artery at the bottom of a deep wound, escapes on the surface in a steady flow. ”

“ Composition of clot. Condition of vessel. Changes in muscles. Causes: muscular tension, embolism. Heart clots, venous clots. Infecting debris. Symptoms: paresis or paralysis on exertion. Local suffering, tenderness, firm swollen artery, derangement of nutrition and function, atrophy. Chronic arteritis: Atheroma. Changes in serosa. Fibrous thickening, atrophy, dilatation. Strongylus. Treatment: rest, anodynes, alkalies, massage.
Inflammation of arteries has been divided into external and internal arteritis, according as it affects the fibrous sheath of the artery or its inner lining membrane. ”

“ While in almost every case of angina pectoris there is disease of the coronary arteries, the contrary does not hold true, for most extensive disease, even embolism, of the arteries is frequently found in persons who never suffered any attacks of pain. This symptom group is more common in males than in females and as a rule occurs only in adult life. "In men under thirty-five syphilitic aortitis is an important factor." ”

“ Always a serious lesion, aortic incompetence due to syphilis, or to syphilis and strain, is particularly grave, as being so frequently associated with coronary [34] disease and consequent myocardial degeneration—fatty or fibroid, acute softening, and sudden fatal failure. A fully-developed basic systolic murmur, audible over the aortic area and manubrium and along the course of the carotid, is a very common sign of atheroma of the aortic arch and valves and great vessels in association with regular or irregular gout, diabetes, corpulence and allied disorders of nutrition. ”

“ The exaggerated pulsation sometimes observed in the abdominal aorta, the “pulsating aorta” seen in women, should not be mistaken for aneurysm.
Prognosis.—When natural cure occurs it is usually brought about by the formation of laminated clot, which gradually increases in amount till it fills the sac. Sometimes a portion of the clot in the sac is separated and becomes impacted as an embolus in the artery beyond, leading to thrombosis which first occludes the artery and then extends into the sac. ”

“ When an arterio-venous sac has once formed, clinical observation shows that the general tendency is towards extension in the direction of least resistance. This direction of course varies with the situation of the aneurism, and also with the nature of the wound track.
Speaking generally the direction of least resistance in a typically pure perforation is towards the vein. Initial flow of blood from the wounded artery is naturally favoured towards the potential space afforded by a canal occupied by blood flowing at a lower degree of pressure. ”

“ If in old age, ossification exists only in the arteries, the circulation is unaffected; if at the origin of the aorta or in the heart, it is irregular. An artery might become a bony canal, and the blood would circulate there as usual, with the difference only of pulsation. What I have said of the chronic affections of the heart may be said of the acute ones. Syncope arrests its motion, it arrests also the pulse. Certain passions, as anger, fear, &c. seem to be a stimulant to it; they hasten also the arterial motion. All kinds of inflammation of the pericardium affect the pulse. ”

“ Aneurisms of the ascending aorta burst most frequently into the pericardium, right auricle, right ventricle, right pulmonary artery, and rarely externally. Tumors of the transverse portion burst into the trachea, left lung and left bronchi, left pleural cavity, oesophagus, and externally. ”

“ When this sudden systemic arteriole spasm extends to the coronary vessels in a heart whose walls are diseased, a fatal attack of angina with the heart full of blood may be induced. The danger increases with the extent of the structural degeneration of the heart-walls. ”

“ For in several animals the arteries do not apparently differ from the veins; and in extreme parts of the body, where the arteries are minutely subdivided,15 as in the brain, the hand, &c., no one could distinguish the arteries from the veins by the dissimilar characters of their coats; the tunics of both are identical. And then, in an aneurism proceeding from a wounded or eroded artery, the pulsation is precisely the same as in the other arteries, and yet it has no proper arterial tunic. This the learned Riolanus testifies to, along with me, in his Seventh Book. ”

“ In the early stages of the disease before the artery or arteries have had time to become strengthened by proliferation of the connective tissue, there is the danger of aneurysm. Later, the very same protective mechanism leads to stiffening and narrowing of the arteries and hence [220] to increased work on the part of the heart with all of its consequences. Thrombosis is favored, and where atheromatous ulcers are formed, embolism is to be feared.
As the complications and results of arteriosclerosis come to the front every one must be considered by itself and as if it were the true disease. ”

“ Shock and hemorrhage lower it. Hemorrhage lowers also the pulse pressure, and it may be possible to prognosticate internal hemorrhage by frequent estimations of the systolic and diastolic pressures (Wiggers) . Compression of the superior mesenteric artery or the celiac axis in dogs raises the blood pressure measured in the carotid artery for a period of at least an hour. This seems to be dependent on purely mechanical causes, and is not a reflex vasomotor phenomenon. ”

“ As age advances the only organ whose weight increases with the number of years, the heart, may become hypertrophied or dilated; its coronary arteries may undergo an alteration; the pericardium thickens, and in fact arterial atheroma and degeneration generally may begin between thirty-five and forty years. ”

“ As long as the circulation in the heart itself is good and not impaired by coronary sclerosis, and as long as this slowly developing chronic myocarditis has not advanced far, cardiac symptoms will not be in evidence; but if these conditions occur, or if the blood pressure is so greatly increased as to damage the aortic valve or strain and dilate the left ventricle, symptoms rapidly appear, and the heart must be carefully watched. ”

“ As I was able to illustrate after my second lecture by a specimen from the Museum of Charing Cross Hospital, a branch of one of the coronary arteries that has been narrowed by atheroma for an indefinite length of time, with consequent cardiac weakness and discomfort, may any moment become thrombosed rapidly, apparently in consequence of some passing depression or other unfavourable influence, just as in thrombosis of degenerated cerebral vessels. ”

“ The only way in which it is possible to cure this disease is, to produce an obliteration of the cavity of the artery. This is the object of the operation. The diseased artery is exposed, and a ligature is passed around it, above the dilatation, by means of which the blood is prevented from flowing into the sac, and inflammation is excited in the vessel; in consequence of which its sides adhere together, and its cavity becomes obliterated. The success of the operation depends entirely on the completeness of the adhesion of the sides of the vessel, and the consequent obliteration of its cavity. ”