Robert C. Batterman

Fate of Gentisic Acid in Man as Influenced by Alkalinization and Acidification

Conclusions 1. The recovery of gentisic acid and salicylate were similar, approximating 62 and 68% respectively of the administered drugs, and 84 and 88% respectively, following alkalinization. 2. Alkalinization increased the combined and free forms of gentisic acid eliminated but did not alter their relative proportions. 3. The amount of gentisic acid recovered from salicylate administration was increased with alkalinization without alteration in the proportion of free to combined gentisic acid obtained with salicylate alone. 4. Whereas the free gentisic acid represented approximately 42% of the total gentisic acid recovered when administered alone, the amount of free gentisic acid obtained from salicylate administration represented approximately 10% of the total genetisic acid. 5. Acidification with dilute hydrochloric acid, but not ammonium chloride decreased the total excretion of gentisic acid at the expense of the combined, the free remaining unaltered. 6. Acidification with both dilute hydrochloric acid and ammonium chloride decreased the total excretion of salicylate and the combined gentisic acid metabolite, the proportion of free to combined gentisic acid remaining unaltered.

Clinical Re-evaluation of Daytime Sedatives

Phenobarbital, butabarbital sodium, acetylcarbromal, glutethimide, meprobamate and prochlorperazine were evaluated under conditions of clinical practice to determine their relative effectiveness in producing daytime sedation, nighttime hypnosis by multiple daytime dosages, and combined daytime sedation and nighttime hypnosis. A therapeutic index (per cent effectiveness: per cent untoward reactions) was established for each drug. Butabarbital sodium provided the highest rating of sedatives studied for control of anxiety and insomnia by daytime dosages.

CLINICAL ASPECTS FOR THE APPRAISAL OF DRUGS USED FOR THE TREATMENT OF THE ANGINAL SYNDROME

Publication of this monograph is itself indicative that treatment of the patient with anginal syndrome and methods for evaluating such treatment leave much to be desired. Before any technique for the appraisal of therapeutic measures is considered it is essential to define the problem precisely. It cannot be too strongly stressed that, from the clinical point of view, this problem can be expressed simply as “a patient with pain in the chest who wishes relief.” Since a i c t ion of the heart is uppermost in both the patient’s and the physician’s minds, a correct diagnosis and appropriate therapy are foremost considerations. Correct diagnosis has been a problem ever since Heberden’s’ classic description of the condition. A recent review2 of thoracic pain mentions 78 different conditions other than coronary insufficiency that might on occasion simulate the anginal syndrome. The specialized knowledge required for correct diagnosis of many of these conditions is usually not available to the majority of us, so that it is more than likely that many a patient without cardiac disease has been treated for the anginal syndrome and has even been included as a “typical” patient in investigations. To assist in the diagnosis, various procedures have been devised. All are based on the assumption that the coronary circulation is impaired and that during a period of stress or anoxia the demand for blood to tbe heart muscle exceeds the supply. The result of this further “coronary insufficiency” presumably manifests itself in electrocardiographic changes or duplication of the clinical picture of the painful state. The electrocardiogram, per se, however, either in its control configuration or after test procedure such as the exercise tolerance test of Master et al? or the hypoxic test of Levy et a1.,4 need not reflect coronary disease or insufficiency. Although the majority of patients with coronary disease present a positive test to both of these procedures, many patients with unquestioned coronary disease have a negative response. The tests may be useful procedures but, in the last resort, the physician must rely entirely upon the clinical facts that are available. An analysis of the patient’s complaints; type, severity, duration, location, and radiation of the pain; associated symptoms; precipitating factors; frequency; response to therapy; social, economic, and family status; and emotional or psychic components are some of the features that must be carefully weighed by the physician. Furthermore, abnormal findings in the electrocardiogram might indicate heart disease but need not mean that the pain for which the patient seeks attention is due to coronary disease. To quote Dry,S “despite all the helpful data which can be derived from the various diagnostic procedures there is no alternative to skillful interrogation of the patient.”

THE PROBLEM OF CONSTIPATION IN THE INSTITUTIONALIZED PATIENT

If the cathartic consumption in institutions were to be examined, no one would question the fact that there is a problem of constipation in the institutionalized patient. Through the courtesy of Dr. Newton Bigelow,* it is known that, for the year of 1952, in 28 New York Slate mental hospitals, an extraordinary amount o€ medication was prescribed to overcome, presumably, “bowel stasis.” Cascara sagrada, the most popular medication, amounted to 615,000 of the 739,000 cathartic tablets consumed. Of the 4,272 gallons of liquid preparations used, mineral oil accounted for over 1600 gallons. Apparently, mild cathartics are insufficient for this type of patient, for 17,500 pounds of magnesium sulfate were also consumed. In institutions other than mental hospitals, the consumption of cathartics may also be very high. In the Bird S. Coler Memorial Hospital and City Home, an institution for chronic disease and custodial care which has recently been opened, it has been noted, almost from its inception, that the cathartic problem would require considerable attention. For a brief three-month period, the cathartic consumption for approximately 550 patients averaged 14,300 doses, which means that every patient received 26 doses of a cathartic during this period, or approximately one dose every three days. The fact that tremendous quantities of cathartic medications are in use in chronic disease institutions should cause us to reflect as to the possible reasons and etiological factors. The problem has many facets which cannot be lightly dismissed by just noting the quantity of cathartics that are consumed. First of all, does the cathartic load represent constipation, or does it reflect the prevalent attitude by many functionaries associated with chronic nursing care that the daily bowel movement is a “inust” and a required routine occurrence? In other words, does the patient actually require a cathartic because there is some delay in bowel function, or does the altending physician or nurse prescribe a cathartic routinely, although the patient cxperiences no discomfort from the delayed function which may be normal for that particular patient? Patients in chronic disease hospitals for custodial care present another interesting facet for cathartic administration, These patients, regardless of the underlying disease, are frequently hospitalized for permanent care because of lack of relatives or inadequate home facilities. The patients often vegetate with few or no breaks in their daily routine living. They seldom fraternize with other patients and tend to withdraw within themselves. Day in and day out, their only contact with reality is their own physical disability and the relationship of this malady to the amount of individual care available to them by the nurses and attendant staff. Patients soon learn that additional attention Recognition of the problem is the first step towards adequate therapy.

Effects of Azetazoleamide (Diamox) Upon Blood Sugar of Normal and Diabetic Patients

Conclusions 1. The influence of azetazoleamide upon fasting blood sugar and the glucose tolerance curve was studied in a group of diabetic and normal subjects. Azetazoleamide was given either as a single dose or for a period of 3 weeks. 2. No significant alteration of the fasting blood sugar or the glucose tolerance curve was noted following the administration of azetazoleamide.