BILATERAL DISLOCATION OF THE HIP, PRESUMABLY CONGENITAL.

1716 better guide than the rhythm and force of respiration patient’s experience prompts him to adopt the position in these cases. Provided the patient is completely of maximum ease of respiration and this posture should ansesthetised before the change of posture is made it as far as possible be maintained throughout the anaeswill be found that as the breathing becomes less deer thesia. If the body is suddenly turned towards the and the rhythm is altered so will the patients require side of the healthy lung there is danger that the pus less and less anaesthetic to maintain them in a state of accumulated in the diseased lung during the anaesthesia Thus if one judges that the will flow across and seriously interfere with respiration, workable anaesthesia. the normal force half the normal Even when this does not take place I have repeatedly seen half of is, say, respiration dose of anaesthetic must be given, and so on. I have notes faintness and threatened syncope occur when the patient is of several cases in which the thoracic movements were rolled over towards the sound side. These dangers are extremely slight owing to pathological pressure on the increased where there is any extreme degree of cardiac displacement. spinal cord high up. The violent cough and suffocative state which in my CASE 5.-In this case it was found that even the most dilute vapour of chloroform produced such alarming experience nearly always accompany any extensive opening respiratory symptoms that eventually I was obliged to into the pleura constitute a further danger and one which I tried several times giving a breath or two may prove fatal if the anaesthesia has.been allowed to become desist. of the anaesthetic, working with an extremely low per- at all profound. While speaking of perils occurring during centage vapour of chloroform, but on each occasion anaesthetising in thoracic operations I would mention the the same procession of events occurred and the respira- danger in .these cases of performing Silvester’s method of tion stopped. There was in this case a high lesion of the artificial respiration should breathing fail. In a number of spinal cord, and no thoracic movements were made as the instances published in the journals in which this restorative intercostal muscles were paralysed, and the diaphragm being measure was recorded as having been adopted a fatal con. also unable to act the breathing, such as it was, was main- clusion to the case occurred. A moment’s consideration will tained solely by abdominal movements. As soon as the show that the effect of this method must be to pump the chloroform began to act even these movements were checked pus and mucus into the trachea and the mouth and then to with the above result. I tried in this case a method which aspirate it back again into both lungs alike, leading to the I have subsequently always adopted. Oxygen is given freely effectual crippling of the sound lung. It is safe to compress coincidently with chloroform, and the chloroform vapour or antero-posteriorly the sound lung, but it is safer to perform the oxygen is pushed according to the requirements of the forced respiration of oxygen by a pair of bellows or Fell’s case.

CASE 6.-In a case similar to the last a man, about 30 years of age, suffering from a growth pressing upon the cord with almost complete respiratory paralysis, was seen by me in consultation to determine whether in his case an anaesthetic could be given without seriously endangering his life. I decided that it could, and accordingly I gave him oxygen with chloroform with the best result. I administered oxygen continuously and exhibited chloroform from my modified form of Junker’s inhaler. In operations on the thorax the obstruction to respiration is of another kind than those mentioned above. In these cases it often happens that there is " one lung"respiration, a condition which renders the patient more liable to danger from obstructive causes, either pre-existing or developed during operation. When the lung or lungs contain large quantities of pus and when this is associated with severe spasmodic cough the most alarming dyspnoea will often develop as soon as the patient becomes anaesthetic. The cause of this dyspnoea is probably the accumulation of thick muco-pus in the larger bronchial tubes which instead of being expectorated is aspirated back into the pulmonary alveoli. It is essential in all cases of thoracic operations when the abscess or source of the pus communicates with a bronchus that the patient should be anaesthetised to the second degree of narcosis only. This ensures analgesia without establishing abeyance of the protective reflex of coughing. A deeper narcosis is fraught with the gravest danger. The dyspneea in these cases is further due to irritation of the over-sensitive mucous membrane of the air passages and this makes it extremely important that a judicious choice of the anaesthetic should be made. In cases of empyema, bronchiectasis, and pulmonary abscess with free expectoration I have found that even the purest ether given with the utmost care will provoke much cough and distressing dyspnoea. Chloroform usually is well tolerated if it is given with extreme dilution and slowly. The irritation and of ether in cases are evidenced in some danger lung giving the following case. CASE 7.-A boy, aged about 10 years, suffering from empyema and copious expectoration, was given ether by the rectum by me. He went under quietly, but as soon as the absorption from the bowel became rapid he grew very dyspnoeic and cyanosed. He was at once inverted, the anaesthetic was stopped, and the sound lung was compressed. A considerable quantity of pus escaped from his mouth and the danger was passed. The case just given occurred some years ago when I had not realised the necessity in using rectal etherisation in thoracic cases to limit the narcosis far short of surgical anaesthesia. The main danger of these cases after that just described is undoubtedly connected with the change of position of the patient resorted to by the surgeon to It must enable him to complete his manipulations. always be remembered that duringconsciousness the

apparatus. In summing

up the teaching which the cases cited afford I think that the following propositions are worth tabulation. 1. The individual patient possesses a certain respiratory power. Individuals differ enormously in this respect, and it is the business of the anaesthetist to make himself acquainted with what I may perhaps be permitted to term the "personal respiratory equation of the patient." 2. This individual power of respiration is interfered with by every form of anaesthetic, more by some than by others, but under any anesthetic the power of inspiration and expiration is lessened and in some cases to a very marked degree. 3. This lessened respiratory power may be of little or no consequence under normal conditions, but it becomes a factor of grave danger should any intercurrent cause of respiratory obstruction occur. For example, a delicate child breathing with difficulty through a blocked naso-pharynx is placed profoundly under chloroform. The mouth is opened and the jaw is depressed while the tongue is forced back. The respiratory power would under these circumstances be wholly inadequate to overcome the increased difficulties of respiration. The child would die and the death would be put down to heart failure, and the same occurs in cases of goitre, of malposition of the patient’s body, of thoracic operation, &c. Thus it appears that all the cases cited fall into line and reveal to us not only the evident, but also the insidious, dangers associated with them. The object which I had in view in bringing this group of cases before you was to point out these dangers and to suggest the remedies and precautions appropriate to them. Mortimer-street, W.

BILATERAL DISLOCATION OF THE HIP, PRESUMABLY CONGENITAL. BY THOMAS PHILIP

COWEN, M.D., B.S. LOND.,

ASSISTANT MEDICAL OFFICER TO THE COUNTY MANCHESTER.

THE

ASYLUM, PRESTWICH,

aged 30 years, suffering from

mania admission to the Lancashire incoherence, County Asylum, Prestwich, to have an old dorsal dislocation of both hip-joints. His friends said that they were positive that the deformity was caused by injury at about the age of seven years and they asserted that there was not the slightest deformity, limp, or difficulty in walking before this. The injury referred to was a most severe thrashing inflicted by a drunken man over the back and hips accompanied with other violence. There was a marked deformity of both hips, but especially of the right. The figures (from photographs) show the condition well. The with

patient,

a

man,

was

found

on

1717 head of the femur on each side was displaced upwards on to was apparent when an attempt to extend fully the legs was the dorsum and was fixed on the dorsum ilii by apparently a made. The apparent width of the hips was great so as to

newly formed capsule in a position above and behind the acetabulum. When the patient stood easily there were some flexion and slight internal rotation of the thighs on the pelvis. There was considerable shortening of both thighs especially marked on the right side. An extreme degree of lordosis Fm. 1.

simulate

a pelvis of the female type. The trochanters were displaced upwards and forwards so as to be nearer to the antericr superior spines than normally. The top of the great

trochanter on the left side was two inches above Nelaton’s line. The top of the right great trochanter was fully three and a quarter inches above Nelaton’s line (Fig. 2). There was a slight downward tilting of the pelvis on the right side. Although there was some interference with the mobility of the thighs in all directions yet within a slight range of amplitude all movements were remarkably free, eversion and rotation out being especially so. Extension of the legs by forcible traction caused no alteration of the position of the trochanters so that the heads of the femora must have been fixed by newly formed ligamentous bands in their new positions. The patient could walk easily for fairly long distances even for several miles without great fatigue ; he could run at a very good pace and could jump to a height of 18 inches with great facility. Progression was by a marked rolling waddling gait. He presented no other congenital deformities nor was there any history of similar affections in the other members of his family. The illustrations show the condition very well. Nelaton’s line was carefully marked in ink on the skin and also the line showing the position of the top of the great trochanter before the photograph was taken. There were no scars of injury or disease about the hips. Whether the deformity was due to a congenital malposition or to a traumatic dislocation is doubtful, but I am inclined to consider the case one of congenital dislocation of the hip in spite of the positive statements of the friends as to the history of causative injury. I think that the rolling shambling gait was probably thought little of until the immediate results of the injury drew special attention to it and the parts concerned. Yet, on the other hand, it is just possible that the cause may be a traumatic one as insisted upon, and it is rather on this account that I have ventured to regard the case as one of. sufficient interest to be recorded.

accompanied

Manchester.

THREE CASES OF PUERPERAL ECLAMPSIA. BY FREDERICK

SPURR, L.S.A. LOND.,

HONORARY DISTRICT SURGEON TO THE ROYAL MATERNITY CHARITY.

Congenital dislocation of the hip. FIG. 2.

Congenital dislocation trochanter

of the hip showing position of regards Nelaton’s line.

as

PUERPERAL eclampsia is described by Playfair as’’one of the most formidable diseases with which the obstetrician has to cope," and he adds: " The attack is often so sudden and unexpected, so terrible in its nature, and attended with such serious danger both to the mother and the child, that the disease has attracted much attention." Those practitioners who have been called upon to treat this diseasefortunately a rare complication of pregnancy and parturition-will quite agree as to its formidable nature. The repeated attacks of convulsions are most distressing to witness and the patient’s condition rapidly becomes so serious as to cause the gravest anxiety on the part of her medical attendant and friends. The three cases now recorded occurred in my own practice in the course of a single year, and it may be noted as one of those coincidences so frequently occurring in medical work that they should follow one another at such short intervals, especially as in my previous midwifery practice, extending to some hundreds of cases, I had only met with one case .previously and that nearly 10 years ago. CASE 1. -On July 12th, 1898,was called to a woman, 19 years of age, who had been attended by a midwife and had been delivered of a full-time female child at about 6.30 A.M. Upon my arrival I found the patient, a slightly built, darkcomplexioned, and ansemic-looking woman, suffering from well-marked eclamptic convulsions. From her friends I learnt that it was her first confinement. Her previous health had been good, she had never suffered from fits of any kind, and she had kept about and at work uncomplainingly up to the commencement of labour, which had been easy and rapid. The midwife told me that during the labour she had noticed the patient’s hands and face twitching and that she had at times appeared to be in a half-dazed condition. The first