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In Reply.— Dr Michelson writes that "I cannot agree with the statement... that an average additional blood loss of 400 mL 'is not of great clinical importance.' " Our overall figures of blood loss include eight different groups of patients. That is to say, we compared patients with primary operations who then had normotensive or hypotensive anesthesia and broke those groups down into patients who received 1.2 or 3.6 g of aspirin a day. There was a second major group composed of patients undergoing revision total-hip arthroplasty. They received either normotensive or hypotensive anesthesia, and each of those groups was subdivided into patients receiving 1.2 vs 3.6 g of aspirin a day. The results in all of these subsets were then compared with those of control subjects who had the corresponding characteristics, ie, primary or secondary total-hip replacement and normotensive or hypotensive anesthesia. If Dr Michelson refers to Table 3, he

To the Editor.— Patients who will not or cannot receive homologous blood transfusion for either elective or traumatic surgery present a dilemma. Attempts to control bleeding during surgical intervention are not new. However, performing major reconstructive hip surgery using blood-saving and retrieving techniques without the use of homologous blood transfusion is not a frequent procedure. Consequently, there is little or no information available. In the past two years, we have successfully combined the use of hypotensive anesthesia and intraoperative autotransfusion in a group of patients whose religious beliefs prohibited homologous transfusion. Hypotensive anesthesia significantly lowered the amount of blood loss by 50% in this group of patients and aided in the insertion of acrylic cement. Also, 40% of the blood lost at surgery could be retrieved and replaced by intraoperative autotransfusion. Lesser amounts could be obtained in patients who bled little at surgery. The data suggest that intraoperative autotransfusion provides

To meet the needs associated with high-speed flying, aviation medicine has developed an inflatable suit to be used for the prevention of blackouts that afflict the flyer when he pulls his plane sharply out of a fast dive. Because these suits were designed to counteract the force of gravity, which is multiplied many times during such maneuvers, they became known as antigravity suits or, more simply, as g-suits. The standard aviation garment consists of inflatable leggings and an abdominal binder, which, by constricting the lower part of the body, prevent pooling of blood. Wood and his co-workers1demonstrated the effectiveness of the g-suit in observations in the human centrifuge. Restall and Smirk2applied the principle to the study of hypotension produced with hexamethonium, while Seiker and his associates3described its mode of action in cases of postural hypotension occurring after sympathectomy. For several years we employed an

THERE are rumbles in the background suggesting that a storm is brewing—that a new concept of the significance of the human organism's response to trauma is evolving which might lead to new techniques for solving many major problems in the management of the sick patient. From France one hears of "artificial hibernation," of "slow-motion life," of "sympathetic neuroplegia"; in Britain "hypotensive anesthesia" has become common practice; in the United States "general hypothermia" is creeping into the armamentarium of the cardiac surgeon. What is the conceptual relationship among these techniques, if any, and what is the evidence to support them? What biological kinship exists between the pharmacologic "lytic cocktail" and the physical agent ice-water? Herein, at the present time, lies the confusion of a welter of undocumented theories. Yet an underlying hypothesis of great attractiveness appears dimly, seeking to be established or refuted, not by claims and rash clinical trial

To the Editor.— Controlled hypotensive anesthesia using pentolinium tartrate has been beneficial in total hip replacement. Hypotensive anesthesia in hip replacement was first advocated by John Charnley in England. Jennings et al recently advocated its use at the American Academy of Orthopaedic Surgeons Meeting in 1973. My personal experience with hypotensive anesthesia has been similarly favorable. Forty patients undergoing total hip replacement were operated on under general anesthesia using pentolinium to lower the blood pressure to the diastolic level. A similar group of patients were operated on under normal tensive anesthesia as a basis of comparison. Patients with a history of coronary insufficiency, advanced arteriosclerosis, or previous renal disease were not included in this study. The patients' blood volumes were evaluated preoperatively in order to assure an adequate volemic state prior to the use of pentolinium. The agent was started prior to the skin incision and maintained throughout the operative

This volume indicates that transurethral resection, developed about 40 years ago in the United States and widely used in the Americas, has now been accepted in the British Isles, at least by some urologists, as a fullfledged procedure in the urological armamentarium, with full status and equality with open surgery. The book is a thorough discussion of the indications, preoperative selection, preparation, instruments, technique and postoperative care as seen in the light of the author's experience and preferences. As stated in the very title, and repeated and emphasized throughout the book, the author holds a major premise that good transurethral surgery is not possible without good hemostasis. In addition to a technique directed towards this end, he enthusiastically advocates the use of hypotensive anesthesia. Transurethral resection for benign hyperplasia of the prostate should be restricted to cases in which the estimated weight of tissue to be removed is 25 to

HYPOTENSIVE anesthesia to reduce bleeding during surgery has recently evoked a great interest among surgeons and anesthesiologists. For the past two years we have been using hypotensive anesthesia in selected cases of radical pelvic and abdominal surgery at the Memorial Cancer Center in New York City. The physiological basis for this type of anesthesia will be discussed very briefly. It is known that the blood pressure varies mainly as the product of cardiac output and peripheral resistance; blood pressure equals cardiac output times peripheral resistance. In case of hemorrhage the blood volume is reduced, leading to decrease in venous return to the heart, with subsequent fall in cardiac output. The compensatory mechanism of the body acting via the sympathoadrenal system tries to maintain normal blood pressure levels by increasing the peripheral resistance. The produced vasoconstriction achieves temporarily this goal, but with further blood loss the blood pressure falls and reaches low