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TREATMENT OF PNEUMONIA BY ARTIFICIAL PNEUMOTHORAX
760
adopted in the General Register Office. In my forming part of the barbed shaft which is left behind experience I have found that the application of the in the victim’s flesh with the sting. rule of selection is invariably followed, and any disease In a recent publication31 have summarised the in a lower group is preferred to one in a higher, reported cases of allergic reaction to various insect .notwithstanding the opinion of the certifying practi- stings, bites, and emanations. tioner. Recently a patient was admitted to a local I am, Sir, yours faithfully, in of a state diabetic almost GEORGE BRAY, M.B. coma, hospital moribund, London, W., Sept. 25th, 1932. and death occurred within a few hours. A postexamination was made and evidence of tuberculosis was found. The death was certified as follows : " (a) Diabetic coma, (b) Tuberculosis of lungs, (P.M.)." In a written communication the certifying medical officer informed me that, although tuberculosis had been found as a result of post-mortem examination, "the immediate cause of death was diabetic coma." A copy of this communication was, therefore, forwarded to the General Register Office, but notwithstanding this information I am officially informed that the cause of death is to be classified to tuberculosis. The recorded cause of death is, therefore, inaccurate, the written opinion of the certifying practitioner is ignored, and the strict rule of selection applied. I am, Sir, yours faithfully, G. SOWDEN. mortem
pulmonary
Medical Officer of Health, St. Pancras.
Sept. 14th, 1932. ___
___
ANAPHYLAXIS FROM BEE STINGS
To the Editor
TREATMENT OF PNEUMONIA BY ARTIFICIAL PNEUMOTHORAX
To the Editor
of THE
LANCET
SIR,—In your issue of Jan. 2nd (p. 13) Dr. J. J.
Coghlan described 6 cases of pneumonia by artificial pneumothorax. I have up
treated to
now
this form of treatment in 11 cases at the General Hospital, Madras, 4 of them being cases of acute fibrinous pleurisy. In the first 3 cases I adopted Coghlan’s method of giving morphia and atropine half an hour before the induction ; in all the other cases morphia was not given, and I did not observe any difference. So as to cause the least possible disturbance the patient is allowed to lie flat on the back with the arm on the affected side I choose an interspace raised over the shoulder. in the anterior axillary line where the lung is not consolidated-a precaution which is unnecessary according to Coghlan. After sterilising the skin thoroughly, I infiltrate with novocain I per cent. the whole track for the pneumothorax needle, including the parietal pleura. In my experience the inflamed parietal pleura is not so hypersensitive as Dr. Coghlan thinks ; in two cases where I wanted to avoid two successivepricks, I performed the induction without novocain, the patients making no demur. In every case 500 c.cm. of air was inserted at the first induction, the amount being varied at the refills. In the cases of simple pleurisy no refill was given, nor in cases where crisis occurred and temperature remained normal after the first operation. I will add brief notes of the 7 cases of pneumonia. CASE 1.—Well-nourished male, aged 35, admitted Feb. 15th, 1932, for fever and cough of four days’ duration. Evident respiratory distress ; temp., 1015° F. ; pulse, 120 ; resp., 40. Left basal consolidation. A.P. (500 c.cm.) on the second day of admission. The effect was dramatic. He had
adopted
of THE LANCET find answers to most of Goodman will SIR,—Dr. his questions in a paper on Allergy in Relation to the Bee Sting, by R. L. Benson and H. Semenov.1 They consider the harmful effects of bees under three headings : (1) The venom of the sting, which may produce a general and non-specific effect of varying intensity depending upon the rapidity of absorption. The pharmacologically active principle of bee venom appears to be non-nitrogenous and has an action suggesting a saponin. This substance may act as a dermolysin releasing histamine actually present in the skin, but Benson and Semenov have conducted interesting experiments from which it seems probable that the venom itself may contain a histamine-like substance. This if introduced into a vein may produce shock. (2) Allergic reactions perspiration in ten minutes and temperature came due to pollen- carried by bees. Cutaneous allergic profuse down to normal in two hours. This was the only case
reactions
can
be
produced experimentally by testing
certain pollen-sensitive individuals with extracts from the bodies of bees, but clinically such a happening must be a very chance phenomenon. (3) Allergic reactions in the human from sensitisation to allergens inherent in the bee. These reactions are of increasing degree with successive bites and consequently common in bee-keepers. One of the earliest of these was that reported by A. T. Waterhouse.2 Desensitisation in these hypersensitive individuals may be brought about by increasing doses of bee extract made from the posterior eighth of an inch of the bee’s body. Dr. Goodman’s case seems to fall into this category, but it is remarkable that the sting a week previously was without any ill-effects. Possibly this sting was only venom, and free from the intrinsic bee protein which seems responsible for this third group. The poison gland system of the bee consists of a small alkaline and a larger coiled acid gland, the secretion of both of which is poured into the bulbous base of the poison canal and mixed to form the poison. From the canal it is expelled during the stinging act by a valve-like structure on each of the hollow darts 1 Jour. Allergy, 1929-30, i., 105. 2 THE LANCET, 1914, i., 946.
in
my series in which a crisis occurred as early as in Dr. Coghlan’s cases. Patient made an uneventful recovery.
2.-Male, aged 23, admitted March 7th, 1932, for over the right side of the chest of 36 hours’ duration. General condition bad though fairly well nourished. For two days signs indefinite, on third day definite consolidation of the right base with extensive pleural involvement. A.P. 500 c.cm. Pain immediately relieved. Temp. fell from 104° to 1015° F. in six hours, with improvement in general condition. Developed delirium tremens the next day. Refill on sixth day after admission. Temp. fell from 104° to 99-5° F. in five hours, but rose again in a few hours and patient died the next evening. CASE
fever, cough, and pain
This case illustrates that A.P. induces an artificial crisis which does not necessarily correspond to the expected natural crisis. CASE 3.-Male, aged 19, admitted March 7th, 1932, for pain on left side of chest and cough duration two days. Left basal consolidation, with well-marked. pleuritic rub. A.P. 36 hours after admission. Temp. fell from 103° to 100° F. in five hours but rose again to 102° after two hours, and dropped to 99° the next morning-i.e., 18 hours after induction. As the evening temp. rose to 100° refill (500 c.cm.) given two days later. Discharged well on March 15th,
1932.
CASE 4.-Male, aged 30, admitted March 10th, 1932, for fever and pain on the right side of the chest and cough duration seven days. Consolidation of right lower lobe. A.P. on the same day. Pain immediately relieved, no 3 Recent Advances in Allergy, London, 1931.
761 actual crisis. Temp. fell from 104° to 102° F. in six hours. On the third day a refill brought down temp. in 12 hours to 99°. Discharged well on March 15th, 1932. CASE 5.-Male, aged 38, admitted March 21st, 1932, for fever, cough, and pain on the left side of the chest, duration two days. Left basal consolidation with pleurisy. A.P. (500 c.cm.) on the first day. Temp. fell from 105° to 102° F. in eight hours, with no marked diminution of respiratory rate. Relief of pain immediate. Temp. oscillating 102°-103° F. for next two days. On third day a refill caused a drop in the temp. in three hours, rose again next morning to 102.° Another refill brought the temp. down to normal in 10 hours time. After oscillating for another day Disor two temp. remained normal from March 28th. charged on April 3rd, 1932. In this case definite crisis Patient became occurred only after the third refill. delirious the day after induction and remained so till the second refill. CASE 6.-Male, aged 21, admitted March 24th, 1932, for fever and pain on left side of the chest of five days’ duration. Commencing consolidation with fibrinous pleurisy on the ’ left base. A.P. on night of admission. Pain immediately relieved. Temp. fell from 105° to 102° in eight hours. Since it did not fall below 102° for the next two days a refill was given on the third day. Crisis occurred after 24 hours. This patient also became delirious the day after A.P. Discharged well on April 3rd, 1932. CASE 7.-Male, came with a history of nine days’ fever and cough. Consolidation of whole of right lung. A.P. on second day after admission. Temp. fell from 103° F. to1 normal in 20 hours. There was no subsequent rise. I
I agree with Dr.
Coghlan that the induction of immediate relief from pain. As regards temperature, in all my cases except one, the drop occurred only after six hours, whereas in his the crisis occurred within three hours. Only in two cases did the temperature drop to normal after the first induction. In all other cases there was only a fall of two or three degrees. In two cases only did profuse perspiration occur after A.P. There is no doubt that A.P. does produce an artificial crisis, often temporary, sometimes permanent ; in our cases, the crisis was more delayed and less dramatic than in the cases described by Dr. Coghlan. He claims that dyspnoea is relieved in half an hour. I was not so fortunate in my results, for though the respiratory distress was relieved owing to disappearance of pain, the rate of respiration came down only with the fall in temperature. Though my results were not so brilliant as Dr. Coghlan’s I am of opinion that treatment with A.P. deserves a trial in pneumonia. In cases of acute pleurisy the results are really dramatic. In lobar pneumonia it is an important auxiliary to other forms of treatment. But, as Dr. Coghlan says, lobar pneumonia is emphatically not the disease on which to gain a knowledge of the A.P.
gives
pressure in
a
But any of
large cavity.
us
working
at
artificial pneumothorax therapy observe from time to time positive and negative pressures which cannot
of pulmonary is an example. It is obvious that if you insert an artificial pneumothorax needle into a vomica you may, on the analogy of artificial pneumothorax, get either a negative,
explained from our knowledge physics. The " paradoxical reading be
"
positive, or atmospheric reading. During the last year my assistant, Dr. Alexander, has taken great trouble to get
A. J. P. accurate information about every case with annular shadows. admitted here, and he has reached the following conclusions, with which I entirely agree :(a) 5 per cent. of all patients admitted showed one or
rings. (b) Tubercle bacilli
more
were found in the sputum of all the who had these shadows. The rings altered in size in no definite direction or time. The study of these rings in a collapsed lung has been
patients (c) (d) of
no practical value. (e) In most cases no definite physical signs
over
were
detected
them.
(fAll the
cases
showed extensive shadows.
was leading us nowhere. The of any real value was that T.B. were every case. If a ring was evidence of tuberculosis this last observation might be useful. When in Canada and America in 1930 I got the
The
work, therefore,
only point present in
impression-erroneous perhaps-that they considered every ring as evidence of a cavity. Dr. Alexander, who has just returned from the German post-graduate course run by the Joint Tuberculosis Council, tells me he got this impression too. If this is correct, the aetiology of the rings is of great practical importance, because collapse therapy is likely to be adopted wherever they are found. As Dr. Sowerbutts says, the question can obviously only be settled in the post-mortem room, with a team consisting of the clinician, the radiologist, and the pathologist. To this team a physiologist might well I am, Sir, yours faithfully, be added. Winsley Sanatorium,
near
J. D. MACFIE. Bath, Sept. 24th, 1932.
LATERAL THORACIC JERK: A SIGN
OF
To the Editor
ANEURYSM
of THE LANCET
SIR,-When I wrote my account of the above sign of aneurysm of the descending aorta I mentioned technique. seen it with Dr. R. M. Scott, of Cleveland, in My thanks are due to Colonel Skinner for allowing having 1926. I have recently received a letter from Prof. F. C. me to try this method of treatment on his cases. of Buenos Aires, calling my attention to a I am indebted to Dr. J. Mani for helping me in the Arrillaga, paper describing the same sign in the Semana Médica operations.-I am, Sir, yours faithfully, of April 9th, 1931, p. 937. Further papers by Dr. R. VISWANATHAN, VISWANATIIAN, M.D., with Dr. J. C. Dabove, appeared in the Assistant Professor Assistant Professor of Medicine Medicine and Assistant Arrillaga, to First Physician, General Hospital. same journal later in the year (1931, ii., 7, 1253, and Physician, General Hospital, Madras. Madras. London, Sept.16th,1932. 1739), and he gives among others the following list. of references to other authors which may be of interest to some of your readers :PATHOGENESIS OF CAVITIES IN THE LUNGS del Sel, M., and Taquini,A. C.: Prensa uTd. Argent., 1931. To the Editor of THE LANCET xviii., 255. Martini, T., and Joselevich, M. :Semana M,4d., 1931, ii., SIR,-I do not think Dr. Sowerbutts’s paper carries 1259. us much farther with regard to the etiology of the Padilla, Cossio, and del Castillo: Ibid., 1932, ii., 76. del Sel, Costa Bertani, and Gerlovich: Prensa Mdd. Argent., annular shadows. I agree with Dr. Andrew Morland when he says that it is far-fetched to imagine that July 10th, 1932, p. 241. Moia, B., and Dondo, H.: Soc. de Med. Interna, August air passes through the bronchial wall, giving rise to 26th, 1932. a single bleb or cyst. On the other hand, Dr. Morland’s I feel that without this letter the above referencestheory of the causation of vomicae cannot possibly may elude readers in this country as they did me. be accepted without careful research. It is partly I am, Sir, yours faithfully, based, if I do not misunderstand him, on the fact that GEOFFREY BOURNE. Dr. Vere Pearson in an isolated case found a positive Queen Anne-street, W., Sept. 26th, 1932. ,
’
’
adopted in the General Register Office. In my forming part of the barbed shaft which is left behind experience I have found that the application of the in the victim’s flesh with the sting. rule of selection is invariably followed, and any disease In a recent publication31 have summarised the in a lower group is preferred to one in a higher, reported cases of allergic reaction to various insect .notwithstanding the opinion of the certifying practi- stings, bites, and emanations. tioner. Recently a patient was admitted to a local I am, Sir, yours faithfully, in of a state diabetic almost GEORGE BRAY, M.B. coma, hospital moribund, London, W., Sept. 25th, 1932. and death occurred within a few hours. A postexamination was made and evidence of tuberculosis was found. The death was certified as follows : " (a) Diabetic coma, (b) Tuberculosis of lungs, (P.M.)." In a written communication the certifying medical officer informed me that, although tuberculosis had been found as a result of post-mortem examination, "the immediate cause of death was diabetic coma." A copy of this communication was, therefore, forwarded to the General Register Office, but notwithstanding this information I am officially informed that the cause of death is to be classified to tuberculosis. The recorded cause of death is, therefore, inaccurate, the written opinion of the certifying practitioner is ignored, and the strict rule of selection applied. I am, Sir, yours faithfully, G. SOWDEN. mortem
pulmonary
Medical Officer of Health, St. Pancras.
Sept. 14th, 1932. ___
___
ANAPHYLAXIS FROM BEE STINGS
To the Editor
TREATMENT OF PNEUMONIA BY ARTIFICIAL PNEUMOTHORAX
To the Editor
of THE
LANCET
SIR,—In your issue of Jan. 2nd (p. 13) Dr. J. J.
Coghlan described 6 cases of pneumonia by artificial pneumothorax. I have up
treated to
now
this form of treatment in 11 cases at the General Hospital, Madras, 4 of them being cases of acute fibrinous pleurisy. In the first 3 cases I adopted Coghlan’s method of giving morphia and atropine half an hour before the induction ; in all the other cases morphia was not given, and I did not observe any difference. So as to cause the least possible disturbance the patient is allowed to lie flat on the back with the arm on the affected side I choose an interspace raised over the shoulder. in the anterior axillary line where the lung is not consolidated-a precaution which is unnecessary according to Coghlan. After sterilising the skin thoroughly, I infiltrate with novocain I per cent. the whole track for the pneumothorax needle, including the parietal pleura. In my experience the inflamed parietal pleura is not so hypersensitive as Dr. Coghlan thinks ; in two cases where I wanted to avoid two successivepricks, I performed the induction without novocain, the patients making no demur. In every case 500 c.cm. of air was inserted at the first induction, the amount being varied at the refills. In the cases of simple pleurisy no refill was given, nor in cases where crisis occurred and temperature remained normal after the first operation. I will add brief notes of the 7 cases of pneumonia. CASE 1.—Well-nourished male, aged 35, admitted Feb. 15th, 1932, for fever and cough of four days’ duration. Evident respiratory distress ; temp., 1015° F. ; pulse, 120 ; resp., 40. Left basal consolidation. A.P. (500 c.cm.) on the second day of admission. The effect was dramatic. He had
adopted
of THE LANCET find answers to most of Goodman will SIR,—Dr. his questions in a paper on Allergy in Relation to the Bee Sting, by R. L. Benson and H. Semenov.1 They consider the harmful effects of bees under three headings : (1) The venom of the sting, which may produce a general and non-specific effect of varying intensity depending upon the rapidity of absorption. The pharmacologically active principle of bee venom appears to be non-nitrogenous and has an action suggesting a saponin. This substance may act as a dermolysin releasing histamine actually present in the skin, but Benson and Semenov have conducted interesting experiments from which it seems probable that the venom itself may contain a histamine-like substance. This if introduced into a vein may produce shock. (2) Allergic reactions perspiration in ten minutes and temperature came due to pollen- carried by bees. Cutaneous allergic profuse down to normal in two hours. This was the only case
reactions
can
be
produced experimentally by testing
certain pollen-sensitive individuals with extracts from the bodies of bees, but clinically such a happening must be a very chance phenomenon. (3) Allergic reactions in the human from sensitisation to allergens inherent in the bee. These reactions are of increasing degree with successive bites and consequently common in bee-keepers. One of the earliest of these was that reported by A. T. Waterhouse.2 Desensitisation in these hypersensitive individuals may be brought about by increasing doses of bee extract made from the posterior eighth of an inch of the bee’s body. Dr. Goodman’s case seems to fall into this category, but it is remarkable that the sting a week previously was without any ill-effects. Possibly this sting was only venom, and free from the intrinsic bee protein which seems responsible for this third group. The poison gland system of the bee consists of a small alkaline and a larger coiled acid gland, the secretion of both of which is poured into the bulbous base of the poison canal and mixed to form the poison. From the canal it is expelled during the stinging act by a valve-like structure on each of the hollow darts 1 Jour. Allergy, 1929-30, i., 105. 2 THE LANCET, 1914, i., 946.
in
my series in which a crisis occurred as early as in Dr. Coghlan’s cases. Patient made an uneventful recovery.
2.-Male, aged 23, admitted March 7th, 1932, for over the right side of the chest of 36 hours’ duration. General condition bad though fairly well nourished. For two days signs indefinite, on third day definite consolidation of the right base with extensive pleural involvement. A.P. 500 c.cm. Pain immediately relieved. Temp. fell from 104° to 1015° F. in six hours, with improvement in general condition. Developed delirium tremens the next day. Refill on sixth day after admission. Temp. fell from 104° to 99-5° F. in five hours, but rose again in a few hours and patient died the next evening. CASE
fever, cough, and pain
This case illustrates that A.P. induces an artificial crisis which does not necessarily correspond to the expected natural crisis. CASE 3.-Male, aged 19, admitted March 7th, 1932, for pain on left side of chest and cough duration two days. Left basal consolidation, with well-marked. pleuritic rub. A.P. 36 hours after admission. Temp. fell from 103° to 100° F. in five hours but rose again to 102° after two hours, and dropped to 99° the next morning-i.e., 18 hours after induction. As the evening temp. rose to 100° refill (500 c.cm.) given two days later. Discharged well on March 15th,
1932.
CASE 4.-Male, aged 30, admitted March 10th, 1932, for fever and pain on the right side of the chest and cough duration seven days. Consolidation of right lower lobe. A.P. on the same day. Pain immediately relieved, no 3 Recent Advances in Allergy, London, 1931.
761 actual crisis. Temp. fell from 104° to 102° F. in six hours. On the third day a refill brought down temp. in 12 hours to 99°. Discharged well on March 15th, 1932. CASE 5.-Male, aged 38, admitted March 21st, 1932, for fever, cough, and pain on the left side of the chest, duration two days. Left basal consolidation with pleurisy. A.P. (500 c.cm.) on the first day. Temp. fell from 105° to 102° F. in eight hours, with no marked diminution of respiratory rate. Relief of pain immediate. Temp. oscillating 102°-103° F. for next two days. On third day a refill caused a drop in the temp. in three hours, rose again next morning to 102.° Another refill brought the temp. down to normal in 10 hours time. After oscillating for another day Disor two temp. remained normal from March 28th. charged on April 3rd, 1932. In this case definite crisis Patient became occurred only after the third refill. delirious the day after induction and remained so till the second refill. CASE 6.-Male, aged 21, admitted March 24th, 1932, for fever and pain on left side of the chest of five days’ duration. Commencing consolidation with fibrinous pleurisy on the ’ left base. A.P. on night of admission. Pain immediately relieved. Temp. fell from 105° to 102° in eight hours. Since it did not fall below 102° for the next two days a refill was given on the third day. Crisis occurred after 24 hours. This patient also became delirious the day after A.P. Discharged well on April 3rd, 1932. CASE 7.-Male, came with a history of nine days’ fever and cough. Consolidation of whole of right lung. A.P. on second day after admission. Temp. fell from 103° F. to1 normal in 20 hours. There was no subsequent rise. I
I agree with Dr.
Coghlan that the induction of immediate relief from pain. As regards temperature, in all my cases except one, the drop occurred only after six hours, whereas in his the crisis occurred within three hours. Only in two cases did the temperature drop to normal after the first induction. In all other cases there was only a fall of two or three degrees. In two cases only did profuse perspiration occur after A.P. There is no doubt that A.P. does produce an artificial crisis, often temporary, sometimes permanent ; in our cases, the crisis was more delayed and less dramatic than in the cases described by Dr. Coghlan. He claims that dyspnoea is relieved in half an hour. I was not so fortunate in my results, for though the respiratory distress was relieved owing to disappearance of pain, the rate of respiration came down only with the fall in temperature. Though my results were not so brilliant as Dr. Coghlan’s I am of opinion that treatment with A.P. deserves a trial in pneumonia. In cases of acute pleurisy the results are really dramatic. In lobar pneumonia it is an important auxiliary to other forms of treatment. But, as Dr. Coghlan says, lobar pneumonia is emphatically not the disease on which to gain a knowledge of the A.P.
gives
pressure in
a
But any of
large cavity.
us
working
at
artificial pneumothorax therapy observe from time to time positive and negative pressures which cannot
of pulmonary is an example. It is obvious that if you insert an artificial pneumothorax needle into a vomica you may, on the analogy of artificial pneumothorax, get either a negative,
explained from our knowledge physics. The " paradoxical reading be
"
positive, or atmospheric reading. During the last year my assistant, Dr. Alexander, has taken great trouble to get
A. J. P. accurate information about every case with annular shadows. admitted here, and he has reached the following conclusions, with which I entirely agree :(a) 5 per cent. of all patients admitted showed one or
rings. (b) Tubercle bacilli
more
were found in the sputum of all the who had these shadows. The rings altered in size in no definite direction or time. The study of these rings in a collapsed lung has been
patients (c) (d) of
no practical value. (e) In most cases no definite physical signs
over
were
detected
them.
(fAll the
cases
showed extensive shadows.
was leading us nowhere. The of any real value was that T.B. were every case. If a ring was evidence of tuberculosis this last observation might be useful. When in Canada and America in 1930 I got the
The
work, therefore,
only point present in
impression-erroneous perhaps-that they considered every ring as evidence of a cavity. Dr. Alexander, who has just returned from the German post-graduate course run by the Joint Tuberculosis Council, tells me he got this impression too. If this is correct, the aetiology of the rings is of great practical importance, because collapse therapy is likely to be adopted wherever they are found. As Dr. Sowerbutts says, the question can obviously only be settled in the post-mortem room, with a team consisting of the clinician, the radiologist, and the pathologist. To this team a physiologist might well I am, Sir, yours faithfully, be added. Winsley Sanatorium,
near
J. D. MACFIE. Bath, Sept. 24th, 1932.
LATERAL THORACIC JERK: A SIGN
OF
To the Editor
ANEURYSM
of THE LANCET
SIR,-When I wrote my account of the above sign of aneurysm of the descending aorta I mentioned technique. seen it with Dr. R. M. Scott, of Cleveland, in My thanks are due to Colonel Skinner for allowing having 1926. I have recently received a letter from Prof. F. C. me to try this method of treatment on his cases. of Buenos Aires, calling my attention to a I am indebted to Dr. J. Mani for helping me in the Arrillaga, paper describing the same sign in the Semana Médica operations.-I am, Sir, yours faithfully, of April 9th, 1931, p. 937. Further papers by Dr. R. VISWANATHAN, VISWANATIIAN, M.D., with Dr. J. C. Dabove, appeared in the Assistant Professor Assistant Professor of Medicine Medicine and Assistant Arrillaga, to First Physician, General Hospital. same journal later in the year (1931, ii., 7, 1253, and Physician, General Hospital, Madras. Madras. London, Sept.16th,1932. 1739), and he gives among others the following list. of references to other authors which may be of interest to some of your readers :PATHOGENESIS OF CAVITIES IN THE LUNGS del Sel, M., and Taquini,A. C.: Prensa uTd. Argent., 1931. To the Editor of THE LANCET xviii., 255. Martini, T., and Joselevich, M. :Semana M,4d., 1931, ii., SIR,-I do not think Dr. Sowerbutts’s paper carries 1259. us much farther with regard to the etiology of the Padilla, Cossio, and del Castillo: Ibid., 1932, ii., 76. del Sel, Costa Bertani, and Gerlovich: Prensa Mdd. Argent., annular shadows. I agree with Dr. Andrew Morland when he says that it is far-fetched to imagine that July 10th, 1932, p. 241. Moia, B., and Dondo, H.: Soc. de Med. Interna, August air passes through the bronchial wall, giving rise to 26th, 1932. a single bleb or cyst. On the other hand, Dr. Morland’s I feel that without this letter the above referencestheory of the causation of vomicae cannot possibly may elude readers in this country as they did me. be accepted without careful research. It is partly I am, Sir, yours faithfully, based, if I do not misunderstand him, on the fact that GEOFFREY BOURNE. Dr. Vere Pearson in an isolated case found a positive Queen Anne-street, W., Sept. 26th, 1932. ,
’
’