Casts are not infrequently found in chemically normal urine from a middle-aged patient. Other things being normal, the finding has no significance. The kidneys must be carefully tested functionally.

Blood pressure readings should always be taken with the patient in the same posture at every estimation. At the first examination it is advisable to take readings from both brachial arteries. Let the patient sit comfortably and relax all muscles.

Differentiate as soon as possible between the uncompensated heart caused by valvular disease and that caused by arteriosclerosis. There is a difference in prognosis. Both give the same symptoms, and are treated similarly until compensation returns; thereafter the management of the two forms is different.

Aortic incompetence that comes on late in life is generally the result of curling of the free margins of the valves caused by syphilitic arteriosclerosis. Prognosis is grave because of the fact that the heart muscle also is the seat of degenerative changes and compensatory hypertrophy is established with difficulty.

When laying down a regime for a patient, consider his disposition, and individualize the treatment. Remember that exercise is an essential feature of the hygiene of the patient's life but do not forget to be explicit about the amount and character of the permissible exercise.

In the prophylaxis of arteriosclerosis, a rational mode of living is the all-important factor. As a rule, the less meat one eats, the less is the liability of arterial degeneration as age advances. The exceptions to this rule are many, and probably depend upon the character of the "vital rubber" with which the individual begins life.

The diet in well-marked cases of arteriosclerosis should be carefully selected with regard to its nutritive and non-irritating character.

Animal proteins should be sparingly used. Milk should have an important place in the dietary.

No drug relieves the pain of uncomplicated aneurysm as surely as iodide of pota.s.sium.

Iodides frequently upset the stomach. Be cautious in the use of them.

The irritable stomach may turn the scales against your patient.

Use cardiac stimulants with care and judgment. If all the valuable ammunition is used up at first, the fight will be lost.

Use digitalis with especial care. Its chief usefulness is in steadying the decompensated heart, improving the conduction of impulses, and increasing the tone of the cardiac muscle. _It should never be given to patients with very slow pulses, the subjects of Stokes-Adams syndrome._ Digitalis has been found to produce partial to complete heart block when therapeutically administered.

Remember that in the uncompensated heart morphine not only eases the oppressive dyspnea, but also steadies and stimulates the heart.

See to it that the patient has a daily movement of the bowels. In the early stage try the effect of liquid paraffin or of the mineral waters such as Pluto, or Hunyadi Janos, or artificial Carlsbad salts (Sprudel salts). These last can be made as follows: Sodium chloride, ounce I; sodium bicarbonate, ounce II; sodium sulphate, ounce IV. Take two tablespoonsful of this in a gla.s.s of hot water before breakfast. Should these not succeed, a.s.sist the action of the drugs by the use of enemata.

The pill of aloin, strychnine sulphate, and extract of cascara, with the addition of a small quant.i.ty of hyoscyamus, is a mild tonic purgative.

In cases of constipation with high tension, there is no drug as valuable as calomel or one of the other mercurials given occasionally.

Never give Epsom salts unless copious watery stools are desired to deplete effusion into the serous cavities or into the subcutaneous tissue.

Chronic constipation increases the gravity of the prognosis.

In case of suppression of urine and anasarca, hot air packs may be of value. The patient may be wrapped in a hot wet sheet and covered with blankets. I do not believe in administering pilocarpine to a.s.sist the sweating.

Remember to treat the patient and not the disease. The careful hygienic and dietetic treatment, combined with the least amount of drugging, is the best and most rational method of treatment.