of eosinophiles (8.5 per cent), and diminution of albumin and globulin. On the seventh day the blood was still less, the white cells did not show any relative increase, but the polynuclears were then 48.73 per cent., and the large mononuclears 34.87 per cent. At the post-mortem examination a rupture of the left posterior cerebral artery was found with a sub-arachnoid coagulum in the neighbourhood, and two clots in the midst of the nerves of the cauda equina. Pressure on the left crus had apparently caused temporary deviation of the head and eyes to the right, and right hemiplegia. At first Gmelin's reaction was negative. On the third day it was present in the blood-serum, but was less marked than in the cerebro-spinal fluid. It was most pronounced at the moment of greatest intensity of the hæmatolysis. On the fifth day it was present in the urine, and on the seventh day urobilinuria existed alone.

R. W. MARSDEN.

MOIZARD and GRENET.

Hæmorrhage in Miliary Tuberculosis. Gazette des Hôpitaux, 1903. No. 146, p. 1437.

THE writers report two cases, one a child 2 years of age, apparently a primary pulmonary tuberculosis after measles, with later hæmorrhage from the bowel, and showing at the autopsy generalised miliary tuberculosis and intestinal ulceration. The other was a boy, 14 years old, who early showed purpuric spots symmetrically placed, especially on the body and lower limbs. At the autopsy there was miliary tuberculosis. The writers express the opinion that the ulcerations of the intestine do not explain the cause of the hæmorrhage, but only its situation. In cases similar to the two reported the hæmorrhagic tendency is, according to them, closely connected with changes in the liver, evidence of which was present in both of their cases. References are given, chiefly French, to previous observations of the association of hæmorrhage with miliary tuberculosis.

R. W. MARSDEN.

Surgery.

DEHIO (K.). A Case of Diaphragmatic Hernia. St. Petersburger med. Wochenschr., 1903. Vol. xxviii., p. 103.

The
On

AN agricultural labourer, aged 61, was suddenly seized with intense pain in the epigastrium, which kept him in bed, and vomiting. For three days he passed neither fæces nor flatus. The case was diagnosed as acute intestinal obstruction, and he was forthwith admitted to the surgical ward. Hot poultices were applied to the abdomen, with great relief to the pain, and a movement of the bowels followed. Operation was therefore negatived. There was a history of similar attacks, lasting several days, about 5 and 20 years previously. On examination the epigastric region was found to be protuberant and dome-like, contrasting markedly with the flatness of the abdomen below the umbilicus. lower part of the thorax on the left side was also enlarged. palpation the distended part above the umbilicus was sensitive, and had the consistency of a strongly inflated air-cushion, whilst the flat portion below the umbilicus was painless and flaccid. On percussion the protuberant epigastrium and the left infra-mammary region round to the scapular line gave a loud deep note, "like the sound of a kettledrum." The liver dulness was diminished. The heart apex was pushed upwards to the 4th inter-costal space. Metallic sounds were heard all over the resonant area. On auscultation no lung sounds could be heard over the lower part of the thorax corresponding to the drum-like percussion area; but on deep respiration amphoric reverberations were distinctly heard not only over this part of the thorax, but also over the distended epigastrium. Gurgling and cooing noises were also heard occasionally. As regards diagnosis, it was evident there was considerable flatulent distension of the epigastrium, but the distinct drum-like sound, the metallic phenomena and the absence of normal lung sounds also pointed to the presence of a hollow space-filled with gas or airin the lower and left portion of the thorax and continuous with the hollow space in the epigastrium. The bowel noises (gurgling, etc.) in this space excluded an ordinary pneumo-thorax, and suggested that a distended portion of the alimentary canal had entered the left pleural cavity, and had displaced the heart and lung. This distended portion of the digestive tube was evidently continuous with another portion in the abdominal cavity, and the diagnosis of a "hernia of the diaphragm' was made. An oesophageal bougie, passed into the stomach, met with resistance 43cm. from the teeth, which yielded to moderate force, and the probe then passed on to a distance of 50cm. No food or gas escaped by the tube. From the shadow thrown by the X-rays the writer concluded that the hernia probably occurred through the natural defect in the diaphragm between the portio-sternalis and the portio-costalis. A portion of gut entering here, immediately under the heart, would

naturally displace the heart upwards, whereas a hernia through the side or hind part of the diaphragm would merely displace it horizontally to the right. The obstructive attacks suggested that a portion of the intestine, probably colon, was the part prolapsed, with possibly a portion of the stomach as well. The protuberant epigastrium was no doubt chiefly due to the distended transverse colon, which presumably had pushed aside the lower edge of the liver. The patient was discharged with his symptoms of obstruction relieved, but with the hernia into the pleural cavity practically unchanged. As to prognosis, about 16 per cent. of all hernias of the diaphragm succumb to internal strangulation, but cases have lived to old age without symptoms, the condition being only discovered post-mortem. Discussing the causation of diaphragmatic hernia, except when due to direct injury to diaphragm with subsequent prolapse of the bowel, most cases are probably congenital, due to defect in the diaphragm, which may result from imperfect development or reversion to an early phylogenetic condition. P. R. COOPER.

CARMICHAEL (E. SCOTT). Leucocytosis in Pelvic Disease in the Female. Scottish Med and Surg. Journal, 1904. Vol. xiv., p. 113. THE writer deprecates the use of a blood examination as the sole diagnostic test of abscess formation. It is only by the experience of a great number of cases, and looking upon the leucocyte examination as one only of many valuable means of diagnosis that most benefit can be derived from its use. He discusses the value under three heads(a) as a means of diagnosis; (b) as an indication for or against operative treatment; (c) as a means of prognosis.

(a) In diagnosis it must be remembered that normally the leucocytes tend to increase towards the end of pregnancy, the average being 10,000 or 11,000, occasionally as much as 13,000 or 15,000. During the puerperium there is a steady decrease to the normal which under physiological conditions ought to be reached before the end of the first week. Details of cases of puerperal septicemia are given, and two in particular are contrasted, in one of which there was a general septicæmia with relatively low leucocyte count, while in the other the septic condition remained localised, giving rise to a local abscess with a high leucocytosis. It is mainly in the acute conditions that the leucocyte count is of greatest value. In the more chronic pus may be present in thick-walled abscess cavities with a leucocytosis of not more than 15,000 or 18,000. Tuberculous pyosalpinx produces no leucocytosis, nor does tubal gestation, but pyosalpinx due to streptococci or to the bacillus coli produces well-marked leucocytosis, whilst the cases due to gonococci are accompanied by a lower degree of leucocytosis.

(b) As an indication for operation. The writer does not accept as covering the whole ground Cürschmann's dictum that a leucocytosis of 25,000 is diagnostic of suppuration. He considers that if in an acute case, after three consecutive examinations at 24 hours intervals,

with all fallacies excluded, the leucocyte count remains about or above 20,000, or if there is a steady increase towards that number, one is justified in suspecting the presence of pus. The more chronic the

condition the more significant is a slight rise of the leucocyte count.

(c) In prognosis the most important point to remember is the lowness or absence of leucocytosis in the fulminating and rapidly fatal forms of septic infection.

CHARLES H. MELLAND.

HINDER (H. CRITCHLEY). Appendicitis. Australasian Medical Gazette,

1903, p. 401.

HINDER Considers that the cause of most cases of appendicitis is a congenital narrowing near the neck of the appendix. In a few cases there is thrombosis of the mesenteric vessel, and the gangrene then tends to spread to the adjoining cæcal wall. The quiescent period immediately after an acute onset is deceptive. It means that the tension of fluid in the appendix has been relieved either by its escape into the cæcum or by rupture of the appendix. In the latter case the pain is relieved only for a short time and again becomes intense.

A. J. RODOCANACHI.

BARLING (GILBERT). Gall Stones. Birmingham Medical Review. Vol. liv., p. 589.

BARLING states that in this disease jaundice is often not present, and so there may be confusion between it and hydronephrosis or movable kidney. In some cases a diagnosis is only to be made by abdominal incision, and it is imperative that this should be done before. inflammatory complications are set up. Infective organisms are almost constantly present, most often the streptococcus pyogenes.

A. J. RODOCANACHI.

SPIVAK (C. D.). Volvulus of the Stomach.

1903, p. 709.

American Medicine,

SPIVAK has collected from surgical literature eight cases of volvulus of the stomach. In these the stomach becomes twisted round its axis 180°, the small omentum acting as a pivot and the cardiac and pyloric orifices being wound round one another and so occluded. In some the great omentum and gastro-splenic ligament were torn off. The transverse colon was compressed between the stomach, liver and diaphragm. The stomach became enormously distended. In the cases

that were recognised the abdomen was opened and the stomach contents evacuated by an aspirator. After that the stomach could be returned to its normal position, and the patients recovered.

A. J. RODOCANACHI.

HAMILTON (T. K.), BRADY (A. J.), GIBSON (J. LOCKHART) and BARRETT (JAMES W.). Adenoid Growths. Intercolonial Medical Journal of Australasia, 1903, p. 437.

ADENOID growths must be very common in Australasia, judging from the fact that each of these surgeons bases his paper on an experience of three or four thousand operations. Hamilton points out a close connection between adenoids and trachoma. In operating he uses gas with or without oxygen, and removes both tonsils and the adenoids within 40 seconds. He condemns chloroform as most dangerous. Brady believes the ring of adenoid tissue in the pharynx yields an internal secretion to an excess of which the mental dulness, pallor and other symptoms are due in the subjects of excessive adenoid development. He uses chloroform as well as gas, believing that the only danger lies in the tongue falling back and causing suffocation. The tonsils should be removed at a previous operation. Gibson operates thus:-(1) Up to two years, with no anesthetic, with the unarmed finger; (2) under 14 years, under complete chloroform anæsthesia, with a special steel nail; (3) above 14, with the help of cocaine and adrenalin he uses forceps guided by a mirror and light. Barrett thinks that both dry catarrh and suppuration, with its complications, of the middle ear are much less common since adenoid growths have been systematically removed. Tonsils will shrink and disappear after removal of the adenoids. He thinks chloroform is responsible for a good many deaths. He clears the pharynx by three sweeps of the curette under gas in 30 seconds.

A. J. RODOCANACHI.

MONNIER (L.).

Gastrotomy for Foreign Bodies in the Stomach. Gazette des Hôpitaux, 1903, p. 1249.

MONNIER Successfully extracted by gastrotomy from the stomach of an imbecile 25 foreign bodies, including sundry spoons, forks and pins. Curiously, though these could be palpated through the abdominal wall and a crepitus felt as they moved against one another, yet radiography gave a negative result. Most of the bodies were of iron, much rusted. A. J. RODOCANACHI.