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the moment an attack begins. Pure oxygen is a lessvaluable stimulant than oxygen to which 5 per cent.carbon dioxide has been added for its effect on thecentres. Lobeline is said to be useful, and an intra-muscular injection of 0-003 g. as a single dose isadvocated. Adrenalin may be injected direct intothe heart as a last resort if the child seems to be onthe verge of death.Such studies as these may help to elucidate some

of the physiological and pathological aspects ofrespiration. Besides throwing light on arrestedrespiration in infants they have a bearing on theso-called asphyxia neonatorum.

CLOSED PNEUMOLYSIS.

IN many cases of pulmonary tuberculosis, including Imost of those occurring in early adult life, artificialpneumothorax is the only method of treatment thatoffers any prospect of cure. The success of suchtreatment depends chiefly upon obtaining effectivecollapse of the diseased lung. If the collapse isincomplete ultimate spread of infection to the oppositelung is almost inevitable. In a recent article Dr.R. C. Matson says that the success of artificialpneumothorax treatment is

" almost in direct propor-tion to the number and character of adhesionspresent " and attributes 40 per cent. of its failures tothis cause. The attempt to stretch adhesions byincreasing the intrathoracic pressure is seldom satis-factory, and is not without danger. Grave risks arealso incurred when open operation is performed. Lessdanger and a greater measure of success haveattended the cauterisation of adhesions by the methodof closed pneumolysis devised by Jacobaeus, whosethoracoscope permits a clear view of the offendingbands and thus enables their severence to be effectedwith the galvano-cautery. Risk of haemorrhage andof the liberation of tuberculous infection is stated tobe lessened if an endotherm is used instead of thecautery. Before deciding to operate Matson rightlyinsists that there should be reasonable assurance thatthe patient will recover if a satisfactory collapse isestablished. The rules which guide the physician indeciding to induce a pneumothorax will obviouslydetermine his decision whether to persist in hisefforts to establish a complete collapse. Matson givesthree chief indications for cauterisation : (1) incom-plete collapse due to adhesions ; (2) satisfactorycollapse maintained only by high intrapleuralpressures which involve discomfort to the patient andrisk of rupture of the lung ; (3) when in a previouslysatisfactory pneumothorax the organisation of bands,or adhesions. is causing expansion of the collapsed lung.The benefit that may be expected from intrapleuralpneumolysis in the hands of an expert is shown byMatson’s own records, for he was able to convert apartial into a complete pulmonary collapse with theabolishment of cough and expectoration in 63 casesout of a series of 100. It is perhaps needless to addthat this method of treatment should only be employedby those whose experience of collapse therapy isextensive, and who by constant practice have masteredthe necessary technique. The correct use of thethoracoscope and the manipulation of the endothermor cautery demand the highest degree of skill.

ANTITOXIC SERUM IN SCARLET FEVER.

THERE is no longer any doubt that certain strainsof streptococci produce a true toxin, in addition toa destructive substance, " haemolysin," which doesnot seem to fall into that category. Such streptococciare chiefly associated with scarlet fever ; and twostrains, known to bacteriologists as " Dick " and"

Dochez," are recognised as being true toxin-forming strains. The toxin produced by streptococciis not comparable with that of diphtheria, save inthat an antitoxin is procurable, for it is not the

1 Amer. Rev. Tuberc., March, 1929, p. 233.

chief weapon of the organism. It is of slight virulenceto laboratory animals, though when concentrated,as by the methods of Percival Hartley and R. J. V.Pulvertaft, it is lethal to rabbits. Where, as

apparently in scarlet fever, the toxic action of theorganism predominates in the clinical picture, theuse of antitoxin is followed by excellent results. Butthe invasive action of the organism is not dependenton the toxin-production.Many problems remain. In the first place, are all

streptococcal toxins, even in scarlet fever, the same ?The famous Park strain of diphtheria bacillus is knownto be the best toxin-producer, and to yield a highantitoxin of general utility. There is doubt whether asimilar strain can be found among streptococci. Wads-worth, Kirkbride, and Hendryl bring forward evidenceto show that, in fact, the best antitoxins are providedby the Dochez strain-which is fortunate for dwellersin England, where this strain is used to make anti-toxin. They further throw doubts on the keepingqualities of the antiserum, which needs carefulcontrol. The most urgent necessity, however, is foran adequate method of standardising antitoxin. Theaccepted one, in America, is the neutralisation of skintest doses in susceptible men. M. B. Kirkbride andM. W. Wheeler have substituted a similar test ongoats. In this country the protection of rabbits againstdeath, within a specified time, from intravenousinjection of living organisms has been used, withexcellent results, by C. C. Okell and H. J. Parish.More recently Hartley and Pulvertaft have suggestedthe use of concentrated toxin on rabbits ; Hartley’smethod is highly commended in the latest annualreport of the Medical Research Council. Wadsworthfinds by the skin test method a great variation in thevalue of antitoxin. Some have as many as 600 unitsper c.cm. ; others are utterly useless, having nodemonstrable antitoxin. So long as human beingsare necessary for the purpose of standardisation, theantitoxin is of necessity limited in amount, expensive,and, it must be said, unreliable.

There is sufficient proof of the efficacy of thisantitoxin, when really standardised, to make it urgentthat the problem should be further examined. Theintroduction of animal tests may put this work on anew footing.

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THE GASTRIC DIGESTION OF MEAT.

SOME important observations on digestion have latelybeen made by M. E. Rehfuss and G. H. Marcil,2 whohave compared the results obtained by a fractionaltest-meal of the usual carbohydrate type and one com-posed of 60 g. of scraped meat, the two meals beinggiven within 48 hours of each other. After the meatmeal they found that the acid response in the normalwas 30 per cent. higher and two types of responsewere noticed, one prompt and decided and the otherslow and indifferent. Meat is a true intragastricstimulant and in health is capable of producing themaximal response from the gastric mucosa. Theresponse in disease is no less interesting. Though,as they point out, only a limited number of caseshave been investigated, too few to allow of completegeneralisation, three groups may be separated. Whilein purely functional cases and in those with pepticulcer the meat produces the extra acid response,there was no response to either carbohydrate or meatmeal in pernicious anaemia, gastric carcinoma,delayed resolution in lobar pneumonia, and chroniccholecystitis. The intermediate stage, in which themeat response is present but is less than normal, isfurnished by such cases as cardiac or renal disease,blood dyscrasias, and " other conditions commonlyencountered in medical ward service." In thesecases the power of the stomach to deal with meat ismerely lowered and not lost. It is suggested thatthese variations in the response to a meat and carbo-hydrate meal may be regarded as a measure of

1 Amer. Jóur. Hyg., March, 1929, p. 371.2 Jour. Amer. Med. Assoc., March 9th, 1929, p. 763.