SLEEP AND REST

During sleep the pressure falls most decidedly and the same applies to absolute rest in the recumbent position. The patient, therefore, should be instructed by the physician to obtain a good night's rest and when insomnia prevents this, some of the mild sedatives should be prescribed.

ELIMINATION

One

In these cases the bowels should be kept well open. or two good loose movements a day should be secured by a morning saline purge and once or twice a week calomel or blue mass should be taken, or the mercurial may be taken when the symptoms of hypertension are particularly annoying.

HYDROTHERAPY

It is my custom to order for my patients electric cabinet baths twice a week. In my dispensary patients, this is obtained in the hydrotherapeutic department of the University Hospital. Elimination through the skin may be aided further when it is impossible to get the cabinet baths by having the patient take Turkish baths once or twice a week and follow this with mild exercise. When hydrotherapy of this type is unobtainable I recommend a prolonged warm bath for fifteen minutes at a temperature of 103° F.

DRUGS

It has been shown conclusively that drugs are of little value in combating high pressure over any length of time. The iodides are of value only in syphilitic cases. The nitrites produce a temporary fall in pressure only and a tolerance of them quickly follows their prolonged use. They should be re

served for emergencies. Radium charged water has not been followed by any particular action, as far as I could determine in the few cases in which I have employed it. Of the newer drugs benzyl benzoate has received particular attention as a reducer of blood pressure.

This drug was introduced by Macht in 1918 and came into general use in the fall of 1919. Benzyl benzoate is one of the so-called minor alkaloids of opium and was isolated by Macht during the course of his study of these alkaloids. He discovered that these preparations have a marked relaxing action on the unstriped muscles of the body and are capable of relieving spasm of such muscle. On account of this antispas

modic and tonus lowering effect Macht had the drug tried out in a variety of conditions which are associated with muscular spasm. He asserts that he received good results in relieving the following spasmodic conditions: Diarrhea and dysentery, intestinal colic and enterospasm, pylorospasm, spastic constipation, biliary colic, ureteral colic, vesical spasam, spasmodic pains in seminal vesicles, uterine colic, bronchial asthma, and arterial spasm hypertension.

It is with this last condition that we are particularly interested to-day and I will recount to you my rather brief experience. In a small series of six cases I religiously gave the drug for some weeks. In order to test it out I used but few auxiliary methods but rather made an effort to see if the benzyl benzoate, plus a few simple general hygienic directions, would lower the pressure. In no case did I see any effect from it whatsoever. Likewise I have talked with some of my colleagues and they have been almost unanimous in expressing the opinion that it has but little effect on the blood pressure.

While I have seen little if any result from the administration of benzyl benzoate in the treatment of increased blood pressure I have had the opportunity of testing it in two cases of angina pectoris and can testify as to its value in this condition. Likewise in several other painful or disagreeable spastic conditions its action has been truly remarkable.

REDUCTION OF SALT AND WATER INTAKE

Some months ago Dr. F. M. Allen published an article (1) on the arterial hypertension in which he advocated the reduction in water intake and the elimination of salt in the treatment of hypertensive cases. Allen's thesis is that in many cases high pressure is a compensating process in which the elevated pressure is necessary "to force a filtrate of water and dissolved substances through a damaged and partially blocked glomerular filter." His theory, while not a new one, has never received much attention in this country or Germany, though to a certain extent the French school has recognized the coexistence of high pressure and salt retention. Allen shows by his results that there is a very definite relation between salt retention, large water intake, and high pressure. To deter mine the value of this procedure we have observed, in the medical dispensary of the University Hospital, the effect of the lowering of salt and water intake upon patients with arterial hypertension, not caused by obvious renal disease.

Likewise in three private cases I have had the opportunity of watching the effect of this treatment upon the blood pressure. Though there are only seven cases to report upon and it is unwise to draw deductions from this small series, nevertheless as the results were so uniform, it does not seem unfair to present them.

In the dispensary cases studied by Dr. Robert McMillan repeated examinations were made of the blood urea, plasma chlorides, and phenolphthalein elimination. He found that the plasma chlorides were raised before reducing the salt intake and that the reduction in chlorides was commensurate with the lowering of the salt intake. Likewise the height of the pressure had a fairly definite relation to the plasma chloride fall. In order to illustrate more satisfactorily the result of this treatment I will recount briefly the history of a patient I have treated with potassium iodide and sajodin, and subsequently placed upon a modified restricted salt-free diet.

Case. Mrs. M., aged fifty-three, widow. Patient referred on account of gastric symptoms. Except for the gastric symptoms, ringing in the ears, nicturia once a night, and an intermittent heart, she had no other complaints. There was no edema nor dyspnea. In her past history there was noted eclampsia sixteen years ago and hysterectomy nine years ago. The family history showed that her mother had died of apoplexy at the age of seventy-one, and one brother of nephritis and apoplexy at fifty-six.

Examination showed a rather well nourished female; eyes, teeth, tonsils, and thyroid negative; lungs clear; heart enlarged down and left. There was heard a presystolic mitral murmur, a much accentuated aortic second sound, and an occasional extrasystole. Abdominal examination showed nothing but a slight ptosis of the stomach. The gastric examination showed a marked subacidity. The urine in repeated tests

showed a specific gravity varying from 1008 to 1024. Occasionally a trace of albumin was found. The preliminary blood pressure was 205-120, the hemoglobin ninety per cent. The eye grounds were negative.

The patient was ordered sodium phosphate daily, prolonged warm baths twice a week, a low protein diet, and was given general directions as to daily hygiene. In a short time iodide of potassium was ordered and subsequently sajodin. For a month the pressure ranged between 205-190 systolic, 120-110 diastolic. At the end of this time, when the pressure was 205-115, the patient was suffering very much from dizziness and tinnitus. She was ordered to cut out salt from her dietary and restrict water to 800 c.c. a day. Eight days later the pressure was 185-105; in nine subsequent examinations it had fallen steadily until at the present time it is 160-100. The patient is now practically free from symptoms and is apparently in good general condition.

There are several minor observations I would like to make upon this phase of the treatment of hypertension. If a reduction of salt intake is ordered, the need of the organism for water for the purpose of diluting the increased chlorides retained in the body is not pronounced. Therefore, with the reduction in the salt the desire for water is decreased and the water intake is almost automatically diminished. The estimation of the plasma chlorides gives positive evidence of the reduction of these salts which is confirmed by the blood pressure observations. While the plasma chloride estimation is of great value and should be used whenever possible in treating the hypertension patients, nevertheless the parallelism of the reduction of the pressure and the chlorides is so close that by simply following the blood pressure a fairly accurate idea may be attained as to the actual reduction of the plasma chlorides when laboratory facilities are lacking. Lastly, it must not be supposed that all cases respond to this form of treatment, as, for example, Case VII. in the table.

CONCLUSION

The management of a case of hypertension requires a careful study of the patient. Unless some threatened vascular cardiac or renal catastrophe seems imminent, physical and hygienic measures should be relied upon more than drugs. The reduction of salt and water intake forms a valuable adjuvant to these measures.-New York Medical Journal.

H

ROCKEFELLER FOUNDATION ELECTION

At its regular December meeting, the Rockefeller Foundation elected to membership in its International Health Board, Doctor John G. Fitzgerald, Professor of Hygiene and Preventive Medicine, and Director of the Connaught Antitoxin Laboratories, at the University of Toronto.

Dr. Fitzgerald was born in Ontario, and received his medical education in Toronto University. He pursued graduate studies in medicine at the Harvard Medical School, Pasteur Institute, Paris, and the University of Freiburg. From 1911 to 1913 he was associate professor of bacteriology in the University of California. He has written many articles on medical subjects, particularly on bacteriology and immunology, and has published several volumes, including "Laboratory Guide in Bacteriology" (1911) and "Introduction to the Practice of Preventive Medicine" (1922). In 1914 he entered the Royal Army Medical Corps of Canada and saw service in France, attaining the rank of major.

Carrying out pledges previously made, the sum of $1,000,000 was appropriated to the medical school of the University of Chicago, $1,000,000 to the medical school of the University of Toronto, and $225,000 to the medical school of the University of Iowa. In addition, $500,000 was appropriated for endowment of the medical school of the University of Alberta, Canada.

Appropriations were made to continue fellowships in physics, chemistry, medicine, and the biological sciences in the United States under the auspices of the National Research Council. An estimate of the expenditures of the Foundation for the year 1924 shows commitments of $10,500,000, leaving a balance of less than $1,000,000 still available for appropriation in 1924 from the regular income of the year and balances carried forward from the previous year.

TO BE HEALTH EXPERT IN FRENCH METROPOLIS At the invitation of the Red Cross League of France, Miss Eunice Dyke, Director of Public Health Nursing, will spend four months in Paris as consultant on public health nursing. The League will pay her travelling expenses and $300 a month. She will be in Paris from February to May.