936

detectable activity. From various considerations wehave come, to the conclusion that insulin is secretedcontinuously and the time up to point A must representthe time taken for it to develop demonstrable activity.This reaction of activation must develop withincreasing velocity and the analogous reaction of theactivation of trypsinogen by enterokinase immediatelysuggests itself. Support is lent to the above interpreta-tion of A by the observation that the interval beforeit occurred varied in accordance with the capacityof injected insulin to depress the blood-sugar. It wasconcluded from these results that insulin as we know

u I I lvi L- JUmm5.

Simultaneous blood-sugar curves in arterial and venous bloodafter administration of 50 g. glucose to a normal subject.

it and as it is secreted by the pancreas is an inactivematerial which requires activating by some unknownsubstance for which we tentatively propose the nameof insulin kinase.

This theory throws light upon many hithertoinexplicable findings. Markowitz, Mann, andBollmann 1 have shown that immediately afterremoving the liver from a dog insulin exerts its usualactivity, but that several hours or more later largedoses of insulin may exert no action on the blood-

sugar. They suggest that the action of insulin oncarbohydrate in the intact animal required some thirdfactor. Althausen and Thoenes 2 have publishedresults showing that in animals, during the stage ofliver necrosis and fatty degeneration which followspoisoning with chloroform, there is a subnormaltolerance to a combined test of insulin and oralglucose ; but that during the stage of liver regeneration,when the organ is full of young cells, there is a super-normal tolerance to the test. Reported cases ofinsulin-resistant diabetes are now numerous and inpractically every one an abnormal state of the liveris recorded and some of the clearest cases have beenthose arising after thrombosis of the hepatic artery.In a case seen personally the progression of resistancewas actually observed, a post-mortem was performedone hour and a quarter after death, gross liver damagewas found, but the pancreas was macroscopicallynormal ; microscopically no evidence of hydropicdegeneration of the islet cells was found and granuleswere demonstrable in these cells by Bensley’sstain.

3 From a consideration of these findings and our1 results the suggestion is put forward that insulin-t kinase is produced in the liver. This obviously. opens up many now possibilities in the pathologyi of diabetes. The question arises to what extentB disease of the liver and the presence or absence ofr this new factor plays a part in the production of- diabetes mellitus. Are there cases of diabetes which are due to disease of the liver and not to disease of. the pancreas f Feeding with fat has been found, to limit the production of insulin-kinase ; does thisthrow light upon the aetiological relationship of

obesity to diabetes ? f Is the syndrome of abdominalpain, vomiting, and rapid descent into coma withtemporary insensitivity to insulin, which supervenes,apparently fortuitously, in balanced diabetics, due toimpairment of liver function f And most importantof all, can a substance be prepared from the liverwhich will remedy those conditions in which insulin-kinase appears to be deficient ? fThe details of the physiological results on normal

subjects which have led to the formulation of thishypothesis are now being prepared for publicationelsewhere. Work is proceeding on the various patho-logical questions that arise in the application of thetheory to the analysis of diabetes, but evidence fromclinical experience cannot soon be collected by oneindividual with conclusive certainty. This preliminarycommunication is therefore made in order to interestothers in the attempt to regard diabetes and its

problems from a new viewpoint.REFERENCES

1. Markowitz, J., Mann, F. C., and Bollmann, J.: Amer. Jour.Physiol., 1929, lxxxvii., 566.

2. Althausen, J. L., and Thoenes, E.: Arch. Int. Med., 1932,1., 46.

OBSERVATIONS ON

THROMBO-PHLEBITIS MIGRANS

WITH NOTES OF A CASE

BY ALEC B. WALKER, M.D., M.R.C.P. EDIN.TUTOR IN CLINICAL MEDICINE, ROYAL INFIRMARY, EDINBURGH

THE type of thrombo-phlebitis first described in 1928 by Moorhead and Abrahamson as thrombo-phlebitis migrans differs from other forms of " wander-ing " phlebitis in its extensive distribution and in. the involvement of peripheral and visceral veins.l The disease usually commences in either the superficial

or deep peripheral veins with symptoms of inflam-. mation, but later the veins of the lungs, abdomen,or more rarely, of the heart and brain, may be affected.Each fresh development is accompanied with feverand a moderate leucocytosis. The course, thoughprolonged, is relatively benign and the setiologyobscure.Moorhead and Abrahamson described four cases,

and Ryle 2 in 1930 recorded five, whilst others havebeen reported from time to time. A summary ofthese is given in the accompanying Table.

NOTES OF A CASE

A man, aged 47, was referred to the Royal Infirmaryby Dr. A. Simpson, of Hawick, with the followinghistory :-

In December, 1931, the patient complained of intensefrontal headache and had a slight temperature. No sinustrouble could be detected. The pain gradually decreasedin intensity and he was able to resume work in 14 days.After two weeks at work he was again confined to bed, thistime complaining of intense pain in the left side of the chest.

937

SUMMARY OF CASES OF THROMBO-PHLEBITIS MIGRANS REPORTED BY VARIOUS AUTHORS

* Test-meal normal. X ray examination for focal sepsis negative.

Pleurodynia was diagnosed at the time, there being no signsof involvement of either lung or pleura. As this was dyingdown, the patient developed similar intense pain in the calfof the left leg. Fomentations and opiates did not affordmuch relief. The pain was due to a phlebitis and afterthree weeks the symptoms and signs were sufficientlyimproved, and he began to move about again. The usualswelling took place and was very persistent. Gentlemassage was commenced, but on Feb. 16th, 1932, the patientdeveloped " definite signs of embolus " in the right side ofthe chest, just below and outside the nipple. In spite oftwo or three weeks in bed, during which the chest conditiongradually cleared up, the swelling of the left leg remained.

On April 6th he was admitted for observation tothe medical wards under the care of Dr. John D.Comrie as a case of multiple thrombo-phlebitis.His further history was uneventful until on April 16th,when in spite of absolute rest and elevation of leftleg, he complained of acute pain on left side ofchest with rapid respirations, increased pulse-rate, and slight temperature. Physical examina-tion revealed an area of dullness posteriorly overthe left lung base with diminished vocal resonancealmost absent to breath sounds and definite pleuriticfriction towards the axilla. The typical frothyblood-stained sputum of pulmonary infarction wascoughed up. A hypodermic of gr. ! morphia plusgr. 1/100 atropine did not ease the pain appreciably,and on the following day a second similar injectionwas found necessary. Gradually the patient’s condi-tion improved, but on May 2nd he became verydepressed and insisted on returning home. He wastherefore discharged a few days later.

Previous History.-Operation for deviated septum someyears ago, otherwise no illnesses.

State own Examination (April 6th).-A stout florid man.Height 5 ft. 9t in. Weight 13 st. 1 lb. Swelling of left leg.Nervous system (report by Dr. E. H. Cameron) :

" Normal fundi and full vision. Right pupil rather larger

than the left and neither reacts to light to any extent. Theleft reacts a little but the right not at all. Both pupilsreact to some extent on convergence." Knee-jerks elicitedwith difficulty. Apart from this nothing abnormal wasfound in the nervous system. The respiratory signs havebeen described above, and no other signs of disease werenoted apart from the swelling of the left leg.

Laboratory Investigations.-Wassermann test negative.Blood-sugar 125 mg. per 100 c.cm. Urea nitrogen 13 mg.per 100 c.cm. Cerebro-spinal fluid : Wassermann testnegative; cells 1 per c.mm. ; colloidal gold 0001000000.Blood culture : growth of B. alkaligenes obtained.Radiography (April 8th) : Elevation and limitation of

movement of left dome of diaphragm and adhesions ofouter margin to parietal pleura. In the middle zone ofthe right lung field there is an area of obscurity associatedwith honeycombing suggesting existence of bronchiectaticdilatation at this point. Similar appearance towards baseof left lung (Dr. D. White). April 30th : Pleurisy left sidewith effusion. There appears to be deviation of hearttowards left side. P Fibrosis at bases. An X ray examinationfor possible foci of sepsis was negative.

DISCUSSION

A glance at the Table shows that thrombo-phlebitismigrans usually commences in the peripheral veinsof the upper or lower extremities, small sections ofthe superficial veins being generally first affected.In Case 9, however, the initial symptoms were dueto phlebitis of the mesenteric veins, in Case 12 tophlebitis of the spermatic veins, and in Case 15 thefirst symptoms suggested venous cerebral thrombosis.The disease affects males and females of all ages, butis more liable to attack those in middle age. Ofvisceral lesions, pulmonary are the most frequent andboth lungs may be affected at different times or

repeated thromboses may occur in the same lung.Peripheral venous inflammation may occur withoutinvolvement of viscera, but in Case 9 visceral lesionsonly occur.The case reported above presents the following

938

features. Severe and persistent headache withmalaise and pyrexia suggesting venous cerebralthrombosis (see Case 15) and later thrombo-phlebitisof left lung, left leg, right lung, and left lung again,in the order mentioned. The symptoms and signs inthe right lung may, however, have been due to anembolus dislodged from left leg by too vigorousmassage.

Campbell and Morgan 3 report an unusual case ofmultiple thrombosis in which the evidence suggeststhrombosis affecting the posterior cerebral arteries.Coombs 4 describes a case and mentions others inwhich there is reason to suspect coronary thrombosis.These though similar in many respects to the casesdescribed by Moorhead and Abrahamson differ inthat the arterial tree is also affected by the diseaseprocess, and are therefore not included in theTable.

The aetiology is still obscure. It has been soughtto associate the condition with influenza, but in nocase was a history of such infection obtained. It ismore likely that those cases of thrombo-phlebitismigrans with initial symptoms of cerebral thrombosisare, in the early stages, diagnosed as influenza inerror. The severity and persistence of the head painin thrombo-phlehitis migrans is of help in makinga differential diagnosis.

In Cases 5, 7, 8, 11, and 15 (1) there was reasonto suspect the influence of chronic streptococcal focalsepsis, but in the others no evidence to support sucha theory was obtained. No specific organism hasbeen isolated, and blood cultures have been consist-ently negative. There were never signs of septicaemia,and Ryle concludes therefore that " if focal infectionis to be regarded as of aetiological importance, thephlebitis must be due to a bacteriaemia rather thana true septicaemia." Cases 13 and 14 followedshortly upon an attack of scarlet fever, but both areatypical in that the thrombo-phlebitis affecting both ’legs was very extensive, spreading upwards over theabdominal wall and chest. It is questionable whether 1these two cases, interesting and unusual as they are,ought really to be described as thrombo-phlebitismigrans. t

Syphilis also is evidently not a factor. In theabove case the ocular phenomena, though not 1conforming to true Argyll Robertson pupils, suggested rthe presence of syphilitic infection, but the laboratoryfindings were all negative. f

It is possible that the main setiological factor isthe " soil "-i.e., the condition of the patient-thedisease depending on some obscure alteration in the

0

chemico-physical composition of the venous blood a(McDonagh 9). p

I have to thank Dr. Comrie for permission to C

publish the notes of the case. ti

REFERENCES

1. Moorhead, T. G., and Abrahamson, L. : Brit. Med. Jour.,1928, i., 586.

2. Ryle, J. A. : THE LANCET, 1930, ii., 731.3. Campbell, M., and Morgan, O. G. : Guy’s Hosp. Reps.,

1930, lxxx., 344. Coombs, C. F. : Quart. Jour. Med., 1929-30, xxiii., 233.5. Low, G. C., and Cook, A. B. : THE LANCET, 1931, i., 584.6. Collier, W. T. : Ibid., 1931, ii., 1408.7. Ellison, J. B. : Brit. Jour. Child. Dis., 1931, xxviii., 207.8. Barber, H. : Brit. Med. Jour., 1932, i., 281.9. McDonagh, J. E. R. : THE LANCET, 1927, i., 845.

DARLINGTON HOSPITAL CHILDREN’S WING.-By theefforts of the Darlington Rotarians, spread over thelast two years, a children’s wing, which has cost .813,000,has been added to Darlington Memorial Hospital. I

THROMBO-PHLEBITIS MIGRANS

BY NORMAN KLETZ, M.B. MANCH., M.R.C.P. LOND.PHYSICIAN TO ANCOATS HOSPITAL; PHYSICIAN AND HON. PATHO-

LOGIST TO STOCKPORT INFIRMARY; VISITING PHYSICIANAND CONSULTING PATHOLOGIST TO PARK

HOSPITAL, DAVYHULME

)f Thrombo-phlebitis migrans is characterised by a,

s thrombo-phlebitis occurring without any pre-existing3. affection of the veins, without any gross cause, andn presenting a tendency to reappear in various situa-5. tions. It particularly involves the superficial veinss of the extremities, but not infrequently there aren associated thromboses of veins of the internal viscera.e By no means a rarity, it nevertheless seems to bee a relatively uncommon affection. The fact of venous

thrombosis developing in relation to acute infectivet and debilitating conditions is too well established to0justify any special consideration. The interest of

s thrombo-phlebitis migrans lies in the peculiars migratory tendency of the recurrent clottings, in

s the prolonged period over which such clottings occur1 and the absence of any causative factor. Though the1 prognosis has been regarded by most writers as

J’ uniformly favourable, this is not so. Lipschitz 1,

records one fatal case, and in the small series aboutto be described there was also a fatal issue. Apart,

l however, from any question of danger to life, thrombo-l phlebitis migrans may involve a prolonged period ofineapacitv and suffering. It is, therefore, worthy of’ consideration especially from the point of view of.

possible treatment.’ Moorhead and Abrahamson 2 described several.

cases, and a further series has been published by,

Ryle.3 Carmichael Low and Cook 4 also describedtwo cases occurring in Asiatics. Both cases had ahistory of dysentery and gonorrhoea, but no causalrelationship is claimed or suggested by theseauthors.So far as the general clinical features of the condi-

tion are concerned these are well summed up byHarkavy 5 as follows :-

1. A tendency to involve superficial veins especially ofthe upper and lower extremities.

2. A decidedly segmental distribution with healthy veinintervening.

3. A progressive spread which is usually accompanied bymoderate fever.

4. A lesion having the appearance of an erythematous,fusiform, nodular mass, sensitive to touch ; oedema may, ormay not, occur.

There is, however, here no mention of thrombosesof veins of the internal viscera upon which Moorheadand Abrahamson, and Ryle rightly lay much emphasis.This last author also quotes cases of similar visceralphlebitis described by Campbell and Morgan, andCoombs.7 A further point of interest is the associa-tion of thrombo-phlebitis migrans with thrombo-angiitis obliterans, as recorded by Buerger and manyothers.

As has been already indicated, the aetiology of thispeculiar wandering thrombo-phlebitis is still obscure.Cases occurring in relationship to syphilis, tuber-culosis, and gout are described, and references to theseare given by Moorhead and Abrahamson, but in thetype of case here under discussion no definite causativefactor has been adduced. The general featuressuggest a bacterial cause, presumably blood-borne.from some cryptic focus. This is the view put forwardby Vaquez and Laconte,9 and others. Naturally,if this be so, as Ryle points out, the process must beone of bacteriemia and not septicaemia, in view ofthe long duration of the illness and the almost