IIHHWHIWIWIIUIWIUIHIHIWIllHWlWIWI CARMOVASC‘JLAR STUDIES IN ADRENAL iN’SUFé‘ECEENT DOGS Thesis for ‘H‘IO Degree c§ Ph. D. MECRIGAN STATE COLLEGE Ciarence F. Decker 31954 THE" :1 ‘ This is to certify that the thesis entitled Cal” :OTJMJCLAlski 3t‘.1di€3 i: Adrenal Insufficient DOE: presented by Clarence P. Decker has been accepted towards fulfillment of the requirements for In.D. Physiology and degree in -.. rnarmacolO' i/mdam Mjor professor CARDIOVASCULAR STUDIES I! ADHANAL INSUFFICIENT DOGS By Clarence F. gecker Al ABSTRACT Submitted to the School of Graduate Studies of lichigan State College of Agriculture and Applied Science in partial fulfillnent of the requirements for the degree of MGR W PHILOSOPRI Department of Physiology Ind thscology Iear 19514 ”£353 "340-56. -_ . _.._..;__‘,_:’p~ ._. _7~,—“m_r,lg_; 7; _,_._~. 74.. ,_.\ ___.. ,717-7 CARDIOVASCULAR STUDIES IN ADRENAL INSUFFICIENT DOGS By Clarence F. Decker An attempt was made to make certain cardiovascular measurements in a group of five trained, unnarcotized, bilaterally adrenalectomized dogs. Heart rate, blood pressure, stroke index and cardiac index were followed simultaneously in the same animal in different states of mild adrenal insufficiency. The cardiac index was determined from the contour of the pressure pulse curve according to the method of Hamilton and Rem- ington. In this method the arterial pressure curve, produced by cardiac ejection of blood, is analyzed in terms of the volume of blood necessary to elicit the pressure fluctuation. To convert a pressure curve to blood volume requires consideration of pulse wave transmission times to various parts of the expansible arterial tree. This is justifiable on the basis that the volume of blood distending the vessel alters the rate of movement of the compression wave. The Hamilton-Remington tables for pulse wave transmission times at various pressures were used in the present work. A strain gage manometer and direct recording galvano- meter were used to record the central pulse from the carotid artery. The earliest noted circulatory alterations following bilateral adrenalectomy were a decrease in systolic and an increase in diastolic pressure with a corresponding reduction in the pulse pressure. A reduc- tion in both stroke index and cardiac index was evident. These changes occured before marked alterations in the electrocardiogram, blood non- -1- protein nitrogen, plasma sodium or potassium had taken place. When adreno-cortical replacement therapy was withdrawn a progressive fall in cardiac output occured which was roughly prOportional to the severity of the adrenal insufficient state as indicated by blood chemistry and hematocrit changes. Re-administration of therapy resulted in an improve- ment in stroke index and cardiac index. This improvement often occured even before marked improvement in blood chemistry had occured. It was suggested that the initial increase in diastolic pressure observed could be explained on the basis of an increased peripheral resistance. Anincreased peripheral resistance coupled with the ob- served reducticn in cardiac output could be indicative of an inadequate blood volume, but the present data do not permit positive evaluation of this factor. The improved flow obtained when replacement therapy was again administered could be explained on the basis of a lowered peri- pheral resistance. It was concluded that the present data indicate that considerable alteration in the output of the heart occurs in adrenal insufficiency before marked changes in blood chemistry and the electrocardicgram.take place. It was suggested that a direct action of adrenal steroids on heart muscle might be implicated, but the possibility of their indirect effect upon the peripheral resistance is not ruled out by the data. -2- CARDIOIASCULAR STUDIES IN ADREIAL INSUFFICIEIT DOGS By Clarence F. Decker A THESIS Submitted to the School of Graduate Studies of Michigan State College of Agriculture and Applied Science in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHI Department of Physiology and Pharmacology l95h ACKNGTLEDCMM The author riches to express his sincere appreciation to those members of the Department of Physiology and Pharmacoloy, Michigan State College, who contributed so much to the com- pletion of this work. In particular the author feels deeply indebted to Dr. W. D. Collings, who gave so generously of his ties during the course of the experimental work and throughout the preparation of the manuscript. The author would also like to thank Dr. B. V. Alfredson, Head Department of Physiology and Phamacolcgy for his most generous provision of space and equipment with which the work was carried out. Mr. Jack R. Schmid and Dr. I. 8. Fang both contributed greatly to the completion of the laboratory work and deserve a special note of thanks. lmerous thoughtful suggestions offered by other washers of the faculty throughout the course of the work are most sincerely acknowledged . W} W W ”iii if ‘I' TABLE OF CONFETS Page mmeTION...OOOOOOOOOOOOIOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO 00000 O... 1 HIflmICALRmmOOOOOOOOOOOOOOOOOOOOOOOOOO.OOOOOOOOOOOOOOOOOOOOOOO b Blood Pressure and Arterielesu................................. S cwmaries am B100d VOIWOOOOOOOOOOOO.OOOOOOOOOOOOOOOOOOOOOOO 9 Potassium lletabolism and Electrocardiographic Changes. . ...... .. . 13 mEMALCIOCOIO'OOIQ'.......O..O... 000000 .OOOOOOOOOOOIOOOOOOOOO 18 Animals andCare................................................ 18 Criteria for State of Adrenal Insufficiency. .......... .......... 2 Cardiac Index, Stroke Index, Heart Rate and Blood Pressure...... 23 Hethod of Obtaining Central Pulse Becord........................ 25 Method of Analyzing the Central Pulse Record.................... 29 Rmseeoeeeeeeeeeeooeeoeeeeoosooeeeeeeoeeeeeeeeeoooeoeeeeoeoeeeee 39 HomnogooOeoeeeeeoee sssssssssss eoeeeeeeeeoeaeoeeeeeeeeoooeeeeo 39 makeyooO00.000.000.000eeoeeooeeeeeea.a...00000000000000.0000... ’43 SpateooooooesoceeeeeeeeeeeoeeeeaoeeeeeeoeooeeaoaeeeeeerOOeeeeas 1‘6 BmmeeooeeoeoeaeeeeeeeeeOOQeoeeeoeeeecoeeeeeeOOeeeesee-00000.. ‘49 ChmPOOOCOOOOCOCOOOOOOOOO0....OOOCOOOOOOOOOOOOOOOOOOOI.000...... 52 DISZUSSIW CF RESJLTS AND CONCLUSIONS”............................ 55 Body Weight and Blood Chemistry................................. 55 Blood Non-Protein Nitrogen................................... 56 Hematocrit and Blood Sodimn.. 57 Plasma Potassimn............................................. 59 Cardiovascular Measurements..................................... Arterial Blood Pressure 61 Electrocardiog‘an............................................ 65 Heart Rate, Cardiac Index and Stroke Index................... 66 WIOOIOOIOOOOO0.0.00...OOOOOOOOOOOOOOOO.OCOOOOOOOOOOOOOOOOOOOOO 73 BMOWQQOOO0.0.00COOOOOOOOOOOOOOO...00.0.00...OOOOOOOOOOOOOI. 7S mmneeeeeee sssss eeeeeeeeeeeeeeeeeseeoo00000000000.0°‘°°“°"'°° 86 LIST OF TABLES PAGE Comparison of a Strain Gage Nanometer System and an Opticu Mameter thMOOOOOOOOO......OOOOOOOOOOOOOO0... 30 Tabulated Experimntal Results: Hound Dog. .. ..... .. .. . .. 142 Tabulated Experimntal Results: Smokey...... ... .. .... ’45 Tabulated Experimental Results: Spot ha Tabulated Experimental Results: Brownie” . . . . . .. . . . . . . . . 51 Tabulated Experimental Results: Cheap 51: Heart Rate, Blood Pressure Cardiac Index and Stroke Index of Anesthetized and nanesthetiaed Dogs . . . . . . . . . . . . 62 Statuary of Cardiovascular Neasurunents on Adrenal- ectqnized DopOOOOOCCOO0.....‘OOOOCOCOOOOOOOOOOOOOO. ..... 69 Blood Pressure, Blood Non-protein Nitrogen and Plasma Sodium and Potassium Values for a Group of Trained Dogs.. 90 Data Tabulated From Pressure Pulse Curves for Calculation of Cardiac Index of Anesthetized and Unanesthetized Dogs. 92 Data Tabulated From Pressure Pulse Curves for Calculation of Cardiac Index of Bilaterally Adrenalectomised Dogs. . .. 9h LIfl OF FIGURES FIGJRE PAGE 1. Schematic Diagram of Strain Gage Amplifier Nanoneter System 2h 2. Central Pulse Record Ootained Hith a Variable Speed Brush RecorderCOOOOOOOOOOOOCOOOOOOOOOOOOOOO.....OOOOOCOOOOOOOOOOO 26 3. Schematic Diagran of Optical nanometer System. . . . . . . . . . . . . . 28 ha. Central Pulse Record Obtained Using an Optical System”... 31 hb . Central Pulse Record Obtained Using a Strain Gage Amplifier mmOOOOOOOOOOOOOOOOO0.0000000000CCOOOOOOOOOOO0.00.0.0... 31 S. Subdivision of a Central Pulse for Computing the Stroke valuneggogeeeoesoeeaeeeeaoeeeoonaeeeeeeeeeeeaoaeeeeaeeeeaa 32 6. Pulse Wave Transmission Times to the Parts of the Arterial Tree at Various Diastolic Pressures. (After Hamilton and Emma”).....OQOOOOCCOOOOOOOOODO...OOOOOOOOOOOOOOCOOOOOOO 3h 7. Capacity per Square Meter Body Surface of the Several Parts of the Arterial Tree at Different Pressures. (After Hanilton andRemington).................................... 36 8. Strain Gage Mancuneter Calibration Curve.................... 86 9. Optical lanoneter Calibration Gm've........................ 87 10. Standard Curve for Blood Hon-Protein Nitmgen.............. 88 ll. Calibration Curve for Plasma Sodium and Potassium Analysis. 89 INTROWCTION The importance of the adrenal glands in the maintenance of an adequate circulatory status has been repeatedly demonstrated. A decline in blood pressure following adrenalectony has been.reported.by numerous workers. Derangement of the capillaries and arterioles has also been reported as a consequence of severe adrenal insufficiency; Terminal collapse of adrenal insufficient animals is almost always accompanied by circulatory failure, characterised by extremely'lcu*blood pressure levels, decreased heart sise, and atonic and dilated capillaries. In addition, henoconcentration, serua electrolyte disturbances and electrocardiographic abnormalities say be present. Little work has been done to determine the effect of the circula- tory disturbances in the adrenalectonised animal on the output of the heart. Harrison gt 5. k 36) reported that the adrenals were essential for regulating the output of the heart, and that in adrenal deficiency crisis induced by acute removal of both glands, the output was severely decreased . These authors attributed the failure of the adrenalsctomised dog to the depression in the output of the heart. The expert-ants upon which Harrison based his conclusions however were acute terminal ones. The procedure employed by this investigator was to exclude the adrenals fro. the circulation‘by placing a loose ligature about the lumbar adrenal veins. An.hour or so after the operation, when the dog‘had IIrecovereda the ligatures were twisted to exclude the adrenals from the circulation, and observations were made on the cardiac output determined by the direct. Pick method. In the first place, it is highly unlikely that the dog had I'recovered" from the operation in this short time interval. In addition, one might question whether such a procedure would appreciably decrease the level of circulating adrenal horaones . Furthermore, the rmoval of the anal]. mount of blood necessary for determining the cardiac output by this nethod could in itself conceiv- ably be sufficient to precipitate circulatory collapse in the aninals . more recently, Raington (81:) has studied circulatory factors in adrenal crisis in sedated anesthetised dogs, and also reported a de- crease in the output of the heart. However, all of Renington's experi- sents were also terainal ones . Blood pressure levels and cardiac indices of dogs still on therapy were shown to be nearly normal whereas crisis levels were almost always indicated in dogs off therapy for one to four days. Benington stated that, I'Once the aninal was sedated, and the surgery acconplished, it declined more or less rapidly into a fatal circulatory collapse ." It is difficult to separate the effect of the adrenalectomy 29.! 33 and that of experimental procedures on the circulation of adrenalectomised animals in experinents such as these two investigators have reported . Such investigations say give infom- ation concerning the effect of induced adrenal circulatory failure upon the output of the heart but can be of only questionable value with respect to obtaining quantitative data on the cardiac output of adrenal insufficient animals not in a crisis state induced by the experimental procedure . The present work was undertaken in an attempt to quantitate certain circulatory variables such as cardiac index, heart rate , blood pressure and electrocardiograms in adrenal insufficient dogs without aw recourse to general anesthesia, and with a minimm of surgery. An attempt was made to obtain several sets of data in the same aninal in different states of insufficiency. The work was particularly restricted by the extreme sensitivity of the adrenalectan- ised animal to any kind of experimental procedure. It is realised that considerable variability exists in the state of insufficiency induced in different animals when subjected to the same treatment. Horeover, replacenent therapy may vary greatly frm one aninal to the next. The amenditure of both tins and material essential to an investigation of this type precludes the use of large numbers of animals . A total of twelve dogs was studied during the course of this work, five of these survived for completion of the experiments . Since it was impossible to treat these five dogs in exactly the same manner, no attempt has been made to group the animals for the purpose of a formal statistical analysis. While it is readily admitted that some of the measurenents may lack quantitative accuracy it is believed that the data show accurate di- rectional trends with at least a good approximation to absolute values . HISTORICAL REVIEW A complete review'of the literature dealing with the functions of the adrenal gland is not only impractical but almost impossible. The treasndous volume of literature relating various aspects of adrenal function to other physiological processes necessarily places a linitstion on the length of this review. Certain features of adrenal function must be arbitrarily omitted . Sane of those which have been asitted or only briefly mentioned in this review are: the interrelationships between.the adrenal gland and other endocrine glands; histological changes which the adrenal gland undergoes under various experimental conditions; and regulation of salt and water netabolisn. The role which the adrenal cortex plays in internediary netabolisn has also been mitted. In this review'amphasis has been placed upon those functions of the adrenal gland most directly concerned with naintensnce of an ade- quate circulatory status of the animal. To the extent that they affect this aspect of the total physiology the other functions of the gland have beenlconsidered as carefully as possible. To facilitate the review, the cardiovascular effects of bilateral adrenslectasy'have been listed under the following‘heedings: (1) blood pressure and arterioles, (2) capillaries and blood values, and (3) potassiu and electrocardio- graphic changes . BLOOD PRESSIRE AND AMERIOLES In 1855 Addison (1) described a syndrome resulting from impaired function of the suprarenal glands, one symptom of which was a lowering of the blood pressure. Harrop _e_t 3;. (143) reported that systolic pressure changes did not Qpear in the dog until after other evidence of circulatory failure had become evident . Britten and Silvette (9) described the pressure changes as a “late” and indirect nanifestation of adrenal removal. Loeb (62) however attached a greater sigrnficance to the pressure changes . According to this investigator the decrease in pressure was slow in onset and secondary to alterations in renal function and electrolyte balance . Several hypotheses were offered to explain the blood pressure decline. Elliot (23) believed the nuscles of the vessel walls lose their ability to contract , but offered no' explanation for this hypothe- sis. Her-rep gt 5;. 0:0) believed the pressure fall was due to a re- duction in circulating blood volme resulting from excessive fluid loss because of impaired kidney function. Loeb gt 3;. (63) attributed the blood pressure fall to a specific ion effect upon the blood vessels following sodim depletion. Single 93; _a_l_... (11h) , on the other hand, showed that adrenalecteniaed s degs maintained on saline without hornone preparations appear normal in nest respects but have lowered blood pressures. Mngle it 5; . (as ,102 ,106,108 ,110) attributed the blood pressure decline to a reduction of circulating blood value because of transudation of plans fluid into the tissues . This same group elaborated upon the concept of a critical blood pressure below which spontaneous recovery was supposed to be impossible , an idea first set forth by Porter (81) . The teminsl collapse of the aninal was always associated with extremely low blood pressure levels . Althouyi no simple relation between blood pressure and blood sugar reduction was found; it was noted that these procedures in the adrenalectoniaed dog against which desoxyeorticosterene offered no protection, but adrenal cortex extract was effective , were the sane procedures following which alteration in blood sugar were most marked (107) . Britten (8) reported a direct relationship between glycogen depletion and blood pressure decline, and considered the pressure changes to be a latent nanifestation of general carbohydrate metabolism impairment. ‘ Thorn (119) stated that ”anemia, reduced plasna volume, and altera- tion in peripheral vascular rasponse" contribute to the production of Impotension in adrenal cortical insufficiency. In a aore recent study of the effect of cortisone on planes volume and arterial pressure in adrenaleotoalised dogs, Swingle at. :14th) have shown that large doses of this steroid gven for prolonged periods of tine can elevate the arterial pres sure in adrenalectmiaed dogs. The effect however , is only slight compared to that of whole extract or desoxycorticosterone . These findings are in agreement with clinical reports on the effect of cortisone upon arterial pressure in non Addisonian patients (100) . It has been often demonstrated that hypertension camot be pro- duced in the adrenalectemised animal even though salt is given (7 ,15, 21. 51,79) . The adrenalectenised dog is also insensitive to injected renin; the sensitivity to this substance can be restored, however, by either cortical extract or desoxycorticosterone (29 ,86 ,129) . Collings at g . (16) observed that the concentration of hypertensinogen was decreased after adrenalectosiy and Gaudim (33) suggested that the . adrenals were involved in the synthesis of hypertensinOgen. Splanchnic stimulation fails to evoke a measurable rise in blood pressure in adrenal. deficient dogs (23) . Barium chloride an! pitressin are also ineffective as presser agents in this experinental aninal (5, 23,86). Adrenalin was shown to exert a full presser response (5,23) , however, the dose of adrenalin aust be large and large doses of renin show the sane effect (86). Combs (17) and Lengsdorf (59) independently presented evideme which they felt indicated a decreased sympathetic tone in adrenalectm- iaed animals. Seeker (9h,95) found that the nicitating nenbrane of the adrenalectonised cat rapidly becnae unresponsive to actor stimu- lation, but would respond to injected epinephrine . Based on these findings he postulated a failure of synpathin formation , which would also emlain the failure of presser respome to afferent sciatic stimulation. Later workers failed to confirn the Seeker hypothesis (5,h8,65). Despite this, Seeker insisted that his findings were correct. Fowler and Oleghorn (27) could find no failure in eplanohnio con- striction in urinals in acute adrenal insufficiency, and concluded that the absence of pressure rise could be attributed to a failure of the heart to respond to the increased peripheral resistance. In a snore recent approach to the preblaa of circulatory failure in adrenalectonised aninals, Banington (85) has followed heart rate, cardiac index and peripheral resistance sinultaneously in anesthetised , sedated adrenalectoniaed degs . Adrenalectomised dogs of three kinds were studied by this author; ta) animals in terminal adrenal insuffic- iency, (b) annals in acute crisis produced by minor mounts of trans or hencrrhage and (c) dogs in acute crisis following bilateral adrenal removal at a single operation. The results can be sunnarised as follows: In all cases the circulatory crisis was initiated by a sharp fall in resistance and blood pressure . In contrast to the nornovolenic , intact dog an increase in cardiac index did not follow the resistance fall. The presser response to epinephrine did not obviously diminish until shortly before death, however, the pressor response to more weakly active agents was lost in early crisis . The presser response to afferent nerve stinulation was also lost early, although respiratory response was still present. in exaggerated, or prominent because unopposed, vagal reflex was canon. The author concluded that, 'The nest reason- able ezplanation of the findings nay lie in a metabolic failure of the nervous system , one characteristic of which is a loss of sympathetic activity) It is apparent that the findings of Ruington are in ages- nent with‘the Seeker hypotheeia. QAPILLARIES AND BLOOD VOLUME A considerable mount of evidence indicates a faulty capillary bed nay be at least partly responsible for the circulatory deranguent in adrenslectomised animals. Host of the evidence seems to indicate that the capillaries of the untreated .adrenalectonised aninal are atonic, dilated and abnorn ally pemeable. Such findings have been used to explain the fact that the reduction in blood values in adrenalectanised animals is greater than one night expect if there were a free transfer of fluid from the interstitial reservoirs (83,111). Grandinescu (32) noted a steady rise in the umber of red blood cells per cubic centi- neter, and believed a change in permeability of the blood vessel wall resulted in escape of plasna to the tissues. Dale (21,22) thought the increase in blood concentration to be associated with an increased susceptability to hietaaine after adrenal ablation. Kellaway and Cowell (55) believed a cortical effect to be responsible for the in- creased blood concentration. These authors did not support the theory of Orandinescu that loss of plasma from the blood took place; they noted there were no collections of fluid in the serous spaces, and that the tissues always appear dryer than usual. Joelson and Sherr (53) found that the blood concentration usually but not invariably increased after adrenalectomy. It was also shown that a serum transfusion could pre- cipitate circulatory collapse in an adrenalectoniaed dog, accompanied by an emess edema (107), and that this edema formation could be counter- acted by cortical extract or desoncorticosterone. 10 An abnomal leakage of protein or of injected dye also indicated a faulty capillary bed. Since heuoconcentration is not an invariable finding in adrenalectony, this cannot be the sole factor. Henkin reported that cortical extract and corticosterone were able to prevent the leakage of injected trypan blue into extravascular tissues after the injection of leucotaxin (71) . Several workers have reported conflicting results on the efficacy of desomorticosterone in preventing dye leakage after peptone or leucotazin injections. Freed and Lindner (28) reported that cortical extracts and eortieosterone prevented dye leakage but that desozycorti- costerone was without effect. This work, however, was criticised by Rankin (71) on the basis of the experimental technique employed. Shleser and Freed (96) reported favorable results with cortical extracts in preventing dye leakage after peptone injections , but negative re- sults nth the corticosterones . Desoxycorticosterone was reported to act like the sex steroids in increasing capillary pomeability in the uterus , but was without effect in this regard in other tissues of the body (L9) . Ham reports have indicated an increase in the protein content of the lymph following adrenalectomy. Cape gt _s_1_. (19) stated that the protein content of the lymph was almost doubled following adrenalectmy. Cope (18) also reported an increased activity in the peripheral lymph When radioactive colloid was injected into adrenal insufficient dogs , and canpared to suitable controls. Levin 33; g. (61) and Human 33 pl. 11 (1.6) both believed the increase in plasma protein in sdrenalectomised dogs was due to an increase in the globulin fraction with little change in the albmnin fraction. This was attributed by Levin to a failure in albumin metabolism (60) . Swingle at El. (105) believed that the circu- latory failure in adrenal insufficient dogs could be attributed to collapse of the peripheral circulation. When it was shown that circu- latory failure could be induced by "shocking procedures" before marked changes in blood volume or composition became evident, the suggestion was made that the adrenal cortical hormone is necessary for maintenance of capillary tone . The capillaries of dogs succumbing from circulatory collapse were described as being asthenic, atonic and abnormally dilated. It was postulated that in the absence of the hormones of the adrenal cortex a huge peripheral reservoir Opens , into which blood flows and stagnates causing capillary damage and a resultant increase in capillary permeability. More recently Overman (78) has studied the effects of cortisone and D C A1 on radioeodium transport in normal and adrenalectouiaed dogs, and concluded that both these steroids effect sodium turnover dynamics, particularly across capillary manbranes. The direction of the effects of D C A was shown to be apposite to that of cortisone. This author concluded that the data supported the hypothesis of antagonism between ll-desoaqrcorticosterone and 11-,17-oxysteroids as they affect membrane permeability . 1 Desoxycorticosterone acetate. 12 A reduction in the plasma volume of untreated adrenalectomiaed animals (M,SS,112,117,132) and of patients with Addison's disease (614,90) has been reported often. Cortical extract was shown to restore the value to nomel, while D C A actually increased the plasma volume above normal in the Addison's disease patients (26,6b,12h) and in intact or adrenalectomiaed dogs (lh,107) . The increased volume is associated with a marked retention of sodium and chloride as well as water. The effect of the cortical steroids on plama volume is probably more specific than a simple production of positive water balance . Cortical extract was shown to prevent the reduction in plasma volume which follows prolonged etheriaation in the dog (70) . It.is apparent that evidence for interaction of adrenal hormones in insuring homeostasis with respect to blood volume is still fragnentary and inferential. 13 scream mammalian WROCARDIOQ‘IAHIIQ amass A rise in serum potassium level following removal of the adrenal glands was first noted almost thirty years ago (6), and has been con- firmed often. Numerous workers have also shown that the adrenalectomiaed urinal is exceedingly sensitive to injected potassium salts (h,13 ,125, 131,133,136). Intact annuals administered Quantities of potassium salts sufficient to raise the plasma concentration to those typical of terminal insufficiency showed many of the symptoms of the adrenal- ectomiaed animals and often died (1.7 ,126,13h,135). Diets low in potassium have been shown to be of therapeutic value in the treatment of Addison's disease, or for maintenance of adrenal- ectomiaed animals (2,3,1; 36,91,128), The increase in plasma potassium concentration was shown to be largely a reflection of a decreased renal capacity to excrete the ion (ho) . This kidney failure could be corrected by cortical extract (38,140) . Harrison and Darrow (37) attributed the renal dysfunction to a disturbance in tubular function, so that potassium was not concentrated in the urine in a normal manner. Several other groups of investigators presented data which indicated that renal failure could not account for the increase in plasma potassium . narenai (66) mind that injected potassium was fixed by the tissue cells less readily in adrenalectomiaed animals. Winkler and associates (131) found that plasma potassium levels were elevated by a smaller amount of injected potassium than that required for the intact deg. It was postu- lated by Harenai (66) that cortical extract was concerned in binding lb potassium in the tissue cells, in regulating the potassiun equilibrium between tissues and plasma and in regulating the excretion of excess plasma potassium. The action of D c A upon potassium metabolism is even greater than that of cortical extract . The effect is probably largely upon the kidney, for this steroid will cause an increase in potassium excretion even in the intact animal (58). On the other hand, Talbott and co-workers (118) found quite low potassium clearances in patients with Addison'sdisease even after long periods of D c A therapy. D C A was shown to prevent the usual increase in intracellular potassiun which accompanies adrenal insufficiency, and it wmfld actually lower the tissue potassium in intact animals (10,25, 7h) . The toxic effect of injected potassium seemed to be directly re- lated to elevation of the serum concentration and only indirectly to the rise in muscle potassium (73). Perrebee e_t_ 3.1. (25) have suggested that the muscle weakness which follows prolonged treatment with D C A may be associated with the decreased muscle potassium, and its replace- ment with sodium. It is generally agreed that the accumulation of potassium in the serum in itself cannot account for the symptoms of adrenal insufficiency (116) . Keith and Binger (sh) reported that induced high levels of serum potassium in nonnal hmnan subjects, and equally high levels in diseased patients, do not necessarily produce toxic symptoms. Schenp (93) was unable to obtain symptoms resembling those of adrenal insufficiency in 15 normal dogs injected for long periods of time with potassium salts. Patients with Addison's disease may show little or no potassium re— tention even in crisis, and on the other hand, may show greatly ele- vated serum potassium levels ani yet remain symptom free (62) . Loeb (62) has reported cases of Addison's disease where the electrolyte pattern of the blood is virtually normal at death. 'Adrenalectomised animals dying of circulatorLfailure after trams show no consistent serum potassium change." (111) ‘ “Electrolne imbalance does}: seem directly: concerned in the production of circulatgyjollapse except as far as it throws a strain upgn an asthenicJeEipheral circulation." (116) Irregular heart rhythus have been shown to be more or less frequent in adrenal insufficiency. licholson and Soffer (75) were among the first to note such effects and believed they might be due to the rise in serm potassiuu concentrations. Cleghorn and his co-workers (11,12) studied adrenalectomized dogs exhibiting high serum potassium when showing symptms of adrenal insufficiency, and concluded that at least part of the circulatory collapse could be attributed to cardiac failure. Cortical extract and D C A were both shown to be able to correct the cardiac abnormalities (12) . Kore recently Roberts (88) and Roberts and Pitts (89) have reported on electrocardiopaphic changes occurring in the adrenalectaniaed dog in insufficiency. The first change in the electrocardiogram (E C G) pattern noted was an increase in height and peaking of the ‘1‘ wave, which 16 was often seen in the early stages of insufficiency even before electrolyte changes were noted. ‘With the progression of severe in- sufficiency and marked alteration in plasma.electrolyte concentrations, there occurred widening of the T wave, bradycardia, disappearance of the P wave and various irregularities in cardiac rhytm. They concluded that the changes in B C G pattern paralleled the alteration in plasma sodium and potassium in.adrenal insufficiency and could be corrected only if adequate concentrations of these ions were restored. The same workers showed that adequate doses of cortisone could prevent such changes but could not correct them once they had occurred. Sodium chloride administration.either alone or with cortisone lowered the serum potassium and restored the E C 0 pattern to normal. In a long tenm study conducted on adrenalectoaised dogs maintained on cortisone at 0.93 mg per kg per day, Swingle gt 3;. (103) showed that this dosage was adequate to maintain adrenalectomised dogs in an active and vigorous state, free from symptoms of insufficiency; This dosage of cortisone was not adequate, however, to prevent changes in the serum electrolyte pattern, the sodium level decreased and the potassium level becane markedly elevated. These workers claim a positive correlation between states of hyperpotassemia in.these animals and electrocardio- graphic changes. Massive doses of cortisone, 1.86 mg per kg per day, were reported to restore the electrolyte and E c 0 patterns to normal (68). As pointed out by Sningle, the changes in ‘E C G noted in adrenal insufficient dogs exhibiting hyperkalemia are very similar to the 17 changes observed by Winkler, Hoff and Snith (130) on E C G records taken during infusion of K61 in dogs. Similar studies on Addisonian patients during crisis and recovery or while maintained on various types of therapy, i.e., salt, D C A in .11, cortical extract and implanted D c A pellets (92 ,98,l21) confirm these findings. - Currens gt .a_l_. (20) on the other hand caution against indiscriminate use of E c 0 changes in animals as an index to alterations in plasma potassium level, and conclude that there is probably a better correlation between intracellular potassium and E C G changes. 18 EXPERIMENTAL Animals and Care healthy male and female mongrel dogs were used in the experimental work. The dogs had been in the laboratory for a period of time ranging from h to 12 months. During this period each animal was trained to lie quietly on its back with a minimum of restraint while various experi- mental procedures were carried out. Each animal was kept in an individual cage, with a constant supply of food and water. The diet consisted of dry Borden's \Chunx), and canned Rival dog food. Each deg was adrenalectasiaed in two stages. The right adrenal was removed soon after bringing the dog to the kennel. The second adrenal was removed just prior to beginning the experimental observations . The time elaps- ing between Operations varied from 3 (one dog) to 12 months. All Operations were performed using 30 mg of sodium pentabarbital per kilogram of body weight as the anesthetic. Imediately prior to removal of the second adrenal gland each dog received 5 mg of D c A3 and 1 cc of Lipo adrenal cortical extract‘ intrasuscularly. Immediately after the operation each animal was given 5 cc of aqueous adrenal cortex extract‘ UL C E) intravenously . Replacement therapy following removal 2 Percorten \Ciba) courtesy of Dr. E. Oppenheimer. 3 Lipo-Adrenal Cortex (The Upjohn Colnpsny) courtesy of Dr. William Haines. ‘ Adrenal Cortex Extract (The Upjohn Company) courtesy of Dr. William Haines. 19 of the second gland was gauged to suit the requirements of the particu- lar annual. 'The exact dosage of extract used is listed in the detailed results for each dog. In cases of crisis additional Lipo or A C B were given. During the period of training of each animl several blood samples were taken to determine the control levels of certain blood constituents such as the non-protein nitrogen, plasma sodium and potassium. Several control E C Gland blood pressure records were taken during this period also. About two weeks prior to removal of the second gland, control values for the cardiac index, stroke index, blood pressure and heart rate were determined. After removal of the second gland each animal was supported for at least seven days with Lipo adrenal cortex. The exact length of time necessary to return the animal to an active and apparently healthy state was somewhat variable from one animal to another. In any case no experimental work was begun until the animal. was in an active post- Operative condition as indicated by the physical appearance and body weight. ‘When the dog was in an active "normal” or near “normal" state, measurement of the blood pressure, cardiac index, stroke index; heart rate and E C G were made simultaneously. Immediately following the vascular measurements, the dog was in- jected intravenously with 5 cc of A C E and 1 cc of the Lipo adrenal cortex extract. This was considered necessary because of the minor surgery accompanying these measurements. At least one week on full therapy was allowed between sets of experimental determinations. 20 After a sufficient length of time had elapsed to insure that the animal had recovered frun the previous experiment, therapy was with- drawn for variable lengths of time and another experiment performed. griteria for State of Adrenal Insufficiency Five measurements were made to determine the state of adrenal insufficiency existing in any particular dog at the tine experimental work was begun. (a) hematocrit. As an index to hemoconcentration the hematocrit was determined in duplicate . Two Wintrobe hematocrit tubes were filled and centrifuged for thirty minutes at 3000 revolutions per minute, after which the hematocrit in each tube was read and the average value recorded. (b) son-protein nitrogen of the blood. A protein free blood fil- trate was prepared by transferring 3 cc of heparinised whole blood to a 50 cc graduated centrifuge tube using an Ostwald-Folin pipette. Twenty-one cc of distilled water were added to this by means of a burette , and the mixture allowed to stand until the blood was hemolysed. After hemolysis was complete the protein was precipitated by adding 6 cc of 20% trichloroacetic acid, while gently shaking the centrifuge tube . The protein material was separated by centrifuging for about ten minutes, a clear supernatant remained. An aliquot of the above protein-free filtrate was used to determine the non-protein nitrogen according to the method of Koch and Heheekin (S7) . All samples were read in a 2]. Coleman model 11 universal spectrophotometer at a wavelength of 1480 mu. A standard curve was prepared and is given in Figure 10 of the Appendix. (c) Plasma sodium and potassium. Plasma sodium and potassium were determined by flane photometry using a Beckrnan D U spectrOphotometer with flane attachnent model no. 9200. The method used was a modifica- tion of that described in Beckman Instrunent technical bulletin DU-12-B. In order to eliminate interferences due to variable amounts of protein, the pleas proteins were precipitated. The protein precipitant contained 5i trichloroacetic acid and 10% isOperpyl alcohol. About 16 cc of the precipitant were added to a 50 cc graduated centrifuge tube from a burette, and 1 cc of heparinised plasma was carefully added. It was then brought to volume with the precipitating reagent. It was necessary to avoid violent agitation which might give rise to floating particles or particles which adhere to the walls. The mixture was allowed to stand for ten minutes, after which time it was centrifuged for ten minutes. The supernatant which was crystal clear was then analysed for sodium and potassium. A sample of a synthetic serum as a standard was prepared at the same time as the unknown. 1. Spectrophotometric procedure: using the standard city-hydrogen flue the percent emission (on the transmittance scale) of the sample was read in comparison to that of the synthetic sermn standard prepared above. The instrument settings employed were: for sodium, wave length '5 Synthetic serum contains 1.683 g seal and 0.071 g £01 per 200 cc distilled water. This is equal to lhh meq Ida/liter and 14.8 meq K/liter. 22 592 mu, ultraviolet sensitive photo tube with 10,000 megohm resistor, selector switch at 0.1, sensitivity at about midpoint, and slit .0); m. For potassium, wave length 770 mu, red sensitive phototube with 10,000 megohn resistor, selector switch at 0.1, sensitivity at 1 1/2 turns clockwise and slit 0.02 mm. 2. Gas pressure: the Optimum pressure settings for analyses under these conditions for our instrument were 18 pounds of oxygen and 1; pounds of tadrogen. Calibration curves for sodiun and potassium were determined and the exact instrument settings adjusted to stay On this calibration curve each time an unknown sample was read. The curves are shown in Figure 11 of the Appendix. When the instrmsnt settings were adjusted using the synthetic standard sample, a reagent blank consist- ing of the precipitating reagent was read and the reading was sub- tracted from both the reading of the standard and of the unknowns (net luminosities). 3. CalculatiOn of results: the response for potassium is linear in the range of samples encountered in this work, so that the concentra- tion of the unknown was detennined either from the calibration curve or calculated from net lminosities of the standard and unknown. Since the range of variation of plasma sodium is so small the sodium line was also considered to be linear and sodium concentration as the unknown determined in the suns manner. (d) The body weight of the animals to the nearest 0.2 1:11on we checked daily after removal of the second gland. 23 (a) Blood pressure. The blood pressure was determined by means or a strain gage manometer discussed in detail under method of measur- ing the cardiac index. (I) Electrocardiograms were determined using a Sanborn Polyviso recorder, model 67-1200. The three standard limb leads were recorded simultaneously. Simultaneous recordings of the three unipolar leads AVE, AVL and AV? also were recorded. In addition, the clinical condition of the animals was noted daily when maintenance therapy was being administered, and at least twice daily when therapy was suspended. The amount of voluntary activity exhibited, and the presence of gastro-intestinal symptoms such as anorexia, diarrhea and vomiting were observed. Cardiac Index, Stroke Index; Heart Rate and Blood Pressure These four measurements were made simultaneously using a strain glgO,‘1IplifiBt system and recorder. The pickup unit of the system con- sisted of a twenty gauge hypodermic needle attached to a Stathau strain gage , model P 2311. The strain gage was connected to a Brush universal analyser amplifier , model BL 320, which was in turn connected to a Brush model 202 , direct recording galvananeter. A schematic diagram of the system is shown in Figure 1. The strain gage was filled with hepariniaed saline and the system calibrated against a mercury manometer. To prevent errors in pressure measurements, the system was calibrated just prior to running each record. It was possible to repeat the calibration values 2!: H53 88:0 aria! mug Egan—h 354E Egg mun—mm Q ? Emma». man—”hag flog Eng be £335 OHM—Rana .H MESH—H from day to day. A calibration curve is shown in Figure 8 of the Appendix. It has been established by Hamilton and Remington (35), that the central pulse, preperly recorded, is the only pressure pulse adeQuate for calculation of the cardiac index. The same authors have also shown that the central pulse obtained from the carotid artery low in the neck is only slightly different from that obtained from the root of the aorta. method of ObifiniggCenjrg Pulse Record The carotid artery of the dog was exposed through a one inch incision low in the neck under local anesthesia (procaine sulfate). A loose ligature was placed under the artery to help in locating it when about to record. When the dog was lying quietly and apparently undis- turbed, the hypodermic needle (20 g.) attached directly to the strain gage , was inserted into the carotid artery . The recorder could be run at three speeds 5, 25 and 125 m per second. To obtain a record of the central pulse adequate for canputing the stroke index and cardiac index the fastest paper speed, i.e., 125 mm per second was used. To obtain a large umber of individual pulses and thus assure a statistically valid measurement or cycle length, systolic, and diastolic blood pressures, paper speed of the recorder was changed during the process of recording to the slow speed, i.e. , S mm per second Figure 2 illustrates the record obtained. 26 l l . s e l ‘; . , . . ‘ vacuum non .EE‘J ‘ m n eoemm ended“ 8:55 ..oa v! u . ,. . 1,2; w iucoomwssm .J Jizlil/IJ 29 :81. .L ,1 , T'mecooom o. I... . . . z , ‘ .5: 0.0.. n uooau nomem : coco £25 1 , A , . i .I . ‘ ‘, a ‘ 9 n . a i , , ' ' ' i ’ t , I ' . . . . _; v . I , . . , I ‘ ‘ ‘ ‘ - I . p . . .. v —a———‘——_._—. 1—“"‘“ .__. _ , ._*___. . , .. > ' ' ' , . t ‘ u . , 4 . . , t .a..__—— v———a———a—-4-—¢_ ——-¢~—"l --k y-«_’-. a .._ ... ~.— ———9.— -—o— _.._._,_.‘- '__ *_., _. - A .~ . . . I , t - ' . . . a . n n . . n . I ~ . s . ‘ , - - . I . . n . - i ‘ . - . --.- -..... --- .- ...—-i._..-_..._ e...— ....__.,-i +__ ..al . _.__g_ H- ._‘ . . i- .__ - *7 - ; . T . » . . . . . - ‘ . . a . . , . . . y 1 t ' i t ' . ' . ; 4 t n . t r - r i . ‘ . v i ‘ ‘ ‘ i i . 1 l | t i -T o—~a——-—o——Q_—Q——o—— ...—.____4 _ ._._‘- —_ o—..-—.o——_._ .___4_—o-—_.._-——6—- .— — _. . . _ 7-- ‘- _ .__ __7 . _ . _ — “ 7‘ ,_ >— a t . I - ' . u 1 n i . . 1 , ‘ . . . n . ‘ . 1 n I . a . . , . i ' l l ' I u i l u i ' ‘ +. .._ ._ ~ _g__ ¢ ‘ A L fi_l____ -r-_—J‘--_.$— .- .e—~ .———e—7 v — ~——- —¢— +——»«—e———-.— “—- —‘..__ .l- __- . ‘_V7 ‘ t v | i L . x . . . . ‘4 - t 4. e \ . . . , t i l y t . \ | ‘ q i t i t . . ~ I ' 1 ‘ ‘s ‘l I ' j | - . . . , . a L a i , _ p ‘ A A .4—‘_—.—-— L a A e—-v+-—$n-—* —-+—— a—__..,__.l _._ __% ... _ 7__ a 0.. 1 t - . . . . , r w—m \ . . | . . y . ‘ l . \ ‘ . \ " u 1 l \ . , i i x t , . . _ . y , ‘ . x t . \ t i ' . A i ‘ ' I , \ . . . . \ A . s u z A A L A A #4 L ‘ A "" ‘ ’ ‘- _ —-_"_— ~~—-«...—‘—__"_, » i ; 32 neuooofla: 5 2.5. |1 OF 84 8; 8m 3“ 00m H cal . m a8“: 8 Lmoaen 30 m emaseag OCH 5 8 H .53. 33 beat per square meter body surface area. Cardiac index is a correction for the minute volume output of the heart for the sine of the animal and is expressed as liters per minute per square meter body surface area. The stroke index and cardiac index were determined from the central pulse record according to the method of Hamilton and Remington (35) using the revised arterial uptake tables (85). The stroke volune is the sum of the arterialuptake, U, plus arteriolar-drainage during systole, 3d. The factor U is calculated from the contour of the central pulse as follows: the uptake of the large arteries by the end of cardiac ejection is calculated for each of the four divisions of the aorta and its major branches, the arch, the head and thorax, the viscera and abdomen, and the legs. Uptake of the arch, U,, is calculated from the difference in the volune of the arch at incisural pressure, P1, kpressure at time of aortic semi-lunar valve closure) and the volume at diastolic pressure, Pd. The uptake of the other three beds is calculated next. This involves laying back into systole from the incisura the pulse wave transmission times, Th, Ty and T1. It is necessary to lay these tines back into systole in order to determine the pressures obtaining in each of the three systems at the instant of closure of the semi-lunar valves, that is, incisural time. These times are obtained by referring to the series of curves in Figure 6 relating transmission time to diastolic pressure level (as established by Hamilton and Remington, 80), using the diastolic pressure obtained from the experimental pulse record. The simultaneous pressures TIME I] HILLISEOIDS 3h 180 [— FIGURE 6. 50 PULSE wan-z rmsusslow TIMES 1 — TOTHE PARTSOFTHE ARTERIAL mas AT vmws DIASI‘OLIC massunss (mm HAHETOI) 1140 __ 120 .. 100 7 so #— (0 _ ho -— T“ T v 20 _ Th I l l l l l L J J L I 20 w (i) 83 100 120 110 160 1% 200 220 DIAfiOLIC PRESS!“ 104 OF HG. 35 obtaining in each of the beds are then noted from the record and are recorded as Ph, Py-and P1. The uptake of blood by each of these beds is then calculated from the difference between the volume of the particular bed at this pressure and the volume at diastolic pressure. These figures are obtained by referring to the series of curves in Figure 7 relating the capacity of the arterial tree to arterial pressure. The individual uptakes are recorded as Uh, Uv and U1. The total arterial uptake then is the sum of these fOur, i.e. U -UasUh+thUl. Remington (81) has also recently simplified the calculation of systolic drainage, 3d. If one assumes that the integrated.mean pressures during the systolic and the diastolic portions of the pressure pulse are equal for all practical purposes, then the ratio of systolic drainage to diastolic drainage should be equal to the ratio of their respective durations, i.e., sd . (T8 " TH ) (1) '53 m, + Tw ) where 5d - systolic drainage volume, DA - diastolic drainage volume, T,3 a ap- parent duration of systole,Td - apparent duration of diastole ,(T, - Tu) - effective duration of systole, (rd + '1'“) - effective duration of diastole. The factor Tw.is an average weighted transmission time and is also obtained from Figure 6. Twpis derived from average transmission times to the various arterial beds weighted according to their relative drainages. Adding Tw to diastolic time accounts for the fact that systolic drainage begins when the pulse wave reaches the periphery and ends at the time of closure of the aortic semi-lunar valves. All drainage .F\1 AI. a I .4] U].‘..I"! new.“ 3‘31." A /‘ Hgn‘ h .15 “Jul. e: v I 1‘ H1 nih‘ “J.\.. 1 .\ .\.v 56 r- h8 - 2" 83 l I canon; cc PER scum METER 8 I 16 - FIGURE 7 . 36 CAPACITI PER slum men eon! SURFACE or THE SEVERAL PARTS or me mmm. TREE AT DIFFERENT PRESSURE (AFTER WILTOI) Head and Thorax Arch Viscera and Abdomen Legs I l l #1. I l l I j l L, 20 U0 63 80 100 120 lhfl 160 180 200 220 2h0 TERESSURE I] HH.OF?NERCURI 37 thereafter is at the expense of blood already accounted for. This correction is used because the actual duration of systole is less than that recorded, by an amount of time equal to the average length of time required for the pulse wave to reach the terminal arterioles of each bed. By the same reasoning adding Tw to diastolic time accounts for the diastolic drainage which occurs after ejection begins and before the pulse wave reaches the periphery. Equation (1) can be written: (1‘, -'r.,) (Td + TV) and since Dd c U, we have (T -'rw) s _ U 5 _ . (3) d (rd + r") or since (Td +Tw) - (Tc - ‘I's +Tw ), then We ’ T") (h) Sd-U —--I_ ‘— (Tc at, +1") where Tc - entire cycle length or T8 + Td The eQuation for the stroke volume can then be written: 5' . U + 5d a U + U 1; _" $91.") or dividing through by the cannon denominator and U '1' combining terms 5' . mu ), Tc and T3 are measured from the pulse contour as shown in Figure 5. TV 18 obtained from the curve in Figure 6 . If flow is to be expressed as cardiac index, hence, liters 60 U per minute per square meter body surface, then F- ' m ° 38 A sample calculation will illustrate the method. Having obtained the central pressure pulse contour shown in Figure 5, the diastolic pressure in this case, 90 mm of mercury, is referred to the series of curves in Figure 6, and the pulse wave transmission time (milliseconds) to the divisions of the aorta are noted. In this example: Th e 3), '1" - 59, T1 - 87. Pressures (m Hg) existing in these portions of the arterial tree are read from the pulse record: Ph - lhh, P, - 1148, P1 - 1113. The pressure at the incisura - 128. The uptakes are then calculated as follows: U‘ - values at P1 - volune at Pd - 18.14 - 13.0 - 5J4 cc Uh - volume at Pb - volune at Pd - 16.2 - 28.5 - 16.7 cc Uv - volume at P7 - volume at Pd - 1h.6 - 9.8 - 14.6 cc 01 - volume at P1 - values at Pd - 13.3 - 9.2 - h.1 cc U - total arterial uptake - 30.8 cc The total arterial uptake during systole is then U - ILB. The cycle length is measured from the initial systolic upswing of the pressure pulse curve being studied to the initial upswing of the next following pulse. In the example: To - 576, T, . 172, and Tw - 66 milliseconds. 1“, is obtained from figure 6. The stroke index is then obtained as {01103483 5 . U Tc . 8.8 X 576 v m 1160 ' 38.1; cc. And th a) U ‘ e flow or cardiac index F - c _ s , w - 14.01 liters per minute per square meter. 39 RESULTS Since it was not possible to treat each of the bilaterally adrenalectomised dogs in the same mamer with respect to replacement therapy, the results obtained on each dog are presented in protocol form in Tables II through VI. Exact dosages of A C E, Lipo and D C A used for each dog are indicated below. HGJID DOG As shown in Table II preoperative control values for blood and cardiovascular observations on this dog are within commonly reported limits for normal healthy animals (10h) . The first experiment (I) was conducted one week after removal of the second adrenal gland while the dog was still on therapy, 3 cc A C E per day. As indicated in Table II there was a slight decrease in systolic pressure and an in- crease in diastolic pressure resulting in a decreased pulse pressure. The cardiac index and stroke index were reduced along with the decreased pulse pressure. The heart rate was not a factor in the decreased cardiac index since it was slightly (but probably not significantly) greater than in the preOperative state. There was a slight decrease in R wave voltage in all leads of the E C G but no other significant alteration in the electrocardiogram. The second experiment (II) was perfomed eleven days after the first; the dog received 3 cc of A C 3 per day for seven days and then no extract for the last four days. The dog was in a mild state of adrenal insufficiency as indicated by all data used for its estimation. Both systolic and diastolic blood pressures had fallen to low levels, the pulse pressure being further reduced below'that observed in experiment I. The heart rate did not change, but the cardiac index and stroke index both were further depressed. The E C G showed a slight further decrease in R wave voltage in all leads and a rounding of the.P wave in lead I only; Following this experiment the dog was weak but still able to walk. Dramatic recovery by the following morn- ing followed the administration of 10 cc of A G Eiintravenously plus 2 cc Lipo extract intramuscularly. The third experiment (III) was performed 11 days after the second experiment while the dog was still on therapy; The dog received 3 cc of A C E per day for eight days then 1 cc Lipo per day for three days. All values indicated an improved condition except plasma potassium which was still elevated. The heart rate was slightly slower than in previous records. The systolic pressure was increased relatively more than the diastolic blood pressure, resulting in an increased pulse pressure. The cardiac index and stroke index were both increased. The E C G showed little change except a less severe rounding of the P wave in lead I. The fourth and final experiment (IV) on this dog was performed six.days after the third one and after the dog had been off therapy for two days. During this time on therapy, 1 cc of Lipo plus 3 so A C E for one day and then 1 cc of Lipo for three days were administered and then no extract for two days. The data show a decrease in systolic blood pressure, with a decrease in pulse pressure . la Again the cardiac index and stroke index were both depressed. The E C G showed a marked rounding and widening of the P wave in several leads. Following this experiment the dog was no longer supported but allowed to decline into a terminal adrenal insufficiency. ‘Within six and one-half days after complete removal of therapy and four and one- half days after completion of the final experiment the animal died. 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Experiment II was performed eight days after the first experiment and while the dog was receiving therapy of 1 cc Lipo per day for three days and then 2 cc Lipo plus 5 mg D C A for one day, then 1 cc Lipo plus 2 mg D C A per day for four days. The blood I P l was higher than in the previous experiment, with little change in plasma sodium and potassium values. The heart rate was much lower than before . Despite the fall in both systolic and diastolic pressures, the pulse pressure was increased. Also the stroke index and cardiac index were both increased. so significant change in the electrocardiogran was noted. Emperiment III was performed eight days after the second. The dog had received 1 cc Lipo per day for six days and then no therapy for the last two days just prior to the experiment. All measurements indicated a severe adrenal deficient state . The hematocrit at this time was quite high, nsnely, 60. The pulse pressure was matly reduced with a corres- ponding decrease in stroke index and cardiac index. Except for a further reduction of the R wave voltage no further change in the E C G record was noted . Experiment IV was performed twelve days after the third experi- ment. During this interval the dog was given therapy consisting of 1 cc Lipo plus 5 cc A C 3 plus 5 mg of D C A per day for four days, then 1 cc Lipo plus 2 so A C 3 and 2.5 mg of D C A per day for eight days. The data, except body weight, indicated an improved condition since the previous experiment. I P l was reduced, sodium was increased and potassium decreased. The blood pressure was improved by the greatest increment obtained in am experiment. Cardiac index was markedly increased. The henntocrit had decreased to 140; no further alteration in the E C G was noted. After completion of the fourth experiment this dog was taken off therapy and allowed to decline . On the fourth day off therapy the final experiment U) was performed. At this time the annual was noticeably weak andappeared to be suffering from gastrointestinal disturbances as indicated by retching. The animal was able to walk about the laboratory but would slip and appeared unsteady. As shown in Table III, the data indicate severe adrenal insufficiency except for the hematocrit. However, the hematocrit had returned from the un- usually low value of the previous experiment to the control value indicating some hemoconcentration. Heart rate was unchanged; cardiac index and stroke index were reduced. The R wave voltage of the E C G had almost completely disappeared. lo further therapy was administered to this dog and the following morning the animal was found dead in the cage. b5 Aboaha Hamel-a3 Jamaicans-oi iguana: etc we caskets an. . no.3”: cams: HHH M993. one no.3: sound axon: new Noun.“ 33.33 .33." v.80: amen: {analogues 3935qu 09:3 Ho owuao>< a i n33 £232... 3.. has”? .3: mum ems 8R2 3 3.0 is? Rs we p as hedge»?- ue mamas 3a: m «3.3 .aheu 4 votes» .xeez be» ...-0.306 Pagan new hashes» «.3 .fi»? .32. was: 693% mdm mun ems 355 3 mm... a: mo um 5 ES 2533 533930 3.5.3.“ on . shun NH poem hue» 5 men he.“ Eugen» no .hafiwasoa 30055 «@230 en mi." mm...” mm." om\n~. 8 mod mmH m: Na HHH Emma 390% use wade-o .ahao noose?" “$22.32 u how ham-hon» mo mam? 623:» mom on can». 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Of the data used to evaluate the state of adrenal deficiency, I P l and hematocrit showed the most significant changes . The systolic blood pressure was unchanged but diastolic pressure was elevated, resulting in a decreased pulse pressure. Cardiac index and stroke index were both markedly decreased although the heart rate was slightly increased. Experiment II was performed six days after experiment I. The dog received 0.5 cc Lipo for 1; due, then no extract for two days. The data indicate the animal was in a state of adrenal insufficiency: plasma potassium was very high, plasma sodium was low, as! blood I P l was more than double the control value. Both systolic and diastolic blood pressures had fallen and heart rate was decreased. The cardiac index and stroke index were depressed to about half the control values. The E C G showed a rounding and widening of the P wave in all leads. Experiment III was performed nine days after the second one. The dOg had received 1 cc Lipo plus 2 cc A C E for three days, then 1 cc Lipo for six days. The l P l was elevated still further. However, all other measurements indicated a slightly improved condition. The cardiac output was especially improved . 147 The final experiment (IV) was performed five days after experiment III, the dog receiving 1 cc Lipo for 3 days, then no therapy the last two days. All measurements again indicated an adrenal insufficiency. Blood pressure had fallen again; heart rate was decreased. Cardiac index and stroke index both were again decreased. A very wide P wave and severe reduction of the R wave voltage were noted in the E. C. G record. “as: 148 v.8 no.2? N35” 83.5.. 05 H005 33.30 .3?" sheen new adage Abuses» 4.93.8.3 .opnoaonsaaoa assumed?“ 25 Ho aways; ...! usages—c.532- Husuwawuca no . needs» oflmfie .53 He owahebq a. 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The dog was maintained for eight days on 0.5 cc Lipo ... ' I! t ad Jinal extract per day, follovdng removal of the second adrenal, then Sij-V-jfienly developed an acute circulatory crisis. Peripheral veins were {East completely collapsed. Cerebral depression was apparent as F indicated by a semi-comatose appearance of the am'nal. As indicated :1 fin Il‘able V the dog was revived by the administration of a large anount if‘fof adrenal extract. Five days after this circulatory collapse and after jhaving received 1 cc of Lipo plus 3 cc of A C E per day for two days S 3}? and then 1 cc of Lipo per day for two days, the animal appeared well ‘5) and strong and experiment I was performed. The body weight was 1 kg 1 below pre-Operative weight , but the blood chemistry data indicated the animal was in a near-normal condition. Systolic blood pressure was decreased about 10 m Hg, the diastolic pressure was elevated about 15 mm Hg and the pulse pressure was reduced accordingly. Heart rate was . markedly increased compared to control values . The stroke index was }’ geatly reduced, whereas the cardiac index was near the control value. 5 j Emeriment II was conducted six days after experiment I, the deg receiving 0.5 cc Lipo per day for four days and then no extract for two days . The data indicated adrenal insufficiency. Despite the fall in blood pressure , the pulse pressure was unchanged since the previous experiment. However, due to a decreased heart rate, the cardiac index was decreased . Experiment Ill was conducted seven days after experiment II dur- ing maintenance therapy (0.5 cc Lipo per day) . A slight improvement in the condition of the animal was indicated by all measurements except I P I. 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A3 a . a 5,536.80 NocaH Kevan ovum 95:95 3&0 .3383 exude—om .9333 83.3% 0:350 $8.5 “3on nevus—em a. as am- hvom £35395 3..ng has 52 ggégg This dog had the slowest heart rate and lowest blood pressure of any of the bilaterally adrenalectomised dogs studied. The control cardiac index and stroke index also were respectively the lowest in the group. Ione of the other control data indicated the animal was not a healthy active deg. As a matter of fact, this dog had the largest appetite and was one of the most active in the group. The first post-operative experiment was perfonmed one week after removal of the second adrenal gland. For these seven days, 1.5 cc Lipo per day were administered. The I P I and hematocrit were elevated. A slight decrease in the systolic blood pressure and an increase in the diastolic blood pressure resulted in a reduced pulse pressure. Heart rate was unchanged.but the cardiac index and stroke index were decreased. There was a reduction in R wave voltage in all leads in the E C G record. Following the first post-operative experiment the dog was again.placed on therapy for 6 days (1.5 cc Lipo per day), then therapy was withdrawn for 2 days and experiment II performed. All criteria used indicated an adrenal insufficient condition. Heart rate was significantly increased. Systolic and diastolic blood pressures had both decreased since the last experiment with a resulting lowrpulse pressure, Although the stroke index was further reduced the cardiac index was little changed since the last experiment. There was a slight further reduction in R wave voltage in all leads . Experiment III was perrOrmed twelve days after experiment II and while the dog was still on therapy (1.5 cc Lipo per day for the twelve days). 53 All criteria indicated an improved condition since the previous experi- ment. Systolic pressure was unchanged but diastolic pressure was slightly lower, the pulse pressure being increased. Stroke index was significantly improved and cardiac index was slightly but probably not significantly greater than the control value. The E C G record showed no further change from that of experiment II. The dog received 1.5 cc Lipo again for six days, then no extract for two days. herment IV was then performed. Body weight decreased one kg; I P I further elevated; and plasma sodium was unchanged, whereas plasma potassium was elevated. The hematocrit was about the same. Both systolic and diastolic blood pressures were greatly decreased. Heart rate was the highest value obtained in any of the experiments. Cardiac and stroke indices were both decreased. Observation of the E c G record showed a slight further depression of the R wave voltage in all leads . Following the fourth experiment, the dog was no longer supported with replacement therapy but allowed to decline into a terminal adrenal insufficiency. 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The first is con- cerned with observations on changes in body weight and blood chemistry, while the second part is concerned with the data pertaining to cardio- vascular measurements . ND! WEIGIT AID BIDOD CHMISTRI Body Weight In the five bilaterally adrenalectomised dogs studied body weight changes paralleled the alterations in appetite and activity of the animals. In all five of the dogs a loss in weight occurred within two to three days after removal of the second adrenal gland. In each instance the dog's weight remained quite constant at the decreased level as long as replacement therapy was being administered. however, in no instance was the pre-operative weight restored during therapy. Withdrawal of replacement therapy even for as little as two days again caused a loss in body weight. Numerous factors contribute to weight loss in adrenal insufficiency. Withdrawal of therapy often results in a rapid loss of weight due to excessive renal excretion of water and s‘alts . In more advanced in- sufficiency, vomiting and diarrhea may contribute to the dehydration (52) . Reduction of food and water intake and impaired intestinal absorbtion may also lead to weight loss. Faulty fat metabolism may be implicated in the body weight reduction (120) . Reduced intestinal so absorption usually occurs in chronic insufficiency of long duration. Vomiting was not observed in any of the animals studied until terminal complete removal of replacement therapy, and then in only two animals. Io cases of diarrhea were noted. Blood Ion-Protein Iitrogen Pre-operative I P I values ranged from 32 to 110 milligrams percent, with a maximum range for any one dog of S milligrams percent. Individual values for each dog are included in Table II of the Appendix. These values are in close agreement with accepted values for normal dogs. In the present work, the I P I tended to increase steadily after removal of the second adrenal gland. An elevation of the I P I was noted within two days after removal of the second adrenal gland despite supportive treatment. (lo-plate withdrawal of replacement therapy caused a sharp increase in the I P I in every case. When maintenance therapy was again ministered to three of the dogs the I P I decreased; Bound Deg, experiment III ; aeokey, experiment 1'; and Champ, experiment III. In two others the I P I rose steadily until the terminal experiment was performed, Spot and Brownie. In general, it was noted that changes in I P I tended to lag behind responses of hematocrit and blood pressure to supportive therapy. Harshall and Davis (68) were the first to observe consistent rises in blood urea (the chief canponent of the excess I P I) associated with impaired kidney function and on the basis of experiments on fasting animals stated that the changes did not involve increased protein 57 catabolism. The findings of these authors were confinmed by HarrOp 335;. (39) and Stahl 3313. (101). Swingle 33 31. (112,113,115) reported a consistent reciprocal relationship between changes in blood urea and blood pressure throughout the deve10pment and recovery from adrenal insufficiency in the dog, and attributed the urea changes as secondary to renal impairment which resulted from reduced blood pressure and blood volume. This group also stressed the importance of’prctein catabolim as a factor in adrenal insufficiency. Lceb (62) supported the idea of renal origin of the increased I P I resulting from reduced blood flow through the kidney, reduced filtration pressure or impaired tone of the renal efferent arterioles. Hartman (RS) suggested that the rise in I P I was a result of kidney damage caused by salt depletion. It was hypothesized by KerpleéPronius (56) that dehydration and not electrolyte unbalance was the major factor in causing increased blood nitrogen. Harrqp (39), however, found a closer relationship between blood potassium and blood urea than between either sodium or chloride and urea and stated that electrolyte changes are not the cause of the raised l P I. Hematocrit and Plasma Sodium Changes in water content and plasma sodium are so closely related that the two can easily be discussed together. Hematocrit and plasma sodium determinations were obtained on all dogs each thee an experiment was performed. Pre-operative hematocrit readings for the five bilaterally adrenal- ectomized dogs averaged h8 percent red blood cells with a group range 58 of h? to h9 percent. Plasma sodium values averaged 1&2 milliequi- valents (meq) per liter with a range of 137 to lhb.meq for the group and a range of not more thanvij meq for any one animal. Hematocrit readings were approximately 5 percent higher than those generally reported for normal dogs. Io explanation can be offered for this. However, since all hematocrits were treated in the same manner the relative changes are valid regardless of the absolute values for the control figure. The values for plasma sodium are in good agree- ment with those reported elsewhere for normal dogs U41). In the five animals studied the hematocrit afforded a somewhat variable index to the condition of the annual. An early elevation was found in four of the five dogs. In four of the five dogs hematocrit readings taken when therapy was suspended were, with one exception Hound Dog, Experiment II, higher than those obtained when therapy was being administered. The hematocrit in the fifth dog (Spot) was elevated very soon after removal of the second adrenal and remained high through- out the course of the experimental work. Salt and water depletion of the blood during the course of adrenal insufficiency has been established beyond doubt. Restoration of normal values follows the administration of adequate quantities of A C E, D C A, or other steroid preparations (30,h0,51,63,97,99,110,112). Changes'in the total plasma content of sodium are always demonstrable, but altera- tions in sodium concentration may be counteracted by simultaneous loss of fluid in excess of electrolytes (122 ,123) . S9 HarrOp 2:5: 9» (L0,hh,h5) and Loeb (62,63) were among the first to emphasize the importance of excessive renal excretion of water and sodium salts during the onset of adrenal deficiency in dogs. A specific regulatory action upon kidney function U41,h2 ,hS,51 ,107) particularly upon the tubular reabsorption of sodium has been postulated (112,118) . Swingle (110 ,113) has repeatedly stressed the importance of the. regulation by adrenal hormone of the distribution of fluid and electro- lytes between the plasma and the tissues, an action not directly re- lated to renal function. Harrop £140,103 believed that the regulation is brought about directly through alterations in tissue permeability. As pointed out early in the review of literature pertaining to capillaries, Swingle U43) regarded whatever capillary permeability changes which can be ‘ demonstrated as secondary to stagnation of blood and localised anoxia. The results obtained in the present experiment with reapect to hematocrit and plasma sodium are in general in good agreement with the literature reports of alterations of these two variables in adrenal insufficient animals. Plasma Potassium In the twelve dogs studied the group mean for the lire-Operative plasma potassium values was 14.71. mg. per liter with a range of t 0.6 “9. per liter. The range for am one animal was not more than 3 0.6 DWI/liter (one animal) with an average range of t 0.25 mg. for the group. These values are well within the normal limits for dags (103) , A rise in plasma.potassium in adrenal insufficiency has been established unequivocally in the past (h,13,125,131,133,136) . Considerable difference in opinion exists concerning the time of on- set and the primary cause of the elevated potassium. The significance of the excess plasma.potassium with respect to its effect on the cardiovascular system in the adrenal insufficient animal has by no means been adequately established. As pointed out in the literature review, acute circulatory collapse in both laboratory animals and humans often occurs even before significant electrolyte alterations have occurred. In the present work plasma potassium values were not elevated in any of the experiments to levels as high as those usually found in more severe, prolonged adrenal insufficiency, yet circulatory disturbances were evident. In one animal an acute circulatory crisis occurred before electrolyte or other changes were apparent. It is concluded that the elevation of plasma.potassium is not a necessary prerequisite for the Observed circulatory abnormalities although it may aggravate them once they have occurred. As shown in Table VIII B Page 695 the cardiac index was sharply reduced below controls, although individual protocols (Tables II-VI) show that all dogs had normal plasma potassium levels. The data obtained in the present series of experiments with respect to body weight and blood chemistry changes in adrenal insufficiency add little to the information already known. These measurements were made . primarily to help provide an evaluation of the state of adrenal in- sufficiency existing in any particular animal at the time cardiovascular measurements were made. 61 CARDIOVASCULARJHEASURflhEITS Arterial Blood Pressure The average blood pressure values obtained for a total of no femoral artery punctures in twelve intact unanesthetiaed dags were 157 , 106 and 50 mm mercury for systolic, diastolic and pulse pressure, respectively; The ranges were 130 to 180 systolic, 75 to 110 diastolic and 55 to 60 pulse pressure. Individual values are included in.Table IX of the appendix; The average pro-operative femoral artery blood pressure values for the five bilaterally adrenalectomieed dogs were 171 systolic, 97 diastolic and.7h pulse pressure, with ranges of 160 to 180, 90 to 113 and 68 to 85 respectively. It will be noted that systolic and pulse pressures are somewhat higher than those ordinarily obtained on dogs when less sensitive methods of measurement are used. The blood pressures as measured at the carotid artery in nine intact unanesthetised dogs and nine intact dogs anesthetized with sodiu- pontabarbital are shown in Table VII. The most obvious difference in these two sets of data is the higher diastolic pressures resulting in a lower pulse pressure in the anesthetized dogs. This is at least partially due to the increased heart rate in the anesthetised dogs, that is, an average of 153 for the anesthetized dogs compared to 106 for the unanesthetised dogs. In four of the five bilaterally adrenalectomised dogs studied the pro-operative carotid artery pressures ranged from 1&5 to 150 8y8t0110, 90 to 98 diastolic and 52 to 60 pulse. In the fifth dog the pressure TABLE VII «I: HEART RATE, BLOOD PRESSURE, CARDIAC II'DEI AID STROKE INDEX OF WHERE!) AND UIAIESI‘HEI‘IZED DOGS Deg Weight Heart Blood Cardiac Stroke Rate Pressure Index Index lit/min/ cc/beat/ Kg. g mm. Hg sq. net. sq. net. Anesthetized“ cm 11 .8 182 1h8/116 2 .90 15 .9 Spits 7 .6 1116 151/123 2 .28 15 .6 Jupiter 10.6 115 1h8/115 2.02 - 17.5 Enter 13 .2 138 158/123 2 .59 18 .7 mm 11. .2 16h 150/123 2 .25 13 .7 Spet-2 12 .0 160 160/123 2 .811 17 .7 Chap-1 15 .5 11:3 158/135 2 .76 19.3 Black a white 13.0 136 180/118 2.70 19.8 Blackie 13 .5 192 Nth/118 2.66 13.8 Mean 12 . 3 153 150/120 2 .55 16 .8 Trained-Unanesthetised Hound Do 11 .6 110 1118/90 11.05 36.8 Collie 18.5 89 180/80 11.16 111.6 Brutus 15 . 2 95 178/105 3 .70 32 .0 Pinto 16.5 116 151/95 b.35 3h.2 Pup 10 .6 95 156/102 3 .08 33 .0 a-okay 10.6 130 170/110 11.29 31.5 spot 15.6 138 150/98 11.28 31.0 Chap-2 15 .5 87 1115/93 2 .60 33 .2 Brewnie 10 .h 100 150/90 3 .58 35 .8 Mean 106 15b/9h 3.78 3b.0 1‘ Measured at the carotid artery. *‘ 30 mg. Sodium Pentqbarbital per kg. bocb' weight. 63 was 180/113, but this animal showed no signs of being abnormal in any other respect. The first change noted in blood pressure recorded at the carotid was a decrease in systolic and an increase in diastolic pressure, re- sulting in a reduced pulse pressure. Withdrawal of therapy for two to four days in every case caused a marked decrease in both systolic and diastolic pressures, and when therapy was again administered, pressure was improved in almost every case, although in these experi- ments the magnitude of the increase was not great, probably due to the short time interval between periods off and on therapy. During re- covery systolic pressure increases in every case preceded diastolic improvement and were of greater magnitude than diastolic pressure changes with a consequent increase in pulse pressure. In experiment IV, Smoky, a combination of D C A and Lipo extract was given for twelve days and the yeatest increase in pressure was obtained. The lowered hematocrit indicated a possible overdose of D C A. One dog, Brownie, peared to be well on the way to recovery from the second adrenal removal then suddenly developed an acute circulatory crisis with a precipitous fall in blood pressure and was revived only by the administration of a large dose of A C E intravenously. In general, in the present work blood pressures tended to reflect most accurately and conclusively the condition of the animal, and the adequacy or inadeguacy of therapy. As cited in the literature review, a lowering of the blood pressure has been associated with adrenal cortical insufficiency since the time of Addison (1) . Today all investigators in the field agree that the blood pressure is reduced following adrenalectomy, but there is con— siderable disagreement as to the importance of this finding, relative to other disorders which develop, the time of onset of the hypotension, and the nature of the underlying mechanisms. In the present work, changes in blood pressure afforded the earliest and most sensitive indication of alterations in the physiological con- dition of the animal. This agrees with the findings of Swingle, at 31. (102,111,112,11b) who reported pressure changes in adrenalectomized dogs as early as twenty-four hours after withdrawal of A C E injections, followed by a steady decline over a period of days , terminating in circulatory collapse and death. The return of blood pressure to normal was described (109) as one of the first and most drmnatic changes following the ministration of A c a to animals in severe insufficiency. Harrop _e_t_ all. (113,1111), Britten and Silvette (9) and Loeb (62) all believed that the pressure changes did not occur until afterother signs of circulatory failure had become evident. The relative insensitivity of the methods of measurement earployed by these investigators may explain in part their failure to observe early changes. In the five dogs studied, in the present work the data show conclu- sively that alterations in systolic, diastolic and pulse pressures occur within a day or two after removal of the second adrenal and often even while the dog is still on therapy. The several hypotheses which have been offered to explain the blood pressure decline in adrenal insufficiency were presented in detail in 65 the literature review. The contention of HarrOp, _e_t_ 31. (h0,h3) that the pressure fall was due to a reduction of circulating blood volume resulting from excessive fluid loss because of impaired kidney function tion seems to be no longer tenable in the light of work flready pointed out showing early pressure changes in adrenal insufficiency. The sodium depletion hypothesis of Loeb (62) in which he postulated a specific ion effect upon the blood vessels following sodium loss is even less acceptable. it was shown conclusively by Gilman \ 1)) that A C E is needed to correct some physiOIOgical defect not directly re- lated to the level of serum sodium. Swingle 33 31 . (1111) showed that adrenalectomiaed dogs maintained on saline without hormone preparations appear normal in most reapects, but have lowered blood pressure. It is concluded that the present work confirms the findings of others that blood pressure changes in adrenalectomised dogs occur alm0st immediately after removal of the second adrenal gland. In addition, the present investigation provided more precise infomation concerning this magnitude of these pressure changes. The possible relationship of blood pressure to the output of the heart is discussed below. Electrocardiogram The early increase in amplitude of the T wave of the E C G was not noted in the present experiments. This can not be explained entirely on the basis of the less severe increase in plasma potassium values already noted, for Roberts (88) has reported that T wave elevation occurs even before electrolyte alterations are apparent. S-T segnent 66 depression reported by others also was not observed. This alteration usually occurs at potassium levels somewhat higher than those obtained in the present experiments. The rounding and widening of the P wave noted in almost every experiment when replacement therapy was withheld has not been reported before, and may or may not be a significant finding. The present experiments are not extensive enough to allow a positive evaluation of this finding. The E C G recordings taken in the final experiments (when the dogs were off therapy) all indicated a severe decrease in R wave voltage. The data certainly indicate that considerable alteration in blood pressure, cardiac index and stroke index in adrenalectonized dogs can occur before alteration in the E C G are apparent. Heart Rate, Cardiac Index and Stroke Index lgtactjpesthetized Dogs. Table VII (page 62) shows the results obtained in the present work using the strain gagevalnplifier system described on page 23. A group of nine dags anesthetized with 30 mg sodium pentabarbital per kg body weight was studied. The mean heart rate was 153 beats per minute with a range of 115 to 192. The mean value for the cardiac index was 2.55 liters per minute per square meter body surface with a range from 2.02 to 2.90. The mean stroke index was 16.8 with a range from 13.7 to 19.8. These figures are in excellent agreement with those obtained by others (67,810 using the sane analytical method but employing Optical systems for recording the central pulse. 67 The pressure pulse contour method has been checked by Hamilton and Remington (35) against the dye dilution method and found to have a correlation coefficient of 0.991.. numerous other workers have com- pared the pressure pulse method with the dye dilution, Pick and rotameter methods. Opdyke (77) has reviewed these comparisons and found the average differences for all investigators between the pres- sure pulse method and the others to be between :8.0 and :13 .0 percent. lormal Unanesthetiaed Degs. Table VII shows the values obtained for nine unanesthetised dogs. The mean heart rate was 106 per minute with a range of 87 to 138. The average figure for the cardiac index was 3.78 liters per minute per square meter body surface with a range fran 2.60 to 14.35. The average stroke index was 314.0 with a range from 30.2 to h1.6 cc per beat per square meter. Figures for the cardiac index of the unnarcotized intact dog by the pressure pulse method are difficult, if not impossible, to find in the literature. Values obtained by the Fick method, by which the pressure pulse method has most often been standardized, are also not numerous for the unnarcotised dog. One of the classic studies on the cardiac output of the trained, conscious dog is that of Marshall (67), who studied the cardiac output of five dogs over a long period of time using the Pick method, and arrived at a figure of 3.10 liters per minute per square meter body surface area, with a range from 2.614 to h.02. Harrison 33 ‘a_l_. (36) using a group of nine trained dogs and also using the Fick method arrived at a figure which when corrected for the surface area of the dogs was equal to h.16 liters per minute per square meter with a range from 3.03 to 5.81. The data of Harrison's group are probably more nearly representative since the study included almost twice as many dogs as that of Marshall (67) . In addition, a much wider range of dogs with reapect to body weight were used by Harrison. In the present study the average cardiac index in nine dogs was 3.78. The range was 2.60 to 15.35 (Table VII). It is concluded that the values obtained in the present study using the pressure pulse con— tour method for computing the cardiac output in normal intact trained dogs are in good agreement with those obtained by others using the direct Pick method in the same type of experimental animal. BilategallLLdrenalectomiaed Dog. The data for heart rate, cardiac index and stroke index are included in protocol Tables II through VI and are summarized in Table VIII. The control figures are those obtained before removal of the second adrenal gland. In every case after removal of the second adrenal gland, the first series of measurements, taken when the dog was receiving replacement therapy, indicated a reduced pulse pressure. The reduction was due both to a decrease in systolic and an increase in diastolic pressures. The mean values for blood pressures illustrate this (Table VIII A and B). The decrease in pulse pressure resulted in a greatly decreased stroke index and cardiac index in four out of five animals in the group. The fifth dog (Brownie) was still on therapy when the first post-operative experiment was performed but had already undergone one acute circulatory collapse . This dog's 69 TABLE VIII SUMMARI OF CARDIOVASCULAR.IEKSDHEHEITS.OI ADREIALECTOIIZED DOGS LCentroI !. fifimentfir Blood Heart Blood Heart WDoL Pressure Rate C. I. S. 1. Pressure Rate 0. I. 5.1 I. Hound Dog 1t8/90 no b.05 36.8 11.0/105 130 2.92 22.5 snakey 170/110 130 h .29 31 .5 150/12 5 156 2 .06 13 .0 Spot 150/98 138 h.28 31.0 150/115 150 2.80 18.6 Brownie 150/90 100 3 .58 35 .8 Ito/106 168 3 .m. 20 .h Chap 116/93 87 2.60 30 .2 136/102 81. 1.55 18.5 Mean 152/91. 113 3.76 33.1 1h3g1 125— 2.55 18.6 c. 0:: Thar D-On Ther 3 Blood Heart Blood Beart Dag Pressure Rate 0.1. 3,1, Dag Pressure Rate 0.1- SJ, Days3 Hound Dog 76/55 130 2.10 17.0 h 100/63 100 2.95 29.5 11 90/55 103 2.614 25.6 2 Smokey 73/50 135 1.92 1h.3 2 11h/75 102 2.61 25.6 15 105/80 156 2.33 1h.9 h 138/105 156 3.25 20.8 12 Spot 80/50 110 1.88 17.3 2 105/72 125 2.78 22.2 9 811/55 110 2.00 18.2 2 Brownie 105/72 110 2.h5 20.5 2 110/65 110 2.70 214.6 7 Champ 111 93 11:5 1.70 11.7 2 108/80 1&5 2.80 19.}; 12 72 55 156 1.77 11.3 2 Mean 85/63 128 2.13 16.6 112/77 123 2.85 23.7 ‘ Performed 7 days after renewal of second adrenal, except 3P“ which was 10 days and Brownie which was 15 days. a Exact dosages of therapy have been indicated in detailed results for each dog. ’ Days either on or off therapy before experiment was performed. 0.1.: Cardiac Index 5.1.: Stroke Index 7O heart rate was much greater than in the control experiment, but the cardiac index was almost equal to the control value. These changes in all dogs were manifest even before significant alterations in E C G and blood chemistry had occurred. Withdrawal of therapy for as little as two days in five out of seven instances (Table VIII C) resulted in a further reduction of the cardiac index and stroke index. When therapy was again administered, and measurements made while the dogs were still on therapy, improve- ment in the cardiac index was noted in each case. The improved cardiac output was associated with an increased pulse pressure with resulting increase in stroke output. The increased pulse pressure upon re-administration of therapy was due to an increased systolic pressure (one exception, Chap, Table VIII D) with a relatively maller increase in diastolic pressure. In the major-8 ’ ity of cases the cardiac output was never returned to the normal control value, but this is believed to be due to the relatively short time on therapy between experiments, as well as less than Optimum hormone re- Placement. However, there can be little doubt that restoration of the cardiac output to the control level could have been attained with more PPOIOnged and vigorous replacement therapy. In one dog (&okey, experi- ment IV) a deliberate attempt was made to restore the animal to an active and strong condition in a rather short time by use of a combina- tion of D C A and A C E. The data taken at this time indicated the greatest improvement in the cardiac index achieved in arnr of the experi- ments (Table II, experiment IV). 71 The data show conclusively that removal of replacement therapy even for as little as two days causes a further depression in the out- put of the heart paralleling increased adrenal insufficiency as indicated by the hematocrit, blood N P N and plasma sodium and potassium levels. lie-administration of replacement therapy brings about improvement in heart function as indicated by an improved output. This work is the first attempt to measure the output of the heart in a totally adrenalectomised dog without recourse to major surgery and without the use of general anesthetics. The first noted change is a marked decrease in the pulse pressure with a resulting decrease in stroke index and cardiac index. These two are depressed to a value about equal to that of an intact dog deeply anesthetized with sodium pentabarbital (compare‘l'able VIII B and Table VII). Since this first depression takes place even before significant alterations in blood chemistry or E C G occur some factor other than these must be respons- ible. The elevated diastolic pressure noted in the first post-Operative experiment performed on each dog is probably indicative of an increased peripheral resistance. in increased peripheral resistance coupled with the observed decrease in cardiac index are congruent with the concept of a somewhat inadequate blood volume. lo consistent indication of hemoconcentration is apparent in the data, however. Two dogs, Brownie and Hound Dog showed no significant changes in the hematocrit, whereas an elevated hematocrit was indicated in the other three animals. 72 The improved cardiac index obtained when the dogs were on therapy (Table VIlI D) occurred in most cases even when marked improvanent in blood pressure had not.yet occurred. A lowered peripheral resistance could explain the inproved cardiac flow and lagging blood pressure. 73 SUHHARI A group of five bilaterally adrenalectomised degs was studied in order to gain information on the output of the heart in adrenal in- sufficiency. Blood pressure, heart rate and cardiac index were followed simultaneously in the same animal in different states of mild insufficiency. The pressure pulse contour method of Harnilton and Rmington was used to determine cardiac output. Pressure recordings of the central pulse were obtained with a strain gage pressure pick-up and recorded with a direct-writing galvanometer. The finding by others that a fall in blood pressure is one of the earliest signs of adrenal insufficiency was confirmed. In addition, the present work involved measuring the central blood pressure and the data indicated that the first change in blood pressure measured at the carotid artery is a decrease in systolic and an elevation in diastolic pressures with an accompamring decrease in the pulse pressure. The decrease in pulse pressure was accompanied by a marked reduction in heart stroke index and cardiac index. Withdrawal of replacement therapy for two to four days in every case caused a further decrease-”in the cardiac index and stroke index. Readministration of therapy resulted in improvement of both indices, even when blood non-protein nitrOgen, plasma sodium and potassium values were not greatly improved. Electro- cardiographic records in the present work fail to confirm reported early alterations such as increased elevation of the T wave and S-T segment 7b depression reported by others, but a decreased R wave voltage in all leads occurred invariably in adrenal cortical deficiency. It is concluded that the data indicate that a decrease in the cardiac output occurs early in adrenal insufficiency which is not dependent upon or necessarily associated with marked changes in the electrocardiogram, blood non-protein nitrogen or plasma sodium and potassium levels. Some direct beneficial influence of adrenal corti- cal hormones on heart muscle could be implicated. 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HERCURI FIGJRE 9. CHICAL MIME CALIBRATIOI CURVE 2°°rr 1504- 1007—. 50.. 0I I 1 1 I g l I 1 n #3 o 10 20 30 1.0.50 60 70 so 90100 DEFLECTION 1/50 INCH 8? OPTICAL DHSITI 88 FICURE 10 . STANDARD CURVE FOR DEI‘HMIIATION 01" 31(1)!) ION PROTEII IITROGH PROM 311381“ 100 10 89 FIGJRE 11. CALIBRATION CURVE FOR SODIUM AID POPASSIUH ANALYSIS Kc» l’ Na+ \\ ’1 1 1 I 1 1 1 1 J O 1 2 3 1: 5 6 7 1+ 70 90 110 130 150 170 1% 210 Na+ COEBI'I‘RATIOI He q/liter 111 111‘ ”can” Ewan-Lurxirr -Lav Lawryzrt G 17th 111:1-1 -11 NH manque)! 1 11 1 If 1 I . .pmuasoaoofianoaca bud—amend“: 55.33039» won a. 13H SH SH 3H 3H 13H SH RH 9: RH SH SH .5321 SH SH 9: EH 2H SH SH RH «.2 RH 2H 3H 282 .mw mm 1&1 .111 1R t R Mn 1.1m 9. M R1 51mm. 9. mm an mm 1m an on 1m 1m om mm 1m mm on R mm .R mm on R R R 2 R an a a: 4m mm mm mm R on an R R R 3 mm 3 m .— .. n: .. . . r. ..h . .1: 1 A 1.” “EH“ 1. - .... . ..phu ... . H 5mm 13H 00H hoRH 1R mOHommH ..mHo 8H .0 0H .2111. 11.11.11.111... 11.21.2111... 811.112.111.11. .. ..._ o o 0 8H m H 8 8H 8 8H S H 288.; 8 SH 353 85.: 8\ H Exam OESH saw me RH 853 853 8H\8H mo 11H ..83 «RH lawn! o. H . . . M. 1.1 1 131 .3 . H mam.— ~1WH m H .o m 4H 0 o. . 1 N a n6 m.oH 1.3 .31 11.3 «.1: 0.3 11...: :.HH m.HH «.2 0.3 0.1 «.11 0.2 13H 231: 11.3 0.1: 0.3 0;: ~.HH 1..HH 0.3 «.3 12 m5 11.1 0.3 .38 new: 1 won 1 q 89a 188 393m 258 33.1 H1830 mega: 9o $258.1 9N c285 Roxana 30% won 3395a Honcho". 9.355 00.39 383» an confidanov 88 3:53. .3 1:55 4 mom mug» Iammdabm g 3238 5615 g «In; Q83 «gamma noonm Eagmfim NH was 91 ABBREVIATIONS FOR TABLES I AND 11 Wetolic pressure in mm. Hg. Incisural pressure in mm. Hg. Diastolic pressure in mm. Hg. Transmission time to head in milliseconds. Transmission time to viscera in milliseconds. Transmission time to legs in milliseconds. Pressure in head system at incisural time, mm. Hg. Pressure in visceral system at incisural time, mm. Hg. Pressure in leg system at incisural time, mm. Hg. Uptake of aorta in cc. Uptake of head system in cc. Uptake of visceral system in cc. Uptake of legs in cc. Total arterial uptake during systole in cc . Cycle length in milliseconds. Length of systole in milliseconds. Average weighted transmission time in milliseconds. 3. I. Stroke index in cc/beat/sq. meter body surface. C. 1. Cardiac index in cc/min/sq. meter body surface. 92 TABLE I DATA TABULATED FROI PRESSURE.PULSE CURVES FOR CALCULATIONS 0F CARDIAC INDEX OF ANESTHETIZED AND UNANESTHETIZED DOGS .2. :1 f:i=:==: Date Dog (Kg) 25 P1 Pd 2,, TV T1 Ph Anesthetized 2/22/sb Blackie" 13.5 11.1. 131 118 21. 176 68 111 2/25 Sh Black& white" 13.0 11.0 126 108 26 51 75 13b 3/6 Sb Black a White" 13.0 110 122 100 27 55 81 138 Q/QS/Sh Police Dog 25.0 1L6 1&0 118 2h. 87 69 Um 3/12/Sh Police Dog" 25.0 122 109 90 3o 58 86 121 3/22/5h Chow-s 11.8 11.8 132 116 27 5h 72 116 3/22/5h Chow‘, 11.8 177 152 130 22 1g 63 172 3/2h/Sh Spitz?“ 7.6 152 11.2 123 21 40 67 152 3/Zh/Sb Spitz“, 7.6 151 11.3 123 23 175 66 151 3/25/5h Jupiter“ 10.6 1h8 11.0 115 25 149 72 1148 3/25/51 Jupiter‘ 10.6 160 11.1. 120 21. 17 69 158 5/b/Sb axeter“ 13.2 158 11.9 123 23 16 67 157 S/h/Sh Exeter‘ 13.2 161. 150 122 23 A6 67 162 5/1/51: Julius” 11.2 150 11.0 123 23 1.6 67 150 5/h/51 Junus‘ 11.2 152 1A1 125 27 52 77 132 S/S/Sh Spot - 2“ 12.0 160 11.0 123 23 16 67 153 5/5/514 Spot - 2' 12.0 162 lhh 126 23 1:1: 66 15; 5/5/51 Champ - 1" 15.5 151. 135 118 21. 1.8 72 118 5/5/511 Champ - 1‘E 15.5 1178 127 112 25 so 73 13 Unanesthetised 061116” 11.. 0 126 80 35 68 10° 135 Collie“ 114.5 1145 129 85 31. 68 100 1162 “tn-77* 15.2 178 151 105 29 SA 78 1 0 Emma“ 15.2 180 153 101. 27 53 77 179 Pin“? 16.5 151 132 95 29 56 86 138 Pink 16.5 165 11.0 98 28 56 81: 13. “‘1’. 10.6 156 1176 102 27 51 79 15 Pup 10.6 158 117 100 26 53 78 15 * Record Obtained usin o ** Record obtained using ptical manometer. 3 strain gage. 93 07 08209 5 1.44162 2 O 3925 585577893 76 018 1121m111111111 1111 9%agamwnngwaamemmm% 2 828201050892hh6 8 ummmmnmmmnmmHnmmnmw 20'“ 222 8 5556 60/08 nmmmwnnmwmwmmxmnmmu 22066h2867060h21u053 00000000000000 29.2222211122le2222 80 36 06229256h2 38765 O 2 SS mwmmmmae 37.390.00.20. «(131.-”6178 333 2322 unwwummm 250000th 914 TABLE II DATA TABULATED FRCII PRESfiJRE PULSE CURVES FOR CAIBULATIQI OF CARDIAC INDEX OF BILATERAILI ADRWOIIZED DOGS Emeriment Deg Weight P8 P1 Pd Th Tv T1 Ph 1‘21 __ _1 Control Hound 12 .0 118 128 90 30 59 87 11:0 Control. Hound 12 .0 159 137 100 27 55 . 81 150 I Hound 11 .5 1110 128 105 27 52 77 136 II Hound 10.5 76 63 55 13 81 123 80 III Hound 10.8 100 85 63 38 73 109 100 Iv Hound 10.2 90 70 55 11 78 118 100 Control Snokey 10.6 170 150 110 26 50 71 162 I Smokey 10 .5 150 115 125 28 15 61 150 II Snokey 10.6 111 100 75 3h 63 98 111 III Smokey 9.2 73 60 50 I42 81 12h 73 Iv snokoy 9.2 138 121 105 27 52 77 136 V Smokey 8.8 105 96 80 33 61 91 105 Control mt 15.6 150 135 98 28 55 82 115 1 Spot 15.5 150 110 115 25 18 72 150 11 Spot 11.7 80 63 50 13 81 123 80 In Spot 11 .0 10 5 93 72 35 68 100 105 1' Spot 13.5 81 70 55 11 78 118 81 Control Brownie 10 .1 150 13 5 90 29 58 85 11:2 I Brownie 9.1 110 128 106 28 52 78 MO II Brownie 9.0 105 91 72 35 68 100 105 ““9501 Champ 15.5 115 120 93 28 58 85 130 1% Cheap 15.1 136 121 102 27 51 79 132 m Chap 11:5 111 105 93 29 58 85 111 n 3"“ 113.0 108 98 80 32 61. 91. 108 MP 13.0 72 65 55 11 78 116 72 0 Record obtuned with Optical manometer 9S 2., P1 a uh uv To T3 5. 1. 0-1 116 119 5.1 15.8 1.1 1.5 30.1 518 161 36.8 1.05 159 158 5.0 13.8 1.2 1.2 27.2 198 166 31.1 1.01 110 110 3.0 10.1 2.8 2.8 19.2 160 120 22.5 2.92 80 55 2.0 11.0 2.8 .8 16.6 160 120 17.0 2.10 100 100 3.6 13.0 1.2 3.6 21.1 623 160 29.5 2.95 90 90 2.5 12.6 1.0 3.8 22.9 581 118 25.6 2.61 168 168 1.7 12.2 3.9 3.6 21.1 110 156 31.5 1.29 115 110 2.2 5.9 2.1 1.0 11.5 376 96 13.0 2.05 113 93 1.2 11.0 3.1 1.8 23.1 585 128 25.6 2.61 73 55 1.8 8.6 2.2 0.8 13.1 118 120 11.3 1.92 136 135 2.6 9.1 2.1 2.3 16.7 352 128 20.8 3.25 96 85 2.8 _ 9.0 1.6 0.1 13.8 336 96 11.9 2.33 115 117 1.6 13.0 3.1 3.6 21.6 121 118 31.0 1.28 150 110 3.0 8.8 2.1 1.8 16.0 100 101 18.6 2.80 80 55 2.0 11.0 2.8 0.8 16.6 560 112 17.3 1.88 100 91 3.1 12.2 3.0 1.8 20.1 180 116 22.2 2.78 .80 62 2.6 10.6 3.2 0.8 17.2 511 120 18.2 2.00 115 150 5.8 15.0 3.9 1.1 29.1 600 176 351%... 3.58 137 130 3.0 10.1 2.5 2.2 17.8 352 101 520.1 “3.11 100 89 3.0 12.0 3.0 1.9 19.9 530 120 - 20.5 ;,.. 2.15 138 115 1.1 12.2 3.8 1.1 21.2 696 201 30.2\., 2.60;» 136 131 2.9 8.6 2.8 2.5 16.8 713 176 18.5 1.55. 110 105 2.0 5.6 1.6 1.1 10.3 392 120 11.7~~ 1.70 100 98 2.9 10.0 2.1 1.8 16.8 108 128 19.1““ 2.8% 65 58 1.8 6.2 2.2 0.1 10.6 381 112 87v..11.3- 17 “100:1 USE 03117 '7} :17. 95.3% D328 0}” y Demco-293 H. 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