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MORPHIA AFTER INJURIES
759
process will be awaited with interest by all radiologists. If the method is simple and gives constant results, this is an important contribution not only to cineradiography but also to mass radiography.
patients are in pain their low blood-pressure will rise to normal levels as the pain is eased by the drug. He reminds us, however, that repeated injections may lead later to massive absorption as the circulation recovers and that chloral and bromides should not be
MORPHIA AFTER INJURIES
forgotten. NoswoxTxY2 finds that by giving scopolamine with a much smaller dose of morphia the respiratory depressive effect of morphia can be avoided. The neurosurgeon insists on the minimal amount of morphia for head injuries-certainly not more than gr. 4 1. The restlessness associated with head injury is better controlled by raising and padding the sides of the bed, and ROWBOTHAM3 recommends phenobarbital gr. 3 intravenously followed by chloral hydrate and bromides by mouth or rectum. The chest surgeon finds that large doses of morphia postoperatively, after a chest injury, lead to lung collapse ; within limits, the more these patients are made to move and not " mollycoddled," as PRICE THOMAS puts it, the better. Thus the practice of using morphia as a routine postoperatively, for every injury, and for shock or suspected shock, needs checking. Pain, and restlessness due to anxiety or haemorrhage are the true indications.
UNTIL lately it was the practice to prescribe morphia for shock as if it was some specific remedy. The larger the wound or the greater the shock the larger was the dose thought necessary. And the doctor felt satisfied that whatever arguments there might be about the other methods of treating shock morphia in full doses had the blessing of the textbooks and experts. Gradually during this war there has emerged the view that not only is morphia often unnecessary after injuries but there are definite dangers from its excessive use. The Army Medical Department Bulletin for October says that morphia is given to many wounded patients who would do better with a cup of tea. It also reminds the medical officer that the ideal is to give the smallest dose that will be effective, and that, though gr. 2 is reasonable for the severe injury with much pain and distress, after this dose no more should be given for at least four hours. In the shocked patient poor absorption may lead to disappointing results from subcutaneous morphia and the intramuscular route is preferable. If rapid relief is required, gr. 6 1-1 4 but never more, diluted to at least 1 c.cm. with sterile water, may be injected intravenously, taking a minute or more over the injection. Intravenous morphia can often be given by injecting it through the rubber tubing (cleaned as if it were skin) of the plasma or blood drip that the patient is having ; the ready made sterile solutions such as ’Omnopon orAlopon,’ which remain stable in solution, are convenient for this purpose. When injection is impracticable one or two gr. 4 tablets work well if placed under the tongue. The pharmacology of this practice is still doubtful. With morphia, which is not acted on by gastric juice, it does not matter much whether absorption takes place through the buccal mucous membrane or lower down, but it would be worth while settling this question once and for all by some properly
‘-
controlled
experiments.
shock, the fall of blood volume reduces the transport available to carry oxygen to the tissues, and In
the aim must be to supply the needs of the vital centres by restricting the oxygen consumption of the less important tissues, such as the voluntary muscles. Morphia does this by allaying the restlessness, due to pain, haemorrhage or anxiety, and by damping down cell metabolism. The use of morphia thus appears to be sound rational therapy. But morphia also depresses the respiratory centre, so that breathing becomes both shallow and slow, and the consequent reduction in oxygen intake will add- to the difficulties of the vital centres. The shallow breathing also reduces the efficiency of the respiratory suction pump, so that the venous return is slowed. There are other effects to be remembered. With the low bloodpressure of shock the additional use of morphia may lead to cessation of urinary secretion. The patient after large doses of morphia is almost poikilothermic, and has to be carefully guarded against changes of temperature. Nevertheless, GRANThas never seen bad results from gr. 1, 4’ and he says that when injured 1. Grant, R. T. Proc. R. Soc. Med. 1942,
35, 445.
AUSCULTATION UP TO DATE by the rather cumbersome name of a phono-electrocardioscope, G. E. Donovan has introduced an instrument which holds out high promise of useful service to the clinician and medical student, as well as to the research worker. As he described it in a lecture to the Institution of Electrical Engineers, the instrument incorporates a double-beam cathode-ray oscilloscope with a fluorescent screen of long afterglow, which permits of the simultaneous direct visual recording of two phenomena such as the phonocardiogram and electrocardiogram, the phonocardiogram and sphygmogram, or the electrocardiogram and sphygmogram. At the same time the heart sounds, picked up by a special microphone, can be heard through an electrical amplifying stethoscope The instrument seems reasonably or a loud-speaker. simple to work, and it is claimed that it is robust, cannot be damaged by overloading or shock, and that maintenA further advantage is that permanent ance is simple. photographic records can be obtained of the phono-
IN what he calls
cardiogram, electrocardiogram or sphygmogram. By means of frequency filters, murmurs or desired sounds can be accentuated and undesirable ones muted. The instrument has an overall frequency range extending from the lowest frequency to over 1000 cycles per second, but this band can be divided by means of filters so that the frequency response of the apparatus can be given any desired slope, as is done by the " tone control " of a wireless set. The most obvious application of the phono-electrocardioscope is in the teaching of auscultation. Donovan says that the amplifying of heart sounds through a loud-speaker can never be 100% satisfactory ; he much prefers multiple headphones, which can, of It seems to be course, be used with his instrument. possible with this instrument for a group of students to hear (and see) the sounds actually produced by the heart, including those not audible to the human ear with the ordinary stethoscope, as well as the sounds and murmurs, reasonably amplified, which he should be able to hear with the simple stethoscope. At the same time they will have visible evidence of the correlation of these sounds with the various phases of the cardiac cycle as demonstrated by the electrocardiogram. Of the usefuhiess of the instrument in the clinic and the research laboratory there can also be little doubt. R
2. 3.
Nosworthy, M. D. Ibid, p. 452. Rowbotham, G. F. Acute Injuries of the Head, London, 1942, p. 114.
process will be awaited with interest by all radiologists. If the method is simple and gives constant results, this is an important contribution not only to cineradiography but also to mass radiography.
patients are in pain their low blood-pressure will rise to normal levels as the pain is eased by the drug. He reminds us, however, that repeated injections may lead later to massive absorption as the circulation recovers and that chloral and bromides should not be
MORPHIA AFTER INJURIES
forgotten. NoswoxTxY2 finds that by giving scopolamine with a much smaller dose of morphia the respiratory depressive effect of morphia can be avoided. The neurosurgeon insists on the minimal amount of morphia for head injuries-certainly not more than gr. 4 1. The restlessness associated with head injury is better controlled by raising and padding the sides of the bed, and ROWBOTHAM3 recommends phenobarbital gr. 3 intravenously followed by chloral hydrate and bromides by mouth or rectum. The chest surgeon finds that large doses of morphia postoperatively, after a chest injury, lead to lung collapse ; within limits, the more these patients are made to move and not " mollycoddled," as PRICE THOMAS puts it, the better. Thus the practice of using morphia as a routine postoperatively, for every injury, and for shock or suspected shock, needs checking. Pain, and restlessness due to anxiety or haemorrhage are the true indications.
UNTIL lately it was the practice to prescribe morphia for shock as if it was some specific remedy. The larger the wound or the greater the shock the larger was the dose thought necessary. And the doctor felt satisfied that whatever arguments there might be about the other methods of treating shock morphia in full doses had the blessing of the textbooks and experts. Gradually during this war there has emerged the view that not only is morphia often unnecessary after injuries but there are definite dangers from its excessive use. The Army Medical Department Bulletin for October says that morphia is given to many wounded patients who would do better with a cup of tea. It also reminds the medical officer that the ideal is to give the smallest dose that will be effective, and that, though gr. 2 is reasonable for the severe injury with much pain and distress, after this dose no more should be given for at least four hours. In the shocked patient poor absorption may lead to disappointing results from subcutaneous morphia and the intramuscular route is preferable. If rapid relief is required, gr. 6 1-1 4 but never more, diluted to at least 1 c.cm. with sterile water, may be injected intravenously, taking a minute or more over the injection. Intravenous morphia can often be given by injecting it through the rubber tubing (cleaned as if it were skin) of the plasma or blood drip that the patient is having ; the ready made sterile solutions such as ’Omnopon orAlopon,’ which remain stable in solution, are convenient for this purpose. When injection is impracticable one or two gr. 4 tablets work well if placed under the tongue. The pharmacology of this practice is still doubtful. With morphia, which is not acted on by gastric juice, it does not matter much whether absorption takes place through the buccal mucous membrane or lower down, but it would be worth while settling this question once and for all by some properly
‘-
controlled
experiments.
shock, the fall of blood volume reduces the transport available to carry oxygen to the tissues, and In
the aim must be to supply the needs of the vital centres by restricting the oxygen consumption of the less important tissues, such as the voluntary muscles. Morphia does this by allaying the restlessness, due to pain, haemorrhage or anxiety, and by damping down cell metabolism. The use of morphia thus appears to be sound rational therapy. But morphia also depresses the respiratory centre, so that breathing becomes both shallow and slow, and the consequent reduction in oxygen intake will add- to the difficulties of the vital centres. The shallow breathing also reduces the efficiency of the respiratory suction pump, so that the venous return is slowed. There are other effects to be remembered. With the low bloodpressure of shock the additional use of morphia may lead to cessation of urinary secretion. The patient after large doses of morphia is almost poikilothermic, and has to be carefully guarded against changes of temperature. Nevertheless, GRANThas never seen bad results from gr. 1, 4’ and he says that when injured 1. Grant, R. T. Proc. R. Soc. Med. 1942,
35, 445.
AUSCULTATION UP TO DATE by the rather cumbersome name of a phono-electrocardioscope, G. E. Donovan has introduced an instrument which holds out high promise of useful service to the clinician and medical student, as well as to the research worker. As he described it in a lecture to the Institution of Electrical Engineers, the instrument incorporates a double-beam cathode-ray oscilloscope with a fluorescent screen of long afterglow, which permits of the simultaneous direct visual recording of two phenomena such as the phonocardiogram and electrocardiogram, the phonocardiogram and sphygmogram, or the electrocardiogram and sphygmogram. At the same time the heart sounds, picked up by a special microphone, can be heard through an electrical amplifying stethoscope The instrument seems reasonably or a loud-speaker. simple to work, and it is claimed that it is robust, cannot be damaged by overloading or shock, and that maintenA further advantage is that permanent ance is simple. photographic records can be obtained of the phono-
IN what he calls
cardiogram, electrocardiogram or sphygmogram. By means of frequency filters, murmurs or desired sounds can be accentuated and undesirable ones muted. The instrument has an overall frequency range extending from the lowest frequency to over 1000 cycles per second, but this band can be divided by means of filters so that the frequency response of the apparatus can be given any desired slope, as is done by the " tone control " of a wireless set. The most obvious application of the phono-electrocardioscope is in the teaching of auscultation. Donovan says that the amplifying of heart sounds through a loud-speaker can never be 100% satisfactory ; he much prefers multiple headphones, which can, of It seems to be course, be used with his instrument. possible with this instrument for a group of students to hear (and see) the sounds actually produced by the heart, including those not audible to the human ear with the ordinary stethoscope, as well as the sounds and murmurs, reasonably amplified, which he should be able to hear with the simple stethoscope. At the same time they will have visible evidence of the correlation of these sounds with the various phases of the cardiac cycle as demonstrated by the electrocardiogram. Of the usefuhiess of the instrument in the clinic and the research laboratory there can also be little doubt. R
2. 3.
Nosworthy, M. D. Ibid, p. 452. Rowbotham, G. F. Acute Injuries of the Head, London, 1942, p. 114.