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SURGEON TO OUT-PATIENTS'DEPARTMENT, GLASOOW ROYAL INFIRMARY.OF recent years operative procedures upon the vasomotor nerves have been increasingly made use of in endeavouring t o alleviate or cure a variety of clinical conditions. The principle underlying these operations is the physiological observation that division of the vasomotor nerves is followed by a peripheral vasodilatation. The usual method is to perform peri-arterial sympathectomy proximally in a limb with a view t o causing increased vascularity distally. The results have been notably varied in all conditions for which the treatment has been tried, and the uncertainty of result may be correlated with our present lack of precise knowledge of the origin, distribution, and function of the vasomotor nerves. Experimental study of the vasomotor nerves in animals can yield useful information, but it has been noted (Woollard,l 1926) HrsToRY.-Mrs. P., age 57, was admitted to Mr. Duffs Surgical Unit a t the Glasgow Royal Infirmary on Oct. 2, 192G. She had suffered from diabetes mellitus for twelve years and had been receiving insulin for one and a half years. Nine weeks before admission gangrene began in the right foot, accompanied by much pain.ON ADMIssIoN.-The patient was in poor general condition and suffering severe pain. There was an area of moist gangrene the size of her hand on the dorsum and outer side of the foot, overlapping the external malleolus. The foot elsewhere was cold and blue, the vessels of the limb were sclerosed, and popliteal pulsation was just perceptible. The urine contained abundant sugar and albumin.During the next two months the glycosuria was controlled by insulin, and local surgical measures were applied t o the foot. Sloughs were gradually removed until a sluggish ulcer remained, making no progress. Morphia was occasionally required for the relief of pain. A trial of peri-arterial sympathectomy was decided upon. and the following extracts from the case record indicate the effect on the leg :-

SUMMARYThe pleural cavity offers a suitable site for permanent pacemaker implantation in infancy. We describe 3 infants in whom this approach was successfully used.Although treatment with permanent pacemakers has been extensively described in

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THE BRITISH JOURNAL O F SURGERYin its long diameter, and about 23 in. in its short diameter. It was bluishwhite in colour and uniformly firm in consistency. It showed in places nodular cxcrescences, whirh had a faintly ycllow colour. On one surface of the tuniour there was evidence that the growth had a thin fibrous capsule. ~IICROSCOPICAL l'IrcD,rlvcs.--'rhe tumour is composed mainly of fibrous tissue, scattered through which are bundles of non-medullatcd nerve-fibres and numbers of large multipolar nerve-cells. Fig. 368 shows a low-power microphotograph of the tumour tissue stained with cresyl violet. Under high magnification (Fig. 369) the large multipolar nerve-cells of the tumour are secn to have a ring of well-defined, peripherally-placed Nissl granules. The fibroblast nuclci are of a long oval shape, showing some irregularity in their contour.In this microphotograph can also be seen a few neurilenimal sheath-ccll nuclei, distinguished by their round or short-oval shape.Occasionally a nerve-cell can be seen undergoing division, and here and there are small collections of lymphocytes lying free in the tumour tissue. With Cajal's gold sublimate stain it is evident that there are large numbers of bundles of non-medullated nerve-fibres running through the tumour and that the main tumour mass is an intimate mixture of neoplastic non-medullated nerve-fibres and fibrous tissue. A silver impregnation picks out differentially the sheath-cell and fibroblast nuclei. With ammoniacal silver oside the fibrous tissue bundlcs do not impregnate deeply, suggesting that thc fibroblasts are somewhat immature. With Weigert's stain small medullated nervc-fibres can be seen running through the tumour in all directions.Processes can be seen arising from the poles of these nuclei.Our thanks are due t o Dr. I. H. Erb, Pathologist to the Hospital for Sick Children, Toronto, for his help.