MYOCARDIAL INFARCTION AND CHRONIC ACNE

585 RETROGRADE EMBOLECTOMY

father had modal numbers of 46, and in all the cells five large acrocentric chromosomes were observed, one of which was particularly large and, further, an extra little acrocentric chromosome (fig. 3a and b). The abortion, III, 8, was chromatin positive in cultured cells and the modal number was 45. Five large acrocentric chromosomes were found, one of which was particularly large and four small acrocentric chromosomes (fig. 3c). Two brothers, 111,5, and 111,7, the father, and the maternal grandmother, had normal karyotypes.

SIR,-Iread with interest Mr. Lynch’s paper.1 I have had occasion to use Dornia’s ureteric stone extractor under precisely the same circumstances and have also found it a most useful instrument for this purpose. I believe that the best way to do an aortic-bifurcation embolectomy is to expose and open both femoral arteries and to clean them and the iliac arteries of clot from below as far as can be done with ease and safety. Thereafter a small subumbilical incision is made. With the right hand the embolus is then broken up through the aortic wall and milked downwards towards the openings in the femoral arteries. By this means one can be certain that the aorta and iliac arteries are completely free of clot. Excessive loss of blood can be prevented by compressing the iliac arteries between the thumb and the index finger of the right hand. The patient does not have to be relaxed for the abdominal incision and the aorta is not opened or exposed. I have had occasion to use this method with success on a desperately ill patient recently. B. J. V. R. DREYER.

The karyotypes of the mother, sister, and maternal grandfather are most easily explained by a balanced reciprocal translocation between two different chromosomes in the 13-15 group. Such individuals can form ten different gamete types-four without, and six with gametic non-disjunction (fig. 4). In this family, four out of the ten possible gamete types were encountered-two without non-disjunction between the translocation chromosomes and their homologous partners, and two in which non-disjunction occurred.

The extra chromosome in the proband must be interpreted then as a deleted chromosome of the 13-15 group, and the patient’s symptoms may thus be due to partial trisomy.10 The abortion probably represents partial disomy for a chromosome in the 13-15 group. Whereas duplication of autosomes or parts of autosomes in a person seems to be compatible with life-albeit not without severe defects-monosomy or partial disomy of the autosomes does not seem to be compatible with life. 11 Further investigation of this family, including blood typing and serum typing, is in progress and will be published elsewhere. The investigation was carried out with the support of Fondet til Forskning af Andssvaghed. We are indebted to Dr. Christiani Rud, senior physician, Central Hospital, Vejle, for help and encouragement. We also wish to thank the staff and the surgical department of the municipal hospital, Horsens, and the Directorate of the National Mental Deficiency Service. Institute for Mental Defectives for South East Jutland, Brejning, Denmark. University Institute for Human Genetics, Copenhagen, Denmark.

PETREA JACOBSEN ANNALISE DUPONT.

MARGARETA MIKKELSEN.

CHROMOSOMES IN TYPUS DEGENERATIVUS AMSTELODAMENSIS (DE LANGE’S SYNDROME)

SIR,-Dr. Laurence and Mr. Ishmael 12 report a chromosomal study of de Lange’s syndrome. We can confirm their observations from investigation of a patient with this syndrome who was admitted a short time ago to MunchenSchwabing Psediatric Hospital under the care of Prof. H. Hilber. .The patient was an 18-month-old mentally retarded boy, the first child of healthy parents. (Among the father’s antecedents there was said to have been some obscure cases of cerebral disorder.)

At birth the child showed

contractures

of the fore-

fingers and club-foot, epicanthus, antimongoloid position of the eyelids, and low-set ears. The bridge of the nose was flat, and the philtrum was lengthened. Convergent strabismus was present.

Nuclear sexing gave chromatin-negative results. term cultures of peripheral blood

of 31

Short-

yielded the following results:

27 had 46 chromosomes, 1 had 44 and 3 had 45 chromosomes. Each of 3 metaphases analysed showed a normal male karyotype. No structural anomaly of the chromosomes was detected. Department of Pathology, H. A. HIENZ. University of Heidelberg.

metaphases counted,

rhromosomes,

10. Patau, K.,

Smith, D. W., Therman, E., Inhorn, S. L., Wagner, H. P. Lancet, 1960, i, 790. 11. Ford, C. E. Acta Genet. med. Roma, 1962, 11, 253. 12. Laurence, K. M., Ishmael, J. Lancet, 1963, i, 1426.

MYOCARDIAL INFARCTION AND CHRONIC ACNE

_

SIR,-Oversimplifying the facts a little, I think that Dr. Read2 suggests an association between sugar intake and acne, and Professor Yudkin3 between sugar and myocardial infarct. Has anyone a suitable series to show whether morbidity or mortality from myocardial infarct is significantly high in chronic acne patients ? R. W. HOWELL. THE RELIABILITY OF THE ELECTROCARDIOGRAM IN MYOCARDIAL INFARCTION

SIR,-Iread with interest the article by Dr. Woods and others (Aug. 10). It is notable that comparisons are made between, on the one hand, a careful three-dimensional analysis of the injected coronary tree (X-rayed and viewed stereoscopically if required) and block dissections of the myocardium (also indicated as possibly missing contracted lesions), and, on the other, a standard 12-lead largely frontal-plane electrocardiogram. Admittedly vectorcardiography itself is limited in that (i) the mathematics deriving vectors from surface action currents on the specially shaped human torso, and of varying internal resistances, is not known completely; and (ii) different reference frames yield different derivations. Surface action currents of three-dimensional lead systems (such as the ABC system) offer analyses which do not include these further distortions. The figure of 82% infarct discovery of the 12-lead system agrees closely with the 84% infarct discovery in a series of 161 acute cases similarly followed, with necropsy and injection studies at death4 for the 12-lead system. But here the infarct discovery with three-dimensional leads (ABC) was 100%. These patients were followed for only two to eight years, so that a comparison with the second feature of only 27% correlation with old infarction cannot be accurately assessed. Survival and necropsy studies were desired here. It is common, however, to obtain three-dimensional ABC tracings from patients suffering from presumed anginal pain where significant E.C.G. evidence of previous infarction is apparent, and standard reading of standard 12-lead electrocardiography (as your contributors also point out) is reported as negative. A simple three-lead system has the further advantage that basic congenital partial bundle block patterns from their special 1. 2. 3. 4.

Lancet, 1963, i, 751. Read, C. H. R. Practitioner, 1963, 191, 83. Yudkin, J. Lancet, 1963, i, 1335. Trethewie, R. E. Brit. med. J. 1958, ii, 1428.

586 distribution

are more

easily distinguished

from

pathological

sequelae. The limitations of frontal-plane electrocardiography well evidenced by the paper of Woods et al. and emphasise the necessity for a better electrocardiographic technique. Vectorcardiography presents special difficulties. These difficulties are overcome with the ABC

are

display. Department of Physiology, University of Melbourne.

E. R. TRETHEWIE.

TRANYLCYPROMINE SIR,-So far there have been 8 deaths associated with tranylcypromine (’Parnate ’). 3 of the patients who died were having imipramine at the same time, 2 had amphetamines, 2 were on tranylcypromine plus trifluoperazine (’ Parstelin ’), and 1 had tranylcypromine only. Cerebral haemorrhage was confirmed in 3 cases and suspected in 1. In addition, 3 patients with intracranial bleeding who recovered have been reported, and Dorrell 12 mentions that there are 4 more cases known but still unpublished. Many other patients while on treatment with

tranylcypromine had sudden attacks of violent and throbbing headache accompanied by hypertension and at least some of the following features: acute fear, palpitations, tachycardia or bradycardia, nausea, vomiting, giddiness, sweating, photophobia, stiff neck and other neurological signs, faintness, and collapse. There is no agreement regarding the frequency of the sideeffects. Lees and Burke3 reported 11 out of 60 patients (18%) in a clinical trial with parnate, but Macdonald4 reported only 14 cases of severe headache in 600 patients treated, and Milligan5 also mentions a very low incidence. Simultaneous administration of imipramine (’ Tofranil ’) or amphetamines seems to be particularly dangerous although Morgan 6 has reported the case of a patient who received large doses of parnate and amphetamine without ill-effects. Blackwell 1has drawn attention to a possible association between the eating of cheese and the symptoms in patients taking tranylcypromine and has described 11 patients in whom typical attacks came on shortly after eating cheese. Womack9 has recorded the case of a healthy youth who died of acute circulatory collapse less than two hours after eating cheese. Recently and within a short time 5 patients attending the Hill End day hospital who were taking tranylcypromine or phenelzine had typical attacks of severe headache. In view of the reports of Blackwell 7and Womack 9 10 we decided to make a retrospective inquiry into the dietetic habits of these patients. 1. Female, 49, on phenelzine (’Nardil’) 15 mg. t.d.s. and chlordiazepoxide (’ Librium’) 10 mg. t.d.s. for three months had a typical crisis at home. She eats cheese about twice a month and does not remember whether she had eaten it before the attack. 2. Female, 47, on phenelzine 30 mg. t.d.s. and chlordiazepoxide 10 mg. t.d.s. for three weeks had three very severe attacks at home and a milder one in the day hospital. She eats cheese almost every day, always with the evening meal. The attacks came at noon or in the morning and not shortly after eating cheese. 3. Female, 40, on parstelin 1 tablet t.d.s. for six months followed by tranylcypromine 10 mg. t.d.s. and chlordiazepoxide 10 mg. t.d.s. for ten days had a severe crisis one evening. She eats cheese almost every evening, but she is quite sure that she did not have cheese that day. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Dorrell, W. Lancet, 1963, i, 388. Dorrell, W. ibid. Aug. 10, 1963, p. 300. Lees, F., Burke, C. W. ibid. 1963, i, 13. Macdonald, R. ibid. p. 269.

Milligan,

W. L. ibid. p. 442.

Morgan, D. H. ibid. p. 389. Blackwell, B. ibid. p. 167. Blackwell, B. ibid. Aug. 24, 1963, p. 414. Womack, A. M. Brit. med. J. Aug. 10, 1963, p. 366. Womack, A. M. Lancet, Aug. 31, 1963, p. 463.

4. Female, 57, on parstelin 1 tablet t.d.s. since Oct. 29, 1962. She had an attack on Jan. 8, 1963, in the morning. She is very fond of cheese, but she eats it with the evening meal, and, therefore, she had not had it before the attack that day. 5. Male, 50, an outpatient, on parstelin 1 tablet t.d.s. since Feb. 25, 1963. He had several violent attacks of throbbing headache between April 3 and July 7. He did not relate these attacks to parstelin. He often eats cheese at lunch and is sure that at least three of the attacks took place after lunch, but he had several other attacks at different times of the day, some of them on days when he had not eaten cheese. There were 9 patients on tranylcypromine during the same period who did not develop side-effects. Of these, 2 never eat cheese, 1 eats cheese only occasionally, 4 eat cheese 1-4 times weekly, and 2 eat cheese almost every day. There were 2 patients on phenelzine who did not develop side-effects, of whom 1 eats cheese occasionally and the other eats cheese twice weekly.

Judged by this series, although not extensive or conclusive enough, one would think that there is no clear relation between eating cheese and the typical side-effects of tranylcypromine. Cheese is such a common article of diet that obviously most patients on long-term treatment with monoamineoxidase inhibitors are bound to eat cheese during the course of treatment, and, of course, some of them will have by coincidence attacks of severe headache shortly after eating cheese. More research is needed. Hill End Hospital, St. Albans, Herts.

L. ARENILLAS.

SiR,ňThere has been much correspondence in your columns recently describing intracranial bleeding in association with the use of tranylcypromine, and I should like to describe one further case lately under our care. A man aged 67 had been depressed for several years after the death of his wife, and had been treated with various antidepressant agents. On June 26, 1963, he was started on tranylcypromine and trifluoperazine (’Parstelin’) by his general practitioner. On July 7 while in a restaurant he had very severe occipital headache which radiated to the forehead and was associated with vomiting. He was taken to the casualty department of a nearby hospital, but apparently no abnormal signs were then found. It is of interest to note that the casualty officer told the patient that his symptoms were probably due to parstelin and referred him to his own general practitioner. The headache continued and was associated with severe neck stiffness. On July 12 he was seen by Dr. L. J. Grant, and a clinical diagnosis of subarachnoid haemorrhage was made. He was admitted to hospital for further investigations. On examination he was alert and cooperative and his bloodpressure was 140/80 mm. Hg. He had severe neck stiffness and a positive Kernig’s sign. The tendon reflexes of the right arm and leg were a little brisker than those of the left and the right plantar response was equivocal. A lumbar puncture was performed on July 13, and the cerebrospinal fluid was xanthochromic with total protein 90 mg. per 100 ml., moderate excess of globulin, 50 red cells per c.mm., and less than 3 lymphocytes per c.mm. An electroencephalogram and skull X-ray were normal. Although the patient had previously had mild occasional headaches, he had never experienced one of this intensity which persisted to some extent for approximately 19 days, but he continued to complain of back pain for a further fortnight. He eventually made a complete recovery. Because of the patient’s age and general condition no further investigations were undertaken.

It case

reasonable to conclude that this is another of intracranial bleeding associated with parstelin

seems

administration. National Temperance Hospital, London, N.W.1.

DOREEN GREENE.