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When treating duodenal ulcer by vagotomy surgeons aim at dividing all the vagal secreto-motor fibres to the stomach. In order to assess whether this aim had been achieved, Hollander (1948) developed the insulin test which has proved a valuable clinical method of judging whether the vagi have been divided completely. The criteria by which the acid secretory response of the stomach to insulin-induced hypoglycaemia is interpreted were established on an empirical basis. Apart from Hollander's criteria, other standards have been suggested for the interpretation of the insulin test by Bachrach (1962), Stempien (1962), and Bank, Marks, and Louw (1967). None of these authors suggested that it might be necessary to employ different criteria for men and women. In this communication we report differences between the secretory response to insulin of male and female patients, and apply them to the interpretation of the Hollander test after vagotomy. PATIENTS AND METHODSInsulin tests were carried out on 55 male and 15 female patients with duodenal ulcer before surgery, and on 138 men and 44 women about 10 days after vagotomy and a drainage procedure (pyloroplasty or gastroenterostomy).All tests were carried out after an overnight fast, a nasogastric tube being positioned under fluoroscopic control in the most dependent part of the stomach. Fasting gastric juice was aspirated and discarded. Basal secretion was collected for two 15-minute periods followed by eight 15-minute collections after the intravenous injection of soluble insulin. Aliquots of the collections were titrated with N/10 NaOH using Topfer's reagent as indicator for free acid. The volume, pH, acid concentration, and acid output of each sample were measured. The dose of insulin used was 20 units in the earlier tests and 0.25 units/kg body weight in the later tests. Blood samples for glucose estimation were taken at the time of injection of insulin, and 30 and 45 minutes later. The tests were rejected if the blood sugar did not fall below 45 mg per 100 ml after insulin.The preoperative tests were analysed to establish whether men and women gave different acid secretory responses to insulin.The postoperative results were analysed in the first instance using Hollander's criteria. A positive response to insulin, indicating incomplete vagotomy, was defined as a rise in acid concentration in any 15-minute period after insulin of 20 or more m-equiv/l above the basal concentration, or of 10 or more m-equiv/l if no free acid was present in the basal secretion. This analysis revealed significantly different incidences of complete vagotomy in men and women. The weights of the patients were studied in order to determine whether heavier patients had a higher incidence of incomplete vagotomy. This did not provide a satisfactory explanation for the difference previously noted and the insulin tests were thereforeanalysed again using different criteria for men and women. RESULTS IN PREOPERATIVE TESTSACID OUTPUT The mean output of free acid in response to insulin in the males and ...

Foetal Heart Rate-Day et al. MEDBRITISHRNAL auscultation can be better taught by explaining the nature of possible errors. A foetal heart rate monitor provides the most effective method for teaching auscultation, as the staff can check their own observations accurately and repeatedly. Nevertheless, the importance of foetal heart rate changes in relation to uterine contractions and the difficulty of detecting these changes by auscultation limits the usefulness of clinical measurement of the foetal heart rate. However, it is sometimes possible to count the foetal heart rate during contractions, and slowing at the end of the uterine contraction was detected in two patients, the observations being confirmed by the monitor record of heart rate. The method of counting the foetal heart rate introduced by Caldeyro-Barcia et al. (1966) has merit. The counting is begun during or immediately before a contraction, and is continued until two minutes after the contraction, the count being taken over 15-second periods with five-second intervals. This technique might involve the observer in making as many as 10 separate counts, and a more realistic schedule in our own hospital would be six counts each of 15 seconds, two taken during the contraction and four spaced over the two minutes after the contraction. In this manner change in the foetal heart rate may be detected both during and immediately after the contraction.With clinical auscultation a rapid foetal heart rate was found important. The reason for the association of a rapid baseline foetal heart rate with depressed babies at birth was apparent when the monitored foetal heart rate was examined in the same patients. The majority of foetal heart rates showing changes in relation to a contraction which are associated with a poor prognosis for the foetus (type 3) were also rapid between contractions. An unusual finding in the present study was the normal Apgar scores associated with a steady baseline foetal heart rate of 100-120 beats per minute. However, a slow but steadily decreasing foetal heart rate may be significant, as evidenced in the following case.The patient, 35 weeks pregnant, had clinical evidence of foetal growth retardation, a reduced urinary excretion of oestriol, and at artificial rupture of the membranes a low foetal scalp blood pH, 7.13. Early in labour the clinical foetal heart rate was normal, while the monitor showed that the foetal heart rate slowed towards the end of contractions. One hour before delivery auscultation revealed a foetal heart rate of fewer than 120 beats per minute, and five minutes before delivery the rate fell to fewer than 100 beats per minute. Subsequently the baby was stillborn. The monitor confirmed the occurrence of a steadily worsening bradycardia over the hour before delivery.Thus when relying on auscultation of the foetal heart rate the constant slow foetal heart rate must be distinguished from the slow but declining foetal heart rate. Brit. med. J., 1968, 4, 424-426 Summary: In 45 patients with chronic uraemia the basal ...

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