Showing papers in "BMJ in 1978"

Correlation of cholinergic abnormalities with senile plaques and mental test scores in senile dementia

Abstract: Necropsy brain tissue from normal (control) patients and patients with depression and dementia was examined for activities of various cholinergic components, and these related to the degree of senile plaque formation and extent of intellectual impairment. Choline acetyltransferase and acetylcholinesterase activities decreased significantly as the mean plaque count rose, and in depressed and demented subjects the reduction in choline acetyltransferase activity correlated with the extent of intellectual impairment as measured by a memory information test; muscarinic cholinergic receptor binding activity remained unchanged with increasing senile plaque formation but butyrylcholinesterase activity increased. The results suggest a close relation between changes in the cholinergic system and Alzheimer's dementia, but the precise role of the system in this disease remains to be elucidated.

Towards positive diagnosis of the irritable bowel

Abstract: A questionnaire to establish the presence of 15 symptoms thought to be typical of the irritable bowel syndrome (IBS) was given to 109 unselected patients referred to gastroenterology or surgery clinics with abdominal pain or a change in bowel habit or both. Review of case records 17--26 months later established a definite diagnosis of IBS in 32 patients and of organic disease in 33. Four symptoms were significantly more common among patients with IBS--namely, distension, relief of pain with bowel movement, and looser and more frequent bowel movements with the onset of pain. Mucus and a sensation of incomplete evacuation were also common in these patients. The more of these symptoms that were present the more likely was it that the patient's pain or altered bowel habit, or both, was due to IBS. We conclude that a careful history can increase diagnostic confidence and reduce the amount of investigation in many patients with chronic abdominal pain.

Proctocolectomy without ileostomy for ulcerative colitis.

Abstract: An operation has been developed that permits total removal of all disease-prone mucosa in ulcerative colitis but avoids the need for a permanent ileostomy. The colon and upper half of the rectum are excised and the remaining inflamed mucosa is stripped from the rectal stump down to the dentate line of the anal canal. A pouch is fashioned from a triplicated loop of terminal ileum. This is drawn down through the denuded rectum and an anastomosis created, via the per-anal approach, between the ileum just distal to the pouch and the mid-anal canal. A temporary ileostomy is made. Out of eight patients so treated, five were available for assessment, and four of them were highly satisfied with the result in improved health and function. The remaining three were awaiting closure of their ileostomies.

Dietary fibres, fibre analogues, and glucose tolerance: importance of viscosity.

Abstract: To define the type of dietary fibre of fibre analogue with the greatest potential use in diabetic treatment, groups of four to six volunteers underwent 50-g glucose tolerance tests (GTT) with and without the addition of either guar, pectin, gum tragacanth, methylcellulose, wheat bran, or cholestyramine equivalent to 12 g fibre. The addition of each substance significantly reduced blood glucose concentration at one or more points during the GTT and generally reduced serum insulin concentrations. The greatest flattening of the glucose response was seen with guar, but this effect was abolished when hydrolysed non-viscous guar was used. The reduction in the mean peak rise in blood glucose concentration for each substance correlated positively with its viscosity (r = 0.926; P less than 0.01), as did delay in mouth-to-caecum transit time (r = 0.885; P less than 0.02). Viscous types of dietary fibre are therefore most likely to be therapeutically useful in modifying postprandial hyperglycaemia.

Towards positive diagnosis of the irritable bowel.

Abstract: of the symptoms preceding sudden and unexpected deaths at home when these are compared with their general rate of occurrence in the child population. Since the conclusions of the study are based on these findings some independent assessment of their reliability is desirable. The conclusion of this paper is that the prevention of cot deaths is dependent firstly on the recognition by parents ofthe significance of certain non-specific symptoms and on their decision to involve the primary care services, and secondly on the efficacy of medical intervention at this stage. Consideration does not appear to have been given to the difficulties that will face parents who are asked to undertake such close surveillance of their children or the anxieties that this is likely to cause; nor has any estimate been made of the presumably very large proportion of cases in which this will prove \"unnecessary.\" Conversely, the implications of the increased work load for the primary care services has yet to be determined. Concerning intervention, the investigators recognise that the value of either hospital referral or drug therapy is at present doubtful, leaving close supervision and observation of the child at home as the only alternative. It has yet to be established what this can achieve. By the nature of the condition, sudden and unexpected death in children is an exceedingly difficult area of study, especially in its community aspects, and many of the criticisms raised here are clearly recognised by the study group and are the subject of further investigation. But because of these unresolved difficulties it would seem premature to urge the \"need to improve the recognition by both doctors and parents of non-specific symptoms as markers of severe illness in young children and their understanding of the necessity for rapid and appropriate action.\

Continuous subcutaneous insulin infusion: an approach to achieving normoglycaemia.

Abstract: A study was performed to examine the feasibility of achieving long periods of near-normoglycaemia in patients with diabetes mellitus by giving a continuous subcutaneous infusion of insulin solution from a miniature, battery-driven, syringe pump. Twelve insulin-dependent diabetics had their insulin pumped through a subcutaneously implanted, fine nylon cannula; the basal infusion rate was electronically stepped up eightfold before meals. The blood glucose profile of these patients was closely monitored during the 24 hours of the subcutaneous infusion and compared with the profile on a control day, when the patients were managed with their usual subcutaneous insulin. Diet and exercise were standardised on both days. In five out of 14 studies the subcutaneous insulin infusion significantly lowered the mean blood glucose concentration without producing hypoglycaemic symptoms; in another six patients the mean blood glucose concentration was maintained. As assessed by the M value the level of control was statistically improved in six out of 14 studies by the infusion method and maintained in six other patients. To assess the effects of blood glucose control on diabetic microvascular disease it will be necessary to achieve long-term normoglycaemia in selected diabetics. The results of this preliminary study suggest that a continuous subcutaneous insulin infusion may be a means of maining physiological glucose concentrations in diabetics. Though several problems remain--for example, in determining the rate of infusion--longer-term studies with the miniature infusion pumps are now needed.

Psychiatric problems in the first year after mastectomy.

Abstract: The psychiatric morbidity associated with mastectomy was assessed in 75 women by following them up from the time they presented with suspected breast cancer to one year after the operation. Fifty women with benign breast disease served as controls. Throughout the follow-up period the incidence of psychiatric problems was higher among the women who had undergone mastectomy. One year after surgery 19 (25%) of these women compared with only 5 (10%) of the controls needed treatment for anxiety or depression or both, and 16 (33%) compared with 3 (8%) respectively had moderate or severe sexual difficulties. Altogether 29 patients in the mastectomy group (39%) and six of the controls (12%) had serious anxiety, depression, or sexual difficulties. Of the eight women in the mastectomy group who sought help for their problems, only two felt that the help given had been appropriate. The inability to recognise and treat these emotional disturbances is a common and serious problem. Monitoring by specially trained nurses and social workers might help to identify them earlier and even reduce them.

The adverse effect of iron repletion on the course of certain infections.

Abstract: The incidence of infections was studied in 137 iron-deficient Somali nomads, 67 of whom were treated with placebo and 71 with iron. Seven episodes of infection occurred in the placebo group and 36 in the group treated with iron; these 36 episodes included activation of pre-existing malaria, brucellosis, and tuberculosis. This difference suggested that host defence against these infections was better during iron deficiency than during iron repletion. Iron deficiency among Somali nomads may be part of an ecological compromise, permitting optimum co-survival of host and infecting agent.

Identification of Clostridium difficile as a cause of pseudomembranous colitis.

Abstract: 695 rest was instituted and the temperature resolved in 24 hours, while all signs and symptoms disappeared in five days. Subsequent investigations showed no evidence of streptococcal infection (a throat swab grew no pathogens and the antistreptolysin titre was < 125 units/ml both one day after admission and six weeks later). The antibody titre for psittacosis LGV was > 1/1000 on admission and six weeks later was still raised at 1/128. Inquiry later showed that before his illness he had visited regularly a neighbouring house in which a healthy, psittacine bird was kept. Discussion In this case there are two major and three minor criteria of rheumatic fever present, but without evidence of a recent streptococcal infection. On the contrary, the presence of a cough and constitutional disturbance associated with patchy shadowing on the chest x-ray film and a significant and changing antibody titre all support a diagnosis of psittacosis. The rashes described in association with this disease include \"rose spots,\"2 erythema nodosum,2 and a macular scaly rash.3 We could find no reports of an exanthem resembling erythema marginatum. Arthritis, which may be migratory,4 is a rare complication of psittacosis in man, though in sheep and cattle polyarthritis it is well recognised.5 This case shows that psittacosis may present with minimal respiratory disturbance and with a clinical picture resembling rheumatic fever with erythema marginatum and polyarthritis. professor of clinical pharmacology and consultant physician Identification of Clostridium difficile as a cause of pseudomembranous colitis The demonstration of a toxinl in the stool of patients with-pseudo-membranous colitis and neutralisation of the toxin by Clostridium sordellii antitoxin2 has provided a valuable tool in the search for the cause of this disease. These findings also implicate Cl sordellii, or an organism producing an antigenically similar toxin, as the causal agent. We tested all clostridial species isolated from patients with pseudomembranous colitis for toxin production and neutralisation by Cl sordellii antitoxin. Eight patients with pseudomembranous colitis3 were studied together with 20 patients with postoperative diarrhoea without evidence of colitis, all of whom had undergone major gastrointestinal surgery within 10 days and had three or more bowel actions each day. Clostridia were isolated on lysed blood agar containing kanamycin sulphate (70 mg/l) or nalidixic acid (10 mg/ 1). Broth cultures of clostridia and faeces from patients were tested for toxin on monolayers of HeLa cells. Toxin was neutralised by incubating samples with antitoxin to Cl perfringens …

Immediate heart-rate response to standing: simple test for autonomic neuropathy in diabetes.

Abstract: The immediate heart-rate response to standing was measured in 22 normal controls and 25 patients with diabetes, 15 of whom had autonomic neuropathy. The response in the controls and patients without autonomic neuropathy was characteristic and consistent, with tachycardia maximal at around the 15th beat and relative bradycardia maximal at around the 30th beat. The diabetics with autonomic neuropathy, however, showed a flat response. In three controls the response was abolished with intravenous atropine but not with propranolol, showing that it is mediated through the vagus. A simplified test using routine ECGs and measuring the R-R interval at beats 15 and 30 with a ruler is easily performed as an outpatient procedure and may be used as a measure of autonomic function in diabetes.

Dyspnoea, disability, and distance walked: comparison of estimates of exercise performance in respiratory disease.

Abstract: Forty-four patients with airway obstruction and 18 with pulmonary infiltration were studied in an attempt to correlate exercise tolerance, as assessed by a simple walking test, with basic respiratory function values and differing subjective assessments of exercise performance. The distance walked in 12 minutes was significantly correlated with the response to a structured questionnaire and with the patients9 assessment of performance using an oxygen-cost diagram. The distance walked did not agree well with simple subjective estimates obtained in the clinical history. It was better correlated with forced vital capacity than with forced expiratory volume in one second in both groups of patients, and was well correlated with carbon monoxide transfer factor in those with pulmonary infiltration. The scatter of results, however, was such that exercise performance could not usefully be predicted from the respiratory function values or from subjective assessments. Simple exercise tests are an essential part of assessing disability and response to treatment in patients with respiratory impairment.

Creamatocrit: simple clinical technique for estimating fat concentration and energy value of human milk.

Abstract: A simple micromethod has been devised for estimating the fat and energy content of human milk based on the centrifugation of milk in a haematocrit centrifuge. The percentage of cream, or "creamatocrit," is read from the haematocrit capillary tube and is linearly related to the fat and energy content. The technique, which is rapid and cheap, may be used in clinical practice, in research, and in epidemiological studies.

Genetic basis of rheumatoid disease: HLA antigens, disease manifestations, and toxic reactions to drugs.

Abstract: Ninety-five patients with rheumatoid arthritis and 200 healthy controls were examined for HLA-D-related (HLA-DR) alloantigens. HLA-DRW4 was significantly more prevalent among the patients and was particularly common in those with a family history of the disease (77% of such patients had DRW4 compared with 34% of controls). Significantly fewer patients than controls had DRW2: patients with this antigen had rheumatoid nodules less frequently and significantly lower titres of rheumatoid factor than patients without DRW2. In contrast DRW3 was significantly more prevalent among severely affected patients with rheumatoid factor titres exceeding 1/1280 and in patients with nodules. There was a significant association between DRW2 and DRW3 and toxic reactions to sodium aurothiomalate and penicillamine. The results suggest that the HLA-DR phenotype is associated not only with susceptibility to rheumatoid arthritis but also with severity of the disease and whether certain toxic reactions to drugs occur.

Changing social-class distribution of heart disease.

Abstract: Analysis of mortality trends over 40 years in England and Wales showed that mortality from coronary heart disease had become progressively more common in working-class men and women than in those from the middle and upper classes. The change was most noticeable for men. Whereas in 1931 and 1951 heart disease was more common in men of social classes I and II, by 1961 it was more common in men of classes IV and V. This change in social-class distribution can only partly be explained by changes in diagnostic methods. The worsening mortality of classes IV and V correlated with relatively more smoking, a higher consumption of sugar, and a lower consumption of wholemeal bread in these classes. There was no correlation between change in heart disease and change in the social-class pattern of fat consumption.

Intermittent claudication: prevalence and risk factors.

Abstract: Risk factors for intermittent claudication (IC) were studied in 54 patients--that is, all patients with IC on the lists of two general practices--and 108 controls. Smoking was the factor most strongly associated with the development of IC, but systolic and diastolic blood pressures and concentrations of triglyceride, urate, and fibrinogen were all significantly higher among the patients with IC than the controls. The presence of more than one factor appeared to be associated with a multiplicative increase in risk. Cholesterol, an important risk factor for ischaemic heart disease, was not associated with an increased risk of IC. IC was present in about 2% of the men and 1% of the women, who were aged 45-69 years. These findings suggest that IC, a common and disabling manifestation of atheroslcerosis, may be largely preventable.

Severity of coronary atherosclerosis related to lipoprotein concentration.

Abstract: The influence of individual lipoproteins on the severity of coronary atherosclerosis was studied in 41 patients undergoing coronary angiography. The extent of athero-sclerosis was quantified by a coronary atherosclerosis score (CAS) based on the number and severity of lesions in eight proximal segments of the coronary circulation. The concentration of high-density lipoprotein (HDL) showed a strong inverse association with CAS, which was independent of the effects of age and other lipoproteins. On multivariate analysis concentrations of other lipids--namely, total plasma cholesterol, low-density lipoprotein (LDL) cholesterol, and the combined effect of LDL cholesterol plus very-low-density lipoprotein triglyceride--showed direct, significant correlations with CAS, but these were weaker than that of HDL. This study shows that concentrations of several circulating lipoproteins are related to the severity of coronary atherosclerosis, HDL having an apparent retarding effect. These findings may partly explain the influence of lipoproteins on the development of clinical coronary heart disease.

Study of 8-year-old children with a history of respiratory syncytial virus bronchiolitis in infancy.

Abstract: Thirty-five children known to have had respiratory syncytial virus bronchiolitis in infancy were examined at the age of 8 and their respiratory function tested. The results were compared with those in 35 controls matched for age, sex, and social class. Although 18 of the children who had had bronchiolitis in infancy had experienced subsequent episodes of wheezing, these were neither severe nor frequent in most cases and had apparently ceased by the age of 8. Nevertheless, the mean exercise bronchial lability of the children who had had bronchiolitis was significantly higher than that of the control children and the mean peak expiratory flow rate at rest significantly lower. Atopy, assessed by family and personal history alone, did not seem to be related to either bronchiolitis or wheezing episodes after bronchiolitis. The parents of the children who had had bronchiolitis smoked significantly more cigarettes during the infant9s first year of life than those of the control children. The results suggest that bronchiolitis and childhood asthma are not closely related. Bronchial hyperreactivity might be inherited independently of atopy, but environmental factors seem the most likely link between severe respiratory infection in infancy and chronic or recurrent respiratory illness in adult life.

Early platelet consumption in pre-eclampsia.

Abstract: One hundred and thirty-one women with chronic hypertension were studied serially during pregnancy to determine the sequence of events in the development of superimposed pre-eclampsia and to discover the time of onset. Twenty-seven women developed a sustained rise in plasma urate concentrations, which began at about 28 weeks' gestation and which is characteristic of pre-eclampsia. The mean platelet count was already significantly reduced and continued to fall until delivery, which was on average at 36 weeks' gestation. A comparable but smaller decrease in platelet count was seen in 55 women who had borderline but consistent increases in plasma urate concentrations. In 49 women whose plasma urate concentrations remained steady the platelet count did not change significantly before delivery. The reduced platelet count in women who develop pre-eclampsia suggests that increased platelet consumption is an early feature of the disorder.

Randomised controlled trial of vancomycin for pseudomembranous colitis and postoperative diarrhoea.

Abstract: The efficacy of vancomycin in pseudomembranous colitis was assessed in a prospective randomised controlled trial. Forty-four patients with postoperative diarrhoea were allocated to five days9 treatment with either 125 mg vancomycin six-hourly or a placebo. Sixteen patients had high titres of the neutralised faecal toxin characteristic of pseudomembranous colitis; nine received vancomycin and seven placebo. At the end of treatment faecal toxins were present in one patient given vancomycin compared with five of the controls. Vancomycin caused the disappearance of Clostridum difficile from the stool in all except one patient, whereas toxicogenic strains of Cl difficile persisted in all but one of the controls. Histological evidence of psuedomembranous colitis had disappeared by the end of treatment in six out of seven patients given vancomycin compared with only one out of seven patients given vancomycin compared with only one out of five patients given placebo. In patients with faecal toxins bowel habit had returned to normal in seven of the vancomycin group compared with only one of the controls, but there was no significant difference in clinical response among patients without faecaal toxins. The results suggest that vancomycin eliminates toxin-producing Cl difficile from the colon and is associated with rapid clinical and histological improvement in patients with pseudomembranous colitis.

Serum prolactin in epilepsy and hysteria.

Abstract: Differentiating between hysteria presenting in an epileptiform manner and epilepsy can present diagnostic difficulties. Differentiation is important, however, since management of the two disorders differs. Electrochemical stimulation of the medial basal hypothalamus in animal models increases prolactin release.' Therefore if the abnormal electrical activity in epilepsy passes through the midbrain it should raise the serum prolactin concentration. This paper reports an investigation of this hypothesis.

Neoplasms of the lung.

Abstract: SIR,-I wish to comment on the excellent paper on the failure of aspirin to prevent postoperative deep-vein thrombosis in patients undergoing total hip replacement (22 April, p 1031). Without faulting the conclusion of Mr J D Stamatakis and his colleagues that aspirin in a dose of 600 mg twice daily is an ineffective prophylaxis against this complication, I think that there are other considerations to be borne in mind. Aspirin inhibits haemostasis through two mechanisms. The most widely known mechanism is inhibition of platelet aggregation,' and for this purpose 600 mg twice daily is apparently adequate. However, and this is less well known but probably as important, aspirin interferes with the hepatic synthesis of vitamin-K-dependent clotting proteins,2 and does so in a manner quantitatively related to the plasma level attained and not necessarily to the dose administered to any given individual.3 It therefore seems evident that optimum results will not be achieved by administration of a standard dose but are more likely to be attained by attention to the plasma level of aspirin in each individual.

Effect of propranolol and phentolamine on myocardial necrosis after subarachnoid haemorrhage.

Abstract: A study was set up to assess the effect on the clinical course of subarachnoid haemorrhage (SAH) of giving propranolol 80 mg eight-hourly plus phentolamine 20 mg three-hourly by mouth for three weeks. Out of the 90 patients studied, 14 died. Two of the deaths occurred in an open pilot study of 10 patients, the remaining 12 deaths occurring in patients in a randomised double-blind placebo-controlled study. Postmortem examination was carried out on 12 of the patients, six of whom had been receiving placebo and six propranolol plus phentolamine. Necrotic myocardial lesions were present in the hearts of all six patients (age range 30-59 years) who died while taking placebo (all had had abnormal electrocardiograms (ECGs). In contrast, no necrotic lesions were found in the hearts of the six patients (age range 28-59) who died while receiving the drugs (all had previously had normal ECGs). We conclude that the necrotic myocardial lesions were induced by catecholamines and that propranolol had a cardioprotective effect. While death from a further haemorrhage in cases of SAH is not affected by propranolol and phentolamine, propranolol may have a beneficial effect in other potentially lethal stresses.

Factors influencing postoperative morbidity and mortality in patients treated with bleomycin.

Abstract: Patients treated with bleomycin are at risk of developing the acute adult respiratory distress syndrome post-operatively. In a prospective study of 12 patients who had received bleomycin preoperatively and were undergoing removal of retroperitoneal lymph nodes or pulmonary metastases several preventive factors were established. These were the use of low concentrations of inspired oxygen during operation and in the immediate postoperative period, careful monitoring of fluid replacement, and restriction of crystalloids in favour of colloids.

Stigmata of recent haemorrhage in diagnosis and prognosis of upper gastrointestinal bleeding.

Abstract: In 277 consecutive episodes of suspected upper gastrointestinal bleeding, lesions bearing stigmata of recent haemorrhage (stigmata) were found by endoscopy in 110 (47%) out of 233 patients who were judged to have bled; 78 (33%) had lesions without stigmata, and in 45 (19%) no lesion was seen. Results in 176 entirely unselected admissions for upper gastrointestinal bleeding were similar.Forty-eight chronic duodenal and 41 chronic gastric ulcers were identified by endoscopy. Stigmata were found in 27 (56%) and 33 (80%) of these cases respectively. Sixteen patients had multiple lesions, and in 12 (75%) the presence of stigmata permitted diagnosis of the source of the haemorrhage. Stigmata were more likely to be seen in cases of duodenal ulcer, Mallory-Weiss lesions, and oesophageal varices when endoscopy was performed within 12 hours of bleeding, but were as common in cases of gastric ulcer after longer intervals.In the absence of stigmata one out of 21 patients with duodenal ulcer had further haemorrhage and one other needed emergency surgery; no patient with gastric ulcer had further haemorrhage or needed emergency surgery. In contrast, when stigmata were present 15 of the 27 patients with duodenal ulcer (56%) had further haemorrhage and 17 (63%) needed emergency surgery; of the 33 patients with gastric ulcer, 10 (30%) had further haemorrhage and 15 (45%) required emergency surgery. Superficial mucosal lesions may have been the source of haemorrhage when an ulcer unmarked by stigmata was seen at endoscopy. Stigmata were superior to any other single factor or combination of factors in predicting rebleeding and the need for emergency surgery.

Prognostic implications of chromosomal findings in acute lymphoblastic leukaemia at diagnosis.

Abstract: Chromosomes were studied on diagnostic bone-marrow samples from 39 children with acute lymphoblastic leukaemia (ALL). The patients were classified, according to the chromosomal characteristics of the major proportion of their leukaemia cells, into five categories; hyperdiploid, pseudodiploid, diploid, hypodiploid, and mixed. Patients in the hyperdiploid category had significantly longer first remissions than those in all other categories, and those in the pseudodiploid category had the shortest. Neither the absence of any normal cells nor the presence of detectable clones appeared to be an adverse feature. We suggest that the proportion of hyperdiploid cells, determined by conventional chromosomal staining techniques, may be used as an additional prognostic feature in childhood ALL.

Fertility after stopping different methods of contraception.

Abstract: Data on the return of fertility after discontinuing various methods of contraception were collected from among the women taking part in the Oxford-Family Planning Association contraceptive study. Return of fertility was measured as the time taken to give birth to a child. The fertility of both nulligravid and parous women who stopped taking oral contraceptives was initially impaired in comparison with that of women who stopped using other methods of contraception. But the effect of oral contraceptives on fertility had become negligible by 42 months after cessation of contraception in nulligravidae and by 30 months in multiparae. Impairment seemed to be independent of the length of use of oral contraceptives. Data relating to IUD users were sparse, but the figures that were available were reassuring. These results suggest that, although women may have temporary impairment of fertility after discontinuing oral contraception, they are unlikely to become permanently sterile through taking the pill.

Cerebral blood flow in diabetes mellitus: evidence of abnormal cerebrovascular reactivity.

Abstract: Cerebral blood flow (CBF) was studied at normocapnia and after a challenge with 5% CO2 in 59 diabetic patients and 28 controls. There was a significant age-related decline in CBF in both groups, which suggests that diabetes does not affect the rate of decrease of CBF with age. After CO2 challenge CBF increased in most of the controls; in the patients CBF increased in 23, decreased in 26, and remained stable in 10. Thus the reactivity of cerebral blood vessels in diabetics is altered. Diabetics have diminished cerebrovascular reserve and are thus at increased risk of cerebrovascular disease because they are unable to compensate when necessary with an increased CBF.

Epidural analgesia improves postoperative nitrogen balance.

Abstract: Postoperative nitrogen balance was monitored in twelve patients undergoing hysterectomy under either epidural analgesia or general anaesthesia. The mean cumulative five-day nitrogen losses were significantly lower after epidural analgesia than after general anaesthesia. Nitrogen sparing presumably results from inhibiting the stress-induced release of catabolic hormones, since epidural analgesia abolished postoperative hyperglycaemia and increase in plasma cortisol concentrations. No adverse effects of inhibiting the stress response were observed. Neurogenic stimuli thus play a crucial part in the catabolic response to surgery. Inhibiting the endocrine metabolic response to trauma by neurogenic blockade may reduce the morbidity precipitated in high-risk patients by the catabolic response to surgery.