Harold C. Edwards

Dyspepsia: An Investigation

The reduction of the fatality rate in the group receiving both surg;cal treatment and antitoxin can be reasonably held to establish the value of antitoxin in the treatment of gas gangrene. It is to be boped that with a more effective use of antitoxin the fatality rate of 45% for treated cases will fall considerably. Speed in the admin.stration of antitoxin is clearly essential for good results, but it is no less important that the amount of antitoxin given should be adequate for the individual case, since the neutralization of toxin by antitoxin is a quantitative reaction. It has been recently recommended (M.R.C. War Memorandum No. 2, revised second edition, 1943) that the initial therapeutic dose of polyvalent antitoxin should be not less-than 50,000 units; the figures in Table VII in-dicate that, though often enough such a dose may be more than ample, it is not excessive as a routine. The clinician still has the onus of judging quickly whether the dose given has been sufficient to neutralize all the toxinthat is to say. whether a previously rapidly progressive toxaemia has been arrested-or whether the dose of antitoxin has been insufficient and the progress of toxaemia is still acute. Delay in the neutralization of the toxin present cannot be compensated by giving an excess of antitoxin at a late stage; on the other hand, since the individual capacity to recover from the effects of toxaemia is incalculable, there is no justification for withholding an adequate dose of antitoxin from a patient received late for treatment, however small the chance of recovery may be. In the treatment of gas gangrene the probability should be borne in mind that the amount of toxin present in the body is increasing so long as the infection is spreading in the affected tissue. A patient received late for treatment, or one in whom surgical and chemotherapeutic measures have not been completely effective in eradicating the infection, may therefore need heroic or repeated doses of antitoxin, not because an excess has at any time a beneficial effect, but because an amount equivalent to the toxin present is the dose justifying a hope of recovery. This is entirely different from deprecating the continued administration of large doses of antitoxin to a patient in whom the infection has been controlled and the effects of the toxaemia are already vanishing. Patients in whom the site of gas gangrene involved the thigh, buttock, or abdomen showed a poorer response to doses of antitoxin of the order recommended than those in whom the site was more favourable to the elimination of the infection both by the surgeon and by Nature. These findin-s support the recommendation that surg:cal treatment should be supplemented by chemotherapeutic measures as well as by antitoxin therapy, and point to the need for local chemotherapeutic agents more effective against clostridia than the sulphonamide drugs alone.

The Technique of Gastroscopy.

The first attempt to examine the lining of the stomach by means of an endoscopic instrument was madeby Kussmaul in 1868. The patient, or victim, was a prow fessional sword-swallower. It goes without saying that the instrument was of the most primitive type, for it was only five years previously that endoscopy had beeLn invented by D6sormeaux (Fig. 1). It consisted of a straight metal tube with suitably placed mirrors lighted by a naked flame placed externally, for electricity had not been adapted to practical usage at that time. The next recorded attempt was by Mikulicz eleven years later.