- Email: [email protected]
THYROIDECTOMY FOR ANGINA PECTORIS
32 treated
orally 1 escaped attack, 12 having a modified attack, and 3
were
regarded
unmodified attack. For both methods of administration the results suggest a favourable issue, but the figures are somewhat difficult to interpret. No control the is available to assess proportion of persons group that would escape attack in the absence of treatment, though it is, perhaps, unlikely" that it would Modification " reach as high a figure as 40 per cent. is a rather vague term. It proved impossible to keep temperature charts, nor could frequent calls be made on the immunised patients in a rural practice. It is stated that in the 1934-35 epidemic most of the cases of measles were of an unusually severe nature, " all symptoms being present, so that the effect of the treated cases stood out in bold contrast On the other to those not receiving treatment." hand, it is reported that no deaths have taken place with the largest number of cases the county has ever seen, and the fatality-rate in the whole State was much lower in 1935 than in the epidemic of 1932. This observation rather suggests a general prevalence of milder attacks. It is concluded tentatively that the death-rate from measles in the county seems to have been lowered during the period of this county-wide project, but it is not stated what proportion of all cases were immunised, which would be of much interest in this connexion. After intramuscular administration slight local reaction occurred in 32 of the 77 patients, and slight febrile reaction was observed in less than one-sixth of the cases, but no severe or general reaction was reported. as
an
THYROIDECTOMY FOR ANGINA PECTORIS
complete removal of an apparently normal thyroid gland in the hope of relieving intractable heart failure, including anginal failure, is a drastic THE
method of treatment for which considerable success has been claimed. The observation has also been made that patients with toxic goitre and angina may derive relief from their pain after thyroidectomy, and the reverse effect, that is ’the development of angina in myxoedematous patients treated with thyroid extract, is also recognised. Weinstein, Davis, Berlin, and Blumgart have investigated the manner in which anginal pain is relieved after removal of the normal thyroid, and have noted that while some weeks elapsed before the basal metabolic rate dropped to any considerable extent the angina improved immediately after the operation. They attributed the benefit to interruption of nervous pathways in the course of the operation, the effect being similar to that of cervical sympathectomy, a surgical method of treating angina at one time in favour. The idea was supported by the observation that hemithyroidectomy gave immediate relief from pain only on the operated side of the body. A recent report on thyroidectomy for angina is made by J. D. Bisgard,l whose patient, aged 67, had an old-standing goitre and a metabolic rate of about -30 per cent. ; there were no symptoms of hyper- or hypo-thyroidism, but he was incapacitated by angina of the effort type. After subtotal thyroidectomy, only a small portion of the right lobe being left, he was almost completely relieved of pain, and able to undertake light work, the period of post-operative observation extending to eleven months. The interesting feature of the case is the initial low metabolism, which showed a definite rise after treatment and at a time when the anginal pain was favourably affected ; this appears to supply strong evidence against the view that such an effect, 1
Jour. Amer. Med. Assoc., May 9th, 1936, p. 1639.
when permanent, is a result of an abnormally low metabolism. Cases of toxic goitre have been reported in which symptoms have been relieved by thyroidectomy, even though the metabolism did not fall. It is also recognised that cardiac disturbances, especially auricular fibrillation, may be associated with oldstanding degenerated goitres, without any increase in metabolism, and that removal of the goitre may be followed by reappearance of normal rhythm. The possibility that the development of angina in a subject with some degree of coronary narrowing is due to some toxic action on the heart independent of interference with metabolism must also be
considered. HEPARIN
HEPARIN, which was discovered accidentally by Jay McLean in 1916, is well known to be an efficient anticoagulant, but has hitherto been little
used on account of its cost. Charles and Scott three years agoobtained a greatly increased yield from the liver and showed that other organs, especially the lungs, are rich in it. Probably if the demand were greater the price could now be reduced. The growing interest in its properties is manifest in five communications to a recent number of the Acta Medica Scandinavica. The chemical nature of heparin has been debated for twenty years and the only point upon which opinion has been unanimous is that it contains11 a group or groups of carbohydrate. E. Jorpes brings forward evidence to show that it consists of a mixture of chondroitin di- and tri-sulphuric acids. He ascribes the anticoagulant effect to the sulphate groups, which perhaps brings it into line with the synthetic anticoagulants such as Congo-red, Germanin, and Liquoid, which are polysulphonic acids. The practical uses of heparin are discussed in the succeeding papers. Widstrom and Wilander have injected heparin into the pleural cavities of rabbits, pleurisy having previously been produced by intrapleural injection of iodine. They found that the precipitation of fibrin from pleural effusions was prevented by heparin, with the result that adhesions are not formed and the effusion is more readily absorbed. They suggest that heparin might be of value in the treatment of pleural effusion and are Hedenius and Wilander now trying it clinically. have investigated the effect of the intravenous injection of heparin in man. They have shown that one dose of 50-150 mg. prolongs coagulation time for 3-7 hours ; repeated injections give an effect of longer duration. The patients suffered no untoward symptoms and the authors suggest its use as a prophy-
lactic for post-operative thrombosis. E. Skold records 24 blood transfusions where heparin was used one or two of the patients as an anticoagulant; suffered mild febrile reactions, but the great majority had no symptoms referable to the transfusion. It is not clear, however, that heparin is superior to citrate for this purpose. Perhaps the most interesting communication is that describing a study of erythrocyte sedimentation-rate (E.S.R.) by Enocksson, Gjertz, Schnell, and Torgersruud, who used heparin instead of sodium citrate. They found that 1/151/20 c.cm. of a 1 per cent. solution of heparin efficiently prevents the coagulation of 2 c.cm. of blood. An exhaustive comparison of results using citrate and heparin on the same material shows that the former tends to stabilise the E.S.R. ; correlation between 2
1 Jour. Biol. Chem., 1933, cii,, 425. Acta Med. Scand., 1936, lxxxviii., 427.
orally 1 escaped attack, 12 having a modified attack, and 3
were
regarded
unmodified attack. For both methods of administration the results suggest a favourable issue, but the figures are somewhat difficult to interpret. No control the is available to assess proportion of persons group that would escape attack in the absence of treatment, though it is, perhaps, unlikely" that it would Modification " reach as high a figure as 40 per cent. is a rather vague term. It proved impossible to keep temperature charts, nor could frequent calls be made on the immunised patients in a rural practice. It is stated that in the 1934-35 epidemic most of the cases of measles were of an unusually severe nature, " all symptoms being present, so that the effect of the treated cases stood out in bold contrast On the other to those not receiving treatment." hand, it is reported that no deaths have taken place with the largest number of cases the county has ever seen, and the fatality-rate in the whole State was much lower in 1935 than in the epidemic of 1932. This observation rather suggests a general prevalence of milder attacks. It is concluded tentatively that the death-rate from measles in the county seems to have been lowered during the period of this county-wide project, but it is not stated what proportion of all cases were immunised, which would be of much interest in this connexion. After intramuscular administration slight local reaction occurred in 32 of the 77 patients, and slight febrile reaction was observed in less than one-sixth of the cases, but no severe or general reaction was reported. as
an
THYROIDECTOMY FOR ANGINA PECTORIS
complete removal of an apparently normal thyroid gland in the hope of relieving intractable heart failure, including anginal failure, is a drastic THE
method of treatment for which considerable success has been claimed. The observation has also been made that patients with toxic goitre and angina may derive relief from their pain after thyroidectomy, and the reverse effect, that is ’the development of angina in myxoedematous patients treated with thyroid extract, is also recognised. Weinstein, Davis, Berlin, and Blumgart have investigated the manner in which anginal pain is relieved after removal of the normal thyroid, and have noted that while some weeks elapsed before the basal metabolic rate dropped to any considerable extent the angina improved immediately after the operation. They attributed the benefit to interruption of nervous pathways in the course of the operation, the effect being similar to that of cervical sympathectomy, a surgical method of treating angina at one time in favour. The idea was supported by the observation that hemithyroidectomy gave immediate relief from pain only on the operated side of the body. A recent report on thyroidectomy for angina is made by J. D. Bisgard,l whose patient, aged 67, had an old-standing goitre and a metabolic rate of about -30 per cent. ; there were no symptoms of hyper- or hypo-thyroidism, but he was incapacitated by angina of the effort type. After subtotal thyroidectomy, only a small portion of the right lobe being left, he was almost completely relieved of pain, and able to undertake light work, the period of post-operative observation extending to eleven months. The interesting feature of the case is the initial low metabolism, which showed a definite rise after treatment and at a time when the anginal pain was favourably affected ; this appears to supply strong evidence against the view that such an effect, 1
Jour. Amer. Med. Assoc., May 9th, 1936, p. 1639.
when permanent, is a result of an abnormally low metabolism. Cases of toxic goitre have been reported in which symptoms have been relieved by thyroidectomy, even though the metabolism did not fall. It is also recognised that cardiac disturbances, especially auricular fibrillation, may be associated with oldstanding degenerated goitres, without any increase in metabolism, and that removal of the goitre may be followed by reappearance of normal rhythm. The possibility that the development of angina in a subject with some degree of coronary narrowing is due to some toxic action on the heart independent of interference with metabolism must also be
considered. HEPARIN
HEPARIN, which was discovered accidentally by Jay McLean in 1916, is well known to be an efficient anticoagulant, but has hitherto been little
used on account of its cost. Charles and Scott three years agoobtained a greatly increased yield from the liver and showed that other organs, especially the lungs, are rich in it. Probably if the demand were greater the price could now be reduced. The growing interest in its properties is manifest in five communications to a recent number of the Acta Medica Scandinavica. The chemical nature of heparin has been debated for twenty years and the only point upon which opinion has been unanimous is that it contains11 a group or groups of carbohydrate. E. Jorpes brings forward evidence to show that it consists of a mixture of chondroitin di- and tri-sulphuric acids. He ascribes the anticoagulant effect to the sulphate groups, which perhaps brings it into line with the synthetic anticoagulants such as Congo-red, Germanin, and Liquoid, which are polysulphonic acids. The practical uses of heparin are discussed in the succeeding papers. Widstrom and Wilander have injected heparin into the pleural cavities of rabbits, pleurisy having previously been produced by intrapleural injection of iodine. They found that the precipitation of fibrin from pleural effusions was prevented by heparin, with the result that adhesions are not formed and the effusion is more readily absorbed. They suggest that heparin might be of value in the treatment of pleural effusion and are Hedenius and Wilander now trying it clinically. have investigated the effect of the intravenous injection of heparin in man. They have shown that one dose of 50-150 mg. prolongs coagulation time for 3-7 hours ; repeated injections give an effect of longer duration. The patients suffered no untoward symptoms and the authors suggest its use as a prophy-
lactic for post-operative thrombosis. E. Skold records 24 blood transfusions where heparin was used one or two of the patients as an anticoagulant; suffered mild febrile reactions, but the great majority had no symptoms referable to the transfusion. It is not clear, however, that heparin is superior to citrate for this purpose. Perhaps the most interesting communication is that describing a study of erythrocyte sedimentation-rate (E.S.R.) by Enocksson, Gjertz, Schnell, and Torgersruud, who used heparin instead of sodium citrate. They found that 1/151/20 c.cm. of a 1 per cent. solution of heparin efficiently prevents the coagulation of 2 c.cm. of blood. An exhaustive comparison of results using citrate and heparin on the same material shows that the former tends to stabilise the E.S.R. ; correlation between 2
1 Jour. Biol. Chem., 1933, cii,, 425. Acta Med. Scand., 1936, lxxxviii., 427.