465

a patient subject to grave lesions of the skin and nailswhen he is exposed to bright sunlight; and domesti-cated animals which have been fed upon vegetablefoods containing exogenous sensitising agents, suchas buckwheat or Swedish clover, are liable to developlesions of the skin and hoofs, and the diseases soinduced are not infrequently fatal. Only unpigmentedanimals suffer severely, but piebald animals developan affection of the skin of the unpigmented areas ofskin.The only disease known to result from the

presence in the tissues of an endogenous photo-sensitising agent is hydroa vacciniforme, which is, innot a few cases, associated with porphyrinuria, andespecially with congenital porphyrinuria. It was theauthor himself who showed that hsematoporphyrinhas a powerful photo-sensitising action upon lowlyforms of life, and also upon white mice. After injec-tion of hsematoporphyrin the mice die quickly ifexposed to bright light; in subdued light theydevelop a chronic light disease, whereas if kept in thedark they do not suffer any harm. Prof. Hausmanngives an excellent discussion of this subject, and ofcertain difficulties which it presents. Other humanmaladies in which light is apparently an exciting ormodifying cause, but in which the photo-sensitisingagent is unknown, are also discussed. A chapter isdevoted to the fatal effects of light upon sensitiveanimal and vegetable organisms, and the concluding,chapter of the book deals with the therapeutic actionof light upon tuberculous lesions.

In compiling this book Prof. Hausmann has donea great service to physiologists and pathologists alike.

MICRO-BIOLOGY.Handbuch der mikrobiologischen Technik. Band 1.,2 Halfte. 3 und 4 Abteilung.: NShrboden undZuchtung. By Prof. Dr. RUDOLF KRAUS, Direktordes Serotherapeutischen Institutes in Butantan-San Paolo (Brasilien), und Prof. Dr. PAULUHLENHUTH, Geh. Rat., Direktor des Institutes furExperiment. Therapie Emil v. Behring in Mar-burg a.d. Lahn. Berlin u. Wien: Urban undSchwarzenberg. 1923. Pp. 535-817.THE two sections which are here under consideration Iconstitute the second part of the first volume of this

book, which will be complete in two volumes. Thepresent part has been written in seven chapters bydifferent well-known authors : E. Gildermeister,W. Noller, W. v. Drigalski, R. Doerr, E. Ungermann,E. Kuster, M. Neisser, and K. Beckey, each of whomprovides a separate part. The whole work is, nodoubt, intended to provide an up-to-date treatisecomparable to the second and third volumes ofKolle and Wassermann’s handbook. The text, ifnot quite so comprehensive, is, on the whole, morereadable, and appears to have been more criticallycompiled than in the latter exhaustive work. Sections3 and 4 treat of the more generally applicable kindsof culture-media and the technique of aerobic methods.Anaerobic technique and some special methods ofculture will, no doubt, find place in the second volume.Several of the procedures for renovating used culture-media, which came into use during the war for the sakeof economy, are given in detail. The technique for thecultivation of protozoa is well dealt with in nearly40 pages by Noller. The complete work promises tobe a most useful book of reference. A list of theauthors quoted is given at the end of each article,including the full titles of the papers.

HANDBOOK OF PHYSIOLOGY.Sixteenth edition. By W. D. HALLIBURTON,M.D., LL.D., F.R.C.P., F.R.S., Professor ofPhysiology, King’s College, London. London : ’,John Murray. 1923. Pp. 968. 21s. ITHERE is certainly no living British physiologist I

to whom this book was not familiar (either under its Ipresent title or as Kirkes’s Handbook) as an estab- Ilished text-book in his earlier student days, and I

Mascagni’s anxious figure displaying his lymphatics(now Fig. 194), or Bourgery’s contemplative fellowshowing his cerebro-spinal axis (Fig. 160) draw fortha sigh as we recall the time when we first bent overthem. Although for three-quarters of a centurythis, our first guide, and best of students’ text-books,has appeared in edition after edition, each has beenbetter than the last. The present editor has himselfseen through the press 16 out of the 28 editions sincethe book appeared in 1848, and will, we hope, give usmore, for the improvements in the present editionare such as to bring the book right up to date andensure its continued popularity. One pleasingaddition to a book which has given shelter to many apassing theory in the course of the wonderful develop-ment which physiology has undergone, is the inclusionof portraits of some great physiologists of the past,two of whom, Ludwig and Claude Bernard, were stillliving in the early days of Kirkes’s Handbook.

Excellent balance is maintained in this bookbetween histological, chemical, and experimentalphysiology, and in these days of specialisation thestudent can still obtain a proper perspective from thereading of it to counteract, if need be, the oral instruc-tion which they receive. We believe that this bookwhich already extends a respectable distance into thepast of British physiology will continue its advance,abreast of the subject, well into the future.

JOURNALS.

QUARTERLY JOURNAL OF MEDICINE.-The Julynumber contains the following articles : The Fixationof the Kidney, by A. H. Southam. The investigationdescribed in this thesis was undertaken with a view ofthrowing further light upon the causation of displace-ments of the kidney. The perirenal fascia was studiedby means of sections of the trunk of six foetuses andseven adult bodies. Plaster casts of the renal fossaewere taken in other cases. The nature of the perirenaltissue was determined by histological sections. A

complete fascial sheath was convincingly demonstratedenclosing the kidney, suprarenal and perirenal fat,and attached to the diaphragm, vertebrae, andtransverse fascia. The pararenal fat lies behind thisfascia, and is probably the site of origin of a perinephricabscess. The perirenal fascia is the greatest factor inmaintaining the position of the kidney, for all itsother attachments can be divided without affectingthe mobility of the organ to any material degree. The

perirenal fat is not of great importance, but it serveschiefly as a protection from injury. Little fat is

present in young children. The intra-abdominalpressure is the second most important factor in themaintenance of the kidney in position. Movablekidney is much more common in women ; this isdue to the widening of the pelvis, which causes analteration in the shape of the renal fossa. In the malethe renal fossa is pear-shaped and narrow at its lowerend, but in the female it is cylindrical and widensbelow. Additional factors in women are lack ofmuscle tone and the effects of pregnancy. Thearticle is illustrated by three plates, which showclearly the various points made by the author.-Endocarditis Lenta (Chronic Ulcerative Endocarditis) :A Note on Thirty Cases seen in Civil Practice sincethe War, by Carey F. Coombs. The most strikingfeatures in this series of cases are the high sex-incidencein the male, the frequency with which the aorticvalves alone are affected, and the fact that the menattacked were, with one exception, of fine physique,good previous health, and had all undergone hard andprolonged war service. The author considers thatthere is evidence that fatigue is the most constantcausal factor, and it is possible that the production oflactic acid in the muscles may increase the rate ofgrowth of organisms of low virulence. This is inaccordance with Walker Hall’s recent bacteriologicalinvestigations. A plate is included showing thelesions as they affect the aortic valve.-A ClinicalInvestigation into the Relationship of the Fat-Soluble " A " Vitamin to the aetiology of Rickets,

466

by Douglas Galbraith. Another blow is here dealtat the vitamin theory of rickets. The investigationis clinical, children and not animals being studied.Severe rickets was found to occur in Glasgow in childrenwith normal amounts of fat in their dietary, and thepercentage of rickets in summer and in winter waslower in those on a fat-poor than in those on a fat-richdiet. In the summer spontaneous healing was seen,even when the children were fed upon a fat-poordiet. In the winter violet rays and massage provedthe most successful therapeutic agents. The X-rayappearances of the bones in varying stages are wellseen in the plates accompanying the article.-On thePhosphorus and Calcium of the Blood in RenalDisease, by 0. L. V. de Wesselow. The inorganicconstituents of the blood in renal disease were

estimated, with a view to correlating changes in theiramounts with variations in clinical symptoms.Seventy-four patients were investigated, includingcases of nephritis, albuminuria of pregnancy, and afew of surgical affections of the urinary tract andcardio-vascular disease. The conclusions arrived at

are that in cases of nephritis in which the prognosisis grave there is a marked retention of phosphates,and on the whole phosphate and urea excretion runparallel. The calcium content of the serum variesinversely with the phosphates, and a low calciumblood figure seems to be associated with the localmuscular twitching in the late stages of uraemia.—A Comparative Study of Basal Metabolism in NormalMen, by Frederick Greig Hobson. There are manyfundamental factors which influence the basalmetabolic-rate, and the author has endeavoured todetermine their relative importance in order toestablish a normal base line for metabolism. Thefactor which varies most in the different methods forestimating basal metabolism is body size, as thishas been calculated according to different formulae.The author, as the result of observations on a largenumber of healthy individuals, considers that Dreyer’sformula, using the calculated body weight instead ofthe observed body weight, gives very satisfactoryresults. The Benedict clinical calorimeter was usedthroughout, and certain defects are noted, and the Imethods adopted for their correction are described.-Critical Review. Jaundice: A Review of RecentWork, by J. W. McNee. This article opens with areference to the important advances which have beenmade during the last ten years in America, France,Germany, and Holland, and which have revolutionisedour views on the pathology of jaundice. A diagram-matic representation of a liver lobule is given as abasis for the new theory of jaundice which is detailed.The importance of Aschoff’s " reticulo-endothelialsystem" is outlined, and the advances made possibleby the van den Bergh test are described. Forclinical instruction jaundice is classified as follows :(1) Obstructive hepatic, (2) toxic and infectivehepatic, and (3) heemolytic. In addition to an

account of the technique employed in the van denBergh test the article closes with a note on the" dissociated jaundice " of the French observers, inwhich it is claimed that in certain cases of hepaticdisorders bilirubin alone may be retained in or

reabsorbed into the blood, while the bile salts areexcreted normally, or the reverse process may occur.

BRITISH JOURNAL OF OPHTHALMOLOGY. July andAugust, 1923.-In the July issue J. B. Lawford andHumphrey Neame write on Binocular ChoroidalTuberculosis with Detachment of the Retina in twokittens, recording a probably unique observation.The kittens were of the same litter. In one case thepresence of the tubercle bacillus was demonstratedin the affected choroid of one eye. In the other it wasdemonstrated not only in the eye but in variousother organs and inoculation of a guinea-pig gave apositive result.-R. R. James has unearthed variouscases of ophthalmological interest from the post-mortem records of St. George’s Hospital.-A paper bythe late Charles Killick tabulates 100 cases of cataractremoved under a conjunctival bridge. The August

issue contains, besides an appreciation of the lateGeorge Critchett (1817-1882) in the " British Mastersof Ophthalmology" series, by A. Maitland Ramsay,a paper by Miss Ida C. Mann on the Embryology ofCongenital Crescents. These may occur in any partof the disc margin, but two-thirds of them are foundbelow the disc and only a small proportion on theouter side, a fact which differentiates them from theacquired crescents of myopia. In the common formof congenital crescent the retinal pigment epitheliumand also the nuclear layers have failed to reach thelower end of the nerve, so that a small area devoid ofevery layer except nerve-fibres is interpolated betweenthe lower edge of the disc and the true lower edgeof the nerve. The embryological cause of this isa slightly abnormal development of the choroidalfissure. This is explained by reference to theembryology of birds.-Also a communication (receivedthrough the Ministry of Health) from Gordon Norrie,who is doctor to the Copenhagen Royal Blind Institute,in which practically all blind children in Denmarkare educated. Since 1900 it has been compulsory forevery midwife to instil a solution of nitrate of silver,1 : 150, into the eyes of the infant after birth. Theresult has been that blindness from ophthalmianeonatorum is almost eliminated in Denmark.

AMERICAN JOURNAL OF OPHTHALMOLOGY. May andJune, 1923.-In the May issue : Iridotasis Operationfor Glaucoma, by M. Goldenburg. This is the descrip-tion of an operation similar to that of Colonel Herbertfor effecting drainage by the inclusion of the iris inthe scar. The author has practised the operation forfive years with success.-N. Yoshida, of Japan, reportsa case of acute glaucoma following Heine’s cyclo-dialysis, an operation devised, but hardly practised inthis country, for the cure of chronic glaucoma.-J. M. Thorington, by means of a single letter, a V,and a movable screen, claims to have devised a testfor visual acuity superior to the ordinary test cards.-A. E. Foster reviews the literature of corneal graftingand adds some original experiments on cats, fromwhich he concludes that a flap of the entire thicknessof the cornea can be removed and replaced with anentirely satisfactory result, but that a transplantationfrom another species is a biologic impossibility.-Ina statistical study of ophthalmia neonatorum in -

Philadelphia, L. Lehrfeld states that one -instillationof any prophylactic is not a positive protection againstthe disease, and that a large proportion of the new-borndo not receive any prophylactic at all. Blindness fromthis cause has not been materially reduced by thepresent methods of prevention, he says, and headvocates more stringent measures, including the useof argyrol in 25 per cent. solution on three successivedays.-In the June issue H. D. Lamb reports twocases of ruptured choroid, illustrated by a plate. Oneof them is of unusual extent and shape.-C. E. Farreeand G. Rand contribute a paper showing the influenceof illumination on the size and form of the colourfields. The charts show how little dependence canbe placed on breadth or shape of field and order ofranking as to breadth, either in diagnosis or in checkingup the advance or recession of a pathologic condition,unless greater precautions are taken for the controlof the intensity of the stimulus light than are possiblein the conditions which ordinarily prevail in office andclinic work.-Two articles give instances of focalinfection from teeth and tonsils. The first, byClarence P. Jones, relates a very unusual case ofinterstitial keratitis, apparently of the typicalsyphilitic variety, but in which syphilis was excluded.It began to clear up at once on the removal of nineteeth with apical abscesses and also infected tonsils.The second article, by John Dunn, gives furtherinstances of various ocular conditions due to focalinfection. In two of them the removal of an oldblind eye proved an effective remedy.-Of theremaining artic’1 +ohe most important is one by W. H.Nardin and P "* mningham on familial retino-cerebral degeriBi1:."",’:’.u, wi‘ich was annotated in ourissue of August 18th.

467POST-HOLIDAY LASSITUDE.-DIVERTIOULUM OF THE BLADDER.

THE LANCET.

LONDON : SATURDAY, SEPTEMBER 1, 1923.

POST-HOLIDAY LASSITUDE.’l.’HAT it is not unusual for the worker of the modern

city type to return from a long-expected holiday feelingrather more tired and worn -out than when he startedis a matter of sufficiently common experience to haverendered it almost a truism that it requires a weekto recover from a holiday. The point was well illus-trated some time ago by Mr. HASELDEN in one of histrenchant cartoons, where he depicted the holiday-maker back from a period of unaccustomed swim-ming, tennis, and long tramps, wondering why he failedto feel recuperated. The cartoon served as an aptillustration of one aspect of the puzzling problem,what constitutes "form" and its absence. Apartfrom the body of purely empirical knowledge accumu-lated by generation upon generation of trainers bothof men and of animals, there has, up to the present,been a very meagre understanding of the factors whichgo to make up this condition of "form." It is commonknowledge that an amount of exercise which, indulgedin immediately after a long period of sedentary exist-ence, will produce nothing but exhaustion with itsdeleterious results, may be accomplished readily andeasily, leaving its performer fitter than before, if ledup to by a period of gradually increasing daily exer-cise. The application of this knowledge constitutes"training."The factors underlying the acquisition of form-

improvement in coordination, hypertrophy of muscles,- speeding-up of the mechanism for the removal ofmetabolites-are not altogether unknown. Littleattention has, however, been paid to the why andwherefore of the deleterious effects of heavy andunaccustomed exercise in untrained individuals. Somelight is thrown upon this subject by observationsrecently made by an American worker, Dr. G. 0.BROUN. 1 Using dogs as his subjects, this observerhas obtained evidence to the effect that several daysof hard muscular effort, following upon months of,sedentary life, result in a pronounced destruction ofthe red cells of the blood ; similar effort indulged in byanimals which had been leading an open-air life withplenty of exercise, on the other hand, had no such effect.The dogs used in the experiments had been kept cagedfor several months, the cage in this instance serving asan excellent representation of the office of the cityworker. They had been fed upon a

"

generous mixeddiet containing considerable meat," in which again theparallelism with the conditions of the city worker is veryevident. They were then exercised for several succes-.sive days upon a treadmill, the exercise being conductedfor four hours daily, in spells of two hours with an Iinterval of one hour. During one day’s exercise theyaveraged a journey of about four miles at an inclina- ’tion of 20°, or the equivalent to an ascent of somethingover a mile. It is recorded that in the early days ofthe experiment the dogs appeared very tired, but thatby the end they showed all the signs of thoroughenjoyment. Examinations of the blood as to thetotal volume of corpuscles by the hsematocrit methodand of the plasma by the vital-red proQ’ure were made

1 Blood Destruction After Exercise. Studies from the Rocke-feller Institute for Medical Research. Reprints, vol. xlv.,i. and ii., 7 and 27.

at frequent intervals before, during, and after theperiod of exercise. The findings showed a remarkableconformity ; in every instance there was a markeddecrease in the total corpuscular volume with a lessmarked increase in the plasma volume. After anaverage of a week’s exercise, Dr. BROUN found that ittook from one to three weeks for the corpuscular volumeto return to its previous level. Interest centres on thereduction of the corpuscular volume, which in one casewas as great as from 101 to 62 per cent. of the normalaverage. The author can find no explanation of hisobserved facts other than a considerable destruction ofred cells. How this destruction is brought about is notevident, but it is suggested by Dr. BROUN that it isdue to the mechanical injury of the red cells by theviolently contracting muscles. One of the factors of

training would appear to be the education of the

hsematopoietic system to replace the destroyedelements ; in the untrained animal the response ofnew blood formation appears to be delayed, in thisrespect resembling the behaviour after haemorrhagein a normal animal.

Hints of some such phenomenon of blood destructionaccompanying unaccustomed exercise have beenconveyed by previous observations; for instance,FETGL2 was able to demonstrate traces of haemoglobinand heematin in the serum and urine of untrainedsoldiers after hard marching ; but the present observa-tions are up to now the clearest and most convincingon the subject. There has always been a tendency tolook upon post-holiday lassitude as a purely psychicaffair. It is worthy of note that the lassitudemay have a physiological basis.

DIVERTICULUM OF THE BLADDER.]-)IVERTICULA of the urinary bladder, as distinct

from the multiple sacculations seen in cases of urethralobstruction, are comparatively rarely met with. Forthis reason little general attention has been paid tothem. This is the more unfortunate in that propertreatment is able to effect a complete cure of thesymptoms which arise from them, whilst neglect is

invariably followed by urinary troubles which arebound to lead eventually to the death of the patient,though the end may be delayed by years of ill-healthand intermittent suffering. Mr. J. SWIFT JOLY, else-where in this issue, relates his experience of this con-dition. He has treated 14 cases by various methods,and has been able to trace the subsequent history ofthe majority of them. A perusal of his paper showshow many years it takes a urinary surgeon to acquirewhat, in comparison with many other diseases, mustbe considered a very moderate experience. The fulldescription of his cases, therefore, together with theconclusions at which he has arrived, form a veryvaluable contribution to the subject, and will doubtlessserve as a guide to other surgeons who have only hadthe opportunity of dealing with an occasional case.In a recent review3 of this disease, llr. W. GiRLiNGBALL relates the successful cure of two men byexcision of the diverticulum, and gives a good accountof views which have been held of the pathology ofoffsets from the bladder cavity.The balance of evidence seems to be in favour of a

congenital origin for these diverticula, very probablyan abnormal budding out of the embryonic ureter.Curiously enough, they do not as a rule give rise totrouble until after the age 40, and the symptomswhich call attention to them are then usuallv those ofinfection. The seriousness of the situation lies in the

2 Biochem. Zeitschr., 1916, lxxvi., 88.3 St. Bartholomew’s Hospital Reports, vol. lvi., part 2.