Atlanta who told me the other day that he knew of two cases where he had removed the ovaries and tubes without improvement and then found that the whole trouble was due to chronic strain of these joints.

I think another thing which is of just as much importance as the mechanical side is the frequency with which we have a toxic inflammation superimposed upon this condition. Whenever a putrefactive condition is present the trouble is precipitated. In one case we put a belt upon the patient, and he was very much relieved, but he began to eat anything and immediately had a return of the trouble. It took a combination of both these means to effect a cure. It is often necessary to combine proper dietetic measures with the proper mechanical treatment to accomplish good results.

I endorse what Dr. Toepel says as to the value of exercise; that is necessary to strengthen the ligaments. The apparatus should be worn only as long as the patient can not maintain proper posture. The important thing to restore proper tone is exercise. It is absolutely indispensible, and it is not general exercise, but special localized exercise that is needed.

As to curvature of the spine, I think some cases are produced by strain upon the sacro-iliac joints, because the body is held away from the diseased joint and in standing that way for any length of time of course curvature is produced.

SIGNIFICANCE OF ARTERIAL HYPERTEN

SION-ITS TREATMENT.

BY RALSTON LATTIMORE, M.D., SAVANNAH.

This is a subject, in my opinion, of great interest to the medical profession, because it is met with so frequently in our every-day practice, and its significance is so often, yes, very, very, often misconstrued by many of us. When it occurs it is, of course, abnormal, but in every sense of the word a symptom and not a clinical entity.

It is common in nephritis, especially chronic interstitial nephritis; but occurs sometimes in cases which present the same cardio-vascular lesions, as chronic Bright's disease, with absolutely no evidence of renal involvement. Such is the history with, and without, apparent kidney involvement.

Now, for a practical working classification, I shall use the classification of Dr. Theodore C. Janeway, of New York, and from whose monographs I shall quote freely.

The question of practical importance to us is: What shall a physician do in the presence of a marked arterial hypertension?

The truism here obtains, as elsewhere: "No treatment without diagnosis."

I.

HYPERTENSION IN ARTERIOSCLEROSIS.

In cases of arteriosclerosis, the high tension pulse is probably due to a physiological contraction as in Bright's disease, more than to the changed condition of the arteries.

2.

HYPERTENSION IN NEPHRITIS.

The theory of the retention of waste products which fail to be eliminated, acting on the heart and vasomotor mechanism must be abandoned because hypertension is most common in that form of nephritis in which the least retention occurs.

A purely anatomical increase of the resistance is extremely improbable. Dr. Janeway reports a response, from 195 to 95, on the blood pressure indicator, from three injections of nitroglycerin, one fiftieth of a grain at fiveminute intervals. This shows almost conclusively to my mind that the vasomotor tone must be the predominant factor and not the anatomical changes.

Hypertension and cardiac hypertrophy are most frequently associated with that type of nephritis in which the glomeruli of the kidneys are most diseased. The functional activity depends on the amount of blood which flows through the glomeruli. The slow flow through the contracted capillaries of the glomeruli calls for a response, not only from the vasomotor centers of the kidneys, but goes beyond to the cerebro-spinal centers, which cause a general contraction, sufficiently strong to maintain a normal flow through the glomeruli.

3. HYPERTENSION OF UNKNOWN ORIGIN. In these cases little can be said, except, possibly, a vasoconstrictor reflex from other organs.

4.

HYPERTENSION A COMPENSATORY MANIFESTATION.

Here we have an attempt of nature to maintain a sufficient flow of blood through the capillaries of the kidneys and other important organs, which would not be possible without a general hypertension. It is a symptom of disease, also an effort of the body to maintain a proper circulation or equilibrium in all organs.

5. RESULT: DANGER OF HYPERTENSION.

A persistent high blood pressure will always cause important changes in the circulatory system, the heart and the arteries. The so-called changes of arteriosclerosis and Bright's disease are probably secondary.

Therapeutic Indications. Now, we approach the practical part. What shall a physician do in the presence of a marked hypertension? First of all, we should try to prevent further mischief, and, as far as we are able to check a more advanced development of kidney trouble and the secondary changes in the arteries and heart.

Diet is very important, and should be planned with the constant idea of physiological economy of nutrition, especially limiting proteid metabolism. Rest in bed and a milk diet are very important when the condition is urgent and the results are often gratifying to both physician and patient.

Occupation requires close supervision. Prolonged and excessive mental work or excitement has a marked tendency to raise blood-pressure. Hard physical labor is unwise, because it puts too much strain on the already hypertrophied heart.

The supervision could easily be summed up in the one word, moderation.

The use of alcohol is usually unwise, though, in some patients, has very little effect on blood pressure.

Tobacco causes a marked hypertension effect; in fact, it stands at the top of the list and should be stopped, either at once or gradually, depending on the individual temperament.

As Dr. Janeway so aptly states, that when no symptom of a threatening nature occurs, preventive measures alone are called for, and under such circumstances a systolic blood pressure of 200, yes, even 250 or over,

is not incompatible with a number of years of comparative comfort: particularly if the response to the treatment is favorable and the patient heartily cooperates.

Comments. It is always well to bear in mind the truism, "No treatment without diagnosis," and that no treatment is better than meddlesome therapy.

The belief that high blood pressure per se is a danger to the patient, and should be attacked by every means in cur power, has just enough truth in it to make it a serious misconception. For example, digitalis is practically the one drug that can combat successfully asystole, because it is known that on account of its power to physiologically raise blood pressure by increasing the systole of left ventricle, and also by vaso-constriction, it is often withheld; the patient progressing by approaching the gates of death: because of the physician's unwillingness to prescribe the one important drug.

Then, what shall we think of a man who, in the presence of a weak heart and loss of vasomotor tone, gives our best vasodilator, nitroglycerin?

Preventive Treatment. Effort must be directed to limiting and ameliorating the primary disease, such as hygiene and dietetic treatment. Often excellent results are obtained in middle life by regulating the diet and mode of life. Occasionally the blood pressure is brought to almost normal. The watchword should be moderation in all things; diet, mental and physical exertion. General massage at times is of considerable service.

Adjuvant Treatment. Digitalis is our mainstay in combatting asystole, secondary to arterial hypertension. Almost any good, reliable preparation of digitalis will do. Personally, I have accustomed myself to the use of an excellent preparation made by P. D. & Co. called, “Digitalone," assayed and equal to one-tenth the strength