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Thrombophlebitis
276
criterion, and it is significant that his figures for completeor very great relief over a period of two to ten years add up to 63%, which is little short of the
72-5% cited by BURNS and YOUNG for three or more
.years. after operation. We must keep in mind BIREETT’S remark 13 . that, though on the surface the statistics of relief after operation are diiferent from those claimed with conservative methods, the recurrence-rate is likely to be much lower after operation; this is not altogether borne out by the above comparison. Indeed,- it is hard- -to resist the conclusion that there is still a great deal to be said for conservatism, .even in cases.which at first sight seem severe enough to call for early operation. As to the form nonoperative treatment, should take, DuRBIN,12 CRISP,14 and others advocate the short plaster jacket, and certainly this has many advantages over simple bed rest. It protects the lumbar spine while allowing the physiological stimulus of getting about,and so encourages the gradual reduction of the disc prolapse. Bed rest is less controlled, delays reablement, and is bad for morale-apart from the fact that there are often no hospital beds in which the rest can be taken. Plaster immobilisation, however, should be accompanied by strenuous hyperextension exercises for the erectores spinæ muscles. Prolapse of a lumbar disc is essentially a flexion injury, and the electromyographic observations of ALLEN,15 and of FLOYD and SILVER,16 show that the erectores spinæ actively contract during the early stages of spinal flexionan active paying-out of slack which keeps the column well under control. Once the spine is fully flexed, these muscles become inactive and the whole load is taken by the ligaments connecting the vertebrae, including the annulus fibrosus of the disc. It is evident that healthy muscles are needed to ensure that the load is passed on to the ligaments smoothly and gradually, and not with a hesitancy or suddenness that endangers the integrity of the discs. We are still no nearer finality on the question whether or not spinal fusion by bone-grafting of the lumbosacral spine is advantageous in disc cases. BARR 17 thinks that the combination of disc removal and fusion-he does not hesitate to do both at the same time,-shows a moderate superiority over simple laminectomy in reducing the incidence of chronic low back disability after operation. BURNS and YOUNG would reserve grafting for cases com-
not-materially
plicated by spondylolisthesis
or
by
adhesions,
and
for the chronic lame back ; and they are opposed to performing fusion at the time of the primary disc operation, since this gives no opportunity of learning whether the second, more formidable, stage is really necessary. Fusion is not alwayscertain, and some workers 18 have recorded a pseudarthrosis-rate as high as 1 in 3. This, and the lack of beds-even with the newer method of BOSWORTH 19 which permits fairly rapid discharge from hospital-limits the application of grafting to the most obvious cases. 13. Birkett, A. N., in Platt’s 14.
15. 16. 17.
18. 19.
Modern Trends in
Orthopædics.
London, 1950. Crisp, E. J., in Bach’s Recent Advances in Physical Medicine. London, 1950. Allen, C. E. L. Brit. J. phys. Med. 1948, 11, 66. Floyd, W. F., Silver, P. H. S. Lancet, Jan. 20, 1951, p. 133. Barr, J. S. J. Bone Jt Surg. 1947, 29, 429. Cleveland, M., Bosworth, D. M., Thompson, F. R. Ibid. 1948, 30B, 302. Bosworth, D. M. Amer. J. Surg. 1945, 67, 61.
Thrombophlebitis THAT blood should be coagulable is an essential prerequisite to theevolution of coelomates. Equally, for efficient survival blood should not coagulate
within vessels to a greater extent than is necessary for the repair of injury. Much of the morbidity and mortality associated with surgical operation, parturition, and severe illness is associated with venous thrombosis in the lower limbs and pelvis. At the Royal Society of Medicine on Jan. 23, Prof. W. MELVILLE ARNOTT cited thrombophlebitis as -an illustration of the principle that the originsof disease Thus the condition is commoner in are rarely single. later life, in the obese, in those whose primary disorder-surgical or medical-is associated with shock and haemorrhage, and in those with extensive WRIGHT1 showed varicosities of the lower limb. and mutual adhesiveness increase that platelets their from the fourth postoperative day to a maximum at about the twelfth day-a change which closely parallels the incidence of thrombophlebitis in relation2 to the time of operation ; WRIGHT has also reported that in those who are kept in bed after operation there is in the lower limbs a slowing, of venous flow which begins about the fourth day and is maximal about the twelfth day. Professor ARNOTT emphasised that thrombophlebitis also often complicates severe medical illness such as myocardial infarction and low-output cardiac failure ; and physicians, no less than surgeons and obstetricians, should make a practice of examining each day the lower limbs of severely ill patients. As might be expected in a condition whose precise setiology is uncertain, opinions differ on the relative value of different treatments. Despite its difficulties and dangers, anticoagulant therapy has been adopted by the majority of workers. Heparin has a swift action, and attempts to develop a retard " suitable for intramuscular injection have not yet succeeded completely. However the action of heparin is easily checked by protamine sulphate and blood-transfusion. The great disadvantage about this substance is that it must be given intravenously at intervals of 3-4 hours if the blood-coagulation is to be held constantly in check. Fortunately heparin seems effective without causing continuous depression of coagulability. Probably this is explained by its vasodilator action-an action that may account for the rapid relief of pain that usually follows its administration. As regards the coumarin drugs, though these can be given by mouth, the great difficulty is that their safe use depends on daily estimation of bloodprothrombin. This exacting test calls for reliable thromboplastin ; and clinicians unable to rely on the test often play safe by giving too little anticoagulant, with recurrence of thrombophlebitis as the penalty.Tromexanhas the - advantage over dicoumarol that its action is established within 8-24 hours and ends about the same time after administrdtion is discontinued. BuRT et al.a report its use in 126 cases with no more untoward effect than transient heematuria in 1 case where a double "
Wright, H. P. J. Path. Bact. 1942, 54, 461. Wright, H. P., Osborn, S. B., Edmonds, D. G. Lancet, Jan. 6, 1951, p. 22. 3. Burt, C. C., Wright, H. P., Kubik, M. Brit. med. J. 1949, ii,
1. 2.
1150.
277
dose was given in error on the fourth day of treatment. Dicoumarol has now been replaced almost completely by tromexan, though with this substance prothrombin estimations are still necessary. The danger of thrombophlebitis and the results of4 anticoagulant therapy ’are indicated by COSGRIFF, who collected 4580 cases treated conservatively and
itself, and the general adaptation syndrome may pass through its three stages-the alarm reaction," the stage of resistance, and the stage of exhaustion. "
The alarm reaction has two "
"
phases, shock" and representing- the initial
counter-shock," the first submission of the organism to the attack, the second the mobilisation of the body’s resources to defend The results itself and to resist the continuing onslaught. Counter2267 cases treated with anticoagulants. shock are as follows : projects into the stage of resistance, which With Without represents the prolonged struggle of the organism, anticoagulants anticoagulants until perhaps it ultimately succumbs during the stage .... Further thrombosis 21% 1-1% of exhaustion. The symptoms and signs of each phase 1.1% Pulmonary embolism ..... 29 % are classical; but their very multiplicity, and the Fatal pulmonary embolism .. 14% 0’9% their occurrence, make the clinical of variability story of anticoagulants is only beginning ; one of confusing diversity. picture certainly better and safer drugs will be introduced features of " shock "-diminished All the cardinal blood-pressure ; (indeed it is rumoured that some have already been found), and the difficulties of today will soon be only lowered temperature ;-, depression of the nervous system ; loss of muscle tone ; haemoconcentration ; a -memory. Some authorities (notably Prof. MICHAEL increased capillary and cell-membrane permeability, BOYD) rely, greatly on paravertebral lumbar sympa- with plasma seeping into the tissues, sodium and thetic block by procaine injection or even sympathe cells, and potassium escaping chloride thectomy ; this improves the blood-flow to the into the entering extracellular fluid ; acidosis ; transient affected limb and at least gives symptomatic relief. The value of venous ligature-femoral, iliac, or even hyperglycæmia, changing to hypoglycæmia ; leucocytosis ; and gastro-intestinal ulceration-all these caval-is still disputed. may be present and may become reversed during counter-shock and the stage of resistance, with the What is Stress ? addition of thymicolymphoid involution and eosinoFOR fifteen years the boundless energy, the apostolic On the other hand, the effect of the stressor fervour, the multilingual education, the cosmopolitan penia. agent may be so mild that only transient hyperknowledge, the encyclopaedic erudition, and the out- glycaemia, tachycardia, and leucocytosis bear witness standing administrative ability of HANS SELYE have to the shock. The succession of events may be rapid been devoted to the study of stress. He is a superb and fulminant, as in an attack of malignant diphtheria, experimental surgeon, as his technique for hypo- or long-continued and delayed, as after exposure to physectomy in the rat bears witness. He has a X rays. The evolution of a particular phase from photostatic mind which retains not only the gist but the preceding one may be gradual and insidious, and the detail of many thousands of scientific publications, reversal of the cardinal features may not occur and enables him to coordinate and correlate the so at one time the simultaneously ; hypoglycæmia of kaleidoscopic facets of physiological, pathological, shock may co-exist with the recovering blood-pressure immunological, biochemical, and endocrine studies in of counter-shock. Further, the classical picture of experimental medicine. He directs a lavishly equipped the general adaptation syndrome may be compLicated institute in Montreal and his reference library is certain special features characteristic of the exhaustive. Still a young man, companionable and by particular stressor agent, such as the haemodilution with humour in his personal contacts, he is neverthehaemorrhage or burns, the cerebral oedema less in deadly earnest. He and his not inconsiderable following of heatstroke,’ or the hæmopoiesis stimulated by following of disciples are devoted to a creed-the anoxia. He writes, as he General Adaptation Syndrome. Resistance to the stressor agent, as well as to and without thinks, prolifically simplicity. It requires all other damaging agents, falls during the shock time and concentration, as well as specialised knowand rises during counter-shock ; hence prophase, ledge, to follow his argument: indeed he complains duction of an alarm reaction by one stressor agent that many authoritative people have not grasped his will temporarily lead to protection against another. meaning. Partly this is because he does not always For instance, previous bleeding will protect a rabbit write in conventional scientific language, but is for intoxication by nitrogen mustard. subsequent against ever creating new words and propounding fresh In fact this " crossed resistance " may explain all definitions. His writings are not only extensive but sorts of such as the effects of non-specific apt to be bulky : they are more appropriately read therapy, phenomena fever therapy, protein-shock therapy, malaria propped on a lectern than skimmed in a subway. therapy, insulin-shock therapy, and even electrical Indeed there can be few who undergo the stress of convulsion therapy. - On the other hand, crossed modern life who can afford the luxurious leisure, and resistance will be manifest only if the second stressor acquire the contemplative contentment, needed to stimulus is applied during the counter-shock phase’of absorb ,.land. fully appreciate SELYE’s gospel, now the alarm reaction brought about by the first stressor proclaimed in his book.5 ; for, during the stage of resistance, nonThe skeleton of the general adaptation syndrome stimulus resistance falls, and in an attempt to conserve (G.A.S.) will be already familiar to the reader.. Under specific the influence of a stressor " agent the body adapts its " adaptation energy " the organism will continue to resist only the original stressor agent, and becomes 4. Cosgriff, S. W. Amer. J. Med. 1947, 3, 740, 753. at the same time vulnerable to other damaging agents, 5. Stress. By HANS SELYE, M.D., PH.D. Prague, D.SC. McGill, F.R.S. (c.); professor and director of the Institut de Médecine which may therefore precipitate another alarm et de Chirurgie Experimentales, Université de Montreal. reaction. Montreal: Acta Inc. 1950. Pp. 1000. £5 5s.
The
"
criterion, and it is significant that his figures for completeor very great relief over a period of two to ten years add up to 63%, which is little short of the
72-5% cited by BURNS and YOUNG for three or more
.years. after operation. We must keep in mind BIREETT’S remark 13 . that, though on the surface the statistics of relief after operation are diiferent from those claimed with conservative methods, the recurrence-rate is likely to be much lower after operation; this is not altogether borne out by the above comparison. Indeed,- it is hard- -to resist the conclusion that there is still a great deal to be said for conservatism, .even in cases.which at first sight seem severe enough to call for early operation. As to the form nonoperative treatment, should take, DuRBIN,12 CRISP,14 and others advocate the short plaster jacket, and certainly this has many advantages over simple bed rest. It protects the lumbar spine while allowing the physiological stimulus of getting about,and so encourages the gradual reduction of the disc prolapse. Bed rest is less controlled, delays reablement, and is bad for morale-apart from the fact that there are often no hospital beds in which the rest can be taken. Plaster immobilisation, however, should be accompanied by strenuous hyperextension exercises for the erectores spinæ muscles. Prolapse of a lumbar disc is essentially a flexion injury, and the electromyographic observations of ALLEN,15 and of FLOYD and SILVER,16 show that the erectores spinæ actively contract during the early stages of spinal flexionan active paying-out of slack which keeps the column well under control. Once the spine is fully flexed, these muscles become inactive and the whole load is taken by the ligaments connecting the vertebrae, including the annulus fibrosus of the disc. It is evident that healthy muscles are needed to ensure that the load is passed on to the ligaments smoothly and gradually, and not with a hesitancy or suddenness that endangers the integrity of the discs. We are still no nearer finality on the question whether or not spinal fusion by bone-grafting of the lumbosacral spine is advantageous in disc cases. BARR 17 thinks that the combination of disc removal and fusion-he does not hesitate to do both at the same time,-shows a moderate superiority over simple laminectomy in reducing the incidence of chronic low back disability after operation. BURNS and YOUNG would reserve grafting for cases com-
not-materially
plicated by spondylolisthesis
or
by
adhesions,
and
for the chronic lame back ; and they are opposed to performing fusion at the time of the primary disc operation, since this gives no opportunity of learning whether the second, more formidable, stage is really necessary. Fusion is not alwayscertain, and some workers 18 have recorded a pseudarthrosis-rate as high as 1 in 3. This, and the lack of beds-even with the newer method of BOSWORTH 19 which permits fairly rapid discharge from hospital-limits the application of grafting to the most obvious cases. 13. Birkett, A. N., in Platt’s 14.
15. 16. 17.
18. 19.
Modern Trends in
Orthopædics.
London, 1950. Crisp, E. J., in Bach’s Recent Advances in Physical Medicine. London, 1950. Allen, C. E. L. Brit. J. phys. Med. 1948, 11, 66. Floyd, W. F., Silver, P. H. S. Lancet, Jan. 20, 1951, p. 133. Barr, J. S. J. Bone Jt Surg. 1947, 29, 429. Cleveland, M., Bosworth, D. M., Thompson, F. R. Ibid. 1948, 30B, 302. Bosworth, D. M. Amer. J. Surg. 1945, 67, 61.
Thrombophlebitis THAT blood should be coagulable is an essential prerequisite to theevolution of coelomates. Equally, for efficient survival blood should not coagulate
within vessels to a greater extent than is necessary for the repair of injury. Much of the morbidity and mortality associated with surgical operation, parturition, and severe illness is associated with venous thrombosis in the lower limbs and pelvis. At the Royal Society of Medicine on Jan. 23, Prof. W. MELVILLE ARNOTT cited thrombophlebitis as -an illustration of the principle that the originsof disease Thus the condition is commoner in are rarely single. later life, in the obese, in those whose primary disorder-surgical or medical-is associated with shock and haemorrhage, and in those with extensive WRIGHT1 showed varicosities of the lower limb. and mutual adhesiveness increase that platelets their from the fourth postoperative day to a maximum at about the twelfth day-a change which closely parallels the incidence of thrombophlebitis in relation2 to the time of operation ; WRIGHT has also reported that in those who are kept in bed after operation there is in the lower limbs a slowing, of venous flow which begins about the fourth day and is maximal about the twelfth day. Professor ARNOTT emphasised that thrombophlebitis also often complicates severe medical illness such as myocardial infarction and low-output cardiac failure ; and physicians, no less than surgeons and obstetricians, should make a practice of examining each day the lower limbs of severely ill patients. As might be expected in a condition whose precise setiology is uncertain, opinions differ on the relative value of different treatments. Despite its difficulties and dangers, anticoagulant therapy has been adopted by the majority of workers. Heparin has a swift action, and attempts to develop a retard " suitable for intramuscular injection have not yet succeeded completely. However the action of heparin is easily checked by protamine sulphate and blood-transfusion. The great disadvantage about this substance is that it must be given intravenously at intervals of 3-4 hours if the blood-coagulation is to be held constantly in check. Fortunately heparin seems effective without causing continuous depression of coagulability. Probably this is explained by its vasodilator action-an action that may account for the rapid relief of pain that usually follows its administration. As regards the coumarin drugs, though these can be given by mouth, the great difficulty is that their safe use depends on daily estimation of bloodprothrombin. This exacting test calls for reliable thromboplastin ; and clinicians unable to rely on the test often play safe by giving too little anticoagulant, with recurrence of thrombophlebitis as the penalty.Tromexanhas the - advantage over dicoumarol that its action is established within 8-24 hours and ends about the same time after administrdtion is discontinued. BuRT et al.a report its use in 126 cases with no more untoward effect than transient heematuria in 1 case where a double "
Wright, H. P. J. Path. Bact. 1942, 54, 461. Wright, H. P., Osborn, S. B., Edmonds, D. G. Lancet, Jan. 6, 1951, p. 22. 3. Burt, C. C., Wright, H. P., Kubik, M. Brit. med. J. 1949, ii,
1. 2.
1150.
277
dose was given in error on the fourth day of treatment. Dicoumarol has now been replaced almost completely by tromexan, though with this substance prothrombin estimations are still necessary. The danger of thrombophlebitis and the results of4 anticoagulant therapy ’are indicated by COSGRIFF, who collected 4580 cases treated conservatively and
itself, and the general adaptation syndrome may pass through its three stages-the alarm reaction," the stage of resistance, and the stage of exhaustion. "
The alarm reaction has two "
"
phases, shock" and representing- the initial
counter-shock," the first submission of the organism to the attack, the second the mobilisation of the body’s resources to defend The results itself and to resist the continuing onslaught. Counter2267 cases treated with anticoagulants. shock are as follows : projects into the stage of resistance, which With Without represents the prolonged struggle of the organism, anticoagulants anticoagulants until perhaps it ultimately succumbs during the stage .... Further thrombosis 21% 1-1% of exhaustion. The symptoms and signs of each phase 1.1% Pulmonary embolism ..... 29 % are classical; but their very multiplicity, and the Fatal pulmonary embolism .. 14% 0’9% their occurrence, make the clinical of variability story of anticoagulants is only beginning ; one of confusing diversity. picture certainly better and safer drugs will be introduced features of " shock "-diminished All the cardinal blood-pressure ; (indeed it is rumoured that some have already been found), and the difficulties of today will soon be only lowered temperature ;-, depression of the nervous system ; loss of muscle tone ; haemoconcentration ; a -memory. Some authorities (notably Prof. MICHAEL increased capillary and cell-membrane permeability, BOYD) rely, greatly on paravertebral lumbar sympa- with plasma seeping into the tissues, sodium and thetic block by procaine injection or even sympathe cells, and potassium escaping chloride thectomy ; this improves the blood-flow to the into the entering extracellular fluid ; acidosis ; transient affected limb and at least gives symptomatic relief. The value of venous ligature-femoral, iliac, or even hyperglycæmia, changing to hypoglycæmia ; leucocytosis ; and gastro-intestinal ulceration-all these caval-is still disputed. may be present and may become reversed during counter-shock and the stage of resistance, with the What is Stress ? addition of thymicolymphoid involution and eosinoFOR fifteen years the boundless energy, the apostolic On the other hand, the effect of the stressor fervour, the multilingual education, the cosmopolitan penia. agent may be so mild that only transient hyperknowledge, the encyclopaedic erudition, and the out- glycaemia, tachycardia, and leucocytosis bear witness standing administrative ability of HANS SELYE have to the shock. The succession of events may be rapid been devoted to the study of stress. He is a superb and fulminant, as in an attack of malignant diphtheria, experimental surgeon, as his technique for hypo- or long-continued and delayed, as after exposure to physectomy in the rat bears witness. He has a X rays. The evolution of a particular phase from photostatic mind which retains not only the gist but the preceding one may be gradual and insidious, and the detail of many thousands of scientific publications, reversal of the cardinal features may not occur and enables him to coordinate and correlate the so at one time the simultaneously ; hypoglycæmia of kaleidoscopic facets of physiological, pathological, shock may co-exist with the recovering blood-pressure immunological, biochemical, and endocrine studies in of counter-shock. Further, the classical picture of experimental medicine. He directs a lavishly equipped the general adaptation syndrome may be compLicated institute in Montreal and his reference library is certain special features characteristic of the exhaustive. Still a young man, companionable and by particular stressor agent, such as the haemodilution with humour in his personal contacts, he is neverthehaemorrhage or burns, the cerebral oedema less in deadly earnest. He and his not inconsiderable following of heatstroke,’ or the hæmopoiesis stimulated by following of disciples are devoted to a creed-the anoxia. He writes, as he General Adaptation Syndrome. Resistance to the stressor agent, as well as to and without thinks, prolifically simplicity. It requires all other damaging agents, falls during the shock time and concentration, as well as specialised knowand rises during counter-shock ; hence prophase, ledge, to follow his argument: indeed he complains duction of an alarm reaction by one stressor agent that many authoritative people have not grasped his will temporarily lead to protection against another. meaning. Partly this is because he does not always For instance, previous bleeding will protect a rabbit write in conventional scientific language, but is for intoxication by nitrogen mustard. subsequent against ever creating new words and propounding fresh In fact this " crossed resistance " may explain all definitions. His writings are not only extensive but sorts of such as the effects of non-specific apt to be bulky : they are more appropriately read therapy, phenomena fever therapy, protein-shock therapy, malaria propped on a lectern than skimmed in a subway. therapy, insulin-shock therapy, and even electrical Indeed there can be few who undergo the stress of convulsion therapy. - On the other hand, crossed modern life who can afford the luxurious leisure, and resistance will be manifest only if the second stressor acquire the contemplative contentment, needed to stimulus is applied during the counter-shock phase’of absorb ,.land. fully appreciate SELYE’s gospel, now the alarm reaction brought about by the first stressor proclaimed in his book.5 ; for, during the stage of resistance, nonThe skeleton of the general adaptation syndrome stimulus resistance falls, and in an attempt to conserve (G.A.S.) will be already familiar to the reader.. Under specific the influence of a stressor " agent the body adapts its " adaptation energy " the organism will continue to resist only the original stressor agent, and becomes 4. Cosgriff, S. W. Amer. J. Med. 1947, 3, 740, 753. at the same time vulnerable to other damaging agents, 5. Stress. By HANS SELYE, M.D., PH.D. Prague, D.SC. McGill, F.R.S. (c.); professor and director of the Institut de Médecine which may therefore precipitate another alarm et de Chirurgie Experimentales, Université de Montreal. reaction. Montreal: Acta Inc. 1950. Pp. 1000. £5 5s.
The
"