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Bioassay of oral diuretics
610
Southern
Society for Clinical Research
variations in perfusion pressure on the caliber of the fundal vessels in normal subjects and patients with postural hypotension. Eyeground photographs were obtained under constant photographic conditions on subjects in the erect and recumbent position while breathing air and 100 per cent oxygen, during and after the Valsalva maneuver and during neck compression. In the normal erect subject the retinal vessels were larger than when recumbent and the magnitude of change was similar to that observed with variations in arterial oxygen tension. The same response was observed in patients with postural hypotension, with a fall in blood pressure before syncope occurred. The Valsalva maneuver and neck compression produced slight alterations in vessel size. This evidence suggests that the retinal circulation is continuously adjusted to maintain a constant retinal oxygen tension. It is postulated that these mechanisms have a role in maintaining normal circulation of the brain and retina and that their impairment may be a factor in the development of some retinopathies. OBSERVATIONS ON MALNOURISHED PATIENTS WITH EDEMA. W. A. Sodeman and K. L. Mukherji (by invitation), School of Medicine, University of Missouri, Columbia, MO., and School of Tropical Medicine, Calcutta, India. Eight famine victims in Calcutta were selected on the basis of (1) malnutrition resulting from inadequate diet and (2) the development of edema in the course of the illness. In some, diuresis occurred at onset of treatment, accompanied by a reduction in weight and in the thiocyanate space with little change in the plasma volume. In four such patients the weight stabilized, minimal edema gradually receded, the thiocyanate space diminished, and plasma volume increased. Diuresis was constant and disproportionately great for the change in thiocyanate space. In two patients diuresis continued during a period of relatively constant weight, and plasma volume and thiocyanate space did not change appreciably. In two, recurring clinical edema followed a primary diuresis during which the clinical edema present on admission had cleared entirely. There was no appreciable change in body weight, the effect presumably resulting from internal shifts in body water. These data indicate that in the edema studied, important water shifts occurred other than those
between vascular and extracellular space, presumably between tissue cells and the extracellular space, suggesting the importance of the participation of the tissue cells in the edematous state studied and in the fundamental mechanism of the edema. BIOASSAYOF ORAL DIURETICS. Charles L. S’urr, Ralph V. Ford (by invitation) and John H. Moyer. V. A. Hospital and the Depts. Medicine, and Pharmacology, Baylor University College of Medicine, Houston, Tex. Four drugs were selected for study: neohydrin,@ 60 mg.; diamox,@ 750 mg.; dirnate,@ 6 gm.; cumertilin,@ 60 mg. The drugs were given in three divided doses daily for two consecutive days. Patients with minimal heart failure controlled on constant sodium intake, which resulted in slow retention of fluid, were followed by measurement of electrolyte excretion (Na, K, Cl), urine volume and body weight. Diuretics were given only at a constant baseline weight for each patient. In support of the use of sodium excretion as a measure of response to a diuretic, the following two facts were noted: First, on the basis of a large number of tests of both oral and parenteral diuretics, a reasonable correlation between sodium excretion increase and additional water loss was found. Second, the response to the diuretics was more consistent when measured in terms of sodium excretion than in terms of water excretion. Indeed, the coefficient of variation (s/j;_) was larger for water loss than for sodium excretion in twelve of thirteen series of tests. A simple, non-parametric test shows that this result is statistically significant (P = 0.0026), and hence the coefficient of variation cannot be regarded as equal for the two measures. The coefficient of variation for body weight change was three to five times larger than that for water excretion. The mean increase in mEq. of sodium excretion was as follows: neohydrin, 51.27 f 25.48; diamox, 50.9 _+ 28.85; dirnate, 37.3 f 28.72; and cumertilin, 20.79 + 18.68. The standard error was 31-constant in each case. While these levels of sodium excretion are not statistically distinct, there is a difference in distribution of the response to the four drugs into two groups. The first group with a mean sodium increase to 16, which was smaller than the standard error of the control sodium excretion, consisted of 78 per cent of the patients receiving cumertilin, AMERICAN
JOURNAL
OF
MEDICINE
611
Southern Society for Clinical Research 57 per cent dirnate patients, 33 per cent neohydrin, and 14 per cent diamox. The second group with a mean sodium increase of 45 to 91 mEq. consisted of 76 per cent of the patients receiving diamox, 67 per cent of those receiving neohydrin, 43 per cent dirnate and 22 per cent cumertilin. SURVIVAL OF HUMAN ERYTHROCXTESTAGGED WITH RADIOACTIVE CHROMIUM: A METHOD YIELDING RESULTSCOMPARABLETO THE A~HBY TECHNIC. D. A. Sutherland (by invitation), Mary Sue McCall (by invitation), Margaret T. Groves (by invitation) and E. E. Muirhead. Radioisotope
Unit, Dallas V. A. Hospital and Depts. Medicine and Pathology of the Southwestern Medical School of the University of Texas, Dallas, Tex. The following method for the estimation of the survival of erythrocytes by radioactive chromium yields results comparable to the Ashhy technic. The plasma from 50 to 65 ml. of blood is withdrawn, set aside and the RBC are incubated with saline having 200 to 300 microcuries of Crsl (Naz Cr 61 04) for one hour at 37”~. while agitated. The RBC are washed three times with cold saline, resuspended in the original plasma and given intravenously. The twenty-four-hour sample is the initial 100 per cent reference. Radioactivity of samples (4 ml. daily for three to five days, then weekly) and correction for decay are measured in a sodium iodide-thallium scintillating well-type crystal. The ratio of radioactivity of each sample to the activity at twenty-four hours is plotted against time in days on linear coordinate paper. Five normal humans received 1 pint of blood for the Ashby technic a segment of which was tagged with Cr 51. The results of the two methods are in the table following: Per cent Loss per Day Case
1 2 3 4 5 AVerage
APRIL,
1954
Ashby
Crsl
0.88 0.82 0.91 0.98 0.95 0.91
1.0 0.85 0.85 0.94 0.91 0.91
In five additional normals the survival of their own RBC tagged with Crsl gave results as in the table. With Cr6i tagging the curve of degradation in normals has been smooth, slightly curvilinear, with extinction at 100 to 112 days. HOMOZYGOUSHEMOGLOBIN C: A NEW HEREDITARY HEMOLYTIC DISEASE. Douglas W. Terry, Arno Motulsky and Charles E. Rath (introduced by Harold Jeghers). Dept. Medicine, Georgetown
University Hospital and Walter Reed Medical Center, Washington, D. C.
Army
A forty-four year old Negress had arthralgia, splenomegaly and mild microcytic anemia. Paper electrophoresis revealed 100 per cent type C hemoglobin. Less than 1 per cent fetal hemoglobin was detected by alkaline denaturation. Sickling was negative. Blood films revealed many target cells, fragmented cells and rare normoblasts. Reticulocytes were 2.1 per cent. The bone marrow showed moderate normoblastic hyperplasia. Osmotic fragility was decreased and mechanical fragility slightly increased. FecaI urohilinogen was increased. Transfused normal cells had a survival of 106 days demonstrated by serial quantitative eIectrophoretic determinations. This excluded an extracorpuscular hemolytic mechanism. Cr5r and Ashby studies of the patients’ red cells were consistent with a survival of approximately sixty days. Family study showed four siblings and two living daughters to be heterozygous carriers of Hh C (34-40 per cent Hh C). Both daughters and a niece with Hh C trait had frequent episodes of arthralgia. Target cells were prominent and osmotic fragility was decreased in C trait patients without further evidence of hematologic disease. The clinical and hematologic picture of homozygous Hb C as found in several other yet unpublished cases has closely resembled the findings in our patient and must he differentiated from Thalassemia minor. Homozygous Hh C disease, a genetic counterpart of sickle cell anemia, represents a definite new hematologic entity. HUMAN SERUM ALBUMIN TAGGED WITH 113’ IN PATIENTSWITH ASCITESCAUSED BY ABDOMINAL CARCINOMATOSISOR HEPATIC CIRRHOSIS: THE RATES OF INTERCHANGEBETWEENTHE VASCULAR COMPARTMENTOF PERITONEALCAVITY. Malcolm P. Tyor (introduced by Arthur C. Guyton). Medical
Division, Oak Ridge Institute Studies, Oak Ridge, Tenn.
of
Nuclear
Southern
Society for Clinical Research
variations in perfusion pressure on the caliber of the fundal vessels in normal subjects and patients with postural hypotension. Eyeground photographs were obtained under constant photographic conditions on subjects in the erect and recumbent position while breathing air and 100 per cent oxygen, during and after the Valsalva maneuver and during neck compression. In the normal erect subject the retinal vessels were larger than when recumbent and the magnitude of change was similar to that observed with variations in arterial oxygen tension. The same response was observed in patients with postural hypotension, with a fall in blood pressure before syncope occurred. The Valsalva maneuver and neck compression produced slight alterations in vessel size. This evidence suggests that the retinal circulation is continuously adjusted to maintain a constant retinal oxygen tension. It is postulated that these mechanisms have a role in maintaining normal circulation of the brain and retina and that their impairment may be a factor in the development of some retinopathies. OBSERVATIONS ON MALNOURISHED PATIENTS WITH EDEMA. W. A. Sodeman and K. L. Mukherji (by invitation), School of Medicine, University of Missouri, Columbia, MO., and School of Tropical Medicine, Calcutta, India. Eight famine victims in Calcutta were selected on the basis of (1) malnutrition resulting from inadequate diet and (2) the development of edema in the course of the illness. In some, diuresis occurred at onset of treatment, accompanied by a reduction in weight and in the thiocyanate space with little change in the plasma volume. In four such patients the weight stabilized, minimal edema gradually receded, the thiocyanate space diminished, and plasma volume increased. Diuresis was constant and disproportionately great for the change in thiocyanate space. In two patients diuresis continued during a period of relatively constant weight, and plasma volume and thiocyanate space did not change appreciably. In two, recurring clinical edema followed a primary diuresis during which the clinical edema present on admission had cleared entirely. There was no appreciable change in body weight, the effect presumably resulting from internal shifts in body water. These data indicate that in the edema studied, important water shifts occurred other than those
between vascular and extracellular space, presumably between tissue cells and the extracellular space, suggesting the importance of the participation of the tissue cells in the edematous state studied and in the fundamental mechanism of the edema. BIOASSAYOF ORAL DIURETICS. Charles L. S’urr, Ralph V. Ford (by invitation) and John H. Moyer. V. A. Hospital and the Depts. Medicine, and Pharmacology, Baylor University College of Medicine, Houston, Tex. Four drugs were selected for study: neohydrin,@ 60 mg.; diamox,@ 750 mg.; dirnate,@ 6 gm.; cumertilin,@ 60 mg. The drugs were given in three divided doses daily for two consecutive days. Patients with minimal heart failure controlled on constant sodium intake, which resulted in slow retention of fluid, were followed by measurement of electrolyte excretion (Na, K, Cl), urine volume and body weight. Diuretics were given only at a constant baseline weight for each patient. In support of the use of sodium excretion as a measure of response to a diuretic, the following two facts were noted: First, on the basis of a large number of tests of both oral and parenteral diuretics, a reasonable correlation between sodium excretion increase and additional water loss was found. Second, the response to the diuretics was more consistent when measured in terms of sodium excretion than in terms of water excretion. Indeed, the coefficient of variation (s/j;_) was larger for water loss than for sodium excretion in twelve of thirteen series of tests. A simple, non-parametric test shows that this result is statistically significant (P = 0.0026), and hence the coefficient of variation cannot be regarded as equal for the two measures. The coefficient of variation for body weight change was three to five times larger than that for water excretion. The mean increase in mEq. of sodium excretion was as follows: neohydrin, 51.27 f 25.48; diamox, 50.9 _+ 28.85; dirnate, 37.3 f 28.72; and cumertilin, 20.79 + 18.68. The standard error was 31-constant in each case. While these levels of sodium excretion are not statistically distinct, there is a difference in distribution of the response to the four drugs into two groups. The first group with a mean sodium increase to 16, which was smaller than the standard error of the control sodium excretion, consisted of 78 per cent of the patients receiving cumertilin, AMERICAN
JOURNAL
OF
MEDICINE
611
Southern Society for Clinical Research 57 per cent dirnate patients, 33 per cent neohydrin, and 14 per cent diamox. The second group with a mean sodium increase of 45 to 91 mEq. consisted of 76 per cent of the patients receiving diamox, 67 per cent of those receiving neohydrin, 43 per cent dirnate and 22 per cent cumertilin. SURVIVAL OF HUMAN ERYTHROCXTESTAGGED WITH RADIOACTIVE CHROMIUM: A METHOD YIELDING RESULTSCOMPARABLETO THE A~HBY TECHNIC. D. A. Sutherland (by invitation), Mary Sue McCall (by invitation), Margaret T. Groves (by invitation) and E. E. Muirhead. Radioisotope
Unit, Dallas V. A. Hospital and Depts. Medicine and Pathology of the Southwestern Medical School of the University of Texas, Dallas, Tex. The following method for the estimation of the survival of erythrocytes by radioactive chromium yields results comparable to the Ashhy technic. The plasma from 50 to 65 ml. of blood is withdrawn, set aside and the RBC are incubated with saline having 200 to 300 microcuries of Crsl (Naz Cr 61 04) for one hour at 37”~. while agitated. The RBC are washed three times with cold saline, resuspended in the original plasma and given intravenously. The twenty-four-hour sample is the initial 100 per cent reference. Radioactivity of samples (4 ml. daily for three to five days, then weekly) and correction for decay are measured in a sodium iodide-thallium scintillating well-type crystal. The ratio of radioactivity of each sample to the activity at twenty-four hours is plotted against time in days on linear coordinate paper. Five normal humans received 1 pint of blood for the Ashby technic a segment of which was tagged with Cr 51. The results of the two methods are in the table following: Per cent Loss per Day Case
1 2 3 4 5 AVerage
APRIL,
1954
Ashby
Crsl
0.88 0.82 0.91 0.98 0.95 0.91
1.0 0.85 0.85 0.94 0.91 0.91
In five additional normals the survival of their own RBC tagged with Crsl gave results as in the table. With Cr6i tagging the curve of degradation in normals has been smooth, slightly curvilinear, with extinction at 100 to 112 days. HOMOZYGOUSHEMOGLOBIN C: A NEW HEREDITARY HEMOLYTIC DISEASE. Douglas W. Terry, Arno Motulsky and Charles E. Rath (introduced by Harold Jeghers). Dept. Medicine, Georgetown
University Hospital and Walter Reed Medical Center, Washington, D. C.
Army
A forty-four year old Negress had arthralgia, splenomegaly and mild microcytic anemia. Paper electrophoresis revealed 100 per cent type C hemoglobin. Less than 1 per cent fetal hemoglobin was detected by alkaline denaturation. Sickling was negative. Blood films revealed many target cells, fragmented cells and rare normoblasts. Reticulocytes were 2.1 per cent. The bone marrow showed moderate normoblastic hyperplasia. Osmotic fragility was decreased and mechanical fragility slightly increased. FecaI urohilinogen was increased. Transfused normal cells had a survival of 106 days demonstrated by serial quantitative eIectrophoretic determinations. This excluded an extracorpuscular hemolytic mechanism. Cr5r and Ashby studies of the patients’ red cells were consistent with a survival of approximately sixty days. Family study showed four siblings and two living daughters to be heterozygous carriers of Hh C (34-40 per cent Hh C). Both daughters and a niece with Hh C trait had frequent episodes of arthralgia. Target cells were prominent and osmotic fragility was decreased in C trait patients without further evidence of hematologic disease. The clinical and hematologic picture of homozygous Hb C as found in several other yet unpublished cases has closely resembled the findings in our patient and must he differentiated from Thalassemia minor. Homozygous Hh C disease, a genetic counterpart of sickle cell anemia, represents a definite new hematologic entity. HUMAN SERUM ALBUMIN TAGGED WITH 113’ IN PATIENTSWITH ASCITESCAUSED BY ABDOMINAL CARCINOMATOSISOR HEPATIC CIRRHOSIS: THE RATES OF INTERCHANGEBETWEENTHE VASCULAR COMPARTMENTOF PERITONEALCAVITY. Malcolm P. Tyor (introduced by Arthur C. Guyton). Medical
Division, Oak Ridge Institute Studies, Oak Ridge, Tenn.
of
Nuclear