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ABSENCE OF THE CEREBELLUM.
1317
peritoneal cavity, 17 were due to compression of the thoracic duct by enlarged glands or neoplasms, 9 to non-tuberculous peritonitis, 6 to occlusion of the left subclavian vein, 5 to pressure from strain or cough, 5 to peritoneal carcinoma, 3 to filariasis, 3 to occlusion of the thoracic duct, 3 to occlusion in lymphatic glands, 3 to occlusion of lymph vessels, 2 to external pressure, 2 to malignant lymphoma, 2 to disease of the liver, 2 to syphilis, 1 to angioma of the lymphatics, and 1 to calculus in the receptaculum chyli. AN
AMERICAN VIEW OF SEX-GLAND IMPLANTATION.
WE have recently on several occasions directed our readers’ attention to the question of sex-gland implantation, more especially to the results of European observers. We now refer to some observations by an American surgeon, G. Frank Lydston, of the University of Illinois, and published in his book, " Impotence and
Sterility and Sex-gland Implantation," and bearing imprint the Riverton Press, Chicago, 1917, but which has only just reached us. The author began his observations in 1914 and was 56 years of age at that time. Amongst other matters he was desirous of investigating the action of the sex hormones, and of testing the practicability of experimental sex-gland implantation, and of employing the procedure in the treatment of dementia praecox. He endeavoured to find the requisite material, but alas! "the double problem of securing human sex-glands under proper conditions and of having a complaisant subject ready and waiting, for the experiment seemed insoluble, until the plan of combining surgeon and subject suggested itself and the author resolved to perform the experiment upon his own person." In the author’s haste to secure the necessary material, the appliances necessary to secure blood for the Wassermann test were forgotten, but in January, 1914, the testes were removed " as aseptically as possible " from a suicide by gunshot, and placed in a jar of sterile normal salt solution, and seven hours after securing the necessary material, and 24 hours after the death of the subject from whom it was removed, " the author implanted in his own scrotal sac one of the experimental testes." On his own statement the conditions, so far as asepsis was concerned, were not those of an up-to-date operating-room, as the heroic autoimplantation was carried out with the aid of his assistant in his " office," without the usual corps of nurses; but they were as satisfactory as was possible in the circumstances. A fistula formed, and about half of the gland, which had already formed vascular connexions, was removed. The " nodule," representing the remains of the implanted testis, gradually decreased in size until at the end of 18 months it could barely be felt. As to the " physiologic effects," after excluding the psychic element, the results to us do not seem either convincing or satisfactory, but the author was satisfied and noted a distinctly perceptible change in his blood-vessels-a moderate varicose condition of the veins of the legs and arms markedly improved, the walls of the temporal arteries became softer, and certain changes in the heart’s action occurred, with reduced blood pressure. Improvement in vision and in circulation in the skin are recorded, as well as the disappearancesof marked keratosis of the soles of the feet, this being an affair of 15 years’ standing. Other cases are recorded, including transplantation of an ovary from a subject 23 hours after death into a woman aged 59 suffering from " nerve wreckage," and grafting of a testis in a senile dement of 60 years. No " physio" logic observations were made, and neither mental nor physical improvement followed. Using material that had been refrigerated from three to seven days the author performed operations in both sexes, comprising two females and eight males suffering from various conditions, three senile dements, two cases of dementia praecox, two of epilepsy, and three of general paresis. In this group the implantations failed in all of the males and in one of the females. The results of these early cases were far from encouraging. Reports of six addi-
tional cases, some of double testicular implantation, of successful implantation, beginning in 1915, are recorded, and, without going into details, the results obtained "confirm the author’s belief that in the sex-gland hormone we have the most powerful cell stimulant, nutrient, and regenerator at present available to medical science." The ages of the patients-all malesvaried from 19 to 69. The author is convinced that his method of sexgland implantation stands on firm ground as a valuable
therapeutic resource-notably as increasing physical efficiency and especially " physio-sexual efficiency." But that is not all. Nothing is lost by ordinary refrigeration of the material for 24 to 48 hours, and glands taken from the healthy dead body at any time prior to the beginning of decomposition are of therapeutic value equal to that of those taken in vivo, and the benefits of implantation probably accrue irrespective of the site of the implantation, but the vicinity of the peritoneum (extra-abdominal) in the female and of the tunica vaginalis in the male are the sites of selection. Moreover, " any chronic disease in which improvement of nutrition is a desideratum should be benefited by sex-gland implantation." Senility may be retarded, longevity possibly increased, and climacteric possibly postponed by it. Its early use should be the logical remedy for dementia praecox. Other vistas open up;’the procedure may be useful in treatment of impotence in the male, possibly in sterility in both sexes-aberrant psychical or physical sex development, intractable neurasthenia, chronic diseases of the skin, arterio-sclerosis and even senile dementia, and such diseases as chronic nephritis and diabetes would seem to be indications for implantation. Such is Dr. Lydston’s view, and so great are the possible, probable, and prospective advantages of sex-gland implantation, in his opinion, that he desires the public to understand that the sacrifice of the thyroid or of a single ovary or testis by a living subject is not disastrous. Indeed, the author in his enthusiasm for his panacea for human ills believes that there are times when tissues obtained by such a sacrifice will restore reason, perhaps even life. " Why (he asks) should there be a waste of material which, if properly used, possibly might add so much to the health, happiness, efficiency, and even to the longevity of the human race? Let us strive for the conservation of biologic energy." As the author’s results were published in 1917 we look forward to the publication of subsequent experiments which may enable him to substantiate his position.
ABSENCE OF THE CEREBELLUM. THE cerebellum is occasionally found in a more or less atrophic condition. This may be in the form of hemiatrophy, as, for instance, is seen with contra-lateral cerebral lesions, or it may be more general, evidently due, in certain cases, to some mechanical cause. Dr. Dorothy Priestley records in this number of THE LANCET a case in which the conditions found in a child a few months old seem to justify its exclusion from the class of atrophies, pointing rather to the state being one of complete absence from failure of development. If this surmise is correct the case is probably unique. Shuttleworth’s case, reported by Ferrier, was really one of extreme atrophy or maldevelopment, affecting the left side especially, with exceedingly poor representation of the pons and peduncles. The girl was able to walk well, but apparently had never been observed to run. In Dr. D. Priestley’s case the age and condition of the child precluded any observations on the functional state during life. The condition in this specimen would not seem to be a concomitant consequence of hydrocephalus, but is rather a primary failure of development, the fluid collection and the brain deficiency being results of the same embryonic fault. The cerebellum forms slowly from the alar laminae of the neural tube, but it begins fairly early, before the end of the first month. Not much is known certainly about the detailed development of the pons, but it is justifiable to assume that the transverse fibres, at any rate, could not form if the cerebellum failed to develop.
1318 Such failure affects the alar laminae and roof-plate, and it seems possible to correlate the hydrocephalus with some failure in the choroid plexus system, which also has to do with the roof-plate ; this would be in keeping with the presence of pyramidal fibres, indicating certain cerebral development, and the existence of spina bifida at the lumbo-sacral level. Speculations of this sort, however, serve little useful purpose, and it is much to be hoped, from many points of view, that this most interesting specimen will be subjected to a thorough and detailed examination of all the regions concerned in cerebellar development and connexions.
BILATERAL DUPLICATION
OF THE
URETERS.
He had the alternative before him of refusing a certificate, and in the circumstances, if he could say that he knew of no cause why there should have been a miscarriage, and of no reason why a miscarriage should have had death as its result, no one could have blamed him for the refusal. It may be noted, however, that if by the refusal of a certificate the case had immediately been brought to the coroner’s notice an inquest would have had to be decided upon by him before he ordered the post-mortem examination which alone would have shown whether an inquest was really desirable. The case, in short, would have illustrated the need for a coroner to have the power to order a post-mortem examination before making up his mind to hold an inquest, although presumably one would have been held if inquiry. had made known the words uttered by the deceased. The amendment of the law relating to the registration of deaths and the holding of inquests is a subject which should engage Parliament as soon as there is time to discuss it thoroughly. Some Members of the House of Commons are evidently fully aware of this, for several questions have recently been addressed to Ministers to call attention to defects in the existing- law. In answer to one of these Dr. Addison has stated that 6698 deaths weree reported to coroners in 1919 as to which inquests were not held, the total number of inquests being 31,488. The statistics did not show whether any, and, if so, how many, of these deaths had been the subject of medical certificates. Other questions elicited that in all cases in which no medical certificate is forthcoming the Registrar-General refers the matter to the coroner; also that attention is being given to the question of coroners sitting, at their discretion and in certain cases, without juries. It will be interesting to observe, whenever legislation is brought about on the whole subject, how far this innovation due to the war has found favour among those best able to judge of its advantages and defects.
Henry 0. Mertz,l of Indianopolis, has made a compilation of 77 recorded cases of bilateral duplication of the ureters, dividing the cases into four types. In the first type, which is the commonest, comprising as it does 40 cases, bilateral duplication is complete on both sides. Unless the bladder is extensively inflamed, as in tuberculous cystitis, in which case a meatus may be missed, the chances of failing to identify the condition is not great owing to the present perfection of -the cystoscope. In the second type, of which there 11 cases, bilateral duplication is complete, are but one ureter has an ectopic orifice, as, for instance, in the posterior urethra, or ends blindly in the bladder wall. Although detection of this type has previously been difficult, the close-vision cysto-urethroscope will enable the ureteral orifice near the colliculus to be identified. In the third type, of which Dr. Mertz has collected 11 cases, bilateral duplication is partial on each side; and in the fourth type, which is represented by 15 cases, the duplication is partial on one side and complete on the other. Of the completely duplicated cases 18 were diagnosed clinically, while there was no instance of bilateral duplication with a bifid ureter on one side or on both being diagnosed clinically, and with two exceptions all were found at ALBUMINURIA OF SMALL WHITE KIDNEY. the post-mortem examination or in the dissecting-room; Fusion of the bifid ureter may occur at any point in its THE differentiation of albuminuria due to severe Of 52 cases of partial duplication collected by, renal disease from those forms course. having no sinister Dr. Mertz, including unilateral cases diagnosed such as the conditions of postural, adolessignificance, mortem or on operation, in 65 per cent. the fusion was cent,.and cyclical albuminuria, remains one of great below the iliac crest, while of the cases diagnosed difficulty in spite of the attention which has been clinically, all unilateral, the bifurcation was above this given to this question. Recently discussions have taken point in five, opposite the fourth lumbar vertebra in place before the Medical Society of London and also one, and in only one instance below this point. before the Assurance Medical. and Dr.
posti
Society,
THE
LAW RELATING TO CORONERS’
INQUESTS.
THE exhumation of the body of a married woman in West London was followed recently by an inquest at which the jury returned a verdict that death was due to acute blood poisoning, but that there was no evidence to show how it was brought about. The medical man who had attended the deceased in’ her last illness had certified that death was due to sapraemia, adding that there had been a miscarriage. Burial had followed, but the Registrar-General had referred the certificate back to the medical man, and an inquest followed. Except. for the evidence of Dr. B. H. Spilsbury, who was of the opinion that the miscarriage had been due either to an operation or a drug, there was nothing pointing to criminal interference, beyond a few words uttered by the deceased when delirious, which the nurse attending her had heard. She had then said, "I told that woman she was hurting me. I shall never go to Notting Hill again," and "Iam paying dearly for my sins." Before that, when questioned by the nurse and also in answer to her husband, she had denied that anything to The procure miscarriage had been done to her. position of the medical man attending such a case is a difficult one. In the instance under comment his suspicion had, no doubt, been aroused, and he gave a certificate which in fact and, no doubt, intentionally called attention to the point which needed clearing up. 1
Urologic and Cutaneous Review, November, 1920.
prominence
has been given to certain tests of renal function, such as the " iirea-concentration test," and to certain chemical investigations of the protein present in the urine, especially the albumin-globulin ratio. We published in THE LANCET of Dec. 18th (p. 1249) an account of an interesting case of chronic nephritis with somewhat unusual features by Dr. Ivor J. Davies. A special point in this case was the long period of apparently good health with a large amount of protein in the urine. Chemical tests of the urine even a few days before the death of the patient from a subacute form of uraemia, showed the characters more usually associated with non-nephritic albuminuria-namely, a globulinalbumin ratio of 2 : 1. Moreover, the urinary diastase In test of renal function gave a normal figure. spite of this, intense albuminuric retinitis was found, which discounted the apparently favourable indications of the urinary examination. The special significance of the-case seems to us that it illustrates the importance of a due correlation of all the evidence in every case of albuminuria. In spite of the high globulin ratio, there was evidence of slowly progressive cardio-vascular changes with increasing blood pressure, since as long ago as November, 1916, the systolic blood pressure was as high as 160 mm. Hg, while in May, 1920, it was 200 mm. Hg. Special tests only become of real value when their limitations or exceptions are recognised. For this reason the record of unusual cases serves a very useful purpose. Dr. Davies’s case should emphasise the importance of adopting a critical attitude of mind to the findings of these tests in every case and of fitting in the
peritoneal cavity, 17 were due to compression of the thoracic duct by enlarged glands or neoplasms, 9 to non-tuberculous peritonitis, 6 to occlusion of the left subclavian vein, 5 to pressure from strain or cough, 5 to peritoneal carcinoma, 3 to filariasis, 3 to occlusion of the thoracic duct, 3 to occlusion in lymphatic glands, 3 to occlusion of lymph vessels, 2 to external pressure, 2 to malignant lymphoma, 2 to disease of the liver, 2 to syphilis, 1 to angioma of the lymphatics, and 1 to calculus in the receptaculum chyli. AN
AMERICAN VIEW OF SEX-GLAND IMPLANTATION.
WE have recently on several occasions directed our readers’ attention to the question of sex-gland implantation, more especially to the results of European observers. We now refer to some observations by an American surgeon, G. Frank Lydston, of the University of Illinois, and published in his book, " Impotence and
Sterility and Sex-gland Implantation," and bearing imprint the Riverton Press, Chicago, 1917, but which has only just reached us. The author began his observations in 1914 and was 56 years of age at that time. Amongst other matters he was desirous of investigating the action of the sex hormones, and of testing the practicability of experimental sex-gland implantation, and of employing the procedure in the treatment of dementia praecox. He endeavoured to find the requisite material, but alas! "the double problem of securing human sex-glands under proper conditions and of having a complaisant subject ready and waiting, for the experiment seemed insoluble, until the plan of combining surgeon and subject suggested itself and the author resolved to perform the experiment upon his own person." In the author’s haste to secure the necessary material, the appliances necessary to secure blood for the Wassermann test were forgotten, but in January, 1914, the testes were removed " as aseptically as possible " from a suicide by gunshot, and placed in a jar of sterile normal salt solution, and seven hours after securing the necessary material, and 24 hours after the death of the subject from whom it was removed, " the author implanted in his own scrotal sac one of the experimental testes." On his own statement the conditions, so far as asepsis was concerned, were not those of an up-to-date operating-room, as the heroic autoimplantation was carried out with the aid of his assistant in his " office," without the usual corps of nurses; but they were as satisfactory as was possible in the circumstances. A fistula formed, and about half of the gland, which had already formed vascular connexions, was removed. The " nodule," representing the remains of the implanted testis, gradually decreased in size until at the end of 18 months it could barely be felt. As to the " physiologic effects," after excluding the psychic element, the results to us do not seem either convincing or satisfactory, but the author was satisfied and noted a distinctly perceptible change in his blood-vessels-a moderate varicose condition of the veins of the legs and arms markedly improved, the walls of the temporal arteries became softer, and certain changes in the heart’s action occurred, with reduced blood pressure. Improvement in vision and in circulation in the skin are recorded, as well as the disappearancesof marked keratosis of the soles of the feet, this being an affair of 15 years’ standing. Other cases are recorded, including transplantation of an ovary from a subject 23 hours after death into a woman aged 59 suffering from " nerve wreckage," and grafting of a testis in a senile dement of 60 years. No " physio" logic observations were made, and neither mental nor physical improvement followed. Using material that had been refrigerated from three to seven days the author performed operations in both sexes, comprising two females and eight males suffering from various conditions, three senile dements, two cases of dementia praecox, two of epilepsy, and three of general paresis. In this group the implantations failed in all of the males and in one of the females. The results of these early cases were far from encouraging. Reports of six addi-
tional cases, some of double testicular implantation, of successful implantation, beginning in 1915, are recorded, and, without going into details, the results obtained "confirm the author’s belief that in the sex-gland hormone we have the most powerful cell stimulant, nutrient, and regenerator at present available to medical science." The ages of the patients-all malesvaried from 19 to 69. The author is convinced that his method of sexgland implantation stands on firm ground as a valuable
therapeutic resource-notably as increasing physical efficiency and especially " physio-sexual efficiency." But that is not all. Nothing is lost by ordinary refrigeration of the material for 24 to 48 hours, and glands taken from the healthy dead body at any time prior to the beginning of decomposition are of therapeutic value equal to that of those taken in vivo, and the benefits of implantation probably accrue irrespective of the site of the implantation, but the vicinity of the peritoneum (extra-abdominal) in the female and of the tunica vaginalis in the male are the sites of selection. Moreover, " any chronic disease in which improvement of nutrition is a desideratum should be benefited by sex-gland implantation." Senility may be retarded, longevity possibly increased, and climacteric possibly postponed by it. Its early use should be the logical remedy for dementia praecox. Other vistas open up;’the procedure may be useful in treatment of impotence in the male, possibly in sterility in both sexes-aberrant psychical or physical sex development, intractable neurasthenia, chronic diseases of the skin, arterio-sclerosis and even senile dementia, and such diseases as chronic nephritis and diabetes would seem to be indications for implantation. Such is Dr. Lydston’s view, and so great are the possible, probable, and prospective advantages of sex-gland implantation, in his opinion, that he desires the public to understand that the sacrifice of the thyroid or of a single ovary or testis by a living subject is not disastrous. Indeed, the author in his enthusiasm for his panacea for human ills believes that there are times when tissues obtained by such a sacrifice will restore reason, perhaps even life. " Why (he asks) should there be a waste of material which, if properly used, possibly might add so much to the health, happiness, efficiency, and even to the longevity of the human race? Let us strive for the conservation of biologic energy." As the author’s results were published in 1917 we look forward to the publication of subsequent experiments which may enable him to substantiate his position.
ABSENCE OF THE CEREBELLUM. THE cerebellum is occasionally found in a more or less atrophic condition. This may be in the form of hemiatrophy, as, for instance, is seen with contra-lateral cerebral lesions, or it may be more general, evidently due, in certain cases, to some mechanical cause. Dr. Dorothy Priestley records in this number of THE LANCET a case in which the conditions found in a child a few months old seem to justify its exclusion from the class of atrophies, pointing rather to the state being one of complete absence from failure of development. If this surmise is correct the case is probably unique. Shuttleworth’s case, reported by Ferrier, was really one of extreme atrophy or maldevelopment, affecting the left side especially, with exceedingly poor representation of the pons and peduncles. The girl was able to walk well, but apparently had never been observed to run. In Dr. D. Priestley’s case the age and condition of the child precluded any observations on the functional state during life. The condition in this specimen would not seem to be a concomitant consequence of hydrocephalus, but is rather a primary failure of development, the fluid collection and the brain deficiency being results of the same embryonic fault. The cerebellum forms slowly from the alar laminae of the neural tube, but it begins fairly early, before the end of the first month. Not much is known certainly about the detailed development of the pons, but it is justifiable to assume that the transverse fibres, at any rate, could not form if the cerebellum failed to develop.
1318 Such failure affects the alar laminae and roof-plate, and it seems possible to correlate the hydrocephalus with some failure in the choroid plexus system, which also has to do with the roof-plate ; this would be in keeping with the presence of pyramidal fibres, indicating certain cerebral development, and the existence of spina bifida at the lumbo-sacral level. Speculations of this sort, however, serve little useful purpose, and it is much to be hoped, from many points of view, that this most interesting specimen will be subjected to a thorough and detailed examination of all the regions concerned in cerebellar development and connexions.
BILATERAL DUPLICATION
OF THE
URETERS.
He had the alternative before him of refusing a certificate, and in the circumstances, if he could say that he knew of no cause why there should have been a miscarriage, and of no reason why a miscarriage should have had death as its result, no one could have blamed him for the refusal. It may be noted, however, that if by the refusal of a certificate the case had immediately been brought to the coroner’s notice an inquest would have had to be decided upon by him before he ordered the post-mortem examination which alone would have shown whether an inquest was really desirable. The case, in short, would have illustrated the need for a coroner to have the power to order a post-mortem examination before making up his mind to hold an inquest, although presumably one would have been held if inquiry. had made known the words uttered by the deceased. The amendment of the law relating to the registration of deaths and the holding of inquests is a subject which should engage Parliament as soon as there is time to discuss it thoroughly. Some Members of the House of Commons are evidently fully aware of this, for several questions have recently been addressed to Ministers to call attention to defects in the existing- law. In answer to one of these Dr. Addison has stated that 6698 deaths weree reported to coroners in 1919 as to which inquests were not held, the total number of inquests being 31,488. The statistics did not show whether any, and, if so, how many, of these deaths had been the subject of medical certificates. Other questions elicited that in all cases in which no medical certificate is forthcoming the Registrar-General refers the matter to the coroner; also that attention is being given to the question of coroners sitting, at their discretion and in certain cases, without juries. It will be interesting to observe, whenever legislation is brought about on the whole subject, how far this innovation due to the war has found favour among those best able to judge of its advantages and defects.
Henry 0. Mertz,l of Indianopolis, has made a compilation of 77 recorded cases of bilateral duplication of the ureters, dividing the cases into four types. In the first type, which is the commonest, comprising as it does 40 cases, bilateral duplication is complete on both sides. Unless the bladder is extensively inflamed, as in tuberculous cystitis, in which case a meatus may be missed, the chances of failing to identify the condition is not great owing to the present perfection of -the cystoscope. In the second type, of which there 11 cases, bilateral duplication is complete, are but one ureter has an ectopic orifice, as, for instance, in the posterior urethra, or ends blindly in the bladder wall. Although detection of this type has previously been difficult, the close-vision cysto-urethroscope will enable the ureteral orifice near the colliculus to be identified. In the third type, of which Dr. Mertz has collected 11 cases, bilateral duplication is partial on each side; and in the fourth type, which is represented by 15 cases, the duplication is partial on one side and complete on the other. Of the completely duplicated cases 18 were diagnosed clinically, while there was no instance of bilateral duplication with a bifid ureter on one side or on both being diagnosed clinically, and with two exceptions all were found at ALBUMINURIA OF SMALL WHITE KIDNEY. the post-mortem examination or in the dissecting-room; Fusion of the bifid ureter may occur at any point in its THE differentiation of albuminuria due to severe Of 52 cases of partial duplication collected by, renal disease from those forms course. having no sinister Dr. Mertz, including unilateral cases diagnosed such as the conditions of postural, adolessignificance, mortem or on operation, in 65 per cent. the fusion was cent,.and cyclical albuminuria, remains one of great below the iliac crest, while of the cases diagnosed difficulty in spite of the attention which has been clinically, all unilateral, the bifurcation was above this given to this question. Recently discussions have taken point in five, opposite the fourth lumbar vertebra in place before the Medical Society of London and also one, and in only one instance below this point. before the Assurance Medical. and Dr.
posti
Society,
THE
LAW RELATING TO CORONERS’
INQUESTS.
THE exhumation of the body of a married woman in West London was followed recently by an inquest at which the jury returned a verdict that death was due to acute blood poisoning, but that there was no evidence to show how it was brought about. The medical man who had attended the deceased in’ her last illness had certified that death was due to sapraemia, adding that there had been a miscarriage. Burial had followed, but the Registrar-General had referred the certificate back to the medical man, and an inquest followed. Except. for the evidence of Dr. B. H. Spilsbury, who was of the opinion that the miscarriage had been due either to an operation or a drug, there was nothing pointing to criminal interference, beyond a few words uttered by the deceased when delirious, which the nurse attending her had heard. She had then said, "I told that woman she was hurting me. I shall never go to Notting Hill again," and "Iam paying dearly for my sins." Before that, when questioned by the nurse and also in answer to her husband, she had denied that anything to The procure miscarriage had been done to her. position of the medical man attending such a case is a difficult one. In the instance under comment his suspicion had, no doubt, been aroused, and he gave a certificate which in fact and, no doubt, intentionally called attention to the point which needed clearing up. 1
Urologic and Cutaneous Review, November, 1920.
prominence
has been given to certain tests of renal function, such as the " iirea-concentration test," and to certain chemical investigations of the protein present in the urine, especially the albumin-globulin ratio. We published in THE LANCET of Dec. 18th (p. 1249) an account of an interesting case of chronic nephritis with somewhat unusual features by Dr. Ivor J. Davies. A special point in this case was the long period of apparently good health with a large amount of protein in the urine. Chemical tests of the urine even a few days before the death of the patient from a subacute form of uraemia, showed the characters more usually associated with non-nephritic albuminuria-namely, a globulinalbumin ratio of 2 : 1. Moreover, the urinary diastase In test of renal function gave a normal figure. spite of this, intense albuminuric retinitis was found, which discounted the apparently favourable indications of the urinary examination. The special significance of the-case seems to us that it illustrates the importance of a due correlation of all the evidence in every case of albuminuria. In spite of the high globulin ratio, there was evidence of slowly progressive cardio-vascular changes with increasing blood pressure, since as long ago as November, 1916, the systolic blood pressure was as high as 160 mm. Hg, while in May, 1920, it was 200 mm. Hg. Special tests only become of real value when their limitations or exceptions are recognised. For this reason the record of unusual cases serves a very useful purpose. Dr. Davies’s case should emphasise the importance of adopting a critical attitude of mind to the findings of these tests in every case and of fitting in the