there is a tonic activity to the vasodilator fibres, but it has been definitely proven that the constrictor may be depressed or stimulated, thus producing a dilatation or constriction.

The effect of myocarditis on the pressure has to be considered carefully. Here you may find a fairly high pressure with a rather weak dilated heart muscle, but you are more likely to find a low systolic pressure with a relatively high diastolic pressure-in other words-a low pulse pressure. This may be an indication for the use of vasodilators in spite of the low systolic pressure.

It is difficult to say positively just how much depends upon the glands of internal secretion. There is, however, little doubt but that a diminished secretion of the adrenals is likely to give a lowered pressure. This is seen in cases of Addison's disease, where the glands cannot function to their full capacity on account of their diseased condition. Barker states as follows: "Outspoken hypotension is the common find in Addison's discase." It is not uncommon to find disturbances in blood pressure at the menopause. There may be an increase or a decrease. There is usually an upset condition of the patient's nerve control. She may have many nervous manifestations. Hot flushes, followed by sweating, and a sense of cold, are ordinary symptoms. In many of these cases where a hypotension exists the symptoms have been allayed by the daily use of corpus luteum extract of ovarian substance, with a resulting increase in pressure. In such cases it is rather hard to know just what has happened, and what has reduced the pressure. It may be that the diminished ovarian function has temporarily upset the secretion of the other glands that have a distinct effect on the pressure, namely the adrenals, and that when the ovarian substance was re-supplied, the proper functional equilibrium was re-established.

It is frequently true that many of the so-called "nervous women" show a hypotension. Probably here we are often dealing with disturbances of internal secretions, but it is difficult to determine whether the nervousness and the tired feeling is the primary cause of the effect. It is entirely possible that the nervousness could affect the function of the glands of internal secretion. There may be headaches, mental depression, and a history of becoming easily exhausted. These cases, associated with hypotension, do not seem to improve until their pressure has been raised in some way. Hydrotherapy, with a good tonic treatment, may be all that is required, but unless the

disturbance can be assigned primarily to the nervous system, it would be well to consider glandular therapy. Of course the latter would be of no particular value, if some type of infection is the real cause of the trouble.

According to Dr. H. A. Hewlett, Professor of Internal Medicine in the University of Michigan, the effect of a low blood pressure upon the medullary centres is likely to be an increase in the heart rate, for it was found that tachycardia could be produced experimentally by reducing the pressure in a completely isolated cerebral circulation.

Hypotension may be due either to a very rapid flow of blood through the arterioles, or to a diminished output from the heart, or a combination of these two factors. A weakened heart muscle may be the cause of the diminished output, and therefore, of the hypotension. However, there may be an increased blood pressure associated with the failing circulation in heart disease, due to a compensatory constriction of the arterioles. If there is a lessened supply of blood to the heart, there may also be a diminished output, this condition resulting either from hemorrhage, or from a collection of blood in the veins or capillaries, following a loss of tone in these vessels. This loss of tone is usually taken care of very promptly by a constriction of the arterioles, so that the diminished blood pressure does not continue for a long time.

In syncope we have an anemia of the brain following a sudden reduction of the arterial pressure-such attacks, when associated with a slow pulse are called Stokes-Adams syndrome. The slow pulse in these cases is due to the heart block, resulting probably from a diminished conductivity in the auriculo-ventricular bundle.

Hypotension, extreme enough to produce fainting attacks, may also be associated with severe tachycardia, because in instances where the heart rate is very fast, there is likely to be a diminished ventricular output. Or, as has already been stated, there must be considerable loss of blood, before there is any appreciable effect upon the pressure. This is probably due, to some extent, to the increased respiratory movement, which in turn hastens the venous flow from the abdomen, and produces an accelerated heart action. This causes an increase in the total cardiac output, and until the hemorrhage has become rather extreme, the compensatory construction of the arterioles maintains the usual pressure.

In conclusion, I wish to summarize a few very important facts. First, that this very important symptom, hypotension, has been sadly neglected by the profession at large, and that its significance cannot always be determined. Second, that careful consideration of the abnormal conditions associated with hypotension, and frequent observations of the blood pressure in such cases, will do much to enlighten us in the future.— Medical Insurance and Health Conservation.

TREATMENT OF ARTERIAL HYPERTENSION

JOHN H. MUSSER, M.D., PHILADELPHIA.

Arterial hypertension is a subject about which much has been written in past years, as to the etiology, pathogenesis, and treatment. In spite of all that has been written and despite the facility with which medical men are accustomed to manage cases of hypertension, several new methods of treating this condition have appeared in the past two years and it is these newer methods that I wish to accentuate. First, however, it might be well to describe briefly just what we understand by hypertension, to present a general outline of the treatment for such high pressure, and then to discuss the more recent therapeutic innovations in the management of these cases, namely, benzyl benzoate and the restriction of salt and water intake.

Hypertension for which there is no obvious cause is a symptom, not a disease, and yet it is a symptom which is so closely related to disease that it is not amiss to treat the symptom, though as a general rule it is wise to observe the well known dictum "treat the disease and not the symptoms.' A high pressure, though merely a manifestation of some underlying pathological process, is so frequently the main symptom and the cause of so many closely related symptoms that it has come to be regarded as a definite entity, no matter whether the increased blood pressure is the result of a nephropathy, an endocrine dystrophy, or a narrowing of the smaller elements of the blood vascular tree. Furthermore, by the ordinary clinical and laboratory tests, with which we are acquainted, in many cases of high pressure we are unable to demonstrate renal changes, internal secretory disorders, or other causes to explain the pathogenesis of the condition of high pressure. We are accustomed to assume in such cases that there is present a glomerular nephritis or a renal sclerosis, yet we are unable

to show any distinct evidence of kidney pathology. This absence of symptoms and signs, except these referable to the high pressure, has led to a variety of names being applied to the syndrome. Janeway, because of the frequency with which such patients died a cardiac death, has labelled the disorder cardiovascular hypertensive disease. Allbutt has applied the term hyperpiesis to a group of cases in which elevation of the blood pressure is rather sudden and associated with many symptoms. Essential hypertension is the name most frequently applied to the disorder.

From this brief preliminary discussion of high blood pressure we may say that by essential hypertension we understand a condition of continuous high blood pressure, systolic pressure over 175 mm. of mercury, of unexplained cause. The patient may have many symptoms referable to the high pressure, yet on the other hand a high pressure may exist without symptoms and only be discovered accidentally when making a routine sphygmomanometer examination. Individuals of this latter type are not truly patients, yet the increasing incidence of disability and death from the results of high pressure and the likelihood of such events taking place within a comparatively short time in the life cycle make such a person a patient, one who requires treatment. He is objectively though not subjectively sick.

GENERAL TREATMENT

In the management of cases of hypertension it must not be forgotten that the hypertension is a compensatory process and that any efforts to reduce suddenly the pressure by drugs, bleeding, and so on should be avoided, unless there is a threatened apoplexy or some such catastrophe imminent. Activę measures are to be avoided unless absolutely necessary, and the pressure should be reduced slowly. Fortunately, Nature in her kindness has so ordained things that it is extremely difficult to reduce pressure at any time and more than difficult to reduce it suddenly. This is indeed a blessing, for many are the attempts to lower suddenly a high pressure, where success would lead to cardiac failure or to uremia. But in most cases the gradual reduction of the pressure is distinctly indicated, if for no other reason than to relieve the heart of a tremendous amount of unnecessary and harmful work.

DIET

The first step, and probably the most important in the handling of these cases, is the correction of faulty habits of life and notably the correction of the more than probable abuse of food. Overeating is to be avoided. Probably overeating has induced high pressure more frequently than any other single cause. Food should be taken at regular hours, eaten slowly, and should be followed by a short rest of fifteen or twenty minutes, as the pressure rises during and immediately after eating. Alcohol should be avoided and tobacco should. be used moderately. The protein foods should be eliminated from the diet to a great extent. Animal foods form the great bulk of the proteins and it is these foods that should be restricted. Fish, white meats, and eggs are as culpable as the long condemned red meats in the production of harmful nitrogenous waste products, so it is of little value to tell the patient to reduce one type of protein while he is given tacit permission. to go as far as he likes with other types. One small slice of meat a day should suffice the patient suffering from hypertension. Milk also should be taken moderately in chronic cases, whereas using it as a food alone, one thousand c.c. a day for several days, will reduce a pressure which has been found resistant to all other means.

PHYSICAL EFFORT

Excessive physical effort is to be avoided, by all means. Work should be much restricted and outdoor recreations should not be too strenuous. A certain amount of physical effort and exercise is advisable, however, as it aids the proper elimination of toxic waste products and brings about a healthy metabolic increase. Sudden severe violent physical effort is especially to be warned against.

HURRY, WORRY, AND MENTAL STRAIN

The patient with high tension should avoid mental stress and strain. The hurry of present day life, the worry incidental to so many diverse factors in business, and the mental strain accompanying such hurry and worry are distinctly to be avoided. The hypertensive patient should cultivate a calm, lethargic mien, if possible.