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.
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.