Hypertension: A Symposium was first published in 1951. Minnesota Archive Editions uses digital technology to make long-unavailable books once again accessible, and are published unaltered from the original University of Minnesota Press editions. In the words of Dr. Eduardo Braun-Menendez of Buenos Aires, brilliant representative of the distinguished South American group of workers in the field, “Hypertension is today one of the deadliest enemies of mankind.” Though most medical men will not dispute the insidiousness of hypertension as an enemy of human health, there is far less agreement on what is of more immediate concern to the physician – the causes and treatment of the disease. This book summarizes existing knowledge with regard to hypertension, its problems, and its therapy, and thereby points the way for future research which may solve the problems. The volume presents the proceedings of a symposium on hypertension which was held at the University of Minnesota in the fall of 1950 in honor of Drs. Elexious T. Bell, Benjamin J. Clawson, and George E. Fahr. Thirty papers by twenty-four physicians, together with the related questions and discussion, are published. A bibliography is given for each paper, and there are 125 illustrations. The authors represent every section of the United States and three foreign countries. The series of papers takes up, in addition to the pathologic anatomy of the disease, such widely different approaches to the treatment as the dietary, the pharmacologic, the surgical, and the psychological.
Front MatterFront Matter (pp. [i]-[vi])
Table of ContentsTable of Contents (pp. [vii]-2)
Greetings and a Word of ExplanationGreetings and a Word of Explanation (pp. 3-4)MAURICE B. VISSCHER and HAROLD S. DIEHL
Dr. maurice b. visscher: It is always a privilege for a student to have an opportunity to pay tribute to his teachers. In the aggregate the three of our beloved colleagues whom we are honoring for their services to the University of Minnesota and to science, particularly in the field of cardiovascular diseases, have spent a total of 95 years in this institution. I am especially happy to be able to open this first meeting of the symposium on the problems of hypertension, because I feel it is a real privilege to be able to say “Thank you” to three...
Anatomical Considerations of HypertensionAnatomical Considerations of Hypertension (pp. 5-21)HARRY GOLDBLATT
It is a great honor and privilege to be the first speaker on this symposium arranged in honor of three great men of medicine for whom I have the highest regard.
Many years before the existence of a hypertensive state in the vascular system of man was first recognized, the anatomical changes in the blood vessels frequently found associated with this condition had already been the subject of exhaustive study. It seems definitely in order, therefore, that a consideration of these anatomical changes should be the introductory contribution to this symposium. It is certainly fitting, also, that a pathologist should...
Experimental Studies on HypertensionExperimental Studies on Hypertension (pp. 22-41)ARTHUR GROLLMAN
The present paper summarizes some of the experimental studies which have been carried out by the author and his associates during the last decade on the general subject of hypertension. These studies have touched upon various aspects of the problem of experimental hypertension as it is induced in the laboratory animal and as it occurs clinically in the human patient; they will be discussed with reference to the generally accepted notions as well as the work of others in the same field. It may be stated at the outset that despite the often repeated statement that experimental and clinical hypertension...
Experimental Hypertension in the RabbitExperimental Hypertension in the Rabbit (pp. 42-47)GEORGE W. PICKERING
Ten years ago it looked as though hypertension produced by constriction of the renal artery was due to the release of renin from the kidney into the renal vein. In the dog it had been shown that hypertension could be produced in the sympathectomized animal, by constricting the artery to a kidney grafted in the neck or groin (4, 5). The Buenos Aires school had found an excess of a pressor substance in the blood (6). The only known renal pressor substance was renin, discovered by Tigerstedt and von Bergmann in 1898 (16), subsequently entombed, and disinterred by many workers...
The Renin-Angiotonin Pressor SystemThe Renin-Angiotonin Pressor System (pp. 48-76)IRVINE H. PAGE
This symposium marks the formal acknowledgment, though certainly not a final conclusion, of the work of three men, Dr. Bell, Dr. Fahr, and Dr. Clawson. Their retirement we must regret, though it is in tune with the orderly course of nature which we all must serve, and whose workings they have so diligently explored. Their varied contributions have been wrought with great skill and favored at times with good fortune. Hence they will endure. No man can wish for more.
It has seemed to me that a symposium such as this serves a highly important function if it is used...
The Participation of Hepatorenal Factors in Experimental Renal HypertensionThe Participation of Hepatorenal Factors in Experimental Renal Hypertension (pp. 79-97)EPHRAIM SHORR
I should like to preface my discussion with a brief statement of the major premise upon which our approach to the study of hypertension has been predicated. This is as follows: to the extent to which any concept of hypertension fails to provide for the participation of the terminal vascular bed, to that extent will it prove inadequate as an explanation of the genesis and evolution of the hypertensive syndrome.
The exclusion of the capillary bed from consideration in the dynamics of hypertension was justifiable only as long as the bed was thought to be composed of inert endothelial vessels...
Blood Volume and Extracellular Fluid Volume in Experimental HypertensionBlood Volume and Extracellular Fluid Volume in Experimental Hypertension (pp. 98-118)EDUARDO BRAUN-MENENDEZ
The importance of the circulating blood volume and especially of the extracellular fluid volume as a possible factor in the causation of hypertension has not received enough consideration. We were led to study this problem by the results obtained in rats after bilateral nephrectomy.
The effect of bilateral nephrectomy on the arterial pressure has been the object of numerous investigations. Some authors observed a rise in the blood pressure, as Mosler did (1912) in 11 of 13 rabbits after total nephrectomy, while most of the others, like Backman (1916), Cash (1926), Hartwich (1930), Harrisonet al. (1936), Goldblatt (1937), Dicker...
The Role of the Adrenal Cortex in the Pathogenesis of Experimental HypertensionThe Role of the Adrenal Cortex in the Pathogenesis of Experimental Hypertension (pp. 119-132)HANS SELYE
Many of us have come a long distance in order to participate in this symposium and thus to pay homage to the three great scientists of the University of Minnesota whom we honor today. Dr. Pickering represents one of the prominent clinical research centers of England; Dr. Braun-Menendez has spoken about the important contributions made in South America by the Argentinian investigators, and I consider it indeed a great privilege to have been chosen to report upon pertinent studies performed by our group in Canada. The work of all of us has been greatly stimulated by the fundamental contributions made...
The Mechanism of Hypertension Due to DesoxycorticosteroneThe Mechanism of Hypertension Due to Desoxycorticosterone (pp. 133-149)EDUARDO BRAUN-MENENDEZ
Probably the first observation of the pressor effect of desoxycorticosterone in animals was made by Kuhlmanet al. (1939), who after injecting 25 mg. per day during 70 days into two dogs observed increases in the blood pressure of 45 and 20 mm. Hg respectively. This study was a consequence of the observation of Loebet al. (1939), who called attention to the abnormal rise in pressure obtained in two Addisonian patients treated with desoxycorticosterone, a fact which was subsequently confirmed by many others. In 1940 Grollmanet al. reported hypertension in rats treated with desoxycorticosterone, and Swingleet al....
Sympatho-Adrenal Factors in HypertensionSympatho-Adrenal Factors in Hypertension (pp. 150-160)MARK NICKERSON
When neurogenic factors in hypertension are discussed, the role of the sympatho-adrenal system is the center of attention. Somatic motor nerves may affect the blood pressure and peripheral blood flow by altering the skeletal muscle tone, and cholinergic portions of the autonomic system may produce similar effects by altering the smooth muscle tone (e.g., gastrointestinal tract) and by limited direct vasodilatation (e.g., blush area). However, these effects are insignificant in comparison with the results of the activation of the sympatho-adrenal system, which includes most sympathetic nerve fibers and the adrenal medulla. This functional division of the nervous system differs from...
Experimental HypertensionExperimental Hypertension (pp. 161-180)EDUARDO BRAUN-MENENDEZ
The title of this lecture is highly presumptuous. Nobody could possibly summarize in the relatively short space of an hour all of what we know and of what we do not know about experimental hypertension. Hypertension is today one of the deadliest enemies of mankind, and in the eagerness to fight with better arms this human disease, numerous research workers all over the world have tried to reproduce it in animals in order to obtain a better understanding of its mechanism. The mere enumeration of the different methods employed, of the type of hypertension obtained, and of the hypotheses formulated...
The Pathological Anatomy in Primary HypertensionThe Pathological Anatomy in Primary Hypertension (pp. 183-198)ELEXIOUS T. BELL
There is no sharp separation between hypertension and normal blood pressure, but many observers agree that the upper limits of normal pressure are 150/90 mm. Hg in persons over 50 years of age and 140/90 mm. Hg in persons below the age of 40 years. Some investigators believe that the upper limit of normal systolic pressure is 140 mm. Hg. Repeated examinations are necessary to establish the diagnosis, since single high readings may be due to emotional disturbances. In the milder forms of hypertension the pressure may fall to normal levels after prolonged bed rest or during sleep, but it...
Some Observations on Renal Vascular Disease in Hypertensive Patients Based on Biopsy Material Obtained at OperationSome Observations on Renal Vascular Disease in Hypertensive Patients Based on Biopsy Material Obtained at Operation (pp. 199-215)REGINALD H. SMITHWICK and BENJAMIN CASTLEMAN
The observations of Richard Bright in 1827 (1) and in 1836 (2) called attention to the fact that diseased kidneys were at times associated with hypertrophied hearts. This important deduction resulted from the correlation of clinical evidence with gross pathological findings at autopsy. Thus it became established that kidney disease of one sort or another was evidenced clinically by dropsy and albuminuria and at autopsy by diseased kidneys and hypertrophied hearts.
The advent of the microscope permitted more detailed study of pathological material from patients dying of so-called Bright’s disease or with hypertrophied hearts. The brilliant observations of Gull and...
The Mechanism of Hypertension in Chronic Genuine NephrosisThe Mechanism of Hypertension in Chronic Genuine Nephrosis (pp. 216-226)GEORGE E. FAHR
Hypertension develops when the circulation through the kidneys is experimentally obstructed by means of clamps on the renal veins or arteries (1, 2). There are a number of pathological mechanisms that obstruct the circulation going through the kidneys, with a resulting production of renal hypertension. The best-known mechanism is the obstruction of the renal circulation brought about by endothelial cell proliferation within the capillaries of the glomeruli in acute and chronic glomerulonephritis. I shall discuss today the mechanism of the production of hypertension in cases of subacute and chronic genuine or lipemic nephrosis, because this mechanism is not widely understood...
Renal Hemodynamics in Essential HypertensionRenal Hemodynamics in Essential Hypertension (pp. 227-238)HERBERT CHASIS
The pattern of alteration in the renal circulation is fairly typical in the majority of patients with hypertensive disease and consists in a decrease in the renal blood flow, a diminished capacity of the tubules to remove diodrast and p-aminohippurate from the postglomerular blood, an eventual decrease in the rate of glomerular filtration, an increase in the fraction of plasma filtered at the glomerulus, an increase in renal resistance, a decrease in the renal fraction of the cardiac output, and a normal renal oxygen arterial-venous difference. In some hypertensive patients the renal circulation and function are in the normal statistical...
The Heart in Essential HypertensionThe Heart in Essential Hypertension (pp. 239-254)BENJAMIN J. CLAWSON
The cardiac deaths due to hypertension and coronary disease as determined by 50,730 autopsies from the records in the Department of Pathology of the University of Minnesota (1910–1947) are here being reported on. This large group (6512 cases) of diseases of the heart is commonly referred to as arteriosclerotic heart disease. There is some objection to this terminology in the hypertensive cases, where death is not due primarily to coronary disease since in this group the coronary arteries are relatively good in a high percentage of the cases. We agree with Levine (1) that this term should be given...
The Adrenal Cortex and Hypertensive Vascular DiseaseThe Adrenal Cortex and Hypertensive Vascular Disease (pp. 257-264)GEORGE A. PERERA
It has been said by some that the adrenal cortex governs the cell, the psyche, sex, and the soul, not to mention most of the diseases of man that hitherto have been of unknown etiology. As the subject of the adrenal and hypertension has been reviewed elsewhere in more detail* and as Dr. Selye and Dr. Braun-Menendez have already discussed certain aspects of the problem, I shall deal principally with our own studies in patients with hypertensive vascular disease.
As background, however, I should like to remind you that the adrenal—and practically every other organ and structure—has been...
Hepatorenal Factors in Essential Hypertension in ManHepatorenal Factors in Essential Hypertension in Man (pp. 265-282)EPHRAIM SHORR
In my initial presentation I summarized the evidence for the participation of the vasoactive factors, VEM and VDM, of renal and hepatic origin respectively, in experimental renal hypertension induced in dogs and rats (1). Specific derangements were observed in the metabolism of both humoral principles, as well as in the structure and function of the capillary bed with whose regulation they are concerned. These observations have provided the basis for a concept relating these humoral and peripheral vascular changes to the development and maintenance of hypertension. They also furnished a set of criteria by which the relation of different hypertensive...
Pulmonary HypertensionPulmonary Hypertension (pp. 283-287)RICHARD V. EBERT
The term arterial hypertension is commonly used to refer to elevated pressure in the systemic arteries. This usage implies a certain lack of interest in arterial hypertension of the pulmonary vascular system. In the past this was due to the absence of methods for measuring the pressure in the pulmonary arteries in human beings. The introduction of cardiac catheterization has rendered this measurement possible, and information is gradually being accumulated regarding pulmonary arterial hypertension.
In considering the subject of pulmonary hypertension, it is important to emphasize certain characteristics of the pulmonary vascular system. The normal pressure in the pulmonary arterial...
A Summary of Experimental Evidence Relating Life Stress to the Pathogenesis of Essential Hypertension in ManA Summary of Experimental Evidence Relating Life Stress to the Pathogenesis of Essential Hypertension in Man (pp. 288-330)STEWART WOLF and HAROLD G. WOLFF
Since the introduction of the sphygmomanometer for routine use in the examination of patients, there has been a lively and increasing interest in the occurrence of pressure readings in the brachial artery elevated beyond the average range. Although the significance of such deviations in terms of sickness and death has not been established, its occurrence from time to time has led to the recognition of a disease, essential hypertension, the diagnosis of which may depend entirely upon the consistent finding of an elevated arterial pressure in the absence of evidence of vascular or other anomaly or primary renal disease. Recently...
Vascular Reactivity and Hypertensive DiseaseVascular Reactivity and Hypertensive Disease (pp. 331-342)EDGAR A. HINES JR.
Quick rises in the blood pressure unassociated with a significant cardiac acceleration or an increased cardiac output are considered to result from vasoconstriction, which produces an increase in the peripheral resistance. “Vascular reactivity” refers to this type of change in the blood pressure—the change, that is, produced by peripheral vasoconstriction. Strictly speaking, the reactivity is largely in the arteriolar and small artery component of the vascular system, and a more limiting term denoting the part of the vascular system mainly involved would be desirable.
Vascular reactivity can be estimated by determining the range of the diastolic blood pressure from...
Cerebral Attacks in HypertensionCerebral Attacks in Hypertension (pp. 343-360)GEORGE W. PICKERING
I suppose that you have asked me to talk on this subject because you know that my views differ from those which have been expressed in most papers and textbooks on neurology and cardiology published in the last 20 years. The chief point in dispute is the extent to which local vasoconstriction or spasm of the cerebral arteries or arterioles is concerned in producing the cerebral attacks that occur in hypertensive disease. Most contemporary writers believe that cerebral vasoconstriction is an important factor in producing the transient cerebral attacks, termed pseudo-uremia by Volhard (1) and hypertensive encephalopathy by Oppenheimer and...
The Natural History of Hypertensive Vascular DiseaseThe Natural History of Hypertensive Vascular Disease (pp. 363-378)GEORGE A. PERERA
“There is something fascinating about science,” said Mark Twain; “one gets such wholesale returns of conjecture out of such a trifling investment of fact.” Today’s student of medicine might even have trouble in obtaining sufficient facts on which to base the conjectures. Take, for example, the medical literature. A San Francisco newspaper reports that “scientists fight high blood pressure—the greatest killer of the middle-aged.” A popular monthly digest states as follows: “High blood pressure? Don’t be alarmed. . . . When the facts become known, a brooding and paralyzing fear should lift from the land.”
Certainly all the facts...
Blood Lipid Transport in Hypertensive Patients and Its Relation to Atherosclerotic ComplicationsBlood Lipid Transport in Hypertensive Patients and Its Relation to Atherosclerotic Complications (pp. 379-399)JOHN W. GOFMAN
Atherosclerosis, a common enough source of disabling vascular disease, is a proper subject for this symposium, in view of the reasonably well accepted evidence that it is an important complication in the course of hypertensive disease and is a disease process accelerated in general in the presence of hypertension.
Concepts concerning the pathogenesis of atherosclerosis are numerous and conflicting, even as to the sequence of steps in the natural evolution of the lesions. Although controversial, a body of evidence has accumulated over the past 30 years indicating that in some way certain of the blood lipids, especially cholesterol and its...
The Hemodynamic Effects of Various Types of Therapy in Hypertensive PatientsThe Hemodynamic Effects of Various Types of Therapy in Hypertensive Patients (pp. 400-409)ROBERT W. WILKINS
Studies of the hemodynamic effects of procedures designed to lower the blood pressure in hypertensive patients are of interest not only in connection with the specific cases studied, but also in relation to the general problems of the nature of the disease and the proper aims of therapy. First of all, such an approach will quickly demonstrate to any investigator who cares to try it that under controlled laboratory conditions the blood pressure of hypertensive patients can be lowered. This is of some importance, particularly now when there seems to be increasing adherence to the view that the pressure in...
Sympathetic Blockade in the Therapy of HypertensionSympathetic Blockade in the Therapy of Hypertension (pp. 410-426)MARK NICKERSON
In the absence of clear-cut evidence regarding the extent and manner in which the sympatho-adrenal system is involved in the development and maintenance of most cases of human hypertension, there is little theoretical basis for the treatment of this condition by sympathetic blockade. However, continued reports of partial, although highly variable, relief obtained from surgical sympathectomy have kept alive the hope that chemical adrenergic blockade might provide similar benefits.
In the treatment of neurogenic factors in hypertension the desired action is the peripheral inhibition of excitatory, vasoconstrictor responses to sympatho-adrenal activity. Blockade of the inhibitory effects of the sympatho-adrenal system...
The Effect of Sympathectomy upon the Mortality and Survival Rates of Patients with Hypertensive Cardiovascular DiseaseThe Effect of Sympathectomy upon the Mortality and Survival Rates of Patients with Hypertensive Cardiovascular Disease (pp. 429-456)REGINALD H. SMITHWICK
The complications of hypertensive cardiovascular disease involving the cardiac, cerebral, and renal areas are responsible for many deaths and for much premature disability among young and middle-aged people. Together, these complications are generally thought to cause more deaths each year than cancer. It is clear that an attempt to lower the mortality rate for hypertensive cardiovascular disease is desirable.
In evaluating a therapeutic measure for this disorder, consideration must therefore be given to its effect upon mortality and survival rates. This is true whether one is discussing dietary, pharmacologic, or surgical therapy. Much has been written in recent years about...
The Management of Hypertensive Patients: Observations on the Pertinence of Life Situations, Attitudes, and Emotions to Variations in the Course of Essential Hypertension and to the Occurrence of Associated SymptomsThe Management of Hypertensive Patients: Observations on the Pertinence of Life Situations, Attitudes, and Emotions to Variations in the Course of Essential Hypertension and to the Occurrence of Associated Symptoms (pp. 457-491)HAROLD G. WOLFF, STEWART WOLF, Beatrice B. Berle, Herbert S. Ripley, William H. Dunn and Edward M. Shepard
Every physician who attempts to manage a patient with essential hypertension exerts some effect merely because he is a physician. Moreover, the impression is widespread that by a skillful development of the patient-physician relationship a significant alleviation of hypertension and its accompanying symptoms may often be effected. Accordingly an attempt has been made to define some of the factors that may operate in these circumstances and if possible to sharpen them by emphasis.
To ascertain whether or not any appreciable modification in the course of essential hypertension can be effected, it is essential that its natural history be clearly evaluated....
Recent Experiences with the Pharmacologic Treatment of HypertensionRecent Experiences with the Pharmacologic Treatment of Hypertension (pp. 492-503)ROBERT W. WILKINS
There is no satisfactory pharmacologic treatment for hypertension. In part this is because we do not understand the etiology of the disease and therefore do not know how to attack it at the source. In part it is because essential hypertension, instead of being resistant, usually is susceptible to treatment, at least temporarily, by many different agents and procedures. But chiefly it is because we still have no agent that will persistently lower the blood pressure without undesirable side effects. For example, the available sympatholytic drugs are neither persistent in action nor free from unpleasant side effects such as postural...
Some Effects of the Rice-Fruit Diet in Patients with Essential HypertensionSome Effects of the Rice-Fruit Diet in Patients with Essential Hypertension (pp. 504-523)CARLETON B. CHAPMAN
The belief that restriction of the salt intake is beneficial to patients suffering from various types of cardiovascular-renal disease is by no means new. The lineage of this notion, with special reference to the treatment of hypertension, goes back at least to the first half of the nineteenth century. Table 1 shows the developments that probably influenced Ambard and Beaujard (1), who were the first to observe that salt deprivation may produce a decline in the blood pressure in hypertensive patients. The most direct line of reasoning began with Redtenbacher (2), who in 1850 observed that the excretion of urinary...
Pyrogens in the Treatment of Malignant HypertensionPyrogens in the Treatment of Malignant Hypertension (pp. 524-536)IRVINE H. PAGE, ROBERT D. TAYLOR and A. C. CORCORAN
Malignant hypertension is a disease which seriously endangers life and usually runs its fatal course within two years. The urgency of treatment is therefore understandable. Measures become acceptable to the patient and the physician which under less trying circumstances would not be entertained. It is in this light that we view the treatment of malignant hypertension with pyrogens.
But first I want to define what we mean by the malignant syndrome, or malignant hypertension. It is a syndrome usually engrafted upon pre-existing essential hypertension, although it may appear without prior cardiovascular disease. Arterial pressure is persistently greatly elevated, especially the...
BIBLIOGRAPHYBIBLIOGRAPHY (pp. 537-573)