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Dicumarol poisoning
454
AMERICAN
HEART
J0URNAL
cardiac lesion was a rheumatic valvulitis in all but two of the patients who had congenital heart lesions. The etiological agent was a green-producing streptococcus in all except three persons in whom Streptococcus fuecalis was responsible for the infection. For the average patient, around 300,000 units of penicillin per day were given intramuscularly in divided doses every three hours, day and night, for a periocl of from three ~CJ six weeks. In more recent months, this was increased to 500,000 to l,OOO,OOO units per day for a period of from five to seven weeks. In the case of organisms showing a high resistance to penicillin in vitro, doses as high as 10,000,000 units a day were given by continuous intravenous drip for periods of from six to eight weeks before a cure could be effected. Of the nine patients who died, four represented definite treatment failures. In three of the nine fatalities the cause of death was unknown, but two of these patients died within a period of three weeks after the treatment \vas stopped and most probably represented treatment failures. In two of the nine fatalities death resulted from congestive heart failure within two months after treatment was stopped, the disease having been bac~criologirally arrested. Thus, of the nine who died, six represented treatment failures while three had achieved bacteriologic arrest of their infections. A minimum of three to four weeks of continuous therapy appears neceshary. The a minimal daily dose, usually 500,000 to l,OOO,OOO daily dose of penicillin must be adequate; units per day, is sufficient in the ordinary case. The authors feel it is safe to predict that if therapy is started early and if it is sufficiently intensive, a remarkably high percentage of recoveries will be obtained. RELLET.
Beaumont, Failure.
G. E., Brit.
and Hear+ M. J. 1:50
A Case J. B.: (Jan. lo), 1948.
of Reversible
Papilloedema
Due
to Heart
A man 61 years of age was admitted to the hospital with a diagnosis of coal-gas poisoning of two days’ duration. Examination revealed some justification for this diagnosis since he was and very cyanosed, the hands and face being a in a stuporous condition, extremely dyspneic, deep blue-plum color. The blood pressure was 145/95. There were marked venous engorgement, a palpable liver, and &es at the base of both lungs. It was thought that this was a case of left- and right-sided heart failure, probably secondary to long-standing emphysema, bronchitis, and asthma. X-ray examination of the chest suggested that there was some pulmonary arterioOn routine examination of the eyes the patient was found to have pronounced papilsclerosis. Iedema of both discs. The patient was treated by venescction “cardophylin,” and digitalis, and in seven days all signs of heart failure had disappeared, with the exception of some residual cyanosis of the extremities, of the ears, and of the fingers. ‘The papilledema gradually cleared, After improvement, the patient was discharged, the blood pressure having fallen to 100/75; bllt two months later he relapsed and died in a second attack of cardiac failure in which the bilateral papilledema was again present. RELLET.
Draper,
A. J-3 Jr.:
Dicumarol
Poisoning.
J. A. M. A. 136:171
(Jan.
17), 1948.
The author presents a case of self-medication with Dicumarol which resulted in widespread hemorrhages of serious import. A 46-year-old graduate nurse entered the hospital complaining of pain across the middle of the back, tightness in the upper part of the abdomen, and the passage of bloody urine for two days. The patient said she had taken “eight or ten tablets” of Dicumarol for “arthritis,” three weeks prior to admission. Fleeting pains throughout the limbs and trunk when the patient arose in the morning led to the diagnosis of arthritis. Physical examination revealed scattered deep purple ecchymoses some 2.0 cm. in diameter over the skin of the forearms, thighs, and flanks. Scattered petechiae were easily seen over the chest, forearms, and calves and in the mucous membrane of the mouth. The bleeding time ~~a.5 5 minutes 30 seconds, coagulation t imc, 10 On the day following admission, the patient was minutes plus, and prothrombin time, 1 per cent. given 30 mg. of Synkayvite (a vitamin K preparation) intramuscularly, in divided doses, 60 mg. of Synkayvite intravenously twice, six hours apart, and a transfusion of 500 C.C. of fresh titrated
SELECTED
455
ABSTRACTS
whole blood. By the third day the patient showed perature beginning the day following admission rose eighth day. The prothrombin level rose successively The coagulation time fell by the fifth day to 2 minutes ute 1.5 seconds. Blood counts had been restored to was discharged on the eighth hospital day.
much subjective improvement. The temdaily but returned to normal levels by the and reached 55 per cent on the eighth day. 6 seconds, and the bleeding time to 1 minnormal by the seventh day. The patient BELLET.
Warren, J. V., Brannon, E. S., Weens, H. S., and Stead, E. A., Jr.: the Blood Volume and Right Atria1 Pressure on the Circulation by Intravenous Infusions. Am. J. Med. 4:193 (Feb.), 1948.
Effect of Increasing of Normal Subjects
The effect of increasing the blood volume by the rapid intravenous administration of 5 per cent albumin solution and physiological saline solution in normal young volunteers was studied. The observations included right atrial pressure, cardiac output, arterial pressure, plasma proteins, hemoglobin content of the blood, plasma volume, and heart size by means of teleroentgenograms. The authors found that the increase in blood volume consistently caused a rise in atria1 pressure, but the cardiac’output, arterial blood pressure, and pulse rate showed no consistent change. No demonstrable change in the transverse diameter of the heart occurred with variations in atrial pressure of approximately 125 mm. of water. They conclude that increasing the blood volume and atria1 pressure throws no demonstrable mechanical burden on the circulation in normal subjects and suggest that this may also be true in patients with heart failure. The question of why fluid tends to accumulate in the lungs to such a striking degree in patients with heart failure is discussed at length. WOODS.
Leiter,
L. : 1948.
Renal
Diseases:
Some
Facts
and
Problems.
Ann.
Int.
Med.
28:229
(Feb.),
Based on newer concepts of renal disease and renal physiology, the author presents a modified classification of the nephropathies. He demonstrates that the integration of pathogenesis with the altered physiology of the lesions provides a rational approach in the therapeutic management of the various types of renal disease. He divides the organic lesions of the kidney into the following: (1) glomerulonephritis, (2) glomerulonephrosis, (3) glomerulosclerosis, (4) glomerulitis, (5) pyelonephritis, (6) vascular, (7) tubular, and (8) congenital anomalies. The functional classification he employs is as follows: (1) vasoconstriction, (2) tubulovascular, (3) tubular (hormonal), and (4) tubular (metabolic). Since he considers the use of the diagnosis of focal glomerulonephritis to be very dangerous from the standpoint of both treatment and prognosis, he recommends the term glomerulitis as a substitute for focal glomerulonephritis. The immunologic mechanisms which might be responsible for the development of poststreptococcal glomerulonephritis are briefly discussed. The problem of diabetic glomerulosclerosis is briefly considered and emphasis is placed on the need The salt retention which is a prominent for recognizing that this is not an infrequent lesion. feature in patients with essential hypertension is related to hormonal factors as well as to a disturbance in renal hemodynamics secondary to a generalized neurogenic vascular derangement. The physiology of the kidney in cardiac failure is reviewed and, on the basis of such knowledge, the author shows the rationale of salt restriction in the treatment of cardiac edema. The late renal deaths in the crush syndrome after incompatible blood transfusion reaction, in postoperative reactions, in the so-called hepatorenal syndrome, various infections and intoxications, metabolic comas, and other conditions are attributed to reflex renal vasoconstriction He favors the term tubulovascular syndrome for this with ischemia of the tubular epithelium. disturbance and considers it synonymous with the terminology of lower nephron nephrosis used by other investigators. The dividing line between the tubulovascular functional disturbances and the organic chemical nephroses or necroses of tubules is a tenuous one, and, perhaps, of only
AMERICAN
HEART
J0URNAL
cardiac lesion was a rheumatic valvulitis in all but two of the patients who had congenital heart lesions. The etiological agent was a green-producing streptococcus in all except three persons in whom Streptococcus fuecalis was responsible for the infection. For the average patient, around 300,000 units of penicillin per day were given intramuscularly in divided doses every three hours, day and night, for a periocl of from three ~CJ six weeks. In more recent months, this was increased to 500,000 to l,OOO,OOO units per day for a period of from five to seven weeks. In the case of organisms showing a high resistance to penicillin in vitro, doses as high as 10,000,000 units a day were given by continuous intravenous drip for periods of from six to eight weeks before a cure could be effected. Of the nine patients who died, four represented definite treatment failures. In three of the nine fatalities the cause of death was unknown, but two of these patients died within a period of three weeks after the treatment \vas stopped and most probably represented treatment failures. In two of the nine fatalities death resulted from congestive heart failure within two months after treatment was stopped, the disease having been bac~criologirally arrested. Thus, of the nine who died, six represented treatment failures while three had achieved bacteriologic arrest of their infections. A minimum of three to four weeks of continuous therapy appears neceshary. The a minimal daily dose, usually 500,000 to l,OOO,OOO daily dose of penicillin must be adequate; units per day, is sufficient in the ordinary case. The authors feel it is safe to predict that if therapy is started early and if it is sufficiently intensive, a remarkably high percentage of recoveries will be obtained. RELLET.
Beaumont, Failure.
G. E., Brit.
and Hear+ M. J. 1:50
A Case J. B.: (Jan. lo), 1948.
of Reversible
Papilloedema
Due
to Heart
A man 61 years of age was admitted to the hospital with a diagnosis of coal-gas poisoning of two days’ duration. Examination revealed some justification for this diagnosis since he was and very cyanosed, the hands and face being a in a stuporous condition, extremely dyspneic, deep blue-plum color. The blood pressure was 145/95. There were marked venous engorgement, a palpable liver, and &es at the base of both lungs. It was thought that this was a case of left- and right-sided heart failure, probably secondary to long-standing emphysema, bronchitis, and asthma. X-ray examination of the chest suggested that there was some pulmonary arterioOn routine examination of the eyes the patient was found to have pronounced papilsclerosis. Iedema of both discs. The patient was treated by venescction “cardophylin,” and digitalis, and in seven days all signs of heart failure had disappeared, with the exception of some residual cyanosis of the extremities, of the ears, and of the fingers. ‘The papilledema gradually cleared, After improvement, the patient was discharged, the blood pressure having fallen to 100/75; bllt two months later he relapsed and died in a second attack of cardiac failure in which the bilateral papilledema was again present. RELLET.
Draper,
A. J-3 Jr.:
Dicumarol
Poisoning.
J. A. M. A. 136:171
(Jan.
17), 1948.
The author presents a case of self-medication with Dicumarol which resulted in widespread hemorrhages of serious import. A 46-year-old graduate nurse entered the hospital complaining of pain across the middle of the back, tightness in the upper part of the abdomen, and the passage of bloody urine for two days. The patient said she had taken “eight or ten tablets” of Dicumarol for “arthritis,” three weeks prior to admission. Fleeting pains throughout the limbs and trunk when the patient arose in the morning led to the diagnosis of arthritis. Physical examination revealed scattered deep purple ecchymoses some 2.0 cm. in diameter over the skin of the forearms, thighs, and flanks. Scattered petechiae were easily seen over the chest, forearms, and calves and in the mucous membrane of the mouth. The bleeding time ~~a.5 5 minutes 30 seconds, coagulation t imc, 10 On the day following admission, the patient was minutes plus, and prothrombin time, 1 per cent. given 30 mg. of Synkayvite (a vitamin K preparation) intramuscularly, in divided doses, 60 mg. of Synkayvite intravenously twice, six hours apart, and a transfusion of 500 C.C. of fresh titrated
SELECTED
455
ABSTRACTS
whole blood. By the third day the patient showed perature beginning the day following admission rose eighth day. The prothrombin level rose successively The coagulation time fell by the fifth day to 2 minutes ute 1.5 seconds. Blood counts had been restored to was discharged on the eighth hospital day.
much subjective improvement. The temdaily but returned to normal levels by the and reached 55 per cent on the eighth day. 6 seconds, and the bleeding time to 1 minnormal by the seventh day. The patient BELLET.
Warren, J. V., Brannon, E. S., Weens, H. S., and Stead, E. A., Jr.: the Blood Volume and Right Atria1 Pressure on the Circulation by Intravenous Infusions. Am. J. Med. 4:193 (Feb.), 1948.
Effect of Increasing of Normal Subjects
The effect of increasing the blood volume by the rapid intravenous administration of 5 per cent albumin solution and physiological saline solution in normal young volunteers was studied. The observations included right atrial pressure, cardiac output, arterial pressure, plasma proteins, hemoglobin content of the blood, plasma volume, and heart size by means of teleroentgenograms. The authors found that the increase in blood volume consistently caused a rise in atria1 pressure, but the cardiac’output, arterial blood pressure, and pulse rate showed no consistent change. No demonstrable change in the transverse diameter of the heart occurred with variations in atrial pressure of approximately 125 mm. of water. They conclude that increasing the blood volume and atria1 pressure throws no demonstrable mechanical burden on the circulation in normal subjects and suggest that this may also be true in patients with heart failure. The question of why fluid tends to accumulate in the lungs to such a striking degree in patients with heart failure is discussed at length. WOODS.
Leiter,
L. : 1948.
Renal
Diseases:
Some
Facts
and
Problems.
Ann.
Int.
Med.
28:229
(Feb.),
Based on newer concepts of renal disease and renal physiology, the author presents a modified classification of the nephropathies. He demonstrates that the integration of pathogenesis with the altered physiology of the lesions provides a rational approach in the therapeutic management of the various types of renal disease. He divides the organic lesions of the kidney into the following: (1) glomerulonephritis, (2) glomerulonephrosis, (3) glomerulosclerosis, (4) glomerulitis, (5) pyelonephritis, (6) vascular, (7) tubular, and (8) congenital anomalies. The functional classification he employs is as follows: (1) vasoconstriction, (2) tubulovascular, (3) tubular (hormonal), and (4) tubular (metabolic). Since he considers the use of the diagnosis of focal glomerulonephritis to be very dangerous from the standpoint of both treatment and prognosis, he recommends the term glomerulitis as a substitute for focal glomerulonephritis. The immunologic mechanisms which might be responsible for the development of poststreptococcal glomerulonephritis are briefly discussed. The problem of diabetic glomerulosclerosis is briefly considered and emphasis is placed on the need The salt retention which is a prominent for recognizing that this is not an infrequent lesion. feature in patients with essential hypertension is related to hormonal factors as well as to a disturbance in renal hemodynamics secondary to a generalized neurogenic vascular derangement. The physiology of the kidney in cardiac failure is reviewed and, on the basis of such knowledge, the author shows the rationale of salt restriction in the treatment of cardiac edema. The late renal deaths in the crush syndrome after incompatible blood transfusion reaction, in postoperative reactions, in the so-called hepatorenal syndrome, various infections and intoxications, metabolic comas, and other conditions are attributed to reflex renal vasoconstriction He favors the term tubulovascular syndrome for this with ischemia of the tubular epithelium. disturbance and considers it synonymous with the terminology of lower nephron nephrosis used by other investigators. The dividing line between the tubulovascular functional disturbances and the organic chemical nephroses or necroses of tubules is a tenuous one, and, perhaps, of only