Document 9J5MdpKbQp4x6doyeKbqkG66e

576 INDUSTRIAL. HYGIENE AND OCCUPATIONAL MEDICINE In August the patient was seen by Dr. Harriet L. Hardy in consultation, who suggested continued supportive therapy, whole blood transfusions as needed, and a high caloric, high protein diet. These suggestions were carried out. Chart 1 demonstrates a typical recording of temperature, pulse rate and respiratory rate during this hospitalization, showing the spiking fever, the tachycardia and the tachypnea. The patient was discharged on Dec. 2, 1949, unimproved. She continued to have oxygen therapy at home. Chart 2 summarizes the observations made after the final admission, during ACTH therapy. The dosage of ACTH varied from 5 mg. to 80 mg. a day, given intramuscularly. Within a few days after this treatment was begun, there was symptomatic improvement, with lessening of cough, dyspnea, cyanosis and increased strength, and 27 days after the treatment started, the patient became independent of oxygen therapy and was able to get out of bed. During this period, however, some side effects of ACTH were noted, consisting of tremor, irritability, headache, dizziness and edema of the labia and thighs. Acne developed and was controlled with progesterone. On June 19, 1950, irritability and depression developed, followed by 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 NOV. 1949 I2 DEC. Chart 1.--Record of the patient's temperature, pulse rate and respiratory rate during her second hospitalization. The patient was discharged on Dec. 2, 1949. emotional lability, and on June 27 she became acutely psychotic, threatening suicide. This acute episode lasted only a few hours and promptly disappeared on reduction of the dose. During July no ACTH was given, because of the development of marked hematuria and renal colic secondary to a calculus in the right renal pelvis, which had appeared during the earlier stages of the disease. On August 14, ACTH therapy was resumed, and again edema became evident in hands, face and mouth and tremor was noted. Treatment was stopped August 26. The final course of ACTH was given in September. Chart 3 shows the laboratory data during ACTH therapy. The circulating eosinophils responded promptly to ACTH. The remaining values' did not vary much from the normal range. The erythrocyte sedimentation rate dropped from 34 mm./hr. to 18 mm./hr. Although hyperpotassemia is evident from the data, this observation was not confirmed by the patient's clinical course. The urine contained many red blood cells throughout, a finding that could be referred to the renal calculus of the right kidney. Until June 13, 1950 the chest roentgenograms'revealed improvement in the aeration of both lung fields and reduction in the size of the pulmonary arteries, but after this little change was seen. The electrocardiogram showed a typical cor pulmonale with a strong right axis,