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EXTREME HYPERGLYCÆMIA WITHOUT KETOSIS
664 The possibility that the A.N.F. found in some patients with conditions other than S.L.E. is a heat-labile macroglobulin, and that the factors occurring in S.L.E. include a heat-stable 7S globulin is now being investigated. Goodman et al. have shown that, in S.L.E., antinuclear factors appear in both 7S and 19S y-globulin fractions.
metabolic disturbance, which can be judged by the bloodsugar level. In this case its-absence cannot easily be
On the basis of the results described it appears that the demonstration in a patient’s serum of antinuclear factor which is inactivated by heating at 65°C is against a diagnosis of S.L.E. We are grateful to Prof. E. G. L. Bywaters and Dr. W. Hijmans for providing sera from their patients and clinical assessments. M.R.C. Rheumatism Research Unit, G. D. JOHNSON " Canadian Red Cross Memorial Hospital, E. Berkshire. J. HOLBOROW. Taplow, Maidenhead,
SIR,-Mr. Ross (Aug. 5) reported the successful use of saline ice crystals applied to the heart to produce arrest during open heart surgery. It must be pointed out that
.,
,-
THE FIBERSCOPE
SiR,—Ihave read with interest the article Hirschowitz."
by Dr.
"
It may be stated unequivocally that the fiberscope has reached the stage where it should replace the conventional gastroscope. We would no longer consider using the " The conventional gastroscope has old instrument " become obsolete on all counts." I have personally used the Hirschowitz fiberscope and find it lacking in three important respects: (1) inability to obtain and maintain an accurate focus; (2) impossibility of proper orientation; (3) unavailability of biopsy. To my mind these three deficiencies make the Hirschowitz fiberscope definitely less useful than many of the conventional gastroscopes.
already
explained. London, S.E.18.
0. P. IYENGAR. M. O.
ICE ARREST OF THE HEART
when saline freezes the concentration of salt in the crystals is significantly less than in the unfrozen supernate; similarly, after decanting the supernate and applying the crystals to the heart, that part which melts first has a lower concentration of salt than have the still frozen crystals. These two sequences ’do not negate each other, however. Since we are striving for an ever less toxic method to cause arrest, it would be helpful to achieve a final saline concentration closer to the physiological one.
Medical School,
University of Pennsylvania.
RICHARD ARKLESS.
...
In principle I believe the fiberscope has great possibilities, but at the present time I believe that it is much less
useful than Dr.
Hirschowitz
claims.
Further
experience with it may modify my opinion. Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.
EDWARD B. B BENEDICT. B NEDICT
EXTREME HYPERGLYCÆMIA WITHOUT KETOSIS
SIR,-Very high blood-sugar levels may be found in Meyer and Salt’spatient had the highest ever recorded, even after receiving 600 units of diabetes mellitus.
soluble insulin-2100 mg. per 100 ml. Lawrence8 described an elderly diabetic in coma whose blood-sugar level reached 2060 mg. per 100 ml. ; 40 units of insulin had been given before this estimation. A Jamaican, aged 34, was admitted to hospital with a twoweek history of weakness, anorexia, thirst, and loss of weight. He was drowsy, severely dehydrated, and wasted; his breathing His temperature was 95° F, pulse-rate 100 per was acidotic. There were no min., and respiration-rate 24 per min. abnormal signs on systemic examination. The urine gave a strongly positive reaction for glucose; and the blood-sugar level was 1996 mg. per 100 ml. But ketones were absent from Treatment was started urine and serum (qualitative test). with soluble insulin (230 units in four hours), intravenous isotonic saline, M/6 sodium lactate solution, and crystalline penicillin; but the patient died in four hours. Necropsy findings were bronchopneumonia due to acute tracheobronchitis, and diabetes mellitus. The pleural fluid (volume 50 ml.) contained 663 mg. glucose per 100 ml.; but ketones were absent. per se does not lead to death except result of changes brought about in renal function. Why diabetic ketosis is so unpredictable has not been resolved. The onset will depend upon the degree of
Hyperglycxmia
as a
5. 6. 7. 8.
Goodman, H. C., Fahey, J. L., Malmgren, R. A., Brecher, G. Lancet, 1959, ii, 382. Hirschowitz, B. I. Lancet, 1961, i, 1074. Meyer, P. C., Salt, H. B. Brit. med. J. 1951, i, 171. Lawrence, R. D. ibid. 1934, i, 377.
INTRAVENOUS ALBUMIN IN THE TREATMENT OF DIURETIC-RESISTANT ASCITES IN PORTAL CIRRHOSIS of SIR,-Infusion protein solutions to patients with cirrhosis of the liver and ascites provides the opportunity for studying the relationships between changing hydrostatic pressure, protein concentration, and colloid osmotic pressure of plasma and ascitic fluid. It might be anticipated that such observations would help to elucidate the factors governing ascites formation and reabsorption. The literature on this subject is’ considerable, but the contribution of Dr. Losowsky and Dr. Atkinson reported recently in your columns (Aug. 19) is extremely valuable, being the first attempt to compare the concurrent changes in hydrostatic and colloid osmotic pressures. The proportion of their patients who responded to therapy is similar to that of other series, and so their group is probably a fair sample of this type of patient. It is very satisfactory that inspection of data on portal pressure has enabled them to show that patients who respond to albumin infusions have, before therapy, a lower mean pressure than those who do not respond. A higher intracapillary hydrostatic pressure is presumably related to a greater leakage of protein and fluid, and therefore a greater load on the lymphatic system. Why some patients should respond to albumin infusions and some should not has puzzled most investigators, and study of Losowsky and Atkinson’s data and explanation unfortunately fails to clear the confusion. They have shown in fig. 4 that whereas in those patients where treatment was unsuccessful there were parallel rises in intrasplenic pressure and plasma colloid osmotic pressure, in those in whom treatment was successful intrasplenic pressure did not rise and in some cases fell considerably, final values being found to lie on the right of a line they have produced from previous observations. They conclude from this that "... this rise in splanchnic capillary pressure may more than counterbalance any rise in plasma colloid osmotic pressure resulting from the infusions, ...". It is, however, surprising that any form of therapy designed to expand blood-volume without greatly increasing cardiac output can result in a fall in any venous pressure, and indeed Starling demonstrated that rapid saline infusions in dogs will raise both systemic and portal venous pressures concormtant with an expansion in blood-volume. The haematocrit measurements of Losowsky and Atkinson suggest an average expansion of total blood-volume of 12-4% and 17 9°o in the 1. 2.
Atkinson, M., Losowsky, M. S. Quart. J. Med. 1961, 30, Starling, E. H. J. Physiol. 1895-6, 19, 312.
153.
metabolic disturbance, which can be judged by the bloodsugar level. In this case its-absence cannot easily be
On the basis of the results described it appears that the demonstration in a patient’s serum of antinuclear factor which is inactivated by heating at 65°C is against a diagnosis of S.L.E. We are grateful to Prof. E. G. L. Bywaters and Dr. W. Hijmans for providing sera from their patients and clinical assessments. M.R.C. Rheumatism Research Unit, G. D. JOHNSON " Canadian Red Cross Memorial Hospital, E. Berkshire. J. HOLBOROW. Taplow, Maidenhead,
SIR,-Mr. Ross (Aug. 5) reported the successful use of saline ice crystals applied to the heart to produce arrest during open heart surgery. It must be pointed out that
.,
,-
THE FIBERSCOPE
SiR,—Ihave read with interest the article Hirschowitz."
by Dr.
"
It may be stated unequivocally that the fiberscope has reached the stage where it should replace the conventional gastroscope. We would no longer consider using the " The conventional gastroscope has old instrument " become obsolete on all counts." I have personally used the Hirschowitz fiberscope and find it lacking in three important respects: (1) inability to obtain and maintain an accurate focus; (2) impossibility of proper orientation; (3) unavailability of biopsy. To my mind these three deficiencies make the Hirschowitz fiberscope definitely less useful than many of the conventional gastroscopes.
already
explained. London, S.E.18.
0. P. IYENGAR. M. O.
ICE ARREST OF THE HEART
when saline freezes the concentration of salt in the crystals is significantly less than in the unfrozen supernate; similarly, after decanting the supernate and applying the crystals to the heart, that part which melts first has a lower concentration of salt than have the still frozen crystals. These two sequences ’do not negate each other, however. Since we are striving for an ever less toxic method to cause arrest, it would be helpful to achieve a final saline concentration closer to the physiological one.
Medical School,
University of Pennsylvania.
RICHARD ARKLESS.
...
In principle I believe the fiberscope has great possibilities, but at the present time I believe that it is much less
useful than Dr.
Hirschowitz
claims.
Further
experience with it may modify my opinion. Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.
EDWARD B. B BENEDICT. B NEDICT
EXTREME HYPERGLYCÆMIA WITHOUT KETOSIS
SIR,-Very high blood-sugar levels may be found in Meyer and Salt’spatient had the highest ever recorded, even after receiving 600 units of diabetes mellitus.
soluble insulin-2100 mg. per 100 ml. Lawrence8 described an elderly diabetic in coma whose blood-sugar level reached 2060 mg. per 100 ml. ; 40 units of insulin had been given before this estimation. A Jamaican, aged 34, was admitted to hospital with a twoweek history of weakness, anorexia, thirst, and loss of weight. He was drowsy, severely dehydrated, and wasted; his breathing His temperature was 95° F, pulse-rate 100 per was acidotic. There were no min., and respiration-rate 24 per min. abnormal signs on systemic examination. The urine gave a strongly positive reaction for glucose; and the blood-sugar level was 1996 mg. per 100 ml. But ketones were absent from Treatment was started urine and serum (qualitative test). with soluble insulin (230 units in four hours), intravenous isotonic saline, M/6 sodium lactate solution, and crystalline penicillin; but the patient died in four hours. Necropsy findings were bronchopneumonia due to acute tracheobronchitis, and diabetes mellitus. The pleural fluid (volume 50 ml.) contained 663 mg. glucose per 100 ml.; but ketones were absent. per se does not lead to death except result of changes brought about in renal function. Why diabetic ketosis is so unpredictable has not been resolved. The onset will depend upon the degree of
Hyperglycxmia
as a
5. 6. 7. 8.
Goodman, H. C., Fahey, J. L., Malmgren, R. A., Brecher, G. Lancet, 1959, ii, 382. Hirschowitz, B. I. Lancet, 1961, i, 1074. Meyer, P. C., Salt, H. B. Brit. med. J. 1951, i, 171. Lawrence, R. D. ibid. 1934, i, 377.
INTRAVENOUS ALBUMIN IN THE TREATMENT OF DIURETIC-RESISTANT ASCITES IN PORTAL CIRRHOSIS of SIR,-Infusion protein solutions to patients with cirrhosis of the liver and ascites provides the opportunity for studying the relationships between changing hydrostatic pressure, protein concentration, and colloid osmotic pressure of plasma and ascitic fluid. It might be anticipated that such observations would help to elucidate the factors governing ascites formation and reabsorption. The literature on this subject is’ considerable, but the contribution of Dr. Losowsky and Dr. Atkinson reported recently in your columns (Aug. 19) is extremely valuable, being the first attempt to compare the concurrent changes in hydrostatic and colloid osmotic pressures. The proportion of their patients who responded to therapy is similar to that of other series, and so their group is probably a fair sample of this type of patient. It is very satisfactory that inspection of data on portal pressure has enabled them to show that patients who respond to albumin infusions have, before therapy, a lower mean pressure than those who do not respond. A higher intracapillary hydrostatic pressure is presumably related to a greater leakage of protein and fluid, and therefore a greater load on the lymphatic system. Why some patients should respond to albumin infusions and some should not has puzzled most investigators, and study of Losowsky and Atkinson’s data and explanation unfortunately fails to clear the confusion. They have shown in fig. 4 that whereas in those patients where treatment was unsuccessful there were parallel rises in intrasplenic pressure and plasma colloid osmotic pressure, in those in whom treatment was successful intrasplenic pressure did not rise and in some cases fell considerably, final values being found to lie on the right of a line they have produced from previous observations. They conclude from this that "... this rise in splanchnic capillary pressure may more than counterbalance any rise in plasma colloid osmotic pressure resulting from the infusions, ...". It is, however, surprising that any form of therapy designed to expand blood-volume without greatly increasing cardiac output can result in a fall in any venous pressure, and indeed Starling demonstrated that rapid saline infusions in dogs will raise both systemic and portal venous pressures concormtant with an expansion in blood-volume. The haematocrit measurements of Losowsky and Atkinson suggest an average expansion of total blood-volume of 12-4% and 17 9°o in the 1. 2.
Atkinson, M., Losowsky, M. S. Quart. J. Med. 1961, 30, Starling, E. H. J. Physiol. 1895-6, 19, 312.
153.