Cardiovascular Renal Disease


Categories: Uncategorized
Sources: Disturbances Of The Heart

With the strennousness of this era, this disease or condition, which

may be regarded as one of the accompaniments of normal old age, has

become of grave importance, and nowadays frequently develops in

early middle life. If it is diagnosed in its incipiency, and the

patient follows the advice given him, the progress of the disease

will generally be inhibited, and a premature old age postponed.



In the beginning the symptoms and signs of this disease are

generally those of hypertension, and the treatment and management is

that advised in hypertension. If the kidneys show irritation, as

manifested by the presence of albumini and casts in the urine, or if

they show insufficiency in the twenty-four-hour excretion of one or

more salts or other excretory product, the diet and life must be

more carefully regulated than advised in hypertension, and the

treatment becomes practically that of chronic interstitial

nephritis.



Sooner or later, in most instances of this disease, whether

hypertension, chronic endarteritis or interstitial nephritis or any

combination of these conditions is most in evidence, the heart will

hypertrophy. As long as the circulation in the heart itself is good

and not impaired by coronary sclerosis, and as long as this slowly

developing chronic myocarditis has not advanced far, cardiac

symptoms will not be in evidence; but if these conditions occur, or

if the blood pressure is so greatly increased as to damage the

aortic valve or strain and dilate the left ventricle, symptoms

rapidly appear, and the heart must be carefully watched.

Subsequently, as the disease advances, if the patient does not die

of angina pectoris, apoplexy or uremia, the symptoms of cardiac

decompensation will develop. As the heart begins to fail, a

dilatation of the right ventricle causes passive congestion of the

kidneys, and the chronic interstitial nephritis may progress more

rapidly. It is often difficult to decide which is more in evidence,

heart insufficiency or kidney insufficiency. The more the heart

fails, the more albumin will generally appear in the urine, and the

lower the blood pressure, especially the diastolic. The more

insufficient the kidneys, the higher the blood pressure, especially

the diastolic. The location of the edema will aid in deciding which

condition is most in evidence. If the edema is pendent in feet, legs

and perhaps genitals when the patient is up, with its disappearance

at night, and more or less backache and pitting of the back in the

morning, it is the heart that is most rapidly failing. If there is

more general edema, the hands and face puffing, and there are

considerable nausea and vomiting, headache and drowsiness, and

perhaps muscular twitchings, with neuralgic pains, the most serious

trouble at that particular time lies in the kidney insufficiency.

Kisch [Footnote: Kisch: Med. Klin., Feb. 27, 1916.] sums up the

procedural symptoms and signs of cerebral hemorrhage. The heart is

generally enlarged and hypertrophied. The patient is likely to be

overweight or adding weight, and to suffer from intestinal

indigestions. Signs of sclerosis of the blood vessels of the brain

are evidenced by transient dizziness; headaches; impaired sleep;

loss of memory, especially for names and words; slight disturbances

of speech, momentary perhaps, and more or less temporary localized

numbness of the hands or feet, or arms or legs, with perhaps

flushing of some part of the body, or little localized spasms of

vessels of other parts of the body, causing chilliness.



There is also a marked hereditary tendency to apoplexy.



Cadwalader, [Footnote: Cadwalader, W. R.: A Comparison of the Onset

and Character of the Apoplexy Caused by Cerebral Hemorrhage and by

Vascular Occlusion, The Journal A. M. A., May 2, 1914, p. 1385.]

after considerable investigation, has come to the conclusion that

large hemorrhages into the brain are the rule in apoplexy, and that

small hemorrhages are rare, and he is inclined to think that even

small, as well as large hemorrhages, are more frequently fatal than

supposed. In other words, he thinks that many of the nonfatal

hemiplegias are caused by vascular obstruction and softening and not

by hemorrhage. He finds that sudden death, or death within a few

minutes, does not occur from hemorrhage, even if the hemorrhage is

large, though a rapidly developing and persistent coma usually

indicates a hemorrhage. If the coma is not profound and is slow in

its onset, with symptoms noticed by the patient, and cerebral

disturbance, he believes it to be caused generally by softening of

the cerebral center, due to some obstruction of the blood flow, and

not to hemorrhage. While occasionally a slowly increasing loss of

consciousness may be due to hemorrhage, he thinks it is doubtful if

real hemorrhage ever occurs without loss of consciousness, while

softening of some part of the cerebrum may occur without

unconsciousness. He thinks that the size of the hemorrhage is of

more importance than its situation in causing the profoundness of

the symptoms, but he repeats that nonfatal cases of hemiplegia are

generally caused by vascular occlusion and subsequent softening, and

not by hemorrhage.





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