only albumin, but also casts, in persons with normal bloodpressure, and where the urinary findings are probably purely metabolic.

Nephritis.-Bearing in mind the difficulty of early diagnosis in cases of chronic nephritis by a single urinalysis, particularly in individuals apparently in normal health, the importance of a blood-pressure test will be apparent, because it is recognized that we cannot have permanent kidney change without a constant elevation in blood-pressure, and even in the presence of albumin or casts we may question their true significance. Here a persistently high blood-pressure, say 150 mm. or over, in an individual below middle age will settle the question at least in regard to the risk. The presence alone of scanty albumin and casts in the urine is not conclusive evidence of a diseased kidney, as these elements may come from any number of transitory and comparatively unimportant complications. The blood-pressure test will serve as a check, so that the applicant with a normal blood-pressure whose urine has occasionally shown albumin and casts will not immediately be rejected, and such individuals will get the benefit of the doubt and the company thereby be prevented from committing perhaps a grave injustice.

Overweights.-The overweights demand careful consideration by the insurance examiner. This is a group which shows an unfavorable mortality in life insurance statistics, particularly in the higher ages. It should be remembered that the amount of adipose tissue covering the vessels does not materially affect the reading, as cases of very large arms present readings of normal or even below, so that findings of high pressure should be attributed

to some other cause. In a person of moderate overweight in whom nothing in the physical examination or history indicates rejection, the final decision is often made upon the relation of the blood-pressure test. The risk is accepted when pressure is found normal and declined when the pressure approaches or passes the high normal limit.

Chronic Myocarditis.-This is probably one of the most difficult conditions to diagnose that is encountered in the course of insurance work. Its possible presence must always be borne in mind and every effort made to eliminate it in the examination, particularly in those past middle life, and in those presenting past history of hard physical labor, excessive brain work, alcoholism or syphilis. This will of course not be difficult to recognize when the disease has progressed sufficiently to affect the general health of the individual. It is in the early stages, where the usual methods of examination fail to reveal it, that the sphygmomanometer is of greatest value. In the early cases the systolic pressure need not be materially affected, so that recourse must be had to the functional tests of Graupner and Shapiro, and to a study of the diastolic and pulse pressures, by which changes in normal reserve of the heart and the strength and volume of its output can be estimated (see page 331).

Incipient Tuberculosis. The presence of a slightly lowered blood-pressure accompanied by slight elevation in pulse rate, with or without fever, combined with a history of slight loss of weight, is very suggestive evidence of an existing pulmonary lesion. In tuberculosis the bloodpressure is usually low and the pulse pressure diminished. In this connection Haven Emerson1 states that hypo1 Arch. Int. Med., 1910.

tension is found in almost all cases of moderately advanced tuberculosis and that it has been found by many observers in early doubtful or suspected cases with or without physical signs of the disease of the lungs, and that it is considered by competent clinicians as a most useful sign. Cook also states that low blood-pressure, if persistently found in individuals or in families should put us on our guard for tuberculosis. In applicants of light weight and a blood-pressure of 100 or under and of poor family history, the risk is bad (see also page 203).

Blood-pressure in Relation to Mortality.-Dr. J. W. Fisher of the Northwestern Mutual Life Insurance Company,1,2 has produced some very valuable work by drawing conclusions from a study and analysis of the mortality statistics of that company beginning in 1907 and continuing until August 1, 1913. This report amply confirms present opinions regarding the value of the blood-pressure test in detecting beginning disease of the cardiovascular and renal systems, and their influence on expected mortality.

From a study of 2661 insured taken from the actuary's tables giving blood-pressure readings between 140 and 149 mm. Hg., with 81.85 expected deaths, thirty-one actual deaths, a percentage of 37.87, which was slightly below the normal death rate of the company on exposure of two years. He shows another table of mortality records of 527 insured persons with a blood-pressure reading of 150 mm. Hg. and over, with 22.19 expected deaths and actual deaths twelve, which is about 35 per cent. in excess of the general average

1 Med. Rec., Oct. 21, 1911.

Jour. A. M. A., Nov. 14, 1914, lxiii, 20, p. 1752.

mortality of the company covering the same period and 10 per cent. higher than the general average mortality during the first five years of exposure covering the twenty years period 1885 to 1905. He further shows a mortality record of 1970 applicants rejected with an average systolic pressure of 161.44 with a mortality of 190 per cent. of the medico-actuarial table, which is more than double the average mortality of that company.

In another table are shown 1082 cases rejected in which there were reported no other impairments than high blood-pressure at the time the application was received at the home office. The expected deaths were 34.78, the actual deaths 40, or 179.53 per cent. of the table. Efforts, made to follow carefully these rejected risks in order to secure data as to the subsequent physical condition of these applicants, more than justified the opinion that the sphygmomanometer was one of the earliest, if not the very earliest, means of detecting departures from normal in this group of cases, as many impairments were later discovered or developed in a large number of cases rejected for high pressure only.

CHAPTER XXIII

THE THERAPEUTIC VALUE OF DRUGS AFFECTING BLOOD-PRESSURE AND THOSE COMMONLY EMPLOYED IN CARDIOVASCULAR AND

RENAL CONDITIONS

In the revision of this work, it became apparent that it was inadvisable, if not indeed impractical, to include a discussion of the management of the many conditions in which high blood-pressure is a factor, as it would extend beyond convenient limits of size. This section is an effort to make up in a measure what to some may have appeared a regrettable omission, noting briefly the effects which may be expected to follow the employment of those drugs which are reputed to affect blood-pressure, but with no attempt to outline definite methods for the management of any specific cases.

We recognize from the therapeutic standpoint that of even greater importance than the employment of drugs is the conservation of cardiac energy, the development of circulatory competence and the promoting of elimination; and finally that the reduction of abnormally high pressures is only of secondary importance. Summing up our knowledge of the therapeutic action of the majority of drugs heretofore relied upon for the control and management of circulatory and blood-pressure changes, it may be said that our confidence in these drugs has been too great, and as a rule mistaken. Thus the experiments