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MEDICINE AND THE LAW
782
pyloric obstruction. Among the causes of vomitare pyelitis, middle-ear disease, pneumonia, or any acute illness, infections of the gastro-intestinal tract, organic obstructions, and functional disorder. Some children are born with complete atresia of the oesophagus and everything taken is returned unaltered, with a good deal of mucus. There is treatment save to ensure a pleasant death. no Children occasionally get cardiospasm and present symptoms after a few months of life ; the returned
no
ing
milk is alkaline and unaltered. The diet should be non-irritating and bougie dilatation may be used in older children. Pyloric stenosis as a rule causes vomiting 7 to 14 days after birth, and the vomit may be thrown a considerable distance, often through the nose. The child may not vomit very frequently but each vomit may be larger than the last feed and may leave the child quite collapsed. As a rule it contains neither bile nor blood, but both may occasionally be found. Constipation necessarily follows any form of fairly severe vomiting, but a pseudo-diarrhoea often occurs. These children have five or six dark green stools daily, composed almost entirely of mucus. This may lead to a wrong diagnosis of diarrhoea and vomiting. The child loses weight and looks thin and ill. Diagnosis is verified by visible peristalsis and palpable tumour. No case should be operated on until the tumour has been felt ; it is unmistakable. The child must lie comfortably with bare abdomen and must be examined just after a feed. Most people are agreed that surgical treatment is correct in the vast majority of cases. Medical measures are only justified in mild and recovering cases which have been missed ; they consist of daily gastric lavage, small dosesof luminal (gr. 1/16) or atropine, and a fairly concentrated diet. The operation should not be done as an emergency, but 24-48 hours should be spent in getting the child fit by gastric lavage, a change of diet, and treating the alkalosis (which is probably present) by means of subcutaneous normal saline. Pylorospasm appears in rather older children and is not accompanied by much wasting or palpable tumour. The child is often nervous and irritable. The treatment is medical. Duodenal obstruction in the new-born infant varies from complete atresia to partial block. The vomiting is projectile and bile-stained and the visible peristalsis very marked. The final diagnosis The correct is established by an opaque meal. treatment is operation, though the results are poor. Vomiting may be due to too large or too frequent feeds. A baby should not have more than 2tor at most 3 oz. of food per lb. of body-weight. The interval should be at least three hours. Possetting is common in breast-fed babies and obviates overfeeding. It does, however, merge into pathological conditions. In dyspepsia something has gone wrong with the chemistry and the stools are never normal; they may be fermented as a result of too much sugar and too little protein, or fatty-associated with either diarrhoea or constipation-and frequent, sour, curdy vomiting. Vomiting may also be caused by large protein curds. The first thing in the treatment of dyspepsia is to cut down fat and then gradually work up to the normal amount. The fineness of the protein curd must be ensured. Air swallowing is a very important cause of vomiting. A breast-fed baby may swallow air by feeding too quickly or too slowly, or by sucking hungrily at an empty breast. Nasal obstruction is a very common cause ; any form of dyspnoea may cause vomiting. The wrong teat may produce it ; the teat should be bulbous .
,
and should be gently pulled against the child’s lips during the feed to prevent air entering. If the child is fed in a sloping position instead of flat, or allowed to " bring up the wind " in the middle of the feed it will not lose milk with the returning air. The nose can be cleared with an ephedrine spray before feeds. Too rapid feeding can be controlled by giving water before the feed or controlling the flow. Many children swallow air when sucking their fingers. An upset and nervous child swallows air, and extraordinarily good results may be obtained from half a grain of chloral given about 20 minutes before each feed. Habit vomiting appears at about two or three months in an apparently healthy bottle-fed child. The child vomits small amounts at any time. The feeds must be concentrated and small. Lavage and drugs give no result. Tube-feeding for 24 hours sometimes breaks the habit. Rumination does not appear before four months and usually starts from some small gastric upset. The child definitely enjoys the process ; but rarely does it under observa. tion ; it must be watched from behind a screen. The condition may be serious, producing inanition. Plugging the nostrils with cotton-wool and tying the chin up have been recommended. Laying the child on its face often works and carrying it about incessantly for an hour and distracting it is almost infallible, but very exhausting. The best method is to put it on solid food as soon as possible. Drugs are not very effective.
MEDICINE AND THE LAW
Atophan (Cincophen) Poisoning AT an inquest on Sept. 27th on a man who died from " acute yellow atrophy" of the liver after taking Atophan for rheumatism, the Birmingham city coroner (Dr. W. H. Davison) declared that the drug ought to be at once placed on Part I. of the Schedule of Poisons. He expressed a hope that the inquest would warn the public and induce members of the medical profession to look upon it in a different light. The practitioner in charge of the case said that the patient came to him in March complaining of sciatica and he prescribed 20 tablets of atophan, one to be taken three times a day after food. Three days later, as the patient lived some distance away, he gave a second prescription. He thought atophan was a safe drug to prescribe in that quantity ; people could obtain it in the ordinary way from the chemist if they wished to. The Coroner : Do you agree they should have control of it ?-A. I have never had any ill-effects from it and I have prescribed it quite a lot. Q. Do you look upon it as a perfectly safe drug to be prescribed without any special limitations ?-A. I always have done up to date. Q. Did you not look upon it as dangerous ?-A. I did not. I had two cases where patients developed a rash. That is all the ill-effects I have known. Q. Have you used it in thirty or forty cases ?-A. Oh yes, more than that. Two years ago my own wife had a course of 100 tablets continuously without any ill-effect whatsoever. He added that he would not order more than three a day, and he did not consider the quantity he ordered in any way dangerous. He had had no experience of its danger to anyone with a liver or kidney condition.
A third supply was ordered on April 10th, and later the patient went back to work. When seen in May
783 He thought the drug should be scheduled as a poison. in better health and was reasonably fit. On 22nd he was injured at work and after the burnsIt was his own practice not to issue a prescription but to hand over the drug. When the drug was being he received had cleared up he developed jaundice used he thought the patient had to be kept quiet, which the practitioner thought was ordinary catarrhal see the man on June llth called to On had to be rather carefully fed, and should have being jaundice. when he was vomiting he found that the jaundice fluids generously. In his opinion atophan was a drug which should be reserved largely for patients who was more marked, and suggested that investigation He did not tell the should be made in hospital. could be kept watched while they were taking it. He hospital doctor that he had been treating the man thought there would be damage to a perfectly healthy with atophan because he did not connect that with liver if enough was taken, but an unhealthy liver his condition. would be more readily damaged. His recommendation was that the drug should be labelled poison and only The Coroner : It appears to me that you were not taken under a doctor’s direction. He considered the aware that atophan under certain circumstances might set up the jaundice ?-A. Until the 15th of this month makers were doing what was reasonable in giving I was not. the warning they gave on the label. Q. Were you aware at all that atophan was a drug Dr. Horst Neumann, medical director to Messrs. which in certain circumstances causes unpleasant sympthe manufacturers, said the drug had been Schering, toms ?-A. Yes. used for the treatment of rheumatism and gout for Q. But not a symptom that might kill ?-A. No. years. During that period they had records Q. You did not look upon it as a dangerous drug ?- twenty-six of 30 to 40 deaths. They recommended that it should A. No, only a drug which did not agree with everyone. be used with caution, and when a layman wrote The practitioner said that the man went to work about it they always referred him to his own medical subsequently after a holiday and then he saw him adviser. During the last eight years 68,000,000 again at the beginning of September, when he was tablets of atophan were issued from their works. very much changed. He sent him to hospital. The coroner said that this was the second death A temporary medical officer at Selly Oak,giving within a short period that he had had to deal with evidence, said he suspected atophan poisoning in which the effects of atophan had been brought and asked the wife for the phial of tablets he had into question. Undoubtedly it had a very powerful been taking, but only got it after the man’s death. effect on the liver, but there was some doubt as to Dr. William Whitelaw, chief pathologist of the whether it acted on a healthy liver or only on a Birmingham municipal hospitals, who carried out a diseased liver. There were no initial symptoms post-mortem examination, said the cause of death which would warn a patient that he should discontinue It was a was acute yellow atrophy of the liver. its use, and in some cases damage would be done typical case of atrophy caused by atophan. Dr. K. D. before anything was known about the effects of the Wilkinson, professor of pharmacology at the Univer- drug. When one realised that the medical practitioner sity of Birmingham, said he had used atophan in his who was prescribing the drug did not expect it to considerable own practice fairly frequently with act in the way it did, one could not expect the general caution. It was known by various trade names, and public to know anything about it, and he thought a he agreed that it was a pity such a drug should have warning should be issued that the drug ought not to so many names. It was used chiefly for gout and he be used under any circumstances by any person had found it to act as a charm in certain conditions. except under the strict supervision and control of a It produced very considerable improvement in certain medical man. At present anyone could walk up to a chemist’s counter and buy as much as he liked. It cases, and that sort of thing was very likely to impress patients so much that they would fly to it at every was true that the manufacturers had wrapped opportunity and were likely to recommend it to instructions round the phial that it should be taken their friends. He knew it could be obtained at the with care, but one knew how lightly those things chemist’s by anyone though it was being considered were regarded, and it did not seem to him that that for the Schedule. His habit was only to prescribe it was sufficient to draw the attention of the public or use it where other remedies had not proved to the dangers attending the taking of the drug.efficacious. He prescribed three tablets a day on He recorded a verdict of death from misadventure. alternate days-that was three days in each week and three weeks in all-and he would not repeat that for a year. He regarded it as a very definitely X RAy TREATMENT FOR CANCER.-Recently Sir Charles Hyde, chairman of the governors of Birmingham dangerous toxic drug and 27 tablets, which was General Hospital, formally accepted a high-voltage X ray just over grs. 200 altogether, was the maximum dose apparatus and a new department to house it, both the gifts which he would give in any year. Much smaller of Sir Herbert Austin. The total cost has been ;!!4000. doses had proved efficacious. Twelve tablets were Sir Herbert said that although the apparatus was primarily reported to have caused a death. But, as they had designed for certain forms of cancer, it had a wide field of heard, much larger doses could be given without useful service in other sections of medicine and surgery. any obvious damage. There were about 50 recorded Dr. J. F. Bromley is in charge of the department. deaths from the drug. He agreed it might have killed CONGESTED HOSPITALS.—One night recently there a good many before its effects were known. From were 173 patients at the King George Hospital, Ilford. 1908 to 1923 there was no recorded instance of This was the largest number it has ever contained, poisoning by atophan, and it was used fairly exten- and 31 more than its normal maximum. The hospital sively in Germany and later in France and England. is constantly congested; beds have had to be put He had seen three fatal cases himself. It was a drug down the centres of the wards, and it is necessary which could do damage, dangerous damage, before to refuse all but the most urgent cases. During the the dangerous symptoms were recognised. It might last two years there has never been a night with a vacant bed,-Scunthorpe War Memorial Hospital, Lincolnbe as long as two months after the last dose was taken before those symptoms appeared. The deceased had shire, is another overcrowded institution. It was originally for 72 subsequently ward space was had something over grs. 300. That was beyond what designed to take beds; 86, but sometimes 94 patients have to arranged he would have ordered, but it was not beyond what be looked after. There is a waiting-list of 300, and it is was quite commonly taken-and taken with impunity. hoped shortly to provide two new wards containing 54 beds.
he
was
May
pyloric obstruction. Among the causes of vomitare pyelitis, middle-ear disease, pneumonia, or any acute illness, infections of the gastro-intestinal tract, organic obstructions, and functional disorder. Some children are born with complete atresia of the oesophagus and everything taken is returned unaltered, with a good deal of mucus. There is treatment save to ensure a pleasant death. no Children occasionally get cardiospasm and present symptoms after a few months of life ; the returned
no
ing
milk is alkaline and unaltered. The diet should be non-irritating and bougie dilatation may be used in older children. Pyloric stenosis as a rule causes vomiting 7 to 14 days after birth, and the vomit may be thrown a considerable distance, often through the nose. The child may not vomit very frequently but each vomit may be larger than the last feed and may leave the child quite collapsed. As a rule it contains neither bile nor blood, but both may occasionally be found. Constipation necessarily follows any form of fairly severe vomiting, but a pseudo-diarrhoea often occurs. These children have five or six dark green stools daily, composed almost entirely of mucus. This may lead to a wrong diagnosis of diarrhoea and vomiting. The child loses weight and looks thin and ill. Diagnosis is verified by visible peristalsis and palpable tumour. No case should be operated on until the tumour has been felt ; it is unmistakable. The child must lie comfortably with bare abdomen and must be examined just after a feed. Most people are agreed that surgical treatment is correct in the vast majority of cases. Medical measures are only justified in mild and recovering cases which have been missed ; they consist of daily gastric lavage, small dosesof luminal (gr. 1/16) or atropine, and a fairly concentrated diet. The operation should not be done as an emergency, but 24-48 hours should be spent in getting the child fit by gastric lavage, a change of diet, and treating the alkalosis (which is probably present) by means of subcutaneous normal saline. Pylorospasm appears in rather older children and is not accompanied by much wasting or palpable tumour. The child is often nervous and irritable. The treatment is medical. Duodenal obstruction in the new-born infant varies from complete atresia to partial block. The vomiting is projectile and bile-stained and the visible peristalsis very marked. The final diagnosis The correct is established by an opaque meal. treatment is operation, though the results are poor. Vomiting may be due to too large or too frequent feeds. A baby should not have more than 2tor at most 3 oz. of food per lb. of body-weight. The interval should be at least three hours. Possetting is common in breast-fed babies and obviates overfeeding. It does, however, merge into pathological conditions. In dyspepsia something has gone wrong with the chemistry and the stools are never normal; they may be fermented as a result of too much sugar and too little protein, or fatty-associated with either diarrhoea or constipation-and frequent, sour, curdy vomiting. Vomiting may also be caused by large protein curds. The first thing in the treatment of dyspepsia is to cut down fat and then gradually work up to the normal amount. The fineness of the protein curd must be ensured. Air swallowing is a very important cause of vomiting. A breast-fed baby may swallow air by feeding too quickly or too slowly, or by sucking hungrily at an empty breast. Nasal obstruction is a very common cause ; any form of dyspnoea may cause vomiting. The wrong teat may produce it ; the teat should be bulbous .
,
and should be gently pulled against the child’s lips during the feed to prevent air entering. If the child is fed in a sloping position instead of flat, or allowed to " bring up the wind " in the middle of the feed it will not lose milk with the returning air. The nose can be cleared with an ephedrine spray before feeds. Too rapid feeding can be controlled by giving water before the feed or controlling the flow. Many children swallow air when sucking their fingers. An upset and nervous child swallows air, and extraordinarily good results may be obtained from half a grain of chloral given about 20 minutes before each feed. Habit vomiting appears at about two or three months in an apparently healthy bottle-fed child. The child vomits small amounts at any time. The feeds must be concentrated and small. Lavage and drugs give no result. Tube-feeding for 24 hours sometimes breaks the habit. Rumination does not appear before four months and usually starts from some small gastric upset. The child definitely enjoys the process ; but rarely does it under observa. tion ; it must be watched from behind a screen. The condition may be serious, producing inanition. Plugging the nostrils with cotton-wool and tying the chin up have been recommended. Laying the child on its face often works and carrying it about incessantly for an hour and distracting it is almost infallible, but very exhausting. The best method is to put it on solid food as soon as possible. Drugs are not very effective.
MEDICINE AND THE LAW
Atophan (Cincophen) Poisoning AT an inquest on Sept. 27th on a man who died from " acute yellow atrophy" of the liver after taking Atophan for rheumatism, the Birmingham city coroner (Dr. W. H. Davison) declared that the drug ought to be at once placed on Part I. of the Schedule of Poisons. He expressed a hope that the inquest would warn the public and induce members of the medical profession to look upon it in a different light. The practitioner in charge of the case said that the patient came to him in March complaining of sciatica and he prescribed 20 tablets of atophan, one to be taken three times a day after food. Three days later, as the patient lived some distance away, he gave a second prescription. He thought atophan was a safe drug to prescribe in that quantity ; people could obtain it in the ordinary way from the chemist if they wished to. The Coroner : Do you agree they should have control of it ?-A. I have never had any ill-effects from it and I have prescribed it quite a lot. Q. Do you look upon it as a perfectly safe drug to be prescribed without any special limitations ?-A. I always have done up to date. Q. Did you not look upon it as dangerous ?-A. I did not. I had two cases where patients developed a rash. That is all the ill-effects I have known. Q. Have you used it in thirty or forty cases ?-A. Oh yes, more than that. Two years ago my own wife had a course of 100 tablets continuously without any ill-effect whatsoever. He added that he would not order more than three a day, and he did not consider the quantity he ordered in any way dangerous. He had had no experience of its danger to anyone with a liver or kidney condition.
A third supply was ordered on April 10th, and later the patient went back to work. When seen in May
783 He thought the drug should be scheduled as a poison. in better health and was reasonably fit. On 22nd he was injured at work and after the burnsIt was his own practice not to issue a prescription but to hand over the drug. When the drug was being he received had cleared up he developed jaundice used he thought the patient had to be kept quiet, which the practitioner thought was ordinary catarrhal see the man on June llth called to On had to be rather carefully fed, and should have being jaundice. when he was vomiting he found that the jaundice fluids generously. In his opinion atophan was a drug which should be reserved largely for patients who was more marked, and suggested that investigation He did not tell the should be made in hospital. could be kept watched while they were taking it. He hospital doctor that he had been treating the man thought there would be damage to a perfectly healthy with atophan because he did not connect that with liver if enough was taken, but an unhealthy liver his condition. would be more readily damaged. His recommendation was that the drug should be labelled poison and only The Coroner : It appears to me that you were not taken under a doctor’s direction. He considered the aware that atophan under certain circumstances might set up the jaundice ?-A. Until the 15th of this month makers were doing what was reasonable in giving I was not. the warning they gave on the label. Q. Were you aware at all that atophan was a drug Dr. Horst Neumann, medical director to Messrs. which in certain circumstances causes unpleasant sympthe manufacturers, said the drug had been Schering, toms ?-A. Yes. used for the treatment of rheumatism and gout for Q. But not a symptom that might kill ?-A. No. years. During that period they had records Q. You did not look upon it as a dangerous drug ?- twenty-six of 30 to 40 deaths. They recommended that it should A. No, only a drug which did not agree with everyone. be used with caution, and when a layman wrote The practitioner said that the man went to work about it they always referred him to his own medical subsequently after a holiday and then he saw him adviser. During the last eight years 68,000,000 again at the beginning of September, when he was tablets of atophan were issued from their works. very much changed. He sent him to hospital. The coroner said that this was the second death A temporary medical officer at Selly Oak,giving within a short period that he had had to deal with evidence, said he suspected atophan poisoning in which the effects of atophan had been brought and asked the wife for the phial of tablets he had into question. Undoubtedly it had a very powerful been taking, but only got it after the man’s death. effect on the liver, but there was some doubt as to Dr. William Whitelaw, chief pathologist of the whether it acted on a healthy liver or only on a Birmingham municipal hospitals, who carried out a diseased liver. There were no initial symptoms post-mortem examination, said the cause of death which would warn a patient that he should discontinue It was a was acute yellow atrophy of the liver. its use, and in some cases damage would be done typical case of atrophy caused by atophan. Dr. K. D. before anything was known about the effects of the Wilkinson, professor of pharmacology at the Univer- drug. When one realised that the medical practitioner sity of Birmingham, said he had used atophan in his who was prescribing the drug did not expect it to considerable own practice fairly frequently with act in the way it did, one could not expect the general caution. It was known by various trade names, and public to know anything about it, and he thought a he agreed that it was a pity such a drug should have warning should be issued that the drug ought not to so many names. It was used chiefly for gout and he be used under any circumstances by any person had found it to act as a charm in certain conditions. except under the strict supervision and control of a It produced very considerable improvement in certain medical man. At present anyone could walk up to a chemist’s counter and buy as much as he liked. It cases, and that sort of thing was very likely to impress patients so much that they would fly to it at every was true that the manufacturers had wrapped opportunity and were likely to recommend it to instructions round the phial that it should be taken their friends. He knew it could be obtained at the with care, but one knew how lightly those things chemist’s by anyone though it was being considered were regarded, and it did not seem to him that that for the Schedule. His habit was only to prescribe it was sufficient to draw the attention of the public or use it where other remedies had not proved to the dangers attending the taking of the drug.efficacious. He prescribed three tablets a day on He recorded a verdict of death from misadventure. alternate days-that was three days in each week and three weeks in all-and he would not repeat that for a year. He regarded it as a very definitely X RAy TREATMENT FOR CANCER.-Recently Sir Charles Hyde, chairman of the governors of Birmingham dangerous toxic drug and 27 tablets, which was General Hospital, formally accepted a high-voltage X ray just over grs. 200 altogether, was the maximum dose apparatus and a new department to house it, both the gifts which he would give in any year. Much smaller of Sir Herbert Austin. The total cost has been ;!!4000. doses had proved efficacious. Twelve tablets were Sir Herbert said that although the apparatus was primarily reported to have caused a death. But, as they had designed for certain forms of cancer, it had a wide field of heard, much larger doses could be given without useful service in other sections of medicine and surgery. any obvious damage. There were about 50 recorded Dr. J. F. Bromley is in charge of the department. deaths from the drug. He agreed it might have killed CONGESTED HOSPITALS.—One night recently there a good many before its effects were known. From were 173 patients at the King George Hospital, Ilford. 1908 to 1923 there was no recorded instance of This was the largest number it has ever contained, poisoning by atophan, and it was used fairly exten- and 31 more than its normal maximum. The hospital sively in Germany and later in France and England. is constantly congested; beds have had to be put He had seen three fatal cases himself. It was a drug down the centres of the wards, and it is necessary which could do damage, dangerous damage, before to refuse all but the most urgent cases. During the the dangerous symptoms were recognised. It might last two years there has never been a night with a vacant bed,-Scunthorpe War Memorial Hospital, Lincolnbe as long as two months after the last dose was taken before those symptoms appeared. The deceased had shire, is another overcrowded institution. It was originally for 72 subsequently ward space was had something over grs. 300. That was beyond what designed to take beds; 86, but sometimes 94 patients have to arranged he would have ordered, but it was not beyond what be looked after. There is a waiting-list of 300, and it is was quite commonly taken-and taken with impunity. hoped shortly to provide two new wards containing 54 beds.
he
was
May