becomes important, therefore, from a prognostic standpoint because the earlier the diagnosis can be made the more probable is it that good results will be secured from treatment. Of recent years the relation of retinal changes to bloodpressure and chronic kidney disease has attracted widespread interest. As such examinations, occurring in the course of routine examinations of the eye, have often been the first clue to the presence of chronic renal changes and should therefore indicate the immediate use of the sphygmomanometer, so also should high blood-pressure readings call for an ophthalmoscopic examination. (See Fig. 55.) PROGNOSIS Except in the later stages, when all signs point to the approach of death, a prognosis cannot be accurately given until careful observation has extended over a period of time sufficiently long to permit the physician opportunity to carefully weigh the many factors in the case which must, of necessity, contribute to his opinion. Generally speaking, the earlier the diagnosis the better the prognosis, although there are exceptions to this. The average blood-pressure level is a factor of first importance. From the standpoint of nephritic involvement as bearing on the ultimate outcome, the prognosis in the case of a robust looking man of fifty or fifty-five, with an average blood-pressure of 200 or over, even with no direct evidence of arteriosclerosis, is not so good as in the case of a man sixty-five or so, with marked evidence of arterial involvement, who is carrying a pressure of between 130 and 160. The former is in daily danger of a sudden total catastrophe, First observa FIG. 61.-Female. Aged fifty-one. Uremic paralysis. tion was made twenty-four hours after an attack of left hemiplegia of uremic origin. The urine showed albumin and hyaline casts in practically all specimens throughout this period of observation, although less in amount in the later ones. Elimination and sedative treatment produced prompt reduction in systolic pressure to a surprising degree, followed by a less marked fall in pulse pressure. At (A) the patient has so far recovered the use of her lower extremity as to be able to get around with help. The rise at this point was probably due to increased muscular activity and did not give any great concern. At (B) the patient had an attack of tachycardia from no apparent cause, the nurse reporting that prior to my examination the pulse was almost imperceptible, being over 200 and uncountable. Absolute rest plus morphin and ice bags resulted in a prompt fall in systolic pressure. Subsequently the course of the case was uneventful, the slight rise in systolic and pulse pressure being due to gradually increasing physical activity. while the latter may live on for years with apparent good health. The most that can be expected from rational treatment is a more or less complete arrest of the progress of the disease, which can be counted upon to delay the fatal termination for a variable period, often for years. The result of clinical observations and the persistence of certain characteristic changes seen at post-mortem examination indicate that one may, in a certain number of cases, forecast the ultimate termination at least in so far as the forecasting of the variety of death is concerned. Janeway1 has reported his findings in a long series of cases, from which the following has been largely taken. In Janeway's series twelve out of twenty-nine cases which died of cardiac insufficiency, began with dyspnea on exertion. On the other hand, out of thirty-two patients, who noted polyuria or nocturnal urination at the beginning of their illness, seventeen died of chronic and seven of acute uremia while only eight died of cardiac insufficiency. Duration of Illness in Relation to Causes of Death (Janeway) The relation of headache and subsequent uremia is most striking. Of fifteen patients complaining of headache, eight died of chronic uremia (Fig. 61), two of apoplexy, and only one of heart failure. Early ocular symptoms were most frequent in those who died of chronic uremia, in five out of eight. Early hemoplegic attacks occurred thirteen times in four patients who finally died of apoplexy. SUMMARY 1. Early dyspnea of either type in a patient with high pressure indicates marked danger of cardiac insufficiency. In such patients the disease should be treated as a cardiac disease. 2. Anginoid pain, even when of marked severity, occurring in persons with high blood-pressure, does not make the prognosis worse than other cardiac symptoms. The majority of these patients will not die of angina. The Relation of Prominent Early Symptoms with High Blood-pressure to Causes of Death (Janeway) 3. Polyuria, nocturnal frequency, marked headache, or visual disturbances in a patient with high blood-pressure, especially if the patient is below fifty years, should make the prognosis very guarded, for uremia is a frequent mode of termination of these cases. TREATMENT From the first inception until the very end, the treatment of chronic high pressure and chronic nephritis should be of the individual and not of the disease. This important fact cannot be too frequently or too positively repeated because there is still a large number of practitioners who are endeavoring to treat solely the kidney condition or one or more of the many symptoms or secondary complications with which all are familiar. One should never forget the fact that nothing can be done to remove the existing degenerations, while much can and should be done toward relieving undue strain where such is found to exist, by promoting elimination, favoring cardiac action and in general, regulating the patient's mode of life, in an endeavor to readjust it to existing conditions. Any other method may not only be useless but may actually work harm. It is absurd to treat any case directly for the blood-pressure elevation, by measures directed toward actively reducing the high pressure, as it has been shown by many, that in point of longevity1 but little difference is found between those whose systolic pressure rises above 200 and those that range between this and 150. Everyone should be fully prepared to accept the statement that very high blood-pressure may exist as a direct 1 T. C. Janeway, Arch. Int. Med., xii, No. 6, p. 755. |