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QUINIDINE IN AURICULAR FIBRILLATION.
1072
QUINIDINE IN AURICULAR FIBRILLATION. EXPERIENCE is steadily accumulating as to the value of quinidine sulphate in the treatment of auricular fibrillation. Great claims often accompany the introduction of a new remedy which later proves not to meet them, but the-specific action of quinidine on the auricle can be demonstrated by graphic records. The dangers of its use were magnified in earlier reports partly because it was then used in more than sufficient doses, and partly because it was tried in unsuitable cases. That it is a valuable adjunct in the treatment of heart disease is becoming steadily apparent, and the observations of Dr. J. G. Emanuel in this issue of THE LANCET add to its position. It is not claimed by cardiologists that quinidine will approach the almost universal application of digitalis in cardiac therapeutics, and we should like to emphasise the fact that digitalis holds exactly as high a place in the treatment of heart failure as ever it did, its employment having become more carefully selective. Indeed, quinidine has no direct value in heart failure, and most of the untoward results are attributable to its use when failure is present. The function of quinidine is to restore the normal regular rhythm to a heart showing auricular fibrillation, and to that extent, and to that extent only, to improve cardiac efficiency. The attempt should be made when failure is in abeyance or when In a word, failure has been allayed by digitalis. digitalis combats heart failure, and quinidine abolishes auricular fibrillation which disposes to failure. Safety is attained if suitable cases are chosen and a moderate daily dose is reached by steps so that an idiosyncrasy towards the drug would be promptly recognised. So guided the danger is slight, but successful results will depend largely upon the care and skill with which the action of the drug upon rhythm is followed day by day during the course of treatment. METHODS OF SLAUGHTER. WHERE animals are killed periodically in an enclosed building there would always appear to be an apprehension of death by them. Fortunately the terror can never be so great as that of the human being who is destined to be hanged on the morrow. If fear before slaughter is to be reduced, in the case of animals, to a minimum, the sight, sound, and as much as possible, the smell of death should be hidden from the victims’ senses. In other words, each animal should be separately and individually slaughtered. The slaughtering in batches and in sight of each other of pigs and sheep has always appeared to us callous and barbarous. The Jewish method of slaughter, which consists in severing the blood-vessels of the neck with a sharp knife, seems to be quite humane. It has the advantage that the animal is effectively controlled before the method of despatch is brought into operation. Providing the control is carried out humanely, as it invariably is, this mode of killing would appear quite merciful. In Pamphlet No. 2, on the Jewish Method of Slaughtering Animals, published by the Board of Deputies of British Jews, the quoted opinions of 285 veterinary surgeons coincide in declaring that the Jewish method of slaughter is devoid of cruelty. It is true that the majority of these opinions are from German sources, but they are those of practical men of good standing. Most experts agree that the animal becomes unconscious within three seconds after the throat is cut, and the real matter at issue seems to be whether the painI produced by a severe blow that smashes the cranial bones and penetrates the brain is more or less than that produced by a sharp knife making a deep incision. Meanwhile onlv the introduction of a practicable way of anaesthetising animals before
I
slaughter, non-injurious to the flesh would satisfy ever5-one. -
as
human
food,
THE Croonian Lectures on the Role of Fats in Vital Phenomena will be delivered on June 7th, 12th, 14th, and 19th, at 5 P.M., at the Royal College of Physicians of London, Pall Mall East, by Prof. J. B. Leathes.
Modern Technique in Treatment. of Special Articles, contributed by invitation, on the Treatment of M edicaZ
A Series
and
Surgical Conditions. XXI.
THE TREATMENT OF ANTE-PARTUM HEMORREAGE. THE first duty when faced with a case of antepartum haemorrhage, whether it be slight or severe, to try to make out whether or not the placenta is attached to the lower uterine segment, since the management of the case after the first haemorrhage will proceed upon different lines according to the position of the placenta. The determination of this point may be very easy or very difficult. If there have been labour pains and the internal os is open, a partially detached portion of placenta may be felt on passing the finger into the uterus, and this will settle the matter. But if the patient has had no labour pains and is a primigravida, the cervix will be closed and the problem then has to be approached in a different way. No assistance can be obtained from the mode or time of onset of the bleeding, the period of pregnancy, or the character and extent of the first Examination of the urine attack of hemorrhage. may, however, give valuable help. The ’differential diagnosis cannot be disposed of in a word and at the first examination the diagnosis must often remain in doubt, but in general terms it may be said that if the head presents and is readily recognised per vaginam, and if the urine contains albumin, the case is almost certainly one of accidental haemorrhage. If, however, the breech lies below and vaginal examination yields little information, and the urine is normal, the case is probably one of placenta prsevia. Common to both conditions is the need of what we may call for simplicity " hospital treatment " ; except in patients of the luxury classes, immediate removal to hospital or nursing home is essential. Treatment of Hc7norrhage Before Labour. The immediate treatment of haemorrhage which is not accompanied by labour constitutes a fairly simple problem. In most cases the first haemorrhage is moderate in amount and the patient should be put to bed, given morphia (gr. 3 to 1), and detailed obstetric examination should be deferred until the bleeding has ceased. A catheter specimen should be examined and an effort to establish the differential diagnosis should be made. Accidental Haemorrhage.-Let us sappose a seven months pregnancy, with head presentation, some albuminuria, and slight oedema of the feet. It is a case of accidental haemorrhage, the essential factor of With careful which is probably a mild toxaemia. prophylaxis there is an excellent chance that the bleeding will not recur. The patient should be kept in bed and careful eliminative treatment carried out. The diet should contain little protein ; diuresis should be produced by drinking large quantities of water, and the bowels should be caused to act loosely twice a day by saline purgatives. The urine should be examined daily, the patient being kept in bed for a week after the bleeding has ceased. Even if no further haemorrhage occurs special care is required for the remainder of pregnancy, the important points being to secure free action of all channels of elimination and to watch for albuminuria. The prognosis is good. If despite prophylactic treatment, or in cases where this has not been carried out, recurrence of the haemorrhage occurs without labour, the same treatment should be applied, and the patient kept under close observation for a longer time. Her general condition will probably deteriorate with each attack of bleeding, for apart from the results of loss of blood, there is the toxaemic factor to be considered. The rare but very grave condition of concealed accidental haemorrhage probably would never be seen
isI
QUINIDINE IN AURICULAR FIBRILLATION. EXPERIENCE is steadily accumulating as to the value of quinidine sulphate in the treatment of auricular fibrillation. Great claims often accompany the introduction of a new remedy which later proves not to meet them, but the-specific action of quinidine on the auricle can be demonstrated by graphic records. The dangers of its use were magnified in earlier reports partly because it was then used in more than sufficient doses, and partly because it was tried in unsuitable cases. That it is a valuable adjunct in the treatment of heart disease is becoming steadily apparent, and the observations of Dr. J. G. Emanuel in this issue of THE LANCET add to its position. It is not claimed by cardiologists that quinidine will approach the almost universal application of digitalis in cardiac therapeutics, and we should like to emphasise the fact that digitalis holds exactly as high a place in the treatment of heart failure as ever it did, its employment having become more carefully selective. Indeed, quinidine has no direct value in heart failure, and most of the untoward results are attributable to its use when failure is present. The function of quinidine is to restore the normal regular rhythm to a heart showing auricular fibrillation, and to that extent, and to that extent only, to improve cardiac efficiency. The attempt should be made when failure is in abeyance or when In a word, failure has been allayed by digitalis. digitalis combats heart failure, and quinidine abolishes auricular fibrillation which disposes to failure. Safety is attained if suitable cases are chosen and a moderate daily dose is reached by steps so that an idiosyncrasy towards the drug would be promptly recognised. So guided the danger is slight, but successful results will depend largely upon the care and skill with which the action of the drug upon rhythm is followed day by day during the course of treatment. METHODS OF SLAUGHTER. WHERE animals are killed periodically in an enclosed building there would always appear to be an apprehension of death by them. Fortunately the terror can never be so great as that of the human being who is destined to be hanged on the morrow. If fear before slaughter is to be reduced, in the case of animals, to a minimum, the sight, sound, and as much as possible, the smell of death should be hidden from the victims’ senses. In other words, each animal should be separately and individually slaughtered. The slaughtering in batches and in sight of each other of pigs and sheep has always appeared to us callous and barbarous. The Jewish method of slaughter, which consists in severing the blood-vessels of the neck with a sharp knife, seems to be quite humane. It has the advantage that the animal is effectively controlled before the method of despatch is brought into operation. Providing the control is carried out humanely, as it invariably is, this mode of killing would appear quite merciful. In Pamphlet No. 2, on the Jewish Method of Slaughtering Animals, published by the Board of Deputies of British Jews, the quoted opinions of 285 veterinary surgeons coincide in declaring that the Jewish method of slaughter is devoid of cruelty. It is true that the majority of these opinions are from German sources, but they are those of practical men of good standing. Most experts agree that the animal becomes unconscious within three seconds after the throat is cut, and the real matter at issue seems to be whether the painI produced by a severe blow that smashes the cranial bones and penetrates the brain is more or less than that produced by a sharp knife making a deep incision. Meanwhile onlv the introduction of a practicable way of anaesthetising animals before
I
slaughter, non-injurious to the flesh would satisfy ever5-one. -
as
human
food,
THE Croonian Lectures on the Role of Fats in Vital Phenomena will be delivered on June 7th, 12th, 14th, and 19th, at 5 P.M., at the Royal College of Physicians of London, Pall Mall East, by Prof. J. B. Leathes.
Modern Technique in Treatment. of Special Articles, contributed by invitation, on the Treatment of M edicaZ
A Series
and
Surgical Conditions. XXI.
THE TREATMENT OF ANTE-PARTUM HEMORREAGE. THE first duty when faced with a case of antepartum haemorrhage, whether it be slight or severe, to try to make out whether or not the placenta is attached to the lower uterine segment, since the management of the case after the first haemorrhage will proceed upon different lines according to the position of the placenta. The determination of this point may be very easy or very difficult. If there have been labour pains and the internal os is open, a partially detached portion of placenta may be felt on passing the finger into the uterus, and this will settle the matter. But if the patient has had no labour pains and is a primigravida, the cervix will be closed and the problem then has to be approached in a different way. No assistance can be obtained from the mode or time of onset of the bleeding, the period of pregnancy, or the character and extent of the first Examination of the urine attack of hemorrhage. may, however, give valuable help. The ’differential diagnosis cannot be disposed of in a word and at the first examination the diagnosis must often remain in doubt, but in general terms it may be said that if the head presents and is readily recognised per vaginam, and if the urine contains albumin, the case is almost certainly one of accidental haemorrhage. If, however, the breech lies below and vaginal examination yields little information, and the urine is normal, the case is probably one of placenta prsevia. Common to both conditions is the need of what we may call for simplicity " hospital treatment " ; except in patients of the luxury classes, immediate removal to hospital or nursing home is essential. Treatment of Hc7norrhage Before Labour. The immediate treatment of haemorrhage which is not accompanied by labour constitutes a fairly simple problem. In most cases the first haemorrhage is moderate in amount and the patient should be put to bed, given morphia (gr. 3 to 1), and detailed obstetric examination should be deferred until the bleeding has ceased. A catheter specimen should be examined and an effort to establish the differential diagnosis should be made. Accidental Haemorrhage.-Let us sappose a seven months pregnancy, with head presentation, some albuminuria, and slight oedema of the feet. It is a case of accidental haemorrhage, the essential factor of With careful which is probably a mild toxaemia. prophylaxis there is an excellent chance that the bleeding will not recur. The patient should be kept in bed and careful eliminative treatment carried out. The diet should contain little protein ; diuresis should be produced by drinking large quantities of water, and the bowels should be caused to act loosely twice a day by saline purgatives. The urine should be examined daily, the patient being kept in bed for a week after the bleeding has ceased. Even if no further haemorrhage occurs special care is required for the remainder of pregnancy, the important points being to secure free action of all channels of elimination and to watch for albuminuria. The prognosis is good. If despite prophylactic treatment, or in cases where this has not been carried out, recurrence of the haemorrhage occurs without labour, the same treatment should be applied, and the patient kept under close observation for a longer time. Her general condition will probably deteriorate with each attack of bleeding, for apart from the results of loss of blood, there is the toxaemic factor to be considered. The rare but very grave condition of concealed accidental haemorrhage probably would never be seen
isI