Hypertension and its surgical treatment by bilateral supradiaphragmatic splanchnicectomy

HYPERTENSION AND ITS SURGICAL TREATMENT BILATERAL SUPRADIAPHRAGMATIC SPLANCHNICECTOMY * MAX

MINOR

Ann Arbor,

presents the most YPERTENSION serious medical problem before us today. No other disease exacts such an appalling annual toll. Its linal manifestations of either cerebral, cardiac or renal damage account for more than 200,000 deaths each year in our country alone. Few realize that near-iv- all cases of so-&led cerebral accidents, which include both intracranial hemorrhages and cerebrovascular thromboses, most cases of heart disease, including those with coronary thrombosis, and the great majority of cases of so-called Bright’s disease have as their primary factor, hvpertension. The financial loss due to necessarily and mental activities curtailed physical resulting simply from the distressing symptoms of hypertension, and the actual loss time due to the semiof productive invalidism of mnn~ victims of hypertension reach staggering figures. When evaluating the enormity of this disease, we must not forget the amount of suffering it causes, irritability, innervrousness, headaches, somnia, nocturia, shortness of breath and the all too frequent clouding of mentality. Any treatment vvhich, with reasonable safety, can reduce this enormous death toll or can alleviate in a worth while degree the distressing symptoms and prolong the life of these patients is certainly worth vvhile. hIedical treatment has signally failed in many cases and we believe that surgery today offers far more than any other type of therap!- a real hope of attaining these ends. Considerable confusion has arisen because of the v.arious designations of hyperof Zlichigan

PEET, M.D. L\licbigan

tension. We prefer the term arterial hypertension but commonly the terms essential or benign hypertension are used. Both are misnomers because it is not essentia1, as was at one time believed, to have an increased blood pressure in order to force blood through a possibly inadequate srterial system; and the disease is never benign aIthough serious manifestations may not appear for many years. The blood pressure may be temporarily or continuously elevated in a wide variety of conditions, for example, in cerebral trauma the blood pressure may rise very rapidly with the increase in intracranial pressure either from hemorrhage or edema. Certain tumors as basophilic adenomas of the pituitary gland and some adrenal tumors can produce either a continuous or recurrent elevation of blood pressure and rather late manifestations of chronic nephritis may also produce hypertension. Coarctation of the aorta, while uncommon, should always be considered a possibility in any patient, especially in a young individual who is found to have hypertension. This is a very brief Iist of the possible causes of elevated blood pressure. Such a list comprising forty-seven pathologic conditions associated with an elevated blood pressure was compiled by Page’ l in 1939. The diagnosis of arterial or, as it is more commonly called, essential hypertension, is therefore made by the exclusion of the other conditions which may present a similar picture. Arterial hypertension is a highly complex disease svndrome characterized at first by only a mild elevation in the systolic

H

* Pr~)l’csscrol’ Surgcrb, Univcrsit\

BY

i\ledicaI 48

School,

:tntl University

IIospitaI,

Ann Arbor,

hlich.

and diastolic blood pressures. From then on its manifestations are many and the progress of the disease varies greatly. One patient may have more or less incapacitating symptoms of headache, nervyousness, in&mnia and ease of fatigue but ivithout evidence of cardiac or renal damage. Another with apparently the same elevation in blood pressure may be practically symptom-free but will shortI>. begin to show evidences of cardiac disease. Still another patient may ha\-e the usual hypertensive svmptoms and some e\*idences of cardiac involvement but on careful examination it is found that the kidneys are chiefly affected. Another patient may first manifest evidences of this disease b! a so-called stroke, either a cerebral hemorrhage or a cerebral arterial thrombosis. The rapidity of progress of the disease \.aries as much as its manifestations. A few live out a normal life span without an? untoward incident but the majority sooner or later ha\re serious constitutional changes renal or cerebral involve\vith cardiac, No one can definiteI\prophes), ment. \vhen such serious organic in\~olvement ma\- occur. Some patients will go with what appears to be an apparent benign form of hypertension for many years, even without the more common symptoms of the and then suddenly and for no disease, rapidly severe known reason develop changes in the heart or kidneys or sufTer a cerebral hemorrhage. The more common course is for the disease to progress slo\~l~., the symptoms gradually increasing In number and severity and within a few renal or cerebral involveJ ears cardiac, ment becomes manifest. A fe\v patients present ;I fulminating type of the disease called malignant hypertension \vith death ensuing in a few months. The manifestations of hypertension are ‘;o man\’ and so varied and the actual progress of the disease so uncertain, embracing a course from the extreme of a fatal termination in a few months to a seemingly benign course for many years,

that :I true e\.n/uation of an! form of therapy is extremely diflicult. This probably accounts for the very large number of therapeutic measures that ha\-e been ad\,ocated. Very thorough and honest appraisals haIre been made of all the usual drugs recommended for the treatment ot hypertension and it has been unequi\-ocnbly demonstrated that the\ are of no practical value. It is true that a number of clrul;s will \‘er?- temporarily reduce the blood pressure but such temporary reduction i.5 of no value in the treatment of a chronic disease. Nitroglycerine is of course indicated in the emergent:\of angina pectoris but onl! for its immedrate and extremely temporar) effect. It is valueless in preventing future attacks. The only drug kvhich toda) is recommended bv some of our leading medical men is potassium thioc! a nate. This must be given with :I great cleal of’ caution and frequent blood level cleterminations obtained. Even bvith the most careful precautions and when the Le\,el is maintained at a theoretical safe ccjncentration, toxic symptoms sometime de\,elop; and it is because of this uncertainty, both in its toxicit? and in its therapeutic benefit, that many leading internists do not recommend it. It is therefore fortunate that surgery offers worth while improvement in a signiticant percentage of cases. The cause of hypertension is unknown but an ever increasing mass ot data indicates that heredity plays an important ri)le. The vast ma’joritv of cases ,gr\‘e :I detinite family history (if hypertension. In fact it is rather unusual to get a histor!of a patient neither of whose parents had an abnormally high blood pressure. Commonly, in addition to either the father or the mother having had hypertension, WC’ obtain a history that one or more brothers or sisters of that particular parent also had an elevated blood pressure. In some families there is a very definite history of se\reraI dying from cerebrovascular accidents. In another family we will have renal cornplications as the cause of death. In ;I fen- Eve

h;1\~(’ bcc~i ;11)1(, to tr:rcr tilt, h,vlx7tc*lixic111 for three gc’ncr:ltions. \C’ith 3 h\.l)crti’nsi\.c family histot-! WC‘ can bc clliitc certain that one or more of the children bvill hn\re hypertension and the percentage greatI> increases if both parents are hypertensi\.e. Frequently the disease xppears at n younger age in the children than in the One young \voman who came to parents. us for n splanchnicectomy to relieve her hypertension gave the following striking fimily history : Her mother had died of cnrdiorennl complications from hypertension, her mother’s sister likewise had hypertension and died of cardiorennl disease. The patient had five sisters, she being the youngest in the family; all five sisters had had hypertension and had died before the patient came to us. mre ha\re had numerous other family histories nearly as striking. CertainI!, with such ex,idence the r8le of heredit>- must be gi\-en \.er?- serious consideration. Il’e do not believe that it is in the autonomic ner\‘ous ;I n 3 bnormalitv system Lvhich ‘is inherited. This variation from the normal is manifested by excessi\-e responses to normal stimuli. In other lvords, we believe that there is n congenital tendency of the autonomic system to overreact and to respond to n gi\ren stimulus fl? either greater or more prolonged vasoconwhich in the hypertensi\,e instriction, \-elves the renal circulation. The de\,elopment of h?-pertension is usually insidious and many times nn earl? hypertensive case is discovered largely b?accident. The routine physical esaminations required by man); industrial firms for all applicants at the trme of employment frequently disclose some ele\.ation in blood pressure In young individuals who are completely symptom-free. A surprisingI> large number of earl?; hypertensi\se cases was found during the induction esamination for the Army and Navy. Life insurance examinations hn\,e been a fruitful source in the discovery of hypertension. In spite of these \,nrious opportunities for the detection of the disease the great mn jorit!. of patients do not knon that the!.

cIc\ atixl I~lootl lxx+ Illi \ c ;lu ;1bnormsll~ hurt until they c.onsult ;I ph\.sici:ln bccnus~ 01‘ SC\ crc symptoms such :I; incnpacit:lting hendaches and abnormal ner\‘ousneys and irritability, or because of actual organic changes ‘in the heart or kidne)-s. It is therefore impossible in the large proportion of our patients to make B definite statement of how long h? pertension has actually existed. seem at Certnin precipitating factors times to be the immedinte cause of hypertension; particularly is this true of pregRather commonly the history disnancy. closes that h)-pertension f;rst developed Sometimes the blood during pregnancy. pressure drops to normal after delivery at full term only to rise again and generalI) to a higher level at a subsequent pregnant>. In such cases the blood pressure level seldom comes down after termination of that We are of the opinion that the pregnancy. pregnant)’ simply precipitates the disease in a Lvoman who, in all probability, would haare de\-eloped hypertension at some time later. In other words she was :I potential hypertensil-e individual and it took onl) &is added change in her physiology to bring on the hypertension at an earlier date: Unfortunatelv, it is impossible to pro\‘e The toxemia or disprove th’is assertion. of pregnancy appears to be much more common in bvomen who do have ele\.ated blood pressure and it has been shown that roughI>. 25 per cent of women who hn\re had such ;I toxemia have :I persistent hypertension postpartum.:’ The magnitude of this factor in the o\-er-all picture of hl-pertension is shojvn by the follokving tjgures: toxemia occurs in about 8 per cent of all pregnancies, therefore, 2 per cent of all women bvho become pregnant w?lI be expected to develop a hypertension which persists. I!’ At the present rate of births in this countr), this lvould give :I figure of more than 70,ooo wwmen each year \vho can bc expected to develop hypertension as the result of pregnant! .I”

l’lolc~tlgc~l cnioliolial strain sucl~ :15 ~VVC)I.I.\ cr liilancial m:lttcrs or clonncstic l~roblenis is frcyucntl\~ gi\.en as a precipitating cause of hvpertension. Certainly in times ot severe stress, as in war, f;n:Gal crises or some other \videsprend causes for se\.erc ;I.nxietj., the number of h\,pertensive patients seems to be greatly increased. There Ii also considerable e
DIAGNOSIS

The diagnosis of arterial hypertension, commonI>. spoken of as essential hypertension and b\., some as diastolic hypertension, is primarily based on the findings ot an ele\xted systolic and diastolic pressure. A single obserjrntion is of little significance. Repeated pressures must be taken under \nrious circumstances. Several criteria to determine the hypertensive state are in use. Goldrinp and Chnsis” make the follo\ving statement, “From three to sixteen \‘e:trs ot age the systolic blood pressure rises progressi\.el!. from 90 mm. Hg to Ilj tnm. Hg and the diastolic from 6; mm. I-lg t0 -j mm. Hg; at fort! !.ears of age the upper limit is 14.0 mm. Hg in the sytolic and 90 mm. Hg in the diastolic phase; above forty the upper normal limit ic I 50 mm. Hg in the s\;stolic and 90 mm. I-lg in the diastolic phise.” Some authors are more extreme and consider :i diastolic rending of o\yer 80 mm. abnormal at an>. age. Howe\.er, the majority of medical nlen consider the diastolic as normal if b~elo\~~ IOO mm. at age fort!. or older. The method of taking the blood pressure nccounts for man?discrepancies. Usually. the blood pressure is different in the and standing positions. wclining, sitting . . It- rna~. defer considerably in the two arms. ‘fhe emotional status of the patient at

thck time. of’ c~s;lminatio~i i:, :I11 iIlll)of-t;lnt I1lctor and must lx consitlctwl in c;lcli c'lse ‘ . A patient manifesting ncr\~ousness o\.er the examination or ansiet\. o\‘er some other matter w,ill hu\,e a pressuit’ dctinitel! ab0i.e his usu;tI le\rel. I saw this dernonstrated m:ln\~ times during the war 1%hen >‘oung men l\,ho hvere particul:lrl! desirous of getting into the airforce M.ere refused because of ;I slightI). ele\r:\ted blood prestheir sure. On numerous examinations, blood pressures were found to be absolutely normal b)- their home physicians and b,v myself. Almost routineI!. the blood pressure will be found at a lower le\,el, both in normal and in hypertensive patients, if the rending is taken following a short rest instead of being taken immediately upon entering the examining room. It is belic\,ed by some that ;I pre-hvpertensive sta,ge can be demonstrated, but there is much conflicting e\-idence in this matter and at present we have no test kvhich bvill dclinitelJ.‘indicate whether a certain indi\~idunl cvill or bvill not subsequentI! de\,elop hypertension. How:e\-er, certain leads ha\,e been established and it can be stated quite definiteI!that the individuals w-ho maintain a relativeI?stable normal blood pressure le\.el under :I \xriet\. of conditions and at different times kvill probabl\. not de\-elop hypertension. Only about 3 per cent of such apparently stable indi\~itlu:lls hn\.e subsequently been found to ha\,e hJ,pertension. Conversely, -0 per cent ot apparently normal individunis who sho\ved temporar!, elevations in systolic and ldiastolic pressures at \,arious times hubsequentl). developed hypertension. The blood pressure should bc t.:\ken initialI> in the horizontal, sitting and standing positions and in each at-m. If an ;cbnormally high le\rel is recorded, the 1x1ticnt should rest tor at least fifteen minutes, preferably. longer, in n horizontal position and the blood pressure readings again recorded. Useful information is sometimes obtained b,y ha\+ng this type of patient exercise such as running up anti doC\.n :I tlight of stairs, recording the blood l)rcssurc

changes from such a standard type of exertion. As a matter of routine we a1ways take three blood pressure readings in quick succession in each arm in each position of the body. If considerable variation is found on these three readings, subsequent readings are taken after a few minutes. It is possible to take direct arterial pressures by using a needle pIaced into the lumen of an artery, but for all practical purposes the mercury manometer or an accurate aneroid manometer with nuscultatory determination of the pulse sounds at the elbow is satisfactory. It is desirable in a11 young people to determine the pulse pressure in the femoral artery since this will determine the presence or absence of coarctation of the aorta as a possible cause of the hypertension. SYMPTOMS

Certain symptoms are so regularly complained of by hypertensive patients that one can be almost certain of the diagnosis, in many cases, before having any knowledge of the actual blood pressure level. However, in the very early case, symptoms are usually absent; even in advanced hypertension, symptoms may be entire1y wanting. There does not seem to be any correlation between the height of blood pressure and symptoms. Some patients with a systolic blood pressure of 190 will complain of excrutiating suboccipital headaches; other patients with pressures ranging from 240 to 260 or even higher may never have a headache. However, it is generally noted in patients who do have symptoms that these are aggravated when the pressure is at an unusually high level. The common symptoms of which a large number of patients complain are: headaches, especially suboccipital, nervousness, irritability, insomnia, nocturia, shortness of breath and ease of fatigue. The headaches are extremely common on awakening in the morning and disappear after the patient is up and about. In the more advanced cases the headaches may awaken the patient very early, sometimes at three

or four in the morning, and it is impossible for them to get back to sleep even after taking the usual headache remedies. The headache may be bifrontal or bitemporal or extend over the entire head but most commonly it is in the back of the neck and suboccipita1 region and from there at times extends forward to the top of the head and frontal area. Severe suboccipital headaches occurring more or less regularly every morning are so characteristic of hypertension that when such a history is elicited I always expect to find a very material elevation in blood pressure. Some patients have a history of such headaches for man\ weeks at a time; others will complain of having them only one or two mornings I week. There may be periods, especialI! when the patient is on vacation or not under stress, when the headaches may entirely disappear. Frequently the taking of food and moving about will give relief but in some cases the headaches persist throughout the day. They may also appear at any time during the day especially if the patient becomes excited or is under stress or physically fatigued. It is rather a common medical practice to advise a patient to lie down in the afternoon and rest but many patients will state to do so will again bring on a suboccipital headache. At times these headaches are so severe as to be completely incapacitating. GeneralIy there is no nausea or vomiting associated with them. Some patients will have complete relief of early morning headaches by sleeping with the head of the bed elevated. This is most easily accomplished by putting blocks of wood under the head of the bed raising it to a height of about I 2 inches. In extreme cases the patient refuses to go to bed and sleeps sitting up in a chair. Increasing nervousness is an exceedingly common complaint although some patients are not aware of this themselves and the family. have to give the definite history. Not Infrequently patients will state that they have always been rather nervous but never to the extent that the:, h ave felt since the onset of hypertension.

Frequently associated with increasing ner\.ousness is irritability. This may be a c.~omparatively minor complaint but in man>. patients it assumes realI>- serious proportions. It may become so pronounced as to interfere with his business and with his domestic happiness. I have frequentI> had a patient make the following statement to me, “I love my children as much as an) lilther possibly could, but it has gotten so 11o\v that anything they do, no matter hou trivi;il, irritates me seriously.” The ner\‘ousness and irritability are not dependent upon the height of the blood pressure. Some patients having this complaint have only. moderately elevated pressures, while others who may ha\re a very marked hypertension are relatively calm. However, in the majorit)of cases the nervousness and irritability are greater during periods in w:hich the pressure is unusually high. A \,;cious circle certainly exists, the increased pressure making the patient more nervous and more irritable and this converseI>. raising the pressure stiIl higher. NearI!. all patients complain of nocturia, g~enerallv once or twice at night, but in an appreciable number of cases nocturia is a \‘ery real problem and seriousI>- interferes uith sleep. A history of having to urinate el,-er>’ hour during the night is not especially uncommon. This is particularly found in those individuals whose concentrating ability is seriously impaired. Nocturnal dyspnea fortunately is a rather uncommon symptom since it indicates verb serious card’& damage. Very mild nocturnal dvspnea ma>. be completely relieved b:,. sleeping with the head on se\,eral pilIOMX, but in the more se\‘ere cases the patient is unable to sleep in bed and has to sit in a nearI); upright position in a chair if the patient is \Yeight reduction, obese, and digtalis may be of great value in relieving this distressing symptom but the o\-et--all picture will always remain grave. Ease of fatigue is an exceedingly common in hypertensive patients. It complaint m:~; be due somewhat to increased nervousness Ijut seems more related to so-called

vital capacity. It does not ha\.e :I delinite relationship with the height of the blood pressure but may have a relationship with the cardiac and renal status. Some patients present just the opposite picture and with the de\.elopment of hypertension become more and more dynamic and tireless. The) feel keyed-up and under tension and do everything quickly. This is the type of personality so commonly considered h,vpertensive. The complaint of feeling aI\\n~-s keyed-up and under tension is not confined, howetTer, to this group and is, in fact, :III of all exceedingly common complaint hypertensive patients. They frequentI> state that they cannot relax and this in itself makes sleep difficult. Shortness of breath on mild physical exertion such as going up one flrg:,ht ot stairs is an extremely common complaint. It may or may not indicate cardiac damage. However, if the symptom is \-et-J definitely progressive and the patient is not unduly overweight, cardiac disturbance can be expected. Palpitation, either under exertion or while quiet, is also a very common complaint. It does not necessarily signif). any organic change in the heart. In fact it ‘is much more frequently associated with nervousness. Angina pectoris, either in a mild or severe form, occurs commonly in hypertensive patients. It ma> be the result of simple coronary spasm but in man?. it is probably due to :rct.uaI arteriosclerosis of the coronar!’ vessels. Particularly is this true when the h!pertension is of long duration. Patients with angina pectoris are advised to stop smoking and to limit their activities and emotional Nitroglycerine is invaluable *as a strain. relief agent at the onset of an attack. The patient cvith frequent angina1 attacks has certainIF a much graver prognosis. FortunateI) many patients with angina have complete relief following splanchniccctom).. This suggests that \,ascular spas111 rather than arteriosclerosis was the immediate factor. Edema of the ankles v:hen occurring regularly is of serious import it is most frequentI>, :issoci.:rtcd since

with carcliac decompensation. Other causes such as varicose yeins should of course be ruled out. Nausea and i.on1itin.g are uncommon s\mptoms of hypertension even in the patients who suffer from severe headaches. A historv of repeated attacks of nausea and vomiting is high15 suggestive of the so-called malignant type of hypertension. In most patients with these symptoms evidences of severe renal damage will be found. of a more or less nlentnl symptoms se\‘ere degree occur veq. commonly in h\,pertensive patients. As a rule they are slight and characterized chiefly b\; ditficulty in concentration and a slightI>impaired memory, especially for recent matters of little consequence. However, man! patients complain that “their head feels thick,” that they cannot think as they formerI>- did, that at times the\: seem to be in a fog; some complain that their loss of memory is a serious handicap in their business. Some patients have apparentI) not been cognizant of any previous mental difficulty until after a splanchnicectomy; then the\- commonly remark that they can . nom- thrnk clearly, that they can concentrate and they often state, “it seems as though a fog had been wiped awry.” From these mild evidences of hyperteniive encephalopnthy we have various grades in the individual who is entirely incapable of carrying on any active mental processes. Usually the mental changes are insidious and their development \rery gradual. Even marked mental deliciency may be found in patients who apparently ha1.e not had a cerebral accident, either cerebral hemorrhage or thrombosis. All the signs and symptoms of hypertensive encephalopathq are greatly increased when a so-called cerebral accident occurs. Small intrncranial hemorrhages can occur without danger to life but I believe the majority of so-called strokes which the patient sur\rives are actually due to \rnscular thrombosis. 1 clo not den), the possibilit,v of cerebral \~ascular spasm but believe, at

least in the majority of cases, that even the transitory symptoms ,of a stroke are due to small thrombii. Blurring of the vision, either recurrent or of more prolonged and transitor;\-, periods is a rather common symptom in the more advanced stages of hypertensive disease. At times the blurring lasts onl) for a few minutes and strongly suggests periods of angiospasm. A,1ore prolonged blurring in one eye or in both are most commonly associated with retinal hemorrhages. As a rule such hemorrhages are associated with a rather marked hypertension but may occur in individuals whose pressure is not over r;o systolic. It is also true that in some individuals \vho have exceedingly high blood pressures, the fundoscopic examination never discloses a hemorrhage. Sudden complete loss of vision in one eye generally indicates either a massive retinal hemorrhage or a thrombosis of a central artery or \,ein or one of their main branches. A massi\re retinal hemorrhage may be slowl?; absorbed and useful vision finally restored, but a thrombosis of the central artery results in complete, permanent loss of \Iision. Impaired vision which Auctuates to some extent may be due to repeated small retinal hemorrhages and exudates but as a rule these do not impinge upon the macula and rather extensive hemorrhages are often seen tvithout noticeable impairment of vision. Severe bilateral impairment of vision is most often due to a high degree of papilledemn with the usually associated extensive hemorrhages and exudates. The finding of papilledema indicates a fulminating type of hypertension usually designated as malignant hypertension. The progress of the disease in these cases is so rapid and the prognosis so poor that many consider malignant hypertension as a separate disease entity. Other hypertensive symptoms rather commonly complained of but which are not indicative of an?; disease picture are dizziness, vertigo, tinnitus and mild deafness. Man\. hypertensive patients com-

plaits 01’ transitor\ dizziness, sometimes :wo&tecJ with. se\yre suboccipital headaches, at other times only present upon \udcJen changing of position. True \.ertigo is quite rare. RZnn\. patients complain of tinnitus , genernIIy ‘in both ears, and of a rather mild degree. Much more frequentI!patients complain of feeling the heart beat in the ear especinll~ Mhen reclining. hlild tleafntw certainI). can be on :I h! 1~ertensix.e lxisis sinw careful audiometer esaminations prior and subsequent to splanchnicectorn?. hn\.c shwvn definite impro\,ernent in the he:tring follorving oprrntion.

\\Tith tv.o exceptions the\, are prob.:lbI,\ of little x-nlue. The exceptions art‘ the rice diet\ and the \-cry IoL\, sociium diet.’ Some patients adherring strictly to the rice diet ha\-e show?-n rather rem:lrk:lble lowering of blood pressure and :lmcIiorntion of their symptoms. Howe\~er, 011 returning to a regular diet the e\-idcnccs of h\.pcrtension quite promptI\ return. A Io\j. sodium diet, that is one cont:kining onlv ZOO mg:. of sodium per da!,, has been found equ:ill~ efFicacious; some patients hn\.e :I reduction in symptoms and in ;I fell cases some reduction in blood pressure. 11’ I\-idne). function is adequate, radical reduction in protein intake is not indicated. Ho\ve\.cr, if the blood non-protein nitrogen The conlmonl! accepted drugs for the IS rather markedI?. ele~.~ted, the diet trcxtrnent of h>.pertension hn1.e been shoulcl be low. in protein. For \veight rcpro\,ed \.:iIueless. Certain general measures, cluction we generaIl>. recommend :I i ,200 Ilo\\.ever, are indicated, especially in the calorie diet; but in \-et-\. obese patients OI c:lrl! or mild h>ppertensi\.e patients. Rein those in u.hom \veight recJuc.tion preduction in \t.cight is important in all obese parator> to :I grentlx~ needed operation patients. Occasionall \ reduction to ;I normust he :\ccomplisheb rapidI>, IVC ha\-c 1n:11 lveight kvill matekll~ louver the hyperprescribed a diet of only 8oo calorie:;, suptension. Iii all cases it takes an added plementing this, of course’, Lvith vklmins. strain from the heart. Uihen surgical On a few occasions ;L dkt as low as 350 therapy is advised, welcrht ‘* reduction is calories has been prescribed. tlelinitel>, indicated since the operation is Potassium thiocy:lnnte has bwn highI> much easier of :~c~ornplishmcnt and the recommended by manv clinicians. It- must patient’s subsequent care and comfort is be g-i\-en with caution and the blood level ynh;tncecl. Of course, not all patients v,ith determined at \veekl>, inter\.:lls. It is genarc overlveight; some in hJ.pcrtension carally considerecl that :I le\.el of at least 1‘ac.t are belo\\. normal. In such indi( I mg. per cent is necessar! to h;i~e an\ \~iclu;ils siipplementnr~feedings, especialI? therapeutic \.nlue and the le\-el should not I)f ;I rather high caloric diet, arc indigo :lbo\.e I z mg. per cent. However, some if the appetite is poor, multi~.xtcci ; and patients show. se\‘ere toxic reactions at \ itamins ma!. clo much to improve it. levels c’\‘cn below A mg. per cent and for 4dcquate rest at night is important ancl this reason man!- clinicians refuse to ust >,vhenel,er possible a rest period after the 15 ;i palliati\,e measure at best. this drug. It .: noon meal should be tnlicn. Fen, patients The s~~mptoms mn,v be :~lle\~iatctl or :IC‘to follow the ad\-ice so com(.‘;II1 afford and in some c’ast’s the tunlly disappear n\onl\ gi\en, nnmel~., to gi\,e up all their l~lood pressure shov-s satistrictor~ ixducabout their l.\or L’ ;t ntl to stop wwrtxing tion, but as soon :IS the drug is cliscon- . factor cwndition. \Vorr\ is a recognized tinued the hypertensive symptoms and in hcightcning the blood pressure, but it is ele\-ated blood pressure return. ;III impossibility for the average person to U!e beJie\,e that surger! offers the best h:c\.e to pi1.e up :I gainful occupation and f;)rrn of therap>. and ;I sutlicient number not \\‘orr\ about doing so. have no\\’ been opcwtcct upon \l:ln! ‘spcc*i:iI diets for the trcatmcnt of‘ of patients 2nd stirdicd for :I sufIicientl\ long lwrio~l 11) ~~c.r~tf~nsion h:r\ e been r~con~n~cnded but

j6

American Journal ol Surgrrg

Peet-Hypertension

to make definite statements as to the value of splanchnicectomy. We do not advocate surgery for all patients. A very mild hypertensive patient may live for many years without apparent organic damage. However, if there are evidences of a progression of the disease, surgery seems definitely indicated. Far too often the medical man watches the progress of the disease until irreparable damage has resulted, either in the brain, the heart or the kidneys and then refers the patient for surgery. This is neither fair to the paitient, the surgeon nor to the procedure which he advocates. RATIONALE

FOR

SURGICAL

TREATMENT

The rationale for the surgical treatment of hypertension is based upon our concept of the disease, particularly of its etiology. Although many theories have been advanced, no one yet has actually been able to establish the true, primary cause of arterial hypertension. We have accepted the renal-humeral theory, first satisfactorily demonstrated by Goldblatt,” who showed conclusively that renal ischemia, or at least the interference with the renal hemodynamic state, produced a continuous elevation of blood pressure without at first any evidence of impaired renal excretion. It has been shown by numerous workers that such interference with the blood supply of the kidneys results in an excessive amount of a renal pseudoglobulin called rennin being liberated into the renal veins. This rennin reacting with another pseudoglobulin probably arising in the liver and named preangitonin (renninactivator of Page) forms an active vasopressor substance called angiotonin. This latter substance causes arteriolar constriction of sufficient degree to raise peripheral resistance throughout the body with a consequent elevation in blood pressure. Goldring and Chasi? make the following statement, “Hypertension is the sign representing the alteration in hemodvnamics , and hypertensive disease is a clinical entitv in which an unknown pressor mechanism ‘initiates arteriolnr vnso-con~. ~~ ~~ _ _ _.

J~vunnr-.

1~8

striction, elevated blood pressure, and We believe this vasovascular sequelae.” pressor substance is angiotonin. The question naturally arises, What is the cause of this change in renal hemodynamics? There are probably numerous causes but we believe in the majority of cases it is of neurogenic origin. The recent brilliant experimental work of Trueta, Barclay, Franklin, Daniel and Prichardl has clearly demonstrated that the splanchnic nerves can be reflexly stimulated with resulting severe renal ischemia. have shown, for example, that They stimulation of the sciatic nerve can reflexly stimulate the splanchnic nerves with a resulting vasoconstriction in the arterioles of the renal cortex so that the blood ffow is partially or even completely abolished through this portion of the kidney. Direct stimulation of the distal end of the cut splanchnic nerve gave the same results. It had previously been shown that electrical stimulation of the splanchnic nerves in dogs elevated the blood pressure, probably by constricting the arterioles in the kidney, resulting in renal ischemia. It is our opinion that in human hypertension an abnormal stimulation of the splanchnic nerves originates in the autonomic centers of the brain, resulting in similar changes in the renal hemodynamics. The activating stimulus may be psychic, reflexes from stimuli originating in other parts of the body, or it may be chemical in nature. Normally stimuli are constantI> influencing the sympathetic nervous svstern but in certain diseases these stimuli result in excessive responses. This is seen for example in Raynaud’s disease. We believe that the abnormal excessive response to normal stimuli, sufhcient to cause renal ischemia, is based on a congenital abnormality in the autonomic nervous system whereby excessive responses are evoked by the normal stimuli reaching those centers. It is our opinnion that this tendency of the autonomic system to overreact, to respond to a given stimulus bq. either greater or more pro-

longed \rasoconstriction of the renal \essels, is inherited. The family history of most h>-pertensive patients lends werght to this theor)!. If our theory is correct and there is a large amount of evidence to support it, splanchnicectom!, if performed before permanent changes occur in the blood v,essels should impro1.e the renal hemodynnmic state. SELECTION

OF

PATIENTS

FOR

SPLANCHNICECTOMt We belie\-e that any patient showing a progressive type of hypertension and whose age and cardiac and renal status is satisf;rctorj should have the benefit of surgical inter\.ention. Age certainly is a factor. The younger group ha\,e a much higher percentage of worth while results than the older age groups. However, so many factors determine the ultimate result of the operation that each individual case should beconsidered on its own merits. We have more or less arbitrarily, fixed an age limit of lift?-three. When we originated the procedure of splanchnibilateral supradiaphragmatic cectom,v for the treatment of hypertension fourteen Irears ago, we set an arbitrary age limit of forty-five; but it was soon found that a rather high percentage of patients at that age frequently responded veq Iveil and so the age limit \?\ras gradualI> extended, still with gratifying results. We may still further extend it. At present we seldom operate on a patient age fifty-four or above, unless that patient has incnpacitating symptoms or shows evidence of a ‘r’t’T> ral,idlJ. progressive tJ.pe of hypertension such as the so-called mahgnant phase. The youngest patient we have operated upon was aged eight, the oldest sixty-three. The question freyuently arises, Should a patient who has had a cerebral accident be operated upon for the treatment of his hypertension? We reahze that a cerebral accident presupposes abnormal pathologic changes in the cerebral vessels and that the risk and the prognosis of such a patient is influenced therebv.. Under no circum-

stances would WC operntc upon :I patient shortI> after a cerebral hemorrhage or thrombosis; but if the patient has made a complete recovery both ph>-sicall!. and mentally and in addition shmvs a pr’ogressive type of hypertension, lve \vould advise operation. flowevrer, if there is ev.idence that the blood pressure has been remaining at the same levyel for a prolonged period and the patient has had no increase in svmptoms or further impairement of renal or cardiac condition and especiall~~ if the patient is over fifty, we would probable advise against splanchnicectom\. Cardiac decompensation is, of course, an absolute contraindication. Hotvevrer, some of patients who ha\,e given a histor\. ankle edema and excesnoctural dyspnea, siv-e shortness of breath on mild exertion but who have responded satisfactorily to be operated digitalis and bed rest may upon with a comparatively low operativ.e mortality and definite hopes of at least It should be temporary improvement. pointed out that the majorit!. of’ deaths in the first fi1.e years postoccurring operatively have been among those patients who had had such evidences of cardiac decompensation before operation.,’ Deaths within this period have occurred in patients whose blood pressure had been reduced d maintained at a normal level up to a I1 the time of death, two, three or more years following operation. Renal insufficient? as measured b! the level of the blood non-protein nitrogen and blood urea is also a definite contraindication to operation. We have found that onI?, in exceptional cases have the patients had more than temporar\ improvement if the uhen the nitrogen, non-protein blood patient had been on a large fluid intake, was above 45 mg. per cent, Such temporar~~ improvement might be for a year or more and possibl>p could be considered a justification for the operation. Howev.er, we generally do not adt,ise operation if the nonprotein nitrogen is above _I$ with the single exception of those patients with malignant hypertension. There we realize that a tlefi-

nitc elncrgcncy c*sists awl \vc ;II’V Lvilling 10 the non-protein nitrogen operate when cannot be brought below $6 mg. per cent. The duration of hypertension probably is a factor in the ultimate outcome but unfortunatelyit is only an exceptional case in bvhich the actual duration is known. \Ve therefore do not have sufficient data upon which to base a positive statement. The various tests such as intravenous pentothal, sodium amytal, spinal anesthesia, cold pressor tests and so forth, which ha1.e been used so extensively in the hopes of finding some criteria which woulddefinitel v indicate the probable result of the operation, have proved \,nlueless. It is true that some of these tests may show a general trend which statisticall!. is of interest, but in the determination of the probable outcome of any individual they need not be considered. Malignant hypertension is a definite indication for splanchnicectomy rather than a contraindication as some believe. It is the only form of therapy offering an\ chance for ‘improvement in this type (if hypertension. The prognosis is so absolutely hopeless kvithout operation and the results of splanchnicectomy in some cases have been so briiliant that we advise operation e\.en when the blood non-protein nitrogen is at a higher level than would be acceptable for the less serious case. Certain tests are routinely made on all hypertensive patients since It is necessar? to ha\,e full data on the cardiac and renal status before making a decision regarding :I splanchnicectom>;. The fundoscopic examination is also Important since it gi\,es us valuable information regarding the type of hypertension and its probable rate of progress. Full preoperative studies with similar postoperative studies o\‘er a period of years are essential if we are to evaluate properI)- the results of surgery-. The ophthalmologic examination is principally of the fundus although the visual ncuit>is recorded and in certain cases \.isuaI fields are made. The fundoscopic examination should be made with the pupil well dilated. The condition of the arteries

and Leitlx and the prtwncc 01 angio5pasrrl and the degree of arteriosclerosis is noted. The recognition of angiospasm as distinct from arteriosclerotic changes requires much belie\.ed that the practice. It is generally presence of angiospasm denotes a progressive type of hypertension. In the earl) stages of the disease the only pathological condition noted may be an increase in the reflex stripe of the arteries and nrteriovenous nicking. Hemorrhages both striate and flame-shaped indicate a more serious phase The presence of cotton of hypertension. wool exudates, Lvith or without associated also indicates rather adhemorrhage, vanced hypertension. Edema of the borders of the discs should be careful13 looked for and the actual presence of papilledemn of I diopter or more is considered pathognomonic of malignant hypertension. The cardiac status is determined by an an orthodiagram and a electrocardiogram, If there is evidence of teleoroentgenogram. coronaq. involvement, an additional electrocardiogram with chest lends is made. In some special studies ballistocardiographic records have also been made. The data from the above findings are of course correlated with the clinical history, \vith particular attention to shortness of breath on exertion, nocturnal dyspnea, ankle edema and attacks of angina pectoris. The renal function is determined by complete urinalysis, urea clearance, water concentration, blood non-protein nitrogen and blood urea, and intra\.enous pyelograms. Formerly we used a thirty-six-hour water concentration test but this proved estremel)burdensome for many of the patients and in recent years \ve ha1.e compromised by using an eighteen-hour test made in the following ~vay. The patient has his usual meal at 6 ta.>l., then no food or fluids of an>- kind are taken until afternoon of the following day. A urine sample is obtained at 8 A.M. again at IO A.M. and apin at 12 noon, and the specific gravit\ and presence and amount, if present, (it albumin separately determined. This test has given somewhat lower \.alues than we

ol)tainc~(l 0tI the thirt\,-sis hoill, Ic5t. ‘Ilit* l~lood non-protein nitrogen and blotid urea cl~termin:ltions should be made Lvhen the lxcticnt is on :I large fIuid intake. lntra\.enous p>.elograms ha\,e been made on all patients to rule out gross pathologic disorder in either kidney. Retrograde pyelograms are necessary when the intra\,enous pi elograms do not’ gi\re unequi\wal data. Considerable discussion has arisen over the requirement of an intral-enous pj.elogram since it is comparatively rare to find ;I gross lx~tholo~ic condition sufficient to be a possible cause of the hypertension. Possibly it is onI\, necessar? to make this test in those illci‘i\ iduals who gi1.e a suggestive history of sv\‘erc’ renal complications and in children ir cvhom :I possible congenital renal lesion map. be present. The presence of bilateral chronicxll!contracted kidne1.s is ;I definite (‘oiitr;liIldic;ltion to operation, so too are polyc.\.st ic kidnew. When one kidney is found 1,~ s-ra,v to be diseased and the other normal, ;I nephrectom!has been atI\-iscd but in only ;I few casts has this materially impro\,ed the hypertension. In nl:~n~. cases the subsequent bilateral sl’l:‘nchni~ectom?. has gi\-en excellent resul ts. Cr:\ig,‘hvho performs his splanchnicectomies in t\l’o stages, acl\vcatcs ;i unilateral sl,l~lnchnicectom? on the side of the diseased kidne>- at the time of nephrectow).; then later if satisfactory. results ha\,c not been obtained, the second stage operation for splanchnicectom! on the opposite sicle is performed. ‘The use of tetra-ethyl-ammonium as ;I test for operati\-e prognosis has been made in ;I rather large series of cases. Like other tests in\,ol\zing generalized \.asodilntion, it has been found of no definite \.aIue in the prognosis of an\. single individual; ho\ve\.er, c.ert:~in generalities can be made.!’ In :I large series it is clemonstrated that those patients drop in \vho rvsponcl lvith ;I significant blood pressure with the administration of tetra-ethvl-l\mmc,nium intravenously nil1 of good results show ;I high percentage ;I nc I conspl~~nchnicectorn!-, following \~erscl~~ the group \vho do not respond to

tt’tra-c‘t h! I-;1tnn1oniuni ha\ (’ ;I IO\\ lx‘rccntage of satisfhctor~ lowering of the blood pressure follotving surger! . Ilovre\.er, the test in no \vn~. indicates Lvhcther the patient M-ill receive\vorth ~~hiles!,mptomatic relief. It has been repeatecll\ demonstrated that the relief of distressing SJ mptams is not closeI). correlated \vith the reduction of blood pressure. Tetw-eth>,Iammonium should not be usecl as :I theraagent but simpl). as a test of the peutic response to a \-aso-dilating drug to help determine the possible result of operation. Man\. hj.pertensi1.e patients she\\, c\.i~ in dences of cncephalopathics \.:ir\-ing degree from slight loss of memor> ‘or difiicult.!, in cvnc*entr:iting to marl\-4 mrntal clouding. \l!e are now making electroencephalograms using an 8 channel maon Simil:lr chine all such patients. recordings bvill be made at suitable postoperative periods. \Ve hope bvith these data to be able to determine ho\v much of‘ the h>pertensi\.e encephalopathy is due to ac.tu:ll organic changes and how mush improvement in the mental status, t;~llow~ing sy>lnn~hnice~tt,m?, mapbe cspec.ted.

The surgical technic for the treatment of hypertension varies in difl’ercnt c%linics, chiefl? in the estent of the s?.mpathctic denervation. Since our first operation’” for hypertension in November, 1933, \I-e ha\-t! routineI\. carried out a bilateral supradiaphragmatic splanchnicectom!.. ‘:I I II some clinics,“-12 this is combined with resettion of the first or first and second lumbar ganglia subdi:lphr:~gmaticaII\~. Other \-ariations in the procedure extencl the excision of the thoracic ganglia up to include the thircl ancl in one clinic the first thoracic, ganglion.” of‘ bilateral suprxdiaThe operation no\\ has sf’fanchnicectom? ph ragmatic been performed in our clinic on about 2,000 patients o\.er ;I fourteen-yearperiod. it consists of the bilateral resection of a \‘t‘r! long segment of each greater splanchnic. ner\.e anti of the lov,er thorac*ic s\‘mp:~-

thetic ganglia with the lesser and least splanchnic nerves arising from them. In our earlier cases we resected about IO to I 2 cm. of each greater splanchnic nerve and excised the tenth, eleventh and twelfth sympathetic ganglia bilaterally. With added experience, the addition of special instruments and a new form of lighted retractor we have been able to resect routineIy 20 cm. or more of the greater splanchnic nerve and the seventh to the twelfth inclusive sympathetic ganglia. In some cases it is possible to resect the sixth and even the fifth thoracic ganglia through the same approach used formerly, namely, resection of a portion of the eleventh rib. Avertin anesthesia, using I IO mg. per Kg. of body weight, supplemented with nitrous oxide and oxygen, has been the anesthetic of choice. Intravenous physiologic glucose solution is given slowly throughout the operation. Two scratch marks outlining the bilateral incisions are made, each about IO cm. long on thin individuals, longer in heavily built or fat patients. These incisions are parallel in vertical direction, about 8 cm. apart and center over the eleventh intercostal spaces. The incision is carried through the skin, superficial fat and lumbodorsal fascia. The longissimus dorsi is retracted medially and the eleventh rib exposed. The intercostal muscles are separated from the rib as is the pleura and a segment 5 or 6 cm. long of the rib resected. The excision extends nearly to the head of the rib. A small piece of the intercostal muscle is removed and saved for biopsyexamination to disclose pathologic changes in the small arterioIes. The intercostal artery and vein lying just above the twelfth rib are double clipped and a segment about 5 cm. long excised, Care is taken not to damage the adjacent intercostal nerve. The pleura is then verv carefully separated by semi-sharp dissection from the bodies of the vertebrae and this dissection is carried medially to the IeveI of the anterior border of the vertebral bodies. The pleura is separated cnudallv to the crus of the

diaphragm and cephalad as far as it can be conveniently exposed, usually to a level above the seventh thoracic ganglion. In some individuals the configuration of the chest is such that this dissection can be carried up above the fifth thoracic vertebra without difficulty. On the right side the greater splanchnrc nerve lies between the pleura and the inferior border of the vertebrae; on the left it lies on top of the aorta which in most hypertensive cases is displaced laterally. The greater splanchnic nerve is grasped with long forceps and upward traction made. Frequently such traction pulls the upper pole of the celiac ganglion through the opening in the diaphragm for the passage of the greater splanchnic nerve. The nerve is then dessicated with an electric current as it enters the ganglion and divided. The distal stump retracts below the diaphragm. The nerve is then carefully dissected from its bed of fascia and freed upward to the level of the sixth or seventh vertebra. The thoracic ganglionated chain lies more dorsally on the bodies of the vertebra. The ramus from the eleventh intercostal nerve to the eleventh thoracic ganglion is dessicated, divided, and then the chain dissected downward exposing the twelfth ramus and ganglion. In many cases, because of rather high reflection of the diaphragm, it is necessary to divide some of the fibers of the diaphragm at their attachment to the vertebrae until the twelfth ganglion is fully exposed. This may even lie on the peritoneal side of the diaphragm. The chain below the twelfth is dessicated and divided and the least spIanchnic nerve avulsed as the sympathetic chain is pulled upward. Resection is then carried upward with a special semi-sharp elevator and in turn the rami to the tenth, ninth, eighth, seventh and some times the sixth, rareI). the fifth, ganglia are dessicated and cut and then the chain above the uppermost exposed ganglia is dessicated with the electric current and divided. As a rule the main trunk of the greater splanchnic nerve will be found arising from the uppermost of the

exposed thoracic ganglia. The entire chain :lnd the attached greater splanchnic nerve are removed from the extrapleural space. The \.nrious lesser splanchnic ner\.es are either avulsed or, if the\. are especialIF strong, dessicated and div~ided at the le\,el c!lf the diaphragm. All bleeding points are carefull! dessicated. The extrapleural space i:; then Irlled with Ringer’s solution and the lung fully expanded by increasing the pressure in the rebreathing bag of the anesthetic machine. If a hole is inad\,ertentlJ. torn in the pleura during an); stage of the operation, it in no wa?- modifies the procedure and the operation IS continued without difhculty. If the pleura has been accidentally torn on the right side, we do not hesitate to proceed with the left splanchnicectom!-. Of course special care is taken to assure full lung expansion before closure of the incision. Rarely is there suction into the pleural caLit! during closure and in such cases aspiration through a needle at the completion of operation may be necessary. The reason for lilling the extrapleural space with Ringer’s solution before expanding the lung is to assure no air being trapped in the mediastinum which would of itself cause no serious complication but ma>- result in some crepitation in the neck and be a c*:luse of worr\; to the patient. An!- Ringer’s solution not forced out by the expansion of the lung is of course readily absorbed. The incision is closed in layers and immediateI,;I similar procedure carried out on the left side. The combined bilateral operation takes from fort).-ti\.e minutes to one and one-half hours. Frequent blood pressure recvordinps are made throughout the operation. If the blood pressure drops below 120 mm. Hg systolic, supportive measures arc used. We have found neosynephrin ver) useful in maintaining the blood pressure at ;I safe le\.el. The blood pressure map. drop at an>’ time during the next few hours and therefore the patient is kept flat in bed with the loot of the bed elevated for the first t\c.el\,e hours. It nin!’ be necessarv to gi\.e neo-

svnephrin on one or two occasions during the first few hours. Patients are encouraged to sit up at an earl!. date and those \vho feel able to be out of bed may get up v,,ithin a da>. or two following operation. On first assuming the upright position there ma) be a postural hvpotension. This as a rule corrects itself within a few da>.s. It has ne\.er been necessary to bandage the legs or put compression upon the abdomen. Ho\ve\,er, ue always advise the patients first to asfor :I few sume the upright position minutes, then to get out of bed slc)~.Iy. Most patients leave the hospital on the twelfth postoperative da>. and it is rather unusual for patients to ha1.e to remain in more than fourteen clays. Cl’e advise a rest period at home of at least four byeel\-s before resuming an\- ncti\,e duties. Few complications ha\:e arisen in about Five patients have had 2,000 operations. an injury to the thoracic duct and ha\,e de\.eIoped extrapleural collections of ch>.le. Three of these were successfully treatecl b,v repeated aspiration for a few davs. The other two required operation; in one the duet was found clamaged leaking thoracic at the crus of the diaphragm; in the other a small radical lying on top of and to the outer side of the aorta about the Ic\.el of the tenth interspace had apparently been torn. A clip upon this radical stopped furthei leakage of chyle and con\.alescencc \v:rs uninterrupted. Occasionall\a mild ntelectatic condition has de\.eloped. Usually this has been controlled by insisting upon the patient coughing but on a few occasions it has been necessary- to bronchoscope the patient ancl aspirate the n~ucous plug. Pneumonia has not been a complication for se\.eral J-ears. Previously, when atelectasis had not been recognized, a few patients de\.eloped mild bronchial pneumonia. Because we insist upon the patient mooring about freeI>- and thromboambulation, earl>. encourage phlebitis of the lower extremities has not occurred. A few. cases ol coronar! thrombosis, either during the operation, immeclintel~-

after or before discharge from the hospital, ha\.e occurred, but in none who did not have a previous history of coronar?; disease. A few individuals have had cerebral apparently as a result of a thrombosis, marked drop in blood pressure occurring during or immediately after the operation. These Lvere all in indi\.iduals with considerable evidence of cerebral arteriosclerosis. It is for this reason that we are exceedingly careful to keep up the blood pressure to at least 120 mm. Hg systolic throughout the operation and during earl>convalescence. SUMSI;\I
OF

INDICATIONS

CONTHAIKDlChTIONS

AND FOli

SPLANCHNICECTOhl\

Our criteria for operation may bc summarized as ~~II~M.s: an age below fifty--four but with occasional exceptions; a more or less continuously ele\.ated blood pressure wth :I systolic over I -0 and a diastolic over 105; delinite evidence in the milder hypertensive cases of a progression in the disease picture; :I non-protein nitrogen below 45 mg. per cent, preferably below _+o mg. per cent; a compensated heart without recent history of coronary thrombosis. th e patient \Ve prefer that have a relntivel>- normal cerebral function but have operated upon man? showing rather marked hypertensive encephnlopathy with grntit\-ing results. Exceptions to the above general rules have been made, especially in operating upon patients \vho are older, generall\~ because of incapacitating symptoms or evidences of a rapidI!, progressive type of h>-pertension. Only in the mnlignant t\pe do we believe operation is worth \vhile If the non-protein nitrogen is nbo\,e 45 mg. per cent.

statistical study is difficult. Arterial hypertension is a generalized disease, all organs of the body being aff‘ected, although the principal pathologic disorder may be greatest in one or two important organs. The commonly accepted classification is that of U’agener and Keith2? but we did not find this entirely satisfactory and hence Isberg and I’” enlarged the grouping from four to six. %‘e suggest the following classification as very useful since it emphasizes the dominant pathologic picture: mild hypertension. Group I. Early, These patients are entirely asvmptomatic, hn\,e normal or grade I fundi, and she\\ no evidence of cardiac, renal or cerebral in\,olvement. Group 2. Symptoms predominate. All of synippatients in this group complain toms and have mild changes in the retinal blood vessels but display no e\.idences of cardiac, renal or cerebrnl’impairment. Group 3. Organic heart disease is predominant. In each case the diagnosis of heart disease is confirmed by either or both :I definitely abnormal electrocardiogr3n~ and a teleoroentgenogrnm showing cardiac enlargement. disease is Group 4. C ere b ro\,ascular in this group predominant. Each patient has had one or more previous cerebral accidents. Group 3. Impaired renal function is predominant. Each patient shows diminished concentrating abilit!, and urea clearance \.alues. Group 6. Malignant hypertension. These patients haAre severe neuroretinitis with hefinite pnpilledema of one diopter OI more and display a rapidly progressi\,c, downhill course. KESU LTS

CL.~SSlFlCATION

OF

HYPEHTESSION

The manifestations of hypertension are so x*arietl that it is neccssnr?to haye a workable classitication in order to c\-aluatc properly the results of surgical ther:ll>J. E\,en Lvlth a \.ery wniplex classilication so

ml n \- factors

are

in\-ol\,ecl

that

:I trlle _._

SL’I’I~.~DfAPfIKXGM~T1C FOR

OF

BILATERAL SPLhNCIINICECTOM\

HYf’Ef
A bilnteral s~~l~r:\di~~~~hrng:matic splanchniccctom~- has been performed upon approsim:itclj, 2,000 patients at the Uni\.crsit\ Hospital over a period of fourteen \‘enrs. A large proportion of these patients have

t-cturtlctd

to the hospital Some ha \,e

1nations. others

oni\-

after

‘l’er> been

complete

man\

vases

nl:ldc

(‘oniv

t ain

to

;I

periodic es:1111returned -earl) ;

for

period

ot’ se\-crnl

postoper:lti\ b,s

the

\\.hcn

us.

\\‘e

i tl cacti

e studies

honle

the

!.e:lrs.

patient

ha\,e

h:t\.e

ph.\ sici:tn could

attempted

cxsc complete

in

to

had

L;nfortun:ttel~. to get complete returning for

Ixtticnt<

This

ac’c’ounts

bet-s of patients

been

pra~ticnll~~

\\.ere

so blind

h(wish

t’aces

\.isunl

ob-

I\-eeks.

that h:t\,e

it

has

not

studies chvc,k-up

for the

included

been

on ~111the

in the

statistics

one to nearI\.

arc

num-

stntisticsal

l)useci

fourteen long

studies

on

1 ears f’ollo\ving

operation.

Special

bc‘c‘n matIc

at one postopetxti\.c

to thirteen

J ears.

period

of ii\-e

tion

in 81.3

Ii\-ing.

~7ho

not tiistinto

noru~al

;I \

lvithin

term

studies

course

had

had

prioci

li\.c

per

t’r\

feu

It’xe

in

in this

of

breath

and

noctitria

rel;tted

\\,ith

improvement

are

quite closeI> in c:~rdi:ic and

renal i’u tlction. The excruciating Lvhich :~re usuallysuboccipital marl\-ccl

ner\.ousness

and

eases completeI?

noc,tut-i:t

and

ha\,cs

been

still enicnt

in li\.ing. has

86

the at-e in

of the

ot- at pet-

This pCrsisted

cent

lens;t of

the

pcrcetltagc~

of

~llt?l~~st

Utl-

I,ostol~c~t.:cti\.c periods OF front Ii\ (’ to t\vc.l\c’ !-cars. Visual inipro\.c.nlcnt 11x< I)cxatt utril\itig c~~px.i:tll\ irt t tic ttt:tlign:tnt eases it1 \vhich \.isioti is oKten \‘et-! In ek-et-\ sur\ i\.ing pa~cric)ttsl~ imp:tired. f;)r-

after

.
II\ ing \vc

olxr;ttion,

blood

in

in mind

tiiecl

that

in

\.

for norm:ll

per

disagree,

cent

prc.xure

fort!.

j’carsI;0 ()j.

J.ears

these ligurcs i1t-c Using this standard

of our

not-mat

had

used the

blood

to

to sixt)

:iccqtecl.

49 per rxwt

pt~riod

14’~ h:t\.e

t\vent>

sonic

that

this

h! pet-tension. age

tained

those I t’ars

irnpro\~rment

bc lmrnc

blood

patients

ha\.c

pressure5

min-

t;)llo\z

ing

splali(.htli(.e~.tolil! for fi\-e to t\\,el\ e ,vwrs. while rctlucThose shc,Lving ;I loot-lh tion to normal or ~~pproximatel~ not-maI at the end of one J-ear ha\.e, \vith \ er!- t’&\. niaint:iined the s;tmc blood exceptions, pressure

Insonini:l,

palpitntic~n

completei!

impro\.4

and

irritabilit\-

relie\.cd.

ciistrcssing

headaches

20:;

stud!

one to t\zrl\.c

series.

malignant

\Vhi[e

vent

pressure.

the

those

generaIl

o\‘er

in JO.- per cent of the entit-r.

i’olIo~~~in(~; criteria

‘This has been striking ntid in general is :tpp:lrcntl! onI!- roughI> corrclatecl \\.ith thr. recluc~tion in blood pressure. Ho\vc\.er, c.vrt;iiti s\ tiiptotiis such as shortness of

blo~~ci

the group

\v;trs

ha L.C clelinitc‘

still

pressure

6 per

statistical

\\.ith

el!.

tne1x.e

onI>

in

M ho had died

to

patients

t 2.- per cent but !‘cars

a

(~pvra-

in blood

increase

include

o\:cr

>.cars after of the

tii:~s-

:t ntl

reciurecl

cent

of’ these 20

patients fi\,c

s> stolic

to Uvcl\.e

\V;IS found

the

It should

ha\.e

both

t 40 90; ag:c fort!.

intpro\

coulci

I” No i mpro\~cnient

readings:

c,h:tnxcd

has

Sornv

;t return

stgnilicnntl,v

pressure

of our

lxtfirnts

cent.

the!.

pressure, was

Ici,el

csamina-

different

Klood

Some

hr.art

per

had

on ;I

impro\-ement

usuall~~

tolic.,

postoper~~ti~

gc;ttl\

diItiwItie:,

the

too

acuitv,

of1 post0per:ttk.e blood pressure Iv\.cls and renal and cardiac status. \I’c bcliv\.cl;t tl intenal ofat Jenstone i.e:tr follo\f~ing oper:~tion should elapse before tnn king an \ c\ :tluntion of the results of the procedure.

most

\-isual

postopetxti\~e

stutlics

from

had basis

including

twdings. possible tiorlx.

\vho

hJyertensi\,e

not:

a careful inter-1 aI histot->, (bc.iil;i r Kit tldoscx)pic czatiitnations, xvater c,otic.~titrntic)ti, u r-en clearance, ~~lood tionl)r.otc.iti nitrcqyn, electroc~nrclio~t-am, ortho(1iagr2 til :t t1cI repeated blood pressure btuciics,

tienr

le\-el at each subsequent

esan-tina-

tion, sometimes ~.,earl)., up to the longest postoper:tti\~e pertod In our ser-ivs, 11hich is nearI> shown

f;)u t-teen

J c:irs

m_ytcyi ,F

1>“stoI~“;iti\.~l~..

tht

this

01’ :ti,tc)riorliic. n1enq

A few c%;ises h:t\.e

of the h\.per+tcnsic~tt :tI’tct* normal Iv\ els from thrw to

rn;tint:iining tctl

J-ears.

;I return

but

;I rtylitc.tic,n

lilx~rs. not

to

of

It

signifies A

:I

has

tt):lt.)\(Yl

3 t1ort11;11 le\el,

o\‘ef

80

mm.

IXen

stlg-

regeneration itlly,t-c~\ l’-

lxIw~.i 011

E-lg

5~~tc~lic‘

Peet-Hypertension and 25 mm. Hg diastolic, has been maintained in 26 per cent of our patients for the entire postoperative period of five to twelve years. An additional 35 per cent have had what we call significant improvement, that is a maintained reduction in of more than 40 mm. blood pressure systolic and 15 diastolic. Combining the three groups, those with a reduction to normal, those with marked reduction, and those with significant reductions, we have an over-all -improvement in blood pressure in 81.3 per cent of the living cases, which have been maintained from five to twelve years. If ne consider the blood pressure of those who died before the end of this period, most of whom were malignant cases, we still have an improvement being maintained in in blood pressure nearly 50 per cent of the cases. FUNDOSCOPIC

CHANGES

AFTER

SPLANCHNICECTOMY

Of our patients showing preoperative fundoscopic findings of angiospastic retinitis with or without hemorrhages or exudates 82 per cent showed no evidence of angiospasm, hemorrhages or exudates at any follow-up examinations five to twelve years after operation. Papilledema usually disappeared quickly and in the twenty-one cases of malignant hypertension still living fi1.e to twelve years after operation it had not returned. HEART

CHAXGES

XFTEI<

SPLANCHNICECTOMY

The response of the hypertensive heart to splanchnicectomy has been very carefully studied.“’ Three hundred eighty-four patients who had been operated upon from five to twelve years previously and who had had complete studies, including electrocardiogram, orthodiagram and teleoroentgenogram, both before and at various periods after operation, showed the following results : It was gratifying that 60 per cent of the patients with known hypertensi\.e heart disease were still living five to twel1.e years after splanchnicectomy and

that 93 per cent of those who had normal hearts prior to operation were still living. Those showing abnormal preoperative electrocardiograms had significant improvement in the tracings in 41 per cent, five years or more after operation. Many patients with gross enlargement of the heart preoperatively have had return to normal size. A significant decrease in heart size has been maintained in those with definite preoperative cardiac enlargement over a five to twelve-year period in 44 per cent. Onlv I o per cent of those with preoperative cardiac enlargement showed any further enlargement over the long postoperative period. Nearly a11 patients who have shown improvement in the electrocardiogram or decrease in heart size have maintained a significant decrease in blood pressure. As previously pointed out patients who had had congestive heart failure but who had responded. to digitalis preparatory to a had a much poorer splanchnicectom; ultimate prognosis. Our recent studies have shown that only one in three of such patients will survive for a postoperative period of five to twelve years. Only 12.5 per cent of patients who had had frequent paroxysms of nocturnal dyspnea survived for this long period. A hypertensive patient who has had a coronary occlusion with a myocardial infarction and whose blood pressure still persists at a high level presents a very However, twelve such serious prognosis. persons have been treated by splanchnicectomy without a fatality and nine of these were still living five to ten years postoperatively. This prolonged survival of 75 per cent of such severe cases is very’ encouraging. Of the hypertensive patients with normal heart size prior to operation 86.6 per cent were still living and of these 92.5 per cent had maintained normal heart size. RENAL

CHANGES

XFTEK

SPLANCHNICECTOMY ‘1’1~ renal functions show drtinite inIprovement in many cases following splanch-

I1

icec~tonl)

telie\,ed

. Nocturia nntl

_tj

per

is

alniwt

cent

of

cotnpletel,v patients

with

~~lmormal urea clearance hL1L.e returned to ttormal and 44 per cent bvith impaired water c~onccntration haire marked itnpro\.crnent. In the rn:1jorit> of cases albumin has completel>. cliwppe;tred from the urine.

E.\~luding c:tses of malignnnt h!!>ertension lift\--eight patients arc still li\.tng fi\,e to thirt:een years after operation of :I total of’ to8 \vho had had definite cerebral :tc,cidvnts prior to operation. Fift! of the liI‘t!,-eight hnx,e had no subsequent cerebral insults throughout this long postoperatix.e period. Ten h>.pertensi\.e Ixttients m.ho h:ld sulfetwl strokes prior to operation ha1.e m~tint~iiticci nortn:il blood pressure levels since sl’l;tnchni~ectom!-, the shot-test period being fi\.c >.ears. These figures indicate thzt, c~en though the patient has had ;I vcrvhro\~:~scular accident, surger). offers rc;iI hopes of ;t prolongeci useful lift. t’iiOHl.I-;\I

Of-

Sl l<\‘II’AL

IK

IIYPEHTE~SION

The ultimate test for an)’ treatment of h!-pet-tension is hvhether or not it alters the ptxJgressiL.c and linall~~ fntal c’oursc pursued hi. ;i great percentage of the cases. Out- rcccnt stud\. of patients who had been op(~r:ttcyl upon fi1.e to thirteen years prek,iousl! sho\ved that 80 per cent of the entire %crivs were still Ii\-ing at the end of 1ix.e ).CiII’S,

j-.7

1xt-

cent

after

ten

y3lrs

of treatment t;Jr the patients si\re hypertension.

The lxtient shoiving definite lx1pilIedema, usually m4th hemorrhages and exudates, and kvith :I high s>.stolic. and diastolic pressure, and frequentI! lvith e\,iclences 01‘ ;I nd renal cardiac da niage presents 3 absolutel\~ hopeless from the standpoint. In Keith, CVagener, series ot patients with h>-pet-tension onI?, 2 I per cent \vere Ii\ ing at the end of the first !.eat-. A similnr group operated upon mith ;1 supradiaphra~:mnti~ splanchnicectoni! had in contrast :I sur\.i\.;1I cbf 04 per cent at the end of one’ J ear. I7 Those treated medicall!. had :I sur\ i\.;tl of onI\ IZ pet- cent at the end of the second ! ear \vhile those treated sur-gicxll~~ had :I sut-\i\.:11 rate of 50 per cent zfter the same length of time. After four J’ears onI\ 2 pvr cent of’ the niedicall~. trtxtecl pntrents U’ere :1li\,c (‘onof’ the trnsting kvith ;j per cent sur\~i\.al surgicxll!treated patients. At the end ot five years onI\. one of I..$5 meclicnll>~ treated patients ~~1s :1li\re, vvhile thirt,v-onca (;! I .O per cent) of r_~s cases bvere li\,ing Ii\ e > ear5 or mot-e after splan~hnicectol~i~.. One ~:IC;C cvith definite preopernti\-e e\~~clence of ;I severe, malignant h,vpertension is no\v Ii\ ing thirteen years I’ostoPet-t1ti\.el!. and the blood pressure has been maint:1it~ed at :I norninl Ie\,el. Pl
and

cent :1fter thirteen ~‘ears. It must be ren~etnbered that the great tnnjorit> of these patients had progressed to \.er>’ set-lous cwnstitutional invol\.etnent of the heat-t, kidneys or cerebral \-essels before opetxtion. The operative mortxlit~ of our entire series is no\v I. j per cent. Compnt-inp the :1bo\.e figures \vith the few :t\.:tilable cIirf th:lt ;1 bilateral supr~tdi:lphrajimLtic sl’l:ttl~hnic,e~torn! offers the \‘er!. best form

w.ith progws-

t;OLLO\\

lh\i(;

SPL4NCttNICECTOM\

41 .L! per

Pregn:tnr\,

presents :I \-et-\. serious pr,jtJFrequentI>the hyperlem in hypertension. tension is present before the patient but in some cases it becomes pregnant fs :I result of pregapparently de\.elops nnncj’. Ordinnril!. the hi-pertensi\.e lenxtlc ‘is much It’ss Iilic:l! who becwrnes prc wnnnt h to go through child-bearing successfulI> than is the \von1;1n Lvith ;1 normal prc’ssurt’. She seems niarliedly vulnerable t0 tllv to.\icmi:1 of pregn;1ncy. AISO it h:ls beet1 estimated that about 3; per cent of \\OI~I~II

66

American

JournalOrSurgery

Peet-Hypertension

who have a toxemia of pregnancy have a persistent postpartum hypertension.” We havre operated upon twenty-eight hypertensive females who subsequently experienced thirty-four pregnancies.‘” Eighteen of these women had maintained normal pressures following their splanchnicectomy and before they became pregnant. Seventeen of these gav-e birth to eighteen living infants and fifteen of the patients were still maintaining normal blood pressure levels at intervals averaging 2.7 years following delivery and 6.3 years following splanchnicectomy. Of the IO remaining patients whose blood pressure had not been reduced to normal onl,v two were delivered of liv-ing infants at full term. None of the women with normal blood pressures following operation and prior to pregnant) developed a toxemia of pregnancy and none suffered any apparent damage to either the heart or the kidneys. Twelve of the vvomen vvith normal pre-pregnancy blood pressures went through thirteen full term pregnancies and maintained normal blood pressure levels throughout. Mild to moderate elevations were noted during fourteen pregnancies. These included the patients vvho had an elevation of blood pressure at the onset of pregnancy. In hve of these, living infants were delivered at full term. In onl,v four cases (these had elevated pressures at onset of pregnancy) did the blood pressure reach or exceed the preoperative level and in each case the pregnancy was interrupted. It is evident from the above figures that if a woman with hypertension desires to have a child she should first have a splanchnicectom!.. If then her blood pressure comes down to normal and remains so for a year, we think it is safe for her to proceed with child-bearing. Her chances are excellent for delivery of a normal infant and she has little to fear from a possible toxemia of pregnnnqor from an): late postpartum sequelae associated v\,rtli her pre\.ious h~~pertension. M’e 1l:rv.e also performed :I splarlch~~icectoniv upon fiv-e women during the second trimester of their pregnancies because of exceedingly high blood pressures

and symptoms of the toxemia of pregnancv.18 It is generally advised to interrupt Hovvever, this ma,v not such a pregnnnc?. be necessary it a splanchnicectom,v; is performed. In two of the five cases brilliant results were obtained. In both the blood pressure returned to normal, the toxemia disappeared and normal liv-ing infants vvere delivered at full term. In these two women the normal blood pressure levels hav,e been maintained for four years and two years, since the delivery. In the respectively, other three cases the splanchnicectom~ appsrentl,v had no infIuence on the toxemia but in one of these cases the blood pressure levels since delivpery have been significantl,v reduced. RELIEF

OF

ISCXP.\ClTXTION

Incapacitation, either because of the se\-ere symptoms of hypertension or because of organic changes in the heart or the kidneys, has been significantly relieved in a large number of our patients b! ” The ability of these splanchnicectomy. patients to resume gainful vvork follovving operation is one of its most gratifying results. In a follow-up study covering seven years, 55.5 per cent of the patients vvho had been incapacitated had had complete recovery from such incapacitation and had returned to their former occupations. Many others had shown so much improv,ement that they vvere again employed although not at their original jobs. This makes a total improv,ement of 8 I .3 per cent. As a rule the patients are able to return to work within a few weeks following operation. CASE

REPORTS

The following three case histories are given to illustrate tvpical results obtained bv bilateral supradiaphragmatic splanchnicectomv in patients with malignant hypertension, severe angina and pregllallc~>’ following s]~lnnchnicccton~~~. c:xst:. t\venty-t\\ I~lood

1. .\I (11.I,iwU~If 1~qwknsioH: 0,

\\iIS laon

pressure she complainetl

11 to

IlaYc

v.

Ii,

ngc

:I ,I clcvntetl

for three vcars. On entrance of sevwc hcacl:~cl~cs, SWOIIC~II

ankles

au1

tle~xJoped

l~lurr~tl severe

arm,

nausea

lined

to fled

se\.crity

and for

vision.

l‘hc

precordial I-omiting, eight

wst hvr l~lootl pressure

and

months

Of ficr symptoms.

patient

pain

the been

had

Ixc.:iuse

In spite :r\wxged

in

s) stolic., 00 dkXolic.

left

of svr11ptoms. ~

l~lectro~ardiograrn

\\.c’rc normal.

At

con-

of the

of tfiis 280

had

long

s\-stolic;

c\-idenct

no

trme

of retinal

pOstopernti\-cly systolic.,

-_ diastolic.

\\c‘r(’

alI

norm:11.

I.28

compIctel\-

antI

Iwtrt

fol I’r)b\irlg

u:ls still

normal

at

I. / I~unduscopic

(Fig.

:111cI

~Ic~troc:irtliogr~Irn

c.xam;natioti,

\exr-s

eras

J.c:\ t-s

the l~loocl pressure

di:rgram

T\vcl\~

l?1~~~troc;~rcliogr:~m

I 10 svsto[ic,

size

IXYW an,\.

pressure

Thirteen

l’rcy

l~cart

there

She I\ as still

norri1:ll.

opwltion

wtiwly :I ntl

had

f~loocl

qo diastolic.

\\vrc

still

clisturlxtnce.

her

2s~ nlptom:~tic. size

She \I:is

SIW

\\:ls

ckrthoerltircl)

s~~riiptom-free. C.4sE 11. ff> pertrnsion will) sewrc flneincc jwctoris: 31. S., age forty, entered the hospit;rl or1 SqItctnlxr

3,

c.wrutiating rclatcd liftwn

to

had

had

I’rorn

examination loc:lliztYl

in\

IGI~S

ckst

inf;rrt.tiorl.

11

01’ vcr?

tl:lil)..

FIcr I)lootl prcssllrr

150 diastolic. mocler:~tc

crted

T

Tlitw \\;I\'cs in

v\ridencc

I-lwrt

I~~~n~dUs~:o~~~c

;Irtt,riosc,lerosis \\ t’t*’

no

l:i~~trc,c~:irtllo~:ratl1

cstidatcs.

11 :intl in

to

t\bo to six cpisoclcs

:Ingiospnsms. or

fik,c ;I Lnon

mc~ilth

pcctoris

sl~o\~~cd d&ply ~;1rdial

disappearing For the put

shov cd

Ilclric)rrhngt5

01‘

chest :Iln;tys

rest. She had Ixcn

230 SJ stolic,,

a\.cr;lgcd :intl

:tnd

after

c ii,r tcri !.ears.

sc\‘crc‘ :Ingin:l

of cyisodt5

across tl1c upper

cwrtion

minutes

li~pertensi\ slit

I()_1I, complaining

pain

sim

Iratls

of :\nterior \\:Is

llc)rtl~81.

I ;l~tl

111\0ShC

period show signilicnnt improvement ah measured by a reduction in the blood pressure, improvement of ocular, renal and cardiac status, alle\?ation of symptoms, relief of incapacitation and a probable prolongation of life. Approximately 2,000 patients ha\.e been operated upon bj; this one procedure at the UniL~ersity Hospital during the past fourteen years and a sutlicient number of these have been studied o\rer a long enough period to make definite statements possible. REFERENCES

The s?-nlptomatolog?; of hypertension is discussed at length and its possible bearing on prognosis given. The etiology of hypertension is considered, especially in reference to its surgical treatment. A bilateral suprndiaphragrnatic splanchnicectom>is recommended as the procedurc of choice in patients shobving :i prugressi\~e type of hi pertension or in those who have already. reached ;I high level. The results of careful studies over a long