SUMMER MORTALITY IN IRISH TOWNS.

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SPINAL ANÆSTHESIA BY STOVAINE AND STRYCHNINE. DURING the visit to London of M.

Jonnesco, Dean of the Faculty of Medicine in the University of Bukharest, members of the profession have had an opportunity of observing the latest development of spinal anaesthesia in the hands of its originator. On Friday last, Nov. 19th, M. Jonnesco delivered a lecture before the Surgical and Anaesthetics Sections of the Royal Society of Medicine, in which he dealt with many features of his subject, and we give here a brief account of certain cases at the IDreadnought,"where, through the courtesy of the staff of the hospital, M Jonnesco was enabled The patients upon whom the to demonstrate his method. method was shown were three in number, and we must say at once that the results did not bear out all the claims made by M. Jonnesco in his published statements. At the same time it is to be remembered that, speaking no English, the operator was unable to gain the confidence on the patient’s part of which he is wont to avail himself. To be able to talk to the conscious patient, to reassure him, and to distract his attention are aids to success which M. Jonnesco usually employs, and which were, of course, denied him in the case of patients whose language is unknown to him. Moreover, he had not himself prepared the ingredients which he used for injection, although these were prepared, we understand, exactly in accordance with his directions. Again, he was showing something new to a large and keenly interested gathering of medical men, and it may be that the comparative want of success was due in part to his natural eagerness to show quickly those effects which perhaps would have been obvious if more time had been allowed for their development. The first case was that of a young man requiring operation for a breaking-down glandular mass on the left side of the neck. The patient was a good subject, not nervous or frightened, of healthy colour, and of fair intelligence. Sitting up, he was injected between the first and second dorsal vertebrse with 1 cubic centimetre of solution which contained 3 centigrammes of stovaine and 2 milligramme of strychnine. After the he was for about a minute and was then injection kept sitting told to lie down, his head resting on a pillow. After about a minute in this position his head was lowered below the level of his shoulders for about half a minute and then placed again on the pillow. There were now some retching and moistening of the lips with the tongue. He was told to turn his head to the right, and all the surgical preparations having been previously made and a piece of lint lightly placed over the patient’s eyes, M. Jonnesco at once made the incision. There was no evidence of pain, and it was obvious that the patient was unaware that he had been cut. Vessels were picked up and tied, the same quiet condition persisting. When, however, a little dragging of tissues was necessary to expose glands or to secure bleeding vessels there was almost continuous moaning on the patient’s part. In answer to questions, however, he admitted that what he felt was not very bad. The skin suturing caused him no sensation at all. This case, then, demonstrated the truth of M. Jonnesco’s assertion that it is possible with perfect safety to inject his solution high up in the spinal canal, and to place the patient in such a position that presumably the solution reaches the brain. There was no evidence of any respiratory paresis, nor of any effect at all upon the medulla, unless the short attack of retching be regarded as such. The colour was well preserved, and the way in which cut arteries spurted showed that there was no depression of circulatory vigour. The skin anxsthesia in this case descended to the level of the middle of the thighs. The corneæ were insensitive to touch, and the arms were paralysed. After-effects were limited to severe headache of some hours’ duration. From

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operation lasted about 15 minutes, was during the time of operation almost perfectly successful. The only drawback was that moaning to which reference has been made. On the next case, a laparotomy for gastric carcinoma, the same judgment cannot be passed. Here there was not only groaning but straining expiration which interfered with the surgeon’s manipulations to an undesirable extent. In fact, it appeared to us that had a gastroenterostomy been attempted it could not have been carried through with the degree of anaesthesia provided. To what extent the straining was due to sensation of pain on the patient’s part we cannot say. It became more obvious when the parietal peritoneum was incised, but it was aroused ta. As there was found a mass. some extent by the skin cut too. of carcinoma in the cardiac portion of the stomach the abdomen was closed. The injection in this case had. been made between the twelfth dorsal and first . lumbar vertebral spines. In the third case the high in was made order to procure anaesthesia injection for a mastoid operation. After two injections, although the skin was perfectly analgesic there was so much agitation on the part of the patient, a boy, when periosteum was dealt with that chloroform was resorted to and the operation performed under its influence. M. Jonnesco lays great stress upon the importance of not sterilising the stovaine itself. The chemists who prepared the stovaine for this occasion declare that it was not sterilised. Its behaviour, however, suggested to some that in reality there had perhaps been a mistake in this respect and that to this the want of. complete success in the demonstration may have been due. SUMMER MORTALITY IN IRISH TOWNS. THE

Registrar-General’s quarterly summary of his weekly during the three months ending with September last shows that the annual rate of mortality during this period in the 22 town districts of Ireland, with an estimated population of 1,142,398, was equal to 15 ’8 per 1000, and exceeded by 4-0 per 1000, or no less than 34 per cent., the mean annual rate during the same period in the 76 largest English towns. This great excess of mortality in the returns

Irish" towns is the more remarkable in view of the fact that 16 of the 22 town districts consist of small towns with populations under 14,000, whereas the smallest of the 76 English towns has an estimated population exceeding 50,000. The annual death-rate during last quarter in the six largest Irish towns was equal to 13.1 in Limerick, 14.6 in Belfast, 15-1 in Londonderry, 17-1 in Dublin, 18.5 in Waterford, and 19.0 in Cork ; it should be noted that only in Dublin, Belfast, and Cork does the population of these Irish towns exceed 50,000. Even in the 16 small town. districts, including two with populations under 8000, the mean annual death-rate last quarter was equal to 14-7 per 1000, which exceeded by 2-9 per 1000 the mean rate in the 76 largest English towns. Infant mortality in the aggregate of the 22 Irish town districts during last quarter, measured by the deaths under one year to births registered, was equal to. 139 per 1000, whereas in the 76 large English towns it did not exceed 119 per 1000; it was equal to 143 in Dublin, 152 in Belfast, 136 in Cork, 147 in Londonderry, 117 in, Limerick, and 232 in Waterford. In the 16 smaller town, districts, however, the mean rate of infant mortality last quarter did not exceed 98 per 1000. The annual rate of mortality from the principal epidemic diseases in the 22. Irish towns last quarter was equal to 2’ 0 per 1000, while in the 76 English towns it did not exceed 1.6per 1000 ; this rate from the principal epidemic diseases in the six largest Irish towns was equal to 1-9in Limerick, 2 .0 in Dublin 2’2 in Belfast and in Londonderry, 3.1 in Cork, and 5-4 in,

1608 Waterford. The mean rate from those epidemic diseases in the 16 smallest town districts did not exceed 0’88 per 1000 ; of the 585 deaths during last quarter in the 22 Irish towns 390 resulted from diarrhoea, 112 from whooping-cough, 28 from diphtheria, and 25 from enteric fever; 358 of the 390 fatal cases of diarrhoea, all but one of the 112 from whooping-cough, 24 of the 28 from diphtheria, and 23 of the 25 from enteric fever occurred in the six largest Irish towns. These statistics relating to last quarter make it impossible to doubt that the sanitary condition of the largest Irish towns compares very unfavourably with that of the largest English towns having far larger populations. The marked excess of infant mortality last quarter in the six largest Irish towns is the more noteworthy because the general rate of infant mortality in Ireland is, as a rule, distinctly lower than that recorded either in England or in Scotland. DELAYED POISONING AFTER CHLOROFORM INHALATION.

Johns,Hopkins Hospital .Bulletin for September Whipple and Dr. J. A. Sperry have published an important paper on so-called delayed poisoning by chloroform based on an extensive experimental investigation in animals and on one remarkable case in man. They have advanced our knowledge a stage. Recent researches have proved that chloroform narcosis in animals for any considerable length of time may in some cases cause central necrosis of the hepatic lobules, and this condition if When recovery occurs repair of this extreme is fatal. I-NT the Dr. G. H.

necrosis, which may have involved one-half or more of every lobule in the liver, is very rapid, and the organ is restored

by absorption of the necrotic cells and multiplication of the remaining cells in two or three weeks. By administering chloroform to dogs for some hours Dr. Whipple and Dr. Sperry induced pathological changes similar to that occasionally observed in man after chloroform inhalation. The animals recovered from the anaesthetic and appeared well, but after a time they began to vomit and someto normal

times diarrhoea occurred. Drowsiness followed and terin death minated after one to four days. Postmortem examination showed central hyaline necrosis of the hepatic lobules, which was sometimes so extreme as to involve all the hepatic cells except a row or two about the portal spaces. There was fatty degeneration of the cells, which was most intense in the boundary zone between the central necrosis and the intact cells about the portal spaces. There was also fatty degeneration of the kidneys and heart. In some cases small submucous hæmorrhages and shallow ulcers, from which there were found in the was sometimes much haemorrhage, and duodenum. Why the hepatic necrosis pro.stomach duced by chloroform should be central is not easy It is well known that in human and animal to say. pathology central necrosis is common and peripheral necrosis is rare. By prolonged chloroform inhalation the necrosis may be made to extend until every hepatic cell is killed except a row or two about the portal spaces. The explanation of the distribution of the necrosis seems to be that lack of arterial blood or accumulation of waste products in the blood (which flows from the periphery to the centre of the lobule) renders the central cells more susceptible to the poison. Dr. Whipple and Dr. Sperry report the following remarkable case in which they believe fatal delayed chloroform poisoning followed a minor operation. A well-nourished negress, aged 19 years, was admitted to hospital with tuberculous cervical glands in the neck and right axilla. In the axilla was a lump which discharged pus. Under chloroform abscesses in the chest wall and axilla were incised and

drained. The duration of the anaesthesia was 35 minutes. The patient stood the operation wall and rapidly recovered from the anaesthetic. But vomiting began in the night and continued on the following day, when there were muscular tremors in the arms and legs, delirium, and slight jaundice of the sclerotics. Convulsions and coma followed, and death occurred at 6.40 P.M. The urine contained a trace of albumin and a few hyaline casts but no acetone. The necropsy showed extreme central necrosis of the hepatic lobules and fatty degeneration of the kidneys and heart. It is stated that ether anaesthesia causes similar visceral changes, but this is denied by Lengeman and others who have found that even prolonged anaesthesia causes no damage to the viscera. It has long been recognised that chloroform, like many other poisons, will, under certain circumstances, produce certain pathological changes in the organs concerned in the metabolism of the body. It has been shown pretty conclusively that chloroform is only one of many factors which are concerned in producing these changes. In ’many of the cases which have been published such extremely small quantities of the anæsthetic have entered the circulation that no doubt can be entertained upon this point. The original workers in this field-Thiene, Fischer, and Strassburg-demonstrated that concentrated doses of chloroform, when given for a long time or repeated within short intervals, cause the curious lesions to which Dr. Whipple and Dr. Sperry refer, but it is all-important to recognise that chloroform in appropriate percentages does not necessarily cause them. It may do so if other contributory circumstances exist, but the fact remains that of the thousands upon thousands of persons who have inhaled chloroform the large proportion have done so without developing acidosis and degenerative changes in the liver. Research in this direction appears to prove the danger of chloroform in concentration and to emphasise that its safety lies, not only in avoiding the classic dangers of respiratory failure and undue fall in blood pressure, but also in restricting the quantity employed to the bare needs of anaesthesia. Deep and prolonged narcosis carries with it the danger of chloroform toxaemia, the destruction of the protoplasm of certain organs of the body, and our present knowledge, due largely to the work of Professor Moore and Dr. Roaf, explains how this destruction may be brought about. We know also that deep narcosis is seldom, if ever, needed in surgery, and certainly need never be greatly prolonged. It would be matter of regret if such work as that of Dr. Whipple and Dr. Sperry were read to mean that chloroform as such possessed intrinsic and uncontrollable toxic properties; to us it seems rather to add one more argument in favour of using chloroform in a scientific manner and by definite doses.

SCIENTIFIC CHILD-STUDY. WE have received a letter signed by Professor J. J. Findlay, President of the Child-Study Society, and Sir Edward Brabrook, its chairman, saying that the council of the society in its effort to place its work on a scientific basis has approached Professor Karl Pearson, F.R.S., who with his laboratory at University College, London, is in a position to render exceptional service. Professor Pearson has drafted a schedule for studying the factors influencing the social life of the child, which he desires to have filled in by heads of families or by teachers intimate with families. The number in the family need not be large, but particulars of father, mother, and at least two children are required. It is considered more important that the schedule should be filled up for families of the upper, middle, or professional classes. The schedules are being distributed through the branch