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" THE HYDERABAD CHLOROFORM COMMISSION."
192
MR. A. H. WARD : "THE HYDERABAD CHLOROFORM COMMISSION."
revaccinated within ten years he would require to be vaccinated and to produce a certificate. He would also be " THE HYDERABAD CHLOROFORM required to state his last place of residence and whether he COMMISSION." had recently been exposed to infection, under a penalty in THE DANGER SIGNAL OF THE CHLOROFORMIST. case of false information. To revert to the book, the manager of the lodging-house or union officer would in all BY ARTHUR H. WARD, F.R.C.S. ENG., cases keep a copy of the entries made in the tramp’s LATE ANÆSTHETIST TO ST. GEORGE’S HOSPITAL. book and also in the books of persons other than at the or so tramps staying that, lodging-house union ; in case of the loss of the book, the statements of the THE recent paper and discussion on the chloroform quesperson admitted into a lodging-house might be confirmed orttion at the Royal Medical and Chirurgical Society, were, from otherwise. In such a case, however, special precautions1the practical chloroformist’s point of view, unconvincing. would require to be taken. The loss ot the book would involve detention as well as rigorous disinfection and, in The final proof of the action or non-action of chloroform times of danger, isolation. Loss of the vaccination certifi-1upon the heart has not, in the opinion of rival experts, yet cate would entail the necessity of revaccination. A penalty 1been demonstrated. It would seem that complex cross.. would be imposed on any person making a false entry in the4circulation experiments are so open to sources of fallacy tramp’s book or for alteration of his own register of theand their tracings so liable to conflicting interpretations that entries in the tramp’s book. As regards disinfection of as to practice their value is not very great. It is not clothing, this would in general be unnecessary in the case of guidesto feel that, at present, Surgeon-Lieutenant-Colonel with possible not been in contact the who intimate had persons person actually attacked by the disease. There is very little Lawrie has proved by experiment the truth of his thesis that. evidence of disease being frequently conveyed in that manner, chloroform is perfectly safe when the respiration alone i& and though as a measure of added security it is well to watched. We have, therefore, for the time being to fall back carry out such measures of disinfection, especially where on the of clinical experience. The opinion of the teachings to it would there has been intimate exposure infection, scarcely be possible systematically to disinfect the clothing of majority of expert anxsthetists who spoke was that the the inmates of lodging-houses. It is by no means one of the respiration alone is an imperfect guide to the condition of a most urgent considerations. Where it could be established patient under chloroform, and we were advised to watch that a limited number of the inmates of a lodging-house had the pupil, the pulse, and the patient as a whole. been intimately exposed to infection their clothing might be It certainly seems probable that if we watch the respiradisinfected by being boiled or it might be taken (as it is) tion alone we are in danger of pushing the chloroform to the public disinfecting station and disinfected by steam. to the point of respiratory narcosis ; and since this wiU At the Manchester union the clothing of all tramps admitted come on gradually we may not recognise the condition till the patient is in a state of extreme danger. It is all is disinfected in a hot air chamber. So far as I very fine to say that the patient can always be brought round One other matter requires careful attention. can judge ignorance of the nature of slight small-pox isby artificial respiration; this, involving as it does the stopping responsible for more damage than the movement of vagrants. of the operation in many cases, is a most inconvenient and Clear instructions for the recognition of slight cases of small- alarming complication and should never be allowed to occur. pox should be widely distributed, and especially all lodging- In my view any interference with the respiratory centrehouse keepers should be specially instructed in regard to the! by chloroform, however slight, is a sign of dangerous disease. No amount of trouble can be considered wasted. overdosing. Again, if respiration alone be watched, how is which aims at extending the recognition of this disease. It isthe beginner-experts even were once beginners-to disa cardinal difficulty both in lodging-houses and in private: tinguish between the shallow and irregular respiration of dwellings, perhaps more so in the latter than in the former. reflex inhibition, which so often precedes vomiting, and the The frequent mistakes between small-pox and chicken-pox c insidious onset of respiratory narcosis2 Some other danger need not be made by attending to these rules : 1. Adultss aignal is required. The pulse ? I think that if chloroform ba, rarely have chicken-pox. If two adults appear to havepushed to the point of affecting the pulse, if this be possible, chicken-pox in one house the medical attendant should sus-- z, a dangerous overdose has again been given. The heart, too, 1 is liable to reflex inhibitions, and often becomes irregular pect small-pox. 2. Properly vaccinated children under seven and depressed during vomiting and also during the violent y years of age very rarely have small-pox. It is curious how people forget to apply this crucial test by looking for thee irritation of the sympathetic system met with in abdominal vaccination marks. 3. With few exceptions children n operations, in either case quite independently of the ansenattacked with chicken-pox experience no initial sense of f thetic. Therefore, as an indication of the degree of the illness. With small-pox they almost always have well- chloroform narcosis, I think the pulse is unreliable. We require some indication which shall tell us when the marked illness. 4. The distribution of the eruption is s cerebrum is completely narcotised, and shall also warn us different. In slight small-pox the eruption is almost always s on the face and limbs, sparing the abdomen and front Lt when we are in danger of affecting the respiratory centre. This indication is found in the pupil. The third nerve centre, In chicken-pox there is generally a large of the chest. e which governs it, is the first of the automatic centres of number of pocks on the front of the chest and abdomen. I. which we can have cognisance ; it is not a vital centre, o 5. The eruptions are different in character. To mention no like the respiratory, and its narcosis is not in itself followed rother points of difference the eruption of small-pox is tolerI regard the pupil, which )f by dangerous complications. ably uniform in size and round in shape. The eruption of is the visible sign of the condition of this centre, as the s, chicken-pox is very variable in size, and many of the pecks, on the body especially, are of an oval shape. 6. The erup3- danger-signal for which we are looking. I find that the pupil)f has a regular cycle as the patient goes under. It is first tion of chicken-pox is itchy in a great many instances ; that of dilated and active, it then becomes contracted, and lastly it ’s small-pox is, at first, not so. Only long experience enables al becomes dilated and fixed. The first state is a sign of imone to tell at a glance which disease one has probably to deal it perfect narcosis, the second of complete and safe narcosis, with, but with due care no one need go wrong in arriving at and the third of danger from imminent narcosis of the a differential diagnosis. Manchester. respiratory centre. The cause of this cycle is, I suggest, == as follows. In imperfect narcosis, going under or coming g round, the pupil is dilated and active ; dilated because THE French Minister of the Interior has awarded a gold medal to Dr. Soulie of Algiers on account of impulses, mental, sensory, or sympathetic, affect the halfnarcotised cerebrum, and cause reflex inhibition of the his devotion to the sufferers in the recent epidemics. third nerve centre ; and active because the centre itself THE SHEFFIELD PUBLIC HOSPITAL. At the le has not been reached by the anaesthetic. A similar dilataannual meeting of the governors of the Sheffield Public ic tion is produced under ordinary conditions by fright, pain, er or a blow on the abdomen. As narcosis deepens theHospital on July 23rd an appeal was made for funds in order to rebuild the institution. The Duke of Norfolk, who was as pupil contracts because the cerebrum is now complete]? in the chair, and who had himself given ,fSCOO towards the he under, all cerebral reflexes are barred, and the third nerve te centre is consequently unimpeded in its action. A similar undertaking, announced the bequest of 6000 by the late Mr. Bernard Wake, but said that .250,000 were still required. d. state is seen in deep sleep. If the narcosis be pushed further be the pupil will slowly dilate and become less and less active to Subscriptions to the amount of 17,000 were promised at the light till it is widely dilated and fixed, because the narcosi& meeting. .
.
.
-
193
CLINICAL NOTES. ’has now reached the centre itself and has gradually overtaken it; consequently nervous control has ceased and the pupil has dilated ; at the same time the light reflex has been abolished. A similar condition of pupil is seen in general - cerebral compression. This fixed dilatation indicates great danger, for respiratory narcosis is imminent ; indeed, under no circumstances should narcosis be pushed to the extent of Thus the golden mean of full dilatation of the pupil. safety is indicated by a contracted pupil, any material dilatation means, "Look out." The patient is either coming round and developing reflexes, or going too far It is easy to distinguish towards respiratory narcosis. between commencing reflex dilatation and early narcosis In the first the pupil is active and other dilatation. reflexes, shallow respiration, vomiting, or movement will follow ; in the second the patient is stertorous, the pupil sluggish, and the eyeballs fixed. In the first the indication is for more chloroform, in the second for the suspension of the drug till contraction recurs in consequence of the recovery of the third nerve centre. I believe that if the pupil be read in this way all interference with respiration I have observed the cycle - or the heart can be avoided. of change many times and I have never been played false ; the explanation, I submit, is reasonable on general principles and agrees with the conditions of the pupil observed in other ’connexion. For all ordinary operations a contracted pupil should be maintained, but in abdominal surgery it is sometimes necessary to combat the violent sympathetic irritation by pushing the chloroform till there is slight narcosis dilatation of the pupil. Beyond this I believe it is useless as well as dangerous to go. Any further abdominal rigidity is, I suggest, due either to inflammatory fibrosis or to the development of abnormal reflex links between the sympathetic and spinal nerves in highly neurotic subjects. In either case the condition is beyond the control of anassthesia. Dc. Hewitt quoted a case in which he found no pulse at the wrist while the respiration was normal. As the case I venture to suggest that the was an abdominal cardiac condition may have been due to inhibition in cor.sequence of violent sympathetic irritation and nothing to do with the anxsthetic. In the frog exposure and irritation of the intestine will stop the heart. In man the cardioinhibitory centre is close to the respiratory centre ; there seems to be no reason why, with sufficient stimulation of the abdominal sympathetic centres, reflex inhibition of the heart should not occur even when the cerebrum is narcotised. Had the patient died doubtless the accident would have, been put down to chloroform ; so in such cases it behoves, the anesthetist to attend to the pulse and to stop the operation if necessary while the heart recovers, but I cannot; think that this case proves of necessity the direct influence, of chloroform. Doubtless chloroform incidentally depresses the heart, as it does all vital processes ; consequently reflex inhibition is more likely to occur than when ether is used. ’Chat equally complete relaxation cannot be induced by ethel I believe to be a legend handed down from the days of foldedl towels, when it was impossible to fully etherise many patients. The time during which I think that the closest attentior should be paid to the respiration is while a patient is going under. At this time he is liable, intentionally or from to( strong a vapour, to hold his breath. The respiratory centrE is thus debilitated from lack of oxygen ; then when thE necessity of breathing overcomes all other impulses a gaspins inspiration is taken, the centre is flooded with chloroforn and cannot resist it, the pupil dilates, and death supervenes Whether or not the heart is affected is undetermined, th. point being to avoid the occurrence in any case. This can bi done by encouraging the patient to breathe regularly, and i he holds his breath by seeing that only a small dose o chloroform is accessible. In children it is better to use : Junker’s inhaler, so that whether they scream or hold thei breath only a limited amount of vapour can be taken in ; a3 overdose is thus avoided. In these cases it is my practice t, give chloroform till contraction occurs with slight stertoi and then to suspend the administration until some slight refle: is seen, then to give a little more, and so on. I do not thin: that the pupil is quite so reliable as in the adult, as sudde: overdosing with fixed dilatation seems sometimes to occm Possibly the pupil reflex is imperfectly developed ; this I ai sure is the case with the corneal reflex, which is quite ur reliable as a sign of narcosis in children. Slight stertor ÍI in my view, the reliable indication. I venture to recommend these considerations to the ir
experienced. I have very often found them of the greatest service in embarking on what may otherwise prove to be a of troubles. Hertford-street, W.
sea
_________________
Clinical Notes: MEDICAL, SURGICAL, OBSTETRICAL, AND THERAPEUTICAL. TREPHINING THE SKULL FOR SPASTIC PARALYSIS. BY NOBLE SMITH, F.R.C.S. EDIN., SURGEON TO THE CITY ORTHOPEDIC HOSPITAL, LONDON, AND SURGEON TO THE ALL SAINTS’ CHILDREN’S HOSPITAL.
THE patient was a boy five and a half years old suffering from spastic paralysis. He was unable to articulate except a few monosyllables. The arms were contracted upon the chest, the legs were crossed and partly flexed at the thighs and knees. He was unable to stand, but was quite intelligent. These symptoms had existed since birth, after a protracted and difficult labour. Any material improvement had been looked upon as hopeless. I found a transverse depression in the occipital bone two and a quarter inches wide and about an inch from above downwards, just below the occipital protuberance. Having explained to the parents the uncertainty as to any good following the operation, and they having agreed to take all risks, I operated upon the depressed bone with a trephine of one inch in diameter, and removed two circular pieces of bone, making one opening. The meninges projected forcibly upwards through the opening, showing that there had been some pressure. There was no pulsation of the brain when it was first exposed, but before the completion of the operation pulsation was quite natural. The operation was performed on April llth, and the wound healed by first intention without a bad symptom. There was at once marked improvement in the child’s general condition, and the limbs have become gradually more relaxed, the legs not so much drawn up, and the patient can give the right hand to be shaken, whereas before he was quite unable to do so. He has since continued to improve in respect to the relaxation of the contractions. (July 5th, 1894.) He has slept more quietly since the operation than he ever did before. Although in this case the degeneration of nerve fibres has probably proceeded too far for perfect recovery, yet the operation seems to have proved that in such cases early interference may sometimes relieve or cure the condition. The extravasation of blood which occurs in many such cases, and the practicability of operating and removing this pressure, are points which seem to me worth consideration, and I hope at some future period to discuss this matter at greater length. I was kindly assisted at the above operation by Mr. Bland Sutton. Queen Anne-street, W.
operation
,
,
;
.
.
FATTY HEART AS A CAUSE OF SUDDEN DEATH DURING LABOUR. BY H. MARTYN EAMES, L.R.C.P., L.R.C.S.ED. & L.M. &c. months ago, d 0.1 ing my temporary absence an urgent message was left for me to attend a woman in her confinement. Reaching home soon after the departure of the messenger, I made all haste to the address given, and arrived at the house at the moment the patient fell dead on the floor at my feet. The history I elicited was that the woman was suffering from chronic bronchitis, had suffered from shortness of breath and occasional fainting attacks, and had been informed by her medical attendant that she had a weak heart. None of her symptoms, however, were so distressful as to prevent her carrying on the usual work of a labouring man’s wife. She was a big, stout, plethoric woman at the full period of gestation, and had expressed herself that morning as feeling exceptionally well for her. The pains had commenced four hours previously, and the medical man whom she had engaged had visited and examined her a couple of hours after, and had informed her that labour was natural and had onlyjust commenced, and hence, of course, there was
WHEN
.
.
.
.
taking charge of
a
practice
some
MR. A. H. WARD : "THE HYDERABAD CHLOROFORM COMMISSION."
revaccinated within ten years he would require to be vaccinated and to produce a certificate. He would also be " THE HYDERABAD CHLOROFORM required to state his last place of residence and whether he COMMISSION." had recently been exposed to infection, under a penalty in THE DANGER SIGNAL OF THE CHLOROFORMIST. case of false information. To revert to the book, the manager of the lodging-house or union officer would in all BY ARTHUR H. WARD, F.R.C.S. ENG., cases keep a copy of the entries made in the tramp’s LATE ANÆSTHETIST TO ST. GEORGE’S HOSPITAL. book and also in the books of persons other than at the or so tramps staying that, lodging-house union ; in case of the loss of the book, the statements of the THE recent paper and discussion on the chloroform quesperson admitted into a lodging-house might be confirmed orttion at the Royal Medical and Chirurgical Society, were, from otherwise. In such a case, however, special precautions1the practical chloroformist’s point of view, unconvincing. would require to be taken. The loss ot the book would involve detention as well as rigorous disinfection and, in The final proof of the action or non-action of chloroform times of danger, isolation. Loss of the vaccination certifi-1upon the heart has not, in the opinion of rival experts, yet cate would entail the necessity of revaccination. A penalty 1been demonstrated. It would seem that complex cross.. would be imposed on any person making a false entry in the4circulation experiments are so open to sources of fallacy tramp’s book or for alteration of his own register of theand their tracings so liable to conflicting interpretations that entries in the tramp’s book. As regards disinfection of as to practice their value is not very great. It is not clothing, this would in general be unnecessary in the case of guidesto feel that, at present, Surgeon-Lieutenant-Colonel with possible not been in contact the who intimate had persons person actually attacked by the disease. There is very little Lawrie has proved by experiment the truth of his thesis that. evidence of disease being frequently conveyed in that manner, chloroform is perfectly safe when the respiration alone i& and though as a measure of added security it is well to watched. We have, therefore, for the time being to fall back carry out such measures of disinfection, especially where on the of clinical experience. The opinion of the teachings to it would there has been intimate exposure infection, scarcely be possible systematically to disinfect the clothing of majority of expert anxsthetists who spoke was that the the inmates of lodging-houses. It is by no means one of the respiration alone is an imperfect guide to the condition of a most urgent considerations. Where it could be established patient under chloroform, and we were advised to watch that a limited number of the inmates of a lodging-house had the pupil, the pulse, and the patient as a whole. been intimately exposed to infection their clothing might be It certainly seems probable that if we watch the respiradisinfected by being boiled or it might be taken (as it is) tion alone we are in danger of pushing the chloroform to the public disinfecting station and disinfected by steam. to the point of respiratory narcosis ; and since this wiU At the Manchester union the clothing of all tramps admitted come on gradually we may not recognise the condition till the patient is in a state of extreme danger. It is all is disinfected in a hot air chamber. So far as I very fine to say that the patient can always be brought round One other matter requires careful attention. can judge ignorance of the nature of slight small-pox isby artificial respiration; this, involving as it does the stopping responsible for more damage than the movement of vagrants. of the operation in many cases, is a most inconvenient and Clear instructions for the recognition of slight cases of small- alarming complication and should never be allowed to occur. pox should be widely distributed, and especially all lodging- In my view any interference with the respiratory centrehouse keepers should be specially instructed in regard to the! by chloroform, however slight, is a sign of dangerous disease. No amount of trouble can be considered wasted. overdosing. Again, if respiration alone be watched, how is which aims at extending the recognition of this disease. It isthe beginner-experts even were once beginners-to disa cardinal difficulty both in lodging-houses and in private: tinguish between the shallow and irregular respiration of dwellings, perhaps more so in the latter than in the former. reflex inhibition, which so often precedes vomiting, and the The frequent mistakes between small-pox and chicken-pox c insidious onset of respiratory narcosis2 Some other danger need not be made by attending to these rules : 1. Adultss aignal is required. The pulse ? I think that if chloroform ba, rarely have chicken-pox. If two adults appear to havepushed to the point of affecting the pulse, if this be possible, chicken-pox in one house the medical attendant should sus-- z, a dangerous overdose has again been given. The heart, too, 1 is liable to reflex inhibitions, and often becomes irregular pect small-pox. 2. Properly vaccinated children under seven and depressed during vomiting and also during the violent y years of age very rarely have small-pox. It is curious how people forget to apply this crucial test by looking for thee irritation of the sympathetic system met with in abdominal vaccination marks. 3. With few exceptions children n operations, in either case quite independently of the ansenattacked with chicken-pox experience no initial sense of f thetic. Therefore, as an indication of the degree of the illness. With small-pox they almost always have well- chloroform narcosis, I think the pulse is unreliable. We require some indication which shall tell us when the marked illness. 4. The distribution of the eruption is s cerebrum is completely narcotised, and shall also warn us different. In slight small-pox the eruption is almost always s on the face and limbs, sparing the abdomen and front Lt when we are in danger of affecting the respiratory centre. This indication is found in the pupil. The third nerve centre, In chicken-pox there is generally a large of the chest. e which governs it, is the first of the automatic centres of number of pocks on the front of the chest and abdomen. I. which we can have cognisance ; it is not a vital centre, o 5. The eruptions are different in character. To mention no like the respiratory, and its narcosis is not in itself followed rother points of difference the eruption of small-pox is tolerI regard the pupil, which )f by dangerous complications. ably uniform in size and round in shape. The eruption of is the visible sign of the condition of this centre, as the s, chicken-pox is very variable in size, and many of the pecks, on the body especially, are of an oval shape. 6. The erup3- danger-signal for which we are looking. I find that the pupil)f has a regular cycle as the patient goes under. It is first tion of chicken-pox is itchy in a great many instances ; that of dilated and active, it then becomes contracted, and lastly it ’s small-pox is, at first, not so. Only long experience enables al becomes dilated and fixed. The first state is a sign of imone to tell at a glance which disease one has probably to deal it perfect narcosis, the second of complete and safe narcosis, with, but with due care no one need go wrong in arriving at and the third of danger from imminent narcosis of the a differential diagnosis. Manchester. respiratory centre. The cause of this cycle is, I suggest, == as follows. In imperfect narcosis, going under or coming g round, the pupil is dilated and active ; dilated because THE French Minister of the Interior has awarded a gold medal to Dr. Soulie of Algiers on account of impulses, mental, sensory, or sympathetic, affect the halfnarcotised cerebrum, and cause reflex inhibition of the his devotion to the sufferers in the recent epidemics. third nerve centre ; and active because the centre itself THE SHEFFIELD PUBLIC HOSPITAL. At the le has not been reached by the anaesthetic. A similar dilataannual meeting of the governors of the Sheffield Public ic tion is produced under ordinary conditions by fright, pain, er or a blow on the abdomen. As narcosis deepens theHospital on July 23rd an appeal was made for funds in order to rebuild the institution. The Duke of Norfolk, who was as pupil contracts because the cerebrum is now complete]? in the chair, and who had himself given ,fSCOO towards the he under, all cerebral reflexes are barred, and the third nerve te centre is consequently unimpeded in its action. A similar undertaking, announced the bequest of 6000 by the late Mr. Bernard Wake, but said that .250,000 were still required. d. state is seen in deep sleep. If the narcosis be pushed further be the pupil will slowly dilate and become less and less active to Subscriptions to the amount of 17,000 were promised at the light till it is widely dilated and fixed, because the narcosi& meeting. .
.
.
-
193
CLINICAL NOTES. ’has now reached the centre itself and has gradually overtaken it; consequently nervous control has ceased and the pupil has dilated ; at the same time the light reflex has been abolished. A similar condition of pupil is seen in general - cerebral compression. This fixed dilatation indicates great danger, for respiratory narcosis is imminent ; indeed, under no circumstances should narcosis be pushed to the extent of Thus the golden mean of full dilatation of the pupil. safety is indicated by a contracted pupil, any material dilatation means, "Look out." The patient is either coming round and developing reflexes, or going too far It is easy to distinguish towards respiratory narcosis. between commencing reflex dilatation and early narcosis In the first the pupil is active and other dilatation. reflexes, shallow respiration, vomiting, or movement will follow ; in the second the patient is stertorous, the pupil sluggish, and the eyeballs fixed. In the first the indication is for more chloroform, in the second for the suspension of the drug till contraction recurs in consequence of the recovery of the third nerve centre. I believe that if the pupil be read in this way all interference with respiration I have observed the cycle - or the heart can be avoided. of change many times and I have never been played false ; the explanation, I submit, is reasonable on general principles and agrees with the conditions of the pupil observed in other ’connexion. For all ordinary operations a contracted pupil should be maintained, but in abdominal surgery it is sometimes necessary to combat the violent sympathetic irritation by pushing the chloroform till there is slight narcosis dilatation of the pupil. Beyond this I believe it is useless as well as dangerous to go. Any further abdominal rigidity is, I suggest, due either to inflammatory fibrosis or to the development of abnormal reflex links between the sympathetic and spinal nerves in highly neurotic subjects. In either case the condition is beyond the control of anassthesia. Dc. Hewitt quoted a case in which he found no pulse at the wrist while the respiration was normal. As the case I venture to suggest that the was an abdominal cardiac condition may have been due to inhibition in cor.sequence of violent sympathetic irritation and nothing to do with the anxsthetic. In the frog exposure and irritation of the intestine will stop the heart. In man the cardioinhibitory centre is close to the respiratory centre ; there seems to be no reason why, with sufficient stimulation of the abdominal sympathetic centres, reflex inhibition of the heart should not occur even when the cerebrum is narcotised. Had the patient died doubtless the accident would have, been put down to chloroform ; so in such cases it behoves, the anesthetist to attend to the pulse and to stop the operation if necessary while the heart recovers, but I cannot; think that this case proves of necessity the direct influence, of chloroform. Doubtless chloroform incidentally depresses the heart, as it does all vital processes ; consequently reflex inhibition is more likely to occur than when ether is used. ’Chat equally complete relaxation cannot be induced by ethel I believe to be a legend handed down from the days of foldedl towels, when it was impossible to fully etherise many patients. The time during which I think that the closest attentior should be paid to the respiration is while a patient is going under. At this time he is liable, intentionally or from to( strong a vapour, to hold his breath. The respiratory centrE is thus debilitated from lack of oxygen ; then when thE necessity of breathing overcomes all other impulses a gaspins inspiration is taken, the centre is flooded with chloroforn and cannot resist it, the pupil dilates, and death supervenes Whether or not the heart is affected is undetermined, th. point being to avoid the occurrence in any case. This can bi done by encouraging the patient to breathe regularly, and i he holds his breath by seeing that only a small dose o chloroform is accessible. In children it is better to use : Junker’s inhaler, so that whether they scream or hold thei breath only a limited amount of vapour can be taken in ; a3 overdose is thus avoided. In these cases it is my practice t, give chloroform till contraction occurs with slight stertoi and then to suspend the administration until some slight refle: is seen, then to give a little more, and so on. I do not thin: that the pupil is quite so reliable as in the adult, as sudde: overdosing with fixed dilatation seems sometimes to occm Possibly the pupil reflex is imperfectly developed ; this I ai sure is the case with the corneal reflex, which is quite ur reliable as a sign of narcosis in children. Slight stertor ÍI in my view, the reliable indication. I venture to recommend these considerations to the ir
experienced. I have very often found them of the greatest service in embarking on what may otherwise prove to be a of troubles. Hertford-street, W.
sea
_________________
Clinical Notes: MEDICAL, SURGICAL, OBSTETRICAL, AND THERAPEUTICAL. TREPHINING THE SKULL FOR SPASTIC PARALYSIS. BY NOBLE SMITH, F.R.C.S. EDIN., SURGEON TO THE CITY ORTHOPEDIC HOSPITAL, LONDON, AND SURGEON TO THE ALL SAINTS’ CHILDREN’S HOSPITAL.
THE patient was a boy five and a half years old suffering from spastic paralysis. He was unable to articulate except a few monosyllables. The arms were contracted upon the chest, the legs were crossed and partly flexed at the thighs and knees. He was unable to stand, but was quite intelligent. These symptoms had existed since birth, after a protracted and difficult labour. Any material improvement had been looked upon as hopeless. I found a transverse depression in the occipital bone two and a quarter inches wide and about an inch from above downwards, just below the occipital protuberance. Having explained to the parents the uncertainty as to any good following the operation, and they having agreed to take all risks, I operated upon the depressed bone with a trephine of one inch in diameter, and removed two circular pieces of bone, making one opening. The meninges projected forcibly upwards through the opening, showing that there had been some pressure. There was no pulsation of the brain when it was first exposed, but before the completion of the operation pulsation was quite natural. The operation was performed on April llth, and the wound healed by first intention without a bad symptom. There was at once marked improvement in the child’s general condition, and the limbs have become gradually more relaxed, the legs not so much drawn up, and the patient can give the right hand to be shaken, whereas before he was quite unable to do so. He has since continued to improve in respect to the relaxation of the contractions. (July 5th, 1894.) He has slept more quietly since the operation than he ever did before. Although in this case the degeneration of nerve fibres has probably proceeded too far for perfect recovery, yet the operation seems to have proved that in such cases early interference may sometimes relieve or cure the condition. The extravasation of blood which occurs in many such cases, and the practicability of operating and removing this pressure, are points which seem to me worth consideration, and I hope at some future period to discuss this matter at greater length. I was kindly assisted at the above operation by Mr. Bland Sutton. Queen Anne-street, W.
operation
,
,
;
.
.
FATTY HEART AS A CAUSE OF SUDDEN DEATH DURING LABOUR. BY H. MARTYN EAMES, L.R.C.P., L.R.C.S.ED. & L.M. &c. months ago, d 0.1 ing my temporary absence an urgent message was left for me to attend a woman in her confinement. Reaching home soon after the departure of the messenger, I made all haste to the address given, and arrived at the house at the moment the patient fell dead on the floor at my feet. The history I elicited was that the woman was suffering from chronic bronchitis, had suffered from shortness of breath and occasional fainting attacks, and had been informed by her medical attendant that she had a weak heart. None of her symptoms, however, were so distressful as to prevent her carrying on the usual work of a labouring man’s wife. She was a big, stout, plethoric woman at the full period of gestation, and had expressed herself that morning as feeling exceptionally well for her. The pains had commenced four hours previously, and the medical man whom she had engaged had visited and examined her a couple of hours after, and had informed her that labour was natural and had onlyjust commenced, and hence, of course, there was
WHEN
.
.
.
.
taking charge of
a
practice
some