A Disorder I've Never Seen

“I’ve been trying to pick up stuff, and I can’t,” said a Ramada guest over the phone.

“You mean your arm is weak?” I asked.

“No. Once I grab it, it’s OK.”

“Is it numb?”

“It feels fine. But when I reach out for something, I miss it. It’s weird.”

The guest was elderly but in good health. I suspected I knew the problem.

“Take your forefinger and touch your nose,” I suggested. “Can you do it?”

“No,” he said. “I keep hitting my face.”

This was something I’d never encountered but luckily I remembered medical school neurology. This lady had suffered a cutoff of blood to her cerebellum, a structure at the base of the brain that controls coordination.

When you reach out, the brain instructs muscles to move your arm in the general direction of your goal. That’s the best it can do. The last few inches don’t require strength or mobility but fine, precise movements. That’s where the cerebellum takes over.

With the cerebellum out of action, you’d have normal consciousness, strength, and sensation but no coordination. You could walk but only slowly with a clumsy, wide-based gait. If you reached for something, your hand would wobble wildly as it approached. The classic test is to ask a patient to put a finger on her nose. With the cerebellum out of action, it’s almost impossible.

It could have been a temporary loss of blood supply, a “transient ischemic attack” (TIA) or a permanent loss, a stroke. Waiting to see which would be unwise, so I urged her to go to a hospital.

The History of High Blood Pressure

For much of his presidency, Franklin Delano Roosevelt’s blood pressure was high. His doctors knew but didn’t do much.

Doctors had been measuring blood pressure since the 19^th century, but they considered it a vital sign – like pulse rate or respiration rate or temperature. They felt better if it was normal but didn’t believe that high pressure was a disease. Everyone knew (as everyone knows today) that stress makes your pressure go up, so avoiding stress was a good idea, but that’s hard for a president. His pressure was spectacularly high the day he died of a stroke in 1945 while relaxing in Georgia.

By the 1950s many doctors believed that high blood pressure was unhealthy. Doctors who act on their beliefs are no different from anyone else. They do a lot of dumb things. So not every doctor treated it.

Proving that high blood pressure kills requires observing thousands of people for years. By the 1960s it was proved. It seems a no-brainer that this means doctors should lower high blood pressure, but that doesn’t follow. After all, a rapid pulse or fever is often an ominous sign, but returning them to normal doesn’t accomplish much.

Proving that reducing high blood pressure saves lives requires observing thousands of people, treated and untreated, for years. By the time I entered medical school in 1968, this had been done, and we heard lectures urging us to treat high blood pressure vigorously.

This was not easy because the drugs available lowered many things beside blood pressure, so they made patients drowsy, dizzy, constipated, and impotent. But things have improved.