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PubMed1986

The first open heart corrections of tetralogy of Fallot. A 26-31 year follow-up of 106 patients.

Tetralogy of Fallot became a correctable malformation on August 31, 1954, and from that data through 1960, 106 patients (ages 4 months-45 years) who underwent open repairs at the University of Minnesota and were discharged, have been followed (99% complete) until death or for 26-31 years (mean: 23.7 years, 2424 patient years). The purposes of this study were to determine survival, morbidity, hemodynamics, educational/employment attainments, and relation of these to surgical technics. Operations were done by cross circulation (6 patients) and bubble oxygenator (100 patients). This group had the first uses of patch ventricular septal defect closure, outflow root, infundibuloplasty, atresia correction, ischemic arrests, and pacemakers among other innovations. Twenty-one (of 105 patients) have died during the followup: eight deaths in the first 10 years, 12 between 10 and 20 years, and 1 greater than 20 years. The causes of death were sudden (5), accidental (4), congestive failure (2), reoperation (2), suicide (2), and other (2). Actuarial survival at 30 years was 77%. Late complications were ten reoperations, five arrhythmias, and one endocarditis. Actuarial freedom from reoperations at 30 years was 91%. Cardiac recatheterizations in 62 patients disclosed only 10 with residual shunts. Peak right ventricular systolic pressures were less than 40 mmHg (34 patients), 41-60 mm (2 patients), 61-70 mm (4 patients), greater than 71 mm (4 patients). Thirty-four patients (32%) completed college, ten of these completed graduate school (5 masters degrees, 2 M.D.'s, 2 Ph.D.'s, 1 lawyer). Fifteen others attended college, and nine received technical school diplomas. Forty patients (18 men, 22 women) had progeny, with 82 (93%) live births and six major cardiac defects (7.3%). In summary, complete repair gave excellent late results in this group cared for very early in the open heart era. Survivors led productive lives without restrictions in education and employment. Many of the deaths/complications that occurred are now easily preventable, which augurs extremely well for this generation.

Adolescent↗
PubMedDate not supplied

Polyacrylonitrile membrane interposition between a xenograft and a patient in fulminant liver failure: the concept of xenohemodiafiltration in clinical practice.

Fulminant hepatic failure is an important cause of morbidity and mortality in intensive care units. Conventional therapies are not sufficiently effective. Liver transplantation may be life saving, but a "bridge therapy" is needed until transplantation is performed. Hepatic extracorporeal xenohemodiafiltration (XHDF) is aimed at the transitory support of a patient with fulminant hepatic failure. The first clinical case of XHDF is presented. The system consisted of cross-circulation between a porcine liver and a patient with fulminant liver failure through a polyacrylonitrile membrane. The procedure lasted for 5 hours and produced hemodynamic, biochemical, and metabolic improvements. Intracranial pressure decreased from 34 to 5 cm H2O, serum ammonia fell from 673 to 370 ng/dl, lactic acid from 11 to 5.3 mmol/L, and bilirubin from 7.4 to 2.5 mg/dl. Hemodynamic values were maintained stable throughout the procedure. The patient was able to undergo transplantation and remains alive 11 months later. XHDF is a clinical experimental method that can constitute an alternative clinical therapy to support patients with fulminant hepatic failure until an organ is available for transplantation.

Acrylic Resins↗
PubMedDate not supplied

Impact of United States artificial organ development in Latin America.

The University of Minnesota may be considered the cradle of heart surgery worldwide. That is where Dr. F. John Lewis carried out the first open heart surgery in September, 1952 and repaired an atrial septal defect in a 5 year old girl. Thenceforth, new solutions to allow systematic heart surgeries have been extensively investigated. This requires boldness and imagination. In 1954, Dr. Walton Lillehei, who had been working in Minnesota since after the war, carried out the first surgery with cross circulation using a second person who worked as a circulatory support, while the patient's heart was operated on. In 1955, he started using extracorporeal circulation using an oxygenator developed in association with Dr. Richard de Wall and the roller pump introduced by Michael DeBakey. By 1956 they had already performed 80 surgeries using the bubble oxygenator.

Artificial Organs↗
PubMed1989

Effect of diltiazem on coronary blood flow distribution in dog heart under ischemia.

Effect of intracoronary infusion of diltiazem (1 microgram/min) on regional myocardial blood flow (RMBF) was studied using 15-microns radioactive microspheres in 11 excised cross-circulated canine left ventricles. With total coronary blood flow (CBF) and heart rate (HR) held constant, regional ischemia was induced by ligating the left anterior descending coronary artery (LAD). Diltiazem at the dose used had no effects on ventricular Emax before and after LAD ligation. RMBF expressed by the counts divided by the counts averaged in all segments in each layer significantly (p less than 0.05) increased under diltiazem only in the low-flow region that had less than 50% RMBF before diltiazem; from 21% (+/- 12%) to 35% (+/- 18%) in the epicardial, from 22% (+/- 12%) to 32% (+/- 18%) in the midwall, and from 24% (+/- 10%) to 31% (+/- 12%) in the endocardial layers. We conclude that the beneficial effect of diltiazem on the ischemic heart involves a direct action on the coronary vascular system and does not necessarily depend on the concomitant changes in hemodynamics.

Animals↗
PubMed1992

Cardiac effects of vecuronium and its interaction with autonomic nervous system in isolated perfused canine hearts.

The chronotropic and inotropic effects of vecuronium bromide and its interaction with the autonomic nervous system were investigated in the isolated, cross-circulated right atrial and left ventricular preparations of the dog. Vecuronium, injected into the external jugular vein of the support dog, induced dose-dependent decreases in heart rate and arterial blood pressure, and increased atrial contractile force with no change in sinus rate in isolated atrial preparations. Vecuronium (1-3,000 micrograms), injected into the sinus node artery of the isolated atrium, induced dose-dependent increases in atrial contractile force with small increases in sinus rate. Vecuronium also increased the ventricular contractile force in a dose-dependent manner. The positive inotropic effect was attenuated in part by propranolol, but not by either tetrodotoxin or imipramine. Vecuronium inhibited in a dose-related manner the negative chronotropic and inotropic responses to parasympathetic nerve stimulation and carbachol (CCh) and the negative followed by positive cardiac responses to nicotine, but did not attenuate the positive responses to sympathetic nerve stimulation. The ID50s for the responses to parasympathetic stimulation, CCh, and nicotine were not significantly different. Vecuronium enhanced the positive chronotropic and inotropic responses to sympathetic nerve stimulation, tyramine, norepinephrine, and isoproterenol. These results indicate that (a) vecuronium causes the positive inotropic responses mediated by nonadrenergic mechanisms and beta-adrenoceptors, (b) vecuronium blocks ganglionic and presynaptic nicotinic and postsynaptic muscarinic receptor-mediated responses similarly, and (c) vecuronium enhances beta-adrenoceptor-mediated responses in the dog heart.

Animals↗
PubMed2000

Comparison of cardiovascular effects of a new calcium channel blocker AH-1058 with those of verapamil assessed in blood-perfused canine heart preparations.

The cardiovascular effects of AH-1058, a novel calcium channel blocker, were examined in comparison with those of verapamil using canine isolated, blood-perfused papillary muscle, atrioventricular node, and sinoatrial node preparations. Intravenous administration of AH-1058 (20, 50, and 100 microg/kg) or verapamil (20, 50, and 100 microg/kg) to the blood-donor dog induced negative inotropic, dromotropic, and chronotropic effects and a coronary vasodilator action in cross-circulated isolated heart preparations, simultaneously inducing the same cardiac effects in the blood-donor dog. The order of potency of the effects of AH-1058 was ventricular contraction > coronary blood flow >> atrioventricular conduction > sinoatrial automaticity, whereas that of verapamil was coronary blood flow >> atrioventricular conduction >> sinoatrial automaticity > ventricular contraction. The cardiosuppressive effects of AH-1058, especially on ventricular contraction, were slower in onset and longer lasting than those of verapamil. These results suggest that this unique cardiovascular profile of AH-1058 may become beneficial for the treatment of certain pathologic processes, in which selective inhibition of ventricular calcium channels would be essential for drug therapy.

Animals↗
PubMed2002

Management of carotid 'blowout' with endovascular stent grafts.

OBJECTIVES/HYPOTHESIS: Since 1992, endovascular techniques for vascular occlusion and stenting have evolved significantly. Endovascular occlusion of the carotid artery has been used in the management of carotid "blowout." Although it seems logical to expand this application to the use of arterial stents to repair rather than occlude the artery when cerebral cross-circulation is inadequate, concerns remain regarding the placement of a foreign body in a contaminated field. The purpose of the present report is to describe our experience with endovascular stents for control of carotid hemorrhage. STUDY DESIGN: Retrospective case review. METHODS: Retrospective review of three cases of acute or threatened carotid hemorrhage managed with endovascular stent placement. RESULTS: Two patients presented with acute carotid blowout, and one patient with a probable sentinel bleed. All patients previously had been heavily treated with surgery and irradiation: Two had developed pharyngocutaneous fistulas, and one had an open wound filled with tumor that surrounded the carotid artery. All were thought to be at significant risk for stroke if the carotid artery was occluded. In all three patients, stent placement resolved the acute hemorrhage. Mean duration of follow-up was 8.3 months. In two patients, the stent became exposed, ultimately thrombosed or extruded, or both. The third patient had no residual sequelae of stenting but died 3 months later. CONCLUSION: When an unacceptable risk of cardiovascular accident makes occlusion unwise, acute carotid hemorrhage can be successfully managed with directed placement of endovascular stents, but the long-term sequelae of placing these foreign bodies in a field with ongoing contamination make this a temporizing rather than permanent measure for use while more definitive long-term solutions are pursued.

Acute Disease↗
PubMedDate not supplied

Extracorporeal liver support: waiting for the deciding vote.

Because acute liver cell failure is associated with an exceedingly high mortality, liver support has been proposed since the 1950s to improve patient outcome. Early devices, including hemodialysis, hemofiltration, exchange transfusion, plasmapheresis, hemoperfusion, plasma and cross-hemodialysis or cross-circulation, appeared inefficient. Meanwhile, documented results of extracorporeal liver perfusion (ECLP) suggested its superiority over conventional treatment. These devices were abandoned with the development of liver transplantation (LT), which allowed a better outcome and longer survival rate. In the present day, the fact that patients die while waiting for LT because of organ shortage led to a renewed interest in liver support as bridge to LT or regeneration. These devices can be classified according to the presence or lack of hepatocytes, whereas biologic devices refers to the presence of cells or other organic and biochemical component. The absence of individual success of early models led to the development of combined hepatocyte free devices, or artificial liver, which are based upon the hemodiabsorption principle (Biologic-DT) or on the "albumin bound toxin hypothesis" (Molecular Adsorbents Recirculating System) with encouraging results. Meanwhile, hepatocyte based bioartificial liver devices (BLD) were conceived for a global "metabolic support." BLD were developed with the use of human hepatoma cell line (C3A) or primary or cryopreserved porcine hepatocytes. Preliminary experience gave promising results bridging patients to LT. Based upon the same principle of global hepatocyte metabolic support, ECLP regained interest, particularly with the development of transgenic pigs. Several concerns were raised about these devices. Artificial livers lacked any metabolic synthetic activity, the use of human liver for ECLP seems hardly acceptable because of organ shortage, and the accepted use of borderline livers for transplantation is pending trials for the use of xenogenic livers. For BLD, the concerns were the low hepatocyte mass, the absence of accessory liver cells, and the potential risk of seeding tumor cells into patient with the use of human hepatoma cell line. The use of porcine hepatocytes (BLD or ECLP) raised physiologic and immunologic concerns and particularly the fear of a possible transfer of porcine viral material. Although recent studies clearly demonstrate clinical improvement of patients with the use of recently developed liver support devices, most of reported prospective, controlled, or randomized trials had a small number of patients. To give the deciding vote and avoid previous pitfalls, trials need to be developed with a larger number of patients based upon statistically significant models with the following characteristics: 1) comprehensive understanding of the acute liver cell failure mechanisms, 2) world wide classification of conditions that require liver support, and 3) a clear definition of treatment success pending patients to LT or recovery without transplantation. There has not yet been conclusive evidence to support the benefits of extracorporeal liver support. We are still waiting for the deciding vote.

Animals↗
PubMed2004

Anesthetic management for separation of craniopagus twins.

We report the anesthetic management of a case of separation of craniopagus twins with unbalanced cross circulation and one twin with renal dysfunction. After intravenous induction, anesthesia was maintained with isoflurane inhalation and propofol infusion. Twin A survived but Twin B died after the surgery. The anesthetic problems during the operation are discussed.

Anesthesia↗
PubMed1996

Lung uptake of lidocaine during hyperoxia and hypoxia in the dog.

BACKGROUND: Lidocaine has been shown to accumulate in the lung following its administration. This study was undertaken to determine effects of dose of lidocaine on lung uptake during hyperoxic and hypoxic ventilation. METHODS: Using cross-circulation of ventilation and constant-flow perfusion of the left lower lobe independently from all other lobes of the dog lung under nitrous oxide and halothane anesthesia, lidocaine was infused into the inflow system, so that plasma lidocaine concentrations in the inflow blood were maintained at 5, 10, 20, 40 and 70 micrograms/ml respectively during ventilation with 50% O2 or 3% O2. During 20 micrograms/ml lidocaine infusion, indocyanine green (ICG), an intravascular marker, was mixed with the lidocaine solution, in such a fashion that plasma ICG concentration in the inflow blood was maintained at 20 micrograms/ml. Actual plasma lidocaine and ICG concentrations in blood drawn from the inflow ([Lid]pa,[ICG]pa) and the outflow ([Lid]pv,[ICG]pv)systems were measured, 1, 3, 5, 7 and 10 minutes after the beginning of lidocaine infusion. Percent lung uptake of perfused lidocaine was calculated as ¿1-([Lid]pv/[Lid]pa)/([ICG]pv/[ICG]pa)¿ x 100. RESULTS: During ventilation hyperoxia, mean percent lung uptakes of lidocaine were 41-52% 1 minute after the beginning of lidocaine infusion, and decreased in time-dependent fashion to 7-12% 10 minutes later. Curves of percent lung uptake of lidocaine over time were similar for the 5 predetermined lidocaine concentration groups (5-70 micrograms/ml). There were no significant differences in percent lung uptakes of lidocaine between the ventilation hyperoxia and hypoxia conditions. CONCLUSIONS: These findings suggest that percent lung uptake of lidocaine is unaffected by hypoxic ventilation and by varying the concentration of lidocaine in the perfusion through the recipient dog lung lobe.

Adsorption↗
PubMedDate not supplied

Inhibition of excitation-contraction coupling in the ventricular myocardium of the dog by SKF 24260.

1. The effects of SKF 24260 on the coronary vasculature and on the electrical and mechanical activities of the ventricular myocardium were studied by the use of papillary muscle preparations of the dog. The preparation was cross-circulated from a donor dog through the anterior septal artery, and driven at a rate of 120 beats/min. Drugs were injected into the anterior septal artery. 2. SKF 24260, in doses of 0-01-100 mug, caused a dose-dependent increase in the rate of blood flow through the anterior septal artery; the mean dose producing a 100% increase in blood flow rate was about 0-7 mug. 3. SKF 24260 in doses of 0-01-0-03 mug produced a slight increase in developed tension of papillary muscles. With 0-1-0-3 mug of SKF 24260 the increase was preceded by a transient decrease, and with doses larger than 1 mug the drug caused a dose-dependent decrease. The mean dose producing a 50% decrease in developed tension was about 2-8 mug. 4. SKF 24260 failed to affect the amplitude and shape of bipolar electrograms even in doses of 39-100 mug which completely abolished the developed tension. 5. The decrease in the developed tension caused by SKF 24260 was overcome by exogenous calcium; the increase in the developed tension in response to exogenous calcium was antagonized by SKF 24260. 6. These results indicate that the dilator action of SKF 24260 on the coronary vasculature is more prominent than the negative inotropic action on the ventricular myocardium, and suggest that the negative inotropic action is probably due to antagonism of the role of calcium in excitation-contraction coupling.

Animals↗
PubMedDate not supplied

Positive inotropic action of glyceryl trinitrate as observed in the blood-perfused papillary muscle preparation of the dog heart.

1. The effects of glyceryl trinitrate on the coronary vasculature and on the contractility of the ventricular myocardium were investigated by the use of papillary muscle preparations of the dog, and that on the sino-atrial node activity by the use of sino-atrial node preparations of the dog. The papillary muscle preparation was cross-circulated through the anterior septal artery and the sino-atrial node preparation through the sinus node artery from a donor dog. The papillary muscles were driven at a rate of 120 beats/min. Drugs were injected close-arterially. 2. Glyceryl trinitrate, in doses of 0-03-100 microgram, produced dose-related increases in blood flow and developed tension. An increase in developed tension caused by 100 microgram of glyceryl trinitrate amounted to about 24% of the basal developed tension. Large doses of glyceryl trinitrate (100-300 microgram) produced a negative inotropic effect after a positive one in some preparations. 3. The positive inotropic effect of glyceryl trinitrate was not modified by propranolol, excluding a possible participation of an adrenergic mechanism. 4. Glyceryl trinitrate in large doses failed to modify the positive inotropic effect of calcium chloride. 5. Glyceryl trinitrate in a wide range of doses (0-03-100 microgram) had virtually no effect on sino-atrial node activity.

Animals↗
PubMed1962

Effect of antisympathomimetic drugs on the plasma concentrations of catechol amines.

Intravenous injection of phenoxybenzamine, choline 2,6-xylyl ether bromide (xylocholine, TM 10), piperoxane or dihydroergotamine increases the vasopressor activity of blood plasma, collected from cats under chloralose anaesthesia. The increased vasopressor activity that follows the administration of piperoxane is due to an increase of adrenaline and noradrenaline in the plasma. Cross-circulation experiments show that catechol amines are liberated from the spleen by piperoxane.

Amines↗
PubMed1972

An analysis of central adrenoceptors for control of cardiovascular function.

1. In dogs anaesthetized with pentobarbitone sodium, bradycardia with hypotension occurred on intracerebroventricular (i.c.v.) injection of noradrenaline (50-200 mug) or phenylephrine (100-400 mug), but tachycardia with hypotension occurred on i.c.v. injection of isoprenaline (100-200 mug).2. These cardiovascular responses were central effects, and from the results obtained after bilateral vagotomy, removal of both stellate ganglia and transection of the upper cervical cord, it was evident that the efferent nervous pathway for all these effects was the sympathetic nervous system.3. An i.c.v. injection of the alpha-adrenoceptor blocking agent phenoxybenzamine (10 mg) blocked the bradycardia and hypotension produced by noradrenaline or phenylephrine, and an i.c.v. injection of a beta-adrenoceptor blocking agent, either propranolol (2 mg) or N-isopropyl-p-nitrophenyl-ethanolamine (INPEA) (10 mg), blocked the tachycardia and hypotension produced by isoprenaline.4. The cardiovascular effects produced by i.c.v. injection of the three sympathomimetic amines could be reproduced in cross-circulation experiments in the recipient dog when the amines were injected into its head circulation, and the effects of noradrenaline and phenylephrine, but not those of isoprenaline, were abolished by the alpha-adrenoceptor blocking agent yohimbine (1 mg/kg) injected intravenously into the donor dog.5. It is concluded that the central alpha-adrenoceptors are concerned with bradycardia and the central beta-adrenoceptors with tachycardia, but that both receptors are concerned with hypotension.

Amino Alcohols↗
PubMed1979

Role of 5-hydroxytryptamine in the vasoconstrictor action of compound 48/80 in the rat femoral vasculature.

1. The effect of compound 48/80 on the rat femoral vasculature was examined by means of a cross-circulation technique. 2. Intra-arterial injection of increasing doses (1.5 to 15 microgram) of compound 48/80 caused dose-dependent vasoconstriction preceded by transient vasodilatation. The vasoconstriction was significantly reduced in reserpine-treated preparations and converted to vasodilatation by methysergide. 3. When the vasoconstrictor response to a large dose (300 microgram) of adenosine was abolished by repeated administration, the response to compound 48/80 remained unaltered. 4. The present results indicate that the femoral arterial vasoconstriction by compound 48/80 in the rat is mediated by the release of 5-hydroxytryptamine (5-HT); this 5-HT may be liberated from a different storage site from that released by adenosine.

Adenosine↗
PubMed1980

Beta-adrenergic dilator interaction with the constrictor response in resistance vessels of skeletal muscle during hemorrhage.

A marked beta-adrenergic dilator interaction with the vasoconstrictor response in skeletal muscle during hemorrhage is described. The dilator influence corresponded to some 40% of the constrictor response both at mild and moderate as well as at large bleeding. In absolute resistance units, the beta-adrenergic dilator influence averaged no less than 14 mmHg/ml X min-1 X 100 g-1) at large bleeding (hemorrhagic hypotension of 50 mmHg). Comparison of the hemorrhage induced resistance effects in the autoperfused innervated muscle, in the autoperfused denervated muscle, and in the innervated muscle cross-circulated from a donor animal, showed that the beta-adrenergic dilator influence more or less completely was caused by blood-borne catecholamines, in all likelihood by adrenaline, which is known to be secreted in large amounts during hemorrhage. The described beta-adrenergic dilator mechanism may serve to maintain nutritional blood flow by counteracting the constrictor response. It deserves consideration also from the point of view that it obviously has to be taken into account for proper evaluation of other vascular control mechanisms brought into action in hemorrhage.

Animals↗
PubMed1995

Efferent renal sympathetic nerve stimulation in vivo. Effects on regional renal haemodynamics in the Wistar rat, studied by laser-Doppler technique.

Intrarenal blood flow regulation probably affects long-term blood pressure homeostasis. We have previously shown that 5 Hz renal sympathetic stimulation inhibits a humoral renal depressor mechanism, otherwise activated when increasing perfusion pressure to an isolated kidney in a cross-circulation set-up. This inhibition was suggested to occur as a result of a reduction of renomedullary blood flow. Little is known about nervous blood flow regulation within the medulla. Therefore in this study, total renal (RBF), cortical (CBF) and papillary (PBF) blood flows were separately measured by ultrasonic and laser-Doppler techniques in Wistar rats during graded renal sympathetic stimulations. Periods of 15 min stimulation at 0.5, 2 and 5 Hz were performed in random order. RBF decreased at 0.5 Hz by 1%, at 2 Hz by 16% (P < 0.001) and at 5 Hz by 49% (P < 0.001). In a similar fashion (r = 0.73, P < 0.001), CBF decreased by 1%, 10% (P < 0.001) and 37% (P < 0.001), respectively. By contrast, PBF increased by 2% at 0.5 Hz and 4% at 2 Hz, while it decreased at 5 Hz, by 4% (P < 0.05, compared with 2 Hz). It seems therefore, that superficial renocortical and total renal blood flows are closely regulated by renal sympathetic nerves with increasing vasoconstriction at higher frequencies, while medullary blood flow, on the other hand, seems to be under strong local control, tending to offset neurogenic flow restrictions.

Animals↗
PubMed1972

Nature and location of the receptors for salt-gland secretion in the goose.

1. The nature and location of the receptors which stimulate salt-gland secretion in the goose have been investigated.2. The rapid injection of homologous blood (sufficient to raise the blood volume by 16 and 9%) into the right atrium failed to induce secretion. In contrast, hypertonic sucrose, Na(2)SO(4) and LiCl initiated secretion.3. These results support the theory that osmoreceptors initiate secretion by detecting an increase in plasma tonicity.4. The minimal amount of hypertonic NaCl required to initiate secretion when infusions were made into a carotid artery or into various arteries and veins in the splanchnic region was not less than that required by an I.V. route.5. Cross-circulation and perfusion studies also showed that a raised [NaCl] in the blood perfusing the head was ineffective in evoking secretion and thus that plasma tonicity must be raised elsewhere in the body.6. Secretion in response to salt-loading was abolished or prevented by cutting the vagus nerves or blocking them with local anaesthetic. Stimulation of the cephalic end of the cut vagi in an isolated, perfused decerebrate head induced secretion, indicating that the afferent fibres from the receptors to the C.N.S. lie in the vagus nerves. Cutting the vagi below the heart, however, had no effect on the secretory response.7. Blocking nerves in the crop with local anaesthetic had no effect on secretion induced by salt-loading but when local anaesthetic was injected into the pericardial sac, secretion decreased immediately, stopped, and recovered with a time course similar to that seen after blocking the vagus nerves.8. Section of the vagi in the neck abolished the tachycardia observed in response to the injection of hypertonic NaCl into the right atrium.9. As in other species, stimulation of the ;secretory nerve' induced secretion in anaesthetized or decerebrate geese.10. Hexamethonium given I.V. or applied topically to the ;secretory nerve ganglion' blocked secretion in response to salt-loading or to secretory nerve stimulation.11. It appears that the receptors for salt-gland secretion are located in or near the heart and that afferent fibres from these receptors travel in the vagus nerves to the C.N.S.12. A possible scheme of the secretory reflex which initiates and maintains salt-gland activity is proposed.

Anesthesia, Local↗