1898

be more likely to be present in cases of caries than an acidsaliva. It is well known that bacteria will not grow at all

readily in even a slightly acid medium, but require a neutralor slightly alkaline reaction in the culture medium. Thusit can readily be understood that-as was long ago pointedout by MILLER-the rapid proliferation of acid-producingorganisms in an alkaline medium would give rise to a greaterproduction of acid in the mouth in a given time than whenthe saliva was freely acid to start with.

Another communication as bearing upon the question ofcaries was published in the British Dental Journal byG. FRIEL. This observer examined 513 Kaffirs in KlipsprintLocation. The conditions under which they lived approxi-mated that of Europeans. In examining the teeth he wasunable to use a probe, so that it is possible that the inci-dence of caries was greater than suggested. He found 1592defective teeth, and, roughly speaking, 60 per cent. of theKaffirs showed caries, the percentage of bad teeth beingabout 5.Ina paper on Drainage and Stagnation, Mr. J. G. TURNER 7

draws attention to the fact that dental disease is in themain due to the stagnation of food débris, &c., in andaround the teeth, and that sufficient note is not taken of this

by operators in their operations on the teeth.Other Papers.

Mr. J. SEWELL ANDERSON gives a detailed account of acase of Facial Hemiatrophy,8 in which the bones on theaffected side were much smaller than those on the unaffected

side, this being most marked in the case of the mandible,the difference being sharply defined at the symphysis. Thenecks and roots of the teeth on the affected side were also

unduly exposed and loose. Another communication worthyof note is one by Mr. MONTAGU HOPSON, entitled "A

Review of Some Modern Theories of Variation and Heredity,and Some Suggestions as to their Application to the Studyof Orthodontia." 9 Mr. C. MANSELL MOULLIN, in a paper onthe Essential Cause of Gastric and Duodenal Ulcer, 10 statesthat he is convinced that the real cause of the vomiting andhæmatemesis so often seen in young women is the persistentswallowing of septic toxins manufactured in the mouth andthroat.

Under the title of "Two Odontoceles and Some Other

Cysts," 11 Mr. HOPEWELL-SMITH describes very fully twointeresting cases of buried teeth associated with cyst forma-tion. In the author’s opinion the cysts met with in con-nexion with the jaws could with advantage be classified

according to their pathological variations. He suggests thefollowing: (1) Dental cysts ; (2) eruption cysts ; (3) follicularodontomes; (4) epithelial odontomes, or multilocular cystictumours ; (5) mucous cysts of the antrum ; (6) odontoceles,(a) subcapsular, (b) extracapsular; and (7) cystic adenomataof the antrum and gum.

In a communication to the Dental Cosmos,12 Professor A.MICHEL of Wiirzburg gives an extended account of his

examination of the fasces of patients in relation to the

digestion of starch and the masticatory apparatus. Brieflystated, he finds : 1. That persons with a sufficient number ofteeth show starch present in the fæces if they are bolters,"and absent if they are masticators. 2. That in persons with

an insufficient number of teeth the fasces contain more

undigested starch in inverse ratio to the number of molarsor premolars present. 3. That the introduction of dentures

in cases where the masticatory apparatus is insufficient leadsto a rapid diminution of the amount of starch in the fasces.

7 Dental Record, vol. xxx., p. 490.8 British Dental Journal, vol. xxxi., p. 627.9 Dental Record, January, vol. xxx., p. 1.

10 THE LANCET, Oct. 1st, 1910, p 993.11 Proceedings of the Royal Society of Medicine, Odontological

Section, April, p. 121.12 Dental Cosmos, November, p. 1272.

Other interesting papers are: A Review of the Manufactureof Artificial Teeth," by THOMAS GIBBONS; The CastingProcess and its Use in Dentistry,14 by J. T. W. DAVIE ;and What Dentists have Contributed to Other Professions, 15by B. J. CIGRAND. The problem of the articulation hasbeen exhaustively dealt with by Dr. A. GYSI in a series ofpapers.16

Bibliography.Amongst the new publications issued during the year the

following may be mentioned :—" An Atlas of Dentistry inStereoscopic Photos," edited by KARL WITZET ; "ModernDental Materia Medica, Pharmacology, and Therapeutics,"by J. P. BUCKLEY; "Dental Surgery and Pathology," byJ. F. COLYER, being the third edition of " Diseases and

Injuries of the Teeth," by MORTON SMALE and J. F.

COLYER; "Dental Surgery Notes," by E. B. DOWSETT; and"The Principles and Practice of Operative Dentistry," byJ. L. MARSHALL (third edition).

ANÆSTHETICS.

General Anœstheties (Inhalation).While various new methods of employing general anæs-

thetics have been contrived by continental surgeons, the

tendency in Great Britain has been to study the reputeddangers and shortcomings of the accepted methods, and ratherto modify than to abandon the modes of procedure whichhave become established. It has been pointed out by theeditor of the Therapeutic Gazette and other American writersthat many of the dangers and difficulties, which continentalsurgeons appear to regard as inherent in the use of chloroformand ether when given by inhalation, are in fact due to thelack of experience of those who are called upon to employthem ; since, while on the continent general anaesthetics arerelegated to junior officers, in Great Britain practitioners ofspecial knowledge and experience usually undertake the

delicate duties of the anaesthetist. This fact has to be bornein mind when statistics of deaths and dangerous sequelæ arequoted to prove that inhalation anaesthesia is beset with

exceptional perils. The newer methods, such as subdural

stovainisation, intravenous and terminal arterial anass-

thetisation, are committed to practised surgeons, and theirresults are comparable to those of the specialists in this

country, who give anæsthetics by inhalation and whoseresults are, upon the whole, extremely favourable to this

method of narcosis.Ohoioe of Anœsthetic.

The range of selection has greatly increased. Formerlyit lay between chloroform and ether; whereas, at the presenttime, spinal and local analgesia, intravenous and intra-

arterial local or general anaesthesia, and the use of scopol-amine with morphine alone or antecedently to a generalanaesthetic, have to be added to the list. Again, the pro-longed use of nitrous oxide for general surgery synergeticallyto scopolamine and morphine, or with spinal or local anæs-thesia, as well as a large number of mixtures of chlorideof ethyl, ether, chloroform, have found advocates. The

methods of using these agents are also considerablymodified, and the selection of the method of using theagent or agents has become as much a matter of importanceas the choice of the anaesthetic itself. Papers dealing withthese subjects have appeared during the year.A discussion on the Choice of the Anaesthetic was held in

the Section of Anaesthetics of the Royal Society of Medicine, 1which was opened by Dr. DUDLEY BUXTON, who discussedthe subject under the heads of (1) condition of the patient;

13 Dental Record, Nov. 1st, p. 621.14 Ibid., May, June, and July.

15 Dental Review, vol. xxiv., No. 9.16 Dental Cosmos, January, February, and March, 1910.

1 Proceedings of the Royal Society of Medicine, vol. iii., p. 63.

1899

(2) necessities of the operation, including the region in- i

volved ; and (3) the duration of the operation. He favoured s

the use of chloroform following ether in all prolonged and t

suitable cases, and its employment in accurate volume (

percentages, together with oxygen. Dr. G. A. H. BARTON and Mrs. F. M. DICKINSON BERRY extolled the employment of ether by of the open method.

The Open Ether Metkod. Mr. H. BELLAMY GARDNER read a paper before the

Section of Anaesthetics of the British Medical Association on ]

the open ether method.2 For suitable cases he speaks in favour of the method. Lung affections he regards as contra-indications. Atropine (1-120th grain) is given before theadministration, and morphine (1-6th grain) is added in the

case of alcoholics and muscular subjects. The ether is

dropped on 12 folds of gauze placed on a wire mask.Dr. BARTON has contributed a useful paper on this

subject. Although advocating the plan, he admits objec-tions-the length of the induction, the large amount of etherused, the difficulty of getting relaxation in muscular subjects,and for laparotomies. To meet these he suggests adoptingthe following plan. An inhaler is used which consists of a

cylindrical chamber open at the top and having anotheropening about the junction of the middle and lower thirdcommunicating with the face-piece. This is lined with lint, sothat the latter dips into the ether well, which is capable of hold-ing two ounces. In this way a large evaporating surface for theether is obtained. A Roth-Drager type of face-piece withvalves is employed, and simple adjustment permits the adminis-trator to lessen or to increase the quantity of ether used.The C.E. mixture and chloride of ethyl, he suggests, may beemployed before the ether is inhaled. Dr. BARTON, how-ever, uses a few inspirations of chloroform vapour during thenarcosis to promote anaesthesia in alcoholic and athletic

persons ; and relies upon morphine with scopolamine beforethe open ether method in laparotomies. Another " inhaler "

suggested for the "open" ether method is described in

THE LANCET of May 21st, p. 1421, by Dr. R. H. HODGSON.

Morphine and Scopolamine Narcosis.A large number of papers dealing with the use of morphine

and scopolamine with the open ether method have appeared,and the experience gained appears, upon the whole, to befavourable. Dr. CLIFFORD 0. COLLINS records 1100 casesin which these alkaloids were used. He regards the objectionsraised by TERRIER and others as unreal. Although he hasused cactin synergetically he found it of little use. Ether

given by a drop method has in his hands proved the bestgeneral anaesthetic to give subsequently to the scopolamineand morphine. He approves of giving repeated injections inthe case of exophthalmic goitre, one being given the night Ibefore the operation is done. Children aged above eight Iyears, in his experience, respond well to this method. This

writer agrees with Dr. CRILE that nitrous oxide with oxygen,when employed after morphine and scopolamine, supply a I,valuable anaesthetic for major surgery. I

Dr. CRILE 5 has compared the values of ether and nitrous oxide when used after scopolamine and morphine. I,Nitrous oxide, he thinks, causes less shock, less in- fection, and fewer after-effects such as nausea, vomit-

ing, and headache. His conclusions are based uponexperimental work, as well as 575 major operations carriedout according to this method. Dr. CRILE has furtherelaborated a scheme which he describes as ° stealing thethyroid," whereby a patient with exophthalmic goitrecan be operated upon with the minimum of risk. Daily

2 THE LANCET, August 20th, 1910, p. 555.3 Practitioner, November, 1910, p. 713.

4 Journal of the American Medical Association, March 26th, 1910.5 New York Medical Journal, Jan. 29th, 1910.

injections of scopolamine and morphine are made, while allsuggestion of operation is avoided, and when the patient hasbecome accustomed to this procedure she is wheeled into theoperating-room and the general anæsthetic—nitrous oxideand oxygen-is given while the surgical condition is dealtwith.

Dr. R. A. HATCHER has contributed to the Council of

Pharmacy and Chemistry of the American Medical Associa-tion an exhaustive report upon the action of scopolamine andmorphine in narcosis and in childbirth. He regards the com-bination as valuable within limits, provided it is associatedwith some general anxsthetic, but he points out that inobstetrics it may increase the risk to the child. He suppliesa valuable bibliography of the subject. A similar investiga-tion undertaken by Dr. R. H. JAMIESON gives experimentalresults which explain the clinical observations recorded byseveral surgeons upon the alarming retardation of respiration.Dr. JAMIESON states that artificial respiration restores

animals whose breathing had dropped to five or six respirationsper minute. RINNE s records two fatalities occurring withinthree days and due to scopolamine and morphine.A somewhat unusual danger under this form of anmsthesia

is reported by Dr. FAUST 9 off Berlin. The patient, a healthyyouth, aged 17 years, developed violent spasm of the musclesof respiration with cyanosis. This occurred within an hourof the completion of appendectomy, and was so severe as torender the performance of artificial respiration impossible.The spasm passed off spontaneously but recurred six timessubsequently ; eventually the patient recovered. FAUST

regards scopolamine as the cause of the spasm.Dr. F. M. BARNES 10 of Baltimore has investigated the

effects on metabolism of the scopolamine-morphine narcosis.When quantities are given sufficient to lessen the vital

activities he found that a decrease of the absolute amounts of

nearly all the normal urinary constituents occurred, whilewhen scopolamine was given by itself there was increase ofthe vital activity and of the urinary constituents. These effectsare transient and appear within 12 hours of the administra-

tion. Repeated doses of the drugs in combination, if givenfor a prolonged period, lead to the establishment of toleraThe influence on metabolism, as shown by the variations inthe urine, seems to arise through indirect or secondaryaction of the drugs. The delayed absorption in the-

alimentary tract is regarded as the primary cause of theurinary variations.A considerable number of papers have appeared, dealings

with this combination in connexion with parturition, Wemay mention contributions by P. SICH,11 and a review of thewhole subject in the columns of the Therapeutio Gazette ofFeb. 15th, which upon the whole speaks favourably of theplan, but would restrict its employment to hospital cases orthose attended by a skilled nurse, as emergencies may arisewhich, if not promptly treated, may lead to serious results.Dr. TORRANCE THOMSON and Dr. DENNIS ATTERILL12 havediscussed the advantages of giving repeated small doses ofscopolamine and morphine, while Dr. H. R. LAWRENCE 13

gives his experience of these drugs in obstetric practice in126 cases. He had no maternal deaths, and the five deathsof the infants were, he thinks, not due to the scopolamineemployed. 13-3 per cent. required resuscitation, while

73.3 per cent. are described as " lively," and 8.8 per cent.as drowsy. In 2 - 2 per cent. the mothers were unaffected ;

6 Journal of the American Medical Association, Feb. 5th and 12th,1910.

7 Brit. Med. Jour., March 26th, 1910.8 Deutsche Medizinische Wochenschrift, Berlin, Jan. 20th, 1910.

9 Ibid., March 17th, 1910.10 Archives of Internal Medicine, April, Chicago (quoted by Journal

of American Medical Association, May 21st, 1910, p. 1725).11 Deutsche Medizinische Wochenschrift, March 3rd, 1910.

12 Edinburgh Medical Journal, December, 1909.is Ibid., November, 1910.

1900

in 17.7 per cent. they remembered, and in 82’2 per cent.they did not remember, the birth of the child. He thinks

that when the infant is prejudicially affected it is the

result of the morphine use Although it remains

an open question whether the labour is prolonged bythese drugs, Dr. LAWRENCE is inclined to negative the

suggestion.The scopolamine and morphine sequence, besides being

advocated for obstetric practice and as a preliminary to theuse of a general anaesthetic, has found advocates amongthose who prefer to employ intrathecal injections of stovaine,tropacocaine, or other analgesic. It has been long recognisedthat nervous patients-and these form the bulk of those whohave to face surgical operations-dread both taking the in-halation of a general ansesthetic and suffer severely also duringprolonged manipulation under spinal analgesia. Dr. CRILE 14has recently emphasised the danger of psychic shock

especially in the case of persons suffering from Graves’s

disease. To meet this peril many surgeons have publishedtheir methods, which consist practically of the preliminaryuse of scopolamine and morphine. That this mind-shock is

not a mere theoretical danger is shown by the experimentalwork of Dr. CRILE, which has demonstrated definite changesin the brain cells the result of fear.

Mr. A. E. JOHNSON15 advocates the use of both intra-

thecal injection to block nerve influences provocative of

shock, and a light general anaesthetic to obviate psychicinfluences, He asserts that "the combination of spinal andgeneral anaesthesia is much more convenient and satisfactory."He points out that with a dosimetric method it is extremelyeasy to control the amount of chloroform if this anaestheticis used, and to preserve an extremely light narcosis whileensuring a complete anxsthesia. A number of workers alongthese lines have adopted nitrous oxide gas or Hillischer’s" Schlafgaz "-i.e., nitrous oxide and oxygen-as the generalanaesthetic, using regional injections of stovaine or other

local analgesic for nerve blocking. This plan Dr. CRILEadvocated at the annual meeting of the British MedicalAssociation.

NEU 16 employs scopolamine and morphine, and thenmaintains anaesthesia by a mixture of nitrous oxide and

oxygen, employing a new form of apparatus, which hedescribes. Dr. S. BUNNELL 17 has extended the use of these Iagents to thoracic surgery. As a result of successful experi-ments upon the lower animals he claims that, given underpositive pressure, the chest can be kept open for nearly twohours. Respiration and circulation can, he asserts, be keptgoing without difficulty, but so soon as the positive pressureis discontinued cyanosis, respiratory distress, and a vagalpulse develop, and death rapidly occurs.Some diversity of opinion appears to exist among the

advocates of scopolamine. While, upon the one hand, thisdrug is regarded as assisting in obtaining muscular relaxa-tion, upon the other we are advised to omit scopolaminein abdominal surgery, as experience has convinced somesurgeons that its use leads to muscular rigidity. Morphinewith atropine should be substituted, it is alleged, whenmuscular relaxation is essential for the success of the

operation.Heart Massage.

An interesting case of cardiac failure under chloroform wasreported by Dr. V. B. ORR18 at the close of last year. The

patient, a woman, aged 30 years, collapsed under chloro-’form. An abdominal incision was made and the heart,

14 Brit. Med. Jour., Sept. 17th and Oct. 1st, 1910.15 Ibid., Dec. 3rd, 1910. See also Archives of Middlesex Hospital,

vol. xvii.16 Münchener Medizinische Wochenschrift, No. 36, 1910.17 California State Journal of Medicine, January, 1910.

18 Proceedings of the Royal Society of Medicine, December, 1909.See also Therapeutic Gazette, May, 1910, p. 338.

which was "flabby," was stroked from below the dia-

phragm. The woman made an excellent recovery. This

case is recalled by others published by Captain T. C.

RUTHERFOORD, I.M.S.,19 and Mr. J. WALLACE MILNE.2o

Dr. ORR pointed out the three methods hitherto tried are:(1) the thoracic ; (2) the subdiaphragmatic ; and (3) the trans-diaphragmatic. Two recoveries by the thoracic route havebeen recorded, but the method takes time and exposes the

patient to serious unnecessary risks-e.g., pneumothorax.The transdiaphragmatic route has so far proved unsuccessful,so that the subdiaphragmatic is by most authorities regardedas the operation by election. Ten successes by this methodare mentioned by Dr. ORR. The use of rubber gloves and therapid sterilisation of the skin with tincture of iodineenable the surgeon, even if engaged upon a septic opera-

, tion, to proceed to the laparotomy without loss of time,while pulmonary perflation with oxygen is carried out by theanaesthetist. In Captain RUTHERFOORD’S case the patient wasa healthy adult native of India suffering from haemorrhoids.The abdomen was opened and the heart was compressed 60times a minute between the hands, one grasping it and oneplaced on the prsecordium. The heart after 12 compressionshardened and resumed beating. Chloroform had been used.Mr. MILNE’S case was also a healthy male, and an2asthesiawas produced in four minutes by chloroform. Comment

upon this fact 21 suggests that the heart failure was due toover-dosage. The operation was for appendicitis. Incision

to the left of the xiphoid cartilage allowed the entrance ofthe right hand which grasped the heart, the thumb beingbehind it. One squeeze initiated cardiac movement, and

eventually the operation of appendectomy was successfullyperformed.

REHN 22 gives details of another case. A healthy boy, aged7 years, collapsed while inhaling chloroform. Brauer’s

positive pressure apparatus was used to maintain respirationfor two and a half hours, by which time complete restorationof respiration and circulation had occurred. The heart had

been massaged by introducing the finger, but the pleura wasunfortunately damaged and pneumothorax, which provedultimately fatal, resulted so soon as the finger was with-drawn. The first heart movements were felt after 70 minutes

and the beat was maintained for four hours. A useful tabula-

tion of 50 cases is given by Dr. J. WHITE.23Shook under Anœstheties.

At the annual meeting of the British Medical Associationa discussion of great interest took place upon this subject.Dr. CRILE advanced his well-known views with regard tothe value of nerve blocking to protect the controllingcentres from exhaustion. He pointed out, further, that bothsubarachnoidean injection and local analgesia fail to obviatepsychic shock. To meet this he uses a general anaestheticor scopolamine and morphine. Mr. JOHN MALCOLM, whodoes not regard as proven the theory of vaso-motor ex-

haustion being the cause of shock, advanced cogent argu-ments in support of what is now termed the acapnia hypo-thetical explanation of surgical shock.We owe to Dr. YANDELL HENDERSON a mass of valuable

experimental work supporting the view that when the bloodhas its content of carbon dioxide lowered to a certainpoint the symptoms of shock supervene. 24 Hyperpncealeads to over lung ventilation, and when the carbondioxide content is lowered the respiratory centre is no

longer stimulated to act. Exposure of serous membranesalso causes escape of CO2 and leads to respiratory failure.

19 THE LANCET, April 30th, 1910, p. 1119.20 Brit. Med. Jour., Nov. 19th, 1199.

21 Ibid., Dec. 3rd, 1910, p. 1822.22 Münchener Medizinische Wochenschrift, vol. lvi., No. 48.

23 Surgery, Gynæcology, and Obstetrics, October, 1910.24 Fatal Apnœa and the Shock Problem, Johns Hopkins Bulletin,

August, 1910; and American Journal of Physiology, vol. xxiii.

1901

The work of Mosso, MISCHER, HALDANE, and the pupils ofthe latter, with the brilliant investigations of Dr. YANDELLHENDERSON, have advanced the theory of acapnia to a

position of essential importance in relation to surgical shockunder anaesthetics. Professor ERNEST STARLING and Dr. E.

JERUSALEM 25 have also studied the subject experimentally,and their results are in accord with those of YANDELL

HENDERSON. A further aspect of the matter of importancein anaesthetics is that it has been found by the last-namedexperimenter that after the oxygen supply of blood, of lungs,and of tissues has been exhausted, and this occurs in two orthree minutes of apncea, the asphyxia of the tissues leads tothe appearance in the blood of the products of incompletetissue combustion. This is, in fact, a kind of acidosis. The

products in moderate amount stimulate the respiratory centreacting with the carbon dioxide. The practical view ofthe matter may be summed up in Dr. HENDERSON’Sadvice to treat cases of respiratory collapse by oxygenand carbon dioxide introduced by a laryngeal tube

rather than by artificial respiration, and using as a pre-liminary an injection of morphine which hinders hyperpnceaand so increases the blood’s supply of carbon dioxide.

Dr. H. H. BROWN26 discusses post-operative shock. Heconsiders that general anaesthetics, if properly used, lessenrather than increase the shock of an operation, and hesupports his view by reference to recent work upon the

general nervous system.lhe Status Lymphaticus.

Lymphatism formed the subject of an important discussionbefore the Royal Society of Medicine.27 Mr. H. BELLAMYGARDNER reviewed the cases and literature published,and a number of physicians, surgeons, and anaesthetists

spoke. Dr. DUDLEY BUXTON’S28 clinical lecture upon thestatus lymphaticus has appeared in our columns. The viewhe advances is that, so far as our knowledge at presentwarrants us to make a definite statement, this condition bearsmuch the same relationship to the use of anaesthetics as doesany other general state which depresses the vitality of the Itissues of the body, and especially of the central nervous system.

Blood Pressure in Ancesthesicc.

Mr. W. GuY, Dr. ALEXANDER GOODALL, and Dr. H. S.REID29 have investigated this subject. They think the

length of time of inhalation makes no difference in the caseof nitrous oxide. Ethyl chloride in large doses depresses theblood pressure and produces cardiac inhibition. G. A.BUCKMASTER and J. A. GARDNER30 record a further researchon the action of chloroform and dealing with the gases ofthe blood under chloroform.

Anœsthesia by Colonic Absorption of Ether.Dr. W. S. SUTTON 31 advocates rectal anaesthesia for

operations about the head, neck, chest, larynx, and mouth.He deprecates its use in abdominal surgery and in emer-

gency operations, since careful preparation of the bowel isessential for safety. His method is to introduce ether vapourby an apparatus he has devised, which allows warmed airor oxygen to pass through ether and vaporise, so that it

enters the colon. The narcosis is commenced by oral

inhalation.Dr. J. H. CUNNINGHAM 32 gives a valuable résumé of the

subject and describes his method. LEQUEU, MOREL, andVERLIAC state that cardiac and respiratory complications

25 Journal of Physiology, May. 1910.26 Practitioner, August, 1910.

27 Proceedings, Section of Anæsthetics, January and March, 1910.28 THE LANCET, August 6th, 1910.

29 Edinburgh Medical Journal, March, 1910.30 Journal of Physiology, vol. xli., p. 246.

31 Annals of Surgery, April, 1910.32 New York Medical Journal, April 30th, 1910.

are liable to occur with this method. Collapse, they con-sider, is due to sudden yielding of the ileo-caecal valve. This

permits of a rush of ether vapour into the small bowel,leading to absorption and consequent over-dosage. Byemploying oral inhalation before the rectal tube is insertedthe valve becomes relaxed and this danger is obviated.

Varioits Papers.Papers dealing with the general principles of anaesthesia

may be noted. Dr. R. H. GREENE 33 published a paper onthe Surgeon’s Responsibility in Anaesthesia. Dr. J. W.

BovEE has pointed out that the Trendelenburg positionlessens and may abrogate renal secretion, and hence increasesrisk in renal and in arterial disease. Dr. CRILE34 has under-taken an experimental and clinical research on nitrous oxideand ether anaesthesia ; and Dr. F. W. BANCROFT35 reviews thepresent knowledge of nitrous oxide anæsthesia. Dr. F. W.

HEWITT, M.V.O., in a paper contributed to our columns36deals with the subject of the Æsthetics of Anaesthetics. He

contends that general anaesthesia is better for the patientthan local or any analgesia which allows the patient’s mindto be harassed by the environment of the operation ; and

that by judicious methods the passage into and from

insensibility can be robbed of horror. The paper is repletewith wise advice, and its theme is one too little considered

by many.Several useful papers dealing with the emergencies of

anaesthesia have appeared. One on Fæcal Vomiting underAnaesthesia37 (Dr. DUDLEY BUXTON) suggests a means

whereby " faecal drowning " can be obviated in serious cases.

Acidosis is considered in relation to anaesthesia by Mr. F. H.WALLACE, and Mr. E. GILLESPIE 38 reviews accepted viewsupon acidosis as a cause of death from operations underanaesthesia.

Dosametry in Chloroform.The report39 of the special Chloroform Committee of the

British Medical Association has been presented to the pro-fession, and its leading features formed the basis of a dis.cussion upon the subject of desimetry which took place onthe opening day of the annual general meeting of the

British Medical Association. The practical side of the

question was introduced by Dr. DUDLEY BUXTON, while Dr.A. D. WALLER, F.R.S., spoke from the side of physiology.The report is too voluminous for us to do more than men-tion. It presents a historical survey of the subject, andphysiological and clinical observations which demonstrate

the effects of definite doses of chloroform upon the respira-tion, circulation, and organism as a whole.

Spinal Analgesia.As has been pointed out above, many observers have

become impressed by the danger attendant upon the patient’spreserving consciousness during an operation. A considerablenumber of papers have been published which describethe merits of a combined method of spinal and generalanaesthesia. Various writers have confirmed the view

commonly expressed in this country that JONNESCO’Smethod of high injection is less safe than the lower

site, and that the addition of strychnine does not

abrogate the danger. A discussion upon the subject wasopened by Dr. J. BLUMFELD during the annual generalmeeting of the British Medical Association, and the viewsexpressed by the anaesthetists who spoke were rather in

depreciation of this method, except under very exceptional

33 Ibid., June 4th, 1910.34 Ibid., vol. liv., p. 233.

35 Ibid., p. 1589.36 THE LANCET, March 5th, 1910.

37 Brit. Med. Jour., April 23rd, 1910.38 Practitioner, February, 1910.

39 Brit. Med. Jour., July 9th, 1910.D D 3

1902

’circumstances. Two deaths have been published in detail-one by Major GABBETT, I.M.S.," who injected novocaineand strychnine in-the interspace between the twelfth dorsaland first lumbar vertebra:; and the second by Mr. VICTORMiLWARD, who also pursued JONNESCO’S method. Mr.

MILWARD regards the death as due to the drugs employed.Mr. H. T. GRAY has published his third series of 100 cases

of spinal analgesia in children,’12 and gives a very fair pre-sentation of the subject from his point of view. The

advantages and drawbacks are carefully tabulated and

appraised. Mr. GRAY’S papers form a valuable addition toour knowledge of this much-debated subject. THE LANCET

(July 30th, p. 325) notes a personal " experience-viz. ofCaptain J. DORGAN, R.A.M.C. It is somewhat more favour-able than that of a fellow officer who published his experi-ence some time back in the journal of his corps. Dr. SBILLERand Dr. LEOPOLD 43 publish a report upon the action of

stovaine upon the central nervous system. Although theresearch cannot be taken to apply in its entirety to the

human being, it appears to indicate that there is danger inrepeated injections, and that the brunt of the injury fallsupon the motor tracts.

Intravase2clar nesthetisatinn.

In the Cameron lecture 44 Professor AUGUST BIER dis-

cussed local anaesthesia with special reference to vein

anaesthesia. He points out the value and limitations of

SCHLEICH’s infiltration method as elaborated by BRAUN, andeulogises the use of BRAUN’s isotonic solutions of novocaineand suprarenal extracts. Failure in this method is caused

usually by not waiting long enough, half an hour at leastbeing required. Other plans are HACKENBRUCH’S perineuralinjection, KROGIUS’S method of conductive ansestbesia, andCORNING’S and OBERST’S systems. Endoneural injectionrequires as severe an operation to produce anaesthesia as

that for which it is merely an adjuvant method. The principleupon which vein anaesthesia is based is that the nerve trunks

are surrounded by dense connective tissues which are hardlypermeable to infiltration. If the analgesic is introducedinto the circulation it readily enters and anaesthetises thesestructures and complete analgesia results. BIER describeshis technique ; he uses a Janet’s syringe and glass cannula,with isotonic solution of novocaine 0’5 per cent., and100 c.c. is the utmost quantity to be injected. It is

essential to obtain ischoemia, to infiltrate and isolate a veincompetent to hold the cannula. BIER distinguishes directanaesthesia, which occurs in the area between the constrictingbands, and indirect, which develops later in the tissues belowthe peripheral bandage. This is a regular conductive

anaesthesia. The analgesia is brief ’ and the addition of

suprarenin did not remedy this. BIER considers the dangersof poisoning can be avoided if due attention is paid to hissomewhat complicated technique and the quantity of the

drug injected is strictly limited. He restricts the method to

cases which cannot be treated by simple local anaesthesia.He has tried it in 244 cases.HITZROT has suggested a modification of the plan BIER

enunciated at the meeting of the German Surgical Societyin 1909.45

Dr. J. L. RANSOHOFF 46 exposes an artery under infiltra-tion ansesthesia, and EsMARCH’s strap is fastened somedistance above the point to be injected and from 4 to 8 c.c.of 0’5 5 per cent. cocaine in normal saline solution are intro-duced into the blood stream. Although we are told the

40 Ibid., March 19th, 1910.41 Ibid., March 26th, 1910. See also Therapeutic Gazette, September,

p. 644.42 THE LANCET, June 11th, 1910, p. 1611.

43 Journal of the American Medical Association, June 4th, 1910.44 Edinburgh Medical Journal, August, 1910.

45 Therapeutic Gazette, January, 1910.46 Annals of Surgery, April, 1910.

method is of great value, it obviously is not free from danger,and depends upon somewhat limited experimental data. It

will be remembered that GOYANE suggested a similar planin 1909.

Intravasoular Injectioot of Ether or Chloroform.BURKHARDT 4T has experimented and finds intravenous

injection of chloroform causes hsemoglobinuria, but with

5 per cent. of ether in saline solution this is absent. 7 percent. of ether, however, caused this complication. Thirtyhuman beings were subjected to this treatment and withoutfatality. Several had the preliminary injection of scopol-amine and morphine. H. KÜTTNER 1" has pursued this methodin 23 cases. He cautions against the danger of thrombosis.Dr. R. GIANI to reports from Dr. DURANI’S clinic two casesof intravenous injection of chloroform. The injection wasstopped when unconsciousness appeared and resumed whenthe patient evinced signs of returning sensation. Slightalbuminuria followed. GOYANE5’ regards intra-arterial assuperior to intravenous injection owing to the absence ofvalves in the arteries.

Local Analgesia.Papers of interest have appeared by H. K. OFFENHAUS,51

describing his method of performing operations upon themouth and bones of the face under local analgesia, and byH. FISCHER B2 dealing with alypin, a drug which he appearsto regard as one of the best of analgesics. A useful paperwhich summarises our knowledge of alypin appears in the1’herapoutic Gazette for January last from the pen of Dr. F. M.FERNANDEZ. J. ROTHMANN 53 gives a useful account of theuse of local analgesics in the routine work of general practi-tioners. K. MAYER 51 has adopted with success the plan inmidwifery of cocainising the nose of women during labourpains. He also injects beside the dura and into the periosteumbetween the coccyx and sacrum. While alleviating their

pains, it has never in his experience done any harm to motheror child. He avoids injecting the dural sac. Dr. F. H.McMECHAN 5B discusses the anaesthesia for prostatectomy, and

regards local injection in the perineum and suprapubic regionas safest. BEVAN, however, while using a local analgesia,prefers to render the patient unconscious by means of nitrousoxMe and oxygen.That local analgesia is not without its perils is once

more forced upon us by the account given by Captain A. D.JAMIESON, I. M.S. 56 In the course of an operation for urethralstricture a 10 per cent. solution of cocaine was injected.As the first injection failed to produce anaesthesia a secondwas made. The patient became convulsed and died.

Dr. BREWSTER ROGERS and Dr. HERTZLER have employed! quinine and urea hydrochloride as a local analgesic, andregard them as equal to cocaine and to possess the property; of conferring analgesia which persists for several days.

PUBLIC HEALTH.

The death of KING E]EIWARD VII., with all its far-reaching, consequences, was an event of special significance in so far: as preventive medicine is concerned. Although there is every

reason to believe that our reigning monarch will take an

.

interest equal with his father in all that appertains to thehealth of the people, the progress of hygiene and the develop-

,

ment of administration during our late KING’S reign would

47 Archiv für Experimentelle Pathologie und Pharmakologie,Band lxi., p. 323.

48 Zentralblatt für Chirurgie, Feb. 10th, 1910.49 Il Policlinico, vol. xvi., No. 51.

50 See communication to Madrid Medical Academy, 1909, and SigloMedico, Oct. 9th-16th, 1909.

51 Deutsche Medizinische Wochenschrift, No. 33, 1910.52 Ibid., Nos. 25 and 38, 1910.

53 Münchener Medizinische Wochenschrift, No. 28, 1910.54 Medizinische Klinik, May 20th, 1910.

55 Boston Medical and Surgical Journal, March 3rd, 1910.56 Journal of the Royal Army Medical Corps, May, 1910.