- Email: [email protected]
THE ORAL INJECTION OF LIPIODOL.
590 established value. The Report of the League of Nations on the Second International Congress on Sleeping Sickness states that all medical officers agree that the former methods of treatment should be replaced by tryparsamide. The examination of the cerebro-spinal fluid and the institutional treatment of all cases presenting modifications of this fluid is advised. The course recommended is one of 12 injections, the maximum dose being 2 g. In the Memorandum submitted by the British Colonial Office to the League of Nations Conference, the
Uganda report refers to the prophylactic value of injections of tryparsamide for members of any hunting party. Sterilisation of the blood was found to persist for a considerable period after such injection ’ that mechanical transmission from one individual cyclical infection of the fly should be prevented by.this means. so
to another and also the
OCCLUSION OF THE CORONARY VESSELS.
I Ii
has been shown to be the case experimentally in animals, where the lower the blood pressure the larger the infarcted area produced. Each observer who has investigated by these methods has been able to add something to our knowledge of the coronary artery circulation, and how it is affected by disease. More particularly we are learning something of the cause for the varied individual reactions to blockage of the same vessel W. Spalteholz, or the same branch of a vessel. in 1907, by means of his injection and clearing technique, claimed to have demonstrated that no end-arteries existed in the heart, and that there was a rich anastomosis in all its muscular and endothelial layers. Gross established the fact with his radioopaque bismuth injection technique. " The heart," he said, is perhaps the richest organ in the body as regards capillary and precapillary anastomoses between branches of the same main vessel and between branches from the two sides." Gross also showed that the accumulation of epicardial fat added to the heart a vascular sheath which slowly thickened with age and made anastomotic communications with the ’’
IT is now 25 years since A. G. Fryett showed that the coronary arteries could be injected post mortem with a underlying muscle, thereby putting a new complexion substance opaque to X rays, making it possible to study ’, on the behaviour of epicardial fat which up till then these vessels and their branches in detail and note thei had often been suspect of causing sudden death
changes in disease.
Since then several observers have where no other cause could be demonstrated. Finally. these lines with variations in technique and Hadfield confirmed2 Gross’s statement and Geoffrey apparatus. In the September number of the was able to show that the anastomoses in the epicardial Practitioner appears an important radiographic study fat of the senile heart helped it to compensate to a of these arteries with special reference to coronary considerable for a diminished flow through degree thrombosis by Dr. E. Wyn Jones, from the heart its atherosclerotic vessels, provided there was no department of the Liverpool Royal Infirmary. It serious drop in blood pressure. Using the celloidin differs from previous work in combining clinical technique of Morison followed by erosion in strong observation of individual cases with subsequent acid, Hadfield confirmed the presence of innumerable pathological investigation-a method that should anastomoses, which explained recovery following be fruitful of results. Dr. Wyn Jones-whose extensive coronary occlusion- In the future it may article was adjudged to be the best submitted in a prove possible to inject some substance opaque to competition open to practitioners of not more than X rays into the veins of the living subject, permitting two years’ standing-devised his own method of a detailed examination of the coronary circulation injection, on the lines of the standard technique during life. introduced by Louis Guss in 1921 but simpler and easier of manipulation. His findings agree in the THE ORAL INJECTION OF LIPIODOL. main with those of previous investigators, but he is able to add two new facts to our knowledge : one, FOR introducing lipiodol into the lungs oral injection that in 5 per cent. of hearts the left coronary artery seems to be the method of choice in America, and is is the sole supply of the neuromuscular tissue, the increasingly employed in this country. The ease other that Iper cent. of all hearts possess three with which it can be done is often almost incredible. coronaries, the accessory vessel being found more With no previous a,nsesthetisa,tion, with the patient commonly on the right in the proportion of 8 : 1. sitting on a chair and holding out his own tongue, Possibly the latter is the accessory vessel demonstrated and with apparatus no more elaborate than an by J. S. Campbell in 1927 at a meeting of the Associa- ordinary 20 c.cm. syringe and a straight cannula tion of Physicians of Great Britain and Ireland, and the oil can be steadily dropped over the back of the judged by him to be a branch arising from the right tongue into the trachea, and the whole affair may be coronary artery near its origin; this vessel was over in three or four minutes. Many patients will present in 20 per cent. of his series.1 Dr. Wyn declare themselves unaware that anything is happenJones notes that the coronary anastomosis becomes ing, but others, of course, are intolerant. Others, much more extensive with increasing age, a fact again, while appearing to allow the oil to descend confirmed by others, and it is of interest to realise that the trachea, will hold the oil above the glottis and previous coronary disease is an advantage to the then expel it all by a sudden cough. In such a case patient whose artery is occluded; the gradual it is an advantage to be able to see exactly where the diminution of the lumen of the vessel by athero- oil is going, and Arnold Josefson, of Stockholm, sclerosis allows an efficient compensatory anastomosis has described3 an instrument for this purpose. to develop, so that when the final block occurs the new It consists of a curved spatula along the upper surface anastomotic channels are ready to take on the of which is affixed a cannula projecting beyond the necessary work. Again a condition ofhigh blood end of the spatula ; above this is a lamp and a pressure is also an advantage to the patient, for the laryngeal mirror. Such a device may be of value in fall of pressure consequent on the shock of the sudden difficult cases, but with gentle persistence it will be thrombosis is not so great as it would be in a patient found that even the intolerant are often able to allow if the pressure were normal, and there is no delay in the oil to flow down the trachea. Lipiodol injections the opening up of new anastomotic channels. This worked
on
____
1 THE LANCET, 1926, ii., 168.
2 Brit. Med. Chi. Jour., 1927, xliv., 257. 3 Acta Med. Scand., 1930, lxxiii.,
-
591
important in diagnosis, and the oral method from maize, was described by H. Chick and E. M. simple and so infinitely more agreeable for the Hume 7; the oedema was rapidly cured by administrapatient than the crico-thyroid route, and so free of tion of casein. After the war period the urgent all dangers, that every effort should be made to practical interest in the problem died down, and it was acquire the technique. Some say it is impracticable left in an interesting but inconclusive position for and inferior to other methods, but this is not the nearly ten years. Last year R. A. Frisch, L. B. verdict of more experienced workers. By suitable Mendel, and J. P. Petersrepeated and extended
are so is so
Kohman’s work and have established that oedema
posture during and after injection, the oil may be made to reach the very apices of the lungs by the oral route, as was well shown in the paper by Dr. W. Burton Wood which we published on June 21st (p. 1339). A full description of the method, which was worked out especially by J. J. Singer, of St. Louis, may be found in a monograph on lipiodol in the diagnosis 4of thoracic disease reviewed in our columns last year.
in rats on a diet in which the protein entirely derived from carrots. The oedema is accompanied by a marked lowering of the serum proteins, which after two to three months are reduced by 40 per cent. When starch up to 18 per cent. of the total calories is withdrawn from the diet and replaced by casein, the cedema does not develop and the It is pointed out serum proteins are maintained.
is is
produced
that E. H. Starling9 first showed that the colloid osmotic pressure of the serum is proportional to the HOSPITAL SWEEPSTAKES. APPARENTLY the promotion of hospital sweepstakes concentration of protein in it, and he advanced the is likely to become a special line of business in the theory that decreased osmotic pressure in the serum Irish Free State. There is, in the first place, the is responsible for the deposition of water in the Starling’s suggestion was subsequently sweepstake being organised on the Manchester tissues. but contested the work just quoted substantiates it, November Handicap by a committee representative besides confirmatory evidence of the affording of six of the Dublin hospitals. This committee has of war oedema upon a poor protein supply. dependence It been registered as " Hospitals’ Trust, Ltd." Not long ago Dr. F. J. Poynton and Dr. J. V. .appears to intend to widen its scope in future, for 10 in our columns a fatal case of it is stated that a meeting was recently held, on the Macgregor described in which oedema developed fistula gastro-jejuno-colic invitation of the hospitals concerned in the Trust, of in of deficient consequence absorption, and two less Tepresentatives of the boards of several hospitals serious cases have been : lately reported at the Mayo the Irish a Free to more State, arrange for throughout Clinic by Dr. A. M. Snell.ll Both Dr. Snell’s patients : in future sweepstakes. Repregeneral participation sentatives from institutions in Cork, Limerick, were suffering from pyloric obstruction and had been on inadequate diets, and both had Waterford, and Louth, as well as from several ini for some time the of large quantities of required Dublin, were present, and tentative agreement was fluid. The administration precipitating factor may have been the reached to organise a sweepstake on next year’s5 Grand National. Side by side with this enterprise, enforced abstinence from food after operation. Pitting ; oedema appeared in the legs of the first patient, a a new private company was registered last week under the title " The Charities Guild, Ltd." with the woman aged 61, fifteen days after excision of an ulcer gastro-enterostomy. Marked oedema object of promoting sweepstakes and drawings of and posterior a fortnight after the same operation in the prizes in aid of charitable institutions in the Irish developed a plumber aged 44. second patient, Investigation of Free State. The managing director is, according to the blood that at this time the serum proteins showed The the press, a " well-known turf accountant." were about 30 per cent. below the normal level-i.e., history of the first sweepstake will be watched with about 5 g. per 100 c.cm. In both cases there was much interest by those concerned with hospital marked secondary anaemia, which may have interfered finance. Whether sweepstakes are to become one with the oxygenation of the tissues and reduced the of the principal sources of revenue to Irish hospitals of the capillaries. The patients were permeability or to sink into disuse will depend on two factorsa diet ofhigh vitamin content with an adequate given and thE amount of money subscribed, namely, the supply of protein ; the first had full doses of ferric proportion of it that reaches them. citrate and rapidly improved until, at her discharge about six weeks later, the concentration of serum ŒDEMA DUE TO INANITION. proteins was 7’7 g. in 100 c.cm. and the haemoglobin AT the end of the Great War the prevalence ofaand red blood-cell count were practically normal. oedema, called " war oedema " or " famine oedema,"The second patient had a transfusion of 500 c.cm. of 1 which caused moderate diuresis for two days. attracted considerable attention in Central Europe, blood, as well as in other parts of the world. It was associatedAfter this the oedema was greatly reduced and the I with a very poor diet, consisting almost entirelyserum proteins rose to 5’9 g. in 100 c.cm. Both These mild of root vegetables, and various explanations of it were patients made complete recoveries. given. Many observers referred it to the high saltgrades of inanition oedema must, Dr. Snell thinks, content of the diet, but A. Schittenhelm and H. often escape recognition. Provided that the causative Schlecht,5 who studied the condition in prison camps, disease is not progressive and a high protein diet can concluded that it was best treated by rest and be taken, treatment is very effective. increased fat and protein in the diet. In 1920 7 Biochem. Jour., 1920, xiv., 135. E. A. Kohman,6 who was investigating the dietary 8 Jour. Biol. Chem., 1929, lxxxiv., 167. of with that the carrots found when rats, 9 Jour. Physiol., 1895, xix., 342. properties 10 THE LANCET, August 2nd, 1930, p. 240. diet consisted of little else a certain number of the 11 Proc. Staff Meetings, Mayo Clinic, July 9th, 1930. rats upon it tended to develop oedema. Further investigation seemed to inculpate the protein as the SOCIETY OF MEDICAL OFFICERS OF HEALTH.—— only significant factor. oedema in a monkey, fed on a diet in which the only proteins were those derived At the provincial meeting of this society to be held at Lowestoft on Sept. 19th-20th, the members will be entertained by the Mayor and Corporation of Lowestoft at THE LANCET, 1929, i., 670. ,
r
,
4
5 Berlin klin. Woch., 1918, lviii., 1138. 6 Amer. Jour. Physiol., 1920, li., 378.
previous
luncheon
on the 20th and not notice.
on
the 19th
as
stated in
our
Uganda report refers to the prophylactic value of injections of tryparsamide for members of any hunting party. Sterilisation of the blood was found to persist for a considerable period after such injection ’ that mechanical transmission from one individual cyclical infection of the fly should be prevented by.this means. so
to another and also the
OCCLUSION OF THE CORONARY VESSELS.
I Ii
has been shown to be the case experimentally in animals, where the lower the blood pressure the larger the infarcted area produced. Each observer who has investigated by these methods has been able to add something to our knowledge of the coronary artery circulation, and how it is affected by disease. More particularly we are learning something of the cause for the varied individual reactions to blockage of the same vessel W. Spalteholz, or the same branch of a vessel. in 1907, by means of his injection and clearing technique, claimed to have demonstrated that no end-arteries existed in the heart, and that there was a rich anastomosis in all its muscular and endothelial layers. Gross established the fact with his radioopaque bismuth injection technique. " The heart," he said, is perhaps the richest organ in the body as regards capillary and precapillary anastomoses between branches of the same main vessel and between branches from the two sides." Gross also showed that the accumulation of epicardial fat added to the heart a vascular sheath which slowly thickened with age and made anastomotic communications with the ’’
IT is now 25 years since A. G. Fryett showed that the coronary arteries could be injected post mortem with a underlying muscle, thereby putting a new complexion substance opaque to X rays, making it possible to study ’, on the behaviour of epicardial fat which up till then these vessels and their branches in detail and note thei had often been suspect of causing sudden death
changes in disease.
Since then several observers have where no other cause could be demonstrated. Finally. these lines with variations in technique and Hadfield confirmed2 Gross’s statement and Geoffrey apparatus. In the September number of the was able to show that the anastomoses in the epicardial Practitioner appears an important radiographic study fat of the senile heart helped it to compensate to a of these arteries with special reference to coronary considerable for a diminished flow through degree thrombosis by Dr. E. Wyn Jones, from the heart its atherosclerotic vessels, provided there was no department of the Liverpool Royal Infirmary. It serious drop in blood pressure. Using the celloidin differs from previous work in combining clinical technique of Morison followed by erosion in strong observation of individual cases with subsequent acid, Hadfield confirmed the presence of innumerable pathological investigation-a method that should anastomoses, which explained recovery following be fruitful of results. Dr. Wyn Jones-whose extensive coronary occlusion- In the future it may article was adjudged to be the best submitted in a prove possible to inject some substance opaque to competition open to practitioners of not more than X rays into the veins of the living subject, permitting two years’ standing-devised his own method of a detailed examination of the coronary circulation injection, on the lines of the standard technique during life. introduced by Louis Guss in 1921 but simpler and easier of manipulation. His findings agree in the THE ORAL INJECTION OF LIPIODOL. main with those of previous investigators, but he is able to add two new facts to our knowledge : one, FOR introducing lipiodol into the lungs oral injection that in 5 per cent. of hearts the left coronary artery seems to be the method of choice in America, and is is the sole supply of the neuromuscular tissue, the increasingly employed in this country. The ease other that Iper cent. of all hearts possess three with which it can be done is often almost incredible. coronaries, the accessory vessel being found more With no previous a,nsesthetisa,tion, with the patient commonly on the right in the proportion of 8 : 1. sitting on a chair and holding out his own tongue, Possibly the latter is the accessory vessel demonstrated and with apparatus no more elaborate than an by J. S. Campbell in 1927 at a meeting of the Associa- ordinary 20 c.cm. syringe and a straight cannula tion of Physicians of Great Britain and Ireland, and the oil can be steadily dropped over the back of the judged by him to be a branch arising from the right tongue into the trachea, and the whole affair may be coronary artery near its origin; this vessel was over in three or four minutes. Many patients will present in 20 per cent. of his series.1 Dr. Wyn declare themselves unaware that anything is happenJones notes that the coronary anastomosis becomes ing, but others, of course, are intolerant. Others, much more extensive with increasing age, a fact again, while appearing to allow the oil to descend confirmed by others, and it is of interest to realise that the trachea, will hold the oil above the glottis and previous coronary disease is an advantage to the then expel it all by a sudden cough. In such a case patient whose artery is occluded; the gradual it is an advantage to be able to see exactly where the diminution of the lumen of the vessel by athero- oil is going, and Arnold Josefson, of Stockholm, sclerosis allows an efficient compensatory anastomosis has described3 an instrument for this purpose. to develop, so that when the final block occurs the new It consists of a curved spatula along the upper surface anastomotic channels are ready to take on the of which is affixed a cannula projecting beyond the necessary work. Again a condition ofhigh blood end of the spatula ; above this is a lamp and a pressure is also an advantage to the patient, for the laryngeal mirror. Such a device may be of value in fall of pressure consequent on the shock of the sudden difficult cases, but with gentle persistence it will be thrombosis is not so great as it would be in a patient found that even the intolerant are often able to allow if the pressure were normal, and there is no delay in the oil to flow down the trachea. Lipiodol injections the opening up of new anastomotic channels. This worked
on
____
1 THE LANCET, 1926, ii., 168.
2 Brit. Med. Chi. Jour., 1927, xliv., 257. 3 Acta Med. Scand., 1930, lxxiii.,
-
591
important in diagnosis, and the oral method from maize, was described by H. Chick and E. M. simple and so infinitely more agreeable for the Hume 7; the oedema was rapidly cured by administrapatient than the crico-thyroid route, and so free of tion of casein. After the war period the urgent all dangers, that every effort should be made to practical interest in the problem died down, and it was acquire the technique. Some say it is impracticable left in an interesting but inconclusive position for and inferior to other methods, but this is not the nearly ten years. Last year R. A. Frisch, L. B. verdict of more experienced workers. By suitable Mendel, and J. P. Petersrepeated and extended
are so is so
Kohman’s work and have established that oedema
posture during and after injection, the oil may be made to reach the very apices of the lungs by the oral route, as was well shown in the paper by Dr. W. Burton Wood which we published on June 21st (p. 1339). A full description of the method, which was worked out especially by J. J. Singer, of St. Louis, may be found in a monograph on lipiodol in the diagnosis 4of thoracic disease reviewed in our columns last year.
in rats on a diet in which the protein entirely derived from carrots. The oedema is accompanied by a marked lowering of the serum proteins, which after two to three months are reduced by 40 per cent. When starch up to 18 per cent. of the total calories is withdrawn from the diet and replaced by casein, the cedema does not develop and the It is pointed out serum proteins are maintained.
is is
produced
that E. H. Starling9 first showed that the colloid osmotic pressure of the serum is proportional to the HOSPITAL SWEEPSTAKES. APPARENTLY the promotion of hospital sweepstakes concentration of protein in it, and he advanced the is likely to become a special line of business in the theory that decreased osmotic pressure in the serum Irish Free State. There is, in the first place, the is responsible for the deposition of water in the Starling’s suggestion was subsequently sweepstake being organised on the Manchester tissues. but contested the work just quoted substantiates it, November Handicap by a committee representative besides confirmatory evidence of the affording of six of the Dublin hospitals. This committee has of war oedema upon a poor protein supply. dependence It been registered as " Hospitals’ Trust, Ltd." Not long ago Dr. F. J. Poynton and Dr. J. V. .appears to intend to widen its scope in future, for 10 in our columns a fatal case of it is stated that a meeting was recently held, on the Macgregor described in which oedema developed fistula gastro-jejuno-colic invitation of the hospitals concerned in the Trust, of in of deficient consequence absorption, and two less Tepresentatives of the boards of several hospitals serious cases have been : lately reported at the Mayo the Irish a Free to more State, arrange for throughout Clinic by Dr. A. M. Snell.ll Both Dr. Snell’s patients : in future sweepstakes. Repregeneral participation sentatives from institutions in Cork, Limerick, were suffering from pyloric obstruction and had been on inadequate diets, and both had Waterford, and Louth, as well as from several ini for some time the of large quantities of required Dublin, were present, and tentative agreement was fluid. The administration precipitating factor may have been the reached to organise a sweepstake on next year’s5 Grand National. Side by side with this enterprise, enforced abstinence from food after operation. Pitting ; oedema appeared in the legs of the first patient, a a new private company was registered last week under the title " The Charities Guild, Ltd." with the woman aged 61, fifteen days after excision of an ulcer gastro-enterostomy. Marked oedema object of promoting sweepstakes and drawings of and posterior a fortnight after the same operation in the prizes in aid of charitable institutions in the Irish developed a plumber aged 44. second patient, Investigation of Free State. The managing director is, according to the blood that at this time the serum proteins showed The the press, a " well-known turf accountant." were about 30 per cent. below the normal level-i.e., history of the first sweepstake will be watched with about 5 g. per 100 c.cm. In both cases there was much interest by those concerned with hospital marked secondary anaemia, which may have interfered finance. Whether sweepstakes are to become one with the oxygenation of the tissues and reduced the of the principal sources of revenue to Irish hospitals of the capillaries. The patients were permeability or to sink into disuse will depend on two factorsa diet ofhigh vitamin content with an adequate given and thE amount of money subscribed, namely, the supply of protein ; the first had full doses of ferric proportion of it that reaches them. citrate and rapidly improved until, at her discharge about six weeks later, the concentration of serum ŒDEMA DUE TO INANITION. proteins was 7’7 g. in 100 c.cm. and the haemoglobin AT the end of the Great War the prevalence ofaand red blood-cell count were practically normal. oedema, called " war oedema " or " famine oedema,"The second patient had a transfusion of 500 c.cm. of 1 which caused moderate diuresis for two days. attracted considerable attention in Central Europe, blood, as well as in other parts of the world. It was associatedAfter this the oedema was greatly reduced and the I with a very poor diet, consisting almost entirelyserum proteins rose to 5’9 g. in 100 c.cm. Both These mild of root vegetables, and various explanations of it were patients made complete recoveries. given. Many observers referred it to the high saltgrades of inanition oedema must, Dr. Snell thinks, content of the diet, but A. Schittenhelm and H. often escape recognition. Provided that the causative Schlecht,5 who studied the condition in prison camps, disease is not progressive and a high protein diet can concluded that it was best treated by rest and be taken, treatment is very effective. increased fat and protein in the diet. In 1920 7 Biochem. Jour., 1920, xiv., 135. E. A. Kohman,6 who was investigating the dietary 8 Jour. Biol. Chem., 1929, lxxxiv., 167. of with that the carrots found when rats, 9 Jour. Physiol., 1895, xix., 342. properties 10 THE LANCET, August 2nd, 1930, p. 240. diet consisted of little else a certain number of the 11 Proc. Staff Meetings, Mayo Clinic, July 9th, 1930. rats upon it tended to develop oedema. Further investigation seemed to inculpate the protein as the SOCIETY OF MEDICAL OFFICERS OF HEALTH.—— only significant factor. oedema in a monkey, fed on a diet in which the only proteins were those derived At the provincial meeting of this society to be held at Lowestoft on Sept. 19th-20th, the members will be entertained by the Mayor and Corporation of Lowestoft at THE LANCET, 1929, i., 670. ,
r
,
4
5 Berlin klin. Woch., 1918, lviii., 1138. 6 Amer. Jour. Physiol., 1920, li., 378.
previous
luncheon
on the 20th and not notice.
on
the 19th
as
stated in
our