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Treatment of Epidemic Dropsy

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Treatment of Epidemic Dropsy human volunteers both with argemone oil and with the incriminated mustard oil in affected areas by La] et al. (1937) and Chopra et al. (1939). There is little to doubt that adulterated mustard oil is primarily responsible for the large outbreaks of epidemic dropsy. More recently S. N. Sarkar (1948) has isolated the toxic alkaloid, sanguinerine, from argemone oil and shown its capillary dilating and other deleterious properties in animals. Bailey, Robinson and Staunton (1950) have lately synthesized the alkaloid sanguinerine and dihydrosanguinerine and suggested for it the formula?7 : 8 : 4' : 5'- tetramethoxy-3 : 4 dihydro-1 : 2 benzphenan- thridone. The avoidance of contaminated mustard oil is, therefore, the first step in pre- vention and treatment. It seems, however, probable that there may be some other factor or factors such as nutritional or vitamin-deficiency or consumption of abnormally high amounts of carbohydrate which condition the toxicity (Napier, 1947) and help the production of symptoms. This might explain why some mem- bers of a group taking the same oil escape while others develop the disease. Chopra et al. (1939) also report the failure of the incriminated oil to produce symptoms in one of the volunteers who took only a limited amount of rice in his diet, Though mustard oil has so far been reported in India as the only article of food adulterated with the products of argemone seeds, the possibility of its presence in other foodstuff, particularly if an epidemic occurs in a com- munity not using mustard oil, should be remembered. Epidemic dropsy has been reported in Africa where no mustard oil is consumed and the cause was found to be adulteration of flour with powdered argemone seeds (Steyen, 1950). Morbid physiology The organic change in the system is brought about by a widespread capillary dilatation and proliferation in the skin and the internal organs and the entire pathology and symptomatology of the disease may be built up round this basic disturbance in the capillary system (Acton and Chopra, 1927; Shanks and De, 1931; De, Article 1933; De and Chatterjee, 1935). Some distinct Special haematological and biochemical changes also occur in the disease. Anaemia is almost universal and ^KEATMENT of epidemic dropsy it is usually of orthochromic normocytic type due to a of By R. N. depression erythropoiesis though (CHAUDHURI microcytic or slightly macrocytic anaemia may x N. CHAKRAVARTY also occur in some cases (Sen and {F K.) Gupta the Epidemic ^TrUpsy Enquiry, financed by the Napier, 1940). The white cell count is either r!}rh<in Council of Medical Research, Department of normal or slightly raised. There is a shift to r?yical School Medicine, of Tropical Medicine, the left in the or Arneth-Cook count Calcutta) Schillings and toxjc neutrophils appear in the blood depend- Aitiology ing on the severity of the disease (Chatter ji and -A- a Rational line of treatment for epidemic Haider, 1935). The eosinophils rise little but ^ be considered normal for Indians. The must necessarily be based on a proper may Un?Psy rate of c?erstanding of the etiological factors and the sedimentation erythrocytes is invariably and some etabolic and organic changes produced in the raised due to anaemia other factor as "^er Sarkar's initial observation the corrected figure (for anaemia) also remains (199 *6) the disease has been reproduced in high. The coagulation time is normal (Ray, 166 THE INDIAN MEDICAL GAZETTE [April, 1950 1927). The biochemical changes were worked the liberation of a histamine-like body in the out by Ray (loc. cit.), Chopra et al. (1935, course of its interaction with the metabolite8- 1940) and others. There is not much change in This paralyses the capillaries, stimulates their total protein but A/G ratio is much altered. proliferation, increases their permeability and Albumin is reduced and rise of globulin raised, through the continuation of the process produces pseudo-globulin being more marked. The reduc- the classical picture of epidemic dropsy. There tion of surface tension and increase of pseudo- are several factors which contribute to the p1'0" globulin seen in this disease have a parallel duction and perpetuation of oedema :? in reaction with which it has some anaphylactoid (1) the osmotic pressure of blood falls due in common et symptoms (Chopra al., 1935). to a reduction of the albumin fraction, Chopra and De also demonstrated the (1937) (2) is presence of histamine in the anterior chamber capillary permeability increased, due to the of the fluid of cases of epidemic dropsy with glaucoma. (3) lowering blood viscosity et cil-> These support the belief that there is an over- hydrostatic pressure is increased (Chopra production of histamine in the system, suggested 1935), clinically by the intense capillary dilatation (4) albumin probably drains out of the with increased permeability and gastro-intestinal damaged blood vessel into the extra-cellulai irritation, but further work is necessary before space and increases the colloid osmotic tension the hypothesis can be accepted. The other of tissue fluid?actually albumin has been found biochemical changes are a reduction of serum in aqueous humour of epidemic dropsy in higliel calcium with rise of plasma chloride and blood concentration than normal, and uric acid, and in chronic or recurrent cases rise of (5) salt retention helps in the maintenance blood cholesterol. Blood glucose, urea, NPN, the (edematous state. creatinine and arc within lipoid phosphorus Sarkar (1948) has worked out the normal limits et poisonous (Ray, 1927; Chopra al, 1940). effect of the alkaloid sanguinerine which he The a urine gives strong reaction for indican believes to be the toxic of marked in the principle argemone indicating putrefactive changes oil for the symptoms of intestine. The of normal responsible epidenu0 pH blood is but its dropsy. The alkaloid has been shown to be buffer action is et reduced (Chopra al., 1935). lethal to animals and to have caused dilatation of the of the iris and retina We carried out blood volume and available capillaries choroid, in albino rats. He has demonstrated that volume estimations in a thiocyanate space interferes with the oxidation number of cases of the details sanguinerine epidemic dropsy acid and leads to its accumulation jn of which will be later. On pyruvic published comparing the Wilson and Ghosh have als? the results with the normal for body. (1937) figures Indians, increase in the sub- it that the volume is raised in reported bisulphite-binding appears plasma stance in actual all the but the blood volume is within (B.B.S.) epidemic dropsy though patients estimation of acid has not been done- normal limits. The changes in plasma volume pyruvic It would appear from Sarkar's work that the are due to plethora and partly to anaemia, partly mechanism is almost the same as that of vitann11 the contraction in the red cell volume being which its by a rise in volume. The Bx deficiency produces symptoms compensated by plasma with cell nutrition as a result of the anaemia is therefore absolute and the total interfering blockage of carbohydrate metabolism at the haemoglobin quantity and RBC volume in the pyruvic acid stage, with the difference that are also reduced. The space a body thiocyanate sanguinerine blocks the radical of which is normally one-fifth of the body-weight sulphydryl main enzyme thus leaving therapeutic admin*?' was increased in all the patients and in some the tration of vitamin Bx ineffective, while vitam1*1 thiocyanate space was high even after clinical Bt acts as a co-enzyme in the oxidation reaction?: oedema had the presence disappeared indicating This would a in the clinic^ of latent cedema the looked envisage similarity though patients and conditions of dropsy all The plasma chloride figures pathological epidemic apparently right. and beri-beri which, however, is lacking. Furthel in our series have been always high and in view experimental arnd clinical studies are necessary of the rise in space and thiocyanate plasma before the can be considered full? volume we can conceive of salt retention problem high elucidated. in the body. The lowering of albumin is partly compensated by the rise of plasma volume Lines of treatment still 0 though the colloid osmotic tension remains It is difficult to.formulate a rational line more in low. The rise of globulin is marked treatment based on the epidemiological observa' view of the rise in plasma volume. The study tions and the functional and organic disturbance of the changes in plasma and extra-cellular fluid produced in the system. However, it will he volume us an to assess the value gave opportunity necessary to consider the following positive fact& of drugs with greater accuracy. in the management of a case :? The above findings do not give a very con- (1) Mustard oil adulterated with argemon^ sistent and clear picture of the morbid oil is the primary cause of the disease. K physiology in epidemic dropsy. They, however, occurs chiefly in a rice-eating population use suggest direct capillary damage by the toxin or to a high carbohydrate, low protein diet. ^Ril, 1950] EPIDEMIC DROPSY : CHAUDHURI & CHAKRAYARTY 167 .. (2) There is extensive capillary dilatation Banana .. 1 only u proliferation with excessive permeability. Salt-free butter .. 1 oz. .. Chhana .. a result, oedema develops with 4 oz. ,^).As .. Potato .. mention of salt and increase of plasma volume. 2 oz. Green vegetable . 8 oz. The serum albumin and calcium are .. r Sugar .. i oz. f4)uced and blood uric acid and cholesterol (in .. Fish .. 4 oz. u?nic and serum raised. cases) globulin Meat .. .. 4 oz. , (5) The carbohydrate metabolism is probably Ghee or vegetable fat 0cked at the .. pyruvic acid stage. (for cooking) 1 oz.
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