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The Nature of the Peripheral Resistance in Arterial Hypertension with Special Reference to the Vasomotor System

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THE NATURE OF THE PERIPHERAL RESISTANCE IN ARTERIAL HYPERTENSION WITH SPECIAL REFERENCE TO THE VASOMOTOR SYSTEM Myron Prinzmetal, Clifford Wilson J Clin Invest. 1936;15(1):63-83. https://doi.org/10.1172/JCI100759. Research Article Find the latest version: https://jci.me/100759/pdf THE NATURE OF THE PERIPHERAL RESISTANCE IN ARTERIAL HYPERTENSION WITH SPECIAL REFERENCE TO THE VASOMOTOR SYSTEM By MYRON PRINZMETAL1 AND CLIFFORD WILSON 2 (From the Thorndike Memorial Laboratory, Second and Fourth Medical Services (Harvard), Boston City Hospital, and the Department of Medicine, Harvard Medical School, Boston) (Received for publication August 22, 1935) From the physiological point of view elevation A. IS THE INCREASED PERIPHERAL RESISTANCB of blood pressure may be due to an increase in GENERALIZED THROUGHOUT THE BODY OR cardiac output, in the volume or viscosity of the LIMITED TO THE SPLANCHNIC AREA? blood or in the resistance of the peripheral vessels. Literature Since cardiac output is not increased in hyper- In view of the known physiological importance tension (1, 2, 3) and the viscosity (4) and volume of the splanchnic circulation it is essential to (5) of the circulating blood have been shown to determine whether the development of hyperten- be normal, there remains only the increased re- sion in man is especially due to abnormal behavior sistance in the peripheral circulation. of this vascular area. Various forms of evidence From an analysis of the literature it appears have been brought forward to support this pos- that investigations on the exact nature of this sibility. In the first place, pathological studies increase in peripheral resistance are compara- show that the arterial lesions in hypertension are tively few in number and have led to conflicting most intense in the splanchnic region, especially results. It is the purpose of this paper. to deal in the kidneys, adrenals, and pancreas. It ap- with the following questions. pears, however, that no constant relationship exists in A. Is the increased peripheral resistance gen- between the severity of arteriosclerosis the splanchnic area and high blood pressure. Long- eralized throughout the systemic circulation or cope and McClintock (7) obtained transitory ele- confined to the splanchnic area? vation of blood pressure by sudden occlusion of B. To what extent are the vessels responsible the splanchnic vessels in dogs. They attribute for the increased peripheral resistance capable of this effect to the increase in peripheral resistance, dilatation ? but find no evidence for regarding the splanchnic C. What part is played by the vasomotor nerves area as specifically important in the production of in the maintenance of the increased peripheral hypertension. Jansen, Tams and Achelis (8) resistance; i.e. if arterial hypertonus is present found in animals that obstruction of the circula- can it be attributed to an increase in sympathetic tion to a limb caused a greater rise in blood vasoconstrictor impulses? pressure if the splanchnic vessels were first oc- We have attempted to answer these questions cluded. In subjects with hypertension they state that an a and by studies on the blood flow in the arm under binding extremity produced higher more sustained elevation of blood pressure than various conditions, using the arm plethysmograph in normal individuals, and conclude from these as described by Lewis and Grant (6), and to results that hypertension is due to vasoconstric- determine whether the nature and distribution of tion in the splanchnic area. Splanchnic section the increased resistance is the same in the different has been performed (9, 10) in patients with hy- forms of hypertension, which have been desig- pertension on the basis of the same assumption, nated benign, malignant and secondary (" renal") and lowering of the blood pressure has been al- hypertension. leged to follow such operations. Critical exami- nation of the above experiments, however, fails 1 National Research Council Fellow in Medicine. to furnish any conclusive evidence that the in- 2 Rockefeller Fellow in Medicine. creased vascular resistance is confined to the 63 64 MYRON PRINZMETAL AND CLIFFORD WILSON splanchnic area. Moreover, in certain forms of Method of determination high blood pressure, e.g. eclampsia and malignant Brodie (15) has shown that when an organ hypertension, vascular spasm may be observed in is placed in an oncometer connected to a volu- the retinal vessels. Volhard (11) has attributed metric recorder, obstruction of the venous outflow pallor of the skin in such patients to generalized causes an increase in size of the organ due to peripheral vascular spasm produced by a circu- inflow of unobstructed arterial blood. This in- lating pressor substance. There is, however, no flow can be measured for only a few seconds after conclusive evidence in support of this theory (12, venous occlusion, since congestion of the organ 13, 14). causes a rapid diminution of arterial flow. Hew- lett and van Zwaluwenburg (16) applied this Principle of method principle to man by enclosing the arm in a plethys- The cardiac output in patients with high blood mograph and occluding the venous return by a pressure is known to be within normal limits (loc. pneumatic cuff at a pressure just below diastolic. cit.). If, therefore, hypertension is due to in- From the increase in arm volume per unit time creased vascular resistance confined to the splanch- the blood flow may be determined. The arm nic area, the caliber of the vessels in the rest of volume is measured, and the blood flow expressed the body remaining normal, the blood flow in cubic centimeters per 100 cc. arm volume per through the latter must be increased. If, on the minute. Hewlett and van Zwaluwenburg found other hand, the increased resistance is generalized the blood flow to be somewhat above normal in and uniform, the blood flow in all parts of the patients with hypertension. Unfortunately, they systemic circulation will be the same as in normal paid no attention to the type of hypertension or individuals-the high blood pressure simply over- to the temperature of the arm during their experi- coming the increased resistance in all areas. This ments. is in accordance with Poiseuille's law that the The arm plethysmograph of Lewis and Grant is admirably adapted to our purpose. It has a blood flow in any cross section of the vascular great advantage in excluding the hand, which bed per unit time is directly proportional to the shows vasomotor responses of great intensity at- pressure and inversely proportional to the resist- tributable to the relatively large area of highly ance. may be expressed as a simple equa- This specialized skin (17). By means of the arm tion, Voo (P/R), where V is the volume of blood plethysmograph we can study a more representa- flowing through an organ per unit of time, P is tive segment consisting chiefly of striated muscle, the effective arterial pressure, and R the resistance. fat and fascia covered by a more " normal " skin We have therefore compared the blood flows area. In using the plethysmograph, the most im- in the arm in patients with hypertension and in portant practical point is to insure water-tight subjects with normal blood pressure. If the rest- junctions where the arm enters and leaves the ing blood flow in the arm in patients with hyper- plethysmograph, without producing appreciable tension is equal to that in normal individuals, the venous congestion. We were unable to obtain peripheral resistance in the vessels of the arm rubber tires of sufficient flexibility to follow must be increased to the same degree as the mean Lewis's method, and used instead the cuffs of peripheral resistance in the splanchnic area.3 If, surgical rubber gloves, which are available in all however, the peripheral resistance in the splanch- sizes. These are prevented from bulging in- nic area is greater than in other parts of the sys- wards or outwards by rings of hard rubber placed temic circulation, the blood flow in the arm in on either side, the whole being held in position hypertension will be greater than in normal indi- by a metal lid which fits tightly onto the end of viduals. the plethysmograph (Figure 1, inset). The arrangement of apparatus is shown in the 8 When referring to the mean peripheral resistance in accompanying diagram (Figure 1). The patient the splanchnic area we recognize the possibility that the in a wheel chair in a semi- increased peripheral resistance may not actually be uni- is seated comfortably form throughout the organs in this area. reclining position. The plethysmograph is fitted PERIPHERAL RESISTANCE IN ARTERIAL HYPERTENSION 65 METAL LID M/RUBBER DISCS RUBBER GLOVE -1 --- FIG. 1. ARRANGEMENT OF APPARATUS. (After Lewis aind Grant (6).) onto the forearm, and filled with water at 240 C. until the blood flow becomes constant. All the Since the volume of the plethysmograph is known, experiments here reported were performed at the the arm volume can be readily obtained. The same room temperature (70 to 720 F.) since varia- arm is placed in a water bath at the same tem- tions in the latter cause alteration in flow. De- perature, and the plethysmograph connected to a terminations were made at approximately the same 35 cc. Brodie's bellows by means of which vol- time after the last meal (one to two hours) owing ume changes are recorded on a smoked drum. to the effect of digestion on the cardiac output Calibration is performed by the syringe as shown (18). Psychic factors exert a considerable in- in the diagram, a 5 cc. increment in volume giving fluence on the blood flow; hence such distractions approximately 1.5 cm. rise on the drum. A 6 cm. as reading and talking were avoided.
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