Treatment


Categories: Uncategorized
Sources: Disturbances Of The Heart

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.





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