By the term blood pressure people are inclined to think of a serious disease of modern civilization. Due to modern stressful life has become the “silent killer”. In certain pathological states the BP rises above the normal figure, sometimes reaching such heights as to become a source of imminent danger to life. This raised BP is not a disease by itself, but a sign or manifestation of a pathological process. It is a measurable external index of an internal malady. The rise of BP is a conservative or compensatory process by which adequate circulation of blood is maintained in the tissues, in-spite of increase resistance or obstruction to the flow of blood. If the BP would fail to rise while the obstruction to the flow of blood is increasing, the inevitable result would be death from failure of circulation.
High BP, which is also known as hypertension, seems to be more common in modern times. It cannot be denied that modern civilization has brought in its wake a great deal of adverse factors tending to raise BP. Intensive struggle for existence associated with continual anxiety, greed, ambition, artificial methods of living, want of faith in religion, intemperance, irregular hours, adulterated and unwholesome food and many vices peculiar to modern civilization do play an important part in its causation. Moreover, with the discovery of the sphygmomanometer, the detection of raised BP has become an easy affair and therefore, more cases are brought to the notice of the profession today than before.
Treating hypertension with anti hypertensive’s and sedatives appeals to the logic of the common-medical practitioner. They are taught that those cases of hypertension with no detectable cause may be treated as “essential hypertension”, which in layman’s language is hypertension of unknown cause. The followers of modern medicine use anti-hypertensives and sedative drugs to save the patient from a possible, probable or rather certain catastrophe that would take place if they were left alone. These antihypertensive drugs in the long run may prove unhelpful if not actually harmful. Undetectable causes of essential hypertension can be overcome by treating the sick individual as a whole according to the laws of Homoeopathy, not by treating him in parts.
An elevated arterial pressure is called hypertension and is the most important public health problem in developed countries. It is a common, asymptomatic, readily detectable, usually easily treatable ailment that often leads to lethal complications if left untreated. The prevalence of hypertension depends on both the racial composition of the population studied and the criteria used to define the condition. In a suburban population study, nearly one-fifth of individuals have blood pressure >160/95mmhg, while almost one-half have pressures >140/90mmhg. In females the prevalence is closely related to age, with a substantial increase occurring after age 50. This increase is presumably related to the hormonal changes of menopause. The ratio of hypertension frequency in women versus men increases from 0.6 to 0.7 at age 30 to 1.1 to1.2 at age 65.
American Heart Association, Recommended Blood Pressure Levels
Recheck 2 years
Recheck 2 years
High Normal (Severe)
130 – 139
85 – 90
Recheck 1 years
Understanding of the etiology of hypertension is far from complete but there seems to be a strong familial and genetic predisposition and a number of modifiable predisposing factors have also been identified. Several studies have demonstrated the influences of:
Rapid heart rate.
PATHOPHYSIOLOGY OF HYPERTENSION-
Blood pressure is defined as the product of cardiac output and peripheral resistance (PR).Hypertension is therefore said to be caused by increased cardiac output and/or increased PR. Each of these primary factors is determined by a complex series of interactions.Increased cardiac output, though involved in the initiation of hypertension, does not persist. The typical hemodynamic finding in established hypertension is an elevated PR and normal cardiac output. It is also suspected that heredity plays a role as a background to most of these abnormalities, along with varying contributions of three environmental factors: sodium, stress and obesity.
Factors involved in increased cardiac output-
1. Increased circulating fluid volume
Excess sodium intake and sodium sensitivity : Excess sodium intake can cause hypertension by increasing fluid volume and preload, thus increasing cardiac output.
Renal sodium retention-excessive sodium retention by the kidney has also been proposed as an important factor.
c) Sympathetic nervous over activity- the sympathetic nervous system (SNS) directly or indirectly dictates the state of cardiac output and systemic vascular resistance. Thus, excessive activity of SNS may increase the blood pressure.
2. Increased peripheral resistance-
The final common feature of established hypertension is a raised peripheral resistance, which can be associated with both functional constriction and structural vascular remodeling and hypertrophy.
3. Other pathogenetic factors-
Insulin resistance and hyperinsulinaemia are often associated with hypertension.
4. Contributing factors-
A variety of factors, such as foetal environment, plasma calcium, intake of calcium and parathyroid hormone, deficiency of potassium or magnesium, alcohol and physical inactivity are considered to be the contributing factors in susceptible individuals.
SYMPTOMS OF HYPERTENSION-
• Blurred vision
• Chest pain
• Difficulty in breathing
History of diabetes, asthma, heart disease, gout, drinking, smoking, self-medication or use of oral contraceptives should also be brought to the notice of the doctor.
COMPLICATIONS OF HYPERTENSION:
In the beginning hypertension is labile, but in due course, it becomes established hypertension. The complications are more common in higher blood pressures. The accompanying arteriosclerosis may be the reason for cardiovascular diseases in uncontrolled hypertension; Ischemic heart diseases like angina pectoris, myocardial infarction or congestive heart failure. 50% of patients die, 33% get cerebral strokes, 15% get renal failure. Renal failure is more common in hypertension with diabetes as the patients suffer from proteinuria, which is an evidence of nephropathy.
The complications are classified into two types-
1. Hypertensive complications;
• Malignant hypertension
• Congestive cardiac failure
• Aortic dissection and aneurysm
• Cerebral hemorrhages and infarctions
2. Atherosclerotic complications;
• Ischemic heart diseases like angina pectoris and myocardial infractions
• Sudden death
• Cerebral thrombotic strokes
• Peripheral vascular diseases
HOMOEOPATHIC CONCEPT OF HYPERTENSION
Homoeopathy considers health as a state indicating harmonious functioning of the life force. Disease is a deviation from health, which develops when the life force is unable to overcome obstructions to its smooth functioning. It can be seen as the total response of the organism to adverse environmental factors, internal or external, conditioned by constitutional factors, inherited or acquired. This stands true for all diseases, including essential hypertension. A closer examination of the modern concepts of health and disease accepted in the medical world today shows that they are coming closer to the homoeopathic model. Perhaps nothing epitomizes this better than the etiological concepts of essential hypertension, which is seen as a product of “constitutional” and environmental factors.
Notwithstanding these similarities, there remain for the most part significant differences in the concept of disease in both systems. The essence of this difference is contained in the Hahnemannian statement — “there are no diseases, but sick people”. Perhaps a more eloquent exposition is given by Dr. Kent in his lecture on “the sick”. He says “the allopath thinks that the house in which the man lives, which is being torn down, expresses all there is in sickness. In other words, tissue changes are all there is to the sick man. But homoeopathy perceives that there is something prior to the results. It is the man who is sick and has to be restored to health, not his body, not his tissues”. Thus in the case of essential hypertension, homoeopathy focuses on the patient with the hypertension, rather than on the hypertension itself. The totality of various characteristic signs and symptoms exhibited by this patient leads the homoeopath to the similar remedy. The similar remedy relieves the totality of symptoms and with it the symptoms of an elevated blood pressure.
MIASMATIC INFLUENCES —
Miasms are the constitutional or diathesis states which determine the mode of existence of the individual. It can be seen as a predisposition towards various chronic diseases. Hahnemann described three basic miasms which he believed to be the underlying causes of chronic disease. In any given patient, there could be the influence of one miasm, or any combination of them. An accurate miasmatic diagnosis depends on the symptoms and signs of the individual patient. A broad understanding of the miasmatic influences in essential hypertension is possible from the examination of the etiological factors, pathology and clinical presentation in general.
A. PSORIC PREDOMINANCE —
Patient with psoric predominance typically have labile hypertension or hypertension caused by emotional disturbances like anger, anxieties worry, grief etc. over a period of time. When these factors settle down, the blood pressure elevation may also subside. They are prone to be more symptomatic, complaining of dizziness, dyspnoea, palpitation etc. which are better by lying down and keeping quiet and worse after eating. The psoric element makes sure that there are many sensations, concomitants and modalities, giving a true picture of the suffering. The heart symptoms are always associated with great anxiety and fear, always fear that they will die from heart trouble.
B. SYPHILITIC PREDOMINANCE —
The predominantly syphilitic patient is usually asymptomatic. They may have a few subjective symptoms, desires or longings. They have little mental disturbance accompanying the heart conditions. These patients are prone to die suddenly and without warning, their lives “snuff out” like a candle. The syphilitic influence in essential hypertension leads to widespread destruction changes in the vital organs like heart, kidney, retina and brain.
C. PSEUDO-PSORIC PREDOMINANCE —
The pseudo psoric or tubercular miasm may reflect many of the subjective symptoms, the mental and emotional reactions of the predominant parent, psora as well as the pathological changes of the younger parent, syphilis. Hypertensives with the tubercular dimension are likely to have wide fluctuations in blood pressure to very high levels of systolic and diastolic pressures. They are prone to hemorrhagic manifestations like epistaxis, retinal hemorrhages etc.
D. SYCOTIC PREDOMINANCE —
In the predominantly sycotic patient, the subjective symptoms are less, like the syphilitic. We find none of the fears and apprehensions of the psoric patients. In essential hypertension, the sycotic element may be responsible for marked ventricular hypertrophy. The combination of psora with sycosis may also cause marked changes in the structure of the heart, as well as dropsical conditions. As a rule the sycotic patients are fleshy and puffy, their obesity contributing to their dyspnoea.The dysponea is painful. There may be soreness and tenderness and pains radiating from the heart to scapula or from shoulder to heart. These pains are ameliorated by motion, walking, riding or gentle exercise. The heart complaints may be accompanied by or there may be a past history of suppressed rheumatic symptoms.
The homoeopathic management of essential hypertension like all other disease conditions is based on the principle of similia. Being a chronic disease, it requires constitutional, anti-miasmatic treatment. It is the totality of symptoms which guides the homoeopath to the indicated remedy. In the search for the similar remedy, homoeopathy lays emphasis on the individuality of the patient in aphorism 153 of the Organon. Hahnemann makes it clear that it is the peculiar, characteristic and individualizing symptoms and not the common symptoms that denote the similimum. Hahnemann also stressed the prime importance of the mental symptoms in all physical disorders. He said that the mental disposition and emotional reactions are to be particularly noted as they often determine the remedy selection. This will apply naturally to cases of essential hypertension where psychological factors play a significant part in the causation of illness. While treating diseases with multiple miasmatic influences like essential hypertension, it is also important that the remedy selected correspond to the dominant miasm. This is very often found to be the psoric miasm. Afterwards, the dormant syphilitic or sycotic miasm, as the case may be, manifests itself and may call for appropriate changes in remedy.
Below are some remedies often used in managing hypertension:
ACONITUM NAPELLUS —
Indicated in tachycardia. Affections of the heart with pain in left shoulder. Stitching pain in chest. Palpitation, with anxiety, fainting, and tingling in fingers. Pulse full, hard, tense and bounding; sometimes intermits. Temporal and carotid arteries felt when sitting. Great fear, anxiety and worry accompany every ailment. Fears death but believes that he will soon die; predicts the day. Fears the future, a crowd, crossing the street. Restless with fullness, heaviness in head. Vertigo worse on rising and shaking head.
ADONIS VERNALIS —
Indicated in mitral and aortic regurgitation. Chronic aortitis. Fatty heart pericarditis. Rheumatic endocarditis. Precordial pain, palpitation and dyspnoea. Marked venous engorgement. Cardiac asthma. Fatty heart. Myocarditis, irregular cardiac action, constriction and vertigo with irregular and rapid pulse.
Indicated in high arterial blood pressure. Roaring in the ears due to high blood pressure. Palpitations and Tachycardia. In the crude form, it causes constriction of the peripheral arterioles resulting in a rise in blood pressure.
ALLIUM SATIVUM —
Pain in the left side of chest with dark urine. Darting pain in the chest which prevents sleep. Bounding of the heart. It suits people who eat a great deal more than they drink. In the mental sphere there is anxiety and impatience. Fears he will not recover; that he will not be able to bear any medicine, fear of being poisoned. It is suited to fleshy people and those used to a high standard of living. Weeping during sleep. Swelling of breast, sensitive to touch. Aggr-change of temperature, open air (chest complaints). Reading, walking (pains in limbs). Amel- sitting in a bent position.
ANTIMONIUM TARTARICUM —
Shortness of breath. Difficult respiration. Rattling of mucus in the chest. Visible and anxious palpitation of the heart, sometimes during an evacuation. Palpitation with loose stool. Pulse – hard, quick and small or weak, quick and trembling, small thread like, imperceptible. Fits of vertigo with sparking before the eyes and dizziness when walking. Aggr- on sitting down, when seated, and on rising from a seat, sitting bent forward. Amel- from sitting erect, from eructations. The patient is anxious about the future. Excessively peevish and quarrelsome. Consequences of anger and vexation. Suicidal mania.
APIS MELLIFICA —
Oppression in the chest, shortness of breath, especially when ascending, inability to remain in a warm room. Dull, aching pain on the left side of the chest, near the middle of the sternum, with sensation of fullness and short breath. Burning, stinging pain throughout chest. Marked edema. Sudden pain just below the heart, extending towards the right side of the chest with suffocation. Very feeble action of the heart, violent pulsations, shaking the entire body, intermittent beats. Region of heart sensitive to least pressure; rasping sounds of systole and diastole unmistakably audible. Depression, feels as if about to die. Dread of death; sensation as if he could not breath again. Aversion to tight things. Prostration leading to fainting. Great debility. Oedematous swellings.
APOCYNUM CANNABINUM —
It produces a depression in the heart’s action, controls dropsical effusions and produces diuresis. Low arterial tension. Fluttering, darting pains, prostrated feeling in the cardiac region. Quick, sharp, catching pain in the heart with palpitations. Pulse slow, labored, irregular, intermittent, at times feeble and slow. Pulse quick, feeble when moved. Fainting on moving the head. Heart action scarcely perceptible. Oedema of feet, ankles and legs. Swelling in every part of the body; cardiac dropsies, pulsating jugulars and general cyanosis. There is aggravation on walking in the morning. Many of the symptoms are aggravated after sleep. Patient is bewildered, nervous low spirited. Dry tongue, immoderate thirst; but water disagrees, causing pain and is immediately thrown out. Cannot tolerate food or drink, which is immediately ejected. Excretions are diminished, especially urine and sweat.
AURUM METALLICUM —
Syphilitic affections of the heart. Hypertension due to valvular lesions and arteriosclerosis. Sensation as if the heart stops beating for two or three seconds, followed by a tumultuous rebound. Paroxysms of suffocation, with constrictive oppression of the chest and bluish discolors of the face. Continuous aching in the left side of the chest. Incisive pain, and obtuse shootings near the sternum. Sensation of great weight on the chest; on the sternum. Difficulty in respiration at night. Walking in the open air, require deep breathing. Pain in the region of the heart extending down to the left arm to fingers. When walking, the heart seems to shake as if it were loose. Sensation as if the heart stood still. Great sensitivity to cold. Melancholy, hopelessness, profound depression, tendency to suicide and longing for death are marked. Aggravation from emotions. Complaints after grief, fright, anger, disappointed love, contradiction, reserved displeasure. Suited to sanguine people with black hair and dark eyes, olive brown complexion and light haired scrofulous people.
BARYTA MURIATICA —
Indicated in arteriosclerosis with a high systolic pressure and a comparatively low diastolic pressure with cerebral and cardiac symptoms. Hypertension and vascular degeneration especially in the aged and mentally- physically dwarfed people. White blood corpuscles increased. Great weakness, which necessitates lying down. Swelling of hands and feet. Loss of appetite. Stools white, hard like stones. Great anxiety, with gastralgia, nausea and retching. Palpitations, heart beats irregularly. Pulse is scarcely perceptible. Periodical attacks of convulsions. Mania with increase of sexual desire.
Belladonna indicates violence of attacks and suddenness of onset. Oppression of the chest in the morning. Cannot breathe in the room, better in the open air. Violent palpitations which are sometimes felt in the head. Palpitation of the heart when ascending. Trembling of the heart, with anxiety and oppressive pain. Neuralgic pains come and go suddenly. Throbbing throughout the body. Melancholy, with grief, hypochondriacal humour, moral dejection, and discouragement. Desire to die and inclination for suicide. Sleepy but cannot sleep. Sweat on covered part only. Belladonna is suited to the bilious, lymphatic temperament. Light hair and complexion, blue eyes.
CARBO ANIMALIS —
Indicated in high blood pressure with obstinate occipital headaches. Great sensitiveness to open, cold dry air. Palpitation of the heart, in the morning and in the evening and when singing in a public place. Panting respiration. Atheroma and aneurism. Numbness of all the limbs. Hard and painful swelling of the glands. Weak digestion. Aggr- while eating; when lying on the side; after shaving; from slight touch, from lifting. Amel from lying hand on part, and rubbing the eyes.
It is an excellent remedy, as difficult gait, trembling, sudden loss of strength while walking, painful stiffness of legs. Great debility in the morning in bed. Weakness of body and mind, trembling, and palpitation. Indicated in Arterio-sclerosis. Excitement causes mental depression. Depressed, timid, averse to society and afraid of being alone. No inclination for business or study, takes no interest in anything. Vertigo when lying down, and when turning over in bed, when turning head sidewise, worse shaking head, headache, stupefying, with nausea and vomiting.
DIGITALIS PURPUREA —
Pulse is weak, irregular and abnormally slow. Weakness and dilatation of the myocardium. Cardiac muscle failure. It stimulates the heart muscles and increases the force of systole. Hypertrophy with dilation. Auricular fibrillation. Heart block and other organic diseases of the heart. Least movement causes violent palpitations, mitral disease leads to an irregular heart. Sensation as if heart suddenly stopped. Cardiac dropsy. Audible palpitations. Oppression of chest with cyanosis.
GELSEMIUM SEMPERVIRENS —
Indicated in the heaviness in the middle of the chest especially in the afternoon. Extreme and alarming difficulty in breathing; extreme restlessness from threatened suffocation. Stitches in the chest and region of the heart. Weak, slow pulse of old age. Irregular heart beat, palpitation. Feeling as if heart would stop beating if she did not move about. Pain in the heart when rising from a seat. Pulse frequent, soft, weak, almost imperceptible. Excessive irritability of mind and body. It is adapted to children and young people of nervous, hysterical temperament, to irritable, sensitive, excitable people. Dread of being alone. It has great muscular weakness and tired feeling. Dizziness, dullness and drowsiness with all complaints. General depression from heat of the sun with thirstlessness.
Indicated in tendency to sudden and violent irregularities of the circulation. Palpitation with dyspnoea. Cannot go uphill. Any exertion brings on a rush of blood to the heart and a fainting spell. Violent action of the heart, distinct pulsations all over the body. Sharp pain in the heart. Severe stitches from the heart, extending into the back. Purring noise in the region of heart when lying, pulse intermittent. Sensation as if the heart would rise to the throat. Pains are bursting, throbbing, pulsative, piercing, stabbing, gnawing. Laboured breathing of the heart with oppression and fluttering. Vertigo aggr- from stooping or moving head, in open air. Great weakness and prostration. Fear as if something unpleasant would happen to him. Cannot bear heat around the head, cannot walk in the sun, must walk in the shade or carry an umbrella; cannot bear heat from a stove; great vertigo on assuming an upright posture, on rising from bed or from a seat. Great sensitiveness to the least jar. Aversion to bright light.
IGNATIA AMARA —
Indicated in high blood pressure due to emotions, disappointed love and/or grief. Fluttering of the muscles of chest. Throbbing cardiac hyperaesthesia. Anxious feeling in precordia. Difficult respiration, as if there is some weight on the chest, shortness of breath when walking. Feeling of suffocation on running. Palpitation of the heart at night. Strong disposition to be frightened. Sadness and concentrated sorrow with sighing. Loves solitude.
KALMIA LATIFOLIA —
Indicated in shooting through chest above heart into shoulder-blade; pain in left arm. Stitches below breast. Indicated in angina pectoris aggr- from every motion. Vertigo is aggr on stooping; on looking down; on rising from a seat. Palpitation is aggr on bending forward and by mental effort. Fluttering of heart. Palpitation, with anxiety. Suppressed breathing, with faint feeling and dyspnoea. Severe pain in cardiac region. Pulse- slow, weak, irregular, remarkably slow; 40-80. Numbness of the left arm. Arms feel weak, scarcely perceptible. Limbs cold. Gouty and rheumatic metastasis of heart. Indicated in tachycardia, sharp pains take away breath. Dyspnoea and pressure from epigastrium towards the heart. Paroxysms of anguish around the heart.
LACHESIS MUTUS —
It is an important remedy for hypertension. The patient is worse on walking up, sleeps into aggravated restlessness cannot bear tight clothes. As soon as he falls asleep, breathing stops. It is particularly suitable to those with a melancholic disposition. Women who “have never been well since the change of life”. Debilitated, weakened people. People who cannot stand the sun and who are aggravated in summers. Tremors of the tongue, frantic loquacity. Insane jealousy. Vertigo and pale face. Unquenchable thirst desires- oysters, wine, coffee. The heart feels too large- cramp like pain in precordia. Palpitation with numbness down the arm. Must have open air aggravation- standing, stooping, motion. Shortness of breath, after a meal and on walking. Pressure on chest as if from on weight. Stitches in the left side of chest, with difficult breathing. Irregularity of beats. Fainting and giddiness. Complaints chiefly during climacteric period sensation as if the heart is hanging by a thread.
NATRUM MURIATICUM —
It reduces blood pressure in patients who have a craving for salt and who worry a lot. Suppressed anger. The patient wants to be alone and any attempt to console, irritates beyond endurance. Wants to be alone to cry. Very inclined to weep and be excited, tears with laughter. It is a great heart remedy. Fluttering palpitation with faint feeling, aggr lying down. Pains in chest dyspnoes on ascending stairs and shortness of breath. Lancinating pains in chest and sides of chest, with impeded respiration. Anxious and violent palpitation of the heart at every movement of body, Tachycardia pulse intermits on lying down. General dropsies and oedema due to salt retention. The throbbing headache has its analogue in palpitation of the heart. It is suited to cachectic persons, old people, teething children, anaemic, chlorotic people with catarrhal troubles and emaciated people.
PLUMBUM METALLICUM —
Cardiac weakness. Cramp like constriction of peripheral arteries causes hypertension. Hypertrophy and dilation of the left ventricles. High blood pressure accompanied with constipation and timidity. The patient’s complexion is waxy, pallid, greasy or shiny looking. Excessive and rapid emaciation. Loss of appetite with violent thirst. Pressure on chest, especially when breathing deeply or laughing. Pulse rapid, jerky, weak. Great anguish and uneasiness with sighs. Anxiety with restlessness and yawning. Weariness of life. Depression, wants to lie down. Throbbing in the entire body after slight exertion. Aggr- from exertion, from excitement , at night, from motion, drinking. Amel – from hard pressure and from rubbing.
RAUWOLFIA SERPENTINA —
This drug has come to the fore only recently and has started receiving laurels in cases of high blood pressure in its various degrees of intensity and acuteness. It has been credited with quickly softening the action of the heart, thereby normalizing the circulation, dissipating the violent congestion of head and heart, thus tending to bring the blood pressure down, even from a frightening level. The violent congestion and bursting throbbing headache quickly subside; hemorrhages from nose or somewhere else stop quickly, giddiness vanishes, normal sleep is restored and the patient soon feels tranquility. The drug has not yet been proven upon the healthy but is being used clinically.
TERMINALIA ARJUNA —
A great remedy for heart maladies. Highly effective in cases of high blood pressure with vertigo, palpitation and a sense of mental and physical exhaustion. It is a good remedy for diseases of the heart, both organic and functional, angina pectoris, weakness and pain in the heart.
THUJA OCCIDENTALIS —
Indicated in high blood pressure, particularly associated with poor arterial wall. Personal and parental history shows coronary thrombosis. Cramp in the heart. Palpitations audible with nausea. Stitches in the region of the heart. Pulse slow and weak in the morning, in the evening accelerated and full. Swelling of veins. Patient is anxious, apprehensions about the future. Music causes him to weep. Talks hastily, very depressed, sad, irritable. Aversion to life. Aggr- in cold damp air, after vaccination, from excessive tea, at 3a.m and 3p.m. Amel. by rest, drawing up the limbs, from warmth and in open air.
VERATRUM VIRIDE —
Induces fall of both systolic and diastolic blood pressure. Auricular fibrillation. Valvular heart disease. Beating of pulses throughout the body especially in the right thigh. Pricking pains in the region of the heart with headache. Burning under the sternum. Dull, hot, aching pain in the heart. Slow action of heart. Palpitation and dyspnoea. Faintness and biliousness; when rising from a lying position, from sudden motion. Pulse – slow, soft and weak, irregular, intermittent; suddenly increases and gradually decreases below normal. It is suited to full blooded, plethoric persons with depression and prostration and great fear of death, fears of being poisoned.
VISCUM ALBUM —
Feeling of suffocation when lying on the left side. Stertorous breathing. Spasmodic cough. Arterial hypertension with valvular insufficiency. Unable to rest in a reclining position. Oedematous swelling of the extremities. Teeth chatter. Eyes sleepy, difficult to open, lids heavy. Bowels obstinately constipated. Urine milky-white after standing. Palpitation during coitus. Heart gives a throb and then a pause. Pulse small, quick and very irregular, slow, full and bounding. Low tension due to dilated blood vessels.