Disturbances of the Heart / Discussion of the Treatment of the Heart in Its Various Disorders, With a Chapter on Blood Pressure

by Oliver T. Osborne

BLOOD PRESSURE AND INSURANCE

An epitome of the consensus of opinion of the risk of accepting persons for insurance as modified by the blood pressure is presented by Quackenbos. [Footnote: Quackenbos: New York Med. Jour., May 15, 1915, p. 999.] Some companies have ruled that at the age of 20 they will take a person with a systolic pressure up to 137; at the age of 30 up to 140; at the age of 40 up to 144; at 50 up to 148, and at 60 up to 153, although some companies will not accept a person who shows a persistent systolic pressure of 150. Quackenbos says that when persons with higher blood pressures than the foregoing have been kept under observation for some time, they sooner or later show albumin and casts in the urine. In other words, this stage of higher blood pressure is too frequently followed by cardiovascular-renal disease for insurance companies to accept the risk.

On the other hand, too low a systolic pressure in an adult, 105 mm. or below, should cause suspicion of some serious condition, the most frequent being a latent or quiescent tuberculosis. Such low pressure certainly shows decreased power of resistance to any acute disease.

Statistics prove that there are more deaths between the ages of 40 and 50 from cardiovascular-renal disease, that is from heart, arterial and kidney degenerations, than formerly. Whether this is due to the high tension at which we all live, or to the fact that more children are saved and live to middle life, or whether the prevention of many infectious diseases saves deficient individuals for this middle life period, has not been determined. Probably all are factors in bringing about these statistics.

While the continued use of alcohol may not cause arteriosclerosis directly, it can cause such impaired digestion of foods in the stomach and intestine, and such impaired activity of the glands, especially the liver, that toxins from imperfect digestion and from waste products are more readily produced and absorbed, and these are believed by some directly or indirectly to cause cardiovascular- renal disease. Hence alcohol is an important factor in causing the death of persons from 40 to 50 years of age.

The question of whether or not a person smokes too much, and what constitutes oversmoking, will soon be asked on all insurance blanks. As tobacco almost invariably raises the blood pressure, and when the blood pressure again falls there is again a craving in the man for the narcotic, it must be a factor in producing, later in life, cardiovascular-renal disease. Hence an increased systolic blood pressure must be in part interpreted by the amount of tobacco that the person uses. BLOOD PRESSURE AND PREGNANCY Evans [Footnote: Evans: Month. Cyc. and Med. Bull., November, 1912, p. 649.] of Montreal studied thirty-eight pregnant women who had eclampsia, albuminuria and toxic vomiting, and found the systolic pressures to vary from 200 to 140 mm. He did not find that the highest pressures necessarily showed the greatest insufficiency of the kidneys, but that the blood pressure must be considered in conjunction with other toxic symptoms. In thirty-two cases he was compelled to induce labor when the blood pressure was 150 mm. or under, while in four cases with a blood pressure over 150 mm., the toxic symptoms were so slight that the patients were allowed to go to term and had natural deliveries.

A rising blood pressure in pregnancy, when associated with other toxic symptoms, is indicative of danger, and Evans believes that a systolic pressure of 160 mm, is ordinarily the danger limit.

Newell [Footnote: Newell, h. S.: The Blood Pressure During Pregnancy, THE JOURNAL A. M. A., Jan. 30, 1915, p. 393.] has studied the blood pressure during normal pregnancy, and finds that when the systolic pressure is persistently below 100, the patient is far below par, and that the condition should be improved in order for her to withstand the strain of parturition. When the systolic pressure is above 130, the patient should be carefully watched, and he thinks that 150 is the danger line. Some pregnant women have an increasing rise in blood pressure throughout the pregnancy, without albuminuria. In other cases this rise is followed by the appearance of albumin in the urine. Thirty-nine of the patients studied by Newell had albumin in the urine without increase in blood pressure; hence he believes that a slight amount of albumin may not be accompanied by other symptoms. Five patients had a blood pressure of 140 or over throughout their pregnancy, and in only one of these patients was albumin found. All passed through labor normally, showing that a blood pressure below 150 may not necessarily be indicative of a serious condition; but a patient who has a systolic pressure over 135 must certainly be carefully watched. A fact brought out by Newell's investigations is very important, namely, that a continuously increased blood pressure is not as indicative of trouble as when a blood pressure has been low and later suddenly rises.

Hirst [Footnote: Hirst: Pennsylvania Med. Jour., May, 1915, p. 615.] also urges that a high blood pressure in pregnancy does not necessarily represent a toxemia, and also that a serious toxemia can occur with a blood pressure of 130 or lower, although such instances are rare. Hirst believes that when a toxemia is in evidence in pregnancy while the blood pressure is low, the cause of the toxemia is liver disturbance rather than kidney disturbance, and he thinks this form of toxemia is more serious and has a higher mortality than the nephritic type. Therefore in a patient with eclamptic symptoms and a low blood pressure, the prognosis is more unfavorable than when the blood pressure is high. He believes that if high blood pressure occurs early in the months of pregnancy, there is preexisting, although perhaps latent, nephritis. In these conditions the diastolic pressure is also likely to be high.

With the patient eclamptic and stupid, whatever the date of the pregnancy, Hirst would do venesection immediately in amount from 16 to 24 ounces, depending on what amount seems advisable. If venesection is done before actual convulsions have occurred, the blood pressure falls temporarily but rapidly rises again. He finds that if a patient is past the eighth month, rupture of the membranes will usually bring a rapid fall of from 50 to 90 points in systolic pressure. Usually, of course, such rupture of the membranes will induce labor. He finds that the fluidextract of veratrum viride is valuable when eclampsia is in evidence or imminent. He gives it hypodermically, 15 minims at the first dose and 5 minims subsequently, until the systolic pressure is reduced to 140 or less. He admits that this is rather strenuous treatment. He does not speak of treatment by thyroid extracts, which has been regarded as valuable by some other workers.

In these patients who show eclamptic symptoms, he maintains a milk diet, and purging and sweating. It should be remembered that venesection or profuse bleeding during induced parturition is more valuable than sweating in all eclamptic cases and in all nephritic convulsions. Profuse sweating does little more than take the water out of the blood, and even concentrates the poisons in the blood.

Hirst causes purging by 2 ounces of castor oil and a few minims of croton oil. He also advises large doses of magnesium sulphate. In such serious disturbances as eclampsia, it is not necessary to give a magnesium salt, which, it has been shown, can have unpleasant action on the nervous system. Sodium sulphate is as valuable and is not open to this danger.

Hirst urges that whatever the blood pressure, with albuminuria, as soon as persistent headache occurs, and especially if there are disturbances of vision, the pregnancy must be terminated at once. On this there can be no other opinion. Temporizing with such a case is inexcusable.

After labor has been induced there is an immediate fall of blood pressure, which lasts some hours. The pressure will again rise, and usually is the last sign of toxemia to disappear, and he finds that this increased pressure may last from two to three weeks when there is not much nephritis, and several months when there is nephritis.

Although he says he has found no bad action from ergot, either by the mouth or hypodermically in these eclamptic cases, it would seem inadvisable to use ergot, which may raise the blood pressure. He finds that pituitary extract "can cause dangerous rise of blood pressure."

Pelissier [Footnote: Pelissier: Archiv. mens., d'obst. et de gynec., Paris, 1915, iv, No. 5.] believes that when there is prolonged vomiting in early pregnancy, with an increase in systolic blood pressure, and with an increased viscosity of the blood, the outlook is serious, and active treatment should be inaugurated.

Irving [Footnote: Irving, F. C.: The Systolic Blood Pressure in Pregnancy, THE JOURNAL A. M. A., March 25, 1916, p. 935.] reports, after a study of 5,000 pregnant women, that in 80 percent the systolic blood pressure varied from 100 to 130; in 9 percent it was below 100, at least at times, but a pressure below 90 does not mean that the woman will suffer shock; in 11 percent the pressure was above 130, and high pressure in young pregnant women more frequently indicates toxemia than when it occurs in older women; high pressure is more indicative of toxemia than is albuminuria; a progressively increasing blood pressure is of bad omen, and most cases of eclampsia occur with a pressure of 160 or more, but eclampsia may occur with a moderate blood pressure. Irving believes that with proper preliminary preventive treatment most eclampsia is preventable.