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THE DIFFERENTIAL DIAGNOSIS OF ANGINA

PECTORIS.

IT is not so long since the clinical picture oj

coronary artery disease, with its many variations,has been rescued from the profusion of symptomslabelled indigestion and made into a clinical entity,To those who have worked hard to differentiate thesyndrome, it is depressing to observe signs thatin diagnosis its cardinal features remain unrecognisedin many quarters. In an article entitled ReferredPain of Gastro-intestinal Origin Simulating AnginaPectoris,l Dr. Robert Palmer does not convince usthat confusion in diagnosis need still occur, certainlynot that the reaction of such patients to " continuedgastric regime " must be studied before a diagnosiscan be arrived at. It is certainly true that reflexgastric symptoms are common in cardiac pain, butthe features of the pain are usually clear cut. Dr.Palmer does not take into account the possibleoccurrence of intermittent claudication of themesenteric vessels, when the mesenteric arteries areaffected by arterios-clerosis; this possibility, with itsresulting digestive symptoms, should be borne in mindwith all patients showing marked atheroma of othervessels. The cases supplied to illustrate difficulty ofdiagnosis are few and incomplete. We are not toldthe blood pressure in any one case ; this is an importantomission, since patients suffering from high bloodpressure may complain of cardiac pain for some

years. No mention is made of the Wassermannreaction in any case. It is acknowledged that it ispossible to mistake pain of gastro-intestinal originfor angina pectoris, but the mistake should be rare,in the light of recent knowledge, among those familiarwith the manifestations of coronary artery disease.

CEREBRO-SPINAL FEVER.

SOME of the problems which arise in the preventionand treatment of cerebro-spinal fever were con-

sidered in our issue of Feb. 21st. Readers who requirefurther light on these difficulties will find it in a report 2

just published by the Ministry of Health, which dealswith the transmission of the disease by carriers, thevalue of serum, the use of vaccines, and the measuresto be taken with contacts. The treatment recom-mended, apart from good nursing, includes early andrepeated lumbar puncture, to relieve pressure and topromote drainage of the cerebro-spinal system ; inaddition the use of antimeningococcal serum is

advocated, to be administered, if possible, with thefirst lumbar puncture. The administration should berepeated at 24-hourly intervals until recovery appearsto be well established and the cerebro-spinal fluid hasbecome clear. It should not be discontinued if thefirst examination of the C.S.F. yields no meningococci ;nor should lumbar puncture be delayed if serum isnot immediately available. The amount of C.S.F.escaping after lumbar puncture in adults is commonlyin the region of 50 to 70 c.cm., and the amount ofserum injected should on no account exceed theamount of fluid withdrawn ; 30 c.cm. of serum is givenas the usual intrathecal dose for an adult, and it is bestinjected with the patient anaesthetised, since the painmay be considerable. With infants, who do nottolerate the injection of serum well, the use of an

1 New England Jour. of Med., 1931, cciv., 1351.2 A Review of Certain Aspects of the Control of Cerebro-spinal

Fever in relation particularly to a scheme for collecting the resultsof serum treatment. Ministry of Health Reports on PublicHealth and Medical Subjects. No. 65. H.M. Stationery Office,1931. Pp. 23. 6d.

anesthetic is considered inadvisable. Satisfactoryresults appear to have been obtained in Rumaniaby giving a daily intrathecal dose of polyvalent anti-

r meningococcal serum combined with an intramuscular. dose of about 60 c.cm. of the same serum for at leasti three or four days. In spite of the promising results, of serum therapy in the early stages, it has undoubtedlyI proved useless in many cases, partly because of the

difficulty of assessing the probable therapeutic. efficiency of antimeningococcal serums by laboratorymethods, and partly because of the multiplicity ofstrains of meningococci responsible for sporadic cases,and apart from the local strains recognisable during an.epidemic. At the present time it is thought thatreliance must be placed on polyvalent serums.

Vaccines, it is stated, may be useful during slowconvalescence, and should consist, if possible, ofkilled cultures of the patient’s own meningococcus,given subcutaneously in fairly large doses, beginningwith 250 millions. No satisfactory data existas regards the use of vaccines in prophylaxis. Theswabbing of contacts is advocated with a view to the.detection of carriers. To be effective, swabs shouldbe taken from the upper end of the posterior pharyn-geal wall, and contamination with saliva should beavoided. Fresh air and exercise, without othertreatment, have been found to be the best means offreeing a carrier of the meningococcus ; the use ofa fine vapour spray of zinc sulphate, I to 2 per cent.,directed through the nostrils and mouth to the naso-pharynx, appears to have been beneficial in some-

cases. ____

AN ADVISORY COMMITTEE TO THE BOARD

OF CONTROL.

THE Board of Control, with the approval of theMinister of Health, have appointed a committee toadvise them on questions arising in connexion withscientific and ancillary mental health services. Themembers are : Mr. L. G. Brock, chairman of th&Board of Control (chairman); Sir Hubert Bond,F.R.C.P. ; Mr. Robert Bruford, J.P. ; Mr. W. E.

Lovsey, J.P. ; Dr. T. S. Good; Dr. AdelineRoberts, J.P. ; Mr. J. C. Grime, J.P.; and Prof.J. Shaw Bolton, F.R.C.P., with Mr. P. Barter as

secretary. The Mental Treatment Act, which came.into operation on Jan. lst, confers upon local author-ities powers to provide for out-patient treatment andfor the after-care of mental patients, and, subject to.the approval of the Board of Control, to undertake orto contribute to research in regard to mental illness.The Board have appointed the advisory committeeto assist them in the consideration of schemes ofresearch submitted for their approval, and in regard-to such questions as the organisation of social servicesin connexion with out-patient treatment and after-care, on which local authorities may seek the Board?sguidance. On technical questions relating to researchthe advisory committee will have the expert advice.of members of the Medical Research Council’scommittee on mental disorders.

LONDON HOSPITAL SATURDAY FUND.—At a

meeting of the council last week it was reported that thefund during the past year had decreased by 25000.The fall was explained to be due to competition from similarorganisations and to the general financial stringency.EXTENSION OF WORKSOP VICTORIA HOSPITAL,

A new wing of this institution was recently opened byViscount Galway, to whose grandmother, Henrietta, LadyGalway, it owed its inception in 1867, and dedicated by the:.Bishop of Southwell.