Original communication| Volume 4, ISSUE 4, P502-509, October 1938

Essential hypertension: The selection of cases and results obtained by subdiaphragmatic extensive sympathectomy

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      The surgical treatment of hypertension, which consists of subdiaphragmatic resection of the major, minor, and lesser splanchnic nerves, celiac ganglion, and lumbar sympathetic ganglions, is associated with a small risk and is followed by satisfactory alleviation of symptoms in selected cases.
      Assuming that all hypertension can be divided into four groups, depending upon the severity, Group 1 does not require surgical treatment and Group 4 is too severe and too far advanced to warrant the expectation of adequate results. Groups 2 and 3 then should be considered for operative treatment. More important than the group are the preoperative tests which indicate the potential physiologic changes that will follow sympathetic denervation of the vascular area below the diaphragm.
      The so-called cold test indicates the upper limits of the blood pressure resulting from emotion or cold. The four other tests indicate the lower limits of the blood pressure readings associated with prolonged vasodilatation, and, therefore, denote the probable values for the blood pressure following extensive sympathectomy. They are as follows: (1) Twenty-four consecutive hourly determinations of the blood pressure are made while the patient is in bed, to establish the maximal blood pressure, the minimal blood pressure, and the mean or average blood pressure. (2) Slow and intermittent intravenous injection of a 5 per cent solution of pentothal sodium is made until there is no further drop in blood pressure. (3) One-half grain (0.032 gm.) of sodium nitrite is administered at intervals of thirty minutes until six doses have been given. (4) Hourly determinations of blood pressure are made during rest and sleep for a minimum of twenty-four hours.
      If the blood pressure drops to nearly normal and if the patient is less than 50 years of age, the operation should be considered.
      The results in a large series of cases have been quite satisfactory. The effect of the operation is physiologic in character, and, if so considered, the results justify the procedure.
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