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Category: Uncategorized
Source: 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

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

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

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.

Next: Drugs In Hypertension

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