When these patients are seen with acute cardiac decompensation, there are, of course, much albumin and many casts in the urine, and the phthalein output is, for the time being, decreased.
Group C. This might be called the arteriosclerotic high-tension group (Stone's cardiac group). The cases are usually over fifty years old. They are men and women who have lived high and thought hard. Often they have had periods of great mental strain. Many men in this group were athletes in their young manhood. Many have been fairly heavy drinkers, although never drinking to excess. They are usually well nourished and inclined to stoutness. The pressure picture is high systolic with normal or only slightly increased diastolic and large pulse pressure. The arteries are large, full, fibrous, usually tortuous. The heart is very large, the apex far down and out. There is no polyuria; nycturia is uncommon, quite the exception. The urine is normal in color, amount, and specific gravity. Albumin is only rarely found and hyaline casts are not invariably present. The phthalein excretion is quite normal and the excretions of salt and nitrogen are also normal. The terminal condition in most of the patients in this group is cardiac decompensation. They may have several attacks from which they recover, but after every attack the succeeding one is produced by less exertion than the preceding one, and it becomes more and more difficult to control attacks. Eventually the patients become bed- or chair-ridden, and finally die of acute dilatation of the heart.
Occasionally patients in this group may have a cerebral attack, but in my experience this is uncommon. Pathologically the heart is large, at times true cor bovinum, dilated and hypertrophied. The cavity of the left ventricle is much dilated. The aorta is dilated and sclerosed.
The kidneys are increased in size, are firm, dark red in color, with fatty streaks in the cortex. The capsule strips readily and the cortex is normal in thickness or only slightly increased. The organ offers some resistance to the knife. The microscope shows small areas scattered throughout where the glomeruli are hyalinized, the stroma full of small round cells, the tubules dilated, and the cells are almost bare of protoplasm. Naturally the tubules are full of granular cast material. Also the arterioles show extensive intimal thickening, fibrous in character, with occasional obliterating endarteritis. One gets the impression that the small sclerotic lesions are the result of anemia and gradual replacement of scattered glomeruli by fibrous tissue. For the most part the kidney, except for the chronic passive congestion, appears quite normal. One can readily understand that in such a kidney function could not have been much interfered with.
Illustrative Case.—C. K., an active, stout, business man, aged fifty-six years, consulted me on account of shortness of breath and swelling of the feet in May, 1915. He had just returned from a hospital in another city, where he had gone with what was apparently cardiac decompensation. In his early manhood he had been a gymnast and a prize winner. He has worked hard, often given way to violent paroxysms of temper, has eaten heavily but drunk very moderately. The heart was greatly enlarged, the arch of the aorta dilated, a mitral murmur was audible at the apex. The radials and temporals were large, tortuous, and fibrous. The blood pressure picture ranged around 180-90-90. He was easily made dyspneic and had a tendency to swelling of the lower legs. The urine was acid, of normal specific gravity, normal in amount, normal phthalein, normal concentration of salt and nitrogen, contained albumin only when he was suffering from decompensation of the heart. Casts were always found. He finally died, after sixteen months, with all the symptoms of chronic myocardial insufficiency. The heart was enormous, a true cor bovinum. The kidneys were typical of this condition, possibly somewhat larger than usual.
Hypotension
When the pressure is constantly below the normal, it is called hypotension. This may be transient—as in fainting—it may be a normal state of the individual, it occurs in most fevers and in a great variety of diseases, including anemias.
In arteriosclerosis, especially the diffuse (senile) type, the blood pressure is invariably low, and may be spoken of as hypotension. The heart in such a case is small, the muscle is flabby, there is brown atrophy of the fibers, and some replacement of the muscle cells by connective tissue. The same causes which have produced general arteriosclerosis have also produced sclerosis of the coronary arteries, and probably the lessened blood supply accounts for much of the atrophy of the heart muscle.
In typhoid fever the maximum blood pressure during beginning convalescence may be as low as 65 mm. Hg. I have frequently seen hypotension of 80 mm. This is common.
Meningitis is the only acute infectious disease in which the blood pressure is more often high than low. This is accounted for by the increased intracranial tension.