John Duncan Emmet.

The American gynaecological and obstetrical journal online

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afterwards the ether, and found that they worked very well.

Dr. L. J. Hammond: Dr. Hammond's paper has been very instruc-
tive in giving us additional knowledge of ethyl bromide as an anaesthetic.
I think such papers should be encouraged, because of the importance of
adding an increase to our therapeutics of anaesthetics. From what has
been said, it would seem to be the drug par excellence in cases of labor.
It certainly does not agree with my past feeling, and that was that chlor-
oform was the ideal drug. It seems to me that chloroform possesses
all the advantages which Dr. Hammond has presented in favor of cthjrl
bromide. We all know that the condition of congestion of the menin-
ges, which takes place during labor, is markedly overcome by chloro-
form that serves as an antidote to the congestion. This makes it,
therefore, almost invariably a safe agent in labor cases. A very small
quantity is requisite, and I have had large experience with its use, with-



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The Philadelphia Obstetrical Society. 349

out any disastrous effects whatever, a few drops being all that is re-
quired, which can be continued for a very long period.

Dr. J. M. Fisher: With reference to the use of ethyl bromide in
obstetrics, I am favorably impressed by the claim that the writer makes
that it does not interfere with the uterine contractions, and that in con-
sequence of that there is not the danger of subsequent relaxation of the
uterus and post-partum hsemorrhage. I have never used ethyl bromide.
J have found frequently in the administration of chloroform that it
does interfere with uterine contractions. Sometimes the contractions
are so reduced in force that it is necessary to withdraw the chloroform
for a time, and sometimes altogether, in order to bring about safe de-
livery. I believe, too, that chloroform, to a certain extent, predisposes
to subsequent haemorrhage. I recall one case in particular in my own
practice in which post-partum haemorrhage took place, I believe, from
too free administration of chloroform. I think I shall try the ethyl
bromide, and see whether the observation can be borne out in my own
practice.

Dr. George I. McKelway: I have had quite a large experience
with ethyl bromide; I have used it, I think, in about a himdred labor
cases, and m quite a number of minor g3maecological operations.
In labor cases I have had the woman anaesthetize herself. I have an
inhaler which gives a concentrated vapor. I tell the woman that when
she feels the pain coming on to take three or four deep inspirations.
This puts her sufiiciently under the influence of the drug to make her
drop the inhaler, and so to prevent her administering an amount that
would do her damage, and at the same time it renders her unconscious
of her pain. I have not found that it influenced uterine contractions
in the least, nor have I found that it predisposed to post-partum haemor-
rhage.

My friend. Dr. F. J. Hammond, speaks of chloroform comparatively
with bromide of ethyl; there is no comparison in the sense that the
patient is practically immediately under the influence of bromide of
ethyl, and almost as immediately out of its influence after it is with-
diawn. Of course, chloroform is very much quicker in its action than
ether, but it does not compare in rapidity of action with bromide of
ethyl. It is more rapid in its action than is nitrous-oxide gas.

I have attempted once or twice to use bromide of ethyl in forceps
cases, but have not persisted, because I feared to use as much as I found
would be necessary, and have supplemented it with chloroform. In
gynaecological operations requiring five or eight minutes, such as the
caning of a pelvic abscess through the vagina, I have used the ethyl



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350 Transactions of Societies.

bromide, and the anaesthesia which can be obtained with it is perfectly
safe, and the shock to the woman is much less than is brought about
by any other anaesthetic. It very seldom causes nausea, and, almost
never, vomiting.

Dr. T. A. Erck : I should like to ask a question with reference to
the comparative safety of ethyl bromide; it has been claimed that it is
perfectly safe if the administration be not prolonged over a certain time.
What is the danger if it is continued for a longer time ?

Dr. George M. Boyd: I have had no experience with bromide of.
ethyl. It would seem to me that if it has the prompt effect of anaesthe-
sia which has been claimed, does not interfere with labor, and is a drug
without danger, it is tlie anaesthetic par excellence; but, until that is
proved, I think we had better stick to the safest anaesthetic, and use the
anaesthetic that has the broadest field of usefulness. In using ether in
obstetrics we only want to modify the pain, and for this ether suffices.
If we want to do a forceps operation, we have the safest of drugs if we
use ether. I have used chloroform to the obstetric degree in certain
cases, but in many cases the anaesthetic must be left, as Dr. McKelway
says, to the patient, and that being the case, in the obstetric case it seems
to me ether is the safest, and has probably the broadest field of useful-
ness, for bromide of ethyl can only be u^ed for a short time. It must
not be used for any of the obstetric operations.

Dr. MoRDECAi Price : I have had no experience with the drug advo-
cated by the writer, but I certainly feel that if it does what he claims for
it, it is unquestionably a great addition to our obstetric armamentaria.
I am not a believer in anaesthetics in obstetrics as a general rule. I do
as Dr. McKelway does — give the patient the ether, and she generally
dn ps it long before she gets much. With the patient etherized in la-
bor, one half of her power for expelling the foetus is unquestionably
lost, the labor greatly delayed, and the chances of secondary haemor-
rhage certainly increased. Therefore, if the drug, bromide of ethyl,
does what they claim it does do, and is safe, a few moments of anaesthe-
sia could do the woman no particular harm.

In regard to chloroform, I would like to say that I have seen two wo-
men die frcMn its effects before the inhaler or towel could be removed
from their face when not more than two or three mspirations of chloro-
form were taken, and all the skill of three or four good men in the room
could not save these women. Both of them I admit were septic. Both
of them might have died without chloroform, but the chloroform was
administered to deliver the placenta and the debris, and both died al-
most instantly. There was a third case, that of Dr. Collins, which died



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The Philadelphia Obstetrical Society. 351

almost with the very first inspiration of chlorofonr for a surgical
operation. The other two went to the coroner, and he absolutely
ignored the possibility of death from chloroform ; said sepsis killed tliem
both. So now neither of them are on record. I, myself, saw them
both die. Both of them were abortion cases, and both of them died
so quickly that I did not know chloroform had been used.

Dr. L. J. Hammond: I am very glad that Dr. Price brought up the
question of septic labors in which anaesthetics are to be used. I believe
ihey (septic labors) are the most dangerous conditions in which anaes-
thetics of any kind can be used. The reduced volume of blood, as well
as its altered character, in these conditions is very likely to produce a
clot, and in that way, I believe, the patient can die from septic embolism
almost as promptly as the cases Dr. Price has referred to. I have no
doubt that the chloroform was the cause of the deaths, but I also be-
lieve ether would have done the same, and the same result would have
met with from any other anaesthetic. I do not think that we in Phila-
delphia know as much about chloroform anaesthesia as would be
well for us. In the South and West they use chloroform very exten-
sively, and the mortality, so far as I know, (and I have had considerable
information on the subject), has been no greater than with ether
with us.

Dr. Noble; I believe the two women had abortions and were sep-
tic; in other words, were not labor cases. The other case, I understand
Dr. Price to say, was a surgical one.

Dr. Price: The surgical operation was for the removal of a
growth in a man, and the other two cases were abortions, one of them
about the third or well into the fourth month, in whom the placenta had
been retained. She was unquestionably septic, and the probabilities
are that she would have died, but she was breathing quietly when I went
into the room. In a few minutes I was told that she was dead. In
reply to my inquiry of what anaesthetic had been used, the physician
said chloroform. I told him he would have to report this to the coro-
ner to avoid any trouble. He did so, and the coroner said : "Sepsis, to
be sure."

I do not believe that ether kills in septic cases ; if it did, we would
kill some one every day. On the contrary, I believe it a life-saving
article. I have kept patients alive longer under it than I could have if
it had been taken away. I recall one case of a ruptured uterus in which
I etherized the woman and removed the child. As long as we kept up
the ether the woman breathed. I believe ether to be a valuable stimu-
lant at times.



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35 « Transactions of Societies.

Dr. A. G. Staunton of Charlestown, W. Va. : I regard myself very
fortunate in happening in at this time. This subject is of exceeding
interest to me. I began my medical trainmg in Philadelphia, and went
back to my home with the idea that ether was the only thing to give.
But for the very unpleasant after-eflfect of ether, which is almost uni-
versal, I should probably not have been won over to the idea of giving
chloroform at all. I am very much afraid of it. I have used it in
obstetric cases, but I am afraid of it, and have always been. I have
known within my own immediate practice one death, at least, under
chloroform in the hands of a careful man, and I always give it with a
sense of discomfort. I think, if the case dies, I cannot help rq>roach-
ing myself, feeling that it is generally admitted a more dangerous anaes-
thetic than ether. I have had no experience with the bromide of
ethyl, and have been very much interested in the discussion to-night
We are in the smaller cities are in the habit of contenting ourselves
with the single anaesthetic, and not branching out or trying new thnigfs
as much as in the larger cities. I am persuaded, from the remarks to-
night, and the experience of those whom I have heard, that it is an
anaesthetic worth tr)ring, and I shall try it in my own work.

Dr. R. B. Staunton of Charleston, W. Va.: I have given chlor-
oform a good trial since I have been in the South, and I give it with a
good deal of nervousness, though I have never had any ill effects from
it. I know nothing about ethyl bromide, not having used it.

Dr. E, B. Glenn of Asheville, N. C. : I received my medical train-
ing also in Philadelphia. Ether was used here almost exclusively.
Since I have been in Asheville chloroform has been used there almost
exclusively. I have seen one death from chloroform in a septic case
since I have been there. I have seen none from ether. I have used
ethyl bromide a few times, but I have found no one where I live who
has used it, and have found some difficulty in having it used. I think
it an ideal remedy for that for which it is recommended, for an immediate
examination where a short anaesthesia is required.

Chloroform I have always considered the safest anaesthetic of any of
the general anaesthetics in labor. I have never seen any bad eflfect
from it, or a post-partum haemorrhage. I have never seen a death from
it in labor, and have never seen any complications. I allow the patient
to take it herself. Ether is given a very few times in labor, and that
is when I cannot get the chloroform. I saw once an almost fatal case
from a very few inhalations of chloroform, but there was a slight heart
complication. The case was in the hands of a very careful physician,
a man of large experience, and for the first time, he said, in his life, he



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The Philadelphia Obstetrical Society. 353

was frightened from the use of chloroform. The operation was for
strangulation; we stopped the anaesthetic and proceeded with the ope-
ration. My experience in the South is that chloroform is the safer
of ether or chloroform. Bromide of ethyl I use sometimes.

Dr. Price : Speaking of deaths from chloroform, only a few weeks
ago one of the chief surgeons of Baltimore had a boy brought to his
office by his parents for operation. In a few minutes the father came
out from the office and told the mother the child was dead.

Dr. Fisher : In my experience a woman appears to be particularly
fortified against the evil influence of anaesthetics during labor. I would
like to ask the Society whether or not within the experience of any one
here a woman has been known to die under the anaesthetic given in
labor?

Dr. Price : Dr. George Pepper had a woman die while he was put-
ting her under chloroform.

Dr. L. J. Hammond: I know of one case that died under ether
during labor — a case in the Southeastern Dispensary, a negress, prim-
ipara, unusually fat, and had taken less than four ounces.

Dr. George I. McKelway: I think it is only fair that we should
remember that there are two elements in anaesthesia, one is the anaesthe-
tic and the other is the anaesthetizer; and sometimes the anaesthetic may
be blamed for what is the fault of the anaesthetizer.

Dr. Charles P. Noble: Bromide of ethyl was one of the first
anaesthetics I ever saw used. I think it was introduced into this coun-
try, practically, by Dr. Chisolm oi Baltimore. He gave it many
hundred times before the use of cocaine in eye-work — ^that is,* prior to
1884. He used it for all his eye operations, and was very partial to it.
Dr. Chisolm was an opponent of ether, and had, perhaps, the largest
experience with chloroform of any one in this country, and, as he used
to report, without any fatal cases. Dr. Chisolm's method of adminis-
tering the bromide of ethyl put the patient asleep in fifteen to twenty
seconds. He put one-half dram of the drug in an air-tight cone, and
excluded air until anaesthesia was secured. I might say as to the deaths
from chloroform, ether, and bromide of ethyl Aat I am quite sure no
matter what anaesthetic is used somebody is going to die. I can say
that I have had at least two deaths from ether. The same day that I
had one of these deaths there was another one in the Howard Hospital
and one in the Johns Hopkins Hospital; in other words, there were
three deaths in one day from ether within a limited area.

Dr. F. C. Hammond: My reason for presenting a paper on the
bromide of ethyl is that in looking over the Transactions of the Society



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354 Transactions of Societies.

I failed to find that a paper had been presented to the Society on this
drug. I find that quite a number of practitioners in the State and coun-
try have never heard of thp drug, and that numerous others who have
heard of it have never employed it. Therefore, the object was to bring
out the discussion, and the gentlemen certainly have responded liberally.

In regard to muscular rigidity, we do meet it once in a while ; cases
in which the patient will become rigid, the rigidity being more marked
in the arms and legs. In these cases, as a rule, withdraw the anaesthetic
and allow the rigidity to subside, and then tr}' again. If, upon two or
three endeavors, the rigidity continues, the best thing to do is to use
chloroform or ether, and I am in favor of chloroform. Some observers
have reported the rigidity so marked as to amount to opisthotonos. I
have never seen it, and several gentlemen who have employed this
anaesthetic have not met with this extreme rigidity.

In regard to the ideal anaesthetic for obstetrical cases. I think that
ether is a rather slow-acting drug, and it is used mostly by men who
are afraid to use either chloroform or ethyl bromide or men who
are not willing to stand up to the responsibility of the drugs which they
are using. What we desire in obstetrics is an anaesthetic that will
quickly alleviate pain, that is, '*take ofF' the "keen edge" of the pain,
and yet allow the patient to maintain her intelligence and be able to act
in accord with the obstetrician. In the administration of ether, by the
time the pain has subsided, oftentimes deep anaesthesia is produced,
which we do not want. In using a drug for producing obstetrical
anaesthesia, the object is to take the "keen edge" oflf the pain, and to
employ a drug which will not favor post-partum haemorrhage or depre-
ciate the strength of the muscular contractions, and at the same time
leave as little disagreeable effects as possible. There is no doubt of the
fact that ether does leave a great many disagreeable after-effects. The
nauseating, and oftentimes vomiting, are certainly very disagreeable,
and often the odor is markedly present in the child after birth, and
it can be detected for some tliree or four days. This will seldom be
observed in chloroform or bromide of ethyl, in which the odor passes
away in a few minutes. The majority of men speaking against bromide
of ethyl do so without thinking of the collection of cases in which it
has been employed. The fact of one man using ether entirely and
exclusively in his practice shows a narrow-minded view, because you
should select your anaesthetic according to the patient. Bromide of
ethyl administered first to produce anaesthesia, and this maintained by
chloroform or ether, whichever drug to be employed renders satisfactory
results, by eliminating the fear and dread apprehended by the patient.



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The Philadelphia Obstetrical Society, 355

In reply to the question why the bromide of ethyl should not be.
continued for more than ten or fifteen minutes: The tendency to
paralysis of the respiratory tract becomes greater the longer anaesthesia
is maintained, bromine poisoning resulting. For a brief space of time
the danger is eliminated.

Clinical History: A Case of Pyosalpinx; Fcecal Fistula; Recovery,

Dr. Wii-MER Krusen: The following history presents one of the
tmpleasant sequels that may follow a severe abdominal operation. The
difficulty in dealing with this condition and the unexpected result ob-
tained are the chief reasons for describing the case. The patient was
first seen, in consultation with her physician, Dr. Charles B. Smith of
Newtown, September 11, 1898, and the following history obtained:
The patient, Mrs. R. W., aged thirty-two years, married, had had one
miscarriage several years previous; had been under the care of Dr.
Smith for eight weeks. Her condition at his first visit indicated mild
septic infection. The s)miptoms were chilliness, slight elevation of
temperature, abdominal tenderness, pain over the lower part of the
abdomen, and some vesical irritation; also, profuse leucorrhoea. She
had had inflamed condition of the vulvo-vaginal glands two years be-
fore, and a previous illness presenting similar s)miptoms while under
the care of another physician several years before. On examination
there was found a fluctuating mass on the left side of the uterus, very
tender, and easily outlined by bimanual examination ; a more indistinct
mass could be felt on the left side; diagnosis of pyosalpinx was made
and an operation advised.

The patient entered St. Joseph's Hospital on September igtb, and
the first operation was perfomidd on September 21st. A .mesial in-
cision was made, and the uterus and its appendages were found to be one
conglomerate mass, filling the pelvis; sigmoidal and rectal adhesions
were present and well organized, and there was every evidence of a
long-standing disease of the appendages. The adhesions were so dense
that no line of cleavage was discernible, and the pus was evacuated and
the pelvis irrigated before the enucleation was accomplished; the left
appendage was then removed and pedicle ligated; subsequently the
right tube and ovary were removed, with much less difficulty, although
there were some appendical adhesions so frequently found in these
cases. The sigmoid flexure and the anterior wall of the rectiun were
firmly adherent to the purulent mass, and the peritonaeal coat of the
intestine was injured in two places, which were immediately closed



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35 6 Transactions of Societies.



with a silk-seroserous suture. Dr. Hammond, who kindly assisted
in the operation, introduced a finger into the rectum in order that any
injury low down in the Douglas cul-de-sac might be detected. After
haemostasis was secured, a gauze drain was introduced and packed
firmly into the pelvis, to insure the control of oozing from the denuded
surfaces, and the abdominal incision closed with figure-of-eight silk-
worm-gut sutures. The patient's condition at the conclusion of the
operation was fairly good, and no complications were apprehended, but,
alas, "the best-laid schemes of mice and men gang aft agley." Gas
was expelled freely, and the bowels moved per rectum on the second
day after operation ; but on the third day it was noticed that the dress-
ings were soiled with a very slight, suspicious fsecal discharge; the
amotmt of this discharge increased daily, until by the sixth day the
entire faecal current pased through the fistulous opening and none per
anum. The dressings were changed and the rectum irrigated frequent-
ly, with the hope that spontaneous closure might occur. The remain-
der of the abdominal wound healed by first intention, and the sutures
were removed on the eighth day. As there was no diminution in the
faecal discharge, on October 7th, the seventeenth day after the first
operation, with the kind assistance of Dr. J. M. Fisher, I reoperated
on the case. The original incision was slightly enlarged, the adherent
intestines and omentum separated, and an opening large enough to admit
a finger was found low down on the anterior wall of the rectimi, about
four inches from the anus. The rectum was freed from the surround-
ing adhesions, and relaxed as much as possible, to prevent undue
tension on the sutures. An assistant introduced his finger into the
rectum, so that the exact site of the injury and its definite relations
could be obtained. A large-sized rubber tube was then in-
troduced through the anus and grasped with forceps and carried
above the opening in the rectum into the sigmoid flexure ; with a great
deal of difficulty the sutures were introduced, bringing the two sides
of the opening together; as accurate approximation as was desirable
could not be effected, because of the inaccessible position of the bowel
opening; but we did the best we could, relieved the ang^ation of the
bowel, loosened the sigmoid flexure, and with a provisional suture held
it in a relaxed position; the omentum was brought down and used to
separate the pelvic from the abdominal cavity; a twist of iodoform
gauze and a rubber drainage-tube were introduced, and the incision
closed with interrupted silkworm-gut sutures. The rectal tube was
permitted to remain in position until the bowels moved. ^ A very slight
amount of faecal matter came through the abdominal incision for two



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TTie Philadelphia Obstetrical Society. 357

or three days, but this soon ceased entirely and the subsequent course
of recovery was uneventftil.

The instructive points in this case are :

1. The possibility of extensive pelvic abscesses, which tend to eva-
cuate into the rectum, being followed by fistula many days after opera-
tion.

2. The value of drainage, in all suspicious cases, where there has
been unavoidable injury to the peritonaeal or muscular coat of the in-
testines, even though those injuries have been recognized and carefully
repaired.

3. The diagnosis of the position of the fistulous opening by the in-
jection of saline solution into the rectum, the fluid appearing quickly
at the external opening.

4. The relaxation of the parts sutured and the relieved tension so
necessary to secure union in intestinal suturing.

5. The value of a large drainage-tube or rectal tube, which can be
readily introduced and carried beyond the injury, acting as a guide or
splint over which to suture, and permitting expulsion of gas and liquid
fseces until healing is initiated.

6. The fact that a general and fatal peritonitis was escaped by the
rapid formation of limiting adhesions.



Online LibraryJohn Duncan EmmetThe American gynaecological and obstetrical journal → online text (page 36 of 76)