652 TREATMENT OF ADDISON’S DISEASE.

professor of genito-urinary surgery at the GeorgeWashington University, publishes results which throwa new light on the operation. Out of 31 cases of

azoospermia following bilateral epididymitis 19,or 61-3 per cent., were cured. Twelve of the 19

patients in whose semen spermatozoa reappearedbecame fathers, and in one of the remaining casesimpregnation occurred but was followed by a mis-carriage. This is the first series of successful casesreported, and Dr. Hagner is to be congratulated on hisperseverance and on the excellence of his technique,which he describes in detail. In all of the successfulcases fine silver wire was employed for sutures,otherwise the operation does not differ radicallyfrom that suggested originally by Martin. Theauthor states that the reappearance of spermatozoain the semen is not immediate, and as long as ninemonths must be allowed to elapse before judgment ispassed. If at the end of this period no changeis noted in the semen the operation may be repeated,provided a sufficient length of vas remains to allowthe surgeon to make a fresh anastomosis. It isof course essential that the patency of the vas deferensshould have been previously demonstrated. Dr.Hagner’s anastomosis with the epididymis is a lateral ’’

one, and he satisfies himself that active spermatozoa i,are present by microscopic examination of the milky fluid that exudes from the cut tubules. If no I,spermatozoa are found another incision is made in adifferent situation and the examination repeated.Dr. Hagner avoids injecting irritating fluids such ascollargol into the proximal section of the vas in orderto test its patency, as he thinks that this is likely toincrease fibrosis at the site of operation.

A TEST FOR ENCEPHALITIS.

A NEW biological test for encephalitis depends onthe effect of the virus on the cornea, first observedby Griiter in 1912. In the last 18 monthsH. Knauer and P. A. Jaensch 1 have made about 100inoculation experiments, mostly with cerebro-spinalfluid. The suspected material was inoculated on thecornea of a rabbit by scarification and the eye wasexamined every 24 hours by direct inspection,before and after staining with fluorescin, and byslit-lamp. Control material, including distilled water,physiological saline, serum from healthy children, andbacterial toxins had only a transitory traumaticeffect, while of the 100 cerebro-spinal fluids and otherpathological material examined 60 caused keratitis

punctata. It proved possible to reproduce thiskeratitis by animal passage, which Knauer andJaensch present as evidence of a living virus in theoriginal material. The positive results were obtainedwith cerebro-spinal fluid from 26 patients. Theseincluded three cases of post-vaccinal encephalitis, oneeach of encephalitis in association with influenza,whooping-cough, and measles, and nine other acutecases of encephalitis, while the remaining 11 cases

were chronic.The positive results raise many points for discussion.

For example, the blood-serum from the case of measlesencephalitis was tested with negative results and itis hence concluded that the virus of measles is probablynot the cause of the encephalitis. On the otherhand, it was found that the blood-serum of a healthychild on the sixth day after vaccination-when, asEckstein has shown, vaccine virus is present always-gave a strongly positive keratitis reaction, suggestinga close relationship between vaccine virus and enceph-

1 Jahrb. f. Kinderh., Feb., 1931, p. 265.

alitis in such cases. The investigation of chroniccases of encephalitis, exhibiting for example thetypical post-encephalitis syndrome, showed that aliving virus capable of producing keratitis in therabbit could be obtained as long as 12 yearsafter the acute phase. In most of the cases of tuber-culous meningitis inoculation of cerebro-spinal fluidgave negative results but in one of them keratitisdeveloped. Histological examination of the brainshowed an undoubted encephalitis besides the méning-itis, while, on the other hand, an emulsion of tuberclebacilli failed to produce the usual keratitis. A caseof septic meningitis also showed encephalitis and itis suggested that in such cases the encephalitis virusis present as well as the other invading organism.Certain cases of chronic hydrocephalus gave positiveresults and other work proceeding at Breslau is quotedto support the view that encephalitis may causehydrocephalus.The negative results are likewise interesting. For

example, in the case of a 10-year-old girl the clinicalpicture was that of the acute stage of encephalitislethargica of a month’s duration. The negative effectof inoculation of cerebro-spinal fluid was a greatsurprise and appeared to throw doubt on the valueof the method. Autopsy, however, showed a cere-bellar tumour as the only intracranial lesion. Nega-tive results were also obtained in cases of chorea andone case each of disseminated sclerosis and acutepoliomyelitis. The strength of the positive reactionscould be measured by classifying the keratitis accord-ing to the time when it was first observed and thetime it took to heal. In one case Knauer and Jaenschsucceeded in demonstrating a gradual diminution ofthe corneal reaction with cerebro-spinal fluid from apatient with post-vaccinal encephalitis treated withparental serum. Both as a diagnostic test and as amethod of investigation this new procedure may wellprove instructive. The fact that similar results wereobtained with fluid from at least three types of enceph-alitis-lethargica, post-vaccinal, and post-infectiosa-by no means invalidates the test and may itselfbe significant.

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TREATMENT OF ADDISON’S DISEASE.

A REVIEW of the current treatment of Addison’sdisease indicates that progress is being made insubstitution therapy. The authors think that threeforms of treatment are of value : (1) the Muirheadtreatment, which consists in giving as much adrenalinas can be tolerated (by rectum, by mouth, and sub-cutaneously) ; (2) the injection of intravenous

glucose and sodium chloride intravenously in thecrises of the disease ; and (3) the administration ofsuprarenal extracts. The first two of these methods,although they may produce temporary improvementcannot, of course, cure the disease, but Swingle andPfiffner have prepared an aqueous extract of suprarenalcortex which is capable of reviving animals on the vergeof death from suprarenal insufficiency and of restoringthem to an apparently normal state of health whichcould be maintained by daily injections. When theuse of this extract was combined with the other twomethods of treatment the clinical results were

sufficiently striking to suggest that it contains themissing cortical hormone in an active state. In

treating the seven severe cases reported the supplyof extract was still very meagre and intermittent ; itsadministration could not be consistent or longcontinued, and it was used chiefly during the crises

1 Rowntree, L. G., Greene, C. G., Swingle, W. W., andPfiffner, J. J.: Jour. Amer. Med. Assoc., Jan. 24th, p. 231.