641

diet. Schistosomiasis is endemic in the area aroundFoochow, and the institute has shown that it accountsfor the cases of splenomegaly there which had beenthought to be examples of Banti’s disease. Patho-

logical specimens have been examined for hospitalswhich needed an expert opinion on difficult cases,and material for teaching purposes has been suppliedto schools of tropical medicine in England and else-where. It seems tragic that such valuable workshould receive a check. We are glad of an assurancethat the institute has so far escaped damage, and wemay hope that Dr. H. G. Earle and his 30 assistantswill soon be free to continue their work unmolested.

THE EFFECT OF AN ELISION

THE doctor’s honesty and the patient’s faith in it,which are one of the themes of Dr. Cronin’s recentbook, are important factors in the welfare of the

community, and it was perhaps natural that the

Daily Express, which has republished this book in serialform, should comment upon our review of it. In thecourse of this review we said we had learned from a

practitioner who came to London as a stranger thathe had received a cheque from the first surgeon hecalled in after buying his practice. He returned the

cheque, the review continues, ascertained from booksof reference that the surgeon’s credentials were nothigh, and troubled him no more. " This calm atti-tude," we remarked, " in the face of an improperproposal, represents that of the average practitioner."In quoting this passage of the review, our contem-porary incorrectly attributes the story to Dr. Cronin’shero and omits to mention the salient fact that thecalmness was manifested in the return of the chequeand the discard of the surgeon. The elision is morethan unfortunate. It is a disservice to the communityinasmuch as it suggests to potential patients, on theauthority of THE LANCET, that the average practi-tioner " calmly " accepts illicit fees.

POST-OPERATIVE HICCUP

A DISTRESSING type of hiccup sometimes com-

plicates convalescence from abdominal operations.The hiccup comes on suddenly in a patient whoseprogress has been smooth, and in the absence ofobvious trouble in chest or abdomen. It is most

likely to start when some effort is made, such as get-ting out of bed for the first time ; and once startedit is quite intractable, persisting day and night,unresponsive to remedies. Gerard De Muylder, in acommunication to the Societe Belge de Chirurgie, hasdescribed two cases which throw light on the aetiologyof the condition.1 In a young girl the hiccup hadstarted when she first got up a week after an opera-tion for chronic appendicitis. It was so bad that shecould not sleep, and could eat and speak only withdifficulty, and it persisted in severe attacks till thetime, two weeks later, when De Muylder first sawher. The least exertion would precipitate an attack.As all efforts to find a cause had failed and the usualremedies had had no effect, the girl had been labelledhysterical and had been sent home with the sugges-tion that the hiccup would leave off as suddenly asit had started. De Muylder carried out all the usualexaminations but got no further till he decided to

explore the site of the appendicectomy. He foundthat the great omentum had been pinched in thewound when the peritoneum was being closed, andwas intimately attached to the peritoneal scar. Thiswas no ordinary adhesion, but a definite nipping ofthe omentum ; excision of the scar and of the piece

1 Scalpel, July 3rd, 1937, p. 976.

of omentum completely cured the hiccup. Whenthe same type of hiccup occurred in one of his ownoperation cases De Muylder naturally explored thewound. Each attack was brought on by effort, andthe last attack which determined De Muylder tooperate occurred just as the patient was about toleave the institution, and this time also he found atag of omentum firmly attached to the middle of thescar. It had to be divided between two ligaturesbefore it could be freed, but the patient was cured.In this case the hiccup had come on nine days afterrepair of an umbilical hernia, and once again it wasprecipitated by the first efforts to get up. In neithercase did any sign or symptom call attention to thescar as the cause of the trouble, the wounds beingwell healed and not tender. In the first case

De Muylder was almost driven to performing a

phrenectomy to relieve the symptoms, and exploredthe wound only on chance.

LYMPHO-EPITHELIOMATA

EVEN pathology is not immune from the tendency .

to make " fashionable " diagnoses. In descriptiveoncology, for example, the history of the " endo-theliomata " shows what confusion may arisewhen a new label becomes over-popular. The termendothelioma was introduced by Golgi in 1869 todescribe the psammomatous type of meningioma.Soon other atypical tumours were classed as endo-thelial in origin, including mixed parotid tumours andtumours of lymph nodes, ovary, bone-marrow, bones,and the intestinal tract. In fact, any undifferentiatedgrowth whose primary site was obscure was con-

veniently regarded as being of endothelial origin andthe term fell into disrepute. Of recent years therehave been attempts to reclassify these " endothe-liomata," and with the aid of accurate histologicaltechnique their histogenesis is shown to be varied.Many are in reality metastases from undiscoveredprimary growths, but in addition certain tumours,such as reticulum cell sarcomata and lympho-epithe-liomata, have been recognised and show a charac-teristic morphology. However, there is still con-fusion. The first of a series of articles on debatabletumours in human and animal pathology by Harvey,Dawson, and Innes,l dealing with the lympho-epithe-liomata is thus welcome, and if the other projectedarticles maintain the standard of this the series willbe of fundamental importance in tumour pathology.In 1911 Trotter 2 described a series of cases of

endotheliomata " of the nasopharynx in whichthe primary tumour was inconspicuous ; but thetrauma caused was serious, the patients showingeither deafness and bilateral cervical lymph nodeinvolvement, or cranial palsies produced by thedeep infiltration of the growth into the sphenoidand base of the brain. Subsequent communicationsfrom University College Hospital 3 4 on the clinicalaspects of these tumours have continued to callthem endotheliomata, but contained no detailedaccount of their histology, though Pilcher has

emphasised the extreme radiosensitivity of the typeshowing early lymph node involvement. In 1921

reports were published from Regaud’s clinic,5 andby Schmincke 6 of tumours termed " lympho-epitheliomata" in the belief that they arose from

1 Harvey, W. F., Dawson, E. K., and Innes, J. R. M., Edinb.med. J. 1937, 44, 549.

2 Trotter, W., Trans. med. Soc. Lond. 1911, 34, 372.3 Gardham, A. J., Brit. J. Surg. 1929, 17, 242.

4 Pilcher, R. S., Proc. R. Soc. Med. 1932, 25, 1006.5 Reverschon, L. and Coutard, H., Bull. Soc. Oto-rhin-laryng.

1921, 34, 203.6 Schmincke, A., Beitr. path. Anat. 1921, 68, 161.