414

way it should be possible to distinguish acute diffuseglomerulonephritis, presenting atypically and healingslowly, or becoming chronic, from the lesions whichare focal from the start.

Measuring Blood-pressureDISCREPANCIES have often been noted between intra-

arterial measurement of blood-pressure and its measure-ment by the conventional cuff and sphygmomanometer.Part of the trouble has been ascribed to the effect ofarm circumference when arterial pressure is measuredwith a cuff; and corrections based on measurementsmade by RAGAN and BORDLEY 1 have been devised.2 Theconnection between sphygmomanometer reading andarm circumference is of more than academic interest:it has obvious implications in population studies, sincearm circumference varies with sex, age, weight, andoccupation; and acceptance for life assurance or for aparticular occupation may turn on an estimate ofarterial pressure made with a sphygmomanometer.

Several workers report good agreement between

systolic blood-pressure determined by the intra-arterialand cuff methods, but some disagree on which of thetwo phases-phase 4 (muffling) or phase 5 (disappear-ance)-represents the true diastolic pressure. PICKERING,3 3

summarising comparisons between direct and indirectmethods of measuring blood-pressure, concluded thatindirect methods underestimate systolic pressures andoverestimate diastolic pressures in ’adults of normal

weight, whereas in the very obese both values will beoverestimated. HOLLAND and HUMERFELT,4 using aHansen manometer and a method of recording blood-pressure free from observer bias, found that thedifference between direct and indirect methods was

greater than had been previously assumed. No signi-ficant relation was found between arm circumferenceand differences in intra-arterial and cuff blood-pressure,or between skin-fold thickness and differences in indirectand direct blood-pressures. They found a significantrelation, however, between the level of direct blood-pressure and differences in indirect and direct blood-

pressures, particularly for diastolic pressure, so that thehigher the direct blood-pressure the greater the differ-ence. Moreover, there was a correlation between armcircumference and the level of direct arterial blood-

pressure. Differences between these findings may beexplained by methods of measurement and selection ofsubjects. 13 of RAGAN and BoxLEY’s original patientshad aortic regurgitation or aortitis. Their first observa-tions were made with a Hamilton manometer and a cuff13 cm. wide and of unspecified length; and they useda microphone to pick up the auscultatory sounds overthe antecubital fossa and an aneroid manometer to recordcuff pressure.

In an analysis of data on physique, occupation, and1. Kagan, C., Bordley, J. Bull. Johns Hopk. Hosp. 1941, 69, 504.2. Pickering, G. W., Roberts, J. A. F., Sowry, G. S. C. Clin. Sci. 1954,

13, 267.3. Pickering, G. W. High Blood Pressure. London, 1955.4. Holland, W. W., Humerfelt, S. Br. med. J. 1964, ii, 1241.

indirect readings of arterial blood-pressure for a popula-tion of over 5000 men aged 15-69 years, LowE 5 con-firmed that, for a given age, sphygmomanometer readingsincreased with body-weight and that weight and armcircumference were closely correlated. When correctionswere made for weight, he found that the effect of armcircumference upon pressure reading was negligible;and he concluded that the greater part, perhaps all, ofthe observed relation between arm circumference and

sphygmomanometer reading is attributable to closeassociation between arm circumference and weight.On reanalysis of the data, using a multiple regressiontechnique, KHOSLA and LOWE 6 found that of the threevariables-age, body-weight, and arm circumference-only age and body-weight seemed to be significantpredictors for sphygmomanometer readings of systolicand diastolic arterial pressure. Accordingly, theyconcluded that the influence of arm circumference uponsphygmomanometer readings was indirect and due toclose correlation with body-weight. In effect, therefore,any attempt to correct sphygmomanometer pressurereadings for arm circumference will eliminate the

important influence of body-weight. But this is indirectreasoning: actual proof that the differences betweenintra-arterial and cuff blood-pressures are not affectedby arm circumference will depend upon confirmation ofHOLLAND and HUMERFELT’S findings.Arm circumference, however, is only one source of

possible variation in the recording of blood-pressure.ROSE et al. 7 summarised some of the chief reasons

why different observers may get different blood-pressurereadings in the same person. These variations are due

partly to true fluctuations in arterial pressure and partlyto different methods of measuring pressures. The

ordinary sphygmomanometer may give inaccurate andbiased readings of blood-pressure owing to systematicerrors. One observer may habitually read higher orlower values than another; and this is serious, because ityields a false estimate of the mean pressure. An arbitrarychoice of the last figure in the reading as a measure ofaccuracy, and individual preferences for particularvalues, distort the frequency-distribution curve. Anothersource of error is the size of cuff. ORMA et al. observedthat pressure readings obtained with a sphygmomano-meter whose cuff bag was 23 cm. long were on average23 mm. Hg systolic and 19 mm. diastolic higher thanthe values produced by a cuff bag of 33-5 cm.; and thiserror was definitely related to the size of the upper-armcircumference. KARVONEN et awl. demonstrated thatthe arm circumference as such had no effect on theerror of the indirect blood-pressure measurement whenthe size of the cuff was taken into account. The thicknessof the triceps skin-fold, however, ’was negatively cor-

related to the error of the systolic measurement when 3small cuff was used or to that of the diastolic phase-4measurement with either large or small cuffs. They found5. Lowe, C. R. Br. J. prev. soc. Med. 1964, 18, 115.6. Khosla, T., Lowe, C. R. ibid. 1965, 19, 159.7. Rose, G. A., Holland, W. W., Crowley, E. A. Lancet, 1964, i, 296.8. Orma, E., Punsar, S., Karvonen, M. J. Duodecim, 1960, 76, 460.9. Karvonen, M. J., Telivho, L. J., Järvinen, E. J. K. Am. J. Cardiol.

1964, 13, 688.

415

that with a large bag random error was significantlysmaller for both systolic and diastolic pressure.These findings show some of the complex variations

in the commonly used method of recording blood-pressure, and they are of considerable importance.For one thing, people with raised blood-pressureundoubtedly have a higher mortality from cardiac

infarction, but there is no cut-off point; the risk isgraded, and to have arbitrary limits for selection andprognostication is nonsense.

Aftermath

TWENTY years have passed since the release of thosewho survived incarceration in prisons, ghettoes, or

concentration camps during the 1939-45 war. Most whodid not directly experience the privations and horrorscan now view the events with some detachment throughthe ever-multiplying arches of the years; but HOCKING "has reminded us that the men and women confined andill-treated in their teens, twenties, or thirties are nowpassing through middle-age bearing both the physicaland the mental scars of their experiences. Working inAustralia, which has received a massive influx of

Europeans, he has made a special study of the mentaldisturbances in concentration-camp victims; but evidencefrom others suggests that the ill-treated prisoner-of-war 12 or the disaster survivor 13 may have the same

problems.Starvation is a prominent factor in the generation of

mental symptoms during incarceration: in the Min-nesota experiment 14 quite short-term semi-starvationwas associated with personality alterations, and anyonewho has experienced significant food deprivation cantestify to its profound effect on the morale of both theindividual and the group. Such short-term effects maybe secondary to the absence of the sensation of comfortoccasioned by a well-filled gastrointestinal tract, thedecline in basal energy expenditure that accompaniessemi-starvation, or the lack of that penumbra of warmth,comfort, solidity, and good cheer that often surroundsan adequate dietary. Certainly, reversal rapidly followsreturn to normal surroundings. It is less clearly realisedthat semi-starvation prolonged for months or years ofconfinement may contribute to permanent, demonstrablecerebral damage, which now afflicts 90% of those

concentration-camp survivors who have severe psycho-social problems.15

Inextricably mixed with the late effects of mal-nutrition in concentration-camp victims are those ofstress: "humiliation, physical restriction, inability tocope with heavy work ... lack of sleep ... not beingalone for a moment, pain, disease, filth, cold, infestationwith fleas and lice, the threat of death... beating, and10. Kagan, A., Gordon, T., Kannel, W. B., Dawber, T. R. Hypertension;

vol. VII. American Heart Association, 1959.11. Hocking, F. Med. J. Aust. 1965, ii, 477.12. Cohen, B. M., Cooper, M. Z. Veterans Administration Medical Mono-

graph. Washington, 1954.13. Leopold, R. C., Dillon, H. Am. J. Psychiat. 1963, 11, 913.14. Keys, A. The Biology of Human Starvation. Minneapolis, 1950.15. Strom, A., Refsum, S. B., Eitinger, L., Gronvick, O., Lonnum, A.,

Engeset, A., Osvik, K., Rogan, B. J. Neuropsychiat. 1962, 4, 43.

knowing that family, friends and race were beingexterminated ".11 Probably, in fact, the worst situationwhich human beings could be expected to survive.Careful assessment in many countries now shows thatthe majority of those tough enough to come through areafflicted by a syndrome 16 characterised by difficulty inconcentration, apathy, nightmares, and inappropriatefatigue coupled with insomnia. They have difficulty inadjusting to social situations and in finding satisfactoryemployment, even if they did return to home or country-which many were unable to do. They may break downmuch more easily if exposed to additional unfavourablephysical or mental circumstances. A collateral studyfrom America suggests that premature biologicalsenescence follows massive stress either in action or in

prison camps, and that long-term morbidity and

mortality are both significantly increased. 12Apart from the national and individual tragedies of

the war years, it is distressing how little we have learntwhich can be applied to the stressful situations of peace.While the need for compassion and understandingtowards a group of people who, as they grow older,become more vulnerable to the long-term effects oftheir experiences is enough to compel our interest andconcern, the lessons from the prisoner-of-war andconcentration camps have almost certainly a wider

importance. Patients now recover after lengthy periodsof stress during a severe illness which until a few yearsago would certainly have killed them. Often theirillness will have included a period of semi-starvation:the after effects, for example, of intensive care may bemore severe than we have realised.

Annotations

"MEDICINE TODAY"

FEW televised programmes have had as much audienceresearch lavished on them as the series for doctors," Medicine Today ", arranged by the Association for theStudy of Medical Education and the British BroadcastingCorporation.i’ At a meeting in London on Feb. 7 Dr. J. S.Cameron described two postal surveys, one by each

organisation, designed to study the reaction of doctors tothe first six programmes. The meeting was one of a seriesorganised jointly by the Scientific Film Association andthe Ciba Foundation for the study of visual communica-tion in medicine.

These programmes, which were devoted to various

aspects of medical practice, were broadcast monthly onB.B.C.2 from January to June, 1965. The potentialaudience was some 5200 doctors in the London and

Birmingham areas. Three-quarters of the doctors whoreceived questionaries took part in the surveys. Each

programme was seen by about a third of the participantsin the ASME survey, and the B.B.C. survey showed that

(assuming non-participants to be non-viewers) half thepotential viewers saw at least one programme and a

quarter saw three or more of the six.As the organisers must have hoped, few doctors thought

the programmes would harm patients who happened to16. Hermann, K., Thygesen, P. Ugeskr. Laeg. 1954, 116, 825.17. See Lancet 1965, i, 280.