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from the appearance of which it is impossible toincriminate any particular one. Here, perhaps, theactual cause of the eruption is not the drug itself, butsome toxic substance produced by its action on thetissues. Certain drugs, however, may evoke eruptionsas specific as those of the eruptive fevers or of thewell-defined dermatoses-for example, the halogens,and, above all, antipyrine. These specific forms ofcutaneous reaction provide one of the most fascinatingproblems not only for the clinical dermatologist butalso for the physiologist and biochemist. To take asingle example, we may cite pityriasis rosea, one

typical lesion of which is sufficient for an expert tomake a certain diagnosis ; that this disease is due toan unknown infective organism is certain, but whatare the factors on which the peculiar configuration ofthe type-lesion and the characteristic distribution ofthe eruption depend ? The morbid histology of theeruptive elements does not help us.At present we can but recognise that, among the

great variety of cutaneous reactions, some, such ascertain forms of erythema, urticaria, and eczema, are

non-specific, and these may be due not to the directaction on the skin of the various toxins that provokethem, but to substances produced by the poisonousaction of the toxins on the tissues ; on the other hand,other reactions are absolutely specific for a giventoxin, and it is on the variety of these specific reactionsthat the differential diagnosis of skin diseases largelydepends. We can recognise clinically the specialcharacteristics of this or that eruption, and in manycases a diagnosis can be made from a microscopicalsection, but at present we are absolutely ignorant ofthe physical and chemical processes that determinethe specific differences in these cuti-reactions. Itseems to us that light might be thrown on this problemby further research along the lines adopted by Lewisand Grant in their recent experiments.

Annotations.

SOCIAL SERVICES IN HOSPITALS.

" Ne quid nimis."

THE report of the Institute of Hospital Almonersfor the year 1923 gives an encouraging account of thisbranch of social service. The income and expenditureaccount shows a small balance on the right side.During the year 11 students completed the course oftraining required and received the certificate of theInstitute, eight almoners and four assistant almonerstrained by the Institute were appointed to varioushospitals, 18 candidates were accepted for training,and a fund for scholarships was placed at the disposalof the Institute. It is no light task in these days toadminister a social service department of a hospitalsuccessfully. Old landmarks have disappeared and anew generation has arisen with new needs and insistentdemands. Adaptability to these new needs is essential;the housing problem, parental responsibility, industrialfatigue, the psychology of the worker, these and manyother matters come from time to time " within the terms of reference " of the hospital almoner. The report cf the social service department of St. Thomas’sHospital for 1923 brings these points into focus froma wide angle. As the report shows, the voluntaryhospital is gradually opening its doors to a largerpublic, highly specialised forms of treatment beyondthe scope of the general practitioner tend to increasein number and complexity, special inquiries, such asthe one now proceeding in chorea and rheumatism,are opening up new fields of research, the after-careof cancer patients has become more and more a socialnecessity, and with all these advances the responsibilityof the almoner’s department increases proportionately.Added to these new developments the needs for financialinquiry, for which the almoner’s departments wereoriginally started years ago, call nowadays for especially

careful and wise handling. The " new poor " is nopolitical myth : it is the outward expression of post-warconditions which will remain with us in the voluntaryhospitals for many a long day. Although it is obviouslyimpossible to comment on the many problems whichconfront the social service departments in this con-nexion, one at least needs reference in passing-viz.,the inter-relation of the various State grants andvoluntary financial aid. The report of the Almoner’sDepartment of Moorfields Eye Hospital emphasisesthis point. State assistance has, as yet, by no meanscovered all the cases requiring help even in so well-regulated a field as ophthalmic work. Moorfieldstreats numbers of myopic children from districts ofthe Home Counties outside the L.C.C. area where thespecial education accorded to London children isimpossible to obtain owing to the scattered natureof some of the county districts. In such cases there isoften no choice between an ordinary elementary schooland a resident school for the blind, and cooperationwith the hospital social service department is neededto bridge the gap. Another instance of the dove-tailing of voluntary effort and State assistance issupplied in the condition of patients who lose theirsight between the ages of 35 and 50. These unfortu-nate patients are too old for training in workshops orother institutions under the education authorities,and too young for the State pensions for the blind,whilst the pensions of the various voluntary organisa-tions are too few to meet the circumstances. Inthese days it is obvious that patient and socialworker alike need the " infection of a good courage."

A GEOGRAPHICAL SURVEY OF HUMAN ANDBOVINE TUBERCULOSIS.

IN the United States of Am.erica the recent rapiddecline in the incidence of surgical tuberculosis inchildhood has been correlated by some authoritieswith the wholesale pasteurisation of milk which hasbeen in force for some years in certain towns. It isvery doubtful if this deduction is correct, for in certainNorwegian towns the incidence of tuberculosis inchildhood has also fallen with dramatic speed duringthe last few years, although the milk-supply of thesetowns is not pasteurised. We may not yet be in aposition to appraise accurately the importance of thebovine tubercle bacillus in the generation of humantuberculosis, but a recent statistical survey, publishedby Dr. A. Lichtenstein in Acta Pcediatrica for June 16th,would suggest that we may in the past have much over-rated the importance of bovine tuberculosis as a sourceof infection to man. Dr. Lichtenstein investigatedthe incidence of fatal tuberculosis among children1 year old and 5 years old in the towns andcounties of Sweden, comparing the figures thusobtained with the figures showing the incidence ofbovine tuberculosis throughout the country. Noconnexion whatever could be found between the twoseries of figures. In the north of Sweden, for example.bovine tuberculosis proved to be practically non-existent, whereas the death-rate from tuberculosisamong children was exceptionally high. Dr. Lichten-

stein classified the 24 counties of Sweden accordingto the frequency of bovine tuberculosis, and he foundthat the 12 worst counties in this respect showed anaverage incidence of 13-8 cases of tubercle per 10,000head of cattle, whereas the corresponding figure forthe 12 counties with the lowest rate of bovine tuber-culosis was only 2-7 per 10,000. In the first group thedeath-rate from tuberculosis among children under theage of 5 was 14-8 per 10,000, and in the second groupit was 12-7 per 10,000. The difference between thehuman rates was thus very slight in the two groupsof counties, although bovine tuberculosis was five etimes more common in one group than in the other.Dr. Lichtenstein has also compared the death-ratefrom tuberculosis among children under the age of5 with the death-rate from tuberculosis at all agesin man, and has found that these two rates runparallel to a remarkable degree in the different counties

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and towns of Sweden. These investigations do notnecessarily invalidate the observations of bacterio-logists who have found the bovine tubercle bacillusin a goodly proportion of cases of fatal tuberculosisin childhood. But Dr. Lichtenstein’s work is animportant addition to the mass of evidence which hasaccumulated during the last few years, and whichpoints unequivocally to the conclusion that man isthe most dangerous source of infection, and thatstrains of tubercle bacilli not conforming to thecharacteristic properties of the human type of tuberclebacillus play a comparatively unimportant part in thetuberculosis of man.

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A FRENCH HISTORY OF MEDICINE.

THE French have always been in the forefront ofthe army of writers on, the history of medicine.Daniel Le Clerc’s " Histoire de Medecine " waspublished in 1702; he was practically a contem-porary of our own Dr. John Freind, physicianand politician, who brought out his History ofPhysick from the time of Galen in 1725; whilein more modern times we have N. L. Leclerc,whose excellent " Histoire de la Medecine Arabe "appeared in 1876. Dr. L. Meunier is a worthy followerlof his eminent countrymen, and we agree with Prof.Ballet, President of the Societe Française d’Histoirede la Médecine, who says in his preface :-

" For a work upon the history of medicine to findacceptance among medical men who are not indifferent tothings of long ago, but who have only little leisure to giveto their study, it is necessary for the book to be completewithout being too long, without obscurity though ofnecessity condensed ?and without neglecting essentials itshould glide lightly over many matters of secondary interestwhich serve to show up in relief those which really makeup the important links of tradition. Such a task is difficultto accomplish, but in my opinion Dr. Meunier may be saidto have succeeded as far as is possible."

In a work of only some 600 octavo pages, whichcovers the whole period from Hippocrates to the endof the nineteenth century, it is impossible to mentioneverything that might be mentioned, but we havenoted one or two places where we think that Dr.Meunier might have added to his facts. For instance,in his fifth book, where he is referring to the editionsand translations made at the Renaissance of the worksof Hippocrates and Galen, he says that previouslyall the translations had been made into Latin froman Arabic version. But Hippocrates and Galenhad been translated certainly in part and possibly intheir entirety in the sixth century, according toCassiodorus who, in the instructions which he compiledfor the use of the monks in his monastery calledVivaria, says :-

" Quod si vobis non fuerit Graecarum litterarum notafacundia .... legite Hippocratem atque Galenum latinalingua conversos id est Therapeutica Galem .... etHippocratis de Herbis et curis."

It is not quite clear whether the two treatisesmentioned by Cassiodorus were the only ones trans-lated, or the only ones which he wanted the monksto read, and we have been unable to find any referencein the Loeb Library to a Hippocratic treatise with atitle in Greek corresponding to De Herbis et Curis.Again, when talking of the eighteenth century, Dr.Meunier remarks that John Hunter treated aneurysmsby opening the sac and ligation of the vessel above andbelow, but he makes no mention of the true Hunterianoperation, one of the greatest advances in surgery,of tying the vessel at a distance from the aneurysm so as to apply the ligature at a healthy part. We Ithink, too, that in the section on pathogenic microbes,p. 504 et seq., a little more might have been said ofLister’s patient and toilsome researehes than that" Lister, from about 1869, without any full under-standing of the microbic complications of operationwounds, promulgates his system of antiseptic dressings

1 Histoire de la Médecine ; depuis ses origines jusqu’à nosjours. Par le Dr. L. Meunier. Preface par le Prof. Gilbert Ballet.Paris : Librairie E. Le François. 1924. Pp. 642. Fr.30.

with satisfactory results from now onwards.’’ These,however, are but slight blemishes in an admirablebook, and we congratulate both Dr. Meunier and theFrench Society of the History of -Aledicine upon itsappearance.

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THE PATHOGENESIS OF CARDIAC ASTHMA.

THE results of a series of investigations undertakenwith a view to explaining the pathogenesis of cardiacasthma are recorded in an important work recentlypublished in Vienna. Having reviewed the clinicalpicture of this well-known syndrome, the authorsconclude, from a survey of the investigations dealingwith the subject, that a theory has not been de-veloped which can satisfactorily explain the breathless-ness and pulmonary oedema of cardiac asthma. Thespeed with which the blood flows towards the heartmay in a rough way be estimated by observing theflow of blood in a superficial vein of the arm, whichhas first been emptied by stripping with the finger thevessels in a peripheral direction, and at the same timeobstructing the flow at the central end. It was foundin many eases of cardiac asthma, by this simplemethod of examination, that the speed with which theblood flowed through the emptied vein was muchincreased as compared with a normal subject. If theseobservations could be confirmed by some exact methodof estimating the speed with which the blood flowswe should be justified in concluding that the oedemaof the lungs in cardiac asthma was due to the failureof the left ventricle to maintain the circulation, andthat this was brought about by the sudden increasein the speed with which the blood reaches the rightauriele.

Three methods were employed to investigate theblood flow in the patients upon whom observa-tions were being made : (1) the plethysmographicmethod, a volumetric method by which it is possibleto estimate the flow of blood through an extremityin a unit of time ; (2) the blood method, whichdepends upon the difference in the oxygen content ofthe arterial and venous blood ; (3) the gas method,which is the most accurate method of estimating thetrue minute volume. By employing the last method itis possible to determine the difference in the oxygencontent of the blood in the right and left sides of theheart. The plethysmographic method employed bythese investigators is not a new one. The techniqueis simple and the apparatus in no way complicated.The forearm, which is always used in this experiment,is covered with a glove and enclosed in a water-containing receptacle; by means of a Riva-Roccisphygmomanometer venous stasis is produced in thelimb and a rise or fall in volume is recorded on arevolving drum. The time required for the plethysmo-graphic curve to rise after obstructing the venousflow in the limb is taken as an index of the speed withwhich the blood flows in the superficial veins of thebody. The Austrian investigators find that the bloodflow towards the heart is quickened by heating thewater and retarded when the temperature of the waterhas been lowered. The plethysmographic curve is aslow-rising one in patients with high blood pressure.In the patient with exophthalmic goitre the rise is arapid one ; in the case with myxcedema, on the otherhand, there is little or no rise, depending upon thetemperature of the limb. In the patient with cardiacasthma, if the observation is made during the attack,there may be a perpendicular rise of the curve theinstant venous stasis is produced, so rapid is theblood flow towards the heart at this time. It is therule for the curve to rise rapidly in these cases duringthe attacks, or shortly before. One curve recordedduring an attack is given showing no real increase inthe blood flow. To confirm the results obtained bythe plethysmographic method the oxygen content of

1 Uber das Asthma Cardiale. Versuch zu einer PeripherenKreislaufpathologie. By Prof. Dr. Hans Eppinger, Dr. L.von Papp, and Dr. H. Schwarz. Erste Modizinische Kilnik inWien. Berlin: Julius Springer. 1924. Pp.217. $2.30.