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REVIEWS AND NOTICES OF BOOKS

Nerve RegenerationThe Conduct and Fate of the Peripheral Segment ofa Divided Nerve in the Cervical Region iohen Unitedby Suture to the Central Segment of another DividedNerve. By Sir CHARLES BALLANCE, ConsultingSurgeon to St. Thomas’s Hospital. London:Macmillan and Co., Ltd. 1934. Pp. 45. 7s. 6d.

IN spite of all the evidence that regeneration of adivided nerve occurs by growth of axis cylindersfrom the central into the peripheral segment, thereare still some who admit the possibility that theperipheral portion of the axis cylinders can be recon-stituted by some mystical activity of the neurilemmacells. Such a fallacy must surely be exposed onceand for all by the account now published by SirCharles Ballance of the nerve suture experimentscarried out in the laboratories of the Royal College ofSurgeons of England. When the central end of thecervical sympathetic was sutured to the peripheralend of the cut hypoglossal nerve, and after the timerequired for regeneration had elapsed, stimulationof the pupillodilator centre in the hypothalamuscaused contraction of the muscles of the tongue.Such a result, though yielding interesting corroborativeevidence of the presence of the sympathetic centrein the hypothalamus, could be explained on eithertheory of regeneration of the axis cylinders. But thechief value of Sir Charles’s work lies in the histologicalstudy of the regenerated nerve, for he has shownthat when the cervical sympathetic is sutured to thehypoglossal nerve the regenerated peripheral endcontains only fine sympathetic fibres and thereforedoes not resemble the original hypoglossal nerve.

On the other hand, when the central end of the hypo-glossal nerve was sutured to the cervical sympathetic,the sympathetic fibres between the site of sutureand the superior cervical ganglion were replaced byhypoglossal nerve-fibres, and the nerve became

nearly twice the size of the original cervical sympa-thetic because of the greater size of the hypoglossalfibres as compared with those of the cervical sympa-thetic. In earlier experiments on nerve suture andregeneration, nerves were used whose axis cylinderswere almost identical in size, and it was thus impossibleto distinguish them under the microscope. But theuse of the cervical sympathetic nerve, which hasbeen sutured in different experiments to many ofthe adjacent nerves, has made identification possible,and the difference in the appearance of the nerve-fibres is clearly shown in the numerous excellent

photographs and drawings which illustrate this book.

Treasury of Human InheritanceVol. IV. : : Nervous Diseases and Muscular Dys-trophies. Part 1. : Huntington’s Chorea. ByJuLiA BELL, M.R.C.P., under the Medical ResearchCouncil. Cambridge : at the University Press.1934. Pp. 67. 10s.A CRITICISM often levelled at eugenics is that we

do not know enough about human heredity to justifyeven such limited action as the giving of geneticadvice in individual cases. This reproach will gradu-ally be emptied of valid content as the main cate-gories of diseases recognised as being hereditaryare covered by successive volumes of the " Treasuryof Human Inheritance." The fourth volume of thismonumental production, which is issued from theGalton Laboratory, University College, and is now

edited by Prof. R. A. Fisher, is to be devoted tonervous diseases and muscular dystrophies ; and ifits parts maintain the high standard set by the firstone, they will be received with deep interest by thewidening circle of persons who see in the utilisationof our knowledge of human genetics the most helpfulapplication of the principles of preventive medicine.

This monograph has twelve plates on which arevery clearly reproduced 151 pedigrees of Huntington’schorea. The essential features of each of these

pedigrees are set out in short descriptive noteswhich occupy more than half of the monograph.These notes are preceded by a very full chrono-

logical bibliography of 113 references ranging fromthe year 1658 to 1932. The value of the bare factsrecorded in these pedigrees is greatly enhanced byDr. Bell’s introductory chapter. The salient pointsof the disease are here summarised under the follow-

ing headings : signs and symptoms ; age of onset;duration of disease and age at death; associateddiseases ; pathological incidence of the disease inthe general community; and sex incidence andinheritance of the disease. These paragraphs are

lucid, and-the average medical reader will be gladto find-are unencumbered by higher mathematics.As is generally known, Huntington’s chorea behavesgenetically as a simple Mendelian dominant; yetDr. Bell’s collection contains six pedigrees showingcases of chorea in sibships both of whose parentsreached old age without showing any symptoms ofthe disease. Dr. Bell concludes her introductionby the remark that it would be contrary to all experi-ence of hereditary affections if cases did not occur

occasionally indistinguishable from those diagnosedas Huntington’s chorea, but providing no evidenceof the genetic determination of the disease ; andshe notes that she has chanced upon a few suchcases in the literature. The hereditary nature of

Huntington’s chorea is so well known that such

sporadic cases, though conforming in all respects tothe typical picture, might escape the diagnosis of

Huntington’s chorea ; and even if they were diag-nosed, they would stand a smaller chance of beingwritten up than would cases occurring in pedigreesshowing other affected members.

Dr. Bell and Prof. Fisher deserve congratulationon an admirable production.

Recent Advances in EndocrinologySecond edition. By A. T. CAMERON, M.A., D.Sc.Edin., F.I.C., F.R.S.C., Professor of Biochemistry,Faculty of Medicine, University of Manitoba ;Biochemist, Winnipeg General Hospital. London :J. and A. Churchill. 1935. Pp. 406. 15s.MORE than any other field in medicine, endocrino-

logy requires the close cooperation of clinician,pathologist, physiologist, and chemist, and theirseveral techniques. The chemist, with his imagina-tion and his precision, is mainly responsible for thespeed and the extent of recent advances, and so it isfitting that a chemist should write the volume onendocrinology in Messrs. Churchill’s series. Prof.Cameron’s second edition brings the story up to

August, 1934, and his handling of the riot of recentliterature is masterly. New evidence is quoted orsummarised simply and clearly, and not obscuredby an over-conscientious attempt to be compre-hensive. At each growing point he indicates howfar the consensus of opinion has advanced, or what

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tentative conclusion the bulk of the evidence justifies.It is most instructive to watch the critical judgmentof the pure scientist applied, with understanding, tothe facts and problems of endocrine medicine. Themost exciting chapter is, of course, the pituitary one.The anterior lobe is credited with eight distinct

hormones, acting on growth, the sex glands, the

thyroid, the parathyroids, the pancreatic islets, theadrenal cortex, the mammary glands, and the meta-bolism of fat, but suggestions are beginning to appearthat other organs, such as the adrenal, the placenta(which is now the likely source of " prolan "), andthe sex glands can in the reverse direction act on theanterior lobe. This would make the pituitary notthe head gland of the endocrine system, but rathera nodal point in its network. We still await, however,a new idea which will give meaning to that networkin the way that the conception of reflex action did tothe nervous system. Prof. Cameron feels that muchspadework must first be done, in the isolation andchemical identification of endocrine principles, beforethat stage is approached. Meanwhile his fascinatingaccount of recent progress and the present stateof knowledge is of the greatest value to all whoare interested in endocrinology and especially to

physicians.

Speech in ChildhocdIts Development and Disorders. By GEORGESETH, M.A., B. Edin., Ph.D., lately Assistant,Combe Psychological Laboratory and UniversityPsychological Clinic, Edinburgh; and DouGLASGuTHRIE, M.D., F.R.C.S. Edin., F.R.S.E., Con-

sulting Aural Surgeon, Royal Hospital for SickChildren, Edinburgh. London : Humphrey Mil-ford, Oxford University Press. 1935. Pp. 224.10s. 6d.

THIS work begins with a full and thorough descrip-tion of the mechanism of speech, and of the problemsconnected with its representation in the cerebralcortex; the sounds employed in speech, and themethods of their production, are discussed, and thesymbols used for these sounds by the InternationalPhonetic Alphabet are explained.. The ground havingthus been cleared, the authors proceed in a long andinteresting chapter to describe the development ofspeech in the growing child. They find, especiallyat the younger ages, that the measurement of voca-

bulary is a valuable means of estimating intelligence,for the results of vocabulary tests correspond closelywith those of other performance tests. But retarda-tion in the time of beginning to speak must not tooreadily be taken as a proof of mental deficiency ; nota few cases like that of Thomas Carlyle have beenreported, where a child has refused for many monthsto utter a single word.The interrelation of speech and hearing is next

discussed, and the problem of the deaf mute sym-pathetically considered ; the authors believe thatthe retardation of the deaf child in respect of hisnative intellectual endowment is much less con-

siderable than is commonly asserted. He is notdeficient in intelligence but is deprived of the prin-cipal tool for making his intelligence effective. Therefollows a well written chapter on the disorders of

articulation, dumbness without deafness, cluttering,lisping, and the like ; and other chapters on nasalspeech, rhinolalia clausa and aperta (the latterincluding the speech of cleft palate), on stuttering,and on the singing voice in childhood, including theproblems of the " breaking " voice.

In a final chapter, on the organisation of speech

clinics, the authors insist that a complete change ofattitude to the spoken word is required on the partof the teacher and the school. It is most importantto encourage attention to clear articulation andrefinement of diction, especially in the education ofchildren from homes or districts where the culturallevel is low and where harsh and crude vocalisationand lip-lazy, slovenly, and uncouth articulation isthe rule. We are entitled to demand of the elemen-

tary school-teacher, first, that she should herselfbe adequately equipped in respect of speech andvoice ; secondly, that she should have some know-ledge of the psychology, physiology, and pathologyof speech in children ; and, thirdly, that she shouldgive adequate time and attention to speech as such,and as distinguished from mere oral reading.The book has been written throughout from a.

sympathetic and thoroughly practical point of view.It covers a great variety of subjects which, on thewhole, do not receive adequate attention, especiallyin this country where " phoniatrie

" has not hithertoassumed the position which it is attaining in theUnited States, France, or Germany. This book willhelp to draw attention to its claims and to improvethe teaching of good diction, with all that this implies,to the rising generation.

Forensic Medicine

Fourth edition. By SYDNEY SMITH, M.D., F.R.C.P.Edin., D.P.H., Regius Professor of ForensicMedicine, University of Edinburgh. London:J. and A. Churchill Ltd. 1934. Pp. 644. 24s.

IN this the fourth edition of Prof. Sydney Smith’swell-known book the text has been revised, thoughthe original form is maintained and the subject matterretains its concise and informative nature. Amongother useful features we would draw special attentionto the good account, in the space of a few pages, of theprinciple and technique of the precipitin test for theorigin of blood. The toxicological section, a matterof some 150 pages, has been generally revised. With

regard to drugs of the barbituric acid group, whichhave recently been the subject of some controversy,there is an extremely useful table (taken from Mutch’swork) which indicates the diversity of these products :the symptoms, treatment, and post-mortem findingsof veronal poisoning are described as representativeof this group. An appendix describes medico-legalproblems peculiar to the East, with special referenceto Egypt, of which subject Prof. Sydney Smith has anunrivalled knowledge.

Gould’s Medical DictionaryFourth edition. By GEORGE M. GOULD, A.M.,M.D. Edited by R. J. E. ScoTT, M.A., B.C.L.,M.D., and C. V. BROWNLOw. London : H. K.Lewis and Co., Ltd. 1935. With illustrations and174 tables. Pp. 1538. 30s.

IN a prefatory note to the first edition of this workthat industrious lexicographer Dr. G. M. Gould referredto Simon Brownewho 300 years ago "took to an employ-ment which did not require a soul, and so became adictionary-maker." He may have had good groundsfor believing that the compilation of a book containingall " the words and phrases generally used in medicineand the allied sciences, with their pronunciationand derivation," is a soul-destroying occupation, buthe is at all events entitled to the gratitude of thosewho have used his dictionaries and these now number

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nearly 900,000. There may indeed be more, for the

figure quoted refers to sales. This fourth editioncontains a new table of prefixes and suffixes used inmedical terms, tables of bacteria, metazoa and

protozoa pathogenic to man and animals compiledby Prof. D. H. Bergey, of Pennsylvania, and-whichwas quite a brain-wave on the part of the new editors-a transcript of the International List of Causes ofDeath. The changes and additions have been madeby condensation without adding to the bulk of thevolume which was already considerable, but for thisbulk the present editors cannot fairly be blamed, andit will not be reduced until the coming of an Inter-national Academy (for which we have already prayed)which can quietly pack away and give decent burialto the many useless words in the medical vocabulary.There is only one word of criticism which appliesnot only to this but to all other illustrated medicaldictionaries : the selection of objects to illustrateseems singularly arbitrary. On one page we mayhave the main features of cataracts, on the next aportrait of Darwin, and on another a picture of aseparatory funnel. This ragged imagination doesno credit to a compilation which has become a modelof exact and logical presentation. There is a certainfuture for a medical dictionary illustrated with thesame genius as that which marks the letterpress ofthe present Gould.

A New Angle on HealthNature’s Provision for the Health and Happinessof 1lZankirad. By Surgeon-Captain D. H. C. GIVEN,M.D., D.P.H., R.N. (Retd.), late Medical Officer inCharge, H.M. Naval Base, Singapore. London :John Bale, Sons and Danielsson, Ltd. 1935. Pp. 160.7s. 6d.

THE author of this book, being impressed withthe difference in the quantity and character of diseaseamong Asiatic labourers on the one hand, and navalpersonnel and white civilians on the other, attemptsto find an explanation in the way of life of the tworacial types. He condemns our Western civilizationas built up on selfish greed, industrialism, and para-sitism, and reflected in racial decay. While we havesucceeded in eliminating the grosser ill-effects ofenvironment, the " health heritage " and " soundbody building " are impaired by urbanization, thedecline of agriculture, extremes of poverty and riches,overcrowding, overfeeding, underfeeding, and improperfeeding (called saccharism "). Because of man’s

biological wrongdoing, modern civilization hangs inthe balance. The basis of industrialism is un-Christianand the remedy for our ills is obedience to the preceptsof our faith. It seems to be implied that there mustbe an efflux from towns, a return to subsistencefarming and unrestricted reproduction.The author’s method is declamatory and allusive

rather than logical. Almost all the incontrovertiblefacts contained in the book are culled from theRegistrar-General’s Decennial Supplement to the

Report on the Census of 1921, and if it serves no otherpurpose than to direct attention to that mine ofinformation, it has been worth while. Except forthe rather scanty but interesting data as to the healthof Asiatic labourers in Singapore, the material ofthis book is familiar to statisticians, epidemiologists,and public health workers. Some of the explanationsof observed phenomena are highly speculative andwhat the writer considers proof will not be generallyaccepted as such. It may be right that our ruralpopulation before 1760 was healthier than it is now,but it is not proven. We know, at least, that local

famine was not uncommon in the days of the manorand village agriculture. If our survival as a race

depends on a return to that way of life, the futureis indeed bleak. If the author means that our

competitive industrialism can be redeemed only byunselfishness and altruism, he is probably near the truth.Much of the statistical by-play is capable of differenttreatment, which might lead to other conclusions.That medicine and specific prevention are almost

helpless against many of the influences of theeconomic and social conditions of our age isadmitted; preventive medicine has reached thisconclusion from no new angle and is slowlyfeeling its way to less revolutionary-or, shallwe say, reactionary-means of amelioration thanthose propounded in the book under review.But more scientific examination of the facts is needed.

The Autonomic Nervous SystemSecond edition. By ALBERT KUNTZ, Ph.D., M.D.,Professor of Micro-Anatomy in St. Louis UniversityMedical School. London: Bailliere Tindall andCox. 1934. Pp. 697. 35s.

THE first edition of this book is so well known as a

comprehensive guide to the literature of the autonomicnervous system that the main object of the revieweris to note the additions to the earlier volume ratherthan to describe the work as a whole.

Until quite recently all the data bearing upon thefunctions of the autonomic system were collectedfrom the results of physiological experiments uponlower animals, and a noteworthy change in theliterature is the steadily increasing number of observa-tions of the sympathetic functions in man. The

change is reflected in this new edition of Prof. Kuntz’sbook. From the point of view of the practitionerits most interesting features are the references torecent work, carried out in the course of the investiga-tion and treatment of patients, on the mechanismof micturition, on the conduction of visceral andreferred pain, and on the effects of excision of

portions of the sympathetic nervous system. The

question of the existence of disease in the sympatheticganglia in conditions which are benefited by ganglion-ectomy is well discussed, and the conclusion is reachedthat the variability in normal ganglionic tissue isso wide that no changes so far described can beidentified as the pathological basis of a disease

syndrome. In view of this laudably non-committalattitude it is surprising to read a few pages later that" Evidence is rapidly accumulating in support of thetheory that pathological conditions of the autonomicnervous system play a role in the genesis as well asthe course of some of the common vascular diseases,particularly Raynaud’s disease."Though recent advances recorded in it are many and

varied, the volume serves only to emphasise the incom-pleteness of our knowledge of the source and pathwayof the autonomic supply to the cesophagus, to the

ureter, and to the caecum and ascending colon, andof the exact distribution and function of the autonomicnerves to the distal colon. It is to be hoped thatin the near future some of the anatomical and physio-logical investigations may be concerned with problemswhich are of pressing importance to the clinician.A feature of outstanding value in this book is thebibliography, but it should be arranged either in

short lists at the end of every chapter or in onecomplete list at the end of the book ; the presentmethod of dividing it into several short lists at theend of the book leads to confusion.

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A Text-book of Gynaecological SurgeryThird edition. By Sir CoMYNS BERKELEY, M.D.,F.R.C.P., F.R.C.S., Consulting Gynecological andObstetric Surgeon to the Middlesex Hospital;and VICTOR BONNEY, M.S.,M.D., F.R.C.S., M.RC.P.,Gynaecological and Obstetric Surgeon to the

Hospital. London : Cassell and Co., Ltd. 1934.

Pp. 863. 45s.

A QUARTER of a century has elapsed since thefirst publication of this text-book and its continued

popularity and usefulness entitles it to join theaustere ranks of "standard works." The authors

express the hope that their efforts may be of valueto those who are proposing to follow this departmentof surgery and also to those who are called upon to

perform gynaecological operations and have not hadthe opportunity for acquiring the ripe experiencewhich accompanies long apprenticeship in the gyneeco-logical wards. They could have added, but have notdone so, that their book is so compiled as to be areal help to all who practise surgery in this regionof the body, no matter what the duration and extentof their experience. Each operation is described indetail and so clearly that misunderstanding is impos-sible and in many places the reason for undertakingthis or that procedure at a certain stage is carefullyexplained. The indication for each operation, the

preparation required for it, and the post-operativetreatment are fully described. The illustrations arenumerous and some are magnificent. Chaptersupon surgical technique, the operating theatre,and operations in private houses are included.The nature and treatment of post operativecomplications are allotted six chapters or nearlyone hundred pages. In order to convey a correct

impression of the relative dangers of the various

operations the results of the work of twentysurgeons over a period of thirty years have beenanalysed. It is, however, the first few pages in thebook that deserve the most attention and praise.The advice that is here given to the surgeon in regardto his conduct and behaviour toward the patientand in the theatre, the assessment of speed in

operating, and the remarks upon operative manipu-lations could be repeated with advantage in everysurgical text-book.

THE FERRIER LECTURE

HUMORAL TRANSMISSION OF NERVOUSIMPULSES

AT a meeting of the Royal Society on June 20th,Dr. Otto Loewi, professor of pharmacology in theuniversity of Graz, gave the Ferrier lecture on

problems connected with the principle of humoraltransmission of nervous impulses. The following isan abstract of his address :-

In 1921 it was proved for the first time that themodifications of the heart’s function, caused bystimulation of its nerves, are due to substances,liberated by the stimulation, called transmitters :

acetylcholine and an adrenaline-like body respectivelywhich in their turn bring about the effects of stimu-lation. This " humoral transmission of nervous

impulses" occurs not only in the heart but also

following stimulation of all the other vegetativenerves. Whether the phenomenon also happenswithin the somatic nervous system is not yet settled.The nerves releasing transmitters on stimulationdo not influence the function of their effective organs

otherwise than by this release. But we must attributeto them an influence-independent of the release of

i the transmitters-on the sensitivity of their effector. organs to peripheral, directly applied stimuli.’ The discovery of the humoral transmission of nervous: impulses discloses the hitherto obscure mechanism of,

the effect of nervous stimulation in general, and also’

particularly of peripheral inhibition.

B THE PLACE AND MECHANISM OF RELEASE OF

L TRANSMITTERS

’ As to the point of attack of nervous stimulation,i.e., the localisation of the release of the transmitters,

’

there are two possibilities : either the nerve-endingor the effective organ. There are many argumentsagainst the latter possibility, but the former issupported by the following facts : (1) after nerve

degeneration the transmitter disappears, even in casesin which the effective organ is not degenerated atall; (2) on stimulation of the preganglionic cervicalsympathetic the transmitter is liberated, not withinthe ganglion cell, but at the synapse-in other words,from the nerve-ending.

Regarding the mechanism of the release we have toconsider also two possibilities : either the transmitteris newly formed by the nerve-stimulation, or it ismade diffusible, being split off from a combinationalready present in the nerve-ending. The decisionbetween these possibilities cannot yet be made.The lapse of time between the nerve-stimulation

and the response of the reacting organ is extremelyshort, even in organs like the heart, where the trans-mitter has to pass a certain distance in order toreach the effector cells. The transmitters disappearsomewhat quickly, the time of disappearance beingdependent on the type of action which they have toproduce.The point of attack of the transmitters is not some

part of the neurone but the functioning, effective

organ itself. The fact that the transmitters, whenartificially injected, mainly act at points in relationto which they are normally liberated, can be given,as yet, only a teleological interpretation. Since thetransmitters can diffuse into the blood from the

point of their release, they can, in principle, alsoaffect remote organs, though under physiologicalconditions this may never happen. Obviously sucha distant action is unnecessary, as such needs are

fulfilled by the hormones.

DIFFERENCES BETWEEN THE ACTION OF HORMONES

AND TRANSMITTERS

Finally, the question arises whether the differencebetween the action of the hormones and that of thetransmitters concerns only the sphere or also thecharacter of their action. The hormones of two ofthe ductless glands, both being neurotropic anddiffering from all other ductless glands by propertiescommon to them only-the adrenal medulla and theposterior lobe of the hypophysis-initiate or modify,according to need, the specific function of the organs,as the nerves or the transmitters do.None of the other ductless glands are neurotropic ;

their development and state depend largely on

the anterior lobe of the hypophysis ; their secretionis going on continuously and automatically, thoughpartly controlled by the nervous system. Their actionis concerned less with the specific functi01/’s of organsthan with general conditions-state and metabolism.In other words, there are differences not only regardingthe sphere but also regarding the character of theaction of the nerves and the transmitters, on the orehand, and that of the hormones on the other.

L