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MEDICAL RECORDS
266 HYPERTENSION AND HYPERURICÆMIA SIR,-I find myself in slight disagreement with some of Dr. Breckenridge’s findings and conclusions (Jan. 1), although most of them accord with those which I reported in 1963 1 on serum-uric-acid levels in pregnancy, particularly when this
complicated by hypertension. Dr. Breckenridge believes that hyperuricsemia in hypertensives does not necessarily prevail in the severe hypertensive, and in this respect he disagrees with some other workers. My findings in the pregnant patient (which I agree are not strictly comparable) showed that those with " essential " hypertension (88) had normal levels of serum-uric-acid, even fractionally lower than in non-hypertensive patients (65 random controls) -mean 3-64 mg. as against 3.80 mg. per 100 ml. In preeclamptic toxaemia hypertensives (244) the level is significantly
was
I
raised-so much so that I concluded that the raised serumuric-acid level could be taken to differentiate the pre-eclamptic toxaemia case from the " essential " hypertension case. In pregnancy one is dealing with a selected group of young women in whom " essential " hypertension has usually existed for no more than a few years. The serum-uric-acid level tends to rise in the elderly, even in non-hypertensives. I believe the hyperuriceemia indicates tubular damage in the kidney, and that the excessive reabsorption which raises the serum level is the direct result of vascular disease at the site-temporary in pre-eclamptic hypertensives, but permanent in other hypertensives. I maintain that it is less misleading to base the severity of hypertension on its effects on the patient-e.g., raised uric-acid level due to kidney damage-than on a sphygmomanometer reading. Consequently, the raised serumuric-acid level should suggest severe disease, and in the majority this will occur in the older longstanding hypertensives. A raised serum-uric-acid level is certainly not a feature in the younger pregnant hypertensive woman, unless she has preeclamntic toxaemia. CALUM N. MCFARLANE.
MEDICAL RECORDS SIR,-This Group is investigating all aspects of the composition and handling of case-records in both hospital wards and outpatient clinics; and also considering possible means of coping with the increasing strain on storage facilities for these records. Recent correspondence regarding the Tunbridge Report on the standardisation of case-sheets indicates that there is a widespread interest in the whole subject, and that widely differing opinions on it are held. I should, therefore, be glad to receive any such views, and should also welcome information concerning the present position in other centres. Nuffield Provincial Hospitals Trust, Medical Records Research Group, Western Infirmary, Glasgow, W.1.
J.
H. MITCHELL.
TREATMENT OF ZOLLINGER-ELLISON SYNDROME and Dr. Marks (Jan. 1) make the following Bank SIR,-Dr. of my paper. At no point did I state or misrepresentations imply that my patient was a case of the Zollinger-Ellison syndrome, nor did I infer that this syndrome can be expected to respond to ganglion-blocking or anticholinergic drugs. I am " is far very well aware that " significant acid hypersecretion from being synonymous with the Zollinger-Ellison syndrome. Nonetheless, such hypersecretion rightly raises a strong suspicion that an islet-cell tumour may be present, and I believe that anticholinergic drugs should always be tried in these patients. The response may be very gratifying, as in the patient described by Dr. Bank and Dr. Marks in their letter. Too often this interesting group of hypersecretors is deprived of 1.
McFarlane, C. N. J. Obstet. Gynœc. Br. Commonw. 1963, 70, 63.
2.
Dean,
A. C. B.
Lancet, 1965, ii,
769.
the benefit of anticholinergic drugs because of the erroneous impression that the Zollinger-Ellison syndrome never responds to this treatment, and despite the evidence that an islet-cell tumour will not be discovered in more than a small proportion of them. Department of Surgical Service, University of Edinburgh.
A. C. B. DEAN.
FORTIFICATION SPECTRA any doctor, unfortunate enough to have fortification spectra, could furnish me with facts about this odd symptom which I have often had. I think these spectra are only seen: (1) in a bright light, and on looking up; (2) early on in an attack, which they often herald; (3) and only by a person with long sight whose focal point lies behind the retina. I believe that fortification spectra may be caused by a sudden reflection of the rods and cones of the retina, for the symptom is accompanied by oedema of the eye-I know of a lady whose attacks are heralded by the watering of an eye. The excess fluid, together with a sudden dramatic rise in blood-pressure, causes tension in the eye, and a reflection of the retina would be possible in a bright light under these conditions. Dr. C. W. M. Whitty (Oxford) has told me that Gowers, eighty years ago, thought fortification spectra were connected with the rods and cones of the retina. Once you have seen the spectra you cannot easily forget them, for they are such a neat, bright vision-I am tempted to think it is what Paul saw on the Damascus Road, and that migraine was his " thorn in the flesh ". ELSPETH STANFORD.
SiR,—Iwonder if
seen
ARTERIAL DISEASE: AN INTERNATIONAL SEARCH SIR,-In your annotation (Jan. 15) you suggest that fluoroscopy of the coronary arteries should be applied in population surveys to estimate the extent of arterial disease among the living. This method has various technical difficulties. Oliver et al.1 pointed out that necropsy findings and postmortem radiology clearly indicate that the prevalence of calcification detected by fluoroscopy during life is probably underestimated. Jorgens et awl.2 found calcification of coronary arteries in 83% of those who came to necropsy, whereas cinefluorography revealed calcification in only 25% of live hospital patients. They ascribe this wide variation to the limitations of the cinefluorographic method. Whatever the merits of this method for the detection of more advanced calcified lesions in the coronary arteries, I do not think that it has a place in population surveys of the extent of arterial disease among the living. You do not mention radiography of the abdominal aorta-a method which I have used in thousands of patients to detect atherosclerosis during life. A calcified plaque about 1 cm. in diameter can usually be seen in the lateral projection on radiographs of this large artery. The detection of atherosclerosis in the abdominal aorta usually indicates more widespread atherosclerosis, not only in the branches of the abdominal aorta but also in the coronary and other large arteries. This method revealed a sex difference in the incidence and severity of calcified lesions in the abdominal aorta,3 and an association of atherosclerosis in the central blood-supply of the stomach with gastric ulcer in the aged.45 This method has also been used as a valuable aid in the radiological differential diagnosis between benign and malignant lesions of the stomach.6In the 30-49year age-group, a distinct relation has been reported between the incidence and severity of calcifications in the abdominal aorta and occlusive or complicated lesions of the coronary arteries.7 1. 2. 3. 4. 5.
6. 7.
Oliver, M. F., Samuel, E., Morley, P., Young, G. B., Kapur, P. L. Lancet, 1964, i, 891. Jorgens, J., Boardman, W. J., Damberg, S. W., Kinney, W. N., Kundel, R. R. Am. J. Roentg. 1965, 95, 667. Elkeles, A. Lancet, 1957, ii, 714. Elkeles, A. Am. J. Roentg. 1950, 70, 797. Elkeles, A. ibid. 1964, 91, 744. Elkeles, A. Br. J. Radiol. 1949, 12, 280. Eggen, D. A., Strong, J. P., McGill, H. C. Archs Path. 1964, 78, 575.
complicated by hypertension. Dr. Breckenridge believes that hyperuricsemia in hypertensives does not necessarily prevail in the severe hypertensive, and in this respect he disagrees with some other workers. My findings in the pregnant patient (which I agree are not strictly comparable) showed that those with " essential " hypertension (88) had normal levels of serum-uric-acid, even fractionally lower than in non-hypertensive patients (65 random controls) -mean 3-64 mg. as against 3.80 mg. per 100 ml. In preeclamptic toxaemia hypertensives (244) the level is significantly
was
I
raised-so much so that I concluded that the raised serumuric-acid level could be taken to differentiate the pre-eclamptic toxaemia case from the " essential " hypertension case. In pregnancy one is dealing with a selected group of young women in whom " essential " hypertension has usually existed for no more than a few years. The serum-uric-acid level tends to rise in the elderly, even in non-hypertensives. I believe the hyperuriceemia indicates tubular damage in the kidney, and that the excessive reabsorption which raises the serum level is the direct result of vascular disease at the site-temporary in pre-eclamptic hypertensives, but permanent in other hypertensives. I maintain that it is less misleading to base the severity of hypertension on its effects on the patient-e.g., raised uric-acid level due to kidney damage-than on a sphygmomanometer reading. Consequently, the raised serumuric-acid level should suggest severe disease, and in the majority this will occur in the older longstanding hypertensives. A raised serum-uric-acid level is certainly not a feature in the younger pregnant hypertensive woman, unless she has preeclamntic toxaemia. CALUM N. MCFARLANE.
MEDICAL RECORDS SIR,-This Group is investigating all aspects of the composition and handling of case-records in both hospital wards and outpatient clinics; and also considering possible means of coping with the increasing strain on storage facilities for these records. Recent correspondence regarding the Tunbridge Report on the standardisation of case-sheets indicates that there is a widespread interest in the whole subject, and that widely differing opinions on it are held. I should, therefore, be glad to receive any such views, and should also welcome information concerning the present position in other centres. Nuffield Provincial Hospitals Trust, Medical Records Research Group, Western Infirmary, Glasgow, W.1.
J.
H. MITCHELL.
TREATMENT OF ZOLLINGER-ELLISON SYNDROME and Dr. Marks (Jan. 1) make the following Bank SIR,-Dr. of my paper. At no point did I state or misrepresentations imply that my patient was a case of the Zollinger-Ellison syndrome, nor did I infer that this syndrome can be expected to respond to ganglion-blocking or anticholinergic drugs. I am " is far very well aware that " significant acid hypersecretion from being synonymous with the Zollinger-Ellison syndrome. Nonetheless, such hypersecretion rightly raises a strong suspicion that an islet-cell tumour may be present, and I believe that anticholinergic drugs should always be tried in these patients. The response may be very gratifying, as in the patient described by Dr. Bank and Dr. Marks in their letter. Too often this interesting group of hypersecretors is deprived of 1.
McFarlane, C. N. J. Obstet. Gynœc. Br. Commonw. 1963, 70, 63.
2.
Dean,
A. C. B.
Lancet, 1965, ii,
769.
the benefit of anticholinergic drugs because of the erroneous impression that the Zollinger-Ellison syndrome never responds to this treatment, and despite the evidence that an islet-cell tumour will not be discovered in more than a small proportion of them. Department of Surgical Service, University of Edinburgh.
A. C. B. DEAN.
FORTIFICATION SPECTRA any doctor, unfortunate enough to have fortification spectra, could furnish me with facts about this odd symptom which I have often had. I think these spectra are only seen: (1) in a bright light, and on looking up; (2) early on in an attack, which they often herald; (3) and only by a person with long sight whose focal point lies behind the retina. I believe that fortification spectra may be caused by a sudden reflection of the rods and cones of the retina, for the symptom is accompanied by oedema of the eye-I know of a lady whose attacks are heralded by the watering of an eye. The excess fluid, together with a sudden dramatic rise in blood-pressure, causes tension in the eye, and a reflection of the retina would be possible in a bright light under these conditions. Dr. C. W. M. Whitty (Oxford) has told me that Gowers, eighty years ago, thought fortification spectra were connected with the rods and cones of the retina. Once you have seen the spectra you cannot easily forget them, for they are such a neat, bright vision-I am tempted to think it is what Paul saw on the Damascus Road, and that migraine was his " thorn in the flesh ". ELSPETH STANFORD.
SiR,—Iwonder if
seen
ARTERIAL DISEASE: AN INTERNATIONAL SEARCH SIR,-In your annotation (Jan. 15) you suggest that fluoroscopy of the coronary arteries should be applied in population surveys to estimate the extent of arterial disease among the living. This method has various technical difficulties. Oliver et al.1 pointed out that necropsy findings and postmortem radiology clearly indicate that the prevalence of calcification detected by fluoroscopy during life is probably underestimated. Jorgens et awl.2 found calcification of coronary arteries in 83% of those who came to necropsy, whereas cinefluorography revealed calcification in only 25% of live hospital patients. They ascribe this wide variation to the limitations of the cinefluorographic method. Whatever the merits of this method for the detection of more advanced calcified lesions in the coronary arteries, I do not think that it has a place in population surveys of the extent of arterial disease among the living. You do not mention radiography of the abdominal aorta-a method which I have used in thousands of patients to detect atherosclerosis during life. A calcified plaque about 1 cm. in diameter can usually be seen in the lateral projection on radiographs of this large artery. The detection of atherosclerosis in the abdominal aorta usually indicates more widespread atherosclerosis, not only in the branches of the abdominal aorta but also in the coronary and other large arteries. This method revealed a sex difference in the incidence and severity of calcified lesions in the abdominal aorta,3 and an association of atherosclerosis in the central blood-supply of the stomach with gastric ulcer in the aged.45 This method has also been used as a valuable aid in the radiological differential diagnosis between benign and malignant lesions of the stomach.6In the 30-49year age-group, a distinct relation has been reported between the incidence and severity of calcifications in the abdominal aorta and occlusive or complicated lesions of the coronary arteries.7 1. 2. 3. 4. 5.
6. 7.
Oliver, M. F., Samuel, E., Morley, P., Young, G. B., Kapur, P. L. Lancet, 1964, i, 891. Jorgens, J., Boardman, W. J., Damberg, S. W., Kinney, W. N., Kundel, R. R. Am. J. Roentg. 1965, 95, 667. Elkeles, A. Lancet, 1957, ii, 714. Elkeles, A. Am. J. Roentg. 1950, 70, 797. Elkeles, A. ibid. 1964, 91, 744. Elkeles, A. Br. J. Radiol. 1949, 12, 280. Eggen, D. A., Strong, J. P., McGill, H. C. Archs Path. 1964, 78, 575.