A SURGICAL TREATMENT OF ESSENTIALHYPERTENSION

Irvine H. Page, George J. Heuer

J Clin Invest. 1935;14(1):22-26. https://doi.org/10.1172/JCI100651.

Research Article

Find the latest version:

http://jci.me/100651/pdf

Pdf

A SURGICAL TREATMENTOF ESSENTIAL HYPERTENSION.

By IRVINE H. PAGEAND GEORGEJ. HEUER(From the Hospital of the Rockefeller Institute for Medical Research, and the Surgical

Department, New York Hospital and Cornell Medical College, New York)

(Received for publication August 3, 1934)

Evidence of varied nature indicates that thearterioles of the splanchnic region are constrictedin patients suffering from essential hypertension,and that this may be an important factor in main-taining the pressure at an elevated level. Inter-ruption, by surgical means, of nerves carryingeffector impulses to this region would thereforeappear to be a logical therapeutic procedure.

Section of the anterior nerve roots close to thecord seems a method which will surely interceptboth the motor and sympathetic innervation. Itis furthermore desirable that denervation be ascomplete as possible without interfering with vitalfunctions. Anatomical considerations suggestthat this can best be accomplished by section ofthe anterior roots from the sixth thoracic segmentto, and including, the second lumbar.

The sixth to the twelfth thoracic motor nervesinnervate the intercostal muscles and the seventhto first lumbar nerves supply the abdominal mus-culature. Part of the supply to the flexor musclesof the hip is derived from the first and secondlumbar nerves. The first lumbar root contributesbranches to the ileoinguinal and ileohypogastricnerves, and both the first and second roots sendfibers to the genito-femoral. The lateral cutane-ous nerves receive fibers from the first, secondand third lumbar roots.

There is some difference of opinion as to theanatomy of the sympathetic system in the tho-racico-lumbar region. All of the anterior nerveroots contribute to the innervation of the cutane-ous vessels, pilomotor muscles and sweat glands.The major splanchnic nerves are derived from thefifth to the tenth thoracic segment, and the minorsplanchnic from the ninth and tenth or the tenthto twelfth roots. These nerves join the celiacplexus. In this manner connection is establishedwith the stomach, liver, adrenals, pancreas, intes-tine and kidneys. Section of the sixth thoracic tothe second lumbar roots, therefore, partially inter-rupts not only the motor nerve supply of the ab-

dominal wall but the sympathetic supply of mostof the abdominal viscera, except the colon, rec-tum, bladder and genital organs. The vagus andphrenic nerves and the intrinsic nerve supply re-main intact to innervate the viscera. The inferiormesenteric ganglion also remains intact except forloss of some fibers from the second lumbar root.

Adson and Brown (1) (1934) were the first tosuggest and perform the operation as outlined.By this procedure they hoped (1) to remove thesympathetic innervation of sufficient arteries tomodify arterial responses, (2) thoroughly to de-nervate the suprarenal glands, and (3) to removethe effects of intra-abdominal tension. They re-port a case of early malignant hypertension in awoman 29 years of age who had had high bloodpressure for at least 18 months. The blood pres-sure in the recumbent position varied from 150to 200 systolic and from 100 to 150 diastolic.The range following operation was from 155 to195 systolic and from 100 to 150 diastolic. Afteroperation no visible sweating was found below thelevel of the epigastric notch anteriorly or belowthe angle of the scapulae posteriorly. There wasno difference in the amount of phenolsulphon-phthalein excreted whether the patient was stand-ing or recumbent. Evidently considerable sclero-sis of the vessels was present in this case. Afteroperation the retinal vessels remained narrowed.Retinitis was, however, less active than on admis-sion. The response to Brown's test of pressorresponse to cold showed that following operationthere was a significant decrease in the maximumrise in blood pressure. While the operation didnot lower the systemic blood pressure level asmuch as might have been hoped for, it was be-lieved that this was due to structural changes inthe blood vessels.

It therefore seemed to us desirable to select acase in which the vascular tree was still flexibleand yet one in which the hypertension was a po-tential source of grave danger to life.

22

ESSENTIAL HYPERTENSION

Hospital No. 8990. The patient, a 23 year old Jewishgirl, complained of fatigue and restlessness for a periodof at least one year and a half. She had had good healthup to the time of her present illness. Temperamentally,however, she was excessively excitable and unstable.

Hler friends found her a "difficult" person.

A chance physical examination showed that her bloodpressure was over 200 mm. Hg. Until a few months agoshe was symptom-free except for the feeling of excessivefatigue. Headaches were frequent and she suffered frompalpitation and dull pains over the precordium. At nighther anikles swelled.

The patient was a well developed, highly nervous girl.She had advanced acne vulgaris over her face, chest, anidback. The hair distribution was normal. The fundusexamination demonstrated that the nerve head was hy-peremic, the arterioles were slightly constricted and theveins dilated. There were no retinal hemorrhages or

exudates. The tonsils were buried and ragged and thethyroid gland was not enlarged. The heart measure-ments were as follows: M.L. = 8.3 cm., M.R. = 4.6 cm.

The chest diameter was 23 cm. The cardiac sounds were

of good quality and A2 and P2 were slightly accentuated.The peripheral vessels were not tortuous or thickened.The blood pressure was 200/140 mm. Hg. The kidneyswere palpable but not enlarged. The superficial and deepreflexes were hyperactive. The hands and feet were coldand perspired freely.

This girl seemed to be suffering from essential hyper-tension of relatively short duration. Her temperamentundoubtedly greatly intensified the disease as we had oc-

casion to observe on many occasions. Her vascular sys-

tem was still flexible as evidenced by the facts that amylnitrate, mecholin (acetyl 13-methyl cholin) and posturalchanges produced marked diminution in her blood pres-

sure. There was also neither palpable sclerosis of herperipheral vessels nor visible changes, except constrictionin her retinal arterioles. Cardiac decompensation was

evident under strain, for edema of her ankles appearedonily after a day's work.

The patient was confined to bed in the hospital and thelevel of the blood pressure measured at 9 :30 every morn-

ing. Ten days after admission sodium thiocyanate was

administered over a period of 20 days. It was necessaryalso to give chloral hydrate (0.5 gram t.i.d.) and amytalat niight. A graphic chart (Figure 1) has been preparedto show the course of the patient while in the hospital.

Thiocyanate treatment apparently caused the level ofthe blood pressure to fall markedly but, on discontinuingthe drug, it rose to its original level. After about tenweeks of strict bed rest it was evident that the bloodpressure would not fall more than it had. It varied froma maximum of 192/134 to 162/108 mm. Hg. Since thepatient showed no improvement it was our belief thatradical surgical intervention was justifiable.

Surgical proceduire. The operation was performedMay 11, 1934, under ether anesthesia. It consisted ofthe exposure and removal of the laminae correspondingwith the sixth thoracic to the second lumbar segments

MopNaP8990 I-5. 9,2 ry7+6 delw

Essential ly_pevtension-ln5idious onoet

_ 200 _ _ _ _ __ _ _ _ = __..........| t00-x- __ _3- __ ___T

u i33 to2 = _ =0g. -<__= ==

.

22 = 3 = =>o ==_l__ =__=-n12 ==x= == ==

208*o=_t = ====16 _t____X. -_ _

0E 164 fiE tEo 2_______________

10 ====,== == =

:C 420 l___o--- _ __

2i-t 3-_ 3--___ __ _

lXTotal 7 = = == =

1,Albtr4 =_= -=_e 8min4==I'_I==_======

2

258 I_I= = I="-Sg120==l_l==== ==I=_211115== I_I===_= = I==

Edema _s]Xt_n|Blood | 1X,3 E_ i. pres- 116021IIWIIX_If = IL

C51ta t -_

rinaDeda ~ ~~~ T= l=

1000 Us rlishitbd_1_

riontls > 24 12 20 27 28 29 30 31 32

FIG. 1.

23

2IRVINE H. PAGE AND GEORGEJ. HEUER

inclusive; ancd the incisioni of the dura mater so as toexpose the spinal cord. With an appropriate instrumenteach pair of anterior nerve roots was separated from thespinal cord as it coursed along this structure and dividedapproximately midway between its point of origin andits union with the posterior roots. Silv er clips wereplaced across several roots, the division of which wasassociated with slight hemorrhage. After completilng thedivision of the roots the wvound was closed throughoutwith silk. The operation required three hours. Thepulse during operation v-aried between 110 and 90.

Recovery from the operation was uneventful. Theblood pressure fell rapidly and progressively to a levelthat was nearly normal. Especially striking was the fallin diastolic pressure. For the first week after operationthe patient lhad moderate difficulty in evacuatilg herbowels. This was remedied by use of enemata. Theabdominal muscles vere completely paralyzed. Althoughrelaxed, when the patient stood up, there was almost no"pot belly." An abdominal binder was not found neces-sary. Slhe sooIn learned how to manage the motion ofher trunk without the use of the abdominal musculature.

There was steady improv-ement in the patient's strengthbut her emotional volatility contiinued unabated. Herheadaches, palpitations and precordial pain, however,disappeared.

Laborator, examinations before and aftertOpceratiola

The renal functioni, as mleasured by the ureaclearance test, was found to be normnal on six

occasions before operation. Nor did it changesignificantly following operation. The ability ofthe kidneys to concentrate was also not mnarkedlyimpaired thouglh the miiaximiiumii non-protein spe-cific gravity 1 fell fromii 1.027 to 1.019, measure-miients being made on a 12-hour specimiien voidedat the end of 24 hours without fluids. Neitlherbefore nor after operation was there ani inicreasein the numiber of red blood cells or casts countedin Addis sedimenit test specimens of urine. Sugarwas not found in the urine.

The l)lasma proteins were normal as was thelhemiioglobin. The latter fell slightly followiiigoperation but quickly returnied to normiial.

The basal metabolic rate was normal both be-fore and after ol)eration.

An electrocar(liogramii takeni about twA7o miionitlhsl)efore operation showedl the following clharacter-istics: T waves +++, conduction timiie 0.17 sec-onds, R:1 split, lowv voltage anid niormiial rlhytlhmii.Anotlher record taken two montlhs after operationshowed: T waves ++-, conduction tillme 0.16,R split and normiial rhy thm.

A miiuscle biopsy remiioved from the lumbar

1 Obtained by subtracting 0.003 from the total specificgravity for each one per cent of protein (6).

FIG. 2.

24

1%I'

ESSENTIAL HYPERTENSION

muscle during operation showed, according to Dr.C. P. Rhoads, that moderate but definite intimalthickening had taken place in the arterioles. (SeeFigure 2.)

Dr. William Lewis measured the minute vol-ume output of this patient 26 days after operationby the acetylene procedure (Grollman et al. (2)).The following results were obtained:

Cardiac output, liters per minute = 4.1.Arteriovenous oxygen difference per liter blood

-53.4 cc.Cardiac output, liters per minute per square me-

ter of body surface = 2.9.Basal metabolic rate + 7 per cent (Dubois

standard).The level of minute volume output is higher

than the average normal (2.2 + 10 per cent).Since only one determination was made it shouldnot be considered as constantly elevated. Itseems certain at least that it is not reduced be-low normal level as the result of operation.

The content of lipid in the plasma was ascer-tained before and after operation by the methodof Kirk, Page and Van Slyke (1934).

level by anterior nerve root section. The bloodpressure has remained at a level which is almostnormal for seven months, in spite of the fact thatthe patient was allowed to go about the hospitalwards without restriction. Emotional excitementcaused the pressure to rise but seldom did it ex-ceed 160 mm. Hg. Nor did it remain persistentlyelevated but rather quickly fell to its original level.

The ability of the kidneys to excrete urea, asmeasured by the urea clearance test, was un-altered as the result of almost complete denerva-tion resulting from rhizotomy. It is interestingto note that no change in efficiency of the kidneysresulted even though a marked fall in blood pres-sure occurred. This corroborates the observationof Page (1934) that the efficiency of the kidneysin cases of essential hypertension and nephritis isnot directly dependent on the level of systemicblood pressure. The power of the kidneys toconcentrate urine was somewhat reduced.

Hemoglobin, plasma proteins, urine proteins,urine sugar and plasma lipids were not appre-ciably altered following operation. The basalmetabolic rate and cardiac output both remained

TABLE I

Lipid content of plasma during fasting

Total Total Free Lipid Lipid Lipid TotalDate lipid cho- cho- amino nitro- phos- phos- " Ceph-

carbon lesterol lesterol nitrogen gen phorus phatidet alin '"tmgm. per mgm. per mgm. per mgm. per mgm. per mgm. per mgm. per mgm. per

100 cc. 100 cc. 100 cc. 100 cc. 100 cc. 100 cc. 100 cc. 100 c".March 6, before operation .......... 479 192 72.6 2.22 6.14 5.47 129 118June 22, after operation ............ 528 241 88.1 6.33 20.4 8.65 202 235Normalaveragevaluesforyoungmen 528 212 83 3.1 9.7 6.3 147 174

t Total phosphatide calculated from lipid phosphorus."Cephalin " calculated from lipid amino nitrogen.

According to the values found by Page, Kirkand Van Slyke (1935) to be normal for youngmen, these results may be considered to fall withinnormal limits. The lipid amino nitrogen or" cephalin " value found after operation is slightlyhigher than normal.

DISCUSSION

Although the level of arterial blood pressure inthis patient was high and tended to remain so,nevertheless the vascular system was flexible. Itis our belief that as a consequence of this flexi-bility it was possible to reduce the blood pressure

normal. There was no increase above normal ofthe excretion of red blood cells in the urine.

CONCLUSIONS

1. Section of the anterior nerve roots from the6th thoracic to the 2d lumbar segment has beenperformed in a young girl suffering from per-sistently elevated arterial blood pressure. Ana-tomical and physiological evidence indicated thather vascular system was yet flexible.

2. The blood pressure level quickly fell to nor-mal, and has remained normal for seven months.

3. Denervation of the kidneys resulting from

25

IRVINE H. PAGE AND GEORGEJ. HEUER

the operation did not alter their power to excreteurea but there was slight loss in ability to con-centrate urine. The kidneys were as efficientwhen the blood pressure was reduced to normalas when it had been elevated. No increase oc-curred in the number of red blood cells excretedin the urine.

4. In spite of the fact that the blood pressurefell to normal, there was no change in the sub-jective feeling of the patient except that head-aches, palpitation, and precordial pain disap-peared.

5. No significant alterations occurred in thehemoglobin, and plasma proteins. The basal me-tabolism and cardiac output also were normal.Electrocardiographic records taken before and af-ter operation showed no change from normal.

6. Determinations were made of total lipid, to-tal and free cholesterol, lipid amino nitrogen, totallipid nitrogen and lipid phosphorus in the bloodplasma both. before operation, when the bloodpressure was elevated, and after when it was nor-mal. Except for slight rise in lipid amino nitro-

gen and total lipid nitrogen, following operation,the changes were insignificant.

BIBLIOGRAPHY1. Adson, A. W., and Brown, G. E., Malignant hyper-

tension. Report of case treated by bilateral sec-tion of anterior spinal nerve roots from the sixththoracic to the second lumbar inclusive. J. A. M.A., 1934, 102, 1115.

2. Grollman, A., Friedman, B., Clark, G., and Harrison,T. R., Studies in congestive heart failure. XXIII.A critical study of methods for determining thecardiac otutput in patients with cardiac disease. J.Clin. Invest., 1933, 12, 751.

3. Kirk, E., Page, I. H., and Van Slyke, D. D., Gasomet-ric micro-determination of lipids in plasma, bloodcells and tissues. J. Biol. Chem., 1934, 106, 203.

4. Page, I. H., Kirk, E., and Van Slyke, D. D., Plasmalipids in normal persons and in patients sufferingfrom essential hypertension, malignant hyperten-sion and Bright's disease. 1935. (In press.)

5. Page, I. H., iThe effect on renal efficiency of loweringarterial blood pressure in cases of essential hyper-tension and nephritis. J. Clin. Invest., 1934, 13,909.

6. Lashmet, F. H., and Newburgh, L. H., An improvedconcentration test of renal function. J. A. M. A.,1932, 99, 1396.

26