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The American Practitioner and News. 83

silver wire or catgut, the interrupted stitches should always be placed
close together. I have preferred Harris' procedure and used chromi-
cized catgut or kangaroo tendon, because either of* these is ulti-
mately completely absorbed, and I introduce four sutures to each inch
of incision.

Unless pressed for time a running suture of fine catgut, as suggested
by Kelly, should bring the edges of the subcutaneous fat together.
This is more important if this layer is very thick. Such a suture takes
tut little time and obliterates a space which frequently, in the old
procedure, became filled with a clot which subsequently broke down
from surface infection.

The skin is so elastic that it is of little use in the prevention of
liernia, but its careful suturing is of the utmost importance, not only from
the prevention of infection but in order to make a sightly scar and to
not too long delay convalescence. One of the most important practical
lessons of the surgical bacteriologist is that the staphylococcus epider-
midis albus is rarely, if ever, entirely removed from the skin by what-
ever method of sterilization has been adopted. Have we any method of
"bringing skin surfaces in such perfect apposition that the danger of in-
fection from pus-forming bacteria in the skin is minimized? Marcy or
Halstead or both have answered the question with their subcuticular
stitch. This is simple, easy to apply after a little practice on the
cadaver, takes but little time, and, if catgut be used, there are no
stitches to remove. The scar left is a slight linear one, and after a few
years is practically obliterated.

To summarize, I would say that the most eflScient method of repair
of the abdominal incision would consist of the following distinct
steps: (i) A continuous peritoneal suture of fine catgut), (2) an inter-
rupted suture of chromicized catgut for the fascia with four sutures to
the inch, (3) a running suture of catgut for the subcutanepus fat, and
{4) a subcuticular subcutaneous stitch of catgut for the skin.

Of the necessity for this or some similar method of tier suture
there can hardly be a question. The time should have long since
passed when any surgeon would use the old through-and-through
suture unless his patient be in such danger of collapse that haste was
a necessity and hernia and infection a secondary matter. I have heard
even noted surgeons, after using the old method for years, say that they
themselves had never had a hernia following one of their laparotomies,
nor a stitch-hole abscess, nor a serious adhesion, nor a contracture of



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84 The American Practitioner and News.

^t. Such statements can only mean that some noted surgeons do
not keep their patients' history after the operation and immediate con-
valescence are passed; but such accidents have happened within the
experience of every general practitioner, and the surgical history of
nearly every county in this or any other State would be incomplete
without a record of one or more such post-operative accidents, the
result in almost every one of them of the use of the through-and-
through suture.

BOWUNG Grbbn, Ky.

THE USE OF CHLOROFORM IN LABOR.*

BY WALKER BOURNE GOSSETT, M. D.

Instructor in Obstetrics^ Gynecology^ and Abdominal Surgery^ Louisville Medical College.

"Among primitive people, still natural in their habits, and living
under conditions which favor the healthy development of their phys-
ical organization, labor may be characterized as short and easy, accom-
panied by few accidents and followed by little or no prostration."

Obstetricians and chloroform would never be needed if women of

to-day had as little pain during childbirth as Wenonah, in Longfellow's

song of Hiawatha :

There among the ferns and mosses,
There among the prairie lilies,
On the Muskoday, the meadow,
In the moonlight and the starlight.
Fair Nokomis bore a daughter.

The civilized woman of to-day is far from being in a physiological
condition. Higher development renders her more susceptible to bodily
suflFering.

** The pain of chilbirth is like unto the torments of hell." Many
physicians say it is a natural pain, and nothing should be given, but
let nature take its course, and let woman suflFer. If the Almighty has
placed an agent on this earth to assist woman to bear this pain, or lessen
the sensibility of the pain without materially decreasing the force of
power of the uterus and increasing the danger to mother or child, it is
our business as physicians to find what this agent is and apply the
same.

Chloroform is our agent, and, if given correctly, it will lessen the
sensibility of the pain, having no marked effect on the force of the
power of the uterus, and not increasing the danger to mother or child..



* Read before the Kentucky State Medical Society, May, 1899.



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The American Practitioner and News. 85

Early in 1847 ^^^ illustrious Sir James Y. Simpson proved that
inhalation of sulphuric ether could be safely and successfully used for
the relief of pain in childbirth, and later in the year he established the
same fact as to the inhalation of chloroform. Obstetric anesthesia soon
found a few in Great Britain and on the Continent to advocate and
practice it. In the United States Dr. N. C. Keep, of Boston, was the
first American physician to administer an anesthetic in labor. Dr.
Walter Channing, a distinguished American physician, advocated the
practice. His treatise on ** Etherization in Childbirth'' was published
in 1848.

The late Prof. Henry Miller, of this city, the author of "Miller's
Text-book of Obstetrics," gave chloroform to a woman in labor on the
13th of March, 1848. This was the first time chloroform was thus used
west of the Allegheny Mountains. Dr. Miller remained faithful to
anesthesia in labor the rest of his honored life ; and he strongly advo-
cated the practice, and with his well-known ability answered the argu-
ments adduced against it. Miller and Channing are the two names in
this country that shine with the most luster in connection with the
early advocacy of obstetric anesthesia.

On the other hand, three of the most eminent obstetric teachers,
Meigs, Hodge, and Bedford, strongly opposed the use of anesthetics in
normal labor, and their influence was more powerful than that of its
advocates. The controversy here was but the reflex of that which was
occurring in Great Britain. Simpson asserted that it was only a ques-
tion of time as to the general adoption of anesthesia in parturition, and
that time has come.

On the other hand, Dr. Ashwell and Dr. Tyler Smith were the most
prominent London obstetricians opposing the practice, and declared
that " unnecessary interference with the providentially arranged process
of healthy labor is sure, sooner or later, to be followed by injurious or
fatal results," ..." that chloroform need only be extensively used to
insure its entire abandonment," and that it was ** a duty to urge every
plea against its further use."

We know that brief surgical operations, much less painful than
childbirth, are not. done without the use of an anesthetic.

Depaul gave some reasonable objections to the use of chloroform in
labor, which are the following: First, it may kill the patient; second, the
anesthetic sleep deprives her of reason, so that she can not participate
in the great act accomplished, and this participation is in almost all



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86 The American Practitioner and News.

cases necessary ; third, the inconveniences and dangers are not com-
pensated by the advantage arising from the diminution or suppression
of pain.

In reply to these objections, first, chloroform has been used in
natural labor many thousands of times, yet not over half a dozen cases
of death are on record where it was administered by a competent med-
ical man.

The following almost completely exempt the danger from chloro-
form : The horizontal position, the intermittency in its use, the anes-
thesia not being profound, the influence of uterine contractions; the
alternately relaxing and contracting of the uterus reinforces the action
of the lungs and heart, and thus asphyxia and syncope are avoided.

In answer to the second objection, it is obstetrical anesthesia and
not surgical which is sought. The patient is not unconscious and
incapable of voluntary effort.

As to the eff*ect of chloroform on the force of uterine and abdominal
contractions, when given correctly, I have never noticed this force
materially decreased. The same holds true of the contractions of the
uterus after the second or third stages of labor, and chloroform does
not predispose to post-partum hemorrhage. Even admitting that the
labor is rendered slower, the lessened suffering makes the trial not so
severe and exhausting. Also admitting that there may be a liability
to post-partum hemorrhage, a proper management of the third stage of
labor and the use of ergot-aseptic, hypodermatically given, will almost
certainly avert the danger.

The Choice Between Chloroform and Ether. Chloroform is pre-
ferred by most men. It is of a pleasanter odor, its action more prompt,
and a less quantity of chloroform is required. Chloroform can be
used at night without any danger from light or fire ; ether can not^
as it is inflammable, and at night we certainly have the greater
majority of obstetrical cases. By some it is held that relaxation
of the uterus and post-partum hemorrhage are much rarer after the use
of ether. King prefers ether, and his main reason is this : ** Ether is
unquestionably safer; and while the advocates of chloroform claim
that but very few deaths are on record from its use when administered
with unremitting care and by the hands of an educated and experienced
physician, yet these conditions can not always be constantly assured.
All men are human ; the unremitting care will sometimes remit ; over-
sights and diverted attention happen to all, and in obstetric practice,



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The American Practitioner and News. 87

with its inevitable fatigue, loss of sleep, and anxiety, are more likely
to happen than in other fields of professional work. Hence, as a
matter of safety, I prefer ether.**

And he also says, ** Ether is inflammable and hence care is required
in using at night,'* and as " all men are human, the unremitting care
will sometimes remit, oversights and diverted attention happen to all,**
and so might not the ether man blow up his patient, himself, and all in
the room ? which would be a calamity far worse than the death of only
the patient.

Dr. J. C. Reeve, in his contribution to the American System of
Obstetrics, "On Anesthetics in Labor,** denies that ether is a safer
anesthetic than chloroform, and, after a careful study of accidents from
chloroform in labor, makes the following statements :

1. But one well-authenticated case of death is on record where the
administration was by a medical man, and in that case no autopsy was
held.

2. Dangerous symptoms have occurred but a very few times, and
that almost always from violation of the rules of proper administra-
tion.

3. The danger when chloroform is used only to the extent of miti-
gation or abolition of the suffering of childbirth is practically nil ; when
carried to the surgical degree for obstetric operations, the danger is far
below what it is in surgery.

4. No proof can be furnished that the parturient woman enjoys a
special immunity from the danger of anesthetics, although facts seem
to indicate that such exists. Her best safeguard lies in the care and
watchfulness of the administrator.

Chloroform is not without danger in other operations, when only
two or three inhalations are taken, and sometimes death results from
heart-failure. But in labor I think there is no danger of this shock
taking place, because the pain of labor is somewhat of a shock to the
patient of itself. The heart is physiologically prepared to meet this
condition, so that the slight additional shock of chloroform, if there be
any, adds little or no gravity to the condition. But if you are afraid of
this heart-failure, you may during the first part of the second stage of
labor administer hypodermatically sulphate of strychnine and nitro-
glycerine.

In every case you should examine the heart, and, if you find any
trouble at all, give strychnine.



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88 The American Practitioner and News.

The following are some causes for the administration of chloroform
in obstetrics: "To lessen suflFering produced by labor pains; to lessen
the pain attending certain obstetric operations; to relax the uterus
when its rigid contraction interferes with version ; to promote dilata-
tion of the OS uteri ; to reduce excessive nervous excitement, which
may interfere with progress of early stage of labor ; to relieve eclampsic
convulsions and mania ; to relax the abdominal wall and lessen pain,
while the uterus is being pushed down in cases of abortion, when the
finger is being introduced to remove retained secundines ; in craniot-
omy to forestall unpleasant recollections; in cases of uterine inversion
to relax the constricting cervix and to facilitate replacement; in
bipolar version to lessen pain of introducing the hand into the vagina ;
in precipitate labor to suspend action of voluntary muscles and retard
delivery ; to dissipate * phantom tumors * while making a differential
diagnosis of pregnancy ; to relax the os and cervix uteri while introduc-
ing finger to diagnosticate between uterine and extra-uterine pregnancy ;
in all cutting operations upon the abdomen ; and sometimes in sewing
up a lacerated perineum, when many sutures are required. In this last
instance, and in all cases when chloroform is used after delivery, the
greatest care is necessary. Chloroform after delivery should be avoided
if possible.''

Hirst says the dangers and disadvantages that it is claimed result
from the use of anesthetics in labor are: "A prolongation of the
process by weakening the uterine contractions and increasing the inter-
vals between them; a disposition to post-partum hemorrhage; an
increased liability to sepsis after labor by a relaxation of the uterine
muscle and subinvolution of the uterus." But he says " these objections
are ill-founded if the anesthetic is administered in a proper way.
Accurate observation in some of the large German lying-in hospitals
has demonstrated that an anesthetic, if not pushed too far, has no
influence on the power, duration, or frequency of the pains. Subinvolu-
tion is never seen as a result of anesthesia unless it is pushed too far.'*

Playfair, in his last edition, says : " The practice has become so
universal that no argument is required to establish its being a perfectly
legitimate means of lessening the suffering of childbirth. Indeed, the
tendency in the present day is in the opposite direction ; and a common
error is the administration of chloroform to an extent which materially
interferes with uterine contractions and predisposes to subsequent
post-partum hemorrhage."



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The American Practitioner and News. 89

Playfair, in speaking of chloroform and ether, says : " Practically
speaking, the only agent hitherto employed in this country is chloro-
form, although the bichloride of methylene and ether have been occa-
sionally tried.*'

The use of chloral in the first stage of labor does not interfere with
the use of chloroform in the second stage.

The Manner in which to Administer Chloroform. You must withhold
the chloroform until the correct time to administer it. The patient will
beg for it, pray for it, cry for it, and even try to make those present use
force to make you give it. But hold until the perineal stage — latter half
of the second stage. This is the time woman suflFers the most ; large beads
of perspiration stand out on her forehead, run down her cheeks, eyes
bulging and quivering with pain, the whole form being on a rack of
misery. Now take your chloroform inhaler and place it firmly over
patient's nose and mouth. If you have not the inhaler, use a small
handkerchief saturated with chloroform, or a tumbler containing a
piece of blotting paper.

As you feel a pain coming on, sprinkle about a drachm of chloroform
on the inhaler, and instruct her to take deep inspirations before the
pain reaches its height. The patient will take two or three deep inha-
lations — for they readily inhale — and at once the severity of the pain
will be lessened. As the pain ceases, remove the inhaler, and then as
the next pain comes on, replace it, only allowing it to remain during
the pain. By this method of administration it will be impossible to
give enough chloroform to cause danger. She may cry out just as loud
as if chloroform had not been used, but afterward will tell you that she
suflFered very little, and invariably will thank you for having used it.

Chloroform may be used in the first stage of labor, though when the
pains are severe in this stage, I prefer hydrate of chloral.

There is danger of having to use chloroform too long when given in

the first stage, thereby decreasing uterine force and predisposing the

patient to hemorrhage. The same, perhaps to a less degree, applies to

the first part of the second stage of labor. During the perineal stage,

or at any stage, the chloroform may be pushed to complete anesthesia —

surgical extent if necessary — but in natural labor only to its obstetrical

extent. If there are any members of this Society who have never used

chloroform, try it, and you will be so well pleased that you will use it

in every case of labor. You will thereby receive the everlasting

gratitude of your patients and be a blessing to the female sex.
Louisville.



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90 The American Practitioner and News.

SUPRARENAL EXTRACT IN THE TREATMENT OF ADDISON'S
DISEASE (CLINIC).*

BY R. ALEXANDER BATE, A. B., M. D.

This case was reported at the Louisville Society of Medicine, and
referred to in a paper upon Animal Extracts read before this Society at
Maysville.

The following history is taken from the notes of the case made
about two years ago, when the patient first came under observation.
Mr. C, aged fifty-four years; occupation, teamster; family history good
with the exception of one child suffering from epilepsy. Upon physical
examination it was observed that the skin of body and limbs was of
a lemon yellow color, face and hands dark bronze, mucous membranes
of the mouth and conjunctivae brownish red, and the hair was black ;
there was tenderness over the epigastric and lumbar regions ; both kid-
neys were elongated and tender; there was also epigastric pulsation due
to a cylindrical aneurism of the abdominal aorta.

There was a history of continuous epigastric and lumbar pain, and
occasional aching in the joiiits and frequent spells of faintness without
loss of consciousness, enfeebled strength with constant weariness.
Diarrhea would occur without any assignable cause, and would be
very persistent in its course ; there was nausea at times, and the mouth
constantly filled with slime.

Pains extending from the epigastric region downward over both
iliac arteries and upward and especially toward the left arm were
considered dependent upon the aneurism.

The urine was voided frequently ; color, bright red ; of acid reaction ;
containing uric acid in proportion to urea of 1-43 ; also uroerythrin^
melanin, biliary coloring matters, and indican in excess. In this case
the aneurism has been recognized for the remarkable period of thirty-
five years.t

At the age of fourteen the patient felt something give way in the
abdomen while straining to save his father from being crushed by a
log. In addition to the aneurism there is a history of traumatic injury
having occurred about twenty-six or twenty-seven years ago that
caused depression of the sternum just above the xiphoid cartilage.

The pathology of morbus Addisonii is still very uncertain, but in
this case it is susceptible of but two explanations. Either the blow
causing depression of the sternum deranged the semi-lunar ganglia, at

• Read before the Kentucky State Medical Society, May, 1899.



t Dr. Kalfus, now deceased, diagnosed aneurism in 1864.



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The American Practitioner and News. 91

least the suprarenal plexus, interfering with the action of the sympa-
thetic, which is tonic to the blood-vessel walls, causing rhythmical
contraction, and would thus permit dilatation of the vessels with
consequent congestion of the suprarenal bodies, or the aneurism may
not only act in this same way, but can press directly at least upon the
left adrenal. Thus both functional and morbid changes in the supra-
renal glands can be understood. So that the symptoms of Addison's
disease can be seen to occur from a deficiency of suprarenal principle
in the system, no matter whether the glandular inadequacy is depend-
ent upon functional or morbid changes.

Consequently -upon isopathic principles this patient was put upon
the suprarenal extract, and a prognosis favorable concerning the
Addison's disease was given.

One twelfth of a grain of the extract of suprarenal glands of sheep
was administered three times daily. This has been kept up more or
less constantly ever since, and for the past year the patient has been
able to earn his living at his usual occupation. The asthenia, nausea^
dizziness, faintness, and pigmentation have almost entirely disappeared.

The pains produced by the aneurism of course still remain, though
somewhat lessened, most likely from potassium iodide, which was
administered for that purpose.

Upon two occasions when the suprarenal extract could not be
obtained within ten days attacks amounting almost to syncope
occurred, there were cold, clammy sweats and muscular twitching fol-
lowed by slight fever and a bounding pulse, averaging about ninety
beats per minute, and there was a general feeling of approaching
dissolution. The extract has apparently been almost specific in this
case. Of course, should the medication be discontinued the symptoms
will return, since we have simply supplied artificially that which is
normally secreted.

This drug should be as nearly specific in exophthalmic goiter as in
Addison's disease, since it is the true antidote to thyroid extract ; it is
indicated in all conditions attended by loss of muscular power, probably
in the same cardiac derangements in which digitalis is used, in subnor-
mal temperature associated with asthenia, is anemia and melanemia,
in neurasthenia and conditions requiring vasomotor stimulants.

At the risk of being tedious this case is again brought before the
Society, believing the results obtained justify repeated efforts to extend
the use of this most valuable agent so generally viewed askance.

Louisville.



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92 The American Practitioner and News.

Reports of Societies.



KENTUCKY STATE MEDICAL SOCIETY.*

[CONTINUBD PROM PAOB 72.J

Discussion of " The Closure of the Abdominal Wound After Lapa-
rotomy,'* by Dr. Arthur T. McCormack, of Bowling Green.

Dr. W. H. Wathen, Louisville: I hardly know what to say upon
the subject that has been so briefly and so scientifically presented by
Dr. McCormack. The method he has described of closing the abdom-
inal wound is certainly as good as any I have heard described or read
of, or that I have practiced. It is impossible, it seems, to jget a con-
sensus of opinion as to what is the best method of closing the abdom-
inal incision. There are, as he says, noted surgeons to-day who will
use a suture through all the wall. The interrupted suture, silver wire,
silk, or silkworm gut — sometimes even chromicized catgut — are used,
and I must agree that there are many cases where the union has been
made by these methods and there has been no future trouble, and the
results have been as perfect as it is possible to have them. In these
instances the results will not be good unless the fascia is pulled well
out and the suture is introduced on the angular projection on which
we have the fascia. However, in order that we may get the best results,
I think the better plan is that described by Dr. McCormack. I am
glad to see that he suggests the interrupted suture for the fascia,
because if you use the continuous suture you will often have suppura-
tion far beyond your expectation. You will compress the tissue more
at one point than at another, and therefore you will have tissue necrosis



Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 65 of 109)