Murphy's Drip Enema of 5 Per Cent. Glucose and 5 Per Course, He Was

522 blood in the latter there was a fall. pressure; gradual FURTHER NOTES* ON THE Four other brains are being investigated. Vascular Theory of Shock: Exæmia of Cannon. INTRAVENOUS INJECTION OF ANTIMONY I have not said anything yet about the vascular TARTRATE. theory; it was formerly held that in "shock" the blood LEUCODERMA AND SKIN COMPLICATIONS ; ADMINIS- pressure fell, owing to its accumulation in the capil- TRATION OF LARGE DOSES. laries and veins of the abdominal organs. But it has BY J. B. been found that this is not the case. There is, how- CHRISTOPHERSON, C.B.E., M.D. CAMB., ever, a concentration of the blood and stasis in the F.R.C.P.LOND., F.R.C.S. ENG., capillaries of the body generally, a condition which TROPICAL DISEASES CLINIC, MINISTRY OF PENSIONS; LATE DIRECTOR Cannon calls " exsemia." The plasma exudes through OF THE CIVIL HOSPITALS OF KHARTOUM AND OMDURMAN. the capillary walls into the tissues ; and in proof of this concentration is the fact that the haemoglobin index is THE temperature chart which I am publishing with increased, likewise the blood cells count. this communication is that of a Sudanese boy, aged 18, a student at the Gordon College, Khartoum, during the TREATMENT OF SHOCK. course of treatment by the intravenous injections of tartrate for kala-azar. He was admitted Intravenous injection of salines proved useless ; in antimony (pot.) into the Khartoum Civil on March 9th, 1918, some cases transfusion of citrated blood and gum saline Hospital and was of tartrate in which was introduced on the that given 87 gr. antimony (pot.) solution, assumption 86 intravenous and on it could not escape from the vessels, have raised the days by injections, discharged 18th, cured so far as we could say. His was blood pressure and led to recovery ; in others, as in the August a well-marked case of kala azar, with considerable four cases of which I have the brains, investigated of liver and and an intermittent these measures were Crile recommends enlargement spleen, unavailing. had noticed his illness for some introduction of fluids natural temperature. He by methods-e.g., months. Leishman-Donovan bodies found in drip enema of 5 per cent. and 5 per splenic Murphy’s glucose on at least three no unfavourable cent. soda bicarbonate solution. Stimulants seem to be punctures occasions ; such as ulceration of useless, also injection of adrenalin and strychnine. complications mouth, diarrhoea, cedema of &c. In 1920, two years after the I have already pointed out that all causes of exhaus- legs, August, he was and he was tion of vital whether or course, quite well, subsequently energy, psychical physical, accepted for permanent Government service. to and shock. In the i predispose primary secondary In this case I do not wish to advocate the case of the wounded in to cold publishing battle, thirst, exposure I administration of of and wet, evacuation, and habitual large doses antimony delayed rough prolonged ’, tartrate even in diseases for which it is transport to and with acute I, appropriate; hospital, suffering physical and its derivatives are and and mental agony to sap the vital!, antimony powerful poten- conspire together in cases and when in of failure tially dangerous drugs, and all the minimum energy, consequence circulatory dose the dose to be and toxaemia the vital centres of the medulla become necessary is given. My object is. and fail to the blood to emphasise the fact that a very considerable amount- refractory discharge impulses li of tartrate be if into- pressure falls progressively, and eventually in spite of antimony may injected necessary the veins without ill-effect, and to comment on certain all remedial measures the circulation and respiration incidents and which occur the cease. complications during In wound and burn shock I did not find course of the administration of antimony tartrate for- secondary and for other diseases within haemorrhages; I conclude, therefore, that in cases of true kala-azar, my experience. "shell shock " this condition is due to physical effects The temperatures in the ordinary native wards of the. produced by the forces generated by the explosion, but Khartoum Civil Hospital are taken by the native attendants, more or less under the of- in some cases to the poisonous effects of gases absorbed supervision the resident and are charted twice The while the man is unconscious. doctors, daily. lying with In resuscitation from surgical shock chart published this article, representing four practical experi- months, to the kala-azar chart ence shows that the treatment of the following corresponds ordinary phenomena have yielded satisfactory results-viz., made under these circumstances, recorded approxi- the fall of blood the fall of the mately at 7 A.M. and 7 P.M. It does not show the (a) pressure; (b) body characteristic kala-azar deviations of temperature; the of the volume of the temperature (c) lessening the 24 hours of the as it would had it been blood. shows that cases of during day, Experience haemorrhage two hours. The rise in combined with little shock yield the best results. registered every temperature till noon, followed a and a rise at 4 P.M., In conclusion, I desire to say that a full of the by drop, again report a notch between 12 and 4 would then will be forming P.M., neurological changes published shortly by have been similar notch occurs at the and Dr. of Tokio, who is at apparent. (A myself Uno, present same the a notch in the in an of period during night,’ making engaged making investigation the microscopic chart of 12 in under direction. during each period hours.) changes my laboratory my The chart indicates: (1) That kala-azar is curable Bibliography.-Reports of the Special Investigation Committee tartrate administered intravenously; this on Surgical Shock and Allied Conditions, Medical Research by antimony Council. National Health Insurance, Special Report Series, No. 25, fact is now too well known to need comment. (2) That. No. 26. Surgical Shock, Crile and Lower, W. B. Saunders and Co. a large quantity’ of the drug is sometimes necessary (87 gr. in 86 days in this case) to effect a cure, and may be given with impunity, provided it is administered Lieutenant-Colonels Walter Lidwell Harnett, with care. (3) That 3 gr. of antimony tartrate may be I.M.S., and Francis Kenneth Kerr, R.A.M.C., and Dr. John injected every other day with beneficial results for Sinclair have been appointed Esquires of the Order of the 16 times in 33 60 in 48 doses Hospital of St. John of Jerusalem in England. days, totalling gr. days, gradually increasing from 1 gr. to 3 gr. (see chart, AN EXTENDED CURFEW IN DUBLIN.-For some May 26th to July llth). (4) That this may be done months past, writes our Dublin correspondent, the curfew soon after the preliminary but insufficient course hours in Dublin have been from 10 P.M. to 5 A.M. Unfortu- nately, a number of attacks on parties of military or police * Previous references to the writer’s work on the subject appeared occurred recently in the streets between dusk and curfew, in THE LANCET, 1919. ii., 299, and 1920, ii., 528 and 1200. and after giving warning that if such attacks did not cease 1 Colonel C. Donovan, I.M.S., pointed this out to me and gave me curfew hours would be last week the a chart to show it. extended, military 2 A should be examined before authorities ordered that in future curfew would at patient commencing the course begin of injections in order to ascertain the existence or otherwise of 9 P.M. instead of 10 P.M. As heretofore medical practitioners, , contra-indications; stone, fistula, and certain renal complications clergymen, and nurses will be granted permits to be abroad often associated with bilharzia do not contra-indicate, whereas on urgent professional business. The earlier hour of curfew organic diseases of heart and kidney do contra-indicate injections will put great difficulties in the way of the various medical for any reason. In far advanced cases of kala-azar it had best be societies whose have hitherto been held withheld. My advice is, having ascertained that contra-indications meetings always not present, inject with confidence. in the No doubt an will be made are evening. attempt to 3 I have sometimes injected 4 gr. ant. pot. tart. at one time in substitute afternoon meetings. j’cases of bilharzia. 523 25’5 gr. in 41 days has been administered, during the injected antimony tartrate, and their epithelium is early period of which 1 gr. antimony tartrate was given liable to damage in the effort of these organs to every day, afterwards every other day (see chart, eliminate it. To watch the effect of the antimony on March 17th to April 28th). the kidneys the urine should be examined after each So much for the cumulative action of antimony. Of iLjection. An attack of jaundice sometimes com- the more usual incidents attending the administration plicates the injections, indicating interference with the of antimony tartrate intravenously, the irritating cough functions of the liver ; but a much commoner complica- at the time of injection-so constant when the potassium tion indicating interference with the metabolism of the salt is used, but less frequent with sod. ant. tartrate- liver-cells by the antimony is shown by pains in the the metallic taste in the mouth and throat, the saliva- shoulders, and "lumbago" or muscular pains in arms tion, colic and occasional diarrhoea, the nausea, or legs, sometimes so aggravated that the patient cannot retching, vomiting, the passage of a large quantity of turn over in bed.

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