The following are typical cases of high blood pressure that if one was to go on what one observed at the primary interview, a grave error in prognosis must inevitably result. I believe that in most of these cases the predominating exciting factors are two in number: worry and over fatigue with insufficient rest.

Emotional factors play an enormous part, and must be allowed for. For that reason, the pressure of any patient should be taken – especially in the case of a strange patient, and still more so in the case of a nervous patient – at the beginning and at the end of the interview. At the end, when the patient is calmer, it is nothing unusual to find a drop of from 10 to 30 mm.Hg. To omit this simple expedient can lead to an error in diagnosis and prognosis.

A woman aged 39, blood pressure 160 mm.Hg.

One patient, aged 39, was seen last year. She  complained mostly of headaches, easy fatigue and shortness of breath. Pressure 160 for some time. Through lack of servants during the war, the strain of many air-raids, much pain from severe haemorrhoids, and a good deal of worry, this patient was nervously exhausted. The piles were removed, and the patient had three months’ rest in a nursing home. From that time the blood pressure has never risen above 130.

Mrs K, aged 36, blood pressure 160 mm.Hg.

Mrs K, aged 36, seen nine months ago, complained of easy exhaustion, headaches, much palpitation, noises in the ears, and some shortness of breath on exertion. Pressure 160. There were no organic signs to be made out. After treatment for a month by rest, bromides, suitable diet, and mild aperients, together with the elucidation and settling of a mental conflict, the pressure fell to the normal and has not since risen above that level. The only aetiological factors were lack of sufficient domestic help and a worrying mental conflict.

Mrs B, aged 49, blood pressure 245 mm.Hg.

The following case of high blood pressure is an example of the type in which often a serious prognosis is given – not, it would appear at first sight, unreasonably.

Four years ago I saw Mrs B, aged 49 years. Menses had ceased 18 months previously. She complained of thumping in the region of the heart and pulsation all over the body; in her own words she felt ‘bursting all over’. Giddiness, tightness across the chest, dyspnoea, and easy exhaustion were all present in pronounced degree. The cardiac impulse was 2 inches out, and she was having many attacks of cardiac asthma: often at night she had to sit up and ‘gasp for breath’. The second aortic sound was clanging and the vessels in the neck were throbbing visibly and violently. Systolic blood pressure 245 mm.Hg. Radial and brachial vessels moderately sclerosed. Retinal condition: calibre definitely reduced, discs slightly pallid, banking of the venous return through crossing arteries. The urine was normal. Altogether the patient was a very ill woman, typical of many a case first seen, at this stage, in the consulting room.

Here, I think, the giving of a grave prognosis might have been an easy matter. There was a combination of some none too happy symptoms – a systolic pressure of 245 (perhaps evidence of a long-standing ‘pre-sclerotic’ stage of high pressure), a 2-inch displacement of the cardiac impulse, definite general and retinal sclerosis and, probably most evil-reputed of all, a clear history of many attacks of genuine cardiac asthma.

The patient faithfully carried out the treatment suggested, and for these four years she has been practically free from all vascular symptoms. The cardiac impulse is now in normal position, and the blood pressure varies from 190 to 210 mm. It is mostly 200. Examination of the retinal vessels a year ago showed distinct retrogression in the vascular changes noted there years previously. Some years ago, I think this retrogression would have been regarded as impossible. The patient now gets about wonderfully well, but exhaustion is still easily produced.

Fortunately for this patient, she can live a life of complete ease; otherwise the prognosis would be very different. This, I think, is a most important point  – what kind of life can the patient live? A life of ease, with the power of being able to procure everything that may be desirable, and a life sheltered from worry – this is the ideal state for influencing the prognosis favourably. For an arteriosclerotic with a high pressure, I should say the most maleficent factor that can enter into his or her life is – worry.