- Email: [email protected]
DEFINITIVE PREOPERATIVE DIAGNOSIS OF OBSTRUCTIVE JAUNDICE
754 In an attempt to determine the best colour under all conditions the following colours were compared: white, blue, green, yellow, and red. Each colour was used on a variety of wounds and sites and on patients of different skin colour, including Caucasians and Afro-Asians. The impressions of the nursing staff, who were chiefly responsible for wound care and the removal of sutures, indicated that red was best, in that it was the most easily seen against the background of skin colour, recently healed wounds, encrusted blood, and adjacent hairs. This conclusion agrees with the selection of red as the identification colour for training aircraft and for safety clothing for those working on highways. The coloured suture material used in these cases was prepared experimentally by Ethicon Ltd., Scotland. Because of the universal applicability of this red suture, it has been designated the international skin suture. 7
Mossgiel Avenue, Ainsdale, Southport,
L. F. TINCKLER.
Lanes.
TREATING THE NERVOUS SYSTEM IN ACUTE LEUKÆMIA SIR,—Referring to your leader of Feb. 5 (p. 297), I should like to make the following points: "
1.
"
Prophylactic cranial irradiation, 2400 rads from a 6OCo given in an overall period of 2! weeks and not in a single
source, is
dose as stated. 2. The name of Auer’s rods was mis-spelt. 3. 2400 rads of " prophylactic " craniospinal irradiation in the treatment of previously untreated acute lymphocytic leukaemia of childhood has produced comparable or slightly superior results. 1,2z St.
Jude Children’s Research Hospital, P.O. Box 318
Memphis, Tennessee 38101,
R. J. A. AUR. * We apologise to Dr. Aur and his colleagues for the mistake in our description of their method of administration of cranial irradiation. The error in our leader was also pointed out by Dr. Collins (Feb. 19, p. 433).-ED. L. U.S.A.
*
DEFINITIVE PREOPERATIVE DIAGNOSIS OF OBSTRUCTIVE JAUNDICE
SIR,-It seems to us a pity that Mr. Bourke and his colleagues (March 18, p. 605) failed to estimate the concentration and output of bilirubin in their fractions aspirated from the duodenum after the injection of pancreozymin. When liver function is adequate, this additional measurement provides a useful means of assessing biliary function. This cholecystokinin test was reported to the British
Society of Gastroenterology in 1951,3 at the time when we introduced pancreozymin into clinical practice4 and appreciated that samples of pancreozymin prepared by the method of Harper and Raper possessed cholecystokinetic
activity. Subsequent reports 5-have emphasised the particular usefulness of the cholecystokinin test in two clinical situa1. Proc. Am. Ass. Cancer Res. 1971, 62, 5. 2. Aur, R. J. A., Simone, J. V., Hustu, H. 3. 4. 5. 6.
7. 8.
O., Verzosa, M. S. Cancer (in the press). Duncan, P. R., Harper, A. A., Howat, H. T., Oleesky, S., Varley, H. Gastroenterologia, 1952, 78, 349. Burton, P., Evans, D. G., Harper, A. A., Howat, H. T., Oleesky, S., Scott, J. E., Varley, H. Gut, 1960, 1, 111. Burton, P., Harper, A. A., Howat, H. T., Scott, J. E., Varley, H. ibid. p. 193. Howat, H. T. in The Biliary System (edited by W. Taylor): p. 249. Oxford, 1965. Howat, H. T. Manchester med. Gaz. 1967, 46, no. 3. Howat, H. T. in Biochemical Disorders in Human Disease (edited by R. H. S. Thompson and I. D. P. Wootton) pp. 703-722. London, 1970.
tions : to confirm impaired function of a gallbladder which has failed to outline during cholecystography; and to elucidate the cause of extrahepatic obstructive jaundice. It is precisely in the area where the studies of Mr. Bourke and his colleagues failed to reveal an abnormality that the cholecystokinin test can distinguish in most cases obstruction of the biliary ducts due to gallstones from obstruction due to malignancy and, in conjunction with the secretin-pancreozymin test, cancer originating in the pancreas from primary cancer of the bile-ducts and gallstones. The results of these tests in 108 patients presenting with obstructive jaundice9 were:
Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL
JOAN BRAGANZA HENRY T. HOWAT.
URINARY OBSTRUCTION AND DEHYDRATION SIR,-The symptoms of polyuria and polydypsia are always clinically significant, and their investigation may reveal more than was suspected. A patient who came under our care in the assessment unit of this department was a 75-year-old white male who presented with confusion and irritability. An accurate history was not forthcoming, but his wife said that he had lost weight and had recently complained of thirst and frequency of micturition. He had also lost his appetite. His own doctor had tested his urine and found 1 % sugar on one occasion. Two years before, he had been in hospital with a toxic confusional state, thought at that time to be due to a urinary infection. He was found to be dehydrated and confused. The bloodpressure was 190/100 mm. Hg (a reading of 230/130 had previously been recorded at home). There was a firm mass arising from his pelvis. A urinary catheter was passed, a large volume of urine was obtained, and the abdominal mass disappeared. The prostate was thought to be normal. Initial investigations revealed intermittent glycosuria but a normal series of bloodsugars. The blood-urea level was 120 mg. per 100 ml., sodium 151, potassium 4-0, bicarbonate 27 meq. per litre, and serumcreatinine 3-5 mg. per 100 ml. There was a heavy growth of a coliform organism in the urine. Serum osmolality was 326 mosmole per kg., and a random urine had an osmolality of 225 mosmole per kg. There was no Bence-Jones proteinuria. Serum calcium and phosphate levels were within the normal range and plasma-protein electrophoresis was normal. Injections of vasopressin tannate in oil made no difference to either the rate of flow of urine or its osmolality. We concluded, therefore, that the patient had nephrogenic diabetes insipidus, as a result of bladder-neck obstruction. The patient was passing about 4 litres of urine a day, and was unable to achieve a positive fluid balance by mouth. The blood-urea level had risen to 170 mg. per 100 ml. and sodium to 160 meq. per litre within 48 hours of admission, so an intravenous infusion of 5% dextrose was set up, with a total allowance of 100 meq. sodium. A positive fluid balance of approximately 5 litres was achieved within the next few days and the patient’s condition improved gradually. The urinary infection had been treated with trimethoprim-sulphamethoxazole (co-trimoxazole). Urine volume fell to between 1-5 and 2 litres a day and he was able to maintain an adequate oral intake of fluid. Blood-urea fell to 40 mg. per 100 ml. (urea clearance had improved from 18 to 39 ml. per minute), sodium to 135 meq. per litre, and creatinine to 1-0 mg. per 100 ml. Diastolic pressure dropped to a steady 75-80, compared with several 9. Braganza, J. M., Howat, H. T. Clinics in Gastroenterology, 1972,
1, 219.
Mossgiel Avenue, Ainsdale, Southport,
L. F. TINCKLER.
Lanes.
TREATING THE NERVOUS SYSTEM IN ACUTE LEUKÆMIA SIR,—Referring to your leader of Feb. 5 (p. 297), I should like to make the following points: "
1.
"
Prophylactic cranial irradiation, 2400 rads from a 6OCo given in an overall period of 2! weeks and not in a single
source, is
dose as stated. 2. The name of Auer’s rods was mis-spelt. 3. 2400 rads of " prophylactic " craniospinal irradiation in the treatment of previously untreated acute lymphocytic leukaemia of childhood has produced comparable or slightly superior results. 1,2z St.
Jude Children’s Research Hospital, P.O. Box 318
Memphis, Tennessee 38101,
R. J. A. AUR. * We apologise to Dr. Aur and his colleagues for the mistake in our description of their method of administration of cranial irradiation. The error in our leader was also pointed out by Dr. Collins (Feb. 19, p. 433).-ED. L. U.S.A.
*
DEFINITIVE PREOPERATIVE DIAGNOSIS OF OBSTRUCTIVE JAUNDICE
SIR,-It seems to us a pity that Mr. Bourke and his colleagues (March 18, p. 605) failed to estimate the concentration and output of bilirubin in their fractions aspirated from the duodenum after the injection of pancreozymin. When liver function is adequate, this additional measurement provides a useful means of assessing biliary function. This cholecystokinin test was reported to the British
Society of Gastroenterology in 1951,3 at the time when we introduced pancreozymin into clinical practice4 and appreciated that samples of pancreozymin prepared by the method of Harper and Raper possessed cholecystokinetic
activity. Subsequent reports 5-have emphasised the particular usefulness of the cholecystokinin test in two clinical situa1. Proc. Am. Ass. Cancer Res. 1971, 62, 5. 2. Aur, R. J. A., Simone, J. V., Hustu, H. 3. 4. 5. 6.
7. 8.
O., Verzosa, M. S. Cancer (in the press). Duncan, P. R., Harper, A. A., Howat, H. T., Oleesky, S., Varley, H. Gastroenterologia, 1952, 78, 349. Burton, P., Evans, D. G., Harper, A. A., Howat, H. T., Oleesky, S., Scott, J. E., Varley, H. Gut, 1960, 1, 111. Burton, P., Harper, A. A., Howat, H. T., Scott, J. E., Varley, H. ibid. p. 193. Howat, H. T. in The Biliary System (edited by W. Taylor): p. 249. Oxford, 1965. Howat, H. T. Manchester med. Gaz. 1967, 46, no. 3. Howat, H. T. in Biochemical Disorders in Human Disease (edited by R. H. S. Thompson and I. D. P. Wootton) pp. 703-722. London, 1970.
tions : to confirm impaired function of a gallbladder which has failed to outline during cholecystography; and to elucidate the cause of extrahepatic obstructive jaundice. It is precisely in the area where the studies of Mr. Bourke and his colleagues failed to reveal an abnormality that the cholecystokinin test can distinguish in most cases obstruction of the biliary ducts due to gallstones from obstruction due to malignancy and, in conjunction with the secretin-pancreozymin test, cancer originating in the pancreas from primary cancer of the bile-ducts and gallstones. The results of these tests in 108 patients presenting with obstructive jaundice9 were:
Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL
JOAN BRAGANZA HENRY T. HOWAT.
URINARY OBSTRUCTION AND DEHYDRATION SIR,-The symptoms of polyuria and polydypsia are always clinically significant, and their investigation may reveal more than was suspected. A patient who came under our care in the assessment unit of this department was a 75-year-old white male who presented with confusion and irritability. An accurate history was not forthcoming, but his wife said that he had lost weight and had recently complained of thirst and frequency of micturition. He had also lost his appetite. His own doctor had tested his urine and found 1 % sugar on one occasion. Two years before, he had been in hospital with a toxic confusional state, thought at that time to be due to a urinary infection. He was found to be dehydrated and confused. The bloodpressure was 190/100 mm. Hg (a reading of 230/130 had previously been recorded at home). There was a firm mass arising from his pelvis. A urinary catheter was passed, a large volume of urine was obtained, and the abdominal mass disappeared. The prostate was thought to be normal. Initial investigations revealed intermittent glycosuria but a normal series of bloodsugars. The blood-urea level was 120 mg. per 100 ml., sodium 151, potassium 4-0, bicarbonate 27 meq. per litre, and serumcreatinine 3-5 mg. per 100 ml. There was a heavy growth of a coliform organism in the urine. Serum osmolality was 326 mosmole per kg., and a random urine had an osmolality of 225 mosmole per kg. There was no Bence-Jones proteinuria. Serum calcium and phosphate levels were within the normal range and plasma-protein electrophoresis was normal. Injections of vasopressin tannate in oil made no difference to either the rate of flow of urine or its osmolality. We concluded, therefore, that the patient had nephrogenic diabetes insipidus, as a result of bladder-neck obstruction. The patient was passing about 4 litres of urine a day, and was unable to achieve a positive fluid balance by mouth. The blood-urea level had risen to 170 mg. per 100 ml. and sodium to 160 meq. per litre within 48 hours of admission, so an intravenous infusion of 5% dextrose was set up, with a total allowance of 100 meq. sodium. A positive fluid balance of approximately 5 litres was achieved within the next few days and the patient’s condition improved gradually. The urinary infection had been treated with trimethoprim-sulphamethoxazole (co-trimoxazole). Urine volume fell to between 1-5 and 2 litres a day and he was able to maintain an adequate oral intake of fluid. Blood-urea fell to 40 mg. per 100 ml. (urea clearance had improved from 18 to 39 ml. per minute), sodium to 135 meq. per litre, and creatinine to 1-0 mg. per 100 ml. Diastolic pressure dropped to a steady 75-80, compared with several 9. Braganza, J. M., Howat, H. T. Clinics in Gastroenterology, 1972,
1, 219.