COLUMBIA LIBRARIES OFFSITE 
 
 HEALTH SCIENCES STANDARD 
 
 . II I lilllllllllll 
 
 HX6413 262 
 RC669.B54 1907 Heart disease and bl 
 
 RECAP 
 
 flEART DISEASE 
 
 and 
 
 BLOOD PRESSURE 
 
 L. F, BISHOP 
 
 Ji If' 
 
Columbia ©nitiersitpx^Qi. 
 
 intf)eCitpofi5eto|?orfe 
 
 COLLEGE OF PHYSICIANS 
 AND SURGEONS 
 
 Reference Library 
 
 Given by 
 
 ^A'V^ \\o\D\^'^o*t^ 
 
 ^^ \ 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/heartdiseaseblooOObish 
 

 
 ji/ .i^'-s^t-r^s, ^^n ^ #«!— e.-«-»^- 
 
 HEART DISEASE 
 
 AND 
 
 BLOOD-PRESSURE 
 
 4. 
 
 ^ Practical Consideration of Theory 
 
 and 
 Treatment 
 
 BY 
 
 LOUIS FAUGERES BISHOP, A. M., M. D. 
 
 Clinical Professor of Heart and Circulatory Diseases, Fordham Univer- 
 sity, School of Medicine, New York City j Physician to the 
 Lincoln Hospital j Late Chairman of the Section on 
 Medicine of the New York Academy of Medicine j 
 Member of the New York Pathological Society j 
 the Neurological Society ; Alumni Asso- 
 ciation, St. Luke's Hospital, etc. 
 
 SECOND EDITION 
 
 mew lorft 
 
 E. B. TREAT & COMPANY 
 
 241-243 West 23d Street 
 1907 
 
COPYRI.GHT 
 
 By e. b. treat & CO. 
 
 1904 and 1907 
 
PREFACE TO SECOND EDITION 
 
 During the four years that have elapsed 
 since the first edition of this book was written 
 a wide interest in the subject has developed, 
 and the concentration of the work of the 
 author on the heart and circulation as a spe- 
 cialty has resulted in certain further conclusions 
 which he is anxious to submit to the judgment 
 of those who received so kindly the first 
 edition. In a chapter on "The Vessel Tone- 
 maintaining Function of the Central Nervous 
 System" will be found a physiological doctrine 
 which does not appear in the literature of the 
 day but which would seem the key to the ex- 
 planation of a large number of cases. Read- 
 ing with this theory in mind, it has often 
 seemed that an author must have had the idea 
 in view but not quite clearly enough to state 
 
4 PREFACE 
 
 it. The chapter on "Hypertonia Vasorum 
 Idiopathica'' is a discussion of the cHnical ap- 
 pHcation of the theory to an important class of 
 cases. The title of the book has been slightly 
 changed, because it was found that "Blood- 
 Pressure" alone conveyed the idea only of 
 laboratory physiology while in fact the book 
 was taken up with the consideration of cases 
 that are popularly called "heart disease." 
 
 The author has been much gratified by the 
 attention given to his classification of disorders 
 of blood-pressure and by the frequent reference 
 by writers on blood-pressure to the condition 
 described by him in a paper reprinted on pages 
 87-90 describing "Constitutional Low Arterial 
 
 Tension.'* 
 
 L. F. B. 
 
 No.~54 West 55th Street 
 
 New York , 
 
PREFACE 
 
 The publication of a treatise on blood-press- 
 ure at a time when so much has been learned, 
 and so many books are appearing on the sub- 
 ject, demands a note of explanation. 
 
 My excuse is that for the past fifteen years, 
 indeed, ever since as an hospital interne I first 
 came in contact with patients suffering from 
 serious disease in which the circulation was 
 involved, the question of the vital relations of 
 the physics of the circulation has been one of 
 the most interesting problems that has con- 
 stantly presented itself in the domain of clinical 
 medicine. During this time the care of pa- 
 tients suffering from those diseases and condi- 
 tions in which the fight for life was a contest 
 with progressive circulatory failure, has formed 
 a serious part of my work. 
 
a PREFACE 
 
 It IS a fact that is constantly appearing in the 
 hterature of the day, that circulatory disease, 
 as represented in statistics of disease of the 
 heart and disease of the kidneys, is relatively 
 more frequent than formerly. It is undoubtedly 
 true that under the strain of modern life, many 
 other causes of disease having been eliminated, 
 disorders of the circulation dependent upon 
 altered blood-pressure have become very im- 
 portant. 
 
 Just as tuberculosis has for its victims the 
 most attractive of the youth of the land, so 
 high arterial tension claims the best and most 
 successful of those past middle life who have 
 borne the weight of the strenuous demands of 
 a modern career. Much attention is now being 
 directed to tuberculosis because its cause and 
 progress have become a matter of public knowl- 
 edge. The victims of circulatory disease, how- 
 ever, still too often go for months and years 
 without intelligent treatment because no one 
 has pointed out to them the danger signals and 
 
PREFACE 7 
 
 the signboards which point to the destruction 
 to which they are tending. 
 
 Admirable as is the work of the rescue of 
 the young, who may or may not become citi- 
 zens of marked usefulness, how much more 
 important to the community is it if some years 
 can be added to the career of the mature and 
 trained worker. 
 
 The subject of the mechanical measure- 
 ment of the actual pressure in the vessels has 
 not been considered, as that is so well discussed 
 in other works, and it was here wished to 
 emphasize the clinical relations of blood-press- 
 ure as interpreted in the light of clinical 
 experience. There is an over-respect in these 
 days for so-called scientific zvork, wrongly 
 limiting the term to that which is in some 
 way connected with a laboratory and apparatus. 
 This is a narrowness of recent times. There 
 are many sciences besides mathematics, ex- 
 perimental biology, and chemistry, and if 
 clinical workers yield the field of medicine 
 
8 PREFACE 
 
 entirely to the so-called research workers and 
 the laboratory men, there is certain to be a 
 halt in the progress of the art of medicine as it 
 bears upon the wise management of the in- 
 dividual during the course of his life. 
 
 These are the reasons for the publication of 
 the conclusions which are the result of clinical 
 work upon a subject which is being well con- 
 sidered from a mechanical and laboratory point 
 
 of view. 
 
 L. F. B. 
 
CONTENTS 
 
 I, ALfERATIONS OF PRESSURE IN THE BLOOD- 
 VESSELS 13 
 
 Importance of a proper relation be- 
 tween pressure in the arteries, resist- 
 ance in the arterioles, and pressure in 
 the veins; physiologic alterations; the 
 error of comparing the circulation in 
 the body to the passage of water 
 through pipes ; the arterial system as a 
 reservoir ; importance of the considera- 
 tion of the evolution of the circula- 
 tion; the author's classification of cases 
 of circulatory disease. 
 
 II. Primary Low-Pressure Cases ... 22 
 Similar symptoms often produced by 
 anemia and congestion; importance of 
 a proper movement of the blood ; valvu- 
 lar disease as a cause of low arterial 
 tension; weakness and strain of the 
 heart-muscle as a cause of low arterial 
 tension; prostration of the circulation 
 as a cause. 
 
 III. The Management of Primary Low- 
 
 Pressure Cases 27 
 
 Treatment dependent upon the cause 
 of the condition; importance of iron, 
 9 
 
10 CONTENTS 
 
 arsenic, liypernutrition, and exercise; 
 management of valvular cases in their 
 early stage; use of iodid of soda; im- 
 portance of the vitalizing effect of diet 
 and climate. 
 
 IV. High- Pressure Cases . . . ... 32 
 
 Defined as cases in which there is 
 undue resistance in the circulatory path 
 of the blood; term not confined to 
 cases in which high-pressure is always 
 actually present ; high-pressure cases 
 not converted into low-pressure cases, 
 but into secondary low-pressure cases; 
 management of high-pressure cases one 
 of the most important problems of 
 modern times; early indications of this 
 condition often referred to the brain, 
 heart, digestive and other organs. 
 
 V. The Management of High-Pressure 
 
 Cases 42 
 
 The removal of the exciting cause; 
 alcohol not always contraindicated ; 
 hydrotherapeutics discussed; Nauheim 
 treatment; health resorts; importance 
 of vacations and the cultivation of the 
 capacity for the enjoyment of them; 
 the effect of temperament on the prog- 
 ress of high-pressure cases; the drug 
 treatment of high arterial tension not 
 altogether satisfactory; dangers to be 
 anticipated. 
 
CONTENTS 11 
 
 VI. Some Obscure Symptoms of Circulatory 
 Disorder, with a Consideration of 
 Their Significance . . . . .55 
 Head noises in elderly people; slight 
 attacks simulating paralysis; pain In 
 various parts of the body; how dis- 
 tinguished from other pains; conges- 
 tion of the liver; chronic congestion of 
 the lungs; mania; change in disposi- 
 tion; convulsions; the relation between 
 neurasthenia and circulatory disturb- 
 ances. 
 
 VII. The Management of Secondary Low- 
 Pressure Cases 62 
 
 The element of constitutional treat- 
 ment most important; the necessity 
 for a closer study of the therapeutics 
 of these cases; the effect of exercise. 
 
 VIII. General Considerations . . * .68 
 The importance of treatment In the 
 early stages of arterial degeneration; 
 the relation of nature's provision for , 
 heart stimulation and control to the 
 use of cardiac drugs In acute disease; 
 the Importance of considering the ele- 
 ment of vasomotor instability in' esti- 
 mating the significance of irregularities 
 of cardiac rhythm; discussion of the 
 author's views by Dr. Albert Abrams; 
 constitutional low arterial tension; 
 prostration of the circulation. 
 
12 CONTENTS 
 
 IX. The Estimation of Blood-Pressure and 
 THE Use of the Nitrites for Its Modi- 
 fication 95 
 
 Observation of the pulse a matter in 
 which great skill exists not to be entirely 
 supplanted by instrumental determina- 
 tions. 
 
 X. The Blood - Vessel Tone - Maintaining 
 
 Function of the Brain 112 
 
 The vital importance of the tonus of the 
 blood-vessels to life; the great capacity 
 of the dilated blood-vessels; the central 
 nervous control of vessel tonus in the 
 higher animals; the existence of a tone- 
 maintaining function in the human brain 
 analogous to a similar function affecting 
 the voluntary muscles; the relation of 
 this function to the vaso-motor center 
 in the medulla; its importance in clinical 
 medicine. 
 
 XI. Hypertonia Vasorum Idiopathica . -.- :.- 116 
 A disease not formerly recognized as 
 having an independent existence; it 
 attacks the most useful members of 
 society; description of a typical case; it 
 may result in apoplexy, sudden heart 
 failure, or Bright's disease; medical 
 treatment very important and drugs of 
 great yalue. 
 
HEART DISEASE 
 
 AND 
 
 BLOOD-PRESSURE 
 
 4. 
 
 CHAPTER I 
 
 ALTERATIONS OF PRESSURE IN THE BLOOD- 
 VESSELS 
 
 Presupposing a knowledge on the part of 
 the reader of the systematized facts concerning 
 disease of the heart and blood-vessels, and some 
 actual experience in the treatment and care of 
 patients, we approach the subject of disorders 
 of the circulation from the viewpoint of the con- 
 sulting room and the hospital ward, rather 
 than from that of the library, the pathologic 
 laboratory, and the classroom. 
 
 We find immediately that we have to deal 
 for the most part with slowly developing or 
 long-established conditions. The study of 
 acute disease is of great importance, particu- 
 larly to the beginner in practice who desires to 
 hang an item of experience upon each peg of 
 recently acquired knowledge, but in actual 
 
 13 
 
14 BLOOD-PRESSURE 
 
 practice, on the principle of the greatest good 
 to the greatest number, the attentive study of 
 chronic disease is at least equally necessary. 
 
 Alteration of pressure of the blood in the 
 vessels constitutes the most striking disorder 
 of the general circulation, and upon a study of 
 its causes, effects, and control, will be built 
 this entire consideration of the subject. In- 
 deed, the whole mechanism of the circulation 
 has to do with the maintenance of high-press- 
 ure or low-pressure in one part or another of 
 the vascular system as may be demanded. 
 
 It is easy to see that the maintenance of the 
 circulation is not a question of the degree of 
 tension in any part of the circulatory system, 
 but of a proper relation in tension between 
 pressure in the arteries, where the blood is 
 stored, and the points at which it is needed. It 
 is usual, however, to study the question from 
 the standpoint of the arteries. In most cases 
 it is only late in circulatory disease that venous 
 pressure becomes of importance. The freedom 
 of passage between the arteries and veins 
 through the arterioles and capillaries is of ex- 
 treme importance. 
 
PRESSURE IN THE BLOOD-VESSELS 15 
 
 , In health the physiologic relations of blood- 
 pressure are instructive. The effect of muscu- 
 lar exercise on blood-pressure is at first to raise 
 arterial pressure, but finally after the exercise 
 has been continued for some time, the pressure 
 falls again to normal. The same is true in 
 regard to the effect of mental effort. 
 
 During the existence of this increase of ar- 
 terial pressure due to exercise, there is a large 
 amount of blood in the arteries. This is ob- 
 tained from the large veins in the abdomen, 
 which act as a source of supply from which, in 
 health, blood can be drawn to flush any part of 
 the arterial system. This tide of blood between 
 the digestive organs and the systemic area is 
 illustrated in many ways. Thus, the coldness 
 after eating indicates that the tide has set to- 
 ward the digestive organs. The indigestion 
 following exercise after eating, and even more 
 markedly the indigestion following strong 
 emotion after a meal, shows that the tide has 
 set the other way. The lethargy and mental 
 inactivity of those who habitually overeat, and 
 the tendency to indigestion of mental workers, 
 indicate the same thing. The relation between 
 
16 BLOOD-PRESSURE 
 
 the circulation in the abdomen and the circula- 
 tion in the brain is an intimate one. The 
 proverbially good mental condition in patients 
 suffering from acute peritonitis may very well 
 be due to the spasm of all the abdominal 
 muscles that prevents the accumulation of 
 large quantities of blood in this part of the 
 body. 
 
 The impression of the circulation obtained 
 by one's early study of physiology is erroneous. 
 It resembles too closely the idea of a series 
 of closed pipes, as in the plumbing of a 
 house, the water entering at a large pipe, 
 going through a system of smaller pipes, and 
 after having been used in certain fairly defi- 
 nite receptacles to be collected by a similar set 
 of pipes which convey it to a common outlet. 
 Of course, in a house the circle is not complete, 
 as the water does not again re-enter. In gen- 
 eral, however, that is the conception of the 
 arrangement that is obtained by the average 
 teaching of physiology. ^ 
 
 The facts, however, are very different in the 
 human body. The arterial system is really a 
 reservoir of blood in which the area of a cross 
 
WESSURE m THE BLOOD-VESSELS 17 
 
 s.ection of the combined vessels very rapidly 
 increases from the heart outward. In this 
 series of passages the blood is contained and 
 held under pressure by a muscular envelope. 
 From this reservoir the blood escapes for use, 
 through the arterioles and capillaries, and the 
 office of the heart is to pump into this reser- 
 voir sufficient blood to maintain the pressure 
 depleted by the blood used by the capillaries. 
 This naturally creates a flow of blood from the 
 heart toward the periphery, but the immediate 
 use of the heart is to maintain this arterial 
 pressure. 
 
 This is well shown by the fact that the 
 actual amount of blood propelled by the heart 
 varies greatly, according to the demand for 
 fresh blood on the part of the body. During 
 exercise, when the peripheral vessels are open, 
 and there is a drain on the arterial system, the 
 heart works harder to supply the deficiency. 
 Thus the arrangement and movement of blood 
 in the body are seen to be more like a system 
 of irrigation than of circulation, there being a 
 reservoir with numerous branches from which 
 the irrigating fluid is distributed, and a system 
 
18 BLOOD-PRESSURE 
 
 of conduits by which it is collected to be again 
 transferred to the storage place. 
 
 The idea of the office of the veins as a store- 
 house of blood is a very old one, and one which 
 has had much influence upon therapeutics. 
 The consideration of the arterial system as a 
 similar reservoir in which suitable pressure is 
 maintained by the muscular elements which go 
 to make it up, seems to have been overlooked. 
 The truth of the fact that the arteries form a 
 reservoir rather than mere conduits is shown 
 by the fact that arterial pressure is practically 
 uniform throughout the arterial system. This 
 means that the blood moves with the utmost 
 freedom throughout the arteries, and that the 
 movement of the blood is controlled, not by 
 pressure from behind, but by the escape of 
 blood from in front. 
 
 The arterial system is thus like a reservoir 
 analogous to the tubular boiler of some types 
 of engines. It is a hollow ramifying organ 
 containing a vital fluid, the capillaries being the 
 ducts. Whenever there is a demand for this 
 vital fluid in any part of the system, the mus- 
 cular covering of the organ contracts, the 
 
PRESSURE m THE BLOOD-VESSELS 19 
 
 arterioles which lead to the proper capillaries 
 dilate, and the demand is supplied. The de- 
 mand upon this organ for the vital fluid is so 
 great that a special mechanism, represented by 
 the heart, conducts the vital fluid from the 
 places where it is manufactured, and the lungs 
 where it is purified, to the high-pressure re- 
 ceptacle from which it is used. 
 
 This conception of the arterial system as a 
 high-pressure receptacle for the blood, is well 
 borne out by a study of the evolution of the 
 circulation in the lower forms of life, where 
 there are first found small interstices in the 
 tissues through which the blood ebbs and flows 
 in an irregular manner. As we ascend the 
 scale the blood is found in more definite re- 
 ceptacles until finally we reach the complex 
 arrangement found in man. 
 
 The action of the vascular system is, on a 
 large scale, not different in principle from that 
 of a secretory gland adapted to the unusual 
 demand for its contained fluid. 
 
 The so-called circulation of the blood was 
 discovered very late in the history of man, and 
 students have become so fascinated with the 
 
20 BLOOD-PRESSURE 
 
 mechanical beauty of the whole arrangement, 
 that they have allowed the mechanical idea to 
 outweigh the realization of a living organism. 
 It is the old truth of the pendulum which has 
 swung too far when once started by Harvey. 
 We need to return a little to the earlier con- 
 ception, which considered more the function of 
 the blood in particular parts of the body than 
 its circulation. 
 
 In all studies of blood-pressure it must be 
 remembered that the blood is subject to the 
 laws of hydrostatics, and that the force of 
 gravity m.ust be discounted. 
 
 There are two great groups of cases which 
 may well be called low-tension cases and high- 
 tension cases, and a third group of secondary 
 low-tension in which there has been a preced- 
 ing high-tension. 
 
 The low-tension cases are all those in which 
 inflammation or degeneration of the heart 
 muscle itself, its envelopes or its valves, has 
 primarily interfered with the blood-propelling 
 function of the heart. 
 
 The high-tension cases are all those in which 
 disorder of the arterioles, due to toxemia or 
 
PRESSURE m THE BLOOD-VESSELS 2l 
 
 other causes, has brought about an unreason- 
 able demand on the part of the system for a 
 high-tension in the arterial reservoir to deter- 
 mine the, proper supply of blood to the tissues. 
 
 It is particularly important from the point 
 of view of practical physicians to distinguish 
 between the two great groups of circulatory 
 disease, both in their early and in their late de- 
 velopment, because there is an essential differ- 
 ence in their management. 
 
 Low arterial tension as a terminal stage of 
 high arterial tension, must, of course, be con- 
 sidered in the light of its development, but is 
 of so great importance that we have studied it 
 by itself. 
 
CHAPTER II 
 
 PRIMARY LOW-PRESSURE CASES 
 
 Disorders of the general circulation are 
 generally first recognized when some particular 
 portion of the body becomes the seat of a 
 marked congestion or anemia. It is under 
 these circumstances that symptoms arise. 
 
 Anemia and congestion often produce symp- 
 toms that are strikingly similar. Delirium may 
 be the result of congestion of the brain, but it 
 may likewise result from anemia. Dyspnea 
 may be an accompaniment of congestion of the 
 lungs, but a deficient blood supply is its most 
 common cause. Acute congestion of the kid- 
 neys causes suppression of urine, while dimin- 
 ished blood supply causes deficiency of secre- 
 tion. 
 
 The effect upon an organ is a matter of the 
 
 proper supply of fresh blood, not merely of a 
 
 greater or less amount of blood being in the 
 
 32 
 
PRIMARY LOW-PRESSURE CASES 23 
 
 vessels of the organ. This explains beautifully 
 the effect of local therapeutics, such as the re- 
 moval of a small quantity of blood, or the insti- 
 tution of some form of counter-irritation, the 
 result of which is to start a stagnant local cir- 
 culation. There is, however, little gain from 
 the treatment of local congestion or anemia 
 without attention to the general circulation in 
 cases where the cause is general. Hence the 
 extreme importance of recognizing which cases 
 are of purely local origin, and which have their 
 origin from the general circulation. 
 
 In this study of the circulation we will not 
 include an extensive consideration of the in- 
 flammatory diseases of the heart, but will con- 
 centrate our attention upon those conditions 
 which we are most often called upon to treat, 
 and leave to the more comprehensive treatises 
 the systematic consideration of the morphology 
 of heart lesions and the discussion of physical 
 signs. 
 
 During the acute stage of valvular disease, 
 in the large majority of cases, circulatory fail- 
 ure does not become a matter of special anx- 
 iety. Low arterial tension usually shows itself 
 
U BLOOD-PRESStJR:fi 
 
 when the patient resumes his ordinary occu- 
 pation. 
 
 The symptoms are practically the same for 
 all forms of valvular lesions, although dif- 
 ferent in degree. Indeed, it is more often an 
 academic than a practical question to decide 
 which valves are at fault. Much more im- 
 portant is the question whether the defect has 
 been properly compensated, and whether this 
 compensation can be maintained. In general, 
 however, it may be considered that in aortic 
 disease the defective circulation is more strik- 
 ingly due to an insufficient supply of blood in 
 the arteries, and in mitral disease to an in- 
 creased pressure in the veins, both resulting in a 
 diminution of the difference in pressure in the 
 arteries and veins, upon which the proper 
 passage of the blood through the tissues de- 
 pends. 
 
 The belief, so firmly held by many, that car- 
 diac disease is usually confined to the left side 
 of the heart is not borne out in practice. The 
 most serious and fatal disorders involve the 
 right side of the heart. This belief that the 
 left side of the heart was almost the sole suf- 
 
PRIMARY LOW-PRESSURE CASES 25 
 
 ferer from heart disease, was founded upon an 
 old pathology which regarded chiefly the val- 
 vular deformities. 
 
 It is true that inflammation and distortion of 
 the valves is almost entirely confined to the 
 left side of the heart, but it is likewise true 
 that both sides sufl:'er equally in the incom- 
 petencies of the valves that come from strain 
 or weakness of the heart -muscle as seen in very 
 many cases of disorder of the circulation. 
 
 The left side of the heart can be markedly 
 deficient in mechanical detail or physical struc- 
 ture, and the patient may get along fairly well 
 until dilatation involving the right side of the 
 heart takes place, with tricuspid regurgitation 
 and its resulting venous engorgement. 
 
 It is necessary to remember that low arterial 
 pressure is only to be regarded as pathologic 
 when it is so little above venous pressure that 
 the tissues and organs are not properly sup- 
 plied with blood. There are instances where 
 the heart is perfectly able and willing to pro- 
 duce more arterial pressure, but the peripheral 
 circulation is so relaxed that it is not needed. 
 
 We get true low-pressure cases when 
 
26 BLOOD-PRESSURE 
 
 the pressure-producing mechanism has failed. 
 These are primary when there has not been a 
 previous over-demand for pressure. 
 
 Low blood-pressure due to general prostra- 
 tion is not to be regarded as a disorder of the 
 circulation except in so far as the circulation 
 fails to respond to demands made upon it. 
 Thus in shock it is the nervous system that is 
 at fault, not the circulatory apparatus. 
 
CHAPTER III 
 
 THE MANAGEMENT OF PRIMARY LOW- 
 PRESSURE CASES 
 
 The indications for treatment in disorder 
 of the circulation characterized by deficiency 
 in pressure in the blood-vessels which is pri- 
 mary in that it has not been preceded by high 
 arterial tension, are simple, though the elabora- 
 tion of the management of each case will tax 
 the judgment and ingenuity of the physician. 
 
 When there is no defect in the valves and no 
 tendency to obstruction in the arteries, the con- 
 dition is usually a weakness of the heart, and 
 much may be accomplished by iron, arsenic, 
 and hypernutrition, by increasing the number 
 of meals, and by outdoor exercise. 
 
 When low-pressure is due to valvular dis- 
 ease we must consider the care of the heart 
 before the establishment of complete compensa- 
 tion, during compensation, and in cases of 
 broken compensation. 
 
 87 
 
28 BLOOD-PRESSURE 
 
 In the early days of a newly acquired val- 
 vular lesion, prolonged rest in bed with the 
 very gradual resumption of a more active life, 
 will enable both the heart and the body in gen- 
 eral to adapt themselves to the new conditions. 
 Of necessity there must be a compensatory 
 hypertrophy, but it is not to the advantage of 
 the patient that the hypertrophy be excessive, 
 hence the desirability of such gradual resump- 
 tion of active work. Until subjective symp- 
 toms and objective signs of defective circula- 
 tion have disappeared, the patient must be re- 
 stricted to a very quiet existence. 
 
 The use of drugs at this time is usually 
 inadvisable, yet in cases of long-delayed com- 
 pensation digitalis may be used. 
 
 When compensation is established and 
 proper pressure in the arteries maintained, 
 these cases may still be classed in the category 
 of low arterial tension because of their tend- 
 ency to this condition, just as we consider 
 cases of Bright's disease as being high-press- 
 ure cases even when the condition is not actu- 
 ally present at the time. 
 
 During the stage of compensation, which 
 
PEIMARY LOW-PBESSURE CASES 29 
 
 may be of long duration, the patient should 
 lead a well-regulated existence — physical over- 
 exertion, mental over-anxiety, and dissipation 
 of all kinds must be avoided. Not only is a 
 quiet life necessary when conscious symptoms 
 are being caused, but also on account of the 
 tendency, without conscious symptoms, to the 
 production of excessive hypertrophy, leading 
 in the end to degeneration. The occasional 
 use, during the stage of compensation, of the 
 iodid of soda as a means of preventing degen- 
 eration of the hypertrophied heart, is a useful 
 procedure even when no other drug therapy 
 seems advisable. 
 
 The treatment of low-tension resulting from 
 ruptured compensation in a valvular case free 
 from the taint of arterial resistance, often con- 
 sists principally in rest in bed with particular 
 care of the alimentary canal, no drugs being 
 used at all. If the attack be more severe, with 
 congestion of the kidneys and edema of the ex- 
 tremities, digitalis should be used for a time. 
 
 It is interesting to note that when a system 
 of treatment has proved applicable to a particu- 
 lar form of disease, very soon its application 
 
30 BLOOD-PRESSURE 
 
 becomes extended to other diseases. The cure 
 of tuberculosis is acknowedged to be a matter 
 of the re-estabhshment of certain forces in 
 the physical economy, the breaking down of 
 which renders the patient susceptible to the 
 disease. 
 
 In the progress of cardiac disease there are 
 many elements that are not unlike the advance 
 of tuberculosis. The term "cardiac ca- 
 chexia " has been applied to a form of this 
 condition accompanied by congestion, but it 
 might well be extended to include the deterio- 
 ration of fiber which leads to failure of the 
 circulatory apparatus. In tuberculosis the con- 
 nection between the cachexia and the disease 
 is so evident that its hygienic management 
 needs no advocate. It is equally true that the 
 progress of circulatory disease is often depend- 
 ent upon nutritional causes, and that the hy- 
 giene of tuberculosis in its demand for fresh air 
 is equally important to the cardiac patient. 
 
 The vitalizing effect of fresh air in these 
 cases will more than counterbalance the dan- 
 gers of catching cold, although care is neces- 
 sary when inflammation or congestion of the 
 
PRIMARY LOW-PRESSURE CASES 31 
 
 kidneys is present. The patient can be trained 
 to sleep with open windows. 
 
 Concerning warm bathing, it seems to be a 
 fact that there is much less danger of taking 
 cold than was formerly supposed. This fear 
 is a tradition handed down from an age when 
 bathtubs were more of a curiosity than they 
 are in modern times. Our ancestors considered 
 the taking of a hot bath before going out, a 
 serious risk. Now, this is something that is 
 done by thousands of people every day without 
 bad results. It seems that the risk of exposing 
 the body to changes of temperature after the 
 bath rapidly diminishes when the patient has 
 become accustomed to regular bathing. 
 
 Low-pressure due to degeneration of the 
 heart-muscle which has not been preceded by 
 hypertrophy is not at all common except in con- 
 nection with acute or chronic general disease. 
 The treatment in these cases is that of the gen- 
 eral disease. But little is accomplished by meas- 
 ures directly influencing the circulation. The 
 same is true of the heart overloaded with fat. 
 Treatment must be hygienic, though the defec- 
 tive heart-muscle demands special precautions. 
 
CHAPTER IV 
 
 HIGH-PRESSURE CASES 
 
 By high-pressure cases in contradistinction 
 to low-pressure cases are meant all those cir- 
 culatory disorders which are characterized by 
 undue resistance in the circulatory path of the 
 blood. It is not necessary, for cases to be 
 classed in this category, that actual high-press- 
 ure should always be present in the blood- 
 vessels. It is enough that there is a tendency 
 toward the necessity for abnormal high-press- 
 ure for the proper circulation of the blood. 
 
 High-pressure cases comprise all instances 
 in which degenerative disease of the blood- 
 vessels or kidneys, or toxemia causing dis- 
 ordered action of the same, and resulting in 
 high arterial tension, precedes or goes hand in 
 hand with the development of cardiac disease. 
 
 Low-pressure cases occasionally become 
 high-pressure cases, as when valvular disease 
 
 33 
 
HIGH-PRESS'URE CASES 33 
 
 of the heart causes secondary Bright's disease. 
 High-pressure cases, however, are not converted 
 into low-pressure cases, as a sharp distinction 
 must be drawn between primary and secondary 
 low arterial tension. 
 
 The management of high-pressure cases, 
 which includes a large proportion of the slowly 
 developed diseases incident to the overwork and 
 luxury of modern times, is relatively more im- 
 portant than that of the low-pressure cases. It 
 is particularly important to detect the earliest 
 development of a tendency to high arterial 
 tension because at this time it is more amenable 
 to treatment. 
 
 Disorder of the general circulation is the 
 great factor which has to do with the limita- 
 tion of life in all persons who escape those 
 causes of death which are more or less acci- 
 dental, so when local disease is eliminated, 
 duration of life depends upon the integrity of 
 the heart and blood-vessels. 
 
 As implied above, in this class of cases the 
 heart, blood-vessels and kidneys go hand in 
 hand, and serious disease of one is not found 
 without involvement of the others. Hence the 
 
34 BLOOD-PRESSURE 
 
 term '' chronic Bright's disease " is frequently 
 used in speaking of these cases. The fact that 
 this law of the co-relation of the heart, blood- 
 vessels and kidneys has been overlooked in 
 the past, has led to much misconception, not 
 only as to disease of the kidneys, but also disease 
 of the blood-vessels and heart. When they are 
 studied together it is found that often the ear- 
 liest indication of disease of the one is found 
 in disorder of the other. Chronic Bright's 
 disease is not essentially a disease of the kid- 
 neys, although in the final catastrophe these 
 organs are often chiefly at fault. Primarily 
 it is a disease of the circulation in which the 
 brain and kidneys, acting as it were as end- 
 organs, first manifest symptoms. 
 
 A case which had been under observation 
 for five years ended fatally by the involve- 
 ment of the circulation of the brain, produc- 
 ing progressive stupor and finally coma, par- 
 alysis, and death. The kidneys at the time 
 were apparently in good enough condition to 
 have functionated fairly well for a much longer 
 time. In this case the greatest care had been 
 exercised in protecting the kidneys by diet, an 
 
filGH-PRESSURE CASES 35 
 
 even temperature, and every other possible 
 means, thus allowing the arterial disease an 
 opportunity for its complete development. 
 The same case, if less carefully guarded, would 
 have progressed by repeated attacks of uremia, 
 to a death by the development of anasarca and 
 exhaustion. We have, then, the paradox that 
 a person may die from Bright's disease with 
 fairly good kidneys, this case illustrating the 
 fact that the brain and the kidneys are both 
 end-organs, and that in particular cases the 
 brain may suffer more than the kidneys. 
 
 This point is important in considering the 
 early symptoms in high-pressure cases. The 
 kidneys are insensitive organs, rarely giving 
 rise to pain, intermittent in their manifesta- 
 tions, and entirely removed from direct ob- 
 servation; for this reason disorder of the 
 kidneys may reach a grave stage before it 
 becomes a matter of consciousness. On the 
 other hand, the brain, as the seat of conscious- 
 ness, is highly sensitive to any interference 
 with its functions. To a certain extent it is 
 also capable of examination through the ob- 
 servation of the fundus of the eye, which is in 
 
36 BLOOD-PRESSURE 
 
 close relationship to the brain. It may be 
 stated that the brain records at all times, in a 
 more or less distinct manner, the condition of 
 the circulation, and a careful study of the 
 symptom-complex soon reveals which dis- 
 turbances of the circulation indicate organic 
 disease of the vessels and early Bright's dis- 
 ease. Attention and observation soon make 
 this symptom-complex of extreme signifi-' 
 cance. 
 
 Even in cases in which chronic Bright's dis- 
 ease follows acute nephritis, the establishment 
 of the chronic condition is characterized by 
 certain detectable vascular changes. In cases 
 of acute nephritis one watches the circulatory 
 system with anxiety, because, when changes are 
 established, the chance of complete recovery is 
 diminished. In acute Bright's disease the 
 heart is temporarily debilitated so that there 
 is often established a blowing systolic murmur 
 at the apex, and the profound anemia and ner- 
 vous phenomena that accompan}^ the disease 
 may lead to other functional disturbances of 
 the circulation. These must, however, be dis- 
 tinguished from the changes that take place in 
 
HIGH-PRESSURE CASES 3V 
 
 the arteries which indicate the transition from 
 subacute nephritis to the chronic general con- 
 dition. The same change sometimes indi- 
 cates the estabHshment of a chronic nephritis 
 in cases of valvular disease of the heart that 
 have been accompanied by prolonged conges- 
 tion of the kidneys. 
 
 Though it is hardly to be supposed that car- 
 diac hypertrophy can be established except by 
 some cause acting for a considerable period of 
 time, still it is often the earliest detectable sign 
 of chronic nephritis. Abnormal arterial ten- 
 sion may for the moment be absent, either on 
 account of treatment or for some other cause, 
 but when physical examination shows distinct 
 cardiac hypertrophy we suspect at once a high- 
 pressure case of circulatory disease. 
 
 It is probable that an increased flow of urine 
 found in early Bright's disease is due as much 
 to increased blood-pressure as to any definite 
 change in the kidneys. Loomis speaks of an 
 increased frequency of urination as an early 
 sign of Bright's disease, and this again may 
 well be accounted for by increased secretion 
 due to increased arterial tension. 
 
38 BLOOD-PRESSURE 
 
 Nose-bleed is another possible result of in- 
 creased arterial tension, and may, therefore, in- 
 dicate the beginning of Bright's disease. An- 
 other accompaniment of increased arterial ten- 
 sion is headache, due apparently to increased 
 vascular tension in the head. 
 
 I would also like to class as one of the early 
 disturbances of high-pressure cases, certain at- 
 tacks of indigestion. These are due at this 
 early stage to disturbances of circulation in the 
 stomach, and are not to be confounded with 
 uremic nausea. 
 
 High-pressure cases more often develop in 
 an atypical than in a typical way, and even in 
 their final fatal course may never present the 
 symptoms that one would expect. The early 
 symptoms are often an unhealthy look, loss of 
 strength, and such disturbances of digestion as 
 may be referred to simple weakness. The 
 urine may only contain albumin at rare inter- 
 vals, so that it would not be detected by any- 
 thing save systematic observation. 
 
 It is fair to say that the early signs of im- 
 pending changes in the blood-vessels also 
 mean the early circulatory changes of Bright's 
 
HIGH-PRESSURE CASES 39 
 
 disease. The first signs of degeneration are 
 manifested by disorder of function. The 
 blood-vessels act as tubes to convey the blood to 
 different parts of the body, but at the same 
 time, through the muscular structure of their 
 walls, they act as regulators of blood-pressure. 
 This pressure-regulating function is an ex- 
 ceedingly complex one and controls the de- 
 termination of blood to the different parts of 
 the body as it may be most needed. It is this 
 regulating function which first suffers when 
 the tendency to high-pressure begins to show 
 itself, so that irregularity of tension is the 
 most important early circulatory indication. 
 
 We have traced those signs and symptoms 
 in the circulation which precede, for a long 
 time, the establishment of that condition known 
 as chronic Bright's disease. The smaller ar- 
 teries are attacked earliest, and these are the 
 first to show disordered function. Increased 
 arterial tension, or a tendency to it, causes ir- 
 regularity of blood-pressure, and is early 
 recognized by symptoms indicating irregulari- 
 ties of circulation in particular parts of the 
 brain. This irregularity may give rise to tern- 
 
40 BLOOD-PRESSURE 
 
 porary unconsciousness, slight paralysis, or 
 simply to clumsiness of a limb. 
 
 The typical high-pressure case as met 
 with in practical work, is usually one which 
 has gone on to its full development without ob- 
 servation or treatment. The patient presents 
 himself because he has symptoms, or because 
 ori some occasion an examination has revealed 
 the chemical or physical signs of the condi- 
 tion. The heart is found hypertrophied, the 
 arterial tension high, and the urine increased. 
 Careful questioning will elicit symptoms of 
 disorder of the cerebral circulation as indi- 
 cated by a subjective feeling of nervousness, 
 headache, insomnia, or attacks of dizziness, or 
 even threatened aphasia, and hemiplegia. The 
 hypertrophied heart is compensatory, having 
 been hypertrophied in order to meet the de- 
 mand for high arterial tension, just as the 
 heart in valvular disease is hypertrophied to 
 meet the demand for normal arterial tension 
 when it is working at a disadvantage. 
 
 So long as the arterial tension is maintained, 
 the patient is not in danger in the direction of 
 the circulation, but is, of course, liable to ac- 
 
HIGH-PRESSURE CASES 41 
 
 cidents due to injuries to the nervous system, 
 or a sudden failure on the part of the kidneys. 
 The circulatory danger arises from the ex- 
 hausting condition under which it is carried on 
 and the inevitable approach of the time when 
 the tension can no longer be maintained, hence 
 the vital importance of seeking out and re- 
 lieving the underlying cause of this high ar- 
 terial tension, and the futility, except as a 
 temporary expedient, of treating the symptom 
 itself as the primary disease by the prolonged 
 administration of vaso-dilators. 
 
CHAPTER V 
 
 THE MANAGEMENT OF HIGH-PRESSURE CASES 
 
 The management of high-pressure cases is 
 perhaps the most important topic of our whole 
 subject, as it is also the one in which the great- 
 est advance Thas been made in the knowledge of 
 circulatory disorders. 
 
 The causes of high-pressure are all those 
 circumstances which occasion a long-continued 
 demand for hyperactivity of the circulation, 
 also those conditions which interfere with the 
 proper carrying out of the chemical operations 
 in the body, whereby there remain in the 
 circulation incomplete chemical products. 
 The same chemical cause may arise in a dif- 
 ferent manner through an interruption of the 
 work of the kidneys whereby toxic substances 
 are retained in the blood. The latter two 
 causes fall under the head of gout and Bright's 
 disease. Certain toxins, as for instance those 
 
 of the infectious diseases, probably only cause 
 
 42 
 
MANAGEMENT OF HIGH-PRESSURE CASES 43 
 
 high-pressure cases through primary damage 
 to the kidneys. 
 
 The first principle of all treatment must be 
 the removal, as far as possible, of the causes of 
 the condition, hence the management of high- 
 pressure cases must begin by the discovery and 
 removal of the influence v^hich has led to their 
 development. Thus, a man v^ho is intemperate 
 v^ith regard to alcohol must be cautioned 
 against its use; the man who has assumed an 
 unusual burden of responsibility in life must 
 readjust his plans so as to lead a life free from 
 anxiety and excitement. The patient who has 
 habitually been addicted to the over-ingestion 
 of food must be restricted as to his diet. The 
 patient with damaged kidneys must be sub- 
 jected to a regimen which will enable these 
 organs to do their work properly. 
 
 A mistake that is often made is in treating 
 these cases all alike and regarding them as 
 primarily disease of the kidney. For instance, 
 a patient with kidneys damaged by disease may 
 often use alcohol in moderation with thera- 
 peutic benefit; the patient whose condition is 
 secondary to mental strain may often be bene- 
 
44 BLOOD-PRESSURE 
 
 fited by the ingestion of food, and by a lux- 
 urious mode of life which is entirely contra- 
 indicated in the patient whose condition is 
 that of the so-called gouty diathesis, or, as we 
 have expressed it, secondary to the breaking 
 down of the chemical functions of the body. 
 So no hard-and-fast rules can be laid down for 
 the management of high-pressUre without re- 
 gard to its origin. The influence of drugs is 
 also a matter depending upon the nature of 
 each case. 
 
 The distinction which we have drawn be- 
 tween high-pressure i:ases and low-pressure 
 cases presents an immense advantage in the 
 power of discrimination between therapeutic 
 measures. Particularly is this true in regard 
 to hydrotherapy. 
 
 The general s-tatement may be made that 
 warm bathing is indicated in high-pressure 
 cases, and cold bathing only in primary low- 
 pressure cases — with this distinction, however, 
 that cold bathing is contraindicated in high- 
 pressure cases, while warm bathing, and even 
 hot baths, may be beneficial, and often are in 
 low-pressure cases. 
 
MANAGEMENT OF HIGH-PRESSUJ^E CASES 45 
 
 These facts are nowhere better illustrated 
 than in the two great modern applications of 
 hydrotherapy— the Nauheim and Brandt sys- 
 tems. In the former we are dealing with high- 
 pressure Tases, though frequently, indeed, in 
 the stage of secondary low arterial tension. 
 In the latter we are dealing with the primary 
 low arterial tension of acute disease. 
 
 The beneficial effect of systematic warm 
 bathing, preferably with the addition of sa- 
 lines, whether combined or not with resistance 
 exercises, in high-pressure cases with a tend- 
 ency to cardiac dilatation, is very striking. 
 Equally striking is the injury observed from a 
 persistence in taking cold baths by elderly peo- 
 ple at the present time who fell under the in- 
 fluence of certain popular doctrines years ago, 
 which entailed a Spartan regimen including 
 cold baths and coarse food. 
 
 The Nauheim treatment is particularly ap- 
 plicable to this form of disease, no matter what 
 its origin, and its great success, though sup- 
 posed to be due to a direct action upon the 
 heart, is really due to the correction of dis- 
 order of the arterial system, particularly in 
 
46 BLOOD-PKESSURE 
 
 cases in which there is a commencing second- 
 ary low arterial tension. 
 
 The baths are essentially tepid baths with the 
 addition of saline ing-redieiits which have an 
 action upon the peripheral circulation. 
 
 The growth of this treatment, met as 
 it has been at first with surprised incredulity, 
 and later with blind faith, is now being ana- 
 lytically studied and is found to be applicable to 
 many patients in many places without much 
 complication of detail. 
 
 The characteristic Nauheim treatment as 
 recommended by Schott is not really a very 
 warm bath. It is never given above 95°, and 
 even as low as 88° F. The presence of car- 
 bonic acid and the salines causes a distinct im- 
 pression upon the skin. 
 
 The Schott treatment, therefore, must not 
 be confounded with the valuable procedure of 
 ordinary hot bathing in persons who have 
 feeble circulation. The former procedure 
 might be accompanied by certain dangers in 
 persons with defective kidneys, while ordi- 
 nary hot bathing with perhaps the addition of 
 bicarbonate of soda has no such danger. Then 
 
MANAGEMENT OF HIGH-PRESSURE CASES 47 
 
 again, the characteristic exercises are an im- 
 portant part of the Schott method. 
 
 Concerning foreign health resorts Sansom 
 makes the following wise remarks : 
 
 " The* patient is apt to misunderstand the 
 word ' cure ' as applied to the treatment of 
 the foreign health resorts, and invests proc- 
 esses there with a certain glamour. He pre- 
 fers, it may be, the counsel of a prophet who 
 bids him do some great thing, to the advice of 
 a friendly doctor who has carefully watched 
 the signs of his disease." 
 
 High-pressure cases are often met with in 
 men who literally lead a life of high-pressure. 
 The successful business man who overworks 
 and worries, and who uses alcohol, is very apt 
 to develop arterial changes and a tendency to- 
 wards pathologic high-tension. To such per- 
 sons, and indeed to many others, the neces- 
 sity of periods of relaxation as a requisite to 
 the maintenance of health is very great. The 
 most foolish thing that any successful man can 
 do is to work throughout the year without an 
 adequate vacation, and it is a rather curious 
 practical observation, even among professional 
 
48 BLOOD-PRESSURE 
 
 men, that, in the long run, the actual income of 
 the year is not diminished by taking several 
 months of travel and recreation. The im- 
 proved morale, the wider view of the world, 
 and the coming in contact with new people, 
 more than compensates for the actual loss of 
 income during the period of cessation of work. 
 Any man whose work is not purely routine is 
 the gainer by a sufficient vacation, and by de- 
 voting some attention to the cjuestion of pleas- 
 ure and rest. 
 
 When health is considered, in view of our 
 present knowledge of the progress of the cir- 
 culatory degeneration which goes hand in hand 
 with the advance of years, and which, as pre- 
 viously stated, is particularly liable to attack 
 those whose lives are most successful, the mat- 
 ter of rest and recreation becomes one of evi- 
 dent importance. 
 
 Unfortunately, if the pursuit of pleasure be 
 put off too long, the faculty of the enjoyment 
 of a quiet life is lost. It is extremely impor- 
 tant that each individual should develop inter- 
 ests during early life that may occupy him 
 during periods of cessation of work, so that 
 
MANAGEMENT OP HIGH-PRESSURE CASES 49 
 
 if the time comes when he suffers from high 
 arterial tension, and is ordered by his physician 
 to travel and rest, he may be able to take an in- 
 terest in the things of the pleasure-seeking 
 world afid not fret and worry through a period 
 of so-called relaxation, only to return to 
 business to find even that distasteful be- 
 cause of ill-health. Instances of this kind have 
 been observed in which it seemed the part of 
 humanity to allow such a man to " die in the 
 harness," as it has been expressed, that is, there 
 are certain cases of the high-tension type that 
 have gone beyond the point where much is 
 gained by a change of occupation. It is im- 
 portant, therefore, that high-tension cases be 
 early recognized, so that proper attention may 
 be given to the conduct of their lives, and the 
 care of their circulation. 
 
 The effect of temperament upon the progress 
 of high-tension cases is marked. A man with 
 a naturally cheerful disposition who is active 
 in the pursuit of pleasure, even though this be 
 accompanied by the abuse of stimulants, suf- 
 fers less from the condition of high arterial 
 tension than does the individual with the same 
 
50 BLOOD-PRESSURE 
 
 physical ailments who is prone to mental anx- 
 iety and depression. The reason for this is 
 probably a complicated matter of the reaction 
 of the brain upon the vasomotor system. 
 
 It is certainly a fact that many men prone to 
 conviviality go on living with this high ar- 
 terial tension in the circulation, while others 
 of a different temperament sink rapidly 
 through the grades of cardiac hypertrophy, 
 broken compensation, renal insufficiency, and 
 circulatory failure, to death. 
 
 Hence, the one most important condition in 
 the management of high-tension cases is the 
 removal, if possible, of overwork, particularly 
 mental work, of worry, and indeed, all de- 
 mands that may put the nervous system under 
 a strain. 
 
 The truth of this is remarkably shown by the 
 occasional observation of a man who, having 
 developed high arterial tension, cardiac hyper- 
 ^trophy and albuminuria during the course of an 
 exciting and successful business career, has 
 finally put his affairs in the form of an estate, 
 and settled down to a life of ease and enjoy- 
 ment of quiet pleasures. In such a man I 
 
MAKAGEMENT OF HIGH-PRESSUKE CASES 51 
 
 found the heart large, but not overactive, an 
 entire absence of arterial high-tension, the kid- 
 neys doing their work reasonably well, and 
 indeed, the whole condition showing a state 
 not characterized by advancement. This is no 
 fancy picture, but a matter of actual observa- 
 tion. 
 
 There are a considerable number of men in 
 the position where they must choose between 
 a few years under the conditions in which they 
 are at present, and a good many more years 
 under circumstances of less strain. 
 
 No condition is so easy to remove tempo- 
 rarily by treatment as high arterial tension. 
 The administration of an efficient dose of one 
 of the nitrites is as striking in its effect as any 
 therapeutic measure in all medicine. The 
 trouble is that the effect is but transitory, and 
 that there are certain disagreeable by-effects, 
 such as irritation of the heart, if the doses are 
 too often repeated. For this reason, much 
 judgment is necessary for the proper adminis- 
 tration of the vaso-dilators in high-tension 
 cases. 
 
 Some physicians give these drugs three or 
 
62 BLOOD-PRESSURE 
 
 four times a day, and flatter themselves that 
 they are keeping- down arterial tension. 
 Others, who know better, give the drug every 
 hour, and really succeed in relieving arterial 
 pressure. 
 
 The prolonged treatment of high-tension 
 must be principally hygienic, but while we have 
 not any belief that a few doses of nitroglycerine 
 during the day w^ill permanently effect a lower- 
 ing of tension^ still, while other methods are 
 being employed it is a useful procedure, as it 
 relieves blood-pressure at intervals, and gives 
 the circulation an opportunity to take ad- 
 vantage of anything that is gained by other 
 measures. As a matter of fact, in the earliest 
 stages of this condition, a few^ doses may for a 
 considerable time counteract a decided tend- 
 ency to arterial tension. 
 
 In the treatment of high-pressure cases we 
 are confronted with the fact that while we are 
 treating high arterial tension, the greatest 
 danger to be feared is secondary low arterial 
 tension. The problem is to remove from the 
 heart the demand for the maintenance of high- 
 tension in order to avert the time when, 
 
Management of high-jpressure cases 53 
 
 through exhaustion, it cannot maintain even a 
 normal pressure. The mere reduction of high- 
 pressure by the dilatation of the peripheral ar- 
 teries, when the demand on the part of the 
 system tor a high arterial pressure has not 
 been removed, often results merely in an irri- 
 tation of the heart. 
 
 This is often observed clinically when nitro- 
 glycerine is used indiscriminately and per- 
 sistently in high-tension cases, particularly of 
 the nephritic type. Quite frequently where a 
 condition of irritation has come about, the sub- 
 stitution of digitalis will result in a calming of 
 the circulation, and an apparent disappearance 
 of tension that is surprising to those who have 
 not tried this experiment. 
 
 The drug treatment of high-pressure cases 
 must be managed by an intelligent observer 
 who subordinates theoretic considerations to 
 practical results. 
 
 The iodid of soda used persistently has a 
 beneficial effect upon patients in whom there 
 has been established a tendency to high-tension 
 and progressive deterioration of the heart- 
 muscle. 
 
54 BLOOD-PRESSURE 
 
 It has seemed to me, and my observations 
 have been confirmed by others, that even in 
 very bad cases of this kind, much advantage 
 results from the use of this drug in this way. 
 
 Ordinarily it is presented in a solution of 
 equal parts of iodid of soda and water, and 
 given in doses of two to fifteen drops in half 
 a glass of water after meals. It is a matter of 
 experiment to determine how much each pa- 
 tient can tolerate. Ordinarily five drops can be 
 taken over a long period of time, although a 
 considerable number of patients can only take 
 two or three. 
 
CHAPTER VI 
 
 * 
 
 SOME OBSCURE SYMPTOMS OF CIRCULATORY 
 
 DISORDER^ WITH A CONSIDERATION OF 
 
 THEIR SIGNIFICANCE 
 
 Not all symptoms of circulatory failure are 
 comprised in dyspnea, edema, and visible con- 
 gestion or anemia, though these are the car- 
 dinal indications. There are certain symptoms 
 of obscure origin that are traceable to circula- 
 tory disease, and are only overcome when that 
 is given proper attention. 
 
 In elderly people one of the most frequent 
 and troublesome of symptoms is that of head 
 noises. I have under observation at the present 
 time no less than four patients who have suf- 
 fered over long periods of time from noises 
 referred to the ear, which they described as 
 puffing or blowing sounds, and which have 
 been extremely annoying. These patients had 
 all been systematically and heroically treated 
 for ear disease without benefit, but when the 
 
 55 
 
56 BLOOD-PRESSURE 
 
 circulation was properly controlled the noises 
 became so slight as not to be complained of, 
 and a good deal of the time not to be noticed. 
 
 These patients are usually found in the group 
 of commencing secondary low arteri-al tension. 
 The explanation of these sounds would seem to 
 be the circulation of blood through badly filled 
 blood-vessels in the neighborhood of the organ 
 of auditory sensation. 
 
 There is no class of cases that has given 
 greater satisfaction, because it is possible to 
 relieve a condition that has caused much suf- 
 fering, particularly at night. 
 
 Another obscure manifestation of circulatory 
 disorder is the simulation of slight attacks of 
 paralysis. These are often overlooked unless 
 they are watched for. They consist of a tem- 
 porary slight loss of power of a transient nature, 
 on the right or left side of the body. The pa- 
 tient usually describes the attack as a " clumsi- 
 ness " of a leg or an arm. If on the right side 
 of the body there is sometimes a slight loss of 
 power of speech, in that certain words are miss- 
 ing. The patient usually considers this a tem- 
 porary failure of memory. These manifesta- 
 
CIRCULATORY DISORDER 57 
 
 tions are the same as often indicate more se- 
 rious disease of the brain with impending 
 thrombosis. However, in many cases, atten- 
 tion to the general circulation will entirely re- 
 move the*symptoms, so that it is hard to believe 
 that the condition was purely local in origin. 
 
 There is a class of obscure symptoms of cir- 
 culatory disorder which consists of pain in 
 various parts of the body. How much of this 
 is purely circulatory, and how much of it be- 
 longs to the gouty, rheumatic, and nutritional 
 disorders that are common in the same class of 
 patients, is often hard to determine. It is sug- 
 gestive that these painful conditions arise at 
 times of circulatory debility and improve when 
 the circulatory disease is in abeyance. At- 
 tacks of. sciatica of a persistent and trouble- 
 some nature are particularly apt to occur in pa- 
 tients commencing to suffer from secondary 
 low arterial tension. 
 
 There is a really pitiable set of patients that 
 might be mentioned here, though perhaps not 
 quite logically. These are the patients who 
 have developed a very painful and chronic neu- 
 ritis subsequent to attacks of extreme circula- 
 
58 BLOOD-PRESSURE 
 
 tory edema of the lower extremities. It may 
 be only a coincidence, but these have been 
 among the most difficult patients to relieve that 
 have come under observation in connection 
 with the treatment of circulatory disease. 
 
 The obscure symptoms of circulatory disease 
 would not be complete without a consideration 
 of the things that may happen during the stage 
 of high arterial tension. Nose-bleed of a trou- 
 blesome character is a frequent occurrence, and 
 in cases where one is puzzled to decide between 
 primary and secondary low arterial tension, 
 the history of a period during which nose-bleed 
 was very troublesome may be of help. It is 
 surprising how often this history is elicited 
 from patients who come for the first time in 
 the stage of broken compensation. 
 
 The number of conditions due to congestion 
 secondary to general circulatory disease that 
 are mistaken for diseases of local origin, is 
 very great. The most striking of these is, per- 
 haps, congestion of the liver. 
 
 This condition develops gradually, so that 
 the blood becomes congested in the liver, giv- 
 ing rise to functional derangements of this 
 
CIRCULATORY DISORDER 59 
 
 organ, and of the other organs of digestion. 
 The Hver is enlarged and tender on pressure, 
 and the condition is often accompanied by very 
 marked disorder of the stomach, on account of 
 which it is frequently mistaken for primary 
 gastric disease. That this is not the case is- 
 proven by the fact that the condition is relieved 
 only when the circulation is strengthened. 
 
 There is a class of cases in which circulatory 
 disorder is shown in its pulmonary effects. 
 There is persistent congestion of the lungs, 
 often with a tendency to the accumulation of 
 serum in one or both pleural cavities. These 
 patients may often have a fairly good systemic 
 circulation and very obscure indications of car- 
 diac disease. The interference is apparently 
 with the function of the right side of the heart. 
 Two patients of this character were watched 
 over a long period of time, while the pul- 
 monary congestion, involving repeated at- 
 tacks of bronchitis and slight edema, ren^ 
 dered them incapable of work. The symptoms 
 of circulatory disorder are obscure because so 
 much more accentuated in the thoracic organs 
 than elsewhere. 
 
60 BLOOD-PKESSURE 
 
 Circulatory disorder may also show itself in 
 its effect upon the function of the brain by at- 
 tacks of acute mania, or more often by the de- 
 velopment of a chronic mania. 
 
 Changes in the arteries in elderly people are 
 apt to be characterized by changes in disposi- 
 tion, by affections of the memory, and by im- 
 pairment of judgment. That these symptoms 
 are traceable to circulatory derangement is 
 shown by the fact that their course is markedly 
 affected by the treatment of the circulation. 
 
 Disorder of the circulation in persons past 
 maturity is sometimes shown by so striking a 
 manifestation as general convulsions. These 
 patients are often supposed to be suffering from 
 idiopathic epilepsy. However, the attacks are 
 so promptly relieved by appropriate treatment 
 directed to the circulation, which would have 
 no effect whatever in epilepsy, that this may be 
 eliminated from the diagnosis. Of course, 
 there are relatively rare cases in which real 
 epilepsy begins late in life. 
 
 A group of symptoms on the border line be- 
 tween neurotic and circulatory disturbances 
 forms in its sum-total a large proportion of the 
 
CIKCULATORY DISORDER 61 
 
 sufferings of humanity. Abnormal sensations 
 in the extremities, numbness and tingHng of 
 the hands and feet, a feehng of formication ex- 
 tending up the legs and thighs, abnormal cold- 
 ness of the hands and feet, cramps in the mus- 
 cles of the legs occurring at night, and the tend- 
 ency of the extremities to " go to sleep," as it 
 is called — all these things may be pure neu- 
 roses, but often enough there is a circulatory 
 element in their causation. 
 
 As in a preceding paragraph in this chapter, 
 we may again suggest that the therapeutic test 
 will decide how much of this is due to disorder 
 of the circulation. Many times the symptoms 
 disappear when the circulation is properly reg- 
 ulated. A few doses of nitroglycerine have 
 stopped all complaint of cold extremities in 
 many patients of this type. The possible se- 
 verity of pain due to interference with the cir- 
 culation is well shown in cases of embolism of 
 the extremities in the course of circulatory 
 disease. No one who has observed this acci- 
 dent will doubt that pain of the severest type 
 may be due to interference with the circulation. 
 
CHAPTER VII 
 
 'THE MANAGEMENT OF SECONDARY LOW- 
 PRESSURE CASES 
 
 The treatment of low arterial tension which 
 is secondary to long-existing high-tension con- 
 ditions has two elements — first, the correction 
 of circulatory errors by the action of drugs 
 which have the power to modify physiologic 
 forces in various parts of the circulatory cir- 
 cuit, and, second, the restoration, as far as pos- 
 sible, of the health of the tissues upon which 
 denangements of function are often founded. 
 
 The attention in diseases of the circulatory 
 apparatus is too often concentrated upon the 
 first. In instances of temporary embarrass- 
 ment, or of extra demands on account of com- 
 plicating diseases, this first element becomes of 
 supreme importance, but in the long-run it is 
 the second element upon which success in the 
 care of circulatory disorders is dependent. 
 
 62 
 
SECONDARY LOW-PRESSURE CASES 63 
 
 In this connection it is important to differ- 
 entiate between the symptoms and the disease. 
 Dropsy of the dependent portions of the body 
 is a symptom which does not always demand 
 treatmeat. If of moderate degree, and depend- 
 ent upon well-understood causes, it is often the 
 part of good judgment to undertake the second 
 element of treatment, neglecting for the time 
 being the symptom, the removal of which 
 would require intervention in the physiologic 
 activity of the heart, such as might neutralize 
 treatment directed to the circulation as a 
 whole ; indeed, there is often much harm done 
 in such cases by violent attacks upon symptoms. 
 
 Most writers on circulatory disease have 
 passed over with scant consideration the man- 
 agement of cases with general edema and stead- 
 ily progressive symptoms, which, if not 
 checked, uniformly lead to a fatal termination. 
 It is unscientific to disregard these cases in 
 considering various forms of treatment at 
 length, dismissing them with a single clause. 
 This is frequently done in speaking of the 
 Nauhelm treatment, progressive cases being 
 usually spoken of as unsuitable. There is al- 
 
64 BLOOD-PRESSURE 
 
 ways the possibility in any particular case that 
 we may be mistaken in our estimate of it, and 
 the patient is entitled to the treatment even at 
 the risk of discrediting the system by the limi- 
 tation of results because of the severity of the 
 case. 
 
 As physicians engaged in the general prac- 
 tice of medicine, who must do our best for 
 those who place themselves under our care, it 
 is our duty to study the best plan for every 
 stage of a case, and to contest skilfully and 
 hopefully every sign of the progress of disease. 
 In the whole range of circulatory disease there 
 is no condition which will so tax the knowl- 
 edge and patience of the physician as the man- 
 agement of this low arterial tension which is 
 secondary to high arterial tension. 
 
 The importance of recognizing this class of 
 cases is very great, because the methods of 
 treatment which tend to the relief of the condi- 
 tion are not those which give the most satisfac- 
 tory immediate symptomatic results, or those 
 which are applicable to low arterial tension 
 which has not been preceded by high arterial 
 tension. 
 
SECONDARY LOW-PRESSURE CASES 65 
 
 . It is true that with many of these patients 
 we are justified in the use of means which 
 temporarily give relief and symptomatic re- 
 sults. 
 
 In primary low arterial tension the heart- 
 muscle is in a position to recover its tone if 
 depleted by acute disease, or to develop a com- 
 pensatory hypertrophy if overtaxed by defect- 
 ive valves. 
 
 In secondary low arterial tension the heart 
 has already for the time being exhausted its 
 power of compensatory hypertrophy, and, 
 while the tendency to resistance in the arteries 
 persists, there is no adequate response on the 
 part of the heart. 
 
 Little is gained symptomatically in extreme 
 cases by the use of vaso-dilators, because the 
 blood-pressure is already low. Little is gained 
 by digitalis, because the heart-muscle is not in 
 a position to respond. The combination of 
 drugs of the digitalis group with drugs of the 
 nitrite group produces a certain amount of 
 symptomatic response, but in the end does not 
 produce permanent results unless combined 
 with measures that will hold the advantage 
 
66 BLOOD-PRESSURE 
 
 gained. Excessive drugging is a mistake. A 
 single large dose of digitalis at night is often 
 better than divided doses. A good fluid extract 
 put into a capsule and swallowed at bedtime, the 
 dose being determined by experiment, has often 
 proved very satisfactory. Attention to the di- 
 gestive organs is often of the utmost impor- 
 tance. Milk is often badly borne and should 
 be replaced with the most nutritious food that 
 will agree with the patient. 
 
 As often as possible these patients should be 
 put upon a regimen directed to the improvement 
 of nutrition and to the healthfulness of the 
 body in general, hydrotherapy in the form of 
 warm saline baths, a nutritious diet without too 
 much regard to theories as to gout or disease 
 of the kidneys, and exercise in the open air up 
 to the point where dyspnea interferes. 
 
 We are dealing often enough with danger- 
 ous conditions, and it is not possible to compare 
 the result in a particular case with what it 
 would have been under other circumstances. 
 A man must be of limited experience indeed 
 who has not seen such a patient do better when 
 disregarding advice that planned treatment of 
 
SECONDARY LOW-PRESSURE CASES Ql 
 
 such a condition by too long rest in bed and a 
 diet too restricted. In cases of threatened 
 circulatory failure those remedies that have a 
 demonstrated physiological action on the circu- 
 , lation are tools to be used for the correction of 
 defects of action while the hygienic measures 
 mentioned above are repairing any shortage in 
 vitality. Each drug should be exhibited by 
 itself and ready mixed tablets or combinations 
 reserved for less serious cases. A good plan 
 is to divide the day into periods of one or more 
 hours and state definitely when each dose is to 
 be taken. Thus the circulation is regulated by 
 various adjustments much like a machine. 
 Vaso-dilators in the evening are often well 
 borne and useful in the same case in which they 
 are harmful in the morning. 
 
 The vitalizing effect of a change of climate, 
 a change of food, and of massage and exercise 
 should always be remembered. Under wise 
 management a patient, the subject of progress- 
 ing circulatory failure, can many times be 
 rescued from a situation which seemed at first 
 most discouraging. 
 
CHAPTER Vin 
 
 GENERAL CONSIDERATIONS 
 
 In the previous chapters the author has sys- 
 tematized his conclusions in the interpretation 
 of blood-pressure as affecting the heart, brain, 
 kidneys, and general circulation. 
 
 In order to obtain an expression of opinion, 
 there was published, just previous to the writing 
 of this little book, a series of short articles in 
 various medical journals. These elicited 
 enough discussion to show that the subject is 
 one in the mind of many general practitioners. 
 Among the articles, one entitled " The Im- 
 portance of Treatment in the Early Stages of 
 Arterial Degeneration "* was commented upon 
 by Dr. Beverley Robinson, of New York, and ,> 
 others, as being a true picture of the condition 
 described. The points brought out were that 
 the term degeneration of the arteries is a better 
 * Medical Record, April 2, 1904. 
 68 
 
GENERAL CONSIDERATIONS 6§ 
 
 term than arteritis, arteriosclerosis or endar- 
 teritis, because it is less definite and can be made 
 to include functional as well as material vices. 
 This condition is the result of the many causes 
 which act in opposition to the tendency of life 
 to go on without loss of quality or impairment 
 of power — in other words, it is the failure of 
 repair, and the failure in the action of the 
 mechanism for the automatic correction of ir- 
 regularities in the circulation. 
 
 The light thrown upon this condition by 
 pathology is extremely unsatisfactory because 
 •we often find a most advanced arterial sclero- 
 sis without marked symptoms, and we find 
 marked symptoms with hardly appreciable 
 physical changes. The degeneration of func- 
 tion is more striking during life than degenera- 
 tion of tissue. So long as we have to deal, 
 then, with living people, the perfection or 
 otherwise of the processes of life is the im- 
 portant element. This element is entirely be- 
 yond the view of the microscopist. 
 
 The failure of circulation may be due to 
 functional causes as much as to a condition 
 represented by appreciable structural change. 
 
iO BLOOD-PRESSURE 
 
 The teaching of modern science has been too 
 much in the direction that phenomena can be 
 wholly explained by structure. This is not 
 true of the working- mechanism of the human 
 organism, nor indeed is it true even of me- 
 chanical things.^ 
 
 I was much struck recently by a description 
 of his own case as given by a gentleman who 
 has achieved success in life through the able 
 manner in which he has managed a railroad. 
 He is suffering from circulatory failure, and 
 said : '' I think I am like one of the old 
 engines on my railroad — about ready for 
 the scrap-heap. You may be able to patch me 
 up and keep me going for a little while, but 
 you cannot make me new again." He said that 
 when an engine first came out of the shop it 
 could do two hundred miles a day, and at the 
 end be just as good as at the start. After a 
 while there would be a little leak in one of the 
 valves and it would have to go to the shop to 
 be repaired. Later on another valve would 
 leak, and then there would be trouble with the 
 fire-box. When this once began, though each 
 time the engine came out of the shop it would 
 
OENERAL COKSIDERATIONS 71 
 
 appear to be all right, it would always be going 
 back again, and at the end of a hundred miles 
 one might always expect something to be 
 wrong. He said further : '' I employ a master 
 mechanic to overhaul the engines every morn- 
 ing, and in this way we manage to keep them 
 going, even though they are old; but there al- 
 ways comes a time when repairs do not pay, 
 and then they are sent to the scrap-heap." 
 This was a simile more true than pleasant. 
 
 There is something about a piece of ma- 
 chinery that has borne the stress of hard usage 
 that is very like the behavior of the human 
 body under the same conditions. It pays in the 
 long-run to buy new machinery, and it would 
 certainly pay to get a new body if that were 
 'possible. A new automobile can be managed 
 and kept running by one of little experience, 
 but to keep an old one running requires the 
 knowledge of an expert. 
 
 Machinery can be replaced, but for the 
 human being there is only one body as far as 
 we know, so we must make the best of it. For 
 this reason the study of the repair of the failing 
 human organism and the discovery of all 
 
^2 BLOOD-PRESSURE 
 
 those methods by which it may be kept 
 smoothly rumiing are well worth our best ef- 
 forts. 
 
 The human organism is a much better ma- 
 chine than any invented by man. It has within 
 itself arrangements for the repair or conceal- 
 ment of the earlier manifestations of many se- 
 rious affections. In a way this is a disadvan- 
 tage, because the earlier signs of degeneration 
 are only to be detected by the trained percep- 
 tion of a skilful observer. This is particularly 
 true of the circulation. The earliest sign is an 
 irregularity of tension in the arteries, and this 
 goes on to a pretty constant high arterial ten- 
 sion. The inherent forces conceal the defect 
 whenever they can and bring about a compen- 
 satory hypertrophy of the heart. 
 
 This is the time when it is a pleasure and 
 satisfaction to the physician to step in, and by 
 proper regime and treatment regulate the ar- 
 terial disorder, and the causes which are lead- 
 ing to it. Once in a while there is a patient 
 who will submit to regulation before the ap- 
 pearance of conscious symptoms. The great 
 majority of such cases, however, have come un- 
 
GENERAL CONSIDERATIONS IS 
 
 der my care only at the stage when the hyper- 
 trophied heart, having wearied of the burden of 
 maintaining the high arterial tension, has be- 
 come feeble and probably dilated. Such was the 
 case of the patient who compared his state with 
 that of the broken-down motor. He presented 
 the picture of cardiac failure — the heart dilated, 
 with blowing murmurs, a feeble and irregu- 
 lar pulse, shortness of breath on the slightest 
 exertion, albuminuria, and anemia. It was a 
 case in which medical aid was sought only 
 after the reparative powers of the body had ex- 
 hausted themselves. Two years, or even one 
 year earlier, the process might have been 
 checked, so that the scrap-heap's day would 
 have been much longer postponed. 
 
 To make an estimate, which must be purely 
 a guess, the expectation of life is in inverse 
 proportion to the postponement of treatment 
 after the earliest signs of irregularities of ar- 
 terial tension due to the changes of degenera- 
 tion. 
 
 In a paper read before the New York County 
 Medical Association* entitled " Ergot in Sur- 
 * Annual Meeting, April i8, 1904. 
 
V4 BLOOD-PRESSURE 
 
 gery," Dr. Alfred T. Livingston, of New York, 
 said : '* In this connection I commend to your 
 perusal and careful consideration a brief but 
 most valuable and pertinent paper by Dr. 
 Louis F. Bishop, of your city [see current vol- 
 ume of Journal A. M. A., page 820]. The 
 paper in question reads as follows: 
 
 " The Relation of Nature's Provision for 
 Heart Stimulation and Control to the Use of 
 Cardiac Drugs in Acute Disease. 
 
 *' Before plunging into the indiscriminate 
 use of drugs which have the property of causing 
 the heart to beat more strongly, it is well to 
 consider what provision has already been made 
 in the same direction by the body itself, and 
 also what is the precise object of such inter- 
 vention in a particular case. 
 
 " The heart is wonderfully responsive to the 
 demands of the body when subject to exertion 
 or disease. In acute conditions, stimulation in 
 the sense of urging the heart to expend more 
 energy, is seldom demanded except in sudden 
 emergencies. Fever is a great heart stimu- 
 lant, as is also inflammation. 
 
 " The use of the term * heart stimulants ' 
 
GENERAL CONSIDERATIONS >j5 
 
 in reference to drugs that are used in the course 
 of disease with the idea of assisting the heart 
 and preventing the failure of its powers when 
 they are most needed, is a crude employment 
 of words, and has led to much misconception. 
 Who would think of whipping a horse that was 
 already struggling under an unusual load, or 
 further opening the throttle of an engine when 
 it was going too fast? 
 
 " The fact is that we have but few heart 
 stimulants in the true sense of the word, and 
 we hardly ever use these. The only time when 
 drugs are used with the direct purpose of stim- 
 ulating the heart is in sudden emergencies. 
 Then we avail ourselves of the fact that many 
 drugs which are useful as heart regulators also 
 possess the property of temporarily stimulating 
 the heart. The best heart stimulants, however, 
 such as ammonia, ether, and nitrite of amyl, 
 are poor regulators, and the best regulators, 
 such as digitalis, strophanthus, and iodid o£ 
 soda, are poor stimulants when quick action is 
 ^' needed. 
 
 "The whole question of heart stimulation 
 needs revision in its clinical aspect. A good 
 
76 BLOOD-PRESSURE 
 
 beginning could be made if the term ' stimulant ' 
 were dropped entirely and the idea of regula- 
 tion substituted. A hundred lives are saved by 
 the judicious control of the over-stimulation 
 which results from disease, where one is saved 
 by direct stimulation as such. The only excuse 
 for the use of heart stimulants is that they have 
 been misnamed, and are useful as regulators. 
 
 ^' The misconception of the importance of 
 stimulation as an element in recovery from dis- 
 ease has unquestionably led to much harm. 
 When in a very sick person it is found that 
 the pulse is slow, reflecting only the weakness 
 of the patient, one should rather rejoice than 
 otherwise. Circulatory failure does not, as 
 a rule, take place in this direction. Primary 
 low arterial tension without excessive rapidity 
 is not ordinarily dangerous if let alone. Such 
 a heart may carry on its work successfully, 
 while if injudiciously drugged, it may be so 
 exhausted that if the stage of the rapid and 
 feeble heart be reached, there may not be re- 
 serve force enough to carry the patient through 
 the disease. I have repeatedly seen cases in 
 which, on account of simple feebleness of the 
 
GENERAL CONSIDERATIONS 77 
 
 pulse in acute disease, the patient had been 
 drugged beyond measure, with the result that 
 the heart and pulse were showing most erratic 
 action, but in which, the occasion for the origi- 
 nal stimulation having passed, the withdrawal 
 of all drugs soon restored the heart action and 
 pulse to normal. 
 
 " Failure of the heart most frequently takes 
 place in the direction of increased rapidity. 
 This is probably due to the failure of a very 
 radical element in the living organism known 
 as inhibition. In connection with the heart, 
 the nerves which conduct this impulse from the 
 great nerve centers which seem to be the cen- 
 ter of life, are well known. The same influence 
 in one form or another affects every organ and 
 tissue of the body. On it depends co-ordina- 
 tion in every vital process. An instance of its 
 failure to act is seen in increased patellar re- 
 flex, due to cutting of the path of connection 
 between the brain and the muscles of the thigh. 
 
 " So increase in rapidity of the heart in dis- 
 ease tending to dissolution is a very radical 
 thing, and is only successfully combated by 
 measures influencing vitality itself^ such as im- 
 
78 BLOOD-PRESSURE 
 
 proved nutrition of the whole body, improve- 
 ment of the nervous system at large, and the 
 removal of those things which are acting con- 
 trary to the interests of the whole physical 
 economy. I can remember as a medical stu- 
 dent, bringing to bear, when opportunity af- 
 forded, every known heart drug in the attempt 
 to control the rapid and feeble heart action of 
 dying patients, and I could not understand at 
 that time why so little was accomplished. 
 
 " In acute disease, while there is life there is 
 hope of the restoration of the patient to health, 
 so one must strongly advocate the most strenu- 
 ous efforts to the very last to avert the tendency 
 to death; but there are certain limits beyond 
 which drugs having a direct influence on the 
 heart are no longer useful. If the patient is 
 to be saved it must be done by the restoration of 
 the inhibitory force by measures directed to 
 the restoration of the whole bodily economy. 
 Hence the value of strychnin, of hydrother- 
 apeutics, of nutrition, and above all, of sleep, 
 and the removal of exhausting influences. 
 
 * " Interesting as they are, and important, the 
 consideration of the mechanics of the circula- 
 
GENERAL CONSIDERATIONS 79 
 
 tion must give way to the consideration of the 
 patient himself as an individual. There is a 
 trite saying that a man is as old as his ar- 
 teries, and in acute disease it may be said, as a 
 rule, that* the heart is as good as the man. 
 
 " The moral of it all is that in acute disease 
 the question of cardiac drugs is a matter that 
 must not be lightly considered." 
 
 In American Medicine, April 2^, 1904, was 
 published a brief note entitled : " The Im- 
 portance of Considering the Element of Vaso- 
 motor Instability in Estimating the Signifi- 
 cance of Irregularity of Cardiac Rhythm," 
 which read as follows : 
 
 " The frequent discrepancies between the 
 heart-sounds as heard by the stethoscope and 
 the pulse as determined by palpation must have 
 impressed all observers. It has been a matter 
 of surprise that hearts, which, by their sounds, 
 seemed to be doing good work, were often ac- 
 companied by a pulse giving a poor impression, 
 and, on the other hand, cases showing irregu- 
 larities of the heart-sounds have been associ- 
 ated with a pulse showing a fair degree of 
 regularity. 
 
80 BLOOD-PRESSURE 
 
 " When it is remembered that, in the Hght of 
 evolution, the heart is constructed of the same 
 elements as the blood-vessels, and is only a 
 differentiation of the circulatory tube, and 
 v^^hen it is appreciated that not only the blood of 
 the heart, but the blood of the whole circula- 
 tion, is surrounded by a muscular envelope 
 that maintains its pressure, it can easily be 
 seen that in palpating any portion of this 
 blood-containing system, the variations in 
 pressure will be a complex of the whole 
 envelope, and not merely of its strongest 
 portion. 
 
 " The vasomotor system is much more liable 
 to disorder than the heart, and the heart is able 
 to compensate for a good deal of misbehavior 
 on the part of the vessels, but in compensating 
 it often appears to be misbehaving itself. 
 Thus, one may fall into the error of predicating 
 disease of the heart-muscle when the trouble 
 really is a functional derangement of the 
 blood-vessels. In many of the cases that are 
 strikingly benefited by the Nauheim treatment 
 the results are undoubtedly obtained by a 
 restoration of the peripheral circulation, and 
 
GENERAL CONSIDERATIONS 81 
 
 the relief of the heart from a struggle to com- 
 pensate for it. 
 
 '' Not only clinical but pathologic study con- 
 firms the fact that diseases of this class, includ- 
 ing myocarditis and nephritis, have their 
 origin most often in degeneration of the blood- 
 vessels, at first functional, and then organic. 
 The coronary arteries of the heart become in- 
 volved and then the heart-muscle suffers. The 
 vaso-vasorum of the blood-vessels suffer, and 
 then the larger vessels, so even in the early 
 stages of circulatory symptoms, the relation- 
 ships should be appreciated and the hygiene of 
 the peripheral circulation becomes a matter of 
 serious supervision." 
 
 This elicited the following reply from Dr. 
 Albert Abrams, of California (author -of 
 " Diseases of the Heart ; Their Diagnosis and 
 Treatment"), who, under the title: "A 
 Clinical Method of Determining the Vasomo- 
 tor Factor in Blood-Pressure," * said : — 
 
 " Dr. L. F. Bishop, in a contribution on 
 * The Importance of Considering the Element 
 of Vasomotor Instability in Estimating the Sig- 
 * American Medicine, May 28, 1904. 
 
82 BLOOD-PRESSURE 
 
 nificance of Irregularity of Cardiac Rhythm/ 
 pubhshed in American Medicine, April 23, 
 1904, directs attention to a significant clinical 
 paradox, viz., the discrepancy often existing 
 between the heart-sounds and the pulse — in 
 other words, the vigor of the one cannot be 
 gauged by the strength of the other. My own 
 observations tally with those of Bishop. I have 
 frequently noted among arteriosclerotics and 
 others, that a high blood-pressure is often 
 coupled with the local evidence ^f cardiac in- 
 compensation. When the heart-tones are 
 weak, increased blood-pressure can never indi- 
 cate a vigorous heart-action, and in estimating 
 the vigor of the latter, blood-pressure is of sub- 
 sidiary value only. When high blood-pressure 
 coexists with cardiac enfeeblement, a vaso- 
 motor factor is concerned in the maintenance 
 of the former, this increase in the peripheral 
 resistance of the blood-vessels acting as a prop 
 to the enfeebled heart. In other words, the 
 arterial system serving the objects of compen- 
 sation acts as a subsidiary heart, which in turn 
 facilitates the circulation of blood. In this 
 way, as I view it, the nervous system, through 
 
GE*[ERAL CONSIDERATIOKS 83 
 
 the vasomotor nerves, may compensate an im- 
 paired myocardium. 
 
 "I have accumulated sufficient data to war- 
 rant recommending the following method for 
 determining the vasomotor factor in the clin- 
 ical measurement of blood-pressure. In my 
 observations, the Riva-Rocci instrument was 
 employed. After determining blood-pressure, 
 according to the conventional method, the pa- 
 tient is instructed to inhale amyl nitrite from 
 a bottle, after which procedure the blood-press- 
 ure is again estimated, and the difference 
 noted. The arm-piece of the instrument need 
 not be removed until the investigations are 
 completed. The patient must be instructed not 
 to practice forced breathing while inhaling 
 amyl nitrite, as observation has taught me 
 that tliis physiologic act alone will reduce 
 blood-pressure, and thus negative the clinical 
 findings. Sufficient amyl nitrite must be in- 
 haled to induce its physiologic action, viz., 
 slight duskiness of the face, fulness in the head, 
 and relaxation of the blood-vessels. The aver- 
 age effect of inhalation of the drug in the nor- 
 mal subject is to cause a slight increase of 
 
U BLOOD-Pl^ESSURfi 
 
 blood-pressure, varying from 2 mm. to 20 mm. 
 The primary effect is to depress slightly the 
 blood-pressure, but it rises at once. 1 am in- 
 clined to conclude that in the average healthy 
 individual inhalation of amyl nitrite relaxes the 
 arterial walls by eliminating the vasomotor in- 
 fluence, thus bringing into play the veritable 
 cardiac pressure. My observations, extending 
 over a period of one year, permit me to formu- 
 late the follov^ing conclusions: 
 
 " I. Blood-pressure is an expression of ac- 
 tion of two chief factors, ventricular force and 
 vasoconstriction. 
 
 " 2. Inhalation of amyl nitrite dissipates the 
 vasoconstrictor factor, and brings into play the 
 ventricular force which is the real factor to be 
 encouraged in a failing heart. 
 
 " 3. The vasoconstrictor factor may and 
 does compensate myocardial inadequacy, for*it 
 is essential in most cardio-arterial diseases for 
 the blood-pressure to be maintained to afford 
 better nutrition of the heart, and to augment 
 arterial elasticity as a means of establishing 
 the blood circulation. 
 
 " 4. The recognition of the myocardial and 
 
GENERAL CONSIDERATIONS 8S 
 
 vasomotor factors in blood-pressure guides us 
 correctly in the administration of cardio-tonics. 
 
 " 5. In the individual endowed with cardiac 
 health, the removal of the vasomotor factor by 
 inhalation of amyl nitrite causes an increase in 
 blood-pressure, whereas the converse condition 
 causes the latter to fall and the degree of re- 
 duction is proportionate to the degree of car- 
 diac enfeeblement. In other words, the high 
 blood-pressure in myocardial disease is main- 
 tained by an augmented tonus of the vasomotor 
 center. Thus the blood-pressure may fall from 
 240 mm. before, to 180 mm. after, inhalation 
 of amyl nitrite in arteriosclerotics with en- 
 feebled hearts. Even this reduction in blood- 
 pressure is not low enough to correspond with 
 the tones of the feeble-acting heart, hence one 
 is constrained to conclude that the action of 
 the amyl nitrite does not suffice wholly to 
 eliminate the vasomotor factor. 
 
 " 6. The execution of the foregoing maneu- 
 vers in estimating heart vigor is by no means 
 comparable to a correct method of cardiac aus- 
 cultation, although the latter method does not 
 indicate how much of the cardiac force may be 
 
S6 BLOOD-PRESSURE 
 
 attributed to increased peripheral resistance; 
 cardiac auscultation, in conjunction with the 
 sphygmomanometer and the inhalation of 
 amyl nitrite, constitutes the ideal method for 
 ehciting the real condition of things. 
 
 •"7. In estimating blood-pressure the sphyg- 
 momanometer only gauges the force of the left 
 ventricle, and to determine the sufficiency of 
 the right ventricle, auscultation of the pul- 
 monic sounds and a physical examination of 
 the lungs are alone adequate. 
 
 ^' I have encountered a number of individuals 
 with very high blood-pressure, and who dem- 
 onstrated no cardiac anomaly, yet the blood- 
 pressure remained the same after as before the 
 inhalation of amyl nitrite. In about half of 
 these individuals the urine was light in color, 
 of low specific gravity, contained a trace of al- 
 bumin, and was excreted in increased quanti- 
 ties. Albumin often disappeared when the 
 blood-pressure was spontaneously lowered, to 
 reappear when the pressure rose, hence the al- 
 buminuria in such instances could be correctly 
 designated as the albuminuria of high blood- 
 pressure." 
 
GENERAL CONSIDERATIONS 87 
 
 With reference to " Constitutional Low Ar- 
 terial Tension,"* the following was published : 
 " It will be found that there are many patients 
 who give evidence, on the most casual examina- 
 tion of* the circulation, that the tension in the 
 arteries is very slight, and in some this will be 
 found a constant condition. It is surprising 
 how little tension there can be in the radial 
 pulse without the patient suffering from any 
 symptoms of circulatory disease. 
 
 '' This low arterial tension in otherwise ap- 
 parently healthy individuals, is undoubtedly a 
 departure from the normal. It may be due to 
 an unusual relaxation of the peripheral circula- 
 tion which makes it possible for the heart to do 
 its work withjDut little effort. Some of these 
 patients are generally feeble, lacking in nerve 
 force and unequal to strains. Others, how- 
 ever, seem to respond to demands for physical 
 or nervous effort, and when so responding 
 there is an improvement in the tone of the cir- 
 culation. 
 
 *' When seen for the first time during some 
 
 * New York Medical Journal and Philadelphia 
 Medical Journal, June ii, 1904. 
 
88 fiLOOD-PRESSURE 
 
 acute affection this condition may give rise to 
 apprehension on the part of the physician as to 
 the outcome of the illness for which he has 
 been summoned. When, however, the patient 
 can be watched from year to year and is seen 
 to get along perfectly well, even though there is 
 this lack of tone in the circulation, the physi- 
 cian comes to realize that with that individual 
 it is a physiologic condition. 
 
 " There is another form of low arterial ten- 
 sion that is of much more importance, and that 
 is the low arterial tension which succeeds the 
 high arterial tension of chronic Bright's dis- 
 ease. Here we have to deal with a most 
 serious complication of the disease. It means 
 that the circulation is no longer maintained by 
 the heart. Thus, it may be stated that low 
 arterial tension may exist in certain individuals 
 without great significance, but that if it has 
 been preceded by high arterial tension it is a 
 factor of grave import. With this condi- 
 tion we have nothing to do in the present 
 discussion, but rather with low arterial 
 tension that is a reflex of a constitutional 
 condition. 
 
GENERAL CONSIDERATIONS 89 
 
 " Experience has shown that nothing is 
 ' gained with these individuals by the use of drugs 
 to increase arterial tension. It is quite possible 
 to make the pulse for the time being approxi- 
 mate the normal; indeed, this often happens 
 spoiitaneously when the heart and circulation 
 are physiologically stimulated by exercise or 
 fever. 
 
 ^' The condition is, in all probability, due to 
 an inherent defect in the nervous system, 
 whereby it does not exercise the proper control 
 over the blood-vessels. The same patients who 
 suffer from this low arterial tension are very 
 apt to manifest other symptoms of defective 
 ' nervous control, and the removal of the under- 
 lying condition will bring about an improve- 
 ment in the circulation. 
 
 " The most important element of treatment is 
 systematic exercise. These patients are often 
 dependent for their well-being upon regular 
 physical exertion. Often they feel much better 
 if they can take a brisk horseback ride every 
 day, or some other form of stirring exercise. 
 There are other cases in which it is found that 
 iron and arsenic improve the condition when it 
 
90 BLOOD-PRESSURE 
 
 becomes very marked. In still other cases very 
 hot baths take the place of vigorous exercise 
 and improve the tone of the circulation. It 
 should be remarked that this is a secondary 
 effect, because, if the circulation be examined 
 immediately after the bath, it will be found to 
 be more relaxed than usual. 
 
 " Although one would expect beneficial 
 results from cold bathing, it is found by 
 experience to b^ unsatisfactory in cases of 
 constitutional low arterial tension. Such 
 subjects do not react, and the effect is not 
 satisfactory. 
 
 ^' These observations refer to a class of pa- 
 tients who are not suffering from any definite 
 disease, but who realize that they are not the 
 same as other people. They have probably 
 been told that they are suffering from a variety 
 of diseases, according as the phenomena were 
 supposedly traced to one or the other organ. 
 To them may be applied the rather trite remark 
 that they are suffering from a condition rather 
 than a disease. Such patients are fortunate if 
 they come under the care of a practitioner who 
 will appreciate the condition and manage it 
 
GENERAL CONSIDERATIONS 91 
 
 properly. The worst thing that can happen is, 
 that there should be repeated efforts to cure 
 supposed disease by different men succeeding 
 one another." 
 
 *' Prostration of the Circulation " * was the 
 title of a paper which read as follows : '' This 
 term is used in reference to the circulatory 
 system as synonymous with neurasthenia in 
 relation to the nervous system. Neurasthe- 
 nia is undoubtedly founded upon a malnu- 
 trition or an exhausted vitality of nervous 
 tissue. Prostration of the circulation is 
 founded upon the corresponding elements, but 
 as the heart and blood-vessels are much more 
 open to direct examination than the nerves, 
 there are signs as well as symptoms. As in 
 neurasthenia both the brain and the peripheral 
 nerves participate in the disease, so in prostra- 
 tion of the circulation the heart and blood- 
 vessels are involved. Neurasthenia and pros- 
 tration of the circulation are two conditions 
 that have many correlations. In neurasthe- 
 nia there is always a certain amount of vaso- 
 motor disturbance, though there are many 
 * Buffalo Medical Journal, May, 1904. 
 
92 BLOOD-PRESSURE 
 
 cases in which the circulation is entirely 
 normal. 
 
 " In prostration of the circulation there is 
 often much depression, but disturbances of sen- 
 sation have a real foundation in alterations of 
 the blood supply, and there are many cases in 
 which there is not the slightest touch of neu- 
 rasthenia. 
 
 " I have suggested the name, prostration of 
 the circulation, to cover those cases in which 
 the terms myocarditis and arterial degenera- 
 tion are too harsh, just as we would not like 
 to speak of neurasthenia as insanity. We have 
 for a long time needed a word to coveF 
 those cases which present disturbance of 
 function, and which are perfectly capable 
 of complete recovery, though as often as not 
 they go on to the manifestation of organic 
 disease. 
 
 " The following case which I saw recently 
 will illustrate the point I wish to make. The 
 case was that of a woman who had worked very 
 hard all her life, had become run down, and 
 began to find that it was difficult for her to 
 carry on her occupation. She presented the 
 
GENERAL CONSIDERATIONS 93 
 
 appearance of health ; there were no evidences 
 of kidney disease, and no history of dissipa- 
 tion. She complained of some shortness of 
 breath on exertion, particularly when there was 
 any sudden demand upon her muscular system. 
 She was not in the least neurasthenic, for these 
 conditions were perfectly real in their existence. 
 The arterial pulse was soft and compressible; 
 her heart-sounds were feeble, and there was a 
 soft systolic murmur at the apex. 
 
 " It seemed to me a simple case of circulatory 
 prostration, and one that was capable of com- 
 plete recovery by a suitable course of treat- 
 ment. It is not easy to describe the differen- 
 tiation of such a case from a case of real myo- 
 cardial degeneration, or a case of circulatory 
 disease in which the kidneys may eventually be 
 the principal sufferers. However, there is this 
 about it — namely, that in myocarditis, irregu- 
 larity of force and rhythm is a very constant 
 symptom, and in commencing arterial degener- 
 ation careful search should be made to discover 
 some signs of irregularity of cerebral circula- 
 tion. Cases of prostration of the circulation 
 show marked hepatic symptoms, principally due 
 
94 BLOOD-PRESSURE 
 
 to the staguation of the circulation in the liver. 
 In other words, in simple prostration of the 
 circulation the blood current is feeble, but 
 regular. In myocarditis and arterial degener- 
 ation it is irregular." 
 
CHAPTER IX 
 
 THE ESTIMATION OF BLOOD-PRESSURE AND THE 
 
 USE OF THE NITRITES FOR ITS 
 
 MODIFICATION 
 
 The estimation of the condition of the cir- 
 culation usually represented by " feeling the 
 pulse" stands for a very important proce- 
 dure in the routine of the practice of medicine, 
 and is the one element of a physical examina- 
 tion that is probably never neglected in any 
 case, or in any country. For this reason the 
 estimation of the pulse, while it has not always 
 lent itself to the most scientific classification, 
 still to the individual physician represents a 
 remarkable amount of experience and observa- 
 tion, checked by the findings of subsequent 
 events. Now, while many physicians are un- 
 able to express in words what they feel in the 
 pulse, still, very often indeed their conclusions 
 are correct. 
 
 The tactile estimation of relative blood- 
 pressure as determined by the experienced 
 
 95 
 
96 BLOOD-PRESSURE 
 
 touch, and checked by clinical symptoms, is 
 usually correct, on account of this high degree 
 of training. There is a possibility that some 
 of this great skill of the profession might be 
 lost if instrumental observation should pos- 
 sibly take the place of direct examination, just 
 as we have lost skill in measuring fever. How- 
 ever, the introduction of instruments of pre- 
 cision far outbalances the benefits of the skill 
 created by their absence. 
 
 In this connection the question is: How 
 may technical skill in clinical pathology be 
 made available to the profession at large? 
 
 It will be noted that so far little has been 
 said as to the actual measurement of blood- 
 pressure in the vessels. The extensive con- 
 sideration of this is left to works devoted to 
 this particular branch of physical exploration. 
 It is undoubtedly true that the systematic in- 
 strumental measurement of blood-pressure by 
 various instruments will eventually lead to 
 important clinical results. 
 
 As remarked in the first chapter, it is the 
 difference in pressure between the place v/hcre 
 the blood is stored and the place where it is re- 
 
THE ESTIMATION OF BLOOD-PRESSURE 9 If 
 
 quired, together with the element of resistance 
 in the intervening blood-vessels, that determines 
 the competency of the circulation. 
 
 The instruments and skill for the quantita- 
 tive measurement of blood-pressure are still 
 not in the possession of the majority of practi- 
 tioners. It is enough to have considered at the 
 present moment the philosophy of those cases 
 in which there is little room for difference of 
 opinion as to the existence of high or low press- 
 ure. In order to bring this branch of clinical 
 observation, as well as others, within easy reach 
 of my fellow practitioners engaged in the gen- 
 eral practice of medicine as distinguished from 
 those engaged in teaching and pure research 
 work, I propose in the near future to establish 
 in a physicians' office building a laboratory of 
 clinical medicine where may be obtained the 
 use of instruments and the services of those re- 
 cently trained in modern methods of clinical 
 pathology, so that all may have the same fa- 
 cilities now enjoyed only by the few physicians 
 whose practice justifies the maintenance of an 
 independent laboratory and staff of assistants. 
 
 The necessity for such a laboratory will 
 
98 BLOOD-PRESSURfi 
 
 always be felt by that great body of physi- 
 cians who, having originally been fairly 
 trained in the clinical methods of the time of 
 their tutelage, have become preoccupied by 
 their work, and do not feel like acquiring 
 skill in newly evolved technical matters. The 
 possession of this technical skill is the best capi- 
 tal the beginner in practice has, and in a clinical 
 laboratory such as I propose it could be made 
 available for those who have the clinical ne- 
 cessity for its use. Particularly is this im- 
 portant in relation to the subject of the obser- 
 vation of blood-pressure, because the condi- 
 tions involved are not truly represented by the 
 patients who are congregated in hospitals and 
 clinics. Disorders of blood-pressure, while 
 found in all classes, present particular phe- 
 nomena among the upper grades of society. 
 
 Bearing upon this question we would quote 
 from an article by Drs. Ruth and Rider, en- 
 titled " Laboratory Aids in Clinical Diagno- 
 sis/' which appeared in the Journal of the 
 ^American Medical Association, May 7, 1904. 
 
 "... The solution of the problem lies in 
 co-operation. With an expenditure of $10, 
 
 Note. — The "Laboratory of Clinical Ohsevvation " was 
 founded 1904, at 616 Madison Ave., New York. 
 
THE ESTIMATION OF BLOOD-PRESSURE 99 
 
 and an arrangement with a laboratory within 
 twenty-four hours' ride, any physician can 
 have laboratory advantages at his disposal. 
 All that is needed is a few glass slides, some 
 culture lubes, platinum needle, alcohol lamp, 
 Thoma-Zeiss white cell pipette, Tallquist hem- 
 oglobinometer, and a book on technic, how 
 to obtain and forward material for a leu- 
 cocyte count, hemoglobin estimation, bacterio- 
 logic examination of blood, urine, exudate, or 
 whatever else may be desired. One member of 
 the community of physicians can go to the ex- 
 pense of fitting a laboratory and becoming pro- 
 ficient in technic. His neighbors can either 
 share the expense and go there to make their 
 examinations, or, what is better perhaps for 
 both, have one who has the time and taste do 
 the work for all. Practice makes perfect, and 
 better observatidhs would be secured by such a 
 plan. A mutual agreement should be made as 
 to the sharing of expense, and by a very small 
 personal outlay a town possessing a faculty of 
 only six or more physicians could have a suf- 
 ficiently well-equipped laboratory and afford 
 enough work to enable one or more of their 
 
100 BLOOD-PRESSURE 
 
 number to become reasonably expert. We 
 have not the time to elaborate this plan, but 
 simply wish to state how, b}^ means of har- 
 mony and mutual aid, it would be possible to 
 bring the means of diagnostic precision within 
 the reach of practically all the profession. 
 
 " In many of the larger cities municipal labo- 
 ratories have been established, and have done 
 much good work, especially in dealing with the 
 epidemic and contagious diseases. Being 
 municipal laboratories only, they reach but 
 a small proportion of the profession. It is not 
 unlikely, in view of the good work done by the 
 city laboratories, that the State will eventually 
 place at the disposal of the general profession 
 an adequate number of well-equipped labora- 
 tories that would not only offer technical aid 
 in general diagnosis, but would require that 
 their services be employed in all cases that 
 might have a bearing on the health of the gen- 
 eral public. It must of necessity be some time 
 before any generally efficient State aid can be 
 expected, and meanwhile the profession must 
 rely on their own efforts to obtain laboratory 
 aid in diagnosis." 
 
NITRITES FOR ITS MODlFICATIOK ]0l 
 
 The other point that we wish to make in this 
 chapter is the necessity for greater conservatism 
 in the use of vaso-dilators in certain cases of 
 cardiovascular disease. In the career of every 
 form of treatment there are several stages. 
 The first is discussion, then, skepticism having 
 been overcome, adoption. The second is intel- 
 ligent application in the light of previous dis- 
 cussion and the consequent general informa- 
 tion. Third, the routine use of an accepted 
 treatment as a matter of course in a particular 
 disease. 
 
 When Brunton applied amyl nitrite to the 
 treatment of angina pectoris, he achieved a 
 signal triumph in therapeutics. Not less was 
 the triumph of the more gradual application of 
 the nitrites in general to the treatment of vas- 
 cular spasm. These were first well used by 
 those who had witnessed their development 
 and were familiar with their philosophy and 
 limitations. Unfortunately the student coming 
 later upon the field of medicine, and finding 
 the nitrites in general use for vascular disease, 
 jumped naturally to the conclusion that they 
 were the remedies par excellence and used 
 
102 BLOOD-PRESSURE 
 
 them in a routine way in the treatment of these 
 cases. The obseryation of this fact makes it 
 seem useful at this time to emphasize the neces- 
 sity of some conservatism in this matter. It is a 
 trite saying that we should always treat the 
 patient and not the disease, meaning by this 
 that we must carefully recognize the exact 
 physiologic and pathologic conditions present, 
 and so influence them as to bring about the 
 cure of disease. Patients differ widely in their 
 behavior under the nitrites, and for that reason 
 every case requires physiologic study to de- 
 termine the amount of drug necessary and 
 how it should be applied. 
 
 There is no more important function of the 
 physician than the early recognition of that 
 tendency to degeneration and death that 
 comes , prematurely to so many of the human 
 race. This shows most often in arterial 
 changes, one of the earliest symptoms of 
 which is alteration in blood tension. The 
 tension of the blood-vessels in health is main- 
 tained at an even point through the action of 
 the unstriped muscular tissue in the walls of 
 the blood-vessesls. The heart is a part of the 
 
NITRITES FOR ITS MODIFICATION 103 
 
 circulatory tubes, and differs only in arrange- 
 ment and degree from the mechanism of the 
 rest of the circulatory path. It contains un- 
 striped muscular fiber as do the blood-vessels, 
 and an arrangement of valves as do the veins. 
 Its muscular action is rhythmic, while the 
 muscular action of the blood-vessels is only 
 slightly so. Both are subject to the control of 
 the nervous system. It is in the disordered 
 action of all these muscles that the first signs 
 of degeneration appear. The muscles in the 
 vessels act badly, the muscle in the heart is ir- 
 ritated, and the result is tension. To apply 
 vaso-dilators without also instituting hygienic 
 measures to reduce the irritability of the heart 
 and restore the disordered or exhausted nerv- 
 ous system, is to overlook an important ele- 
 ment in the problem of cure. 
 
 The necessity for the use of vaso-dilators is 
 diminished in proportion to the intelligence 
 and success attending these accessory meas- 
 ures. In Bright's disease there is probably 
 some substance circulating in the blood that 
 irritates the muscular coats of the vessels and 
 causes contraction. This, with the physio- 
 
104 BLOOD-PRESSUEE 
 
 logic attempt of the heart to carry on the 
 circulation, again brings about high-tension. 
 When high-tension antedates the onset of ne- 
 phritis it may well be supposed that the ten- 
 sion has something to do with the production 
 of nephritis. 
 
 A physiologic increase of blood-pressure is 
 caused whenever there is nervous, muscular, or 
 physiologic exertion. 
 
 Prolonged nervous strain, such as that met 
 with in an exciting business career, or in pro- 
 longed dissipation, keeps up a tendency to ten- 
 sion that is particularly apt to lead to arterial 
 degeneration. Muscular action is less prone to 
 produce damage, and probably does so only in 
 rare instances of long training and severe con- 
 tests of strength. The reason for this is that 
 exercise is accompanied by natural dilatation 
 of the arterial circulation, improved nutrition, 
 and relief afforded by perspiration. The 
 physiologic activities of the body are usually 
 accompanied by too slight a stimulation of the 
 circulation to count for much in health, but are 
 worth considering in disease. 
 
 In the case of a person suffering from ab- 
 
NITRITES FOR ITS MODIFICATION 105 
 
 normal tension it is especially important to do 
 away with mental strain and responsibility. 
 Such a person, should not indulge in violent 
 exercise, but is benefited by slow exercise. 
 Food should be moderate in amount, taken at 
 frequent intervals. Sugar and alcohol should 
 be done away with entirely if possible, and 
 meat used only in Limited amount. 
 
 When the vaso-dilators are given it is to 
 produce a definite physiologic effect which is 
 capable of being appreciated by the observer. 
 The dose required to produce this effect differs 
 widely in different individuals and under dif- 
 ferent circumstances. In a large number of 
 cases they are now so given that no effect what- 
 ever is produced. Crude therapeutic thought is 
 responsible for this. The idea is conceived that 
 the nitrites are good for kidney- and heart-dis- 
 ease, and so they are administered with the 
 hope that the patient may be benefited thereby. 
 If improvement takes place the medicine re- 
 ceives the credit, whether it has done its work 
 or not. The word " conservatism " means 
 more than caution, more than small dosage. It 
 means the working out of the possibilities of 
 
106 BLOOD-PRESSURE 
 
 the remedy and its application in such a way as 
 to fulfil its broadest mission, so that it may not 
 be wasted or abused — wasted w^hen used in 
 non-active doses, and abused when used too 
 often, or in too great quantity. With the vaso- 
 dilators a careful regulation of the dose is of 
 vital importance, for their final action may be 
 dilatation and paralysis of the heart through a 
 complete breaking down of that great power 
 called inhibition which moderates all muscular 
 activity. 
 
 When nitrites are used it is also of the utmost 
 importance that the preparation selected should 
 be reliable. I have known patients to take for 
 a long time tablets supposed to be nitroglycerine 
 which were subsequently found to be inert. 
 When no benefit is obtained in conditions in 
 which nitroglycerine is clearly indicated this 
 may be fairly suspected. As a test, one of the 
 tablets should be given to a healthy person, who 
 should immediately feel the throbbing in the 
 head due to the dilated blood-vessels and the 
 stimulation of the heart. If no effect is felt, a 
 new preparation must be sought and this tested. 
 The I per cent, solution of glonoin is probably 
 
NITRITES FOR ITS MODIFICATION 107 
 
 more reliable, but is not nearly so convenient 
 for patients as the tablet. 
 
 Cases must be studied from time to time by 
 the withdrawal of these drugs, and by the sub- 
 stitution of other drugs of a different class. 
 Particularly is it important in every such case to 
 know from actual observation the effect of 
 digitalis in such doses as bring about dis- 
 tinct physiologic phenomena. 
 
 But few diseases can be treated by specific 
 measures, and cardiovascular disease is par- 
 ticularly remote from such an ideal. The end 
 which drugs accomplish is to so control the cir- 
 culation as to tend to benefit the condition 
 of the tissues, or to prevent the condition of 
 these tissues from working injury to the body 
 as a whole. The management of cardiovas- 
 cular disease is like the running of an intri- 
 cate machine. The physician must study the 
 machine itself and learn all its resources. He 
 must know the use of every tool, and the ef- 
 fect of the turning of each screw. It is no 
 abuse of the privileges of the physician to study 
 his cases therapeutically by testing from time 
 to time the effect of different classes of drugs, 
 
108 BLOOD-PRESSURE 
 
 though he return after each trial to the original 
 plan of treatment. It is the height of arro- 
 gance to assume that his inductive reasoning 
 can plan for each case a permanent course of 
 management. Such action will only lead to 
 humiliation and disappointment. How exas- 
 perating it is when for a long period of time, 
 on theoretic grounds, we have abstained from 
 the use of such a drug as digitalis to find some 
 time or other that our patient has taken it 
 through the advic of the corner druggist and 
 has received appreciable benefit from it. Of 
 course, we know very well that the corner 
 druggist had no right to experiment, but per- 
 haps the risk was worth taking after all. 
 
 There is a particular form of pulse in which 
 nitroglycerine is not as valuable as a number of 
 other drugs. This is a high-tension pulse 
 with persistently rapid heart-action. In these 
 cases I have sometimes seen the greatest benefit 
 from the use of digitalis. Nitroglycerine has a 
 twofold action in stimulating the heart and di- 
 lating the blood-vessels. Digitalis has a two- 
 fold action in slowing the heart and contract- 
 ing the blood-vessels. Theoretically digitalis 
 
NITRITES FOR ITS MODIFICATION 109 
 
 would not act in these cases, but practically in 
 a case of nephritis with a high-tension and 
 rapid pulse, digitalis will often show its con- 
 trolling action upon the heart in greater de- 
 gree than any of its other effects, and in that 
 way bring about a slower pulse with less ap- 
 parent tension. At the same time digitalis will 
 clear up congestion of the kidneys and cause a 
 better secretion of urine. 
 
 Even when tension does c :ist in cardiovas- 
 cular disease with nephritis, it should be real* 
 ized that some tension may be desirable. Ae 
 time goes on in such a case, the greatest dangej^^ 
 to be feared is a too great lowering of the blood 
 tension with its accompanying congestions and 
 effusions. In the presence of symptoms indi- 
 cating disturbances of cerebral circulation, stich 
 as numbness or awkwardness of one of the ex- 
 tremities, or slight difficulty in speech, the 
 vaso-dilators are imperatively needed. Sodium 
 iodid has also an undoubted power to postpone 
 paralytic attacks due to the plugging of blood- 
 vessels. 
 
 'A word as to the possibility of recovery from 
 cardiovascular degenerative disease. The heart 
 
no BLOOD-PRESSURE 
 
 symptoms are those of myocarditis, and the 
 kidney symptoms those of chronic nephritis. 
 The tendency of the blood is to become of 
 poor quahty. With a properly planned regi- 
 men and the possibility of carrying it out, and 
 with careful medication and other therapeutic 
 measures, the heart may recover its tone so 
 that all symptoms of degeneration will dis- 
 appear, and the kidneys may settle down to do 
 their work according to a particular plan, but 
 well enough for the maintenance of health. 
 
 It is hard to prove the regeneration of kid- 
 ney tissue, though the physiologic hypertrophy 
 of one kidney when the other is removed leads 
 to a belief in its possibility. Certainly there 
 are many persons passing a large quantity of 
 urine of low specific gravity, and with a slight 
 trace of albumin, who maintain year in and 
 year out signs of health. Their hearts, blood- 
 vessels, and kidneys have readjusted them- 
 selves, and though bearing the scars of 
 disease are carrying on the functions of 
 the body in a satisfactory manner. I have 
 pictured this condition because it is extremely 
 interesting to decide in these cases how much 
 
NITRITES FOR ITS MODIFICATION HI 
 
 we should intervene with drugs to alter the 
 heart-action or relax the blood-vessels. It 
 seems to me that in the absence of symptoms 
 sodium iodid will accomphsh the best purpose, 
 and that the use of the nitrites should be 
 limited. 
 
 The hypertonicity of the arteries found as a 
 part of nature's attempt to compensate for a 
 failing heart muscle and present in many cases 
 of secondary low blood-pressure must be dis- 
 tinguished from high blood-pressure. The 
 contraction of the arteries disappears upon the 
 recovery of the power of the heart to fill them 
 with blood. 
 
CHAPTER X 
 
 THE BLOOD-VESSEL TONE-MAINTAINING FUNC- 
 TION OF THE BRAIN 
 
 The maintenance of tone in the muscular 
 coats of the blood-vessels is so essential to the 
 continuance of life and health that, when it 
 fails, death follows in a very few moments. 
 The capacity of the hollow organs that contain 
 the blood, when completely relaxed, is so great 
 that the blood in the body can only fill them to 
 the extent of one-third. It is evident that the 
 complex movements of the blood, constituting 
 the circulation, cannot be carried on in a sys- 
 tem of tubes that are only one-third filled. 
 The circulation is, therefore, dependent not 
 only upon the muscular contractions of the 
 heart, but also those of the blood-vessels. In 
 the course of evolution from the lower to the 
 higher animals, there is found in the earlier 
 stages a simple tube, and this gradually be- 
 
 m 
 
THE BLOOD-VESSEL AKt) THE BRAIK 113 
 
 comes more and more changed until in its 
 course there are developed special collections of 
 muscles, known as hearts, and when we get to 
 the higher animals we find the greatly dif- 
 ferentiated single organ, as in man. 
 -- So, while, of course, in man the heart is 
 relatively of great importance, still the muscles 
 that remain in the blood-vessels are absolutely 
 essential to the maintenance of the circulation. 
 In the control of the muscles of the heart and 
 blood-vessels there comes into play a complex 
 arrangement of nerves and nerve centers that 
 is only secondary in its awe-inspiring perfec- 
 tion to the machinery of the intellect itself. 
 
 As we trace the development of the circula- 
 tion from the lower forms of life up through 
 the scale, we find that the control moves closer 
 and closer to the central nervous system. In 
 the higher forms of animals a tone-maintaining 
 function is easily traced to the medulla, and the 
 author believes that in man, at least, an im- 
 portant part of this function is found in the 
 cerebral hemispheres. 
 
 It is w^ell known that there is a tone-main- 
 taining influence originating in the motor areas 
 
114 BLOOD-PRESSURE 
 
 of the brain that presides over the tonicity of 
 the voluntary muscles. When a stroke of 
 paralysis occurs, due to damage to the part of 
 the brain that presides over the motion of a 
 limb, that limb is paralyzed with regard to 
 voluntary motion, but at the same time there 
 occurs a relaxation, a loss of tone, in the blood- 
 vessels that causes swelling. This suggests 
 the fact that the involuntary muscles were like- 
 wise involved in a loss of tone, and would seem 
 strong evidence of this blood-vessel tone-main- 
 taining function. Not only may local blood- 
 vessel tone be affected by changes that occur in 
 the brain, but also the general tonicity of the 
 whole circulatory system. In all brain condi- 
 tions we look for changes in the peripheral 
 circulation. Emotion may cause a rapid rise 
 of blood-pressure. It is said that insane 
 asylums are full of high-pressure cases due to 
 cerebral excitement. In cerebral neurasthenia 
 the blood-pressure is apt to be low. 
 
 In advocating the recognition of a blood-ves- 
 sel tone-maintaining function of the brain it is 
 not necessary to minimize the importance of the 
 center in the medulla, whose actiwties in this 
 
THE BLOOD-VESSEL AND THE BRAIN li5 
 
 direction are so well known. It is only neces- 
 sary to believe that the activity of this center is 
 dependent upon stimulation received from the 
 brain. A recognition of this function of the 
 brain, which exercises a general control over a 
 vessel'tone, and therefore over blood-pressure, 
 makes it much easier to understand many im- 
 portant disorders of the circulation and the 
 benefits of certain plans of treatment experi- 
 ence has proved of the greatest value. 
 
 It explains why exercise of the voluntary 
 muscles has so good an influence over disorders 
 of the tone of the involuntary muscles. It 
 makes clear why resistance exercises have 
 vindicated their right to a place in the treat- 
 ment of disease of the heart. It also reveals 
 the development and points the way to treat- 
 ment of a disease, the importance of which is 
 becoming more and more recognized every 
 day, and which we will discuss in the next 
 chapter,— Hypertonia Vasorum Idiopathica. 
 
CHAPTER XI 
 
 HYPERTONIA VASORUM IDIOPATHICA 
 
 This is par excellence the disease of the 
 present day, and is looming up as of more and 
 more importance in proportion as it is better 
 understood. The time cannot be remembered 
 when successful men were not stricken down in 
 the midst of their activities by apoplexy or so- 
 called heart failure. Of late years, it is in- 
 creasingly common for those men and women 
 who play the most prominent part in the world, 
 and carry the heaviest burden of responsibility, 
 to develop finally disorders of the arteries of 
 the brain or of other vital organs, resulting on 
 the one hand in apoplexy, or on the other in 
 Bright's disease. We have attributed these 
 breakdowns too often to chemical causes aris- 
 ing from disorders of the digestive system, or 
 we have regarded them as primarily disease of 
 
 116 
 
HYPERTONIA VASORUM IDIOPATHIC A ll^ 
 
 the kidney, developing in some mysterious 
 way. Too often has alcohol been blamed when 
 in reality it was hardly a factor in the case. 
 Why should it be that persons preeminent for 
 the use of their brains, and singled out for the 
 
 4. 
 
 heaviest responsibilities, suffer in the direction 
 of the circulation so much more than those 
 whose occupation is of another character? 
 The reason is to be found in the effect of 
 mental strain in exaggerating that tone-main- 
 taining function of the brain that was dis- 
 cussed in the previous chapter. 
 
 Let us trace the development of such a case, 
 resulting in an attack of apoplexy. A com- 
 posite picture, drawn from the mental concept 
 of this disease, tallies almost line by line with 
 many concrete examples. The patient is a 
 man of good family history, inheriting sturdy 
 qualities from an ancestry that has developed 
 strength through the successful contest with 
 the difficulties of the development of a new 
 country. He has been well educated, and has 
 led a healthy and active youth. From the very 
 beginning he has been a worker among his 
 fellows, and spurred on by one success after 
 
1 1 8 BLOOD-PRESSURE 
 
 another, by middle life he has attained a posi- 
 tion of importance and usefulness. Now his 
 qualities have been recognized, and one burden 
 after another has been laid upon him. He has 
 become a factor in government, in business, in 
 intellectual pursuits, and in philanthropy. 
 Such a man, unmindful of the fact that 
 he is past middle age, and that the body no 
 longer has the recuperative power of youth, 
 continues his work unceasingly, without those 
 relaxations that attract men of a lighter turn of 
 mind. The man feels perfectly well, but a 
 change has taken place in the machinery of his 
 body. The influence from the central nervous 
 system, which maintains the blood-vessels in a 
 proper state of tonicity, has become exag- 
 gerated through the overflowing of the mind 
 strain, and the blood no longer circulates with 
 ease. Now it is hard for the heart to keep the 
 blood in proper circulation, but without any 
 manifest symptoms it becomes enlarged and 
 still carries on the w^ork. The two factors of 
 arterial contraction and cardiac hyperactivity 
 result in high arterial tension. This in turn 
 results in structural damage to the blood-vessels 
 
HYPERTONIA VASORUM IDIOPATHICA 119 
 
 in the brain, the kidneys and elsewhere. Un- 
 consciously, the man is living in constant dan- 
 ger. Some day there arises some incident in 
 the man's career that leads to an unusual de- 
 ,gree of worry or mental strain, and there 
 develops a tendency to inflammation in the 
 already damaged blood-vessels of the brain, and 
 the blood clots and stops the circulation, most 
 likely in the speech center on the left side, and 
 another prominent man has fallen victim to an 
 attack of apoplexy. Sometimes the picture is 
 varied and one of the arteries that supply the 
 heart substance with blood is stopped, and the 
 man drops dead in his tracks; or in another 
 case the kidneys gradually give out. Not in- 
 frequently the abdominal arteries show the first 
 indications by terrific digestive disturbance 
 causing great distention of the stomach with 
 wind and marked irregularity of the heart. 
 This is my mental concept of hypertonia vaso- 
 rum. 
 
 Even after any one of these serious acci- 
 dents much can be done for a man made of 
 such good stuff, but how much more satis- 
 factory would be the prevention of such an 
 
120 BLOOD-PRESSURE 
 
 accident by proper medical treatment and a 
 suitable regimen. 
 
 I would like to register a protest against 
 those who decry the use of drugs in circulatory 
 disease, because in all medicine there is no 
 condition in which proper drug treatment is 
 of greater value, and none in which, to my 
 mind, its usefulness seems more easily demon- 
 strated. The remedies must, however, be used 
 with appreciation of the fact that they are to 
 regulate an active mechanism that is always 
 changing in its demands, and that the one 
 needed at one time may be contraindicated a 
 little later. 
 
 This implies very careful medical super- 
 vision, particularly when the case first comes 
 under treatment. By a process of re-educa- 
 tion of physiological processes control of func- 
 tion becomes easier and easier, and as the 
 patient becomes familiar with his tendencies, 
 the physician can in a measure yield control. 
 The details of treatment must be worked out 
 for each individual with due regard to the 
 relation of blood-pressure, heart disease and 
 blood-vessel damage. 
 
\ 
 

 1^