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Postgrad Med J: first published as 10.1136/pgmj.29.333.365 on 1 July 1953. Downloaded from 365

@~HE M4ANAGEMENT OF CARDIAC INFARCTION By RAYMOND DALEY, M.A., M.D., M.R.C.P.

This article is concerned with patients suffering sulphate, 5 gr. q.d.s. by mouth, or pronestyl (pro- from cardiac infarction, rather than so-called acute caine amide hydrochloride), 250 mg. q.d.s. by coronary insufficiency. For complete diagnosis mouth, reduces the incidence of ventricular the former should have, during the first few days, arrhythmias. a mild fever, raised sedimentation rate, leucocytosis (b) Of patients with extensive infarction. and excess urine uroblinogen. In addition a Here the picture may be of intense pain or significant Q wave should be present in the syncopy, dyspnoea and elevation ofjugular venous electrocardiogram. pressure. In those with syncopy, and in some without, the may drop to well Immediate Management below ioo mm. Hg systolic, and as this represents

(a) Of patients without extensive infarction. a ' vaso-vagal ' attack there may also be a brady- by copyright. When first seen within a few hours of the onset, cardia. If such patients feel faint they are best these patients are usually recovering from their lain flat, but if they do not, and especially if the , have mild dyspnoea and have little or jugular venous pressure is much raised, a few no drop in blood pressure. Especially if pain pillows should be allowed. The dose of morphia has been severe the blood pressure may even be a required depends upon the severity of pain, but it little higher than the normal level for them. There is always wise to give a large dose and, if necessary, is sometimes a presystolic heard but intravenously. There is still insufficient evidence the jugular venous pressure is seldom raised. The concerning the of such patients, for

main symptom is anxiety. Such patients should be the obvious reason that in http://pmj.bmj.com/ propped up on several pillows which will reduce patients especially susceptible to arrhythmias the work of the and often relieve pain. should not be performed. It is hoped that in- Morphia should be given in adequate dosage. The formation will be forthcoming by the use of the dye decision whether or not to nurse at home must de- method of calculating output. With this deficiency pend upon social circumstances. In any case it is of knowledge therapy of the ' shocked' patient is rarely necessary to move any patient for the first still not established. Methods tried have been 24 hours. Subsequently hospital care has the ad- intra-arterial transfusion and the use of various

vantage of removing patients from domestic and pressor agents such as methedrine and nor- on September 25, 2021 by guest. Protected working worries and makes easier the control of adrenalin. anticoagulant therapy if it is decided upon. Oxygen therapy has been used when pain is During the first few days there is statistical intense with some relief. Clearly there is no reason evidence that the diet with advantage should con- why the arterial oxygen saturation should be re- tain about 8oo calories per day. Morphia is best duced and it is presumed that the effect is to in- given for the first few nights before patients are crease the plasma oxygen tension. weaned on to a barbiturate. By day, small doses of Early movement of these patients to hospital phenobarbitone are usually prescribed. If patients may be highly dangerous and, if at all possible, they do not worry about their bowel action the doctor should be nursed at home at least for several days. need not either, but as this is so rare liquid paraffin or other mild aperient may make circumstances Later Management happier. It is not often necessary to give an enema, The routine practice following cardiac infarction but if it is olive oil is the best form. Bed pans are is bed rest for four weeks, followed by three to to be condemned and a commode should be used. four weeks moving quietly about at home, and a There is experimental evidence that quinidine final three to four weeks increasing activity before Postgrad Med J: first published as 10.1136/pgmj.29.333.365 on 1 July 1953. Downloaded from 366 POSTGRADUATE MEDICAL JOURNAL YIy I953 returning to work. These are not just haphazard present the mortality was 3.5 per cent. and the periods of time for in experimental infarction in incidence of thrombo-embolism 0.7 per cent. animals three weeks are required for the infarcted They conclude that it is pointless to subject the area to become firmly fibrotic, and certainly cardiac second group to the hazards of anticoagulant infarction in mental patients who cannot be con- therapy and this seems to be a most reasonable trolled is associated with an increased incidence of point of view. cardiac rupture. Good prognostic signs are If anticoagulants are decided upon heparin is absence of cardiac failure and gallop rhythm, slight the safest and most expensive. It is best given or absent chest pain on effort, return of blood through an indwelling intravenous needle in the pressure to near-normal for the patient, and dosage of iojooO units six-hourly. Alternatively it ability to lead a life without excessive tension or may be given with procaine in the same dosage effort. intramuscularly into the upper and outer quadrant Levine and Lowe (1952) reported last year the of the buttock; in the thigh haematoma formation arm-chair ' treatment of nursing at the end of the is much more likely. By either method control of first week unless patients were debilitated, still clotting time is usually unnecessary because the ' shocked,' or had cerebrovascular accidents. They effect wears off so quickly. If bleeding should claim that cardiac output and pulmonary con- arise and must be stopped, transfusion or the gestion were reduced, that thrombo-embolic com- intravenous injection of 5 to 10 cc. of protamine plications were less and anxiety lessened. This is sulphate are recommended. a very practical suggestion and it is only hoped that Heparin may be continued for three weeks or more suitable arm-chairs will be provided in used only for the first day, tromexan being given at hospitals. the same time by mouth and carried on for three weeks. The usual dose of tromexan is 0.3 g. four The Anticoagulant Problem times during the first day, 0.3 g. twice on the There is no doubt that'the risks of thrombo- second day and then the dose regulated by daily embolic complications can be reduced by using prothrombin estimations in order to keep the pro-by copyright. anticoagulants. This especially applies to pul- thrombin time about twice normal. Attempts to monary embolism secondary to phlebothrombosis stop bleeding during tromexan therapy may be of the legs and, to a lesser extent, to systemic made by transfusion or intravenous injection of embolism from ventricular mural thrombosis. Vitamin K (or preferably K'). There is little evidence that, following coronary arterial occlusion, much retrograde thrombosis Management of Complications occurs in the coronary , and even less that this is influenced by anticoagulants. Ventricular must be urgently treated evidence because it may be a prelude to fatal ventricular There are numerous reports that in all cases of http://pmj.bmj.com/ myocardial infarction the overall mortality is re- fibrillation; i,OOO mg. of pronestly should be in- duced by 6 to io per cent. by anticoagulants, but jected slowly intravenously, always remembering very few of these reports state the number of that it is a powerful hypotensive agent. Supra- deaths attributable to their use. It is the un- ventricular are best treated by a fortunate experience of most clinicians to have combination of digoxin, o.25 mg. twice daily, and seen at least one death due to dicounarol or quinidine sulphate, 5 to 7 gr. four-hourly by tromexan therapy. This being so it does seem that mouth. Auricular fibrillation is treated by it is desirable to select in some way those patients quinidine sulphate, 5 gr. two-hourly up to a on September 25, 2021 by guest. Protected particularly liable to thrombo-embolic complica- maximum of 30 gr., and auricular flutter by either tions and reserve treatment for them. As there is aural digoxin, 0.25 mg. four times a day (stopping not yet any sure haemotological test to assess either when normal rhythm or vomiting occur), or liability to thrombosis the decision has to be made 0.5 mg. of digoxin intravenously. Any of these on clinical grounds. This has been done by arrhythmias considerably worsen the prognosis. Russell et al. (I952). They found that in ' poor Left ventricular failure is also a very serious risk' patients who had evidence of previous myo- complication and' is treated in the usual manner cardial infarction, intractable pain, extreme degree with low salt diets, mercurial diuretics and digitalis. and persistence of , marked cardiac enlarge- When it becomes chronic it is one of the most dis- ment, congestive , arrhythmias, tressing and refractory conditions encountered in diabetic acidosis, marked obesity, varicose or cardiology. evidence of previous thrombo-embolism, that the Ventricular aneurysm, diagnosed radiologically, mortality in hospital was 70 per cent. and the in- may present a frightening appearance and clearly cidence of thrombo-embolism 12.4 per cent. In may rupture, but it is at times surprising how long 'good risk' patients in whom none of these were such patients may survive. Postgrad Med J: first published as 10.1136/pgmj.29.333.365 on 1 July 1953. Downloaded from Yuly I953 Clinical Section 367 The surgical treatment of ischaemic heart but weight reduction in the obese is logical and disease is not yet established and many attempts to may improve residual pain on effort. try and revascularize ischaemic areas have failed. However, progress is now being made and it is probable that a valuable operation will arise in the BIBLIOGRAPHY next few years. A reduction in the number of LEVINE, S. A., and LOWE, B. (I952), J. Amer. med. Ass., I48, further attacks of infarction by modification of diet, I365. MASTER, A. M. (I936), Amer. Heart Y., 12, 549. such as a diet low in cholesterol, is not yet proved, RUSSELL, H. I., et al. (I952), Circulation, 5, 707.

CLINICAL SECTION

.4s. DYSGERMINOMA IN ASSOCIATION WITH EXFOLIATIVE DERMATITIS AND FEBRILE EPISODES By H. J. HAMBURY, M.D., F.R.C.S., and S. F. HANS, M.D., M.R.C.O.G., F.R.C.S.

Resident Surgical Officer and Clinical Assistant, St. JQhn's Hospital; S.E.I3 by copyright.

Dysgerminomas are comparatively rare tumours during the first week. Apart from a sedimenta- but are probably commoner than granulosa cell tion rate of 24 mm. in the hour, routine blood tumours of the ovary. Their histology and vary- tests were negative. ing malignancy are well known and their variable Treatment at this stage was by intravenous association with features of infantilism and thiosulphate and boracic ointment to sore areas. http://pmj.bmj.com/ abnormal hormonic output has been discussed in Progressive improvement of the skin lesions, apart the literature. The case under review showed from loss of hair, continued until the eighth week some unusual associated features. of hospitalization, when the first febrile episode occurred. It consisted of high fever (I04° F.), Case Report vomiting, tachycardia, dyspnoea and cyanosis, fall Jean C., a schoolgirl, aged i15 years, was ad- of blood pressure and extreme prostration. After

mitted at the request of her doctor who, while 24 hours these features disappeared. Three on September 25, 2021 by guest. Protected treating her for dermatitis, discovered a large further similar episodes took place, five days, I2 abdominal swelling. Oedema of the legs had days and six weeks later, the last one three weeks prompted abdominal . The dermatitis after laparotomy. During the third episode a had started three weeks prior to admission and the temperature of I050 F. and a blood urea of 300 oedema had been present for one week. mgm. per cent. were recorded. Biochemical in- Past history: Menstruation had commenced vestigation on the blood, cerebrospinal fluid and when the patient was aged 14 years and had been urine during these episodes showed no abnormality. normal apart from two months' amenorrhoea when Ten weeks after admission the skin and general aged I5 years. The last period was two months condition had improved sufficiently to allow before admission. laparotomy. This revealed a left ovarian tumour The girl was ill but normally developed. There and a small quantity of fluid in the peritoneal was a severe generalized exfoliative dermatitis, cavity. The right ovary, uterus and other ab- oedema of the ankles and a solid tumour arising dominal organs appeared to be normal. The from the pelvis to 3 in. above the umbilicus. The tumour was attached only by its pedicle and was temperature varied between 040 F, and 970 F, easily removed, It wfs Qid in shape and had an