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has noted a pressure of 70 in a girl aged six in a mild attack, and a pressure of 150 in a girl aged fifteen, where there were no signs of nephritic involvement.
The average case will run between 105 and 75, the individual readings being modified as in the normal, particularly by the age factor. The occurrence of laryngitis, owing to the respiratory obstruction, may be expected to cause a rise of from 20 to 30 mm.
Hypotension is the rule. Low blood-pressure during the stage of collapse is a valuable guide to the necessity of transfusion. The blood-pressure is always below 100. The most satisfactory treatment, or the one most likely to combat complications, such as uremia, is administering the intravenous solution of adrenalin. By this means in one epidemic the death rate was reduced almost one-half.1
In cases showing very low pressures, Rodger and Megrawa consider the estimation of blood-pressure of great value in determining the frequency and quantity of saline solution to be injected; they state that the restoration of the circulation thus brought about, not only affords great relief to the patient but materially aids in the elimination of toxins through the kidneys and the bowel.
In chronic malaria, in the absence of complications, the blood-pressure, as would naturally be supposed, is usually low. In acute cases the pressure curve follows the rise and fall of the fever, being high during the chill and in the febrile stage, falling as the sweating process begins, and remaining low until the onset of the next rigor. As this phenomenon is the natural accompaniment of the conditions with which they are associated, irrespective of the cause, the findings by the sphygmomanometer have but little significance in this disease.
1 Leonard Rogers, Therapeutic Gazette, Nov. 15, 1909. 2 Indian Med. Gaz., March, 1908.
EPIDEMIC CEREBROSPINAL MENINGITIS
G. C. Robinson' found that elevated intracranial pressure is almost a constant phenomenon in epidemic cerebrospinal meningitis, and that this usually is accompanied by elevated blood-pressure. This rise in the bloodpressure appears to bear some relation to the severity of the disease, being high when the symptoms are severe and low when mild, and during convalescence. Robinson's observations in reference to the effect of lumbar puncture are not in accord with those of later observers, particularly Sophian. This author states that the withdrawal of fluid in meningitis is usually accompanied by a drop in blood pressure, sometimes quite a marked one, especially if the amount of fluid withdrawn be great. He depends absolutely upon this observation as a guide to the amount of fluid to be withdrawn and the quantity of serum to be injected in the treatment of this disease. Sophian's procedure is as follows: Commencing with an ordinary case with a systolic pressure of 110 mm. Hg., fluid is withdrawn until a fall of pressure amounting to 10 mm. in adults and 5 in children occurs.
If the pressure begins to fall quickly, the rapidity of the flow should be reduced. Occasionally
Arch. Int. Med., May, 1910, Vol. B.
there is no fall in pressure (there may even be a rise) and the indication here is to remove as much fluid as possible or until the cerebrospinal pressure is normal. After the fluid has been withdrawn the serum is warmed and then slowly injected. When, contrary to expectations, the blood-pressure continues to fall, the indication here is as follows: Beginning with a 10-mm. drop from fluid removal, the injection is terminated with the development of a total drop of 20 mm. By this method the average dose of serum is smaller, averaging not more than 25 c.c. in adults and in children in proportion.
Muscular movements and pain may interfere with the correct observation of pressure while the presence of internal hydrocephalus usually causes an increased systolic pressure.
OTHER ACUTE INFECTIONS
In the other acute infectious diseases there is little to state that is of practical importance regarding the bloodpressure, because many of them are so mild as to have no appreciable effect upon arterial tension, and also because observations as far as they have been made, shed very little light. In general it may be stated that the development of toxemia from any cause, results in depression of the normal pressure curve which tends to return to normal with relief from the toxemia.
Statistics upon blood-pressure observations in tuberculosis made by different observers show wide variations in the results recorded, though they agree upon two points: first, that the systolic blood-pressure is lessened when this disease is active and that it becomes progressively lower as the disease advances, and second, that it rises toward normal as the process is arrested and the disease cured. The first of these points is exemplified by the following statistics which have been collected, tabulated and averaged by Pottenger. These observations are grouped for comparison according to recognized divisions into first, second and third stages, and are as follows: In Strandgaart's series? the systolic pressure ave
veraged in the
125 mm. Hg.
Burckardt, 3 making his examinations at Basel, found that the average systolic pressure in the
107.6 mm. Hg.
IN. Y. Med. Jour., Aug. 31, 1912, p. 418. 2N. J. Strandgaart, Internat. Zentralb. f. Tuberkulose, 1908, p. 224. * Zeitsch. f. Tuberkulose, v, p. 19, viii, pp. 465–8.
Ingersheim' found in the
100.4 mm. Hg.
Pottenger? examined twenty normal persons and compared the findings with those in 135 tuberculous patients divided according to stages of the disease. The average systolic and diastolic pressures were as follows:
Diastolic 20 normal individuals...
108 mm. Hg. 11 patients in first stage..
106 78 mm. Hg. 21 patients in second stage..
81 mm. Hg. 103 patients in third stage..
75 mm. Hg.
Thus we have average blood-pressure readings as follows:
.from 100.4 to 125 mm. Hg. ..from 97.3 to 121 mm. Hg. .from 75.4 to 118 mm. Hg.
That a depression in systolic level is an early sign of tuberculosis is accepted by most observers. The importance of this point has been emphasized by Cook who makes the following significant statement: “When low bloodpressure is persistently found in individuals or in families it should put us on our guard for tuberculosis," and Haven Emerson,3 dwells upon the fact that hypotension should be sought for just as carefully in a physical examination as we customarily search for pulmonary signs. Many cases of so-called idiopathic low pressure will be found later to develop signs of pulmonary involvement so that hypotension, when otherwise unexplained, should suggest a
1 Zeitsch. f. Tuberkulose, viii, p. 467. 2 Arch. Int. Med., October, 1909. 3 Arch. Int. Med., April, 1911.