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EPITOME OF CURRENT MEDICAL LITERATURE.

Medicine.

308. Hemiplegia in Typhoid Fever.

G. TIZIANELLO (II Policlinico, Sez. Prat., August 18tb,

p. 1065) states that among more than a thousand

typhoid fever admitted to the typhoid pavilion of the

hospital at Venice in the course of the last seven

two developed heuiiplegia. Only a few instances

complication of typhoid have been recorded in medical litera-

ture, all of which ended in recovery, so that it was

to determine the nature of the causal lesion. Tizianello's

first case occurred in a woman, aged 29, who developed

hemiplegia, followed by gangrene of the left armin

week of a severe attack of typical typhoid fever. Death

place after about five weeks' illness, and the autopsy

an area of softening in the basal ganglion on the

involving the putamen part of the globus pallidus and

capsule and a small portion of the external capsule.

second case was in a girl, aged 18, who on the fifth

the temperature had become normal, and on the thirtieth

of disease, complained of headache, and a few hours

suddenly developed right hemiparesis. Almost

recovery eventually took place. Tizianello

process as thrombotic in both cases. He thinks

probably the primary cause of the hemiplegia always

typhoid arteritis. The similarity of the two cases

that the typhoid toxins may have their seat of

the grey nuclei of the base, probably the putamen.

307. High Blood Pressure.

ACCORDING to E. KYLIN (Ktin. Woch., September 16th,

p. 1712) the disturbance in the autonomic nervous is

the point to which treatment should be directed in cases

high blood pressure. A rest cure should be tried first,

this often gives good results, though when the patient

to his former occupation the pathological condition

reappear. For some time the author has treated

high blood pressure by calcium salts and atropine

the mouth. Theoretical grounds for this treatment

supposed predominance of the vagus nervous system

sympathetic nervous system in essential hypertonus

indicated by the adrenaline reaction) and the view

calciumions bring about stimulation of the sympathetic

system. It has been shown also thatin essential

the calcium of the blood is diminished. By the administra-

tion of atropine the author endeavours to restore

librium between the vagus and sympathetic nervous systems.

Four cases are recordedin detail illustrating theimprovement

under the administration 'of calcium chloride and

four times a day. These patients were in hospital,

similar improvement was obtained in out-patients,author considers that the treatmentis worthy of further

SOS. Three-day Fever with Rashin Children.

E. GLANZMANN (Schweiz. med.WVoch., June 26th, 1924,

discusses the diagnosis of this condition, a comprehensive

account of which was first published in 1910 by

who calledit "roseola infantilis." The author

it since 1918 in Bern, and publishes several case

illustrate its most salient clinical features. The is

practically limited to children between the ages

and 2 years; it begins with three days of comparatively

fever, the fall of which by crisis is rapidly followed

appearance of a rash resembling that of fever,measles, orrrbeola. During the three days

patient is restless, sleepless, and obviously in pain;old enough to speak complain of headache.

eruption stage of the disease there is only one

to the diagnosis-a leucocyte counit. The author

that it is remarkable that such a brief and mild exanthematous

diseaFe should have so profound an influence on

cytes. Great leucopenia occurs, associated

relative increase in the number of the lymphocytes

80-90 per cent. of all the leucocytes. The the

polynuclear leucocytes, both absolute and relative,

reduced, and the few polynuclears which remain

degenerative changes; a few myelocytes and metamyelocytesmay be found. The relative number of the

leicocytes is Increased. With regard to

this disease, the author has not seen it in more

of the same family at the same time, perhaps

age limit of this disease is comparatively

30. Abortion of Measles by the Serum of Convalescents.S. BUTTENWIESER (Deut. med. WFoch., June 27th, 1924, p. 876)publishes several tables illustrating the importance ofmeasles as a remote or immediate cause ordeath amonginfants in hospital. Almost one sixth of all the deaths ina children's hospital during 1922 were due to measles con-tracted in the hospital. He recoimmends the adoption of theDegkwitz system of injecting the serum of convalescent sinto children who have been exposed to infection, and whomay possibly be in the early stage of the incubation period.He reports the successful use of this prophylactic measureon several occasions. According to him, as much as 100 c.cm.of blood can be taken from a convalescent child, if not tooyoung, this quantity being sufficient for twelve children. Heurges the medical authorities to orca nize a system of collect-ing the serum of convalesceints and to educate both the publicand the medical profession as to its value. Munich andStuttgart have already organized the distribution of thisserum, and Buttenwieser mlaintains that if such organizationwere ubiquitous thousands of infants could be saved everyyear.

310. Epidemic Encephalitis in Sweden,E. BERGMAN (Hygiea, July 15th, 1924, p. 426) states thatabout 2,500 cases of epidemic encephalitis have alreacdy beennotified in Swe(len, and that more than half of the casesoccurred in 1921. January, 1921,marked the culmination ofthe epidemic, aud there were as many as 520 now cases inthis month. About 500 cases were notified in 1923. A studyof 67 cases in Upsala was macle by the author, who foundthat in about 50 per cent. the onset of the disease wasmarked by vague febrile symptoms. In no case was itsonset insidious, and only in 2 cases were there generalsymptoms without fever at the onset. In as many as 18 caseslethargy and paralyses of the ocular muscles occurred at thebeginning of the disease. The cranial nerves and ocularmuscles were affectedin 85 per cent., and in most of thesecases the lesiofts of the cranial nerves began very early.Indeed,in some cazes the disease was first detected whenthe patient went to an eye hospital on account of diplopia.Most of the facial paralyses passed off rapidly. The amyo-static symptom-complex, or Parkinsonism, was observed inas many as 29 cases. Ten cases terminated fatally, and only15 of the 67 patients were cured completely, though another10 patients recovered sufficiently to resume full work. Tbeprognosis was worse and the mortality higher for thehyper-kinetic than for the lethargic cases. It was often noticedthat neurasthenic and psychasthenic conditions developed assequels, and eitherinsomnia or persistent drowsiness con-tinued long after the onset of the disease. The authorexpresses considerable pessimism with regard to the variousmethods of treatment tried.

Surgery.3i1t Congenital Duodenal Occlusion.

J. M. SMELLIE (Brit.Journ. Child. Di8., July-September,1924, p. 192) records three cases of this rare condition whichhe has seen during the last year. Two died within a fewdays of birth, asis the almost invariable rule, but one caseliVed for nearly three months. Only three cases on recordhave survived longer. In Keith's case, where the duratiouof life was nine months, the autopsy showed that the occlu-sion was complete, but in Buchanan's case, which lasted foreighteen months, and in Cautley's case, extending overtwelve months, the atresia was incomplete. The site of theocclusionin Smellie's first case was just below the openingof the common bile duct, of which type there are abouttwenty-three recorded cases, and in the second case theduodeno-iejunalflexure was the site of occlusion, of whichtype eleven instances have been observed. In the third casethe occlusion would seem to have occurred just above theopening of the common bile duct, but in addition- therehadlbeena complete interruption In the continuity of the gut, andthe second part of the duodenum appeared to have takenorigin from the junction of the common bile duct and thepancreatic duct. No previous examples of this varietyappear to have been described. While a developmentalorigin appears to be the most probable explanation of thecondition in the majority of cases, some are probably due toa localized foetal peritonitis, or foetal volvulus, especially

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those occurring at the duodeno-jejunal flexure. In favour ofthe developmental theory is the presence in a small per-centage of cases of other congenital abnormalities. One ofSmellie's cases had an imperforate anus, and in another thegall bladder was absent. Relief for the obstruction can onlybe obtained by operation, which was successful in casesrecently described by Jewesbury and Page and Hutchison.

312. Cholecystenterostomy.F. G. DU BOSE (Surg., Gynecol., and Obstet., September, 1924,p. 235) considers that the results of gall-bladder surgery areunsatisfactory, repeated operations for recurrence being areflection on surgical efficiency. He records his experiencewith cholecystenterostomyin twenty cases covering a periodof eleven years, and insists that since the gall bladder con-centrates bile, secretes mucus, and is a reservoir, it shouldbe conserved wvhenever possible. Cholecystenterostomy hasbeen considiered hitherto an operation of necessity ratherthan of choice; it remains to be seen whether it may not berather the operation of choice. Du Bose considers that it Isindicated in common duct obstructions in patients who are"poor surgical risks," also in jaundice secondary to diseases ofthe liver and pancreas causing common duct obstruction. Inperforated duodenal ulcer he flnds that ib promnotes healing ofthe ulcer by bathing it continuously in the alkaline bile. Incases of strictutre of the bile ducts he prefers it to choledocho-touiiy or plastic surgery, being simpler, safer, and equallyeffective. The operative technique recommended is theformation of an anastomosis between the gall bladder andstonach round a rubber tube. After the suturing is com-pleted an omental graft is placed round the suture line forcomnplete protection. The anastomosis may be made betweenthe stomach or the duodenum. This operation is contra-indicated in cancer of the gall bladder, in cases of gangrenousor atrophic cholecystitis, and also in the presence of cysticduct occlasion or obstruction due to causes other than stone.

313. Depressed Fracture of Zygoma.J. C. LEHMANN (Ze7ntralbl. f. Chir., September 13th, 1924,p. 2016) states that there are very few recorded cases of thisinjury. Lehmann's patient was struck on the left cheek byan iron-headed " life preserver." When admitted there wasa(lepression over the zygomia as large as the tip of a finger,but there was no external wound nor could crepitus be felt.No discoloration of the skin was present around the depres-sion, and the pain elicitedl on pressure appeared to be sos ight that it was difficult to believe that the injury hadoccuLrred on the preceding day. Next day, lhowever, trismus-was present, due to the pressure of the depressed bone on thetemnporal muscle. Under local anaesthesia a small incisionwas nmade along the upper border of the zygoma; throughthis opening the bone was explored and an elevator intro-duced; the depressed fragmient was easily replaced and thepatient was relieved imnmediately, as trismus completelydisappeared. A small metal splint was applied externally,but it was not found necessary to wire the fracture, asrecommended by Matas. There was no recurrence of dis.placement through the action of the msasseter. Lehmannremarks that it is impossible to reduce a fracture of thezygomna by manipulation with a finger in the mouth, as thetemiporal muscle is an obstruction.

314. Intestinal Obstruction by Meckel's Diverticulum.K. A. ROMBACH (NVederl. Tijdsch-. v. Geneesh., August 9th,1924, p. 776) states that Meckel's diverticuluw, which is theresult of incomplete obliteration of the oml)halo-euteric duct,is found 20 to 24 inches above the ileo-caecai valve. Albertsaw it in 2 per cent. of the bodies examined by him, whileP. Turner in 10,360 autopsies noted its presence in 81 cases,in 18 of which it was of pathological significance. Thesymptoms caused by Meckel's diverticulum may be classifiedas follows: (1) Those due to persistence of the duct and itspermeability throughout its entire length. (2) Those due tointestinal obstruction by intussusception or strangulation ofthe intestine by the diverticulumn. (3) Those due to infectionor perforation of the diverticulum. The definite diagnosis ofMeckel's diverticulum being the cause of these symptomscannot be made, and the possibility only can be suspected.In a certain number of recorded cases appendicitis wassupposed to be the cause of the symptoms. Ronmbach recordsa case in a previously healthy man, aged 31, who developedsymptoms of intestinal obstruction which laparotomy showedwere due to strangulation of the ileum by a Meckel's diver-ticulum one inch long. Symptoms of peritonitis developedthe next day, necessitating a further operation, which showedthat the condition was due to paralysis of the portion of the .gtut from which the diverticulum had been removed, butultimately recovery took place.

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Therapeutics.315. Treatment of Tapeworm Infections.

H. IACOBAELTS (Ugeskrift for Lqeger, September 11th, 1924,p. 669) reviews his experience of 132 cases of tapeworm infeo.tion, 125 of which were due to Ta,eniam mediocanellata aud 7 toBothriocephlalus latus. In only a few cases could such sym-ptoms as colic, vomiting, and emaciation be definitely tracedto the intestinal parasites; in most cases there were eitherno symptoms or the gastro-intestinal symptoms present wereunconnected with the worms. In only one of the 7 cases ofBothrioccphalu8 latus was there definite anaemia. Since thelife of a cestode mnay be a matter of twenty-five to thirty years,he remarks that it is well to get rid of them and not to waitfor their spontaneous expulsion or their death from old age.With regard to the amaurosis recorded in about 100 casestreated with extract of male fern, the author notes that mostof these cases occurred in South Germany and Switzerland.In the Scandinavian countries no such accident has beenrecorded, although the extract of male fern is much used.A common cause of failure of treatment with this drug is thevomiting it provokes, and Iacobaeus has found that by givingveronal on three evenings in succession, before the male fernis given, tlle tendency to vomit is greatly reduced. He givesphenacetin with the veronal, 6 grains of each being takenevery evening. To an adult 2i drachms of the extract ofmale fern is given at 7 a.m. ia a little wine. At 8.30 a.m.a powder containing calonmel and jalap is given, and at 10a.m.a strong iufusion of senna leaves; he think.s it well to giveaperients for a couple of days beforehand. By combiningmale fern mnedication with veronal and phenacetin in everycase likely to be troublesome on account of vomiting, theauthor has considerably increased the proportion of cases inwhich the head of the worm was evacuated; in the period1922-24 he treated 49 cases, in 40 of which the head of theworm was found.

316. Se-um Treatment of Anterior Poliomyelltls.F. S. CLARKE and A. G. DOW (Journ. Amler. Ned. Assoc.,August 9th, 1924, p. 421) discuss the use of Rosenow's horseserum in the prevention of paralysis due to anterior polio.myelitis, andl give brief accounts of six cases in which itwas succes-sfully employed. They urge the necessity ofrecognizing this infection before the onset of paralysis, andattach special significance to the following diagnostic points:pyrexia rarely over 1010 F., neck rigidity, and inflamedtonsils and faucial pillars. Hyperaesthesia and resistaniceto exanmination are also said to be important symptoms;Kernig's sign, if present, is suggestive, but its absence doesnot rule out the disease; and the patellar reflexes are usuallyexaggerated, but vary from day to day. The authors donot consider that the cell count of the spinial fluid offers areliable basis for diagnosis. In each of the six cases reportedrapid improvement followed the injection of Rosenow's serum,and recovery was complete without paralysis.

317. Sulfarsenol in the Treatment of CongenitalSyphilis.

G. AHMAN (Ilygiea, August 15th, 1924, p. 481), who is in chargeof a Welander hospital for congenital syphilis in Sweden,points out that in such an institution it is irnpossible for themedical officer to give all the necessary injections of anti.syphilitic remedies, and in order that nurses may give themthey should not have to be administered by the intravenousroute. For this and other reasons the author has foundsalvarsan, neosalvarsan, and various other arsenical pre.parations unsatisfactory; but he has found sulfarsenol,a French preparation introduced by Lehnhoff-Wyld, andclosely related to neosalvarsan in its chemical formula, almostideal. Injected subcutaneously as a 6 per cent. aqueoussolution it causes little pain and does not leave a persistentinfil ration. The author has given about 300 injections to26 children, 19 of whom had previously been treated withother preparations of salvarsan to which the disease hadproved more or less refractory. The success of the sulfarsenolinjections was the more striking as most of the patients hadshown themselves to be refractory to salvarsan.

318. Tuberculin Treatment in Infants.R. OssWALD and H. SCHONFELD (Monatschr. f. Kinderheilkc.,August, 1924, p. 413) have endeavoured to determine (1) theclinical results in young children of two of the specific formsof treatment for tuberculosis, and (2) the effect of the treat-m6nt on the cutaneous sensitivity of the patients to tuber-culin (von Pirquiet test). Poundor's m-ethodl of vaccinatingthe patients repeatedly with a prepared serum was appliedto 36 children suffering from tuberculosis of the lungs, lymphglands, bones, or abdominal viscera. The results werewatched for periods varying from three to eighteen months,

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but no difference could be observed clinically between thepatieuts who received this specific treatment and those who*did not. In the absence of clinical manifestations the authorstried to determine whether the reaction of the patients tothe biological von Pirquet test showed any variation, andthey applied the test to 23 children before, during, andafter their treatment according to Ponndor's technique. In

15 cases the cutaneous sensitivity showed an unfavourablealteration, in 2 it was unchanged, and in the remainder therewere minor alterations, first in one direction and later in theother. Moro's method of inunction was applied to 22 childrensuffering from tuberculosis of the peritoneum, lymph glands,or lungs, and, as before, the patients were kept under observa-tion for many months. From clinical observations the authorswere unable to convince themselves that the treatment hadany therapeutic value. They again resorted to the vonPirquet test, and found that in 17 out of the 22 childrenthe local cutaneous reaction showed no definite change, in4 it was altered unfavourably, and in only one case favour-abl-y. It-cannot therefore be said from these results thatMoro's treatment has any effect on the cutaneous sensitivityto tuberculin.

Dermatology.319. Herpes Zosterin Hodgkin's Disease.

H. K. PANCOAST andE. P. PENDERGRASS (Amer. Journ.MSed.Sci., September, 1924, p. 326) consider that herpes zoster ispresent in Hodgkin's disease with sufficient frequency to

justify its inclusion among the skiu manifestations of thatdisease. Notes are given of four cases of Hodgkin's disease,and one of ovarian sarcoma, in which an attack of herpeszoster occurred. While a certain number of-cases are theresult of a propagated neuritis, the zoster being due toan inflammatory irritation of a nerve transmiitted to thecutaneous elemlenats along its distributioni, such a conditionimay also arise from compression by a tumlour. In secondarymalignant disease of the spine and in new growths of thechest herpetic eruptions may appear along the course of thenerves involved in the comnpression. In the first case ofHodgkin's disease a typical zoster on the right side, lastingabout eight weeks, wvas associated with palpably enlargedglands in the right kii(dney region, wvhile in the second a

severe right intercostal herpes occurred witlhout any demon-strable mediastinal enlargement, the disease being followvedby keloid formation; in the third case, during a slight attackof left intercostal zoster, the hilum shadows were enlarged,and in the fourth the herpes was situated along the distribu-tion of the righit femoro-cutaneal nerve without any glandularcenlargem:ent in the inguinal or pelvic regions. In the case

of ovarian sarcomia general peritoneal metastasis was founidat operation, and herpes zoster involving the left eleventhaind twelftlh intercostal and first lumbar nerves developedand lasted eiglht Nveeks, x-ray examuination of the clhest andspine being nlegative as regards evidence of a neNv growth.Thlei patient later developed a mediastinal miletastasis, but

inmproved un(ler x-ray treatmnent in spite of the extensiveinvolvemiient; shec was still alive. In the four cases ofHodgkin's diseasie the severity did not appear to have any

i-elation to the eru)tion, which was probably due to irritationcaused by the proximity of the glandular enlargement to thegantlion.

320. Symmetrical Lines on the Back in Tuberculosis.OLGA ELIASCREFF (Ann. de Dermn. et de Syph., June, 1924p. a55) notes that cases have been recorded in which pul-

monary lesions in young subjects have been accompanied bythe appearance on the thorax of lines of reddish colour, andthat in the instanees hitherto recorded these lines have-beenlocated on die side opposite to the pulmonary lesion. Shenow reports a case of pulmuonary tuberculosis where the lineswverc observed on both sides, although the lesion was in theleft lung. There were nine rows on the right side of the backand six on the left,; they weere symmetrical, and correspondedin direction with tle zones of cleavage of Langerlians. In-

ter-nally they were lituited by the vertebral column, exteriallyby the axillary border, and they extended from the seventhrib above to a linle drawn transversely three flngerbreadthsabove the iliac crest below. They wvere disposed in obliquebands, some of which were interrupted by areas of healthyskin ; their length was from a thiird of an inch to four incbes;their breadth was just over an inclh. The colour vas bright

red, the surface filely folded, tle edges well defined. Palpa-tion gave the inmpression of a skin rather thin andlsoft throughwvhich blood vessels were visible in places. The horny layer

was poorly developed in parts, and from soicie places the

granullar layer -was absent; where present the latter was

epr esented by fine 'cells filled with minute granulations.

While pigment was lacking in the lesions the adjoining basal

cells were richly pigmented. The conn.ective tissue appaarednormal, butround the -vesiels of the chorion there was a

dense infiltration, composed for the mostpart of roundcoellsand of some epithelial cells and fibroblasts. The elastictissue in the papillae and thechlorion was broken, and wassoattenuated in the upper layers of the latter as to be repre-sented by fine granualations; but in the healtlhy parLs itseemed to be a den-ser network than normally. The lairfollicles, sebaceous glands, and sweat glands were normnal.The author discards the thieoryof a mechanical cause for thelesions-overdistension of the skin-nor does she favour theview that the conditionimay result fromn a weakiless of tlheintegument-congenital or acquired in consequence of toxicinfection. The lesions have been observed in areas w-herethere has been an actual shrinking, and have muade theirappearance at the onset of shrinking. Blhe considers them tobe a direct consequence of fragmentation of the elastic tissueof the skin attributable to trqphic trouble, and suggests thatas it is reasonable to suppose that this tissue depends for itsnutrition on a glandoL glands of the endocrine class, thecondition may be due to a derangemwent of endocrinemechanism.

321. Pigmentation of the Skin.S. BANG (Ugeskrift for Leteger, July 17th, 1924, p. 543) suggeststhat light precipitates as pigment in the£skin a substancewhich, if not thus linked to the skin, is capable of being toxic.Pigmientation, he thinks, depends on two factors-a pro-

pigment derived from the blood and a ferment in theepiLhelial cells which converts propigment into pigument. Hestates that thlis propigment is related to adrenaline, and is

similar to, or identical with, dioxyphenylalanin or dopa."This'; dapa" can be converted into pigment artificially byvarious oxidizing agents. Not only is the chemical formulaof IIdopa" very similar to that of adrenaline, but there are

many othler points of similarity. When the suprarenals arefunlctioning imperfectly inioreased pigmientation of the skuinoccurs in those areas where light normally produces pig-lmlentation. The author concludes that dopa" is a by-product in the secreting of adlrenaline by the suprarenals,and that the excessive pigmentation of Addison's disease is

due to an overproduction of dopa."

Obstetrics and Gynaecology.322. Kielland's Forceps.

G. BARBARO (Gynecol. et Ob8tet., 1924, x, 1, p. 36) describesand illustrates the obstetric forceps introduced in 1915 byKielland. MIany reports, mostly laudatory, have appeared inGerman literature, buit the forceps hias scarcely beeni noticedin. English, Americain, or Frexch l)ublications. lie concludesthat althouglh the instrumiienat is 1oI ideal nor universallyapplicable as was claimiied, it is yet of considerable use incertain cases, and deserves systetatic trial in countries otherthan tllat of its origin. The blades of the forceps liavealmost no pelvic curve, and the articulation of the blade; iascontrived so as to allow a certain freedom of iuterplay in thelongitudinal direction, variation being possible in the heightof application to the foetal head. The instrument is chieflyintended for high forceps application, and is reported to beparticularly suitable for seizing the biparietal diameter,whatever its relation to the pelvis may be. It is generallyconceded that it is admirably adapted for rotating the head,but opinions differ as to its efficacy as a tractor.

323. The Dystrophies of-Puberty.G. BOULANGER-PILLET (Joutrn. de Mld. et de Chir. Prat.,September 10th, 1924, p. 646) classifies the dystrophies ofpuberty as those in which changes in the skeleton or staturepredominate and those in which the weight increases owingto abnormal obesity. In the first -group the dystrophy ofHutinel, which is imore frequent in males, is the exaggerationof a normal physiological process; the excess of growthaffects the lower limbs especially, and the extremities arelengthened without showing the thickening which occurs inacromegaly. In girls ovarian disturbance is signified byamenor'hoea, oligomenorrhoea, or menorrhagia. There is acoincident disturbance of other functions with generalizedm-uscular insufficiency. The dy-strophies accomnpanied by

adiposity are more frequent in females; in certain cases atransitory dystrophy disappears after puberty, but in othersthe malady increases progressively with advancing age,miiarriage, pregnancy, and lactation. The etiology of theseconditions is uncertain. A morbid condition of the pituitarybody has been blamed; little evidence of this, however, isgained from radiological or ophthalmological or biologicaltests, and recent work tends to show that the majority of the

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so-called hypophyseal signs indicate in reality morbid con-ditions in the tuber cinereum and adjacent regions. Inseveral cases the author has found other signs pointing tomorbid cerebral conditions-for example, convulsive crises,generally epileptiform, and severe intractable headache.Almost constantly he has found that the cerebro-spinal fluidshows a meningeal reaction. In a certain number of cases

signs of syphilis have been present, pointing to a therapeuticpossibility which it is important not to neglect. It is probablethat nerve alterations in the floor of the third ventricle playa prominent etiological part.324. Pregnancy and Acute Appendicitis.

A. G. J. HERMANS (Nederl. Tijdschr. v. Gencesk., August 23rd,1924, p. 1004), who records six personal cases with a reviewDf the literature, states that out of 1,000 operations for appen-dicitis performed by Kiimmell, two occurred in the third orflfth month of pregnancy, while among 2,009 cases of appen-licitis seen by Sonnenburg three occurred in pregnancy andone in the puerperium. Szenes states that, among 325women operated on at the Ztirich Surgical Clinic in theperiod 1919-21, four, or 1.14 per cent., were pregnant. Theassociation of pregnancy and appendicitis is thus a rarecondition. While some writers, such as Renvall andFraenkel, regard the occurrence of appendicitis in pregnancyas a Inere coincidence, others, such as Sonnenburg, Karewski,and Pinard, consider that pregnancy predisposes to exacerba-tions of chronic appendicitis. Others again, such as Konig,Boye, and Runge, look upon pregnancy as a safeguard againstappendicitis, inasmuch as the hyperaemia of the pelvicorgans occurrinig in pregnancy favours the absorption of theinfective material present in the appendix and thus preventsthe outbreak of an acute attack. Boye reports 12 illustrativecases from Engstr6m's clinic in which chronic appelndicitisdid not relapse during pregnancy. The prognosis of appen-dicitis in pregnancy is generally regarded as very grave. Notonly is there the possibility of perforation of the appendixand septic peritonitis, but there is a special danger owing tothe prospect of abortion or premature delivery and greaterlikelihood of puerperal sepsis. Of 42 cases of appendicitisoccurring in all st iges of pregnancy reported by Fiith, 22were fatal. Accor-ding to Halban, the mortality from appen-dicitis, which is ustually 12 per ceut., ranges from 31 to 59 percent. in pregnancy, and Pribram estimates the mortalityfrom appendix peritonitis in pregnancy at 50 per cent.Hermans agrees with De Lee that appendicitis during preg-nancy should always indicate immediate operation, and thateven in cases of doubt operation is the safer course. Theearlier the operation is performed the better the prognosis isfor the mother and the child. In the puerperium theprognosis is graver the earlier the attack occurs afterdelivery, as the chances of puerperal infection are thengreater.325. Pregnancy and Disease of the Heart.

S. PRASSULIDES (Arch. f. Gyndk., July, 1924) shows thatall hearts, whether normal or damaged, increase in sizeduring pregnancy. He maintains that in many cases thishypertrophy is desirable, and that, contrary to the generalopinion, the occurrence of pregnancy does not damage theprognosis in heart diseases. He goes further and states thatthe appearance of a heart lesion, or even commencing failureof compensation, is not necessarily an indication for interferingwith the pregnancy. If compensation is established, if theheart muscle is active and undamaged, and more especiallyif there are no other complications, he believes that there isno danger, either immediate or remote. It is only whensuch complications as recurrent endocarditis, nephritis, oradvancing tuberculosis are added to an existing heart lesionthat danger occurs. Women with heart lesions (of these theworst are mitral) should be kept under medical- supervisionduring the whole of their pregnancy and should never 'beleft to the care of a midwife. If the pregnancy is ter-minated, special attention must be paid to asepsis, in viewof the dangers of recurrent endocarditis, thrombosis, andhaemorrhage.

Pathology.326. A Scarlet Fever Toxin.

J. D. TRASK, jun., and F. G. BLAKE (Journ. Exper. Aled.,September, 1924, p. 381) show that a toxic substance can bedemonstrated in the blood of patients acutely ill with scarletfever, a similar substance being also found in the urine of aproportion of these patients. This investigation was under-taken to provide further evidence in support of the conceptionthat scarletfever is (due to a local infection of the throat by aspecial type of Streptococcus haemnolyticits, which is capableof prodticing a soluble toxic substance, that this toxic sub-

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stance is absorbed frolmi the throat and causes the generalmanifestations of the disease, and that immunity, whethernatural or acquired, is antitoxic in nature, and can be deter-mined in an individual by finding out whether or not hisserum blanches the rash in a patient with scarlet fever. Theserum of patients acutely ill with scarlet fever was injectedintracutaneously into two classes of persons-those whoseserum failed to blanch the rash in scarlet fever and thosewhose serum blanched the rash. In the former class areaction was noted, consisting of a bright red local erythema,varying from 20 to 70 imm. in diameter, of one to four days'duration. The severer reactions were moderately indu-rated and tender, and were followed by pigmientation anddesquamation. Control injections in persons whose serumsblanched the rash in scarlet fever caused no reaction. Inone case in which daily investigations were made the toxicsubstance was found in the blood from the second to the fifthday, and in the urine from the third to the sixth day. Thetoxic substance was not neutralized by mixture with a humansertum which gave a negative blanching test, but was readilyneuitralized by a human serum which gave a positive blanchingtest. It was unaffected by normnal horse serum, but wastotally neutralized by the scarlatinal antistreptococcic serurof Dochez.

327. Carnivorous Diet and In!ection with IntestinalProtozoa.

R. W. HEGNER (Anmer. Journ. Iyg., July, 1924, p. 393) hasmade a careful study of the literature, and has himself carriedout some experimental work on the relationship between acarnivorous diet and the extent of protozoal infections of theintestine. Reviewing the literature, lie finds that intestinalprotozoa in mnamnmals are mlost abundant in rodents audungulates, wlhich feed alumost exclusively on vegetation; thatthey occur frequently in those primates which are largelyvegetable feeders, but that only on very rare occasions arethey found in carnivorous animals. He fed three rats for174 days on a carnivorouis diet; all of them-n were found to befree fronm Giardia mitris an(d Triclhomnonas muris, but two ofthem had a few specimens of Ilexamitits marlD'7is; control ratsftom the satne colony that ha- been fed on various diets,largely carbohy,drate in nature, w%ere well provided with allthree of these tlasellates. In another experiment 15 ratswere fed on a carnivorous diet for one wveel, and were com-pared witlh 15 other rats fed principally on vegetable proteinsand carbohydrates. It was found that in the former groupof animals tite numbers of G. mnuris decreased to one-tenth,and the numbers of T'. snuris to one-fifty-fourth of thosepresent in the latter group. Examinations were then nmadeof faecal specimens, at intervals during a period of seventeendays, from 12 carnivorous animals belonging to ten differentspecies -which were livitng in tlle Zoological Gardens atBaltimore; no protozoa of any kind were discovered exceptin one instance-that of a wild cat which harboured somegiardia cysts. He considers that a carnivorous diet is un.favourable for the intestinal protozoa of mammals. Possiblythis nmay be due, he thinks, to the putrefactive flora whichoccurs in the intestilne -when a carnivorouLs dietary is beinggiven. At present he is working to test the value of a carnivoroulsdiet in cases of human protozoal infection of the intestine.

328. The Leucocytes in Various Forms of Arthritis.G. KAHLMETER (Hygiea, July 31st, 1924, p. 449) has investi-gated the numbers and proportions of the leucocytes in 169cases of arthritis treated during the past seven years in twoSwedish hospitals. The cases were classified in five maingroups, according as they could be regarded as (1) acuterheumatic fever, (2) prinmary chronic polyarthritis with fever,(3) secondary chronic polyarthritis, (4) primary chronic poly-arthritis without fever, and (5) arthritis deformans. Theaverage mean leucocyte count in these five classes diminisheduniformly from above downwards: it was 9,394 in the firstMlass and 6,036 in the fifth class. If a leucocyte count of6,900 to 7,000 be taken as the normal, the flgures obtained bytloe author suggest that arthritis with fever is generallyassociated with leucocytosis. The differential count showedthat the leucocytosis was mainly due to the lymphocytes;in all the classes of chronic polyarthritis there was a certaintendency towards an absolute lymphocytosi3, which wasleast mnarked in the cases of arthritis deformans. Theauthor is of the opinion that there are two main groups ofpolyarthritis, the disease in one group being due to infec-tions, whereas in the other it is the result of constitutional orendocrine disturbances. The flist groulp consists miainly ofyoung persons with aniaemuia la red Ce11 coLlnt below 4 inillionper c.mm.), leuicocytosis, ancd fever associated with disturb-ances in the joints. The second group is mainly composedof persons in or beyond the aae of the clitmiacteric: tlheirpolyarthritis is never associated w%vitlh fever, and their leuco-cyte count is approximately normal.

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