132 TUBERCLE [December, 1934

out. Microscopic examination, as in the first case, showed characteristic tuberculous lesions over most of the breast tissue, many of these being caseous. Tubercle bacilli were demon- strable in stained sections of the organ.

PARODI,, E. and CAL~/I, F. Linfoan- goite tubercolare della mammella nell' rome. Riv. di I'atol. e Clin. della Tuber- colosi, 1933, 7, 709.

A record of four cases of tuberculous lymphangitis of the breast in young men whose exact age is not stated. The condition was unilateral in three and bilateral in one. There did not appear to be auy relation between the severity of the puhnonary lesion and the extent of the infiltration of the mammary region, but a specific pleuro-pulmonary lesion was present in all eases. The prognosis was good. Treatment con- sisted iu residence in a sanatorium and tuberculin therapy, wi~h the result that the mammary infiltration subsided with a maximum period of three months.

PHRENICECTOMY.

MAZZETTI, M. Di un rare tncidente operatorio helle exeresi del frentco sinistro: la lacerazione del dotto toracico. Ospedale Maggiore, 1933, 2 t , 417.

The writer records the case of a man, aged 37, in whom the thoracic duct was injured during avulsion of the lett phrenic nerve for pulmonary tubercu- losis. A copious discharge of lymph took place and the patient lost about 5 kg., but on the sixth day after phrenieectomy when all efforts to check the discharge had failed and the patient's condition had become very serious the duct was sutured and rapid recovery took place.

ZANNELLI, C. I l lustrazionc di un ease di doppm frenieo bilaterale. Lo f t s centre la Tubercolosi, 1933, ~, 979.

The writer records the case of a woman, aged 28, suffering from bilateral pulmonary tuberculosis, in whom right phrenicectomy was performed. The operation was followed by paralysis of

the diaphragm, which lasted only two months, after which the muscle resumed its function, and it was not until after a second operation on the same side when an accessory phrenie nerve was discovered that a permanent paralysis of the diaphragm was effected. The second operation on the right side was suggested during phrenicectomy on the left side (performed shortly after the first operation on the right side) when two branches of the nerve were found, both contained in the fascia of the scalcnus anticus. The temporary paralysis of the diaphragm was probably caused by the injury to the main trunk of the phrenie nerve resulting from avulsion of one of its roots.

LUNDE, S. Har frcnikoeksairesen sore selvetendig operasjon red kavcrner i lungens kraniale felt nogen betyd- ning ? Tidsskr. f. d. NorsT~'e Laegeforening~ 1933, 53, 1268.

Has phrenic avulsion any effect on the lung with cavities in the field of operation ? The answer to Otis ques- tion provided by the extensive literature of the subject is most ambiguous. At

one extreme there are the optimists who claim success in 80 per cent. of their cases. At the other extreme are those who rate their successes at nil. Lundc is inclined to join the latter group after a systematic study of 73 patients, on whom phrenic avulsion was performed at the Glittre Sanatorium in Norway in the period 1928-32. Cavities in the field of operation were demonstrable by the X.rays in 66 of these patients, 61 of whom belonged to the third stage of the disease (Turban- Gerhardt). On discharge, 43 of these 73 patients showed some general ira-

�9 provement, but there was little change in the number of positive sputa. The proportion of patients showing general improvement on discharge was lower in the phrenie avulsion group than among the other patients in the third stage of the disease.

Lunde succeeded in tracing 50 patients from one to four years after discharge. Only four of them were then perfectly fit for work, without cough, sputum-free and sputum-nega-

December , 1934] PHRENICECTOMY 133

rive. Eleven had died, 95 were totally unfit for work, coughing and sputum- positive, and 10 were partially fit for work, though still coughing and bring- ing up sputum. Lunde notes that his discouraging observations are shared by Sauerbruch, who has come to regard phrenic avulsion by itself as being of negligible value.

T U B E R C U L O S I S OF T H E EAR. ORMEROD, F.C. Tuberculous Otitis

Media. Prec. 27oyal Soc. Medicine, 1933, 26, 564.

The case is reported Of a man, aged 27, giving a history of cough for nearly two years and a series of hmmoptyses eighteen months previ- ously, when artificial pneumothorax was induced. Three months after the hmmoptyses both ea r s began to dis- charge, tubercle bacilli being found in the pus from each ear. The larynx was normal. Both lungs were severely infected and the prognosis, as regards the pulmonary condition, appeared to be very bad, but the condition improved after the onse t of the otorrhcea. The ears were treated with hydrogen peroxide and spirit drops and healed in a few months, but the deafness was still severe and the lungs were in a stationary condition. The writer believes that cases of this kind are secondary to chest disease and that tubercle bacilli ascend by the Eustachian tube.

DESPONS, J. S u r u n cas de tubercu- lose primit ive de l 'oreille ehez l 'enfant, t~evuc de .Laryngol., Olol., .Rhinol., 1933. 54,387.

Pr imary tuberculosis of the ear in children often takes the form of an ordinary acute otitis with fever and mastoid complications. The chronicity of the case usually suggests a tuber- culous mtiology. In the present case a child, aged 3 years, gave a history of

pain in the right ear a month previously followed by otorrhcea. The pain had disappeared but the otocrhcea was per- sisting. There was some enlargement of the mastoid and carotid glands, and over the mastoid was a small fluctuating swelling. At operation the lesions in this situation were so extensive that a mastoidectomy had to be performed. At the antrum the lesions extended up to the meninges. A further operation a month later, a resection of the posterior wall of the bony canal, was necessary; but suppuration still con. tinuing the petro-mastoid region was cleared out three months later. Histo- logical examination of the material showed absolutely typical tuberculosis. The child made a good recovery, and the cavity was becoming eicatrised.

The writer points out that this, and another analogous case published a year ago in an infant of 10 months, shows I~he importance of the naso- pharyngeal route in the propagation of tuberculosis in the child. These forms of primary tuberculosis of the middle- ear are curable by surgical methods, as in other osseous localisations.

URBANTSCHITSCH, E. Ueber klin. isch pr imare Tuberkulose des GehSr- organcs. Folia Oto-larynffol. Orient., 1933, l, 142.

The writer, who reviews the literature and records three personal cases in patients aged 65 months, 7 months and 69 years respectively, states that tuberculosis of the ear is usually only a local manifestation of generalised tuberculosis. In some cases on record, however, including his two cases in infants, the tuberculosis may be, at least clinically, primary in the ear. The case in the adult was remarkable owing to the patient 's sex and advanced age, most of the cases of th6: kind having been recorded in young males. The prognosis is more unfavourable for clinically primary than secondary tuber- culosis of the ear, as in pr imary cases sequestrum formation is much more frequent.