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GLOBIN OR PROTAMINE INSULIN ?
418
Boarding-out
too has its dangers, as everyone knows; it leads to happy adoption. Yet some voluntary societies (as Lady Allen of Hurtwood has pointed out2) discourage adoption, and one at least insists on a boarded-out child returning to the home at 16 for trade or occupational training, even though the foster-parents have come to regard him as their own child and wish to have a hand in settling his future. This is carrying responsibility almost into the realm of officiousness. Certainly adoption needs to be arranged with the greatest care, and foster-parents for boarded-out children must be chosen scrupulously ; and certainly the sight of a houseful of sleek and happy children is more impressive to the casual visitor than a page of figures showing children successfully boarded-out. But the well-being of children is a subtle thing, not to be assessed easily from appearances. It would be unfortunate if this memorandum shook confidence in the Curtis Committee’s
but in
some cases
several hours. With globin insulin this risk is minimised since hypoglycaemia is most likely to occur during the afternoon. There will always be diabetics who cannot be satisfactorily controlled with single daily injections of either globin or protamine zinc insulin. For these Roberts and Yater suggest two injections daily of globin insulin-one (70%) in the morning and the other (30%) about 3 P.M. MANAGEMENT OF EMPYEMA
THE treatment of empyema has suffered from the failure to distinguish the various forms of pleural infection. This was clearly brought out in a discussion at the Royal Society of Medicine opened by Mr. R. C. Brock It should be and Mr. T. Holmes Sellors on Feb. 5. obvious that an acute and diffuse inflammation in the early stages requires different handling from a longstanding localised purulent collection, but since the introduction of chemotherapy there has been a tendency nndings. to concentrate on the sterilising effect and ignore the GLOBIN OR PROTAMINE INSULIN ? final healing processes. GLOBIN insulin was originally introduced as a delayedThe influenza pandemic of 1918 brought out very action insulin intermediate in time of action between clearly the dangers of ordinary drainage in the early soluble insulin and protamine zinc insulin. There was stages of empyema, and Graham’s work showed that the the further advantage that globin was cheaper and more patient already suffering from an acute pulmonary readily obtainable than protamine. In spite of these inflammation could ill support the addition of an open claims it has not yet been widely adopted in Great pneumothorax. The lessons then learnt resulted in delayed Britain, though our American colleagues have been more drainage being employed after preliminary and repeated enthusiastic. In a renewed attempt to clarify the issue, aspiration had reduced the volume of the original pleural two American workers 3 have compared the action of infection. An intercostal tube and closed drainage had these two insulins in 84 diabetics, several of whom were a considerable vogue along with various methods of tidal studied on more than one admission, thus giving a total irrigation and drainage, but the basic principles of treatof 97 hospital admissions. During the investigation the ment were not always fulfilled and results were often patients were kept in hospital and received a constant poor. Failure to remove the products of inflammation diet. Frequent blood-sugar estimations were made. completely or to establish adequate and continued When all the relevant data were assessed-blood-sugar drainage were-and still are-responsible for chronic curves, hypoglycsemia, and the patient’s general stateempyemata and consequent grave disability. The healing it was found that, on the same doses, 65 were controlled process or obliteration of the cavity has been greatly better with globin, 25 with protamine zinc, and 7 equally helped by physical treatment which by stimulating well with the two insulins. Composite curves drawn inspiratory efforts encourages lung expansion. Breathing from the average blood-sugar levels at different times of exercises can play a very valuable part in chest work, the day showed that the fasting blood-sugar was the but the most assiduous attention and concentration are same with the two insulins, but at every other time required if they are to achieve their aim-the restoration (i.e., 9 and 11 A.M., 1, 4, 7, and 11 P.M.) the blood-sugar of complete respiratory function. was higher in patients receiving protamine zinc insulin The sulphonamides and penicillin have had a dramatic than in those receiving globin insulin. With globin influence on the primary cause of empyema-—pneumonia. insulin the blood-sugar returned to normal limits before -but how far they have affected the incidence of lunch, supper, and midnight, which it never did with empyema is still doubtful. In most cases penicillin will protamine zinc insulin. Glycosuria was significantly control the virulence of the pleural infection, and it is less with globin than with protamine zinc insulin ; and, here that the drug is most valuable. The pleural fluid though the incidence of hypoglycsemic reactions was can often be sterilised by the injection of penicillin in, low with both insulins, only one mild reaction was suitable concentration after aspiration. Repeated aspirarecorded with globin, compared with three mild and two tion and injection, persisted with along the lines suggested moderate reactions with protamine zinc. by Fatti and his co-workers,l can produce good results, It is often said that globin insulin is unsatisfactory but in the later and more localised forms of empyema because, if given in the morning, it does not control the the value of penicillin therapy is more doubtful, unless it blood-sugar during the following night. Roberts and is supplemented by orthodox drainage methods. Neither Yater do not bear this out, for the fasting blood-sugar penicillin nor any other known drug will close an empyema was the same in patients receiving the same number of cavity, though it may sterilise the contents. Established units of globin and of protamine zinc insulin. In this abscesses contain masses of debris and fibrin which cannot country a combination of soluble insulin and protamine be removed through an aspirating needle or even an zinc insulin is often prescribed, on the principle that the intercostal tube. Here it is more satisfactory in the long rapidly acting soluble insulin will control the blood- run to follow the standard principles of surgical drainage. In draining a localised pleural abscess the actual ribsugar until the protamine zinc insulin comes into action. This combination often works in practice, but many resection should afford room not only for a wide-bore patients find it more difficult to give themselves a single tube but for removing all fibrin masses and inspecting the injection consisting of different volumes of two insulins interior-in short, for an efficient pleural toilet. The than two separate injections of soluble insulin, morning drainage-tube must be carefully sited to permit of gravity and evening. Another disadvantage of prQtamine zinc drainage and kept in position until the empyema cavity has been completely obliterated. During closure pleuroinsulin is that when given in the morning it may induce hypoglycaemia during the following night, when it may grams enable the surgeon to visualise the shape and size not be discovered until the patient has been in coma for of the cavity and make adjustments as required. 2. Times, Oct. 21, 1946. Roberts, J. T., Yater, W. M.
3.
1.
Ann. intern. Med. 1947, 26, 41.
Fatti, L., Florey, M. E., Joules, H., Humphrey, J. H., Sakula, J. Lancet, 1946, i, 257, 295.
Boarding-out
too has its dangers, as everyone knows; it leads to happy adoption. Yet some voluntary societies (as Lady Allen of Hurtwood has pointed out2) discourage adoption, and one at least insists on a boarded-out child returning to the home at 16 for trade or occupational training, even though the foster-parents have come to regard him as their own child and wish to have a hand in settling his future. This is carrying responsibility almost into the realm of officiousness. Certainly adoption needs to be arranged with the greatest care, and foster-parents for boarded-out children must be chosen scrupulously ; and certainly the sight of a houseful of sleek and happy children is more impressive to the casual visitor than a page of figures showing children successfully boarded-out. But the well-being of children is a subtle thing, not to be assessed easily from appearances. It would be unfortunate if this memorandum shook confidence in the Curtis Committee’s
but in
some cases
several hours. With globin insulin this risk is minimised since hypoglycaemia is most likely to occur during the afternoon. There will always be diabetics who cannot be satisfactorily controlled with single daily injections of either globin or protamine zinc insulin. For these Roberts and Yater suggest two injections daily of globin insulin-one (70%) in the morning and the other (30%) about 3 P.M. MANAGEMENT OF EMPYEMA
THE treatment of empyema has suffered from the failure to distinguish the various forms of pleural infection. This was clearly brought out in a discussion at the Royal Society of Medicine opened by Mr. R. C. Brock It should be and Mr. T. Holmes Sellors on Feb. 5. obvious that an acute and diffuse inflammation in the early stages requires different handling from a longstanding localised purulent collection, but since the introduction of chemotherapy there has been a tendency nndings. to concentrate on the sterilising effect and ignore the GLOBIN OR PROTAMINE INSULIN ? final healing processes. GLOBIN insulin was originally introduced as a delayedThe influenza pandemic of 1918 brought out very action insulin intermediate in time of action between clearly the dangers of ordinary drainage in the early soluble insulin and protamine zinc insulin. There was stages of empyema, and Graham’s work showed that the the further advantage that globin was cheaper and more patient already suffering from an acute pulmonary readily obtainable than protamine. In spite of these inflammation could ill support the addition of an open claims it has not yet been widely adopted in Great pneumothorax. The lessons then learnt resulted in delayed Britain, though our American colleagues have been more drainage being employed after preliminary and repeated enthusiastic. In a renewed attempt to clarify the issue, aspiration had reduced the volume of the original pleural two American workers 3 have compared the action of infection. An intercostal tube and closed drainage had these two insulins in 84 diabetics, several of whom were a considerable vogue along with various methods of tidal studied on more than one admission, thus giving a total irrigation and drainage, but the basic principles of treatof 97 hospital admissions. During the investigation the ment were not always fulfilled and results were often patients were kept in hospital and received a constant poor. Failure to remove the products of inflammation diet. Frequent blood-sugar estimations were made. completely or to establish adequate and continued When all the relevant data were assessed-blood-sugar drainage were-and still are-responsible for chronic curves, hypoglycsemia, and the patient’s general stateempyemata and consequent grave disability. The healing it was found that, on the same doses, 65 were controlled process or obliteration of the cavity has been greatly better with globin, 25 with protamine zinc, and 7 equally helped by physical treatment which by stimulating well with the two insulins. Composite curves drawn inspiratory efforts encourages lung expansion. Breathing from the average blood-sugar levels at different times of exercises can play a very valuable part in chest work, the day showed that the fasting blood-sugar was the but the most assiduous attention and concentration are same with the two insulins, but at every other time required if they are to achieve their aim-the restoration (i.e., 9 and 11 A.M., 1, 4, 7, and 11 P.M.) the blood-sugar of complete respiratory function. was higher in patients receiving protamine zinc insulin The sulphonamides and penicillin have had a dramatic than in those receiving globin insulin. With globin influence on the primary cause of empyema-—pneumonia. insulin the blood-sugar returned to normal limits before -but how far they have affected the incidence of lunch, supper, and midnight, which it never did with empyema is still doubtful. In most cases penicillin will protamine zinc insulin. Glycosuria was significantly control the virulence of the pleural infection, and it is less with globin than with protamine zinc insulin ; and, here that the drug is most valuable. The pleural fluid though the incidence of hypoglycsemic reactions was can often be sterilised by the injection of penicillin in, low with both insulins, only one mild reaction was suitable concentration after aspiration. Repeated aspirarecorded with globin, compared with three mild and two tion and injection, persisted with along the lines suggested moderate reactions with protamine zinc. by Fatti and his co-workers,l can produce good results, It is often said that globin insulin is unsatisfactory but in the later and more localised forms of empyema because, if given in the morning, it does not control the the value of penicillin therapy is more doubtful, unless it blood-sugar during the following night. Roberts and is supplemented by orthodox drainage methods. Neither Yater do not bear this out, for the fasting blood-sugar penicillin nor any other known drug will close an empyema was the same in patients receiving the same number of cavity, though it may sterilise the contents. Established units of globin and of protamine zinc insulin. In this abscesses contain masses of debris and fibrin which cannot country a combination of soluble insulin and protamine be removed through an aspirating needle or even an zinc insulin is often prescribed, on the principle that the intercostal tube. Here it is more satisfactory in the long rapidly acting soluble insulin will control the blood- run to follow the standard principles of surgical drainage. In draining a localised pleural abscess the actual ribsugar until the protamine zinc insulin comes into action. This combination often works in practice, but many resection should afford room not only for a wide-bore patients find it more difficult to give themselves a single tube but for removing all fibrin masses and inspecting the injection consisting of different volumes of two insulins interior-in short, for an efficient pleural toilet. The than two separate injections of soluble insulin, morning drainage-tube must be carefully sited to permit of gravity and evening. Another disadvantage of prQtamine zinc drainage and kept in position until the empyema cavity has been completely obliterated. During closure pleuroinsulin is that when given in the morning it may induce hypoglycaemia during the following night, when it may grams enable the surgeon to visualise the shape and size not be discovered until the patient has been in coma for of the cavity and make adjustments as required. 2. Times, Oct. 21, 1946. Roberts, J. T., Yater, W. M.
3.
1.
Ann. intern. Med. 1947, 26, 41.
Fatti, L., Florey, M. E., Joules, H., Humphrey, J. H., Sakula, J. Lancet, 1946, i, 257, 295.