The treatment of these pseudo-angibas depends, of course, on the diagnosis of the cause, and the cause should be eliminated or modified. If the heart shows real disturbance from this reflex cause, the treatment aimed toward it depends on whether the heart action is weak or strong and the circulation poor or good. If the circulation is poor, digitalis in small doses may be needed, either 5 drops of an active tincture twice a day, or 8 or 10 drops once a day. If digitalis is not indicated, strophanthus sometimes is valuable. While strophanthus has been shown not to be a real cardiac tonic like digitalis, still there seems to be a nervous sedative action when it is given by the mouth, and it often does good in these cases. The dose is 5 drops of the tincture, in water, three times a day, after meals. Strychnin in small doses may be needed, but in these patients, who are generally nervous, it is usually better not to give it.
One of the best sedatives to a heart that is irregular in its action and not acting strongly is lime; a good way to administer it is in the form of calcium lactate, and the dose is 0.3 gm. (5 grains), in powder or capsule, three times a day, after meals.
If the circulation is good and the heart is strong, and yet these irregular pains and irregular contractions occur, the bromids act favorably and successfully. This is probably on account of their ability to quiet the central nervous system, to quiet and soothe the irritability of the heart, and to relax the peripheral blood vessels. The dose should be from 0.5 to 1 gm. (7 1/2 to 15 grains), in water, three times a day, after meals. It is not necessary or advisable to continue the bromid very long. Whatever general tonic or eliminative treatment the patient, requires should be given. The value of hydrotherapy, massage and graded exercise should not be forgotten.
STOKES-ADAMS DISEASE: HEART BLOCK
Stokes-Adams disease, or the Stokes-Adams syndrome, is a name applied to a combination of symptoms which was described by Stokes in 1846, and had been observed by Adams in 1827. The disease is characterized by bradycardia and cerebral attacks, either syncope or pseudo-apoplectic or convulsive attacks.
To understand the phenomena of this disease, it will be well to refer to the first chapter of this book. Until 1893, when His described the bundle of muscle fibers which is now known by his name, the transmission of the cardiac stimulus to contraction was not understood. It has been found, by studying the pathology of Stokes-Adams disease, as well as by clinically noting with instruments the contractions of different parts of the heart, that these slow heart beats are really due to interruptions of the impulse passing from auricle to ventricle through the bundle of His, and degeneration in this region is generally the cause of Stokes- Adams disease. The auricles often beat many times more frequently than the ventricles, even two or three times as frequently, and, of course, these auricular contractions are not transmitted to the arterial system, and the radial pulse notes only the contractions of the ventricles. The phrase that is used to describe this nontransmission of the auricular stimulus to the ventricles is "heart block."
While this disease almost invariably has a pathology, cases have occurred in which no lesion of the heart could be found, but it generally occurs coincidently with arteriosclerosis, in which the coronary arteries are more or less involved and the arterial system of the brain may be diseased. It occurs more frequently in men than in women, and in them mostly after middle, or in advanced, life. The previous history of the patient has often disclosed syphilis. The intermittence of the pulse may be regular or irregular, and may not be constant in the early stages of the disease; but when the disease is established, the rate of the pulse may be reduced to forty, thirty, or even twenty beats a minute, and it has been known to be even less. When these intermittences are regular, perhaps two beats to one intermittence, or three beats to one intermittence are the most frequent types. When the auricles also beat slowly, perhaps the vagiare for some reason overstimulated and thus inhibit the heart's activity.
The attacks of syncope are doubtless due to anemia of the medulla, because of the infrequent ventricular contractions. This anemia of the medulla and of the brain may also cause an epileptic seizure, or a partial paralytic seizure without any apparent paralysis. It is probable, however, that in these cases there may be coincident arterial disease in the brain. These sudden syncopal attacks are likely to occur when a patient suddenly rises from a reclining posture, especially if he has been asleep. Many persons whose circulation is none too strong may feel faint on suddenly rising, but in a person whose pulse is slow and the circulation weak the danger of causing anemia of the brain by the sudden erect posture is much increased. Slight faint turns are of frequent occurrence with these patients; or the faintness may be so rapid and so intense that the patient may drop in his tracks. Venous pulsation in the neck is generally marked, showing an impeded contraction of tile right auricle.
If the auricles are heard or found by instrumental readings to contract more frequently than the ventricles, the trouble is quite likely to be a heart block from disease in the heart itself, in the bundle of His. If the heart is slowed as a whole, the trouble might be due to diseased arteries or pressure from a growth, a gumma, perhaps, or other brain tumor in the region of the pons Varolii or medulla oblongata; or a hemorrhage into the fourth ventricle, causing pressure, could be the cause.