759

process will be awaited with interest by all radio-

logists. If the method is simple and gives constantresults, this is an important contribution not onlyto cineradiography but also to mass radiography.

MORPHIA AFTER INJURIESUNTIL lately it was the practice to prescribe morphia

for shock as if it was some specific remedy. Thelarger the wound or the greater the shock the largerwas the dose thought necessary. And the doctor feltsatisfied that whatever arguments there might beabout the other methods of treating shock morphia infull doses had the blessing of the textbooks andexperts. Gradually during this war there has

emerged the view that not only is morphia oftenunnecessary after injuries but there are definitedangers from its excessive use. The Army MedicalDepartment Bulletin for October says that morphia isgiven to many wounded patients who would do betterwith a cup of tea. It also reminds the medical officerthat the ideal is to give the smallest dose that will beeffective, and that, though gr. 2 is reasonable for thesevere injury with much pain and distress, after thisdose no more should be given for at least four hours.In the shocked patient poor absorption may lead todisappointing results from subcutaneous morphia andthe intramuscular route is preferable. If rapid reliefis required, gr. 6 1-1 4 but never more, diluted to atleast 1 c.cm. with sterile water, may be injected intra-venously, taking a minute or more over the injection.

‘-

Intravenous morphia can often be given by injectingit 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 ’ Omnoponor Alopon,’ which remain stable in solution, are con-venient for this purpose. When injection is imprac-ticable one or two gr. 4 tablets work well if placedunder the tongue. The pharmacology of this practiceis still doubtful. With morphia, which is not actedon by gastric juice, it does not matter much whetherabsorption takes place through the buccal mucousmembrane or lower down, but it would be worth whilesettling this question once and for all by some properlycontrolled experiments.

In shock, the fall of blood volume reduces thetransport available to carry oxygen to the tissues, andthe aim must be to supply the needs of the vital centresby restricting the oxygen consumption of the less

important tissues, such as the voluntary muscles.Morphia does this by allaying the restlessness, due topain, haemorrhage or anxiety, and by damping downcell metabolism. The use of morphia thus appearsto be sound rational therapy. But morphia also

depresses the respiratory centre, so that breathingbecomes both shallow and slow, and the consequentreduction in oxygen intake will add- to the difficultiesof the vital centres. The shallow breathing alsoreduces the efficiency of the respiratory suction pump,so that the venous return is slowed. There are othereffects to be remembered. With the low blood-pressure of shock the additional use of morphia maylead to cessation of urinary secretion. The patientafter large doses of morphia is almost poikilothermic,and has to be carefully guarded against changes oftemperature. Nevertheless, GRANT has never seenbad results from gr. 1, 4’ and he says that when injured

1. Grant, R. T. Proc. R. Soc. Med. 1942, 35, 445.

patients are in pain their low blood-pressure will riseto normal levels as the pain is eased by the drug. Hereminds us, however, that repeated injections maylead later to massive absorption as the circulationrecovers and that chloral and bromides should not be

forgotten. NoswoxTxY 2 finds that by giving scopo-lamine with a much smaller dose of morphia therespiratory depressive effect of morphia can beavoided. The neurosurgeon insists on the minimalamount of morphia for head injuries-certainly notmore than gr. 4 1. The restlessness associated withhead injury is better controlled by raising and paddingthe sides of the bed, and ROWBOTHAM 3 recommendsphenobarbital gr. 3 intravenously followed by chloralhydrate and bromides by mouth or rectum. Thechest surgeon finds that large doses of morphia post-operatively, after a chest injury, lead to lung collapse ;within limits, the more these patients are made tomove and not " mollycoddled," as PRICE THOMAS putsit, the better. Thus the practice of using morphia asa routine postoperatively, for every injury, and forshock or suspected shock, needs checking. Pain, andrestlessness due to anxiety or haemorrhage are the trueindications.

AUSCULTATION UP TO DATEIN what he calls by the rather cumbersome name of a

phono-electrocardioscope, G. E. Donovan has introducedan instrument which holds out high promise of usefulservice to the clinician and medical student, as well asto the research worker. As he described it in a lectureto the Institution of Electrical Engineers, the instrumentincorporates a double-beam cathode-ray oscilloscopewith a fluorescent screen of long afterglow, which permitsof the simultaneous direct visual recording of two

phenomena such as the phonocardiogram and electro-cardiogram, the phonocardiogram and sphygmogram, orthe electrocardiogram and sphygmogram. At the sametime the heart sounds, picked up by a special microphone,can be heard through an electrical amplifying stethoscopeor a loud-speaker. The instrument seems reasonablysimple to work, and it is claimed that it is robust, cannotbe damaged by overloading or shock, and that mainten-ance is simple. A further advantage is that permanentphotographic records can be obtained of the phono-cardiogram, electrocardiogram or sphygmogram. Bymeans of frequency filters, murmurs or desired sounds canbe accentuated and undesirable ones muted. The instru-ment has an overall frequency range extending from thelowest frequency to over 1000 cycles per second, but thisband can be divided by means of filters so that the fre-quency response of the apparatus can be given anydesired slope, as is done by the " tone control " of awireless set. The most obvious application of thephono-electrocardioscope is in the teaching of ausculta-tion. Donovan says that the amplifying of heart soundsthrough a loud-speaker can never be 100% satisfactory ;he much prefers multiple headphones, which can, ofcourse, be used with his instrument. It seems to be

possible with this instrument for a group of students tohear (and see) the sounds actually produced by the heart,including those not audible to the human ear with theordinary stethoscope, as well as the sounds and murmurs,reasonably amplified, which he should be able to hearwith the simple stethoscope. At the same time they will Rhave visible evidence of the correlation of these soundswith the various phases of the cardiac cycle as demon-strated by the electrocardiogram. Of the usefuhiessof the instrument in the clinic and the research laboratorythere can also be little doubt.

2. Nosworthy, M. D. Ibid, p. 452.3. Rowbotham, G. F. Acute Injuries of the Head, London, 1942,

p. 114.