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The circulation in man in certain postures before and after extensive sympathectomy for essential hypertension
THE
CIRCULATION IN ;MAN IN CERTAlN POSTURES AND AFTER EXTENSIVE SYMPATHECTOMY FOR ESSENTIAT, HYPERTENSION
BEFORE
IT. EFFECT OF CERTAIN
~WECHANICAL RGEETS AKD PAREDRINOL ON BLOOD PRESSURE AND PULSE RATE*
EARL E. GAMEILL, M.D.,t
EDGAR A. HIKES, !JR.? M.J).,$ ALFRED W. ADSON, W.U.g ROCHESTER, MINX.
AND
N A PREVIOIJS paper1 we reported someof the physiologic effects on the circulation of extensive splanchnic sympathectorny and postural change in casesof essential hypertension. The studies to he reported in this paper were made on the same ten patients (Cases 1 to 10). In general, the same air-conditioned soom and basic procedure, including t,he samedates of study, were employed in both instances. This part of the investigation was concerned wit.h modifications of blood pressure and pulse rate by (1) a tight abdominal binder, (2) bilaterally inflated cuffs around the thighs, (3) an abdominal binder plus cuffs around the thighs, (4) exercise of the legs, and (5) t,he administration of paredrinol sulfate. The blood-pressure-raising effects of some of these agents were compared to similar effects of the coldpressor test. Controlled observations preceded each of the investigations. Each study was done before and aft,er extensive sympathectomg, and, in most instances, while the patients were in the horizontal and in the 60-degree head-up postures.
I
TIGHT ABDOMINAL
HINDER
The primary purpose of this portion of the study was to see whether such a binder would relieve the orthostatic hypotension and tachycardia which often follow extensive splanchnic denervation. The word ‘(orthostatic” is used in this paper to denot,e any upright or partially upright position in which the head is higher than the feet. In most instances, this was the 60-degree head-up posture. Various workers2mghave noted the beneficial effects of abdominal compression on the low blood pressure of certain persons and of animals under certain conditions when the upright posture is assumed. W7hile studying vasomotor adaptation in animals, Hill, as early as Received for p,nblication May 3, 1943. *Abridgement of a Bortion of thesis submitted by Dr. GsmbiiI to the Fae&ty of the Graduate School of the University of Minnesota in partial fulfillment of the requirements for the degree of M.S. in Medicine. fFirst Assistant in Division of Medicine, Mayo Clinic. SDivision of Medicine, Mayo Clinic. lDivision of Neurologic Surgery. Mayo Clinic. 381
of
-
mqz%72---___-----
8 9 10
pressures readings operation,
72
80
R.P.
146/lPO
l&k/108
88 90
94
88
represent posture not tolerate
liO/lZ?
160/118
B.P.
(MM.
PULSE
80
91
104
in almost every were taken after the 604epree
175/126
~~~~~_~___
m--z--
214/140
194/140 -108 160/130
150/116
88
84 88
94
164/104
100
100
54/
50
130/r
GO/102
iKqiE1os132
132
86
74
WITR BINDER
64
rest hence
170/11"
166/128
72/
114/1oa
204/144
m/lo8 ll(i/lOO 18'2/126
126/
ASD
-
HEAD-UP
6
4
postwe
1 /
FROM
intervals.
+20/tlO +ll/+ 8
+18/+14 t 2/t
+14/+ 8
+24/+
-l-i/4 -22/ 0 +"2/t16
- 2/+10
+44/tl6
B.P.
LOSS
OR’~HOSl’A’lT~’
BO-DEGREE
at two-minute on the table. a JO-degree head-up
120
124
98
140
128
108 112 114
104
'"IJJ
POSTPRE
----------iiz141/105 readings taken of
B.P. lOti/
HEAD-UP
138/100 128 16O/luJ 118--180/138 128 lOO/ 96rp-__~
12S/ 76 164/112
WITHOUT BINDER 6Ei;.g,A '"I;;
POSTOPERATIVE HO-DEGREE
instance the third of a series of approximately twenty minutes head-up posture without ssncope:
iYsi-i%T
100
190/1x
104
'""py
HORIZONTAL CONTROL ,,B=.,,
-88
I
HG.) AND PULSE R,ATE IN HORIZOXTAL AXD AFTER SYMPATHECTOMY+
_________~_____166/------------96 178,'120
WITH BINDER
POSTURE
160/120 98 ---84ixqm-i!%-164/110
206/140
HEAD-UP
96
92
j PGLSE --
PREYSCRE
TILTED POSTUEES, BEFORE
ON BLOOD
la&/118 -168/1a-1 112
198/136
and pulse rates in the horizontal patient could
180/11778-------
___---____
194/X24 ii@iiz-i%---
_--___-----p-_
6 7
Mean
PULSE
WITHOUT BINDER
(;&DEGREE
PREOPERATIVE
BINDER
220,'140 88 200/130 __--~-__~___I__________
_I__I_
r3.P.
164/120 izipizss-----
2 3
1t
OF ~~BDOXISAL
HORIZONTAL CONTROL
4 5
*Blood control tAfter
___---p-
CASE
EFFECT
TABLE
The was
0
serie? use~l.
-12 -' It
-34 +16
-12
ts -16 -4
t4
pcLSE -44
GAIX OR BINDER al
GAMBILL
ET
AL.
:
EFFECT
O!?
POSTURE
OS
CIRCULATIOX.
II
383
1895, found that abdominal compression prevented the syncope and death which resulted when animals were maintained in the vertical head-up posture, especially after chloroform poisoning or after splanchnicectomy. Such compression restored the blood pressure, which otherwise fell when the animal was in t,he head-up position. Adson and Krown2 and Adson, Craig, and Brown” have noted the beneficial effects of a tight abdominal binder in counteracting the hypotension which oecurs on assumption of the upright position after extensive sympathectomy. In the present study, a many-t,ailed abdominal surgical binder was employed. Under the binder and over the abdomen were placed several folded towels which extended from the level of t,he lower ribs to the pubic region, so that, when the binder was tightened, pressure would be exerted posteriorly and upward as well as laterally against the abdomen. From two to four consecutive determinations of blood pressure and pulse rate were made at intervals of two minutes, first with the patients in the horizontal, and then in t,he 60-degree head-up, posture. The binder was then released, after which one or two determinations of blood pressure and pulse rate were made while the patient was still in the head-up posture. The patient was then returned to the horizontal posture. The results were compared to the control series of blood pressure and pulse rate readings which had been made in each position a few minutes previously. Tn some instances, the binder was bightened after its release while patients were in the head-up posture in order to note its effect under such circumstances. Six of the ten cases were studied before sympathectomy and all of the ten cases were studied after sympathectomy. Results.-The results of this study are shown in Table I. Before operation, at the end of about five minutes in the head-up posture, the binder resulted in an average increase of 8 mm. Hg in the systolic, and 4 mm. in the diastolic, pressure, and an average decrease of 3 beats per minute in pulse rate. After operation the effect was an average increase in t,he systolic pressure of 11 mm., and, in the diastolic pressure, of 8 The most mm., and a decrease in the pulse rate of 9 beam per minute. striking benefit resulted when the binder was used in cases in which considerable orthostatic hypotension and tachycardia occurred, as in Case 1 (Fig. 1). In the 40-degree” head-up posture the systolic blood pressure at the end of the control period of three minutes was 62 mm., the diastolic, 58 mm., and the pulse rate, 132 beats per minute. At this time the patient was quite pale and cold and was virtually in syncope. By contrast, even at the end of seven minutes in this position, during which time the binder was tightly in place, the systolic pressure was 106, the diastolic pressure, 74, and the pulse rate, 88. The binder thus produced a net increase of 44 mm. Hg in systolic pressure and 16 mm. in *This
posture
wits
used
because
more
erect
postures
resulted
in
syncope.
diastolic pressure, and a decrease of 44 bt’ats per n1inut.c in the pulse’ rate. The pulse pressure rose from 4 to 32 mm. a,s a result of rising the binder. Tn Case 8 the reduction in blood pressure was only fair as .a result of the operation. Before operation, when this patient was in the headup posture, the binder had little effect on the blood pressure and pulse rate. After operation, however, the binder resulted in a net incrc>ase of 18 mm. in systolic pressure and 14 mm. in diastolic pressure. and a decrease of 34 beats per minut.e in pulse rate. With these ehangcs, much less pallor, clamminess of the skin, and faintness were noted, and the patient felt much stronger. Horizoti Preop.
posture ~~~~i
CXX-ltPOl
&)170-
Postop. tilt 7min. with7min. out binder with bin&z
.
E; 160 _ Systolic r, 1503
>140'tl30-
-u 8 12001 1105 8
loo ?90-
Diastolic O
hox % ,g .-(o - pzg %
60-
Fig. l.-Effect of tight cardia after sympathectomy up posture.
abdominal in Case
1.
binder on orthostatic hypotension and Patient was tilted on table to IO-degree
tachyhead-
In all cases after operation, release of the binder while the patient. was in the head-up posture resulted in a decrease in blood pressure and increase of pulse rate, often sufficient to produce mild syncope. HOW much of this effeet was due to reactive hyperemia and how much to other factors, such as the sudden release of mechanical support to the hypotonic intra-abdominal vascular bed, is not known. Both factors were probably present. It is interesting that patients who had the greatest degrees of postoperative orthostatic hypotension derived the most benefit from the binder. Thus, the binder appears to correct a defect that is situated, at least in part, within the abdomen, and which is an etiologic factor in the orthostatic hypotension. The most reasonable assumption is that this defect is excessive pooling of blood in the dilated, hypotonic splanchnic vascular bed. The binder probably
GAMBILL
ET
AI,. :
EFFECT
OF
I’OSTURE
OS
CIRCUL1TIO~.
II
385
counteracts this tendency by indirectly supporting or compressing these reservoirs. The net effect is the establishment of a larger gradient of venous pressure between the abdomen and thorax, which results in better cardiac filling and a more favorable ratio of circulating blood volume to vascular capacity. In Case ‘i the effect of alterlmte tightenin g and release of the binder was observed while the patient was standing erect, and the results were compared with control values. As in all cases which were studied, a tightening of the binder resulted in a net increase in blood pressure, a Release of the decrease in pulse rate, and an increase in pulse pressure. binder resulted in opposite effects. Horizontal
posture: 'OstopQRltivG
184
ll-60”
head-i
posturQ.
‘ostopcrative
~eoIx2rative
/
176 ’2 168 160 ?j 152 $44 ‘b 136 8 128 tz 1.20 2 112 8 104 “t 96 ‘?Q 28 86 80 72 64 Fig.
Z.-Effect
30 0 5 Duration
30 0 5 in minutes
30 0 5 for each
on orthostatic blood pressure and pulse in Case 1. Patient was tilted to 40-degree BILATERALLY
INFLATED
THIGH
30 0 5 condition
rate of bilateral head-up posture.
thigh
cuffs
CUFFS
In order to study further the location of the defect responsible for orthostatic hypotension, we desired to see whether this condition could be lessened or corrected by the use of tight cuffs around the thighs, which would cut off momentarily the circulation in the legs. Stead and Ebert’O felt that, in cases of spontaneous orthost,at,ic hypotension, the vasoconstrictor response to a normal amount of pooling is abnormal. Other investigators have stated that perhaps there is an abnormal amount of
B.P.
*4!%degree head-up tCutPs in this case the Anal averages.
90
B.P.
WITHOUT
82
194/129
170/112 138/104 173/120
___ 198/136
158/112
CUFFS
92
92 174/114
p~‘essure
in
PULSE
B.P.
B.P.
WITHOUT
the
so
that
163/109
90 thigh,
19cl/Ml
--
Iso/llc,T
88
84
90
these
89
100
___~___
~.
80 88 84
PULSE
CUFFS
HORIZONTAL
74 ---84 118/ 78 96 164/ 88 ~___~~___~___ 19og.14 100 150/114 100
CUFFS
168/108 ------201i/130 218/132 166/134
II RATE OF BILATERAL THE THIGH
WITH
-220/14e88--92 ___~I__ ___-176/122 84 80 158/110 ~_____~ 18ii/124 90
-----
96 9F
POSTURE
FIG) AND PULSE PRESSURE IN
HEAD-T-P
PULSE ~________
in this case. above the systolic
76
80
84
---168/114 68 ___~ 88 190/132 ---imQi%----%--96 ---15ti/118 84
PULSE
CUFFS
190/120
d14/134
---176/110
178/116 ?06/100 218/140 174/136
B.P.
WITH
posture was used were not inflated
68
74
PULSE
CUFFS
(MM.
GO-DEGREE
PREOPERATIVE
BLOODPRESSURE
POSTTJRE
ON ORTH~STATIC
HORIZONTAL
WITHOUT
170/
---194/12484------_----- 6 7 ---16o/1o8T--8 ~_____~~~ 9 ---iwmT-----Mean
---i5q-z 5
---200/13484’ 2 -22(i/140943 -ziqi%i-x-4
----F----------
CASE
EFFECT
TABLE
figures
173/113
196/126
190/l
in
22
ISFIATBD
the
90
120
-sci/ ____~
88
7G 8G
PULSE
CUFFS
16
hem-up
119
140 112 108
118
~~~100 I?8
144
PULSE
postwe
66/ GO 166/128 ___-__~ l%/ 95
160/118
136/l
168/110
70/ 66 i3iv-E106------
B.P.
WITIIOUT
aw
not
149/111
____~ 1::0/122 88/80 iTqa6llB
included
-198/134
13ot/ Jl4t
10.1
124
116
78 84 94 128t.
PVLSE
CUFFS
POSTURE
116/ S6 146/ 82 ____~ 206/130
B.P.
WITH
SYSTOLIC
HEAD-UP CUFFS
-~BoVI?
CO-DEGREE
POSTOPERATIVE
CUFFS
8476-----
160/ 84 204/130 170/130-%-
118/
B.P.
WITH
POSTURE
THIGH
in
5
i
1: m $
z
g
2 m z?
GAMBILL
ET
AL.
:
EFFECT
OF
POSTURE
ON
CIRCULATION.
II
387
pooling of blood when such patients are placed in the head-up posture. It may be that this type of hypotension is not comparable to that which occurs after sympathectomy, for in t,he former the pulse usually does not accelerate to any significant degree. Cuffs for taking blood pressure in the thighs were placed about both thighs just above t,he knees and inflated, while the patient was in the horizontal posture, to a point well above systolic pressure in the thigh. The patient was then moved on the t,ilt table to the 60-degree head-up posture, and, at the end of one minute and three minutes, the blood pressure in the arm and pulse rate were determined. One thigh cuff was then deflated, after which blood pressure and pulse rate were again determined. Then the second cuff was deflated and similar determinations were made; the patient then was returned to the horizontal posture. Results.-Comparison with control values after sympathectomy indi. cates that using the cuffs resulted in an average increase in orthostatic systolic blood pressure of 24 mm., and, in the diastolic pressure, of 16 mm., with a decrease of 16 beats per minute in the pulse rate (Table II). It would appear that, in cases in which the greatest degrees of orthostatic hypotension and tachycardia occurred after operation, the blood pressure increased the most, when the cuffs were employed. Thus, in Case 1 (Fig. 2), the cuffs, when the patient was in the 60degree head-up posture, produced an increase of 46 mm. Hg in the syst,olic. and an increase of 20 mm. in the diastolic, pressure over the control value. The pulse rate was decreased a total of 66 beats by using the cuff. In contrast, in this case, the cuffs, when used before operation, did not produce an increase in the orthostat,ic systolic pressure, produced an actual decrease in the orthostatic diastolic pressure, and decreased the orthostatic pulse rate only a third as much as after operation. In all cases, release of one cuff, followed by release of the second cuff, resulted in successive decreases in blood pressure; the decline was greater after release of both cuffs than it was after release of either cuff. Obviously, effects produced by cuffs are only of academic interest, for it is not practical to use them therapeutically. ABDOMINAL
BINDER,
PLUS
THIGH
CUFFS
Since both the abdominal binder and thigh cuffs increased blood pressure and decreased pulse rate, it seemed desirable to ascertain what effect a combination of these agents would have on blood pressure and pulse rate. They were accordingly applied and used, as previously described, on six of the ten patients, while they were in the horizontal and in the 60-degree head-up postures, before and after extensive sympathectomy. Results.-As indicated in Table III, the combined use of these procedures on patients in the head-up posture after operation produced an average rise in systolic pressure which was twice as great as before
2 ')
1%
+Tonc~s
*40-degree
Mean-
____-__
4 -194/1.31846
L
--A
CASE
HORIZONTAL
ORTIIOSTATIC
faint,
~___
srade
head-up
160/12~>
3+.
posture
82
WITHGIJT CUFFS OR BINDER PUI,SE __- BP. lSO/ 91, 74
EFFECTOE
“10/l
30
used.
194/l‘w
83
m/l36
72
__.-~
146/120
2oo/l::Y ~-
100
POSTURE WITII CUFFS AND BINDER H.P. / PULSE
180/12(i
(MM.HG)
AND
PULSE
RATE
--______ 92
91:
88 21(;/142
220/1::-1 84
92
PREOPERATIVE t;G-DEGREE HEAD-UP POSTURE WITHOUT CUFFS WITII CIJFFS AND BINDER OR BINDER R.P. B.P. PULSE PULSE iz@iET 178/12fl 80 __-.- 76
~~ooDpREssuRE
TABLE
B.P.
190/1:14
118/
YO 88
PULSE 80 190/128
136/
80
CUFFS
90
52
PLUS
ABDOMINAL
BINDER
70/
66
144
______
130/
92
BO-DEGREE HEAD-UP POSTURE WITHOUT OUFFS WITH CUFFS OR BINDER AND BINDER B.P. B.P. PULSE PULSE
POSTOPERATIVE
THIGH
POSTURE WITH CUFFS AND BINDER B.P. PULSE
INIQLATED
HORIZONTAL WITHOUT CCFFS OR BINDER
OF BILATERALLY
III
9 z
z
k
GAMBILL
ET
AL.
:
EFFECT
OF
POSTURE
ON
CIRCUL.\TIOS.
II
580 t
operation. The average increase in the diastolic pressure was more than three and a half times as great? and the arerage decrease in pulse rate was six times as much after. operation as before operntiou. Specifically, the cuffs and binder produced an average increase of 20 mm. in the systolic blood pressure before operation and 43 mm. after operation, an increase of 7 mm. in the diastolic pressure heforr, ant1 of 25 mm. Hg after, operation, and a clecrease in the pulse rate of 5 beats before, and 30 beats per minute after, sympathectomy. Jn general, the greatest increase in blood pressure and slowing of the l)ulse rate after operation occurred in cases of the most, severe orthostatic hypotension and orthostatic tachycardia. COMPARISOS I’IJLSE
OF EFFECTS RATE CUFFS,
OF
(3)
ON (1)
ORTHOSTATIC ABDOMINAL
ABDOMIS:\L AND
(4)
BLOOD
DISDER COLD-FRESSOR
PRESSURE
(2)
BIKDER, PLUS
.\ND
13ILATERAL
TIIIGH
ORTHOYTATIC THIGH
CUFFS>
TEST
The t,echnique for the first three procedures has already been described. The cold-pressor test was done according to the technique of one of us (Hinesll), as outlined in a previous report. As indicated in Fig. 3, when the patients were in the head-up posture before operation, the binder, thigh cuffs, bincler plus thigh cuffs, and cold-press01 test produced respective average increases in systolic pressure of ‘i, 13, 20, and 23 mm. Hg. After operation, the blood-pressure-elevating effects of the first three agents were about twice as great, whereas the response to the cold-pressor test was unchanged, or, in cases of postoperative orthostatic hypotension and tachycardia, was even decreased. All agents except the cold water caused a postoperati\-c rise in diastolic pressure which was two to three t,imes greater t.han the effect produced preoperatively. After operation, in the head-up posture, the binder did not affect the pulse rate, whereas the cuffs decreased it an average of sixteen beats per minute, and the binder plus cuffs decreased it thirty beats per minute. The pulse rate was not counted during the cold-pressor test in any case. Patients who had the greatest orthostatic hypotension after sympathectomy derived the greatest, benefit from t,he use of these agents. Thus, in Case 1, binder and cuffs caused a rise in systolic pressure of 10 mm. before operation and 60 mm. Hg afterward, a rise in diastolic pressure of 6 mm. before, and 26 mm. after, operation, and a decrease in pulse rate of 1.6 beats per minute before operation and 72 beats afterward. The cold water caused a rise of 12 mm. in systolic pressure before operation and only 8 mm. after operation. Col)t7ulenf.-If discomfort were important as a cause of the elevation in blood pressure after the use of the agents named, the cold water should elevate the blood pressure, for its pressor eRect is presumed to he the result of the discomfort which it induces. If discomfort were an important factor in the effects of these agents on pulse rate anal
blood ptessure, such marked differences \\ould not be expected between pktients who had severe orthostatic hypotension and those who did not have this phenomenon after sympathectomy. We might suggest as a possible explanation for the good effects of t,he binder and cuffs on orthostatica hypotension and orthostatic tachyca.rdia that sympathectomy apparently decreases vasomotor tonus ilt a large bortion of t,he vascular bet1 below the level of the diaphragm. Cold fvssor tes 'rQOp.
POStOF
+44 $ $40 9 +36 t +32 Q-i ‘$ +.a 9 +24 "9 +zo 4 +16 8 +12 $ q
3
+8 +4 0
e
-4 -8 3% -12 T -16 4 -20 0, gj -2.4 t -18 k Q -32 I
Duration
in minutes
for
each
1 1 condition
Fig. 3.-Comparative blood-pressure-raising and pulse-slowing effect of abdominal binder, bilateral thigh cuffs, abdominal binder plus thigh cuffs, and cold-pressor test before and after extensive sympathectomy. Average for all patients in Wdegree head-up pobture. Values given denote deviations from control values represented by zero lines.
The vessels, as a result, become more readily distensible under the influence of the hydrostatic pressure which is brought into play by the head-up posture. The tonus which is inherent in the wall of the vessels cannot fully compensate for this force, so that, as a result,
GAMBILL
ET
AL .:
EFFECT
08
POSTURE
ON
CIRCULATIOS.
II
391
the vessels in t,he regions affected by sympathectomy become more capacious, creating thereby an unfavorable disproportion between vascular capacity and circulating blood volume. The result of this would probably be an impairment in venous return and in cardiac filling, and a decrease in blood pressure and an increase in pulse rate whet) the patient is in the head-up posture. The increased pulse rate ma> be related to the decrease in blood pressure, resulting in inhibition of pressoreceptive stimuli which originate in the thoracic aorta and carotid sinuses. The marked hypot.ension and evidence of defective venous return to the heart seem to exclude the Bainbridge reflex as a mediator of the rapid pulse which occurs in cases of postoperative orthostatic hypotension and orthostat,ic tachycardia.l The slowing of the pulse rate, along with an increase in blood pressure when venous return is presumably improved by the use of a tight abdominal binder, supports this view. The abdominal binder probably tends partially to correct the defect responsible for orthostatic hgpotension and orthostatic tachycardia by reducing the size of the splanchnic vascular resevoirs through external support to the hypot.onie vessels. By this means and by t,he increased intra-abdominal pressure which the hinder procluces, the venous pressure gradient between the abdomen and thorax is pwsunlably increased. The cuffs, by eliminating ‘the vascular segment below- the knee, decrease the size of the vascular reservoirs and reduce the hydrostatic column against which the circulation must work while the patient is in t,he head-up posture. The sum total of these effects seems to be the establishment of a more favorable balance between vascular capacity and circulating blood volume, with resultant improvement in cardiac filling, cardiac output, and blood pressure. Some support for t,his hypothesis is afforded by the studies of Bjure and Laurel&” who found that, when patients with marked orthostatic tachycardia stood in water up to the level of the heart, the pnlse rate did not increase. Stead and Ebert”’ made similar studies, and found that the blood pressure of patients who had orthostatic hypotension and orthostatic tachycardia was the same when they stood in water at axillary level as it was when they were in the horizontal posture. Standing in water at lower levels resulted in corresponding decreases in blood pressure. It, is i’cIt that the binder used in the present studies acted in a somewhat- similar manner. EXERCISE
It seems ciated with pulse rate ture after of the legs, counteract
OF
THE
LEGS
likely that decreased venous return to the heart is assothe marked decreases in blood pressure and increases in which occur when certain patients are in the upright posextensive sympathectomy. We wondered if active exercise in cases in which possibly excessive pooling occurred, would orthostatic hypotension by increasing venous return to the
392
AMERICAX
HEART
.JOURSAl,
heart,. The importance of the venopressor mechanisnl in the c*irculation has been studied by Henderson and his associates.‘“~ ‘+ The role of muscle tonus in aiding venous return is well known. Freeman and Rosenblueth15 and Pinkston and his (ao-workers.16 however, noted ;I tendency to a decrease in blood pressure during muscular activity it1 dogs after total sympathectomy. In the present study t,he patients st,ood still on the floor for three minutes. Control blood pressures and pulse rates were obtained after one and after three minutes in this position. They then rose up and down on the toes at a uniform rate of about thirt,y times a minute for two minutes. Blood pressures and pulse rates were obtained at t.hc end of one and of two minutes of exercise. M%hin one and a half minutes after cessation of exercise, blood pressure and pulse rate were taken again. The results were compare~l t(J c*ontrol values. The effect of exercise was difficult t,o evaluate because it was not possible accurately to standardize the actual amount of work whiczh was done. In two instances, exercise could not, be done because the patients were on the verge of syncope at. t,he end of t.he control period and had to sit down to avert syncope. Exercise apparently produced a greater increase in blood pressure before than after operation. The pulse rate during exercise increased 15 beats per minute before operation and 12 be& per minute after operation. This difference does not seem significant. In three of six cases studied, the blood pressure COW tinued to decrease during exercise. Only in one case did the pulse rate decrease and the blood pressure increase during exercise after operation, In most cases, apparently, the good effects, if any. on the blood pressure of exercising t,he legs were not enough t.o oppose th(> hydrostatic pressure within vessels with drrreasrtl contractility resulting from sympat,hetic denervation.
Stead and Kunkell’ showed that a-N-dimethyl-p-l~ydroxyphen&ylamine sulfate (paredrinol sulfate) increases venous tone and venous pressure, slows the heart rat,e, and produces hypertension. We desired to see whether it woulcl be helpful in counteracting excessive orthostatic decreases in blood pressure after sympathectomy, inasmuch as Stead and Kunkel found it beneficial in certain types of circ4ulatol.y collapse. Accordingly, this drug was given in doses of 10 to 20 mg. subcutaneously in Cases 7 and 8 after a series of blood pressures ant1 pulse rates were taken Lvhile t.hc patients were in the horizontal an(l then in the erect posture. The drug was given about two weeks after the second stage of sympathectomy, after the pat,ients had been walking around in the hospital for four or five days. In Case 7 the orthostatic blood pressure was 54 mm. higher after using the drug, and the orthostatic pulse rate was 24 beats slower than the cont,rol rate. Whereas the patient was near syncope after stalld-
GAhlBILL
ICT AL. :
EFFECT
OP POSTURE
OS
C’IRCULhTIOS.
II
393
ing for one minute before talk g the drug, she had no such difficulty after fifteen minutes of standing after receiving 10 mg. of paredrinol sulfate. There was subjective, as well as objective, benefit from the use of the drug. She did not feel faint, and was comfortable except for mild cardiac palpitation caused by the pnredrinol. The results in Case 7 are shown in Fig. 4. As will be seen, a decrease occurred in orthostatic blood pressure and an increase iti orthostatic pulse rate,
BQforQ I pamdrinol ixwzdrinol Bcfom
After Ly inq
Ly inq S;zd3
200200 190 100 170 2 160. Q 150 fi, 140' % > 130. pL0. $ 110. 100 r 90 3 80 g 70 60 g 5050 Q 4040 30 20 20 10 ~-
Standing
T 2
X
Felt much s&on& No ftintness. Mild palpitation Objectivelykss palloT?PUbQ mu StrongQr!
: 8!
:: *
..3 $2
$,
$ \
4.-Effect blood
r
Systolic
O Control Fig.
paredrinol
of 10 mg. pressure
3i
Time
of paredrinol s,ulfate, and pulse rate after
in minutes given subcutaneously, sympathectomy in
on orthostatic Case 7.
even after paredrinol had been used; the extent of these, however, was less. The level of blood pressure was raised in both postures, which seems to be the main effect of the drug. The net effect of the drug apparently was to increase the orthostatic systolic pressure 28 mm. and the diast,olic pressure 20 mm., and to slow the orthostatic pulse rate I6 beats, when compared to t,he control values. In Case 8, the
394
AMERICAN
HEART
JOURNAL
injection of 20 mg. of paredrinol sulfate rendered the orthostatic systolic pressure 30 mm. higher a~nd the orthostatic pulse rate 14 beats slower than the control values. It seems that paredrinol might be beneficial in counteracting excessive decreases in blood pressure when certain patients stand soon after sympathectomy, at a time when vascular adjustments are still imperfect. Stead am1 Kunkel found, howerr, that this drug t.euds t.o become less efiectirth \\:ith repentetl use.
Ten cases of essential hypertension were studied before and aft,er extensive splanchnic sympathectomy. The following observations were made : The use of a tight al)dominal binder was of ronsiderahle benefit in counteracting excessive degrees of postoperative orthostatic hypotension and tachycardia. To be effec+tivc, t,he hinder must be properly applied. The fact that the binder had little effect preoperat,ively 01 postoperatively in those c;lses in which orthost,at,ic hypotension and orthost.atic t.achycnrdia were not great, hut did increase the blood pressure and slow the pulse rate after operation in cases in which these phenomena occurred, suggests t,hat the defect responsible for this condition lies, at least in part, within the abdomen. Cnffs Gghtly applied above both knees in order to cut off the circulation to the legs tended t,o elevate the blood pressure and slow the pulse rate. This effect was greater after, than before, sympathectomy, and was greatest after operation among patients who had the greatest degrees of orthost,atic hypotrnsion and tachycardia. The combined use of an abdominal binder aud thigh cuffs had a greater blood-pressure-raising and pulse-slowing eftect than either procedure alone. The effect of the tight abdominal hinder, thigh cuffs, or both, in connt,er.acting orthostat,ic hypotension and tachycardia was due chiefly to factors other than the discomfort which was induced by these agents. Exercise of the legs did not produce a conclusive effect on orthostatic blood pressure and orthost,atic pulse rate. l’aredrinol sulfate definitely raised the level of the postoperative blood pressure in the horizont,al and erect postures, and alleviated most of the symptoms which otherwise resulted when patients were in the It reduced somewhat the amount of orthostatic deerect posture. crease in blood pressure. It may be helpful, therefore, in counteracting excessive degrees of orthostatic hypotension when patients begin to walk soon after sympathectomy. REFERENCES
1.
Gambill, E. E., Hines, E. A., Jr., and Adson, A. W.: The Circulation in Man in Certain Postures Before and After Extensive Sympathectomy for Essential Hypertension. I. Physiologic Agents, AM. HEART J. 27: 360, 1944.
GAMBILL
ET
AL.
:
EFFECT
OF
POSTURE
OK
CIRCULATION.
II
395
2. Adson, A. W., and Brown, G. E.: Malignant Hypertension Treated by Section Report of a Case, Proc. Staff Meet., of the Anterior Spinal Nerve Roots: Mayo Clin. 8: 739,&1933. 3. Adson, A. W., Craig, W. MIX., and Brown, G. E.: Surgery in Its Relation to Hypertension, Surg., Gynec. & Obst. 62: 314, 1936. 4. A&on, A. W., and Brown, G. E.: Malignant Hypertension: Report of Case Treated hy Bilateral Section of Anterior Spinal Nerve Roots From the Sixth Thoracic to the Second Lumbar. Inclusive. J. A. M. A. 102: 1115. 1934.
5. Ellis, L. B., and Haynes, Florence W.: Postural Hypertension With Partieulax Reference to Its Occurrence in Disease of the Central Nervous System, Arch. lnt. Med. 58: 773. 1936. 6. Hill, Leonard: The Influe&ce of the Force of Gravity on the Circulation of the Blood, J. Physiol. 18: 15, 1895. 7. MaeWilliam: Quoted bv Hill. 8. Roy and Adami; Quo&d by Hill. 9. Turner, Abby A., Newto?, M. Isabel, and Haynes, Florence W.: The Circulatory Reaction to Gravity in Healthy Young Women: Evidence Regarding Its Precision and Its Instability, Am. J. Physiol. 94: 507, 1930. 10. Stead, E. A., Jr., and Ebert, R. V.: Postural Hypotension; Disease of Sympathetic Nervous System, Arch. Int. Med. 67: 546, 1941. 11. Hines, E. A., Jr.: Technic of the Cold Pressor Test, Proe. Staff Meet., Mayo Clin. 14: 185, 1939. 12. Bjure, Alfred, and Laurell, Hugo: Om abnorma atatiska cirkulationsfenomen och diirmed sammanhSingande sjuklega symptom. Den arteriella orthostatiska aniimin en fSrsummad sjukdomsbidd, Upsala Kkaref f&h. 33: 1, 1927. 13. Henderson, Yandell: The Volume of the Circ.ulation and Its R,egulation by the Venonressor Mechanism. J. A. M. A. 97: 1265. 1931. 14. Henderson, Yandell, Oughterson, A. W., Greeiberg, L. A., and Searle, C. P.: Muscle Tonus, Intramuscular Pressure and the Venopressor Mechanism. Am. J. Physiol. ilk: 261, 1936. 15. Freeman, N. E:, and Rosenblueth, A.: Reflex Stimulation and Inhibition of Vasodilators m Sympathectomized Animals, Am. J. Physiol. 98: 454, 1931, 16. Pinkston, J. O., Partington, P. F., and Rosenblueth, 9.: A Further Study of Reflex Changes of Blood Pres’sure in Completely Sympathectomized Animals, Am. J. Phvsiol. 115: 711. 1936. 17. Stead, I& A.: Jr., and K&kel, Paul: Mechanism of Arterial Hypertension Induced by Paredrinol (a-N-dimethyl-p-hydroxyphenethylamine), J. Clin. Investigation 18: 439, 1939.
CIRCULATION IN ;MAN IN CERTAlN POSTURES AND AFTER EXTENSIVE SYMPATHECTOMY FOR ESSENTIAT, HYPERTENSION
BEFORE
IT. EFFECT OF CERTAIN
~WECHANICAL RGEETS AKD PAREDRINOL ON BLOOD PRESSURE AND PULSE RATE*
EARL E. GAMEILL, M.D.,t
EDGAR A. HIKES, !JR.? M.J).,$ ALFRED W. ADSON, W.U.g ROCHESTER, MINX.
AND
N A PREVIOIJS paper1 we reported someof the physiologic effects on the circulation of extensive splanchnic sympathectorny and postural change in casesof essential hypertension. The studies to he reported in this paper were made on the same ten patients (Cases 1 to 10). In general, the same air-conditioned soom and basic procedure, including t,he samedates of study, were employed in both instances. This part of the investigation was concerned wit.h modifications of blood pressure and pulse rate by (1) a tight abdominal binder, (2) bilaterally inflated cuffs around the thighs, (3) an abdominal binder plus cuffs around the thighs, (4) exercise of the legs, and (5) t,he administration of paredrinol sulfate. The blood-pressure-raising effects of some of these agents were compared to similar effects of the coldpressor test. Controlled observations preceded each of the investigations. Each study was done before and aft,er extensive sympathectomg, and, in most instances, while the patients were in the horizontal and in the 60-degree head-up postures.
I
TIGHT ABDOMINAL
HINDER
The primary purpose of this portion of the study was to see whether such a binder would relieve the orthostatic hypotension and tachycardia which often follow extensive splanchnic denervation. The word ‘(orthostatic” is used in this paper to denot,e any upright or partially upright position in which the head is higher than the feet. In most instances, this was the 60-degree head-up posture. Various workers2mghave noted the beneficial effects of abdominal compression on the low blood pressure of certain persons and of animals under certain conditions when the upright posture is assumed. W7hile studying vasomotor adaptation in animals, Hill, as early as Received for p,nblication May 3, 1943. *Abridgement of a Bortion of thesis submitted by Dr. GsmbiiI to the Fae&ty of the Graduate School of the University of Minnesota in partial fulfillment of the requirements for the degree of M.S. in Medicine. fFirst Assistant in Division of Medicine, Mayo Clinic. SDivision of Medicine, Mayo Clinic. lDivision of Neurologic Surgery. Mayo Clinic. 381
of
-
mqz%72---___-----
8 9 10
pressures readings operation,
72
80
R.P.
146/lPO
l&k/108
88 90
94
88
represent posture not tolerate
liO/lZ?
160/118
B.P.
(MM.
PULSE
80
91
104
in almost every were taken after the 604epree
175/126
~~~~~_~___
m--z--
214/140
194/140 -108 160/130
150/116
88
84 88
94
164/104
100
100
54/
50
130/r
GO/102
iKqiE1os132
132
86
74
WITR BINDER
64
rest hence
170/11"
166/128
72/
114/1oa
204/144
m/lo8 ll(i/lOO 18'2/126
126/
ASD
-
HEAD-UP
6
4
postwe
1 /
FROM
intervals.
+20/tlO +ll/+ 8
+18/+14 t 2/t
+14/+ 8
+24/+
-l-i/4 -22/ 0 +"2/t16
- 2/+10
+44/tl6
B.P.
LOSS
OR’~HOSl’A’lT~’
BO-DEGREE
at two-minute on the table. a JO-degree head-up
120
124
98
140
128
108 112 114
104
'"IJJ
POSTPRE
----------iiz141/105 readings taken of
B.P. lOti/
HEAD-UP
138/100 128 16O/luJ 118--180/138 128 lOO/ 96rp-__~
12S/ 76 164/112
WITHOUT BINDER 6Ei;.g,A '"I;;
POSTOPERATIVE HO-DEGREE
instance the third of a series of approximately twenty minutes head-up posture without ssncope:
iYsi-i%T
100
190/1x
104
'""py
HORIZONTAL CONTROL ,,B=.,,
-88
I
HG.) AND PULSE R,ATE IN HORIZOXTAL AXD AFTER SYMPATHECTOMY+
_________~_____166/------------96 178,'120
WITH BINDER
POSTURE
160/120 98 ---84ixqm-i!%-164/110
206/140
HEAD-UP
96
92
j PGLSE --
PREYSCRE
TILTED POSTUEES, BEFORE
ON BLOOD
la&/118 -168/1a-1 112
198/136
and pulse rates in the horizontal patient could
180/11778-------
___---____
194/X24 ii@iiz-i%---
_--___-----p-_
6 7
Mean
PULSE
WITHOUT BINDER
(;&DEGREE
PREOPERATIVE
BINDER
220,'140 88 200/130 __--~-__~___I__________
_I__I_
r3.P.
164/120 izipizss-----
2 3
1t
OF ~~BDOXISAL
HORIZONTAL CONTROL
4 5
*Blood control tAfter
___---p-
CASE
EFFECT
TABLE
The was
0
serie? use~l.
-12 -' It
-34 +16
-12
ts -16 -4
t4
pcLSE -44
GAIX OR BINDER al
GAMBILL
ET
AL.
:
EFFECT
O!?
POSTURE
OS
CIRCULATIOX.
II
383
1895, found that abdominal compression prevented the syncope and death which resulted when animals were maintained in the vertical head-up posture, especially after chloroform poisoning or after splanchnicectomy. Such compression restored the blood pressure, which otherwise fell when the animal was in t,he head-up position. Adson and Krown2 and Adson, Craig, and Brown” have noted the beneficial effects of a tight abdominal binder in counteracting the hypotension which oecurs on assumption of the upright position after extensive sympathectomy. In the present study, a many-t,ailed abdominal surgical binder was employed. Under the binder and over the abdomen were placed several folded towels which extended from the level of t,he lower ribs to the pubic region, so that, when the binder was tightened, pressure would be exerted posteriorly and upward as well as laterally against the abdomen. From two to four consecutive determinations of blood pressure and pulse rate were made at intervals of two minutes, first with the patients in the horizontal, and then in t,he 60-degree head-up, posture. The binder was then released, after which one or two determinations of blood pressure and pulse rate were made while the patient was still in the head-up posture. The patient was then returned to the horizontal posture. The results were compared to the control series of blood pressure and pulse rate readings which had been made in each position a few minutes previously. Tn some instances, the binder was bightened after its release while patients were in the head-up posture in order to note its effect under such circumstances. Six of the ten cases were studied before sympathectomy and all of the ten cases were studied after sympathectomy. Results.-The results of this study are shown in Table I. Before operation, at the end of about five minutes in the head-up posture, the binder resulted in an average increase of 8 mm. Hg in the systolic, and 4 mm. in the diastolic, pressure, and an average decrease of 3 beats per minute in pulse rate. After operation the effect was an average increase in t,he systolic pressure of 11 mm., and, in the diastolic pressure, of 8 The most mm., and a decrease in the pulse rate of 9 beam per minute. striking benefit resulted when the binder was used in cases in which considerable orthostatic hypotension and tachycardia occurred, as in Case 1 (Fig. 1). In the 40-degree” head-up posture the systolic blood pressure at the end of the control period of three minutes was 62 mm., the diastolic, 58 mm., and the pulse rate, 132 beats per minute. At this time the patient was quite pale and cold and was virtually in syncope. By contrast, even at the end of seven minutes in this position, during which time the binder was tightly in place, the systolic pressure was 106, the diastolic pressure, 74, and the pulse rate, 88. The binder thus produced a net increase of 44 mm. Hg in systolic pressure and 16 mm. in *This
posture
wits
used
because
more
erect
postures
resulted
in
syncope.
diastolic pressure, and a decrease of 44 bt’ats per n1inut.c in the pulse’ rate. The pulse pressure rose from 4 to 32 mm. a,s a result of rising the binder. Tn Case 8 the reduction in blood pressure was only fair as .a result of the operation. Before operation, when this patient was in the headup posture, the binder had little effect on the blood pressure and pulse rate. After operation, however, the binder resulted in a net incrc>ase of 18 mm. in systolic pressure and 14 mm. in diastolic pressure. and a decrease of 34 beats per minut.e in pulse rate. With these ehangcs, much less pallor, clamminess of the skin, and faintness were noted, and the patient felt much stronger. Horizoti Preop.
posture ~~~~i
CXX-ltPOl
&)170-
Postop. tilt 7min. with7min. out binder with bin&z
.
E; 160 _ Systolic r, 1503
>140'tl30-
-u 8 12001 1105 8
loo ?90-
Diastolic O
hox % ,g .-(o - pzg %
60-
Fig. l.-Effect of tight cardia after sympathectomy up posture.
abdominal in Case
1.
binder on orthostatic hypotension and Patient was tilted on table to IO-degree
tachyhead-
In all cases after operation, release of the binder while the patient. was in the head-up posture resulted in a decrease in blood pressure and increase of pulse rate, often sufficient to produce mild syncope. HOW much of this effeet was due to reactive hyperemia and how much to other factors, such as the sudden release of mechanical support to the hypotonic intra-abdominal vascular bed, is not known. Both factors were probably present. It is interesting that patients who had the greatest degrees of postoperative orthostatic hypotension derived the most benefit from the binder. Thus, the binder appears to correct a defect that is situated, at least in part, within the abdomen, and which is an etiologic factor in the orthostatic hypotension. The most reasonable assumption is that this defect is excessive pooling of blood in the dilated, hypotonic splanchnic vascular bed. The binder probably
GAMBILL
ET
AI,. :
EFFECT
OF
I’OSTURE
OS
CIRCUL1TIO~.
II
385
counteracts this tendency by indirectly supporting or compressing these reservoirs. The net effect is the establishment of a larger gradient of venous pressure between the abdomen and thorax, which results in better cardiac filling and a more favorable ratio of circulating blood volume to vascular capacity. In Case ‘i the effect of alterlmte tightenin g and release of the binder was observed while the patient was standing erect, and the results were compared with control values. As in all cases which were studied, a tightening of the binder resulted in a net increase in blood pressure, a Release of the decrease in pulse rate, and an increase in pulse pressure. binder resulted in opposite effects. Horizontal
posture: 'OstopQRltivG
184
ll-60”
head-i
posturQ.
‘ostopcrative
~eoIx2rative
/
176 ’2 168 160 ?j 152 $44 ‘b 136 8 128 tz 1.20 2 112 8 104 “t 96 ‘?Q 28 86 80 72 64 Fig.
Z.-Effect
30 0 5 Duration
30 0 5 in minutes
30 0 5 for each
on orthostatic blood pressure and pulse in Case 1. Patient was tilted to 40-degree BILATERALLY
INFLATED
THIGH
30 0 5 condition
rate of bilateral head-up posture.
thigh
cuffs
CUFFS
In order to study further the location of the defect responsible for orthostatic hypotension, we desired to see whether this condition could be lessened or corrected by the use of tight cuffs around the thighs, which would cut off momentarily the circulation in the legs. Stead and Ebert’O felt that, in cases of spontaneous orthost,at,ic hypotension, the vasoconstrictor response to a normal amount of pooling is abnormal. Other investigators have stated that perhaps there is an abnormal amount of
B.P.
*4!%degree head-up tCutPs in this case the Anal averages.
90
B.P.
WITHOUT
82
194/129
170/112 138/104 173/120
___ 198/136
158/112
CUFFS
92
92 174/114
p~‘essure
in
PULSE
B.P.
B.P.
WITHOUT
the
so
that
163/109
90 thigh,
19cl/Ml
--
Iso/llc,T
88
84
90
these
89
100
___~___
~.
80 88 84
PULSE
CUFFS
HORIZONTAL
74 ---84 118/ 78 96 164/ 88 ~___~~___~___ 19og.14 100 150/114 100
CUFFS
168/108 ------201i/130 218/132 166/134
II RATE OF BILATERAL THE THIGH
WITH
-220/14e88--92 ___~I__ ___-176/122 84 80 158/110 ~_____~ 18ii/124 90
-----
96 9F
POSTURE
FIG) AND PULSE PRESSURE IN
HEAD-T-P
PULSE ~________
in this case. above the systolic
76
80
84
---168/114 68 ___~ 88 190/132 ---imQi%----%--96 ---15ti/118 84
PULSE
CUFFS
190/120
d14/134
---176/110
178/116 ?06/100 218/140 174/136
B.P.
WITH
posture was used were not inflated
68
74
PULSE
CUFFS
(MM.
GO-DEGREE
PREOPERATIVE
BLOODPRESSURE
POSTTJRE
ON ORTH~STATIC
HORIZONTAL
WITHOUT
170/
---194/12484------_----- 6 7 ---16o/1o8T--8 ~_____~~~ 9 ---iwmT-----Mean
---i5q-z 5
---200/13484’ 2 -22(i/140943 -ziqi%i-x-4
----F----------
CASE
EFFECT
TABLE
figures
173/113
196/126
190/l
in
22
ISFIATBD
the
90
120
-sci/ ____~
88
7G 8G
PULSE
CUFFS
16
hem-up
119
140 112 108
118
~~~100 I?8
144
PULSE
postwe
66/ GO 166/128 ___-__~ l%/ 95
160/118
136/l
168/110
70/ 66 i3iv-E106------
B.P.
WITIIOUT
aw
not
149/111
____~ 1::0/122 88/80 iTqa6llB
included
-198/134
13ot/ Jl4t
10.1
124
116
78 84 94 128t.
PVLSE
CUFFS
POSTURE
116/ S6 146/ 82 ____~ 206/130
B.P.
WITH
SYSTOLIC
HEAD-UP CUFFS
-~BoVI?
CO-DEGREE
POSTOPERATIVE
CUFFS
8476-----
160/ 84 204/130 170/130-%-
118/
B.P.
WITH
POSTURE
THIGH
in
5
i
1: m $
z
g
2 m z?
GAMBILL
ET
AL.
:
EFFECT
OF
POSTURE
ON
CIRCULATION.
II
387
pooling of blood when such patients are placed in the head-up posture. It may be that this type of hypotension is not comparable to that which occurs after sympathectomy, for in t,he former the pulse usually does not accelerate to any significant degree. Cuffs for taking blood pressure in the thighs were placed about both thighs just above t,he knees and inflated, while the patient was in the horizontal posture, to a point well above systolic pressure in the thigh. The patient was then moved on the t,ilt table to the 60-degree head-up posture, and, at the end of one minute and three minutes, the blood pressure in the arm and pulse rate were determined. One thigh cuff was then deflated, after which blood pressure and pulse rate were again determined. Then the second cuff was deflated and similar determinations were made; the patient then was returned to the horizontal posture. Results.-Comparison with control values after sympathectomy indi. cates that using the cuffs resulted in an average increase in orthostatic systolic blood pressure of 24 mm., and, in the diastolic pressure, of 16 mm., with a decrease of 16 beats per minute in the pulse rate (Table II). It would appear that, in cases in which the greatest degrees of orthostatic hypotension and tachycardia occurred after operation, the blood pressure increased the most, when the cuffs were employed. Thus, in Case 1 (Fig. 2), the cuffs, when the patient was in the 60degree head-up posture, produced an increase of 46 mm. Hg in the syst,olic. and an increase of 20 mm. in the diastolic, pressure over the control value. The pulse rate was decreased a total of 66 beats by using the cuff. In contrast, in this case, the cuffs, when used before operation, did not produce an increase in the orthostat,ic systolic pressure, produced an actual decrease in the orthostatic diastolic pressure, and decreased the orthostatic pulse rate only a third as much as after operation. In all cases, release of one cuff, followed by release of the second cuff, resulted in successive decreases in blood pressure; the decline was greater after release of both cuffs than it was after release of either cuff. Obviously, effects produced by cuffs are only of academic interest, for it is not practical to use them therapeutically. ABDOMINAL
BINDER,
PLUS
THIGH
CUFFS
Since both the abdominal binder and thigh cuffs increased blood pressure and decreased pulse rate, it seemed desirable to ascertain what effect a combination of these agents would have on blood pressure and pulse rate. They were accordingly applied and used, as previously described, on six of the ten patients, while they were in the horizontal and in the 60-degree head-up postures, before and after extensive sympathectomy. Results.-As indicated in Table III, the combined use of these procedures on patients in the head-up posture after operation produced an average rise in systolic pressure which was twice as great as before
2 ')
1%
+Tonc~s
*40-degree
Mean-
____-__
4 -194/1.31846
L
--A
CASE
HORIZONTAL
ORTIIOSTATIC
faint,
~___
srade
head-up
160/12~>
3+.
posture
82
WITHGIJT CUFFS OR BINDER PUI,SE __- BP. lSO/ 91, 74
EFFECTOE
“10/l
30
used.
194/l‘w
83
m/l36
72
__.-~
146/120
2oo/l::Y ~-
100
POSTURE WITII CUFFS AND BINDER H.P. / PULSE
180/12(i
(MM.HG)
AND
PULSE
RATE
--______ 92
91:
88 21(;/142
220/1::-1 84
92
PREOPERATIVE t;G-DEGREE HEAD-UP POSTURE WITHOUT CUFFS WITII CIJFFS AND BINDER OR BINDER R.P. B.P. PULSE PULSE iz@iET 178/12fl 80 __-.- 76
~~ooDpREssuRE
TABLE
B.P.
190/1:14
118/
YO 88
PULSE 80 190/128
136/
80
CUFFS
90
52
PLUS
ABDOMINAL
BINDER
70/
66
144
______
130/
92
BO-DEGREE HEAD-UP POSTURE WITHOUT OUFFS WITH CUFFS OR BINDER AND BINDER B.P. B.P. PULSE PULSE
POSTOPERATIVE
THIGH
POSTURE WITH CUFFS AND BINDER B.P. PULSE
INIQLATED
HORIZONTAL WITHOUT CCFFS OR BINDER
OF BILATERALLY
III
9 z
z
k
GAMBILL
ET
AL.
:
EFFECT
OF
POSTURE
ON
CIRCUL.\TIOS.
II
580 t
operation. The average increase in the diastolic pressure was more than three and a half times as great? and the arerage decrease in pulse rate was six times as much after. operation as before operntiou. Specifically, the cuffs and binder produced an average increase of 20 mm. in the systolic blood pressure before operation and 43 mm. after operation, an increase of 7 mm. in the diastolic pressure heforr, ant1 of 25 mm. Hg after, operation, and a clecrease in the pulse rate of 5 beats before, and 30 beats per minute after, sympathectomy. Jn general, the greatest increase in blood pressure and slowing of the l)ulse rate after operation occurred in cases of the most, severe orthostatic hypotension and orthostatic tachycardia. COMPARISOS I’IJLSE
OF EFFECTS RATE CUFFS,
OF
(3)
ON (1)
ORTHOSTATIC ABDOMINAL
ABDOMIS:\L AND
(4)
BLOOD
DISDER COLD-FRESSOR
PRESSURE
(2)
BIKDER, PLUS
.\ND
13ILATERAL
TIIIGH
ORTHOYTATIC THIGH
CUFFS>
TEST
The t,echnique for the first three procedures has already been described. The cold-pressor test was done according to the technique of one of us (Hinesll), as outlined in a previous report. As indicated in Fig. 3, when the patients were in the head-up posture before operation, the binder, thigh cuffs, bincler plus thigh cuffs, and cold-press01 test produced respective average increases in systolic pressure of ‘i, 13, 20, and 23 mm. Hg. After operation, the blood-pressure-elevating effects of the first three agents were about twice as great, whereas the response to the cold-pressor test was unchanged, or, in cases of postoperative orthostatic hypotension and tachycardia, was even decreased. All agents except the cold water caused a postoperati\-c rise in diastolic pressure which was two to three t,imes greater t.han the effect produced preoperatively. After operation, in the head-up posture, the binder did not affect the pulse rate, whereas the cuffs decreased it an average of sixteen beats per minute, and the binder plus cuffs decreased it thirty beats per minute. The pulse rate was not counted during the cold-pressor test in any case. Patients who had the greatest orthostatic hypotension after sympathectomy derived the greatest, benefit from t,he use of these agents. Thus, in Case 1, binder and cuffs caused a rise in systolic pressure of 10 mm. before operation and 60 mm. Hg afterward, a rise in diastolic pressure of 6 mm. before, and 26 mm. after, operation, and a decrease in pulse rate of 1.6 beats per minute before operation and 72 beats afterward. The cold water caused a rise of 12 mm. in systolic pressure before operation and only 8 mm. after operation. Col)t7ulenf.-If discomfort were important as a cause of the elevation in blood pressure after the use of the agents named, the cold water should elevate the blood pressure, for its pressor eRect is presumed to he the result of the discomfort which it induces. If discomfort were an important factor in the effects of these agents on pulse rate anal
blood ptessure, such marked differences \\ould not be expected between pktients who had severe orthostatic hypotension and those who did not have this phenomenon after sympathectomy. We might suggest as a possible explanation for the good effects of t,he binder and cuffs on orthostatica hypotension and orthostatic tachyca.rdia that sympathectomy apparently decreases vasomotor tonus ilt a large bortion of t,he vascular bet1 below the level of the diaphragm. Cold fvssor tes 'rQOp.
POStOF
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Fig. 3.-Comparative blood-pressure-raising and pulse-slowing effect of abdominal binder, bilateral thigh cuffs, abdominal binder plus thigh cuffs, and cold-pressor test before and after extensive sympathectomy. Average for all patients in Wdegree head-up pobture. Values given denote deviations from control values represented by zero lines.
The vessels, as a result, become more readily distensible under the influence of the hydrostatic pressure which is brought into play by the head-up posture. The tonus which is inherent in the wall of the vessels cannot fully compensate for this force, so that, as a result,
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the vessels in t,he regions affected by sympathectomy become more capacious, creating thereby an unfavorable disproportion between vascular capacity and circulating blood volume. The result of this would probably be an impairment in venous return and in cardiac filling, and a decrease in blood pressure and an increase in pulse rate whet) the patient is in the head-up posture. The increased pulse rate ma> be related to the decrease in blood pressure, resulting in inhibition of pressoreceptive stimuli which originate in the thoracic aorta and carotid sinuses. The marked hypot.ension and evidence of defective venous return to the heart seem to exclude the Bainbridge reflex as a mediator of the rapid pulse which occurs in cases of postoperative orthostatic hypotension and orthostat,ic tachycardia.l The slowing of the pulse rate, along with an increase in blood pressure when venous return is presumably improved by the use of a tight abdominal binder, supports this view. The abdominal binder probably tends partially to correct the defect responsible for orthostatic hgpotension and orthostatic tachycardia by reducing the size of the splanchnic vascular resevoirs through external support to the hypot.onie vessels. By this means and by t,he increased intra-abdominal pressure which the hinder procluces, the venous pressure gradient between the abdomen and thorax is pwsunlably increased. The cuffs, by eliminating ‘the vascular segment below- the knee, decrease the size of the vascular reservoirs and reduce the hydrostatic column against which the circulation must work while the patient is in t,he head-up posture. The sum total of these effects seems to be the establishment of a more favorable balance between vascular capacity and circulating blood volume, with resultant improvement in cardiac filling, cardiac output, and blood pressure. Some support for t,his hypothesis is afforded by the studies of Bjure and Laurel&” who found that, when patients with marked orthostatic tachycardia stood in water up to the level of the heart, the pnlse rate did not increase. Stead and Ebert”’ made similar studies, and found that the blood pressure of patients who had orthostatic hypotension and orthostatic tachycardia was the same when they stood in water at axillary level as it was when they were in the horizontal posture. Standing in water at lower levels resulted in corresponding decreases in blood pressure. It, is i’cIt that the binder used in the present studies acted in a somewhat- similar manner. EXERCISE
It seems ciated with pulse rate ture after of the legs, counteract
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likely that decreased venous return to the heart is assothe marked decreases in blood pressure and increases in which occur when certain patients are in the upright posextensive sympathectomy. We wondered if active exercise in cases in which possibly excessive pooling occurred, would orthostatic hypotension by increasing venous return to the
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heart,. The importance of the venopressor mechanisnl in the c*irculation has been studied by Henderson and his associates.‘“~ ‘+ The role of muscle tonus in aiding venous return is well known. Freeman and Rosenblueth15 and Pinkston and his (ao-workers.16 however, noted ;I tendency to a decrease in blood pressure during muscular activity it1 dogs after total sympathectomy. In the present study t,he patients st,ood still on the floor for three minutes. Control blood pressures and pulse rates were obtained after one and after three minutes in this position. They then rose up and down on the toes at a uniform rate of about thirt,y times a minute for two minutes. Blood pressures and pulse rates were obtained at t.hc end of one and of two minutes of exercise. M%hin one and a half minutes after cessation of exercise, blood pressure and pulse rate were taken again. The results were compare~l t(J c*ontrol values. The effect of exercise was difficult t,o evaluate because it was not possible accurately to standardize the actual amount of work whiczh was done. In two instances, exercise could not, be done because the patients were on the verge of syncope at. t,he end of t.he control period and had to sit down to avert syncope. Exercise apparently produced a greater increase in blood pressure before than after operation. The pulse rate during exercise increased 15 beats per minute before operation and 12 be& per minute after operation. This difference does not seem significant. In three of six cases studied, the blood pressure COW tinued to decrease during exercise. Only in one case did the pulse rate decrease and the blood pressure increase during exercise after operation, In most cases, apparently, the good effects, if any. on the blood pressure of exercising t,he legs were not enough t.o oppose th(> hydrostatic pressure within vessels with drrreasrtl contractility resulting from sympat,hetic denervation.
Stead and Kunkell’ showed that a-N-dimethyl-p-l~ydroxyphen&ylamine sulfate (paredrinol sulfate) increases venous tone and venous pressure, slows the heart rat,e, and produces hypertension. We desired to see whether it woulcl be helpful in counteracting excessive orthostatic decreases in blood pressure after sympathectomy, inasmuch as Stead and Kunkel found it beneficial in certain types of circ4ulatol.y collapse. Accordingly, this drug was given in doses of 10 to 20 mg. subcutaneously in Cases 7 and 8 after a series of blood pressures ant1 pulse rates were taken Lvhile t.hc patients were in the horizontal an(l then in the erect posture. The drug was given about two weeks after the second stage of sympathectomy, after the pat,ients had been walking around in the hospital for four or five days. In Case 7 the orthostatic blood pressure was 54 mm. higher after using the drug, and the orthostatic pulse rate was 24 beats slower than the cont,rol rate. Whereas the patient was near syncope after stalld-
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ing for one minute before talk g the drug, she had no such difficulty after fifteen minutes of standing after receiving 10 mg. of paredrinol sulfate. There was subjective, as well as objective, benefit from the use of the drug. She did not feel faint, and was comfortable except for mild cardiac palpitation caused by the pnredrinol. The results in Case 7 are shown in Fig. 4. As will be seen, a decrease occurred in orthostatic blood pressure and an increase iti orthostatic pulse rate,
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even after paredrinol had been used; the extent of these, however, was less. The level of blood pressure was raised in both postures, which seems to be the main effect of the drug. The net effect of the drug apparently was to increase the orthostatic systolic pressure 28 mm. and the diast,olic pressure 20 mm., and to slow the orthostatic pulse rate I6 beats, when compared to t,he control values. In Case 8, the
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injection of 20 mg. of paredrinol sulfate rendered the orthostatic systolic pressure 30 mm. higher a~nd the orthostatic pulse rate 14 beats slower than the control values. It seems that paredrinol might be beneficial in counteracting excessive decreases in blood pressure when certain patients stand soon after sympathectomy, at a time when vascular adjustments are still imperfect. Stead am1 Kunkel found, howerr, that this drug t.euds t.o become less efiectirth \\:ith repentetl use.
Ten cases of essential hypertension were studied before and aft,er extensive splanchnic sympathectomy. The following observations were made : The use of a tight al)dominal binder was of ronsiderahle benefit in counteracting excessive degrees of postoperative orthostatic hypotension and tachycardia. To be effec+tivc, t,he hinder must be properly applied. The fact that the binder had little effect preoperat,ively 01 postoperatively in those c;lses in which orthost,at,ic hypotension and orthost.atic t.achycnrdia were not great, hut did increase the blood pressure and slow the pulse rate after operation in cases in which these phenomena occurred, suggests t,hat the defect responsible for this condition lies, at least in part, within the abdomen. Cnffs Gghtly applied above both knees in order to cut off the circulation to the legs tended t,o elevate the blood pressure and slow the pulse rate. This effect was greater after, than before, sympathectomy, and was greatest after operation among patients who had the greatest degrees of orthost,atic hypotrnsion and tachycardia. The combined use of an abdominal binder aud thigh cuffs had a greater blood-pressure-raising and pulse-slowing eftect than either procedure alone. The effect of the tight abdominal hinder, thigh cuffs, or both, in connt,er.acting orthostat,ic hypotension and tachycardia was due chiefly to factors other than the discomfort which was induced by these agents. Exercise of the legs did not produce a conclusive effect on orthostatic blood pressure and orthost,atic pulse rate. l’aredrinol sulfate definitely raised the level of the postoperative blood pressure in the horizont,al and erect postures, and alleviated most of the symptoms which otherwise resulted when patients were in the It reduced somewhat the amount of orthostatic deerect posture. crease in blood pressure. It may be helpful, therefore, in counteracting excessive degrees of orthostatic hypotension when patients begin to walk soon after sympathectomy. REFERENCES
1.
Gambill, E. E., Hines, E. A., Jr., and Adson, A. W.: The Circulation in Man in Certain Postures Before and After Extensive Sympathectomy for Essential Hypertension. I. Physiologic Agents, AM. HEART J. 27: 360, 1944.
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2. Adson, A. W., and Brown, G. E.: Malignant Hypertension Treated by Section Report of a Case, Proc. Staff Meet., of the Anterior Spinal Nerve Roots: Mayo Clin. 8: 739,&1933. 3. Adson, A. W., Craig, W. MIX., and Brown, G. E.: Surgery in Its Relation to Hypertension, Surg., Gynec. & Obst. 62: 314, 1936. 4. A&on, A. W., and Brown, G. E.: Malignant Hypertension: Report of Case Treated hy Bilateral Section of Anterior Spinal Nerve Roots From the Sixth Thoracic to the Second Lumbar. Inclusive. J. A. M. A. 102: 1115. 1934.
5. Ellis, L. B., and Haynes, Florence W.: Postural Hypertension With Partieulax Reference to Its Occurrence in Disease of the Central Nervous System, Arch. lnt. Med. 58: 773. 1936. 6. Hill, Leonard: The Influe&ce of the Force of Gravity on the Circulation of the Blood, J. Physiol. 18: 15, 1895. 7. MaeWilliam: Quoted bv Hill. 8. Roy and Adami; Quo&d by Hill. 9. Turner, Abby A., Newto?, M. Isabel, and Haynes, Florence W.: The Circulatory Reaction to Gravity in Healthy Young Women: Evidence Regarding Its Precision and Its Instability, Am. J. Physiol. 94: 507, 1930. 10. Stead, E. A., Jr., and Ebert, R. V.: Postural Hypotension; Disease of Sympathetic Nervous System, Arch. Int. Med. 67: 546, 1941. 11. Hines, E. A., Jr.: Technic of the Cold Pressor Test, Proe. Staff Meet., Mayo Clin. 14: 185, 1939. 12. Bjure, Alfred, and Laurell, Hugo: Om abnorma atatiska cirkulationsfenomen och diirmed sammanhSingande sjuklega symptom. Den arteriella orthostatiska aniimin en fSrsummad sjukdomsbidd, Upsala Kkaref f&h. 33: 1, 1927. 13. Henderson, Yandell: The Volume of the Circ.ulation and Its R,egulation by the Venonressor Mechanism. J. A. M. A. 97: 1265. 1931. 14. Henderson, Yandell, Oughterson, A. W., Greeiberg, L. A., and Searle, C. P.: Muscle Tonus, Intramuscular Pressure and the Venopressor Mechanism. Am. J. Physiol. ilk: 261, 1936. 15. Freeman, N. E:, and Rosenblueth, A.: Reflex Stimulation and Inhibition of Vasodilators m Sympathectomized Animals, Am. J. Physiol. 98: 454, 1931, 16. Pinkston, J. O., Partington, P. F., and Rosenblueth, 9.: A Further Study of Reflex Changes of Blood Pres’sure in Completely Sympathectomized Animals, Am. J. Phvsiol. 115: 711. 1936. 17. Stead, I& A.: Jr., and K&kel, Paul: Mechanism of Arterial Hypertension Induced by Paredrinol (a-N-dimethyl-p-hydroxyphenethylamine), J. Clin. Investigation 18: 439, 1939.