935REVIEWS AND NOTICES OF BOOKS.

Reviews and Notices of Books.A Manual of Pharmacolo{JY and its Applieations to Ther6

peuties and Toaeieolo{JY. By TORALD SOLLMANN, M.DProfessor of Pharmacology and Materia Medica in thSchool of Medicine in the Western Reserve UniversityCleveland, U.S.A. With 29 figures in the text. Londoand Philadelphia : W. B. Saunders Company. 19nPp. 901. Price 20s. net.

THE revision of the United States Pharmacopoeia haapparently induced Professor Sollmann to bsue a nev

edition of his well-known text-book, or rather, it might bi

said, to write a new one, for the changes are so many an(the outlook in therapeutics so different since the first editioiappeared in 1901 that it cannot be regarded as a menrevision. As is stated in* the preface, the book has tw(

objects : first, to convey the broad conceptions and generalisations which are necessary for the everyday work of thestudent and practitioner and which must be assimilated irundergraduate days ; secondly, to serve as a book of refer.ence in regard to questions which may present themselves ajany time in the use of drugs, and in the instructionof more advanced students. With these objects inview, the manual is printed in two types, the largeisubserving the first of giving a general view while thesmaller type deals with less essential details. Opinionsmay, differ as to the appropriate allocation of some

paragraphs, some of those printed in small type might bedignified with the larger, and vice versa, but, on the whole, thecompromise seems satisfactory. In the smaller type the recentliterature is succinctly dealt with ; we wish that ProfessorSollmann had more often expressed his own views in regardto contradictory statements cited ; his wide experience inexperimental work would often aid in determining contestedquestions where ordinary readers may have difficulty fromtheir unfamiliarity with the original papers and their

ignorance of the capacities of the conflicting writers.The arrangement of the chapters in a text-book ot

pharmacology presents great difficulties and has not been

entirely successful in any hands so far. Professor Sollmannstates that he follows in the main the classification intro-duced by Buchheim, and as far as the grouping of veryclosely related bodies-for examf le, the atropine class-heagrees with that adopted by all the better text-books of theday. But we have failed to understand on what principlethe larger arrangement is based. Has the author given itup in despair ? For example. why should phlorhizin be

placed in the midst of the animal extracts and why is thediscussion of anaphylaxis inserted between the paragraphon viburnum and the chapter on nitrites ? IOn some minor points we would join issue with the i

author. He seems to doubt the identity of yohimbine withquebrachine, though this was established by Fourneau’sresearches, for he appends the former rather notoriousalkaloid to the cocaine group and makes no reference toit under aspidosperma. It may be doubted whether chloro- Iform or morphine causes the appearance of glycuronic acidin the urine, but the juxtaposition of these drugs with chloraland camphor (p. 477) suggests that the evidence is equallyvalid for all four. Professor Sollmann still encourages theuse of alkali carbonates along with the salicylates, although I’this is deprecated by most authorities who have worked on Ithe subject. On p. 551, the concentration of alcohol in theblood of drunkards is stated to be sometimes as much as I21 per cent., an impossible number; it is obviously a mis-print for 24 per mille.These are, however, trivial blemishes ; the Manual is a

most successful presentation of the present knowledge of theaction of drugs in health and disease, and is a mine of infor-mation from which both student and practitioner may draw i

with benefit and with confidence. We can cordially recom- lmend it to their attention, and wish it a wide circulation in lthis country as well as in the United States. One featurethat will prove of special value to workers on therapeutics inthis country is the full treatment of the valuable work doneby many clinical and experimental investigators under theAmerican Medical Association and independently. Thesepapers are sometimes difficult to obtain on this side of the n nAtlantic, but they have justice done them by the author, n

The more important preparations of the United States and pthe British pharmacopoeias are discussed, and some of those c

of the various pharmaceutical commentaries. A very useful

bibliography extending to nearly 60 pages is appended. Thedirections for practical laboratory work for students, whichformed a feature of the first edition, is omitted in this one,

’1/- but is promised in the form of a separate volume.

te Malingering and Eeigned Si()7lness, with Notes on the

, Workrnf’n’s Compensation A()t, 1906, and Compensatiann for Inj2lry, including the Leading Cases Thereon. By Sir7. JOHN COLLIE, M.D Aberd., J.P., Physician, Hospital for

Epilepsy and Paralysis, Maida Vale; Honorary andtS Temporary Lieutenant-Colonel, R. A.M. C., &e. Illustrated.;v Second edition, revised and enlarged. 1917. London:e Edward Arnold. Pp. 680. Price 16s. net.dTHE first edition of Sir John Collie’s useful and practicaln work on "Feigned Sickness" was published in 1913,e and he mentions in his preface to the second thato " much of the leisure time of four years has been spent- in amplifying and bringing it up to date."e The war is naturally responsible for a new chapter on 11 Mili-tary Malingering," but the additions deal chiefly with phases- of the main subject more closely connected with industrialt and social conditions in normal times. Chapters have been1 , added upon self-inflicted injuries, upon malingering ini connexion with skin affections, miner’s nystagmus glycos-f uria and incontinence of urine, upon the Workmen’s Compen-! nation Act, 1906, and scheduled diseases, "return to work,"s the effect of recent legislation upon sickness and accident claims, suppuration and its prevention, immobility after; joint injury, rheumatism and fibrositis and their relationshipto accident, and upon the ligaments and muscles of the

back. Many illustrations have also been added. The’ quite valuable chapter upon " Return to Work " ex-

plains and discusses the drawbacks which accompanythe advantages attending the invitation issued frequentlyI by employers to injured workmen to resume their dutieson full wages which, in fact, they are not capable of

earning. The author’s observations on the policy ofworkmen’s compensation and its administration are well

worth the consideration of employed, employers, and theirlegal advisers.Sir John Collie seems to be as well conversant with

the legal as with the medical side of his subject. Wemay call special attention to the chapter on the conductand position of medical witnesses, which will be found

among those towards the end of the volume which dealwith more or less legal matters, for it contains informationwhich anyone expecting to be called as a medical witnessmight lead with advantage. We have here a brief summary ofthe question of such a witness’s privilege, together with soundadvice upon the manner in which the witness should prepare

for his task and comport himself when fulfilling it. Some

of the author’s maxims upon conduct in the witness-boxare amusirgly precise, but his instruction to "Watch thejudge’s pen " would have had to be qualified a few years agoby the exception" unless it be Sir Fltz James Stephen," forthat distinguished but sometimes rather peremptory judgeused to declare himself disconcerted by a witness who timedhis replies by observing when his lordship’s notes were com-pleted. There may be others even now whose nerves are

similarly affected, though they be less emphatic in theiradmission of their peculiarity. That a witness should be" exact, lucid, and succinct" is, of course, desirable,whether he be a medical man or not, and Sir John Collie’swriting forms a good example of these virtues. Thesecond edition of his work amplifies the information in thefirst, and deals satisfactorily with a subject of growing im-portance and with a large literature accumulating round it.It can safely be recommended to medical men concerned withthe examination of persons whose interest it is to feign or toexaggerate symptoms of disease, and we may add the hopethat it will noc be introduced too liberally into those freelibraries in which, it is said, the malingerer is able to trainhimself to play his part.

Insanity in Everyday Practice By E. G. YOUNGER,Insanity in Everydccy Practice By E. G. YOUNGER,-M.D Brux., M.R.C.P. Lond. Fourth edition. London:Baillière, Tindall, and Cox 1917 Pp. 134. Price 5s. net.

IN this new edition Dr. Younger has added brief notes onneurasthenia as seen during the present war, and on thenodern cult of psycho-analysis. The latter, whatever itsPsychological interest, he finds unlikely to be of assistance inlases of insanity met with in general practice.

936 REVIEWS AND NOTICES OF BOOKS.

The Treatment of Diabetes Mellitus. With Observations uponthe Disease based upon Thirteen Hundred Cases. ByELLIOTT P. JOSLIN, M.D. Harv., M.A. Yale, AssistantProfessor of Medicine, Harvard Medical School, &c.Second edition, enlarged and thoroughly revised. Illus-trated. Philadelphia and New York : Lea and Febiger.1917. Pp. 559. Price$4.50.

IN recent years the study of metabolism has been vigorouslyprosecuted in the United States of America, and the researchwork that has been done there has contributed largely to ourpresent knowledge of the subject. Among other problemsthat have attracted attention and been attacked with a con-siderable degree of success are those relating to the dis-turbances in the chemistry of the body met with in diabetesmellitus. Although the essential causes of the condition areas yet obscure, sufficient new information has been obtainedradically to alter many of our previous conceptions of thedisease and its complications, with resulting changes intheir treatment. This state of things has been contributedto by a number of observers, most of whom have beenenabled to carry on their work through the far-sightedgenerosity of wealthy Americans who have founded labora-tories where research can be carried on under ideal condi-.tions of endowment and equipment, but the improvement inthe immediate outlook of patients suffering from diabetes islargely owing to the painstaking researches of Dr. F. M.Allen, of the Rockefeller Institute of Medical Research,who demonstrated first on animals and subsequently onman the increase in carbohydrate tolerance that may be

brought about by prolonged fasting and regulated physicalexercise in the diabetic condition. Since Allen publishedhis results in 1913 a number of text-books dealing with thismethod of treating diabetes have appeared, but in none ofthem has it been so thoroughly and authoritatively dealtwith as in that written by Dr. E. P. Joslin, assistant pro-fessor of medicine at Harvard. The first edition of Dr.Joslin’s book, appearing in 1916, was quickly exhausted, andis now followed by a second, which has been enlarged andlargely rewritten. In the additional 120 pages or more ofthe new edition questions raised by doctors and patientssince the previous publication are dealt with, and a largeamount of fresh material has been introduced. The further

experience gained in the treatment of 300 additional caseshas been made use of and enabled the author to give a moredefinite description of the treatment he finds most successful,besides showing in what respects it has been found advisableto deviate from the plan, based upon Allen’s originalexperiments, previously followed.The most notable innovations in this edition are the new

teaching with regard to the treatment of acid intoxicationand the limitation of the initial fasting period. Dr. Joslinnow condems the use of sodium bicarbonate to combatacidosis, holding that the dangers attendant upon the

employment of this or any other alkali far outweigh theiradvantages even in impending coma. Instead he wouldprevent the development of acid poisoning by controllingthe fat in the diet from which the acid bodies are mainlyderived ; this he considers is safer, easier, and more agree-able for the patient. As it’ is not the fat itself that isharmful but the suddenness with which the ratio of fat tocarbohydrate in the diet is changed, any alteration must begradual, bearing in mind that an excess of carbohydrateis often less harmful to a diabetic than fat with littleor no carbohydrate to promote its utilisation. In orderto prevent the appearance of acidosis during fasting,and to control it when present, great care is advisedin preparing the patient for the withdrawal of food. As afirst step fats should be omitted from the ordinary diet;a couple of days later the proteins are dropped ; next the Icarbohydrate is halved until only 10 grammes are being litaken, and not until then is the fast commenced. When theurine has been rendered sugar-free the precautions against acid poisoning are continued by increasing the diet in thereverse order, commencing with carbohydrates, passing toproteins, and finally adding fat, to which the patient mustbe gradually accustomed, for " although fat forms the chiefconstituent of a diabetic’s diet he must not be poisoned withit." Considerable stress is laid, too, upon the importance ofa sufficient quantity of liquid being taken, especially liquidscontaining salts, such as brnths and mineral waters. bypatients during the fasting period and when acid intoxica-tion assumes threatening proportions. Dr. Joslin maintains

that the exclusion of salt from the diet of a severe diabetichastens coma and that occasionally a case of coma may berescued by the free use of salt. Since these principleshave been adopted the proportion of deaths from comahas fallen from 64 per cent. for the 18 years endingDec. 18th, 1915, to 44 per cent. for the year 1916.It is important to note, however, that a new cause ofdeath has made its appearance in Dr. Joslin’s statistics,three patients having succumbed to inanition. It is

probably in part owing to this that he has discontinuedthe long fasts, originally advised by Allen, that are occa-

sionally necessary to free the urine from sugar at the firsttrial, and now limits the initial fast to four days. If glycos-uria persists at the end of that time a system of inter-mittent fasting is employed, periods of abstinence from foodof diminishing length being interspersed between periodswhen a limited diet is allowed. It is stated that with thisplan no uncomplicated case has failed to become sugar-freeand the expectation of life has been prolonged. Formerlythe first year after the discovery of diabetes proved to be themost dangerous, 68 per cent. of deaths occurring in thatperiod, but now the mortality has fallen to 17 per cent. forthe first year, and the second has come to be the mostdangerous.

In his enthusiasm for a new method Dr. Joslin does notforget that in the past good results were obtained with themajority of diabetics without systematic fasting, and thatgradual restriction of the carbohydrate intake was the meansgenerally employed. When this is combined with carefullimitation of the protein and fat allowance even betterresults are secured and actual fasting often becomes un-necessary. It is chiefly in the management of long-standing,complicated, obese, elderly, and severe cases that he findsAllen’s method has simplified the treatment and proved ofgreatest service, but even here it must be used with discre-tion and understanding. Fasting resembles in its action thedrugs morphine and digitalis ; they frequently give sur-

prisingly good results even when carelessly employed, butthey often do harm, and their true worth can only berecognised when they are prescribed with intelligence. Itshould always be borne in mind that when a patient’sstrength has been diminished by fasting an incorrectlybalanced diet will sooner or later cause a return of theglycosuria with increasing acidosis, and that the last s’ageof the case will then be worse than the first. It is com-

paratively easy to get the urine of a diabetic free from sugar,but to keep him so, and in good health, is much moredifficult. The determination of the carbohydrate toleranceis only a small part of the problem ; the fats and proteinsmust also be given in proper amounts, and the patient mustbe educated to carry out his diet with understanding, whileappropriate changes in the food allowance must be madefrom time to time to meet changing circumstances. Thesooner the treatment is started the more thoroughly it iscarried out ; and the more completely the patient understandsthe principles on which it is based the better will be theresults. So impressed is Dr Joslin with the importance ofearly diagnosis that he would advise everyone to have theurine examined at least once a year on some fixed day, suchas a birthday.

It is claimed that one of the great advantages of thefasting treatment is its simplicity, complicated analyses ofthe urine, blood, &c., being rendered unnecessary, and wehave it on Dr. Joslin’s own authority that he keeps hislaboratory records on slips six and a quarter by one and one-sixth inches, "so as not to impress the patients with awe."In mild cases simple qualitative and quantitative methodsare no doubt sufficient to allow of satisfactory regulation ofthe treatment, but we cannot agree that it is true in severecases where secondary disturbances of metabolism haveoccurred and where the utilisation of protein and fat, as wellas carbohvdrate, is seriously at fault. The problem is thentoo complicated to be solved by the imperfect data affordedby such analyses or by any rule-of-thumb procedure, theinterests of the patient demand that all the information tobe secured by a complete investigation of his defectivemetabolism by every method known to modern science shouldbe employed and to withhold even part, simply because itinvolves a considerable amount of laborious work, cannot begood treatment, although it may make it easier for the

physician. It is possibly owing to the fact that Dr. Josltnconsiders more than simple methods of analysis of theurine now unnecessary that the section of his book dealing

937REVIEWS AND NOTICES OF BOOKS.

with the chemistry of the urine is the least satisfactory paof it. To mention only one example, we should have thouglthat, even in a book entitled The Treatment of DiabetEMellitus," a more adequate account of the reducing sulstances other than dextrole met with in the urine would havbeen desirable than is given in the page and a half devoteto the subject, for in addition to the question of differentisdiagnosis it is surely worth considering whether their presenccalls for some particular treatment. It is now generallrecognised that analyses of the urine should be controlle,by examinations of the blood and respiration as much apossible, and that the aim of our treatment should be noonly a sugar-free urine, but also a normal sugar and lipoi,content of the blood with a normal carbon dioxidtension of the alveolar air. A thorough account of thmodern methods employed in these estimations is give]by Dr. Joslin, who devotes nearly 40 pages to theiiconsideration. He emphasises the importance of exercis,in reducing hyperglycsemia, and points out that Allen hashown that a single fast-day with exercise may reduce th,blood-sugar as much as several fast-days without exercisewhile his clinical experience indicates that patients retaiitheir strength and appearance better during fasting whetmoderate exercise is taken than when they are allowed tcremain in bed.

In agreement with most modern writers on diabetes DrJoslin is averse from the routine employment of drugs, especially those that are supposed to control the excretion o:

sugar, and states that in his experience those who use drug:most examine the urine quantitatively the least. Thfadministration of medicines to control the glycosuria caronly be regarded as a confession that a proper diet has n01been prescribed ahd that the confidence of the patient ha!not been secured. His rule is to wait at least a year before

prescribing any drug. Since diet is the keystone of treatment,it is necessary that every physician who undertakes thecare of a case of diabetes should make himself thoroughlyacquainted with the composition of the food materials thatare commonly used. For that. purpose the information andtables given in this book will be fuund of great service, forthey include the standard analyses of American foods com-piled by Atwater and Bryant and also figures abstractedfrom the special reports on so-called diabetic foods made byStreet for the agricultural experiment station of New Haven.Wiih regard to these anaty.-es of "diabetic foods it shouldbe noted that although some of them contain only a verysmall percentage of carbohydrate their protein content isalmost invariably high and that they are therefore capableof furnishing a large amount of sugar. Failure to recognisethis fact, and the fraudulent character of many ofthe most widely advertised bnad substitutes have beentwo of the commonest causes of fflilure in the treat-

ment of many cases of diabetes in the past. Theiruse should be discnuraped. at any rate at the beginningof treatment, and if they are alloweii later they should beemployed for one, or both. of two definite purposes : (1) Asan aid in determining carbohydrate tolerance ; (2) whenthe tolerance has been learnt. a, a food containing a reducedamount of carbohydrate. In either case it is essential thattheir exact composition should be known and that theyshould not be prescribed indiscriminately hut. in definiteamounts. Dr. Joslin considers that no patient should beallowed to become dependent upon special diabetic foods ; ;they are expensive, are sometimes unoht,ljinable. alwaysmake him conspicuous, and may eventually become so

nauseous that it is difficult to adhere to a diet containingthem One of the great merits of modern methods of

treating diabetes is that the use of special foods is un-

necessary, for by a quantitative regulation of the diet suchas is now generally employed most diabetics are ahle to takeordinary foodstuffs in Rufficient amounts to meet their

requirements and yetavoid glycosuria. The untreated diabeticis a fo()d spendthrift. and. according to Dr. Joslin, the foodhe wastes in a week may he sutficirnt to ferd a soldier for aday. a matter of no small importance at. the present time.The prevention of this waste is largely in the hands of themedical profession. as the elimination of unutilised sugar inthe u’ine by moct diabetics can he av. ided by early diagnosis,prompt treatment, and anirahle education of the patient.To those who wish to make themselves famitiar with

Allen’s method, so as to give their patients the benefit ofits most recent developments, we can thoroughly reco mmend

this book, which is dedicated to the Medical Profession of

ht the United States of America and her Allies, upon whomes devolves the training of their million diabetics." It bearsb- the stamp of wide clinical experience, combined withve scientific knowledge, and presents in an eminently readablesd manner a subject full of difficulties and pitfalls for theal unwary.;e

LIBRARY TABLE.

Practical Guide to Diseases of the Throat, Nose, and Ear,for Senior Students and Junior Practitioners. By WILLIAM

d LAMB, M.D Edin., M.R.C.P. Lond. Fourth edition. London :Baill1ère, Tindall, and Cox. 1917. Pp. 372. Price 8s. 6d. net.-

e This helpful guide to the beginner has been revised and brought

n up to date for its new issue after three years. The author has

r contented himself with filling up various small lacunæ with-

e out adding materially to the size of the book, which will be

s found, as before, to fulfil its modest purpose admirably.e Eleatro-Therapeutics for Military Hospitals. By WILFRID, GARTO, M.R.C.S., L.R.C.P. Lond., Temporary Captain,R.A.M.C. London : H. K. Lewis. 1917. Pp. viii. + 48. Pricen 2s. 6d. net.-This small monograph consists essentially in ao plea for the more general use of electrical applications in the

many disabilities brought about in the course of the presentr. war. While the author is right in his contention that’- electro-therapeutics have not received full employment,f there is nevertheless much cause for gratification in thes enormous development of the use of these methods sincee the war began. We have only to visit one of the manygeneral military hospitals, or more particularly one of thet several orthopaedic hospitals, to see how much electricals treatment is now relied upon to alleviate and cure the resultsleft by wounds and disease. The author tells us nothing, that is new to those who specialise in this line of work,but his book will be of help to those who have to carry outelectro-therapeutics, especially in military hospitals.t Sanitary Law and Practice: A Handbook for Students ofPublic Health and Others. By W. ROBERTSO,11, M.D. Glasg.,rand CHARLES PORTER, M.D, Edin. Fourth edition. London:’ The Sanitary Publishing Co., Ltd. 1917. Pp. 750. Price

12s 6d. net.-The stasis in health legislation has necessi-tated little alteration in the text of this handbook since its

’ last appearance five years ago, and 20 pages of appendicessuffice for the summary of recent Acts and regulations. The

’

handbook facilitntes a study of the heterogeneous mass ofconflicting data which constitutes our present sanitary code

as far as such help is possible, but we sincerely trust thiJ,t by’ the time the next edition is called for the whole precarious

edifice may have been bonded together by a Ministry ofHealth into a single consistent structure. We doubt notthat the authors will welcome this addition to their labours.

Easy Italian and How to Pronounce It. By CaptainKEYWORTH. Third edition. Hove: Combridges. Price 3d.-In this little book Captain Keyworth puts out in conver-sational form the phrases that would be most useful to thestranger, especially the soldier, who found himself in Italyin circumstances where a little knowledge of the languagewas made necessary by his circumstances. The questionsnecessary to find a locality or a route, to obtain food, drink,lodging, or clothing, to obtain a date or reach a hospitalor a doctor, are simply set out in English and Italian, and inthe latter language they are spelt out phonetically. A fewmilitary terms are given, and, to meet the exigencies of thewoun(ie(i in particular, the Italian terms for the parts of thebody are included.

L’ Exploration Radiologique des Voies Urinairvs. Byle Dr. ARCELIN. Chef de Service de Radiologie à 1’HopitaISaint-Joseph et à l’Hôpital Saint-Luc. Paris: Masson etCre. 1917. Pp 175. Price 6 francs.-This work is one of

Special appeal to all those who are more or less directlyicterested in the X ray examination of he urinary system,compri.,ii3g as it does all the latest id.’as of the Frenchschool on this very important subject. The work is so

written that it will be of value to the physician and thesurgeon as well as tn the rarliologist, and eath will finddetailed information on almost any phase of the subject inwhich he is more particularly interested. The illustrationsand ’diagrams leave nothing to be desired, and a veryvaluable chapter is devoted to the localisation of projectilesin the vicinity of the urinary organs.

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