TREATMENT
Although it has been rather dogmatically stated (vide supra) that every
one who reaches old age has arteriosclerosis, it must not be inferred
that absolutely no exceptions to this rule are found. Cases are known
where persons of ninety years even had soft arteries, and we have seen
persons of eighty whose arteries could not be palpated. When infants and
children are seen with considerable sclerosis, it proves that, after
all, it is the quality of the tissue even more than the wear and tear,
that is the determining factor in the production of arteriosclerosis. It
would be well if those who can not bring healthy progeny into the world
were to leave this duty to those who can.
In general the treatment of arteriosclerosis is prophylactic and
symptomatic. In the preceding chapter I had something to say about
prophylaxis in general; I must again refer to it in detail.
Arteriosclerosis is essentially a chronic progressive disease, and the
secret of success in the management of it is not to treat the disease or
the stage of the disease, but to treat the patient who has the disease.
To infer the stage of the disease from the feeling of the sclerosed
artery, may lead to serious mistakes. Persons with calcified arteries
may be perfectly comfortable, while those with only moderate thickening
may have many severe symptoms. The keynote is individualization. It is
manifestly absurd to treat the laboring man with his arteriosclerosis as
one would treat the successful financier. The habits, mode of life,
every detail, should be studied in every patient if we expect to gain
the greatest measure of success in the treatment. One may treat fifty
patients who have typhoid fever by a routine method and all may
recover. Individualizing, while of great value in the treatment of acute
diseases, yet is not absolutely essential in order that good results may
be obtained. Far different is it when treating a disease like
arteriosclerosis. One who relies on textbook knowledge will find himself
at a loss to know what to do. Textbooks can only outline, in the
briefest manner, the average case, and no one ever sees the average book
case. At the bedside with the patients is the place to learn
therapeutics as well as diagnosis. All that can be hoped for in
outlining the treatment of arteriosclerosis is to lay down a few
principles. The tact, the intuition, the subtle something that makes the
successful therapeutist, can not be learned from books. So the man who
treats cases by rule of thumb is a failure from the beginning. There are
certain general principles that will be our sheet anchors at all times
and for all cases. The art of varying the application of these
fundamentals to suit the individual case, is not to be culled from
printed words.
=Hygienic Treatment=
Every man is more or less the arbiter of his own fate. Granted that he
has good tissue to begin life, his own habits and actions determine his
span of comfortable existence. No one cares to live after his brain
begins to fail, and the failing brain is often due to disease of the
cranial arteries. The hygienic treatment resolves itself into advice in
regard to prophylaxis.
First and foremost is exercise. It has seemed to us that the revival of
out-of-door sports is one of the best signs of promise of the
preservation of a virile, hardy race. That women, as well as men,
indulge in the lighter forms of out-of-door exercise should bring it
about that the coming generation will start in life under the most
advantageous conditions of bodily resistance.
Among all the forms of exercise, golf probably is the best. It is not
too violent for the middle-aged man, yet it gives the young athlete
quite enough exercise to tire him. It is played in the open. One is
compelled to walk up and down in pleasant company, for golf is
essentially a companionable game, while he reaps the full benefit of the
invigorating exercise. The blood courses through the muscles and lungs
more rapidly; the contraction of the skeletal muscles serves to compress
the veins and so to aid the return of blood to the heart: the lungs are
rendered hyperemic, deeper and fuller breaths must be taken; oxidation
is necessarily more rapid, and effete products, which if not completely
oxidized would possibly act as vasoconstrictors, are oxidized to
harmless products and eliminated without irritating the excretory
organs.
Other forms of out-door exercise that can be recommended are tennis,
canoeing, rowing, fishing, horseback riding, swimming, etc. Tennis is
the most violent of all the sports mentioned and might readily be
overdone. Rowing as practiced by the eights at college is undoubtedly
too violent a form of exercise, and may be productive in later life of
very grave results. Canoeing is a delightful and invigorating exercise.
The muscles of the arms, shoulders, and trunk are especially used, the
leg muscles scarcely at all. Nevertheless, the deep breathing that
necessarily comes with all chest exercises aerates every portion of the
lungs, and is of great benefit to the whole body.
Swimming as an exercise has much to recommend it. In this sport all the
muscles take part and at the same time the chest is broadened and
deepened.
All these methods of using the muscles to keep oneself in trim, so to
speak, are part and parcel of the general hygienic mode of life that is
conducive to a healthy old age. Exercise can be overdone, as eating can
be overdone. Both are essential and yet both can be the means of
hastening an individual to a premature grave.
When the arteriosclerosis has advanced so far that it is easily
recognizable, certain forms of exercise should be absolutely prohibited.
Such are tennis, rowing and swimming. Horseback riding to be allowed
must be strictly supervised. At times this may be an exceedingly violent
exercise. As an out-of-door sport, there is nothing that equals golf.
The physician, knowing the character of the course, and the length of
it, can say to his patient that he may play six, nine, twelve, or
eighteen holes, depending on the patient's condition.
For those who are not able to get out, exercise in the room with the
windows open must take the place of out-of-door sports. Here the use of
chest weights is a most excellent means of keeping up the tone of the
muscles. By adjusting the weights, the exercise may be made light,
medium, or heavy. Every physician should be familiar with the chest
weight exercises. They are not as good as open air exercise but they
undoubtedly have been the means of saving years of life to many patients
with arterial disease.
There comes a time when all forms of exercise must be prohibited on
account of the dyspnea, edema, dizziness, etc. It seems unwise to keep
such a patient in bed, even though the edema be considerable. Once on
his back in bed he becomes weak, and the danger of edema of the lungs or
hypostatic congestion of the bases, with subsequent bronchopneumonia, is
very great.
Such patients may be allowed to sit up in a comfortable chair with the
legs supported straight out on a stool or other chair. The half
reclining position is not easy to assume in bed. Considerable ingenuity
must often be exercised by the physician in making the patient
comfortable without increasing the symptoms from which the patient
suffers following the least amount of exercise. Although such persons
can not exercise actively, they should have passive exercise in the form
of massage, carefully given, so that no injury is done to the rigid
vessels. It is possible to rupture a vessel, the walls of which are
encrusted with lime salts, and full of small aneurysmal dilatations.
Every patient must be watched carefully and measures instituted for the
individual.
=Balneotherapy=
As a tonic and invigorator, the cold or cool bath (shower or tub), in
the morning on arising can be highly recommended. It promotes skin
activity, is a stimulant to the bowels and kidneys and to the general
circulation, besides being cleansing. We find today that the morning
bath has become such a necessity to the average American that all new
hotels are fitted with private baths, and old hotels, in order to get
patronage, are arranging as many baths connected with sleeping rooms as
is possible. Our generation assuredly is a ruddy, clean-bodied one. What
the actual results of this out-door life and frequent bathing will be
for the race remains to be seen, but one can not but feel that it must
build up a stronger, more resistant race of people, who not only enjoy
better health than did their forefathers, but enjoy it longer.
Not every one can stand a cold bath. It is folly to urge it on one to
whom it is distasteful, or on one who does not feel the comfortable glow
that should naturally result. For the well, or those with a tendency to
arteriosclerosis, or those in whose families there have been several
members who had early arteriosclerosis, such proceedings as recommended
could not be improved upon. However, for the person who has well
recognized sclerosis, only warm baths should be advised, and these not
daily. The water should be at a temperature of 90-95 deg. F. Care should be
taken that persons sent to spas be cautioned against hot baths. It is
not inconceivable that the increased force of the heart beat that
accompanies a hot bath might be sufficient to rupture a small cranial
vessel. Hence, Turkish and Russian baths should be most unqualifiedly
condemned. As a matter of fact, persons vary so in their habits with
regard to bathing that what might suit one person would do another much
harm.
=Personal Habits=
The personal habits of the individual, more than any other factor,
determine whether or not arteriosclerosis sets in early in his life. The
man or woman who is moderate in eating and drinking, sees that the
kidneys are kept in good condition, and attends strictly to regularity
of the bowels, lays a good basis for the measure of health which is so
essential for happiness. It has been shown that sclerosis of the
splanchnic vessels may be due to constant irritation of toxic products
elaborated in digesting constantly enormous meals. In obstinate
constipation, many poisons, the nature of which we do not know, are
absorbed and circulate in the blood. We have not sufficient data to
prove that constipation favors the production of arteriosclerosis, but
our impression has been that it does favor it. Constipation can often be
relieved by a glass of water before breakfast, a regular time to go to
stool, and abdominal massage or exercises. Some maintain that it is a
bad habit only, and can be readily overcome. Whatever is done, avoid
leading the patient into the drug habit, for the last state of the
patient will be worse than the first. Habits of sleep are not of such
great importance. Most persons get enough sleep except when under severe
mental strain. Most adults need from seven to eight hours' sleep,
although some can do all their work and keep in prime health on five or
six hours' sleep.
Tobacco has been accused of causing many ills and has been thereby much
maligned. We can not see that the use of tobacco in any form in
moderation is harmful to most men. Undoubtedly the blood pressure is
raised when mild tobacco poisoning occurs, and individual peculiarities
of reaction to the weed are multitudinous. But to condemn offhand its
use is the height of folly. There is no reason why the arteriosclerotic
who has always used tobacco in moderation, should not continue to use
it, whether he smoke cigarettes, cigars, or pipe. His supply should be
decreased, but there is no sense in depriving a man of one of the
solaces of life, unless, as is sometimes the case, abstinence is easier
for the patient than moderation.
As for alcohol, opinions differ widely.[19] Some see in alcohol one of
the most frequent causes of arteriosclerosis; others do not believe that
the part played by alcohol is a serious one, only in conjunction with
other poisonous substances is it dangerous. Probably unreasoning
fanaticism has had much to do with the wholesale condemnation of
alcoholic beverages. The general effect of alcohol is to lower the blood
pressure by causing marked dilatation of all the vessels of the skin.
True, the alcohol circulates in the blood, and is broken up in the
liver, and this organ would seem to bear the brunt of the harm done.
Alcoholic drinks in moderation, I do not believe have any deleterious
effect on health. On the contrary, I believe that they may in some cases
assist digestion and assimilation. Indiscriminate indulgence is to be
condemned, as is overindulgence in exercise or eating. What may be
moderate for A, might be excessive for B. Every man is then the arbiter
of his own fortune and within his own limits can indulge moderately (a
relative term after all) without fear of doing himself harm. In advanced
arteriosclerosis it is necessary to decrease the supply of alcohol just
as it is necessary to cut down the food supply. This must rest entirely
on the judgment of the physician, who must not act arbitrarily, but must
have his reasons for every one of his orders.
[19] Discussion of alcohol at present has value only as it relates
to the past. The present is dry. The future is in the lap of the gods.
=Dietetic Treatment=
Most persons eat too much. We not only satisfy our hunger, but we
satisfy our palates, and, instead of putting substantial foodstuffs
into our stomachs, we frequently take unto ourselves concoctions that
defy description.
Foodstuffs are composed of one or all of three classes: (1) proteins,
(2) fats, (3) carbohydrates. As examples of the first are beef and white
of egg; of the second, the oils, butter, lard; of the third, sugar,
potato, beet, corn, etc.
The physiologists and chemists have shown us that both endogenous and
exogenous uric acid in excess will cause a rise of blood pressure, but
the bodies most concerned in the production of elevated blood pressure
are the purin bodies, those organic compounds which are formed from
proteins and represent chemically a step in the oxidation of part of the
protein molecule to uric acid. Red meat contains more of the substances
producing purin bodies than any other one common foodstuff, and for this
reason the excessive meat eater is, _ceteris paribus_, more apt to
develop arteriosclerosis comparatively early in life.
The fats and carbohydrates contain practically no substances that react
on the body of the ordinary individual in a deleterious manner during
their digestion. The extra work that is put on the heart by the
formation of many new blood vessels in adipose tissue is the only
harmful effect of overindulgence in these foodstuffs.
It has been found that nitrogen equilibrium can be maintained at a wide
range of levels. Formerly 135-150 gms. of protein daily were considered
necessary for a man doing light work. Now it is known that half that
amount is sufficient to keep one in nitrogenous equilibrium, and to
enable one to keep his weight. A person at rest requires even less than
that. One who is engaged in hard physical labor burns up more fuel in
the muscles, and so must have a larger fuel supply.
Although we habitually eat too much we drink too little water. For those
who have any form of arterial disease an excess of fluid is harmful, as
the vessels become filled up and a condition of plethora results, which
necessarily reacts injuriously on the heart and circulation. The
drinking of a glass of water during meals is, in the author's opinion,
good practice. The water must be taken mouthful at a time, and not
gulped down. If this is done, there results sufficient dilution of the
solid food to enable the gastric juices successfully and rapidly to
reach all parts of the meal.
Some are in favor of a rigid milk diet for those who have
arteriosclerosis. Some men have lived on nothing but milk for several
years and have not only kept in good health, but have actually gained
weight and led at the same time active lives. It has been held by others
that rigid milk diet is positively harmful on account of the relatively
large quantity of calcium salts that are ingested. This was thought to
favor the deposition of calcareous material in the walls of the already
diseased arteries. While possibly there may be some danger of increased
calcification, the majority of clinicians are in favor of a milk cure
given at intervals. Thus the patient is made to take three to four
quarts daily for a period of a month. There is then a gradual return to
a general diet, exclusive of meat, for several weeks, then another rigid
milk diet period.
If we are bold enough to follow Metschnikoff in his theories of
longevity, we might advise resection of the large intestine, on the
ground that it is an enormous culture tube that produces prodigious
amounts of poisonous substances which are thrown into the general
circulation. To combat such a grave (?) condition as the carrying of
several feet of large intestine, we are recommended to take buttermilk
or milk soured by means of the _b. acidus lacticus_. Clinical experience
has taught that in arteriosclerosis buttermilk is of great value,
whether it be the natural product, or made directly from sweet milk by
the addition of the bacilli. The latter is a smoother product and has,
to my mind, a delightful flavor. It may be diluted with Vichy or plain
soda water. Cases that can not take milk or any other food will often
take buttermilk, and do well on this restricted diet. From two to four
quarts daily should be taken. It should be drunk slowly as should milk.
=Medicinal=
It has long been thought that the iodides have some specific effect on
the advancing arteriosclerosis, checking its spread, if not really
aiding nature to a limited restoration of the diseased arteries. It is
possible that the eulogies upon the iodides owe their origin to the
successful treatment of syphilitic arteriosclerosis, in which condition
these drugs have a specific action. However that may be, there is no
doubt that the administration of sodium or potassium iodide is good
therapeutics in cases of arteriosclerosis.
Unfortunately many persons have such irritable stomachs that they can
not take the iodides, even though they be diluted many times. They may
be made less irritating by giving them with essence of pepsin. Unless
the case is syphilitic, it is doubtful whether it is of value to
increase the dose gradually until a dram or even more is taken three
times daily after meals. Usually a maximum dose of ten grains seems to
be quite sufficient. This may be taken three times a day, well diluted,
for three months. There follows a month's rest, then the treatment is
resumed for another period of three months, and so on. Either sodium or
potassium iodide in saturated solution may be given. The sodium salt is
possibly less irritating, and contains more free iodine than the
potassium salt, although the latter is more generally used. The
strontium iodide may also be used.
One sees a patient now and then who can not take the iodides, however
they may be combined. For such patients one may obtain good results with
iodopin, sajodin, or other of the preparations put up by reputable
firms. Personally I have never yet seen a patient who could not take the
ordinary iodides in some form or other, and I am opposed to ready made
drugging.
The action of the iodides is to lower the blood pressure, and they are
of greatest value when the blood pressure is high, and when headache and
precordial pain are present.
When the case is moderately advanced, very mild doses, gr. 1/2, morning
and evening, of the thyroid extract may be given. It is generally
believed that the internal secretion of the thyroid and the adrenal are
antagonistic. That the thyroid secretion lowers blood pressure in
certain forms of hypertension is certain, possibly on account of its
iodine content. Some combinations of iodine and thyroid such as the
iodothyroidin have been used and have had some measure of success
attributed to them.
Hypertension does not always demand active measures for its reduction.
Viewed from the physiologic standpoint, hypertension is but the
expression of a compensating mechanism which is designed to keep the
blood moving through narrowed channels. Heart hypertrophy then is
absolutely essential to the maintenance of life. It has been said that
the highest blood pressures occur in chronic disease of the kidneys. The
poisonous substances produced in the kidneys must exert their action
through absorption into the general blood stream. This toxin may be
completely eliminated, if we accept as our criterion the reduction of
tension to normal together with the complete return of the affected
individual to health. A concrete example is as follows: A man aged 44
years was brought to the Milwaukee County Hospital in coma. His systolic
blood pressure was over 280 mm. Hg, diastolic 170 mm., his urine
contained considerable albumin and many casts. He had general anasarca.
Venesection was done at once and 300 c.c. blood obtained. Immediately
following this operation the pressure was 210-150, but within twelve
hours it was again above 280-170. He was given no medication to reduce
pressure except that he was freely purged. He was given a steam sweat
bath daily. Frequent blood pressure readings were taken. Within seven
days the pressure was 130-86. He had, in the meantime, completely
recovered from his symptoms. He was kept in the hospital for two weeks
longer assisting in the work on the ward, and he was discharged with a
pressure (systolic) between 130 and 136 diastolic 80-84. The treatment
was rest in bed, free purging, venesection, and sweat baths, simple but
exceedingly effective.
Should there be actual indications for reducing the blood pressure, I
must admit that it can not always be done. The majority of cases will do
well on the sodium nitrite or erythrol tetranitrate. However, these do
not always lower blood pressure and keep it within normal limits. When a
man has very high tension we do not wish to reduce it to what it should
normally be for the age of the patient, as symptoms of collapse might
set in at any time under such conditions.
Observations made with the sphygmomanometer[20] show that the effect of
nitroglycerin is transient or of no effect except in doses which are
relatively enormous (one drop of the one per cent solution given every
hour). Sodium nitrite may lower the blood pressure but the effects will
have worn off in two hours. It is the same with erythrol tetranitrate.
Sodium sulphocyanate in doses of from one to three grains three times a
day is highly recommended by some. My own experience with it does not
lead me to believe that it is of any great value in hypertension. It,
however, may be tried. Benzyl benzoate has been used recently to reduce
the high blood pressure of hypertension. Macht has reported some
success. In the author's hands it has been efficacious in a few cases.
As long as the patient takes the drug the pressure may be slightly
reduced, but upon the withdrawal of the drug the pressure returns to its
former level. It is well worth a trial and further experimentation may
reveal better methods of administration. The dose is from 2 to 6 c.c.
mixed with water at intervals.
[20] Miller, Jos. L.: Hypertension and the Value of the Various
Methods for Its Reduction. Jour. Am. Med. Assn., 1910, liv, p. 1666.
In the hypertension of the menopause some have had success with large
doses of corpus luteum extract. As a matter of fact the drug treatment
of hypertension, when it becomes necessary to treat this condition with
drugs, has suffered a notable set-back since more careful control has
been made with the blood pressure instruments. In giving any of the
depressor drugs their action should be controlled by blood pressure
measurements, for only in this way can we be sure that the drug is
exerting its physiological effect and we may expect results. The
individual reaction to these drugs varies greatly and no rule for dosage
can be dogmatically laid down. The only successful therapy is rigid
individualization. This is the keystone to treatment in cases of
arteriosclerosis and high tension.
It must not be inferred from what has been said that the nitrites are of
no value. They are of decided value but they have their limitations. The
most evanescent of these drugs is amyl nitrite. This is put up in the
form of capsules, or pearls, containing from one to three minims. When
it is desired to dilate the peripheral vessels suddenly, one or two of
these capsules are broken in a cloth held to the nose. The effect is
almost instantaneous. There is flushing of the face and other peripheral
vessels, particularly near the head, denoting a relaxation and widening
of the bed of the blood stream, and a consequent decrease in pressure in
the arteries. These effects are over in a short while. It is only used
in attacks of cardiac spasm, as in angina pectoris. Nitroglycerin, the
Spiritus Glonoini of the U. S. P., acts in about the same manner as amyl
nitrite but the effects last usually a trifle longer. One drop of the
one per cent solution may be given every hour until physiologic effects
are produced. It may be given hypodermically. This may be a means of
reducing pronounced high tension. This drug has been found of benefit
especially in cases where arteriosclerosis combined with chronic
nephritis causes cardiac asthma. The other drug which may be of service
in these conditions, one whose sphere of action is somewhat broader,
because its effects are more lasting, is sodium nitrite. This is given
in water in doses of one to three or five grains every four hours. Some
have objected to the use of this drug, but my experience has made me
place considerable confidence in its harmlessness, provided that the
patient is carefully watched. This, however, applies to all of the
nitrite compounds. My experience with erythrol tetranitrate is not
large. It may be used in place of sodium nitrite.
For a mild case, one often finds that sweet spirits of niter is
sufficient to control the pressure and relieve the distressing symptoms,
and it is undoubtedly the least harmful of all the nitrites. Drugs that
are of great value, but of which little is noted in textbooks, are
aconite and veratrum viride. Both of these drugs are well known to be
marked circulatory depressors. Veratrum viride in my experience should
be very cautiously used, and never used unless a trained attendant is
constantly at hand. With regard to aconite I have no such feeling, and a
mixture of tincture of aconite and spiritus etheris nitrosi may be given
for several weeks with no fear of doing any harm. Personally, of all the
drugs mentioned, I prefer the nitrite of sodium or the combination just
given. They may be advantageously alternated.
My own feeling is that the most successful means of treatment of acute
high tension is without the use of drugs. The most important measure is
absolute rest in bed. This often suffices to lower the blood pressure
and to arrest the symptoms produced by high tension. Venesection I
believe is also of value. True the arterioles appear to contract almost
immediately upon the lessened quantity of blood, or there is immediate
interchange of serum from the tissues which brings the blood volume
back to the original amount. Whatever happens the pressure is not
greatly reduced, at times not reduced at all, but often the symptoms are
relieved. Hot packs or sweat baths assuredly do reduce the pressure in
many cases. This seems to me to be an exceedingly valuable measure.
Finally the diet should be nourishing, but very light, not too much
fluid should be ingested, and the bowels should be freely opened.
With the fibrolysin of Merck, I have had no experience. Some men assert
that they have had good results from its use, but on the whole the
evidence is not highly favorable.
Morphine is invaluable. No drug is of such value in the nocturnal
dyspneic attacks that occur in the late stages of arteriosclerosis when
the heart or the kidneys are failing. Morphine not only relaxes spasm
and quiets the cerebral centers, but is an actual heart stimulant under
such conditions, and should never be withheld, as the danger of the
patient's becoming addicted to its use is more fanciful than real.
However, morphine, at times, suppresses the secretion of urine. So that
if after trial the urine becomes scanty and the edema increases,
recourse must be had to other drugs. The various hypnotics may be used
with caution. One which seems to be very useful is adalin.
As heart stimulants, one may use strychnine, spartein, caffein, or
camphor. In desperate cases, where a rapidly diffusible stimulant is
needed, a hypodermic syringeful of ether may be given, and repeated in a
short while.
Several years ago a so-called serum was brought out by Trunecek which
was said to have a favorable effect on the metabolism of the vessel
walls. It was given at first hypodermatically or intravenously but the
former method was painful. It was later stated that given by mouth it
acted just as well. The results with the Trunecek serum have not come up
to the expectations that the early favorable reports promised. The
original serum was composed as follows: NaCl, 4.92 gm.; Na_2SO_4, 0.44
gm.; Na_2CO_3, 0.21 gm.; K_2SO_4, 0.40 gm.; aqua destil. q. s. ad. 100.0
c.c. Later this was modified for internal use to the following
prescription:
R_{x} Natrii chlor. 10. gm.
Natrii sulphat. 1. gm.
Natrii carbonat. 0.40 gm.
Natrii phosphat. 0.30 gm.
Calcii phosphat.
Magnesii phosphat. aa. 0.75 gm.
M. Ft. cachets No. XIII.
The contents of every cachet corresponds to 15 c.c. of the fluid serum
or to 150 c.c. of blood serum. The preparation called antisclerosin
consists of the salts contained in the serum. As to its efficacy, I can
not judge, as I have never felt that it was worth while to use it.
Reports of cases in which it has been tried do not speak very highly of
it.
In the general treatment of arteriosclerosis, there is no one factor of
more importance than the regular daily bowel movement. Attention to this
may save the patient much discomfort and even acute attacks of cardiac
embarrassment. The choice of the purgative is immaterial, with this
reservation only, that the mild ones, such as cascara, rhubarb, licorice
powder and the mineral waters, should be thoroughly tried before we
resort to the more drastic purgatives. Plenolphthalein in 3 to 5 grain
doses acts remarkably well in some people as a pleasant laxative.
Agar-agar with or without cascara may be useful.
Liquid paraffin under a variety of names is a most useful and
efficacious laxative. As its action is purely mechanical it may be taken
indefinitely without doing harm to the intestinal musculature.
The old Lady Webster dinner pill is an excellent tonic aperient. When
the heart is embarrassed and edema of the legs and effusion into the
serous cavities have taken place, then it becomes necessary to use the
drastic purgatives that cause a number of watery movements. Epsom salts
given in concentrated form, elaterin gr. 1-12, the compound cathartic
pill, blue mass and scammony, or even croton oil may be used. Since the
observation of a greatly congested intestine from a patient who had been
given croton oil, I have ceased to use this purgative, and I doubt much
whether its use is ever justifiable in these cases.
The management of the ordinary case of arteriosclerosis resolves itself
into a careful hygienic and dietetic regime with the addition of the
iodides, aconite, or the nitrites. A diet consisting of very little
meat, alcohol in moderation or even absolutely prohibited, and not too
much fluid should be prescribed. Condiments and spices should also be
used sparingly. Cold baths, shower baths, cold and hot sheets
alternating, are of great benefit in assisting the heart to do its best
work by making the large capillary area of the skin more permeable. It
is not true that such baths raise the blood pressure so markedly.
Certain acts, as sneezing, violent coughing, etc., increase the blood
pressure much more than judicious bathing.
=Symptomatic Treatment=
The fact that arteriosclerosis really loses much of its own identity
and, in later stages, becomes merged with the symptomatology of the
diseases of various organs, as the kidney, brain, heart, compels us, for
completeness' sake, to say a few words about the treatment of these
complications.
One of the results of arteriosclerosis of the coronary arteries, angina
pectoris, demands prompt treatment. In the acute attack, the chief
object is to relieve the spasm and pain. Pearls of amyl nitrite should
be inhaled, and morphine sulphate with atropine sulphate given
hypodermatically at the very earliest moment. It is senseless to
withhold morphine. The only possible reason for withholding it would be
uncertainty as to the diagnosis. It is probably better to err on the
safe side, and should the case prove to be one of pseudo angina, in the
next attack sterile water can be given instead of the morphine and
atropine.
When a patient is seen in the condition of broken compensation with the
much dilated heart, anasarca, dyspnea and suppression of urine, there is
no better practice than venesection. Especially is this valuable when
the tension is still fairly high and the individual is robust. Following
the abstraction of six to eight ounces of blood (300-500 c.c.)[21] the
whole picture changes, so that a man who a short while before was
apparently at death's door, notices his surroundings and takes an
interest again in life. This should be followed up with thorough
purgation, and cardiac stimulants should be ordered. In such cases
digitalis is useful, but its action is never so striking as in cases of
this general character due to uncompensated valvular disease. It must be
remembered that in arteriosclerosis the changes in the myocardium must
be of a considerable grade for the heart to give away. Therefore,
digitalis can not be expected to act on a diseased muscle as it acts on
a comparatively healthy muscle. It is only in such cases of broken
compensation that digitalis should ever be used.
[21] I have taken as much as 1700 c.c. from a large man. He
recovered and went back to work.
Digitalis is not a general vasoconstrictor as used to be taught. Its
action on the kidney is actually a vasodilator one. And in its action on
the heart the digitonin dilates the coronary arteries, according to
Macht, while the digitoxin acts on the heart muscle. Overdosing with
digitalis has produced partial heart block in many cases. It is
absolutely contraindicated in Stokes-Adams syndrome.
There are, however, some cases, especially those with transudations,
when digitalis may be carefully tried even though high tension be
present. It is sometimes of advantage to combine digitalis with the
nitrites although they are said to be physiologically incompatible.
Still another drug, that is of great value in conditions such as have
been described, is diuretin. This may be given in capsule or tablets,
grs. x. three times daily. There is only one caution to express in the
use of this drug. It should not be given when the kidneys are the seat
of chronic inflammatory changes; in fact, actual harm may be done by
administering the drug under such conditions.
The same is true even to a greater extent with theocin. This is a
powerful diuretic. If given by mouth it should be well diluted as it is
most irritating to the stomach. It is best given intravenously in doses
of two and a half to three grains dissolved in five to six cubic
centimeters of distilled water. One must be reasonably sure that the
kidneys are not the subject of chronic disease and are functionally,
therefore, below par. The intravenous dose should not be given oftener
than once in four days.
For the pain in aneurysm, nothing (except, of course, morphine) is so
valuable as iodide of potassium. Patients who are suffering agony, when
put to bed and given KI grs. x. three times a day, soon lose all the
distressing symptoms. This applies particularly to aneurysms of the arch
of the aorta.
When the sclerosis has affected the cerebral arteries to such an extent
that symptoms result, the case is, as a rule, exceedingly grave. Not
much can be done except to relieve the headaches and keep down the blood
pressure, if this is high, by means of rest in bed, the iodides,
aconite, or the nitrites. The cases of transient monoplegias or
hemiplegias can be much relieved by careful hygienic measures and
judicious administration of drugs. Much ingenuity is sometimes required
to overcome the idiosyncrasies of patients, but care and patience will
succeed in surmounting all such difficulties.
The treatment of intermittent claudication is the treatment of
arteriosclerosis in general. Sometimes the circulation in the affected
leg or legs is much helped by daily warm foot baths. Light massage might
be tried and the galvanic current may be used once or twice daily.
There are a few distressing symptoms that occur usually late in the
disease, when complications have already occurred, which frequently
baffle the therapeutic skill of the physician. The chief of
these--insomnia, dyspnea, and headache--may not be late manifestations,
but insomnia and headache are frequently associated with the moderately
advanced stages of arteriosclerosis. At times all the symptoms seem to
be due to the high tension, the relief of which causes them to
disappear. There are, unfortunately, times when high tension is not
responsible for the headache and insomnia. Under these circumstances
such drugs as trional, veronal, amylene hydrate, ammonol, etc., may be
tried until one is found which produces sleep. For the headaches,
phenacetin, alone or in combination with caffein and bromide of sodium,
may be tried. Acetanilid, cautiously used, is at times of value. There
have been cases of arteriosclerosis with low blood pressure, accompanied
by severe headaches, that have been relieved by ergot. Codeine should be
used with care, and morphine only as a very last resource.
Great care must always be exercised in giving drugs that depress the
circulation, for it is easily conceivable that more harm than good can
come from injudicious drugging.