- Email: [email protected]
PROTAMINE INSULIN (WITH ZINC)— SUSPENSION
596
PROTAMINE INSULIN
(WITH ZINC)-SUSPENSION
he treated by manipulation at St. Thomas’s Hospital on July’22nd, 1936. Case 1 was said to be a case of recurrent dislocation of the shoulder of 15 years’ duration. The shoulder had " dislocated " hundreds of
times, sometimes daily.
It had
never
had to be
reduced by a doctor. I described the pathology of recurrent dislocation of the shoulder, I believe for the first time, in 1923 (Brit. med. J. 2, 1132). ’The condition is due to a wide traumatic separation of the fibrocartilaginour, glenoid ligament from the anterior margin of the glenoid cavity. The defect is permanent, because there is no tendency for the torn ligament to reattach itself to the bone. The head of the humerus is therefore free to leave the joint anteriorly on the slightest provocation. The anatomical condition is quite constant and can be seen and verified by any surgeon who cares to expose the anterior margin of the glenoid cavity in a genuine case of recurrent dislocation of the shoulder. It is then obvious that the only rational treatment is to reattach the glenoid ligament (or the capsule) to the bone from which it has been torn. This operation never fails. With regard to Case 1 (above), I have yet to meet the man who could reduce a dislocation of his own shoulder-joint, and it would be interesting to know precisely what happened on the hundreds of occasions when this shoulder was alleged to have been dislocated. When Barker examined the man he said, " It is obvious that there is no large defect in the capsule in this case "-a statement which I would suggest is a contradiction of his diagnosis, since dislocation of the head of the humerus cannot occur without such a defect. In conversation I once asked Barker how he accounted for his success in view of what we know about the pathology of recurrent dislocation. He replied frankly that he did not know, but he could only suppose that his manipulation caused such a stirring up of the tissues that the dislocation was prevented. If this is the true explanation, it must surely be unique in Barker’s experience (as in ours), for in no other region of the body is manilimitation of moveto indeed it is difficult see how it could ment ; do so. Moreover, nothing that Barker did to this man (Case 1) in our presence could possibly have produced such a violent reaction as is suggested by this explanation. Recurrent dislocation of the shoulder-joint is not I think it is quite clear that the very common. condition which Barker calls " recurrent dislocation of the shoulder " is not the same as that which we call by that name. It is more than doubtful whether the man here referred to (Case 1) ever dislocated his shoulder. That he felt something " slip " in his shoulder joint I do not doubt, and that this " slipping" was due to adhesions or contracture in or about the posterior part of the capsule of the joint is more than likely. We are familiar with such cases, and incidentally we have treated them by manipulation, but we do not call them cases of recurrent dislocation of the shoulder. At the same time we must admit that recurrent dislocation of the shoulder has been apparently cured by the most irrational surgical procedures, and, if it can be cured by manipulation, we are only too willing to learn. But it is fair to demand that the diagnosis should be unequivocal, and it is not unreasonable to ask for an intelli-
pulation designed
to
produce
gible explanation. I am, Sir, yours faithfully, A. S. BLUNDELL BANKART.
PROTAMINE INSULIN (WITH ZINC)— SUSPENSION To the Editor of THE LANCET
SIR,-The retarding
action of protamine, with the insulin has been the subject of Protamine Insulin some time past. (with Zinc)-Suspension is now made available by the four firms associated with the manufacture of insulin in this country, Messrs. Allen & IIanburys Ltd., Boots Pure Drug Co. Ltd., The British Drug Houses Ltd. and Burroughs Wellcome & Co. The preparation is a suspension of insulin, with added protamine and zinc, of such a character that it is readily and evenly diffused on shaking prior to administration. As it is more slowly absorbed than unmodified insulin it should be of particular use in cases where unmodified insulin does not provide adequate control or where several administrations daily are necessary. While extensive clinical trial has determined the issue of a satisfactory preparation, there is still much to be learned about its general use ; therefore care will be necessary if reactions are to be avoided due to unfamiliarity with its use or deviations from a properly balanced dietary. Protamine Insulin (with Zinc)-Suspension is issued, at present, in one potency (40 units per c.cm.). Two sizes are available : 5 c.cm. containing 200 units and 10 c.cm. containing 400 units. The packings will be distinct in colour from existing packings of unmodified insulin.
addition of zinc, investigation for
on
We are, Sir, yours faithfully, ALLEN & HANBURYS LTD., BOOTS PURE DRUG Co. LTD., THE BRITISH DRUG HOUSES LTD., BURROUGHS WELLCOME & Co. TREATMENT OF FRACTURE OF THE NECK OF THE FEMUR
To the Editor
of
THE LANCET
SiR,-Mr. Bailey seems to have missed the point of my previous letter. I contend that radiological control is the essential part of the technique of extraarticular nailing. Instruments to place the guide may be classified as luxuries. The many advantages of this new surgical technique that can successfully replace a large exposure of the hip are obvious. I criticised Mr. Bailey’s technique because he contended that his instrument, replaced close radiological control. I remind Mr. Bailey that I agreed that skeletal traction sometimes reduces, with accuracy, a medial fracture of the femoral neck, but the large majority of these fractures are not so reduced. I contended that X rays were wanted first to control the manipulations necessary to obtain accurate reduction in this, larger group, and next to confirm the accuracy of the reduction. Now, an instrument can place a. guide wire with accuracy. In common with Mr. Bailey I use one that enables me to do this. Its advantages are a speeding-up of the operation and a decrease in the number of necessary radiograms, but I think that is all we can expect of it. Recently Bohler and Felsenreich (who together have nailed nearly 200 necks) have shown me the complications that can occur during this operation, and I remain quite convinced that the steps of it need the closest " watching." With regard to the complication I instanced in my previous letter: I have watched the oncoming nail displace an accurately reduced head from its position on the neck on three-
PROTAMINE INSULIN
(WITH ZINC)-SUSPENSION
he treated by manipulation at St. Thomas’s Hospital on July’22nd, 1936. Case 1 was said to be a case of recurrent dislocation of the shoulder of 15 years’ duration. The shoulder had " dislocated " hundreds of
times, sometimes daily.
It had
never
had to be
reduced by a doctor. I described the pathology of recurrent dislocation of the shoulder, I believe for the first time, in 1923 (Brit. med. J. 2, 1132). ’The condition is due to a wide traumatic separation of the fibrocartilaginour, glenoid ligament from the anterior margin of the glenoid cavity. The defect is permanent, because there is no tendency for the torn ligament to reattach itself to the bone. The head of the humerus is therefore free to leave the joint anteriorly on the slightest provocation. The anatomical condition is quite constant and can be seen and verified by any surgeon who cares to expose the anterior margin of the glenoid cavity in a genuine case of recurrent dislocation of the shoulder. It is then obvious that the only rational treatment is to reattach the glenoid ligament (or the capsule) to the bone from which it has been torn. This operation never fails. With regard to Case 1 (above), I have yet to meet the man who could reduce a dislocation of his own shoulder-joint, and it would be interesting to know precisely what happened on the hundreds of occasions when this shoulder was alleged to have been dislocated. When Barker examined the man he said, " It is obvious that there is no large defect in the capsule in this case "-a statement which I would suggest is a contradiction of his diagnosis, since dislocation of the head of the humerus cannot occur without such a defect. In conversation I once asked Barker how he accounted for his success in view of what we know about the pathology of recurrent dislocation. He replied frankly that he did not know, but he could only suppose that his manipulation caused such a stirring up of the tissues that the dislocation was prevented. If this is the true explanation, it must surely be unique in Barker’s experience (as in ours), for in no other region of the body is manilimitation of moveto indeed it is difficult see how it could ment ; do so. Moreover, nothing that Barker did to this man (Case 1) in our presence could possibly have produced such a violent reaction as is suggested by this explanation. Recurrent dislocation of the shoulder-joint is not I think it is quite clear that the very common. condition which Barker calls " recurrent dislocation of the shoulder " is not the same as that which we call by that name. It is more than doubtful whether the man here referred to (Case 1) ever dislocated his shoulder. That he felt something " slip " in his shoulder joint I do not doubt, and that this " slipping" was due to adhesions or contracture in or about the posterior part of the capsule of the joint is more than likely. We are familiar with such cases, and incidentally we have treated them by manipulation, but we do not call them cases of recurrent dislocation of the shoulder. At the same time we must admit that recurrent dislocation of the shoulder has been apparently cured by the most irrational surgical procedures, and, if it can be cured by manipulation, we are only too willing to learn. But it is fair to demand that the diagnosis should be unequivocal, and it is not unreasonable to ask for an intelli-
pulation designed
to
produce
gible explanation. I am, Sir, yours faithfully, A. S. BLUNDELL BANKART.
PROTAMINE INSULIN (WITH ZINC)— SUSPENSION To the Editor of THE LANCET
SIR,-The retarding
action of protamine, with the insulin has been the subject of Protamine Insulin some time past. (with Zinc)-Suspension is now made available by the four firms associated with the manufacture of insulin in this country, Messrs. Allen & IIanburys Ltd., Boots Pure Drug Co. Ltd., The British Drug Houses Ltd. and Burroughs Wellcome & Co. The preparation is a suspension of insulin, with added protamine and zinc, of such a character that it is readily and evenly diffused on shaking prior to administration. As it is more slowly absorbed than unmodified insulin it should be of particular use in cases where unmodified insulin does not provide adequate control or where several administrations daily are necessary. While extensive clinical trial has determined the issue of a satisfactory preparation, there is still much to be learned about its general use ; therefore care will be necessary if reactions are to be avoided due to unfamiliarity with its use or deviations from a properly balanced dietary. Protamine Insulin (with Zinc)-Suspension is issued, at present, in one potency (40 units per c.cm.). Two sizes are available : 5 c.cm. containing 200 units and 10 c.cm. containing 400 units. The packings will be distinct in colour from existing packings of unmodified insulin.
addition of zinc, investigation for
on
We are, Sir, yours faithfully, ALLEN & HANBURYS LTD., BOOTS PURE DRUG Co. LTD., THE BRITISH DRUG HOUSES LTD., BURROUGHS WELLCOME & Co. TREATMENT OF FRACTURE OF THE NECK OF THE FEMUR
To the Editor
of
THE LANCET
SiR,-Mr. Bailey seems to have missed the point of my previous letter. I contend that radiological control is the essential part of the technique of extraarticular nailing. Instruments to place the guide may be classified as luxuries. The many advantages of this new surgical technique that can successfully replace a large exposure of the hip are obvious. I criticised Mr. Bailey’s technique because he contended that his instrument, replaced close radiological control. I remind Mr. Bailey that I agreed that skeletal traction sometimes reduces, with accuracy, a medial fracture of the femoral neck, but the large majority of these fractures are not so reduced. I contended that X rays were wanted first to control the manipulations necessary to obtain accurate reduction in this, larger group, and next to confirm the accuracy of the reduction. Now, an instrument can place a. guide wire with accuracy. In common with Mr. Bailey I use one that enables me to do this. Its advantages are a speeding-up of the operation and a decrease in the number of necessary radiograms, but I think that is all we can expect of it. Recently Bohler and Felsenreich (who together have nailed nearly 200 necks) have shown me the complications that can occur during this operation, and I remain quite convinced that the steps of it need the closest " watching." With regard to the complication I instanced in my previous letter: I have watched the oncoming nail displace an accurately reduced head from its position on the neck on three-