822 BRITISH MEDICAL ASSOCIATION : PHYSIOLOGY AND BIOCHEMISTRY.

endocrine function. Certain of these may be relievedby hormone therapy.

3. Those in whom treatment is required :—

(a) General Measures.-Daily life should be so

regulated as to conserve energy and to raise thestandard of vitality. It. is a mistake to try to raisepressures too rapidly. In the former case metabolicbalance may be still further upset, whilst in the latterthrobbing in the head, followed by irritability, maybe induced. Seldom is it necessary, or even possible,to raise pressures to any great extent. Experienceshows that a rise in pressure of only a few millimetresmakes all the difference between comfort and dis-comfort. One should be content gradually to raisepressures to and maintain them at a level whichappears to be the optimum, checking results byreadings at regular intervals. Diet should benourishing, balanced, and easily assimilable. A

sufficiency of vitamins should be ensured. In additionto ordinary drinks, a pint of water for each 5 st. ofbody-weight should be taken daily. As a general rulealcohol is best avoided, but in cases of gastricneurasthenia, or anorexia due to mental or physicalexhaustion, a little stimulant with meals tends torestore vital balance. For exhaustion bed is indicated,followed by rest after the chief meals, and by earlyhours. Exercise should never be persisted in tillbreathlessness, palpitation, or other symptomssupervene. Horse-riding and dancing, within moderatelimits, by sending up arterial pressure to more

standard levels, act as beneficial stimuli. Excessiveexertion depletes vitality and drops pressures tolevels of discomfort. Graduated exercises, at first onthe level and later on prescribed gradients, favouroxidation and counteract respiratory deficiency.These objects are also furthered by physical exercisesof stretching and bending, in combination with deepbreathing. For most hypopietics who live in cold,damp, and changeable climates holidays and sunshineare beneficial. The craving for sunshine is often- greater than that for food.

(b) Special Measures.-Relaxation, passive move-ments, massage with graduated resistance exercises,ultra-violet radiation, static electricity, oxygen foambaths or injections, and hydro- and balneo-therapyall have their appropriate uses. In the majority ofcases of hypopiesis endocrine dysfunction is present.Thyroid gland should not be given in too large doses,otherwise further instability may be added. It shouldbe combined with other glands in accordance withdefinite indications. Next in importance comes thepituitary. Whole gland, in doses up to two grains,thrice daily is given until slight throbbing in thehead or palpitation point to the limit of tolerance.Thereupon the dose should be reduced by half,continued for several weeks in accordance withpressure readings. A convenient method of givingposterior pituitary is by an intranasal spray. Aspitrescin it may be given hypodermically. Wholegland pituitary and suprarenal when administered bymouth are best prescribed with a coating so as torender these glands insoluble in the gastric juice.Pure suprarenal crystalline substance (tab. supra-medulla) is active by mouth, and may be given indosage of gr. 1/1000 up to gr. 1/100 twice daily.Pluriglandular syndromes may originate in disordersof the gonads, but up to now I have found no testicularor ovarian preparation to fulfil its promise. Mostparathyroid preparations by mouth are inert, para-thormone hypodermically or intramuscularly being theonly one that yields appreciable results. As regardsdrugs, ephedrine is one of the most generally useful.It possesses low toxicity and stimulate cardiac action,at the same time increasing basal metabolism andurinary output. The usual dose is gr. - in tablet formby mouth, or hypodermically if more rapid action isdesired. For emergencies, cardiazol or coramine areserviceable. In cardiac failure, nothing equalsstandardised preparations of digitalis in sufficientamount. Similarly with auricular fibrillation, quini-dine being also useful in certain of the more chronicforms if cautiously administered.

In acute infections low arterial pressure is broughtabout by a combination of vasomotor paresis withmyocardial weakness and hormonic depletion. Treat-ment should be directed to whichever of these factorsis in the ascendant. After diphtheria, influenza, andpneumonia it is essential that during convalescencethe heart shall be given prolonged rest. For rheumaticfever rest must be continued for three months or evenlonger, otherwise a state of permanent low pressuremay be entered upon.

BRITISH MEDICAL ASSOCIATION.ANNUAL MEETING IN MANCHESTER.

(Continued from p. 774.)

SECTION OF PHYSIOLOGY ANDBIOCHEMISTRY.

PHYSIOLOGICAL TESTS OF RENAL FUNCTION.

Prof. H. S. RAPER (Manchester) being in thechair, Prof. E. B. VERNEY (London) opened the dis-cussion by defining tests of renal function as observa-tions of the response of the kidney to stimuli super-imposed upon that which it is already receiving, andinterpreted in terms of renal reserve. Renal reserves,he said, were structural, in that there was a largeexcess of renal tissue over and above that which wascompetent to carry on the excretory work duringresting metabolism, and functional, represented byan inherent and variable capacity for the performanceof increased work. He briefly reviewed the work ofA. N. Richards and his colleagues which so clearlyestablishes the existence of these reserves, which, heheld, constituted a first line of defence against theinroads of disease. First, as the work demanded of thekidney increased more units (glomeruli plus tubules)would become active and the rest pauses would bediminished. As the work demanded of each unitincreased further its commencing failure would bereflected in changes in the composition of its secretion,a change exhibiting an approach towards the com-position of blood plasma, such as is seen in thepolyuria of chronic nephritics. This change in com-position indicates a drain on functional, as againstmerely structural, reserves, and is probably initiatedby a change in the glomerular capillary pressure.An analogy was here suggested, said Prof. Verney,

with the work of the heart as observed in the Starlingheart-lung preparation, and he went on to developthe comparison between right auricular and glome-rular capillary pressures. In the kidney, however,the work is osmotic in character, and to all intents akidney engaged in producing a urine having thesame composition as the protein-free filtrate of theblood plasma is doing no work ; failure is complete.As Rose Bradford had demonstrated, a diminutionin the amount of kidney substance led to an increasein the urine production of the remaining tissue.Similarly, a diminution in the anatomical reservesof the kidney was partially or completely com-pensated by an encroachment upon its functionalreserves. Further guidance in the interpretation dfa case was afforded by the facts that the excretionof urea and the substances eliminated by a similarmechanism was dependent mainly upon the amountof kidney substance, that of chloride mainly uponthe rate of urine flow.

In renal failure there were theoretically threetypes to be considered : (1) that due to a severediminution in the number of renal units ; (2) thatdue to a fall in the magnitude of the pressure stimulus;and (3) that due to impairment in the tone of thesecretory units, and possibly there was a clinicalparallel to all three of these, or all might be involvedtogether. Caffeine had been shown to affect thenumber of effective glomeruli and the pressurestimulus, and much might be learnt from the responseto its exhibition under controlled conditions. The

823BHITIHH MEDICAL ASSOCIATION : PHYSIOLOGY AND BtOCHHMfSTRY.

surest indication of renal function would, he con-cluded, be given by administering urea or some

such substances as phenol red, and comparing theelimination in a given time at any given concentra-tion in the blood plasma with that of the normal.Any assessment of renal reserve was, however,fraught with difficulty.

Discus8ion.Sir WILLIAM WILLCOX (London) said he regarded

the information given by blood-urea determinationsas most useful, especially in colon bacillus infections,and in chloroform and alcohol nephritis, but wemust remember that the blood-urea concentrationmight be high without serious import. The indigo-carmine test was useful, but he did not use phenol-sulphone-phthalein as he had found that its excretionmight be identical with that in the normal subjectin a patient at the very onset of ursemia. Observa-tions on the rate and concentration of chlorideexcreted were of great value. He had found caffeinecitrate useful for a short time only, a few days atthe most. There was no doubt, though it was liableto be overlooked, that uraemia might be purelycardiac in origin instead of being due to damagedkidneys.

Prof. E. C. DODDS (London) said that in assessingthe value of a test we must ask ourselves to whataspect of kidney function the test was directed. i

The tests were of value in estimating the extent ofthe lesions in chronic nephritis, with or withoutcedema, in albuminuria prior to the administrationof an anaesthetic, and in renal dwarfism. He recom-mended the estimation in the blood of urea, non-protein-nitrogen, cholesterol, and total protein, theselast two being especially helpful in the oedematoustype of nephritis. Patients with low cholesterol andtotal protein responded well to a high protein diet.As an aid to prognosis in cases of uraemia, he recom-mended the estimation of blood calcium and phos-phorus. He would like to emphasise his view thatthe mere estimation of blood-urea was liable to leadto a fallacy, if a look out was not kept for dehydra-tion, which alone might account for a blood-ureaof over 100 mg. per 100 c.cm. An estimation of thetotal solids of the blood in such a case might show arise from 20 to 28 per cent. As regards urine analysis,if the urea reached 2 per cent. or over gross renalchanges might be regarded as excluded.

Prof. J. SHAW DUNN (Manchester) described theresults of his observations on animals, both normaland diseased. He had so far failed to produce experi-mentally the equivalent of human nephritis. Inman the damage was usually glomerular at first, inanimals there was a tubular necrosis affecting ureaexcretion, but water and chloride excretion was notaffected till later, with the onset of oedema. He hadrepeated Frankson’s work on urea excretion, ureabeing given by the mouth, and was able thus toinduce the non-drinking rabbit to become a water-drinker for the elimination of the urea. In animalswith nephritis urea by the mouth caused a large risein blood-urea when on a dry diet, but no rise inurinary urea, and it was clear that the rise in blood-urea was greater than could be accounted for, asProf. Dodds had suggested, purely by a concentrationof the blood. He would like to stress the importanceof free water-supplies for the excretion of urea, andthe value of dry diet as a test of urea excretion.Mr. H. D. KAV said that a simple and conclusive

test, devoid of ill-effects on the patient, was still tofound, but that the glycerophosphate test, whichhad now been tested on 70 cases at the LondonHospital, had definite advantages over the urea-

concentration and phenol-sulphone-phthalein tests.The principle of the test lay in the estimation of theexcess phosphate excretion after the administrationof sodium /3-glycerophosphate, a chemically puresubstance which was cheap and easily obtainable,harmless, and sterilisable. The routine of’the testwas as follows : At 8 A.M. the bladder is emptied,400 c.cm. of water or weak tea is taken, and at

9.30 A.M. 10 c.cm. of a sterile 8 per cent. aqueoussolution of the drug, corresponding to 550 mg. ofphosphate, is given intravenously. The urine istaken in an hour, and its phosphates estimated afterprecipitating the proteins. The excess of phosphatemay vary from nil (in chronic nephritis) to 250 mg.or more. After a solution had been prepared onlytwo urinary analyses were required, and these couldbe satisfactorily performed by any sensible laboratoryattendant. There was no decomposition of thesubstance to be estimated if the analysis could notbe done at once, and the test was independent of thevolume passed and unaffected by urinary pigment orblood. Their results so far had been as follows :

1. A normal subject excretes at least 150 mg.2. If there be less there is renal involvement, which varies

inversely as the amount excreted.3. The test compares favourably with any other test

as regards the correspondence of its finding with the wholeclinical picture.

Mr. J. B. MACALPINE (Manchester) spoke as a

genito-urinary surgeon who was using these testsconstantly. Estimation of the blood-urea, he found,brought precision to his knowledge, and was a greathelp as a supplement to the clinical picture. Heregarded the tests as widening the rungs of theursemic ladder ; for example, before a prostatectomyhe carried out bladder drainage until the blood-ureafell below the 40 mg. level. Sometimes the drainageprovoked a profuse polyuria. He had got over

200 ounces from one case within 12 hours. Thispolyuria, when extreme, was an unfavourable omen,tending to end with a fatal anuria. As regards testsof the separate function of the kidneys this was acystoscopic problem, and he liked the indigo-carminetest because it was simple, quick, and avoidedureteral catheterisation. He was unwilling, whereit was avoidable, to catheterise a possibly aseptickidney through a septic bladder, and he was not a

. strong believer in the quantitative value of the urea-j concentration and phenol-sulphone-phthalein testsl because he had satisfied himself that urine escaped. around the average ureteral catheter. Mr. Macalpine

also dealt with the problems of hypertrophy and the: great value of pyelography, especially in stone, and, particularly where a stone was seen on one side and, the other kidney seemed to be inactive.

Dr. F. H. SMIRK (Manchester) described the effectson the normal and the nephritic of the administra-tion of water, urea, and caffeine by the mouth. Inthe nephritic the loss of water was slow and delayed,and, after urea, the -urinary urea concentration mighteven fall. After urea the sodium chloride excretionrises in the normal but not in -the nephritic, and of22 normals examined 18 had above 0-8 per cent.sodium chloride, while of 60 nephritics only 4 hadabove 0-8 per cent. He had tried giving grs. 5 ofcaffeine by mouth as a routine test, and found thisincreased the chloride excretion out of all proportionto the other constituents. The urea increase wasless marked. Caffeine caused a greater rise in chloridesthan urea did. .

Prof. E. P. POULTON (London) took Prof. Verneyto task for not developing, from his extremely valu-able observations on kidney function, a physiologicaltheory of Bright’s disease. To the glomerular filtrate,which could be increased by caffeine, the tubuleadded urea and subtracted chloride and (at a moredistal point) water. Bright’s disease was primarilydue to impervious glomeruli. He did not approveof Calvert’s test, and thought that half the value ofthe urea-concentration test was lost if the totalexcretion was not considered as well as the con-

centration.Mr. J. SWIFT JOLY (London) thought that, from

the surgeon’s point of view, an excretion of 1 grammeof urea per hour was satisfactory. He agreed withProf. Poulton that for this water was necessary.

I

Reply.Prof. VERNEY said there was so much disagreement

as to the precise location of the functions of the

824 BRITISH MEDICAL ASSOCIATION: PUBLIC HEALTH.

kidney in the organ itself that he preferred nut todissociate entirely glomerulus and tubule. lie hadbeen very pleased to hear of the use of the caffeinetest by Dr. Smirk, and was full of admiration forMr. Kay’s contribution to the discussion.

SECTION OF PUBLIC HEALTH.

HUMAN TUBERCULOSIS OF BOVINE ORIGIN.

Dr. W. G. SAVAGE (M.O.H., Somerset), in opening Ithe discussion, estimated the human deaths causedannually by the bovine tubercle bacillus at 2000 to2300. Most of them were the deaths of children, andwe had no knowledge as to how many non-fatalinfections occurred. As to the extent of bovinetuberculosis among cattle in this country, he thoughtthat about 40 per cent. of the cows were infected ; Ithat about 1 per cent. of the cows were " opencases ; and that about 0-3 per cent. had tuberculosisof the udder. He passed on to consider methodsfor the reduction of the prevalence of tuberculosis incattle under five heads :-

(1) Elimination of all tuberculous cattle-viz., bythe destruction of reactors. This could be donesuccessfully in small areas—e.g., the Channel Islands.It was the official plan in the U.S.A., where 207,830tuberculous cattle were slaughtered in 1927. Theaverage percentage of reactors in the U.S.A. was only3-3, and it would be impracticable in England withmore than ten times that percentage of reactors toadopt the elimination plan.

(2) Building up of herds free from tuberculosis.-Theprocedure advocated by Prof. Bang was theoreticallyeasy, but there were many administrative difficulties,and the method even in Denmark had not made theprogress that was expected. The same principle hadbeen followed in England with regard to Certified andGrade A (T.T.) milks, but the increase in the numberof herds, which produced these two designated milks,had been slow. At the end of September, 1928,

there were only 152 Certified and 207 Grade A (T.T.)milk producers-an entirely insignificant proportionof the whole. In Somerset, with at least 7300 pro-ducers, there were only 11 producers of these twotypes of milk at the end of 1928. This method couldnot, therefore, be regarded as a practical solution ofour problem.

(3) Elimination of particular classes of tuberculouscows.-Theoretically we could reduce the infectionamong bovines and the risk to humans if we eliminatedall infectious cows. In fact, however, partly fromadministrative but mainly from scientific difficultiesthese animals were not removed from the herds assoon as they became " open " cases, but only afterthey had done most of the harm they were capable ofdoing. The discovery of the infectious cases was notbeing followed up by a systematic examination of theother animals, and the cases of tuberculosis of theudder were not being detected until after the milk-supply had been affected for long periods. Syste-

matic veterinary inspection was being urged as ameans for the reduction of the amount of bovinetuberculosis. The first difficulty was that the ablestveterinary inspector could not detect infectiousanimals in their early stages, and the second difficultywas that financial considerations severely limited thefrequency of inspection. The third difficulty was :Would the removal of some of the infection in the caseof physiologically overlooked cows play any decisivepart in reducing the amount of bovine tuberculosis ?The figures available from places where routineinspection has been in vogue for years did not showany such reduction. He estimated the cost of anadequate system of veterinary inspection at aboutz6300,000 a year, and was of opinion that veterinaryinspection must stand or fall on its merits as a meansof reducing bovine tuberculosis. The onus was ontheir veterinary friends to demonstrate that veterinaryinspection could bring about such a reduction. If itcould, it was a true preventive measure and worththe price.

(4) Measures directly airraed at reducing the amountof tubercle bacilli in 7rei.llc.-When milk was found tocontain tubercle bacilli, it was feasible in somethinglike 60 per cent. of the cases to find an infective animaland eliminate her, but only an insignificant proportionof the milk-supply was tested for tubercle bacilli,and after the expenditure of public money in searchingout the cow with the tuberculous udder the farmerwas in no way penalised, but, on the contrary,received compensation for the cow. Pasteurisationof the milk-supply would probably largely eliminatethe dangers of tuberculous milk. Its adoption wouldbe a confession of failure, and the acceptance of thesecond-best.

(5) Immunisation of cows against tuberculosis.-Calmette’s vaccine was on trial, and should be veryfully tested, but the latest results were not veryfavourable.

After considering the various remedies advocated,Dr. Savage went on to summarise his suggestions.Routine veterinary inspection as a thing by itself heconsidered was not worth doing, but it occupied quitea different place as part of a comprehensive attack onbovine tuberculosis. The cow should be kept undermuch more open-air conditions. A more activeeducational campaign must be undertaken. Part ofthe onus of preventing the spread of infection must beput on the cow-keeper. Feeding problems and otherfactors likely to affect tuberculosis must be carefullyconsidered. In such a comprehensive scheme im-munisation experiments, the formation of tubercle,free herds, the operation of a modified TuberculosisOrder, and the routine veterinary inspection of cowswill all find a place. If the agricultural communitywas not prepared to cooperate actively in the schemesof the State, and of local authorities for reducingthe incidence of bovine tuberculosis, pasteurisationseemed less of an evil than "the present tinkeringprocedures." He himself, however, favoured theadoption of a comprehensive scheme such as he hadindicated.

Discussion.

Colonel J. W. BRITTLEBANK (Chief VeterinaryOfficer, Manchester) thought that Dr. Savage wasunduly pessimistic. He estimated the loss to agri-culture through bovine tuberculosis at .81,000,000annually. He thought something had been done toreduce the incidence of tuberculosis by veterinaryinspection in Manchester from 1904 onwards. TheWest Riding, Cumberland, and Durham had alladopted veterinary inspection, and such schemesshould not be limited to inspection, but includefeeding, housing, management, &c.

Mr. A. GoFTON, M.R.C.V.S. (Edinburgh), thoughtDr. Savage’s figures of the incidence of bovine tuber-culosis were too low, and that the percentage of cowswith tuberculous udders in Edinburgh was nearer0-5 than 0-3. The designated milk scheme had madea great appeal to the agricultural community, andthe safe milk in question, in both Edinburgh andGlasgow, very largely went to the children who weremost at risk. He regarded the Tuberculosis Orderas purely a public health measure, and he believedthat the Order and veterinary inspection had beeninstrumental in bringing about a reduction in theincidence of tuberculosis among Edinburgh children.

Dr. F. H. MoRisoN (M.O.H., Cumberland) thoughtthat 5 per cent. of the cows had diagnosable tuber-culosis. He referred to the dope use of tuberculine,and to the difficulty in maintaining herds free fromtuberculosis. He had found Certified milk highlyinfected with tubercle bacilli. The graded milkswere a failure, and pasteurisation was only doubtfullysafe. He believed that milk dried by the rollerprocess was the best solution, and he looked forwardto the establishment of milk-drying factories through-out the country.

Dr. T. EUSTACE HILL (M.O.H., Co. Durham)said that his county had just appointed a chiefveterinary surgeon and four whole-time assistants.They would both inspect the cattle and preach

825l3ItITISII MEDICAL ASSpCIAT’1<)N : ANAESTHETICS.

sanitation. He anticipated an enormous improve-ment in the sanitation of the cow-sheds as a result.When milk samples were found to be tuberculousthey usually succeeded in finding the offending cow.They had found the direct microscopical test quiteuseful in saving the delay incidental to the biologicaltest.

Dr. MIDDLETON MARTIN (M.O.H., Gloucestershire)said that their cattle were examined every half yearby part-time veterinary surgeons, but that they seemedto get the same percentage of emaciation, &c., ateach inspection.

Dr. VEITCH CLARK (Manchester) stated that theyhad succeeded in maintaining a tubercle-free herd forsupplying the local hospitals.

Reply.Dr. SAVAGE remarked that Colonel Brittlebank had

not answered his question as to the resistance toinfection of a physiologically overworked cow. Ifinspection was to be adopted it must be thoroughlydone, and at least every quarter, and, of course, if thecows were out at grass, it was the farmer’s business tobring them in for the inspection.

SECTION OF ANAESTHETICS.

SPINAL ANAESTHESIA WITH SPINOCAIN.

Dr. GEORGE P. PITKIN (New Jersey, U.S.A.) gavean account of the experimental work done by himselfand his co-workers in producing what he claims to bea controllable spinal anaesthetic. They set out, hesaid, to produce a spinal anaesthetic that wouldminimise toxic reactions, be certain in effect, constantin duration, act in direct ratio to the amount ofanaesthetic agent injected, and be without effect onthe heart action, vascular tension, and respiratoryfunction. The chief factor in the control of a spinalanaesthetic being to prevent its diffusion in the sub-arachnoid space, they had tried to find a substancewhich would prevent this diffusion until the anaesthetichad been absorbed. They had evolved what, for thelack of a better name, was called amyloprolamin ;it was derived from gliadin, the mucilaginous contentof wheat starch. They had also determined thecapacity of the dural sac at various heights in adultsand in children of different ages. Novocain waschosen from the other drugs used in spinal anaestheticsas giving a complete anaesthesia of the sensory nerves,affecting the tactile and muscular sensation onlyslightly, not increasing the cell count of the spinalfluid, and not raising the intradural pressure. Faultytechnique was responsible for the production of hypo-tonic headaches, which were more often seen whenthe puncture was made with the patient sitting up,owing to the greater amount of spinal fluid lost. Toprevent extensive trauma of the dura the use ofneedles of small gauge with a short bevel was advisable.As a result of these experiments and reports on overa thousand inductions they were now justified inasserting that spinocain was controllable within thedural sac. This method of producing spinal anaesthesiahad been developed as a protection to the surgeon,owing to the difficulty of procuring expert anaesthe-tists, the large proportion of anaesthetics in theUnited States being given by nurses who were merelytechnicians. He considered it important that thetechnique of giving spinocain should be in experthands. Dr. Pitkin concluded by showing on thescreen the essential points of his method.

Dr. FRANK A. KELLY (Detroit) limited himself tothe clinical aspects of controllable anaesthesia. Hesaid that Dr. Pitkin’s technique had negatived allprevious objections to spinal anaesthetics. Thetransitory nature of the anaesthetic had been correctedby the addition of a mucilaginous substance, theheight and extent of the anaesthesia was controlledby the tilting of the table, the depression in bloodpressure-so often a serious objection in the past-was prevented by the preoperative injection of ephe-

drine. Another safety factor of great importance wasthe use of the lighter gravity solution, for if a seriousfall in blood pressure occurred the head of the tablecould be lowered so as to prevent cerebral anaemia.What they called low anaesthesia was a true sacralor caudal anaesthesia where only the perineum,vagina, and rectum were involved, together with thesaddle area on the inner side of the thigh. In orderto obtain this, one-half of an ampoule of spinocainwas injected at the fourth lumbar interspace, andthe patient immediately tipped into at least a 15&deg;Trendelenburg position, the degree being reckonedby Dr. Pitkin’s tiltometer. What they called highanaesthesia extended to the costal arch, and wasobtained by injecting the anaesthetising agent intothe first lumbar interspace and mixing it with 6 c.cm.of spinal fluid ; when this anaesthesia extended tothe costal arch it was considered complete, and thepatient was placed in the Trendelenburg position tostop the upward extension. His experience in doingvery high abdominal work was that if the anaesthesia.was carried to a level high enough to allow the opera-tion to be completed without difficulty, some patientscomplained of difficulty in breathing and a feeling ofweakness. It was therefore his practice to limit thespinal anaesthetic, and to supplement it with an inter-costal block of the eighth, ninth, tenth, and eleventhcostal nerves at the angle. Ephedrine before thespinal injection prevented any fall in blood pressure ;the drug, given intramuscularly or subcutaneously,acted as rapidly as when it was given intravenously,in contrast to adrenalin which, in skin or muscle,caused a local ischaemia, but was quickly absorbedintravenously, though its action was transitory. Ina cinema demonstration Dr. Kelly showed points oftechnique, including a common fault in the positionof the patient, resulting in a " corkscrew spine."He demonstrated the presence of peristaltic actionduring an abdominal operation under spinal anoes-thesia, and explained it by the unopposed action ofthe sympathetic and vagal nerves, due to the blockingof the vasomotor nerves. Barbital, he said, wasregarded as an antidote to novocain poisoning, buthe had never had occasion to use it.

Dr. E. FALKNER HILL (Manchester) agreed thatDr. Pitkin’s method did away with previous objectionsto spinal anaesthesia. From his own experience ofthe method, however, he was inclined to think thatthere was some fall in blood pressure due to operativeprocedure, but this was not a bad thing for the patient.He gave illustrations from bad surgical risk cases insome of which he had given chloroform and ether aswell. He did not think that strychnine should beincluded in the anaesthetic solution, as it increasedthe irritability of the spinal canal.

Dr. A. L. FLEMING (Bristol) said he hoped Dr.Pitkin and Dr. Kelly might come to give their patientsthe benefit of inhalation anaesthetic as well. Peri-stalsis, he thought, was not always inhibited underan inhalation anaesthetic ; he had seen it on one ortwo occasions.

Dr. K. B. PiNsoN (Manchester) gave his experienceof stovaine and novocain anaesthesia ; he had hadonly 55 per cent. of complete success on all counts,from the point of view of patient, operation, andrecovery. He was much struck by the absence ofshock with this method. He considered that 45 percent. of failures made the use of spinocain somethingof an experiment; they might have been due to thehuman response to novocain. An improvement in thesolution might obviate the difficulties.

Dr. W. SALISBURY (Northampton) narrated hissuccess with stovaine and glucose in shock-producingoperations. He always used the heavy solution, andattributed his success to attention to small points oftechnique.Dr.DoNAUD said he had had a happy experi-

ence of spinocain in some cases ; his six partial failureswere all in young virile men with acute appendicitis.He thought that women and patients with loweredresistance did better under spinocain. He found it

826 REVIEWS AND NOTICES OF BOOK.

difficult to decide whether the good effects he notedwere due to the spinocain or ephedrine.

Dr. E. A. GERRARD (Manchester) gave an accountof the use of spinocain in obstetrical work, notingthe ease with which the cervix dilated, the extremerelaxation of the perineum, and the delight of thepatient. The parturient woman could bear downbetter, because the pressure of the head on theperineum was not too painful. For instrumentaldelivery he advised that the anaesthetic should becarried higher than the sacral or caudal type ; pituitrinshould in any case be used with care.

Demonstrations.Dr. G. A. ScHWARTZ (New York) gave a demon-

stration of the apparatus used in intratrachealanaesthesia and resuscitation by the Flagg method.He showed on the screen the intubation of the larynxby a flexible catheter, and a simple method of main-taining the anaesthesia by fixing a tube connectedwith the catheter to a can of ether. He also demon-strated on the screen the resuscitation of a new-bornchild with oxygen and carbon dioxide through apharyngeal tube. ’

Dr. F. L. RICHARDSON (Boston, U.S.A.) gave acinema demonstration on the teaching of anaesthetics.The student, he said, should be taught to give one ortwo drugs well; it was not possible to teach every-thing by the film, but important points could bebrought out by slowing down the projection. Thedemonstration included the administration of spino-cain and ether vapour.

Avertin.Dr. G. EDWARDS (London) read a paper on the use

of avertin or tri-brom-ethyl-alcohol, a white crystallinesolid, soluble in water to the extent of 3i per cent. atbody temperature. Introduced in solution into therectum it was readily ,absorbed, appearing in theurine in combination with glycuronic acid. Avertinwas a basal narcotic ; once a patient was under itsinfluence only a very small quantity of inhalationanaesthetic was required to make the anaesthesiacomplete. The anaesthetic could be given in the wardwithout fuss, induction was gradual, and though thenarcosis had been light there was no memory ofanything unpleasant. Avertin was of particularvalue in dealing with highly nervous patients, withcases of Graves’s disease, and with children. Avertinwas contra-indicated in ulcerated conditions of therectum and colon, in the presence of severe renal andhepatic disease, acidosis, and serious blood diseases.On the other hand, cases of hyperthyroidism toleratedmassive doses of avertin and could eliminate themquickly. The fall in blood pressure was usually withinthe limits of that observed in deep sleep, between10 and 30 mm. Hg. The respiratory centre wasdepressed, and a slight cyanosis was usually observed,more particularly after a preliminary dose of morphia.Marked cyanosis did not occur if the dose had notexceeded 0-1 g. per kilo of body-weight, and the airwaywas kept clear. Anaesthesia took 20-30 minutes toreach completion, the ocular reflexes disappeared inthe usual way, and a skin reflex might remain. Asudden blast of strong ether vapour might produce acough-a useful preliminary test to determine howmuch inhalation anaesthetic would be needed. Theactual administration was simple ; some observersthought it good to give a sedative overnight. Theusual duration of narcosis was 1 i-2 hours from thetime of injection ; about four hours from the startthe patient was usually quite conscious. In onlyone case had he seen any trouble directly due to theavertin anaesthesia ; in this case 1 the patient died20 hours after the administration of a dose at therate of 0’125 g. per kilo. Probably a deficiency ofthyroid secretion had diminished the power ofdetoxicating and eliminating the drug. In delayedreturn to consciousness the respiration might bestimulated by injection of lobeline or inhaling carbon

1 See THE LANCET, 1929, i., 1365.

dioxide and oxygen, the circulation by injections ofephedrine.

Dr. E. F. HILL (Manchester) suggested that avertin,combined with spinal anaesthesia, would be an idealanaesthetic.

Dr. H. P. FAIBUE (Glasgow) described a case inwhich the patient did not respond well to avertin,but with gas-oxygen the operation went off well.The trouble with avertin began six hours after opera-tion, when there was intense rectal irritation withdiarrhoea and passage of mucus. He considered thedeath-rate with this method was unduly high.

Reviews and Notices of Books.PHYSIOLOGY.

Bainbridge and ltlenzies’ Essentials of Physiology.Sixth edition. Edited by H. HARTRIDGE, M.A.,M.D., Sc.D., F.R.S., Professor of Physiology,University of London. London : Longmans,Green and Co. 1929. Pp. 497. 14s.

Elements of Physiology. By E. G. MARTIN, Ph.D.,Professor of Physiology, Stanford University,California; and F. W. WEYMOUTH, Ph.D., Asso-ciate Professor of Physiology in the University.Philadelphia : Lea and Febiger. Pp. 784.

THE sixth edition of Bainbridge and Menzies’" Essentials of Physiology " has been revised andbrought up to date by Prof. Hartridge. The bookretains its original character-that is, it gives in aclear, dogmatic manner a brief but adequate accountof human physiology. Certain sections are perhapstoo brief-for example, the section on reproduction.Prof. Hartridge has, however, found space to mentiona great deal of new work without materially increasingthe size of the book. The new chapters on exerciseand work, and on the nervous system are excellent-the diagrams in the latter being particularly good.Unfortunately, a few mistakes have been allowed tocreep in-for example, on p. 495 we read that " Parkesand his co-workers have extracted from ovariantissue a substance ’ cestrin’ which causes menstrua-tion when injected into the blood," whereas, ofcourse, it does not. The use in the index of thicktype for the principal subdivisions under each letterfacilitates quick reference to any subject.

Dr. Martin and his colleague have written theirbook with the object of expressing a point of viewrather than that of teaching examination students.They explain in their preface that they have tried topresent the subject of physiology " by developmentof two key-principles." The first consists in theapplication of physico-chemical laws to physiologicalprocesses, and the second is that " every proto-plasmic cell is inherently a self-sustaining system."The book is divided into four chief sections, the firsttwo of which contain material usually found in workson general physiology. It is written with little regardfor economy of words ; moreover, these tend to bearranged in sequences which seem strange to Englishreaders. The second section of the book deals moresystematically with human physiology. It is, how-ever, very unequal, and the arrangement makes itdifficult to read. For example, the section on therespiratory system does not mention haemoglobin-for that we must turn to the earlier section on generalphysiology; in the section on digestion, the pancreasis discussed without mention of insulin, and here, too,we must refer back to the earlier section for completeinformation. Great prominence is given to the specialsenses, at the expense of other subjects ; the sectionon the special senses contains 216 pages, that on thecentral nervous system only 45. From these examplesit will be seen that the " key-principles " have notenabled the authors to give us a very clear generalview of physiology.