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or great nervous agitation, in which case anæsthetic agents might be necessary.
They are often useful in puerperal convulsions of a hysterical character, also when they are excited and kept up by powerful impressions made upon the nerves of sensation, whether this impression proceeds from exalted sensibility or from an excessive stimulus applied to them which might produce pain.
The exalted action of the excitor nerves might be allayed in such cases, and quiet restored to the muscular system. In uramic eclampsia, or convulsions attended with uræmia, chloroform narcotism is said by Dr. Braun, of Vienna, to have surpassed all expectations. Here the chief object is also to diminish as much as possible the reflex excitability, to weaken the paroxysms, in order to diminish the dangers and gain time for entering upon rational treatment. To accomplish this object, the tem should be brought rapidly under the anæsthetic influence when indications of an impending paroxysm show themselves, and this influence to be maintained until the premonitory symptoms pass off, and quiet and sleep follow. If, however, the paroxysm is not cut short, the inhalation should be discontinued during the convulsive attacks and comatose condition. Fresh atmospheric air to the lungs then becomes essential.
In the apoplectic form, or in advanced stages of the epileptic, the effect would undoubtedly be injurious, their applicability being confined to exalted nervous irritability, and injurious where there exists organic change or deep congestion of the nervous centres. In cases of retention of the placenta dependent upon spasmodic contraction of the uterus, the relaxing and stupefying effect of an anæsthetic usually enables the practitioner to finish the delivery without difficulty.
I have now passed in review briefly and imperfectly all of the different conditions that occur to me at the present time in which the use of anæsthetic agents may prove beneficial in labor. It will be seen that they are useful in securing the safety of the woman in many cases of peril. In very few, if any, of the conditions named do I deem it expedient to produce entire insensibility, and in the majority of them a very slight influence is all that is required.
The nerves of sensation seem to be first affected by these agents, so that pain and its results are first relieved, which is sufficient for nearly all obstetric purposes. In this way, excessive suffering may be obviated in many cases in which the physiological condition of pain is not entirely suspended.
The anæsthetic I prefer is a mixture of chloroform and sulph. ether, in the proportion of one fluid-ounce of the former to two of the latter.
In using them, of course, the precautions so necessary when full anæsthesia is desired should be carefully observed, even when a slight effect is intended.
The reading of Dr. Mendenhall's paper was followed by an interesting discussion, conducted mostly by Drs. White and Murphy.
Dr. J. F. White remarked that the essayist had shown great prudence in the preparation of his paper. He fully coincided with him in his
views on the subject, and therefore at present had but little to say. His individual experience in the use of anæsthetics in obstetrical practice was very limited, and, therefore, he would pass it by. He would make a few remarks founded upon the experience of others. A great deal has been written on this subject both pro
Able men, with large fields for observation, have placed upon record the results of their observations and investigations. The diversity of opinion is remarkable. It is contended, on the one hand, that anæsthetics are so full of danger that they ought not to be given under any circumstances; on the other hand, it is claimed that, in proper quantities, with proper watchfulness, there is no more evil to be apprehended than in the use of many other articles of the Materia Medica. In consequence of these conflicting opinions, the student must find it difficult to decide in reference to the safety or the contrary of these powerful agents, chloroform and ether. Dr. White spoke at some length of the views of Simpson, Snow, Murphy, Scanzoni, and others. In conclusion, he expressed the opinion that the same principles which guide us in the administration of other agents, with the action of which in particular cases we are ignorant, should guide us in the use of these articles. A great deal more might be said on this subject, but it was not necessary to detain the Academy with additional remarks. He had no hesitation in saying that, when used under proper circumstances, in proper quantities, and when the chloroform or ether are chemically pure, not only we need fear no great danger, but decided good will result in the majority of cases in which an anæsthetic is indicated. Complete anesthesia is but seldom required.
Dr. Murphy complimented the author, especially for the highly conservative views which he had expressed. Hoped, however, Dr. Mendenhall would not suppose he had a desire to attack his paper in expressing his opinions somewhat in opposition to those given by him. At some considerable extent, and with a great variety of illustration, he then spoke in deprecation of the use of anæsthetics in labor. The following are the principal points, however, made by him: That in giving these agents we can never tell what will be the results; we can't tell whether the patient takes a full inspiration or a half inspiration; we can't tell with any certainty when there is fatty degeneration, disease of the valves, or thinning of the walls of the heart; and he thought it always dangerous to administer an anæsthetic with these uncertainties before you. Spoke of the diversity of effects in producing vomiting, giving some cases by way of illustration; contrasted the effects of opium with chloroform, speaking of the former as less marked and more controllable.
Spoke of veratrum viride as another article similar in character with chloroform, and thought Dr. Norwood would have a serious account to give hereafter for the indiscriminate use of the remedy in all cases of accelerated pulse. Dr. Murphy thought that a meddlesome midwifery was bad, and for himself would only give chloroform in cases where operative proceedings are necessary. Thought its use in labor tended to break down the moral heroism of the mother. In a thin, undilatable os, etherization does not promote dilatation; it only diminishes the pain of resistance. He likes to hear a woman cry out and manifest a vigor of life in her labor-pains;
and there was nothing he so much disliked as to see a woman pass through her accouchement with a passive indifference to her suffering. The effects of etherization on the infant is destructive in its tendency, and he was inclined to suspect that it was as fatal as ergot.
Veratrum Viride.—Some reference having been made during the discussion to the use of veratrum viride as a therapeutic agent, Dr. Thacker read to the Academy a letter which he had recently received on that subject from Dr. J. J. McIlhenny, Superintendent of the Lunatic Asylum near Dayton. Dr. M. says: “I have used verat. vir. to a considerable amount in acute mania, particularly in that form where there appeared to be much arterial excitement. Indeed, I may say I have used it in almost all forms of insanity, and been much pleased with its action.
“In five or six cases of acute mania, I kept them under its influence most of the time for two weeks, scarcely ever pushing it to the extent of vomiting. I must consider it an admirable sedative—one which possesses the power, in a remarkable degree, of controlling the action of the circulation, of allaying the excitability of the nervous system, without leaving any of the ill effects of opium. In several of those upon whom I tried it the most effectually, I found them awakening, as it were, from an apparently long dreamy spell, half sane and half insane, several of whom improved regularly, never having another paroxysm. Others went back to their former state of mind, but much less disposed to rave and be boisterous. My favorite mode of prescribing veratrum viride is as follows:
“R. Tinct. verat. vir., zi. ; spts. nitre dulc., 3vij. M.
“Of this I give a teaspoonful every half hour until I find some effect, then prolong the time of its administration to suit circumstances. I give it in many cases of mania in quantities that might astonish practitioners in general. Whether such cases are less susceptible of its action than sane persons I am not fully apprised, but think they are."
Prolapsed Funis.-Dr. Mendenhall called the attention of the Academy to the subject of prolapsed cord, and to the very feasible plan of returning it, as first suggested by Dr. Thomas, of New York city. Dr. M. had recently published a case, in the Lancet and Observer, treated in this way successfully, but he thought the matter of sufficient importance to call the particular attention of the members to it again. He then made some extended remarks upon the facility with which such cases are managed by this plan.
Dr. Murphy reported a case of prolapsed funis, in a recent case in his practice; but the cord had ceased to pulsate when he arrived, and of course the child was still-born.
Dr. W. Krause announced that he would read a paper at the next meeting of the Academy, “On Bronzed Skin, with Disease of Supra Renal Capsules."
PROCEEDINGS OF THE NEW YORK ACADEMY OF MEDICINE.
REGULAR Meeting, October, 1858. Dr. S. C. FOSTER, Vice-President, in the chair.
DISCUSSION ON PUERPERAL FEVER.
DR. BARKER said : One year ago this evening, I had the honor of offering to the Academy some remarks on the pathology and therapeutics of puerperal fever. Since that time, this body has been mainly engrossed, during four of its sessions, by the consideration of this important subject. The Academy of Medicine in Paris have also been engaged in a most zealous discussion of the same subject for many months past, in which MM. Beau, Cazeaux, Cruveilhier, Danyau, Depaul, Dubois, Guerin, Hervez de Chégoin, Trousseau, Velpeau, and others, have participated, a list of names comprising the first talent of that body. Many articles have also appeared in the French medical press, among which I should mention as specially valuable those by M. Jacquemier, in the Gazette llebdomadaire, and those by M. Behier, in L'Union Médicale.
I may also add that, during the last twelve months, my practical experience in this disease has been greatly enlarged both in hospital and in private practice, as we have not only had the misfortune of encountering it in the Lying-in Wards of Bellevue Hospital, but it has also been unusually rife in this city. From October, 1857, to October, 1858, one hundred and seventy-three deaths from puerperal fever have been reported at the City Inspector's office.
The following table gives the deaths from puerperal fever for each month, and it is interesting to note the parallelism between the deaths from this disease and erysipelas :
Oct. Nov. Dec. Jan. Feb. Mar. Apr. May June July Aug. Sept 1857 1857 1857 1858 1858 1858 1858 1858 1858 1858 1858 1858
In Paris there has certainly been afforded an immense field for studying this disease, as in five years, 1852–56, six hundred and forty-four deaths have occurred, in six of the principal hospitals, from puerperal fever.
I may be pardoned for saying that I have most carefully and conscientiously read all that has appeared in the French medical journals, and that I have observed, with the most earnest desire for truth, in order that I might correct any error in reasoning or deduction into which I may have previously fallen.
Before alluding to some points, in regard to the pathology of this affection, I will give a very brief summary of the views of the principal
speakers in the French Academy. The discussion originated with M. Guerard, who stated his belief that, so far as the nature of the disease was concerned, we must look for something beyond the mere local lesions, and that its phenomena cannot be explained by means of purulent infection. M. Depaul was the most able advoeate of the doctrine of the essentiality of puerperal fever, although, instead of the term puerperal fever, he would prefer calling it puerperal typhus, or puerperal' septicæmia. He believes that its essential character consists in a primary alteration in the blood.
In the autopsies which he has made, he has uniformly found the blood in this disease to possess a peculiar fluidity, and to be generally of a violet red color, easily impregnating and coloring the tissues. It often also presents a remarkably oily appearance, and coagulates with difficulty. He quotes from Vogel, (in Virchow's Handbuch,) who states that lactic acid confers an acidity upon the blood in this disease, and that in some cases carbonate of ammonia, in others the hydrosulphate, is found in it. The fluid loses its aptitude for coagulation, as do the globules to redden, on the contact of air, and therefore their fitness for the respiratory act. The globules are in part decomposed and dissolved in the serum, giving it a reddish or dirty brown color. Scanzoni asserts that in some cases there is an increase of fibrin; in others, a true pyæmia, the constituent elements continuing in their normal proportions; and in others, again, a true putrefactive dissolution or septicæmia. M. Depaul regards the epidemic occurrence of this disease as presumptive proof of its essentiality. He also, as do several of the other speakers in the French Academy, refers to the fact that the lesions of the solids are of the most varying character, and that in some fatal cases these do not exist at all, nothing being appreciable, save alterations in the blood. M. Beau considers puerperal fever as due to local inflammation, (most frequently of the peritoneum,) united to an inflammatory diathesis depending upon an alteration of the blood—this alteration being an increase of the fibrin, a characteristic of inflammation. In the opinion of M. Piorry, the disease in question is primarily a metritis phlebitis or peritonitis, septicæmia or pyæmia. M. Caseaux also believes that it belongs to the phlegmasiæ. Jacquemier, Legroux, and Behier, hold similar views. M. Bouillaud considers it due to purulent or putrid infection with an inflammatory element. Velpeau holds that it is a metro-peritonitis, a lymphangitis, or phlebitis, (purulent infection,) modified by the puerperal state. Trousseau considers it as a phlegmasia of a peculiar kind due to a specific cause. Hervez de Chégoin sees in puerperal fever only the results of purulent or putrid infection. Dubois, Depaul, Danyau, and Guerard, were the only members of the French Academy who advocated the opinion that puerperal fever is an essential disease, not dependent at all upon
local inflammation. M. Cruveilhier considers this disease as both a fever and an inflammation, and expresses his opinion in nearly the same words as Dr. Clark used in this Academy six months before. In common also with Dr. Clark, he regards the anatowical lesions as an essential feature in the disease. The following are his conclusions :
1. Puerperal fever is essentially a traumatic fever.