Clinical lectures on Graves' disease : delivered at the Hospital for Consumption and Diseases of the Chest, Brompton / by Hector W.G. Mackenzie.

Mackenzie, Hector W.G.

Date:: 1890

Credit: Clinical lectures on Graves' disease : delivered at the Hospital for Consumption and Diseases of the Chest, Brompton / by Hector W.G. Mackenzie. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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$stage inrra-paitum; thirty-one weie of this type. The others, eleven in nvmber, were chosen at random The drug was not given until labour had commenced, and until the dilating pains had set in regularly ; the number occurring in an hour was noted, and then compared with those which passed in the same time shortly after the administration of the drug. The temperature and pulse were taken at regular intervals, and notes made at the time as to the severity of the pains and the patient’s state- ments as to the relief or not given by the medicine. I append a typical case :—The patient was aged twenty- nine years and a primipara. Induction of premature labour at about the thirty-sixth week for slight pelvic contraction. March 11th, 1889 (3 PM ) : Induction by passage of a catheter. 12th : At 4 5 A.M. pains began, and recurred at 4.20, 4 32, 4.45, 4 62, 5.10 (or about six in one hour). At 5.27 A.M. fifteen grains of antipyrin were administered. The pains occurred at 5.55, 6.0 (sick), 6.7, 6.20, 6 30, 6 42, 6.55 (or seven in one hour, about), 7.10, 7.23, 7.30 A M. At 7 45 A.M. a second dose of anti pyrin (fifteen grains) was given. At 8.5 A.M. the patient w'as sick ; at 8.15 she slept for eight minutes ; pains occurred at 8.40, 8.55, 9.15, 9.40, 9 53, 10.15, 10 30, 10.35, 10.57, 11.20, 11.47, 12.16 noon (fourteen pains in four hours, or less than four in the hour). Cervix fully dUated, waters ruptured artificially. Labour terminated at 6.40 P.M. ; living female child. Between rupture of waters and termination of labour, six hours and a half (nearly). The method of administration was by the mouth and in 15 gr. doses, made up with half a drachm of compound spirit of ammonia and cinnamon water, including two doses given during the expulsive stage. Sixty grains were given. Sick- ness occurred after each dose during the first stage, and after the second during the expulsive stage. It will be noticed that the medicine had a slight effect on the rapidity of the pains, if anything there being a tendency to slight retardation at first, becoming more marked after the second dose. There was no doubt as to the relief from the pain after the first dose, both from the patient’s own statements and from her appearance to bystanders, more after the second, but absolutely none during the expulsive stage. There was no post partum hsemorrhage, and successful lactation followed. Appended is a table showing the results of the administration of the drug in the forty-two cases. It will be seen that I have divided this into four columns, and under the heading “Result” have given the value of the drug as judged by results obtained—i. e., whether from the patient’s evidence or from her change in behaviour. Result. Good. Mode- rate. Nega- tive. stage of dilatation (а) Primiparre .. (б) Multipart .. 31 il 15 4 6 3 10 4 Stage of expidsion (a) Primipar.'e .. (ft) Multiparse .. 12 5 0 0 4 1 8 4 Post-partum .. (a) Primipara .. (ft) Multipar® .. 1 8 0 5 0 0 1 3 As an agalactic .. (a) Primiparse .. (ft) Multipart .. 3 4 1 0 0 2 2 2 Taking, first, the stage of dilatation, it will be seen that in 15 cases out of the 31 in which the drug was adminis- tered, or nearly 50 per cent., it was very beneficial—i.e., the patient either strongly asserted that she felt great relief, or it was self-evident by her falling asleep or be- coming more quiescent. Among the multiparse the cases relieved were not so great in proportion—viz , 36 3 per cent. On the other hand, the absolute failures among the primiparse amounted to 32-2 per cent., while among multiparse it was 36‘3 per cent. Queirel,® who admits the value of the drug chiefly in this stage, found its success undoubted in 15 women out of 20, or 75 per cent. Of these 15 patients, 11 were multiparse, the other 4 being primiparse. Of the 5 refractory patients, only 1 was a multipara, thus concluding rather that the action of antipyrin is more marked on that class. Winkle^ now never administers it # La Semaine M^dicale, 1888, p. 93: De TAntipyrine dans les Accouchements. 7 New York Medical Journal, 1889, vol. xlix., p. 14 : Antipyrin during the First Stage of Labour. except during this first stage, and he has found the relief following its administration almost general. By comparing statistics when the drug tvas taken and when not, he gathered that it does not increase the duration of the first stage ; but, on the contrary, tends to shorten it on an average about half an hour; while in the second stage it remains practically the same. Grandin® corroborates these views. In the expulsive stage the results were practically negative,, as absolute relief was never observed either in primiparous- or multiparous patients. I believe that this statement i& corroborated by all the writers on this subject, with one or two exceptions—viz , Fauchon® and Lielski.i® the latter of whom found the results in his four cases “ invariably excel- lent.” Its administration post-partum for after-pains was chiefly among multiparse, indeed I only once had a case of a primipara in which it could be called necessary, and thei« it was quite without effect. In the 8 multiparse to whom it W'as given it was certainly very beneficial in 5, or 62-5 per cent.; and I found that the failures were those in which the after-pains were chiefly due to collection and expulsion of blood clot, while the successful ones were those in which the pains were more of a grinding and neuralgic character, and not followed by passage of clot. Milne'^ and Chouppe^® both found anti pyrin of great value in these cases. Froni the nervous influence which is doubtless at work in connexion with the process of lactation, it would be almo&ti concluded without experiment that antipyrin would have some marked effect on the amount of milk secreted. Saleini^ mentions the case of a primipara of robust constitution. Weaning was necessary from the breasts being neglected and having become covered with sores. Ten days were occupied in attempting to effect this, including the use C(f iodide of potash and compression, but they all failed. He then gave 50cgr. of antipyrin divided into three doses ; the secretion dimioished the first day, ceased the third, and did not return. My own experience is not so favourable; the drug failed entirely in two cases out of three in which it was given, but certainly succeeded in one. The patienfi was a nervous primipara confined prematurely, with much distended breasts and large quantities of milk. Her child died on the fifth day of immaturity. I used compression and 15gr. doses thrice daily and ordered the usual diet; the effect was very rapid, and she felt relief after twenty- four hours, and the secretion ceased practically on the fourth day. The two multipart were absolute failures. Antipyrin is not eliminated by the milk secretion, and hence its use is not contraindicated in these cases. The effects of the administration of antipyrin on the cardio- vascular functions and the nervous system are well worthy of note. Knorr and FUehne''* first pointed out the usual pulse retardation in 1884, while Wjnkle observed that enerally the temperature fell from half to one and a half egrees F. After a dose of 15 gr. he found the pulse become somewhat more frequent and respiration quickened; but if the pulse at the time of giving it was rapid, it decreased it. My own experience is that in the greater number of cases, in addition to a slight reduction of temperature, half an hour after administration the pulse was diminished ia frequency, the patient having at the same time, however, a sensation of palpitation, respiration did not appear to be appreciably affected. Dark and thin patients of neurotia- type certainly seem to be more susceptible to its influence,, and this is corroborated by Adams,who, in an elaborate paper on the therapeutics of the drug, warns us to administer it in small doses “to phthisical and thin people.” Anti- pyrin may be administered by mouth, rectum, or by sub- cutaneous injection. The last is rendered much less painful by the addition of cocaine. By mouth it should always be taken with some diffusible stimulant like ammonia. Fatal cases as the consequence of its administration have been several times reported, but never during labour, and I know of no reason why it should not be given without apprehen- sion provided the dose is below 25 gr. Conclusions.—1. That antipyrin in doses of fifteen grains, repeated at jrroper intervals, is a remedy of great value in the dilating stage of labour, and more especially in primi- 8 Ibid., 1888, vol. xlviii., p. 38 9 Bulletin G^n^ral de Therapeutique, 1888, tome cxv., p. 81. 19 Wiadomoscie Lekarskie, 1888, No. 10, p. 289, quoted in New Orleans Med. and Surg. Journal, 1888, p. 233. ri New York Medical Record, 1888, vol. xxxiii., p. 38. 19 Loc. cit. 19 Bulletin General de Therapeutique, 1888, cxiv., p. 554 : L'Anti- pyrine centre le Secretion du Lait. 11 Berlin. Klin. Wochen., 1884, No. 20. 15 Journ. Amer. Med. Assoc., 1885, vol. v., p. 621$