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COTTON SUTURES
1162 the
the gluteus region into the dorsal lymphinto the ventral subcutis. This technique avoids any leakage. A neutral pH of the fluids to be injected is essential and it should be adjusted carefully in order to prevent toxic effects.
hindleg through
sac or
Concentration of A.C.T.H. from Blood 1. 20 ml. of blood withdrawn from the cubital vein is immediately transferred to a bottle containing 20 ml. of distilled acetone and 0-5% glacial acetic acid. This procedure inactivates any A.C.T.H.-decomposing enzyme of the blood and precipitates inert proteins. 2. The suspension is sucked through a 1-2 in. Buchner funnel with Whatman filter-paper no. 1, and the precipitate is washed with 5 ml. of 50% acetone. The pooled filtrates (approximately 25 ml.) contain the whole A.C.T.H. 3. This filtrate is carried over to a 100 ml. bottle, and 60 ml. of distilled acetone is added, which precipitates A.C.T.H. within an hour. In order to facilitate precipitation and sedimentation, 10 ml. of ether is added immediately and the bottle is allowed to stand overnight in the refrigerator. 4. Next morning the supernatant fluid is decanted ; the precipitate is washed with about 5 ml. of ether, the ether decanted, and the residue freed from traces of ether by standing for about 30 minutes. 5. The A.C.T.H. precipitate is dissolved quantitatively in 0-8 ml. of N/20 NaOH with the addition of 1-2 drops of a standard bromthymol-blue indicator solution. If the precipitate does not completely dissolve, the bottle should be shaken in a shaking apparatus. Finally, some drops of N/4 acetic acid are added until the solution becomes green, avoiding, however, iso-electric precipitation. 6. The concentrated A.C.T.H. solution (approximately 1 ml.) is injected into green-adapted tree frogs as follows : Frog 1.-0-1 ml. (i.e., 2 ml. of blood corresponding to 500 frog units per litre blood). Frog 2.-0-3 ml. (i.e., 6 ml. of blood corresponding to 166 frog units per litre blood). Frog 3.-0-6 ml. (i.e., 12 ml. of blood corresponding to 83 frog units per litre blood). It is difficult to correlate the frog unit with the international unit. With the international standard preparation of A.C.T.H. 1 n.g. is equivalent to 1 frog unit. This correlation is, however, not necessarily directly applicable to other preparations.’7
The above simple method enables the A.c.T.H. content of blood to be determined within 12 hours. I feel that this assay is as easily carried out as an Aschheim-Zondek test. It is of obvious use in the differential diagnosis adrenal between pituitary Cushing syndrome and
Cushing syndrome. Department of Pharmacology, Hebrew University—Hadassah University-Hadassah Medical School, School, F. G. C. Jerusalem, Israel.
MAURICE LEE.
London, W.I.
COTTON SUTURES SIR,-In your leading article of March 1 you refer to possible economies in the hospital service. One possible economy is to use cotton sutures. Chiefly for the sake of economy, we use at this hospital ordinary sewing cotton, of grades 40 and 60, for almost every type of suture, including peritoneum, muscle. sheaths, ligatures, and skin. We use catgut only in vaginal and perineal repairs, and in operations for haemorrhoids and on the bowel mucosa. If properly
sterilised by boiling or autoclaving these non-absorbable sutures are innocuous and in many ways superior to catgut ; for example, in old people with poor tissue reaction one knows that there is no danger of the wound breaking down as there is after catgut has been absorbed. Since being introduced to cotton sutures four years ago, by Dr. R. A. Hughes, of Shillong, I have seen not a single instance of wound sepsis or malunion in a varied series of major and minor cases. I. T. PATRICK Christian Mission Hospital, Medical Superintendent. Rajshahi, Pakistan. POSTURAL NERVE BLOCK FOR INTRANASAL OPERATIONS
SIR,-I was interested to read the article by Dr. Curtiss in your issue of May 17. I have myself used Moffett’s instillation method of local analgesia with good results. The modification suggested by Dr. Curtiss eso seems
satisfactory. SULMAN. SULMAN SULMAI3.
AN ILLUMINATED SUCKER TUBE
SiR,—The sucker tube which Mr. Everidge illustrates in your issue of May 3 is very similar to the one I have been using for some time. I believe that my instrument has some advantages over that of Mr. Everidge. For instance, I have had a short retractor welded to the sucker (see figure). With the retraction of the tissues that is thus possible the sucker and light can be got down more readily to the source of bleeding. Thus in either a transvesical or retropubic prostatectomy the capsule of the prostatic cavity can be retracted, and the sucker and light applied direct to the bleeding-point without any obstruction to vision. In addition, the sucker tube can be advanced or retracted at will by means of a small knob on the shaft 7. Sulman, F. G.
of the instrument. This again is an advantage, because it prevents the bulb of the light being coated with a film of blood, so obscuring the field of vision. The sucker-light retractor is curved so that it does not obscure the field from the operator. This instrument has been a great boon to me in doing prostatectomies, as it enables me to see exactly where the bleeding is taking place. It also has advantages in many other operative fields, such as thyroidectomy (in retract. ing the infrahyoid muscles), cholecystectomy (if hmmor. rhage occurs deep down in the wound), and in other operations where suction, light, and retraction are needed simultaneously. It does away with a multiplicity of instruments deep down in a wound. I am indebted to Messrs. Allen & Hanburys Ltd., who cooperated with me in evolving this sucker-light retractor.
Endocrinology (in the press).
It would appear, however, that there is always a risk that the patient may swallow some of the cocaine solution. Perhaps a safer method is to use a 25% cocaine paste made up as follows :
This is smeared
on
to
a
cotton-wool
applicator,
which is
applied directly to the region of the sphenopalatine ganglion. The ganglion is immediately behind the posterior end of the middle turbinate bone. Positioning of the applicator is not difficult, and need only be approximate. Two further cotton-wool-mounted applicators are required; one is directed to the roof of the nose to block impulses along the anterior ethmoidal nerve, and the other is placed along the inferior meatus of the nose to catch the nasal branches of the anterior and posterior superior dental nerves. Preliminary light spraying with a weak solution of cocaine renders the introduction of these applicators painless, and with reasonable
care
there is
no
trauma to the mucosa.
The
big advantage of using paste is that absorption is virtually only local. Cocaine is not ingested, and so intoxication is rare. Another advantage is that the procedures can all be carried out in the ward before the patient is brought down to
the gluteus region into the dorsal lymphinto the ventral subcutis. This technique avoids any leakage. A neutral pH of the fluids to be injected is essential and it should be adjusted carefully in order to prevent toxic effects.
hindleg through
sac or
Concentration of A.C.T.H. from Blood 1. 20 ml. of blood withdrawn from the cubital vein is immediately transferred to a bottle containing 20 ml. of distilled acetone and 0-5% glacial acetic acid. This procedure inactivates any A.C.T.H.-decomposing enzyme of the blood and precipitates inert proteins. 2. The suspension is sucked through a 1-2 in. Buchner funnel with Whatman filter-paper no. 1, and the precipitate is washed with 5 ml. of 50% acetone. The pooled filtrates (approximately 25 ml.) contain the whole A.C.T.H. 3. This filtrate is carried over to a 100 ml. bottle, and 60 ml. of distilled acetone is added, which precipitates A.C.T.H. within an hour. In order to facilitate precipitation and sedimentation, 10 ml. of ether is added immediately and the bottle is allowed to stand overnight in the refrigerator. 4. Next morning the supernatant fluid is decanted ; the precipitate is washed with about 5 ml. of ether, the ether decanted, and the residue freed from traces of ether by standing for about 30 minutes. 5. The A.C.T.H. precipitate is dissolved quantitatively in 0-8 ml. of N/20 NaOH with the addition of 1-2 drops of a standard bromthymol-blue indicator solution. If the precipitate does not completely dissolve, the bottle should be shaken in a shaking apparatus. Finally, some drops of N/4 acetic acid are added until the solution becomes green, avoiding, however, iso-electric precipitation. 6. The concentrated A.C.T.H. solution (approximately 1 ml.) is injected into green-adapted tree frogs as follows : Frog 1.-0-1 ml. (i.e., 2 ml. of blood corresponding to 500 frog units per litre blood). Frog 2.-0-3 ml. (i.e., 6 ml. of blood corresponding to 166 frog units per litre blood). Frog 3.-0-6 ml. (i.e., 12 ml. of blood corresponding to 83 frog units per litre blood). It is difficult to correlate the frog unit with the international unit. With the international standard preparation of A.C.T.H. 1 n.g. is equivalent to 1 frog unit. This correlation is, however, not necessarily directly applicable to other preparations.’7
The above simple method enables the A.c.T.H. content of blood to be determined within 12 hours. I feel that this assay is as easily carried out as an Aschheim-Zondek test. It is of obvious use in the differential diagnosis adrenal between pituitary Cushing syndrome and
Cushing syndrome. Department of Pharmacology, Hebrew University—Hadassah University-Hadassah Medical School, School, F. G. C. Jerusalem, Israel.
MAURICE LEE.
London, W.I.
COTTON SUTURES SIR,-In your leading article of March 1 you refer to possible economies in the hospital service. One possible economy is to use cotton sutures. Chiefly for the sake of economy, we use at this hospital ordinary sewing cotton, of grades 40 and 60, for almost every type of suture, including peritoneum, muscle. sheaths, ligatures, and skin. We use catgut only in vaginal and perineal repairs, and in operations for haemorrhoids and on the bowel mucosa. If properly
sterilised by boiling or autoclaving these non-absorbable sutures are innocuous and in many ways superior to catgut ; for example, in old people with poor tissue reaction one knows that there is no danger of the wound breaking down as there is after catgut has been absorbed. Since being introduced to cotton sutures four years ago, by Dr. R. A. Hughes, of Shillong, I have seen not a single instance of wound sepsis or malunion in a varied series of major and minor cases. I. T. PATRICK Christian Mission Hospital, Medical Superintendent. Rajshahi, Pakistan. POSTURAL NERVE BLOCK FOR INTRANASAL OPERATIONS
SIR,-I was interested to read the article by Dr. Curtiss in your issue of May 17. I have myself used Moffett’s instillation method of local analgesia with good results. The modification suggested by Dr. Curtiss eso seems
satisfactory. SULMAN. SULMAN SULMAI3.
AN ILLUMINATED SUCKER TUBE
SiR,—The sucker tube which Mr. Everidge illustrates in your issue of May 3 is very similar to the one I have been using for some time. I believe that my instrument has some advantages over that of Mr. Everidge. For instance, I have had a short retractor welded to the sucker (see figure). With the retraction of the tissues that is thus possible the sucker and light can be got down more readily to the source of bleeding. Thus in either a transvesical or retropubic prostatectomy the capsule of the prostatic cavity can be retracted, and the sucker and light applied direct to the bleeding-point without any obstruction to vision. In addition, the sucker tube can be advanced or retracted at will by means of a small knob on the shaft 7. Sulman, F. G.
of the instrument. This again is an advantage, because it prevents the bulb of the light being coated with a film of blood, so obscuring the field of vision. The sucker-light retractor is curved so that it does not obscure the field from the operator. This instrument has been a great boon to me in doing prostatectomies, as it enables me to see exactly where the bleeding is taking place. It also has advantages in many other operative fields, such as thyroidectomy (in retract. ing the infrahyoid muscles), cholecystectomy (if hmmor. rhage occurs deep down in the wound), and in other operations where suction, light, and retraction are needed simultaneously. It does away with a multiplicity of instruments deep down in a wound. I am indebted to Messrs. Allen & Hanburys Ltd., who cooperated with me in evolving this sucker-light retractor.
Endocrinology (in the press).
It would appear, however, that there is always a risk that the patient may swallow some of the cocaine solution. Perhaps a safer method is to use a 25% cocaine paste made up as follows :
This is smeared
on
to
a
cotton-wool
applicator,
which is
applied directly to the region of the sphenopalatine ganglion. The ganglion is immediately behind the posterior end of the middle turbinate bone. Positioning of the applicator is not difficult, and need only be approximate. Two further cotton-wool-mounted applicators are required; one is directed to the roof of the nose to block impulses along the anterior ethmoidal nerve, and the other is placed along the inferior meatus of the nose to catch the nasal branches of the anterior and posterior superior dental nerves. Preliminary light spraying with a weak solution of cocaine renders the introduction of these applicators painless, and with reasonable
care
there is
no
trauma to the mucosa.
The
big advantage of using paste is that absorption is virtually only local. Cocaine is not ingested, and so intoxication is rare. Another advantage is that the procedures can all be carried out in the ward before the patient is brought down to