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TORSION OF THE FULLY DESCENDED TESTIS
95
variety. Usually pneumothorax,
left to itself, will and is therefore the only test time; treatment required-although it is often supplemented by aspiration of air from the pleural cavity. If the condition recurs these means may still suffice; but frequently the opportunity is then taken to carry out some form of pleurodesis to prevent further episodes. The technique of pleurodesis varies from the instillation of silver nitrate, iodised oil, or camphor in oil, to poudrage with iodised talc. Most of these methods, followed by tube suction, are successful; but they all carry a definite, though small, morbidity. Where the patient has been admitted under a surgeon’s care, the commonest form of treatment is controlled thoracotomy tube suction, although other methods, such as thoracotomy and stripping of the parietal pleura, are occasionally used. Klassen and Meckstroth5 have treated 135 cases by thoracotomy and tube suction: they found that the method successfully achieved prompt re-expansion of the lung without subsequent collapse in 81 %. The great advantage of this method is the short stay in hospital required; five days are usually sufficient. Klassen and Meckstroth performed thoracotomy with resection of subpleural blebs in 30 cases because of recurrence or because tube suction failed. be reabsorbed in
There is
single ideal method of treating spontaneous pneumothorax. The first episode is probably best managed conservatively, although if there is respiratory distress, and especially if there is a positive intrapleural pressure, the air is commonly aspirated. The more drastic the surgical measures taken to obtain re-expansion of the lung and to prevent recurrence of the collapse, the greater the probability of untoward results. Doctors in this country are therefore likely to remain more conservative than those in America where, with no free health service, swift discharge from hospital is bound to be emphasised. no
TORSION OF THE FULLY DESCENDED TESTIS
WHEN the imperfectly descended testis undergoes torsion it can be mistaken for a strangulated inguinal hernia. This is not serious for the patient, because operation is unlikely to be- delayed and the true state of affairs will then be revealed. But in torsion of the fully descended testis the signs and symptoms resemble those of epididymo-orchitis, and here an incorrect diagnosis can have dire consequences. In spite of general recognition for nearly half a century1 that the two conditions simulate each other, nobody can " say how often torsion is misdiagnosed as orchitis "; for the outcome in both is much the same, especially if antibiotics were used to treat the supposed orchitis. One reason for the mistake is the prevalent impression that torsion cannot take place in a normal testis.2 But the testes may be normal in size and situation and yet display developmental defects. These may take the form of an abnormally long mesorchium, unipolar attachment of the epididymis to the body of the testis, or high fusion of the visceral and parietal layers of the tunica vaginalis. Except for one important detail discussed by Mr. J. C. Angell in our last issue, these abnormalities are not detectable clinically. The fact to which he draws attention is that any or all of them tend to tip the testes into a horizontal plane, instead of the normal vertical plane. The lie of a swollen and tender testis is unlikely to be easily determined; but 1. 2.
Roche, A. E. St. Bart’s Hosp. Rep. 1928, 61, 183. Bailey, H. Diseases of the Testicle. London, 1936.
in these cases the testes on both sides display similar anatomical variations. Though Ewert and Hoffman3 could find only 26 out of 489 collected cases in which torsion had eventually affected both testes, this does not by any means exclude the possibility that many more had a predisposing anatomical abnormality on the other side. Angell, therefore, maintains that torsion is the most likely diagnosis in a patient who complains of sudden onset of pain in the testis unaccompanied by signs of urethritis, and in whom the testis on the other side is found to lie horizontally when he stands up. The time has come for abandoning the practice of treating such patients with scepticism and antibiotics.
usually
MANGANESE-INDUCED HYPOGLYCÆMIA
FOR centuries infusions of various plants were used for treatment of diabetes mellitus. Such infusions may significantly reduce raised blood-sugar levels, sometimes by undesirable means such as hepatocellular damage, but how most of the botanical hypoglycaemic agents act is unknown. This storehouse of folk-medicine may include drugs of clinical value and hypoglycaemic mechanisms of wide interest. In a report of manganese-induced hypoglycxmia Dr. Rubenstein and his colleagues4 describe the case of a muscular young diabetic who had himself found that infusions of lucerne (Medicago sativa) controlled hyperglycxmia more effectively than insulin in daily doses of up to 200 units. Rubenstein et al. repeatedly confirmed that infusions of lucerne lowered this diabetic’s high blood-sugar levels dramatically and quickly. The only constituent of lucerne known to be unusual was its high content of manganese; and administration of manganese chloride by mouth and by vein brought about a very similar type of hypoglycaemic response. Whether such a response is at all common in other diabetics or in nondiabetics is unknown; but trials on a few healthy individuals and by obese and juvenile-onset diabetics had negative results. It may be relevant that the young
the
manganese-sensitive diabetic was peculiarly resistant to ketosis. Perhaps the most striking event in the course of this diabetic’s
the elimination of his responsiveness lucerne infusions and to manganese by removal of the body and tail of the pancreas, undertaken in an effort to find a hypothetical islet-cell tumour. It seems probable, then, that the mechanism of the hypoglycasmic action of the manganese chloride was associated with tissue in the excised part of the pancreas, even although no structural abnormality was seen in it. Manganese, one of the so-called transition elements, is an essential dietary constituent. It is usually ingested to the extent of some 5 mg. daily,5 and yet the total body 6 manganese is only about three times this figure. Manganese is known to be a cofactor in several enzyme systems, including a mitochondrial oxidative phosphorylation and others concerned with the synthesis of fat and cholesterol.7 Studies involving radioactive isotopes of manganese have shown that virtually all the manganese in the body is rapidly exchangeable,8 and most of it is associated with the mitochondria, especially in the treatment was
to
3. 4. 5. 6. 7. 8.
Ewert, E. E., Hoffman, H. A. J. Urol. 1944, 51, 55. Rubenstein, A. H., Levin, N. W., Elliott, G. A. Lancet, 1962, ii, Kent, N. L., McCance, R. A. Biochem. J. 1941, 35, 877. Schroeder, H. A. Advanc. intern. Med. 1956, 8, 254. Cotzias, G. C. Fed. Proc. 1961, 20, part 2, p. 98. Borg, D. C., Cotzias, G. C. J. clin. Invest. 1958, 37, 1267.
1348.
variety. Usually pneumothorax,
left to itself, will and is therefore the only test time; treatment required-although it is often supplemented by aspiration of air from the pleural cavity. If the condition recurs these means may still suffice; but frequently the opportunity is then taken to carry out some form of pleurodesis to prevent further episodes. The technique of pleurodesis varies from the instillation of silver nitrate, iodised oil, or camphor in oil, to poudrage with iodised talc. Most of these methods, followed by tube suction, are successful; but they all carry a definite, though small, morbidity. Where the patient has been admitted under a surgeon’s care, the commonest form of treatment is controlled thoracotomy tube suction, although other methods, such as thoracotomy and stripping of the parietal pleura, are occasionally used. Klassen and Meckstroth5 have treated 135 cases by thoracotomy and tube suction: they found that the method successfully achieved prompt re-expansion of the lung without subsequent collapse in 81 %. The great advantage of this method is the short stay in hospital required; five days are usually sufficient. Klassen and Meckstroth performed thoracotomy with resection of subpleural blebs in 30 cases because of recurrence or because tube suction failed. be reabsorbed in
There is
single ideal method of treating spontaneous pneumothorax. The first episode is probably best managed conservatively, although if there is respiratory distress, and especially if there is a positive intrapleural pressure, the air is commonly aspirated. The more drastic the surgical measures taken to obtain re-expansion of the lung and to prevent recurrence of the collapse, the greater the probability of untoward results. Doctors in this country are therefore likely to remain more conservative than those in America where, with no free health service, swift discharge from hospital is bound to be emphasised. no
TORSION OF THE FULLY DESCENDED TESTIS
WHEN the imperfectly descended testis undergoes torsion it can be mistaken for a strangulated inguinal hernia. This is not serious for the patient, because operation is unlikely to be- delayed and the true state of affairs will then be revealed. But in torsion of the fully descended testis the signs and symptoms resemble those of epididymo-orchitis, and here an incorrect diagnosis can have dire consequences. In spite of general recognition for nearly half a century1 that the two conditions simulate each other, nobody can " say how often torsion is misdiagnosed as orchitis "; for the outcome in both is much the same, especially if antibiotics were used to treat the supposed orchitis. One reason for the mistake is the prevalent impression that torsion cannot take place in a normal testis.2 But the testes may be normal in size and situation and yet display developmental defects. These may take the form of an abnormally long mesorchium, unipolar attachment of the epididymis to the body of the testis, or high fusion of the visceral and parietal layers of the tunica vaginalis. Except for one important detail discussed by Mr. J. C. Angell in our last issue, these abnormalities are not detectable clinically. The fact to which he draws attention is that any or all of them tend to tip the testes into a horizontal plane, instead of the normal vertical plane. The lie of a swollen and tender testis is unlikely to be easily determined; but 1. 2.
Roche, A. E. St. Bart’s Hosp. Rep. 1928, 61, 183. Bailey, H. Diseases of the Testicle. London, 1936.
in these cases the testes on both sides display similar anatomical variations. Though Ewert and Hoffman3 could find only 26 out of 489 collected cases in which torsion had eventually affected both testes, this does not by any means exclude the possibility that many more had a predisposing anatomical abnormality on the other side. Angell, therefore, maintains that torsion is the most likely diagnosis in a patient who complains of sudden onset of pain in the testis unaccompanied by signs of urethritis, and in whom the testis on the other side is found to lie horizontally when he stands up. The time has come for abandoning the practice of treating such patients with scepticism and antibiotics.
usually
MANGANESE-INDUCED HYPOGLYCÆMIA
FOR centuries infusions of various plants were used for treatment of diabetes mellitus. Such infusions may significantly reduce raised blood-sugar levels, sometimes by undesirable means such as hepatocellular damage, but how most of the botanical hypoglycaemic agents act is unknown. This storehouse of folk-medicine may include drugs of clinical value and hypoglycaemic mechanisms of wide interest. In a report of manganese-induced hypoglycxmia Dr. Rubenstein and his colleagues4 describe the case of a muscular young diabetic who had himself found that infusions of lucerne (Medicago sativa) controlled hyperglycxmia more effectively than insulin in daily doses of up to 200 units. Rubenstein et al. repeatedly confirmed that infusions of lucerne lowered this diabetic’s high blood-sugar levels dramatically and quickly. The only constituent of lucerne known to be unusual was its high content of manganese; and administration of manganese chloride by mouth and by vein brought about a very similar type of hypoglycaemic response. Whether such a response is at all common in other diabetics or in nondiabetics is unknown; but trials on a few healthy individuals and by obese and juvenile-onset diabetics had negative results. It may be relevant that the young
the
manganese-sensitive diabetic was peculiarly resistant to ketosis. Perhaps the most striking event in the course of this diabetic’s
the elimination of his responsiveness lucerne infusions and to manganese by removal of the body and tail of the pancreas, undertaken in an effort to find a hypothetical islet-cell tumour. It seems probable, then, that the mechanism of the hypoglycasmic action of the manganese chloride was associated with tissue in the excised part of the pancreas, even although no structural abnormality was seen in it. Manganese, one of the so-called transition elements, is an essential dietary constituent. It is usually ingested to the extent of some 5 mg. daily,5 and yet the total body 6 manganese is only about three times this figure. Manganese is known to be a cofactor in several enzyme systems, including a mitochondrial oxidative phosphorylation and others concerned with the synthesis of fat and cholesterol.7 Studies involving radioactive isotopes of manganese have shown that virtually all the manganese in the body is rapidly exchangeable,8 and most of it is associated with the mitochondria, especially in the treatment was
to
3. 4. 5. 6. 7. 8.
Ewert, E. E., Hoffman, H. A. J. Urol. 1944, 51, 55. Rubenstein, A. H., Levin, N. W., Elliott, G. A. Lancet, 1962, ii, Kent, N. L., McCance, R. A. Biochem. J. 1941, 35, 877. Schroeder, H. A. Advanc. intern. Med. 1956, 8, 254. Cotzias, G. C. Fed. Proc. 1961, 20, part 2, p. 98. Borg, D. C., Cotzias, G. C. J. clin. Invest. 1958, 37, 1267.
1348.