logic effect is shown in a slow pulse rate, a diminished force of the heart's action, and vasodilatation. Administration.-Fluidextract, one to three drops, tincture three to six drops. It should be given at intervals of two or three hours, when continued effect is desired, and its activity may be hastened by gradually increasing the dose until the physiologic limit is reached. In some cases annoying vomiting may occur. CHAPTER XXIV PHYSICAL MEASURES EMPLOYED IN THE MANAGEMENT OF CONDITIONS PRESENTING ABNORMAL BLOOD-PRESSURE Causes of Failure.-A large percentage of the unsuccessful results in the treatment of cardiovascular-renal diseases can be traced to one or more of the following causes: 1. The diagnosis has not been made sufficiently early. 2. The case may have been carelessly or unskilfully studied. 3. The predisposing causes have not been found. 4. As a result, the condition is but imperfectly understood. 5. The therapy is irrational because it is based upon an incomplete knowledge of the case in question, plus a deficient knowledge of therapeutic methods by drugs or other measures. 6. Too great dependence has been placed upon drugs alone, especially the vasodilators, to the neglect of the newer so-called physiologic methods. It may be said in general that while drugs are at times invaluable in the treatment of pathologic circulatory conditions, especially in emergency, their value is usually much overestimated. The secret of successful treatment usually lies in a careful study, an early and complete diagnosis, rigid supervision and regulation of the individual habits, rather than attempts to lower blood-pressure and relieve symptoms by the employment of drugs. A properly conducted study will sometimes yield gratifying results even in advanced cases, and at times in those cases commonly regarded as hopeless. The most satisfactory results naturally follow an exhaustive examination immediately following the appearance of the first suggestive sign or symptom of impairment of the circulatory apparatus. This should be followed by a careful estimate of the functional power left in the impaired organs and the immediate adoption of a life and habits suited to the limitations determined. Thus we attempt to produce an adjustment of the individual's manner of life which will give an equivalent to relative good health. By "correct diagnosis" the broadest meaning of this phrase is intended and not the mere statement that the patient has "cardiovascular-renal disease." To arrive at a correct diagnosis, one must take a full history, including a complete analysis of social history and personal habits, carefully considering both business and social activities, making a comprehensive physical examination, including blood and urine examinations, and taking the blood-pressure, not omitting the functional tests. In fact the success of treatment depends primarily upon the completeness in which each problem is studied and upon the intelligence with which the remedies are employed and only in a minor degree upon the particular remedial measures applied. Direct therapeutic measures aimed at distinct pathologic conditions will not be considered, as they are beyond the object and scope of this book. This chapter will consist more of a résumé of existing literature and will be more in the nature of a reference chapter to be consulted when knowledge of the relative value of certain measures and information concerning the effect of any particular drug is desired. PHYSICAL MEASURES Under the head of physical measures valuable in controlling and in reducing high pressure, we find: Rest. Exercise. Massage. Diet. Hydrotherapy. Electrotherapy. Rest and Posture.-Preëminently rest is the first essential in the treatment of all cardiovascular and renal conditions. It is safe and beneficial to begin every course of treatment by rest. The term rest as here used may be purely relative or may mean absolute recumbency. The degree of rest enforced will depend on the physician's judgment as based upon experience and the extent of his knowledge of the case and its requirements; no set rule can be adhered to blindly. In the cases suddenly developing signs of incompetency, with dyspnea, a large heart, venous congestion, etc., the decision is obvious; absolute rest and mental relaxation are imperative-nothing else will do. First and foremost, all unnecessary strain must be removed from the overburdened and dilated heart. This alone may suffice to break the vicious circle, allow the heart muscle to regain its lost tone and so pave the way for a period of at least relative health. Rest in bed will alone often be sufficient to reduce a dangerously high blood-pressure. I have repeatedly seen a pressure of over 200 mm. fall to and maintain a new level of from 15 to 25 mm. lower. Occasionally even a greater reduction than this will be effected by this measure. Effects of Sleep and Rest on Blood-pressure.-Brooks and Carroll1 studied this question in sixty-eight patients showing average systolic pressure, in thirty with low pressures and in twenty-nine with abnormally high pressures. The results are, in a general way, illustrated in the cases with average pressure, in which readings taken between one and two hours after the beginning of sleep showed an average drop of 24 mm. Hg. For three hours after awakening in the morning there was still an average depression of 12 mm. and from this time onward the pressure gradually rose until usual highest level was reached in the afternoon. The greatest nocturnal fall in pressure took place in those individuals having the highest initial systolic reading. Disturbance of patients during the first sleep was found to delay, but not necessarily prevent, the maximal fall in pressure; frequent interruption did, however, prevent it. Special tests were made to determine whether the sleep drop could be artificially increased in order to secure a lower general pressure curve in cases of hypertension; potassium bromid in doses as high as 120 gr., and chloral hydrate up to 50 gr. each night were not found to increase the degree or persistence of the fall. Physical rest in general did not appear to alter materially either supernormal or normal blood-pressure, but Brooks and Carroll 1 Archives of Int. Med., August, 1912. |