It has been pointed out by Daland [Footnote: Daland: Pennsylvania Med. Jour., July, 1913.] that nervous exhaustion may raise the blood pressure in those who are neurotic, and he finds that this hypertension may exist for months in some cases. On the other hand, in neurasthenics the blood pressure is generally lowered. As he points out, there is often a very great increase in the systolic blood pressure at the menopause, while the diastolic pressure may not be high. This makes a very large pressure pulse. This suggests the possibility of disturbances of the glands of internal secretion. This hypertension is generally improved under proper treatment.

Schwarzmann [Footnote: Schwarzmann: Zentralbl. f. inn. Med., Aug. 1, 1914.] studied the blood pressure in eighty cases of acute infection, and found that a high diastolic blood pressure during such illness indicates a tendency to paralysis of the abdominal vessels, and hence a sluggish circulation in the vessels of the abdomen. He found that in seriously ill patients this high diastolic pressure is of bad prognosis. He also found that a lower systolic pressure with a lower diastolic pressure is not a sign that the heart is weakening, but only that the visceral tone is growing less. On the other hand, when the diastolic pressure rises while the systolic falls, this is a sign of failing heart.

Newburgh and Minot [Footnote: Newburgh, L. H. and Minot, G. II: The Blood Pressure in Pneumonia, Arch. Int. Med., July, 1914, p. 48.] find that the blood pressure course in pneumonia does not suggest that there is a failure of the vasomotor center. They found that "low systolic pressures are not invariably of evil omen." They also found that the systolic pressure in fatal cases is often higher than in those in which the patients recovered, and they found that the rate of the pulse is more important in determining the treatment than the blood pressure measurements.

The work which has been described under this section is of interest as indicating the newer experimental work on the physiology of blood pressure. Much of it is new, however, and it is difficult to draw absolute therapeutic conclusions from the evidence offered.

THE EFFECT OF DRUGS ON BLOOD PRESSURE

Free catharsis is a well established and valuable method of relieving the heart in many cases of broken compensation, and in cases with high blood pressure even while compensation is still good, salines administered once or twice a week assist in elimination, and in the reduction of blood pressure.

However, profuse purging in heart disease may be followed by unfavorable symptoms, especially when the systolic blood pressure is low. When there is hypotension, or when the diastolic pressure is high and the venous pressure is high, and when there is edema or effusion, watery catharsis should be caused only after due consideration, and always with a careful watching of the effect on the heart and blood pressure. The blood pressure is lowered by such catharsis, and the heart is often slowed. Neilson and Hyland [Footnote: Neilson, C. H., and Hyland, R. F.: The Effect of Strong Purging on Blood Pressure and the Heart, THE JOURNAL A. M. A., Feb. 8, 1913, p. 436.] studied the effect of purging on the heart and blood pressure, and were inclined to the view that in serious heart conditions brisk purging should not be done. They think that the slowing of the heart after such purging may be, due to an increased viscosity of the blood, or perhaps to a reflex irritation from the purgative on the intestinal canal.

Pilcher and Sollmann [Footnote: Pilcher and Sollmann: Jour. Pharmacol. and Exper. Therap., 1913, vi, 323.] have shown that the fall of blood pressure after the administration of nitrites is mostly due to the action of these drugs on the peripheral vessels. Chloroform, of course, depressed the vasomotor center, but ether had no effect on this center, or slightly stimulated it. Such stimulation, however, Pilcher and Sollmann believe may be secondary to asphyxia. Nicotin they found to cause intense stimulation of the vasomotor center. Ergot and hydrastis and its alkaloids seem to have no effect on the vasomotor center. Strophanthus acted on this center only moderately, and digitalis very slightly, if at all. Camphor in doses large enough to cause convulsions stimulated the vasomotor center. In smaller doses it generally stimulated the center moderately, but not always. Even when this center was stimulated, however, the camphor did not necessarily increase the blood pressure. The rise in blood pressure from epinephrin is due entirely to its action on the peripheral blood vessels and the heart. It has no action on the vasomotor center. They found that strychnin in large doses may stimulate the vasomotor center moderately, but usually it did not act on this center unless the patient was asphyxiated; then it acted intensely. The conclusion to be drawn from their experiments is that when there is asphyxia, increased venous pressure, and also a rising blood pressure from the stimulation of carbon dioxid, strychnin is contraindicated.

It should be recognized that digitalis very frequently not only does not raise blood pressure, but also may lower it; especially in aortic insufficiency and when there is cyanosis. Even with some forms of angina pectoris, digitalis in small doses may reduce the frequency of the pain. This decrease of pain following the use of digitalis has in some cases been ascribed to the improvement of coronary circulation and resulting better nutrition of heart muscle. Of course under these conditions the action of digitalis must be carefully watched, and it should not be given too long.

Although sodium nitrite and nitroglycerin have but a short period of action, in laboratory experimentation, in lowering the blood pressure, when given repeatedly four or five times a day the blood pressure is lowered in very many instances by these drugs. Sometimes when the blood pressure is not lowered, there is relief of tension in the head from high pressure, and the patient feels better. There is also relief of the heart when it is laboring to overcome a high resistance. One drop of the official spirit of nitroglycerin on the tongue will cause a lowering in the peripheral pressure pulse, the radial pulse becoming larger and fuller. This effect begins in three minutes or less, reaches its maximum in about five minutes, and the effect passes off in fifteen minutes or more. [Footnote: Hewlett, A. W., and Zwaluwenburg, J. G. Van: The Pulse Flow in the Brachial Artery, Arch. Int. Med., July, 1913, p. 1.]

It has been stated that iodids are of no value except in syphilitic arteriosclerosis, but iodids in small doses are stimulant to the thyroid gland, and the thyroid secretes a vasodilating substance. Therefore, the use of either iodids or thyroid would seem to be justified in many instances of high blood pressure.

Fairlee [Footnote: Fairlee: Lancet, London, Feb. 28, 1914.] has studied the effect of chloroform and ether on blood pressure, and finds that there is a fall of pressure throughout the administration of chloroform, and but little alteration of the blood pressure during the administration of ether. It may cause a slight rise, or it may cause a slight fall, but changes in pressure with ether are not marked. When there is slight surgical shock present, as from some injury, they found that chloroform would lower the pressure considerably. Hence it would seem that chloroform should not be used as an anesthetic after serious injuries.

THE EFFECT OF DRUGS ON VENOUS BLOOD PRESSURE

Capps and Matthews [Footnote: Capps, J. A., and Matthews, S. A.: Venous Blood Pressure as influenced by the Drugs Employed in Cardiovascular Therapy, THE JOURNAL A. M. A., Aug. 9, 1913, p. 388.] have shown that even with first class preparations of digitalis, there may be only a moderate gradual rise in arterial pressure, but not much change in venous pressure. Venous pressure was not much affected by small doses of epinephrin, but with large doses it rose from 10 to 80 mm. Pituitary extract acts somewhat similarly to epinephrin. Caffein, though raising the arterial pressure, did not influence the venous pressure. Strychnin did not raise either pressure until the dose was sufficient to cause muscular contractions. They found that the nitrites caused a fall in venous pressure as well as arterial pressure, although the heart might be accelerated and more regular. They think that the nitrites act by depressing the nerve endings in the veins as well as the arteries. Morphin they found did not act on the venous pressure, although it lowered arterial tension, in ordinary doses of 1/8 or 1/6 grain; but with doses of from 1/4 to 1/2 grain, both arterial and venous pressures were lowered. They found that alcohol in ordinary doses did not influence the venous pressure, although it lowered the arterial pressure; but very large doses lowered the arterial and raised the venous pressure. They think that when the venous pressure is increased only by large doses of epinephrin, pituitary extract and alcohol, the effect is due to failure of the heart, although it may be due to an increase of carbon dioxid in the blood, in other words, to asphyxia.



HYPERTENSION

Arterial hypertension may be divided into stages. In the first stage the arteries are healthy, but the tone, owing to contraction of the muscular walls, is too great. This condition or stage has been termed "chronic arterial hypertension." This condition may be due to irritants circulating in the blood, to nervous tension, to incipient chronic interstitial nephritis, or may be the first stage of sclerosis of the arteries. If from any cause this hypertension persists, the muscular coats of the arteries will become more or less hypertrophied, and sooner or later degenerative changes begin in the intima, and finally fibrosis occurs in the external coat of the arteries; in other words, arteriosclerosis is in evidence. If the patient lives with this arteriosclerosis, a later stage of the arterial disease may occur which has been termed atheroma, with thickening, and possibly calcareous deposits in some parts of the walls of the vessels, while in other parts the coats become thinner and insufficient. At this stage the heart, which has already shown some trouble, becomes unable to force the blood properly against this enormous resistance of inelastic vessels and the blood pressure begins to fail as the left ventricle weakens.

Edema, failing heart, perhaps aneurysms, peripheral obstruction, or hemorrhages are the final conditions in this chronic disease of arteriosclerosis.

Riesman [Footnote: Riesman: Pennsylvania Med. Jour., December, 1911, p. 193.] divides hypertension into four classes hypertension without apparent nephritis or arterial disease; hypertension with arteriosclerosis; hypertension with nephritis, and hypertension with both arteriosclerosis and nephritis. These classes are given here in the order of the seriousness of the prognosis.

ETIOLOGY

One of the most common causes of hypertension is clue to excess of eating and drinking. The products caused by maldigestion of proteins, and the toxins formed and absorbed especially from meat proteins, particularly when the excretions are insufficient, are the most frequent causes of hypertension. Whatever other element or condition may have caused increased blood pressure, the first step toward improving and lowering this pressure is to diminish the amount of meat eaten or to remove it entirely from the diet. In pregnancy where there is increased metabolic change, when the proteins are not well or properly cared for in gout, and when there is intestinal fermentation or putrefaction, hypertension is likely to occur. The increased blood pressure in these cases is directly due to irritation of the toxins on the blood vessel walls.

While alcohol does not tend to raise arterial blood pressure, in large amounts it may raise the venous pressure. Also, by causing an abundant appetite and thus increasing the amount of food taken, by interfering with the activity of the liver, and by impairing the intestinal digestion, it can indirectly disturb the metabolism and cause enough toxin to be produced to raise the blood pressure.

Any drug or substance that raises the blood pressure by stimulating the vasomotor center or the arterioles, when constantly repeated, will be a cause of hypertension. This is particularly true of caffein and nicotin. Also, anything that might stimulate, or that does stimulate, the suprarenal glands will cause a continued high blood pressure. It is quite probable that in many cases of gout the suprarenals are hypersecreting and it has been shown by Cannon, Aub and Binger [Footnote: Cannon, Aub and Binger: Jour. Pharmacol. and Exper. Therap., March, 1912.] that nicotin in small closes increases the suprarenal secretion. Therefore, nicotin becomes a decided cause of hypertension and arteriosclerosis.

Thayer found that heavy work is the cause of about two thirds of all cases of arteriosclerosis, and one of the functions of the suprarenals is to destroy the waste products of muscular activity; hence these glands, in these cases, are hypersecreting. Furthermore, the reason that many infections are followed later by arterio- sclerosis may be the fact that the suprarenals have been stimulated to hypertrophy and hypersecrete.

Many persons in middle life, and especially women at the time of the menopause, show hypertension without arterial or kidney reason. At this time of life the thyroid is disturbed, and often, especially if weight is added, it is not secreting sufficiently. Whether, with the polyglandular disturbance of the menopause the suprarenals are excited and hypersecreting, or whether they are simply relatively secreting more vasopressor substance than is combated by the vasodilator substance from the thyroid, cannot be determined. These women are energetic, and look full of health and full of strength, but their faces frequently flush, sometimes they are dizzy, and the systolic blood pressure is too high. Reisman has pointed out that these patients are likely to have very large breasts, and there is reason to believe that we must begin to study more carefully the effect of large breasts on the metabolism of girls and women. There certainly is an internal secretion of some importance furnished by these glands.

In hyperthyroidism at first the blood pressure may be lowered on account of the increased physiologic secretion of the thyroid gland. Later the blood pressure may be raised by stimulation of the suprarenals, or it may become raised from the irritated and stimulated heart becoming hypertrophied. If the heart is normal the ventricles should hypertrophy with the increased work that they are under; and the blood pressure could increase for this reason. Later in exophthalmic goiter the heart muscle may become degenerated, a chronic myocarditis, and the ventricles may slightly dilate. At this time the blood pressure is lowered. When such a condition has occurred, the heart bears thyroidectomy badly; hence an operation on this gland should, if possible, be performed before the heart muscle has become injured. If the heart shows signs of loss of power, minor operations to cut off the blood supply of the thyroid should first be done, and the patient's heart allowed to improve before a thyroidectomy is performed.

Men with hypertension without kidney or arterial excuse are likely to have been athletes, or to have done some severe competitive work, or, as above stated, to have labored hard, or to have worked at high tension, or in great excitement, or with mental worry, all of which tend, as long as there is health, to increase the blood pressure. These men may add weight from the age of 40 on, or they may be thin and wiry. Besides the hypertension there is likely to be a too sturdily acting heart, which is often hypertrophied, and there is an accentuated closure of the aortic valve. There may be dizziness, or no head symptoms at all. Nicotin is likely to be an etiologic factor in this class.

These women and these men may all be improved by proper treatment, and the condition may not develop into arteriosclerosis or nephritis.

Neurotic conditions, and in some instances neurasthenic conditions, may show a blood pressure higher than normal. Lead may be a cause of increased blood pressure, and diabetics occasionally have a high pressure, although more frequently there is a lowering of blood pressure in diabetes.

Richman believes that syphilis is the most common cause of hypertension and arteriosclerosis without renal disease. When arteriosclerosis and renal disease are combined, of course the highest systolic readings occur. He thinks that when high tension occurs under 40 years of age, kidney disease is generally the cause. Of course it may be the only cause later in life.

High blood pressure due to syphilitic conditions may be greatly improved by the proper treatment, although some one or more blood vessels are likely to have been seriously damaged. Although these patients may live for many years, they are likely to have an apoplexy, cerebral disease or an aneurysm.

While hypertension is not a disease, and while it often should not be combated, still, as it is always the forerunner of more serious trouble, there can be no excuse for not most seriously considering it and generally attempting its reduction. At the moment high tension is discovered, there may be no special symptoms; but troublesome symptoms are always pending, and while the patient need not be unduly alarmed, there is no excuse for not rearranging the individual's life so as to prolong it. This is not to state that every high tension must be lowered, but every hypertension must be studied and a safer systolic pressure caused if it is possible without interfering with the person's efficiency. A high diastolic pressure, one above 105, certainly must receive immediate attention, and a diastolic pressure of 110 must be lowered, if possible. On the other hand, a high systolic pressure without a high diastolic pressure should not be rapidly lowered, else depression will be caused.

SYMPTOMS

In hypertension, as long as the heart, which is probably hypertrophied, remains perfectly competent, there are few symptoms, and the person does not seek advice until he notices one or more of several possible conditions. He may be dizzy, his head may feel full and tight, he may have headaches, or he may have some cardiac pain or distress. Other persons do not seek advice until there is a slight weakening of the heart, showing the strain under which it is laboring. In most of these high tension cases, the patients have rather a slow heart, provided the heart is sufficient. Eyster and Hooker [Footnote: Eyster and Hooker: Am. Jour. Physiol., May, 1908.] found that the slowing of the heart in high blood pressure is due to action through the vagus nerves either from the inhibitory center in the medulla or reflexly by stimulation of the peripheral nerves of the vessels.

Another symptom for which the patient frequently seeks advice is that he is unable to relax from his business cares, when off duty. He also finds that he works at a higher tension, and that coffee and tea, alcohol and tobacco stimulate him more than usual. He sleeps restlessly, and dreams at night. He has an increased frequency of urination in the morning, especially after taking coffee, and sometimes gets up once or twice at night to urinate. He is irritable at times; short breathed on exertion, and sometimes has indigestion. He may have pains or aches in his heart. He may find that he dislikes to lie on his left side.

However much it may upset the patient and render him more nervous to inform him that his blood pressure is too high, it is necessary to give him this information. People now suspect the condition, and they frequently seek their physicians to determine if the blood pressure is too high and, from reading health journals, more or less realize some of the things, at least, that must be done to decrease the pressure. Consequently, the very things that are advised or ordered give the patient the diagnosis, whether he is told directly or not. Hence, we must talk freely with the patient, much as we do in heart defects, and get his cooperation, stating how frequent the condition is, how often it is readily improved, and how little it may interfere with long life.

Wiener and Wolfner [Footnote: Wiener, Meyer, and Wolfner, M. L.: A Reaction of the Pupil, Strongly Suggestive of Arteriosclerosis with Increased Blood Pressure, THE JOURNAL A. M. A., July 17, 1915, p. 214.] state that they have found with blood pressure that the pupils of the eyes are larger than normal, and that they readily contract to the stimulus of light, but immediately return to their previous size.

PROGNOSIS

Janeway [Footnote: Janeway, T. C.: A Clinical Study of Hypertensive Cardiovascular Disease, Arch. Int. Med., December, 1913, p. 755.] presented statistics of 458 patients with high blood pressure, 67 percent of whom were men. Of these 458 patients 212 had died, and he found that the women with high blood pressure lived longer than men with high blood pressure. They did not seem as likely to have apoplexy or cardiac failure. About 85 percent of high tension cases occur between the ages of 40 and 70.

While he believes that a systolic pressure of over 160 mm. is pathologic, he does not find that any definite prognostic conclusions can be drawn from the height of the pressure. Of course the most important concomitant symptoms of high pressure are cardiac, renal, and cerebral, and the typical headache, as he terms it, is a symptom of serious import. In considering headache in persons over 40, we must eliminate the eye headaches produced by the need of presbyopic glasses or by the need of stronger lenses, as this need is a frequent cause of headache. Dizziness and vertigo may occur without headache, and drowsiness, though not so frequent a symptom as insomnia, often occurs.

Janeway finds that all kinds of apoplectic attacks may occur from simple transient aphasia to complete hemiplegia, and thirteen of his patients who had died and thirteen of those living at the time of this report showed failure of eyesight as an initial symptom of arterial disease.

Janeway deplores the too frequent diagnosis of neurasthenia in these patients. This diagnosis probably accounts for the frequency with which neurasthenics have been said to have high blood pressure. Patients with high blood pressure may show all kinds of symptoms simulating neurasthenia, but hypertension is a much better diagnosis than neurasthenia for such patients, and will lead to more rational treatment.

Ninety-seven of these patients had hemorrhages somewhere, most frequently epistaxes, sometimes hemoptysis. Janeway did not find that purpuric spots on the skin occurred early in the disease in any of his patients.

Gastro-intestinal disturbances were not much in evidence unless the kidneys were insufficient. Intermittent claudication in the legs occasionally occurred. While angina pectoris and edema of the lungs were not infrequent causes of death in men, it was a rare cause of death in women. Dyspnea is a frequent symptom, and one for which many patients seek medical advice.

A constant systolic blood pressure of over 200 shows a probability that the patient will ultimately die either of uremia or of apoplexy. Janeway found that those patients who are to die from cardiac weakness show cardiac symptoms early in their disease. He found that rapid continuous loss of weight pointed to an early fatal termination.

Of the 212 patients who had died, seventy-one had shown cardiac insufficiency at the time of the first examination; twenty-one showed albumin or casts at that time. Of course it should be repeatedly emphasized that chronic interstitial nephritis may be in evidence with either albumin or casts alone, or without either being present.

Janeway sums up his conclusions by stating that "from the time of the development of symptoms indicative of cardiovascular or renal disease, four years will witness the death of half the men and five years of half the women. By the tenth year half the remainder will have died, leaving one fourth both of the men and the women who have lived beyond ten years." The causes of death he would place in the following order: gradual cardiac failure; uremia; apoplexy; some complicating acute infection; angina pectoris; accidental causes; acute edema of the lungs and cachexia. An early occurrence of myocardial weakness shows a 50 percent probability that death will be caused by cardiac insufficiency. Heart pains comprise another important indicator of future cardiac death, perhaps not an angina. Nocturnal polyuria would indicate a uremic death in about 50 percent of the patients, and typical headache or cerebral symptoms show the probability of uremic death in more than 50 percent, and death from apoplexy in a large number of the other 50 percent As just stated, rapid loss of weight is a bad symptom.

Janeway [Footnote: Janeway, T. C.: A Study of the Causes of Death in One Hundred Patients with High Blood Pressure, THE JOURNAL A. M. A., Dec. 14, 1912, p. 2106.] has previously reported seven patients with hypertension who had diabetes. Diabetes generally, on the other hand, causes a low blood pressure. Patients with this trouble and with hypertension, and without nephritis, probably have an increased secretion from the suprarenals.

We may sum up the prognosis in hypertension as follows: Hypertension alone is not of unfavorable omen; if it is not readily reduced by ordinary means, it is more serious. If associated with kidney, heart or liver defect, it is most serious. If there are such serious conditions as edema, ascites, lung congestion, cyanosis and great dyspnea, the prognosis is dire.

Obesity being a cause of high blood pressure, it should be treated more or less energetically, even if the individual does not continue to add weight.

Stone [Footnote: Stone, W. J.: The Differentiation of Cerebral and Cardiac Types of Hyperarterial Tension in Vascular Disease, Arch. Int. Med., November, 1915, p. 775.] believes that the higher the diastolic pressure the greater danger there is of cerebral death, while a patient with a very high systolic, but a diastolic pressure of 100 or lower, is in more danger of cardiac death. He urges a greater consideration of the pressure pulse in determining the load of the heart and the great danger from a sustained diastolic pressure of over 105 as sooner or later bound to cause myocardial symptoms. This load of the heart is also shown by an increased pulse rate and increased respiratory efforts. In cardiac failure, as the systolic pressure falls the diastolic is likely to be increased, and the pressure pulse thus diminishing, allows insufficient blood to go to the medullary centers, and death soon occurs. Therefore, in acute illnesses a sustained pressure pulse gives a better prognosis than a diminishing pressure pulse. The strenuous measures that should he used to lower a high diastolic pressure are contraindicated when the diastolic pressure is already low, even if the systolic pressure 1s high. If a high systolic pressure begins to fall more or less rapidly the heart shows fatigue, and should be stimulated by digitalis or strophanthin.

Rowan [Footnote: Rowan, J. J.: The Practical Application of Blood Pressure Findings, THE JOURNAL A. M. A., March 18, 1916, p. 873.] finds that a diastolic reading of 100 mm. or more usually means that there is a narrowing of the lumen of the vessels, owing to stimulation of the vasoconstrictors, although it may mean the existence of a true arterial fibrosis. While a real atheroma generally causes a reduction in diastolic blood pressure, or at least but slight increase, he has found in syphilitic cases with arteriosclerosis a high diastolic pressure. If the blood pressure cannot be reduced by ordinary measures, arteriosclerosis is probably present. Several blood pressure examinations must be made, while the patient is being treated, to establish the diagnosis.

Rowan finds the reading of the pulse pressure to be of great importance, as this will indicate, sometimes before any other symptom is present, that the patient is either improving or doing badly, and it also aids in indicating the proper medicinal treatment.

In arteriosclerosis the systolic pressure may be high while the diastolic is low; hence there is a large pressure pulse. If the heart becomes weak the systolic pressure will drop, and any improvement caused, especially in aortic regurgitation, is by an increase of the systolic pressure.

Rowan finds, as has long been recognized, that a conclusion as to whether or not cerebral hemorrhage will occur cannot be made from the condition of the radial arteries, as patients with soft radials may suffer from cerebral hemorrhage, while those "with hard, sclerosed, pipestem-like arteries may live to a great age and die of anything rather than apoplexy."

Swan, [Footnote: Swan: Interstate Med. Jour., March, 1915, p. 186.] has studied the blood pressure in fifty cases of disturbed thyroid, and finds that functional myocardial tests show that the myocardium is nearly always disturbed in these patients.

Before taking up the subject of treatment of high blood pressure, it may be suggested that a high diastolic pressure with a falling systolic pressure may require vasodilators on the one hand or cardiac tonics on the other, and sometimes the decision can be made only by proper tests. In other words, if the diastolic pressure is lowered the heart will be relieved. On the other hand, if the diastolic is being raised by an increased venous pressure from a failing heart, digitalis, strychnin and caffein may be of benefit in lowering the diastolic as well as raising the systolic. However, if there is a high systolic and a low diastolic pressure, vasodilators are often contraindicated.

TREATMENT

In this rapid high tension age the physician should be as energetic in teaching prevention of arterial hypertension as he is in preventing contagion. As infectious diseases are reduced in frequency, more patients live to die of diseases later in life, and (as previously stated) diseases with hypertension are on the increase. It is therefore the duty of the physician to urge youths and adults to abstain from all kinds of excesses so common in this age. We live at such speed, even the children, that this caution is almost daily needed. We must caution against severe athletic competition, against personal "stunts," against recreation excesses, even golfing, automobiling and dancing, against excess in the use of tobacco, in eating, in late dinners, in coffee, tea and alcohol. We must take better care of patients during their convalescence from some serious illness lest they have circulatory debility by becoming strenuous too soon after their recovery. The pregnant woman must be more carefully watched, not only for her own sake, but also for the sake of her child. Intestinal indigestion, while not the cause of all disturbances that occur in man after 40, is still an important element in his deterioration and degeneration, and it should be prevented if possible.

The tendency for hypertension and arteriosclerosis to occur early in life in patients who have suffered some serious acute infection, whether blood poisoning, typhoid fever, or other, shows that in all probability in these acute illnesses the internal secretions are so disturbed that the suprarenal activity is greater than normal, while the thyroid activity may be less than normal, and hypertension is the consequence. Therefore, these infected patients who recover should probably have a longer convalescence in order for the more delicate structures of the body, such as the internal secreting glands, to have a better chance to recover and become normal.

The enumeration of these causes and the causes that have been mentioned before not only suggest, but also direct the treatment of hypertension after it has occurred. The most important of all treatment for hypertension is rest. That means for an individual, well except for his hypertension, a vacation, that is, a rest from physical and mental labor. For a patient who is in serious trouble from hypertension, bed rest is the most important element in the management. As has been previously shown, good sleep lowers the blood pressure, and Brooks and Carroll [Footnote: Brooks, Harlow, and Carroll, J. H.; A Clinical Study of the Effects of Sleep and Rest on Blood Pressure, Arch. Int. Med., August, 1912, p. 97.] showed that the greatest drop in blood pressure occurs in the first part of the night's sleep. In other words, a patient who lies awake long loses the best part of his night's rest as far as his circulation is concerned. This is one more reason for abstinence from tea and coffee in the evening by those patients who are at all disturbed by the caffein. On the other hand, patients who are not seriously ill should not remain for days in bed, as the blood pressure does not tend to continue to fall, although the heart may become weakened by such bed rest. This is especially true if the patient is nervous and irritable and objects to such confinement.

A systolic pressure much over 200 probably never goes down to normal, and if such a high systolic pressure goes down to below 170, we should consider the treatment successful.

Every active treatment of hypertension should begin with a thorough cleaning out of the intestinal canal by purgation, best with mercury in some form. Then the diet should be modified to meet the individual case and the person's activity. If the blood pressure is dangerously high, he should receive but little nourishment, best in the form of cereals and skimmed milk.

On the other hand, if he has edema or dropsy, or if the heart showed signs of weakness, large amounts of liquids should certainly not be given, and in such cases it is better that he receive small quantities of milk if that agrees, rather than large quantities of skimmed milk. The amount of water should also be fitted to the circulatory ability and the condition of the kidneys.

When more or less active treatment does not soon lower the hypertension, and especially a high diastolic pressure, the prognosis is bad. In a patient who is in more or less immediate danger from his hypertension, the food and liquid taken, the care of the bowels, and the measures used to cause secretions from the skin must all be governed by the condition of his other organs. There is no excuse for excessive, strenuous measures when the heart is failing or when the kidneys are becoming progressively insufficient. Strenuosity in treatment is as objectionable in these cases as is neglect of treatment in earlier stages of the trouble.

Bie [Footnote: Bie: Ugesk. f. Laeger, March 4, 1915.] believes there is no direct connection between the blood pressure and the anatomic condition in the kidneys, although abnormal conditions in the two are almost invariably found parallel.

A patient with simple hypertension and otherwise well, which means that his diastolic pressure is at least no higher than 110, should have his diet, tobacco, coffee and tea regulated; should have recreation periods one or more times a week, and vacations not too infrequently; should take some brisk purgative once or twice a week, and may receive one or other of the physical treatments for the reduction of blood pressure, whether Turkish baths or electric light baths. If he does not sleep well, there is no hypnotic drug so valuable in his case as chloral. This should not be long given, but it will produce the purest kind of sleep and lowers the blood pressure.

If any other drug is needed, nitroglycerin is the best. If arteriosclerosis is present, sodium iodid in small doses, 3 grains two or three times a day, is valuable. Larger doses of sodium iodid are not needed, unless it is advisable to give such doses for a short period. The value of iodid in these cases is best obtained by small doses long continued. If the patient is obese, shall doses of thyroid extract long continued are of value, such as 2 or 3 grains once a day. If the thyroid extract causes the heart to become more rapid, it should be discontinued.

Whether the diet should be meat protein free, or whether meat may be allowed once a day, depends entirely on the individual and on his physical activities. It is frequently a mistake to take all meat out of his diet.

When there is obesity, the bulk of the food should be greatly diminished, and anything that tends to stimulate the patient's appetite should be withheld. This means all condiments, and at times even salt. Sugar should be greatly reduced, and starches greatly reduced, but he must have some. In other words, he should not be cut down to a diabetic diet. No more liquid should be taken with the meals than is essential to swallow the food. Water should be taken between meals. There is no question that almost every one today should have a very light breakfast, except perhaps those who labor hard physically and are exposed for hours, daily, to the inclemencies of the weather. Such patients probably need more food. It is also well, in hypertension cases, to have one day a week in which a very minimum amount of food is taken, whether that be milk, or skimmed milk, or a small amount of carbohydrate, without protein food.

If the foregoing management does not reduce hypertension, the kidneys are generally beginning to become involved in the sclerotic degeneration, whether the urine shows such a condition or not. On the other hand, there are exceptions to this rule.

As indican in the urine gives evidence of putrefactive changes in the intestines and the probability of the absorption of toxins from the intestines, although we have no real proof that these toxins are the direct cause of hypertension, our patient is undoubtedly physically better, and will have less arterial tension when this intestinal condition is removed. Therefore, our treatment of the individual is not a success as long as such fermentation and putrefaction persist. If such putrefaction cannot be removed by diet and laxatives and mental rest and the prevention of physical strenuosity, radical changes in diet are advisable, although it may not be necessary to continue such a diet more than a few days at a time. A rigid milk diet for a few days may change the flora of the intestine completely; then a vegetable diet may be given, with return to a mixed diet; or the various lactic acid bacilli may be given, or one of the various fermented milks may be the diet, the object being to change the flora in the intestine and thus modify the ferments. So-called bowel antiseptics, such as salol, for a short time may be of advantage. Colon washings may be of great advantage. Liquid petroleum may be advantageous.

Besides preventing the absorption of toxins from the intestine, we must prevent such absorption from any latent infection. The most frequent kind of such infection is pyorrhea alveolaris.

A simple method that sometimes is an efficient aid in lowering the blood pressure is complete muscular and mental relaxation. The patient lies down for a while in the middle of the day and relaxes every muscle of his body. With this he may take slow breathing exercises. He should be in a dark room, quiet if possible, and alone, and should teach his brain to be for a short time mentally inert.

The physical methods of lowering the blood pressure are hydrotherapeutic, whether by warm baths or more strenuously by Turkish baths, by hot air baths (body baking) which is occasionally very efficient, or, perhaps more now in vogue, by electric light baths. The duration of these baths, and the frequency, must be determined by the results. If the heart is made rapid, and the heart muscle shows signs of weakness, the duration of these baths must not be long, and they may be contraindicated. These baths are most efficient in lowering the blood pressure when the patient reclines for several hours after the bath. The amount of sweating that is advisable in these cases depends on the condition of the heart. If the heart muscle is insufficient, profuse sweating is inadvisable. Also if the kidneys are insufficient, profuse sweating is inadvisable as tending to concentrate the toxins in the blood. On the other hand, when the surface of the body tends to be cool, and there are internal congestions, the value of these baths is very great. Sometimes the electric light baths increase the tension instead of diminishing it, and when properly used they may be of benefit in some cases of hypotension. The frequency of the baths and the question of how many weeks they should be intermittently continued, depend on the individual case. After a course of such treatment sometimes patients have a diminished systolic blood pressure not only for weeks, but even for months, provided they do not break the rules laid down for them.

The Nauheim baths, while stated not to raise the blood pressure, are not much advocated in hypertension, and Brown [Footnote: Brown: California State Jour. Med., November, 1907, p. 279.] who made more than 500 observations of patients of all ages, found that the full strength Nauheim bath would raise the blood pressure in all feverish and circulatory conditions. He also found that a fifteen minute sodium chlorid bath, 7 pounds to 40 gallons, at a temperature of from 94 to 98 degrees F., lowered the pressure from 10 to 15 mm. This is not different from the effect obtained from a fifteen minute warm bath at from 94 to 98 degrees F., or a fifteen minute mustard bath of the same temperature. In other words, the slight irritation of mustard or of salt in a warm bath made no special difference in the amount of lowering of the blood pressure. On the other hand, he found that a fifteen minute calcium chlorid bath, 1 1/2 pounds to 40 gallons, at 94 degrees F., raised the blood pressure 15 mm.

The autocondensation treatment to lower the blood pressure is not so satisfactory as it was hoped to be. The blood pressure can thus be lowered, but it soon again rises, and probably generally more rapidly than after the bath treatments, and in some persons it causes considerable depression. Van Rennselaer [Footnote: Van Rensselaer: Month. Cycl. and Med. Bull., November, 1912, p. 643.] has reviewed this subject of high frequency treatment, and recalls the fact that Nicola Tesla demonstrated, in 1891, the form of electricity which we now term high frequency. High frequency means more than 10,000 cycles per second, at which frequency muscles do not contract and pain is not felt, whereas in medicine the frequency of the currents used runs up into the hundreds of thousands, or even into the millions. The French investigator, d'Arsonval, studied the physiologic action of these high frequency currents and found that the respiration and heart are made more rapid and the blood pressure is reduced, while the intake of oxygen is increased and the carbon dioxid excretion is increased. The temperature may rise. The excretion of the urinary solids is mostly increased. Perspiration may be caused, and he believes the glandular activities are increased. In a word, metabolic changes in the body are made more active and the blood pressure is lowered.

Besides the effect of altitude on blood pressure, as previously declared, patients with dangerously high blood pressure should, if possible, not be subjected to intense cold. In other words, a person with hyper-tension, if financially able, should not remain in a cold climate during the winter. On the other hand, even if he is stout and feels sufficiently warm with light clothing during the winter, his skin becoming chilled adds to his tension. Therefore he should be clothed as warmly as he will tolerate.

After a period which may be termed the normal period of hypertension in normal life, as age advances the systolic tension may lower, provided there is no kidney lesion. This is due to the slowly developing chronic myocarditis and a lessening of the tension and therefore lessening of the resistance to the heart. This may be nature's method of lengthening the life of the individual. In other words, as the arteries grow older the force of the heart slightly lessens, the blood pressure lowers, and the individual is safer. This frequently occurs in otherwise perfectly normal individuals, without treatment.

When the blood pressure is suddenly excessively high from any cause, venesection may be life saving, and should perhaps be more frequently done than it is. It may save a heart that is in agony from tension, and may prevent an apoplexy. It is of little value except temporarily in uremic conditions, but at other times it may, at the time, save life and allow other methods of reducing the dangerous tension to become effective. A chronic high tension patient may be repeatedly bled, although such treatment will not long save life, as the blood pressure in many such cases soon returns to its previous height.

Some very high tension cases, especially in women at the menopause, and where there is no kidney involvement, have the blood pressure reduced successfully only by large doses of thyroid, sometimes well combined with bromids, especially if the thyroid causes excitation. Such treatment persisted in for a time may cause months of improvement, and even years.

DRUGS IN HYPERTENSION

The drugs that are mostly used to lower blood pressure are nitrites or drugs which are like nitrites, and these are nitroglycerin, sodium nitrite, erythroltetra nitrate and amyl nitrite, and the frequency of their use is in the order named. Other drugs used to lower blood pressure are iodids, thyroid, alkalies, chloral, bromids and aconite, the latter rarely.

Amyl nitrite is required only when a sudden immediate effect is desired in angina pectoris or in some other serious spasmodic condition. Sodium nitrite is more likely to upset the stomach than is nitroglycerin. It acts, however, a little longer, but not enough to warrant its frequent selection. The dose of sodium nitrite is from 0.03 to 0.06 gm. (1/2 grain to a grain), best in tablet form and given with plenty of water. The tablet should of course be dissolved or crushed with the teeth. It should not be given on an empty stomach, as it may cause considerable irritation and pain. It more or less actively lowers the blood pressure for about an hour.

Erythrol tetranitrate is preferred by some clinicians who find that its effect lasts somewhat longer. There is probably, however, no better nitrite or nitrate than nitroglycerin. While it acts but a short time, it acts effectively, and although no nitrite has vasodilating effects for any length of time from one dose, when the doses are given repeatedly and for days at a time, the blood pressure will generally be more or less reduced. The dose is from 1/500 to 1/100 grain, three or four times a day, or every three hours, as desired. The best form in which to use it is in a very soluble tablet, and the tablet should not be dissolved unless intense immediate action is desired. It acts when absorbed from the tongue almost as rapidly as when given hypodermically; it acts in two or three minutes, and the blood pressure may drop from 20 to 30 mm. In experimental tests the action does not last more than from fifteen minutes to half an hour, but clinically the effect of repeated doses is much more satisfactory. Spirit of glyceryl trinitrate or spirit of Nitroglycerin, dose 1 minim, keeps well if care is taken to guard against evaporation of alcohol; tablets if well made and kept in bottles properly corked, will retain their activity for months.

The closer a physician is to the laboratory, the less he believes in the value of nitroglycerin in hypertension. The nearer he is to clinical work the more he believes in it. It is a fact that in some instances, even with a dose as small as 1/200 grain of nitroglycerin, three or four times in twenty-four hours, the blood pressure will be lower, whatever the diet is and whatever the other treatments are, than if the patient does not take the nitroglycerin. Also the value of these short relaxation periods from the standpoint of a strained and tired heart should not be underestimated, the same as the value of a night's rest, or the value of a recreation period of an hour or two. If a patient has hypotension and a systolic pressure of 110, and is given nitroglycerin, the very unpleasant results from its administration will be immediately noticed. Hence nitroglycerin is one of the most valuable drugs that we possess for the treatment of hypertension, and some patients are even benefited by as small a dose as l/500 grain. Lawrence [Footnote: Lawrence, C. H.: The Effect of Pressure-Lowering Drugs and Therapeutic Measures on Systolic and Diastolic Pressure in Man, Arch. Int. Med., April, 1912, p. 409.] found that the fall of diastolic pressure from nitrites was about half of the fall of systolic pressure. When there is no kidney lesion a very high systolic pressure falls more under nitroglycerin than does a medium high systolic pressure.

Alkalies, whether potassium or sodium citrate or sodium bicarbonate, are often of advantage in so changing and aiding metabolism, or perhaps reducing the irritation from hyperacidity or a mild condition of acidosis, that their administration causes a lowering of blood pressure.

While iodids may not be direct vasodilators and do not render the blood more aplastic or diminish its viscosity, as shown by Capps [Footnote: Capps, J. A.: Effect of Iodids on the Circulation and Blood Vessels in Arteriosclerosis, THE JOURNAL A. M. A., Oct. 12, 1912. p. 1350.] still, iodids in small doses, 0.1 to 0.2 gm. (1-1/2 to 3 grains) given from once to three times a day, after meals (these small doses do not disturb the stomach), will stimulate the thyroid gland to greater activity, and when this gland secretes properly, the blood pressure is somewhat lowered. Of course, in syphilitic sclerosis large doses of iodids are indicated and are valuable.

In obese patients with hypertension, in the hypertension of women at the menopause, and in hypertension with insufficient kidneys, thyroid medication is often of great value. Sometimes a small dose of from 0.1 to 0.2 gm. (1 1/12 to 3 grains) once a day is all that is needed. At other times, especially when there is no marked arteriosclerosis and no marked kidney or liver lesion, very high blood pressures are reduced only by very large doses, even as much as 10 grains a day. Such treatment is often of very great benefit. Of course, if one of the persons under consideration has symptoms of hyperthyroidism, or if small doses of thyroid cause palpitation, the treatment is not indicated, on the one hand, and should be stopped, on the other. Sometimes when the blood pressure cannot be reduced, in these cases without apparent organic lesions, and thyroid treatment is more or less successful, but at the same time causes great excitation, it may be combined with bromid medication, and then the benefit is sometimes very great.

A patient who cannot sleep and who has hypertension may receive bromids if he is very irritable or if there are symptoms of thyroid irritability; but the most successful sleep and lowering of blood pressure is caused by chloral. A dose of 0.5 gm. (7 1/2 grains) at night is generally sufficient and need not be long continued. Chloral has been frequently given to reduce pressure in 0.2 to 0.25 gm. (3 or 4 grain) doses, three times a day, after meals.

Bromids, of course, will lower the blood pressure, but they depress all metabolism, interfere with digestion, and are not advisable for any length of time. However, in some cases they cause a marked improvement in the patient's condition.

Patients under treatment with chloral, bromids, and thyroid especially, should be carefully watched and the treatment modified to meet the varying conditions. Patients under iodid need not be seen so frequently; those under nitroglycerin or alkalies still less frequently. But all patients under the active management of hypertension should be seen at from one to three week intervals, and the urine should be repeatedly examined and the blood pressure carefully recorded.



HYPOTENSION

A low systolic pressure and a low diastolic pressure may not cause any symptoms or give any cause for anxiety. It does show, especially if the systolic pressure is below normal for the age of the person, a lack of reserve power, and such patients will not well stand serious illnesses, operations, injuries or serious physical and mental strains. If there is a low systolic pressure and a high diastolic pressure, this shows impairment of the heart, whether or not any other organic lesion is present.

Generally speaking, a low systolic pressure shows a weak acting heart muscle, and a very low diastolic pressure shows a dilated condition of the arterioles. In aortic regurgitation this low diastolic pressure is constantly in evidence, and, if the systolic pressure is not below normal, does not signify that the circulation is insufficient. If the systolic pressure is not very low but the diastolic is high, vasodilator drugs, by lowering the diastolic and increasing the pulse pressure, are often of benefit. If there is increased venous congestion and increased venous pressure and a high diastolic pressure with a low systolic pressure, digitalis not only will often raise the systolic pressure, but also will lower diastolic by improving the general circulation and removing venous congestion.

While intestinal indigestion and absorption of toxins often tend to raise the blood pressure, some toxins thus absorbed, especially of the ptomain variety, lower blood pressure and cause shock, perhaps by weakening the muscle of the heart or by acting on the vasodilator vessels; or they may cause dilation of the vessels of the abdomen and in this manner lower blood pressure.

Very low blood pressure after exertion, after severe physical exercise, or after competitive athletic tests shows that the heart cannot sustain such strains and should not be again subjected to them. In severe mental and physical strains the suprarenals may be inhibited in their activities, and a hypotension, more or less prolonged, may result.

Sewall [Footnote: Sewall: Am. Jour. Med. Sc., April, 1916, p. 491] believes that hypotension is frequently due to splanchnic stasis, and that sluggish circulation in this region, especially when the person is in the erect posture, is an important factor in general physiologic disturbances or lack of general tone. When the splanchnic vessels are dilated there is also a lack of proper tone to the cerebral vessels, and this may be a cause of mental weariness and neurasthenia. While ptosis of organs in the abdomen and a flaccid condition of the musculature of the abdomen are frequent causes of this splanchlnic stasis, and therefore hypotension, especially in women, it is quite possible that suprarenal insufficiency will allow this condition of the splanchnic vessels to occur frequently.

Serious illness and infections will lower the blood pressure sometimes to a dangerous point. Of course, hemorrhages lower the blood pressure. Shock and collapse cause lowering of blood pressure, frequently to a fatal point, and Cornwall [Footnote: Cornwall: New York Med. Jour. March 7, 1914, p. 470.] finds that a patient may live several hours with a systolic pressure below 60, and several days when it is below 70; that he may walk around with a systolic pressure of 90, provided the pressure pulse is sufficiently large, that is, that the diastolic pressure is low enough to cause a circulation of blood. Of course, if the difference between the systolic and the diastolic pressure is diminished to the vanishing point, the patient cannot stand it, and dies. It should be remembered that just before death venous pressure is likely to rise, and this may raise the diastolic pressure.

With the progressive toxemia of typhoid fever the blood pressure will become lowered from the myocardial degeneration. Of course, the blood pressure will drop suddenly from a hemorrhage, but Piersol [Footnote: Piersol: Pennsylvania Med. Jour., May, 1914, p. 625] finds that with perforation the peritoneal irritation may cause a rise of blood pressure, and he thinks that this sign may precede for several hours more positive signs of the accident.

As in other infections, the blood pressure will fall in scarlet fever; but if it suddenly rises, a kidney complication is to be looked for. The blood pressure always falls in diphtheria, and always falls in acute rheumatism; consequently, strenuous sweating measures in the treatment of rheumatism should not be used as soon as the blood pressure has become low.

Failing circulation in pneumonia, if accompanied by low blood pressure, requires different treatment from the failure of circulation in these cases when the blood pressure is high. Hence the relationship of the systolic to the diastolic pressure in pneumonia is of very great importance in deciding on the proper treatment. In one instance the blood pressure must be lowered; in the other, the heart must be stimulated.

While tobacco, in ordinary conditions, raises the blood pressure, after the heart has been seriously injured by the nicotin, the blood pressure is likely to be found lower, and such patients are quickly benefited by the withdrawal of the tobacco and the administration of digitalis.

Anemia almost invariably causes low blood pressure. Also in a patient who has hypotension without any distinct evidence of disease, especially if there has been any possible exposure to tuberculosis, that disease should be suspected and every test made to eliminate such a cause.

Serious cachexia, such as that caused by carcinoma or other growths, gives low blood pressure. Diabetes causes low blood pressure, provided there are no nephritis and no marked suprarenal stimulation.

Excessive use of alcohol, while tending to promote hypertension by the disturbances that it causes, may give, by causing a weak heart muscle, a permanent low blood pressure. A single large dose of alcohol always lowers the blood pressure.

Arteriosclerosis frequently reaches a stage when the blood pressure is low, and with atheroma of the arteries of the arms a true blood pressure is difficult to obtain. Addison's disease, or any other organic lesion of the suprarenals, will lower the pressure, while stimulation of the suprarenals increases the pressure. Any great drain on the system, whether from diabetes without nephritis, or from profuse diarrhea of any type, will cause hypotension. Occasionally a girl with chlorosis who is not menstruating may have an increased blood pressure. Many of the hemorrhagic or purpuric conditions will show a hypotension.

Meningitis in various forms may show a hypertension from cerebral and nervous irritation. Neurasthenic patients quite generally have hypotension, although occasionally with suprarenal disturbance they may have an increased tension.

In the hypotension of surgical shock and in shock during anesthesia, Henderson's findings [Footnote: Henderson: Am. Jour. Physiol., 1910, xxvii, 158.] that hyperoxygenation and insufficient carbon dioxid may be partially responsible for the condition should be remembered, and it has long been known that carbon dioxid congestion, as caused by laughing gas anesthesia, for instance, increases the blood pressure.

A systolic pressure of 110 mm. or lower in an adult should be considered hypotension, anything below 105 mm. calls for treatment, and a systolic pressure of 100 or lower in an adult calls for rest from all active duties.

These patients are weary, they have mental and physical tire, may get short breathed, may have palpitation of the heart, and often have headaches and dizziness from imperfect circulation in the head. There may be edemas of the legs and ankles toward night. If such patients have the systolic blood pressure raised even a small amount, or if the diastolic pressure, which is very low, is raised even a small amount, they immediately feel better.

If the kidneys are normal, they should have meat as part of their diet. If they are not nervous and irritable, coffee and tea should be allowed, except at the evening meal. While sleep may tend to lower pressure somewhat, these patients' hearts require a long bed rest; in other words, they should go to bed at an early hour. They should rise early, however, in the morning, and, as recommended by Goodman, [Footnote: Goodman: Am. Jour. Med. Sc., April, 1914, p. 503.] they should perform mild calisthenic exercises before dressing.

The increased muscle tone thus caused raises the blood pressure somewhat, and the great depression before breakfast is not experienced. These patients rely oil their morning coffee for bracing. If they have much indigestion at night which keeps them awake so that they do not get good comfortable rest, their largest meals should be the morning and noon meals, and the evening meal should be very light.

Pendent abdomens or ptosed abdominal organs should be held up by proper abdominal bandages or corsets.

If the bowels are constipated, only the vegetable laxatives should be used, if it drug is needed at all. Salines should not be allowed, or other cathartics which cause profuse watery discharges. If a brisk purge is required, castor oil is the best.

Plenty of fresh air, and mild exercises in the open air all tend to increase the pressure. Graded walking, climbing, or other more interesting exercises are advisable, as all tending to raise the pressure, provided that at no time are they carried to the point of exhaustion.

Forced feeding may be useful. Cool sponging in the morning, if there is proper reaction, is often of benefit. Iron may be indicated; bitter tonics may be indicated. Digitalis and strychnin are often of advantage. Caffein may be used as a drug as well as given in coffee and tea. Atropin may be of value in some forms of hypotension.

At times with a low systolic pressure, but a relatively high diastolic pressure, nitroglycerin is valuable.

More or less actite hypotension may occur in hot weather or with overheating, often termed heat exhaustion. Such patients should, if possible, go to a cooler region, whether to the seashore or to the mountains is unimportant. The treatment of dangerous sudden low blood pressure, as shock, will be discussed elsewhere.



PERICARDITIS

ACUTE PERICARDITIS

As this inflammation is generally secondary to some other condition, its treatment cannot be positively outlined. Furthermore, it is often a terminal condition, and in such instances the results of treatment are of necessity nil. The most frequent terminal cause is nephritis; other terminal causes are pulmonary tuberculosis, adjacent abscesses, cancer or other growth.

The most frequent infectious cause is rheumatism; other infectious causes are cerebrospinal fever, typhoid fever, acute miliary tuberculosis, pneumonia and Sepsis. Accidental causes are traumatism and an adjacent inflammation of the pleura.

The result of an inflammation of the pericardium may be a fibrous exudate, or an exudate which is both serous and fibrous, or one in which pus is present in considerable amount.

The onset of pericarditis may be more or less acute, or it may commence insidiously. For this reason, during severe illness, and especially in those diseases which are known to have pericarditis often as a sequence, frequent examination of the heart should be made as a routine procedure.

SYMPTOMS AND SIGNS

If there is pain or much aching in the cardiac region, it tends to disappear with the exudate, if such is to occur, in the same way as does the pain of pleurisy. If there is much exudate, the pressure on the heart of course increases, the cardiac dulness enlarges, dyspnea occurs and even perhaps later cyanosis. As the exudate accumulates, the patient must lie higher and higher in order that the fluid may gravitate to the lowest part of the sac and give the heart the greatest ability to work. Reflex pain may occur from disturbances of the pneumogastric nerve, or from the weight and pressure of the enlarged and heavy pericardium. Reflex vomiting may be a troublesome and distressing symptom.

Acute pericarditis occurring in rheumatism, in acute infections, and from simple injuries tends to recovery. In dry pericarditis with serious adhesions, or if adhesions occur as a sequence of acute pericarditis, the future prognosis is bad, as myocarditis may develop and sudden death or acute dilatation may occur. As stated above, if pericarditis develops during the progress of chronic disease, such as interstitial nephritis, or during sepsis, or from abscesses or growths in the region of the pericardium, the prognosis is bad.

TREATMENT OF ACUTE PERICARDITIS

In acute pericarditis, absolute mental as well as physical rest is essential. Even if the patient does not appear to be seriously ill and has not much fever, he should not be allowed to have visitors, to discuss business matters, or to carry on any conversation, however little exciting. Anything which increases the heart beat increases the irritation of the inflamed surfaces of the pericardium. He should not be allowed to sit up, either to eat or to attend to the calls of Nature. These rules are imperative, and when they are followed the pain is less, the heart beats less rapidly, is less hampered by pressure from whatever exudate may be present, and the adhesions which are liable to form will be less in amount and less serious for the future work of the heart.

The treatment, of course, depends largely on the cause of the pericarditis, as, if the cause is one of those just enumerated in which the prognosis is dire, any treatment directed toward the pericardial inflammation is almost useless. The periearditis under these conditions will be more or less benefited, if at all affected, by the treatment directed toward the cause.

The indications for treatment in all other instances are:

1. To attempt to abort the inflammation.

2. To stop the pain.

3. To limit, if possible, the amount of exudate, and to diminish the exudate already present.

4. To diminish the rapidity of the heart and to strengthen it.

1. Abortive Treatment.—For many years bloodletting was considered of the greatest importance in the early treatment of this disease; but owing to the fact that, except from traumatism, pericarditis rarely occurs except as a sequela of acute disease after the patient has been sick along time, or as a terminal condition in a patient who has long been chronically diseased and therefore has already lost more or less strength, venesection has been nearly abandoned. Leeches may be used over the region of the pericardium, and cups are sometimes used. Dry cupping is more frequently used. These measures sometimes seem to reduce the inflammation, and certainly often relieve pain, but the most valuable local treatment is cold, which may be applied either in the form of an ice bag or by a small coil through which ice water is caused to flow by siphonage. Cold may be applied more or less continuously, depending on the sensations of the patient. The bag or ice cap must not be overfilled and must not be heavy, as the patient often cannot stand pressure over the pericardium. Sometimes the relief from pain and the diminution of the number of the heart beats is marked, and for this reason alone the cardiac inflammation may be inhibited. If cold applications are not tolerated by the patient (and they often are not in children) warm applications may be used, such as an electric pad or cloths wrung out of hot water and covered with oiled silk, and the pain will often be relieved thus. While hot applications would not tend to abort the inflammation, they probably do not tend to promote it.

A diminished diet, of small amount at a time, and such purging as the patient's strength will allow are essential in attempting to hasten recovery.

Just what can be done locally or generally to combat the inflammation actively must depend on the cause. When the inflammation occurs as a complication of acute rheumatism, it has been suggested that salicylates, which arc not inhibiting rheumatism and may be depressant to the heart, should be stopped if they are being administered; but if the salicylates are apparently improving the inflammation in the joints, pericarditis would not contraindicate their continued use. Except in large doses, salicylates probably do not depress the heart. In pericarditis it is perhaps well always to administer an alkali in some form unless otherwise contraindicated, whether or not the cause is rheumatism. A diminished alkalinity of the blood would always increase the likelihood of an augmented amount of pericardial or endocardial inflammation. The blood must be kept strongly alkaline. It is possible that one of the reasons why pericarditis or endocarditis occurs so frequently in serious prolonged fevers is that the patient has not eaten enough cereals or other carbohydrates, and the system has become more or less endangered by acidosis. Carbohydrate starvation is inexcusable with our present understanding of the danger from acideinia, and even from a diminished amount of alkalies in the blood.

The cause of pericarditis being so varied, any anti-toxin treatment or any vaccine treatment could be indicated only if the cause of the inflammation rendered the serum or vaccine advisable.

2. Stopping the Pain.—Nowhere else in the body should pain be so speedily combated as when it occurs in the region of the heart. Morphin, with or without atropin, as deemed best, should be administered hypodermically in the amount and with the frequency necessary to stop the pain and quiet the restlessness. As stated above, the frequent need for morphin may be prevented by use of the ice bag. Morphin might even be considered an abortive treatment, as nothing tends so much to inhibit this inflammation as the quietude of the heart caused by the absence of pain, the production of sleep and the prevention of restlessness, muscle twitching and muscle movements. The more quiet the patient is, the more quiet is the heart.

If for any reason morphin is contraindicated, and if pain is not a symptom, the patient's nerves may be quieted and rest may be given by sodium bromid, or by veronal-sodium, the dose of the former being 2 gm. (30 grains) two or three times in twenty-four hours, according to its action and the necessity for it, and the dose of the latter 0.2 gm. (3 grains) once in six hours, if deemed necessary.

Especially if there are cerebral symptoms, as typically presented in cerebrospinal meningitis, and especially if the arterial tension is low, the subcutaneous administration of an aseptic ergot will quiet the central nervous system, increase the blood pressure, quiet the heart, and prolong the action of a single dose of morphin. It is the best plan to administer ergot deep into the muscles, with the deltoid as the place of choice. If the skin is properly cleansed, the syringe clean and the preparation of the drug aseptic, no inflammation or abscess will ever occur. If there is any painful swelling, a wet alcohol dressing to the part will soon relieve it. The frequence with which ergot should be so administered depends on the results and the indications. Once in twelve hours for several doses is generally the best method for its use.

3. The Exudate.—When a fluid exudate into the pericardium has occurred from inflammation that is, when it is not an exudate from disturbed kidneys or circulation—it will continue to increase to some extent in spite of any treatment. Just how much this exudate may be prevented by the use of small blisters over or around the heart, and just how much watery stools and diuresis may prevent the advance of the exudate is difficult to determine. Small blisters, properly applied, have many times seemed to be the determining factor in stopping the increase in the fluid, or to have been the starting cause of the resorption of the exudate.

The amount of purging that should be caused by saline cathartics such as sodium sulphate (Glauber salt), potassium and sodium tartrate (Rochelle salt), or the official compound jalap powder cannot be declared dogmatically. Saline purging should be governed by the character of the circulation. If the heart is strong, the pulse not weak, and the blood pressure good, nothing is more valuable in this condition. Portal depletion is of great advantage, especially if the amount of liquid ingested is kept as low as possible, so that the blood vessels may become thirsty and thus tend to absorb an exudate wherever they find it. Much harm has been done, however, and death has been caused by saline purgatives in endeavoring to relieve edemas from a failing heart or to prevent a uremia from kidney inflammation. The depression following such purging is often serious. If the circulation is weak, dependence should be placed on purgation by some of the simple vegetable cathartics or a small dose of calomel. While it is advisable to give a saline in concentrated solution, it should not be so strong as to cause vomiting. With our better understanding of magnesium absorption and the depressant effect of magnesium on the nervous system, magnesium salts should not be used in serious conditions.

Diuretics often do not act well when most needed. The simplest diuretic is potassium citrate, given in wintergreen or peppermint water, in doses of 2 gm. (30 grains), three or four tunes in twenty- four hours. One or more of the vegetable, nonirritant diuretics may be tried if preferred. If the sickness preceding the pericarditis was not a long fever, and the heart muscle is considered in good condition, digitalis in small doses may be the best possible diuretic. Incidentally it will slow the heart, if there is not much elevation of temperature, and will give some cardiac rest.

Although the patient's diet should be limited in bulk, and especially in amount of liquids, good nutrition should soon be given. Systemic weakness certainly tends to increase the exudate; systemic strength aids in absorption of the exudate.

Iron is early indicated, and nothing is better than 5 drops of the tincture of chlorid of iron in a little lemonade or orangeade, administered once in eight hours.

If the exudate tends to decrease, it perhaps may be hastened by the local application of tincture of iodin over the cardiac region. Also the administration of small doses of an iodid, as 0.3 gm. (5 grains) of sodium iodid, given in plenty of water three times a day, is useful. An iodid circulating in the blood seems to aid absorption. It has long been believed that iodin in the blood tends to promote absorption of thickened, left-over material from exudates, and to prevent the formation of strong fibrous adhesions. Until our knowledge is more exact in this matter, it is advisable to use iodid as suggested. If the above-named dose is not tolerated, less should be given.

If in spite of all the therapeutic measures suggested, the fluid increases and the pericardium becomes more distended and the heart's action more labored, paracentesis must be done. The point at which the aspirating needle should be inserted into the pericardium depends somewhat on the conditions in each individual case. It is often best to insert an exploratory needle first. This will determine the fluidity and character of the exudate. If pus is found, a more radical surgical procedure than simple paracentesis must be done immediately. The point of puncture for aspiration most frequently chosen is in the fourth or fifth intercostal space, about an inch to the left of the sternal margin. Paracentesis is also often done in the region of the normal apex beat. The position of the patient is determined by his dyspnea; he should lie in the position most comfortable for him. The fluid should be withdrawn slowly and the pulse carefully watched. The withdrawal of a small amount of fluid may later seem to be the starting cause of resorption of the rest of the fluid. On the other hand, it may often be not of more value than the simple removal of the immediate pressure, the fluid may again accumulate, and more radical surgery must be performed.

4. To Strengthen the Heart.—Most of the methods of meeting this indication have already been stated, namely, absolute rest; absolute quiet; the use of the bed pan; any movement that must be made should be deliberate; the nurse and other attendants must be quiet; necessary conversation must be brief, and every method must be used to quiet and prevent the heart's action from becoming rapid. The food taken should be small in amount and nonstimulating; that is, no tea or coffee should be given, and nothing too hot or too cold. Movements of the bowels should be caused with the least possible general disturbance. If the patient does not sleep, he must be made to sleep. The whole body and the nervous system must have periods of rest. If the heart is very weak, small closes of morphin may be used. If the heart is not weak, bromids or chloral may be given. If the blood pressure is high, such hypnotics will lower it, or if the heart is strong and the condition does not contraindicate it, aconite may be used in small doses, for a day or two, unless the fever is high and it seems advisable to use one of the coal-tar antipyretics, which reduce the blood tension and the heart activity.

As stated above, pain must not be allowed. Sometimes, when the heart has not been injured by prolonged fever, digitalis in small doses may slow the heart and act for good.

Convalescence.—The convalescence should be prolonged as in any other cardiac inflammation. The patient should be given more and more nourishing food, and the iron tonic may be changed to a capsule containing 0.05 gm. of quinin and 0.05 gm. of reduced iron, three times a day.

It is a question as to when patients convalescent from pericarditis should be permitted exercise. It has been thought that gentle movements and possibly exercise, sooner than theoretically justified, might cause the heart to beat a little more actively and possibly prevent the formation of tight adhesions between the two layers of the pericardium. Whether such activity of the heart will prevent adhesions is something that has not been determined.

The small doses of sodium iodid, perhaps 0.2 gm. (3 grains) two or three times a day, should be continued for some time. Iodid in this dosage does no harm and may do a great deal of good.

ADHERENT PERICARDITIS

Following dry pericarditis or pericarditis with an exudate, especially when the exudate is fibrinous in character, the fibrous substance which is not absorbed or resorbed may develop into connective tissue, and the two pericardial surfaces become permanently grown together, causing the so-called adherent pericarditis. These adhesions between the two surfaces of the pericardium may be general throughout the entire pericardial sac, or they may be limited to some one or more parts of the pericardium. Perhaps one of the most frequent points of adhesion is the anterior part of the pericardium, while the apex is the part most likely to be free, even when other parts of the pericardium have grown together. This freedom of the apex is probably due to the constant and more extensive motion of the apical portion of the heart, and is the reason that it has been suggested, as referred to under acute pericarditis, that, other conditions not contraindicating, the patient may be allowed to move about a little during convalescence to cause the heart to beat more actively. Sometimes the surfaces of the pericardium are not closely adherent to each other, but bands of adhesion stretch from one surface to the other.

After adhesions have taken place between the two layers of the pericardium, the action of the heart is impaired, serious interference with the cardiac action may develop, and sudden death may occur. If the heart is given all the rest possible during the acute phase of the disease, there will be less likelihood of the surfaces becoming so irritated that adhesions readily form. Anything which permits complete absorption and resorption of tile exudate will tend to prevent these hampering adhesions. If the adhesions are such as to cause irregular heart, recurrent pain and the danger of sudden death, surgical help has been suggested. This surgical procedure is to remove a portion of the ribs, perhaps of the third, fourth and fifth, to allow the heart more freedom of action to compensate for the impairment of its activity from the adhesions. Such an operation was first suggested by Brauer of Heidelberg in 1902.

The question of the best method of producing anesthesia in this condition of the heart is a serious one. A patient might die during the anesthesia; but he might also die at any time from cardiac spasm. In certain instances, in adults, local anesthesia might be sufficient. Pain reflexes, however, would be serious. Such an operation would be indicated when the apex is fixed so that there is a constant sensation of hugging of the heart at the fourth and fifth ribs, with paroxysms of pain and cardiac weakness.



MYOCARDIAL DISTURBANCES

While the myocardium is the most important muscle structure of the body, it has but recently been studied carefully or well understood clinically or pathologically. A heart was "hypertrophied" or "dilated" or perhaps "fatty." It suffered from "pain," "angina pectoris," from some "serious weakness" or from "coronary disease," and that ended the pathology and the clinical diagnosis. This is the age of heart defects; no one can understand a patient's condition now, whatever ails him, without studying his heart. No one can treat a patient properly now without considering the management of the circulation. No one should administer a drug now without considering what it will do to the patient's heart.

Although we are scientifically interested in the administration of specific treatments, antitoxins and vaccines; although we have a better understanding of food values, and order diets with more careful consideration of the exact needs of the individual, and although we are using various physical methods to promote elimination of toxins, poisons and products of metabolism, we have until lately forgotten the physical fact that one thirteenth of the weight of a normal adult is blood. A man who weighs 170 pounds has 13 pounds of blood. This proportion is not true in the obese, and is not true in children. Whether the person is sick in bed, miserable though up and about, or beginning to feel the first sensations of slight incapacity for his life work, his ability properly to circulate this one thirteenth of his weight through the various arterial and venous channels and capillary tracts must, with the increasing tension and speed of our lives, be taken into consideration.

The more and more frequently repeated statements that the operation was successfully performed but that the patient died of shock, and that the typhoid fever and the pneumonia were being successfully combated, but that the patient died of heart failure, together with the increase in arteriosclerosis, cardiac disturbances and renal disease, emphatically present the necessity of more carefully studying the circulation. A better understanding and the constant study of the blood pressure shows nothing but the necessity of the age. The unwillingness of the patient to suffer pain, even for a few minutes, without some narcotic, generally a cardiac debilitating drug, means that, if he is a sufferer from chronic or recurrent pain, he has taken a great deal of medicine which has done his heart no good. Repeated high tension of life raises the blood pressure and puts more work on the heart. Therefore the heart is found weary, if not actually degenerated, when any serious accident, medical or surgical, happens to the patient.

The requirements of the age have, then, necessitated that the heart be more carefully studied, and therefore the heart strength and its disturbances are better understood. The mere determination as to where the apex beat is located, and as to what murmurs may be present is not sufficient; we must attempt to determine the probable condition of the myocardium. The following conditions are recognized: (1) acute myocarditis, (2) chronic myocarditis (fibrosis, cardiosclerosis), (3) fatty degeneration, and (4) fatty heart.

ACUTE MYOCARDITIS

Probably most acute infections cause more or less myocarditis, depending on their intensity and their prolongation. This disturbance of the heart is often unrecognized, and has been simply referred to as "the heart growing weaker from the fever process." The acute infections most likely to cause a myocarditis are rheumatism, influenza, sepsis, cerebrospinal meningitis, diphtheria, typhoid fever, scarlet fever, and mouth and throat infections. It is probably rare when acute endocarditis occurs that more or less myocarditis is not present. The acute myocarditis may develop some fatty degeneration, and with this softening and weakening of the heart muscle acute dilatation readily occurs, which may be a cause of sudden death, or, if less serious, may be the cause of prolonged disability, if the heart ever recovers its original size and strength.

The symptoms are often indefinite, and the diagnosis of the condition hardly possible. It may be taken for granted, however, that hardly any serious illness can long continue without cardiac muscle disturbance. If endocarditis is present, soft systolic murmurs soon appear. With the acute myocarditis developing, the apex beat is less positive, less accentuated, and later it becomes diffuse and even feeble. The closure of the aortic valve is less typically sharp, showing that the blood vessels are not so thoroughly filled. The peripheral circulation is not so active, the blood pressure falls, and the heart becomes more rapid, especially on the least exertion. All of these signs indicate myocardial weakness.

The treatment of this condition is largely preventive. It should be well recognized that prolonged high fever, prolonged insufficient or improper nutrition, prolonged acute pain, and especially prolonged septic processes will always cause myocardial degeneration. It should be recognized that after ether and chloroform anesthesia, especially after chloroform, the heart muscle may be disturbed and the tonicity be lost. Therefore after anesthesia, after operations, and after all illnesses which have lasted more than a few days, the convalescence of the patient must be more or less deliberate. Sudden rising, sudden erect posture, the exertion of walking too early, going up stairs too early or taking moderate, and later severe exercise too early, may cause dilatation of the heart muscle that has become weakened by acute myocarditis. If acute myocarditis is believed or known to be present, cardiac tonics such as digitalis should not be given; large doses of strychnin should not be given; vasocontractors such as ergot should not be given; large amounts of food or large bulks of liquid should not be taken into the stomach at one time; in fact, unless there is some special indication, the twenty-four hour amount of fluid should be diminished. The surface circulation and the muscle circulation should be improved by such cold or warm water applications as the disease or condition calls for. Massage should be early inaugurated to promote the return circulation. The heart should be treated as though it were the frailest of Venetian glass and would crack with the least rough handling, or even with a rapid change of temperature, great cold or too much heat. A prolonged, tedious convalescence, with the return to activity so graded as to give the heart no strain, and to keep its work always just below what it is able to do, will often mean return to perfect strength and health.