- Email: [email protected]
SERUM-INSULIN RESPONSE TO GLUCOSE
41 I found that, of 300 male children under five years of age, 25% had partial or complete non-retractability of the foreskin. I fail to understand the " purely anatomical grounds on which circumcision has been condemned "; more important whole organs, such as the tonsils, stomach, and uterus, continue to be removed. In 1932 you advocated circumcision as a prophylaxis against penile and cervical cancer.2 Serious rethinking on the question of early circumcision is needed. R. V. RAJAM. Madras. India.
READING, WRITING, AND WRITHING SIR,-Your annotation (March 27) appears to me very timely. The expanding volume of scientific publication in medicine urgently calls for action to prevent the number of periodicals increasing by 0-1 log or so every year. Instead of the " recording journals ", which were proposed by Sir Theodore Fox3 for registering all kinds of research observations and case-reports, it might be even better to publish research papers in the form of the currently used reprints without having any bound journals. The author’s summary could be published in a reference periodical at the same time as the original paper is printed. By this means, all the costly and cumbersome work at present undertaken by scientists to review others’ articles for all the existing reference periodicals would be spared. The interested scientist would be able to obtain the article as usual from the author, provided that the author’s address was included in the reference periodical. I do not think that the presentation of material is bound to deteriorate in this new system-why should it ? In the new as in the old system the papers are being read by the same small group of scientists expert in their own fields of research. Institute of Hygiene and Microbiology, Medical Faculty, Saarland University, Homberg, R. .y. WIGAND. Federal Republic of Germany. SERUM-LIPID LEVELS SIR,-Dr. Pazzanese and his colleagues 4 say: " Generally speaking, a population that eats food rich in animal fat or saturated fat has a higher mean level of serum-cholesterol. This higher level is mainly due to the -cholesterol fraction and is accompanied by higher levels of serum-p-lipoprotein of
Sf20-100." 1. When speaking about lipoproteins of Sf 20-100, or other values of Sf, it is necessary to specify also the range of densities of such lipoproteins, because their compositionincluding the proportion of cholesterol-changes for the different densities.5 Assuming that lipoproteins of density < 1-0630 g. per ml. are referred to (because the title of table n suggests Gofman’s nomenclature), it is still not known how Dr. Pazzanese and his colleagues change, qualitatively and quantitatively, from
electrophoresis serum-(3-lipoproteins to low-density serumlipoproteins of Sf 20-100, and vice versa. Pezold et al.showed that serum low-density lipoprotein (L.D.L.) (d < 1-0630 g. per ml.), with Sf 0-400 and serurn-3-lipoproteins from the same sample, travelled about the same distance on paper electrophoresis strips, but no localisation off 20-100 or other subranges of Sf lipoproteins was made, within the range of Sf0-400, on the strip. So it does not seem correct to speak of " higher levels of serum-(3-lipoproteins of Sf 20-100 ". 2. As Nichols et al.,’ Hatch et a].,’ Ahrens,9 and Walker et al.1O have demonstrated, and as has been verified in more than five hundred cases over many years at this laboratory, 2. ibid. 1932, i, 116. 3. Fox, T. F. Crisis in Communication. London, 1965. 4. Pazzanese, D., Portugal, O. P., Ramos, O. L., Finatti, A. A. C., Lanfranchi, W., Barreto, H. P. C. B., Sustovich, D. R. Lancet, 1964, ii, 615. 5. Lindgren, F. T., Gofman, J. W. Bull. schweiz. Akad. med. Wiss. 1957, 13, 152. 6. Pezold, F. A., De Lalla, O. F., Gofman, J. W. Clin. chim. Acta, 1957, 2, 43. 7. Nichols, A. V., Doblin, V., Gofman, J. W. Geriatrics, 1957, 12, 7. 8. Hatch, F., Abell, L., Kendall, F. Amer. J. Med. 1955, 19, 48. 9. Ahrens, E. J., Jr. ibid. 1957, 23, 928. 10. Walker, W. J., Weiner, N., Milch, L. J. Circulation, 1957, 15, 31.
eating food rich in animal fat or saturated fat is not usually accompanied by higher levels of Sf 20-100 L.D.L. (< 1-0630 g. per ml.), but is usually accompanied by higher levels of Sf 0-12 and Sf 12-20-the elevation of Sf 20-100 being due mainly to eating food rich in carbohydrate. Experimental Laboratory, Institute of Cardiology of São Sao Paulo, Caixa Postal, 215, São Sao Paulo, Brazil.
RAPHAEL FARO NETTO. NETTO
THE PREMENSTRUAL SYNDROME SIR,-May I add a clinical footnote to the scholarly article (June 5) by Dr. Sutherland and Dr. Stewart ? My experience of the premenstrual syndrome is based on about 500 cases in private practice. One cannot produce mathematically precise ratios, but clinical impressions are clear and strong. Dr. Sutherland and Dr. Stewart use the term " cyclical syndrome " to describe the essentially physiological, emotional, and physical symptoms that occur in about three-quarters of women before menstruation, and regress and disappear during menstruation. The symptoms are closely associated with water retention in soft tissues, presumably the result of pituitary activity. This clinical picture is easily recognisable in many patients for years after the menopause (whether natural or induced), in some young girls before the menarche, and in pregnancy and the postnatal period. The term " cyclical syndrome " is therefore preferable to premenstrual tension ". Water retention is manifest as breast engorgement, distension of the abdominal wall, and slight oedema of the face and, " often, the ankles. Assuming the brain to be a soft tissue " it is easy to predicate that the mood-changes, so often recognised and acknowledged, are due to cerebral oedema. Shortly after the 1939-45 war a survey at Holloway Prison showed that " 93% of female crime was committed during the premenstrual "
phase Although
its degree and type in usual for all patients to observe some gain in weight, amounting to as much as 6-7 lb. in the " water-retainers ". The introduction of the oral diuretics (chlorothiazide to frusemide) has been a boon to hundreds of women in my practice. A tablet every other day during the premenstrual week is the usual instruction. Patients are delighted to be relieved of the unpleasantnesses they formerly experienced, and are willingly converted to following this safe and simple programme. Benefits to postmenopausal patients, who take a tablet twice a week, include a diminution of hot flushes and the
syndrome varies in
different women, it is
night
most
sweats.
London, S.W.7.
ROBERT SWAN.
SERUM-INSULIN RESPONSE TO GLUCOSE SIR,-Dr. Karam and his colleagues (Feb. 6) pointed out the correlation between obesity and excessive levels of serum insulin, as shown by the loss of such hyper-response in a young woman after she had reduced to just below her ideal weight. Other findings in obese and non-obese diabetic patients, with active or inactive acromegaly, and in healthy subjects whose serum-insulin levels were determined after treatment with human growth hormone (H.G.H.) led Dr. Karam and his colleagues to consider the correlation between obesity and excess serum-insulin levels as more important than that between excess serum-insulin levels and the pre-diabetic state. Thus Grodsky et aLl reported a low serum-insulin response after glucose load in non-obese pre-diabetic subjects. We have observed such correlation between obesity and excess serum-insulin levels in a young obese woman of the suprarenal-pituitary type (due to diencephalic causes) whose weight exceeded her ideal weight by 75%. She showed not only decreased tolerance to carbohydrates and abnormal bloodglucose levels, but also very high serum-insulin levels (rat
epididymal fat). The patient was put on a low-calorie diet and was given high doses of testosterone, which brought about a hypophysis block, 1. Grodsky, G. M., Karam, J. H., Pavlatos, F. Ch., Forsham, P. H. 2.
Lancet, 1965, i 290. Balsano, F., Pappalardo, A., Di Noto, V. Diagnosi Terap. 1964, 2, 305.
42 and reduction of her weight to a level exceeding her ideal weight by only 45%. Basic blood-glucose levels, glucose-load curve, and serum-insulin levels showed normal values. Since the loss of hyper-response of serum-insulin levels immediately followed the hyophysis block, we suggested that the peripheral antagonists of insulin, particularly H.G.H., might be responsible for excess serum-insulin levels. It is probable, however, that weight reduction also contributed to the restoration to normal of the serum-insulin levels. On the basis of such observations it is therefore questionable whether diabetes may be ascribed to different causes in non-
obese
or
obese
patients with an equal hereditary taint.
Medical I Clinic, General G eneraMedical CI’ . 1n1c, University of Palermo.
F. BALSANO Di NOTO V. DI A. PAPPALARDO. 1 APPALARDO.
V. DI ry
THE DOCTOR’S THERAPEUTIC FUNCTION SIR,-I am not certain about the xtiology of exfoliative cheilitis in the patient described in Dr. Balint’s article (June 5). In addition to his somatic complaint this boy had had a surfeit of female company, and was indignant at the suggestion of lipstick patch-testing. Was his cheilitis self-inflicted by biting or scratching, or did he in fact have an undisclosed contact with lipstick ? It will be interesting to know the outcome of this patient’s complaints and whether he had any further treatment. The Hospital for Sick Children, London, W.C.1.
N IGEL NIGEL L EGG. LEGG.
PNEUMOPERITONEUM FOR PERITONEAL DIALYSIS SiR,ńPeritoneal dialysis is finding increased acceptance and wider use,l-3 but its use is limited by the danger and technical difficulty of inserting the catheter and trocar into the peritoneal cavity. Although improved techniques have been proposed 4-1 this difficulty remains. Moreover, the risk considerably increases when dialysis has to be repeated, because of the possibility of adhesions.’7 I have overcome this difficulty by doing a preliminary pneumoperitoneum, and by this simple technique the following advantages are obtained: (1) The insertion of the trocar through the abdominal wall into the peritoneal cavity is surprisingly easy and practically without risk. (2) The most convenient site for the insertion of the trocar can be chosen and also the continuous two-catheter dialysis is made practicable. (3) When peritoneal dialysis must be repeated, the formation of adhesions is prevented, provided that the pneumoperitoneum is maintained and renewed in the intervals between the successive dialyses. To inflate the peritoneal cavity I prefer filtered atmospheric air. In this way the technique is made very simple, because no special equipment is needed, as is the case when other gases (oxygen, nitrous oxide, and carbon dioxide) are used. It is sufficient to have available ordinary pneumothorax equipment or, better, a big syringe (100 ml.) and a three-way tap. It is advisable to include a manometer (calibrated in centimetres of water) in the air-injecting system (see accompanying figure) as this permits control of the expansion of the peritoneal cavity and the progressive increase of air-pressure. The abdominal wall is perforated, preferably by a Verres-type needle after slight local anaesthesia. Air must be injected slowly, reaching 1.
Boen, S. T. Peritoneal Dialysis in Clinical Medicine. Springfield, Ill.
2.
Stevens, R. E., Baskin, S., Greene, J. A., Weller, J. M. J. Am. med. Ass. 1964, 190, 1128. Thomson, W. B., Buchanan, A., Doak, P. B., Peart, W. S. Br. med. J. 1964, i, 932. Maxwell, M. H., Rockney, R. E., Kleeman, C. R., Twiss, M. R. J. Am. med. Ass. 1959, 170, 917. Palmer, R. A., Quinton, W. E., Gray, J. E. Lancet, 1964, i, 700. Henderson, L. W., Merrill, J. P., Crane, C. Trans. Am. Soc. artif. internal Organs, 1963, 9, 108. Chamberlain, M. J., Longbridge, L. W., Taylor, D. J. E. Br. med. J. 1964 i, 1116.
1964.
3. 4.
5. 6. 7.
the optimal pressure of 15-20 cm. H2O in not less than fifteen minutes. X-ray examination controls the efficiency of pneumoperitoneum and detects the adhesions. After anaesthesia of the punch site, the trocar is thrust into the cavity through the abdominal wall. Previous skin incision is optional. Further steps in the procedure do not differ from the wellknown technique of peritoneal dialysis.4 Excess air can be evacuated through the catheter. At the end of dialysis two possibilities occur: (1) Where peritoneal dialysis is not to be repeated, the pneumoperitoneum can be wholly evacuated and residual air is expelled from the cavity through the catheter by external compression of the abdomen. (2) Where peritoneal dialysis is to be repeated periodically the pneumoperitoneum must be maintained through repeated air replacement by injecting 500-1000 ml. of air after the last fluid outflow, and, if necessary, air can be reintroduced on subsequent days by ordinary
pneumothorax equipment. dialysis, with this modification, was carried out patients, in 1 of whom it was repeated eleven times in a
Peritoneal in 3
period of two months. Results were favourable and technical difficulties insignificant. Only wide experience by other workers can determine the value of this technique. Department of Internal Medicine, Civil Hospital, Macerata, Italy.
..
,
G. MENGHINI.
HYALINE-MEMBRANE DISEASE AND PULMONARY BLOOD-FLOW 19618 SIR,-In I put forward the thesis that hyalinemembrane disease (idiopathic respiratory distress syndrome) in the neonate was the result of altered pulmonary haemodynamics and blood-flow. I suggested that after birth the change from the generally flexed intrauterine position to a more extended one was an important factor in producing such alterations, and that this in turn precipitated a disturbance in pulmonary dynamics. I concluded that the retention of the intrauterine position might be of value in limiting these changes in pulmonary hoemodynamics. I tried to maintain newborn infants in the intrauterine position by wrapping them in a nylon-mesh net, but this gave equivocal results; hence the study was not
pursued.
The recent article by Chu et al.supports my thesis and offers evidence that alterations in flow through the pulmonary vascular system are important in the production of hyalinemembrane disease. Their work implies that the maintenance of satisfactory pulmonary flow (which might more readily be accomplished by maintaining the infant in the in-utero position) might help to prevent hyaline-membrane disease. I write to inquire whether in some part of the world neonatal care includes early wrapping of infants in the flexed position, and whether this is associated with a change in the prevalence or severity of hyaline-membrane disease. Department of Pediatrics, University of Colorado Medical Center, r. H K. HENRY HENRY K SILVER. K. Denver, Colorado, U.S.A. 8. Sliver, H. K. Meeting of Hawaii Medical Association Advisory Committee 9.
Chu, J.,
to et
the Bureau of Maternal and Child al. Pediatrics, 1965, 35, 733.
Health, Honolulu,
1961.
READING, WRITING, AND WRITHING SIR,-Your annotation (March 27) appears to me very timely. The expanding volume of scientific publication in medicine urgently calls for action to prevent the number of periodicals increasing by 0-1 log or so every year. Instead of the " recording journals ", which were proposed by Sir Theodore Fox3 for registering all kinds of research observations and case-reports, it might be even better to publish research papers in the form of the currently used reprints without having any bound journals. The author’s summary could be published in a reference periodical at the same time as the original paper is printed. By this means, all the costly and cumbersome work at present undertaken by scientists to review others’ articles for all the existing reference periodicals would be spared. The interested scientist would be able to obtain the article as usual from the author, provided that the author’s address was included in the reference periodical. I do not think that the presentation of material is bound to deteriorate in this new system-why should it ? In the new as in the old system the papers are being read by the same small group of scientists expert in their own fields of research. Institute of Hygiene and Microbiology, Medical Faculty, Saarland University, Homberg, R. .y. WIGAND. Federal Republic of Germany. SERUM-LIPID LEVELS SIR,-Dr. Pazzanese and his colleagues 4 say: " Generally speaking, a population that eats food rich in animal fat or saturated fat has a higher mean level of serum-cholesterol. This higher level is mainly due to the -cholesterol fraction and is accompanied by higher levels of serum-p-lipoprotein of
Sf20-100." 1. When speaking about lipoproteins of Sf 20-100, or other values of Sf, it is necessary to specify also the range of densities of such lipoproteins, because their compositionincluding the proportion of cholesterol-changes for the different densities.5 Assuming that lipoproteins of density < 1-0630 g. per ml. are referred to (because the title of table n suggests Gofman’s nomenclature), it is still not known how Dr. Pazzanese and his colleagues change, qualitatively and quantitatively, from
electrophoresis serum-(3-lipoproteins to low-density serumlipoproteins of Sf 20-100, and vice versa. Pezold et al.showed that serum low-density lipoprotein (L.D.L.) (d < 1-0630 g. per ml.), with Sf 0-400 and serurn-3-lipoproteins from the same sample, travelled about the same distance on paper electrophoresis strips, but no localisation off 20-100 or other subranges of Sf lipoproteins was made, within the range of Sf0-400, on the strip. So it does not seem correct to speak of " higher levels of serum-(3-lipoproteins of Sf 20-100 ". 2. As Nichols et al.,’ Hatch et a].,’ Ahrens,9 and Walker et al.1O have demonstrated, and as has been verified in more than five hundred cases over many years at this laboratory, 2. ibid. 1932, i, 116. 3. Fox, T. F. Crisis in Communication. London, 1965. 4. Pazzanese, D., Portugal, O. P., Ramos, O. L., Finatti, A. A. C., Lanfranchi, W., Barreto, H. P. C. B., Sustovich, D. R. Lancet, 1964, ii, 615. 5. Lindgren, F. T., Gofman, J. W. Bull. schweiz. Akad. med. Wiss. 1957, 13, 152. 6. Pezold, F. A., De Lalla, O. F., Gofman, J. W. Clin. chim. Acta, 1957, 2, 43. 7. Nichols, A. V., Doblin, V., Gofman, J. W. Geriatrics, 1957, 12, 7. 8. Hatch, F., Abell, L., Kendall, F. Amer. J. Med. 1955, 19, 48. 9. Ahrens, E. J., Jr. ibid. 1957, 23, 928. 10. Walker, W. J., Weiner, N., Milch, L. J. Circulation, 1957, 15, 31.
eating food rich in animal fat or saturated fat is not usually accompanied by higher levels of Sf 20-100 L.D.L. (< 1-0630 g. per ml.), but is usually accompanied by higher levels of Sf 0-12 and Sf 12-20-the elevation of Sf 20-100 being due mainly to eating food rich in carbohydrate. Experimental Laboratory, Institute of Cardiology of São Sao Paulo, Caixa Postal, 215, São Sao Paulo, Brazil.
RAPHAEL FARO NETTO. NETTO
THE PREMENSTRUAL SYNDROME SIR,-May I add a clinical footnote to the scholarly article (June 5) by Dr. Sutherland and Dr. Stewart ? My experience of the premenstrual syndrome is based on about 500 cases in private practice. One cannot produce mathematically precise ratios, but clinical impressions are clear and strong. Dr. Sutherland and Dr. Stewart use the term " cyclical syndrome " to describe the essentially physiological, emotional, and physical symptoms that occur in about three-quarters of women before menstruation, and regress and disappear during menstruation. The symptoms are closely associated with water retention in soft tissues, presumably the result of pituitary activity. This clinical picture is easily recognisable in many patients for years after the menopause (whether natural or induced), in some young girls before the menarche, and in pregnancy and the postnatal period. The term " cyclical syndrome " is therefore preferable to premenstrual tension ". Water retention is manifest as breast engorgement, distension of the abdominal wall, and slight oedema of the face and, " often, the ankles. Assuming the brain to be a soft tissue " it is easy to predicate that the mood-changes, so often recognised and acknowledged, are due to cerebral oedema. Shortly after the 1939-45 war a survey at Holloway Prison showed that " 93% of female crime was committed during the premenstrual "
phase Although
its degree and type in usual for all patients to observe some gain in weight, amounting to as much as 6-7 lb. in the " water-retainers ". The introduction of the oral diuretics (chlorothiazide to frusemide) has been a boon to hundreds of women in my practice. A tablet every other day during the premenstrual week is the usual instruction. Patients are delighted to be relieved of the unpleasantnesses they formerly experienced, and are willingly converted to following this safe and simple programme. Benefits to postmenopausal patients, who take a tablet twice a week, include a diminution of hot flushes and the
syndrome varies in
different women, it is
night
most
sweats.
London, S.W.7.
ROBERT SWAN.
SERUM-INSULIN RESPONSE TO GLUCOSE SIR,-Dr. Karam and his colleagues (Feb. 6) pointed out the correlation between obesity and excessive levels of serum insulin, as shown by the loss of such hyper-response in a young woman after she had reduced to just below her ideal weight. Other findings in obese and non-obese diabetic patients, with active or inactive acromegaly, and in healthy subjects whose serum-insulin levels were determined after treatment with human growth hormone (H.G.H.) led Dr. Karam and his colleagues to consider the correlation between obesity and excess serum-insulin levels as more important than that between excess serum-insulin levels and the pre-diabetic state. Thus Grodsky et aLl reported a low serum-insulin response after glucose load in non-obese pre-diabetic subjects. We have observed such correlation between obesity and excess serum-insulin levels in a young obese woman of the suprarenal-pituitary type (due to diencephalic causes) whose weight exceeded her ideal weight by 75%. She showed not only decreased tolerance to carbohydrates and abnormal bloodglucose levels, but also very high serum-insulin levels (rat
epididymal fat). The patient was put on a low-calorie diet and was given high doses of testosterone, which brought about a hypophysis block, 1. Grodsky, G. M., Karam, J. H., Pavlatos, F. Ch., Forsham, P. H. 2.
Lancet, 1965, i 290. Balsano, F., Pappalardo, A., Di Noto, V. Diagnosi Terap. 1964, 2, 305.
42 and reduction of her weight to a level exceeding her ideal weight by only 45%. Basic blood-glucose levels, glucose-load curve, and serum-insulin levels showed normal values. Since the loss of hyper-response of serum-insulin levels immediately followed the hyophysis block, we suggested that the peripheral antagonists of insulin, particularly H.G.H., might be responsible for excess serum-insulin levels. It is probable, however, that weight reduction also contributed to the restoration to normal of the serum-insulin levels. On the basis of such observations it is therefore questionable whether diabetes may be ascribed to different causes in non-
obese
or
obese
patients with an equal hereditary taint.
Medical I Clinic, General G eneraMedical CI’ . 1n1c, University of Palermo.
F. BALSANO Di NOTO V. DI A. PAPPALARDO. 1 APPALARDO.
V. DI ry
THE DOCTOR’S THERAPEUTIC FUNCTION SIR,-I am not certain about the xtiology of exfoliative cheilitis in the patient described in Dr. Balint’s article (June 5). In addition to his somatic complaint this boy had had a surfeit of female company, and was indignant at the suggestion of lipstick patch-testing. Was his cheilitis self-inflicted by biting or scratching, or did he in fact have an undisclosed contact with lipstick ? It will be interesting to know the outcome of this patient’s complaints and whether he had any further treatment. The Hospital for Sick Children, London, W.C.1.
N IGEL NIGEL L EGG. LEGG.
PNEUMOPERITONEUM FOR PERITONEAL DIALYSIS SiR,ńPeritoneal dialysis is finding increased acceptance and wider use,l-3 but its use is limited by the danger and technical difficulty of inserting the catheter and trocar into the peritoneal cavity. Although improved techniques have been proposed 4-1 this difficulty remains. Moreover, the risk considerably increases when dialysis has to be repeated, because of the possibility of adhesions.’7 I have overcome this difficulty by doing a preliminary pneumoperitoneum, and by this simple technique the following advantages are obtained: (1) The insertion of the trocar through the abdominal wall into the peritoneal cavity is surprisingly easy and practically without risk. (2) The most convenient site for the insertion of the trocar can be chosen and also the continuous two-catheter dialysis is made practicable. (3) When peritoneal dialysis must be repeated, the formation of adhesions is prevented, provided that the pneumoperitoneum is maintained and renewed in the intervals between the successive dialyses. To inflate the peritoneal cavity I prefer filtered atmospheric air. In this way the technique is made very simple, because no special equipment is needed, as is the case when other gases (oxygen, nitrous oxide, and carbon dioxide) are used. It is sufficient to have available ordinary pneumothorax equipment or, better, a big syringe (100 ml.) and a three-way tap. It is advisable to include a manometer (calibrated in centimetres of water) in the air-injecting system (see accompanying figure) as this permits control of the expansion of the peritoneal cavity and the progressive increase of air-pressure. The abdominal wall is perforated, preferably by a Verres-type needle after slight local anaesthesia. Air must be injected slowly, reaching 1.
Boen, S. T. Peritoneal Dialysis in Clinical Medicine. Springfield, Ill.
2.
Stevens, R. E., Baskin, S., Greene, J. A., Weller, J. M. J. Am. med. Ass. 1964, 190, 1128. Thomson, W. B., Buchanan, A., Doak, P. B., Peart, W. S. Br. med. J. 1964, i, 932. Maxwell, M. H., Rockney, R. E., Kleeman, C. R., Twiss, M. R. J. Am. med. Ass. 1959, 170, 917. Palmer, R. A., Quinton, W. E., Gray, J. E. Lancet, 1964, i, 700. Henderson, L. W., Merrill, J. P., Crane, C. Trans. Am. Soc. artif. internal Organs, 1963, 9, 108. Chamberlain, M. J., Longbridge, L. W., Taylor, D. J. E. Br. med. J. 1964 i, 1116.
1964.
3. 4.
5. 6. 7.
the optimal pressure of 15-20 cm. H2O in not less than fifteen minutes. X-ray examination controls the efficiency of pneumoperitoneum and detects the adhesions. After anaesthesia of the punch site, the trocar is thrust into the cavity through the abdominal wall. Previous skin incision is optional. Further steps in the procedure do not differ from the wellknown technique of peritoneal dialysis.4 Excess air can be evacuated through the catheter. At the end of dialysis two possibilities occur: (1) Where peritoneal dialysis is not to be repeated, the pneumoperitoneum can be wholly evacuated and residual air is expelled from the cavity through the catheter by external compression of the abdomen. (2) Where peritoneal dialysis is to be repeated periodically the pneumoperitoneum must be maintained through repeated air replacement by injecting 500-1000 ml. of air after the last fluid outflow, and, if necessary, air can be reintroduced on subsequent days by ordinary
pneumothorax equipment. dialysis, with this modification, was carried out patients, in 1 of whom it was repeated eleven times in a
Peritoneal in 3
period of two months. Results were favourable and technical difficulties insignificant. Only wide experience by other workers can determine the value of this technique. Department of Internal Medicine, Civil Hospital, Macerata, Italy.
..
,
G. MENGHINI.
HYALINE-MEMBRANE DISEASE AND PULMONARY BLOOD-FLOW 19618 SIR,-In I put forward the thesis that hyalinemembrane disease (idiopathic respiratory distress syndrome) in the neonate was the result of altered pulmonary haemodynamics and blood-flow. I suggested that after birth the change from the generally flexed intrauterine position to a more extended one was an important factor in producing such alterations, and that this in turn precipitated a disturbance in pulmonary dynamics. I concluded that the retention of the intrauterine position might be of value in limiting these changes in pulmonary hoemodynamics. I tried to maintain newborn infants in the intrauterine position by wrapping them in a nylon-mesh net, but this gave equivocal results; hence the study was not
pursued.
The recent article by Chu et al.supports my thesis and offers evidence that alterations in flow through the pulmonary vascular system are important in the production of hyalinemembrane disease. Their work implies that the maintenance of satisfactory pulmonary flow (which might more readily be accomplished by maintaining the infant in the in-utero position) might help to prevent hyaline-membrane disease. I write to inquire whether in some part of the world neonatal care includes early wrapping of infants in the flexed position, and whether this is associated with a change in the prevalence or severity of hyaline-membrane disease. Department of Pediatrics, University of Colorado Medical Center, r. H K. HENRY HENRY K SILVER. K. Denver, Colorado, U.S.A. 8. Sliver, H. K. Meeting of Hawaii Medical Association Advisory Committee 9.
Chu, J.,
to et
the Bureau of Maternal and Child al. Pediatrics, 1965, 35, 733.
Health, Honolulu,
1961.