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During the past years many investigations and clinical studies have been made for the purpose of determining the primary causative factor of hypertensive vascular disease, or essential hypertension, but this factor has not as yet been established. Hypertensive vascular disease is considered a clinical entity. It is extremely prevalent and in its terminal stages is liable to produce disastrous involvement of the vital organs. Its cardinal symptom is persistent high blood pressure. Two forms of hypertensive disease are considered in this paper : essential benign hypertension and malignant hypertension. This classification is not accepted by all internists, but since it is in general use it will be employed here. Essential benign hypertension (benign nephrosclerosis) occurs generally in middle-aged persons with persistent high blood pressure. The subjective symptoms are of a mild and chronic nature. The patient is apparently in good health and may live for many years. The vision frequently is

The corneomandibular reflex, or von Solder phenomenon, is an automatic, involuntary movement of the mandible elicited by touching the cornea. This phenomenon is helpful in diagnosis of supranculear lesions of the trigeminal nerve. It simply requires observation of the relaxed and slightly opened jaw when the cornea is stroked with a cotton wisp, and it can be handily included in the testing of corneal sensation. A prominent deviation of the jaw, the result of homolateral contraction of the external pterygoid muscle, constitutes a positive response. Because this reflex has not been previously reported in the ophthalmic literature to our knowledge, the following cases are presented. Report of Cases Case 1. —This 61-year-old Negro male was seen in October, 1961. He had known severe hypertensive vascular disease for many years. He suffered a sudden right hemiplegia in 1952 and a left hemiparesis in 1955. Three weeks prior to admission, he developed

To the Editor:— Dr. Juanita, a charming, intelligent, young Latin lady who wore big gold earrings, was the first foreign resident in a large American hospital in 1950. Her knowledge of English became adequate, but abbreviations such as p.i.d., s.o.b., p.t.a., hx, bx, dx, etc continued to baffle her. Particularly difficult were abbreviations with two meanings. CVA might mean "costovertebral angle" or "cerebrovascular accident," but the one that really floored her was HVD. With some difficulty we explained to her that when HVD appeared in a medical record, it meant "hypertensive vascular disease," but when it occurred in a gynecologic record, it meant "hot vinegar douche."

An earlier editorial (233:897, 1975) denounced too much laboratory testing of a patient for whom continuity of care and a direct, discriminating approach to diagnosis were not pursued. In his presidential address to the Association of American Physicians, published in the October 1975 issue ofArchives of Internal Medicine, David E. Rogers, MD, beats the same drum when he calls for "technologic restraint." Rogers is no iconoclast; he applauds the astounding advances in technologic methods for diagnosis and for treatment that are the mark of his generation of medical scientists. He cites two cases that exemplify opposite poles: one, the case of Franklin D. Roosevelt who died of severe hypertensive vascular disease in 1944 at a time when modern-day antihypertensive drugs were not yet available, the other, the case of FDR's wife, Anna Eleanor, who died in 1960 of disseminated tuberculosis, probably as a consequence of corticosteroid therapy given for

INTEREST in the use of preparations of Veratrum viride for treatment of essential hypertensive vascular disease has recently been revived. This interest stems from a number of reports indicating favorable effects on blood pressure and a better understanding of the pharmacologic action of the Veratrum alkaloids.1The preparations employed clinically have been, for the most part, mixtures of alkaloids said to be therapeutically effective and efficiently nontoxic for extended use. More recently,2oral administration of a purified alkaloidal fraction of Veratrum viride, standardized on a chemical basis and given the proprietary name veriloid,®1bhas been reported to produce lowering of blood pressure for periods as long as five months, while accompanied with "fewer toxic reactions than any other oral preparation of Veratrum viride presently available."2Its pharmacologic actions have been described.3Because of the promising clinical results reported, we studied the effects on arterial pressure

Although many reports have appeared describing follow-up findings in thousands of patients with previous toxemia of pregnancy, no clear-cut answer can be found to the question of whether toxemia of pregnancy is an etiological factor in the development of permanent hypertensive vascular disease. The variation in available data is illustrated by the fact that previous reports have placed the incidence of hypertension following toxemia from 0 to 78%. The average reported incidence following preeclampsia is 45%, and that following eclampsia is 22.5% approximately one-half as much. This tremendous variation might be explained in part by the lack of uniformity of criteria for a diagnosis of toxemia and post-toxemic hypertension. The reported level of blood pressure constituting hypertension has varied from 130/70 to 170/100 mm. Hg. Today most investigators consider 140/90 mm. Hg as the dividing line between a normal blood pressure and hypertension. Master, Dublin, and Marks1have shown

The purpose of this volume is to serve as a practical guide to the investigation and management of the hypertensive patient. This goal has been achieved admirably. The well-informed physician confronted with the hypertensive patient knows that the management of hypertension is a far more complicated problem now than it was two decades ago. We now have at our disposal a number of antihypertensive drugs of varying degrees of potency, each with its own constellation of adverse effects. In addition, we are constantly reminded that we must not overlook potentially curable forms of hypertension. To facilitate their recognition we have new (sometimes risky and costly) methods of investigation. "In the evaluation of the patient with elevated blood pressure there is still room for the use of good clinical judgment without recourse to elaborate laboratory investigation," say the authors. Ample evidence of sound clinical judgment is displayed throughout the text, and

Two cases of hemiballism are reported, in 1 of which the disease was severe and in the other moderately severe. Both cases were typical instances of hemi¬ ballism, presumably associated with destruction of the opposite corpus subthalamicum by thrombotic softening. Both patients had hypertensive vascular disease and cerebral arteriosclerosis, so that vascular thrombosis appeared the most likely cause. A mastectomy five years before admission in case 1 raises the possi¬ bility of metastatic carcinoma, though histologie diagnosis of the amputated breast

Wine and water might be unexpected sources of error in the dietary treatment of heart or kidney disease or hypertensive vascular disease. If the daily intake of sodium is to be restricted, for instance, to 8.5 mEq (the amount in 0.5 gm of table salt) or even to less than 4 mEq (as in the basic rice diet) a daily intake of 1 qt of "unsatisfactory" water containing more than 13 mEq of sodium per quart (which is the case in many places in this country) would already exceed the total permissible allowance even though the patient might not eat or drink anything else. Proponents of rigid sodium restrictions, therefore, have stated: "If the sodium concentration of the plain water available is greater than 20 mg/liter (0.87 mEq/liter), distilled water should be used." 1 We have recently analyzed the sodium contents of 68 different kinds of domestic and foreign wines

SYMPATHECTOMY for hypertension remains a controversial subject. Lack of uniformity in case selection, modification of standard operative procedures and variations in methods for analysis of results are factors which have contributed to the confusion existing in the field. Successful case selection has been a most difficult problem. This report is based on an analysis of the results of sympathectomy on the blood pressure in 52 patients who were selected for operative intervention according to reported criteria 1 from a total of 210 hypertensive patients available for study and surgical consultation. These patients have been followed for a period of one to three years postoperatively. The analysis is primarily concerned with the blood pressure responses, although it is conceded that other factors beside high blood pressure are of great importance in hypertensive vascular disease. METHOD OF CASE SELECTION A total of 210 hypertensive patients were referred for complete hypertensive study and

SINCE Richard Bright,1in 1836, described the renal syndrome which came to bear his name, innumerable authors have contributed to the clarification and classification of renal disease and hypertension. Johnson,2in 1868, was the first to describe the presence, in cases of Bright's disease, of a diffuse disease of the smallest arteries characterized by hypertrophy of the media. At the Mayo clinic, since the papers of Keith3and Keith, Wagener and Kernohan,4a number of studies5have served to emphasize the diffuse nature of hypertensive vascular disease. Beginning with the work of Kernohan, Anderson and Keith,6an attempt has been made to establish the normal thickness of the wall of an arteriole as compared with its lumen and to determine what changes are to be found in hypertension. With a few notable exceptions, to be discussed later, it has been found that although the

IN A PREVIOUS paper, 1 a survey was given of the serum electrolyte pattern of patients on strict rice diet who had hypertensive vascular disease without advanced renal involvement. It was found that in 95% of these patients, serum electrolyte concentrations were well maintained. One should expect this to be different in patients with advanced kidney disease, and doubts are occasionally expressed whether or not salt restriction is applicable at all in such instances. The purpose of this paper is to report on the tolerance to rigid salt restriction in a series of patients with severe renal disease who were treated with the rice diet. The presence of renal insufficiency greatly complicates the study and interpretation of chemical changes which take place in the body fluids as a result of dietary measures. Whereas in the previous group of patients a systematic approach was possible, determining the serum electrolytes at equal

THE LITERATURE contains reports of several thousand patients who have undergone various forms of sympathetic denervation for the relief of hypertensive vascular disease. A comparison of the various types of operative procedures employed has been made by us elsewhere.1In general, the majority of patients reported on have undergone resection of the sympathetic chain from the ninth thoracic through the second lumbar ganglion combined with bilateral resection of the splanchnic nerves. Although our operations, especially in the more severe cases, have recently tended to be more extensive, we have usually limited our resections to this extent. As our familiarity with this operation has grown, we have become aware of certain problems associated with it, which, while they are not of a magnitude to limit seriously the use of the operation, are of importance if the optimum results are to be obtained and if the procedure is to be kept

SINCE the advent of thoracolumbar sympathectomy as a treatment for primary hypertensive vascular disease, various tests have been used postoperatively to determine the extent of the sympathetic resection. One of the tests commonly employed is the Minor starch-iodine test, which is based on the change in color occurring when a starch-iodine mixture becomes moist with the occurrence of sweating. The actual mechanism of sweating is not well understood. Best and Taylor1stated that the stimulus for sweat secretion is a rise in blood temperature, which has a twofold effect: the stimulation of nerve centers in the brain and the stimulation of heat receptors in the skin, which reflexly cause the secretion. This contention has been supported by other investigators.2With these two concepts of the mechanism of sweating in mind, i. e., direct stimulation via the sympathetic nerve fibers from the heat centers in the brain and stimulation

ARTERIOLAR nephrosclerosis is the term applied to involvement of the renal area by hypertensive vascular disease. The benign form is characterized by sclerosis of small arteries and arterioles, while the malignant form has in addition necrotizing vascular lesions which involve particularly the vasa afferentia supplying the glomeruli.1Malignant nephrosclerosis is the typical renal lesion of malignant hypertension, although it is by no means always present in that disease2and may also occur in far-advanced glomerulonephritis3and pyelonephritis.4 Malignant hypertension is a clinical condition characterized by persistent hypertension, a progressive downward course, and distinctive changes in the retina (edema of the disc or retina, hemorrhages, and exudates). Renal failure is a late or terminal event.5The constancy of the typical retinal changes has been emphasized in studies of the disease both in adults6and in children.7Excluding cases of far-advanced chronic glomerulonephritis or pyelonephritis

IN RECENT years great strides have been made in the direction of determination of the pathogenesis of hypertensive vascular disease. However, there is conflicting opinion concerning the relation between basal heat production and hypertensive vascular disease. 1 Clinically, an elevated basal metabolic rate has been noted in patients with hypertension. Mountain and his co-workers 1h reported that there was a direct correlation between basal heat production and the height of the blood pressure; others 2 failed to demonstrate this relation. The exact mechanism underlying these metabolic changes has not been definitely proved. Some investigators 3 have indicated that an interrelationship among the brain, the thyroid and the adrenal sympathetic system exists. Hayasaka 1f concluded that the basal metabolic rate remains unchanged in hypertensive patients with normal renal function but becomes elevated in those with renal insufficiency. Because of these opposing viewpoints, it seemed of real value to reinvestigate the entire problem. In

Hypertension is different in black people. It develops earlier in life, is frequently more severe, and results in a higher mortality at a younger age, more commonly from strokes than from coronary artery disease. Experience over the past 20 years with an inner city population readily attests to the high incidence of hypertension in blacks. Studies conducted in the Toxemia Clinic at D. C. General Hospital presented evidence that 70% of the patients originally diagnosed as toxemia of pregnancy by the obstetricians actually had hypertensive vascular disease as shown by a history of an elevated arterial pressure prior to pregnancy, and by arteriovenous nicking seen on ophthalmoscopic examination. 1-3 Studies during the past year conducted in the Birth Control Clinic at this hospital have reemphasized the high incidence of hypertension in young black women. 4 Forty-eight percent of a random sample of black patients attending the Birth Control Clinic were

Recent favorable reports of the use of the veratrum alkaloids in essential hypertension suggest the need for revaluation of the drug which had passed into "deserved oblivion." 1 In 1946 Hite 2 reported the first clinical evaluation of the use of the biologically standardized whole powdered drug. He observed in a series of 30 cases that 60 per cent had a fall of greater than 25 mm. of mercury in systolic pressure and 26.6 per cent a reduction of 20 mm. in diastolic pressure. Daily dosage varied from 15 to 30 Craw units. 2a The only reactions noted were vomiting in 1 patient and headache in another. No effect of the drug was noted on occasional electrocardiograms. More recently, Freis and his associates 3 reported extensive studies on the hemodynamic effects and clinical use of veratrum viride in man. In their group of 34 ambulatory hypertensive patients, 30 (88 per

In the two-year period, 1955 and 1956, 104 selected hypertensive patients were subjected to aortography. Of these, 30 were found to have unilateral or bilateral obstructive lesions of the renal artery. Most of these lesions were considered to be the primary cause of the hypertensive disease but some aggravated an existing essential hypertension. Most of the obstructive lesions were arteriosclerotic plaques. There were six instances of poststenotic aneurysmal dilatation. Currently the most important means of recognizing renal artery disease is renal angiography accomplished by means of translumbar aortography. Of the 30 patients, 19 had either nephrectomy or corrective renal artery surgery, which usually resulted in remission of the hypertensive vascular disease.