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MISDIAGNOSIS OF ARTERIAL DISEASE
828 alities.
thought,
These, it is reaction, sharing
may be manifestations of origin with ulcers accompanying burns or other trauma ; but alternatively ischaemia may be primarily responsible, or cold may have a effect. These animals had not at any time been in a steady state of suspended animation. To achieve that state the temperature would have had to be reduced to very low levels in order to avoid a wide variety of deleterious biophysical and biochemical changes The workers not halted at temperatures around 0°C. at the National Institute suggest that some means of permeating the animal with glycerin or propylene glycol must be found before suspended animation becomes an
alarm
a common
specific
physiotherapy or through surgical trauma. Prompt diagnosis is more than ever important now that arterial surgery can offer many of the patients with disease of major vessels relief from pain with only a moderate risk. SURGERY FOR SPINAL TUBERCULOSIS
possible. Perhaps
IN Russia, as elsewhere, conservative measures alone have proved inadequate for the complete cure of tuberculous spondylitis ; and the optimism of the early streptomycin days has not been sustained. Russian surgeons seem to concentrate mainly on psoas abscesses and to aim at complete excision of the abscess and capsule-a more radical procedure than is usual in this country. On the other hand, British surgeons seem to tackle mediastinal abscesses more often than their
is
Russian colleagues.
this extreme state may always elude us ; but it clear that living mammals can withstand cooling not only until breathing and heart-beats have been at a standstill for many minutes, but until ice has formed in the peripheral tissues and until the whole body is sufficiently frozen to be rigid, and further that frostbite need not accompany this process. Obviously this work cannot be immediately applied to man. Nevertheless from it must come a reappraisal of our thinking about cold and its effects ; and medicine stands in considerable debt to this group of investigators, who have swept away many misconceptions. now
MISDIAGNOSIS OF ARTERIAL DISEASE
A PATIENT complaining of pain in the calf on walking, which is rapidly relieved by rest, is not likely to have vascular disease overlooked. But when the pain is in an unusual site the possibility of its being caused by arterial disease may not be thought of ; and Bonney1 reports 9 cases, seen in the past four years at one of two hospitals, in which pain in the buttock or thigh was demonstrably caused by aortic or iliac-artery occlusion. In each of these cases osteo-arthritis of the hip or vertebral-disc degeneration had previously been dia,gnosed, and the patients had been treated accordingly. One common source of mistaken diagnosis is failure to realise that thrombosis of a major proximal artery is not necessarily associated with absent ankle pulses when the patient is at rest, although these will invariably disappear on walking until the onset of pain. The exercise pain, which may be felt anywhere in the upper leg or low back, is usually associated with severe fatigability of the limb and general muscle wasting. Nor has Bonney exhausted the vagaries of diagnosis in degenerative vascular disease. Aneurysms of the aorta may present as palpable swellings, acute or chronic abdominal pain, hematuria, or backache : aneurysms in the groin as abscesses, and at the back of the knee-joint as an ache simulating osteoarthritis. Tissue wasting in the sole of the foot due to peripheral ischsemia may be wrongly ascribed to painful flat feet and the foot manipulated ; claudication in the small foot muscles may be misdiagnosed as metatarsalgia, and the pain in the os calcis, unprotected by its fibrofatty covering, ascribed to a spur. Sepsis in the bed of the nail can be confused with an ingrowing toenail, with disastrous results. Ischaemic nerve palsies are not uncommon.
Simple clinical observation will usually confirm or exclude arterial disease. Colour changes, vein guttering on elevation, tissue wasting, and temperature differences are all helpful. Oscillometry may confirm the presence of ischaemia, as will re-examination immediately after exercise. Arteriography should be reserved for cases in which grafting is contemplated. As Bonney points out, mistakes in diagnosis may not only involve a delay in treatment but also cause deterioration in the condition of the limb through the application of over-energetic 1.
Bonney, G.
J. Bone Jt
Surg. 1956, 38B, 686.
These comparisons are prompted by Kirilov and Kon’s recent paper,from the B.M. Molotov Bone Tuberculosis Sanatorium, on the surgical treatment of hypostatic Of 298 patients abscesses in tuberculous spondylitis. with tuberculosis of the vertebrae, 288 had abscesses. Up to two years ago treatment consisted of a " sanatorium cum orthopaedic " regime. Since then 30 patients with psoas abscesses have been operated on ; in 5 the operation was bilateral, in 22 a partial excision was performed, and in 8 a radical excision of the abscess and capsule The technique included postoperative was completed. drainage and the local instillation of streptomycin. In all but 4 patients the tuberculous process became inactive, and 20 out of the 30 patients have been discharged from hospital with quiescent lesions. Shulutko and Elochina,2 of the Sverdlovsky Children’s Tuberculosis Sanatorium, report that 17 operations have been performed on 14 children with tuberculosis of the spine ; 13 had lumbar lesions and 1 thoracic. In the lumbar region, radical excision of the abscess and capsule was the operation of choice. 2 patients have been completely discharged and 4 have been allowed to get up and walk. THIRTY-FIVE YEARS OF NEUROLOGY in 1920 that Guy’s Hospital Gazette announced appointment as assistant physician for nervous diseases of the distinguished neurologist who retired from the active staff of the hospital last year. The editors of Guy’s Hospital Reports have recently marked the retirement of Sir Charles Symonds by dedicating to him a collection3 of papers on various neurological subjects. Written by members of the Guy’s medical school staff, these papers provide an illuminating commentary upon the ramifications of contemporary research into the IT the
was
nervous
system.
-
Three of the ten papers can fairly be classified under the heading of neurochemistry-a recent but lusty neophyte in the neurological hierarchy-but the morphology, immunology, and experimental pathology of the nervous system are also represented ; and there is a fitting clinical touch in an article by I. C. K. MacKenzie on multiple sclerosis. Among the neurochemical contributions, the review by K. P. Strickland on " energetics and cerebral metabolism shoys clearly the relevance of the ideas of modern dynamic biochemistry to an understanding of how neurones are powered by complex sequences of enzyme reactions which permit the graded liberation of the chemical energy of glucose. R. H. S. Thompson and G. R. Webster carry the study of enzyme mechanisms into the field of pathology, by indicating how recent investigations on the detailed chemistry of the lipids of the nervous system and the enzymes which act upon them give promise for the ultimate elucidation of the process of demyelination, which, though it has long occupied a central place in neuropathology, has remained essentially a histological concept. J. Dobbing and B. McArdle stay on the fringe of neurochemistry. Dobbing discusses the blood-brain barrier, which, "
1. 2. 3.
Kirilov, B. P., Kon, I. I. Surgery, Moscow, 1956, 5, 53. Shuhitko, M. L., Elochina, N. P. Ibid, 1956, 6, 62. Guy’s Hosp. Rep. 1956, 105, no. 1.
thought,
These, it is reaction, sharing
may be manifestations of origin with ulcers accompanying burns or other trauma ; but alternatively ischaemia may be primarily responsible, or cold may have a effect. These animals had not at any time been in a steady state of suspended animation. To achieve that state the temperature would have had to be reduced to very low levels in order to avoid a wide variety of deleterious biophysical and biochemical changes The workers not halted at temperatures around 0°C. at the National Institute suggest that some means of permeating the animal with glycerin or propylene glycol must be found before suspended animation becomes an
alarm
a common
specific
physiotherapy or through surgical trauma. Prompt diagnosis is more than ever important now that arterial surgery can offer many of the patients with disease of major vessels relief from pain with only a moderate risk. SURGERY FOR SPINAL TUBERCULOSIS
possible. Perhaps
IN Russia, as elsewhere, conservative measures alone have proved inadequate for the complete cure of tuberculous spondylitis ; and the optimism of the early streptomycin days has not been sustained. Russian surgeons seem to concentrate mainly on psoas abscesses and to aim at complete excision of the abscess and capsule-a more radical procedure than is usual in this country. On the other hand, British surgeons seem to tackle mediastinal abscesses more often than their
is
Russian colleagues.
this extreme state may always elude us ; but it clear that living mammals can withstand cooling not only until breathing and heart-beats have been at a standstill for many minutes, but until ice has formed in the peripheral tissues and until the whole body is sufficiently frozen to be rigid, and further that frostbite need not accompany this process. Obviously this work cannot be immediately applied to man. Nevertheless from it must come a reappraisal of our thinking about cold and its effects ; and medicine stands in considerable debt to this group of investigators, who have swept away many misconceptions. now
MISDIAGNOSIS OF ARTERIAL DISEASE
A PATIENT complaining of pain in the calf on walking, which is rapidly relieved by rest, is not likely to have vascular disease overlooked. But when the pain is in an unusual site the possibility of its being caused by arterial disease may not be thought of ; and Bonney1 reports 9 cases, seen in the past four years at one of two hospitals, in which pain in the buttock or thigh was demonstrably caused by aortic or iliac-artery occlusion. In each of these cases osteo-arthritis of the hip or vertebral-disc degeneration had previously been dia,gnosed, and the patients had been treated accordingly. One common source of mistaken diagnosis is failure to realise that thrombosis of a major proximal artery is not necessarily associated with absent ankle pulses when the patient is at rest, although these will invariably disappear on walking until the onset of pain. The exercise pain, which may be felt anywhere in the upper leg or low back, is usually associated with severe fatigability of the limb and general muscle wasting. Nor has Bonney exhausted the vagaries of diagnosis in degenerative vascular disease. Aneurysms of the aorta may present as palpable swellings, acute or chronic abdominal pain, hematuria, or backache : aneurysms in the groin as abscesses, and at the back of the knee-joint as an ache simulating osteoarthritis. Tissue wasting in the sole of the foot due to peripheral ischsemia may be wrongly ascribed to painful flat feet and the foot manipulated ; claudication in the small foot muscles may be misdiagnosed as metatarsalgia, and the pain in the os calcis, unprotected by its fibrofatty covering, ascribed to a spur. Sepsis in the bed of the nail can be confused with an ingrowing toenail, with disastrous results. Ischaemic nerve palsies are not uncommon.
Simple clinical observation will usually confirm or exclude arterial disease. Colour changes, vein guttering on elevation, tissue wasting, and temperature differences are all helpful. Oscillometry may confirm the presence of ischaemia, as will re-examination immediately after exercise. Arteriography should be reserved for cases in which grafting is contemplated. As Bonney points out, mistakes in diagnosis may not only involve a delay in treatment but also cause deterioration in the condition of the limb through the application of over-energetic 1.
Bonney, G.
J. Bone Jt
Surg. 1956, 38B, 686.
These comparisons are prompted by Kirilov and Kon’s recent paper,from the B.M. Molotov Bone Tuberculosis Sanatorium, on the surgical treatment of hypostatic Of 298 patients abscesses in tuberculous spondylitis. with tuberculosis of the vertebrae, 288 had abscesses. Up to two years ago treatment consisted of a " sanatorium cum orthopaedic " regime. Since then 30 patients with psoas abscesses have been operated on ; in 5 the operation was bilateral, in 22 a partial excision was performed, and in 8 a radical excision of the abscess and capsule The technique included postoperative was completed. drainage and the local instillation of streptomycin. In all but 4 patients the tuberculous process became inactive, and 20 out of the 30 patients have been discharged from hospital with quiescent lesions. Shulutko and Elochina,2 of the Sverdlovsky Children’s Tuberculosis Sanatorium, report that 17 operations have been performed on 14 children with tuberculosis of the spine ; 13 had lumbar lesions and 1 thoracic. In the lumbar region, radical excision of the abscess and capsule was the operation of choice. 2 patients have been completely discharged and 4 have been allowed to get up and walk. THIRTY-FIVE YEARS OF NEUROLOGY in 1920 that Guy’s Hospital Gazette announced appointment as assistant physician for nervous diseases of the distinguished neurologist who retired from the active staff of the hospital last year. The editors of Guy’s Hospital Reports have recently marked the retirement of Sir Charles Symonds by dedicating to him a collection3 of papers on various neurological subjects. Written by members of the Guy’s medical school staff, these papers provide an illuminating commentary upon the ramifications of contemporary research into the IT the
was
nervous
system.
-
Three of the ten papers can fairly be classified under the heading of neurochemistry-a recent but lusty neophyte in the neurological hierarchy-but the morphology, immunology, and experimental pathology of the nervous system are also represented ; and there is a fitting clinical touch in an article by I. C. K. MacKenzie on multiple sclerosis. Among the neurochemical contributions, the review by K. P. Strickland on " energetics and cerebral metabolism shoys clearly the relevance of the ideas of modern dynamic biochemistry to an understanding of how neurones are powered by complex sequences of enzyme reactions which permit the graded liberation of the chemical energy of glucose. R. H. S. Thompson and G. R. Webster carry the study of enzyme mechanisms into the field of pathology, by indicating how recent investigations on the detailed chemistry of the lipids of the nervous system and the enzymes which act upon them give promise for the ultimate elucidation of the process of demyelination, which, though it has long occupied a central place in neuropathology, has remained essentially a histological concept. J. Dobbing and B. McArdle stay on the fringe of neurochemistry. Dobbing discusses the blood-brain barrier, which, "
1. 2. 3.
Kirilov, B. P., Kon, I. I. Surgery, Moscow, 1956, 5, 53. Shuhitko, M. L., Elochina, N. P. Ibid, 1956, 6, 62. Guy’s Hosp. Rep. 1956, 105, no. 1.