A Prize-Wnning Paper

THE POSTURAL BLOOD PRESSURE METHOD

OF EVALUATING ADRENAL HYPOFUNCTION.

Paper written by
D. C. RAGLAND, M.D.
Los Angeles, Cali,, 1920

WHAT IT IS A screen -t e st for hypoadrenia accomplished by measurio:g the body's ability to

compensate for the: hydrostatic: effects of gravity.

WHAT IT MAY Hypofunction of the adr.enal glan ds:

INDICATE
a. Cardiovasular efficiency
b. O b 1ect ive method of di agnosin g the asthenic syndrome:

weakne ss
d izz iness
chronic fatigu e

PHYSIOLOGICAL The s p l an chn ic veins, being devoid of valves, ore dependent upo n nerve function
BASIS for their tone .

The tone of the splanchnic nerves is under the control of the adrenal system,
THEREFORE:
Week s p l anchni c veins mean
Week splanchnic nerves, hence
Weak adrenols

CLINICAL The systolic blood pressures are cmpored between two different readings:
METHOD a. One taken in recumbent po si t io n , end
b. One token in erect or standing position.

ln. the n ormal , the sys tolic blood press u re is som e 4 to 10 mm. higher in the stand
ing position than it is in the recumbent.

If, however, the blood pressure is lower in the s tanding posi t ion, hy poadre n ia may
be s uspected . We have observed a drop of as much a s 40 mm. nd it is our ex
a

per i en ce that the degree of drop is proportionate to the degree of hypoadrenia

present.

CONCLUSION Often th s simple screen-test may be all that is n e eded to indicate the hypoadrenia
sy n d ro me . The test requires but little extra office time. !t is also useful,.i
evaluating the results of treatment.
 A Prize-Winning Paper

THE POSTURAL BLOOD P R ES S URE lETHOD OF EVAUATING ADRENAL HYPOFUNCTION

Written by
D. C. RAGLAND, M.D.
Las Angeles, Calif. 1920

1. Adrenal Hypofunction In Everday Practice

The patient with adrenal hypofunction as seen in everyday p ract i ce is not necessarily a case of
Addis on .1 s Disease1 bu t the common conditions unquestionably suggest an adrenal basis.

Many of the more pronounced cases come complaining of weakness, among othe r things. BUT,
HOW ARE WE TO KNOW OBJECTIVELY THAT THEY ARE WEAK?

In these cases, determine the POSTUHAL GLOOD PRESSURE (in the recumbent and in the
erect positions) and you will be surprised many times at the great difference in the systolic

figures.

2. P h ysi o l og ical Basis

In the normal , the systolic blood pressure is some 4 to 10 mm . higher in the standing or erect
position than it is in the recumbent position. This is d ue to the ability of the body mechanism
to over-compensate for the hydrostatic effects of gravity. If we exa r:nine the splanchnic veins ,
\Ve fin d hat they are devoid of valves , and in this way differ from veins of the extrem i ties . The
strength of the splanchnic veins is dependent upon the qu ality of the nerve tone , for ariy muscle
is weak in proportion to the weakness of its nerve tone. If the nerve tone is wea k , the vein
wall is weak and cannot compensate for the effects of gravity. Hence t he drop in systolic
blood pressure in the erect posit ion a s compared with the recumbent position. T he spl anchnic
nerves are controlled by the adrenal system; therefo re , weak splanchnic veins mean weak
splanchnic nerves and weak adrenals.

3. Studi es Cited

Hill ( l) found that anything that weakens the spl anchnic vasomotor mechanism interferes with
compensation . Sewall (2) has s hown that persons in whom there is an excessive gravitation of
blood to the lower limbs and spla nchnics are p hys ic all y weak, nervously unstable a nd fre
quently suffer from headaches and dizziness in the errect positio n . Schneider ( 3) utilizes
pas tural systolic blood pressure determinations in rating the cardiovascular e fficiency of men
in air service. Crampton ( 4) has shown that the systolic pressure falls in the erect p osition in
people weakened by dissipation, overwork, loss of sleep or disease.

4. Subacute Hypoadrenia

Among the subacute cases, we find those following severe illness asso ciated with fever, such
as typhoid, influenza, pneumonia, etc., also, anesthesia, alcoholism, prolonged worry (which is
in fact really excessive mental work), focal infections and intoxications.

A recent case will serve to i llust rate the pronounced a drenal depression which may be caused
by worry: Mrs. E.J. W. had been feeling very dizzy and weak for ten days. She compla ined of
11
her head "feeling queer. Systolic blood pressure was 128 recu m b en t, 100 erect. Urine a nd
physi c a l examination negative. Adrenal in chloride solution 1: l 000, 10 drops e very 22
hours was given by mo uth. Next day, July 14th, 1920, recumbent 120, erect 110; Ju ly 15th;
1920, recumbent 116, erect 116, s ystoli c blood pressures. The patient said she felt fine.
;:, , F ocal Infect io n Ca se

The effect of focal infection upon the activity' of the adrenals is n i cely shown by the following
case his tory : an old man, age 70, was seen a y ear ago wi th Dr. J .R. Perry, of herman, Calif.
His bl ood pressure had been elevated to 196 mm. Dr. Perry found some pus teeth and advised
their removal. This was done and in two weeks the blood p re s u re fell t'o 136 mm . systolic, but
at t he same time he developed " spells " lastin g 10 to 15 seco nd s. These spells were always
pre ced ed by a " c hewing movementu of the face and jaw musc les. Jacksonian epilepsy was
suspected by the attending phys ician.
The systolic blood pressure was now 136 recumbent, bu t was o n ly 100 ere ct . Sergenes White
Lin e (not e : this . method outlined below) was also present. Adrenal ,h ypo fun ct ion was my d iag no
sis. I reasoned that t he toxins .from the pus teeth had serv ed t o i rr i tate and stimulate the
adrenals; when these toxins were no longer formed t he excessive s t imu la tion ceased and there
was a depression following. Adrenal gland with thyroid, sperrn in and calcium glycerophosphate
were g i ven, with prompt recovery and r eturn to ranch life by the patient in about one month.

6. H y po adren ia and the Chronically Ill

The term 11 neuro-circulatory a sthenia " is good as far as it goes, b ut is it not r eally hypo..
adrenia? Often I have been confronted by people who say to me, "What is t he matter with m e ?
I'm not worth any th i n g! My doc t or tells me there is nothing the matter with me, but I know there
is." Anyone doing much work with these chronically ill, those who are not sick eno ugh to be in

bed , but at the same time are not we ll enough to efficiently pe r form their da ily tasks. Their
. chief complaint is t ha t they do n ot feel well .

I d i stin c t ly remember a p ro mine n t business man who ha d the "flu'' in 1918. He consulted s e ve ral
doctors about his condition and was advised to 'take a trip and forget it!" He t ook the trip, bt.tL
was no t benefited. Then, his own doctor told him "he was lazy."

Sergent's "WHITE ADRENAL LINE" a d ermogra phical reaction was

de scri be d as "la lign e blanche surrenale" by Emile Sergen t , of Paris

(Endocrinology, 1917, i. p. 18), upon which a con ven ie nt test is based.
The test consists .in lightly stroking the skin over the abdomen with
a blunt ins trum e nt such as a fountain pen. A positi ve reaction con
sist s in t he appearance, within a few seconds or not more than a half
a minute , of a pale line or band fo llowing t he course of t he stroking.
G rad ually this becomes more and more di s t inc t and extensive, so tha t
eventually the l in e exceeds in size the actua l area stroked. The
white line attains it s maximum clearnes s in about a m inut e and per..
sists for two or thre e minutes before gradual ly d isappearing.

This, at le ast , is w hat is to be expected in well-defined cases of

adr enal insufficiency - the only instance n wh ic h t he test has any
real value. This sign does not always occur in e very case , and is
therefore of only supplementary diagnostic value. .. .. from Harro w er' s
11
Pract i ca l Endocrinology" p. 255

His c o m pla in t was about like this: he arose and felt fairly well, breakfasted and w e n t to his
work. By noon he was tired, by 3 P.M. he was very tired, and by 6 P.M. h e was "all in."
After dinner he had no desire for readin g 1 dancing, cards or thea ter; the only th in g he wanted to
do was go to bed. This he did by 8:30 or 9 P.M. an d then w o u ld lie awake u n til l or 2 A.M.
b efore he could go to s l e ep . Examination sho we d no organi c d i sea se .

Olood pressure recumbent w as 132, e rec t 118 mm. systolic, Nov e m be r 13, 1919. Small dose s of
 adrenal gland with thyroid, spermin and c alciu m glycerophosphate was given daily. Finally on
January 15th, 1920 he called me up and sai d, err think you. had better give me the once-over,
doctor." When he came in, his systolic pressure was 118 in the recu m ben t and 118 mm. in t he
erect positions . I remarked that he ought to f eel fine. He. then said, "If people only knew what
these capsules would do for them, they would be fighting for them. with guns."

7. Acidosis Case His to ry

I wish to re la te my experience with a case seen with Dr. B. G. Pi nke rton of Los Angeles. In
August, 1918, D. R., age 18, one Monday night suddenly develop ed a fe ve r of 104 degr ee s ,
which by Tuesday noon subsided to 97 degrees. The b oy was delirious con t inu o u sl y from the
onset. Tuesday afternoon he began to vomit and have involu ntary urination and defecation. One
consultant suggested nn early tuberculous meningitis; another suggested thrombosis of the
l ateral sinus, or perhaps a brain abscess. Wednesday morning brought no change. At 9 A.M.
Wednesday I saw the patient and f ound the above condition, with a temperature of 97 deg r ees,
pulse 140, systolic blood press ure 90 mm. The urine contained both albumin and casts, wi th
plenty of acetone.

My diagnosis was acute adrenal exhaustion from the acidosis. Adrenalin chloride and Kalak
Water were given by mouth with a solution of bicarbonate .of soda and sodium chloride by rectum,
b y the Murphy Drip Method. This regime soon ch anged the whole picture. By 5 P.M. the pulse
was 1 10, t h e systolic pressure was 100 mm. , with the cessation of the vomiting a nd les sening of
the delirium. The next morning the puls e was 76, systolic blood pressure was 120, te mperatu re
98.6 and the boy wanted to go home. If that boy had been anesthetized and an operation per
formed for sinus thrombosis, what chance would he have had for recovery?

8. The Re lation of the Mineral Metabolism

The subject of acidosis is clos ely allied to demineralization. The adrenals, and, in fact, all the
duc t l ess glands, must have the proper amount of the proper mineral salts in the plasma for thei r
perfect functioning. Hypoadrenia, then, also means demineralization, and adrenal feeding will
not accomplish much unless we s uppl y these mineral salts. Stheeman (s) has shown, by using
th e method of De Waard, hat the calcium content of the blood is low in neuroses of the vegeta
tive nrvous system, universal asthenia, and tuberculosis; and that the seve ri ty of the condition
is reflected in the lowness of the blood calcium conte n t and that the calcium content rises as
t he cond itio n improves.

9. P os sible Causes of Acute Hypoadrenia

In the acute cases there has been one of the follo w ing:

a. Violent injury
b. Severe hemorrhage
c. Over wh elming infection and intoxication
d. Severe psychic s hock
e. Acute acidosis

10. S ugg este d Procedure

The treatment of hypoadreni a, whether it be acute, subacute , or chronic should be as follows:

1. Support the adrenals by adrenal feeding instead of whipping them .,vith s trychnine .

2. Sp a re them by removing focal infection and combating intoxication.

3. S u pply the mineral sa l t s as found in the blood stream, e spe cia tly calcium ( t his can be
done by administering the various salts in definite amounts).
 4. Insist upon a diet rich in foods containing bases, with a minimum of foods that produce
acids.

11. Bibliography

( t) Hill: J. Physiol. (London), 1895, xviii, 15

( 2) Sewall (H): 11 Clinica l Significance of Postural Changes in Blood Pressure1 etc. 11, Am. 1.
l\ied. Sc. (Phila.), 1918 clviii, 786
( 3) S chneider (E.C.): "Cardiovascular Rating as Measure of Physical Fatigue and Eff iciency "
J .A.l.A. (Chicag o), 1920, lxxiv, 1507
(4) Crampton (C.W.): "The Blood Ptosis Test and Its Use in Experimental Work in Hygiene",
Proc. Soc. Exper. Biol. & Med. (New York), 1914-15, xii, 119
( s) Stheeman (H.A.) and Arntzeius (A.K. W . ) : "Signs of Calcium Defici t" Nederl. Tijdschr. v.
Geneesk, (Amsterdam), 1920. i. 1030

FORM NO. LK55S