939

recognised. It had been found that the earliereczema passes into the flexural prurigo, and thatasthma begins to be noted at about four or five yearsof age. Ichthyosis to a greater or lesser degree wasalways present. The skin condition tended to clearat puberty, but the asthma remained. Most of the

patients were sensitive to something-usually to ’,food proteins-and it was interesting to note that thefirst signs appear about the time that foods otherthan milk are added to the diet. Wheat was com-monly a factor. Two cases under his care were thefollowing :-A girl, aged 14, had almost every conceivable treatment.

She was put on a wheat- and egg-free diet, and was free fromasthma for four weeks. On adding wheat and eggs theasthmatic attacks returned. She is now again free on therestricted diet.A boy, also aged 14, showed ichthyosis, patches of prurigo

of the Besnier type, and a typical asthmatic chest with greatantero-posterior widening and indrawing of the lower ribs.He lived on a farm and was sensitive to cattle hair. In

hospital he was free from attacks. He was also kept on awheat-free diet.

These cases, said Dr. Freeman, were usually statedto have achlorhydria. One of these reported had,and the other had not. The basal metabolic rateswere low.

Dr. CYRIL MURPHY mentioned a case of asthma

in which the patient was sensitive to dog’s hair.Her dog was given away and she remained free fromasthma. Recently however she had come in contactwith dogs, and the asthma had returned. He wasnow treating her with injections of dog’s hair antigenand the result was very satisfactory. He thoughtthat wherever the offending protein could be avoided,it was possible to bring about a cure of the disease.-Dr. W. G. HARVEY referred to the use of auto-hsemotherapy in these cases, and said that he had foundproteose injections useful in many conditions, but not

in asthma.-Dr. ABRAHAMSON laid stress on theimportance of a careful history. Without it the skintests were often confusing and misleading.

Dr. FREEMAN in replying said that it was almostimpossible to cure asthma in elderly people, or incases which arose from infection in the lungs. The

only cases in which it was possible to obtain reallygood results were young people, and cases in which theoffending protein could be eliminated. He had found

auto-hsemotherapy of use in cases of pruritus, but notin asthma.

Dr. 0’CoxrroR read a note on Some Cases of Arti-ficial Pneumothorax, and Dr. ABRAHAMSON demon-strated lantern slides illustrating the gradualstretching of adhesions by pneumothorax.

REVIEWS AND NOTICES OF BOOKS

The Inborn Factors in Disease. iBy Sir ARCHIBALD E. GARROD. Oxford : Clarendon ’’,Press. 1931. Pp. 160. 7s. 6d.

THERE are many good texts in this pregnant littlebook. And perhaps the best is Ryle’s definition ofa diathesis as " a transmissible variation in the struc-ture or function of tissues rendering them peculiarlyliable to react in a certain way to certain extrinsicstimuli." For it keeps clearly before our minds theessential consideration that a disease is a processin which the body is taking an active part and notmerely a something by which it is possessed andinjured. The extrinsic factors of disease-microbic,-dietetic, cecological-have been hunted out these50 years with such success that the inherent qualitiesof the organisms on which they impinge have been agood deal neglected, and we are grateful to SirArchibald Garrod for reminding us, with all his

graceful erudition, of many things which we oughtto remember about the human constitution. Andas we should expect from such a fruitful investigator,he is continually speaking as much of what is to bediscovered as of what we know already. If, for

example, we have such obvious congenital defectsas alkaptonuria or hsematoporphyrinuria, or sucherrors as cystinuria, which attracts attention by whatis really the accident of a stone in the bladder, maythere not well be other metabolic abnormalities,rare perhaps and not of vital import, which waitdiscovery ? How much too there must be still tofind out about the varying reactions of bodies whichwe can reasonably call normal to infections and theother changes and chances of social life.

Extrinsic hygiene is far from exhausted. But therates of return are beginning to fall off, and no onewith a liking for prophecy can doubt that personalconstitution must inevitably come to play a largerand larger part in public health as well as in individualmedicine. We know, for instance, that heritablequalities may be important factors in deciding whethera mouse develops a malignant tumour or how long

i a guinea-pig will survive inoculated tuberculosis.Sir Archibald Garrod’s urbane philosophy forms anexcellent background for the rigorous and difficultinquiries which are needed before we know how farthe like applies to human populations. These are

being pursued in various ways ; to those to whom thedull and laborious task of accumulating humangenetical data does not appeal, we commend Draper’smethod of exploring the association between particulardiseases and the different types of bodily configuration.

Text-book of Ophthalmology.Vol. I. : The DM’elopment, Form, and Function of theVisual Apparatus. By W. STEWART DUKE-ELDER,M.D., Ch.B., F.R.C.S. Eng., Surgeon, Royal LondonOphthalmic (Moorfields) Hospital ; OphthalmicSurgeon to St. George’s Hospital. London : HenryKimpton. 1932. Pp. 1124. 1:3 3s.

Mr. Duke-Elder has planned a text-book ofophthalmology on a monumental scale. The firstvolume deals solely with the anatomical, physio-logical, optical, and psychological foundations of thesubject. A short opening section traces the genesisof the rudimentary eye beginning with the photo-tropism of the primitive organism. This is followed

by a section on the anatomy of the human eye, itsadnexa, and the central nervous mechanism of vision,in which are explained, not only the visual paths, thesensory, the sympathetic, and the oeulomotor systems,but also the primitive connexion with the labyrinthinenerves and the postural centres in the mid-brain.A chapter on embryology comes next, and then otherson the ocular pigment and on heredity. With thesection on the physiology and biochemistry of theeyes the author comes to that part of his subjectto which he has himself made original contributions,and the chapters on the vascular circulation and itscontrol, on the metabolism of the eye, and on intra-ocular pressure may be considered the most authori-

tative part of the work. Chapters follow on thephysiology of the pupil and of the extra-oeular

940

muscles. We do not find the author’s account of the.anatomy and the physiology of the ciliary musclealtogether satisfactory. The term " scleral spur".oecurs several times but to understand what it is,its connexion with the longitudinal fibres of the

.ciliary muscle on the one hand and with Schlemm’s- canal on the other, we have to turn to the originaldescription by Prof. Arthur Thomson, of Oxford.(Ophthalmo8cope, 1911, ix., 470). It is a pitythat the figures accompanying this original articlewere not reproduced, for nowhere else have we metsuch a clear explanation of the action of the

longitudinal fibres of the ciliary muscle in opening upSchlemm’s canal.The action of the ciliary muscle in accommodation

presents difficulties and is not fully explained by Mr.Duke-Elder. While agreeing that Helmholtz’s theoryin its original form needs modification, he fails toshow how the different portions of the ciliary musclecooperate with each other in causing relaxation of thezonule. Mr. Thomson Henderson, of Nottingham,believes that the only fibres which are directlyconcerned in positive accommodation are the circularfibres, the longitudinal fibres, which he calls"sustentaculum zonulae," and the radiating fibres,which he calls " tensor zonulse," being concerned inmaintaining the zonular curve while accommodationis relaxed. According to this view these two lattersets of fibres are antagonistic to the first and theirpositive action is called into play not in accommodatingfor a near object, but in fixing a distant one. Itwould have been interesting to have this view eithercriticised or confirmed. After a section which includeschapters on optics-physical, geometrical, and physio-logical-we come to parts of the subject which are stillsomewhat obscure. These include the action ofvisible light on the retinal cells, colour vision, adapta-tion and after images, and the duplicity theory ofvision-that rods and cones are adapted respectivelyfor vision in twilight and daylight. This theoryMr. Duke-Elder now regards as established, thoughsome authorities, notably Dr. Edridge Green, still

oppose it. The last chapter deals with visual per-ceptions and especially with binocular vision.

This work is not an introduction to the study ofophthalmology. The student who should attemptto use it in this way would soon get lost in a mazeof technicalities which would take him considerabletime to master and this process would postponeunnecessarily his contact with actual clinical problems.It is rather a book of reference for the use of those who.already have considerable knowledge of the subject,and contains copious references to authorities on

.each section of ophthalmology. This volume containsover 1000 illustrations, including seven coloured

plates. We look forward to the publication ofits fellows, for the work when complete will be arich contribution to the literature on normal andabnormal conditions of the eye.

Life : Outlines of General Biology.By Sir J. ARTHUR THOMSON and PATRICK GEDDES.London : Williams and Norgate, Ltd. 1931. TwoVols. Pp. 1515, with 202 figures. 63s.

Geddes and Thomson on " The Evolution of Sex "was published in 1889-forty-two years ago. It wasa famous book which led to much productive work,and thought. Since then they have both been fullyactive in their respective spheres-Thomson mainlyas a biological zoologist, Geddes as a botanist andsocial reformer. They come together again now

in the ripeness of their knowledge and experience andhave produced an extraordinary compendium inwhich they survey the whole field of biologicalknowledge and speculation with a comprehensivesuccess that one would have thought hardly possible.They deal in turn with the essential characteristicsof organisms, with their relation to environment,with physiology, reproduction, behaviour, organicarchitecture, development, evolution, human biology,and the general theory of life. To any one reader,some parts will naturally seem better than others;to the present reviewer the chapters on evolutionappeal as particularly excellent. The easy fluencyof Thomson will suit most people better than Geddes’scraggy sentences and strange formulae. But if someparts are better than others, there are no parts whichare bad, and if anyone wants to have a serious know-ledge of where biology stands to-day we advise himto get the book and spend some weeks or months inreading it right through. Detailed criticism ofsuch a book is obviously impossible but we may notethese points about the general outlook of the authors;they believe in evolution, past, present, and future,as the most fundamental fact about live organisms;they are vitalists and hold that mind is an integralpart of life ; they believe that human life in all itsaspects is a proper subject of biological study, howeverfar a cry it may seem from chromosomes to civics.

Diet and Pleasure.The Art of Enjoying Medical Régirne8. By PAULREBOUX. London : G. P. Putnam’s Sons Ltd.1932. Pp. 248. 6s.

THIS small book has the unusual merit of presentingsound and valuable information under the guise ofamusing chit-chat ; the anecdotes and illustrationsare often quite funny, while the general regimenslaid down are sound, and the culinary instructionsaccurate and sometimes elaborate enough to haveproceeded from Alexis Soyer-who may have beenoccasionally the source of inspiration. The planof the book is extremely simple : some dozen condi-tions, not so much diseases in themselves as symptomscommon to many diseases, have been chosen fordiscussion, and general information as to the causa-tion is supplied in justification of a series of menussuitable to the patient’s needs. Many of thesemenus call for very expert cooking and the ingredientsincluded in some of them cannot always be readilycome by, but the fare provided would be charming.For the help of housewives the author has collectedtogether in lists at the end of the book a series ofmenus for the week suitable to each of the maladiesdealt with. Some of the items would considerablytry any cook who wished to produce them.

CITY OF LONDON MATERNITY HOSPITAL.-In 1931the number of mothers admitted was 1759, an increaseof 110 ; of the 1673 delivered 7 died, or 3-82 per 1000.The patients stayed on an average 14-60 days, and cost28 6s. 2d. each-a small decrease. The income was 216,486,and there was left a credit balance of B56.

THE AFFAIRS OF STAMFORD INFIRMARY.-Werecorded last week (p. 914) that the Marquess of Exeter,president and chairman of Stamford and RutlandInfirmary, and other governors, had resigned in consequence)f a threat that an annual grant of 2300 would be withdrawnunless Dr. G. Staveley-Parker, who had been dismissed fromhe honorary staff, was reinstated. The reinstatement;ook place, and since then 15 governors, including thepresident, have resigned. At a meeting of the governorsast week a vote of confidence in Lord Exeter was passedInanimously, and a committee of five members was appointed, to investigate and report on the conduct of Dr. Staveley-Parker towards the Infirmary." _

_

941ECONOMIC ASPECT OF THE RHEUMATIC DISEASES.

THE LANCET.

LONDON: SATURDAY, APRIL 30, 1932.

ECONOMIC ASPECT OF THE RHEUMATICDISEASES.

IT is, in a sense, unfortunate that the death-rate- from chronic rheumatism should be insignificant ;were this not so it can be accepted as certainthat more attention would long since have been.directed to the solution of the many problemsconnected with this protean disease. The social

importance of the rheumatic group of diseases is

to-day greater than that of the two more successfulclaimants to official attention-tuberculosis andcancer. Adult rheumatism is in fact probablythe greatest single factor in the production ofindustrial invaliditry and in the depletion ofnational health insurance funds. Sir WALTERKINNEAR has estimated the cost to the countryof this group of diseases as little short of seventeenmillion pounds a year. While our knowledge of theiraetiology and treatment falls very short of whatmight be desired, it should not be forgotten thatconsiderable stores of knowledge have beenaccumulated in recent years, and could be madeavailable in the event of any renaissance of interestin the subject. The field is vast ; much of thesoil is still virgin and presents a legitimate fieldfor specialisation.

The first organised outlet for much of this

knowledge, for discussion of the main problems’confronting us, and for constructive planningfor the future was provided earlier in the yearby the Royal Institute of Public Health. This

tody, recognising the serious social menace ofthe rheumatic group of diseases to be a subject Iwhich could properly and profitably be approachedfrom the public health aspect, organised a

series of weekly lectures on " Rheumatism andarthritis as a public health problem," which

may be taken as a sign of the awakening of amore progressive attitude towards the problem,and of promising augury for the future. SirWILLIAM WILLCOX in the opening lecture, whilegranting the existence of doubt in the origineven of cases properly recognised as of infectivenature, expressed his conviction that these diseasesare largely preventable and in the earliest stagescurable. Dr. FORTESCUE Fox traced the rise ofpublic interest in chronic rheumatism from theearly nineteenth century, when the five great spahospitals were solitary voices of hope crying in amedical wilderness, up to the time of the establish-ment in London of the British Red Cross Society’sexperimental clinic at Peto-place three years ago.The care of all diseases of social importance had,he said, in the past gradually been forced bypublic opinion to become the responsibility of

competent bodies. With the recognition by themedical profession of the value of physical methodsat some period in almost every rheumatic case,the need for properly organised study and attackwas seen, and the establishment of physical treat-ment centres in industrial areas as part of a

comprehensive scheme should follow. Dr. D. M.CONNAN, medical officer of health for the Boroughof Bermondsey, which is proposing to deal witharthritis on these lines, pointed to signs that certainmunicipal and insurance bodies are determinedin the near future to see that these methods oftreatment are available for the insured population.It would, he thought, be disastrous for the medicalprofession to find, when their interest was awakened,that others had been before them. Dr. M. B.RAY attributed the lack of progress in our studyof the origins of rheumatic disease to relianceon the shibboleth of focal sepsis and to neglect ofsuch factors as endocrine imbalance, exhaustion,heredity, and occupational stress. Dr. A. R.NELIGAN, as the result of prolonged study ofmethods in other countries, showed how the moreconcentrated effort abroad is based on a beliefthat the results repay the cost of the subsidies

granted. In the final lecture, of which an abstractappears on p. 967, Dr. W. S. C. CoPEMAN outlineda scheme for an organised campaign againstrheumatism in this country.

For financial reasons Dr. CopEMAN believes it

necessary to segregate diagnosis and investigationin special centres, and to centralise all treat-ment. But the basis of any such scheme must, ashe very reasonably points out, be the insurancepractitioner. At the present time when facedwith a case of arthritis, whether in the potentiallycurable or in the advanced stage, his scope islimited by the provisions of the National HealthInsurance Acts which provide general practitionerservice and nothing more for the insured popula-tion. Additional benefits have however beensanctioned for the use of approved societies ableto show a surplus on the quinquennial valuation, andfour years ago, following on Dr. ALISON GLOVER’Sreport,l physical medicine was placed on the listof these additional benefits. Coming sixteenth onthe list as it does its application must remainrestricted to members of the wealthiest societies.Moreover it is idle to advocate the employ-ment by the insurance practitioner of methodswhich find no place in the regular teaching ofmedical schools. If these methods are to becomeavailable on a large scale for the insured population,some way must be found whereby treatment canbe administered under skilled direction and

according to the proper indications in centralisedclinics. The success of such clinics, if forth-

coming, is assured by the example of the Peto-place clinic, which was the outcome of the demandmade by approved societies for the provision ofskilled investigation and treatment for theirmembers. Its foundation was the dawn of a

new era for the arthritic. In the United States

1 A Report on Chronic Arthritis. Ministry of Health. Reportson Public Health and Medical Subjects. No. 52. H.M.Stationery Office. 1928. 1s. 6d.