Alan P. Grant

The association of acute stroke and myocardial infarction in elderly medical emergencies

SummaryA retrospective study was made in an acute medical ward over 10 years. Patients 70 years and over who were admitted within 72 hours of the onset of an “acute stroke” were reviewed as to the possibility of a coexisting myocardial infarction. The latter diagnosis was based on clinical grounds (E.C.G. and enzyme elevation) and on autopsy reports.In a series of 266 “acute strokes”, 30 (11.28%) were considered to have a coincidental cardiac infarction. Six of 31 autopsies (19.4%) showed unsuspected cardiac lesions. The mortality of the group was 76.6% inside 6 weeks. Recognition of the true incidence of cardiac infarction presenting as a stroke may require a large autopsy series. The problem seems generally underestimated and does not seem to have received the clinical recognition it deserves.

The use of sequential analysis in preliminary studies of “tersavid” in the treatment of angina pectoris

SummaryWithin the clinical and statistical limits of the preliminary trial the monoamine oxidase inhibitor “Tersavid ” produced no dramatic improvement in a small series of patients suffering from angina. Side-effects especially of a gastric type, may have biassed patients of the more simple and nervous type against it. The more reliable patients obtained perhaps some help, but on the results it would be difficult to justify the use of this drug.The value of sequential tests, both open and restricted, has been discussed and the methods explained.

The coincidence of infarcts of the heart and brain an analysis

SummaryA STATISTICAL analysis of consecutive routine autopsy reports was carried out in an attempt to clarify the epidemiological and clinical importance of coincident cerebral and cardiac infarction. Three thousand five hundred and thirty two autopsies fulfilled our basic criteria, being performed on subjects over 20 years of age and dying from natural causes. These were examined and only those in whom macroscopic recent infarcts of the brain and heart were found were accepted for the study. Therefore only infarctions which could produce unambiguous clinical symptoms were analysed. Out of a total 906 infarctions 282 were cerebral alone, 532 cardiac alone and 92 coexisted in both the heart and brain.The analysis recognised that the problem of combined infarction overlies two populations, namely patients dying from cerebrovascular disease and those dying from coronory heart disease. Its objectives were to ascertain if a large series of autopsies on such subjects would prove that there was an important and significant association between acute infarcts coinciding in the brain and the heart, and to examine the importance of age and sex. The association between cerebral and myocardial infarctions was highly significant (p<0.001) this being more marked in females. Analysis by age age cohorts showed that significance (P<0.001) was really confined to the decade 70–79 years with male predominance. Cardiac infarction alone was the most common lesion up to 80 years, after this age cerebral infarctions became predominant and combined lesions became infrequent.We suggest that patients presenting wth a stroke in the decade 70–79 years should have the possibility of cardiac infarction fully investigated so that proper management A00IA200

Experience of chlorpropamide in 100 cases of diabetes mellitus

Summary and conclusionsThe results of chlorpropamide treatment of 100 diabetic patients observed for up to one year are recorded. The average initial dosage was 500 mg. and maintenance dosage 250 mg. The following conclusions are drawn:1.Chlorpropamide is a potent antidiabetic compound capable of producing hypoglycaemic symptoms. In the present series it gave a good or excellent response in 71 per cent, of diabetic patients. With better co-operation a further 10 per cent, would have had similar control.2.The main contraindication to this form of treatment irrespective of the patient’s age is the presence of ketonuria without infection. Disordered fat and glucose metabolism in “ juvenile type ” diabetes requires insulin treatment.3.Severe obesity tends to produce refractoriness to chlorpropamide.4.Weight gain in responsive patients is common and does not depend only on the diet.5.No significant difference of response in the sexes was observed.6.Toxic reactions sufficient to stop treatment occurred in two patients, one suffering allergic erythema and the other leucopenia. One patient had minor digestive upset. Reference is made to the literature regarding the results obtained by other workers and the incidence of toxic effects. Evidence from the literature relating to an anti-ketotic effect from chlorpropamide is presented.

Treatment of tetanus with intravenous thiopentone and pethidine.

Summary1. Thiopentone, 0.4 per cent. solution, given for ten days intravenously, together with Pethidine 100 mgms. six-hourly, intramuscularly, appeared to be a suitable combination in producing satisfactory relaxation in a severe case of tetanus.2. Skill in controlling administration was rapidly acquired by medical students and nursing staff.3. Profuse sweating required adequate control of fluid and salt balance.4. Oral feeding was dangerous but the high metabolic rate occurring in this severe illness, necessitated replacement of protein plus suitable calorific intake. Intravenous “Casydrol” and dextrose proved adequate.5. Blind bronchial suction with a catheter through an endotracheal tube was life-saving on two occasions, and eliminated the necessity of performing a tracheotomy.6. Antibiotics did not affect the tetanus, but were useful in preventing a pneumonia, which would otherwise undoubtedly have occurred.

Melanoma of small bowel as a cause of melaena.

Summary(i)An unusual case of melaena is presented.(ii)The literature on malignant melanoma of the small bowel is reviewed.(iii)The importance of histological examination of all pigmented biopsy specimens is stressed.

Lobster, port and lympangiomatous dysplasia: A variety of the klippel-trenauney syndrome

SummaryA case of multiple dysplasia is reported. There is an involvement of the capillaries, veins and lymphatics with angiomata of the trunk and upper limb. In addition the patient displays a gigantic enlargement of two fingers and the nipple. A similar case has not been found in the literature but review articles suggest that this is a variant of multiple telangiectatic syndromes possibly combined with neurofibromata.

The syndromes of chest wall pain

The present study would confirm that there are two main thoracic syndromes, and that chest wall pain is a common and frequently misdiagnosed complaint. It is suggested, however, that the previous nomenclature is confused and unsatisfactory on the following grounds. Firstly, there are two types of pain, namely neuralgia or pain due to mechanical strain which may be found in affections of either the rib alone or of the dorsal spine and the ribs arising from it. The description of the pain merely localises it to the thoracic cage although bilateral pain suggests the cause to be vertebral. Secondly, the treatment of the two syndromes differs, and where the rib alone seems to be affected this can usually be simply dealt with. As little is known about the basic aetiology it seems reasonable to name the syndromes provisionally on an anatomical basis.

Rapidity of action of chlorpropamide in diabetes: A clinical assessment

Summary and ConclusionsA study comprising 23 diabetic patients over the age of 40 years treated on 500 mg. Chlorpropamide each morning is described. One patient was excluded from statistical analysis because of non-conformity to diet; one patient failed to respond, and in 3 patients increase of dosage above 500 mg. was required for control. The remaining 17 showed a significant fall of average daily blood sugar on the second day of treatment and a continued drop in this level for 5–8 days.This investigation would suggest that in the majority of patients in this category a significant fall in average daily blood sugar level on the second day of treatment is a reliable criterion of response to continued treatment on chlorpropamide.The same dietary care is essential in control of patients judged suitable for treatment with chlorpropamide as in those on insulin.No toxic reactions occurred.