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regularly. Thermofuge was applied from the start on a

back "breast-plate," and hypodermic injections nightly ofheroin 1/6th grain and atropin 1/100th grain were giventhroughout, sometimes twice or thrice daily. By the thirdday of my attendance both lungs were dull and non-aeratedfrom the bases to the middle of the scapulas, and frictionflounds were distinctly audible at the upper limit and justbelow it. The consolidation was extending, in spite of thephylacogen, which I daily increased by 5 minims. Each

injection was followed within an hour or two bv giddiness,violent retching, and what the patient described as ’’ pinsand needles all over her." These apparently disadvantageoussymptoms seemed hopeful as showing there was an energeticreaction somehow to the phylacogen, so I persevered. Afterthe fourth injection the dullness and friction remainedstationary. The temperature fell to 98° and the cyanosisbecame less marked, though the apnoea continued and wasonly relieved by more frequent oxygen inhalations. Collapsewas dangerous, but I went on. By the sixth injection, thelast two of 30 minims each, there began evident clearanceof the lungs at the upper limit of dullness. Frictionremained for three or four days, but from thenonwards the consolidation rapidly disappeared. I gave nomore phylacogen. By the tenth day the air-stream againreached the bases of both sides; the pulse fell to 90 andrespiration became normal. The attack was over, and onlygeneral weakness and the usual pneumonia wreckage " ofdilated heart, anemia, and exhaustion remained. Curiouslyenough, all the cerebral symptoms, with the exception of thesibilant speech, completely vanished.

I gave the patient up as doomed on the fourth visit,both because of the advancing symptoms and the diffi-culties she raised in the way of treatment. She refusednurses, she insisted on getting out of bed and even

staggering about the room, and she would not take fluidfood. From my first visit she said she knew she was goingto die, and I think she believed it, but though I thought thesame myself I tried to keep her hopeful in spite of the super-vention on the fifth day of a distinct cloud of albumin,scanty excretion of urine, and oedema of the feet andankles. The lungs became quite clear, and were so for afortnight after the commencement of convalescence ; theblood-stained sputum, of which there was at no time anyconsiderable quantity, became absentPS. --Since the above was written the patient has died ; all

the pneumonic symptoms entirely cleared up, and she hadbegun a hopeful convalescence. Death occurred from acute

meningitis and exhaustion.Wanstead, Essex

AT the last meeting of the Bideford (Devon)board of guardians the resignation was accepted, with muchregret, of Dr. Charles Sinclair Thompson, who has beenmedical officer and public vaccinator of the district for thepast 40 years.A MARY MURDOCH MEMORIAL FUND.-The Hon.

Mrs. Franklin writes: "Dr. Mary Murdoch’s friends haveexpressed a wish to contribute towards a memorial whichwould perpetuate her memory among medical women

even after the generation of those who have known andloved her has passed away. Her high professional standard,the inspiration and encouragement she was to her colleaguesand friends, her work for women, and her belief in them andthe part they can take in the nation’s welfare, are wellknown. At this moment, when the demand for medicalwomen is far greater than the supply, it is felt appropriateto her memory as well as to the nation’s needs, that amemorial should be chosen which would help some youngmedical women in the first years of their practice. Whileactual details have yet to be settled, it is intended that afund shall be raised to found a bursary or bursaries on theselines, in connexion with the London (Royal Free Hospital)School of Medicine for Women. It is in the belief thatthere are many who would wish to help in such a memorialthat it has been decided to make its existence widely known."The following are acting as the committee of the MemorialFund: Miss L. B. Aldrich Blake, M.D., M.S., Dean of theLondon School of Medicine for Women ; Mrs. Edwin Gray,National Union of Women Workers; Mrs. H. Fawcett,LL.D., National Union of Women’s Suffrage Societies; MissJane H. Walker, M.D. ; Miss Helen Webb, M.B.; Miss L.Martindale, M.D., B.S. ; Miss F. M. Edmonds, M.D., B.S. ;Miss F. Stacey, M.B., B.S.; Miss S. Watt; and theHon. Mrs. Franklin, honorary treasurer of the fund, 50,Porchester-terrace, London, W. (to whom contributions maybe sent).

Medical Societies.ROYAL SOCIETY OF MEDICINE.

SECTION OF PATHOLOGY.

Bacteriology of Cerebro-spinal Fever.-Trangplantable Tumourcf the Guinea-pig.-Toxic Hepatitis.-Treatment of WoundInfections.-The Mechanical Causation of Appendicitis.A MEETING of this section was held on May 2nd, Professor

F. W. ANDREWES, the President, being in the chair.The PRESIDENT gave a short account of the Bacterio-

logical Results in 11 Consecutive Cases of Cerebro-spinalFever admitted to St. Bartholomew’s Hospital during thefirst four months of 1916. Only one was a military case ; ofthe civil cases four were under 4 years of age and six wereolder children or adults. The type of coccus was determinedin each case by agglutination with sera supplied from

Millbank by Lieutenant-Colonel M. H. Gordon. The twoearliest cases proved to be Gordon’s Type I., the remainderType II., except one case in an infant which could not bereferred to any known epidemic type. The pharynx wasalways examined and the meningococcus was found in everycase, twice in great abundance, sometimes only in smallnumbers. In each case the pharyngeal and spinal strains werecompared by agglutination and were invariably referable toidentical types, indicating that the pharyngeal infection wasan integral part of the disease. Most of the cases remainedcarriers for several weeks, one for more than 70 days.Treatment was by repeated lumbar puncture, with the newLister Institute serum, prepared with numerous diversestrains isolated during last year’s epidemic. The serumhad been successful, for though 4 cases out of 11 died

(mortality 36 ’36 per cent.), 2 of these were infants under ayear old and one a child of 3 years. Only one adult died,of streptococcal septicaemia following mastoid suppuration,after the meningococcal infection had been overcome. Incases over 4 years old the mortality was only 14’3 per cent.The improvement following the serum was in most cases

immediate; in 3 severe cases in which it was given on thesecond or third day the patients were convalescent in48 hours. One baby aged five months recovered. Bloodculture was carried out in 3 early cases. Twice it was

negative and once positive, the meningococcus beingrecovered from every tube. This case recovered promptlyafter serum had been given (intravenously as well as intra-thecally). In a fatal case the coccus was also recoveredfrom the heart’s blood after death.

Dr. J. A. MURRAY read a short paper on a TransplantableTumour of the Guinea-pig. The tumour grew in the inguinalregion, was fatty, fibrous, and slightly cellular, and was-regarded as a fibro-lipoma. It was grafted into a largenumber of guinea-pigs through several generations. After a

long latent period it grew very slowly. This long period oflatency was an extraordinary feature, for sometimes, evenafter two months, fresh tumours formed. Another strikingfeature was the size it attained, some of the tumours weigh-ing little less than the animal. The cells of the tumourshowed marked metachondritic changes. Having regard toits transplantability and the finding of tumour cells in apulmonary arteriole in one instance, the term liposarcomaseemed to fit it most closely.

’

Dr. B. H. SPILSBURY exhibited and described a series oflivers affected by Toxic Hepatitis. The first was from acase of tetrachlorethane poisoning, and showed irregularfibrosis, cellular destruction, very marked regeneration inone part, and an almost complete absence of fat. Anotherwas from a case of poisoning by dinitrobenzol. It showed

irregular fibrosis, little degeneration of the cells, muchbile-duct proliferation, and no fat, and was obviously anexample of a very chronic form of toxic hepatitis. A thirdliver had been poisoned by trinitrotoluene. It was reducedin size, and showed irregular nbrosis and very advancedfatty degeneration. The liver from a case of acute yellowatrophy was shown as a contrast. Its particular featureswere the absence of fat in liver cells and the marked fattydegeneration of the endothelial cells.

Dr. W. PARRY MORGAN, in a paper on the Treatment ofWound Infections, dealt with Sir Almroth Wright’s proposal,made on the ground of laboratory experiments, to substitute

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for treatment by antiseptics treatment by saline solutions.He questioned the interpretation of these experiments, andmaintained that the laboratory did not justify the changesproposed. In the first place, with regard to the use of

hypertonic saline, he reviewed Sir Almroth Wright’s experi-ments, and contended that they did not show any such

drawing power as was ascribed to salt, and that the onlysense in which salt could be said to draw water to itself wasthat recognised when such a process as osmosis took place ;and, further, that salt could not draw lymph to itself evenby osmosis. He then dealt with the ways by which theflow of lymph could be promoted, and suggested that hyper-tonic salt solution might in some cases do this by causing anosmotic diffusion of water out of the cells, the shrinkageof which would cause the opening up of lymph channels,just as the ground is fissured in dry weather. The

lymph would then have free passage to the surface, andany lymph-bound condition be relieved. But this effectwould not be permanent, and often would not be seen at all.Dr. Morgan then pointed out that hypotonic fluids, such aswater and hydrogen peroxide, would act in the opposite wayto hypertonic, causing swelling of the cells and possibly adiminished flow of lymph, and therefore suggested that anti-septics should be diluted with an isotonic fluid such as

physiological saline and not as is usual with water. Henext discussed the question of chemotaxis, and con-

tended that the method of estimating it was fundamentallyfaulty ; and that the experiments could not possibly justifythe claim " the polynuclear white corpuscles are carriedforward by a chemotactic movement in the direction ofthe free surface upon which the physiological solutionhas been imposed." On the other hand, he agreedthat the experiments showed that antiseptics, bacterial

suspensions, and above all hypertonic saline inhibitedthe emigration of leucocytes, but in this connexion

pointed out that of more practical significance thanthe laboratory experiments were the observations madeon the wound itself as to whether there was a good flow oflaudable pus. If there was any after an application, suchapplication could not materially affect the physiologicalprocesses. This test showed that antiseptics did notinterfere to any extent with the flow of pus, but that hyper-tonic saline would give us a wound as free from pus andclean as meat. He inferred from this that hypertonicsaline renders ineffective the only defence against the

streptococcus and staphylococcus, whilst with the applica-tion of an antiseptic or of physiological saline, this defencecomes again into action. Pus, as long as it was not" corrupted," was a good thing in a badly infected wound,but it should not be allowed to remain there long enough tobecome corrupted. Hence the necessity for washing awaypus, and, if possible, destroying the organisms which corruptit. In regard to washing out a wound by constant irrigation,the fluid should be delivered at blood temperature, asotherwise the activities of the leucocytes would bediminished. The attempt to destroy organisms was madein two ways: (a) By washing with antiseptics, and (b) bythe application of antiseptic dressings. In washing out thewound, the portion of the wash which was not immediatelydrained away and the film of pus which still adhered to thesurface should be considered. In both cases the antisepticwould be in great excess, and would have to be rapid in itsaction to be effective. From his experiments he concludedthat here the neutral hypochlorous solutions were veryefficient whilst carbolic acid was comparatively ineffective.In the case of the dressing the pus would tend to be inexcess and the action of the antiseptic would be pro-longed. Here his experiments showed that hypochloroussolutions would be practically useless, whilst carbolicacid would in its action on the organisms be fairlyefficient. The experiments by which he showed this wereas follows: pus showing one or two organisms per fieldof a film was mixed with an antiseptic and incubated. Ifthe organisms became more numerous it was clear that theygrew in spite of the antiseptic. In these experiments heshowed that four parts of pus and one of antiseptic greworganisms when the following antiseptics were used : carbolicacid, 1/60; mercuric salts, 1/200 ; iodine, 1/200 ; chlora-mine, 1/20 ; hypochlorous solutions, 1/200 availablechlorine. It was inferred from this that it was unreason-able to expect enough antiseptic to diffuse into the tissues toinhibit the growth of organisms, still less to kill them. In

similar experiments where organisms were added to sterile

pus or to blood the antiseptics were found to be much moreefficient, so Dr. Morgan inferred that they would be speciallyuseful when applied to recent wounds and to prevent con-tamination from without. He considered, in conclusion,that antiseptics, as such, could not sterilise the tissues andwould not be likely to do more than reduce the number oforganisms on the surface of a wound. This they could do,and since it could hardly be possible that the depth andintensity of the tissue infection would be independent of thevirulence and proportion of the surface organisms it wouldbe an important gain, and was the role of the antiseptic inantiseptic treatment.

Professor S. G. SHATTOCK communicated a paper dealingwith the Mechanical Causation of Appendicitis, based uponthe examination of a series of appendicular concretions, andof the contents of 125 appendices in persons dying fromvarious causes, 100 being over 40, and 25 between the agesof 15 and 25 years. Any such mechanical cause, if it isadequately to account for the alleged increase in appendicitis,would have to be (1) of recent introduction ; and (2) of akind that would extend to all classes of the community.One such that had been suggested was the ingestion ofparticles of the silica glaze detached from the enamelledhardware now in such general use. These particles were, ofcourse, absolutely insoluble in the alimentary canal.Professor Shattock had not found a single flake of enamel inany of the many concretions he had examined, nor in thecontents of any of the 125 appendices studied. In regard to thepossible injury producible by the ingestion of silica in miners,Dr. W. Watkins-Pitchford, the present director of the SouthAfrican Institute for Medical Research, Johannesburg, hadkindly obtained for him the following information: " Dr. F.Aitken, the superintendent of the Miners’ Phthisis Sanatorium,near Johannesburg, states that 537 cases of miners’ phthisishave passed through this institution without his having seena single case of appendicitis amongst them, nor has he notedany history of attacks before their admission. Dr. H. A.Loesser, the senior medical officer of the Crown Mines, hasneither noticed nor heard it suggested that appendicitis ismore common amongst miners than amongst others. TheDirector of the Native Affairs Department states that inJuly, 1915, there were 210,247 natives employed on theworks and mines of the Rand ; appendicitis is so rare thatdeaths from this cause are not classed separately; he holdsthat mine natives are not at all liable to the disease." Theuse of ’’ French chalk" " in dentifrices was another possibility,this material-magnesium silicate-being quite insoluble inthe alimentary canal. The material was easily recognisablemicroscopically, but Professor Shattock had never found anyin the appendicular contents or as forming the centreof a concretion. The use of Cerebos salt. which containsa notable amount of magnesium phosphate, could be

ignored, since the latter was readily dissolved at 370 0.in a solution of HCI of the percentage in which the acidis present in human gastric secretion.The hypothesis of most promise was that put forward by

Mr. W. H. Battle-viz., that a new factor in the causation ofappendicitis had been furnished by the particles detachedfrom the steel rollers now almost universally used in

grinding wheat for flour. After a lengthy investigation,Professor Shattock had somewhat reluctantly come to theconclusion that no proof of the theory was forthcoming. Hehad traced the fate of steel filings in flour, to which they hadpurposely been added, in bread made from such flour, andin vitro under the action of hydrochloric acid. Steel filingsmight be kept in flour indefinitely without undergoingoxidation. When flour containing such was made intobread (by means of yeast), the particles became slightlytarnished from an extremely superficial formation of ferricoxide (rust). When these particles were extracted from theloaf, and incubated at 37° 0., in a solution of HCl of thegastric percentage, an abundant evolution of H took place.The fluid on being tested gave a ferrous (chloride)reaction only, without any ferric. (This was explainedby the fact that any trace of ferric chloride producedfrom the minute amount of ferric oxide was reduced toferrous in the presence of the free hydrogen. The pointof this was that as ferrous chloride produced no constipatingeffects, no intestinal and appendicular stasis, favouring theformation of a concretion, could be attributed to the ingestionof steel particles-assuming this to take place. The amount

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of solution which steel underwent in the acid within twohours, at 370 C., was small; the metallic particles would,therefore, pass with little change into the intestine, andhere all further decomposition would be prevented by theaction of the sodium carbonate of the pancreatic secretion,which rendered the intestinal contents alkaline. Steel filingsmight be kept for an indefinite period in a solution of sodiumcarbonate (of the percentage in which this is present inthe pancreatic secretion) without undergoing any oxidationwhatever. Mr. Battle had cited the pigmentation of theappendix which he had come across in certain cases furnishedby’ operation, as suggestive of the prolonged ingestion ofsteel derived from flour. Professor Shattock had criticallyexamined nearly all of these specimens, microscopicallyand microchemically, with the following result :-Thecolouration was due to the presence of somewhat trans-lucent spherules of dull brownish colour contained inconnective-tissue cells lying in the lymphatic tissue whichsurrounds the crypts ; there was none in the muscular wall.When the sections were heated, secundum artem, in HCland potassium ferro-cyanide or potassium ferri-cyanide noferric or ferrous reaction was obtained in the spherules.When sections were freely treated with pure HCl no solutionof the pigment took place. The pigment was clearly, there-

fore, iron free, and it followed from this that it could not

possibly be iron or iron oxide that had reached the lumen ofthe appendix and been translated into its walls. The exactnature of the pigment was a more difficult question. In

general characters it resembled iron-free blood pigment, andits presence was possibly due to the absorption of blood fromthe interior of the appendix. In cases of melæna ProfessorShattock had on several occasions found blood in itslumen. Passing on to the study of a series of appendi-cular concretions, these were examined, after beingincubated in dilute alcohol, by careful scraping whilst

they were rotated beneath water, the whole procedurebeing conducted under a lens. The actual centrewas examined microscopically in toto by removingit to a slide and washing it in Farrant’s medium.In certain cases appendicular concretions formed upon a

foreign body, such as a pin or fruit seed. The presence ofa nucleus, however, was not only unnecessary, but in thegreat majority of cases there was none. The most carefulexamination ad koo demonstrated that there was no

differentiated centre whatever. The common appendicularconcretion, as told microscopically, consisted solely of

undigested plant debris. Cellulose was digested only in thelarge intestine, and by bacterial action alone. The debrisreferred to comprised free spirals, sclerenchymatous cells,the thick-walled, stiff, and sharply pointed hairs from thepericarp of the oat and wheat (abundant in oatmeal andflour), disintegrating wood and bast, &c. These consisted oflignine or cutine, and were incapable of digestion. ProfessorShattock had found no cellulose in the concretions ; thisexcluded the possibility that their formation resulted from adefective digestion of cellulose. The amount of calcareous

deposition (calcium carbonate and calcium phosphate)occurring about the debris which formed the concretionwas variable ; in many examples it was of very limited

extent, the concretions in the wet state being hardlyfirmer than clay. Such deposition was to be ascribedto bacterial action ; the deposit, in fact, might not

inappropriately be termed "appendicular tartar." He hadnot yet met with a proper appendicular calculus ; theconcretions consisted chiefly, or very largely, of vegetabledebris, and the most accurate name for them was that of"stercolith." One factor that might conceivably lead to anincrease in the formation of appendicular concretions, andso to an increase in appendicitis, was the recent rise ofvegetarianism ; a diet consisting almost solely of fruit andvegetable would furnish a greater abundance of indigestibleresidue. In some appendicular concretions there were con-spicuous numbers of oat and wheat hairs ; but ProfessorShattock had not come across a concretion composed solelyof such, and corresponding with the oat-hair concretionsat times met with in the human colon. In the Museum ofthe Royal College of Surgeons of England there were severalspecimens of these curious formations, the first identified

having occurred in a Lancashire carpenter, who was accus-tomed to take oatmeal daily in some or other form at every oneof his meals. The augmentation of intestinal debris, it wastrue, did not, per se, make for the formation of a concretion ;it was necessary to assume an appendicular stasis or some

functional or organic irregularity of the appendix as a secondfactor ; for under normal circumstances free ingress andegress took place from and to the colon. The different causesthat led to stasis in the colon would bring about the samecondition in the appendix; and, given a superabundance ofindigestible residue, the latter would contribute a not

unimportant factor to the origin of a concretion. In factjthere was no very abrupt line between concretions and scybala,and the actual centre of a laminar concretion was at times asmall collection of minute scybala.

In regard to the results of the speaker’s examination of thecontents of 125 appendices from persons dying from othercauses than appendicitis, the observations were made bypinning out the organ, slitting it up under water, and

sweeping out the contents, which were then broken down withthe brush, and carefully irrigated, any sedimentary residuebeing examined in Farrant’s medium. For the present pur-pose it was enough to state that he had in no case discoveredany particles of steel. He had selected for examination100 appendices from individuals over 40 years of age, inorder that ample time might have elapsed for the accumula-tion of metallic ingestion, and 25 from persons between 15and 25 years, since this was the period of the highestincidence of appendicitis. Professor Shattock hadencountered during these examinations two forms of

neoplasm, for the presence of which the patients had notbeen admitted. In one case many small pedunculatedadenomata projected from the mucosa, of the kind whichat times grew in large numbers from the colon. Inthe other case the appendix was the seat of a

typical columnar-celled carcinoma, which was in processof ulceration and had deeply invaded the muscularwall-an exact miniature of a carcinoma of the colon.The general conclusion at which Professor Shattock arrived,therefore, was that no evidence was forthcoming to showthat appendicitis was due to damage inflicted on the mucosaby ingested physical irritants ; and that the appendicularconcretions often associated with acute inflammation werenot attributable to an accumulation of inorganic materialwhich might serve as a nucleus for the subsequent depositionof fæcal debris.

__

SECTION OF ANÆSTHETICS.

The In,fL2cence of Anœsthetics on the Temperature of the

Body.-Exhibition of Apparatus.THE annual general meeting of this section was held on

April 14th, Dr. HAROLD Low, the President, being in thechair.A resolution was unanimously passed expressing the

great loss the section had sustained by the death of SirFrederic Hewitt, M.V.O.

Dr. M. S. PEMBREY and Dr. F. E. SHIPWAY communicateda paper entitled Observations on the Influence of Anæstheticson the Temperature of the Body." In this preliminary paperthey did not refer in detail to the work of previousobservers upon this subject. The influence of anaestheticson the temperature might be exerted upon the loss of heat,the production of heat, or upon both of these processes. Inman the practical methods of observation were the deter’mination of the deep and surface temperatures, and as ameasure of the production of heat the determination of therespiratory exchange. The former method they had used inman, and both methods had been employed by one of themin the case of animals. Deep anaesthesia abolished the

regulation of both the loss and production of heat, so thatthe response of the warm-blooded animal to external heatand cold resembled that seen in cold-blooded animals ; afall of external temperature diminished, a rise increased theproduction of heat. It was this fact which complicated theproblem. The internal temperature of a patient might showa fall, a rise, or no change according to the conditionsinvolved during the period of anaesthesia. A fall in therectal temperature from 100° to 970 F. was within physio-logical range when the whole extent of the daily variation intemperature was considered, but in the case of an anæs-

thetised patient subjected to an operation in a warm

theatre (72°-74° F.) such a fall might occur withinone hour. During short operations of slight severity thenecessity for precautions against the loss of heat was not

urgent, for in an adult there was, owing to the mass ofthe body, a reserve of heat which was not rapidly dissipatedin a hot theatre. In such cases the advantages of warm

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ether as compared with cold ether might not be so apparent. IIOn the other hand, in the case of long operations or opera-tion upon a patient possessing a low resistance the differencemight be of great practical importance. The "openmethod " of giving ether used in these observations wasthat in which ether was dropped continuously on to somefabric spread over a Schimmelbusch mask, which was soclosely applied to the face that the whole of the respiratorycurrent passed through the fabric; when warm anaestheticvapours were given the end of the tube from Dr. Shipway’sapparatus was placed under the mask and warm ether vapourwas pumped in at each inspiration. Either two layers ofdomette or 10-16 layers of gauze were used. With thismethod the temperature under the mask varied from 48.20to 78’8° F. with cold ether, whereas with warm ether it wasabout 90° F. A patient breathed about 5 litres of air perminute, and the expired air was raised to 960 F. or there-abouts. It was obvious, therefore, that more heat must belost from the respiratory tract, although the expired air withcold ether might not be warmed to the same extent. Withsuch an "open method they had never observed a lowertemperature in the inspired air under the mask than 48-2° F.,the temperature of the air of the theatre being 770 F., andsome explanation was necessary for the exceedingly lowtemperatures recorded by some observers. It was necessaryto remember that the air in the mask was being warmedconstantly by the skin of the face and every few seconds bythe expired air. For example, with a Schimmelbusch mask,two layers of domette, and a pad placed over the face’the temperature of the air was 914° to 93-20F. fiveminutes after the mask had been placed over the’face, the temperature of the room being 716° to 73-4° F.The mask and pad were removed from the face and etherdropped upon the domette as during an administration,the temperature of the air fell to 320 F.; they were

immediately placed over the face and within one minute thetemperature of the air rose to 617° F. As regards thetemperature of the body, observations of the rectal tempera-ture were necessary, for the determinations in the mouthwere unreliable. The surface temperature of the skin mightrise under the influence of ether, owing to dilatation of thecutaneous vessels, and thus increase the loss of heat so muchthat the internal temperature fell. With warm ether theloss of heat from the skin could be more readily compensated.The excitability of the medulla was increased by a rise,diminished by a fall, in the internal temperature ; this effectupon the respiratory centre was well known, and in a pro-nounced form was seen in heat polypnoea or dyspnoea. Theheart was stimulated by warmth and the exchange of thegases between the blood and the tissues was facilitated by arise, delayed by a fall, in temperature. A normal man re-acted to external cold by diminishing his loss and increasinghis production of heat; the anaesthetised man, paralysed forsensation and movement, had lost this control, and the levelof the chemical changes which were a measure of vital

activity could be maintained only by external warmth. Thisloss of control involved also the possibility of an abnormalrise in the temperature of the patient if he were exposed toexcessive heat. A great practical advantage of warm vapourswas that they enabled the surgeon to operate in a coolertheatre ; high temperatures had a depressing effect onthe staff. Apart from diminished efficiency and endur-ance, a warm and moist atmosphere introduced thedanger of the sweat of the surgeon undoing theelaborate precautions taken to preserve aseptic conditions.The "open method" was not strictly an open one. Themask placed upon a pad over the face confined the air to aconsiderable extent ; this was shown by the determinationsof the moisture and the carbon dioxide in the air space. Thusthe dry and wet bulb thermometers recorded 88 7° and 86° F.under the mask, and waved in the air of the room 72-5° andfi5-3° F. The breath moistened the air, and thus obviatedthe necessity of adding moisture to the air laden with ethervapour. The amount of carbon dioxide might be 3 or 4 percent. of the total 250 c. c. of air under the mask ; there was,according to the closeness with which the mask was appliedto the face and the thickness of the material, a certainamount of rebreathing, which might be an advantage whenthe stimulating effect of carbon dioxide was required.

Dr. SHIPWAY said he had used warm vapour anaesthesiafor 18 months and had published a description of the method,its advantages, and of an apparatus in THE LANCET ofJan. 8th, 1916. One part of the evidence for the use of

warm vapours had been given in the joint paper just read;the other part was due principally to some Americananaesthetists who had shown by experiments on animals andby clinical observations that warm vapours were safer anddiminished the loss of heat of the ansesthetised patient.He himself had found that the anaesthetic could be pushedwith greater safety and with lessened liability for respirationto become dangerously weak ; the reason was physiological,in that in the ansesthetised patient warmth increased respira-tory activity and stimulated the heart. Induction wasquicker and calmer and respiration was quieter since warmvapours were more easily absorbed and less irritating thancold. Shock was certainly less ; his results had been betterthan with " open ether." An apparatus was then shown bymeans of which the warm vapours of ether, chloroform,or of mixtures of the two could be given in concentrationsadequate for any operation. Other advantages had beenalready described.

Mr. C. CARTER BRAINE did not advocate open ether";he employed the " closed method," working either with theClover or Ormsby inhaler. He thought the pioneers ofether administration in this country had endeavoured toemploy warm ether vapour by the method of rebreathing,by warming the inhaler prior to use, or by warming thesponge of the Ormsby inhaler. He had returned to the useof the Clover of late in place of the Ormsby, and found itan excellent machine in conjunction with morphine andatropine. In order to render the administration of a slightlyopen ether type he had fixed a tap at the lowest part of thebag, by means of which air could be admitted and some ofthe contents of the bag expelled during expiration. Acertain amount of rebreathing was beneficial, and the verysatisfactory results obtained he attributed to the patientbreathing a warm atmosphere with conservation of his CO2,

Mr. G. RowELL said that in two cases of warm etheranaesthesia symptoms of faintness gradually arose whichappeared to be directly associated with the very warm

vapour administered. He preferred many layers of gauzeto two layers of domette, which offered much more obstruc-tion to the breathing. He still employed the Clover onoccasion ; most of the advantages of the open method couldbe gained by using the Clover nearly all the time withoutthe bag.

Mr. H. BELLAMY GARDNER was glad to hear that it wasonly necessary to warm the patient by means of a warm tableand dry cloths, and perhaps preventing the fall of tempera-ture in the vapours inhaled by artificial means, instead of byraising the temperature of the theatre and thereby exhaustingthe patient and those taking part in the operation.

Dr. G. A. H. BARTON was not convinced by the evidenceoffered of the value of the warmed-ether method.

The PRESIDENT said that the question of loss of heat

during anaesthesia was a very vital one, especially since wewere told that in the narcotic state man became a cold-blooded animal and lost for the time being much of hisnormal power of readjustment of his temperature. Thewarm-ether method was therefore to be preferred to that ofthe open-ether method, where the ether was allowed to

evaporate on the mask and in its evaporation to abstract heatfrom the patient. The discussion had narrowed itself toomuch into a controversy between the Clover and the open-ether method. Successful anaesthesia depended more uponthe administrator than upon the apparatus.

Dr. SHIPWAY, in replying, said that the pioneer anres-thetists warmed the inhaler in order to aid the administratorand not in order to help the patient. He had never seen faint-ness or pallor due to the use of warm vapours ; they must beused with judgment, very high temperatures caused sweating,flushing, and oozing in the wound.The PRESIDENT showed an apparatus for the intra-

tracheal insufflation of ether, designed by Mr. K. H.McMillan, of St. Thomas’s Hospital, and Dr. SHIPWAYshowed an apparatus of new design.

Captain C. T. W. HIRSCH,R.A.M.C., showed a modificationof Waller’s chloroform inhaler (see p. 1003).

WEST OF ENGLAND CENTENARIANS.-Mrs. AnnMoore, ot Torrington-place, Plymouth, died last week. Shecelebrated the 105th anniversary of her birthday on Jan. 20th.- mars. Mary Shittler, of Buckshaw Farm, near Sherborne,Dorset, recently celebrated the 102nd anniversary of herbirthday.