states Edebohls on page 29, "are most liberally supplied with blood-vessels both are brought together by my operation over the whole surface of the kidney the necessary result must be the formation, on the most extensive scale possible, of new vascular connections between the kidney and the fatty capsule embracing it "; and on page 27, “The increased and adequately maintained blood-supply to the kidney established by my operation leads, most probably, to gradual absorption of the interstitial or intertubular inflammatory products and exudates, thus freeing the tubules and glomeruli from external compression, constriction, and distortion, and permitting the re-establishment in them of a normal circulation. The result of this improved circulation in and between the tubules and glomeruli is the regenerative production of new epithelium capable of carrying on the secretory function."

Edebohls' work is based on the above proposition—the establishment of a new vascular supply between the cortex of the kidney and the peri-renal tissues.

On turning to experimental evidence on this point, in the British Medical Journal of April 9, 1904, Walker Hall and Herxheimer state that "after decapsulation of the kidney in some thirty-five rabbits, we also have not observed, either by ordinary or serial sections, any marked formation of new blood-channels between the kidney and the adherent tissues." A full bibliography is appended to this paper, and they quote Boncz-Osmolowsky as confirming their own results: did not observe any new formation of blood-vessels in the reformed capsule.

Again, Gifford publishes, in the Boston Medical and Surgical Journal of July 14, 1904, his conclusions of the results of experiments on dogs and rabbits on which he had decapsulated the kidneys. He finds (5) no histological change in the renal epithelium follows the operation of decapsulation of the kidneys; (7) no new vessels are formed which anastomose with those in the kidney.

Theleman, in the Deutsch. Med. Woch., 1904, No. 15, p. 538, regards the question as not proven.

These references suggest doubts of the validity of the premiss on which Edebohls has based the theory and practice of decapsulation of the kidneys as a rational means of treatment of chronic Bright's disease. A trenchant criticism of Edebohls' work appears in the review of his book in the British Medical Journal of November 19, 1904. This cursory review of the literature of the subject of the surgical treatment of nephritis at least indicates the importance of the work that has been, and is being, done. An exhaustive summary of the question is to be found in an article by Yvert, entitled, "Operative Intervention in Nephritis, and in Certain Medical Affections of the Kidney," in the Revue de Chirurgie of September 10, 1904.

A. W. NUTHALL.

SPINAL

OPHTHALMOLOGY.

LYMPHOCYTOSIS AND OCULAR
AFFECTIONS.

LAPERSONNE (Recueil D'Ophtalmologie, June, 1903), as the result of seventeen examinations of cerebro-spinal fluid, abstracted from patients suffering from certain eye diseases, obtained eight positive and nine negative results, which were made up as follows

The method of puncture employed was that recommended by Widal, Sicard, and Ravant. It was necessary to keep the patients lying down with the head low after the operation. By adopting these precautions the puncture gave rise to no inconvenience. On two occasions it gave much comfort. One of these was a case of cerebral tumour, and the withdrawal of a small quantity of cerebro-spinal fluid had the effect of relieving the violent headaches and clearing the sight.

In estimating the diagnostic value of the lymphocytosis, the author found that the positive reactions in the cases of neuritis and chorioretinitis were obtained in those which were comparatively recent, i.e., within three months of their onset, whilst the results were negative in those cases in which the lesion was retrogressing. A case of syphilitic neuritis, with dust-like vitreous opacities, showed lymphocytosis at first, but after energetic treatment for three months the result was negative. Syphilitic iritis gave positive results on two occasions. Lymphocytosis is, however, by no means diagnostic of syphilis, as a case of tubercular meningitis gave a positive result, and three cases of post neuritic atrophy gave negative results. It appears, however, to be a valuable aid in the ætiological diagnosis of recent lesions of the anterior and posterior segments of the globe when the syphilitic antecedents are doubtful.

MENTAL DERANGEMENTS IN EYE PATIENTS.

Kipp (Archives of Ophthalmology, July, 1903) relates several cases of the mental derangements which are not uncommonly observed, in patients past middle life, after operations on the eye. Two of the author's cases were exceptional in that no operation had been performed on them. The onset of symptoms occurred between the second day and the third week, and was marked by restlessness and sleeplessness. These were very soon followed by signs of maniacal delirium, which was sometimes suicidal or homicidal. Recovery from the mental trouble was very speedy in all cases where it was possible to send the patients to their own homes immediately after the outbreak. Less rapid improvement was obtained by getting members of the patient's household to stay with him and moving him to another part of the hospital.

In none of these cases could the condition be ascribed to the use of bandages, atropine, dark room, or alcohol. All were in good health and mentally sound on admission. Kipp is of opinion that the cause of the delirium is largely psychical, and agrees with Parinaud that it is due to pre-occupation on the part of the patient prior to and after operation.

The treatment consisted in the administration of bromides and chloral, and removal of the patient to his own home where possible. Constant oversight and tactful nursing were required. The removal of bandages and the discontinuance of atropine were not considered necessary.

THE VALUE OF OPHTHALMIC EXAMINATIONS IN THE DIFFERENTIAL DIAGNOSIS BETWEEN TYPHOID FEVER AND ACUTE MILIARY TUBERCULOSIS.

Loeb (Archives of Ophthalmology, September, 1903) found tubercles in the choroid on ophthalmoscopical examination of a patient who was suffering from an ill-defined illness which had been diagnosed as typhoid fever. His observation was confirmed by a post mortem histolo-bacteriological examination of the deposits in the choroid. He gives the following description of tubercle of the choroid based on the study of the literature published on the subject. The classical tubercles of the choroid lie in the region surrounding the optic disc and macula lutea. They are roundish, and vary in size from .3 mm. to 2.5 mm. They must be at least 6 mm. to be ophthalmoscopically visible. Though originating in the choroid, they grow towards the retina, pushing apart the cells of the pigment epithelium, thus causing a focus of white discolouration of the fundus. There is a gradual transition from the whitish centre of the tubercle to the normal red of the fundus, and a pigment ring is very rarely seen. The tubercles generally project forwards towards the vitreous, often raising the retinal blood-vessels over them. There are usually no hæmorrhages, and no refractive changes. The tubercle may appear at any stage of the disease. They sometimes grow so rapidly as to become visible ophthalmoscopically overnight.

Atiologically, tubercle of the choroid may arise from two different causes, viz. (1) Ectogenous the infection being conveyed into the eye from without, as by a trauma; and (2) endogenous-when the organisms are carried to the eye from some other part of the body. Ocular tuberculosis may be a part of a general miliary tuberculosis or a localised

form limited to the eye, and which may act as the source of a secondary general infection. Opinions differ as to the frequency of tubercle of the choroid in general miliary tuberculosis. Loeb quotes the following figures :-Cohnheim 100 per cent. (practically), Bock 82.7 per cent., Litten 75 per cent., Carpenter and Stephenson 50 per cent., Demme 21 per cent., Bonchert 10 per cent. Loeb concludes that 50 per cent. is a fair average. Its absence does not disprove the presence of the general process, but its presence, when its development can be followed, coupled with other less characteristic symptoms, is pathognomonic of general miliary tuberculosis.

All cases of typhoid fever running an atypical course should be examined ophthalmoscopically, and it is well to repeat the examination two or three times, as certain ophthalmoscopically invisible submiliary tubercles may at any moment grow so rapidly that they may be seen intra vitam.

TABETIC ATROPHY OF THE OPTIC NERVE, AND THE PREATROPHIC PERIOD AND ITS TREATMENT.

Fabre (Recueil D'Ophtalmologie, October, 1903) describes the symptoms of tabes which precede optic atrophy. These may be very vague and ill-defined, or they may be somewhat pronounced and characteristic. In any case it is well to look for evidence of previous secondaries, such as inflammatory complications in the region of the cornea, old iritis, choroidal and peripapillary changes. Among symptoms observed before or during the development of optic atrophy are the following:

Muscular Paralysis occurs in about a third of the cases. It is generally confined to one eye and to the third nerve either in its entirety or its internal part. More rarely the fourth nerve is affected. These paralyses are sudden in their appearance, and transient, but often recur. They are evidenced by transitory diplopia and generally convergent strabismus. Ptosis may occur, but it is inconstant and fugacious.