1543

-,as to make a little cage in which a small sponge is

placed. When ethyl chloride is sprayed into a bagoff, the usual size part of it vaporises and the other

part tends to fall to the bottom and to vaporiseas the patient breathes in and out. A young infantdoes not make a sufficient respiratory effort to pro-.duce the necessary amount of vaporisation and for this.reason induction is often unduly delayed and the anaesthesiais not smoothly maintained. The sponge inside the bag

..inter.cepts the anaesthetic and by holding it nearer to thechild obviates these defects, making it possible for the patientto inhale it more rapidly and without effort. The sameresult is obtained if a bag.d about half the usual size is

employed, but it is not always convenient to change thebag between the cases.A celluloid face-piece is generally preferable since it not

only permits the anaesthetist to observe the patient morereadily but also resists the action of the vapour better thanrubber. For infants of a few days or a few weeks old Icommence by spraying three cubic centimetres into theinhaler; for those of six months and upwards I give fivecubic centimetres at once. The mask is then approached tothe face but not pressed against it so that the baby hasseveral breaths of air and vapour mixed ; it is then moreclosely applied so as to exclude all air except that which isalready in the bag, and in a few seconds the child becomesunconscious. When one is sure that the anaesthesia is deepand the surgeon has made his incision or begun the opera-tion the mask should be removed from the face and afew breaths of air should be given. If it is desired tocontinue the period of narcosis for some time the maskshould not be kept off for long but only raised occasionallyfor air. If the respiration indicates the lightening ofthe narcosis a few more cubic centimetres may be addedto the bag ; on these lines the anaesthesia may be indefinitelyprolonged. I think it is desirable that the induction shouldbe as quiet as possible and for this reason I dislike to havethe child much restrained. All that is necessary is that thenurse or attendant shall prevent the child from clutching theface-piece or bag, otherwise free movement of the legs andarms does no harm. Physical restraint is annoying to theinfant and adds to his excitement ; in older children itproduces terror. Respiration is the most certain guide as tothe depth and duration of the anaesthesia ; it should never bedisregarded. When the patient is well under it is quickerthan is normal, deep, rhythmical, and often stertorous ;when he is coming out it becomes softer and more shallow ;when an overdose has been given it suddenly changesin character and from being full and deep becomes

very soft and short, then after a breath or two ceases

altogether. The pulse is usually hastened but in manyinstances there is no appreciable difference. The cornealreflex is abolished very early ; the pupil in infants is so

uncertain that it cannot be considered as a sign of any value.In older children it seems always to dilate ; in babies it maybe contracted or dilated, and I have observed it also to altermore than once during the same anaesthesia without beingable to give any reason for the variation. The secretion ofmucus, especially when the anaesthesia is prolonged, is notso frequent among children in their:first year as among olderchildren. I have had two cases in which it caused incon-venience ; both children were cutting teeth and had increasedsalivation at the time. No fatalities occurred among theseinfants but four of them stopped breathing during the.administration. This happened when I had comparativelylittle experience in the administration of this particularanaesthetic. Since I have adopted the method of givingplenty of air I have not had any difficulties. These fourcases occurred during the operation for phimosis, duringwhich a deep anmsthesia is desirable. Two of the patientswere vigorous and healthy children and it is possible thatthey were not sufficiently deeply anaesthetised and that thesuspension of respiration was due to surgical shock ; theother two were weak and feeble infants under four monthsold and the cause remained uncertain. In one case respira-tion was suspended before the operation, which was sub-sequently successfully completed, had been begun. Anima-tion was restored by the application of brandy and friction tothe lips ; and though in two cases the tongue was drawnforward and artificial respiration was resorted to there wasnever any real difficulty in reviving them and it was alwayspossible to finish the operation.

Infants probably suffer less than any other class of patientsfrom after-effects. After a small dose they become conscious

at once ; after a large one they sleep for 10 or 20 minutes,unless they are in pain when they rouse up sooner. At this

age vomiting and convulsions as the consequence of theanaesthetic do not occur, and the food which the mothers are

apt to press upon the infants as soon as they have beenrestored to them does not seem to cause them any ill-effects.Unless they are in much pain they are fit to be dressedand removed from the hospital in from a quarter tohalf an hour. I used ethyl chloride in one case of

intussusception ; the child, aged six months, was veryill -and reduced and did not require much of theaneesthetic. The actual operation lasted 20 minutes, theadministration 23 minutes, the amount of the drug used was15 cubic centimetres, there was no preliminary struggling, theabdomen was well relaxed, and the anaesthesia was perfectlyeasy and smooth, the child recovering from it almost at oncewithout any vomiting or other unpleasant after-effects. Inthis case ethyl chloride was chosen with a view to shorteningthe narcosis.One of the principal factors in producing shock in children

is the length of the ansesthesia ; by using ethyl chloride theperiods of induction and recovery are so much shortened asto make an appreciable difference to a patient in a bad con-dition. It is probably the easiest and pleasantest ansestheticto inhale. The smell of the drug is not obtrusive and it issuch a strong respiratory stimulant that the patient does notrequire to make any effort; on the contrary, it promotesrespiration against his will. Herein lies its chief danger,for if large doses over-stimulate the respiratory centre andcause a tonic contraction of the diaphragm the patient maydie from paralysis of the respiration. This event is liableto occur soon after induction, the heart remaining unaffected.The alternative anaesthetic for babies is chloroform and its

mixtures, which entail a certain amount of risk for veryyoung and very weak infants. The depressing action on theheart, the tendency to vomit or retch during induction, andthe excitement produced add to the ordinary risks in thesecases. The length of the narcosis and especially of the

recovery period are serious disadvantages and the danger ofconfiding these children to the care of an irexperiencedguardian afterwards is considerable. At this age ethylchloride is not liable to cause vomiting or retching and theperiod of excitement is reduced to a minimum. Further,there is practically no risk in sending the children away inunskilled hands, all of which advantages will no doubt tendto_popularise its use for infants.Belgrave Hospital for Children, S. W.

TWO CASES OF SPASM WITH HYPER-TROPHY OF THE PYLORUS IN

INFANTS CURED WITHOPIUM.

BY NEWMAN NEILD, M.B. VICT.,ASSISTANT PHYSICIAN TO THE BRISTOL GENERAL HOSPITAL.

THE theory of the causation of the so-called congenitalhypertrophic stenosis of the pylorus which has obtained themost support is the theory that the hypertrophy is the

rapidly acquired result of frequently recurring spasm of thepylorus. The following two cases appear to lend a furtherargument in favour of that theory. The question as to thecausation of that spasm is still a matter for conjecture.The first case was that of an infant, aged five weeks,

brought to me at the Bristol General Hospital. The child wasbreast fed and the mother appeared healthy and had a goodsupply of milk. She complained that the child was wastingand vomited shortly after taking the breast. The vomitingcommenced a few days after birth and the child, "a fine bigbaby born," began to lose flesh. As a rule there was con-

stipation but there were occasional attacks of diarrheea, The

vomiting was usually forcible. The child was very wastedand the abdominal parietes were thin. A few slow contrac-tions of the stomach could be made out, although thepylorus could not be felt. The last feed had been taken anhour previously and the child had been s?ck shortly after-wards. Three days later the child was seen immediatelyafter taking the breast and after a few minutes there wereplainly visible the ’characteristic gastric waves and thepylorus was distinctly palpable and appeared to be tender.

1544

The little patient was recommended for admission but no fbed being then available, the infants’ ward being full, a <

mixture containing bismuth and soda was prescribed. Aweek later the child was again brought to the hospital <

unimproved. It then occurred to me to give an antispas- ‘

modic and on account of its marked action upon the spasm (of unstriped muscle, as shown in asthma, renal and biliary i

colic, and so on, opium was selected. The susceptibility of i

infants to opium-most of us carry in our minds the (

warning fact that one minim of laudanum has proved fatal lto an infant-led to my prescribing a small dose with the i

intention of increasing it later. One minim of the tincturewas added to ten ounces of water and the mother wasdirected to give the child one teaspoonful of this 20 minutesbefore each feed. A week later the patient was seen againin the out-patient department, the child having shown suchmarked improvement that the mother had refused to allowthe child to become an in-patient when written for.Vomiting was said to be less frequent and the child seemedto be gaining flesh. During the next seven days the fre-quency of the vomiting had dropped to twice a day andthe child was obviously greatly improved in appearance,although it is interesting to note that the mothernow complained of the child’s increased peevishness andirritability. Three weeks afterwards the opium was

stopped but the vomiting beginning to return the motherwas told to continue the opium and when the bottlewas half empty to fill it up with cold boiled water and tocontinue the teaspoonful doses as before-a convenient, ifsomewhat rule-of-thumb, method of gradually reducing thedose. The child is now, some months later, plump andseems in no way abnormal.

Shortly after this case I saw an infant at the BristolGeneral Hospital suffering from daily frequent and forciblevomiting in whom I thought that I could detect waves

,of gastric contraction. The child was bottle-fed and certainmodifications were made in the milk, and opium was pre-scribed as before. The recovery was rapid but I am unwillingto include the case as the diagnosis was not absolutelycertain and also because modifications were made in thediet.The next case came under my care at the Bristol General

Hospital on Oct. 9th. One could not wish for a more

typical case for the purpose of putting a certain treatmentto the test. The patient, aged eight weeks, had beenbottle-fed from birth, the mother having suffered fromwhite leg. Shortly after birth the child had jaundice, other-wise it was "a fine strong baby." At the end of the firstweek the vomiting was first noticed and at the same timethere was constipation. Various modifications of diet hadbeen tried with no good result; the vomiting graduallybecame more forcible until the present time when the childlying in the cot would vomit over the side of the cot onto the floor. When I saw the child at the end of theeighth week there was great emaciation, the gastric waveswere strong, and the pylorus was plainly palpable. Nochange was made in the diet in use at this time, equal partsof milk and water, but a teat bottle was substituted for onewith a long rubber tube. Opium was prescribed as before,one-eightieth of a minim in a drachm of water 20 minutesbefore each feed. A week later there was no improve-ment, so one-fortieth of a minim was ordered. It was

subsequently found that very early the first bottle ofmedicine had been brokpn-how early the mother seemeddisinclined to admit-and the child, for some days at anyrate, had been without medicine. A week later there wasdistinct improvement in the appearance and vomiting haddropped in frequency to twice in the day and once at night.The scales of the local grocer having been requisitionedthe child was weighed every other day and duringthe next fortnight, with surprising regularity, there wasan increase of from one to four ounces in the two days.The improvement is continuous and the child is doingwell.Two cases successfully treated with opium are insufficient

to allow one to claim that opium is a specific in this disease,but the following conclusions may be fairly drawn fromthem : 1. Some cases of spasm with hypertrophy of thepylorus may be successfully treated with opium in theordinary routine of the hospital out-patient department.2. In some cases modification of the diet, stomach washing,and tube feeding are not necessary to the cure. 3. Nocase should be subjected to an operation until opiumhas been tried, unless, possibly, some other antispasmodics,

such as the belladonna group, have been found equally ’

efficacious.NOTE.-Since the above was written I find in this month’s

Soottis7t Medical and Surgical Journal (article by Dr. JohnThomson) that Heubner recommends tincture of opium(G.P.) in doses of from one-twentieth to one-tenth of a

minim. Whether it is given before each feed or not I donot know. It is interesting to note that he considersoperation unjustifiable in these cases. I may add that Ihave now under my care a third case, breast fed, aged threemonths, doing well as an out-patient under opium.

Clifton.

Clinical Notes:MEDICAL, SURGICAL, OBSTETRICAL, AND

THERAPEUTICAL.

NOTE ON A CASE OF SECONDARY PAROTITIS.

BY A. W. PEAKE, M.R.C.S.ENG., L.R.C.P.LOND.

I HAVE read with much interest the article on the Patho-

logy and Prevention of Secondary Parotitis by Mr. RupertT. H. Bucknall, which appeared in THE LANCET of Oct. 21st,p. 1158, and should like, with your kind permission, to placeon record a case under my care which ended fatally on thedate of publication of the paper.

, The patient, a man, aged 88 years and eight months, had

an abdominal growth which was diagnosed as carcinoma ofthe cascum. There were increasing ascites and oedema ofboth legs. For the last few weeks of his life he kept hisbed and lived on liquid food. His mouth was attacked bystomatitis some four weeks before death, with much fcetorof breath and dribbling of saliva. A week later swellingof the left parotid appeared, accompanied by difficultyand pain in opening the mouth. The swelling graduallysubsided and in eight days had disappeared, whenthe right parotid became inflamed, together with the

submaxillary gland on the same side. Movement of the jawwas now attended with so much pain that considerable per-suasion was necessary to induce the patient to take anynourishment. The parotid enlargement increased until hisdeath on Oct. 21st. On the morning of that day when I sawhim he was very drowsy. His temperature was 100’8&deg; F.,his pulse was 124 and thready, and his breathing was

hurried, with loud tracheal rales. The swelling then wasenormous ; the overlying skin was red and shiny and thetumour was hard and brawny, with a softening centre belowthe angle of the jaw. The right upper eyelid was so

cedematous that the globe could not be exposed. Thedrowsiness deepened into coma, in which state he died.Bishopston, Bristol.

A CASE OF FRACTURE OF THE FIRST CERVICALVERTEBRA.

BY WILLIAM EWART MAW.

RECENTLY, I was called to see a man who had fallen downsome area steps, eight or ten in number. On my arrival at

the house, ten minutes or so after the message was received,I found an elderly man lying at the foot of the stairs quitedead; the heart had ceased to beat and the extremities werebecoming cold. It was subsequently ascertained that he was74 years of age. Beyond three or four superficial abrasionson the top of the scalp no injury could be detected. Aninquest was of course necessary and at the post-mortemexamination all the organs were found to be in a healthycondition with the exception of a little atheroma aboutthe valves of the heart and aorta. On opening up thevertebral column, however, it was seen that the posterior archof the first cervical vertebra was broken off and althoughheld in position by the ligaments could be moved by thefinger. The fracture was quite symmetrical on both sidesand was just anterior to the grooves for the vertebralarteries. There was no displacement of the bone and noindentation was perceptible on the spinal cord, either