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Use of fluorescein method in establishment of diagnosis and prognosis of peripheral vascular diseases
Abstracts
an
Selected Abstracts maage, K., Diagnosis 175,
and Linn, J. and Prognosis
Use of of Peripheral
33.:
Fluorescein Vascular
Method Diseases.
in ~stab~~s~ment Arch. Int. Fifed.
of 74:
1944.
Fluorescein, when injected intravenously, can be made visible by a beam of long wave ultraviolet radiation on reaching any area of exposed skin or mucous membranes with the bIood stream. The physical prerequisites for a good visualization of huoreseein in the riu~u.e and capillaries are the use of an appropriate long wave ultraviolet ray source and a darkroom. A photoelectric method to indicate the arrival of the dye and to measure the intensity of staining may also be used. Flaorescein is not toxic. Over 1,000 patients have been examined by this method without untoward reactions, except that 11 patients !:ad vomiting of short duration during the injection. Experiments on animals showed extremely low toxicityl. The dye travels with the blood stream and diffuses immediately through -the capillaries into the interstitial spaces. Dead cells do not stain. Fluorescein is partly adsorbed to the plasma proteins. Pathologic changes in plasma proteins do not change the amount of fluorescein immediately available for diffusion. UltrafiXration experiments show that the amount of dye diffusing into the tissue (depends on intracapillary pressure; if the latter rises, the amount which diBuses Changes into the tissue with the water increases without changing the coucentration, in capillary permeability change the amount which diffuses as well as the coneentraCon. Even slight inflammation increases the fluorescence of the tissue. Pigmentetion, especially in colored people, makes the test unreliable, a.lthough certain basic facts can still be elicited. The degree of fluorescence depends on the amouot of blood flowing through a certain part of the body, Objective determinatious of circulation time in normal persons showed that the circulation time between the arm and the lips is between fifteen and seventeen and one-half seconds, :&ile the time to the legs normally should not exceed twice this figure. Nine patients with acute embolism of the legs were examined. It was possible to define exactly the lowest possible level of amputation as far as the skin is concerned and to decide immediately on the probable formation of sufficient collateral circulation to avoid amputation. Block of the sympathetic lumbar ganglions should be performed to avoid mist&es caused by vasospasm. The immediate diagnosis of thrombotic occlusion can also be made. Small gangrenous areas in arteriosclerotic peripheral vascular disease can be judged as to the prospect for healing, localization, or further spread. There are two functional types of arteriosclerotic peripherai vascular disease as The first form concerns the larger vessels, mainly eausirrg shown by this test. rapidly spreading gangrene in the periphery, while the other occludes mainly sma’i! arteries with capillaries, thereby not necessitating large amputations. Thromboangiitis obliterans has usually a higher fluorescence than one would This discrepancy is a kading sign. expect from the lack of arterial pulsations. Spotty fluorescence may complete the picture. 819
820
AMERICAN
HEART
JOURNAL
Vasospastic disorders have a low fluorescence during the attack, which immediately returns to normal or even increases above normal on blockage of the sympathetic chain. Rubor on an inflammatory basis in a limb with arteriosclerotic peripheral vascuIar disease can be me11 differentiated from venous congestion (rubor on dependency). Thrombophlebitis of superficial vessels can be well made out as long as it is inflammatory and the extent of the inflammation can be outlined. Ulcers of the leg on a varicose vein basis can be judged as to their outlook for healing and skin grafting. Syphilitic ulcers of the leg have a specific picture in the fluorescein test which distinguishes them from varicose vein ulcers. AUTHOES.
Bain, C. W. C.:
Incomplete
Bundle
Branch
Block.
Brit.
Heart J. 6: 139, 1944.
Six cases of incomplete bundle branch block have been described. In none did the duration of the QRS exceed 0.10 second when ineomplete bundle branch block was judged to be present. In all of the cases normal complexes have been present for comparison, either in the same record or within a short period. The evidence suggests that the cases could be divided into three groups. The first shows a slight increase in the QRS without axis deviation as exemplified by the aberrant ventricular response to an auricular premature systole. These are probably due to a bilateral delay down each main branch (Case 1). The second shows delay down one branch, fulfilling the criteria for bundle branch block except that the QRS does not exceed 0.10 sec. (Cases 1, 2, 3, 4 and G). The third shows transitional complexes (Cases 5 and G). In these cases it is likely that the transitional complexes were due to a combination of bilateral delay down each main branch with additional delay down one branch, since both cases had an unstabIe branch block which sometimes changed from right to left, and there was not much axis deviation, although the QHX duration was 0.10 second. AUTHOR.
Hume, W. E., and Szekely, P.: Brit. Heart J. 6: 135, 1944.
Cardiac
Involvement
in Spirochaetal
Jaundice.
The authors report a case of spirochetal jaundice with electrocardiographic evidence of transient myocardial involvement. For five days following admission the electrocardiogram showed auricular fibrillation and a sinus rhythm with Twave changes, all of which had disappeared four months later. It is believed that, if more extensive studies were made in cases of jaundice, especially those with very low blood pressure and changes in the character of the heart sounds, more instances of myocardial involvement might perhaps be encountered. The authors believe that the electrocardiographic changes can be accounted for by direct involvement of the heart either in the form of multiple hemorrhages or of toxic damage to the heart muscle, or both. AUTHORS.
Bramwell, C., and Jones, A. M.: 129, 1944.
Acute Left Auricular
Failure.
Brit. Heart J. 6:
Two cases of mitral stenosis with acute pulmonary edema leading to death about the middle stage of pregnancy are described. The mechanism of production of this complication is discussed and it is attributed to acute left auricular failure. AUTHORS.
an
Selected Abstracts maage, K., Diagnosis 175,
and Linn, J. and Prognosis
Use of of Peripheral
33.:
Fluorescein Vascular
Method Diseases.
in ~stab~~s~ment Arch. Int. Fifed.
of 74:
1944.
Fluorescein, when injected intravenously, can be made visible by a beam of long wave ultraviolet radiation on reaching any area of exposed skin or mucous membranes with the bIood stream. The physical prerequisites for a good visualization of huoreseein in the riu~u.e and capillaries are the use of an appropriate long wave ultraviolet ray source and a darkroom. A photoelectric method to indicate the arrival of the dye and to measure the intensity of staining may also be used. Flaorescein is not toxic. Over 1,000 patients have been examined by this method without untoward reactions, except that 11 patients !:ad vomiting of short duration during the injection. Experiments on animals showed extremely low toxicityl. The dye travels with the blood stream and diffuses immediately through -the capillaries into the interstitial spaces. Dead cells do not stain. Fluorescein is partly adsorbed to the plasma proteins. Pathologic changes in plasma proteins do not change the amount of fluorescein immediately available for diffusion. UltrafiXration experiments show that the amount of dye diffusing into the tissue (depends on intracapillary pressure; if the latter rises, the amount which diBuses Changes into the tissue with the water increases without changing the coucentration, in capillary permeability change the amount which diffuses as well as the coneentraCon. Even slight inflammation increases the fluorescence of the tissue. Pigmentetion, especially in colored people, makes the test unreliable, a.lthough certain basic facts can still be elicited. The degree of fluorescence depends on the amouot of blood flowing through a certain part of the body, Objective determinatious of circulation time in normal persons showed that the circulation time between the arm and the lips is between fifteen and seventeen and one-half seconds, :&ile the time to the legs normally should not exceed twice this figure. Nine patients with acute embolism of the legs were examined. It was possible to define exactly the lowest possible level of amputation as far as the skin is concerned and to decide immediately on the probable formation of sufficient collateral circulation to avoid amputation. Block of the sympathetic lumbar ganglions should be performed to avoid mist&es caused by vasospasm. The immediate diagnosis of thrombotic occlusion can also be made. Small gangrenous areas in arteriosclerotic peripheral vascular disease can be judged as to the prospect for healing, localization, or further spread. There are two functional types of arteriosclerotic peripherai vascular disease as The first form concerns the larger vessels, mainly eausirrg shown by this test. rapidly spreading gangrene in the periphery, while the other occludes mainly sma’i! arteries with capillaries, thereby not necessitating large amputations. Thromboangiitis obliterans has usually a higher fluorescence than one would This discrepancy is a kading sign. expect from the lack of arterial pulsations. Spotty fluorescence may complete the picture. 819
820
AMERICAN
HEART
JOURNAL
Vasospastic disorders have a low fluorescence during the attack, which immediately returns to normal or even increases above normal on blockage of the sympathetic chain. Rubor on an inflammatory basis in a limb with arteriosclerotic peripheral vascuIar disease can be me11 differentiated from venous congestion (rubor on dependency). Thrombophlebitis of superficial vessels can be well made out as long as it is inflammatory and the extent of the inflammation can be outlined. Ulcers of the leg on a varicose vein basis can be judged as to their outlook for healing and skin grafting. Syphilitic ulcers of the leg have a specific picture in the fluorescein test which distinguishes them from varicose vein ulcers. AUTHOES.
Bain, C. W. C.:
Incomplete
Bundle
Branch
Block.
Brit.
Heart J. 6: 139, 1944.
Six cases of incomplete bundle branch block have been described. In none did the duration of the QRS exceed 0.10 second when ineomplete bundle branch block was judged to be present. In all of the cases normal complexes have been present for comparison, either in the same record or within a short period. The evidence suggests that the cases could be divided into three groups. The first shows a slight increase in the QRS without axis deviation as exemplified by the aberrant ventricular response to an auricular premature systole. These are probably due to a bilateral delay down each main branch (Case 1). The second shows delay down one branch, fulfilling the criteria for bundle branch block except that the QRS does not exceed 0.10 sec. (Cases 1, 2, 3, 4 and G). The third shows transitional complexes (Cases 5 and G). In these cases it is likely that the transitional complexes were due to a combination of bilateral delay down each main branch with additional delay down one branch, since both cases had an unstabIe branch block which sometimes changed from right to left, and there was not much axis deviation, although the QHX duration was 0.10 second. AUTHOR.
Hume, W. E., and Szekely, P.: Brit. Heart J. 6: 135, 1944.
Cardiac
Involvement
in Spirochaetal
Jaundice.
The authors report a case of spirochetal jaundice with electrocardiographic evidence of transient myocardial involvement. For five days following admission the electrocardiogram showed auricular fibrillation and a sinus rhythm with Twave changes, all of which had disappeared four months later. It is believed that, if more extensive studies were made in cases of jaundice, especially those with very low blood pressure and changes in the character of the heart sounds, more instances of myocardial involvement might perhaps be encountered. The authors believe that the electrocardiographic changes can be accounted for by direct involvement of the heart either in the form of multiple hemorrhages or of toxic damage to the heart muscle, or both. AUTHORS.
Bramwell, C., and Jones, A. M.: 129, 1944.
Acute Left Auricular
Failure.
Brit. Heart J. 6:
Two cases of mitral stenosis with acute pulmonary edema leading to death about the middle stage of pregnancy are described. The mechanism of production of this complication is discussed and it is attributed to acute left auricular failure. AUTHORS.