The Treatment of Severe Hypertension

LECTURE IOf recent years two Oliver-Sharpey lecturers have de- voted themselves to the subject of hypertension.In 1943 George Pickering reviewed the circulation in hypertension, while last year Clifford Wilson (1953) discussed renal factors in its production.Both have done much to elucidate the cause and nature of hyper- tension, and the advances in our knowledge of physio- pathology have been, to some extent at least, applied to therapy.A review of the present methods of treat- ment of severe hypertension may therefore not be out of place.I shall start with a case history.Case 1.-The patient, a young woman, was quite fit when, in 1942, at the age of 18, she joined the Forces.Her past FIG.1.-Intravenous pyelogram in Case 1, showing large left kidney with small, deformed, but functioning right kidney.history was uneventful and there was no family history of hypertension.In 1944 she began to have severe mornidg headaches and to vomit, and, shortly after, she was admitted to hospital in a series of epileptiform fits.Her blood pres- sure was about 200/140 mm.Hg, and at that time her optic disks were sharp.She was unconscious for four days, and upon recovery her blood pressure remained raised.Renal function was good.A few months later she was seen by Professor (now Sir) Arthur Ellis, who noted bilateral papilloedema, macular stars, and haemorrhages.At his suggestion an intravenous pyelogram was done, and this showed a normal left kidney, while the right was small but functioning.Invalided from the Forces, she married, and in August, 1945, * The Oliver-Sharpey Lectures delivered at the Royal College of Physicians of London on March 16 and 18, 1954.Many lessons can be learnt from this case; the out- standing one is the complete reversal of the train of events which we usually associate with severe hypertension and which have, in the past, been considered irreversible.There was first a spontaneous remission of the malignant features, and then the persistent grossly raised pressure was cured by nephrectomy.The hypertensive process was severe enough to lead to foetal death in three, and perhaps four, successive pregnancies, and no better demonstration of cure could be given than the subsequent occurrence of completely normal pregnancies.489&