toms a marked reduction in systolic pressure and in pulse pressure, and because of the comparative rarity of the disease the chart (Fig. 41) has been introduced. NEUROLOGIC DATA As would naturally be supposed both functional and organic affections of the central nervous system produce definite and easily demonstrable effects upon the circulation and blood-pressure. Neurasthenia (See Hypotension, Chapter VIII).—Neurasthenia or the fatigue neurosis resulting from lack of nervous energy and instability of the sympathetic nervous system is naturally, when uncomplicated, accompanied by hypotension. We may include under this head the psychic instability of blood-pressure, so beautifully discussed by Schrump1 where he shows that before we may arrive at a decision that a low blood-pressure is pathologic, we must make sure that it is not psychogenic. He also makes the interesting statement that a rise in pressure of psychogenic origin affects chiefly the systolic pressure; as the mind does not seem to have an influence upon the diastolic pressure, which is unaltered. Psychic instability is almost constantly present, in all individuals to some degree, but is much more marked in the neuropath. It is sometimes difficult to determine by one examination a normal from a pathologic alteration in blood-pressure, and it may become necessary to divert the patient's attention and to repeat the test at a subsequent time. Furthermore, it must not be overlooked that the period of absolute rest which 1 Deutsch. med. Wochen., Dec. 22, 1910. usually begins the treatment of grave neurasthenia, is itself a cause for a lower blood-pressure. The degree to which the pressure falls in this condition depends somewhat upon the 119/3 H 120 FIG. 42.-Female. Single. Aged forty-one. Typical neurasthenia with ever-changing symptoms. Lacks initiative and is morose. Constantly worrying about her condition. Phthisophobe. Many kinds of treatment have been only temporarily successful. Elevation of pressure as shown in the first few observations probably result of mental excitement. This chart shows well the depressed systolic pressure, which in spite of measures directed toward restoring normal pressure fails to respond, and the extremely variable pulse pressure, which under usual conditions is smaller than normal. The reduction of pulse pressure tends to follow the general physical condition of the patient, yet in spite of the small pulse pressure this patient at no time shows either renal or circulatory embarrassment. gravity of the disease and the temperament of the patient, but is usually moderate. I have been unable to find any reference to a hypotension lower than 80 mm. systolic in neurasthenia. See Fig. 42. The treatment of this disease when successful may be indicated by a gradual return of the pressure to normal. It must be borne in mind that complicating nephritis may so affect the blood-pressure as to render the findings of no value. Epilepsy. According to Fisher,1 in patients over forty there is a general tendency toward an elevation in pressure which is not usually seen in younger cases. During the paroxysm authorities agree that the systolic pressure may rise to a great height and remain high throughout the attack, falling to an abnormally low level during the subsequent stage of depression. This point may be of value in separating an epileptic from an uremic attack, as the postepileptic fall does not occur in cases of uremic origin. Tabes Dorsalis.-Lewellys F. Barker recently reported some cases of this disease in which the blood-pressure varied between 190 and 215 mm. Hg. Other authors have had similar experience, noting the rise usually during the paroxysm of abdominal pain. Jump2 calls attention to this important differential point, that while with abdominal pain in gastric crises of tabes the blood-pressure is nearly always markedly elevated, it is usually low or normal in renal or biliary colic. The common occurrence of arteriosclerosis in tabetics does not appear to be a cause for continued high pressure, which in the majority of cases is normal between the crises. It has been noted by some observers that the pressure rises some time before the pains begin, which fact, if detected by means of the sphygmomanometer, may be used therapeutically to ward off the impending attack. Edward D. Fisher, Jour. A. M. E., Aug. 3, 1912, lix, No. 5, p. 395. 2 Internat. Clinics, Vol. i, Series 21, p. 49. Mania.-Hawley1 reports certain alterations in bloodpressure in maniacs, which he considers as typical of the different stages of this affection. Thus both the systolic pressure and the pulse pressure increase as the restlessness of the patient becomes more marked, to decrease again as the patient recovers from the attack. Arteriosclerosis existing in maniacs accentuates this rise, which is generally then maintained during the intervals of quiet and depression. In stuporous cases the systolic pressure and pulse pressure are usually below normal and are accompanied by a slow pulse. In depressed cases the systolic pressure is low and the pulse pressure small, but not so low as is usually encountered in stuporous cases. Melancholia.-In melancholia the average systolic pressure and the pulse pressure remain at or near normal as long as there is no muscular resistance, or no other factor such as arteriosclerosis to produce a rise. Paresis.—In the majority of paretics the systolic pressure tends to a lower level than in normal individuals, although this is by no means the rule, because of the frequency of arteriosclerosis with its cardiac and its renal accompaniments. Walton2 compared two groups of cases, the first showing the complications just referred to, while in the second group there was no record of arterial, cardiac or renal disease. 'M. C. Hawley, Arch. Int. Med., November, 1913. Schmigergeld1 briefly summarizes our knowledge of blood-pressure in general paresis as follows: 1. The blood-pressure in this disease is variable. 2. In the absence of complications the pressure in the majority of cases is subnormal. 3. There appears to exist no relation between the mood of the paretic and the state of the blood-pressure. 1 N. Y. Med. Jour., Aug. 28, 1909. |