Search

The types of cardiac dyspnea in this study included exertion dyspnea, orthopnea, cardiac asthma, and Cheyne-Stokes breathing. The condition of pulmonary edema accompanies orthopnea which often seems to have been used as a synonym of cardiac asthma. Although clinical reports on the signs and symptoms of cardiac asthma have hitherto been made by many and much has been discussed as to the cause of the disease, precise elucidation is yet to be made in their development. The purpose of the present study is to clarify pathophysiological aspects of cardiac asthma from clinical fingings. Consecutive observation was made of the hemodynamics of cardiac patients during day-time and at night with special reference to the attacks of cardiac asthma, and comparative studies were also undertaken with various cardiopulmonary diseases in acute stage with allied clinical symptoms. The tolerance tests with several drugs as well as exercise tests were tried in the cardiac patients in an attempt to induce attack of asthmatic dyspnea. Method and Materials Forty-four cardiac patients who had been admitted to the First Medical Clinic of Kobe University Hospital were examined. The first examitotion was routinely carried out in the supine position around 3;00 p.m. shortly after admission that is before a specific treatment was instituted. Following the examination the patients were left quiet in the supine position and allowed to sleep until about 8:00 p.m. The second examination was performed at 10:00 p. m. Hemodynamic examination was made in respiratory frequency, pulse rate, cardiac rate, blood pressure., venous pressure, pulmonary circulation time, cardiac output, stroke volume, and pulmonary blood volume. The Riva-Rocci sphygmomanometer was used for taking pressure, a modified MORIZ-TABORA method for venous pressure, UEDA'S method according to Stewart-Hamilton principle, using radio-iodinated serum albumin (RISA), for determining pulmonary circulation time and cardiac output. The pulmonary blood volume was calculated by the following fomula

This study is primarily concerned with the question of normal blood pressures and pulse rates under varying conditions. The observations on patients cover only a restricted field and are introduced, in the main, as illustrations of the deductions which may be drawn from comparison with the normal data. The work falls naturally into two parts, one, the measurement of the level of pressure and pulse rate under fixed conditions, with which this paper is concerned; the other, the measurement and interpretation of the changes in pressure and pulse rate induced by alteration of the conditions, which are dealt with in a succeeding paper. Most of the observations were made on soldiers at Camp Lewis, Wash. For the opportunity to do this work I am indebted to Dr. Kerr, who was in charge of the medical division of the Base Hospital, to Dr. Northington and Dr. Fulton who were successively in

1. The renin-like substance isolated from the placenta of the rabbit produces a prolonged increase of blood pressure in the nephrectomized rat. If incubated with renin substrate from ox serum, it forms a pressor substance that elevates blood pressure in exactly the same way as does angiotensin. 2. This angiotensin-like principle was concentrated by means of ion-exchange chromatography and compared with Val-5-angiotensins I and II in two paper-chromatography systems and in paper electrophoresis. 3. In all the three methods the unknown principle behaved like a mixture of the two reference compounds. 4. It is concluded that incubation of the renin-like substance of placental origin with substrate from ox serum gave a mixture of Val-5-angiotensins I and II. This is evidence that the enzyme isolated from the placenta is either closely related to, or identical with, renin.

Examination of those plant extracts which were previously found (Feng and others, 1962) to have transient depressor activity has led to the isolation of γ-aminobutyric acid, from the leaves of Artocarpus incisa L. and of Piper amalago L. and to the demonstration by paper chromatography of its presence in several extracts. Extracts showing pressor activity were also examined and tyramine has been isolated from Phoradendron wattii Kr. and Urb. and dopamine has been shown by paper chromatography to be present in Piper amalago L. and Stachytarpheta jamaicensis Vahl.

The present communication gives an account of the isolation, structure and pharmacological properties of the caerulein-like polypeptide occurring in the skin of Phyllomedusa sauvagei from north-western regions of Argentina. For the new polypeptide, a nonapeptide closely resembling caerulein both from a biological and chemical point of view, the name phyllocaerulein is proposed. This paper also describes the occurrence of phyllocaerulein or related peptides in the skin of other Phyllomedusa species. A complete description of methods used in the isolation of phyllocaerulein as well as in the determination of amino-acid composition and amino-acid sequence of the polypeptide may be found in a preceding paper dealing with the isolation and the amino acid sequence of caerulein (Anastasi, Erspamer & Endean, 1968 ; Anastasi, 1969)., Material digitalizado en SEDICI gracias a la colaboración del Dr. Jorge Williams (FCNM-UNLP)., Facultad de Ciencias Naturales y Museo

A multicentre, placebo-controlled, double-blind, cross-over study conducted in general practice on 100 patients has shown clonidine to have a statistically highly significant effect in controlling the number and the severity and duration of menopausal flushes. The relatively mild side effects and the absence of potentially harmful oestrogenic effects suggest that clonidine in the dose range 25 to 75 mug twice daily is a useful addition or alternative to the existing therapy for this common symptom of the menopause.

Renal biopsies were performed on 11 patients considered clinically and histologically to have pre-eclampsia. Immunofluorescent studies with fluorescein-labelled anti-IgG, IgA, IgM, and IgE complement, albumin, fibrin, and fibrinogen were carried out on the tissue obtained. Significant correlation was obtained between the clinical severity of the disease and the density and pattern of IgM and IgG deposition. Complement was found in glomeruli in severe cases, while complement deposition in the walls of afferent and efferent arterioles was a constant finding. These findings support the concept that an immunological mechanism may be responsible for the renal lesions in pre-eclampsia. If immunity does play a part in the pathogenesis of pre-eclampsia, possible mechanisms include the involvement of histocompatibility antigens and cross-reactivity of fetal and maternal tissues. Renal fibrin deposition in pre-eclampsia may be secondary to an immune process, an occurrence well-described in other forms of glomerulonephritis in man and other species.

1 The effects of oral doses of the bronchodilator drugs, salbutamol (4 and 8 mg) and terbutaline (5 and 10 mg), on physiological tremor, bronchial tone, heart rate and blood pressure were studied in six normal subjects. 2 Both drugs produced a significant increase in physiological tremor, compared with placebo. Terbutaline, but not salbutamol, produced a dose related response. No significant differences were observed between drugs. 3 Terbutaline (5 and 10 mg) and salbutamol (8 mg) produced a significant bronchodilatation compared with placebo. Dose related responses were obtained with both drugs, although this reached significance only with terbutaline. 4 Both doses of each drug produced a tachycardia, although this was only statistically significant with the high doses. 5 No significant change in blood pressure was observed with either drug. 6 Peak effects of salbutamol occurred between 1 and 3 h and terbutaline between 1 and 4 hours. Both drugs were still active at 6 hours.

1 Fifteen patients with diastolic blood pressures between 90 and 120 mmHg were admitted to a trial comparing placebo with practolol at doses up to 500 mg 12 hourly. 2 The trial was a double blind cross over study. Treatments were allocated at random and each treatment block lasted 12 weeks. 3 Ten patients completed the trial, and none of those who withdrew experienced serious unwanted effects. 4 Practolol caused significant falls in standing systolic and diastolic pressures and the supine diastolic pressure.

1 ST-91, 2-(2,6-diethylphenylamino)-2-imidazoline hydrochloride produces in animal experiments bradycardia, and in larger doses, also hypertension, due to α-sympathomimetic activity and probable central sympathetic inhibition. 2 The effects of ST-91, after oral administration, were studied in 10 healthy volunteers. A dose-dependent, significant decrease of the heart rate was observed. On average the resting heart rate was reduced by 11-19 beats/min (15-29%). During exercise the decrease of the heart rate was less pronounced. After the largest dose there was a fall of the systolic blood pressure during exercise averaging at 14-15 mmHg (11-12%). Otherwise the blood pressure remained unchanged. 3 Eight out of the 10 test-subjects complained of hair-raising and goose-flesh after all doses, due to the α-sympathomimetic effect of the drug. No toxic effects were observed.

Fourteen women taking oral contraceptives were admitted during a five-year period because of acute cerebrovascular lesions. A diagnosis of major cerebral embolism was established in four of them. No source of embolism was found, and thorough investigation failed to reveal any predisposing illness. Cerebral embolism was a probable diagnosis in several of the remaining 10 patients. A comparison was made with the strokes occurring in women not taking contraceptive pills in corresponding age groups.

Renal function was studied in 17 patients with rheumatoid arthritis who had each consumed between 5 and 20 kg of aspirin. After an interval of two years 14 of these patients—seven of whom had consumed a further mean of 2 kg of aspirin—had their renal function retested. No relation was found between total dose, rate, or duration of ingestion and any aspect of renal function that was studied. All patients had plasma creatinine levels within the normal range, though slight depression in creatinine clearance was not uncommon. From this study and other published data we conclude that aspirin rarely if ever causes analgesic nephropathy when prescribed alone in doses appropriate to the treatment of rheumatoid arthritis.

Data obtained in long-term epidemiological studies of arterial blood pressure in the general population in South Wales were analysed to provide background information for the rational planning of screening programmes for hypertension. The incidence rates for cardiovascular complications emphasize the much greater prognostic value of blood pressure measurements in men than in women. Proportionately fewer men are treated for hypertension at all ages and blood pressure levels; in the survey areas treatment for hypertension is less than satisfactory in both sexes but particularly inadequate among men. The data suggest that once a screening programme has been carried out rescreening can be made more efficient by allowing the intervals before re-examination to be determined by the initial findings rather than by age.

A method is described for distinguishing coagulation from fibrinolysis by three estimates of fibrinogen. This “fibrinogen series” together with plasma antithrombin and urinary urokinase have been compared in pregnant patients with venous thrombosis and pre-eclampsia. Evidence is presented for active coagulation during deterioration of the pre-eclampsia state and for enhanced fibrinolysis during improvement.

1 The effect of RX 72601, neostigmine plus atropine, or saline on neuromuscular blockade with (+)-tubocurarine was studied in a double blind trial in four healthy male volunteers. 2 The methods used to assess neuromuscular function were voluntary grip strength and indirectly evoked muscle twitches. The muscarinic action was assessed by measuring intestinal motility with a pressure sensitive radio pill, and auscultation of the abdomen. Blood pressure and pulse rate were also recorded. The degree of acetylcholinesterase inhibition achieved in whole blood was determined before and at intervals after the administration of the anticholinesterases. 3 Both RX 72601 (0.66-0.83 mg) and neostigmine (2.5 mg) completely reversed the neuromuscular blockade produced by tubocurarine, but the time course of reversal differed. RX 72601 (0.66-0.83 mg) produced similar inhibition of acetylcholinesterase in whole blood to neostigmine (2.5 mg). The doses of RX 72601 used caused minimal stimulation at muscarinic sites as evidenced by the limited effect on pulse rate and intestinal activity. 4 It was concluded that RX 72601 could be safely used to reverse the effects of neuromuscular blockade without the need for premedication with atropine.

Episodes of clotting that occurred in 22 patients on regular haemodialysis were studied over a six-month period. The venous pressure during dialysis and the radiology of the Teflon-Silastic arteriovenous shunt were found to be satisfactory guides for the management of the shunt. The failure of the shunt during the early stage was mainly due to technical reasons. Histological study of the excised vessels in removed long-term shunts showed that these had failed because of rigidity and thickening of the vessel wall due to calcium and iron deposits or chronic inflammation, or both.

Thermal, metabolic, and circulatory responses were studied in six hill-walkers taking part in a 28-mile (45-km.) walk in rough country in autumn and winter, air temperatures being 6 to 12 degrees C. and -2 to 2 degrees C., respectively.Though they were an apparently well-matched party, the walkers had to split into three pairs to avoid exhaustion. They adjusted their clothing so that mean skin temperatures were similar in both warm and cold conditions, the average value being 30.5 degrees C. compared with the resting comfort range of 33 to 34.5 degrees C. When, on the winter trial, skin temperatures were lowered by reduction of clothing, mean skin temperatures fell to 26.5 to 27.8 degrees C., one subject showing a value of 21.3 degrees C. These temperatures were associated with moderate discomfort from cold.Gut temperatures during exercise, measured with a radio pill, averaged 38.7 to 37.9 degrees C. on the autumn exercise. Slightly lower values were observed in winter, but this was associated with slower walking rather than cold stress. A fat and a thin subject walking together with minimal clothing showed widely different temperature responses, the fatter subject having a lower skin temperature and higher gut temperature than his companion. These results were compared with other results on extreme cold stress and discussed in relation to hypothermia. Heart rate and blood pressure findings were unremarkable, except for increased post-exercise heart rates and standing/lying heart rate differences, and a tendency to postural hypotension associated with exhaustion. Blood volume was not reduced in exhaustion and there were no significant changes in blood electrolytes or other constituents apart from a small rise in potassium. Ketonuria developed in all subjects.

Direct arterial pressure and electrocardiogram have been measured continuously over a period of 24 hours in 15 patients. Observations have been made on the behaviour of these variables during 30 separate episodes of motor car driving. The patients were divided into three groups: (1) five normotensive subjects, (2) five patients with essential hypertension who were not receiving therapy, and (3) five patients with angina pectoris who were either normotensive or hypertensive.In all but one subject, apart from variable changes in heart rate, no significant arrhythmias or S-T segment changes were observed in the electrocardiogram. The arterial pressure remained remarkably stable throughout the driving period in all three groups and there was no significant difference between the levels of blood pressure at the beginning and end of a journey. There were short periods of raised arterial pressure during driving related to such episodes as overtaking, but these quickly returned to baseline levels. Two patients experienced anginal pain during driving.It is concluded that motor car driving does not have such a pronounced effect on the blood pressure as might have been thought.

The circulatory and metabolic effects of inhalation of oxygen in high concentration were investigated in 50 patients with acute myocardial infarction. The heart rate, arterial blood pressure, cardiac out-put, blood gas tensions, pH, and lactate and pyruvate levels were measured. In general, oxygen inhalation produced a fall in cardiac output and stroke volume and a rise in blood pressure and systemic vascular resistance. In a small number of patients with very low cardiac out-puts there was a rise in output. A substantial rise in arterial oxygen tension was obtained even in patients with low initial values. The raised arterial blood lactate levels which were frequently present were reduced after oxygen. The therapeutic implications of these effects are discussed.

Massive pulmonary embolism was confirmed by pulmonary arteriography in 23 patients. All were seen between 2 and 48 hours after the onset of embolism and none had pre-existing cardiorespiratory disease. Fifteen were treated with streptokinase and eight with heparin. Factors which might influence prognosis and rate of resolution were similar in the patients in each group, and there was no significant difference between the groups in terms of pretreatment haemodynamic or arteriographic findings. Haemodynamic and arteriographic findings after treatment for 72 hours provided an objective measurement of resolution, which was significantly greater in the streptokinase-treated patients. There was no mortality in either group, but treatment had to be changed in two heparin-treated patients because of clinical deterioration. The principal complication of treatment, seen more often in the streptokinase-treated patients, was bleeding from cut-down or operation sites.

Three patients with severe tetanus had episodes of profound arterial hypotension lasting from minutes to hours. The blood pressure was recorded continuously for 13, 19, and six days respectively by an intra-arterial catheter, and other measurements included heart rate, central venous pressure, cardiac output, and blood gases. The hypotension was distinguished from that of “shock”, for there was no clinical evidence of peripheral vasoconstriction and no tachycardia. It could not be attributed to disturbances of salt and water balance. During episodes of hypotension the blood pressure fell as low as 32/16 mm Hg, the heart rate fell from a mild tachycardia to normal values or a mild bradycardia, and the central venous pressure did not rise. The onset and the end of such episodes was often abrupt and the hypotension was often produced in response to a stimulus. In one patient extreme hypotension followed the aspiration of secretions from the trachea. These changes may represent another effect of tetanus on autonomic nervous activity, including impairment of baroreceptor reflexes.

The incidence of dumping after truncal or selective vagotomy with pyloroplasty and highly selective vagotomy without a drainage procedure was assessed both clinically and experimentally. At a gastric follow-up clinic dumping was found to be significantly less frequent in patients who had undergone highly selective vagotomy without a drainage procedure than in patients who had undergone truncal or selective vagotomy with pyloroplasty (P < 0·05 or < 0·001, respectively). Hypertonic glucose given by mouth provoked the onset of dumping in 20% of patients with duodenal ulcer before operation, in 73% after truncal vagotomy and pyloroplasty, in 80% after selective vagotomy and pyloroplasty, and in 47% after highly selective vagotomy. The test meal also produced significantly greater decreases in blood pressure and increases in pulse rate in patients who had undergone vagotomy with pyloroplasty than in patients who had undergone highly selective vagotomy.

Intermittent methohexitone for conservative dentistry has been shown to cause clinically undetectable respiratory obstruction, depression of the laryngeal reflex, and arterial hypoxaemia. Because of the pronounced decrease in total peripheral resistance, the blood pressure was maintained only by large increases in cardiac output. Furthermore, the output of the heart could not increase when challenged by hypoxia.

Cerebral blood flow was studied by the arteriovenous oxygen difference method in patients with severe hypertension and in normotensive controls. The blood pressure was lowered to study the lower limit of autoregulation (the pressure below which cerebral blood flow decreases) and the pressure limit of brain hypoxia. Both limits were shifted upwards in the hypertensive patients, probably as a consequence of hypertrophy of the arteriolar walls. These findings have practical implications for antihypertensive therapy.When the blood pressure was raised some patients showed an upper limit of autoregulation beyond which an increase of cerebral blood flow above the resting value was seen without clinical symptoms. No evidence of vasospasm was found in any patient at high blood pressure. These observations may be of importance for the understanding of the pathogenesis of hypertensive encephalopathy.

When used in the treatment of hypertension propranolol is at least of similar potency to bethanidine, guanethidine, and methyldopa. Propranolol does not produce postural or exercise hypotension and it seems that it is often more acceptable to patients than conventional drugs. It usually produces the best control of the supine blood pressure. A series of 109 hypertensive patients was treated with propranolol; in nine the drug was withdrawn. In 92 of the patients a supine or standing blood pressure of 100 mm. Hg or less was achieved. Eighty of the patients had previously been treated with other potent drugs, and close comparisons and prolonged follow-up in 17 patients showed that diastolic pressures of 100 mm. Hg or less were achieved in more patients after propranolol than with guanethidine, bethanidine, or methyldopa. Sensitivity to propranolol varies widely, and dosage should be increased gradually. The hypotensive effect often takes six to eight weeks to reach its maximum. Propranolol reduces cardiac output but may also act by reducing the cardiac component of pressor stimuli; as a result the baroreceptors gradually regulate the blood pressure at a lower level. It is contraindicated in patients with obstructive airways disease or in uncompensated heart failure.

Metabolic studies in 100 women developing hypertension on combined oestrogen-progestogen oral contraceptives have been compared with similar studies in normotensive women on oral contraceptives, matched for age and duration of contraceptive use, and in women not taking contraceptives. The metabolic changes known to be induced by oral contraceptives—impaired glucose tolerance, elevated blood pyruvate levels, and raised serum lipid concentrations—were found to be exaggerated in the matched hypertensive group, largely due to pronounced abnormalities in 33 subjects with diastolic blood pressures over 110 mm Hg. Women developing severe hypertension were older, more obese, and of higher parity than those with mild hypertension and there was a high incidence of previous toxaemia of pregnancy in the hypertensive group. The results show that in women on oral contraceptives changes in blood pressure and in metabolic functions tend to be correlated with one another, and are consistent with the hypothesis that oral contraception induces a primary biochemical effect whose expression in the individual is determined by intrinsic factors including genetic constitution, age, weight, and parity.

In a study of 2,149 emergency admissions because of haematemesis or melaena during a 15-year period, the sex ratio, age distribution, and main diagnostic groups showed no major change. Various factors affected the prognosis, such as the age of the patient, the underlying diagnosis, a low blood pressure on arrival at hospital, gross anaemia on arrival there, and the pattern of bleeding after admission. The fatality rate remained virtually constant throughout the period studied in spite of changes in diagnostic methods and management. There was a changing pattern in the type of operation performed in the treatment of bleeding peptic ulcer. Vagotomy combined with a drainage procedure and with a direct surgical attack on the bleeding point became more widely used at the expense of Polya or Billroth I partial gastrectomy and gave the best results. It is at first paradoxical that improved surgical results should not be reflected in a general improvement in the fatality rate, but this finding can be explained by the smaller proportion of patients treated by emergency surgery in the later years of the period studied. It is concluded that emergency surgery should be performed more frequently and that vagotomy plus drainage is the operation of choice in the peptic ulcer group.

The integrity of the autonomic nervous system was assessed in 11 Parkinsonian patients with symptoms suggestive of autonomic dysfunction. Three had the additional clinical features of the Shy-Drager variant of idiopathic orthostatic hypotension and were found to have a gross disturbance of vasomotor, sudomotor, pilomotor, and bladder function; assessment indicated that a lesion was present at sympathetic ganglionic level or beyond in two cases, though a more centrally placed lesion may well have been present also, as in the third case. In the remaining eight patients with paralysis agitans no unequivocal functional disturbance was found except in the bladder; nevertheless, the low resting blood pressure and the supersensitivity to intravenously infused L-noradrenaline in the three patients in whom it was tested is taken to imply defective regulation from higher centres, with a consequent reduction in impulse traffic at sympathetic nerve terminals. Such a concept is supported by experimental studies in animals and would account for the low renin and aldosterone secretion rates and reduced noradrenaline formation reported by others in patients with paralysis agitans.

In a titrated dose cross-over trial of debrisoquine and methyldopa in 38 hypertensive patients neither drug was superior in lowering supine or standing diastolic pressure with a minimum of side effects. Methyldopa caused significantly greater reduction of supine (P

Four patients are reported in whom perforation of the colon followed exchange transfusion for haemolytic disease of the newborn. This association seems to be more than coincidental, and possibly the perforation is due to a vascular accident occurring as a mechanical result of the exchange transfusion. The insidious onset of colonic perforation may be recognized early by the passage of blood per rectum. There is no place for conservative treatment, and once the diagnosis has been made treatment must include broad-spectrum antibiotics and laparotomy.

Hypertensive patients were treated with either chlorthalidone or frusemide for periods of two to four months. Reduction in blood pressure was seen with chlorthalidone but not with frusemide. This hypotensive effect appeared to be independent of the natriuretic effect.A significant reduction in total exchangeable potassium (K(E)) was seen with both agents, but no patient showed adverse symptoms or signs. There was no alteration in maximal urinary concentration or acidification, or in intravenous glucose tolerance or plasma insulin. It is concluded that potassium depletion of this degree does not require replacement therapy on a routine basis in hypertensive patients.

A daily infusion of 500-1,000 ml of 50% glucose containing 100-120 units of soluble insulin and 100-120 mEq of potassium chloride per litre was given to six patients suffering from hyponatraemia and congestive cardiac failure resistant to digoxin and diuretic therapy. In two patients there was no response, but four showed a striking improvement with a sodium and water diuresis, a rise in plasma sodium level, and in two cases a reversion from atrial fibrillation to sinus rhythm. It is suggested that insulin, glucose, and potassium given by the intravenous route in adequate dosage forms a useful adjunct to the management of severe congestive heart failure.

A controlled double-blind study of verapamil in 16 anginal patients used two dose levels—40 mg. t.d.s. and 120 mg. t.d.s.—and was compared with propranolol 100 mg. t.d.s. At the higher dosage verapamil produced a significant improvement in frequency of angina, trinitrin consumption, and exercise tolerance, and had a favourable and significant effect on the amount and duration of ischaemic S–T depression occurring in the electrocardiogram during exercise. In the lower dose verapamil produced significant subjective improvement but no objective benefit in the electrocardiogram. No significant differences were found between the favourable results with the higher dosage of verapamil and propranolol. The action of verapamil is not fully understood, but its favourable effects in angina may be due to a direct action on the myocardium, possibly with accompanying coronary vasodilatation.

The clinical, laboratory, and radiological findings in a group of 107 non-pregnant bacteriuric women and 88 controls have been compared. A previous history of urinary tract infection was more commonly obtained from the bacteriuric women. The means of the diastolic blood pressures, serum ureas, and erythrocyte sedimentation rates were significantly higher in the bacteriuric group, and acquired renal abnormalities were demonstrated in 18% of the bacteriuric women as compared with 4% of the controls. It is concluded that screening for asymptomatic bacteriuria in the adult non-pregnant female population in many instances fails to detect urinary tract infection at an early and reversible stage.

Blood pressure, plasma renin activity, plasma sodium concentration, plasma potassium concentration, dietary sodium intake, and duration of dialysis have been measured under standard conditions in 89 patients on maintenance haemodialysis. No significant relation was found between plasma renin activity and blood pressure. Statistically significant correlations were found between plasma renin activity and plasma sodium concentration and between plasma renin activity and dietary sodium intake. Only one patient was found to have uncontrollable hypertension associated with a markedly raised plasma renin activity. Reasons are given for not performing bilateral nephrectomy in this patient. We believe the low incidence of uncontrollable hypertension and hyperreninaemia in our patients to be due to their slow introduction to haemodialysis, thus preventing violent swings in body weight, blood pressure, and renin secretion. Although plasma renin activity did fall with duration of dialysis, all 15 patients who have been on maintenance dialysis for longer than five years have normal levels.

Not much is known about the feasibility or the advantages of treatment of subjects with only mild hypertension. There are also many unresolved problems in the outpatient management of hypertension of any severity. In this study an analysis is made of the results of a controlled treatment trial of 56 subjects with mild hypertension, 26 of whom were treated with active drug and 30 initially with placebo, and a treatment programme involving 81 patients with moderate or severe hypertension, all of whom received treatment with active drug. The drugs used in this study were bethanidine, debrisoquine, and guanethidine. Follow-up for 12 months or more was achieved in 87% of individuals admitted to the study with mild hypertension and in 80% with severe hypertension. Many subjects with only mildly raised blood pressure were found to have cardiac enlargement on chest x-ray (up to 45%) and left ventricular hypertrophy on electrocardiogram (up to 51%). Rapid rates of rise of blood pressure were observed in many placebo-treated subjects; but good blood pressure control was achieved in 63 out of 104 patients (61%) receiving active drug in both the mild and the severe hypertension groups. The drugs used showed approximately equal effectiveness in controlling blood pressure.