Tu BHamu SEPT. 20, I913] I MZmcM JOUBINAB 3

AN EPITOME OF CURENT MEDICAL LITERATURE.

ptom is never found in normal persons, and it is usually MEDICINE. associated with exaggerated tendon reflexes. Cases are recorded illustrating the occurrence of clonus in infectious 128. The Effect of Temporary Occlusion of Renal diseases-for exarnple, septicaemia, typhoid, and tuber- Circulation on Renal Function. culosis either unilaterally or bilaterally, and generally not FITZ AND ROWNTREE (Arch. of Intern. Med., July 15th, persisting for more than a few days or weeks. Ankle 1913) studied experimentally the effect of temporary clonus is not uncommon in uraemia, arising in chronic occlusion of renal circulation upon renal function, because cases several days before a seizure, thus furnishing a of the surgical importance attached to the question con- valuable prognostic indication, and during narcosis from cerning the length of time that the renal vessels can be ether and chloroform its presence has been frequently clamped without permanent injury to renal function or noted. Its occurrence in hysterical and neurasthenic renal tissue. The vessels in rabbits and dogs were patients should always arouse suspicion of organic nervous clamped for varying periods of time, the renal function disease, suspicion becoming a certaiilty if the Babinski being subsequently tested by the excretion of phenol- toe sign is also present. After the use of hyoscine in sulphonephthalein, lactose, potassium iodide, and salt medicinal doses ankle clonus was noted in from one and water. The presence or absence of albumin or casts quarter to one half the cases, while the Babinski toe sign was also observed, and the functional results were con- was present in the still greater proportion of 86 per cent., trolled by histological examination of the kidneys. Pre- indicating a curious selective action on the part of the vious observers had lnoted that such clamping for periods drug not found after any other drug, and forming an ex- up to an hour may produce temporary anuria, albumin- ception to the rule that a positive Babinslii sign in adults uria, and cylindruria, and that permanent inter- indicates organic nervous disease. Chronic arthritis often stitial tissue increase follows prolonged interference causes increased reflexes of the corresponding linmb, and, with the renal circulation, but beyond this no sys- if the ankle is involved, clonus is by no means uncommon temnatic study had been made. In the authors' ex- apart from any organic nervous disease. Since the periments etherized rabbits and dogs were employed, concdition may appear in many toxaemias quite apart from the abdomen being opened aseptically in the niedian any demonstrable lesion of the central nervous system its line, the left kidney exposed, and the vessels freed diagnostic importance is restricted, but in the absence of from the surrounding tissues and clamped with a small toxic states it is still of practical value in the diagnosis rubber-protected bulldog clamp. No attempt was niade of organic nervous disease. In infectious diseases its to prevent the capsular circulation, and after the left presence addls to the gravity of the prognosis, as it indi- vessels had been clamped the right renal vessels were cates a high degree of toxaemia, but it does not preclude ligated and the right kidney remove(d and weighed. In the possibility of recovery. a few animals, for control, the right kiidney was left untouched. With the .clamp in sitit the abdomen 130. Glycosuria and Syphilis. was closed and covered with a warm saline pad FOLLOWING the publication by Laurent of a case and towel, light anaestlhesia beina maintained, and, of syphilis associated with glycosuria, MALHERBE of the desired time having elapsed, the clamp was Nantes (Ann. de Dcrmi. et Syph., June, 1913) describes removed, and, after the macroscopic appearance of the the case of a man aged 50 who consulted him ten kidney had been noted, the peritoneum and abdomen were years ago for the symptoms of diabetes. His urine sewn up, the bladder emptied, and tlle animals placed in contained 5 grams of sugar per litre, which, in spite metabolism cages. Tlle clamp was applied in series of of a mlonth's strict regime, showed no diminution animi-als for ten, twenty, thirty, forty, and sixty minutes, at the endl of that time. A thorou'gl examination and repeated studies of renal function were made, the revealed the presence on his forehead of seven or eight animals being finally killed, and the kidneys examined ham-coloured papules and other suspicious macular histologically. The excretion of lactose was regarded as and papular lesions on the front of the arms along the the index of vascular functional capacity; that of phthalein veins. There was typical enlargement of the inguinal and as an index of total renal function (though predominantly retro-mastoid glands. The patient, after much pressing, tubular); and the excretion of salt and iodide as the index admitted having had a sore some months previously, and of tubular functional capacity. In the majority of cases the penile scar was still evident. It was thought at first clamping of the renal circulation up to forty minutes that the diabetes had existed before the syphilitic infec- produced a definite disturbance of renal function the tion and had only lately produced symptoms, but in view intensity of which bore no relation to the length of time of the multiplicity of the lesions and the general state of the vessels were clamped, nor was the vascular or tubular the patient, an eniergetic mercurial and iodide administra- function chiefly affected, as shown by the presence of tion was immediately instigated, with the result that three albumin and casts, diminished phthalein output, and weeks later the sugar had (lisappeared from the urine, and delayed lactose and iodide excretion. Salt was constantly after six weeks the eruption was no longer visible. well secreted, and after recovery nearly normial function vas regained within six days, showing that the disturb- ance was slight and temporary. One animal failed to return to normal phthalein output, and two died quickly SURGERY. with marked signs of renal insufficiency. In every instance with one kidney renmoved and the other clamped 131. Cerebellar Tumour after 8light Injury. for an hour death took place within eight days. The THEILAND-POULSEN (Ugeskrift J. Laeger, June 19th, 1913), important role in renal surgery of the unoperated kidney in support of hIis contention that apparently trivial was seen in the series with a normal kidney renlaining in injuries iliay cause fatal cerebellar tumours, records the which clamping for an hour produced but slight temporary case of a farmer, aged 30, Nvho was tripped over, and falling disturbance. Pathologically the gross changes were backwards inlto a shallow ditch, stiucli the soft grass- marked congestion with scattered minute liaemorrhages, covered border with the back of hiis neck. He felt violent and microscopically haeniorrhage, oedema, necrosis, and pain in the back of his head, but as there was no other cellular infiltration. There was no evidence of any pro- sign of an injury lie continued his work. From this date gressive lesion. Except in extreme cases, no definite he suffered from constant headache, which was most relation was demonstrable by functional tests between the severe in the back of the lneclk, although lie had been per- pathological and functional disturbances produced. fectly well before the accident. After about three months lie could not continlue his work on account of headache 129. Ankle Clonus. radiating from the back of the neck to the forehead, TILESTON (Amer. Journ. of Mled. Sci., July, 1913) discusses vonmiting, giddiness, and dimness of vision. His gait was the importance of ankle clonus in diagnosis and prognosis, unsteady, but there was no paralysis of the limbs nor pointing out those conditions in which its presence is tender areas over the brain. The sensory and motor unaccompanied by other evidence of disease of the nervous functions were normal, and Romberg's sign was not present. system. True ankle clonus only is considered-that is, The left patellar and cremasteric reflexes were absent. wlhen continuous upward pressure on the sole of the foot The pupils were equal and their reactions normal. The is followed by a series of rhythmical oscillations with a optic disc was infiltrated and blurred, and the congested frequency of from five to seven a second, and often con- veins in this area disappeared under greyish-white stripes tinuing as long as the pressure is maintained. The sym- and spots. Surrounding the optic disc were some small, 744 A 34 TxYc^ JOURm]U-,A. PITOME OF CURRENT MEDICAL LITERATURE. [$F,PT. Zo, 1913a-,

scattered haemorrhages, which were most numereus below sent to an isolation hospital. The pharynix was rather the disc. Potassium iodide and mercury did not improve red, btut there-was no cervical rigidity, no enlargemffent of matters; the ocular symptoms progressed, and the head- the spleen, or a characteristic roseola. Ficlier's reaction aches necessitated the use of morphine. Lumbar puneture was positive in dilutions of 1 in 50 andl 1 in 100. The tli-- -was also fruitless, and retinal haemorrhages appeare(d in perature rose gradually with remissions in the morning, botlh eyes. About five months after the accident the right and was suggestive of typhoid fever. After a month the parietal bone was trephined, and the dcura mater was patient was about to get up when the temperature became found distended, but otherwise normal. The brain sub- subfebrile, and the left foot became painful. Ficker's and stanee protruded somewhat throuah an incision in the dura Widal's tests were made, with positive results for the para- mnater, but it showed no pulsation. Tlle vomiting and typhus bacillus. 'But this bacillus could not be grown fromn hea(lache ceased after the operation, the wound healed the urine or faeces. There was a diffuse red swelling on satisfactorily, and the patient was afebrile till the eighth the dorsum of the foot, which was slightly tender. Deep dlay, when a fatal attack of plneumonia set in. At the fluctuation was demonstrable in a small area over the necropsy the brain was found to be somewhlat congested, ouiter aspect of the navicular bone. An incision yielded a witl a few flakes of flbrin on its surface. The base of the small quantity of thin, greyish-yellow pus, wvhicli was right cerebellar henmisphere was rather firmii and pro- found between the navicular and the thirdcuneiform bone. ininent, and on section showed a sharply (lefined cyst, of A tampon was inserted and a splint applied. No bacteria the size of a hen's egg, containing a firm, greyish-brown could be found on staining the pus with methylene blue; tumour, and about 30 grams of serous fluid. The micro- but cultivation of the pus on various media yielded several scope showedl a system of cubical cells surrounding a net- colonies of bacteria, the reaction of which to bacteriological work of capillaries. The alveolar growth was diagnosed tests placed themr in the group of paratyphus bacilli. The as a perithelioma, originating either in the meninges or patient made a slow but uneventful recovery, and was able thee choroid plexus. In somoe places the tumour exhibite(d to walk in two months' time. The striliing features of this cystic degeneration and haemorrhages. The author is con- case are the late appearance of the abscess after the general vinced that the fall eaused a lhaemorrhage into the symptoms had subsided, and its localization, to which the cerebellum, and thereby started the development of the authors can flnd( no parallel. In the scanty records of tumour. metastatic abscesses due to the paratyphius bacillus, the ribs, the sterno-clavicular joint, the lower end of the femur, 132. Anaesthesia and Anoci-association. and the mastoid process appear to be the sites most often CRILE (Suirgery, Gynaecology, and Obstetrics, June, 1913) affected. The recognition of this ty )e of ahscess is often summiiarizes his theories upon operative and post-operative (lifficult, as the precedinig general symptoms of infection " slhock," and the relation this has to anaesthesia, in may be slight, and interpreted as those of simple enteritis. a paper read before the Clinical Congress of Surgeons of In doubtful cases a definite diagnosis can alone be made North Amlerica, at New York, on November 12th, 1912. by a serological examination. He observes that the technique of surgery the world over is now well standardized; but one of the greatest of out- standing problemns is the elimination of the harmful effects of tlle necessary procedures, incltuding the anaesthetic. OBSTETRICS. These effects are (lue to exhaustion of the brain cells from psychic and traumatic stimutlation. Under inhalation 134. Cystic Degeneration of -Kidneys and Liver: anaesthesia these traumatic stinmuli reach the highest Pregnancy. centres and cause a discharge of brain cell energy by HEINSIUS (Zen.tralbl. f. Gyndik., August 16th. 1913) reporte(d a process of oxidation. Nitrous oxide, by interfering at the Obstetrical Society of Berlin an instance of a with the use of oxygen by the brain cells, protects the woman, aged 32, who since her first conflnement, four latter durina a surgical operation. By-so doing it prevents years previously, had been under treatment for floating the destruction of the chemical compounds in which is kicdney. She became pregnant once more, and went on stored the energy of the brain cell. This explains its satisfactorily until the eighth month, when she had a great value as an anaesthetic. Crile also draws attention sudden attacli of vomiting, headache, extreme dyspnoea, to the fact that powerful stimuli, whether psychic or and disturbance of vision with temporary blindness. traumatic, and whether received by the brain while There was a high degree of anasarca and scanty secretion awake or under inhalation anaesthesia, cause a lowering of albuminous urine, but ino loss of consciousness. The of the threshold to stimuli. This " lowering of the extremities were cold, the pulse 140. Colpo-hysterotomia, thlreshold " is the source of the nervousness, irritability, anterior, was performred and the child deliveredl by tllC and altered personality which so frequently follow forceps. The patient's condition at once improved. There operation. To the principle of the exclusion of all was a tumouir lilie an ovarian cyst on the right of the harmful stimuli during operationi the author has applied uterus, which was rightly taken for a cystic kiidney. It the term " anoci."' Its successful practice requires diminished in size during the puerperiunm, and the patient careftul personal management, unitecl with the use of seemed convalescent. A few days later the tumour sueh chenmical agents as will exclude from the brain all increased in size again, and the right lower extrenmity lharimiful stimuli. The technique employed by Crile is -became swollen; the urine contained blood and pus. briefly. as follows: One hour before operation 4 grain of 'Rigors set in, and the integtuments over the right loii morpliine anid 1A grain of scopolamine are administere(l. becamiie swollen, red, and slhiny. Infected hydroneplhritis, Nitrous oxide, cither alone or witlh ether, added as pyelonephritis, and perinephritic abscess xvere diagnosed, required, is then given until the patient is unconscious. and the tumour was removed. It proved to be an enior- Intiltration of the skin and subcutaneous tissue with nmouis suppurating small cystic degenerated kidney. The i,* grain of novocaifi is next made, and in order to spreadl patient died. The left k.idney ancl the liver were founid to the latter inlmedliate local pressure with the hand is be in a similar condition. There wvas hypertrophy of the, applied. Anaesthesia is immediate and the incision m-ay left ventricle. Heinsius concluided that pregnancy was; be made at once. The fascia, muscle, and peritonaeuin gravely compromiise(d by the presence of bilateral slmiall are infiltrated in turn and (livided. The latter is also cystic (legeneration of the kidnevs, but the complication everted and injected with & per cent. solution of quinine was fortunately rare. andl urea lhydrochloride, coln)pletely surrounding the line of proposed sutures. If "Iblocking ' has been complete, 135. Diabetes and Pregnancy. upon opening the abdomlen no increased intra-abdominal FRUHINSHOLZ (Ann. de gy?iec. ct d'obstet., Augtust, 1913) pressure will be foundl. There is no tendency to expulsion analyses in full three cases which have recently conioc of the intestines and no muscular rigidity is present. under his care, since Le Folliet and Parisot published During tlhe past year Crile and his associate, Lower, per- their experiences in 1911 and 1912. In the first, diabetes; formed 629 abdominal sections under anloci-association, developed during gestation in a patient aged 35, a prinmi- with a miortality-rate of only 1.7 per cent. para, whose father died of diabetes. The fetus was big, and died dutring delivery; the forcepswas used on account 133. Arthritis Tarsi Paratyphosa. of uterine inertia, and there was difficulty in deliveriitg J. TILLGREN AND A. TROELL (Wien. klin. Wfoch., May 29'th, the shouilders. The placenta was very large, and had to 1913) record the case of a boy, 6 years old, who had pre- be extracted nmanually. The perineum was slightly torn, viously suffered fronii no other illness than wvhooping-cough. and was suture(l. The child was a male, nearly 10% lb. in In the end of April, 1912, lie and his sister were out for xveight. The patienit did well, and the perineal xvotunid esevral hours in cold and wet weather, and suffered in the healed. ThIe second case xvas attended by Fruhinshol_1 evening from tiredness, anorexia, and general malaise. during the patient's third pregnancy; she was 35, and lhad The sister recovered in a few days, while the boy developed given birth within a year of her marriage to a male child diarrhoea, wvith green and very offensive motions. Fever, weighing 7 lb. six weeks before term; it was cyanosed, and headachle, and abdominal pain led to the patient being diedin forty-eight hours. Hydramnion was marked, and was 744 B THz BlTTms 35 SEPT. 20,- I.l3J EPITOME OF CURREN-Jr MEDICAL LITERATURE. tMEDICAL JOURNA& 5 also preseut in the second pregnancy, where a macerated organs might occur was very strong, and there could be fio male fetus weigliing 8 lb. was delivered in- the Oighth doubt that tubercle in the uterine appendages often mnonth. Fruhinsholz found that the patient was given to extended beyond the genital tract. drinking water freely, and complained of pruritus vulvae, .and lie (liscovere(d that she was diabetic. There was 1S7. "Giant Ovary" free from Neoplasm or liydramnion as before. The patient was put on the iodo- Inflammation. miiercurial treatment. Labour set in during the eighth POZZI AND RoUHIER (Bull. et ?W)n. de la Soc. Anat. de miionth; 2* pints of liquor aInnii came away, and a male Paris, July, 1913) publish au account of an ipstance where child weiglhing nearlv 11 lb. was deliveredi asphyxiated. a painftul ovary was amputated, and, though distinctly It was revived, but died on the next day; the mother enla-ged, was free from any flbromatous or sarcomatouis (lid well. The third case was a remarkable instance of elements and showed none of the appearanices seen in diabetes and syphilis combined. The patient was 35 years obphoritis. It measured 3 in. in length, nearly 1J in. in old(; her grandmother died of diabetes, hier father appears breadth, and i in. in thickness, and thus was nearly gix to have been syphilitic, and the mother, whose only child times the bulk of a normal ovary, its relative proportions she was, succumbed to tuberculous phthisis at the age of being maintained. The patient was an embroiderer, 33. The husband seemed free from syphilis. She married aged 28. She had been subject to leucorrhoea and attacks at 24, and had three abortions between the ages of 25 and of pain in the heel, temporo-maxiliary joint, and phalan- 29; slhe suffered at the same time fronl intolerable thirst, geal articulations. This had been followed by severe polyuria, and bulimia, and later from neuralgia, intercostal abdominal pains aggravated by walking, coitus, etc. and radial, in botlh arms. Then diabetes was detcctlud by Pozzi detected a tender mass in Douglas's pouch, and a physician. At 31 there was abortion in the fourth nmonth, apparently two enlarged and tortuous tubes. There was and next year pregnancy again occurred. A 'macerated slight elevation of temperature. He suspected double fettus, dead about ten days, yet weighing 8* lb., was salpingitis and operated. The uterus was found three delivered at.term. All trace of sugar disappeared during times as big as when non-gravid, congested, and this pregnancy, but septic symptoms developed in the softened. The Fallopian tubes were normal, the ovaries puerperium, with rheumatic pains, scarlatiniform ery- greatly enlarged without alteration of form. The right thema, otitis, cystitis, and albuminuria, yet the patient ovary, which was smooth, was not removed; the left was recovered, whilst the diabetic symptoms, on the other amputated, as it was somewhat irregular, and was the lhand, reappeared. Once more; and this time when undler mass in Douglas's pouch which had been very painful Fruhinsholz's care, she, became pregnant. At first the when touched. Convalescence was speedy. The ampu- urine held much glucose, yet it disappeared, and no sugar tated ovary, of which the Proportions are given above, could be detected down to her spontaneous delivery at bore a big corpus luteum. On section the cicatrices of ternm. She was kept unider treatment from: the fifth atresic follicles and slight oedema were detected. There miionth, Deret's elixir biiode being given. On thisoccasion was no sclero-cystic degeneration of the stroma. Tlle tlle cllild weighed onily 5 lb., and as it was being reared condition seemed to be pure hyperplasia. the appearances of hereditary syphilis developed. The mother recovered speedily, yet directly after delivery the gluicose reappeared (September, 1911), and when the report was published the patient's urine contained a high propor- tion of sugar. FrLuhinsholz notes how diabetes resemnbles THERAPEUTICS. syphilis in respect to the big fetuses ancl placentae, the fre(uency of hydramnion, and the low vitality of the fetus. 138. Secretin in the Gastro-Intestinal Disorders But vhilst specific treatment is most beneflcial to mother of Children. and child in the case of syphilis, no method of treatment HARROWER (Pediatric.s, July, 1913) diraws attention to seemiis of any avail to the child when the mother is dia- this new idea in the treatment of summer dyspepsias." betic. Her malady undergoes a kind of eclipse during Wientworth found that secretin was absent in the duodenuin gestation, only to reappear in the puerperium. Thus it is of children dying from infantile atrophy and malnutrition. highly inadvisable for a diabetic woman to become Boardman Reed has used secretin in the form of a pregnant. preparation called " secretogen," in cases of dige-stive insufficiency; he regards it as superior to ordinary digestives and tonics. Secretin acts as a very effective stimulus to gastro-intestinal digestion, controls flatulence GYNAECOLOGY. and fermentation, and is not followed by any injurious 136. Acute Miliary Tuberculosis; Primary Disease reaction. It acts not only on the stomaell and pancreas, in Female Genital Tract. but also on the production of bile and of succus entericus VON KUBINGI (Zentralbl. f. Gyndk., August 9th, 1913) from the pylorus to the ileum. Its therapeutic use does recently discussed at a meeting of a society in Budapest not interfere with ordinary dietetic or drug treatment. The the question of primary tuberculosis of the uterus and author praises it in achylia gastrica, gastric and duodenal appendages anid its possible diffusion. He reports a case catarrh, " ildigestiona," and pancreatic insuffleiency. where. this complication, in his opinion, followed an He considers it is equally indicated in adults. Up to abortion. The patient was 26; she had married when 15 the present time but little pathological study has been years of age, and had suffered from long ill health after directed to the subject of secretin; but it is probable that an abortion at the fouLrtl mointh. She became pregnant in many intestinal disorders, such as typhoid fever, dysen- again and aborted in the miiddlle of the tlhird month. tery, spirue, pellagra, etc., there is diminution or loss of Feverishness followed, and she was a(dmitted into hospital. secretin in the intestinal mucosa, or a perversion of its The uterus was enlarged and the appendages swollen. secretory funictions. The whole subject, then, n lay Har(d infiltratioln, clearly of old standing, was detected in possibly have a great future in front of it. the posterior fornix. Rigors set in, with the physical signs of pleutropneuinonia and pyacmlic changes. Extremne 139. Cerebritis following Salvarsan. dyspnoea and cyanosis developed, without anly cerebral or CAESAR of Dres(len (Demmnzat. Zeitschmr., xx, No. 7) describes miienital symiptom;s. Death occurred on the forty-fifth clay the clinical and patlhological featuLres of 7 cases in great after admuission. At the necropsy, old-standing tuber- detail, and (draw s som-le valuable conclusions from his culous disease of the uterus andl tubes wasdiscovered, and findings. In all 7 cases there was a history of alcolhol, acute mliliary tuberculosis of the lungs. Scipiades, in epilepsy, nmild demiientia from birth, or some other ill- discussion, observed that Kronig (leniedl that absolutely defined cerebral condition in wlhieh the brain or its isolate(d geiiital tuberculosis without isolated foci else- capillaries were probably to some (legree abnormal, even where had ever been auitlienticated at a necropsy. The before the salvarsan injections. He is of opinion that bones in particular vere ofteni entirely overlooked. salvarsanl has a toxic action on tlle cerebral capillaries, Von Kubingi replied that some living authorities tlhought tending to paralyse their contractile elenients. In the otherwise. Wheni all surgeons aiid physicianas could cases where encephalitis supervenes there must have denmonstrate the existence of primary tuberculosis in been, he thinIks, preceding capillary damage, and there- almost every other part of the body, it seemed strange fore every patient who is to be injected should be pre- that so wellk0nown a disease as tuberculosis of the viously most minutely questioned and examined for the Fallopian tube could never be primary. No doubt possible existence of this, and excluded from the treat- tubercle bacilli might be concealed in an enlarged gland or ment if positive evidence is forthcoming. Besidles arterio- in an old scar, o-verloolied by a clinidal reporter, but still sclerosis as a causation or concomitantof cerebral capillary the lungs, kidneys, and other organs were undoubtedly degeneration, he 'instances the chronic intoxications, par- the seat of primlary tuberculosis, and nobody urged that ticularly alcohol andl existing disease of the central in every case there might be an overlooked primary focus. nervous system. In conclusion he cites the cdnflrmation The evidence that primary tuberculosis of the internal of his views by the pathologist, Schmorl of Dresden, 744a B - Ir TE rrU 11 EPITOME OF CURRENT MEDICALtRATURE. rfgi.T iO-s 0t3- who from microscopic examination of Caesar's post- culosis, on etbases of asthma suspected of pulmonary mortem specimens, in which he found fatty degenera- tuberculosis. -He also suggests the injection of a series of tion of the endothelial capillary wall entirely apart from control cases cDf asthma with normal saline solution. thrombosis and cerebral softening, is in agreement with the former's hypothesis of a toxic action of salvarsan on the capillaries of the brain. 140. Duodenal Ulcer in Infancy. PATHOLOGY. AT a meeting of the American Pediatric Society held in May, 1913, EMMETT HOLT (Amterican Journ. of 142. The Sensory Fibres of the Phranic Nerve. Ob8tet. and Dis. of Vomen and Children, July, 1913) IN the course of an experimental study of the innervation described 4 cases of duodenal ulcer that occurred at of respiratory muscles, G. C. MATHIESON (Rev. of Neitrol. the Babies' Hospital, New York. The ulcers averaged and Psychiat., December, 1912) observed the effects about a centimetre in diameter, and were all situated of stimulation of the central end of the divided phrenic just below the pyloric ring in the posterior wall of nerve or of one of its roots in more than twenty-five dogs, the duodenum. No inflammatory reaction was present, five rabbits, and five cats. The anaesthetic was varied and the base was necrotic without any sign of repair. according to the animal used; on several occasions The author noted that since 1903 groups of such cases decerebrate cats were employed. In dogs Mathieson had been published by several observers, and the in- found, on half a dozen occasions, that the right phrenic creasing number of reports appeared to show that the nerve gives off, near the diaphragm, branches which condition had previously been overlooked, and is not at all ascend in two strands along the inferior vena cava to be uncommon. Certainly, as compared with gastric ulcers, distributed to the pericardium, one branch going to the duodenal ulcers in infants are relatively common. Thus auricular portion; this arrangement corresponds with that in 1908 Entz of Budapest found 10 cases of duiodenal ulcer described by Luschka in 1853 for the right phrenic nerve and only 1 of gastric ulcer in 364 autopsies. Helmholz of man. The left phrenic gives off two small branches, as found 16 cases in six months in various European hos- it passes behind the heart, which go to the pericardium; pitals, and Schmidt has reported 20 cases in 1,109 autopsies they are composed of about a dozen medium-sized medul- upon infants during the first year of life. In several of lated fibres and a similar number of non-medullated the recorded cases marasmus and infantile atrophy have fibres. Mathieson found that stimulation of the central coexisted, but Holt regards this connexion as an accidental end of the phrenic nerve brings about a reflex rise of one. The diagnosis during life is very dlifficult, and has blood pressure due to excitation, partly of muscle-sense beein made in but a small proportion of cases. In a few fibres from the diaphragm, partly of sensory fibres frorn instances the of or the serous membranes. The pleura and pericardium have vomDiting blood "coffee-ground" additional fibres material occurred, but in many the only symptom was apparently -ensory to those supplied by acute followed death due to or the phrenics. Stimulation of the central end of the collapse, by peritonitis nerve about an increase internal haemorrhage. In the mnajority of cases the coIn- phrenic brings in rate and depth dition was fatal, although spontaneous recovery has of respiratory movemnents, a result similar to that produced occurred in a small proportion. Owing to the uncertainty by stimulating any sensory nerve. In no case was any of treatment is out of the expiratory retlex evoked; " sensory impulses passing ul) diagnosis, surgical practically the nerve little or no in the question. In one of the author's cases the passage of a phrenic play part normal duodenal catheter led to the diagnosis of a duodenal ulcer regulation of respiratory movements." At the same time which was at Holt Mathieson holds that afferent impulses f lomn the diaphragm, confirmed autopsy. urges upon all its nerve-fibres those who perform autopsies upoIn infants to make a nanmely, muscle-afferent which consti- careftul and systematic search of the duodenum, since tute the somiiatic afferent fibres of the phrenic nerve, ulcers may readily be overlooked in a superficial examina- probably play a part in the miaintenance of reflex tonus of tion of the intestine. the muscle, and in bringing about its steady co-ordinated contraction. His paper contains other points of anatomical 141. The Treatment of Bronchial Asthma with and plhysiological interest. Tuberculin. DURING the past six years, 0. FRANKFURTER (Wien. hlin. 143. Histological Studies of Intestinal Polyadenoma If'och., June 12th, 1913) has observed 8 cases of bronchial during and after X-ray Treatment. asthma in which he also suspected the presence of THE results of two comparative biopsies in a case of poly- pulmonary tuberculosis. Some authors have conclusively adenonma of the large intestine, wlhich was submnitted to demonstrated that a patient does not suffer simultaneously x-ray treatm-lent, are given by AUBERTIN and BEAUJARD from asthma and pulmonary tuberculosis, while others (Ais-ch. d'lectr. med., July 10th, 1913). For three years have with equal assurance found a close relation between previously the patient had been subject to diarrhoea, with these conditions. All the author's patients exhibited sus- mueo-sanguineous stools. Rectoscopic examination showed picious signs of pulmonary tuberculosis, such as dullness that the mucosa of the intestine was covered with polypi and diminution of respiration over the apices; and in one of various sizes, some having the dimensions of a cherry. case rales were heard over the right apex. Treatment The flrst histo!ogical examination, made after only a suitable for consumptives was accordingly prescribed, but few x-ray sittings, showed the usual aspect of mucous rest combined with other hygienic, dietetic measures was polypi of the rectum; the second was made after an futile. Tuberculin (Bkraneck) was then cautiously pre- interval of eighteen months, by which time the patient scribed in the first 6 cases with excellent results. These had considerably improved in health; the polypi ha(l can hardly be attributed to the psychic effects of the sub- diminished in number and size, and there were sound cutaneous injections, for improvement was seldom marked mucous areas between the polypous zones. The patient till several had been given, in one case eleven and in had had twenty-flve x-ray sittings, at each of which three another nine injections. The fact that on two occasions applications (two abdominal and one perineal) of 4 Holz- relapses occurred after appreciable intervals suggests the knecht units had been given, the rays having been filtered presence of a potent, if not a permanently active, factor. through aluminium (1J to 3 mm.). At the second biopsy A detailed account of the 6 cases shows that the recovery the histological modiflcations, corresponding to the diminu- effected by the flrst patient was maintained two years tion in volume of the tumours, were found to be essentially: later; that the second patient relapsed after an interval (1) diminution in volume of the glandular culs-de-sac; of two years; that the third patient improved much after (2) transformation of mucous cells into indifferent cylin- nine injections, but was unable to continue the treatment drical cells, with, corelatively, diminution of the mucous for private reasons; that the fourth patient's condition secretion; (3) condensation of the stroma, with trans- was " satisfactory" a long time after the comiipletion of formation of the connective cells into plasma cells, the the treatment; that the fifth patient hadl no serious attack stroma at the same time becoming less vascular, and the after the treatment was started, her cough and dyspnoea eosinophile granules, which formerly were very numerous becolmling much less troublesome; that the sixth patient in the middle of the stroma, emigrating to the interior of was unable to continue the treatment after the second the glandular culs-de-sac; (4) disorganization and atrophy of injection for various reasons. It is possible that peri- the lyniphoid masses. X rays brought about, in short, the bronchial, tuberculous foci may have been responsible for loss of the specifle character of the epithelial cells of the the asthma in these cases, and that the tuberculin tumours; frorn the state of being muciparous, the cells affected them beneflcially. If this be so a large dose of became indifferent. It is interesting to place by the si(lo tuberculin should cause a focal reaction, and thereby of this disappearance of the muciparous cells the dis- precipitate an attack of asthma. This test of his theory appearance of the muco-sanguineous diarrhoea. The histo- the author has not carried out, an(d he leaves it to others logical result is therefore in accord with the clinical, to inivestigate the effect of rapidly increasing doses of showing that x rays act indisputably on such adenomatous tuberculin, as used for diagnostic purposes in tuber- tumours. 7i4 D