317REVIEWS AND NOTICES OF BOOKS

produced all the results it seemed to do. Each childneeded studying individually, and he would like

every school to have a medical officer who knew

every child personally. Boys survived the effectsof too much homework by refraining from doing it.The burden should be measured according to the

ability of the individual child. It was essential to

give children some free time after breakfast, and tobring them directly from work to the midday meal.If there was a gap, they filled it with a visit to thetuck shop.

Miss E. M. TANNER, head mistress of RoedeanSchool, remarked that girls had not the same self-protective ability as boys when afflicted with toomuch homework.Dr. E. K. LE FLEMING said that the physical

education committee had discussed the burnt-outathlete with Mr. H. M. Abrahams, who had saidthat boys were often so worn out by physical trainingthat they failed to develop to a maturity of excellence.Mr. Lindsay had found the same thing on the intel-lectual side. It was difficult enough to assess physicalfitness ; and the present methods of mental assess-ment were wrong. Qualities of value in outside lifewere not examined for, under our present system,and therefore were not cultivated as they should be.

Miss M. T. TALBOT said she was a cookery instructorin a poor district, and she considered not enoughattention was given to local tastes in drawing updietaries. Tastes varied greatly in different districts,and it should be possible to begin with those articlesin the local diet which were good and build up adiet based upon them.

Dr. J. G. WOOLHAM drew attention to the valueof the Royal Air Force tests for assessing physicalefficiency.-Sir ROBERT MCCARRISON urged the

value of a proper supply of vitamin B, which wasmainly distributed in grain ; the more purified thecereal the less the vitamin-B content. He also putin an approving word for the herring as an articleof diet.-Dr. MoRTLOocK BROWN entered a plea fora piped water-supply in labourer’s cottages. Muchmoney had been spent to subsidise certain food-stuffs but very little to ensure safe and adequatewater-supplies. This handicapped particularly themothers in the management of their homes.

Dr. GEORGE V. PORTER, of Toronto University,said that physical training was compulsory at alluniversities in Canada and the United States. As aresult, all students had to submit to examinationby the medical staff, and this made it possible forthe doctor to advise the student on points affectinghis choice of career and his future.

Mr. WARREN DERRY, head master of Wolverhamp-ton Grammar School, reminded his hearers that

people who talked of the hard lot of children in

secondary schools seldom compared them withchildren of the same age employed in industry. Asixth form boy did 40 hours work a week and had15 weeks’ holiday yearly.Dr. D. R. EDWARDS mentioned the value’ of

swimming as a form of physical training.-Dr. R. E.SMITH, medical officer of Rugby School, said thatone symptom of overwork was for a boy to be woundup like a clock. If you put him to bed and gave hima Strand Magazine he instantly began to do the

"perplexities." These boys responded well tosmall doses of bromide. He thought the scale of

games should be reduced for small boys. Boys atpreparatory school played cricket on a pitch 21instead of 22 yards long, but it should be muchshorter.-The openers of the discussion replied.

REVIEWS AND NOTICES OF BOOKS

The Extra-Ocular MusclesA Clinical Study of Normal and Abnormal OcularMotility. Second edition. By LUTHER C. PETER,A.M., M.D., Sc.D., Professor of Diseases of the

Eye in the Graduate School of Medicine of theUniversity of Pennsylvania. London : HenryKimpton. 1936. Pp. 351. 21s.

Dr. Peter’s monograph, long a standard work,has now been brought up to date. The first part-nearly a quarter of the whole book-gives a goodaccount, first of the anatomy and fascial connexionsof the eye muscles and the paths of the nerves whichconnect them with the brain, then of their physio-logy ; and in this connexion the point is stressedthat in any movement of the eye all the musclesand not merely one or two are concerned. Thereis also a section on the theoretical aspects ofbinocular vision.The second part of the book deals with hetero-

phoria and its various forms, their symptoms andtreatment. Heterophoria implies that the externalmuscles are not perfectly balanced, so that even inthe position of rest some of them have constantlyto do extra work in order to maintain binocularvision. Some sorts of want of balance may be com-paratively innocuous, others may prove too great astrain on the nervous system and may thereforerequire treatment either by prismatic glasses or

in rare cases by operation. Errors in the verticalmeridian are always more important than those inthe horizontal, but the sort of error that is liableto produce most disturbance of all is a want of

balance in the muscles causing torsion of the eyeball-cyclophoria. It is often associated with obliqueastigmatism, and an accurate correction of the refrac-tion may be enough to relieve it. If it is not, theauthor discusses treatment by exercises with cylinderscalculated to strengthen the weak muscles or thepossibility of prescribing weak cyclinders calculatedto relieve them of some of their work. In any casethe first essential in treating any form of hetero-phoria is accurate refraction.The next part of the work deals adequately with

" heterotropia" or concomitant squint, and someattention is paid to the modern treatment by orthopticexercises, though for a full account of the methodsnow being tested it would be necessary to go else-where. Paralytic squint is then fully discussed, andthen follows a section on surgical technique in whichthe author’s favourite methods of operation are

described. The work closes with a short sectionon nystagmus. The book affords a comprehensiveview of its subject.

Manual of EmergenciesThird edition. By J. SNOWMAN, M.D., M.R.C.P.London : John Bale, Sons and Danielsson Ltd.1936. Pp. 401. 10s.

IN this third edition Dr. Snowman has incor-

porated the modifications and advances which haverecently been made in our knowledge of the natureand treatment of the dangerous emergencies of

medicine, surgery, and obstetrics. The book covers

318 REVIEWS AND NOTICES OF BOOKS

a wide field, including the respiratory, circulatory,nervous, alimentary, and genito-urinary systems,as well as an account of acute poisoning and theemergencies which occur in midwifery. It is intendedprimarily for general practitioners, and since it isof such a size that it may be slipped into a pocketor a small hand-bag it may well prove a valuable

help in many difficulties. It is true that the bookcontains nothing which cannot be found in standardtext-books, and that the industrious student will havemade his own abstract of its subjects in the courseof his reading. But it is convenient to have thetreatment of emergencies grouped together in one

small volume, especially when there is little or notime to spare for hunting for the necessary facts.Some of the advice offered is clearly the fruit of theauthor’s experience, and therefore most useful; inother sections the treatment advocated has just asclearly been taken from the printed word and istherefore of much less value. This applies parti-cularly to many of the surgical emergencies, thedescription and management of which require cor-

rection and elaboration. The fact that the mostalarming incidents in a doctor’s life fall into thiscategory provides some justification for the argu-ment that the experience gained as a house surgeonis an essential preparation for the emergencies ofpractice.

Recent Advances in Genito-Urinary SurgeryBy HAMILTON BAILEY, F.R.C.S., Surgeon, RoyalNorthern Hospital; Consulting Surgeon, ClactonHospital; Surgeon and Urologist, Essex CountyCouncil; and NORMAN M. MATHESON, F.R.C.S.,Surgeon, Central Middlesex County Hospital.London: J. and A. Churchill Ltd. 1936. Pp. 213.158.

IN the 200 odd pages at their disposal, the authorshave collected in this book everything that is neces-sary to bring up to date the knowledge of a readerwho already has a sound groundwork in genito-urinary surgery. In a work of this kind, compressionis essential so that only the briefest outline of surgicaltechnique or diagnostic methods can be given, andit is especially to the genito-urinary expert or thegeneral surgeon with a good knowledge of this

specialty that the book will appear invaluable. Anyone of these who opens this book will read it fromcover to cover and will marvel that so much valuableinformation can be compressed into so small a com-pass. In several places the whole of a new operativetechnique is epitomised in a single drawing, andepitomised more clearly than could be done bymany paragraphs of text. The illustrations are

excellent and the general make-up of the bookmaintains the high level established in this series.

Handbook of SurgeryBy ERIC C. MEKIE, M.B., Ch.B., F.R.C.S. Edin.,Medical Officer, Malayan Medical Service; for-

merly University Tutor, Royal Infirmary, Edin-burgh. Edinburgh : E. and S. Livingstone. 1936.

Pp. 699. 12s. 6d.

WITH recent developments text-books of generalsurgery have of necessity increased very much insize. The modern student has no light task whenhe sets out to read one of them for his pass examina-tion ; and, when he has systematically worked

through it, he may find himself with insufficienttime for a second reading. It is then that he should

turn with gratitude to this small book. Though ithas 700 pages, their size is small, and they containa thoroughly sound epitome of surgery, by thestudy of which the student will find himselfable to revise large sections of his subject in a veryshort time. Indeed if he keeps his larger treatise byhis side for reference where the facts in the smallerbook appear to need amplifying he will find himselfgetting through his work in a convenient and efficientway. Mr. Mekie has the gift of making his subjectclear in a minimum of words. He has summarised

surgery in an attractive and readable fashion. Ifthe student realises the limitations of this manual hewill undoubtedly derive profit from its use.

A Manual of the Common ContagiousDiseases

Second edition. By P. M. STIMSON, M.D., AssistantProfessor of Clinical Pediatrics, Cornell UniversityMedical College. London : Bailliere, Tindall andCox. 1936. Pp. 440. 18s.

THIS is the second edition of a book designed topresent in compact form and in concise manner

the salient features of the common contagiousdiseases and recent developments in knowledge ofthese diseases. Dr. Stimson is visiting physician tothe Willard Parker Hospital, New York, and hisbook, written to meet the requirements of bothmedical students and nurses in infectious diseaseshospitals, reflects the practice of that well-knownand progressive hospital. Competent accounts are givenof the common acute specific infections of the upperrespiratory tract-i.e., of those diseases which are con-veyed mainly by droplet spray, thus excluding mentionof erysipelas, the enteric group, and the dysenteries.The descriptions of meningococcus meningitis(Chapter XIII.) and of poliomyelitis (Chapter XIV.)are of outstanding merit, especially the latter. It is

noteworthy that in every instance the account ofmethods of prophylaxis takes precedence of treat-ment. This is as it should be. For those whose worklies in fever hospitals or in children’s wards one ofthe most valuable chapters is the last (Chapter XV.);nearly 50 pages are devoted to the general manage-ment of contagious diseases. The account of medicalaseptic technique as carried out at the WillardParker Hospital will come as a revelation to thosewho imagine that the medical administration of a

modern fever hospital is a simple affair. The authorconsiders that " to carry out an adequate medicalaseptic technique in a ward, pavilion or entire hos-pital, the services of two nurses for each three patientsare desirable." When, he adds, fewer nurses thanin this proportion are provided, cross-infection,complications, and deaths are apt to increase, andin addition this expensive hospitalisation of patientswill be unnecessarily prolonged. Training in aseptictechnique is not confined to the medical and nursingstaff at the author’s hospital; ward maids andporters also receive adequate instruction. It is a

pity that the price of this book is likely to provesomewhat high for the pockets of many nurses inthis country, because it is one which every nurseengaged in the care of sick children would do wellto read and to possess. The three plates borrowedfrom another work are really not very informative;unless these illustrations of the exanthemata are

reproduced in full colour and by the most expensiveprocesses they are rarely worth while and merelyadd to the cost of the book.

319HYPERTENSION : THE HEN AND THE EGG

HYPERTENSION: THE HEN AND THE EGG

THE LANCET

LONDON: SATURDAY, AUGUST 8, 1936

VOLHARD was the first to point out that patientsafflicted with high blood pressure can be dividedinto " red " and " pale " types, the former com-prising cases of essential or benign hypertension,the latter including the more serious nephriticvarieties, malignant hypertension and eclampsia.VoLHARD suggested that both the pallor andthe high blood pressure of " pale " hypertensionmight be due to the presence of vasoconstrictoragents in the blood. But it is one thing to postulateand another to demonstrate. Bogrr studied the

problem, at VoLHARD’s suggestion, and reportedthat alcoholic extracts of blood obtained from"

pale "

hypertensives raised the blood pressureof anaesthetised cats. WEISER, MLARX, and HEFKE,and ANSELMINO and HoFFMANN confirmed BoHN’s

findings. On the other hand DE WESSELOw andGRIFFITHS, PAGE, AITKEN and WrrLSON and othershave been unable to do so.These discordant findings, attributable to the

technical difficulties and numerous sources of errorencountered in demonstrating pressor bodies, haveled to widespread scepticism and, in Englandand America at least, opinion has been driftingtowards the belief that the search was hopeless.Much interest is therefore likely to be arousedby a paper 1 in which Prof. PAUL GOVAERTSpresents strong evidence for the existence of

pressor agents in blood-serum, cerebro-spinalfluid, and alcoholic extracts of serum obtained fromcases of " pale " hypertension. Dr. GovAERTSuses anaesthetised dogs as test animals, recordsthe carotid blood pressure, and injects the testfluid into the saphenous vein. In 11 cases of

nephritis with high blood pressure, malignanthypertension, and eclampsia injections causedconsiderable rises in the animals’ blood pressure.In non-hypertensive uraemia (7 cases), benignhypertension (7 cases), and in miscellaneous con-ditions unaccompanied by hypertension (19 cases)consistently negative results were obtained. The

agent responsible is neither adrenaline nor pituitrin,for extracts prepared from blood to which thesehormones had been added were inactive. Noris it, apparently, a product of normal metabolism,since no trace of it could be recovered from normalblood. There is, however, substantial evidenceincriminating tyramine, or some closely alliedsubstance. It is known that constriction of therenal arteries of an animal leads to systematichypertension and the appearance of tyramine inthe circulating blood. Tyramine has also beenfound in the blood in " pale " hypertension, and,finally, Dr. GovAERTS has found that he can get

1 Ball. de l’Acad. Roy. de Méd. de Belgique, 1936, 6th ser.,i., 141.

pressor responses, very similar to those obtainedwith hypertensive blood, by injecting solutionsof tyramine. He therefore advances the tentative

suggestion that the high blood pressor in " pale "hypertension is due to the presence of tyraminewhich is formed in the kidney as a result of impededcirculation.

This is a very interesting suggestion, for if therenal vessels share in the vasoconstriction causedby tyramine then more tyramine will be formedand an explanation is available of the viciouscircle which is apparent in several forms of Bright’sdisease. Confirmation of Dr. GovAERTS’s resultsshould therefore throw some welcome light on

the problem of hypertension. But completeunderstanding still seems remote. An attemptto analyse a vicious circle is rather apt to leavethe inquirer asking himself the familiar philo-sophical poser-" which came first, the hen or

the egg " ? Dr. Gov AERTS has presented us withan egg in the shape of renal ischaemia and a hendisguised as the vasoconstrictor tyramine. Whatwas responsible for the first egg ? Was it anotherhen-that is, some unknown vasoconstrictor ?It is not easy to accept this last suggestion. Inthe first place, it is very doubtful whetherVoLBABD’s explanation of white hypertension isstill tenable. Patients suffering from this conditionare almost always cedematous or ansemic, or both,and the characteristic pallor must to some extentbe attributed to these symptoms. Moreover,although peripheral vasoconstriction is certainlypresent in malignant hypertension, M. PRINZMETALand C. WILSON,2 and G. W. PICKERING,3 workingindependently, have lately demonstrated that itis no less certainly present in " red " or benignhypertension. In the latter condition, wheredeath is usually the result of cerebral haemorrhageor heart failure, the kidneys show changes whichhave been universally attributed to ischaemia.Dr. GovAERTS has shown that in spite of this renalischoemia, the blood of such patients neithercontains tyramine nor exerts any pressor effect.The egg was there. Why did it not hatch ? It isto be hoped that future research will remove

the problem from the realms of metaphysicalspeculation.

VIRUSES AND NEW GROWTHSTHE discussion which attracted most general

attention at the International Congress of Micro-biology held last week was undoubtedly that on" evidence concerning the agency of viruses in theaetiology of new growths." This was partlyattributable to the universal interest in new

growths, partly to the definite progress made inthis particular aspect of their study, and partlyto the fame of the investigators gathered togetherfrom the ends of the earth to exchange experiences.The committee were fortunate in securing PEYTONRous, whose achievements in this field (includinghis recent demonstration of the influence of avirus in the production of tar cancer in the skinof the rabbit) are most important, to preside at

2 Jour. Clin. Invest., 1936, xv., 63.3 Clin. Science, 1936, ii., 209.