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in all sputum. The centrifugalisation of thebacteria is by this means rendered easy by theelimination from the liquid of the organic substanceswhich spoil the clearness of the preparations, and thetubercle bacilli are readily shown by the Ziehl-Neelsenmethod. In some cases investigation by this methodhas shown only occasional groups of agglutinatedtubercle bacilli. Prof. Pane considers this to indicatea slight immunising defence in the organism.

THE PROBLEMS OF HOOKWORM CONTROL.

RECENT investigations upon the spread of anky-lostomiasis in soil and the gradual accumulationof information upon the life-cycle of Ankylostomaduodenale have made it possible to apply controlmeasures with increasing precision. In spite of thelarge amount of work carried out in this disease by theenergetic workers of the Rockefeller Foundation, it isbecoming increasingly evident that there remainconsiderable gaps in our knowledge. A series ofimportant papers have recently appeared in theAmerican Joicrnal of Hygiene from the pens of W. W.Cost, D. L. Augustine, J. E. Ackert, J. E., F. K., andG. C. Payne. Their work is founded to a greatextent upon work done in Sumatra in 1917 byBaermann,l who worked out a simple method bywhich infective hookworm larvae can be isolated fromthe soil. His method is based upon the fact thatthe larvae will migrate from the dense soil to water of aconsiderably higher temperature, and, under theseconditions, nematodes from a sample from an areareputed to be infective can be collected andcounted. The procedure is a modification of thatof Baermann, more exact standardisation beingaimed at. It is claimed that the mature hookwormlarvae can be differentiated from other free-livingnematodes by certain morphological characters.Eradication of hookworm disease by radical treatmentof all infected individuals still leaves much to bedesired. It is practically impossible to renderdiagnostic methods so critical as to detect everyinfected case, and it is felt that a large proportion oftime and money is expended in attempts to cureradically every case. It is, of course, much moreprofitable to prevent the spread of the disease bytreating the life-cycle of the hookworm. Efficientsanitation would effect this result, but, unfortunately,in most areas where ankylostomiasis is rife this isdifficult to attain. Intimately connected with thequestion are the educational campaigns which arenow being actively conducted. The newly hatchedand the mature larvæ are much more easily affectedby disinfectants than are the ova, but the disinfectantof election is yet to seek.The problems which appear to need further

investigation can be summed up under three headings :(1) the distribution of the ova and young larvae inthe soil ; (2) the spread of infective larvae by activemigration, by physical agencies, by man himself, orby domestic animals ; (3) the life-span of themature larvae and the conditions necessary for theircontinued existence. Augustine considers that, con-trary to previously expressed opinions, the life-spanof the mature larvae is limited to about six weeks.Furthermore, the more tropical the environmentthe shorter is the free existence of the larvae, sincetheir stored food-supply becomes rapidly exhausted.Efficient control of hookworm disease has not fromthe preventive side yet been attained. As to the cureof the disease, oil of chenopodium is a drug whichhas been recently advocated for the radical treatmentof ankylostomiasis, especially in America. Its use isnot unattended with risk. The maximum individualdose would appear to be 1 c.cm., but it is best given in three cachets of 0-5 c.cm. each at two-hourlyintervals, followed three hours later by a saline purgeof 1 oz. of magnesium sulphate. Experiments oncarbon tetrachloride, now being carried out in Suva,

1 Baermann, G. : 1917. Geneesk. Tijdsch. v. Neder. Ind.,vol. lvii., pp. 579-669.

Fiji, by Mr. C. Hall,2 senior zoologist to the U.S.Bureau of Animal Industry. would seem to indicatethat in this drug we possess an anthelmintic ofgreat potency. No exact information as to the exactdosage employed in Fiji is as yet available, but about3 c.cm. in gelatin capsules has been suggested. It issaid that over 80 per cent. of the worms are expelledafter a single dose. ____

INTRACRANIAL TUMOUR OF THE OPTIC

NERVE.

Two cases of tumour of the intracranial part of theoptic nerve are reported in the March issue of theAmerican Journal of Ophthalmology from the Depart-ment of Surgery at the Johns Hopkins Hospital,Baltimore, and it is claimed that these are the firstcases which have been both diagnosed and successfullyoperated on. The first case occurred in a girl of 13 ;the chief symptoms were : (1) A partial paralysis ofboth third nerves. Temporary attacks of diplopiaattended with vomiting had recurred at intervalsduring the previous six years. (2) Progressive loss ofvision during the same period but no headache.(3) Primary optic atrophy. Skiagrams showed noenlargement of the sella turcica and no distension of thethird ventricle, so that pituitary tumour and hydro-cephalus were excluded. Neither was there anychoked disc or distension of the nasal sinuses. An

operation was performed and two collar-like growthswere found symmetrically situated, surrounding eachoptic nerve in front of the chiasma, with processesextending forwards through the optic foramina. Thetumour was wholly removed on the right side andpartially on the left with good result, vision in the lefteye being partially restored. In the second case

practically the only symptom was progressive failureof vision, and an operation to expose the optic nerveswas undertaken, as it was thought that all otherpossible diagnoses had been excluded. A tumour wasfound attached to the optic nerve on the left sidethough the sight of the right eye was the worse, anda band constricting the right nerve was divided. Here,too, the usual results of freeing the nerve from constric-tion were excellent, although it was impracticable atthis operation to remove the tumour. Details ofoperation and the histological structure of the tumoursare described, and the treatment hitherto adopted incases of intra-orbital optic-nerve tumours is criticised.

The suggestion is made that in view of their tendencyto extend back through the optic foramen it would bewiser in many instances to treat them as intracranialtumours from the first. " ]If either a primary intra-cranial tumour of the optic nerve or a secondaryintracranial extension of an intra-orbital tumour bepresent, only an intracranial operation which aimsat the removal of the tumour offers the patient anychance of the preservation of life or vision."

COLOUR RESPONSES AND INTERNAL

SECRETION.

! THE striking transitory changes in body colorationwhich are seen in the lower vertebrates, such asreptiles-e.g., the chameleon-amphibia, and fishes

are brought about by the activity of cells chargedwith pigment granules and situated in the skin.

These chromatophores are partly under the controlof the sympathetic nervous system ; but recent workindicates that ductless gland secretions play an impor-tant role in regulating pigment responses. Dr. LancelotHogben and Mr. F. R. Winton have shown thatextracts of the posterior lobe of the pituitary glandhave a very characteristic and highly specific effecton the chromatophores of amphibia, inducing con-tracted melanophores (black pigment cells) to expandand the xantholeucophores (yellow pigment cells) tocontract, so that an intense darkening of the skinresults. A frog which half an hour previously was of a

2 See THE LANCET, Feb. 25th, 1922, p. 391.3 Proc. Roy. Soc., B, May, 1922.

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pale yellow tint will change after an injection, intra-venous or intraperitoneal, of less than 0-00025 c.cm.of a 20 per cent. extract of pituitary (posterior lobe)to a coal-black hue, remaining in this condition forseveral hours. Adrenalin has precisely the reverseeffect, causing the melanophores to contract andinducing pallor in a frog which was previously dark.The melanophore stimulant in pituitary extracts is

apparently secreted by the intermediate portion(juxtaneural epithelium) of the gland. It is readilydestroyed by trypsin like the pressor, oxytocic, anddiuretic principles ; but it is not identical with thepressor substance, since it is only slowly destroyed byacid hydrolysis. Expansion of frog melanophoresmay be induced by extracts of the pituitary gland ofmammals, birds, amphibia, and iishes. It is notobtained with extracts from the pituitary of thelizard, nor is it found to follow injection of extractsof the subneural gland of tunicates, a structure whichmorphologists homologise with the vertebrate pitui-tary. The reaction may be obtained on the isolatedfrog’s skin, so that its nature is local ; and since itis not prevented by paralysis of the nerves whichsupply the melanophores, it appears that pituitaryextracts act directly on the melanophores. Sufficientof the melanophore stimulant can be obtained fromthe pituitary gland of one frog to induce darkeningof the skin in 30 other individuals of the same species.This opposing action of posterior pituitary andadrenalin in the regulation of pigment responses isextremely interesting in connexion with humanphysiology and pathology. The pigmentation inAddison’s disease, where the most constant post-mortem change is a lesion of the suprarenal bodies,may be attributable to the unopposed action of thepituitary ; and the areola of pregnancy may also beconnected with a disturbance of endocrine balance.

LINGUAL TUBERCULOSIS.

IN a recent thesis devoted to this subject Dr. MariusPinel 1 states that tuberculosis of the tongue was firstdescribed by Ricord whose pupil Buzenet pointed outthe differences between it and syphilitic ulceration inhis Paris thesis of 1858. Although less common thanlaryngeal involvement, tuberculosis of the tongue ismore frequent than of any other part of the bucco-pharyngeal cavity. Of 44 cases of tuberculous diseaseof this region collected by Spillmann 21 were examplesof tuberculosis of the tongue as compared with 18 inwhich the pharynx and 5 in which the lips were affected.The male sex is most frequently attacked, 17 of the 21cases being found in men and only 4 in women.Tuberculosis of the tongue is characterised by itschronic character, progressive course without any ten-dency to a spontaneous cure, resistance to treatment,and severity of the symptoms. Two clinical forms aredescribed. The first, which is much the more frequent,is the tuberculous ulcer, the second, of which only about20 cases have been reported, is the tuberculoma. Theonset of tuberculous ulceration of the tongue oftenescapes notice, and it not infrequently happens thatthe patient does not become aware of the conditionuntil the ulcer is fully developed. The ulcer is almostalways single and is usually situated on the tip andsides of the tongue, occasionally on the dorsum, butvery rarely on the inferior surface, and almost alwaysnearer the tip than the back. The ulcer extendsexcentrically by the formation and coalescence of smallround macules known as Trélat’s granules, whichconsist of miliary abscesses due to caseation of thefollicles in the mucous membrane. In most cases thereis an absence of enlargement of the submaxillary andcervical glands. The principal symptoms are pain andexcess of salivary secretion, which is aggravated bymastication, deglutition, and phonation. The ulcera-tion slowly increases in extent so that it finally involvesthe whole surface of the organ. Lingual tuberculoma,the size of which varies from that of a pea to that ofa walnut, as a rule is single but is occasionally multiple,

1 Thèse de Paris, 1922, No. 12.

so that the whole tongue may be studded with smallnodules. It is usually situated immediately below themucous membrane ; much less frequently it is foundin the substance of the muscle. The prognosis oflingual tuberculosis is very gloomy, the conditionbeing almost always fatal. As a rule, it indicates anadvanced pulmonary infection. The prognosis of

lingual tuberculoma, especially if it is primary orthe pulmonary lesions are not too advanced, is lessserious and a cure may be effected by surgicaltreatment.

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CHRONIC INTUSSUSCEPTION IN CHILDREN.

I LAST year Dr. G. F. Still described chronicintussusception in children-a form of intussusceptionwhich does not appear to have been previouslyrecognised. He used the term " chronic " for cases inwhich the intussusception was present for many daysor even weeks without producing acute obstruction.His description was based on four cases, which are ofgreat clinical interest. In all cases the children werebrought by the puzzled practitioner to Dr. Stillfor help in the diagnosis, because the symptoms hadnot suggested any surgical affection. Intussusceptionwas overlooked because the picture with which it isassociated-bloody stools and acute obstruction-was absent. Dr. Still constructed the followingcomposite case on the basis of this experience. On aparticular day the child seemed to have abdominalpain and vomited once or twice. During the nextfew days he vomited occasionally in association withcolicky pain. The vomiting became less frequent,occurring only once in two or three days and the painwas only occasional. The bowels, which before theonset were open daily, became less regular andaperients were necessary; but they worked well andthe stools were normal except that once or twice theremight be a streak of blood, such as may occur in anyconstipated child. The symptom which troubled theparents most was wasting, which was obvious after ,

three or four weeks. The temperature throughoutwas normal. A sausage-shaped lump was felt in theabdomen, but it suggested the diagnosis of tuberculousperitonitis. By detecting this and especially by itsvarying consistence during palpation the diagnosis canbe made. Dr. H. S. Schlink 2 has reported a case ofchronic intussusception, evidently unaware of Dr.Still’s paper. He saw a girl, aged 7 years, with thehistory that two months previously she was seizedwith vomiting and diarrhoea after eating bananas.She was put to bed on starvation diet for a week, withthe result that the pain ceased and the bowels actedless freely. When she got up and took solid foodthe pains and diarrhoea returned. At no time didshe pass blood-a fact which was responsible forvarious diagnoses made by half a dozen practitionerswho saw her. On examination she was emaciated andsat in a stooping attitude, holding the abdomen withher hands and complaining of terrible pain in theback and around the umbilicus. A large sausage-shaped tumour could be felt in the left lower abdomen.On rectal examination a mass could be felt. X rayexamination after a bismuth meal showed that thetumour, which had been variously diagnosed as

malignant disease of the sigmoid, sarcoma of thekidney, hvdronephrosis, enlarged retro-peritonealglands, and malignant cyst of the ovary, was anintussusception. On operation it was found to be anintussusception of the cæco-iliocæcal variety (Clubbe).The apex reached well below the junction of the pelviccolon and rectum. The colon was thickened, stiff,and swollen, but of good colour. At first it seemedalmost impossible to unfold, but gradually, bysqueezing from below and gentle traction from above,the thickened washleather-like colon was unravelled.Although the surface was slightly rough and granular,no adhesions had formed. A few gut sutures wereinserted in some peritoneal tears and the abdomenwas closed. Recovery was uneventful.

1 Archives of Pediatrics, March, 1921, p. 174.2 Medical Journal of Australia, March 11th, p. 269.