respiration and anÆsthesia
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UNIVERSITY REFORM IN LONDON.1
"Ne quid nimis."
FOR those who have and those who have not studiedthe difficulties to which the University of Londonhas been ever subjected, a volume entitled " UniversityReform in London," by Mr. T. L. Humberstone,which includes chapters that have already appearedin the Times, the Journal of Education, and elsewhere,makes interesting reading. For those who have hadoccasion to watch the various controversies as theydeveloped the book will have its pathetic side, whenit is recognised that voluminous discussions, in whichmen lost their temper as well as the general threadof the debate, can be fairly reduced in a detailedhistory to a few lines of summary. This is not to saythat Mr. Humberstone’s story takes the place, forthose who want a fully detailed record, of the writingsof Sir William Allchin, the reports of various Com-missions, and the plenteous serial literature whichwas topical at the different dates; but this smallvolume does enable us to see clearly why and howmany of the large and bitter divergencies of opinionhave arisen.
The attempt to reconcile the ideals of an Imperialexamining board with those of a teaching universityhas been the origin of many schemes during the last75 years, resulting in proposals for the creation offive or more separate universities, or at any rate of finstitutions having the right to grant degrees ; andall of these various movements have been due tothe firm belief of their sponsors that only in theirparticular way could wisdom be advanced andparticular sections of students obtain their best chance.The part that medicine has played in the controversieshas been significant, because a faculty of medicinecannot be imagined which takes into considerationonly an examining board and not the schools whereinstruction is given. Again, the fact that, while themetropolis contains a group of the finest medicalschools in the world, the university of the metropolisdoes not offer the students opportunities of graduationcomparable to those obtaining elsewhere has neededconstant recollection ; we may all know the pros andcons of this situation, and how far it has recentlyundergone modification, without feeling that theinequalities have been removed. The medical aspectof the affairs of London University is not, however,any special feature of Mr. Humberstone’s book,though he is clearly aware of the position while dis-cussing the Selborne, the Gresham, and the HaldaneCommissions. A particularly interesting chaptermakes the complicated episode of the ImperialCollege of Science and Technology comprehensible,and this is followed by a setting out of the argumentsfor a single university for London with a summary ofrecent work under the present charter.On the vexed question of a central site, Mr.
Humberstone has no doubts ; he is in favour of theplacing of the university on the Bloomsbury sitewhere the area available could be profitably used " foradministrative buildings, halls, libraries, headquartersfor University societies, and for the Officers’ TrainingCorps, for residential hotels and for numerous social,athletic, and extra-academic purposes, as well as for agroup of schools and institutes for research and specialsubjects, such as a school of law, a school of journalism,a school of military studies, research institutes forcomparative pathology and numerous arts, sciences,and professional subjects." The various advantagesof the Bloomsbury site are set out presumably asa rejoinder to those who object to this departure, andit is a fair criticism of a valuable piece of work that
1 By Thomas Lloyd Humberstone, B.Sc. Lond., Associate ofthe Royal College of Science, London; late Mitchell Student ofthe University of London. With an introduction by H. G. Wells.London: George Allen and Unwin, Ltd. 1926. Pp. 192.7s. 6d.
neither is the formidable nature of the objections dealtwith, nor is there any full rejoinder to those who desireto remain in Kensington.
RESPIRATION AND ANÆSTHESIA.
THE more that the physiology of anaesthesia, isstudied the more striking becomes the predominanceof the part played in the process of narcosis byrespiration. Indeed, the physiology of respirationmay be said to dominate the physiology of anaesthesia,and all else to be subservient to the part played by therespiratory current and its resultant effects on thecomposition and the circulation of the blood. Theoverwhelming part played by respiration in boththe induction and the maintenance of inhalationanaesthesia is, or should be, as obvious to the prac-tising anaesthetist as it is to the worker in the physio-logical laboratory. Nevertheless there has certainlybeen a tendency for his attention to be drawn toomuch to other subsidiary phenomena-blood pressure,for example, or the state of the eye-and too littleriveted on what is actually the key to the wholeproblem-the breathing. It is true, of course, thatmechanical obstructions to respiration have receiveddue attention, and indeed the importance of evadingobstructive swelling and spasm of the upper airpassages was a fundamental doctrine of the teachingof the late Sir Frederic Hewitt. The less obviousdefects of respiration, however, and their directinfluence upon the patient’s condition were undetectedor little understood, and it is to physiological workthat we owe an advance in knowledge of thesepractically most important matters. When thephysiologist and the anaesthetist are allied in workof investigation the results are likely to be bothinteresting scientifically and valuable in practice.The paper read recently by Prof. M. S. Pembrey inconjunction with Dr. F. E. Shipway is a case in point.Prof. Pe abrey’’s observations on apnoea are enlighten-ing, while his insistence on the r6le of carbon dioxideas the paramount respiratory stimulant is paralleledon the clinical side by cases that Dr. Shipway quotesto show how the breathing may be brought to anend in practice by the free washing out of that gas.Apnoea is most likely to arise during the anaesthesia.produced by intratracheal insufflation. Pembreyrecords a case in which 16 litres of air per minutesufficed to oxygenate the blood, but 30 litres producedapncea for a period of two minutes. The bloodpressure fell during the period of rapid lung ventila-tion. During the period of apnoea it gradually rose,and as the tension of carbon dioxide in theblood increased the patient began slowly to breatheagain. Another form of anaesthesia which may beassociated with apnoea is that due to "gas andoxygen " breathed through valves over considerableperiods of time. The acapnia which may be thusinstituted is shown by pallor, a cold, clammy skin,feeble breathing and a quickened pulse, and is instriking contrast to the full colour, exaggeratedrespiratory movements. and full pulse that are broughton by the presence of carbon dioxide in excess. Boththese types of cyanosis are not uncommonly seenclinically, and their essential difference has to beappreciated by the practical anaesthetist. It is aroundthe function of carbonic acid gas in the lungs andin the blood that the chief recent contributions tothe physiology of anaesthesia have arisen. Startingfrom Haldane’s original demonstrations of the signi-ficance and relations of the volume of air breathed,workers, among whom are prominent YandellHenderson, H. W. Haggard, and S. R. Wilson, havearrived at important truths concerning respirationin anesthesia which had hitherto not been madeplain. The practical application of these truths liesin the suggestion that by due use of CO, in inductionthe respiration may be so stimulated that withexaggerated ventilation of the lungs a large supplyof anaesthetic at the safe concentration may berapidly inhaled. In this way the concentration ofanaesthetic in the nerve centres necessary for anaes-
thesia may be rapidly and safely reached. Theother practical use of 00, is at the close of anaesthesiawhen again, by inducing vigorous respiration, theansesthetic may be rapidly washed out of the bloodand lungs, and recovery be expedited with consequentdiminution of after-effects. With regard to the firstof these two practical propositions there is an objec-tion that arises in practice which is not apparentin the laboratory. This depends on the sensationsof the patient. Anyone who has experienced thesensation of entering anaesthesia with nitrous oxideor with ether through the medium of forced breathingwill assert that he has no desire to repeat the experi-ence. There is no doubt that the physiologicalmethod is safe and certain, but it is extremely uncom-fortable as compared with a more gradual induction.Moreover, although so far with ether it has appearedsafe, there is the general principle to be borne in mindthat sudden changes of bodily conditions are,generally speaking, inadvisable as compared withgradual changes. Medicine provides numerous
examples which show that a particular conditionmay be harmless if gradually reached, dangerous ifsuddenly instituted ; and it is not unlikely that anoes-thesia complies with this general rule. So far as weare aware the experiment has not been made ofrushing a patient into chloroform anaesthesia byexaggerated inhalation of a safe percentage vapour,and we are inclined to doubt the wisdom of makingthe experiment. The value of forced breathing torid the body of the inhaled anaesthetic is anothermatter and appears to be a most valuable additionto the anaesthetist’s powers to avoid deleteriousresults from his administration. It is obvious thatso efficient a weapon as carbon dioxide needs carefulhandling, and scrupulous control must be exercisedof the percentage vapour administered after anoes-
thesia. The proper percentage in oxygen appearsto be about 7. The disadvantage of employingthe obvious and most simple means of supplyingCO—namely, by making the patient re-breathe hisown expirations-is that these must contain a
considerable amount of the very anaesthetic vapourwhich is to be expelled. The necessity for carryingyet another cumbrous cylinder, containing therequired percentage of C02 in oxygen, may be avoided,as Dr. 1. W. Magill has pointed out in our columns,
Iby the use of sparklet bulbs. B
SOME remarkably interesting particulars of theextent to which hospital accommodation is providedor aided by local authorities were recently given bythe Minister of Health in answer to a Parliamentaryquestion. Mr. Chamberlain stated that there isonly one large general hospital provided by a localauthority. He did not mention its name, but he wasobviously referring to the City of Bradford MunicipalGeneral Hospital, with its 750 beds. Add to thisthree relatively small accident hospitals and thenumber of general institutions so provided is exhausted.There is no official information on the number ofcases in which voluntary hospitals are municipallyaided apart from services rendered to the municipality,but before long they will probably reach a respectabletotal. By last year’s Public Health Act, which hasbeen in operation only six months, local authoritieshave power to help voluntary hospitals to the extentof a penny rate, but it has as yet been very littleexercised. Municipal hospital activities of a statutorycharacter have now become very extensive. Thus,there are 158 tuberculosis hospitals with nearly 11,000beds; 1040 hospitals for acute infectious diseaseswith approximately 37,700 beds ; 68 maternityinstitutions with 908 beds, not including maternitywards in general and Poor-law hospitals ; and a dozenbabies’ hospitals with 260 beds. The tens of thousandsof beds in the infectious diseases hospitals include2230 for the treatment of tuberculosis. A largenumber of voluntary hospitals receive payments fromthe rates in return for services rendered in connexion
with tuberculosis, venereal diseases, maternity, andchild welfare schemes. For tuberculosis there are
153, and for venereal diseases 139 hospitals whichprovide beds as and when they are requi ed, and formaternity and child welfare a dozen hospitals provide175 beds. In this category there are 127 specialtuberculosis hospitals with 8563 beds, 52 maternityinstitutions with 917 beds, and 12 b shies’ hospitalswith 334 beds. These figures are exclusive of accom-modation in homes for unmarried motheis and theirbabies, observation wards in connexion with maternityand child welfare schemes, and convalescent homes.The Poor-law authorities provide 64 institutions, with35,250 beds, wholly for the sick, exclusive of institu-tions for mental cases, and 590 mixed institutionscapable of housing 180,000 persons, with 79,000 bedsfor the sick. If, and when, the councils take over thefunctions of the boards of guardians, they will thusreceive an enormous addition to their public healthresponsibilities. Meanwhile, these figures add greatlyto the strength of the case for the coordination ofofficial health services.
A GERMAN VIEW OF NICOTINE.
THE third and fourth parts of the seventh volumeof " Ergebnisse der gesamten Medizin," which isappearing in instalments under the general directionof Prof. T. Brugsch, contain articles on subjectsas diverse as the diagnosis and treatment of cancer,the radiological diagnosis of gastric and duodenalulcers, ankylostomisis, tetany, the nervous child,suggestion and auto-suggestion, and the adrenalblood reactions. In an article on Nicotinism Prof.Heinrich Kionka presents a summary of existingknowledge on the effects of tobacco and their treat-ment. Nicotine, he states, exists in tobacco in quantityvarying from 1 to 3-8 per cent., while in France,where the plants are set wide apart, the percentagemay reach 6. Few people, he thinks, realise what adeadly poison this alk,Ûoid is ; one drop of the fluidpreparation is fatal to a dog and nearly so to a man.Its action on the nerve centres is violent stimulationquickly followed by paralysis ; function is acceleratedfor the time, and unstl iped muscle is stimulatedby the over-secretion of adrenalin. It is partlythis tonic effect that makes tobacco so universallydesired, and partly the assistance which it gives todigestion by making all the glands secrete morecopiously. The sedative effect he attributes to carbonmonoxide rather than to nicotine. This, it is stated,is present in tobacco-smoke in startling quantities,and is the real cause of most of the symptoms of thenon-smoker who feels unwell when surrounded byeager devotees in a railway compartment or un venti-lated room. The reason why nicotine does not domore harm amongst smokers is, of course, thattolerance is easily acquired, and though the beginnershows signs of poisoning at once, he soon becomesimmune. Nevertheless, the limits of this toleranceare easily passed, and, according to Prof. Kionka,the inveterate smoker who oversteps the marksuffers far more than the beginner, for his tissues aremore or less saturated and he has less resilience.Tiie quantity of nicotine present in tobacco-smokevaries considerably. The content in the leaf is Scddto be unexpectedly independent of the strength ofthe tobacco. Whereas with Dixon’s apparatus100 g. of light cigars gave up 1000 mg. of nicotine,compared with 480 m. yielded by tne same weightof strong cigars, two German brands of so-callednicotine-free cigars gave 420 and 320 mg. respectively.The quantity the smoker actually absorbs varieswith the capacity of the cigar, cigarette, or pipe fordistilling and trapping the nicotine from the burningtobacco. A long pipe is better than a short one,a dry cigar than a damp one, and the first half of anysmoke does much less harm than the last. Thecigarette, says Prof. Kionka, is the worst of all,
1 Ergebnisse der gesamten Medizin. Siebenter Band. Berlinund Wien: Urban und Schwarzenberg. 1925.