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BILHARZIAL APPENDICITIS.
28
yet been diagnosed before operation, but the writer suggests that in older cases a diagnosis might be established by X rays. The outcome of twin tubal pregnancies is recorded in 40 cases : 29 recovered. 10 died, and 1 was not recognised until the autopsy. never
ARE
FEMALES OF
LOSING THE ADVANTAGE
LOW
MORTALITY?
THE differences in vitality of the two sexes are of perennial interest to the physician as well as to the .statistician, and no completely satisfactory explanation of these differences at various ages has been advanced. Both in the United States and in this country this difference is shown even in the first year after birth. Thus in the year 1920 in the registration area of the United States the female death-rate among infants under 1 year of age was 20 per cent. and in England and Wales was 23 per cent. lower than the male infant death-rate, and an excess of male over female rate of mortality was shown consistently in each month of infancy. After infancy in the United States the excess of male over female mortality continues throughout each stage of life ; while in England and Wales at ages 10-15 there is seen some The ages at excess of female over male mortality. which this excess of female over male ’mortality occurs in England have gradually narrowed with the . course of time ; and the absence of this feature in America is interesting. In the May issue of the Statistical Bulletin of the Metropolitan Life Insurance Company of New York attention is drawn to the fact that in the experience of persons insured in this company a reversal of the usual relationship occurred, the female mortality at all ages exceeding the male by 2-6 per cent. in 1920, while the male excess in 1922 was 1-2 per cent. Among white insured persons an excess of female mortality over male occurred at ages 15-35 in 1920. These oscillations in the relation of male to female mortality are interesting, but their explanation is obscure. The factors producing this result are not confined to insured persons, for in 1920 taking the whole of the American registration area the death-rate at ages 20-25 and at ages 25-35 was higher in women than in men. These differences of experience in the American statistics will deserve further study, directed to a determination of the causes of excess of female over male mortality in each age-period. It is probable that similar studies of various large towns in this country would reveal exceptional sex-incidence of mortality at different ages, and that thus much light might be thrown on possibilities of preventive work. A great difficulty in pursuing this line of
is constituted by the delay in the issue of the census reports for a large number of counties, as without a statement of the 1921 population according to age and sex detailed death-rates cannot be calculated.
investigation
____
CHRONIC ECZEMA PRODUCED BY WHEATFLOUR.
sensitisation to wheat-flour which produced chronic eczema is well reported1 by Dr. H. Grenet and Dr. R. Clement. A woman of 63 had developed the trouble at 40 ; the lesion was so extensive and itched so badly as to preclude sleep, and this in spite of constant attempts at treatment. Inquiries into the family history showed nothingno eczema that is, for the authors do not say if other types of toxic idiopathy were looked for. Finding that among the various drastic food restrictions bread seemed to be the only foodstuff which had never been curtailed, they prescribed a normal dietary, minus bread ; and bread proved indeed to be the disturbing factor, for the patient improved forthwith. It is worth noting that a very definite intra4lermal reaction was obtained with flour mixed with A
CASE
of
1 Bulletins et Mémoires de June 7th.
la
Soc. Méd. des Hôpitaux de
Paris,
’,
normal serum, but this mixture gave no skin reaction. At this stage 100 g. of bread were deliberately administered and produced the typical blood crisisdrop of pressure in five minutes and a leucopenia reaching a maximum after 45 minutes. Desensitisation was effected with the same wheat and serum mixture ; details are given in culinary terms-" one coffeespoon of flour to two dessert-spoons of serum" ; doses of half and later of 1 c.cm. of this mixture proved effective in spite of a somewhat sharp general reaction. The patient was then habituated to a bread diet by easy stages, till after three months she was allowed normal diet. Even then she was afraid to eat green peas or strawberries-foods which - had previously provoked attacks of eczema ; but on trial she found that these no longer harmed her. This additional success the authors ascribe to a wide group-desensitisation ; and, given any specificity at all, the group must indeed be wide which includes wheat, strawberries, and green peas ! We would suggest rather that, on the summation theory of protein irritants, while bread had been a constant factor making for trouble any other irritant could always produce an increase of symptoms, but with the wheat factor removed by desensitisation other and slighter irritants were not enough to cause an attack. The authors quote another less clearly established instance of wheat-eczema, and note that Sabouraud has pointed out the dangers of bread in certain cases; they conclude that such cases are commoner than is generally supposed. This may be true ; but it is also true that seldom can the protein cause for eczema and asthma be established as quickly and certainly as in the case of Dr. Grenet and Dr. Clement.
BILHARZIAL APPENDICITIS. Dr. C. H. Bailey and Dr. E. A. Bullard,of Woman’s Hospital, New York, who describe a case which came under their own observation, remark that though infections with the trematode parasite schistosoma are very common in certain parts of the world, especially Africa, cases in which the symptoms are confined to the vermiform appendix are extremely rare. As is well known, the commonest sites of infection by the Schisto8oma haematobium described by Bilharz in 1852 are the bladder and urethra, rectum, vulva, and
vagina. Urinary symptoms, especially hpematuria,
are
the commonest, both in the male and in the female, in whom bilharzia infections, according to Burfield, are 24 times less frequent than in the male. The writers have been able to find only two previous cases on record in which symptoms of bilharzia infection were confined to the appendix. The first was that described by J. Burfield in THE LANCETin a man 36, in whom abundant ova of schistosoma were found in the submucosa of a suppurating appendix. The patient had no symptoms of genito-urinary or rectal involvement. The other case is one attributed to Aireton by Kelly of exclusive localisation of the ova of the parasite in the appendix, but no further description is given. The writers’ case occurred in a woman, aged 25, who had lived in South Africa until she was 15. Her chief complaints were sterility, dysmenorrhoea, and frequent dull pains in the right lower quadrant of the abdomen for nearly two years. Examination showed an undeveloped uterus with stenosis of the cervix and evidence of chronic appendicitis which was confirmed by operation, when the entire meso-appendix and distal two-thirds of the appendix were found to be thickly studded with tiny greyish-white nodules resembling tubercles. Microscopical sections showed that the nodules were present in moderate number in the submucous and serous coats and throughout the meso-appendix. There were none in the mucous membrane or muscular layer. The nodules contained one or more ova with a very definite cell membrane, some of which were calcified. Numerous giant cells with many nuclei were seen
aged
1
and Obstetrics, May, 1923. 2 THE LANCET, 1906, i., 368.
Surgery, Gynecology,
29 to or completely surrounding an ovum. In the older lesions the ovum was surrounded by dense fibrous tissue. Examination of the blood one month A Series of Special Articles, contributed by after the operation showed a leucocytic count of invitation, on the Treatment of Medical 5600 ; polymorphonuclears, 24 per cent. ; small and Surgical Conditions. 52 large mononuclears, per cent ; lymphocytes, 7 per cent. ; eosinophils, 17per cent. No ova were XXVII.-THE TREATMENT OF ASTHMA. found in the stools. Improvement took place under USED in its broadest sense, the term asthma is treatment by intravenous injections of sodium to a state of affairs in the smaller bronchi, applied in 2 tartrate cent. until in antimony per solution, which hinders the exchange of air between the larger May, 1922, 14 months after the operation, the blood bronchi and the alveoli of the lungs. We know little count showed that the eosinophils had fallen to the obstruction, but arguing from the nature of about In cent. the the 1’5 per following August patient was the analogy of the plain muscle of the intestine or in excellent health and no evidence of bilharzia was bladder, we may assume that the bronchial muscle, found. which possibly contracts slightly during each normal expiration, may in asthma at one time be tonically LABORATORY DIAGNOSIS OF VENEREAL contracted, and at another time undergoing a series DISEASE. of violent rhythmic contractions and relaxations. THE first edition of the Medical Research Council’s (Edema or congestion of the mucous membrane may report on the laboratory diagnosis of gonococcal infec- also play a part, and is, perhaps, especially important tions and methods for the detection of Spironema in those cases where there is sensitisation to foreign pallidum is well known to all those engaged in the proteins, inasmuch as the latter may produce oedema laboratory diagnosis of venereal disease, and the elsewhere-e.g., urticaria or angio-neurotic oedema. From the definition given above we see that the service which it has rendered in this field of work is undoubted. Unfortunately, it has been unobtainable term asthma is often used to denote a symptom, latterly, having been out of print for some months. or perhaps a syndrome, rather than a disease-a It will, therefore, be a matter of great satisfaction to syndrome in fact that may be caused by different those engaged in venereal diagnosis to know that a agents. Thus in considering the treatment of asthma second editionis now available. At the important it is essential to diagnose the underlying cause. discussion on Metastatic Gonorrhoea, the conclusion (1)Sensitisation to a Foreign Protein. of which is reported on p. 18, doubt was thrown on In this case the asthma may be associated with the validity of some of the assumed localisations of other symptoms, such as coryza, gastro-intestinal gonorrhoeal infection, in the absence of actual disturbances, urticaria, angio-neurotic oedema, eczema, The first part of or acute dermatitis. demonstration there of the virus. Hay fever due to grass the report, dealing with the laboratory diagnosis is the commonest variety, but there are also pollen of gonococcal infections, which has been revised the animal asthmas, where the hairs or feathers are and brought up to date by Dr. G. T. Western, responsible, and sensitiveness to certain foods or therefore of is special value. Amongst the beverages, such as cereals, eggs, potatoes, lobster, improvements to be noted here is the reduction in strawberries, cocoa, &c. These foods usually produce the number of alternative media given for the cultivadisturbances in susceptible people, gastro-intestinal tion of the gonococcus. The preparation of nutrient but asthma may occur as well. Finally, there may be a agar-which can be enriched with human plasma or sensitiveness to micro-organisms of the respiratory or serum-and of tryptamine blood-extract agar and alimentary tracts, or to certain drugs. In some cases broth is dealt with in detail and gives a sufficient the diagnosis follows from the history of the case. choice without being excessive. A valuable addition But in any case, testing may be carried out with a has been made to that portion of the report by series of proteins, which can be obtained commercially. Mr. J. E. Barnard which treats with the demon- The skin after cleaning is slightly scarified, and the stration of spirochsetes by dark-ground illumination. solution of the protein applied by means of a platinum This is a method for differentiating between S. pallidum If the protein is in powder form, it may be loop. and other spironemata. Briefly, this method consists added to a drop of N/10 sodium hydrate, which has in estimating the number of spirals in the spirochaete been placed over the scarified area. An urticarial wheal to a given length, the standard suggested being the of at least inch in diameter indicates a positive result. diameter of a red blood cell. As it is not a common Single protein testing, though it gives more satisfacoccurrence to find spironemata in close proximity to tory results, is a rather tedious business, and can be red cells in the preparations, an ingenious eye-piece made shorter by the combination of various allied scale has been devised which introduces a number of cat’s, dog’s, and horse’s hair into a The proteins-e.g., artificial blood cells into the field of view. group, with various feathers, so that a single test procedure is simple and the apparatus inexpensive, answers for several different proteins. Some workers and it should prove of very material aid in arriving in this country and America have found that as many at a correct diagnosis. Revising the section which as 50 per cent. of asthmatics are sensitive to some treats of the staining methods to be used for foreign protein ; but usually the positive results are spironemata, Dr. Clifford Dobell has added some much fewer than this. Sometimes patients rather valuable advice on the use of Romanowsky stains, disconcertingly react once and fail to react next time. which will be read with advantage by those making If a particular protein is answerable the best use of this procedure. The new edition of this report treatment is to avoid its presence altogether. Hay should prove of even greater value than its fever patients should stay in town in the early summer, predecessor. or use a thick veil when walking in the country. Articles of diet containing the specific substance Tim Canadian Parliament has unanimously voted ’, should not be eaten. If prevention is unsuccessful, to Dr. F. G. Banting an annuity of$7500 (iH500) to z, desensitisation be carried out by means of may enable him to carry on his scientific work. ’, hypodermic injections of the specific protein in gradually increasing doses. Oral administration has THE Gold Medal of the Royal Society of Medicine, also been carried out, particularly in France. These " awarded triennially to a scientist, man or woman, various antigens may be obtained commercially. who has made valuable contributions to the science Sensitiveness in hay fever may be tested by subcuand art of medicine," has this year been awarded to taneous injections or by dropping solutions, gradually mixture of pollen extracts Prof. F. Gowland Hopkins, F.R.S., Professor of increasing in strength, of afew minutes examining for after a and the into eye, Biochemistry in the University of Cambridge. slight signs of inflammation. When a reaction is 1 Medical Research Council Special Report Series, No. 19 obtained, desensitisation may be carried out by revised). H.M. Stationery Office. Price 1s. 6d. injecting 1 c.cm. of a solution slightly weaker than that
adjacent
.
Modern Technique in Treatment.
____
yet been diagnosed before operation, but the writer suggests that in older cases a diagnosis might be established by X rays. The outcome of twin tubal pregnancies is recorded in 40 cases : 29 recovered. 10 died, and 1 was not recognised until the autopsy. never
ARE
FEMALES OF
LOSING THE ADVANTAGE
LOW
MORTALITY?
THE differences in vitality of the two sexes are of perennial interest to the physician as well as to the .statistician, and no completely satisfactory explanation of these differences at various ages has been advanced. Both in the United States and in this country this difference is shown even in the first year after birth. Thus in the year 1920 in the registration area of the United States the female death-rate among infants under 1 year of age was 20 per cent. and in England and Wales was 23 per cent. lower than the male infant death-rate, and an excess of male over female rate of mortality was shown consistently in each month of infancy. After infancy in the United States the excess of male over female mortality continues throughout each stage of life ; while in England and Wales at ages 10-15 there is seen some The ages at excess of female over male mortality. which this excess of female over male ’mortality occurs in England have gradually narrowed with the . course of time ; and the absence of this feature in America is interesting. In the May issue of the Statistical Bulletin of the Metropolitan Life Insurance Company of New York attention is drawn to the fact that in the experience of persons insured in this company a reversal of the usual relationship occurred, the female mortality at all ages exceeding the male by 2-6 per cent. in 1920, while the male excess in 1922 was 1-2 per cent. Among white insured persons an excess of female mortality over male occurred at ages 15-35 in 1920. These oscillations in the relation of male to female mortality are interesting, but their explanation is obscure. The factors producing this result are not confined to insured persons, for in 1920 taking the whole of the American registration area the death-rate at ages 20-25 and at ages 25-35 was higher in women than in men. These differences of experience in the American statistics will deserve further study, directed to a determination of the causes of excess of female over male mortality in each age-period. It is probable that similar studies of various large towns in this country would reveal exceptional sex-incidence of mortality at different ages, and that thus much light might be thrown on possibilities of preventive work. A great difficulty in pursuing this line of
is constituted by the delay in the issue of the census reports for a large number of counties, as without a statement of the 1921 population according to age and sex detailed death-rates cannot be calculated.
investigation
____
CHRONIC ECZEMA PRODUCED BY WHEATFLOUR.
sensitisation to wheat-flour which produced chronic eczema is well reported1 by Dr. H. Grenet and Dr. R. Clement. A woman of 63 had developed the trouble at 40 ; the lesion was so extensive and itched so badly as to preclude sleep, and this in spite of constant attempts at treatment. Inquiries into the family history showed nothingno eczema that is, for the authors do not say if other types of toxic idiopathy were looked for. Finding that among the various drastic food restrictions bread seemed to be the only foodstuff which had never been curtailed, they prescribed a normal dietary, minus bread ; and bread proved indeed to be the disturbing factor, for the patient improved forthwith. It is worth noting that a very definite intra4lermal reaction was obtained with flour mixed with A
CASE
of
1 Bulletins et Mémoires de June 7th.
la
Soc. Méd. des Hôpitaux de
Paris,
’,
normal serum, but this mixture gave no skin reaction. At this stage 100 g. of bread were deliberately administered and produced the typical blood crisisdrop of pressure in five minutes and a leucopenia reaching a maximum after 45 minutes. Desensitisation was effected with the same wheat and serum mixture ; details are given in culinary terms-" one coffeespoon of flour to two dessert-spoons of serum" ; doses of half and later of 1 c.cm. of this mixture proved effective in spite of a somewhat sharp general reaction. The patient was then habituated to a bread diet by easy stages, till after three months she was allowed normal diet. Even then she was afraid to eat green peas or strawberries-foods which - had previously provoked attacks of eczema ; but on trial she found that these no longer harmed her. This additional success the authors ascribe to a wide group-desensitisation ; and, given any specificity at all, the group must indeed be wide which includes wheat, strawberries, and green peas ! We would suggest rather that, on the summation theory of protein irritants, while bread had been a constant factor making for trouble any other irritant could always produce an increase of symptoms, but with the wheat factor removed by desensitisation other and slighter irritants were not enough to cause an attack. The authors quote another less clearly established instance of wheat-eczema, and note that Sabouraud has pointed out the dangers of bread in certain cases; they conclude that such cases are commoner than is generally supposed. This may be true ; but it is also true that seldom can the protein cause for eczema and asthma be established as quickly and certainly as in the case of Dr. Grenet and Dr. Clement.
BILHARZIAL APPENDICITIS. Dr. C. H. Bailey and Dr. E. A. Bullard,of Woman’s Hospital, New York, who describe a case which came under their own observation, remark that though infections with the trematode parasite schistosoma are very common in certain parts of the world, especially Africa, cases in which the symptoms are confined to the vermiform appendix are extremely rare. As is well known, the commonest sites of infection by the Schisto8oma haematobium described by Bilharz in 1852 are the bladder and urethra, rectum, vulva, and
vagina. Urinary symptoms, especially hpematuria,
are
the commonest, both in the male and in the female, in whom bilharzia infections, according to Burfield, are 24 times less frequent than in the male. The writers have been able to find only two previous cases on record in which symptoms of bilharzia infection were confined to the appendix. The first was that described by J. Burfield in THE LANCETin a man 36, in whom abundant ova of schistosoma were found in the submucosa of a suppurating appendix. The patient had no symptoms of genito-urinary or rectal involvement. The other case is one attributed to Aireton by Kelly of exclusive localisation of the ova of the parasite in the appendix, but no further description is given. The writers’ case occurred in a woman, aged 25, who had lived in South Africa until she was 15. Her chief complaints were sterility, dysmenorrhoea, and frequent dull pains in the right lower quadrant of the abdomen for nearly two years. Examination showed an undeveloped uterus with stenosis of the cervix and evidence of chronic appendicitis which was confirmed by operation, when the entire meso-appendix and distal two-thirds of the appendix were found to be thickly studded with tiny greyish-white nodules resembling tubercles. Microscopical sections showed that the nodules were present in moderate number in the submucous and serous coats and throughout the meso-appendix. There were none in the mucous membrane or muscular layer. The nodules contained one or more ova with a very definite cell membrane, some of which were calcified. Numerous giant cells with many nuclei were seen
aged
1
and Obstetrics, May, 1923. 2 THE LANCET, 1906, i., 368.
Surgery, Gynecology,
29 to or completely surrounding an ovum. In the older lesions the ovum was surrounded by dense fibrous tissue. Examination of the blood one month A Series of Special Articles, contributed by after the operation showed a leucocytic count of invitation, on the Treatment of Medical 5600 ; polymorphonuclears, 24 per cent. ; small and Surgical Conditions. 52 large mononuclears, per cent ; lymphocytes, 7 per cent. ; eosinophils, 17per cent. No ova were XXVII.-THE TREATMENT OF ASTHMA. found in the stools. Improvement took place under USED in its broadest sense, the term asthma is treatment by intravenous injections of sodium to a state of affairs in the smaller bronchi, applied in 2 tartrate cent. until in antimony per solution, which hinders the exchange of air between the larger May, 1922, 14 months after the operation, the blood bronchi and the alveoli of the lungs. We know little count showed that the eosinophils had fallen to the obstruction, but arguing from the nature of about In cent. the the 1’5 per following August patient was the analogy of the plain muscle of the intestine or in excellent health and no evidence of bilharzia was bladder, we may assume that the bronchial muscle, found. which possibly contracts slightly during each normal expiration, may in asthma at one time be tonically LABORATORY DIAGNOSIS OF VENEREAL contracted, and at another time undergoing a series DISEASE. of violent rhythmic contractions and relaxations. THE first edition of the Medical Research Council’s (Edema or congestion of the mucous membrane may report on the laboratory diagnosis of gonococcal infec- also play a part, and is, perhaps, especially important tions and methods for the detection of Spironema in those cases where there is sensitisation to foreign pallidum is well known to all those engaged in the proteins, inasmuch as the latter may produce oedema laboratory diagnosis of venereal disease, and the elsewhere-e.g., urticaria or angio-neurotic oedema. From the definition given above we see that the service which it has rendered in this field of work is undoubted. Unfortunately, it has been unobtainable term asthma is often used to denote a symptom, latterly, having been out of print for some months. or perhaps a syndrome, rather than a disease-a It will, therefore, be a matter of great satisfaction to syndrome in fact that may be caused by different those engaged in venereal diagnosis to know that a agents. Thus in considering the treatment of asthma second editionis now available. At the important it is essential to diagnose the underlying cause. discussion on Metastatic Gonorrhoea, the conclusion (1)Sensitisation to a Foreign Protein. of which is reported on p. 18, doubt was thrown on In this case the asthma may be associated with the validity of some of the assumed localisations of other symptoms, such as coryza, gastro-intestinal gonorrhoeal infection, in the absence of actual disturbances, urticaria, angio-neurotic oedema, eczema, The first part of or acute dermatitis. demonstration there of the virus. Hay fever due to grass the report, dealing with the laboratory diagnosis is the commonest variety, but there are also pollen of gonococcal infections, which has been revised the animal asthmas, where the hairs or feathers are and brought up to date by Dr. G. T. Western, responsible, and sensitiveness to certain foods or therefore of is special value. Amongst the beverages, such as cereals, eggs, potatoes, lobster, improvements to be noted here is the reduction in strawberries, cocoa, &c. These foods usually produce the number of alternative media given for the cultivadisturbances in susceptible people, gastro-intestinal tion of the gonococcus. The preparation of nutrient but asthma may occur as well. Finally, there may be a agar-which can be enriched with human plasma or sensitiveness to micro-organisms of the respiratory or serum-and of tryptamine blood-extract agar and alimentary tracts, or to certain drugs. In some cases broth is dealt with in detail and gives a sufficient the diagnosis follows from the history of the case. choice without being excessive. A valuable addition But in any case, testing may be carried out with a has been made to that portion of the report by series of proteins, which can be obtained commercially. Mr. J. E. Barnard which treats with the demon- The skin after cleaning is slightly scarified, and the stration of spirochsetes by dark-ground illumination. solution of the protein applied by means of a platinum This is a method for differentiating between S. pallidum If the protein is in powder form, it may be loop. and other spironemata. Briefly, this method consists added to a drop of N/10 sodium hydrate, which has in estimating the number of spirals in the spirochaete been placed over the scarified area. An urticarial wheal to a given length, the standard suggested being the of at least inch in diameter indicates a positive result. diameter of a red blood cell. As it is not a common Single protein testing, though it gives more satisfacoccurrence to find spironemata in close proximity to tory results, is a rather tedious business, and can be red cells in the preparations, an ingenious eye-piece made shorter by the combination of various allied scale has been devised which introduces a number of cat’s, dog’s, and horse’s hair into a The proteins-e.g., artificial blood cells into the field of view. group, with various feathers, so that a single test procedure is simple and the apparatus inexpensive, answers for several different proteins. Some workers and it should prove of very material aid in arriving in this country and America have found that as many at a correct diagnosis. Revising the section which as 50 per cent. of asthmatics are sensitive to some treats of the staining methods to be used for foreign protein ; but usually the positive results are spironemata, Dr. Clifford Dobell has added some much fewer than this. Sometimes patients rather valuable advice on the use of Romanowsky stains, disconcertingly react once and fail to react next time. which will be read with advantage by those making If a particular protein is answerable the best use of this procedure. The new edition of this report treatment is to avoid its presence altogether. Hay should prove of even greater value than its fever patients should stay in town in the early summer, predecessor. or use a thick veil when walking in the country. Articles of diet containing the specific substance Tim Canadian Parliament has unanimously voted ’, should not be eaten. If prevention is unsuccessful, to Dr. F. G. Banting an annuity of$7500 (iH500) to z, desensitisation be carried out by means of may enable him to carry on his scientific work. ’, hypodermic injections of the specific protein in gradually increasing doses. Oral administration has THE Gold Medal of the Royal Society of Medicine, also been carried out, particularly in France. These " awarded triennially to a scientist, man or woman, various antigens may be obtained commercially. who has made valuable contributions to the science Sensitiveness in hay fever may be tested by subcuand art of medicine," has this year been awarded to taneous injections or by dropping solutions, gradually mixture of pollen extracts Prof. F. Gowland Hopkins, F.R.S., Professor of increasing in strength, of afew minutes examining for after a and the into eye, Biochemistry in the University of Cambridge. slight signs of inflammation. When a reaction is 1 Medical Research Council Special Report Series, No. 19 obtained, desensitisation may be carried out by revised). H.M. Stationery Office. Price 1s. 6d. injecting 1 c.cm. of a solution slightly weaker than that
adjacent
.
Modern Technique in Treatment.
____