After many years of observation of cases of high blood pressure I believe the prognosis, with certain reservations, is not so grave as has been thought.

No physician having seen a case but once can give anything like an  accurate prognosis until that patient has been for some time under observation and treatment. Yet one has repeatedly seen patients who, on account of a simple pressure of 160, 180, or 200 mm.Hg., have been ordered to live the life of an invalid; cheese, bread, and milk, has been the diet ordered; work has been stopped, and the patient lives in a world of dread, expecting his pressure to “burst” somewhere – as often as not in the brain. The result to that patient is neurasthenia; he lives in the consulting room and on his readings. A vicious circle is produced.

In hyperpiesis the results of long observation of these cases do not warrant the prescribing of so dark a future. The prognosis is worse in cases that have been so condemned. In the nervous the effect on the pressure is only too real. It is a hard task to allay their often-times groundless fears. On no few occasions the relatives are awaiting anxiously for the advent of the dire “stroke” that may never come. Relatives abhor a looming stroke.

A prognosis should never be given on seeing a patient for the first time, especially if that patient is a woman. It is often impossible to exclude early Bright’s disease at a primary interview, and nervousness, fatigue, strain, the climacteric, and worry (especially the latter) may account for a very great deal.

Ten and a half years ago I saw in consultation a lady of 62 years of age. Blood pressure, 195 mm.Hg. She had obvious shortness of breath, even when lying in bed. The heart was considerably enlarged, the rhythm tick-tack. She had persistent headaches and there was a mild grade of cyanosis. The vessels were degenerate, and she was sleepless and depressed. As onerous duties devolved on her, I was pressed by the relatives for a definite opinion on the outlook. I gave it as an opinion that, at the rate she was deteriorating, the chances were that she would not survive for more that a year. That was in 1909, and I still have the pleasure of seeing her now in 1921.

In giving a prognosis, special care must be taken in the case of women at or near the menopause. These patients frequently develop a systolic pressure of from 160 to 180, and on investigation this rise is found to be of a functional nature, purely temporary, and of all types probably the most amenable to treatment. These cases often present many of the trying symptoms of the highly organic case; frequently, owing to the instability of the nervous system at this time of life, these symptoms are of an exaggerated type. The pathology is probably an endocrine disturbance, associated with emotional states and a hypersensitivity of the nervous and vasomotor systems.

Under suitable treatment, the symptoms arising from the disturbed pressure vanish in a most gratifying manner, and the pressure returns to normal, but with occasional fluctuations.

During the last two years one has seen many “war” cases in women. The symptoms they present are similar to those of the menopausal cases. Many women, of leisure in pre-war times, have had to turn to and cope with work usually done for them by maids; to this increase in physical labour has to be added the anxiety of having relatives in the fighting areas, financial and housekeeping worries, and last, but not least, the strain of air-raids, present and anticipated.

Such patients react satisfactorily to treatment, but the improvement is sometimes slow. Both in the menopausal and the “war” cases one has been able to eliminate  organic disease, and the result of treatment has been proof of the soundness or otherwise  of the diagnosis of a purely functional and temporary increase in pressure. In those two types I have not seen any pressures over 185 mm.Hg.

To give grave – indeed, anything but a favourable – prognosis in such cases naturally leads to a rather large error; that such an error has been frequently made, and in consequence over-drastic treatment adopted and patients and relatives unduly frightened must be my excuse for laying stress on this type of case.

Such cases often occur in neurasthenic subjects. Generally they do not show evidence of vascular degeneration, but they may do, even at ages surprisingly young, and this must naturally alter the prognosis whether or not the raised pressure responds to simple as opposed to more drastic treatment.