Current topics in anæsthetics

T H E I R I S H J O U R N A L M E D I C A L S C I E N C E

THE OFFICIAL JOURNAL OF THE ROYAL ACADEMY OF MEDICINE IN IRELAND.

OF

SIXTH SERIES. No. 9-54. FEBRUARY, 1947.

CURRENT TOPICS IN AN!ESTHETICS*

By IVAN W. ~[AGILL.

I T gives me great pleasure to express my sincere appreciation of the nonour which you have conferred upon me by inviting me to address you at this Inaugural Meeting of your Section of Anaesthetics.

Although I live abroad, I ~was born and educated in this island and it is very gratifying to find that if " a prophet has no honour in his own country ", apparently an anaesthetist has! The importance of this occasion to me is further enhanced by its occurrence in the centenary

year of the discovery of surgical anamthesia. I am proud to be associated with you in celebrating the formation of your Section of Anaesthetics at such a time, and I shall look forward with keen interest to the subse- quent proceedings of the Section.

Medical science in Ireland requires no boost from any visitor, for the fame of Irish medicine and Irish hospitals is world-wide. This Academy of Medicine was in existence long before its corresponding body, the Royal Society of Medicine in England. Stokes, Graves, Colles, Freyer, McCarrison, these are but a few Irishmen who will be famous for all time in medical history, and others such as Terence Millin are now adding to the lustre of the Irish medical schools.

In the field of anaesthetics, Irish surgeons were among the first to appreciate the value of ether one hundred years ago, and one has only to consult the recent Centenary of Anaesthesia issue of the Academy's Journal to find ample and gratifying evidence tl~at the profession has kept well abreast of the times. Hence you will appreciate my difficulty in the choice of a subject for this address. To anaesthetists so fully con- versant with every branch of the speciality, as has been so ably demon- strated in the recent Journal, it would be presumption on my part, to say the least of it, to deal at length and in detail with any particular angle. Moreover, there may be members of the profession other than anaesthetists present--surgeons and physicians who take an occasional interest in anaesthetics hence I have selected a title embracing a wide field in the hope that reference to some current topics may prove interesting and acceptable to all.

Slow Progress ~n Development. This year, we celebrate the centenary of surgical anaesthesia, and

much justifiable attention has recently been given to the history of the

*Opening Address to the Section of Anmsthetics of the Royal Academy of Medicine in Ireland, delivered 12th December, 194{}.

46 IRISH JOURNAL OF MEDICAL SCIENCE

pioneers. I shall spare you, therefore, a repetition of events already familiar. One fact, however, is outstanding: the extraordinary absence of progress in the field of anmsthetics for so many years. Even Hick- man's original conception of painless operation on the unconscious patient remained unfulfilled for fifteen years after his death. It is a strange reflection that his suggestion failed to stimulate further investi- gation by the scientists of his time.

In 1846, the new-found boon of ether anmsthesia provided surgeons with such a contrast to the pre-existing operative conditions that they remained complacent and contented; herein lies the reason for the long period of stalemate which followed. Controversies arose from time to time over the relative merits and demerits of chloroform and ether. Nevertheless, these two drugs held the field alone for many years, and they continue to be used, where nothing else is available, because they ai'e capable of producing good operative facilities 'when used by simple methods.

Rapid Progress in Recent Years.

It was only in the early part of this century that the science of anesthesia began to make considerable progress. In our own time wc have seen, for example, the development of accurate dosimetric apparatus, of valuable new anmsthetic agents, some of which have enabled us to abolish entirely the unpleasant period formerly associated with induction, and of effective methods of dealing ,with the old nightmare of respiratory obstruction. It must be admitted that with the help of modern anmsthesia the scope of the surgeon has been vastly extended, and practically every region of the body has now been made accessible. Disease can be attacked with safety and a reasonable hope of cure, in patients whose condition had been considered beyond the reach of surgery in the past. Unbiassed observers ,will agree that these developments in anaesthesia are definite advances. There is as yet, however, no occasion for easy complacency on the part of the anmsthetist. The fact remains that in spite, of what has been achieved, and of the high stan- dard of surgical skill existing today, comparatively simple operations are still attended occasionally, not only by complications due to the ancesthetic, but by a definite mortality rate.

Factors in Successful Ancesthesia.

The advances claimed for modern anmsthesia are not due, as some are inclined to believe, solely to the discovery of new drugs, and the swing over from " rag and bot t le" to complicated machinery. Whatever .the agent, apparatus or mode of application, the fundamental keynote of successful anmsthesia is an accurate estimation of the patient's condition. There is in every individual what may be called a physiological balance. In youth and health, this balance is elastic within a certain range. In the presence of disease on the other hand, and in old age, interference with this balance may turn the scales against the patient. Moreover, unlike the laboratory animal, the human being is an unknown quantity in whom even in health, environment and habits of life require

CURRENT TOPICS IN AN,~STHETICS 47

careful consideration before the condition of the individual can be assessed in relation to the anmsthetic.

The majority of the agents employed in anmsthesia are depressant in their effect; some are actually destructive. It is essential, therefore, to judge beforehand as far as possible the capacity of the patient to withstand this action, coupled as it is with unavoidable operative trauma. At the present time this precaution is more imperative than ever, owing to the tendency to elaborate the anaesthetic prescription with drugs .which are irrecoverable once they have been administered. A skilful administration of the anaesthetic is now naturally expected, but something more than that is essential for success. For example, in all operations of gravity it falls to the anaesthetist to keep a careful record of blood pressure and give warning when the need for replace- ment of body fluids arises; and when the operation is over the responsibility of the anaesthetist is not ended. It is his duty in the immediate postoperative period to see that means are provided for keeping the airway free from obstruction, that the need for oxygen is satisfied, and that sedatives are administered only in safe doses. He may be required at times to clear the trachea and bronchi of blood and pus, ,which means that he must be dexterous ,with a bronchoscope. The activity of the anaesthetist at this time is an important factor in the prevention of pulmonary complications. It may be noted here that at the Mayo Clinic transfusion is now entirely in the hands of the Anaesthetics Department~ and all patients are placed for 24 'hours after operation in recovery rooms where restorative measures are under the same direction.

A further "important contribution to successful anaesthesia is the co-operation forthcoming from the surgeon, especially from the younger generation. In former times, there were no specialists in this branch and any doctor was supposed to be able to administer the anmsthetic, whatever the operation. The surgeon usually regarded the choice of the agent as his prerogative and, so long as the patient was deep enough, as often as not the surgeon was completely oblivious to the side-effects of the procedure. In marked contrast is the attitude of a surgeon who keeps abreast of the times, who realises that an expert anaesthetist may possibly know more about the subject than he does, and who is prepared to consider the views of the anaesthetist as those of a consultant on an equal footing. In fact, he is content to leave the whole matter in the hands of his colleague.

Precautions with Modern Methods.

Although we are still in pursuit of the ideal, we have the means at the present time to produce anmsthesia which far surpasses anything which has been achieved in the past. But these means require skill and judgment for their successful application. Barbiturates for example are easy to administer--" fatally easy ", as some wit has said! Indeed, it has been occasionally hinted that modern anmsthesia is nothing short of a menace, especially when in the hands of a novice. Naturally, under ideM conditions, every patient should have the benefit of expert service, but it is too often forgotten that a newly-qualified and inexperienced doctor may be called upon to give a major anaesthetic, although it is rarely that he is expected to undertake a major surgical operation.


Teaching of Ancesthetics. Clearly, then, the teaching of anaesthetics is highly important, and

there is much room for improvement in this direction. In contrast to the days of open ether, the student nowadays rarely sees an anaesthetic given except by means of a machine. With the fascination of youth for the mechanical and spectacular, he learns to think in terms of bags, flow: meters and gauges, and, as Blomfield so aptly puts it, " he notices more what his machine is doing than what effect it is having ". With his attention thus divided between machine and patient, sound clinical observation is all too often neglected. Trained in this manner, the newly-qualified doctor of today is ill-equipped to administer anaesthetics if he finds himself without a machine, and compares unfavourably With the old-time student who learned to be skilful with open methods. To remedy these defects in our teaching system, it is not suggested that we should put back the clock and revert to open ether to the exclusion of all other agents and techniques." We might, with great advantage, however, urge a return to the meticulous observation of the condition of the l~atient and his changing needs, which used to be an essential part of the training of anaesthetists. I t is only upon such close observation of the patient that sound clinical judgment can be attained, and not by attaching him to any machine, however perfect this may be.

Pre-operative Medication. Pre-operative sedation of some kind is now regarded as an essential

part of every anmsthetic. In its milder form, the administration of an opiate, it is a useful contribution to the main agent. But the casual administration of opiates before operation requires more discrimination than is commonly given to it. Individuals vary in their reaction to opiates, and frequently the dose is in excess of the patient's need. Respiratory depression is the result, particularly when sufficient time has not elapsed before the beginning of induction. Induction is then delayed. In thes~ circumstances it is not uncommon to see an anEesthetist stimulating with CO~ the respiration of a patient who is already over- loaded with CO~ of his own manufacture. I f a patient requires th~ addition of C02 from a cylinder, or is forced to rebreathe to keep his tidal exchange adequate during maintenance of anaesthesia, that patient has received too much premedication of a depressant nature. It must fur ther be remembered that susceptibility to the action of CO~ varies with different patients, and in some the addition of even a small percentage of C02 increases respiratory depression instead of being a stimulant. It is hardly necessary to point out the increased risk of pulmonary complications which profound respiratory depression entails. CO~ is a good example of a useful agent which has been the subject of much abuse. One prominent American anaesthetist has stated recently that the service in his department has been vastly improved by the removal of the C02 cylinders from all anaesthetic machines.

Basal Narcosis.

We know that in the popular estimation " being put to sleep in b e d " is regarded as an outstanding advance, particularly by patients who

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have vivid and evil memories of previous unskilled inductions. None will deny the benefit of basal narcosis to the child or nervous adult, but anaesthetists are inclined to pander too easily to the popular clamour for this new-found boon. They feel that it is good business to be able to guarantee that the beginning of an anaesthetic will be pleasant, whatever the end-result may be! The necessity and even the safety of such routine procedure is questionable. The old conception of the operating theatre as a place of torture is gone, and the average patient today is willing to co-operate when a reasonable explanation is given of that which is best for his own welfare. In this connection anaesthetists unfortunately have often to cope with the family doctor or even the surgeon, who have been known to promise casually that the patient " will be put to sleep in his bed ", regardless of his condition or of the facilities available for transporting him to the theatre. However, the safety factor must always be the first consideration. In intestinal obstruction, for example, the only safe place for induction is in the operating theatre on the table, which can be tilted at once if necessary; there all measures for dealing with regurgitant vomiting are at hand. No great stretch of imagination is required to appreciate the sequence of events which may occur in corridor or lift, when such a patient has been induced in bed, and is on his journey to the theatre. Anyone familiar with the laryngeal spasm which occasionally follows an injection of pentothal knows that the middle of the staircase in a small nursing home is not the best place to deal with such a condition.

An interesting change is noticeable in the present attitude of the public to amesthesia. The public are now well informed of the newest methods, and know that anaesthesia can be robbed of its terrors and some of its discomforts. In the past it was customary for patients to demand the best surgeons for their operations, but they were content and even anxious to leave the anaesthetic " in the hands of their own doctor, .who knew their case ". But nowadays it is not unusual for a patient to ask for a certain type of anaesthetic and also demand an expert to give it. Anaesthetists must bear in mind, however, that the operation is the first consideration. The anaesthetic is merely a subsidiary agent.

I n t r a v e ~ m u s A n e s t h e s i a .

One of the most useful and satisfactory methods of anaesthesia which we have developed in the past ten years is the administration of barbiturates by the intravenous route. This applies especially to pentothal sodium. The intravenous route itself is not new, as it was used many years before for ether, alcohol and hedonal, but a fresh impetus was given to the method when chemistry developed the short-acting barbiturates. The action of these intravenous agents, however, is by no means reversible, as is that of the volatile and gaseous agents in common use. Once a barbiturate is inside a patient, it has to be detoxicated in his body, an important point to remember when dealing with a patient who is old or gravely ill. During the late war, it was seriously impressed on anmsthetists that casualties in air-raids, and those wounded severely in battle, showed a marked susceptibility to pentothal. One must, therefore, place a limit on the total amount of the barbiturate one is prepared to give. Many will agree that a maximum dose of 1�89


grammes of pentothal should not be exceeded for even a robust patient, and if any patient proves abnormally resistant it is much safer to resort to a volatile agent which is more easily eliminated.

l%ntothal sodium is the most outstanding example of the barbiturates now in use, and the one most commonly employed. It has already stood the test of several years and its value is unquestionable. Attempts have been made to improve it, but so far nothing has been achieved in this direction. For short operations, such as extraction of difficult teeth, orthopaedic manipulations, etc., pentothal fulfils the demand for an agent superior to N20 or ethyl chloride. When the intention is to employ pentothal alone, the injection should be deferred until the surgeon is ready to operate. For operations of longer duration a useful method of employing pentothal' has been devised by Organe and Broad. Anaesthesia is induced by intravenous injection and followed b~ stabilisation of the patient on nitrous oxide and oxygen, without cyanosis. Further injections of pentothal are then given as the need for deeper anmsth~sia arises. The advantage of this method lies in the restriction of the total quantity of pentothal required. The mixture of N~O and 0 functions as a synergist and at the same time corrects the respiratory depression which pentothal causes when given alone. The ease with which pentothal sodium can be given has naturally led to some abuse, and it is to be deprecated that some anmsthetists use the drug in such large doses, for example, 4 to 5 grammes. A case of interest may be quoted: A child of seven required an operation for acute appendicitis. Pentothal was the choice of the anaesthetist. The operation proved difficult, but was completed in three-quarters of an hour with the aid of "pentothal alone "--amount unstated! The child remained unconscious for 20 hours, during which time efforts at resuscitation were unavailing, and the pulse at times uncountable. Recovery eventually occurred, but not without more anxiety than might be reasonably expected after an appendicectomy. On the other hand, the opposite results can happen. It may be dramatic for the patient to wake up and find himself on the operating table, but not so satisfactory for all concerned. This trying situation can happen when agents such as pentothal sodium, nitrous oxide, or cyclopropane, which are all rapidly eliminated from the system, are employed unskilfully.

Cyclopropane. Among the gases which have been tried out as anaesthetics in the

laboratory and afterwards used successfully on the human subject, cyclopropane has maintained a prominent position since it was first used by Waters in 1934. Its composition is represented by a closed-ring formula, in virtue of which it is reputed to be excreted unchanged, without causing any interference with kidney or liver functions. Besides being a non-irritating respiratory depressant, it is effective when given with a high percentage of oxygen. It is therefore particularly useful in thoracic surgery, but like all other new agents, there was a tendency at first to over-estimate its value in other fields.

In general surgery cyclopropane is sometimes disappointing. It is not so effective as ether in securing muscular relaxation, even when pushed to the point at which spontaneous respiration is abolished. In

CURRENT TOPICS IN AN.~STHETICS 51

some cases it causes troublesome capillary oozing which is particularly undesirable, for instance in radical mastectomy. Its worst feature is the nausea which follows its administration. In this respect it is not so good as nitrous oxide-oxygen with minimal ether.

Methods. Endotracheal Anesthesia. With reference to methods of administra-

tion apart from agents, nothing perhaps has proved of more value than the endotracheal tube. I t solves the age-old battle, so common in the past, between the surgeon operating under difficulties and the anmsthetist endeavouring to keep the patient anmsthetised and the airway free. It is unnecessary to dwell at length on the advantages of this method ; the)- are now well known. It is sufficient to emphasise the main one, namely, the provision of an absolutely free airway. However, it is well to remember that before the endotracheal tube attained its present popularity, thousands of operations of every kind had been successfully performed without its aid. Control of the airway can still be obtained by simple means, yet few anaesthetists will now take the trouble to employ them. We are bound to admit, if strictly honest, that the lure of con- venience, and not the benefit of the patient, has led to abuse of this method. In experienced hands a pharyngeal airway still has its uses, and it is, at any rate, less likely to inflict trauma than an endotracheal tube. There is no justification for the use of the endotracheal tube in every case, as the procedure is not free from the risk of complications even in experienced hands. The complications may be slight, but they can be annoying. The method is justified only when the indications are clearly defined. A patient has good cause for complaint if, after an ~)peration for appendicectomy, he wakens up and finds himself suffering from a painful throat, or finds a discharge of blood from his nose. An example in lack of judgment in the use of this method may be opportune :

A man required the removal of a small sequestrum from his lower jaw. He was induced with pentothal in the anaesthetic room, and the anaesthetist failed after many attempts, accompanied by much blood, to pass a naso-tracheal tube. I t became necessary then to deepen the anmsthesia with gas oxygen and ether. Eventually a tube was passed with the aid of a laryngoscope, and after a delay of 35 minutes, the patient was taken to the theatre, attached to the gas oxygen machine. The operation took exactly two minutes! It could have been accomplished quite well with the aid Of an ordinary mouth gag and the pentothal used for induction alone.

Naso-tracheal intubation requires special mention, and particularly the blind method of passing the tube. The " blind " manoeuvre, which has its uses, appears likely to fall into disrepute--not entirely because of its inherent defects, bu t through the hard work of persistent prodders, who refuse to use a laryngoscope, and gracefully admit defeat. The main defect in naso-tracheal intubation lies in the inability of the nasal passages to accommodate in all cases a tube of sufficient calibre to permit perfect free to-and-fro respiration through it. When the choice is free, the nasal route should be reserved in future for operations in which it is especially indicated. In this category tonsillectomy in children may well be excluded. Apart from the fact that it is inadvisable to pass a


tube through the nose when adenoids are present, the tube must be with- drawn when the adenoids are removed at the end of the operation, precisely at the moment when the protection it affords to the airway is most valuable.

Closed Anesthesia. While it is not necessary to discuss in detail the points of various anaesthetic machines, reference must be made to the value of C02 absorption technique. This principle has several advantages. It economises the use of anaesthetic agents and prevents their escape into the atmosphere of the theatre, lessening the risk of explo- sion. It maintains respiration on physiological principles, and it prevents loss o f heat and moisture from the respiration of the patient. There is no doubt that any modern apparatus should include an efficient absorber in its construction.

Major Abdominal Surgery. Abdominal surgery is a most exacting test of anaesthesia on the con-

dition of the patient, both on the operating table and during the postoperative period. One may discuss here some of the various methods in use at the present time.

Local an0esthesia, in the form of a field block of the abdominal wall combined with anterior splanchnic block, has always been popular on the Continent, and in the hands of Finsterer it has given excellent results. In England, Ogilvie prefers a similar technique. At the West Middlesex Hospital, James has popularised the intercostal block, combined with posterior splanchnic block, and" large doses (up to gr. 1�89 of omnopon intravenously. High spinal is still the fashion in localities where efficient general anaesthesia is not available. No doubt ,when the temperament of the patient is suitable, and the surgeon accustomed to work on a conscious patient, dispensing occasional vocal encourage- ment, the results are excellent with any of these methods. The patient is certainly spared the risk of pulmonary complications due to inhala- tion anaesthesia, and it is very dramatic to see a patient sit up and drink a cup of tea one hour after a gastrectomy. It is no reflection on our for- titude, however, to say that the average patient in these islands prefers general anaesthesia for abdominal operations, as do the majority of surgeons.

A severe fall in blood pressure is a common accompaniment of splanchnic block and of high spinal. In patients who are in poor condition it appears unjustifiable to subject them to this additional risk. Muscular relaxation is the keynote of anaesthesia for abdominal operations, and one satisfactory and comparatively atraumatic combination for providing this is a pentothal induction, light cyclopropane and local infiltration along the costal margins, and line of incision. In place of local anaesthesia dextro-tubocurarine appears at the moment to be a "g i f t from the gods" to anaesthetists. It provides relaxation compar- able to that obtainable with a spinal, without causing a fall in blood pressure. It is early yet to be dogmatic about its virtues, fatalities having already occurred even in expert hands. But it is easy to administer, and, as with all new agents, enthusiasts are apt to use it at times when satisfactory relaxation could be obtained by less drastic measures. It is well to remember that dextro-tubocurarine in safe doses has no anmsthe-

CURRENT TOPICS IN ANAESTHETICS 53

tic properties. When given to a patient under a light general anaesthetic, shock may result from any painful stimulus, without any warning sign. The combination of pentothal and tubocurarine is a tempting proposi- tion, but since pentothal causes respiratory dePression and tubocurarine causes paralysis of the respiratory muscles, it is obvious that a machine capable of being used for pulmonary ventilation must be ready for immediate use.

Thoracic Surgery. Aneesthetic developments continue to be of particular service in this

important field. It is no exaggeration to say that without the advances in anaesthesia, thoracic surgery could not have reached its present high level. Surgery has already reached its limitations in the thorax, with operations on the heart itself.

Pneumonectomy and lobeetomy, operations which were rare but a few years ago, are now accepted as routine procedures in hospitals devoted to the treatment of chest diseases. It would be idle to pretend, however, that they are not still an. exacting and anxious responsibility for the anaesthetist. Although there exists a divergence of opinion over the choice of anesthetic for any thoracic operation, there is at least uniformity on one point. Where formerly the presence of the cough reflex during operation was thought to be a protection to the patient when secretions are present, it is now agreed that "vicious circle cough- ing" (as it is called) has the effect of shifting secretions from affected to unaffected parts of the lungs. It is the practice, therefore, to keep the cough reflex in abeyance during operation. When thoracoplasty is performed under local anaesthesia, care is taken to obtain the co-operation of the patient by avoiding injudicious pre-medication. During the critical stages of the operation, when the pleura is being stripped from the ribs, for example, the patient will be asked to withhold the cough.

In thoraeoplasty, pneumonectomy or lobeetomy under general anaesthesia, dextro-tubocurarine has already proved useful in keeping the cough reflex under control.

Mechanical means of preventing the spread of secretions .were devised and continue to be practised in pneumonectomy and lobectomy in adults. The device used at present for this purpose is a rubber modifi- cation of the double channel gum elastic catheter, and inflatable cuff. It is placed in position with the aid of a bronchoscope. An endotracheal tube is passed independently for the purpose of the anaesthetic. As already pointed out, tracheo-bronchial toilet at the end of a thoracic operation is the responsibility of the anmsthetist.

Status of the AncBsthetist. One cannot forecast the course of events in the organisation of the

medical profession in this country. In England, however, the fate of specialists including anaesthetists is in the melting pot, and State medical service in some form is more than a possibility in the future. While any curtailment of our freedom would be regrettable, so far as the work of anaesthetists is concerned there would appear to be advantages to both patients and anaesthetists in some scheme that would centralise this work. Under present conditions too great a proportion of the


anmsthetist's time and energy is spent in a hectic endeavour to keep appointments at different points of the compass. One can visualise a large clinic or hospital organised on the lines of the Mayo Clinic, in which an efficient team will work continually together to the benefit o~ workers and patients alike.

Conclusion. In a short address of this nature it is obviously impossible to deal

with every aspect of anaesthetics, but the subject-matter may serve to emphasise the necessity for regarding anaesthetics as a speciality. In this connection, your medical school is to be congratulated in having established a Diploma in Anmsthesia. That is the first important step in consolidating the position of anmsthetics in the medical curriculum, and undoubtedly serves as a stimulus to efficient teaching.

In a science so young, enthusiasm for what is new is commendable, and the pursuit of the ideal will always continue. It is well to remember, however, that no matter ~what developments the future may hold in the line of drugs, methods or machines, it is not upon invention alone that we must reply, but upon the tedious acquisition of knowledge, practice and sound judgment.

SOCIETE I N T E R N A T I O N A L E DE CH IRURGIE.

The XIJ[th Congress of the In ternat ional Society of Surgery will be held in London from the 14th to the 20th of September, 1947, with Dr. Leopold Mayer (Brussels} as President.

The l ~ r m a n e n t committee and the scientific committee have judged i t inopportune to consider all the subjects which were pu t down for discussion a t the Brussels Congre~ in 1938. They have decided, moreover, t ha t they will no t publish the papers beforehand, bu t will hold a conference, to be followed by discussion, on each of the new subjects which have been chosen, and which ~re as follows : I. The Operative Treat. ment of Fractures, by Professor 1~. Danis (Brussels). II. The Role of Penicillin in Surgical Practice, by Sir Alexander Fleming {London). A practical domonstrat ion will be arranged in conjunction with this paper. I I I . Recent Advances in Arteriography and Venography, by Professor 1~. dos Santos (Lisbon). IV. Recent Advances in Vascular

Surgery, by Professor R. Leriche (Paris). V. The Surgical Treatment of Pulmonary Stenosis, b y Professor Blalock (Baltimore). VI. The Role of Vasodilatati~on in Arterial Diseases, b y Dr. J. Diez (Buenos-Aires). VII. The Results of tIeparine in Surgery, by Dr. Crafoord (Stockholm). VIII . Skin Defects ; their Repair by Flaps and Free Skin Grafts, by Professor T. Pomfret Kilner {Oxford). IX. Results of Early Operation in War Wounds of the Lungs, by Dr. M. Bastos-Ansaxt (Barcelona). X. Recent Progress in the Treatment of Burns, by a l~ussian surgeon.

The English committee (Chairman, Prof. G. Grey Turner) have arranged a pro- gramme of enter ta inment not only for members of the Society who will take par t in the conference, but also for those ladies who will accompany them. I t is hoped also to arrange for visits to other towns which will be of interest to those a t tending the Con- gress.

Current topics in anæsthetics

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