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OpeMOM.—A horizontal incision was made along It will be noted that in every case the dilatation the clavicle after drawing down the skin, and the was distal to the rib, so obstruction to the circulation swelling readily exposed. It turned out to be a apparently played no part in the causation. In my saccular diverticulum of the size of a cherry, springing case the wall of the sac was thin and the swelling from the front of the third part of the artery-itself increasing in size ; to all appearance rupture of the apparently normal in other respects. The wall was sac at no distant date must have occurred. On the thin and the sac could be emptied by compressing it. general question of the necessity for operation in cases The incision was converted into an angular one by of cervical rib, it is noteworthy that, so far as published making a second one parallel to the edge of the cases go, the mortality of operation is nil. On the trapezius. The rib was readily exposed, cleared up to other hand, cases have been described by Sherren7 its neck, and well beyond the brachial nerves, and and others where the operation caused trouble from divided there ; its distal end was united to the dorsal nerve involvement in the scar, and by Thorburn11 rib by a joint with cartilage and capsule complete. where a troublesome sinus, not due to sepsis, formed It was disarticulated and removed. The pleura and some time afterwards and remained in one case as some fibres of the scalene muscle were attached to it. long as 18 months. To anyone in search of informa- Nothing was seen of the suprascapular artery and tion on any subject connected with cervical ribs, the nerve, or of the subclavian vein. The transverse exhaustive bibliography collected by Honeij may cervical artery was easily identified and avoided. be recommended. Attention was next turned to the aneurysm. References.—1. Halsted, W. S.: Jour. Exp. Med., Balt., 1916. 271. 2. A. H.: itself as the ideal mode xxiv., Tubby, Deformities, 1912, i., 24, Aneurysmorrhaphy suggested 3. Murphy, J. B.: Annals of Surgery, xli., 398. 4. Keen, W. W.: of treatment, but it would have been impossible Amer. Jour. Med. Sci., February, 1907, p. 173. 5. Ehrieh, E.: to apply a distal clamp without dividing the clavicle. Beit. zur Klin. Chir., xiv., 199. 6. Adams, R.: Med. Chir. Trans., On the other hand, the coats of the looked 1869, lii., 288. 7. Sherren. J.: Clin. Jour., 1908, xxxii., 98. artery 8. Thorburn, W.: Proc. Roy. Soc. Med., Clin. Sect., 1913, quite healthy on either side ; there was no matting to vol. vi., part 1., 117. 9. Honeij, J. A.: Surg. Gyn. Obst., surrounding parts and there seemed no reason to 1920, xxx., 481. anticipate trouble in the arm from tying the artery. A kangaroo-tendon ligature was therefore placed on either side of the sac. The operation was straight- BLOOD-SUPPLY OF THE DENTATE forward throughout and almost bloodless. NUCLEUS OF THE CEREBELLUM. Next day the arm was normal, except for absence of the radial pulse. The circulation differed in no BY JOSEPH L. SHELLSHEAR, M.B., CH.M., other respect from that of the opposite side and all DEMONSTRATOR OF ANATOMY. UNIVERSITY COLLEGE, LONDON. movements were unimpaired. There was a little surgical emphysema of the right chest and face, but IT is surprising how little is known about the arrange- none of the left side, and no clinical signs of pneumo- ment of the blood-vessels of the cerebellum. The thorax. Recovery was uneventful. The radial pulse summary accounts of the arteries found in the text- began to reappear on the fourth day, and the aneurysm books represent all that is known. It seemed worth could be felt, but no longer seen, as a firm non- while to investigate this subject more fully, not pulsating mass. The piece of rib removed was 2 inches merely to get the morphological information itself, long and showed a well-marked neurovascular groove but also in the hope of throwing some light on the at its distal end. functions of the cerebellar and the clinical manifesta- Rewards. tions of lesions affecting it. Here, then, was an undoubted case of subclavian With this object in view a number of brains were aneurysm with a cervical rib. As to the causal injected by the method described by Beevor 1 (1909). connexion between the two conditions, it is worth The cerebellar cortex is supplied by three vessels, the remarking that the aneurysm sprang from the front posterior inferior cerebellar, the anterior inferior of the artery and not from the part in contact with cerebellar, and the superior cerebellar arteries. The the rib. The presence of a normal radial pulse freedom of anastomoses between these vessels on the seemed to indicate that there was no compression of surface of the organ renders it a difficult task exactly the artery. In this connexion, Halsted’s experiments to delimit the areas of their cortical distribution. In on the partial obstruction of arteries with aluminium this note no attempt is made to deal with this aspect bands are noteworthy. A prolonged search of the of the problem. Attention will be concentrated on literature has revealed no case quite parallel with the the blood-supply of the dentate nucleus. The above. Some cases, loosely called aneurysm in the posterior inferior cerebellar artery has been described early days, were normal arteries pushed up by the by Stopford (19ltJ) and I can verify his account of rib. Others revealed themselves as expanded arteries, its course and relations and also of the variability of which returned to normal calibre as soon as the rib its origin. He has given a comprehensive account of was removed, as in Tubby’s case, where the operator the blood-supply of the pons and medulla oblongata, actually saw this occur before he closed the wound. but did not include the cerebellum in his investigation. In Murphy’s case the sketch shows a well-developed It will he seen from the iigure here reproduced that aneurysm, but the author has stated that the artery the blood-supply of the dentate nucleus comes from was merely flattened and spread out, the appearance the posterior inferior cerebellar artery as this vessel is of it being much exaggerated by the artist. Keen 4 lying between the medulla oblongata and the hemi- had a case in which the calibre of the artery, beyond sphere of the cerebellum. It passes upwards between the edge of the scalene muscle, was twice its normal the tonsil and the lobus bi venter, enters the medullary size. He doubted if any of the recorded cases were substance to reach the dentate nucleus, where it ’’ genuine aneurysms and remarked, In no case has breaks up into numerous terminal branches. It is an the vessel been ligated ; a very wise abstinence." end-artery. In Ehrich’s 5 case the aneurysm developed after the References to cases of thrombosis of the posterior removal of the rib, which he attributed to the effect inferior cerebellar artery (up to 1916) will be found in 3 on the arterial wall of the loss of support. Perhaps Stopford’s paper. Since its publication Winkler the most convincing case is that of Adams."6 The (1918) has described a case of thrombosis of this patient came under treatment in 1836 for some eye vessel with a further bibliography. Whilst agreeing trouble and was noticed to have a pulsating swelling with Stopford that the cases recorded show a certain above the left clavicle, and a hard swelling to its inner degree of variability, for which the vessel itself is side. A diagnosis of aneurysm with cervical rib was partly responsible but partly also whether the vertebral made, and many consultations held as to the advisa- or basilar are involved at the same time, nevertheless bility of operation. Three years later the patient the symptoms are sufficiently constant in the majority died of pneumonia and a fusiform aneurysm 3 inches of cases of thrombosis to warrant the conception of a long was found, starting beyond the edge of the posterior inferior cerebellar syndrome. In this scalenus anticus. There was a double cervical rib syndrome we tind a dissociated anaesthesia, there being, and no visible disease of the arterial wall. as a rule, loss of appreciation of pain and tempera- 1047

ture in the face on the side of the lesion (due to the involvement of the descending root of the trigeminus), loss of pain and temperature appreciation on the Clinical Notes : opposite side of the body (due to involvement of the AND tractus spinothalamicus) and dysphagia (due to MEDICAL, SURGICAL, OBSTETRICAL, involvement of the nucleus ambiguus), and among THERAPEUTICAL. other symptoms we find ataxia on the side of the lesion and analogous cerebellar lesions. Hun describes a case in which the nucleus dentatus "FOCAL TENDERNESS" IN THE DIAGNOSIS is depicted with a number of very small foci of soften- OF GASTRIC ULCER. ing. In the interpretation of the cerebellar symptoms due regard has not been paid to the lesions of the BY GEO. VILVANDRÉ. M.R.C.S., L.R.C.P. LOND. dentate nucleus. In fact, Hun is the only writer, so By palpating with one finger along the whole of the small curvature, from a point nearly as high as the cardia, starting from the infra-chondral margin down as far as the pylorus, a test is applied in the X ray of gastric ulcer which, in my experience, is of greatdiagnosis value. In a certain proportion of penetrating gastric ulcers any other evidence but the visibility of the ulcer is not needed, the size of the crater being sufficient to cast a shadow on the screen or film that defies any other interpretation but that of penetrating ulcer. It is sometimes accompanied by a gas bubble above the barium shadow and sometimes also by a sinus leading from the mucosa to the depth of the ulcer which may even reach the pancreas. But in the more difficult cases, none the less numerous, which one encounters among hundreds of patients, the finger test of what I like to call " focal tenderness is to me of great value. The less developed or less chronic gastric ulcer may show as only a pin-point, or of a size reaching that of a small pea, and the smaller the shadow the less the certainty of its diagnosis on the screen or film. Espe- - clrtt cially is this so in the region of the fundus where the post. ce re- bet jejunum crosses posteriorly the body of the stomach. Diagi’am illustrating the blood-supply of the dentate nucleus. The relationship of the fundus and first portion of the jejunum just beyond the duodeno-jejunal flexure is far as I am aware, who has noted the lesion. He states not constant, owing to the variability of the stomach (p. 614): " There is nothing in the clinical history level and size in different individuals and the length which enables us to assign any date to the focus of of the mesentery of the jejunum. These points count in the inasmuch as it lies softening cerebellum, but, much in accurate and often one is close to the focus of in the diagnosis, puzzled quite softening medulla, for a while as to whether the small shadow seen at it is not that both are " " improbable regions supplied that level is a variable amount of barium hanging the same arterial the inferior by trunk, posterior in the jejunum, or the visible evidence of a small cerebellar It is that some of the artery." apparent penetrating ulcer. The difficulty is real to one who are due to the to the dentate symptoms damage examines many gastric cases. In such dilemma I have nucleus and the resulting degeneration of the superior often found that with the of the index cerebellar and other tracts from the pressure tip peduncle passing finger has elicited definite pain and calling out on the dentate nucleus. It must be borne in mind, however, of the in to the stimulus that the free cortical anastomosis the part patient response applied may permit directly over the point where the ulcer is present. dentate nucleus to escape in some cases of thrombosis other of the of the inferior cerebellar This Palpation similarly applied along points posterior artery. small curvature elicits no response. The more intelli- affords an of the of the explanation variability gent the patient, the more rapid and definite the cerebellar in these cases. The fact of the symptoms response. But I have found the chief aid to diagnosis to the dentate nucleus an artery being end-artery in those cases to occur where a spasm or incisura is opens up the possibility that many of the cases of present in the outline of the great curvature, especially localised lesions of the dentate nucleus are of vascular in the of the fundus. On Buzzard 5 and 6 have described similar upper portion tentatively origin. Spiller applying finger pressure opposite the spasmodic con- cases. The middle cerebellar receives its peduncle traction, a is often elicited at which " focal from the basilar and the point blood-supply artery, superior tenderness " is definite and sometimes severe. I have from the cerebellar peduncle superior artery. made meal examinations on medical men and The of certain cerebellar lesions be opaque explanation may other intelligent patients and in some of these I have facilitated by these anatomical facts, but the author obtained " focal tenderness " and leaves such to the clinicians and definitely repeatedly interpretations at the same and in those cases it coincided with physiologists. spot, the presence of an ulcer. The facts, I believe, are Bibliography.—1. Beevor, C. E.: On the Distribution of the somewhat to the of but Different Arteries Supplying the Human Brain, Phil. Trans., opposed teaching neurologists, Ser. D., vol. cc., 1909. 2. Stopford, J. S. B. : The Arteries I feel certain of the value of the test.. of the Pons and Medulla Oblongata, Journal of Anatomy, Whereas tenderness over an ulcer is obtained by vols. 1. and li., 1915-16. 3. Winkler, Cornelius : A Case of in the I have observed Occlusion of the Arteria Cerebelli Posterior Inferior, Opera palpation standing position, Omnia, Haarlem, 1918. 4. Hun, H.: Analgesia, Thermic that on placing the patient on his back the painful Anæsthesia and Ataxia, due to Occlusion of the Left Posterior point is not found. This may be due to the fact that Inferior Cerebellar Artery, New York Medical Journal, vol. lxv., the when filled with is stretched 1897. 5. Buzzard, F. : Brain, 1906. 6. Spiller, W. G. : Journal stomach, heavy barium, of Nervous and Mental Diseases, 1908. to some extent, whilst in decubitus the posterior portion of the fundus contains most of the meal and the small curvature is more What PRESENTATION TO A MEDICAL MAN.——Dr. F. W. placed posteriorly. is the cause of this tenderness ? It is distinct from Apthorp has been presented on his retirement with a cheque distension nor is it the same as that for f0172 Is. 7d., a silver cigarette case, and an album contain- pain, apparently ing the names of over 600 subscribers, as a token of complained of by the patient when, according to the appreciation of a professional career in the Burgess Hill position of the ulcer, he gives the time of the appear- a district of Sussex extending over period of 30 years. , ’, ance as from after to one and a half varying directly