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MESENTERIC THROMBOPHLEBITIS MIGRANS
131 ACERIN of a new bacteriostatic agent is unlikely discovery to arouse more than polite interest today, but a substance active against viruses is always news. Fischer1 has studied the action of an extract from the fruit of the Norwegian maple (Acer platanoides) on 3t’ bacteriophage and on vaccinia virus. The active substance in these extracts, to which he has given the provisional name " acerin," appears to have a rapid phagicidal action on a Bacterium coli bacteriophage in concentrations which do not inhibit the growth of the host bacterium. A small number of experiments suggest that acerin may also have a virucidal action on vaccinia virus. Apparently it has no significant effect on a staphylococcus bacteriophage, and a few experiments suggest that it is not toxic to mice and rabbits in the dosages tested. This is only a preliminary communication, and clearly much more information is needed about the range of activity, mechanism of action, and chemical structure of acerin before deciding whether it will prove an important chemotherapeutic substance, giving the lead to more of its kind, or merely a laboratory curiosity.
THE
OBJECTIVE TESTS FOR CORONARY INSUFFICIENCY IN the absence of abnormal signs in the heart and electrocardiogram, the diagnosis of coronary disease often depends solely upon clinical interpretation of the history. The story of angina pectoris is usually characteristic enough, but there are always a few patients with atypical chest pain in whom objective evidence of Standard coronary insufficiency would be valuable. tests, based on the well-known capacity. of exercise and anoxaemia to provoke electrocardiographic changes similar to those sometimes recorded in an anginal attack, have been used for some time and found helpful. The exercise test consists in climbing steps either a fixed number of times2 or until pain or breathlessness appear.3 In the anoxoemia test a mixture of 10% oxygen and 90% nitrogen is breathed from an ansesthetic apparatus for periods up to 20 minutes. The electrocardiogram may be affected in several ways : the chief changes are depression of the RST segment, inversion of the T wave, and, more rarely, shortening of the 1--R interval.4 These changes are found to a limited extent in apparently healthy people in response to exercise or anoxaemia, but when the RST depression in leads I, II, III, and IV totals 3 mm. or more, or when there is inversion of the T wave in accompanied by RST depression of 1 mm. or more s lead I, they are generally regarded as abnormal. 6 Turner and Mortonhave lately confirmed this view and emphasised the importance of using lead IV. An abnormal response either to exercise or to anoxaemia may be expected in between a quarter and a half of those with known angina or with a history of infarction. The mechanism of the changes is obscure, for their unpredictable appearance cannot be correlated with the degree of oxygen desaturation of the blood or with the extent of coronary arteriosclerosis.8 However, provided that the effects of a recent heavy meal, a cold drink, or severe anaemia can be excluded, they may be taken as evidence of coronary insufficiency. There is little to choose between the exercise test and the anoxaemia test, and the two are probably best used in conjunction.9 Satisfactory electrocardiograms are less easy to obtain 1. Fischer, G. 2.
3. 4. 5.
6. 7.
8. 9.
Acta path. microbiol. scand. 1952, 31, 433. Master, A. M., Friedman, R., Dack, S. Amer. Heart J. 1942, 24, 777. Riseman, J. E. F., Waller, J. V., Brown, M. G. Ibid, 1940, 19, 683. Greene, C. W., Gilbert, N. C. Arch. intern. med. 1921, 27, 517. Levy, R. L., Williams, N. E., Bruenn, H. G., Carr, H. A. Amer. Heart J. 1941, 21, 634. Burnett, C. T., Nims, M. G., Josephson, C. J. Ibid, 1942, 23, 306. Turner, R. W. D., Morton, E. V. B. Brit. Heart J. 1952, 14, 514. Burchell, H. B., Pruitt, R. D., Barnes, A. R. Amer. Heart J. 1948, 36, 373. Biörck, G. Ibid, 1946, 32, 689.
after exercise ; on the other hand, the anoxaemia, test has caused unpleasant and even dangerous effects, although its advocates believe it to be safe enough provided that a supply of 100% oxygen is immediately available. Clearly, both tests have disadvantages, especially since negative results do not exclude angina pectoris ; but they have a definite place in diagnosis. Turner and Morton suggest that they should be used for those cases of suspected angina without positive signs and where the pain is atypical. They also suggest their use as a method of assessing recovery from myocardial infarction, as a test of fitness for surgical operations, and as an index of the therapeutic action of drugs on the coronary circulation. Nevertheless the limitations of the tests emphasise the importance of adequate history-taking and complete electrocardiographic investigation. MESENTERIC THROMBOPHLEBITIS MIGRANS
THROMBOPHLEBITIS is a mysterious disorder. Occasionit manifests itself-nearly always in men under the age of 50-as a series of episodes involving mainly superficial veins but sometimes a vena eava. North and Wollenman1 report 3 cases of venous mesenteric thrombosis occurring in series with migratory thrombophlebitis. From their account it is clear that this grave complication has a characteristic clinical picture; and prompt diagnosis and resection of the infarcted segment or segments of gut may be life-saving. A vital clue is the history of an attack, perhaps years previously, of superficial thrombophlebitis with, in about a quarter of the cases, evidence of pulmonary involvement. The actual mesenteric venous thrombosis does not present-like arterial occlusion-as a fulminating catastrophe. The principal disturbance is abdominal pain becoming, over several days, increasingly severe. There is a notable absence of signs of peritoneal irritation, although in the later stages tenderness may be present over the infarcted segment, which is often palpable. The lumen of this segment is not occluded; hence vomiting and distension are inconstant and late. Red blood is often passed per rectum. Operation reveals an imperfectly demarcated infarcted portion of large. or small intestine. The veins draining this segment are filled with dark-red thrombi whose uniform age suggests that their extension proximally to the collecting veins is more likely to result from propagation than from intermittent involvement. The arterial bed is not thrombosed. North and Wollenman point out that resection, while it saves life, has no influence on the disease and further In thrombophlebitis thrombotic episodes are likely. migrans anticoagulant therapy with dicoumarol or ethyl biscoumacetate (‘ Tromexan, ’) should perhaps be continued for many months or even years. The disease may subside as mysteriously as it starts ; so the true efficacy of such therapy cannot be gauged.
ally
NUFFIELD CHAIR OF SURGERY: AN APOLOGY OUR last issue contained an announcement that Professor T. Pomfret Kilner had been appointed to succeed the late Sir Hugh Cairns as Nuffield professor of surgery in the University of Oxford. This announcement was based on a newspaper statement which, though explicit and detailed, was quite incorrect-: the position at Oxford remains as it was last October, when we reported that Professor Kilner had been asked to carry on the duties of the Nuffield chair during the current term, and the successor to Sir Hugh Cairns has not yet been chosen. We greatly regret the inconvenience caused by our giving currency to inaccurate information. 1. North, J. P., Wollenrnan, O. J. jun. Surg. Gynec. Obstet. 1952, 95, 665.
THE
OBJECTIVE TESTS FOR CORONARY INSUFFICIENCY IN the absence of abnormal signs in the heart and electrocardiogram, the diagnosis of coronary disease often depends solely upon clinical interpretation of the history. The story of angina pectoris is usually characteristic enough, but there are always a few patients with atypical chest pain in whom objective evidence of Standard coronary insufficiency would be valuable. tests, based on the well-known capacity. of exercise and anoxaemia to provoke electrocardiographic changes similar to those sometimes recorded in an anginal attack, have been used for some time and found helpful. The exercise test consists in climbing steps either a fixed number of times2 or until pain or breathlessness appear.3 In the anoxoemia test a mixture of 10% oxygen and 90% nitrogen is breathed from an ansesthetic apparatus for periods up to 20 minutes. The electrocardiogram may be affected in several ways : the chief changes are depression of the RST segment, inversion of the T wave, and, more rarely, shortening of the 1--R interval.4 These changes are found to a limited extent in apparently healthy people in response to exercise or anoxaemia, but when the RST depression in leads I, II, III, and IV totals 3 mm. or more, or when there is inversion of the T wave in accompanied by RST depression of 1 mm. or more s lead I, they are generally regarded as abnormal. 6 Turner and Mortonhave lately confirmed this view and emphasised the importance of using lead IV. An abnormal response either to exercise or to anoxaemia may be expected in between a quarter and a half of those with known angina or with a history of infarction. The mechanism of the changes is obscure, for their unpredictable appearance cannot be correlated with the degree of oxygen desaturation of the blood or with the extent of coronary arteriosclerosis.8 However, provided that the effects of a recent heavy meal, a cold drink, or severe anaemia can be excluded, they may be taken as evidence of coronary insufficiency. There is little to choose between the exercise test and the anoxaemia test, and the two are probably best used in conjunction.9 Satisfactory electrocardiograms are less easy to obtain 1. Fischer, G. 2.
3. 4. 5.
6. 7.
8. 9.
Acta path. microbiol. scand. 1952, 31, 433. Master, A. M., Friedman, R., Dack, S. Amer. Heart J. 1942, 24, 777. Riseman, J. E. F., Waller, J. V., Brown, M. G. Ibid, 1940, 19, 683. Greene, C. W., Gilbert, N. C. Arch. intern. med. 1921, 27, 517. Levy, R. L., Williams, N. E., Bruenn, H. G., Carr, H. A. Amer. Heart J. 1941, 21, 634. Burnett, C. T., Nims, M. G., Josephson, C. J. Ibid, 1942, 23, 306. Turner, R. W. D., Morton, E. V. B. Brit. Heart J. 1952, 14, 514. Burchell, H. B., Pruitt, R. D., Barnes, A. R. Amer. Heart J. 1948, 36, 373. Biörck, G. Ibid, 1946, 32, 689.
after exercise ; on the other hand, the anoxaemia, test has caused unpleasant and even dangerous effects, although its advocates believe it to be safe enough provided that a supply of 100% oxygen is immediately available. Clearly, both tests have disadvantages, especially since negative results do not exclude angina pectoris ; but they have a definite place in diagnosis. Turner and Morton suggest that they should be used for those cases of suspected angina without positive signs and where the pain is atypical. They also suggest their use as a method of assessing recovery from myocardial infarction, as a test of fitness for surgical operations, and as an index of the therapeutic action of drugs on the coronary circulation. Nevertheless the limitations of the tests emphasise the importance of adequate history-taking and complete electrocardiographic investigation. MESENTERIC THROMBOPHLEBITIS MIGRANS
THROMBOPHLEBITIS is a mysterious disorder. Occasionit manifests itself-nearly always in men under the age of 50-as a series of episodes involving mainly superficial veins but sometimes a vena eava. North and Wollenman1 report 3 cases of venous mesenteric thrombosis occurring in series with migratory thrombophlebitis. From their account it is clear that this grave complication has a characteristic clinical picture; and prompt diagnosis and resection of the infarcted segment or segments of gut may be life-saving. A vital clue is the history of an attack, perhaps years previously, of superficial thrombophlebitis with, in about a quarter of the cases, evidence of pulmonary involvement. The actual mesenteric venous thrombosis does not present-like arterial occlusion-as a fulminating catastrophe. The principal disturbance is abdominal pain becoming, over several days, increasingly severe. There is a notable absence of signs of peritoneal irritation, although in the later stages tenderness may be present over the infarcted segment, which is often palpable. The lumen of this segment is not occluded; hence vomiting and distension are inconstant and late. Red blood is often passed per rectum. Operation reveals an imperfectly demarcated infarcted portion of large. or small intestine. The veins draining this segment are filled with dark-red thrombi whose uniform age suggests that their extension proximally to the collecting veins is more likely to result from propagation than from intermittent involvement. The arterial bed is not thrombosed. North and Wollenman point out that resection, while it saves life, has no influence on the disease and further In thrombophlebitis thrombotic episodes are likely. migrans anticoagulant therapy with dicoumarol or ethyl biscoumacetate (‘ Tromexan, ’) should perhaps be continued for many months or even years. The disease may subside as mysteriously as it starts ; so the true efficacy of such therapy cannot be gauged.
ally
NUFFIELD CHAIR OF SURGERY: AN APOLOGY OUR last issue contained an announcement that Professor T. Pomfret Kilner had been appointed to succeed the late Sir Hugh Cairns as Nuffield professor of surgery in the University of Oxford. This announcement was based on a newspaper statement which, though explicit and detailed, was quite incorrect-: the position at Oxford remains as it was last October, when we reported that Professor Kilner had been asked to carry on the duties of the Nuffield chair during the current term, and the successor to Sir Hugh Cairns has not yet been chosen. We greatly regret the inconvenience caused by our giving currency to inaccurate information. 1. North, J. P., Wollenrnan, O. J. jun. Surg. Gynec. Obstet. 1952, 95, 665.