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PITUITARY EXTRACT IN OBSTETRICS
95 wheel-chair she described her own initial inexperience of the disease, which was epidemic in Cleveland this year, what she gradually learned, what plans should be made for the future, and the different ways in which the disease started and its very different results. She recounted her own initial symptoms - the fears they aroused, her reactions to those fears, and the final going to bed. When paralysis set in she believed all was up with her. She was sure she felt short of breath at times Her and she had nightmares about artificial respirators. doctors varied. Then, when paralysis receded her hopes returned, and although left with some disability she described what she could do, what sort of careers were still open to her, and what long-term care was going to mean. The third case was of a young working man, married, fit, who had never been ill before. He described an attack of acute lobar pneumonia which had brought him to hospital The results of as an emergency a few weeks previously. examination and treatment were described and illustrated and comparison made with the disease and its effects as between the ’30s and ’40s of this century. The development of chemotherapy and the antibiotics was sketched in.
The whole afternoon went with a swing and three hours passed without notice. I talked with students afterwards and it was obvious that their enthusiasm had been roused. Terminology had been simple and that there were many aspects of illness was clearly appreciated. One student said to me I’ll never forget it." Another said apologetically " I feel dedicated already." I myself was deeply impressed. Here we had young people beginning their medical career who were introduced to sick people on their third day in college. They were shown that illness is an intricate affair which could be looked. at in many different ways. The implications of illness and the doctor-patient relationship were portrayed, and the prime importance of the basic sciences was there for all to see. The whole afternoon was carefully planned and the contributions of the staff To me it was were thoughtful, clear, and sympathetic. a great improvement on- the traditional address with a high-sounding title delivered by some distinguished visitor. The hoary old themes of art and science, medical "
humanism, hippocratic tradition, changing patterns, and disintegration, specialism, the profession, and prospect retrospect, theory and practice, which adorn the columns of our journals at the opening of each academic year, seem unsuitable and unhelpful to the new student. There is much more that could be said about the Western Reserve experiment. No-one there is dogmatic. Staff cooperation has been remarkable, and authoritarianism, that stumbling-block of the curriculum (Latin : " race chariot ! ") is laid flat. And how !
integration
JOHN D. SPILLANE. PITUITARY EXTRACT IN OBSTETRICS
SIR,—Professor Nixon and Dr. Schild (Jan. 3) call attention to the very real danger of giving whole posterior pituitary extract in obstetric practice. The toxic vasopressor factor, in addition to its toxic action on the coronary vessels, invokes a rise in blood-pressure which may be unfavourable or fatal. Unfortunately the loose " use of the word " pituitrin may cause it to be given when these vasopressor actions have serious ill-effects. Some years ago a new house-surgeon delivered a primigravida who had hypertension and albuminuria which had appeared just before labour. He ordered " a c.c. of pituitrin," and within a short time the patient started having eclamptic fits. There was no doubt that the vasopressor part of the posterior pituitary extract had raised the patient’s blood-pressure and precipitated the eclampsia. In my hospitals we use pituitary extracts very little because ergometrine has such a reliable action and because the oxytocic effect of injectio oxytocini, B.P., or ’ Pitocin ’ is so variable. But we have had to make arrangements to prevent the pituitrin accident recurring.
The hospital pharmacist no longer supplies the extract of posterior pituitary to the maternity department, but he does provide injectio oxytocini, B.P. (1/2-1 ml. or 5-10 units), or the similar preparation, pitocin. Furthermore, if anyone uses the term pituitary extract or pituitrin, whether he be a member of the staff or an examination candidate, I take up the word and ask him whether there is any doubt of his using the word
correctly. ALISTAIR GUNN. ORAL ANTIBIOTICS AND SPONTANEOUS HÆMORRHAGE SIR,—Dr. Payling Wright’s letter1 prompts me to report a case of spontaneous haemorrhage due to hypoprothrombinæmia occurring within 48 hours of the administration of aureomycin. The patient was a primigravida at term, who developed a concealed accidental haemorrhage with complete suppression of urine from the moment of onset. When she was first seen five hours later, the foetus was dead ; there was no urine in the bladder, and none had been voided since before the onset of the catastrophe. The blood-pressure was 160/110 mm. Hg. A lower-segment cæsarean section was performed, and a typical large retroplacental clot was discovered ; there was no evidence of retroperitoneal haemorrhage. The anuria was treated by the method recommended by Bull et awl.2 Diuresis commenced on the sixth day. On the twelfth day the patient developed basal pneumonia, which was treated by aureomycin. By this time she was having a moderate diet by mouth, and had had 6 pints of packed red cells by three separate transfusions. Forty-eight hours later the patient developed a large spontaneous haemorrhage into the abdominal wall, which burst the healed abdominal wound, and multiple purpuric spots over the body. The blood-prothrombin time by the Quick method was over 100 seconds. The condition was treated by injections of vitamin K continued for some days. Thereafter the patient made an uneventful recovery.
D. T. O’DKISCOLL. BUTAZOLIDINE AND SALT EXCRETION SiR,,-In view of the widespread use of butazolidine, one aspect of its toxicity on a preliminary report - i.e., œdema—and on the comparison of its clinical effect with that of cortisone does not appear out of
place. patients with rheumatoid arthritis were put on salt-free diet, and then 7-5 g. sodium chloride per day was issued as a ration. The total daily urine was collected for a preliminary week, for one to two weeks during which the patients had 600-1200 mg. butazolidine per day, and for a subsequent week ; and in 7 cases the results were compared with a period during which 75-150 mg. cortisone was administered. In 11of the 14 cases there was slight retention of sodium on the first two days of administration, and in the remainder there was a similar period of retention about four days after treatment was started. After this initial decrease in excretion the levels fluctuated ; but in 6 cases there was a distinct increase in salt excretion directly butazolidine was discontinued, and in 5 others this peak excretion occurred on the eighth to tenth day of treatment-as not uncommonly happens during cortisone treatment. At no time this experiment was any change in excretion of uric acid observed, although the usual increase was found when 2 of the cases were checked with administration of salicylate. The clinical response did not correlate with the excretory pattern in this group of patients. In this series of cases no gross oedema occurred ; and neither in these cases nor in others where oedema developed has any albuminuria, or haematuria. been produced. Of 3 7 patients subsequently received cortisone. who gave a poor clinical response to butazolidine 2 also 14
a
during
,
1. 2.
Payling Wright, H. Lancet, 1952, ii, 1180. Bull, C. M., Joekes, A. M., Lowe, K. C. Ibid, 1949, ii, 229.
The whole afternoon went with a swing and three hours passed without notice. I talked with students afterwards and it was obvious that their enthusiasm had been roused. Terminology had been simple and that there were many aspects of illness was clearly appreciated. One student said to me I’ll never forget it." Another said apologetically " I feel dedicated already." I myself was deeply impressed. Here we had young people beginning their medical career who were introduced to sick people on their third day in college. They were shown that illness is an intricate affair which could be looked. at in many different ways. The implications of illness and the doctor-patient relationship were portrayed, and the prime importance of the basic sciences was there for all to see. The whole afternoon was carefully planned and the contributions of the staff To me it was were thoughtful, clear, and sympathetic. a great improvement on- the traditional address with a high-sounding title delivered by some distinguished visitor. The hoary old themes of art and science, medical "
humanism, hippocratic tradition, changing patterns, and disintegration, specialism, the profession, and prospect retrospect, theory and practice, which adorn the columns of our journals at the opening of each academic year, seem unsuitable and unhelpful to the new student. There is much more that could be said about the Western Reserve experiment. No-one there is dogmatic. Staff cooperation has been remarkable, and authoritarianism, that stumbling-block of the curriculum (Latin : " race chariot ! ") is laid flat. And how !
integration
JOHN D. SPILLANE. PITUITARY EXTRACT IN OBSTETRICS
SIR,—Professor Nixon and Dr. Schild (Jan. 3) call attention to the very real danger of giving whole posterior pituitary extract in obstetric practice. The toxic vasopressor factor, in addition to its toxic action on the coronary vessels, invokes a rise in blood-pressure which may be unfavourable or fatal. Unfortunately the loose " use of the word " pituitrin may cause it to be given when these vasopressor actions have serious ill-effects. Some years ago a new house-surgeon delivered a primigravida who had hypertension and albuminuria which had appeared just before labour. He ordered " a c.c. of pituitrin," and within a short time the patient started having eclamptic fits. There was no doubt that the vasopressor part of the posterior pituitary extract had raised the patient’s blood-pressure and precipitated the eclampsia. In my hospitals we use pituitary extracts very little because ergometrine has such a reliable action and because the oxytocic effect of injectio oxytocini, B.P., or ’ Pitocin ’ is so variable. But we have had to make arrangements to prevent the pituitrin accident recurring.
The hospital pharmacist no longer supplies the extract of posterior pituitary to the maternity department, but he does provide injectio oxytocini, B.P. (1/2-1 ml. or 5-10 units), or the similar preparation, pitocin. Furthermore, if anyone uses the term pituitary extract or pituitrin, whether he be a member of the staff or an examination candidate, I take up the word and ask him whether there is any doubt of his using the word
correctly. ALISTAIR GUNN. ORAL ANTIBIOTICS AND SPONTANEOUS HÆMORRHAGE SIR,—Dr. Payling Wright’s letter1 prompts me to report a case of spontaneous haemorrhage due to hypoprothrombinæmia occurring within 48 hours of the administration of aureomycin. The patient was a primigravida at term, who developed a concealed accidental haemorrhage with complete suppression of urine from the moment of onset. When she was first seen five hours later, the foetus was dead ; there was no urine in the bladder, and none had been voided since before the onset of the catastrophe. The blood-pressure was 160/110 mm. Hg. A lower-segment cæsarean section was performed, and a typical large retroplacental clot was discovered ; there was no evidence of retroperitoneal haemorrhage. The anuria was treated by the method recommended by Bull et awl.2 Diuresis commenced on the sixth day. On the twelfth day the patient developed basal pneumonia, which was treated by aureomycin. By this time she was having a moderate diet by mouth, and had had 6 pints of packed red cells by three separate transfusions. Forty-eight hours later the patient developed a large spontaneous haemorrhage into the abdominal wall, which burst the healed abdominal wound, and multiple purpuric spots over the body. The blood-prothrombin time by the Quick method was over 100 seconds. The condition was treated by injections of vitamin K continued for some days. Thereafter the patient made an uneventful recovery.
D. T. O’DKISCOLL. BUTAZOLIDINE AND SALT EXCRETION SiR,,-In view of the widespread use of butazolidine, one aspect of its toxicity on a preliminary report - i.e., œdema—and on the comparison of its clinical effect with that of cortisone does not appear out of
place. patients with rheumatoid arthritis were put on salt-free diet, and then 7-5 g. sodium chloride per day was issued as a ration. The total daily urine was collected for a preliminary week, for one to two weeks during which the patients had 600-1200 mg. butazolidine per day, and for a subsequent week ; and in 7 cases the results were compared with a period during which 75-150 mg. cortisone was administered. In 11of the 14 cases there was slight retention of sodium on the first two days of administration, and in the remainder there was a similar period of retention about four days after treatment was started. After this initial decrease in excretion the levels fluctuated ; but in 6 cases there was a distinct increase in salt excretion directly butazolidine was discontinued, and in 5 others this peak excretion occurred on the eighth to tenth day of treatment-as not uncommonly happens during cortisone treatment. At no time this experiment was any change in excretion of uric acid observed, although the usual increase was found when 2 of the cases were checked with administration of salicylate. The clinical response did not correlate with the excretory pattern in this group of patients. In this series of cases no gross oedema occurred ; and neither in these cases nor in others where oedema developed has any albuminuria, or haematuria. been produced. Of 3 7 patients subsequently received cortisone. who gave a poor clinical response to butazolidine 2 also 14
a
during
,
1. 2.
Payling Wright, H. Lancet, 1952, ii, 1180. Bull, C. M., Joekes, A. M., Lowe, K. C. Ibid, 1949, ii, 229.