Angioneuroses

ANGIONEUROSES, vascular vasomotor neuroses, are functional disorders of the innervation of blood vessels. The latter have nerves that constrict the vascular lumen (vasoconstrictors) and nerves that dilate it (vasodilators), corresponding to the circular and longitudinally arranged cells of the muscular coat of the vessels. Capillaries also have their own innervation and can actively constrict and dilate. Blood vessels contain a large number of sensory nerve fibers. The nerve fibers that constrict the vessel lumen belong to the sympathetic nervous system, while those that dilate it belong to the parasympathetic. If there is irritation of the vasoconstrictors, the vessel constricts, and paleness of the tissues occurs—angiospasm; if, however, the outflow vessels constrict, we have cyanosis. In the case of paralysis of the vasoconstrictors or irritation of the vasodilator nerves, active hyperemia occurs, expressed by redness of the corresponding area of the body; if this takes place in the cutaneous vessels, the skin becomes pinkish-red, reacting with paleness to finger pressure, but this paleness quickly disappears. Conversely, when pressure is applied to cyanotic skin, although it also pales, it then slowly returns to its former color. As a result of the altered state of the vascular wall under the influence of disturbed innervation, and its greater porosity, fluid passes into the surrounding tissue, causing the latter to swell, apparently due to a disturbance of the physical-chemical relations in the cell—an increase in its hydrophilicity. On this basis, irritation of the terminal sensory nerve endings occurs, giving a sensation of itching, burning, and a peculiar fullness or engorgement—a common characteristic companion of angioneuroses. If the nutritional disturbance of the tissues is even more pronounced, the patient feels a peculiar pain. With a highly pronounced nutritional disturbance of the tissues, further trophic disorders occur: increased glandular secretion, dystrophic disorders, atrophy, and necrosis appear. Thus, angioneurosis transitions into angiotrophoneurosis, with which it has much in common from the general pathological standpoint.—The most prominent clinical forms of angioneuroses are the following: a) on the part of the integument—urticaria, acrocyanosis, erythema, dermographism, pruritus, local symmetrical asphyxia (see Asphyxia localis symmetrica), spontaneous gangrene, erythromelalgia, acute neuropathic edema (Quincke's disease), chronic edema in its various sub-types; b) on the part of the cardiovascular system—certain neuroses of the heart, false angina pectoris (see Angina Pectoris), essential hypertension, intermittent claudication; c) on the part of the respiratory organs—vasomotor rhinitis, hay fever, bronchial asthma; d) on the part of the digestive tract—urticaria of the oral cavity, colic of the stomach and intestines with subsequent vomiting and diarrhea, membranous colitis, certain forms of gastric ulcer and gastric neuroses; e) on the part of the genitourinary organs—polyuria, paroxysmal hemoglobinuria, membranous dysmenorrhea, etc.; f) on the part of the brain and its membranes—migraine, false tumor (pseudotumor cerebri); g) on the part of the joints—intermittent hydrarthrosis; h) on the part of general neuroses—certain manifestations of sympathicotonia and parasympathicotonia (vagotonia), phenomena of general vasomotor neurosis and angioneurotic constitution.—The causes of the appearance of angioneuroses can be various factors: congenital predisposition, weakness and underdevelopment of the vascular system, physical and mental fatigue, strong emotions, worries, exogenous and endogenous intoxications (autointoxications), infectious agents, trauma, any factor causing reflex disorders, such as a scar, disorder of the endocrine glands, metabolic diseases (especially gout), irregularities and deviations in sexual life (especially often various measures against pregnancy, particularly coitus interruptus), a neurasthenic state with highly pronounced disorders of the emotional sphere, etc. Congenital predisposition is understood as a hereditary burden in the direction of nervous and endocrine diseases, as well as the presence of signs of a special kind of neuro-vegetative constitution, the carriers of which a number of clinical researchers characterize as "vegetatively stigmatized," vagus-labile people (exudative, vaso-neurotic, and vasomotor diathesis, etc.). This constitution is expressed by a lively reactive play of the vasomotors of the skin and face, mobility or a definitely expressed peculiarity in the activity of the heart (bradycardia, tachycardia), developmental defects of the heart, valves, and large vessels, peculiarities of circulation in the periphery of the limbs (sweaty, cold or hot, chilly cyanotic hands and feet), characteristic features of the capillaries established capillaroscopically, signs of hyperthyroidism, sharp changes in well-being and mood during menstruation, an increased reaction to testing with pharmacological preparations (adrenaline, atropine, pilocarpine, etc.), idiosyncrasies to medicinal, food, and other substances, etc. Among the exogenous factors affecting the vasomotors, one must especially mention alcohol, nicotine, occupational hazards (lead, nitro compounds, etc.), toxicomanias to such alkaloids as opium, hashish, cocaine, etc. Among the autointoxications causing angioneuroses, one must include especially intestinal autointoxications, disorders of the endocrine glands, such as Graves' disease, disturbances in the activity of the adrenal glands, thyroid gland, sex glands (especially during puberty and menopause), etc. Both infection and trauma can leave behind a disturbance in some part of the autonomic nervous system related to vascular innervation, resulting in angioneurosis. As a consequence of the reflex influence of a formed scar or pathological process on the periphery or in the vicinity, a spasm of the vessel may occur, followed by phenomena of functional impairment of the nervous system in various directions, up to deep trophic disorders inclusive (reflexogenic origin of angioneurosis and subsequent angioneuropathy). Particularly many such angioneurotic disorders are observed as a result of war injuries. On the basis of reflected influences on the vascular system, disorders very complex in their pathogenesis and manifestations can develop, expressed, for example, by persistent pain (causalgia) or trophic disorders (non-healing ulcer). Recently, a view has been put forward on some angioneuroses as allergic diseases, the result and manifestation of anaphylaxis; such are the new views on urticaria, bronchial asthma, hay fever, Quincke's edema, vasomotor rhinitis, migraine, etc. This leads to the recognition of the possibility of understanding the development of angioneurosis, on the one hand, as a reaction of the organism to a minimal amount of some exogenous substance, and on the other, as an angioneurotic reactive capacity existing in the organism. Angioneuroses in sympathicotonia and parasympathicotonia represent congenital or acquired functional disorders. Their significance in such cases is symptomatic.—Angioneuroses can have as their consequence very gross and severe, anatomically speaking, trophic disturbances. A typical symptom complex of such dystrophies can be observed not only in the absence of any pathological-anatomical changes known to us, but also as a result of a definite process in the vessel itself or the central nervous system. In the latter cases, one should no longer speak of angioneurosis, but of angioneuropathy. In any case, in the presence of deep dystrophic lesions, we may not find and do not know the pathological-anatomical changes for the starting point of these disorders. —Individualization is extremely important in the treatment of angioneuroses. Rest and reassurance play a very large role. This also includes psychotherapy. General strengthening treatment is very important. If the visible cause can be eliminated (tobacco, alcohol, a certain kind of food, etc.), success can be complete. Preventive work in industry is extremely important in the case of occupational hazards. It is particularly important to clarify all kinds of deviations from normal sexual life. It is very important, if possible, to clarify the character of the patient's constitution in order to direct attention to the resulting defects (asthenia, vasomotor instability, sympathicotonia, parasympathicotonia, gout, etc.). The search for an allergen, even if there are no definite indications of it, is necessary in some angioneuroses. If it is not possible to find the allergen, attention is directed to studying the question of a suitable diet for the patient. Of the physical methods of treatment, general soothing water procedures, especially baths and warmth, come to the fore; then—ultraviolet rays, heliotherapy, four-chamber galvanic baths, ionogalvanization, franklinization, diathermy, d'arsonvalization, massage, gymnastics, etc. Of the medicinal preparations for angioneuroses, the most effective are strengthening agents (arsenic, iron, phosphorus). In addition, calcium, atropine preparations, bromides, opiates, nitrites, adrenaline, etc., are resorted to. In a number of cases, it is possible to use reflexotherapy of the type of inducing the nasal reflex (cauterization in the nasal cavity according to Bonnier).

In severe cases of angioneuroses (angioneuropathies), surgical assistance was applied.

V. Khoroshko.

Surgical treatment of angioneuroses. From the group of angioneuroses, it is only in Raynaud's disease that surgical treatment methods have recently begun to be quite widely used. From a surgical point of view, two stages (or two forms) of this disease are distinguished: the first stage is "pure" angioneurosis, when neither clinical observation nor pathological-anatomical examination can detect anatomical changes; in the second stage of the disease, these changes are present; clinically, the following are determined: disappearance of the pulse, compensatory expansion of collaterals, persistent ischemic phenomena in the periphery (pain, atrophy of the skin and nails, and eventually gangrene); the pathological-anatomical process is manifested either by thrombosis due to degenerative changes in the wall or by inflammation (arteriitis, perivasculitis). In the first stage of the disease, when only angiospastic phenomena are present, the idea of the operation is to interrupt the vasomotor reflex arc in its sympathetic part (since the vasoconstrictor nerve is the sympathetic nerve). Then the vasodilators should gain a dominant position, and the pulse, circulation, and nutrition of the limbs should improve. This idea originated in the Lyon surgical school, in the clinic of Jaboulay, who in 1899 proposed, in cases of circulatory disorders in the lower extremities, to perform "exposure" of the femoral artery, isolating it from its sheath ("denudation" of French authors) for a certain distance; in doing so, the branches of the sympathetic nerve entwining the vessel were torn; good results were obtained: the limb became warm, pink, and the pain disappeared. Leriche modified (in 1917) the operation in the sense that he began to remove the entire outer coat of the artery for a distance of 6–8 cm; he believed that this would make the operation more radical; his operation received the name "periarterial sympathectomy" or "decortication" of the artery. Leriche obtained success in a number of cases, and periarterial sympathectomy became widely used. Egorov showed in dogs that after removal of the adventitia, the vessel turns into an immobile connective-tissue tube. A number of surgeons noted severe complications after Leriche's operation. In addition to experimental verification, an anatomical-histological revision of the data on which the operation is based was also carried out. Jaboulay and Leriche believed that sympathetic nerve fibers run in the form of a long continuous network within the outer coat of the artery from the top to the bottom of the limb. Recent anatomical-histological studies have shown that this concept is erroneous: the innervation of vessels occurs segmentally; at different levels of the limb, sympathetic branches branch off from the mixed nerve, supplying a specific segment of the vascular bundle; for the human lower extremity, for example, the innervation of the femoral artery from the femoral nerve, and of the popliteal vessels from the sciatic nerve at the site of its division in the popliteal fossa, has been proven. These data explained, on the one hand, the clinical observations of some surgeons who saw good results when performing Leriche's operation at two levels—on the thigh and in the popliteal fossa; on the other hand, these same data brought to life new surgical methods. A. D. Prokin proposed to desympathize the vessels of the lower leg by transecting those sympathetic trunks that branch off from the sciatic nerve and its primary branches in the popliteal fossa. V. I. Razumovsky proposed injecting 80% alcohol into the sciatic, tibial, common peroneal, and saphenous nerves, and also saw a favorable effect. Blanc and Fortacin perform traction of the sciatic nerve, and Läwen freezes it. Finally, some surgeons perform operations on the central sympathetic system: removal of a part of the sympathetic nerve trunk (Herzen), ganglion stellatum (Loyal-Davis, Allen, Kanavel), rami communicantes (Leriche). Indications and surgical measures change somewhat when we are dealing with the second stage of Raynaud's disease, i.e., a patient with anatomical changes in the vessels. In these cases, circulation suffers from two factors: from the mechanical difficulty created by obliteration at the site of one or another vascular disease, and from the accompanying spasm (irritation of the sympathetic vascular plexus). In these cases, a number of surgeons (including Leriche) propose to resect the diseased section of the vessel; in this case, removal of a segment of the vessel can sometimes purely mechanically facilitate collateral circulation, but the main result of the operation is the removal of the focus that irritates the sympathetic nerve plexus and causes reflex spasm in the periphery. Leriche points out that the removal of the diseased part of the vessel must be performed in healthy tissues, and gives an instructive example of recurrence after incomplete removal of the diseased section of the brachial artery. (On the removal of the adrenal glands—see Gangrene, spontaneous). Other forms of angioneuroses are subjected to surgical operations only under exceptional conditions; thus, for example, in angioneurotic edema of the larynx, tracheotomy may be required as a life-saving measure against suffocation.