The Physiological Effect of Pilocarpine in Conjunction with the Administration of Chloroform

A. L. Galabin
1879 BMJ (Clinical Research Edition)  
Nov. 8, I879.] THE -BRITI-SH MEDICAL ?OURLVAL. 79.~~~~~~~~~~2 very small sprigs about an inch apart, so that their sharp points might project slightly on the rough side. I have not found this necessary, being careful when lifting the bandages to hold firmly with the fingers. By this means, the whole layer of bandages can be lifted between the two hands and dipped in fluid plaster; but before doing so, a second layer of bandages must be made ready in the same manner. No water having been as yet
more » ... having been as yet employed, all these arrangements can be gone about with perfect leisure, and it may be well to cause the patient to lie down on the arranged bandages to make sure that the correct size has been taken. If the jacket is to be strengthened with slips of tin, these should now be cut to the proper length and laid at hand. Everything being now ready, a thin mixture of plaster is prepared by mixing two pounds in forty ounces of water, and this is then poured on a flat tray broad enough to accommodate the depth of the jacket.* One of the layers of bandages is now drawn slowly through the plaster on the tray twice or thrice, care being taken that it is thoroughly saturated, by turning first one side and then the other down; which having been properly done, it is laid aside on any convenient place. The other layer of bandages, having been treated in the same manner, is laid on the bed behind the patient, being carefully placed on the spot previously marked, and the layer which was first dipped then laid upon it. By placing them in this order, the first dipped, and therefore nearest setting, will be first applied to the patient. The patient is now laid back carefully on the bandages, the arms extended as before, and, the slips of wood having been detached from the upper layer, each bandage in succession is brought round and overlapped in front. The slips of wood holding the ends of the bandages firmly between them having prevented the saturation of these portions with fluid, an assistant, while they are being crossed in front, pours on with a spoon some of the fluid plaster from the tray. The second layer is put on in the same way, pieces of tin being interposed where thought desirable. As much as may be necessary of the remaining liquid plaster is now smeared over the surface of the jacket, and smoothed with the hand as it sets. The whole procedure, after commencing to mix the plaster and water, occupies, with ordinary despatch, about five minutes; and on the last occasion, the patient being a child, the whole time occupied, after placing the patient on the bed till the jacket was completed, was fifteen minutes. I have only had four opportunities of employing this method, the last two being by the courtesy of the surgical staff of the hospital. The cases have not been suitable for ascertaining the effect of the recumbent position as compared with that of suspension in straightening the spine and adding to the stature, but Dr. Walker speaks decidedly on this point. The best opportunity of testing the matter would be, in the case of an adult patient about to have a jacket removed, which had been put on during suspension, his height being carefully noted before its removal, and again after the application of a new one in the recumbent posture. married woman, aged 35, was a patient of the Guy's Hospital Lying-in Charity. She was subject to epileptiform convulsions, which, from the description given of them, appeared to partake in some degree of the hysterical character. These convulsions were usually increased in severity and frequency on any excitement. During her last labour, epileptiform fits had occurred. Assistance was sent for at 2.30 P.M. on September 6th, I879, on account of the onset of repeated convulsions. She was then at about the full term of her eighth pregnancy. The fits appeared to be purely epileptiform in character, but without any violent clonic convulsion. During the fit, the eyes were widely open, conjunctiv;e insensitive to touch, teeth tightly closed and ground together, with saliva flowing from the mouth; limbs rigid and semiflexed. Each fit lasted about two minutes, and ended in a deep inspiration, after which consciousness returned. Weak and infrequent labour-pains had occurred, and the os was found to be dilated to about the size of a florin. the obstetric resident, on visiting the patient at 3.30 P.M., found the pulse to be 120, temperature IOO.6°. A small quantity of uirine was withdrawn by the catheter, and found to be free from albumen. Fifteen grains of hydrate of chloral, with the sanie quantity of bromide of potassium, were then administered every halfhour. I was summoned to see the patient about 7 P.M. The fits had then diminished in frequency, three only having occurred within the last forty minutes. The patient in the intervals was not fully sensible, but could answer questions, although somewhat incoherently, and was able to swallow. The pulse had fallen to about 8o. The membranes wete ruptured, but the os uteri was scarcely so much as two-fifths dilated, and its edges were rigid and undilatable. Labour-pains had almost entirely ceased, and the body of the uterus was lax. A sphygmographic tracing showed the pulse to be regular, and of somewhat high pressure, the maximum good working pressure being six ounces, and the systolic summit somewhat broad, but without any distinction between primary and tidal wave. The hypodermic syringe having been accidentally left behind, onethird of a grain of pilocarpine was administered by mouth. As scarcely any manifest physiological effect was produced, a second and a third dose of the same amount were given after intervals of twenty minutes each. Soon after the third dose, salivation commenced. A little later, violent vomiting came on; and, upon this, sweating, hitherto scarcely noticeable, became profuse. The salivation also became very extreme, and the condition of the patient generally very miserable. No labourpains occurred, the uterus remained quite flaccid, and the os unrelaxed. A sphygmographic tracing was again taken, the pulse having risen from 8o to about go. The curve had now become somewhat higher and more pointed, and a slight notch was shown between the primary and tidal (or predicrotic) wave. The maximum good working pressure, however, was only very slightly diminished, being now five instead of six ounces; still remaining, therefore, above the normal level. Thus some degree of diminution of arterial tension was shown as the effect of the pilocarpine, but much less in degree than that which may be easily produced by a moderate dose of nitrite of amyl, although the general physiological effects of the drug were developed in extreme degree. With the object of facilitating digital dilatation of the os uteri, and the subsequent application of forceps, the administration of chloroform was now commenced. Before, however, anaesthesia had been fully produced, an alarming change took place in the pulse. Having been previously full, strong, and regular, at the rate of about go, it ran up suddenly to at least i8o, becoming at the same time extremely irregular and compressible, and fluctuating so much with respiration that, during the inspiratory period, it could scarcely be felt at the wrist. The chloroform was at once discontinued, since it appeared dangerous to prolong the administration. As soon as consciousness had returned, the pulse again became strong and regular, at its former rate of about go. Chloroform was then again administered, in order to test whether the effect really depended upon its use. Again, before the stage of rigidity had passed, the pulse became rapid, irregular, and almost imperceptible, its rate going up to quite 200. As before, it returned to its original quality and rate as the effect of the chloroform passed off. Digital dilatation of the os, which remained rigid, by means of the fingers of one hand in the form of a cone, was then continued for about an hour. After this, forceps was applied by the obstetric resident, Mr. Pedley, the diameter of the os having now reached a diameter of two inches and a half, and the head being still high up in the pelvis. A living male child was delivered, about half an hour being occupied in the extraction. No uterine action whatever occurred until the forceps was applied; but, under the stimulus of their use, some pains came on. Since the effect of chloroform in labour is ordinarily to diminish the rapidity of the pulse, the effect on the pulse in this case must have been due, not to the chloroform alone, but to chloroform acting in conjunction with a large dose of pilocarpine. Since pilocarpine is known to have an accelerating effect upon the heart, it would seem probable that the chloroform paralysed some inhibitory mechanism by which this influence was kept in check so long as consciousness existed. As in this instance it did not appear safe to continue the anaesthetic, the case appears to suggest that there may be an inconvenience in treating puerperal eclampsia by pilocarpine, when it is likely that an anaesthetic will soon afterwards be called for in order to terminate the delivery. No convulsion occurred after the administration of the first dose of pilocarpine, although fully three hours elapsed before delivery was completed, and notwithstanding the prolonged digital dilatation of the os, and the slow extraction by forceps, both which proceedings in a case of eclampsia would be likely to bring on convulsions in the absence of an anaesthetic. Some complication was introduced by the fact of chloral and bromide of potassium having been given previously; but, since there had been no interval free from convulsion longer than about fifteen minutes until the administration of the pilocarpine, there appeared to
doi:10.1136/bmj.2.984.729 fatcat:jvfl5u3jdfaopbqekwqpdvp7ue