earlier report appeared in the literature by Pyle (1784) which he had diagnosed as "true hernia," although it was typical of eventration of the diaphragm. This occurred in a newly born infant, whose left diaphragm was turned and distended into a sac, containing the stomach, spleen, ileum and part of the colon. Thoma believed that the condition was secondary to congenital malformation of the lung, which would account for eventration occurring most frequently of the left diaphragm. He found these malformations occurring in the left lung, as compared with the right, in the proportion of 49 to 8; this is about twice as frequent as eventration is found clinically or at autopsy, based on the report of 49 cases in which series, the anomaly occurred 46 times on the left side and 4 times on the right. The mechanism, from point of view, is obvious. He states that when the lung is too small the diaphragm rises to fill the space in the pleural cavity, dragging with it the intestinal contents. Thoma's Doering, on the other hand, favors the view that the condition primarily is a deficiency in the musculature of the affected side of the diaphragm; this condition has been demonstrated microscopically in all autopsied cases. He also holds that the symmetrical condition of the thorax in these cases support his view. Hoffman is of the opinion that "eventration" is acquired and that chronic dilatation of the stomach, with which it is usually associated, is the beginning of eventration. Falkenstein has shown that ideopathic degeneration of the diaphragm ANNALS OF CLINICAL MEDICINE, VOL. I, NO. 6 frequently occurs-the lesion being a fatty degeneration of the muscle tissue. Frankel and Benda have described a unilateral fatty degeneration associated with extreme stretching of the diaphragm—a fact which would make it seem possible that eventration may be acquired. The external symmetry of the chest, which is almost invariably present, is an argument adduced in favor of the congenital origin. Ellis collected 18 cases of congenital absence of the lung from the literature, and reported one of his own in which the configuration of the chest was normal. Clinical experience in chronic diseases of the chest associated with elevation of the diaphragm, due to traction from adhesions, demonstrates that malformation and asymmetry of the chest wall is usually the result. Cruveillner attributes the condition to the effect of a lesion of the phrenic nerve, the muscles of the diaphragm, or some abdominal disease causing unequal pressure on the two sides. Symptomatology Age. The condition was found in one case in a foetus, in another in a new born. The oldest case on record was seventy-five years of age. Sex. It occurs more frequently in men than in women. Based on the collected cases the ratio is 4 to 1. Subjective symptoms. Unquestionably, many of the cases do not develop symptoms for a long period of time. If the congenital origin of the malady is accepted, the case herewith reported manifested no symptoms until the twenty-third year of his life when they were apparently superinduced by an attack of typhoid fever. When symptoms do develop they usually fall into one or the other of two groups; namely, the thoracic and the abdominal. Included in the thoracic group are such symptoms as palpitation, tachycardia, dyspnea on exertion, asthmatic attacks, cough, substernal pain, etc. To the abdominal group belong dyspepsia, gastric pains, epigastric pressure, belching, vomiting, hematemesis, constipation, etc. The pain has been described as cramp-like or cutting, and is frequently relieved by food. The symptoms are occasionally strongly suggestive of peptic ulcer. Other symptoms, which have been mentioned are weakness, loss of weight, cyanosis, states of anxiety, neurasthenia and melancholia. Physical signs. The chest is usually symmetrically developed. Expansion is limited on the affected side. In left-sided eventration, the heart's apex is not visible at its normal area, as the heart is displaced usually to the right. Allen reports a case in which it was displaced upward and Reinhold three cases of hypoplasia of left lung in which the heart was displaced to the left. A pulsation is sometimes seen at the ensiform and to the right of the sternum. The pulmonary signs are those usually found in pneumothorax or hydropneumothorax. There is marked tympany of the affected lung base. This note may extend almost to the apex; usually, however, there is an area of normal or hyperresonance above and tympany below with absence of breath sounds, tactile and vocal fremitus. Gurgling and bubbling sounds can frequently be elicited, if the stomach contains fluid with air and fills the cavity of the eventrated diaphragm. Associated pathologic conditions On reviewing the case reports and autopsy findings, one is impressed with the frequent occurrence of congenital deficiencies and malformations, which lend considerable support to the view that eventration of the diaphragm is a congenital affection. Hernias are particularly common and include unilateral inguinal, bilateral inguinal, and pelvic hernias. Hypoplasia of the left lung is frequently mentioned. In a case of a new born child, the left lung was described "in size somewhat larger than a bean." Malformation of the left lung, consisting of the formation of three lobes, were found at several autopsies. Anomalies of the diaphragm are constantly observed. Doering states that there is marked deficiency in the muscular tissue of the affected side of the diaphragm. All cases examined microscopically showed atrophy and degeneration. Diminution in the size of the pillars of the diaphragm has also been observed. Ideopathic dilatation of the colon (Hirschsprung's disease) was associated in a case reported by Aronson. Dilatation of the stomach is not unusual and gives rise to the most distressing gastric symptoms. BIBLIOGRAPHIC SUMMARY APPEL: Zur Kenntnis der Eventratio diaphragmatica. Inaug. Dissert. Griefswald, 1911. ARNSPERGER, H.: Deutsch. Arch. klin. M., 1908, xciii, p. 88. ARONSON, E. A.: Hirschsprung's disease with eventration of the right half of the diaphragm. New York Med. Jour., 1918, cviii, p. 196. BAETGE, P.: Deutsch. Arch. klin. M., 1913, cx, p. 49. BECKER, T.: Fortschr. Geb. Röntgenstrahlen, 1911, xvii, 183. BEHRENROTH, E.: Samml. klin. Vortr., 1911, no. 642, Inn. Med. No. 205. BYLOFF, K.: Z. angew. Anat. u. Konstitut., BAYNE-JONES: Eventration of the dia- CRISPINO, M.: Riforma med., 1900, iii ologique générale, 1849, ii, 617 (Paris). DOERING, H.: Deutsche Arch. klin. M., 1902, lxxii, 407. EGGELING, H.: Münch. med. Woch., 1912, EPPINGER, H.: Allg. u. spez. pathol. FRORIEP: Kleiner's Repertorium, 1837. Cited by Lacher, Deutsch. Arch. klin. FUNK, E. H., AND MANGES, W. F.: Even- GRIFFIN, H. Z.: Ann. Surg., 1912, lv, 388. HERZ, A.: Wien. klin. Woch., 1907, xx, 1463. HOFFMANN, F. A.: Münch. med. Woch., HURST, A. F.: Note on eventration of the diaphragm. Guy's Hospital Reports, JAMIN: Festschrift J. Rosenthal, 1906, ii, 85. KAYSER, K.: Fort. Geb. Röntgenstrahlen, KIENBÖCK, R.: Z. klin. Med., 1907, lii, 321; Wien. klin. Woch., 1898, xi, 539. KÖNIGER, H.: Münch. med. Woch., 1909, KRAUSE, P.: Deutsch. Z. Nervenh., 1913, LAENNEC, R. T. H.: L'Auscultation Médiate, LAWRENCE: Lancet, 1852, ii, 212. LOUSTE AND FATOU: Bulletine et Mémoires VON MALKOW: Russk. Vrach., 1912, li, MANGES, M., AND WESSLER, H.: Med. Rec., MARSH, F. H.: Lancet, 1867, lviii, 298. NEISSER, E.: Z. klin. Med., 1901, Ixii, 88. PETIT, J. L.: Traité des maladies chir., PYL, J. T.: Aufsatze u. Beobacht. a. d. ger. REUSS: Deutsch. med. Woch., 1913, xxxix, RISEL: Münch. med. Woch., 1907, liv, 637. SCHEIDEMANDEL, E.: Münch. Med. Woch., SCHLIFFE, P.: Deutsch. Arch. klin. Med., The Use of Schick Test and Toxin, Anti toxin Immunization, with a Bibliographic Review' T BY RUDOLPH DURYEA MOFFETT, New York City HE Schick Test (1) was originated in 1913 by Dr. B. Schick of Vienna as an intracutaneous reaction to detect the immunity of the individual against diphtheria. This advancement in medical knowledge was a decided step forward in the caring for great numbers of children, in determining which of them, if exposed, could contract diphtheria. It also reduced the amount of anti-toxin used as prevention against diphtheric infection. Studies confirming the observations of Schick have been made by Park (12), Zingher (13), Kolmer (35), Graeff (38), Weaver (21), Moffett (30), Conrad and others. The usual method of investigation is that followed by Römer. This method is complicated and unsatisfactory for ordinary routine hospital examinations. To overcome this, Schick proposed the intracutaneous injection of of the minimum lethal dose for a guinea-pig weighing up to 300 grams and when so employed, observed that he obtained at the site of injection a characteristic reaction which has become known as the "Schick reaction." He used as a basis for his observations the work of 1 From A. Jacobi Divison for Children, Lenox Hill Hospital, New York. Von Behring (13), who discovered that as little as of a unit of antitoxin per cubic centimeter of serum will protect a person against diphtheria. If there is less than of a unit of antitoxin per cubic centimeter of serum, there is marked reaction within from thirty-six to forty-eight hours at the site of injection. This is characterized by redness, swelling, itching and slight infiltration. Such is a positive reaction and means that the person injected has not sufficient anti-toxin to neutralize the toxin injected, while if it is negative it indicates that there is circulating in the blood sufficient anti-toxin to neutralize the toxin injected. The unneutralized toxin is the irritant which produces the local reaction. The original diphtheretic toxin is diluted in this way: 0.6 cc. (minimum lethal dose) of toxin-9.4 cc.-0.5 per cent phenol solution; and of this primary dilution, 1 cc. is diluted in 99 cc. of normal saline solution. Of this secondary solution 0.2 cc. is injected intracutaneously with a Record syringe and a no. 26 platinum iridium needle, or a no. 3 steel needle made by Burroughs, Wellcome and Co., London. The usual site of injection is over the forearm, after the arm has been cleaned with alcohol. This secondary |