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SURGERY IN DIABETES MELLITUS
499 SURGERY IN DIABETES MELLITUS
SiR,-Dr. Oakley’s letter (Aug. 7) ignores the texts, referred to in our letter (July 31), which discuss the indications for the use of insulin preoperatively and the possibility of developing ketoacidosis in diabetics undergoing elective surgery. Despite Dr. Oakley’s longer though not necessarily greater experience, we consider: (1) that the control of the patient, whose case he cites, was far from satisfactory if it resulted in her showing such gross glycosuria and ketonuria just before elective surgery; and (2) that the routine administration of glucose and insulin to insulin-dependent diabetics before elective surgery is both unnecessary and undesirable, since such patients, if properly prepared along the lines suggested by ourselves and Dr. Fletcher and his colleagues (July 10), do not
develop ketoacidosis before regaining consciousness unless the operation is exceedingly long and traumatic. L. J. P. DUNCAN Diabetic Department, Royal Infirmary of Edinburgh.
B. F. CLARKE.
ABDOMINAL WOUND DISRUPTION SIR,-I, too, appreciated Mr. Efron’s review of abdominal wound disruption.1 I should like to add to Mr. Shepherd’s pertinent comment (July 10). His clinical classification of wound rupture is thoroughly satisfactory, but I wonder if all clinicians have had sufficient experience of his type 3 (gradual complete rupture) to agree that " the warning signs may be
apparent. I have found such abdominal-profile films extremely helpful, but would add that several views with slightly altered angulation may be necessary for accurate diagnosis. A tremendous advantage is that this diagnosis can be made well before the seventh day. Pembroke,
R. R. GILFILLAN. GiLFILLAN.
Ontario.
IDIOPATHIC PULMONARY HÆMOSIDEROSIS SiR,ŃThe aetiology of idiopathic pulmonary hxmosiderosis (I.P.H.) is still unknown. Immunoallergy1 and milk allergy2 have been suggested particularly, but familial or hereditary factors are not reported to influence the disease.3-6 We-here present the first recorded case-reports of I.P .H. in twins. Male twins
were born on Jan. 9, 1962; the first twin 2600 g. and the second 2500 g. They were reported weighed to be clinically well until their first year of age when the parents noticed that they were anaemic, despite prolonged
iron treatment. Since December, 1964, recurrent episodes of respiratory infections have been reported in both twins. TWIN A was admitted to hospital on April 4, 1965, because of fever, cough, pallor, and difficulty in breathing, for 3 days. He was febrile (39°C), pale, and tachypnceic. Dullness was detected at both lung bases, and rhonchi were easily heard. The liver was palpable 4 cm., and the spleen 2 cm., below the costal margin. Haemoglobin was 4-7 g. per 100 ml. ; haematocrit 18%; red blood-cells showed hypochromia and anisocytosis; reticulocytes 10%; leucocytes
14,000 per c.mm., neutrophils 80%, lymphocytes 20%; direct bilirubin 0-4 mg., and indirect bilirubin 0-8 mg., per 100 ml. ; blood-urea 25 mg. per 100 ml. ; Coombs’, Motulsky’s, and sickling tests negative; haemoglobin electrophoresis normal; urine normal; electrocardiogram (E.C.G.) normal. Siderophages were found in the sputum and gastric aspirate. Chest X-rays showed small and large shadows
bilaterally. The patient was treated with blood-transfusion, steroids, and antibiotics, and was discharged 10 days later on a minimal dose of steroids. He was readmitted on May 11 because of another respiratory infection, and was finally discharged, on May 14, on steroids and a milk-free diet. TWIN B was admitted, on April 7, for investigations on account of his twin-brother’s illness. He was pale. The spleen was palpable 3 cm., and the liver 2 cm., below the costal margin. Haemoglobin was 6-3 g. per 100 ml. haematocrit 21%; hypochromia and anisocytosis was detected; reticulocytes 25%, leucocytes 7500 per c.mm., neurophils 70%, lymphocytes 30%; blood-urea 20 mg. per 120 ml.; Coombs’, Motulsky’s, and sickling tests negative; hxmoglobin electrophoresis normal; urine normal; E.C.G. normal. Siderophages were found in the sputum and gastric aspirate. Chest X-rays showed mottling of both lungs. He was discharged on a milk-free diet, readmitted for 5 days because of fever and cough, treated with blood-transfusion, steroids, and antibiotics, and finally discharged on steroids and a milk-free diet.
Although precise determination of monozygosity is difficult 78 complete investigations were not carried out on these twins, we think that they are most probably monozygotic. Conclusions on the hereditary factors in I.P.H. cannot be drawn and
readily detected by the watchful clinician ... before skin dehiscence occurs ". My own limited experience suggests that, particularly in the obese patient, the early signs of dehiscence (serous effusion, bulging on coughing, and lack of tissue density behind the actual suture-line) are difficult to elicit. And it may well be that the clinician is not in attendance when the sutures are removed. A tangential soft-tissue X-ray of the patient’s abdomen, taken during the Valsalva manoeuvre, is an additional aid to diagnosis (see accompanying figure). The gas-containing loops protruding through the abdominal musculature are readily 1. Efron, G. Lancet, 1965, i, 1287.
from these
two cases,
discordancy
are
since
more cases
of
concordancy
and
--
needed.
University Department of Pædiatrics, Saint Sophia’s Children’s Hospital, Athens, Greece.
C. B. CHOREMIS J. M. MESSARITAKIS J. G. KARPOUZAS.
Steiner, B. Archs Dis. Childh. 1954, 29, 391. Heiner, D. C., Sears, J. W., Kniker, W. T. Am. J. Dis. Child. 1962, 103, 634. 3. Lancet, 1952, i, 1005. 4. Tait, G. B., Corridan, M. Thorax, 1952, 7, 302. 5. Schuler, D., Flesch, I. Annls pœdiat. 1955, 185, 96. 6. Soergel, K. H. Pediatrics, Springfield, 1957, 19, 1101. 7. Macklin, M. T. Am. J. Obstet. Gynec. 1950, 59, 359.
1. 2.
8. Benirschke, K. Obstetl gynec. Surv. 1958, 13, 88.
SiR,-Dr. Oakley’s letter (Aug. 7) ignores the texts, referred to in our letter (July 31), which discuss the indications for the use of insulin preoperatively and the possibility of developing ketoacidosis in diabetics undergoing elective surgery. Despite Dr. Oakley’s longer though not necessarily greater experience, we consider: (1) that the control of the patient, whose case he cites, was far from satisfactory if it resulted in her showing such gross glycosuria and ketonuria just before elective surgery; and (2) that the routine administration of glucose and insulin to insulin-dependent diabetics before elective surgery is both unnecessary and undesirable, since such patients, if properly prepared along the lines suggested by ourselves and Dr. Fletcher and his colleagues (July 10), do not
develop ketoacidosis before regaining consciousness unless the operation is exceedingly long and traumatic. L. J. P. DUNCAN Diabetic Department, Royal Infirmary of Edinburgh.
B. F. CLARKE.
ABDOMINAL WOUND DISRUPTION SIR,-I, too, appreciated Mr. Efron’s review of abdominal wound disruption.1 I should like to add to Mr. Shepherd’s pertinent comment (July 10). His clinical classification of wound rupture is thoroughly satisfactory, but I wonder if all clinicians have had sufficient experience of his type 3 (gradual complete rupture) to agree that " the warning signs may be
apparent. I have found such abdominal-profile films extremely helpful, but would add that several views with slightly altered angulation may be necessary for accurate diagnosis. A tremendous advantage is that this diagnosis can be made well before the seventh day. Pembroke,
R. R. GILFILLAN. GiLFILLAN.
Ontario.
IDIOPATHIC PULMONARY HÆMOSIDEROSIS SiR,ŃThe aetiology of idiopathic pulmonary hxmosiderosis (I.P.H.) is still unknown. Immunoallergy1 and milk allergy2 have been suggested particularly, but familial or hereditary factors are not reported to influence the disease.3-6 We-here present the first recorded case-reports of I.P .H. in twins. Male twins
were born on Jan. 9, 1962; the first twin 2600 g. and the second 2500 g. They were reported weighed to be clinically well until their first year of age when the parents noticed that they were anaemic, despite prolonged
iron treatment. Since December, 1964, recurrent episodes of respiratory infections have been reported in both twins. TWIN A was admitted to hospital on April 4, 1965, because of fever, cough, pallor, and difficulty in breathing, for 3 days. He was febrile (39°C), pale, and tachypnceic. Dullness was detected at both lung bases, and rhonchi were easily heard. The liver was palpable 4 cm., and the spleen 2 cm., below the costal margin. Haemoglobin was 4-7 g. per 100 ml. ; haematocrit 18%; red blood-cells showed hypochromia and anisocytosis; reticulocytes 10%; leucocytes
14,000 per c.mm., neutrophils 80%, lymphocytes 20%; direct bilirubin 0-4 mg., and indirect bilirubin 0-8 mg., per 100 ml. ; blood-urea 25 mg. per 100 ml. ; Coombs’, Motulsky’s, and sickling tests negative; haemoglobin electrophoresis normal; urine normal; electrocardiogram (E.C.G.) normal. Siderophages were found in the sputum and gastric aspirate. Chest X-rays showed small and large shadows
bilaterally. The patient was treated with blood-transfusion, steroids, and antibiotics, and was discharged 10 days later on a minimal dose of steroids. He was readmitted on May 11 because of another respiratory infection, and was finally discharged, on May 14, on steroids and a milk-free diet. TWIN B was admitted, on April 7, for investigations on account of his twin-brother’s illness. He was pale. The spleen was palpable 3 cm., and the liver 2 cm., below the costal margin. Haemoglobin was 6-3 g. per 100 ml. haematocrit 21%; hypochromia and anisocytosis was detected; reticulocytes 25%, leucocytes 7500 per c.mm., neurophils 70%, lymphocytes 30%; blood-urea 20 mg. per 120 ml.; Coombs’, Motulsky’s, and sickling tests negative; hxmoglobin electrophoresis normal; urine normal; E.C.G. normal. Siderophages were found in the sputum and gastric aspirate. Chest X-rays showed mottling of both lungs. He was discharged on a milk-free diet, readmitted for 5 days because of fever and cough, treated with blood-transfusion, steroids, and antibiotics, and finally discharged on steroids and a milk-free diet.
Although precise determination of monozygosity is difficult 78 complete investigations were not carried out on these twins, we think that they are most probably monozygotic. Conclusions on the hereditary factors in I.P.H. cannot be drawn and
readily detected by the watchful clinician ... before skin dehiscence occurs ". My own limited experience suggests that, particularly in the obese patient, the early signs of dehiscence (serous effusion, bulging on coughing, and lack of tissue density behind the actual suture-line) are difficult to elicit. And it may well be that the clinician is not in attendance when the sutures are removed. A tangential soft-tissue X-ray of the patient’s abdomen, taken during the Valsalva manoeuvre, is an additional aid to diagnosis (see accompanying figure). The gas-containing loops protruding through the abdominal musculature are readily 1. Efron, G. Lancet, 1965, i, 1287.
from these
two cases,
discordancy
are
since
more cases
of
concordancy
and
--
needed.
University Department of Pædiatrics, Saint Sophia’s Children’s Hospital, Athens, Greece.
C. B. CHOREMIS J. M. MESSARITAKIS J. G. KARPOUZAS.
Steiner, B. Archs Dis. Childh. 1954, 29, 391. Heiner, D. C., Sears, J. W., Kniker, W. T. Am. J. Dis. Child. 1962, 103, 634. 3. Lancet, 1952, i, 1005. 4. Tait, G. B., Corridan, M. Thorax, 1952, 7, 302. 5. Schuler, D., Flesch, I. Annls pœdiat. 1955, 185, 96. 6. Soergel, K. H. Pediatrics, Springfield, 1957, 19, 1101. 7. Macklin, M. T. Am. J. Obstet. Gynec. 1950, 59, 359.
1. 2.
8. Benirschke, K. Obstetl gynec. Surv. 1958, 13, 88.