Consideration of human hypertension with respect to its renal origin and therapy

Good therapeutic effect in essential hypertension has been claimed for such diverse methods as salt restriction on the one hand, and sympathectomy on the other, to say nothing of thiocyanate therapy, psychotherapy and a host of others. Such an attitude toward treatment can lead only to the conclusion that none is adequate. This is quite understandable in view of the fact that the ultimate cause of hypertension is unknown and that all treatment at the present time is purely empirical. Accepting this then as a fact, we have to define more closely our objective in treating persons with hypertension with our limited information. There appears to be a distinct division of opinion among those who believe that alleviation of subjective symptoms is a desirable objective and those who believe that lowering the level of blood pressure is a more desirable objective. It seems clear that subjective symptoms in hypertensive disease do not, with perhaps few exceptions, depend upon the level of blood pressure since it is a common observation that lowering of the blood pressure level by any means is not necessarily accompanied by alleviation of symptoms and that alleviation of symptoms may occur even when the blood pressure level has not been altered. The ultimate goal of symptomatic measures is relief of subjective symptoms and while this is frequently accompanied by lowering of the blood pressure level, the latter is of secondary importance. Decline of blood pressure level is not to be interpreted as regression in the underlying cause of the disease, but rather as amelioration of those secondary and reversible factors which are superimposed on the basic causative mechanism. While relief of subjective symptoms may completely rehabilitate a hypertensive patient, mere lowering of the blood pressure level without relief of symptoms serves no such purpose. This is not to imply that lowered blood pressure is necessarily without some benefit, but rather that it is not to be considered the prime objective of a plan of symptomatic management. Perhaps the most valuable single device in rehabilitation of the hypertensive patient is psychotherapy; the planned and detailed methods employed by the psychiatrist are not necessarily superior to repeated conferences with a sympathetic physician who will give attention to problems responsible for emotional instability. A physician properly trained in general medicine and with an interest in psychiatry is competent to undertake such treatme