Sir Zachary Cope (1970) recently suffered an attack of acute cholecystitis. Until noting a palpable gall bladder he initially thought the symptoms might be due to coronary ischaemia, especially since over the preceding six months he had experienced a number of attacks of perspiration accompanied by tachycardia. This confusing presentation and the wellknown association between the two diseases stimulated him to record for the first time some of the earliest manifestations of cholecystitis-namely, heavy epigastric/central chest pain accompanied by a palpable gall bladder. He noted that the initial symptoms may then abate for an interval only to be followed by the typical syndrome of severe right upper quadrant pain, etc.We report two similar cases that were brought to our attention because of their simulation of a cardiac condition.Case 1 Early on 28 November 1969 an 81-year-old man was admitted to hospital because of central lower chest discomfort and mild diaphoresis accompanied by some nausea but not by vomiting or hypotension. Physical examination showed a generally healthy man in no acute distress, with normal heart and lungs, except for a bradycardia of 56-60/min No abdominal masses or tenderness were noted; the electrocardiogram was normal. A provisional diagnosis of angina pectoris was entertained. After his evening meal he complained of nausea and mild right upper quadrant pain which did not radiate. Physical examination showed splinting of the muscles in the right upper quadrant and a poorly-defined mass. Heart rate was about 50. He admitted to two similar attacks which subsided spontaneously over the previous 18 months. Next morning he was apyrexial, but a slightly raised white cell count and a shift to the left were noted. Liver function tests, serum lactate dehydrogenase, and E.C.G. remained normal. The abdominal splinting receded, the mass in the right upper quadrant disappeared, and his pulse stabilized at 70-80 without medication.On 1 December a cholecystogram showed no gall-bladder function, but during that day the pain in the right upper quadrant recurred, became more severe, and was accompanied by vomiting of green fluid. No mass was palpable at this time; however, the usual therapy for acute cholecystitis was initiated (intravenous fluids, gastric suction, vagolytic drugs, and antibiotics and epigastric pain with vomiting of green fluid over the preceding six hours. He had been treated during the previous week for symptoms attributed to a renal tract infection. The pain, initially midline, became more intense and radiated to the right upper quadrant. Physical examination showed a somewhat pale and slightly diaphoretic man, otherwise not in distress, with normal heart and lungs, except for a pronounced (regular) bradycardia of 38-42.We saw the patieipt because the chest pain and bradycardia were considered compatible with an impending inferior-wall myocardial infarction. An E.C.G. was normal except for a sinus bradycardia of 38-42. There was a slightly tender mass in the right hypochondrium, pal...

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A concise, easy to read system of recording the results of coronary arteriography using a diagram and symbols is presented with a number ofdescriptive examples. This system has proved itself invaluable in a busy laboratory (40-50 cases a month) over the past 2 years.The precise and detailed recording of the results of coronary arteriography requires a lengthy and involved description of lesions, and, where present, collateral channels. To this must be added the status of the myocardium in the distribution of the diseased vessels, details of the adequacy of collateral flow, and the presence or absence of lesions in the parent vessels providing the collaterals.To view all these details clearly and in true perspective when recorded in words is impossible: one is usually forced to review the angiograms which may not be immediately available. To overcome the problem and facilitate an easy, complete, and rapid recording of the overall picture on a filing card for each patient, we have (in the course of over 1500 arteriograms) evolved the following system which seems far superior to our previous method of tabulating coronary arteriograms, and accordingly present it here for the benefit of others. PrincipleThe information is stored on 5 x 8 file cards. The left side is occupied by a large skeleton diagram of the coronary arterial system, the right by a line drawing of the left ventricle in the right anterior oblique projection, the space below by a tabulation of the lesions, with collaterals where present, and a notation concerning myocardial integrity in the distribution of the vessel.The relative positions of all the vessels on the coronary artery skeleton are represented as they would appear on the angiograms at 450s6o' rotation in the left anterior oblique projection except for the distal circumflex and its branches, which are shown in outline as the mirror image of their appearance in 25°-30o right anterior oblique projection. In addition, the anterior descending system is spread out rather like it would appear with the patient rotated to about 750 left anterior oblique.These modifications have the advantage of both spreading out the right and circumflex systems such that their posterior atrioventricular branches can be represented as one gentle sweeping arc, with the usual posterior descending, posterior left ventricular, and posterolateral left ventricular offshoots. At the same time, branches which are commonly interconnected by collateral channels come to lie adjacent to one another. The sinuatrial and atrioventricular nodes are inserted at the upper and lower borders respectively near the midportion of the chart. The point of division between the right and circumflex systems is easily inserted at the relevant location depending on the degree of balance/dominance in each individual case. Symbols and labellingPatent vessels are inked in over the faint line diagram using a felt pen. The four main trunks (left main stem, anterior descending, circumflex, and right coronary artery) are labelled at their origin, and ...