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Categories: Uncategorized
Sources: Disturbances Of The Heart

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 fai
ure. 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


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


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


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


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.