The physiological effects of extensive sympathectomy for essential hypertension

THE PHYSIOLOGICAL EFFECTS SYMPATHECTOMY FOR” ESSENTIAL EDGAR

V.

ALLEN,

M.D.,

AND

ALFRED

OF EXTENSIVE HYPERTENSION” IV.

ADSON,

M.D.

MI-K-.

ROCHESTER,

T

HIS study of physiological changes resulting from extensive sympathectomy is based on forty-five patients who were operated on for essential hypertension from February, 193.3 to .January, 19.37. Studies of patients operated on since .Jannar-, 1937 are not included in this report. The technique used, which has bee11 described in detail elsewhere,l~ 3 consists of bila,teral subdiaphragmwtic, ext,raperitoneal resection of the splanchnic nerves, celiac ganglions, ant1 the upper two lumbar sympathetic ganglions. The second operation is performrtl about ten days after that on the opposite side. In twenty-five instances partial suprarenalectomy was performetl ; one-third to two-fifths of each gland was removed to see if this woultl acc~rntuate the effects on blood pressure of extensive sympathectomv. Surgical treatment of hypertension has been attempted beeausr it is apparent that there is no means of controlling hypertension adequately. hi- nonsurgical management, in many instances ; the high mortality from hypertension is adequate testimony for this observation.ls 2 It is known that elevation of blood pressure in essential hypertension is due to a generalized increase in resistance to the flow of blood t.hrough the periphery of the arterial system. The fault, which seems to be that of the arterioles chiefly, appears to be abnormal vaso(aonstriction or increased arteriolar tonus, at least in early stages of hypertension. Later in the disease organic> changes affecting small arteries and a,rterioles may contribute to incarrased resistance f o tilt> flow of blood through them. There is evidence that. at. least in early hypertension, the abnormal state of the arterioles is an expression of abnormal vasomotor stimuli arising ill the vasomotor (*enter> lvliic*h are transmitted to arterioles by way of’ sympat~llrtic* llervcs. 01’ that the arterioles respond with an abnormal state of vasc~~onstrictic)ll OL tonus to normal stimuli transmitted by way of the sympathetic: nervous system. In advanced hypertension the arterioles may assume all independent function of increased resistantde to the flop of 1~10011 through them either by virtue of structural changes or by virtue of an inherently increased tonus independent. of stimnli transmitted OWI. the sympathetic nervous system from the vasomotor center. Goldblatt’s experimental work’ has shown that diminution of blood suppI>, to the kidneys produces hypertension (alosely simulating essential ]I>-*From the Mayo Clinic. Read before era1 Circulation,

Division

of

the American at Atlantic

Medicine

and

the

Heart Association, City, N. J., June 41s

Section Section ‘7, 1937.

on

Neurological for

the Study

Sargar.~., of thr

~q,.

I’rriptl-

416

THE

AMERICAN

HEART

JOURNAL

pertension of man. Whether or not this mechanism of elevation of blood pressure is effective in essential hypertension of man cannot, at present, be either categorically affirmed or deuied but the possibility of it must be considered. The chief purposes of sympathectomy are disconnection of the a,rterioles from the vasomotor center, thus inducing a state of decreased tonus or of decreased vasoconstriction, and of increasing blood flow through the kidneys by performing sympathetic denervation of them. The reduction of blood pressure by operation may depend on either or both of these effects which may decrease the resistance offered by arterioles to flow of blood through them. Previous experience with cervicothoracic and lumbar sympathectomy indicated that these procedures were of little avail in the trea,tment of essential hypertension. The failure of these procedures seemed based largely 011 the probable fact tha,t too small a part of the arteriolar bed was sympathectomized or that sympathetic denervation of the kidneys was not accomplished. The next logical step was splanchnic and upper lumbar sympathectomy, for within the abdomen there exists a relatively enormous arteriolar bed. Diminished liberation of epinephrine from the suprarenal glands may occur incidental to operation and may perhaps contribute importantly to reduction of blood pressure. Also extensive sympathectomy for hypertension may decrease a. state of increased tonus in the arterioles of the kidneys, thus improving circulation to them and reducing blood pressure. Experience has taught us that the surgical procedure employed does not produce uniform effects on blood pressure. We recognize that return of the blood pressure to normal is desirable in essential hypertension but that this does not occur routinely as a, result of operation. However, we believe that while such an accomplishment is desirable it is not necessary, for substantial reduction of the blood pressure may relieve symptoms, prevent the disastrous results of sustained abnormally high blood pressure, and prevent marked increases in blood pressure resulting from emotional stimuli which are themselves harmful. We do not believe that surgical operation for hypertension is necessarily the ultimate contribution to the treatment of this serious condition but the results which we have observed following operation have encouraged us to continue with this type of treatment until a better method has, been devised. SELECTION

OF FOR

PATIENTS EXTENSIVE

WITH

ESSENTIAL

HYPERTENSION

SYMPATHECTOMY

Some patients with essential hypertension do not require operation for the elevation of blood pressure is not great, does not gradually increase, and does not produce significant changes in the arterial system. Perhaps, as more information is gathered relative to the effects of operation, more patients who have mild, apparently nonprogressive

ALLEN

AND

ADSON:

SYMPATHECTOMY

IN

HYPERTENSION

41i

hypertension will be operated on as a prophylactic measure. IIowev~~ at present we reserve operation, largel>-, for patients whose hypertension, if mild, is definitely progressive in spite of metlicnl supervision and for those who ha,ve severe hypertension which has not responded Following extensive sympathectomy the blood to medical treatment. pressure is not decreased in the same degree in all cases of essential hypertension in which permanent reduction of blood pressure is an urgent need. If patients of this classification who hare this disease are operated on, the results vary from extremely good to vrrx poor. This has led us to attempt to select. from a large group of patients who have essential hypertension, those whose blood pressures will We kno\v no infallible criteria for respond favorably to operation. such a selection at the present time. However, patients whose blood pressures decrease to normal or nearly to normal as results of rest, or sleep, of oral administration of 3 grains (0.2 gm.) of sodium amytal hourly for three successive hours, of administration of one-half g
418

THE

AMERICAN

HEART ‘I’ARIX

EFFECTS

ON

RESPONSE TO PENTOTHAL

BLOOD OF- BLOOD

_-

PRESSURE

OP

.I

PENTOTHAL

T

PRESSURE

TO OPERATION*

AND

RESULT PREDICTION

13ead in seven mo. 158/132 17oj130 160/120 (9) t 155/110 (11) 165/122 184/134 255/160 (9) 146/106 168/100 (9) 150/112 1.54/106 (8) 158/112 190/120 (7) 154/110 194/120 (9) 148/114 200/130 (6) 154/116 170/115 (2) 132/106 174/118 (IO) 158/ 98 194/120 (6) 120/ 90 140/100 (5) 142/100 150/ 90 (4) 118/ 90 170/100 (10) 140/100 180/110 (5) *Mean of three determinations. tMonths after operation.

JOURNAL

EXTENSIVE

OF OPERATION T

Poor Poor Poor Poor Fair Fair Fair Fair Fair Fair Fair Fair Good Good Good Good

ACTUAL

SYMPATHECTOMY

- I

AOCURACY PREDICTION

Poor Poor Poor Poor Fair Fair Poor Poor Poor Fair Fair Poor Good Good Fair Fair

OF

Good Good Good Good Good Good Poor Poor Poor Good Poor Poor Good Good Fair Fair

it advisable to accept the least favorable response of the blood pressure to rest and sleep, and to administration of amytad, sodium nit,rite, and pentothal as the basis of preoperative prediction. We do not consider apparent sclerosis of the retinal arteries, moderate enlargement of the heart, inversion of T-waves in electrocardiograms, albuminuria, slight reduction in renal function or cerebrovaseular accident from which recovery has been satisfactory, contraindications, in themselves, to operation. However, we do not a,dvise operation for patients who have congestive heart failure, marked renal insufficiency, advanced arteriosclerosis, or angina pectoris. Perhaps as experience increases some of these patients may be considered suitable subjects for operation. MORTALITY

AND

MORBIDITY

A series of eighty-five successive operations has been performed without a death. Three patients have died subseyuently. A girl, seven years of age, with hypertension of Group IV (malignant hypertension) l, 2* and repeated convulsions died seven months following operation which did not influence the blood pressure significantly. A man, aged fortyone years, with renal and myocarclial failure owing to hypertension of Group II died seven months after operation which did not significantly influence blood pressure. A woman, twenty-five years old, with hypertension of Group III which was fixed sufficiently that the minimal blood pressures during rest and sleep were 160 and 120 died fourteen months following operation. Because of information we have gained we would consider none of these patients suitable candidates for operation at the present time. A patient whose blood pressure was very favorably influenced by operation and whose physical condition was good committed suicide because of depression resulting from business *The

classification

of essential

hypertension

is that

of Keith

and

Wagener.

ALLEN

AND

ADSON:

SYMPATHECTOMY

IN

419

HYPERTENSIOS

worries. Two patients have had cerebral hemorrhages. The remainder of the entire group of patients are not disabled although the blootl pressure of ma,ny of them was not greatly decreased by operatioll, a:, will be emphasized later. The symptoms of many patients of this group were not benefited by operation. EFFECT

OF

OPERATION

ON

WHEN

BLOOD

PRESSI:RF:

PATIENTS

AND

PrT.HE

RATE

STAND

It is a common observation that after operation the blood pressure decrea,ses and the pulse rate increases when the patient stancls. While such reactions are common to some degree in many instances before operation, they are usually greatly exaggerated after operation (Table II). These disturbances undoubtedly nrtrom~t. at least in a major deTABLE EFFECT

OF UPRIGHT

II

ON PULSE RATE OPERATION*

POSTURE (TEN

ILLUSTRATIVE

AND BLOOD PRESSURE C'asm)

I_.-.-

BLOOD PRESSURE BEFORE

OPERATION

1

STANDING 200/110

LYING 220/110

198/m

PTJLSE

AFTER

OPERATION

170/95

X8/110

182/116 200/110 162/110

164/120 192/120 162/122

140/112 192/110 194/122

134/94 128/92

to three

weeks

1 :;://:i",

RATE 1 AFTER

STANDING

94

16Oj106

1 -I:;',:::

OPERATION

LYING _______ 112

154/110 150/108 168/114

*Two

1 BEFORE

LYING

200/126 148/112 160/114 182/130

210/138 200/130

FOLLOWING

80 70 8; 80

LYING

104 SO8

84 80

116

76

124

88

120

130

92

84 84

followinfi

19 124 120 115

156

92

8X 100

1 llij80

~-

STANDING ___--.-.

92

100 108

/ /

OPERATIOF

x4

124 13X I“0i I"8 0

1%I

operstion.

gree, for weakness (and occasionally syneope), breathlessness, and palpitation which are commonly notrtl by patients when they stand following operation. Usually orthosta,tic tachycardia and hypotension disappear graclually over variable periods following operation (Table III). This occurs independently of whether the effect of operation on the blood pressure was good, for in casesof poor and good results alike there is a gradual tendency of response of the pulse rate and blood pressure to the upright position to be less marked 11,stime passes after operation. R-Pquently orthostatic tachycardia persists after orthostatic hypotension has disappeared. EFFECT

OF

OPERATION TO

IMMERSION

ON

THE OF

R,ESPONSE A HAND

OF IN

'I-III':

COLD

BLOOD

PRESSURE

WATER

We place a good deal of importance on the response of the blood pressure to a standard stimulus, for which we use the cold test devised by Hines and Brown8 This test is carried out by determining blood

420

THE

AMERICAN

HEART TABLE

THE

EFFECT

OF THE

UPRIGHT (TEN

JOURNAL

III

POSTURE ON BLOOD AFTER OPERATION ILLUSTRATIVE

PRESSURE;

VARYING

PERIODS

CASES)

= TIME

AFTER

BLOOD

OPERATION

P

lSSURE

LYING

STANDING

Two weeks Sixteen months

170/120 188/120

160/115 200/130

Two Four

120/90 140/95

SO/60 135/95

164/112 214/130

138/120 234/140

194/122 230/135

94/78 255/160

Two weeks Six months

168/112 160/140

132/100 152/130

Two Two

170/95 210/126

SO/50 192/120

Two Ten Two Three

weeks months weeks months weeks months

weeks months

Two Ten

weeks months

148/104 165/122

134/110 185/135

Two Ten

weeks month8

110/86 108/88

SO/65 134/98

134/96 118/94

122/90 120/96

118/88 110/80

68/58 115/100

Two Eight

weeks months

Two Four

weeks months

-

pressure with the patient resting, until it reaches a basal level. A hand is then immersed to the wrist in water at 4’ C. for one minute and blood pressure determined at the end respectively of thirty seconds and of one minute of immersion of the hand. The highest value is considered characteristic of the response. We believe that the response of the blood pressure to this test is a meaSsure of the way in which it responds on innumerable occasions to such stimuli as anxiety, fright, and mental stresses and strains. In Table IV it is shown that when the blood pressure has been favorably influenced by operation, the increase in it as a result of the cold test is greatly reduced in most instances. This is particularly true of the systolic blood pressure. When operation does not produce a significant decrease in the blood pressure, the response of it to the cold test is ordinarily less t,han before operation but distinctly abnormal (Table V) . As in cases in which operation has produced significant decrease in blood pressure, the systolic blood pressure responds less sharply to the test than does the diastolic pressure. EFFECT

OF

OPERATION

ON

SYMPTOMS

RESULsTING

FROM

HYPERTENSION

The effect of operation on symptoms, while variable, is roughly proportional to the effect on blood pressure. However, not infrequently patients note relief of headache, fatigue, pain in the chest, “dizziness,” and nervousness in spite of the fact that. the blood pressure has not

ELLEN

AND

ADSON:

SYMPATHECTOMY TABLE

RESPONSE

OF THE BLOOD

EFFECT

146/100

170/110 200/130 182/102

158/128 174/110 170/118

THE

Caswj AFTER 128/100

--

170/9.5 X8/100 IX/80

130/90 160/106

OPERATION to 138/104 to 210/120 to

154/E':'

to 170/108 to rt;ylocl to 198/130

136/100

to

13yo4 133/90 130/1no

to 144/11x to 158/11X to 175/130

140/104

140/100

to

160/100

140/90 1?6/94 II?/86 150/106

to tn to to

188/x8 150/148 146,'124

170/120

V

PRESSURE TO THE COLD TBST IN CASES IS 1VrrIc~II OF OPERATION ON BLOOD PRESSURE Was NOT F.~wR.wLF: BLOOD

(FIFTEEN BEFORE 170/130 156/122 190/120 180/120 200/130 170/120 182/116 210/134 192/130 180/112 192/120 170/120 190/120 "00/136 170/118

1V

ILL~~TRATIYE

OPERATION to 192/132 to 250/130 to 260/170 to 238,030 to 184/120 to 278/160 to 240/150 to 178/126 to 204/135 to 200/145 to 258/162 to 248/150 to 190/150 to 218/156 to 202/134

OF THE

EFFECT

431

PRESSURE TO THE COLD TEST IX CASES IN WHIC.H ON THE BLOOD PRESSURE WAS FAVORABLE

TABLE RESPONSE

HYPERTENSION

OF OPERATION

(FIFTEEN BEFORE 168/118 200/110 190/135 190/110 158/118 198/116 200/130 154/110

IN

OPERATION to 240/156 to 190/120 to 220/130 to 214/144 to 240/158 to 256/150 to 230/150 to 232/176 to 238/146 to 240/140 to 230/165 to 235/160 to 240/175 to 250/146 to 336/1tiO

1LLUSTRBTIVE

CASRS)

__- ---_-

TIW

AFTER OPERATION 160/122 to 190/1X 152/118 to 185/12S 1 iO/l,"O to 185/130 198/132 to 214/136 JOO/140 to %20/170 166/114 to 200/1X 140/112 to 178/128 '00/119 to 210/128 100/122 to 236/150 1,0/112 to 174/120 l!G/135 to 225/160 175/120

to

l70/120 170/112

to 218/136 to 204/13,4

l~~~l,/l"o

to

-__

210/140

"18/156

been grea,tly reduced by operation. It is probable that some of tltc symptoms associated with hypert,ension. such as headache, n1a.y OWIII* only when the pressure reaches an excessively high level. Operation which may reduce blood pressure only slightly may lower it enough so that some of the symptoms do not O~c’Llr. r~liel-r seems no other logical explanation for the observation that, relief of symptoms is much more marked than reduction of blood pressure in many instances. 1r1 most instances in which the blood pressure has been greatly reduced by operation headache is relieved, pain in the chest disappears, fatigue is lessened, and the patients gaiu weight ant1 feel in general greatly improved. Many of them note diminution of nervousness and of a “let down” feeling. which gratifies them. Some patients have stated they feel ‘ ’ entirely well ’ ’ or “better thall in several years.” In geueral, about 70 per cent of the entire group of patients were benefited

422

THE

AMERICAN

HEART

JOURNAL

clinically. Some patients whose blood pressure has been greatly reduced by operation continue to note undue fatigue, weakness, and dyspnea for weeks or months after operation. One patient whose condition was followed closely did not regain normal strength until about six months after operation. We have not been able to determine definitely that the patients who notice these symptoms following operation are those who continue to have orthostatic hypotension but it appears that this is so. Efect of Operation on Xweating.-The area of anhidrosis following operation is variable and not always equal in extent on the right and left sides. Extensiveness of anhidrosis depends on what part of the thoracolumbar sympathetic chain is resected at the time of operation. In the various cases studied the greatest area of anhidrosis begins at a line midway between the umbilicus and symphysis and extends distally. Efect of Operation on the Heart.-When operation is successful, T-waves originally inverted in the electrocardiogram may become upright and the transverse diameter of the heart demonstrated by roentgen films exposed at 6 feet may decrease. Tachycardia occurs commonly when the patient stands after operation. When orthostatic hypotension is marked followin g operation, the increase in the pulse rate when the patient stands is also marked; 120 beats per minute is commonly observed and occasionally the cardiac rate is as great as 150 beats per minute when the patient stands. As time passes after operation, the increase in the rate of the heart when the patient stands decreases and the improvement pa,rallels roughly decrease in orthostatic hypotensiou. However, tachycardia when the patient stands may persist after orthostat,ic hypotensiou disappears. Efect on Renal lGc?&ion.-Most of our patients who were operated on had no significant impairment of renal function; patients whose renal function was impaired were not operated on. Since we have not had opportunity to study the renal function of many of our patients after considerable time following operation has elapsed, and since tests for renal function when function is not significantly impaired are not always reliable for comparative purposes, we cannot say that renal function is improved following successful operation. Such an observation has been made by Freyberg and Peet.G It is quite apparent that renal function is not impaired when the blood pressure is greatly reduced by operation. This observation agrees with those of Freyberg and Peet,6 of Pa,ge,” and of Page and Heuer.lO Diminution in the amount of albumin in the urine or disappearance of it occurs commonly following successful operation. Effect art Temperature and Motor Fwnction of the Extrenaities.--Pollowing operation the feet are warm and dry. If the blood pressure has been significantly decreased by operation the hands may be cold, appasently owing to persistence of vasoconstriction in these parts. An

ALLEN

AND

ADSON:

SYMPATHECTOMY

IN

HYPERTENSIOS

?I‘,!!1

occasional patient notes generally increased tolerance to warmth. The sensation and motor fun&m of the lower extremities are not impaired. An occasional patient, ment,ions an area of numbttess, whic~tl is variabl*> in extent in difYerent cases and which is t11leto srcdtion of or tractiotl on the lateral branches of the eleventh and twelfth intercostal ~WWS at the time of operation. Efect of Operation on the Reties.-Thr ret,inas of all out’ patients were examined by Dr. Wagener, an exprriencetl ophthalmologist. Thr> changes immediately followin g operation are not (Joiistant and Vailnot be correlated with the effect of operation on the blood pressure. The retina,s of patients who are examined several mouths after opratiw, and whose blood pressures have not been significantly influenced, have not appreciably changed in appearance in most instances. In inst,anc*rs in which the blood pressure has beet1 greatly reduced by operation, retinitis may disappear, and apparent sclerosis and arterial spasm may be greatly diminished. The cause of this is not entirely clear f(~r reduction of pressure by extensive sympathectomy should not influenc~t~ spasm of the retinal arteries as sympathetic control of them is 1101 impaired, unless hypertension itself provokes arteriolar spasm or IIIIless operation removes so&e mechanism whic*h causes both. Again. if the results of the experimental work of Goldhlatti (*an be transferret to human beings wit,h hypertension, it is possible that an increase of the renal blood flow may cause generalized decrease in arterial tonus, thus relieving spasm of the retina,1 arteries. It is also possible that retinal arterial spasm is compensatory. to prevent rupture in hypertension, and disappears when blood pressure is reduced. However. ill spite of a sipnificallt reduction in blood pressure, examination of the retinas may disclose changes of the same degree as those observed preoperatively. These observations are irl agreemrllt, with those 01 Fralick and Peet.;’ Efect 011Opcratiore on the In,tc.sti,les.--Disturbances of intestinal flunction were noted in a number of instances ill wltic.11periods of th IW to four bowel movements daily, with stools of soft consistency, alicrIlated with periods of normal bowel movements. In some ills1N.II(*(AS constipation was relieved. Flatulence or other evidence of disturbt>d motor activity of the gast,rointestinal tract were uniformly absent. Effwt of Opsmtl:on. on Sexual ~l~r1Cf~ot~.-Or~~illa111$libido and ere(dtion are not impaired. However, some pat.ients note diminished libido. Nocturnal orgasms occur as before operation but emission is usualI) absent or greatly diminished. Orgasm occurs normally during sexll:ll intercourse but there is either no ejaculation of fluid or the amount is reduced. Male patients may be sterile after operation but this is not certain. Sexual satisfaction may be uuimpa~ired or reduced. nle~~struation occurs normally following operation and dysmenorrhea whelp present before operation may disappear following operation.

424

THE

AMERICAN

HEART

JOURNAL

Effect of Operation on Basal &fetabolism.-We have known for a long time that the basal met,abolism is increased in many easesof essential hypertension. There is an almost uniform tendency for basal metabolism to be lower two to three weeks following the second operation than it was before operation. However, it is probable that several factors, such as prolonged rest in bed, anesthesia, operation and weakness contribute to reduction of the basal metabolism in addition t,o the diminution of blood pressure. In Table VI it is shown that of six TABLE EFFECT

OF OPERATION

ON BLOOD

(EIGHT BEFORE BLOOD PRESSURE

RATE,

188/120 to

three

CENT

t14 -9 tl t9 t12

154/90 X36/112 150/110 *Two

PER

PRESSURE

ILLUSTRATIVE

OPERATION BASAL METABOLIC

160/100 200/m 180/120 180/120

VI AND BASAL

METABOLISM

CASES)

AFTER OPERATION* BASAL METABOLIC BLOOD PRESSURE RATE, PER CENT 140/90 t7 130/90 -4

-2 +3

112/80 140/100 116/72 130/80 140/110

+ll

160/120

-16 -i-7 +18 .ll -2

-5

weeks.

instances in which there was substantial reduction of blood pressure following operation, in five there was reduction of basal metabolism. However, in two instances in which there was no substantial reduction of blood pressure by operation, the basal metabolism was decreased after operation. We hope to have further information on this interesting subject when we have ha,d opport,unity to determine basal metabolism considerable periods of time following operation. Effect of Operatio,n O~I8uprarenrrl C:la,nds.-Although partial suprarenalectomy was a part of the surgical procedure in twenty-five instances, Addison’s disease has never been observed. No significant changes in the amounts of sodium and chlorides in the blood, as results of operation, have been determined regardless of whether or not the suprarenal glands were partially resected. However, a regular increase in the amount of potassium, averaging 3 mg. in each, has been observed in eight cases, in five of which partial suprarenalectomy was not performed. EFFECTS

OF

OPERATION

ON

BT,OOD

PRESSURE

As stated previously the results of operation for hypertension are not uniform; they vary from extremely poor to excellent. The results depend on selection of patients. At first patients were operated on who would not now be considered suitable for operation. The additional knowledge that operation for hypertension can be carried out with very little risk is further reason for surgical trea,tment of hypertension.

ALLEN

AND

SYMPATHECTOMY

ADSON:

4%

IN HYPERTENSION

Whatever may be said about this procedure, it seemsundeniably true that the patient is not harmed by it. The impression that some physicians have that operation itself leaves patients tlisable(l and unable to carry on normal activities has no foundation in fact. An analysis of the results of operation on this group of patients indicates that about 45 per cent of the patients operated on had HO ma,terial change in blood pressure following operatioll (Table ITIT) ; TABLE EFFECT

OF OPERATION

(TWENTY

MAXIMUM

160/110 150/105 130/100 170/115 140/105 180/115 160/120 160/90 140/100 180/112 160/110 190/m 190/100 210/110 208/170 150/90 180/130 170/120 140/95 200/110

140/190 210/135 230/154 220/130 175/120 252/145 *In this table lowest of twenty-four patient rested in tRough mean

RESLXTS)

PRESSURE AFTER

MEAN

PRESSURES+ 192/122 “lo/130

19 1-l

180/130 180/130

235/m 215/15n 170/124 190/120 "o/l35 215/150 liO/l:!O 180/130 190/130 200/130 200/120 220/170

18

180/120 200/120 220/150 180/110 200/130 180/130 200/126 170/100 220/130

MONTHS

lti 17 Iti 10 1-i 9 9

i ti i 8

Dead 200/125 190/130 214/130 180,'120 252/134

200/134

195/125 164/112 1

---_

OPERATION

180/125

220/115

in Tables VIII and IX blood pressures determine? bed or slept. in three determinations. and

BLOOM PRESWRF:

OF POOR

OPERATION

MINIMUM*

205/130 210/130 190/140 215/150 220/140 226/155 250/180 208/160 220/140 230/160 210/150 230/140 250/140 240/160

OK

INSTANCES BLOOD

1BE FORE

VlI

1 3 term xmrly

“minimum” and consecutively

7

ti ti 4 10 ti applies

to while

the the

about 30 per cent received fa.ir results in relation to blood pressure from operation and about 25 per cent received good results (Tables VIII and IX). With the methods of selretion which we use now the incidence of failures is materially redluted. In Tables VII, VIII, and IX, it is shown that the minimal blood pressure resulting from rest and sleep before opera,tion is a fairly good indication of the effects of operation on the blood pressure. It is well to emphasize again that errors in prediction of effects of operation on blood pressure are rarely made when preoperative tests indicate a poor result, but that errors of prediction occur occasionally when preoperat,ive tests indicate a good result, of operation. As a result of these observations we feel justified ordinarily in refusing to operate on patient,s when preoperative tests indicate that response of the blood pressure to operation will be unsatisfactory. We do not know that good results which follow operation will persist. Good results which persist for only several

426

THE

AMERICAN

HEART TABLE

EFFECT

MAXIMUM

',tsee

Tnble

I MEAN

180/120 175/110 170/110 140/100 168/110 140/90 130/75 145/90 170/108 130/90 140/108 200/130 170/120

AFTER PRESSURESt

160/106 190/110 E(ij104 180/104 x0/104 I60/106 X0/108 170/P 182/110 170/100 170/115 170/104 170/115

190/120 180/110 180/120 160/110 170/105 200/120 160/120 235/135

OP ERATION MONTHS _-

17 14 12 12 11 9 8 i 5 3 2 2

-

VII.

EFFECT

OF OPERATION

(ELEVEN

MAXIMUM

OF GOOD

PRESSIJRE RESULTS)

PRESSURE AFTER

OPERATION

MINIMUM* 140/100

205/135 225;130 240/105 190/135 180/114 240/140 220/150 205/120 200/135 220/140 210/130

IX ON BLOOD

INSTANCES DLOOD

BEFORE

Table

PRESSURE RESULTS)

PRESSlTRE

TABLE

*,tsee

OF FAIR

OPERATTO

MINIMUM*

260/160 235/120 230/136 220/120 210/168 230/140 210/140 200/120 228/142 205/130 200/130 260/140 210/130

ON BLOOD

INSTANCES BLOOD

BEFORE

VI.11

OF OPERATION

(THIRTEEN

JOURNAL

15oj1oo 130/95 140/90 144/90 145/100 170/120 175/90 150/90 146/78 150/92

MEAN

PRESSURESt

160/110 190/110

150/90

lSO/lld_ 174/110 170/120 190/130 200/110 MO/114 230/150 170/110

r

128)90 160/90 140/100 150/90 128/80 140/100 165/95 140/100 140/f 140/78

OPERATION MONTHS

23 15 15 15 15 14 13 10 5 3 2

VII.

months may justify operation, Ior patients are relieved of distressing and frequently disabling symptoms. F’or example, some pa.tients feel that operations were worth while because of the relief of headache, if for no other reason. CONCI*USIONS

1. The results of operation for essential hypertension can be predicted with reasonable certainty by observing the response of the blood pressure to rest and sleep, to ingestion of sodium a,mytal and sodium nitrate, and to intravenous injection of pentothal sodium. When poor results of operation are predicted as a result of these tests, the results are almost uniformly unfavorable. When good results are predicted, some patients do not receive as much benefit from operation as was anticipated.

ALLEN

AND

ADSON:

SYMPATHE,CTOMT

IN

HYPERTENSION

427

2. There have been no operative deaths in a series of eighty-five cases. The operation itself does not disable, although anhidrosis oi the lower extremities and loss of ejacnlatiotl alltl probably of fet+ility of the male result. 3. Following operation orthostatic hypoteiisiou and tac*hyciartliw w’cur but disappear as time passes. 4. Operation diminishes the response of the blood pressure to inimersion of a hand in ice water. 5. Operation usually relieves symptoms when blond pressure is greatly reducecl but may do so when there results no great redwtion of blood pressure. About 70 per cent of patient,s were benefited clinically. 6. As a result of operation the heart may decdrease in size. invertcad T-waves in the electrocarcliopram n1a.v become upright, retinitis and spasm of the retinal arteries may diminish or disappear, albuminwin may decrease, and renal function may be improved. The basal m&bolism may be decreased. 7. The blood pressure was not materially reduced by operation in 45 per cent of this series of pakients. Many of these patienk would uot be operated on now because preoperative tests woulcl indicate that, operation would not significantly reclu~ the blood pressure. About 30 per cent receivecl fair results in relation to blood pressure a,lld 25 per cent of them received excellent, rrsnlts. REFERfENCES 1.

2.

3. 4. 5. 6. 7. 5. 9. 10.

A. W., and Allen, E. V.: Essential Hypertension: 1. (:enpral (lonsidera. tions, Proc. Staff Meet., Mayo Clin. 12: 1, 1937. II. The Rationale an,] Methods of Surgical Treatment, Ibid 12’ -iq 1937. .. IJI. Selection of Patients for and Results of Surgical T;eatiend,‘Il,id. 12: 73, 1937. Adson, A. W., and Allen, E. V.: Essential Hypertension: General (!onaider:ltions and Report of Result,s of Treatment l,y Extensive Resection of Sym. pathetic Nerves and Part,ial Resection of Both Ruprarenal Glands, Pror. Inter-State Postgrad. Med. Assemb. N. Amer., p. 151, 1936. Adson, A. W., Craig, W. McK., and Brown, G. $2.: Surgery in Tts Relatioll to Hypertension, Surg. Gynec. & Obst. 62: 314, 1936. Allen, E. V., Lundy, J. S., and Adson, A. W.: Preoperative Prediction of Effects on Blood Pressure of Neurosurgical Treatment of Hypertensiorl, Proc. Staff Meet., Mayo Clin. 11: 401, 1936. Fralick, F. B., and Peet, M. M.: Hypertensive Fundua Oculi After Resection of the Splanchnic Sympathetic Nerves: a Preliminary Report, Arch. Ophth. 15: 840, 1936. Freyberg, R. H., and Peet, M. M.: The Effect on the Kidney of Bilateral Splanchnicectomy in Patients With Hypertension, J. Clin. Investigation 16: 49, 1937. Goldblatt, Harry: Experimental Hypertension Due t,o Renal Ischemia. Read at twenty-first annual session of American College of Physicians, St. Louis, 1937. Hines, E. A., Jr., and Brown, G. E.: Cold Pressor Test for Measuring Reactibilitv of the Blood Pressure: Data Concerning 5il Normal and Hypertensive Subjects, Aol. HEART J. 11: 1, 1936. The Effect on Renal Efficiency of Lowering Arterial Blond Page, I. H.: Pressure in &MeS of Essential Hypertension and Nephritis, J. Clin. Investigation 13: 909, 1934. Page, I. H., and Heuer, G. J.: The Effect of Renal Denervation on the Level of Arterial Blood Pressure and Renal Function in Essential Hypertension, J. Clin. Investigation 14: 27, 1935. Adson,