EPITOME OF CURRENT MEDICAL LITERATURE

1922 BMJ (Clinical Research Edition)  
1922, p. 331), in discussing the question of sensitiveness to non-bacterial toxins and proteins, considers that sensitiveness to external irritants should not be confused with the anaphylaxis of protein sensitization, because, while in the former first contact usually causes some reaction, and further contacts cause reactions varying in inverse proportion to the interval between them, and the sensitiveness is exalted rather than destroyed thereby, in the latter no disturbance results from first
more » ... results from first contact, and reactions follow further contacts only after a considerable interval, and the sensitiveness is destroyed by the reaction. That some patients react to the extravasation of blood into their tissues with the production of an erythematous eruption was shown by four cases in which erythemato-urticarial eruptions occurred on the tenth day after severe traumatic ecchymoses unaccompanied by any breach of surface, recovery taking place in a few days. Auto-sensitization of the patient's skin to the serum of his own blisters was shown in a case of acute bullous eczema in which the trickling of serum from the bullae produced, in rapid succession, an erythematous streak, or wheal, and finally a row of vesicles. No such effects occur in Rhus toxicodendron poisoning, thus supporting the contention that there is a difference in kind between plant sensitiveness and serum sensitiveness (anaphylaxis). Attention is called to the phenomenon observed in some cases associated with muscular rheumatism where a patchy eczematous eruption frequently occurs on the outer sides of the limbs, notably above the external malleolus and oVer the great trochanter and subcutaneous border of the ulna. If these patches are rubbed briskly erection of-the hair follicles, followed by redness and swelling of the part owing to serous effusion, takes place, and shortly after the subsidence of this urticarial reaction itching may be complained of in various asymmetrical regions widely separated from the original site. While this may be due to absorption of bacteria or to a reflex nervous irritation, its possible etiology from absorption of exuded lymph producing a toxic urticaria is suggested. Two other cases are recorded-one in which an insect bite on the leg was followed fourteen days later by the development of a herpetiform group of vesicles at the site, and an acute vesicular eczema all over the face. The other case was one of severe hay fever, accompanied in each attack by marked pityriasis of the scalp and falling out of the hair; this patient was also a chronic dyspeptic in who:n strawberries always produced indigestion and all the symptoms of hay fever. 456. Paroxysmal Tachyeardia due to Digitalis ard Strophanthus. D. DANIPLOPOLU (Arch. des Mal. du6 Coenr, des Vaisseaux et du Sang, August, 1922, p. 537) observes that the very complex action of digitalis and drugs belonging to the same group on the normal myocardium becomes still more difficult of comprehension in myocardial failure. While in one direction these drugs diminish auitomatism and conductivity, in another they increase excitability and contractility. Thus in some cases of cardiac failure digitalis relieves, while in others it aggravates, the condition. The author refers to recent researches by Cushny and others which show that in an advanced stage of digitalis poisoning the ventricle may begin to contract automatically, with an acceleration of auricular pulsations. Other observers have found that strophanthin produces an intense stimulation of the normal and heterotopic centres, characterized by tachyeardia and extra-systolic arrhythmia, leading to ventricular fibrillation. Numerous clinical observations are cited, which show that digitalis and strophanthin may produce (in addition to "coupled rhythm") paroxysmal tachycardia. Details are given of two cases, women aged 30 and 25 years respectively, both having enormously dilated hearts following polyarticular rheumatism. In the first case large and repeated doses of digitalin (Nativelle) failed to relieve the condition. In the second case the same. drug improved the myocardial action and promoted diuresis, followed, however, by vomiting; all drugs were stopped, and after forty-eight hours the rhythm became normal at 120, but a slight recurrence of acute polyarticular rheumatism was followed by "coupled rhythm" and paroxysmal tachycardia lasting three days. A third (fatal) case was that of a man, aged 88, suffer. ing from chronic nephritis with much hypertrophy of the left side of the heart and dilatation of the right; transient improvement followed two intravenous injections of 0.25 mg. strophanthin daily for -three days, followed by daily injections of the same amount. The dilatation then increased and digitalin was given, but the heart continued to enlarge and the pulse rose to 112; digitalin, strophanthin, and quinine were given alternately or in combination, and transient improvement occurred at intervals but was not maintained, and the patient died in six days. Dani6lopolu concludes: (1) The chief phenomenon of myocardial failure is diminution of contractility accompanied by increase of excitability. In chronic dilatation where the myocardium is still capable of responding to cardiac tonics these substances act typically-they increase contractility, restore coronary nutrition, which itself lessens excitability. (2) In unrelieved dilatation, where contractility is seriously lessened, digitalis has no effect, as in the "1 eserinized " heart (Frolich and Pick) it lessens contractility. The vagus is often hyperexcitable in asystolic cases. If the myocardial excitability is not very great (this is rare) the vagotropic action of digitalis slows the pulse rate (direct negative chronotropic action of digitalis). This is P. Merklen's dissociated action, where the aggravation of myocardial failure is not due solely to lengthening of diastole but above all to its negative inotropic action. Then, almost always, myocardial hyperexcitability Is greatly increased. Negative chronotropic action does not follow, for it cannot overcome the greatly increased myocardial hyperexcitability. By its negative inotropic action digitalis lessens contractility, while, either directly or indirectly, it increases excitability, producing either normotropic or heterotropic tachyeardia or pulsus bigeminus. This is the "1 inverse action " of digitalis, the commonest of its typical effects. (3) Dissociated or inverse effects are rarer with strophanthus than with digitalis; when they appear after administration of strophanthus in the ultimate phases of cardiac failure we may consider the patient doomed.. 457. , 1922, p. 313) discuss respectively the medical, surgical,and neurological aspects of infection of the gastro-intestinal tract. The medical treatment (G. R. SATTERLEE) of chronic intestinal toxaemia consists of diet, massage, hydrotherapy, and vaccines ol serum, and the removal of all obvious foci in the mouth5 rectum, or elsewhere is essential to prevent the resulting toxaemia becoming generalized and causing a lowering ol resistance. From the experience of over 500 cases treated by autogenous colon vaccines, it appears that the colon bacillus is the primary cause of the lowered resistance, and that the streptococcal and other bacterial infections are secondary. 'lThe chief foci of infection are found in the tonsils, teeth, in abscesses and necrosis of the jaw, and in the nasal sinuses, rectum, seminal vesicles, and cervix uteri, and thorough investigation, followed by efflcient treatment, is essential to success. From the surgical point of view (J. W. DRAPER, with pathological report by J. EWING) colon pathology in its relation to the etiology of systemic disorders requires further investigation, since there is not enough evidence as yet available to prove that any particular group of mental symptoms can with certainty be attributed thereto, and the extirpation of considerable portions of the ileum is unwarranted if based solely upon anatomical conditions. In all functional psychoses extensive colon pathology exists in 20 per cent. of the cases, and mental symptoms have been arrested or improved by operation in a large percentage, though colectomy is contraindicated until the patient has had all other foci removed and has been treated with vaccines and serums. The mortality from the operation was found to be 12 per cent. in 77 consecutive cases. Froin the neuro-
doi:10.1136/bmj.2.3233.e85 fatcat:2euc2kbk6bc4bknlbj3trathzy