War Surgery and Medicine
First World War Cases of Hypertension—Deaths
First World War Cases of Hypertension—Deaths
It has been stated above that 288 of the 499 cases collected by Dr Carbery from 1932 to 1940 have died between then and 1952. Screening these 288 dead cases as was done with the living, 245 can be accepted as having suffered from definite hypertension. Some few cases have been included in the list of whom there was only one recorded abnormally high blood pressure, but death occurred shortly afterwards from either a cardiac or cerebral accident. There are many deaths from coronary disease without any previous hypertension and therefore the etiological relationship, if any, between mild hypertension and coronary disease requires further investigation.
Deaths from hypertension occur as the result of cardiac or cerebral accidents or renal failure.page 663
The following table shows details of the 245 deaths from hypertension according to immediate causes of death, the average ages at death, the standard deviations from the average ages, and the extremes of age at death.
|Deaths from Cardiac Causes||Deaths from Cerebral Accidents||Deaths from Renal Failure||Deaths from Causes Unrelated to Cardio-Vascular Disease|
|Number of cases||122 (50 per cent)||63 (26 per cent)||15 (6 per cent)||45 (18 per cent)|
|Average age at death||61 years||61 years||49 years||63 years|
|Standard deviation from average age||8||8||6||7|
|Extremes of age in each group||42–77 years||40–76 years||39–58 years||51–76 years|
In the above cases deaths from cardiac and cerebral accidents occurred at the same average age. On the other hand, deaths from renal failure occurred at a much earlier age. Renal failure is the common termination of malignant hypertension.
When noting the ages and age groups referred to above, it must be remembered that all these cases are drawn from a body of exservicemen whose greatest numbers in 1920 belonged to the age group 25 to 40 years. Therefore by 1952 the mass of this population belongs to the 57 to 72 age group.
In the group of 245 deaths under review, 2 cases died before 1930 and 46 between 1932 and 1939. The hypertension was recorded only a short time before death in these cases, and thus it is impossible to determine the period during which this condition existed. Some details regarding these 48 deaths are as follows:
|Cause of Death||Number||Average Age||Extremes of Age|
|Conditions unrelated to cardiovascular disease||4||56||51–61|
Regarding the remaining 195 cases, the following table gives the number of deaths in each year, the average age at death, the standard deviation of the average age, the minimum and maximum age at page 664 death each year, the average known period of duration of hypertension, and the number of these 195 dying each year of conditions unrelated to cardio-vascular disease.
|Year of Death||Number of Deaths||Average Age at Death||Standard Deviation||Minimum and Maximum Age at Death||Average Duration Period of Blood Pressure||Number of Deaths not due to Cardio-Vascular Disease|
Of the Carbery list, only 43 deaths remain to be noted. These are not included as hypertension cases because the records held do not disclose blood pressures even as high as S. 160 and D. 100 on two occasions. The following table analyses these 43 deaths according to age groups and cause.
|Age Group at Death||46–50||51–55||56–60||61–65||66–70||71–75||76–80||Total|
|Deaths from cardio-vascular disease||1||2||5||5||5||2||1||21|
|Deaths from other causes||2||7||3||3||5||1||1||22|
In Table II it is shown that 82 per cent of patients suffering from definite hypertension died from cardiovascular disease. Of the 43 not accepted as hypertension cases, the deaths from cardiovascular disease were 21 or 49 per cent.
Study of Large Group of Ex-servicemen Dying from All Causes
Before making any further observations on the cases in the Carbery list, it may be of interest to note the ages at death of 2226 ex-servicemen of the 1914–18 War dying of all causes during 1951 and 1952.
|Age Group||45–50||51–56||56–60||61–65||66–70||71–75||76 and over||Total|
|Died of cardio-vascular disease||4||77||255||279||222||159||98||1094|
|Died from other causes||5||83||281||256||233||167||107||1132|
The cardio-vascular deaths represent 49 per cent of the total, which actually is the same percentage as in the 43 cases in Table V. The nine youngest cases at death were all 48–50 years of age and represent the comparatively small group who served at an early age in the last year of the war, either in the Navy or who joined the Army giving a false age. These details are taken from copies of death certificates supplied by medical practitioners.
It will be noted from Table I that in 130 living cases of hypertension, the condition has existed for various periods, the shortest twelve years and longest thirty-four years. From Table III it is learnt that in only 68 out of 195 cases which have died did the period of hypertension last for less than ten years. Thus in this group of 325 cases, 79 per cent lived for more than ten years, while 166, or 51 per cent, lived for at least fifteen years, and of that 166 some 130, who have already averaged over seventeen years, are still living.
It must be remembered that when the Carbery list was compiled after 1930 the population from which it was drawn had already, in the main, reached middle age, and consisted only of males who had during the 1914–18 war years been selected for their medical fitness.
The complete ‘follow-up’ of all cases in this Department has enabled the duration period of the hypertension to be stated in most cases. A perusal of death certificates confirms how rarely the general practitioner can state definitely the duration period of the hypertension when a cause of death.
Deaths of Returned Servicemen in 1952
During 1952, 164 deaths occurred amongst returned servicemen of the 1914–18 War certified due to hypertension. Not being war pensioners, nothing was known to the Department of these cases until notifications of death were received. The numbers of deaths in each age group and immediate cause of death are given in the following table.
|Cause of Death||50–55||56–59||60–65||66–69||70–75||76–79||80||Totals|
* 1 Death—age unknown.
The impression gained was that the certifying doctor very often had only known the patient for a relatively short period. Thus the periods of possible longevity quoted above in so many cases may cause some surprise.
Survey of Unselected Group of Living Pensioners of 1914–18 War
During the survey of this selected group of 499 cases from the 1914–18 War servicemen it occurred to the writer that a knowledge of blood-pressure conditions in an unselected group of living returned servicemen from the 1914–18 War might be of interest. Some 938 files were examined. While these cases were unselected in the sense that records were routinely taken from files only when the patient applied to the Department for treatment, it must be remembered that all cases suffered from some type of disability and were males past middle age.
Of the 938 files, six related to cases already in the Carbery list and are therefore excluded. A further 145 files contained no record of any blood-pressure readings. These were cases where the only disabilities known to the Department were war wounds of the limbs, skin conditions, and eye, ear, nose, and throat disabilities where there had been no general examinations and consequently no records of blood pressure made by the specialists.
In all 787 cases had blood-pressure records. None of these patients, when the blood pressures were taken, was suspected of suffering from hypertension, and the blood-pressure record was merely a routine entry. While in many cases there is no recent reading recorded, it must be remembered that all cases are living, and if there is no record the pensioner has not complained of symptoms suggesting to the specialist that investigation of the blood pressure should be undertaken.
Of the 787 cases, 669 had normal blood-pressure readings. Systolic pressures were not above 160 nor diastolic above 100. In 214 of the cases the blood pressure had not been taken since 1942. None of the 669 cases at the time of recording of the blood pressure suffered from, and in 1952 none complained of, symptoms suggestive of hypertension, while the youngest is now over fifty years of age.page 667
While some suffer from more than one disability, the following are the major disabling conditions:
|Diseases of lungs||207|
|Rheumatic diseases of all types||68|
One hundred and eighteen cases out of the 787 have at some period between 1930 and 1952 exhibited a blood pressure with the systolic above 160 or the diastolic above 100.
The following table gives the year and age group of the patient when the high pressure was first recorded:
|Year||41–45||46–50||51–55||56–60||61–65||66–70||71–75||Total Each Year|
If the cases are screened for hypertension on the American minimum systolic and diastolic pressures quoted above, it is found that 86 of the 118 cases would be considered to have shown definite evidence of hypertension. Seventy-seven of these 86 cases are drawn from 96 cases in Table VIII varying in age from forty-one to sixty-four, already accepted by the 160 S. and 100 D. standard, and the remaining 9 drawn from 22 cases varying in age from sixty-five to seventy-five years.page 668
Thus the records of 787 servicemen who have been suffering disabilities of various types since 1918 approximately, reveal that 86 have shown evidence of hypertension up till the year 1952. Three cases developed acute nephritis in recent years, and the blood pressure has been abnormal only since these illnesses. They cannot be classified as cases of essential hypertension, and therefore the total of essential hypertension cases is 83. Two hundred and fourteen cases have not had the blood pressure taken during the past ten years, but in 1951 and 1952 complain of no symptoms suggestive of hypertension. Their disabilities are mainly the end results of war wounds and eye, ear, and nose conditions.
Second World War Cases of Hypertension
Turning now to the 1939–45 War, a survey has been made regarding the incidence of essential hypertension amongst servicemen during and since the war.
The men who proceeded overseas were all expected to be medically fit, and it is of interest to learn something of the incidence of abnormally high blood pressure likely to occur in such a male population.
The survey made of cases occurring amongst the personnel of the 1914–18 War covered only a certain few, who were all aged from forty to seventy-six years. Now it is possible to get a comprehensive idea of the incidence of hypertension occurring in personnel of the 1939–45 War from the year 1939 when the first recruit was examined.
In the medical examination of the recruit for the 1914–18 War the recording of the blood pressure played no part, whereas in the 1939–45 War it was an integral part of the examination, and indeed the acceptance or rejection of an otherwise apparently fit man might depend solely upon the blood-pressure reading.
The following instruction was issued to medical examiners of army recruits in 1939:
Blood Pressure—A systolic blood pressure persistently over 160 m.m. Hg. and/or a diastolic of over 100 and/or under 50 should not be above Grade II.
In 1942 this instruction was amended to read, ‘a systolic blood pressure persisting as high as 160 m.m. Hg. and/or a diastolic of over 100 and/or under 50 should not be above Grade II. Before concluding, especially in a young man apparently otherwise healthy, that the blood pressure is abnormal, the readings should be repeated at least three times at intervals of five minutes, the man resting at ease on a couch during this period.’
The man who could not reach Grade I standard of fitness was page 669 considered to be physically unfit for full training and service overseas. The age limits for service overseas were twenty-one and forty years. It should be noted that the above instruction regarding the blood pressure was applied to all age groups.
The American observers already quoted consider that for the age groups eighteen to thirty-nine the minimum systolic hypertension reading is from 145 to 160, with the diastolic also rising with the age from 95 to 100.
It is not known how many recruits were accepted for overseas service whose blood pressure was persistently at the maximum of the allowable figures, but the standard laid down was not a cause of much invalidity in the Army overseas. Only 29 men with hypertension and 44 with effort syndrome were evacuated to New Zealand from the Middle East and Italy out of a total 6076 medical cases boarded as unfit for further service overseas. Colonel J. R. Boyd, Consulting Physician to 2 NZEF MEF, advises that to his knowledge there were no deaths from essential hypertension either in the Middle East or Italy.1 This represents a wastage out of approximately 80,000 troops. The number of young recruits otherwise fit who were declined for service solely because of hypertension is unknown, but it is gathered that there could not have been many.
Recruits were first accepted into the services in September 1939, and from that date until 1952 some 309 cases who saw overseas service have been diagnosed on discharge from the services as suffering from hypertension. As their medical examination on enlistment was the first health record known of each individual, there is set out in the following table the age group at enlistment and year of enlistment relating to each man.
|Year||18||19||20||21–25||26–30||31–35||36–40||41–45||46–50||51–55||Total Each Year|
|1936||Serving in Air Force on outbreak of war||1||1|
It will be seen upon reference to Table IX that some 13 men were younger and 42 older than the official age allowable for page 670 overseas service. Actually the 18 to 20 year group were examined as Territorials serving within New Zealand and escaped the examination prior to embarking overseas when 21 years of age. The 42 in the 41–55 group represent personnel for special duty, men who gave a false age on enlistment, and a group of Grade II men sent to the Pacific in 1943 as garrison troops. Considering the comparatively few of this age group who served overseas, it is noticeable how many appear amongst the hypertension cases. Inquiry will be made into the subsequent medical history of these 309 cases, when it will be found that not all can be held to be suffering from essential hypertension.
Deaths—Second World War Cases
In a follow-up of these 309 cases until 1952 it is found that 34 have died.
The following table gives the ages at, and year of, death of 34 cases of hypertension.
|Year||29||31||35||36||37||38||39||40||41–45||46–50||53||58||62||67||Total Each Year|
If Table X is studied beside Table IX, it will be noted that the numbers in the older age groups preponderate amongst the deaths. All statistics amongst civilians show a similar incidence, and there is nothing to indicate that war service produces a higher mortality rate amongst younger people from hypertension. The majority of the men who served overseas in the 1939–45 War are still in 1952 under the age of forty-five, and yet 24 out of the thirty-four deaths occurred amongst the forty-years-old and older.
Seventeen cases ranging in ages from twenty-nine to sixty-seven died from cardiac accidents, 9 from cerebral vascular accidents in ages thirty-one to forty years, and 4 from renal failure (1 associated with diabetes), from thirty-eight to sixty-two years of age. Four, ages thirty-two to fifty, died of conditions unrelated to the hypertension, but the death of one dying of ruptured aneurysm of the Circle of Willis and one from bilateral thrombosis of the renal arteries, with renal failure, might be considered accelerated by the hypertension. Two cases died from the results of accidents.page 671
Fifteen of these 34 dead were rejected by medical boards as unfit for overseas service, three on account of age and twelve because of abnormally high blood pressure. However, for one reason or another, they were sent overseas. A further case, included because he had been officially diagnosed as a case of hypertension, scarcely warranted the diagnosis. The following is a brief history of the case:
1942 Enlisted when aged 44. B.P. S. 150, D. 76.
1945 Discharged on account of nasal sinusitis. B.P. S. 180, D. 100.
1947 B.P. S. 145, D. 90. 1948 S. 145, D. 90.
1951 Found dead. Coroner's verdict was death due to coronary thrombosis.
If these 16 cases are excluded, it would seem that 18 men fit on enlistment during the war years and on return to New Zealand have since died from the effects of essential hypertension. The following table gives particulars of these 18 cases embracing the age at and year of enlistment, the systolic and diastolic pressure recorded at the enlistment medical examination, the year of discharge from the service with systolic and diastolic pressures recorded at the discharging medical board, the year of death, and age at death.
|No.||Age at Enlistment||Year Enlisted||S||D||Year Discharged||S||D||Year Died||Age at Death||Cause of Death|
|4||23||1939||140||80||1945||164||92||1952||36||Ruptured cerebral aneurysm.|
|6||27||1941||140||80||1944||135||90||1951||37||Ventricular hypertrophy-malignant hypertension.|
|10||33||1941||150||95||1944||140||90||1951||43||Ventricular hypertrophy-malignant hypertension.|
* These two deaths occurred as the result of accidents and not due to cardio-vascular causes.
To present a picture showing the rapid deterioration until death in these cases recordings of blood pressures are given in four of the cases:
1. 1941, 152/74; 1944, 150/80; 1946, 120/70; 1950, 230/130; 1951, In Hospital 215/140. Died coronary infarction.
3. 1940, 135/80; 1945, 150/100; 1946, 230/120; 1947, 250/180; 1949, 250/170. Died cerebral haemorrhage. In 1948 underwent Bilateral Thoraco-Lumbar sympathectomy. He stated he was relieved of headaches but hypertension persisted. This man was 5′ 8½′′ in height and in 1940 weighed 192 Ib. and was described as ‘obese’.
4. 1939, 140/80; 1943, 190/120 Anxiety neurosis; 1944, 190/85; 1945, 164/92. 1952, Died from ruptured cerebral aneurysm of Circle of Willis.
16. 1940 Height 6 ft., Weight 223 Ib. B.P. 134/86.
1944 158/108 W. 221 Ib. 4.9.44 210/120 No complaints. 5.10.44 Headaches and giddiness 180/120. 30.11.44 In-patient for Essential Hypertension. Fundi vessels show early arterio-sclerosis.
1945 200/150; 1946 204/150; 1947 276/160 Died Uraemia and Malignant Hypertension.
These details serve to emphasize the known fact that malignant hypertension may manifest itself without much warning and terminate in death in a brief period. Except in three cases where there was obesity and one case with associated diabetes, there is no apparent cause for the onset and aggravation of the hypertension. Compared with the incidence of malignant hypertension in the civil population, army service does not produce any increase. Amongst the 34 deaths which have occurred, only one man had reported sick overseas and been evacuated back to New Zealand on account of hypertension. Having given a false age, he had proceeded overseas when aged forty-six, and within a few months was medically boarded because of being easily fatigued and blood pressure S. 172, D. 120. In 1950 the B.P. was S. 210, D. 110, and in 1951 he died of coronary thrombosis, aged fifty-seven. The records of any enlistment medical examination are missing from his file. The man who developed diabetes in 1947 was the only page 673 prisoner of war amongst these cases. He was a prisoner in Italy for two and a half years, being repatriated in 1943. His first symptoms of thirst and polyuria occurred in 1947 after being back in New Zealand four years.
Living Cases from Second World War
If a follow-up check is made of the 275 living of the 309 cases originally diagnosed as hypertension after Second World War service, it is found that 120 can be excluded as they are not hypertension cases. These are all cases which were diagnosed as hypertension when discharged from the forces, their pressures being only slightly or moderately above the normal. All subsequent recordings, usually over a period of years, have been normal and the individuals complain of no symptoms and are following their normal employment. Therefore a table is given of cases which, on the last evidence available, had abnormally high blood pressures. The age group at date of enlistment is given for each man. This table of 189 cases of recognised hypertension includes the deaths and should be compared with Table IX above, as Table XII gives a truer picture of the incidence of hypertension.
|Year||18||19||20||21–25||26–30||31–35||36–40||41–45||46–50||51–55||Total Each Year|
It should be pointed out that in 34 of the 155 living cases the blood pressure at enlistment was higher than the recommended limits for normal, and that in all but 9 of these cases the blood pressure was again abnormally high on discharge.
However, it must not be thought all these 155 living cases suffer from a disabling condition. Actually 87 of them suffer no disability and are engaged in normal employment, in hard manual work, trades, farming, and, in a few cases, clerical and professional work. There are cases where the systolic pressure remains over 160 or diastolic over 100, but all less than 175 systolic or 115 diastolic pressure. Possibly if some of these cases had been followed up longer it would have been found that their pressures had fallen as in other cases, and none has reported with symptoms suggesting any page 674 worsening of his health. These 87 cases of symptomless raised blood pressure are found in the age groups as follows:
2 aged 18 years.
26 aged 21–25 years.
13 aged 26–30 years.
19 aged 31–35 years.
16 aged 36–40 years.
11 aged 41–50 years.
Thirty-four cases suffer from severe hypertension, the systolic being 200 or more or the diastolic pressure above 100.
Seven of these cases have arisen amongst those who were in the age group 19–25 at enlistment. Two of these were aged only nineteen years, and their particulars are as follows:
Case 423: Enlisted 1941 aged 19 years in the Air Force. B.P. on enlistment was 185/110. At discharge from the service in 1944, B.P. was 195/115. Later in 1944 the pressure is again recorded as 185/110. He was suffering no symptoms of ill health and was occupied as an engineer.
Case 474: Enlisted 1942 aged 19 years in the Air Force. B.P. on enlistment was 170/95. At discharge in 1945 B.P. was 175/105. In 1946 B.P. was recorded as 210/105. He complained of no symptoms and was occupied as a grocer.
According to the rules laid down for the medical examination of army recruits neither of these should have been accepted for service because of the blood-pressure readings at the initial examinations. However, both recruits served their full term of duty without illness and apparently without any detriment to themselves.
Four of these 34 serious cases have arisen in the enlistment 26–30 age group, 9 in the 31–35 group, 7 in the 36–40 group, and 7 in the 41–50 group. Four cases have been treated with Hexamethonium and two have undergone splanchnectomy.
Many cases in the whole series of Second World War cases were discovered at routine examinations on return to New Zealand, the patient being unaware of any disability. The following case is an example:
Case 396: Enlisted 1940 aged 32. B.P. 158/85. Served overseas and at his medical examination on return in 1944, B.P. was 200/100. Subsequent reports on the B.P. are 1944 190/110, 1945 200/110, 1947 210/130, 1948 220/130, 1949 210/130. He is employed and has no symptoms.
More will be said subsequently regarding the incidence of hypertension amongst the Maoris, but in the meantime the following case is quoted.
Case 260: Enlisted 1940 aged 28. Height 5′ 8′′. Weight 301 Ib. The blood pressure is recorded as 165/95 and there was a faint trace of albumen in the urine. Proceeding overseas he suffered a G.S.W. with page 675 fractured femur in Greece and was a prisoner of war until 1945. The fracture finally united with 3½′′ shortage in the limb.
1946 B.P. 160/120. Some albumen in urine.
1947 B.P. 160/116. Albumen still present.
1948 Electro-cardiograph normal. Weight 329 lb., B.P. 170/130. He has no complaint relating to the cardio-vascular system.
This case is included in the essential hypertension list, as so far as is known there was no pre-war nephritis and the kidney function appears normal. Attention is drawn to the weight of the patient.
A further two cases are noted as they have some bearing on theories relating to the etiology of essential hypertension.
Case 270: Enlisted 1941 aged 30 years, B.P. 140/90.
1944. Suffered haematuria with headaches-and blurring of vision. B.P. 180/135 and there was albuminuria. Hydronephrosis was diagnosed and B.P. eventually rose to 260/150. He developed ileus following pyelography and the B.P. fell to 130/90.
1944 Right Nephrectomy was performed. The B.P. fell after operation to 140/90 but subsequently rose to 180/120.
1950. B.P. is 175/130. The function of the left kidney is normal. He is employed.
Case 79: Enlisted 1939 aged 35 yrs. Gave a history of accidentally ruptured kidney in 1932. B.P. on enlistment was 170/90 and he was placed in Grade II on account of the blood pressure and he appeared ‘highly strung’. However, he proceeded overseas to the Middle East and in 1942 was admitted to Hospital with renal colic.
1943. Returned to New Zealand with a Furlough Draft. Complained of pain in the right kidney area stating it had been present since his injury in 1932. B.P. 170/100. Investigation by dye test showed the Right kidney not functioning properly.
1946. Some evidence of an Anxiety State B.P. 156/108.
1948. B.P. 150/110.
1949. 170/110 and later 200/120.
1950. Right nephrectomy was performed and three months after the operation the B.P. was 140/90. In 1952 he is employed as a factory hand and suffers no disablement.
Only one case suffers from a cardiovascular accident:
Enlisting in 1940 at the age of 52, he was accepted for overseas service, his B.P. being 160/100. In 1944 he was medically boarded overseas as he was considered too old for service in the field and his B.P. was found to be 180/110. In 1945 he was medically examined, complained of no disablement and his blood pressure was 140/85. In 1950 he suffered a cerebral thrombosis.
To summarise, approximately 130,000 served in the three New Zealand services overseas and approximately 100,000 of these in the Army. Of the 309 cases quoted, all served in the Army except 19 in the Air Force and 6 in the Navy. Up till the year 1952, 189 page 676 cases of known essential hypertension have occurred amongst the personnel of these overseas forces whose enlistments took place mainly between 1939 and 1943. Thirty-four of the 189 cases have died between the years 1941 and 1952.
Study of General Group with Overseas Service in Second World War
Just as a survey was made of files of living servicemen of the 1914–18 War as each applied for treatment, so a similar survey was made of the files of the 1939–45 War. The object in view was to obtain information regarding the blood pressure in a body of men who were not under observation for known hypertension. To this end over 2000 files were routinely perused, including some 15 of the 309 cases just reviewed, and they are therefore not included. Also a great number of cases have been under observation only for conditions such as eye, ear, nose and throat disabilities or wounds of limbs, where no record of the blood pressure has been entered since the final service medical board. They are excluded as it was desired to report only on cases in which there was some ‘follow-up’ history subsequent to service life. Cases of hypertension discovered before or at discharge have already been discussed. To get a picture of present conditions in a population, all of whom had been medically examined according to the same standards on entry to the service, only the files of servicemen who served overseas in the Army have been used. This survey is taken from the medical files of 1936 servicemen who served overseas during the 1939–45 War and who applied for treatment during a period of some months in 1951 and 1952.
The earliest date upon which the medical history of any man is first known is the enlistment examination, and the survey will be made of the cases according to the years of enlistment. Thus it was found that of the 1936 cases 432 were enlisted in 1939, 1021 in 1940, 235 in 1941, 188 in 1942, 28 in 1943, 18 in 1944, and 14 in 1945.
In collecting material for the survey, notes were taken of all cases in whom the diastolic pressure had risen to 90 or over at any time since the date of enlistment or the systolic pressure to over 160. Of the 432 cases enlisted in 1939, in 333 the diastolic blood pressure has never been as high as 90 at any of several readings taken during the intervening years nor the systolic pressure as high as 160.
Thus of the 1939 enlistment group, 99 have since enlistment exhibited a diastolic pressure of 90 or more. The following table shows at a glance the age group to which each of the 99 belonged page 677 in 1939 and the year in which a diastolic pressure of 90 or more was first recorded.
|Year B.P.||Age Group||Tota Each|
It will be noted from Table XIII that 58 of these 99 cases had a diastolic pressure of 90 or more on enlistment. Of these 58 cases, 24 had a diastolic pressure less than 90 at all subsequent examinations, while the other 34 have remained between 90 and 100. The systolic pressure in these 58 cases has averaged 138, with an extreme maximum of 170 (on one occasion only) and the minimum 110.
Of the 99 cases the diastolic pressure has been above 100 in six only. It is a striking fact when the age groups of these 99 cases is studied in Table XIII that not one of these six cases had a diastolic pressure over 100 before he was thirty-eight years of age.
As these cases represent the highest pressures found in the 1939 enlistment group of 432, a few details are quoted of two of them:
(1) Aged 34 in 1939. B.P. 150/88.
1943 B.P. 182/104 while a prisoner of war in Germany.
1944 Recording while a prisoner of war. 160/95. 180/95. 138/88.
120/88. The last two were taken after prolonged rest.
1945 Repatriated to the United Kingdom. 142/100.
1950 Under treatment at Hanmer. 162/98.
1952 Has been a V.B. in a Mental Hospital on two occasions and leucotomy recommended.
(5) Aged 40 in 1939. B.P. 130/80.
1946 155/110. Suffers from chronic indigestion and cholecystitis.
1950 180/125. Appears to be a definite case of Hypertension but he was aged 47 before the diastolic rose above the 100 in 1946.
As stated above, 1021 of the cases studied enlisted in 1940, and it is found that 253 of these have recorded a diastolic pressure of at least 90 on some occasion from the date of enlistment until 1952.page 678
The following table gives the age group to which the individual belonged in 1940 and the year when the diastolic of 90 or more was first noted:
|Year B.P.||Age Group||Total Each|
It will be noted from Table XIV that 165 out of the 253 cases exhibited a diastolic blood pressure of 90 or more when first examined upon enlistment in 1940. A subsequent follow-up check discloses that 149 of these 165 had a diastolic pressure of less than 90 at all subsequent examinations. The systolic pressure has never been above 160 and seldom as high, except in one where a reading of 186/74 was recorded on one occasion. In the remaining 16 cases the diastolic pressure has varied between 90 and 100, but never above 100, while the average systolic was 145, the highest being 160.
Fifty-seven cases whose diastolic pressure was below 90 on enlistment in 1940 have since exhibited a diastolic pressure of 90 to 100, with a systolic pressure not above 160 on at least one occasion.
Twenty-one cases have exhibited a diastolic pressure at times rising above the 100 to 109 with a systolic pressure not above 160, but the diastolic pressure subsequently reverted to under 100.
In only 11 cases has the diastolic pressure risen to 110, but except in two cases this was at the most recent examination in 1951 or 1952, and time will tell if this pressure will revert as none of these cases suffers any symptoms of hypertension at present.
One case aged forty-seven in 1948 has the following readings: 1940, 150/90; 1942, 150/95; 1946, 150/90; 1948, 178/110; 1949, 180/100; 1951, 180/110. Disability is bronchitis.
One case aged thirty-five in 1940 with B.P. 160/100; 1946, 145/90; 1949, 148/110; and 1951, 180/110. Suffers from deafness and hysteria.page 679
Enlistments during the year 1941 provided 235 cases of this survey, and it was found that 51 of these have exhibited a diastolic pressure of 90 or more some time since that date. Thirty-two of the 51 had a diastolic pressure of 90 to 100 on enlistment, but in 24 of these all subsequent diastolic pressures have been under 90. Eight of the 32 cases have persisted with a diastolic pressure of 90 to 100 with the systolic pressure ranging from 130 to 160.
Nineteen cases have shown a diastolic pressure of 90 or more only since the initial enlistment examination, but in only four cases has the diastolic been higher than 100 on any one occasion.
In one case, although taken on several occasions during the intervening years, the diastolic pressure did not rise above 90 until 1951, when the patient, aged twenty-nine, had a B.P. 170/110 but was found to be suffering from diabetes and chronic dyspepsia.
In two cases the systolic pressure rose to 170 and 180 respectively, each with a diastolic of 105 in 1951, and it remains to be seen if the pressures will revert. However, the age of one is sixty-five, so perhaps a pressure of 180/105 is scarcely abnormally high. The second case was aged twenty-nine in 1951 and suffers from rheumatic carditis.
The fourth case enlisted in 1941, aged thirty-three and B.P. 138/72. He was discharged in 1942 with B.P. 130/80. In 1950 B.P. was 130/90. He was operated upon for left carotid aneurysm, which was followed by a right hemiplegia. 1952 B.P. 168/110.
From the 1942 enlistments 188 cases appear in this series, of whom 48 have had diastolic pressures 90-100 on some occasions since enlistment. In 26 cases the diastolic pressure was 90-100 on enlistment, and 19 of these have never again had the diastolic as high as 90. Of the remaining 7 cases, in 5 the diastolic pressure has persisted at 90, but never been higher. One case, aged forty-seven, has a blood pressure of 160/100 in 1952, and the remaining one is quoted below. The remaining 22 cases of the 48 have all exhibited a diastolic pressure from 90 to 100 at some period between 1942 and 1952, but in only one has the diastolic pressure ever been above 100, while in 19 cases it has never been above 90.
Details of the two cases exhibiting diastolic pressures over 100 are as follows:
One case enlisted 1942, aged 30, with B.P. 136/88; 1944, 136/86; 1950, 170/130; 1952, 160/110.
One case enlisted 1942, aged 47, B.P. 136/94; 1943, 140/90. Suffered pneumonitis with debility. 1944, 140/92. 1946, diagnosed Tabes Dorsalis B.P. 140/80. 1947, 134/90; 1948, 150/100 - 170/100; 1949, 180/110; 1950, 190/120; 1951, 180/110.
Sixty cases appeared in the series from the enlistment years 1943–45. This decrease in numbers actually corresponds with the page 680 decreased numbers entering the Army compared with the years 1939–42. Twenty-four of these sixty cases exhibited a diastolic pressure of 90 at the enlistment examination, but none had such a high diastolic pressure on any subsequent occasion.
Thus a review has been made of the recorded blood-pressure readings of 1936 service patients of the 1939–45 War to learn the incidence of hypertension amongst the group generally. The cases were unselected from the applications for treatment, but were all suffering some war disability, were all males ranging in ages in 1951 from twenty-five to fifty-five approximately, and had all been medically examined and pronounced physically sound between the years 1939 and 1945. In addition to these 1936 cases a further 15 cases of hypertension included in the accepted cases reviewed earlier also routinely came before the reviewer.
From the details given above it will be seen that these 1936 cases produced 8 cases of hypertension, 1 of these being associated with diabetes, 1 with rheumatic carditis, and 1 with a right carotid aneurysm.
In addition, there were 13 cases of potential hypertension, these cases having a diastolic pressure of over 100, with systolic of 160 or more only on the last and recent occasion. Therefore, subsequent examinations will disclose if the diastolic rise is permanent. Of the 8 cases, 2 are aged twenty-nine (one with associated diabetes and one with carditis), 1 is thirty-eight, 4 range from forty-four to forty-eight, and the other is aged fifty-three. Thus the essential hypertension without any associated cause occurred mainly after middle age. This survey has shown that, in a survey of 1951 files, 23 definite cases of hypertension have arisen when the 15 already accepted cases are added.
Home Service Personnel
It is not proposed to survey the cases which have occurred in service personnel who served in New Zealand only, as individuals of both sexes, diverse ages, and various degrees of physical fitness were all enlisted for office and non-combatant jobs required in camp. Many suffered from hypertension when enlisted, but the standard of health required for much of the Home Service duty allowed anyone who was fit to earn his living in civil life, even if only in a sedentary occupation, to be accepted.
Some 194 were discharged from Home Service with a diagnosis of ‘Hypertension’, but 69 have in this survey been excluded because the diagnosis was made without sufficient observation or evidence. These 69 include two cases who have died subsequent page 681 to discharge from cardiac accidents, but they were both over fifty years old and neither had any blood-pressure record of systolic above 160 nor diastolic pressure above 90.
One hundred and twenty-five are accepted as true hypertension cases, and of these, 83 are living and 42 are dead. Particulars of these 125 cases are given in Tables XV and XVI.
|Eighty-three cases of hypertension occurring in Home Service personnel of the 1939–45 War, giving the numbers in each age group in 1952 and the average known duration in years of the hypertension, with the extreme ranges in each age group.|
|Number of cases||1||1||1||4||8||17||16||16||9||8||2|
|Average duration of hypertension in years||7||10||7||11||8.5||9.5||10.5||9.5||10.5||10||12.5|
|Extremes of periods noted in each age group||8-12||3-10||4-12||1-12||7-12||8-12||7-12||12-13|
The majority of cases, especially in the older age group, were suffering from hypertension when enlisted, but as the duration periods are only calculated from the earliest known date, the duration periods in most cases are actually longer than the table suggests.
|The number of cases, age groups at death, and average duration periods of hypertension in 42 cases of hypertension that have died since discharge from Home Service in the 1939-45 War.|
|Number of cases||1||2||5||7||11||6||6||3||1|
|Average duration period of hypertension in years||2||2||6||7||6·5||6||7||8||6|
|Extremes of periods||1–3||1–10||1–11||1–12||3–8||3–12||1–12|
The duration periods shown are only approximate as again hypertension was often present on enlistment.
|Herein is shown the causes of death in each age group of the above 42 cases.|
|Cerebral vascular accidents||2||2||3||1||8|
In Table X and Table XVI the numbers and age groups at death are given of personnel who served overseas and in New Zealand only, and it is remarkable how closely they resemble each other. In the overseas personnel in the vast majority of cases only the younger and fit men were included. For service in New Zealand large numbers of personnel aged from forty-five to sixty-five and known to be hypertension cases were enlisted, in addition to younger territorials (18–21 years) and men down-graded for various physical causes. Approximately 70,000 served in New Zealand only, with, of course, a much higher percentage of females than in the overseas forces.
1 Deaths in 2 NZEF in Middle East and Italy possibly, but not necessarily, related were: coronary thrombosis, 1; coronary atheroma, 1; myocarditis, 6; endocarditis, 2; heart failure, 4; subarachnoid haemorrhage, 4; cerebral haemorrhage, 4.
a If one case of 4 years' duration omitted, average would be 15.3 years.
b If 3 cases, 1, 3 and 7 years' duration omitted, average would be 17.4 years.
c If 2 cases, 1 and 7 years' duration omitted, average would be 16.6 years.