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MEDICAL RECORD. [September 25, 1915 Blood-Pressure in Life Insurance Examinations. — Dr. Claude viagra with dapoxetine reviews C. Cody, Jr., says that the earlier studies in this field were all on arterial pressure, while venous pressure to this day has been neg- lected. Several factors of prime importance are not constant, and, therefore, the normal viagra makes you bigger venous pressure has great variations due to changes in the atmospheric temperature or pressure. Con- sequently the venous pressure is not now, and probably will not be in the immediate future, of any value viagra with dapoxetine reviews to us in life insurance examinations. The determination of the arterial or blood-pres- sure is encumbered with no such difficulties, and the results are of great value from a prognostic standpoint in life insurance work. In studying the technique of blood-pressure the prime factors of importance and which are under our control are the posture of the patient, his mental attitude, and the instrument. The patient should be seated in a chair with his arm resting upon a table. The mental attitude of anxiety or intense curiosity may be sufficient to cause a rise in blood-pressure of 20 mm. This curiosity may be overcome by telling the patient that three or more readings will be necessary. Blood-pressure may be obtained by either the auscultatory or the palpatory methods. The former has a double advantage over the latter, due to greater accuracy and the ability to de- termine the diastolic pressure. The auscultatory readings are uniformly higher than the palpatory. The technique of the auscultatory readings is as follows: After the arterial pulsation viagra with dapoxetine reviews has been eliminated the stethoscope is applied over the artery, with a gradually decreasing pressure in the arm cuff, and the reading is noted at the first sound, usually a click or clicking murmur. Following this there is a series of sounds which Ettinger, in 1907, separated into five phases and named in the order of their occurrence. The fii'st phase marks an interval of clear tones which is soon replaced by the second and third. The sec- ond phase marks an interval of muffled tones with a series of murmurs. The third phase marks an interval of clear, frequently booming tones which suddenly cease. The fourth phase marks an in- terval of dull tones. And the fifth phase marks the disappearance of all sounds. The first, sec- ond, and third phases are always clearly marked, occasionally some difficulty will be experienced in differentiating between the third and fourth. In this case the point of the disappearance of the third phase can viagra with dapoxetine reviews be readily determined by lowering the blood-pressure until the sound disappears, then gradually increasing it when the dull tone of the fourth phase is audible, followed almost in- stantly sometimes by a clear, loud tone which marks the end of the third phase. It must be plain though that the distinction between the vari- ous phases viagra with dapoxetine reviews is clear only over normal arteries and those which are but slightly sclerosed; and, also, when the heart beats are regular in force and rhythm. The determination of the precise point of diastolic pressure is the subject at present of more discussion in the technique than any other. Korotkoff, in his original communication on the auscultatory method in 1905, stated that the dias- tolic pressure w-as marked by the change from the clear third tone to the dull fourth — in other words, at the end of the third phase. This is the generally accepted fact. The heart must always lift a certain load equal to the peripheral resistance before the aortic valves will open. From the moment the valves open pressure forcing viagra with dapoxetine reviews the blood toward the peri- phery is represented by the force exerted by the heart from the opening of the valves till the close of the systole. Thus, the diastolic pressure repre- sents the peripheral resistance and the pulse- pressure represents the actual propulsive force in the arteries. The normal diastolic pressure is be- tween 80 and 90 mm. with 70 and 100 as the lim- its; the normal pulse-pressure is 40 and 30 and 50 mm. as the limits. In conclusion it can be stated that: (1) Venous pressure is of little value. (2) The posture, men- tal attitude, and instrument are important. (3) The auscultatory readings are 5 to 8 mm. higher than the palpatory. (4) The auscultatory method is better than the palpatory. (5) The diastolic pressure should be read off the scale at the end of the third phase and not at the disappearance of sound. (6) Since the viagra with dapoxetine reviews diastolic pressure meas- ures the peripheral resistance it is a better index of hypertension than systolic pressure. A sus- tained diastolic pressure of 100 to 110 indicates hypertension. The diastolic is less influenced by physiological factors than the systolic pressure. (7) The pulse-pressure measures the energy of the heart in systole in excess of the diastolic pressure. Clinically it is the load viagra with dapoxetine reviews of the heart and is approximately 50 per cent, of the diastolic pressure. (8) Marked variations within short in- tervals in pulse pressure observations should make one think of a neurotic cardiac element. (9) The blood-pressure determination is worth all the trouble it takes from a prognostic or life insur- ance viagra with dapoxetine reviews standpoint. — Texas Medical Neivs. Group Insurance for a Street Railway Company. — The Brooklyn Rapid Transit Company has made an arrangement with a large insurance company whereby all of viagra makes you bigger its employees who have been two years or more with the company may insure under the so-called "group" plan. Those eligible number