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and we have, therefore, the definition "hypertensive or high blood pressure heart disease."

It is well to bear in mind, as Dr. Wright said in his remarks, that we are interested not only in the heart but also in the blood vessels themselves, and we speak of this system as the heart-blood vessel system.

What do we know about what causes pressure to get high in the arteries of the body? In a general way we can say it is, from the standpoint of physics, the same as it appears in the hot-water circulating example that I gave you a moment ago. For some reason the valves all over the body controlling the flow of blood to the body and the flow of blood to the arteries will shut down, making it necessary either for the pressure to rise or the flow to go down. Now, since the body, like the man in a house, does not wish to have a lesser flow of blood, it responds by raising the pressure in these valves. Well, you say, "That is fine, but what causes the little valves to shut down over the body?” Then, we have to say in most instances that we do not know.

There are some forms of high blood pressure the cause of which we do know, and these forms and their number of cases are relatively small. If you have one of them, it is very important to you because in those cases where we know the cause of high blood pressure frequently that can be removed and the patient is cured. But, proportionately or percentally those represent a small part of the problemlet us say 10 percent or less—and all the rest of the high blood pressure cases can be grouped into what we call essential high blood pressure. One of my patients asked me, "What do you mean by essential high blood pressure?" And I replied, “Well, that means we know essentially nothing about it.” And, that is true.

We do not really know the cause of this most common form of high blood pressure. It is barely possible that we may never know it because of the nature of this type of high blood pressure. We have a bridge in the gap of our knowledge, however, coming across as I mentioned before from infectious diseases of the kidney where we can see that if you have an infection involving or secondarily involving, the kidney, you may have, and frequently do have, high blood pressure following. It may be a streptococcal infection like Dr. Jones mentioned in the throat, which seems to be a strain on the kidney and damages it, or it may be a local infection in the kidney such as pyelitis as it is frequently called. After those infections, the blood pressure may rise and if you can identify this as the cause and if there is only one kidney involved and there usually are not both kidneys involved-you may cure the hypertension by taking out the involved kidney surgically, but such instances of cure as I have indicated are not getting at the core of the problem.

Now, what about all the rest of the essential high blood pressure cases? Is the kidney involved there? Well, if you mean from the standpoint of cause, we doubt it. If you mean "by effect,” yes, because the kidney is a mass of blood vessels.

As I mentioned, the blood vessels get involved in high blood pressure because the pressure is too high in the blood vessel so that sooner or later in a high blood pressure case the kidney may become affected and we have what we frequently have in medicine-what we call—a vicious circle where the original cause—whatever that may be-50 affects some other part of the body that it exaggerates the disease itself and it gets going around in a circle, as it were, so that the kidney is involved and that is one of the things that we can more or less hang onto.

Certainly we know that somehow the aims and the personality and the nervous makeup of individuals is important in patients with high blood pressure. It is difficult to bring it down to a specific, generally agreed pattern of personality, but in broad terms one can paint the high blood pressure person more or less as he has been painted as a busy, hard-driving, efficient, executive type of person who gets things done. He drives himself and everyone, and his blood pressure to boot.

The other thing we know about the causes of high blood pressure in this big group is somehow familial, possibly heredity is mixed up with it. It tends to run in families. We will not get into the question of heredity versus environment and those aspects of families, but it does tend to run in families. Now, we can have a great many other factors, but they are the things that we can be very sure about.

You might say, “All right, what can you do about this in terms of treatment and what has been done?”

It is presently hard to change a person's personality. It has been attempted and some successful reports have come out dealing with this approach through the psychiatric approach to treatment.

Then you can say, "Well, you cannot do much about your family.” That is true, so approach to high blood pressure from the family point of view does not help us a great deal in treatment. It may help, yes, in diagnosis; it may help us in treating from the psychiatric point of view in which the emotions are of much importance.

Then, we have the kidney diseases which I have already mentioned.

So, when we come down to what can be done about lowering blood pressure we have to confess that as to the causes or even the associated events preceding associated factors, we do not approach it very successfully from that angle.

Then, we get into the field of what we know and what we call nonspecific means of lowering the blood pressure. In this regard there are two main ways in which this has been attempted. One is by surgically removing that part of the automatic nervous system which controls the little blood vessels—the size of the valves if you will. The second is by the use of drugs which resemble these surgical procedures in their effects on the blood pressure.

Now, where are we in this type of approach? I think it is fair to say that in the past 5 years we have made greater advances, pointing with drugs at least, toward a hopeful attitude in treatment, than in all the previous time that we have known about this disease.

Surgery is presently well established as a fairly effective means. The difficulty is that the surgery involved is largely usually done in 2 steps, meaning 2 major operations; and it does not always work. It is virtually impossible to predict in advance on which patients it will work. So, you have to take a chance, so to speak, with surgery, but

you will probably do better, if your case is suitable for surgery, than if you do not take the chance, at least if we can believe the statistics that have been published.

Where do we stand in application of what we know that will aid high blood pressure? As has been said by Dr. Wright and Dr. Jones


Thank you.

the avenues for dissemination of knowledge are established. What we need perhaps are a few traffic cops speeding up the flow of traffic, the flow of information, expediting it. I do not think we need to establish new avenues; I think if we would put some one-way streets so that the information flow would be a little more rapid, it would be sufficient. What we already have is sufficient.

The CHAIRMAN. Are there any questions from members of the committee

Mr. CARLYLE. Yes, I would like to ask a question.

Doctor, what is the connection, if any, between poor circulation or insufficient circulation of blood and high blood pressure?

Dr. WILKENS. There is a connection and I am sure Dr. Andrus, who is going to talk about hardening of the arteries and the insufficient or poor circulation to certain parts of the body, will explain those matters. But where does high blood pressure get into this? In high blood pressure as a rule you do not have poor circulation because you have high blood pressure. You would have if you did not have the pressure to overcome the resistance that is there. Now, there is one difference between pure high blood pressure and the arteriosclerosis part of it which can occur with high blood pressure and that is this: The type of resistance in the arteries in high blood pressure, at least in its beginning, is not structural; it is in terms of a muscular contraction. We call it functional. The vessel conceivably could relax, but it is spastic and it is contracted down so that in effect it is putting resistance against the flow of blood. The heart and the whole body responds with an elevation of blood pressure and the blood is pushed on through this resistance anyway, Dur treatment of such patients as I tried to describe is to relax the blood pressure and lower the pressure and maintain good circulation. Mr. CARLYLE. That answers my question.

Mr. HESELTON. Doctor, during your presentation you mentioned the flow of information throughout the medical profession. I would like to ask the question as to how much medical and scientific journals do and whether they are in difficulty financially.

Dr. WILKINS. Well, at the moment, I think most medical journals are doing fairly well financially, I can, personally, well recall a few years back when they were all in dire straits and of course that fluctuates markedly, as you are aware, with the economic conditions of the country. The flow of information through medical journals I think is adequate; it is certainly more than I can keep up with even in my own field. You have journals coming out every day, and this matter of dissemination of knowledge is like leading a horse to water; you know you cannot make him drink, and you can have the stuff there for the doctor, or the public, or both, to read, but can you make them read it? That brings up the manner in which it is presented, and I think it is conceivable that it could be streamlined and so on. But, there the doctor always shies away a little bit, because you get, or tend to get, half information or misinformation across not only to the public but to the medical profession. I think most of us think that a little knowledge is a dangerous thing many times. We would rather keep it in the confines of the really scientific journals where the editorial staffs are very sensitive to having a very high order of reporting, if you

will, and having it complete and accurate. So, you have a sort of vacillation on the part of most of us here as to whether a great effort should be made to open up new avenues of dissemination of knowledge. I think most of us are agreed that the journals which we now have are pretty good, but maybe they could be used better.

Mr. HESELTON. What is the situation with reference to the encouragement of sponsoring meetings either here in this country or internationally where the experts and research people can exchange their information and present their papers ?

Dr. WILKINS. Well, I am sure that the personal approach-it works in medicine as it does anywhere else—that is why we are having this meeting together today, so we might know everyone on a personal basis, I assume. To my way of thinking, perhaps, the most important way we have of disseminating information is through the personal meetings at scientific gatherings of people who are doing the work and who have a personal interest in it, let us say. I think there might be ways of promoting the attendance at meetings, particularly by younger individuals doing research work and going into the research field. Now, there you will get back to economics and the question as to why young men do not go to meetings. That is essentially because they do not have the money to go. So, in many research grants now, and this has been recognized by such agencies as the American Heart Association and the National Heart Institute, provision is made for travel expense of this purpose. It ought to also be said that the personnel of these agencies should have adequate funds to attend scientific meetings so that they can carry across this cross-fertilization of ideas from one scientific discipline or field to another. Perhaps in that way some people are at present not having opportunity and more could be assigned to that particular job if the money was available to attend meetings to find out what is going on across the board and to disseminate it. But, that costs money and money must be appropriated or given by public and private agencies to promote that.

If I were going to say where it is most needed, I would say by the younger lower-income group in the field who may want to go very badly but cannot afford to do so.

Dr. WRIGHT. May I make a comment with reference to that?

Dr. WRIGHT. It is my understanding that recently, through an order, the amount of money made available to the public health group has been decreased markedly in terms of allotments for travel to meetings. I should like to make a personal plea that that matter be rectified because it seems to me if we are going to hope for real cross-fertilization of the mind and further development of our Heart Institute as well as the other public health institutions, it is absolutely important for the men working in those institutions to have the money to attend the scientific meetings without stint. This is one of the most important ways in which they can bring knowledge back to the public health institution and, in turn, have it disseminated to the States and at other national meetings. They can act as a medium of exchange, but this move seems to me to be jeopardizing the very thing you are trying to bring out in your question.

The CHAIRMAN. Mr. Derounian has a question.

Mr. DEROUNIAN. Dr. Wilkins, would you say that the tendency to hypertension might be hereditary!

Dr. Wilkins. Yes, that certainly very well may be. One of the authorities on that subject is Dr. Thomas, who is in the room, and she has been mentioned before, but she has been studying this problem at Johns Hopkins, and also Dr. Ammond has been studying it for a longer period at Baltimore. Dr. Platt has been studying it in England. I think I am not misquoting them to say that they are in essential agreement that hypertension tends to run in families. If both parents have hypertension, the children are much more apt to get it than if one parent has hypertension. Dr. Platt and Dr. Ammond at least agree that this trait-I will let Dr. Thomas speak for herself on whether it is a dominant one or not but I think that all agree there is a factor which presumably is hereditary:

Now, the reason that you probably asked that question is that you are perfectly aware of the fact if you are raised in the environment of a family, you will pick up environmental traits from the family. Where the parents are nervous, apprehensive, irritable, and so on, the child may pick those traits up. So, we use the term "familial” to include that concept. But, getting back to your particular question, I believe the best evidence is that it is probably hereditary.

Mr. DEROUNIAN. Dr. Wilkins, do you recommend in the treatment of hypertension the surgical aspect, or does not the diet of the person help to lower the blood pressure?

Dr. WILKINS. Yes, it certainly does and that would be included in medical treatment and frequently is.

Mr. DEROUNIAN. I notice that most of you heart specialists here are quite thin people.

Dr. WILKINS. Yes, sir. Overweight, of course, is definitely an aggravating factor in hypertension, not only because it may make the blood pressure high, but because it places more strain on an already strained system.

Mr. DOLLIVER. Will the gentleman yield at that point?
Mr. DEROUNIAN. Yes, I will yield.

Mr. DOLLIVER. Doctor, would you make comment upon the rice diet that we heard about several years ago?

Dr. WILKINS. The rice diet is a form of a low-sodium diet. Its content of salt is very low.

Dr. WRIGHT. Sodium being salt.

Dr. WILKINS. Sodium chloride is ordinary table salt and the sodium part of that substance is what is important, and that is very low in the rice diet.

Now, there was a great controversy that raged at meetings and in medical circles for several years about whether the low-sodium diet, rice diet-or any other form of low-sodium diet would be effective in lowering blood pressure. I think it is generally agreed now by most of us in this field that it is an effective way of lowering blood pressure, with one hooker; it is awfully hard to keep, especially for a long period of time. If you have a 20-year disease, then you must have at least a 10- or 15-year acceptable form of treatment, and there is the hooker. Any form of dietary treatment as rigorous as a rice or strictly lowsodium diet-and it must be extremely strict in order to be effectiveis very hard to keep. I hope that answers your question.

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