AUG.
30, 1958 CHRONIC MIDGUT ISCHAEMIA
stroke" (Klass, 1953). Where symptoms are subacute or
of a recurrent nature, it is possible that repeated incomplete
peripheral mesenteric occlusions, the result of either throm-
bosis or embolism, may be occurring. Such events can
hardly explain the constant day-to-day symptoms described
in the above cases, and there seems no alternative but to
attribute them to persistent ischaemia. Apparently the
period of chronic ischaemia may be punctuated by acute
ischaemic episodes leading to characteristic symptoms such
as vomiting, bloody diarrhoea, and peripheral vascular
collapse (Warburg, 1905). When these acute symptoms
occur initially, as in Case 1, the subsequent development
of chronic ischaemia is more easily recognized.
Abdominal pain, an altered bowel habit, and weight loss
comprise a triad of symptoms characteristic of chronic mid-
gut ischaemia. To these can be added the finding of occult
blood in the stools and the development of malabsorption.
The most outstanding feature of the abdominal pain is its
constancy. Although initially it may be intermittent (Klein,
1921), coming on after meals, it soon becomes persistent,
being present every day and increasing greatly after meals,
particularly of a heavy variety. It is presumably related
to ischaemia, but its mechanism remains unexplained. Dur-
ing the early stages the patient is often constipated (Klein,
1921). Latterly diarrhoea becomes very troublesome. This
persistent diarrhoea is not the result of acute- ischaemia, but
is probably due to fat malabsorption (Case 2). Klass (1953)
has mentioned that absorption defects of the small bowel
may occur in patients who have survived superior mesen-
teric arteriotomy, and Shaw and Maynard (1958) have re-
ported a successful case of superior mesenteric endarterec-
tomy in which the acute ischaemia caused absorption defects
for fat, protein and carbohydrate.
The malabsorption in Case 2 appears to have been severe,
leading to a fall in the level of the plasma proteins to below
5 g. per 100 ml. It is surprising that oedema was never
present. The defective absorption and anorexia contribute
to the weight loss, which may eventually be considerable.
In the presence of ischaemia, experimental evidence suggests
that the mucosa and submucosa are most seriously affected
(Klein, 1921). This probably explains the development
of the malabsorption, and also accounts for the presence
of mucosal ulcerations. The latter were described by Howse
(1878), and are an adequate cause for the presence of occult
blood in the stools.
Summary
Two cases of chronic midgut ischaemia are presented.
These indicate that abdominal pain, altered bowel habit,
and weight loss are the characteristic symptoms. In addi-
tion there is usually occult blood in the stools and evi-
dence of malabsorption.
The suggestion is made that in cases of narrowing or
occlusion of the superior mesenteric artery where symp-
toms are present direct surgery should be undertaken
whenever possible. Without it, extensive bowel infarc-
tion is the eventual sequel.
REPERENCEs
Burt, C. C., Learmonth, J.. and Richards, R. L. (1952). Edinb. med. J.,
59, 65.
Chiene, I. (1869). J. Anat. Physiol., 3, 65.
Howse, H. G. (1878). Trans. path. Soc. Lond., 29, 101.
Johnson, C. C., and Baggenstoss, A. H. (1949). Proc. Mayo Clin., 24, 649.
Klass, A. A. (1953). J. tnt. Coll. Surg., 20, 687.
Klein, E. (1921). Surg. Gynec. Obstet., 33, 385.
Larson, L. M. (1953). Ibid., 53, 54.
Leriche, R., and Morel, A. (1948). Ann. Surg., 127, 193.
Martin, P., and Gaylis, H. (1957). Brit. med. J., 2, 371.
Mavor, G. E. (1958). J. roy. CoU. Surg. Edinb., 3, 264.
Rob, C. G., Eastcott H. H. G., and Owen, K. (1956). Brit. J. Surg., 43,
449.
- and Wheeler, E. B. (1957). Brit. med. J., 2, 264.
Shaw, R. S., and Maynard, E. P. (1958). New Engi. J. Med., 258, 874.
- and Rutledge, R. (1957). Ibid., 257, 595.
Turner, W. (1863). Brit. For. med. chir. Rev., 32, 322. Quoted by Burt
et al. (1952).
WarburY (1905). Mtinch. med. Wschr., 52, 1174. Quoted by Klein (1921).
M
TREATMENT OF TONSILLITIS
A THERAPEUTIC TRIAL OF PHENOXYMETHYL-
PENICILLIN IN A FOOD-BORNE EPIDEMIC OF
TONSILLITIS
BY
M. A. McDONALD, M.R.C.S., D.ObstxR.C.O.G.
Late Squadron Leader, Royal Air Force
AND
P. J. TAYLOR, M.B., M.R.C.P.
Squadron Leader, Royal Air Force
The treatment of acute sore throat is still a matter for
discussion. Most of the therapeutic trials which have
been recorded on this subject have been concerned with
sporadic cases collected over a period of months. In
such groups there is inevitably a multiple aetiology, and
it might be supposed that penicillin would improve only
those patients with sore throat of bacterial origin. In
one such trial (Brumfitt and Slater, 1957) it was con-
cluded that penicillin therapy was unlikely to affect
acute sore throat unless streptococci were isolated. In
contrast to this, Chapple et al. (1956) concluded that
oral potassium penicillin or sulphadimidine reduced the
length of illness in patients in both streptococcal and
non-streptococcal infections.
In trials conducted on food-borne epidemics the
results have again been conflicting. In the epidemic
at Fort Bragg, the Commission on Acute Respiratory
Diseases (1945) concluded that no worth-while benefit
was derived from the use of sulphadiazine. McDonald
and Watson (1951) criticized this work; and in a series
of young Service men found that, although there was
little difference in the average duration of symptoms and
signs, sulphonamides nevertheless hastened recovery. A
food-borne epidemic in many respects similar to that
described in the present paper was reported by Gardner
(1953). His claim that crystalline penicillin and sulpha-
dimidine were equally effective in shortening the illness
by about a half was not supported by adequate statistical
evidence.
Penicillin V has recently become accepted as a valu-
able addition to the therapeutic armamentarium, achiev-
ing its success by the ease of its administration: a point
of great importance in large-scale treatment. This paper
describes an epidemic of 116 cases of food-borne strepto-
coccal tonsillitis in which a controlled trial of " sulpha-
triad " and phenoxymethylpenicillin was made.
Epidemiology.-The outbreak occurred in a large
Royal Air Force station at Akrotiri, Cyprus, in August,
1957. Earlier in the summer there had been two similar
outbreaks involving 719 cases. Strong circumstantial
evidence led to the conclusion that all three epidemics
were caused by contamination of milk in the airmen's
mess (Taylor and McDonald, 1958). In contrast to the
first two outbreaks, in which all streptococci were group
A, those grouped in the present series were either A or
G. The epidemic began on August 3, and the chrono-
logical sequence of cases is shown in the accompanying
Table.
Daily Incidence of Tonsillitis and Scarlet Fever
Aug.: 3 4 5 6 7 8 9 10 1 12 13 Total
Total cases 25 40 6 16 9 9 3 3 1 3 1 116
Scarlet-fevor 12 17 2 ________ 31
 538 AUG. 30, 1958 TREATMENT OF TONSILLITIS BR1TisH
MEDICAL JOURNAL

Methods and Treatment

Clinical.-All the patients were males within the 19-30
age group. They were seen before admission, when a
history was taken and a physical examination made. A
throat swab was taken at the same time. Thereafter patients 0
were examined daily by one of us (P. J. T.), when each patient cc
I
was asked whether or not his throat felt sore and his
answer recorded. The degree of injection, oedema, and 60
w
exudate was noted. Oral temperatures were taken at four- cc.

hourly intervals until the temperature had been normal for 0

U, N
24 hours, and thereafter twice daily. The clinical criteria
for discharge were symptom-free, afebrile, and a clean I 40
throat. A throat swab was then taken, and the patient left
hospital next morning provided that no haemolytic strepto-
cocci had grown overnight. If this organism was found the
20
patient was retained in hospital and given a three-day course
of-phenoxymethylpenicillin regardless of his previous treat-
20
ment. No patient was allowed to leave hospital until his
throat swab had been found clear. Two further throat
swabs were taken at weekly intervals, and on all these three I 2 3 4 5 6 7
occasions urine was tested for proteinuria. DAYS OF ILLNESS
Cases were treated by one of three methods on a non- FIG. 1.-Duration of sore throat. Aspirin, . . sulpha, ----
selective basis for a minimum of three to four days: (1) penicillin,
soluble aspirin tablets, 10 gr. (0.65 g.) four-hourly in 40
cases; (2) sulphatriad tablets, 4 g. stat. and 1.5 g. four-
hourly in 37 cases; (3) phenoxymethylpenicillin tablets, 120
mg. eight-hourly in 39 cases. Patients in the last two groups
also received soluble aspirin. All patients remained in bed 80
until their temperature had been normal for 24 hours.
Patients were allocated into treatment groups alternately,
depending solely upon the order in which they were ad-
mitted to hospital-an administrative list beyond our L
60
control. cc.

Results LL

Clinical features were very similar to those noted in our ; 40

previous paper and in other descriptions of the illness.
Those patients admitted on the first two days were more
ill than those admitted on subsequent days. Injection of
the throat was seen in every case, together with a variable 2'
amount of oedema. Exudates were seen in those with ton-
sillar tissue. 17 had a temperature of 99' F. (37.20 C.)
or less, although they had a sore throat. Four others did
not complain of sore throat. Scarlet fever developed in 31 1 2 3 4 5 6 7
cases (see Table). DAYS OF ILLNESS
Laboratory Findings.-Every patient had a throat swab FIG. 2.-Duration of fever. Aspirin, ....; sulpha, ----;
taken on admission, and 65 (56%) were found to carry penicillin,
Streptococcus pyogenes. Of seven cultures sent to the
Streptococcal Reference Laboratory, four were Lancefield
group A and three were group G.
Comparison of Treatment Groups.-108 patients were
admitted to the trial having had the unselective course of
treatment without amendment until they were clinically fit
for discharge from hospital. No distinction is made be-
tween those with positive or negative throat swabs on ad-
mission. This is because the outbreak showed all the char- -J

acteristics of a food-borne infection and there was no

clinical difference between the two groups: aspirin, 35
cases; sulphatriad, 35 cases; phenoxymethylpenicillin, 38
cases.
Of the many methods availabIe for assessing the efficiency 0
40

of treatment we have selected four: duration of "soreness "

of the throat, duration of fever, length of stay in hospital,
and the carrier rate.
Duration of " Soreness " of the Throat.-The answers 20
received from daily questioning of patients are shown in
Fig. 1; it is clear that there was no difference between the
three groups.
Duration of Fever.-Fig. 2 shows that there was no L.
0 -.. .
--
difference between sulphonamides and aspirin, while peni- 3 4 5 6 7 8 9 10 11 12 13
cillin showed a slight difference on the third day only, DAYS
although it is not statistically significant (difference/standard FIG. 3.-Days in hospital to clinical discharge. Aspirin, ....;
error= 1.6). sulpha, ; penicillin, ----
 AUG. 30, 1958 TREATMENT OF TONSILLITIS
Length of Stay in Hospital.-In the present epidemic,
when patients with a positive throat swab were kept in for
a further three days, this figure is dependent upon two
factors: clinical recovery and bacteriological normality. The
latter factor depends on the carrier rate of the treatment
concerned, and Fig. 3 represents the time taken for clinical
recoverv alone. Here again there was no difference be-
tween the sulphonamide and aspirin groups. Those patients
treated with penicillin, however, showed a tendency to
recover more quickly, but this did not become significant
until the seventh day (difference/standard error = 2.15).
Positive Throat Swabs following Treatment.-Only 10
patients were found to have a positive throat swab after
clinical recovery: penicillin, 1 case (2.6%); sulphatriad,
1 case (2.8%); aspirin, 8 cases (22.8%). The difference here
is self-evident. The overall carrier rate two weeks after
discharge was 6.9%.
Complications.-No cases of rheumatic fever or acute
nephritis were discovered. Two cases of mild otitis media
as evinced by injection of the tympanic membrane were
discovered on admission, but these had settled by the next
day. Two patients had brisk diarrhoea lasting one day
only, and examination of stools did not indicate dysentery.
DiscuWon
The present trial has shown that neither sulphatriad nor
oral penicillin reduced the duration of soreness of the
throat. The only positive finding was the fact that they
both reduced the number of positive throat swabs following
treatment. In what is perhaps the most important assess-
ment-namely, the duration of the illness as a whole-the
results showed only a slight but significant reduction with
the use of oral penicillin. The duration of fever was
slightly less in those patients on penicillin, although the
difference was not statistically significant.
The length of the illness is usually the resultant of three
factors: cessation of fever, the disappearance of pain, and,
in all patients under medical supervision, a reasonably nor-
mal appearance of the throat. We have shown that the first
two factors are independent of treatment. It is well recog-
nized that, in cases of sore throat, people with tonsils have
more visible exudate. It has also been shown that the
presence of tonsillar tissue is associated with a higher re-
covery of bacteria (Bloomfield and Felty, 1923; Taylor and,
McDonald, 1958).
Penicillin kills the pathogens more quickly than symp-
tomatic treatment, thereby hastening the recovery of the
throat to a normal appearance, thus shortening the illness.
It has been claimed that a further indication of the value
of a given treatment may be obtained from an examination
of its more obvious failures (Chapple et al., 1956). Of the
eight patients who were taken out of the trial because their
treatment had been altered, five had received aspirin alone,
two sulphonamides, and one penicillin. While this may
seem to suggest that aspirin was the least effective form of
treatment, this is not necessarily the correct conclusion.
The results of previous trials suggest that there seems to
be little difference in the symptomatic effects of penicillin
whether the infection is considered to be streptococcal or not variant in the same proportion. The family is of
(Chapple et al., 1956).
It may well be that tonsillitis is often a double infection are purely English. Thus this is the first observation in
of viruses and bacteria. This may be the reason why peni-
cillin has no strikingly beneficial effect in the treatment of
tonsillitis.
Summary
A food-borne epidemic of 116 cases of streptococcal father
tonsillitis, including 31 cases of scarlet fever, is described. the haemoglobin A2 fraction was not increased.
A controlled trial using sulphonamides and oral
phenoxymethylpenicillin is presented.
The results suggest that oral penicillin has no bene-
ficial effect on the soreness of the throat but speeds the distinguishable from haemoglobin J on paper electrophoresis
recovery of the normal appearance of the throat, the at alkaline pH-moving slightly faster (Fig. 1). However,
lowering of temperature, and the duration of illness.
BRIrrSIE 539
MEDICAL JOURNAL
We thank the Director-General of the Royal Air Force Medical
Services for permission to publish. We also thank Dr. R. E. 0.
Williams, of the Streptococcus Reference Laboratory, and Dr.
J. C. McDonald, of the Public Health Laboratory Service, for
helpful advice and criticism in the compilation of the paper.
REFERENCES
Bloomfield, A. L., and Felty, A. R. (1923). Arch. intern. Med., 32, 483.
Brumfitt, W., and Slater, J. D. H. (1957). Lancet, 1, 8.
Chapple, P. A. L., Franklin, L. M., Paulett, J. D., Tuckman, E., Woodall,
J. T., Tomlinson, A. J. H., and McDonald, J. C. (1956). Brit. med. J.,
1, 705.
Commission on Acute Respiratory Diseases (1945). Bull. Johns Hopk. Hosp.,
77, 143.
Gardner, D. L. (1953). J. roy. Army med. Cps, 99, 104.
McDonald, T. C., and Watson, I. H. (1951). Brit. med. J., 1, 323.
Taylor, P. J., and McDonald, M. A. (1958). In preparation.
HAEMOGLOBIN "NORFOLK": A NEW
HAEMOGLOBIN FOUND IN AN
ENGLUSH FAMILY
WITH OBSERVATIONS ON THE NAMING OF
NEW HAEMOGLOBIN VARIANTS
BY
J. A. M. AGER, M.B., BS.
Jenner Laboratory, St. Thomas's Hospital, London
H. LEHMANN, M.D., Sc.D., M.R.C.P., F.R.I.C.
Department of Pathology, St. Bartholomew's Hospital,
London
AND
F. VELLA, M.D.
Department of Biochemistry, University of Malaya,
Singapore
In a survey of blood used for transfusion in Singapore it
was noted that the blood of a young Englishman con-
tained two haemoglobins, one with the electrophoretic
properties of haemoglobin A and one other, amounting
to 27%, which "was moving faster than A on paper
electrophoresis using barbiturate buffer of pH 8.6. By
comparison with eight AJ specimens-one from Africa
(Dr. J. Stijns), three from Indians (Dr. A. B. Raper; Dr.
L. D. Sanghvi, and Mr. P. K. Sukumaran), one from
Indonesia (Dr. Lie-Injo Luan Eng), and three from
Chinese in Singapore-it was established that the
electrophoretic mobility of the fast component on paper
at pH 8.6 was similar to, although slightly faster than,
that of haemoglobin J.
There was no haematological or clinical abnormality.
When the young man's immediate family in England
was examined it was found that his mother possessed
only haemoglobin A, and that his father and his younger
brother were also carriers of this new haemoglobin
Norfolk farming stock and so far as they are aware they
an English family of an abnormal haemoglobin. Neither
the father* nor the brother of the propositus was
anaemic, and a full haematological investigation of the
yielded normal values only; in particular there
were no target cells and no abnormal osmotic fragility;
Investigation of the New Haemoglobin
The new variant from the Norfolk family was only just
whereas haemoglobins A and J do not separate on chromato-