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limitations. The difficulty is to find a graft of theright diameter, especially when a fresh graft from adog is used. Gosset and Bertrand, quoted by Chris-tophe, have reported success with grafts of rabbits’spinal cord. The graft is immediately fixed informalin, washed in saline a few days before use,and then kept in alcohol till the time of the operation.However the graft is done, the aftercare of thedenervated parts is of paramount importance if down-growth of the nerve is to restore function.

ALKALIS IN PEPTIC ULCER VINDICATED

ALTHOUGH the use of alkalis in the treatment ofgastric disorders dates back to long before the 17thcentury, treatment of peptic ulcer by neutralisationreally began with the work of Cruvelhier in 1832.The beginning of the 20th century saw the use ofalkalis widely established but the work of Sippy inthe United States towards 1915 was probablyresponsible for the more thorough attempts that havesince been made to secure continuous correction ofacidity and the consequent improvement in medicaltreatment. The introduction of fractional gastricanalysis has also facilitated the investigation of gastriceases as regards the acidity of the stomach contentsafter food and treatment, and the work of Rehfusson the response of the normal stomach to varyingfoods was important in this respect. But it is some-what surprising that the medical treatment of pepticulcer has seldom been carried to its logical end. Few

patients with peptic ulcer receive treatment by properfood and alkalis in such a manner that anythinglike complete neutralisation of the stomach contentsthroughout the twenty-four hours is secured. The veryincomplete neutralisation effected by milk alone, or bymilk combined with the popular alkalis has lately beendemonstrated by Wvllie.1 Observation of the actual

acidity of the gastric contents at half-hourly intervalsthroughout the waking hours with various antacidsestablished the outstanding value of magnesium tri-silicate and aluminium hydroxide. A year agoBennett and Gill demonstrated the effective qualitiesof aluminium hydroxide gel, and their results are

borne out by the observations of Wyllie. Whethermagnesium trisilicate has advantages over aluminiumhydroxide is not shown, but it seems to be establishedthat these modern remedies are superior to many, ifnot all, of their rivals. It is important to note thatWyllie pays the same attention to food as he doesto medicine. His work confirms that of others in

demonstrating that six-ounce feeds of milk givenevery two hours with a drachm of aluminiumhydroxide or magnesum trisilicate half an hour aftereach feed will produce complete control of freeacidity in almost every case. With larger feeds anddoses the intervals might be extended but even thisis doubtful. This vindication of orthodox treatmentis welcome from a school which had tended in recentyears to revive the centuries old doubt as to its value.

VITAMIN B1 FOR TIC DOULOUREUX

Sixc’E synthetic vitamin Bl has been easily obtain-able it has been used in the treatment of nearly everydisease of the nervous system. Convincing resultshave been reported in certain forms of peripheralneuritis, but in other nervous diseases its value hasbeen doubtful. There seems little doubt, however,that some patients suffering from spasmodic trigeminalneuralgia gain relief from the vitamin, and the experi-

1. Wyllie, D. Edinb. med. J. May. 1940, 336.2. Bennett, T. I. and Gill, A. M. Lancet, 1939, 1, 500.

ence of Borsook, Kremers and Wiggins 3 suggests thatthe results are best if large doses are given by injec-tion for a long time. They advise giving 10 mg. ofvitamin B1 (thiamin chloride) daily by the intra-venous or intramuscular route, and an injection ofliver extract three times a week, making up a weeklytotal of 22-5 U.S.P. units. Thev prescribed a highvitamin and low carbohydrate diet with 30 c.cm. ofan aqueous concentrate of rice polishings daily by themouth, providing 1500 international units of vitaminBi as well as other components of the vitamin Bcomplex. They report 58 cases which have beenunder observation and treatment for from six to four-teen months, and 37 of these were " markedlyimproved." But the authors say that the treatment

may have to be continued for as long as six monthsbefore the maximum benefit is obtained. The pain oftic douloureux shows so many spontaneous remissionsthat it is difficult to assess the value of a new formof treatment, especially when it has to be continuedfor several months. This regime is both expensiveand laborious, but it has so far been justified byresults.

MAKING BABY BREATHE

A BABY may tail to breathe when it is born eitherbecause its respiratory centre is depressed or becausethe stimuli needed for respiration have been appliedtoo soon or are insufficient. Depression of the respira-tory centre is most likely to be due to sedative drugsgiven to the mother. Premature respiration will beencouraged by anything that raises the foetal carbon-dioxide concentration or by appropriate sensorystimuli. If the anaesthetic given to the mother is toolight she may have a laryngeal spasm or may vomit,so raising her carbon-dioxide concentration to a levelwhich will call forth an inspiratory effort from thebaby. Exposure of the baby’s body in breech deliveriesor csesarean section may also give rise to prematurerespiratory movements. In such cases the baby willbreathe in liquor which may induce laryngeal spasmand may so coat the alveoli that the respiratory sur-face is seriously interfered with. An insufficientstimulus will produce asphyxia if the mother hyper-ventilates, as she is likely to do when anaesthesia is toolight, so that her carbon-dioxide concentration is low.It then takes an unduly long time for the carbon-dioxide in the baby to reach the threshold level forstimulation of the respiratory centre. By then oxygenlack may have desensitised the centre, widening stillfurther the gap between stimulus and threshold.Nosworthy says it is unwise to promise any patienta painless labour, since in order to keep one’s wordone may have to give enough sedative to depress thebaby’s respiratory centre. A middle course betweentoo light and too deep anesthesia must be steered.The essential measures once the baby is born are tokeep the infant head downwards, and to suck outliquor and mucus thoroughly from the upper air-pas-sages. A stimulant to the respiratory centre, suchas lobeline gr. 1/20, may be a great help and is usedby some as a routine, although prompt and efficientdrainage should be sufficient in most cases. Carbon-dioxide administration can be dangerous, for it isaccumulating naturally and a further dose may raisethe concentration to toxic levels. This gas also tendsto quicken rather than deepen breathing. An amplesupply of oxygen, on the other hand, is essential bothto maintain life and to prevent the threshold of therespiratory centre rising too high. It should be given

3. Borsook, H., Kremers, M. Y. and Wiggins, C. G. J. Amer.med. Ass. April 13, 1940, p. 1421.

4. Nosworthy, M. D., St. Thomas’s Hosp. Rep. 1939, 4, 164.

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under pressure to inflate the alveoli, either by squeez-ing a breathing bag attached to a face-piece, or byintubation. The latter method is far more efficient,and is easily applied once the simple technique ismastered. The direct vision method of Blaikley andGibberd may be used, or a blind oral method advo-cated by Nosworthy, which requires less apparatusand in his opinion is unlikely to do any damageeven in unskilled hands. The left forefinger isintroduced into the baby’s mouth until the tiprests on the arytenoid cartilages. A No. 12 or

14 French open-ended gum-elastic catheter is thenpassed into the mouth with the free hand, its tipbeing deflected forwards into the glottis by the left

forefinger, and through this the operator can suckmucus out of the trachea. The catheter is then with-

drawn, the mucus blown out, and after a secondintubation the lungs are inflated by connecting a bagto the catheter. Normal inflation of the lungs is

brought about in the first few hours after birth bycrying. In weakly infants who do not cry normallya vicious circle of oxygen want and carbon-dioxideretention may be set up, and Nosworthy feels thatearly intubation and pulmonary inflation may thensave life.

IMMUNISATION AGAINST RICKETTSIAL

DISEASES

WITH the possible exception of heart water, whichaccording to Neitz can be successfully treated in

sheep by injections of Uleron, rickettsial infectionsresemble the virus diseases, other than lymphogranu-loma inguinale and probably trachoma, in beingentirely unaffected by chemotherapeutic drugs. It istherefore not surprising that much thought has beendirected to the discovery of methods of immunisingagainst rickettsial infections, more especially againstexanthematic typhus in the Old World and RockyMountain spotted fever in the New. In opening adiscussion on immunisation against rickettsias at theRoyal Society of Tropical Medicine on May 16, Dr.F. Murgatroyd pointed out that two methods werenow in use involving the injection of rickettsise eitherliving, perhaps attenuated, or killed. For immunisa-tion against exanthematic typhus living murine typhusrickettsias have been extensively used in North Africa,either coated with egg yolk and mixed with sodiumphosphate as in Tunis (Laigret and Durand’), or

treated with bile immediately before injection as inMorocco (Blanc and Baltazard 8). As their source ofrickettsias the latter workers first used fresh guineapigtissues, but more recently they have found that murinetyphus rickettsiae remain active for a considerabletime when present in the dried fasces of rat fleas. Theflea faeces are treated with bile immediately beforeinjection. Dr. G. M. Findlay, who had recently visitedTunis, said that some three million natives in Moroccoand Tunis have been treated with living murine

typhus rickettsise by one or other of these procedures.Few reactions, it is claimed, have been recorded innatives, but when living murine typhus rickettsise areinjected into Europeans about 30 per cent. of themshow febrile reactions, some of them severe. In addi-tion, Blanc’s vaccine, when employed in Chile, gavesomewhat unsatisfactory results, for of 800 peoplevaccinated 23 per cent. developed grave typhus and5 died. While people who have suffered from murinetyphus are solidly immune to exanthematic typhus,

5. Blaikley, J. B. and Gibberd, G. F. Lancet, 1935, 1, 736.6. Neitz, W. O. Berl. Münch. tierärztl. W schr. 1939, 55, 134.7. Laigret, J. and Durand, R. Bull. Soc. Path. exot. 1939, 32, 735.8. Blanc, G. and Baltazard, M. Rev. Hug. 1940, 61, 593.

almost certainly for life, the exact value of livingmurine typhus rickettsial* in bringing epidemics ofexanthematic typhus to an end is still uncertain, sincecritical experiments with adequate controls have notyet been carried out. In the present circumstancesliving murine typhus rickettsise can hardly be usedfor immunising Europeans. Unfortunately killedmurine typhus rickettsise produce little immunity inman against living exanthematic typhus rickettsias,but dead exanthematic typhus rickettsias, if injectedin sufficient quantities, do produce immune bodiesagainst living exanthematic rickettsiag. The problem,therefore, has been to obtain enormous numbers ofexanthematic typhus rickettsias. The first successfuleffort was made by Weigl" who injected lice withsuspensions of Rickettsia prowazeki per rectum. Afterfive or six days the intestines of the lice, then teemingwith rickettsise, were removed, ground up, and treatedwith 0’5 per cent. phenol. Since nearly two hundredlice are required for the immunisation of a singlehuman being, this method cannot well be applied ona large scale. Within the last year, however, certainother techniques have been developed in order to obtainsufficient numbers of rickettsias. Zinsser, FitzPatrickand "BVei,’o for instance, grew the organisms on agarslopes covered with a layer of mouse or chick embry-onic tissue. Monkeys and guineapigs were success-

fully immunised with the rickettsiae thus obtained aftertreatment with 0.2 per cent. formol in saline, andmore recently Zia, Pang and Liu 11 in China haveutilised such vaccines for human immunisation. Afurther development which is capable of exploitationon a large scale has been made by Durand andGiroud." When exanthematic typhus rickettsiaga areinjected intranasally into half-grown mice they set upan intense pneumonia, which after a few intranasalpassages proves fatal within forty-eight hours. Toobtain the greatest number of rickettsial* the miceshould be killed when their temperature falls to 30°-32° C. By differential centrifugation an almost puresuspension of rickettsias may be obtained which aftertreating with 0.2 per cent. formalin can be used asa vaccine. A number of people have now beenimmunised by this method both in France and in thiscountry. Immunity is shown by the development of apositive Weil-Felix reaction, and by the presence ofspecific immune bodies against rickettsia. It is tooearly to say how long this immunity lasts, but itcertainly seems to last longer than six months. Ifother rickettsial infections should appear in WesternEurope it is possible that satisfactory vaccines couldbe produced by one or other of these methods.

9. Weigl, R. Arch. Inst. Pasteur Tunis, 1933, 22, 315.10. Zinsser, H., FitzPatrick, F. and Wei, H. J. exp. Med. 1939,

69, 179.11. Zia, H. S., Pang, H. K. and Liu, P. Y. Amer. J. publ. Hlth

1940, 30, 77.12. Durand, P. and Giroud, P. C.R. Acad. Sci. Paris, 1940, 210,

125.

BLOOD-TRANSFUSION IN NEW ZEALAND.-In 1937a National Blood Transfusion Council was set upin New Zealand to organise a blood-transfusionservice on a voluntary basis throughout the dominion.Since its formation 13 new branches have beenestablished and over a thousand donors have beenenrolled. In February the council issued its firstbulletin which contains an account of a system ofstorage of blood which has been successfully under-taken by the North Canterbury branch. The hou.secretary of the association may be addressed atP.O. Box 25, Te Arc, Wellington, C.2.