Allen, Edgar V.

The successful treatment of essential hypertension remains one of the most difficult problems in medicine. Approximately 18 years have elapsed since extensive sympathectomy was first performed for essential hypertension. Extensive sympathectomy occasionally produces striking decrease in blood pressure of patients with essential hypertension; in many instances it fails to decrease blood pressure or modify the course of the disease. That which is most desired are some standards for preoperative selection of patients so that only patients who will be benefited by sympathectomy will be operated on. Unfortunately this apparently cannot be accomplished. The indications for sympathectomy remain at least partially uncertain and there is no agreement among those most experienced in the field of hypertension relative to the results of operation. There also are differences of opinion about the extensiveness of sympathectomy which is advisable. This paper indicates clearly differences of opinion among those most experienced in this field and emphasizes some of the points of agreement. It seems clear that additional technics of sympathectomy cannot be devised for the treatment of essential hypertension. There seems little doubt that sympathectomy would not be performed were adequate medical treatment available. This presentation gives the opinion of internists and surgeons who are particularly interested in hypertension and its treatment.

The authors investigated the effect of repeated inunction with 2 per cent glyceryl trinitrate in lanolin on the blood flow and skin temperature of the extremities in 14 cases of Raynaud's disease and in 8 cases in which Raynaud's phenomenon was associated with such vascular diseases as acrosclerosis (3 cases), chronic occlusive disease of the arteries (3 cases), occupational disease of the arteries (1 case) and livedo reticularis (1 case). The inunction almost invariably caused an increase in the blood flow and in the skin temperature of the digits in the 14 cases of Raynaud's disease.

Experienced clinicians have known for some time that bleeding owing to the use of dicumarol is not entirely a measure of the degree of prothrombin deficiency. This presentation emphasizes that bleeding may occur when prothrombin deficiency is not great and that bleeding may fail to occur when prothrombin deficiency is marked. Nonetheless great prothrombin deficiency causes bleeding more frequently than lesser degrees of prothrombin deficiency. Time is an important factor, for patients are much more apt to bleed when prothrombin deficiency has endured for several days than when it has been present only a day or so.

Clinical experience has not confirmed previous observations that intravenous injection of vitamin C and intramuscular injection of histidine monohydrochloride are useful in the treatment of peripheral ischemia observed in arteriosclerosis obliterans. Clinical experience with intravenous injection of ether has failed to indicate that this method of treatment is of value in improving the peripheral arterial circulation in thrombo-angiitis obliterans and arteriosclerosis obliterans.