1354

glycine therapy seem to warrant a more extensivetrial of this method of treatment, though it hasno Bound theoretical basis.

CHEYNE-STOKES BREATHINGAT the beginning of the year we referred to a

paper in which J. A. Greene of Iowa distinguishedbetween two clinical types of periodic breathing, onecharacteristic of increased intracranial pressure and theother of cardiovascular disease. A case recorded byGarnot, Caroli, and Fiehrer of Paris 2 now

suggests that the Cheyne-Stokes respiration ofcardiac disease may be explained by pressure on

the respiratory centres. Their patient was suffer-

ing from an attack of auricular fibrillation, accom-panied by considerable oedema, and ultimatelylapsed into a comatose condition with conspicuousCheyne-Stokes breathing. Lumbar puncture revealeda considerable increase in the pressure of the cerebro-spinal fluid, and relief of this was followed by a returnto consciousness and normal respiration. Garnot andhis colleagues draw attention here to what may havebeen a fortunate coincidence-namely, the simul-taneous occurence of a copious diuresis and a dis-appearance of oedema. They regard the abnormal re-spiration as due to cerebro-meningeal oedema obstruct-ing both the venous return from the brain and thecirculation of cerebro-spinal fluid, and point out thatwhile lumbar puncture may alleviate the symptoms,only subsidence of the oedema can remove the ultimatecause of the increased intracranial pressure. The

sequence of events is very clear in this case, and thereis no reason to dispute the interpretation advanced.Cheyne-Stokes breathing occurs, however, not onlyin cerebral, renal, and cardiovascular disorders, butin the very young and very old, especially during sleep ;it is also seen in hibernating animals during the winter.Another common type is that due to lack of oxygen inthe inspired air and met with in mountain sickness ;the conventional interpretation of this is that theincreased ventilation necessary to ensure an adequatesupply of oxygen washes carbon dioxide out of thealveoli, thereby removing the normal stimulus torespiration, and produces a period of apncea whichpersists until the combination of oxygen-lack andmounting carbon dioxide is sufficient to initiatea further respiratory cycle. This purely chemicalexplanation is obviously applicable to specialcases only ; in most instances there exists some

impairment of the respiratory centre which is atleast contributory. As we pointed out before,1there is probably a series of respiratory centres inthe brain-stem, each under the control of those aboveit ; moreover, the lower ones show a type of periodicactivity similar to that encountered in some animals,particularly aquatic mammals. The partial release ofthese lower centres would be highly probable in

descending impairment of the central nervous system,and might well account for periodic breathing, Thework of Greene and of Lian and Deparis 1 shows thatin man not only the brain-stem, but the cerebrum isinvolved ; in certain patients stimulation of theattention is sufficient to restore normal breathing.It is easy to visualise the reverse processtaking place during sleep, and indeed it isdoubtful if periodic breathing in this state isconfined to children and the aged ; those who havehad the misfortune to be kept awake by the snoringof an otherwise normal person must have noticed therhythmical waxing and waning of the sound. This

may not amount to Cheyne-Stokes respiration, which1 THE LANCET, 1934, i., 142.

2 Bull. et mém. Soc. méd. hôp. de Paris, Oct. 29th, 1934,p. 1313.

is cha,racterised by dcfuiite apiioea, but the differencemay be only quantitative.

A PARIS TRANSPLANT

THE former fortified zone embracing Paris has,since the war, been given over to a vast experiment inhousing. The architects of the Habitations a, BonMarche (H.B.M.) financed by the municipality have ebuilt upwards rather than sideways, their creationsrunning to six or eight storeys in imposing blocks.Early in 1933 they housed over 74,000 persons,36,000 of whom were children under 16, and 12,000adolescents between 16 and 20. Although these

buildings have been supplemented by parks forchildren, under the supervision of trained welfareworkers, it was feared in some quarters that thedensity of population created by this system ofarchitecture might favour the spread of infectiousdiseases. Fortunately a voluntary organisation hadbeen started in 1925 to provide these buildingswith a medico-social service staffed by trained socialworkers. The statistical information provided by thisservice shows that the general mortality of theH.B.M. was only 78 per 10,000 inhabitants in 1933,against 150 for the whole of France. Pulmonarytuberculosis was however responsible for 19 per cent.of all the deaths in these quarters in 1933, the corre.sponding figure for the whole of Paris being 12 percent. ; the disparity reflects the low general mortalityin these quarters and the high proportion of juvenilepopulation. It is important to note that the tuber-culosis mortality has been falling since 1930 fasterin the H.B.M. than in the rest of Paris ; the deathsper 100,000 inhabitants were as follows :

1930. 1931. 1932. 1933.Paris.... 195 .... 187 .... 170 .... 156H.B.M..... 238 .... 191 .... 17H .... 155

From a survey of these and other figures 1 Dr. Y. deHurtado draws the conclusion that much of thetuberculosis recognised as such in the H.B.M. is theirheritage from the slums whence their tenants wererecruited. To the sunny, airy, and otherwise sanitarybuildings is due the credit for its rapid decrease.

A MEDICAL LIBRARIANTHE death on Dec. 4th of Alr. Hubert E. Powell,

F.S.A., librarian of the Royal Society of Medicine,was announced in our last issue. Mr. Powell hadbeen 27 years in the service of the Society, first asassistant and from 1920 as chief librarian. Duringhis term of office the library increased to an extentwhich made it the largest of its kind in the BritishEmpire, and it offers facilities for study not yetreached by other medical libraries. In all this progressMr. Powell played a prominent part. His knowledgeof medical bibliography was comprehensive andaccurate and at all times it was placed ungrudginglyat the disposal of every reader. In the preparation ofmany medical works for the press his hand can easilybe traced, and there must be hundreds of doctorswho first learned from him the importance of accuracyin medical bibliographies. Mr. Powell may truly besaid to have lived for the R.S.M. library and its

development will long remain a monument to his careand efliciency.

AT a meeting on Dec. llth the Prince of Wales,as president of King Edward’s Hospital Fund forLondon, announced that for the third year insuccession the " ordinary distribution " of the Fundwas being maintained at 300,000, and with 20,000in special grants towards the pensions scheme thetotal to be distributed was 320,000.

1 Rev. de Phtisiol., Sept.-Oct., 1934, p. 671.