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central part of the diaphragm is a true referred pain. The

afferent impulses reach the spinal cord through the fibresof the phrenic nerve and excite painful impressions in theskin and superficial tissues supplied by the third and fourthspinal segments. The maximum point of pain has a markedtendency to appear along the ridge of the trapezius muscle.The pains elicited by irritation of the peripheral portionsof the diaphragm are also referred pains, being distributedover the thorax and epigastrium in areas corresponding to thedorsal segments from the seventh to the twelfth. Both with

these pains and with the neck pain there are associated

cutaneous hyperassthesia and hyperalgesia. The distribution

of the referred pains varies with the part that is touched andwith the degree of irritation. The more intense it is the

greater the tendency of the pain to spread down over thelower abdomen. When the posterior part of the diaphrag-matic pleura is irritated the pain is most marked in the

lumbar region. Irritation of the pericardial pleura was

followed by pain in the neck similar in character to thatinduced by irritation of the central portion of the diaphragm.It is interesting to note that in a series of cases of diaphrag-matic pleurisy, in some of which the diagnosis was confirmedby necropsy, pain was present in the lower thorax, abdomen,or lumbar region in the great majority, while in about halfof the cases there was pain in the neck. This affords an

interesting illustration of the practical value of Dr. Capps’sobservations, which demonstrate clearly the origin and

nature of pleural pain, and explain the difficulties whichnot infrequently arise in the diagnosis of conditions imme-diately above and below the diaphragm. Dr. Capps furtherstates that he has a few observations which tend to showthat the phrenic and intercostal nerves supply the peritonealsurface of the diaphragm with pain-sense as well as the

pleural. His observations merit very careful consideration,and are an important contribution to the study of pleurisy.

THE TREATMENT OF BURNS.

I the International Journal of Surgery Dr. J. F. Alexanderhas reported an interesting investigation of the treatment ofburns. Having the unusual opportunity of treating simul-taneously 27 cases of burns of the first, second, and third

degrees he made a comparative test of five methods. All

the patients were injured in trying to escape from the

second floor of a burning building, and nearly all presentedburns of the face, arms, and chest. Varying but very extensiveareas of skin were involved; in four cases duodenal ulcersoccurred ; all the patients recovered. Seven cases of burnsof the first, second, and third degree were treated by theboric acid solution bath, 5 of same degrees by picric acidsolution, 5 of the second and third degree by carron oil, 5of the second and third degree by unguentine, and 5 of thethird degree by ichthyol ointment (48 grains of ichthyoladded to 2 drachms of olive oil and incorporated with enoughlanolin to make three ounces). The boric acid baths were

given for two to six hours and repeated at intervals of two tosix hours. A little experience showed that the parts shouldremain three hours in the bath. In the second group of cases

gauze was saturated with picric acid solution and coveredwith oiled paper. The gauze was kept continuously moistand the dressing was renewed every second or third day.The ichthyol ointment was applied to the burns and coveredwith gauze and then with oiled’paper. In all cases the

lesions were thoroughly cleansed with soap and water beforeany dressing was applied. If there was considerable destruc-tion of skin peroxide of hydrogen solution was then applied.If the dressing adhered to the raw surface a few drops ofthis solution allowed to fall on the gauze quickly dissolvedthe inspissated material and allowed easy and painless

removal. All exfoliated epitheliam was removed. In burnsof the first degree the picric solution gave much the bestresults, and in burns of the second degree perfectly satis-

factory results. In spite of extensive areas of skin involved.no symptoms of picric acid poisoning were observed. In

some cases the urine was darkened, but this condition sooncleared up under the administration of magnesium sulphate.The boric acid baths gave the best results in burns of thesecond degree and the ichthyol ointment in burns of thethird degree.

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CAVIARE.

IN spite of the esteem which caviare enjoys we have knownit to be regarded by medical men as oily, indigestible, andunwholesome. We are inclined to dispute the accuracy ofthis view, having regard to the peculiar character of the con-stituents which the roe of the sturgeon contains. Numerous

analyses have from time to time been made and the com-position of caviare when averaged appears to be as follows:-Water, 50-92 per cent. ; protein, 27-92 per cent. ; fat, 13 - 59per cent. ; and mineral salts, 7’ 57 per cent. It differs sharplyfrom the flesh of fish by containing a much larger quantityof fat. Moreover, this fat contains the peculiar oily phos-phorus compound known as lecithin, which is a stimulant tometabolism affecting favourably the processes of nutrition.Caviare is, in fact, highly nutritive, and its digestibility hasbeen determined, the time taken for its absorption beingrelatively short. If there is anything to be said unfavourablyof caviare it is that its constituents err slightly on the side of" richness." The proteins of caviare contain a good deal ofnuclein, and physiological experiments have shown that

nuclein is a source of uric acid. The same is true, however,of sweetbread, kidney, foie gras, and these delicacies sharewith caviare the drawback of prohibition for persons of a goutydisposition. Like most foods with a peculiarly attractive anddelicate fiavour, caviare is expensive, and this fact holds anyimportant consumption of it in check. It may be added, how-ever, that caviare differs but a very little in composition fromthe much more familiar milt of the herring or the bloaterroe. Bloater roe, like caviare, is rich in lecithin, thoughwe are not prepared to assume that a measured course ofbloater roe would have the same favourable effects in neuras-thenia and in disturbances of nutrition generally as areobtained by administering the isolated fatty phosphoruscompound.

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THE RELATIONSHIP OF TUBERCULOSIS TOACCIDENT AND INJURY.

IN another column we publish an address by Dr. W. C.Bosanquet on the relationship of tuberculosis to accident

and injury. This is a subject which has claimed considerableattention during the past few years, mainly on account of itsimportance in connexion with the Workmen’s CompensationAct. There is, unfortunately, a tendency on the part of

workmen to try to attribute any illness to an accident,with the result that numerous cases are tried under arbi-tration which have no sound foundation in fact, and thetime of the court is wasted, and the masters or the insurancecompanies are put to-large needless expense. It is not deniedthat direct infection with tubercle bacilli may take place ;numerous instances are on record. Further, many authoritiesmaintain that tuberculosis of joints may follow injury, andDr. Bosanquet quotes the French military surgeons who main-tain that the majority of cases in their army in which

amputation of the foot has to be carried out for tuber-culous disease are attributable to old sprains. Instancesof tuberculosis of the lungs following injury to thechest have been recorded, but in most of the cases

it is not absolutely clear that the tuberculosis was

111

produced by the injury. It has also been suggestedthat in regard to pulmonary tuberculosis the accident

may stir into activity a latent or quiescent lesion.To deny such a possibility would be difficult, but it is atleast doubtful whether such a sequel could be proved. Onthe other hand, when active disease is present cases have

been recorded in which an accident has apparentlyaggravated the disease. In a legal case, however, whendamages are claimed on such a ground, the time that

elapsed between the accident and the alleged aggrava-tion would have an important bearing on the facts.

Dr..Bosanquet remarks that if it were claimed that

an injury and its resultant shock had so depresseda healthy person’s resistance that he subsequently fell avictim to tuberculosis of the lungs considerable doubt

would arise. We are acquainted with a case in which a

widow of a deceased workman made a claim of this nature. I

The man sustained a Pott’s fracture and died some ninemonths afterwards from pulmonary tuberculosis. For the

woman it was suggested that the accident had so loweredthe man’s resisting power that he had become tuberculous.A medical assessor was sitting with the judge and the casewas stopped without the defendants being called upon. toreply. The occurrence of such legal cases by themselvescause the subject of " traumatic tuberculosis," as it is

sometimes called, to be an important one, and many problemsare involved which merit close attention and study.

THE CYTO-ARCHITECTONIC STRUCTURE OF THECEREBRAL CORTEX1

WITHIN the last few years, owing largely to the researches Iof A. W. Oampbell in this country, and of Brodmann and the leYogts in Germany, immense strides have been taken towardsthe perfecting of our knowledge of the structure of the cere-bral cortex; and as this knowledge is sure to prove, indeed hasalready proved, to be of the first importance as a key to thepathology of certain mental and nervous states, it is well forthe physician who is interested in the scientific side of his

profession to have an intelligent idea of the progress that hasalready been made. It was known years ago, of course (sincethe researches of Bevan Lewis), that the cerebral cortex variedin thickness and in naked-eye and microscopical characters indifferent areas, but incompleteness of knowledge led in-

variably to confusion of thought until the subject was tackledafresh in its entirety, and with the aid of comparativeanatomy, by the investigators whose names have been givenabove. Basing their work on the examination of transversesections of the cortex from all its different parts, cut inseries, they have definitely established the following first

principle-viz , that the cerebral cortex is everywherestratified, i.e., its cells are arranged in layers. In mammals

the fundamental type of stratification is the six-layer type.By inversion, division, or diminution there may be derivedfrom this type other varieties, to be referred to subsequently.The six layers, from without inwards, are described as

(1) the zonal layer ; (2) the external or outer granularlayer ; (3) the pyramidal layer ; (4) the internal or inner

granular layer ; (5) the ganglionic layer ; and (6) the

multiform layer, according to the terms employed byBrodmann. Layers 1 and 6 are constant in man and

the mammals generally, whereas layers 2 and 4 are veryinconstant, and are frequently absent in man in certainareas of the cortex ; layers 3 and 5 are also variable, but to aless extent than the preceding. Brodmann has also shownthat this six-layer type may be present in the foetus in partsof the cortex where at a later stage variation sets in, andthat the rate of development of the six layers is not the same

1 See, in particular, a recent paper by Dr. Ladame, of Geneva, in theRevue Neurologique, Nov. 30th, 1911.

for all divisions of the cortex. The next point is that thereare certain parts of the cortical surface where this six-layertype is not found, even in the embryo, constituting, roughlyspeaking, about one-tenth of the cerebral surface, nine-tenths being normally six-layered. Further, there are areaswhere during embryonic evolution the six-layered cortex

becomes considerably modified, by augmentation or diminu-tion of the number of layers. These areas take up aboutone-fourth of the cerebral superficies, and are of greatimportance, for they correspond to well-known physiologicalareas. Among them may be mentioned the visual area roundthe calcarine fissure in the occipital lobes, the motor area infront of the fissure of Rolando, certain parts of the frontallobes, and the cortex of the island of Reil. In the calcarine

area, for instance, the fourth layer is subdivided into three :in the motor area the fourth layer is awanting, while thegiant pyramidal cells of Betz appear in the fifth layer, andso on. In this way it becomes readily understandable thatthe cerebral cortex can be mapped out into areas just like ageographical chart, each area corresponding to a particulartype of cyto-architectonic arrangement. It is true, no

doubt, that in the present state of our knowledge manyof these areas are not of definite clinical interest, but

some certainly are. Brodmann has distinguished 48different regions, and it is a remarkably interesting factthat two of them are without homologue in the whole

mammalian series-viz., the area corresponding to Broca’sconvolution and the area corresponding to the posterior endof the upper temporal convolution. These areas are a

speciality, so to speak, of man, and naturally they may betaken to be of significance in connexion with the develop-ment of the faculty of speech. There is reason to supposethat not a few mental diseases have for their anatomicalbasis some disturbance, as yet not fully recognised, of thestructure of the cortical stratification, and this is a patho-logical field on which investigation is only commencing.The belief, however, that in the prosecution of research alongthe lines sketched above, and based on the splendid work of

, Brodmann and others, results of far-reaching importance will

: sooner or later be attained, seems amply justified by the, progress that has already been accomplished, of which theI recent Goulstonian lectures of Dr. J. Shaw Bolton afford. convincing evidence.2

THE MEDICAL LIBRARY ASSOCIATION OFAMERICA.

THE first two numbers of the Bulletin of the Medical

Library Association, of America, edited by Dr. JohnRuhrah and Miss M. C. Noyes, have been forwarded to

us. This well-printed journal is worthy the considerationof the profession here, and of all those who take aninterest in medical libraries, medical education, or the

bibliography of medicine, surgery, and the kindred sciences.In a prefatory note the purposes of the Bulletin are

briefly outlined as being primarily a means of communica-tion between members of the association and a medium

for the publication of lists of ’’ wants" and of books and

journals for exchange. In addition to this, at least one

article on the work of medical libraries will be publishedin each issue of the journal. The first of these is from the

accomplished pen of Dr. John H. Musser, president of theassociation. It is the record of his address, delivered at

Atlantic city in May last. Dr. Musser reviews the work of

the association and its finance, now flourishing under themanagement of an experienced treasurer. He further

makes the satisfactory announcement that he was enabled,during the past twelvemonth, to hand to the association acud catalogue of the important books published in

2 THE LANCET, vol. i., 1910, pp. 905, 980, 1047, 1077.