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SECURING THE T-TUBE
1056 a patient with an air embolism 100% oxygen to inhale will in fact be to increase the size of the air bubbles as the more soluble oxygen passes into them more quickly than the less soluble nitrogen can escape ? Death or other serious consequence from air embolism nearly always develops in the course of a few minutes. For this reason it seems that the suggestion of Dr. Kylstra (March 30) that the ambient pressure should be raised is more likely to be helpful in treating such patients, always providing that a compression chamber is immediatelv available.
giving
Royal Infirmary,
A. R. HUNTER.
Manchester.
SECURING THE T-TUBE SiR,ŃThe inadvertent dislodgment of a common-duct T-drain by the patient during sleep or by the nurse when she is changing a dressing is a surgical misfortune. Fixation of the T-tube to the skin by sutures may prevent this mishap, but may bend the tube in such a way that the flow of bile through the tube stops. If bile finds its way to the peritoneal cavity serious complications may
,
(3) Idiopathic osteonecrosis-which may also occur in nonsubjects. distinguishes these conditions from the subcapital fracture which complicates steroid osteoporosis, and mentions the possible setiological role of both rheumatoid and steroid vasculitis in idiopathic osteonecrosis. At this hospital we often use intra-articular hydrocortisone injection as an ancillary measure in fully integrated medical, physical medical, and orthopaedic management. This diminishes the use of long-term oral corticosteroid administration, with its attendant risks of the bone and join complications of osteoporosis and vasculitis. We warn patients that intra-articular steroids will not necessarily prevent joint destruction or instability, but we have been unable to show any increase in these complications.3 Injections are repeated only as long as patients derive relief and functional benefit. In this way some patients select themselves for short-term and long-term intra-articular steroid treatment. Those who develop a subacute boggy synovitis-not susceptible to control by this means-are treated surgically. arthritic Coste
"
"
In short, one should have some knowledge both of the natural history of joint destruction and of the potentialities and limitations of intra-articular steroid therapy before embarking upon it. Then, as Hollander4 has amply demonstrated, it will prove to be a safe and useful weapon in the fight against arthritis. Queen Elizabeth Hospital, Rotorua, New Zealand.
B. S. ROSE.
OSMOLAR AND ELECTROLYTE CHANGES IN HÆMORRHAGIC SHOCK
SIR,-Dr. Maffiy (April 27) is justified in pointing out that there is considerable evidence that mammalian cells are in osmotic equilibrium with the extracellular fluid. However, it would be misleading to suggest that the argument has been settled; and, to me at least, much of the opposing evidence, particularly that derived from recent cryoscopic measurements in intact mammalian tissue, remains unanswered. arise. Nurses may be energetic in their efforts to keep the T-drains functioning and still find their endeavours wasted by a moment’s negligence. If promptly recognised, the situation may be saved by inserting a drain or by operation. Occasionally it is a real disaster to see a T-tube coming out when a new operation may mean difficult dissection and much bleeding. It may seem trivial to some surgeons to recommend a special technique for fixing the T-tube to the skin, but we recommend the method illustrated in the accompanying figure. It has been suggested by Sister Emerita of this
hospital. Hospital, Copenhagen. N.
St. Joseph’s
Westminster Medical School, London, S.W.1.
D. E. PEGG.
F. SKOVBORG.
INTRA-ARTICULAR STEROIDS AND DESTRUCTIVE ARTHROPATHY 1
SIR,—Your annotation acknowledges that jointdestruction can occur without intra-articular injection of steroid, but fails to take into account the natural history of joint destruction. Coste2 drew attention to three varieties of hip-joint destruction, which may happen in the absence of steroid therapy: (1) Massive osteolysis. (2) A particular type of destruction of the superior external quadrant of the femoral head. 1. 2.
It is also true that even if the majority of the body-cells are in osmotic equilibrium with the extracellular fluid some specialised cells may not be, and it may be relevant that some of the strongest evidence for intracellular hyperosmolarity has been obtained with renal tissue which is among those most sensitive to anoxia. I would also like to emphasise that J. R. Robinson’s experiments, to which I referred previously (March 23), are relevant to the interpretation of the results obtained by Brooks et al. (March 9) irrespective of the outcome of the osmotic equilibrium argument; Robinson has shown in his more recent review5 that it is correct to say that an " isotonic" medium is hypotonic for anoxic cells, even if the explanation lies in alterations in the permeability of the cellmembrane rather than intracellular hyperosmolarity.
Lancet, 1962, ii, 1156. Coste, F. Proceedings of 10th Congress of International League Against Rheumatism; vol III, p. 71. Turin, 1961.
SiR,-May I reply briefly to the letter last week from Dr. Brooks and Mr. Williams and then retire from this controversy ? I am aware that sodium enters damaged cells in exchange for potassium, as described in your editorial of March 9. Indeed, this is presumably the reason for the fall of sodium and the rise of potassium in the plasma of the control dogs, which mostly died. My calculations, however, were for the dogs given hypertonic sodium solutions, which mostly survived and whose plasma-potassium levels fell (no doubt owing to the expansion of the extracellular fluid volume); presumably their cells were less damaged, and subject to an insignificant cation exchange. I Isdale, I. C. Ann. rheum. Dis. 1962, 21, 23. Hollander, J. L., Brown, E. M., Jessar, R. A., Udell, L., Bowitt, M. A., Shanahan, J. R., Stevenson, C. R. Arch. Inter-Amer. Rheumat. 1960, 3, 171. 5. Robinson, J. R. Physiol. Rev. 1960, 40, 112. 3. 4.
giving
Royal Infirmary,
A. R. HUNTER.
Manchester.
SECURING THE T-TUBE SiR,ŃThe inadvertent dislodgment of a common-duct T-drain by the patient during sleep or by the nurse when she is changing a dressing is a surgical misfortune. Fixation of the T-tube to the skin by sutures may prevent this mishap, but may bend the tube in such a way that the flow of bile through the tube stops. If bile finds its way to the peritoneal cavity serious complications may
,
(3) Idiopathic osteonecrosis-which may also occur in nonsubjects. distinguishes these conditions from the subcapital fracture which complicates steroid osteoporosis, and mentions the possible setiological role of both rheumatoid and steroid vasculitis in idiopathic osteonecrosis. At this hospital we often use intra-articular hydrocortisone injection as an ancillary measure in fully integrated medical, physical medical, and orthopaedic management. This diminishes the use of long-term oral corticosteroid administration, with its attendant risks of the bone and join complications of osteoporosis and vasculitis. We warn patients that intra-articular steroids will not necessarily prevent joint destruction or instability, but we have been unable to show any increase in these complications.3 Injections are repeated only as long as patients derive relief and functional benefit. In this way some patients select themselves for short-term and long-term intra-articular steroid treatment. Those who develop a subacute boggy synovitis-not susceptible to control by this means-are treated surgically. arthritic Coste
"
"
In short, one should have some knowledge both of the natural history of joint destruction and of the potentialities and limitations of intra-articular steroid therapy before embarking upon it. Then, as Hollander4 has amply demonstrated, it will prove to be a safe and useful weapon in the fight against arthritis. Queen Elizabeth Hospital, Rotorua, New Zealand.
B. S. ROSE.
OSMOLAR AND ELECTROLYTE CHANGES IN HÆMORRHAGIC SHOCK
SIR,-Dr. Maffiy (April 27) is justified in pointing out that there is considerable evidence that mammalian cells are in osmotic equilibrium with the extracellular fluid. However, it would be misleading to suggest that the argument has been settled; and, to me at least, much of the opposing evidence, particularly that derived from recent cryoscopic measurements in intact mammalian tissue, remains unanswered. arise. Nurses may be energetic in their efforts to keep the T-drains functioning and still find their endeavours wasted by a moment’s negligence. If promptly recognised, the situation may be saved by inserting a drain or by operation. Occasionally it is a real disaster to see a T-tube coming out when a new operation may mean difficult dissection and much bleeding. It may seem trivial to some surgeons to recommend a special technique for fixing the T-tube to the skin, but we recommend the method illustrated in the accompanying figure. It has been suggested by Sister Emerita of this
hospital. Hospital, Copenhagen. N.
St. Joseph’s
Westminster Medical School, London, S.W.1.
D. E. PEGG.
F. SKOVBORG.
INTRA-ARTICULAR STEROIDS AND DESTRUCTIVE ARTHROPATHY 1
SIR,—Your annotation acknowledges that jointdestruction can occur without intra-articular injection of steroid, but fails to take into account the natural history of joint destruction. Coste2 drew attention to three varieties of hip-joint destruction, which may happen in the absence of steroid therapy: (1) Massive osteolysis. (2) A particular type of destruction of the superior external quadrant of the femoral head. 1. 2.
It is also true that even if the majority of the body-cells are in osmotic equilibrium with the extracellular fluid some specialised cells may not be, and it may be relevant that some of the strongest evidence for intracellular hyperosmolarity has been obtained with renal tissue which is among those most sensitive to anoxia. I would also like to emphasise that J. R. Robinson’s experiments, to which I referred previously (March 23), are relevant to the interpretation of the results obtained by Brooks et al. (March 9) irrespective of the outcome of the osmotic equilibrium argument; Robinson has shown in his more recent review5 that it is correct to say that an " isotonic" medium is hypotonic for anoxic cells, even if the explanation lies in alterations in the permeability of the cellmembrane rather than intracellular hyperosmolarity.
Lancet, 1962, ii, 1156. Coste, F. Proceedings of 10th Congress of International League Against Rheumatism; vol III, p. 71. Turin, 1961.
SiR,-May I reply briefly to the letter last week from Dr. Brooks and Mr. Williams and then retire from this controversy ? I am aware that sodium enters damaged cells in exchange for potassium, as described in your editorial of March 9. Indeed, this is presumably the reason for the fall of sodium and the rise of potassium in the plasma of the control dogs, which mostly died. My calculations, however, were for the dogs given hypertonic sodium solutions, which mostly survived and whose plasma-potassium levels fell (no doubt owing to the expansion of the extracellular fluid volume); presumably their cells were less damaged, and subject to an insignificant cation exchange. I Isdale, I. C. Ann. rheum. Dis. 1962, 21, 23. Hollander, J. L., Brown, E. M., Jessar, R. A., Udell, L., Bowitt, M. A., Shanahan, J. R., Stevenson, C. R. Arch. Inter-Amer. Rheumat. 1960, 3, 171. 5. Robinson, J. R. Physiol. Rev. 1960, 40, 112. 3. 4.