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doses. He had had some therapeutic success with apolyvalent staphylococcal vaccine, but had now givenit up for curative purposes. He was under theimpression (40-50 cases tried) that this vaccine wasuseful in preventing recurrences. He quoted a nursewho had apparently been saved from relapses byits use for over two years, although previously neverfree, after renewal of the eruption, for more thansix to eight weeks. He had had success with aDanysz vaccine in one or two cases, but he agreedthat the results were most uncertain and could neverbe foreseen.

Dr. BARBER thought ultra-violet light in somecases did more harm than good. He advocatedconcerted action among British dermatologists todetermine the f’a’U.>;f, of psoriasis, and alluded to thefrequency of tonsillitis as a precedent to the eruption,especially in rheumatoid cases. In conjunction withDr. D. Embleton he had found an organism of thestreptococcus group in some cases of psoriasis asso-ciated with rheumatic symptoms in the joints. Inone of these, a very severe case which had gone onto generalised exfoliative dermatitis with highpyrexia, it had been recovered from the blood andcultured. The autogenous vaccine injected imme-diately checked the fever, and may have been partlyresponsible for an ensuing cellulitis of the thigh, fromwhich the same organism was cultivated. Thepatient eventually recovered. Dr. Barber admittedthat the cases were at present too few for him todraw any conclusions as to the setiological importanceof a bacteriological cause of psoriasis.

Dr. E. F. SKINNER (Sheffield) said he had made anexperimental clinical investigation of the comparativevalue of chrysarobin and X rays in the treatment ofpsoriasis. In two selected groups, in which dieteticand other factors remained the same, he was able todemonstrate the definite superiority of the chry-sarobin method, both in the rapidity of involution ofthe individual lesions and in the prolongation of theimmunity intervals. The average duration of treat-ment in hospital by this method was from 20-30 days.In the group selected for radiotherapy one-third of aunit dose was given to each patch. Dr. Skinnershowed some slides illustrating both the clinical andmicroscopic results of treatment. His investigationshad led him to believe that a diminished intradermal

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pressure with increased oxygen tension were invariable

associations of the psoriatic lesion. He was not muchimpressed with the results of ultra-violet ray treat-ment in psoriasis.

Sir Norman WALKER emphasised the fact thatthere is no generally applicable treatment for psoriasis.Every case had to be treated individually, and longexperience was the only safe guide. He entirelyagreed with Dr. Skinner in his estimate of the valueof chrysarobin. In connexion with tar applicationsit should be remembered that there were varioustars-some derived from coal, some from pitch-pine-and that they were not all suitable in every case ofpsoriasis. While there was no remedy which couldbe relied upon as a specific, Sir Norman Walkerprotested against the practice of giving a bad prog-nosis. The policy of laissez faire was bad, and thepatients must be encouraged to use the best possiblemeans to rid themselves of every ensuing attack.

Dr. WHITFIELD said that he would exereiseextreme caution in prescribing arsenic to acute orirritable cases, and in those non-scaly glazed typeswhich were by no means uncommon. He said thatwhen he prescribed arsenic he found it did most goodwhen pushed to the limit of tolerance.

In his reply Dr. MACKENNA expressed himself asmuch interested in Dr. Dyson’s remarks on thepreventive effect of treatment by vaccines. Hethought that his views, perhaps too optimistic onthe results of phototherapy, might have been due tothe fact that the majority of his cases were treatedin the winter months, at a time when sunlight wasdeficient..

Reviews and Notices of Books.CHRONIC RHEUMATIC DISEASES.

Their Diagnosis and Treatment. By F. G.THOMSON, M.D., F.R.C.P. Lond., and R. G.GORDON, M.D., D.Sc., M.R.C.P. Edin. OxfordMedical Publications. London : HumphreyMilford, Oxford University Press. 1926. Pp. 202.8s. 6d.

THE appearance of this book is well timed, followingthe report of the Ministry of Health on rheumaticdiseases, in which it was shown that about one-sixthof the total amount of sickness occurring amongst theinsured population is due to diseases in this group,and that every seven insured persons cost the insurancefunds 21 per annum in respect of these diseases-a total of z2,000,000 per annum amongst our insuredpeople alone. However, students still can and dograduate from our large hospitals with little knowledgeof chronic rheumatism beyond the fact that it is adisease prevalent amongst out-patients, and is usuallytreated with salicylates internally and liniment asa placebo. The authors of this handy volume donot claim to describe any hitherto unpublishedoriginal research ; none the less, its study will give eipfOlmation which will be new to many.The book is divided into three parts. The firstdeals briefly with aetiology, and then describes theclinical types, showing clearly how they differ or

overlap. The following reason is given for droppingthe name " rheumatoid arthritis " and substituting" focal arthritis." " The name rheumatoid arthritis ’conveys no suggestion of the main eetiological factor,and may even mislead by suggesting a false relation-ship to rheumatic fever. On the other hand, theterm focal arthritis’ not only emphasises the under-lying cause, but serves as an emphatic reminder tothe medical attendant that it is his duty to find outwhere the infection lies, and to treat it thoroughly-and effectively at the earliest possible moment." The-nomenclature throughout is simple, and the reader-cannot fail to grasp exactly what the authors mean.The clinical descriptions of fibrositis, neuritis, lumbago.the various forms of arthritis and gout are all good.The 24 pages which comprise Part II. deal withcommon mistakes in diagnosis. Read in conjunctionwith the clinical descriptions in Part I., they cover

. the ground thoroughly and supply a reminder thatroutine physical examination is necessary even of

, the patient who makes no more than a casual complaint tof a touch of rheumatism. Neglect of this precautionmay bring serious trouble to doctor and patient alike.

: Treatment is described in Part III. under the headings: drug treatment, hydrology, climate, physiotherapy, orthopsedic treatment, vaccines, and diet. It would, appear that the authors have not seen the ill-effects

l from the use of drugs of the atophan group describedby other clinicians, otherwise these dangers might. have been more stressed. There is a short paragraph, summarising the points to be considered by the doctor: who is debating whether or not to send his patient’

to a watering-place. The information under theheadings physiotherapy and orthopaedic treatment

will be quite as useful to the general practitioner asthat concerning drug treatment. Not only is it, emphasised that joints must be kept in the positionb of optimum efficiency during acute inflammation, butL it is shown how this may be done.

A doctor who has had the depressing experience3 of seeing a patient become crippled and deformed3 in spite of his efforts will appreciate the value of the3 teachings, though even with the knowledge they impart1 treatment is difficult enough. No enthusiam is shown) for vaccine therapy ; protein shock is regarded as still1 sub judice, but without much promise. The facts that this book is written by two spa physicians hassome significance. Although our large mineral water

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hospitals do not confine themselves to the treatmentof rheumatic diseases, patients suffering from thesediseases form the majority of their cases, and, as theurgent routine work of pathological and biochemicaldepartments is less than that of general hospitals,it is to spa institutions that we may look for furtheradvances in our knowledge of these economicallydisastrous diseases. This book contains all essentialinformation concerning its subject and has no padding.It is light to hold, and is well produced.

MEDICAL DIAGNOSIS.

Sixth edition. By CHARLES LYMAN GREENE,M.D., formerly Professor of Medicine and Chiefof Medical Clinic, University of Minnesota;Chief of Staff, St. Luke’s Hospital. LondonWilliam Heinemann, 1926. Pp. 1468. 23 3s.

THIS costly and richly illustrated volume shouldprove attractive to the studious medical man whowishes to possess a work on general medicine whichescapes from the usual format of text-books. Dr.Lyman Greene is well qualified to produce such awork, both by a wide experience and a clear styleof writing. After sections dealing with fundamentalprinciples and case-taking he discusses in detail themethods of investigating and the clinical features ofdiseases of each system of the body. If there is amajor criticism to be made, it is that the space devotedto the cardiovascular system is disproportionate tothat given to other parts of the body. This portionof the book is filled with accurate observations andreadable descriptions, and the author has expressedhis personal views with a fearlessness which mustcommend itself to critics. But the general readermay yet be disappointed at the relatively smallamount of space devoted to other important sections,notably to diseases of the lungs and to abdominaldiseases. As is always the case with books of thismagnitude, the laboratory methods, sometimesdescribed in great detail, may be out of date by thetime they reach the reader ; thus page 999 containsfull description of the original Rosenthal test forhepatic efficiency ; the method is here placed aloneunder the heading Determination of Liver Function,whilst a footnote only refers to the method whichhas since completely supplanted the one described.Still more surprising to English readers will be theomission of reference to the van den Bergh test or tocholecystography, whilst many less important methodsof examination are prominently recorded. But suchomissions are inevitable in a production of this sizeby one observer, and we are well content to ignorethem in a work which carries such a strong individualmessage.

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ORTHOPEDIC SURGERY.

By W. A. COCIIRANE, M.B., Ch.B., F.R.C.S. Edin.,Assistant Surgeon, Edinburgh Royal Infirmary;late Clinical Assistant, Orthopaedic Department,Massachusetts General Hospital, Boston, U.S.A.Edinburgh: E. and S. Livingstone. 1926.Pp. 528. 21s.THIS book, written by an Edinburgh surgeon, is

largely inspired from American sources, and givesprominence to views and lines of treatment towhich little attention has been paid in this countryhitherto.

Following the lead of Joel E. Goldthwait, a schoolhas arisen in the United States which attributes muchmore importance to the effects of posture than hasbeen admitted elsewhere. Whether or no bad carriageof the body is more a cause than a result of abnormality,it is time that the profession in Great Britain shouldhave the arguments in favour of Dr. Goldthwait’sconclusions adequately put before them. These Mr.Cochrane has well presented in Part I., whichincludes also chapters on physical education andreconstruction. The rest of the book deals, by meansof a regional and not an setiological classification,

with disabilities and affections which Mr. Cochraneincludes under the six heads into which he has dividedthe surgery of the locomotory apparatus, a titlehardly comprehensive enough to cover all the domain.Beginning with the feet and ankles, the author takeshis readers to the knee, hip, spine and thorax, shoulder,elbow, and hand and wrist, to reach in the final chaptertorticollis, acute anterior poliomyelitis, and spasticparalysis. Fractures in the neighbourhood of joints,such, for instance, as those of Colles and Pott, receiveattention, but for information about fractures ingeneral the reader must turn elsewhere and then couldnot do better than consult the joint work on Fracturesand Dislocations of Wilson and Cochrane, publishedin 1925. Trauma and disease of the sacro-iliacjoints are conditions to which much more attentionis paid in certain schools of surgical thought inAmerica than in Europe. Such injuries must bemuch commoner in New England than here, or elsetheir occurrence is here overlooked. Mr. Cochranegives a good description of the symptoms andmorbid appearances on which American surgeonsrely, and his account of this subject should arouseattention to these conditions in Great Britain.

This book is well printed and illustrated, and it offersin a handy form a useful guide for practitioners in thetreatment of orthopaedic cases.

CARBOHYDRATE METABOLISM AND INSULIN.

Monographs on Physiology. By JOHN JAMESRICKARD MACLEOD, F.R.S., M.B., LL.D.Aberd.,D.Sc. (Hon.), Professor of Physiology, Universityof Toronto, Canada. London : Longmans, Greenand Co. 1926. Pp. 357. 18s.

THE monograph under consideration deals mainlywith the physiological aspect of insulin. Prof.Macleod sets out to prove that insulin is derived fromthe islets of Langerhans, and commences the mono-graph with a detailed account of the histology of theislets, and a very interesting summary of the compara-tive anatomy of these structures. This -part of thetext is illustrated with photomicrographs, some ofwhich are very clear, but others are of rather doubtfulvalue. For instance, it is difficult to imagine whatFig. 4 is meant to illustrate. Prof. Macleod pointsout that by far the greatest yield of insulin is obtainedfrom the islets, and, although he refers to the observa-tions of other investigators who have shown thatinsulin can also be obtained from the acinar tissues,he does not consider that this weakens his argument.There is no reference to the observations whichdescribe the presence of insulin in the tissues ofdepancreatised dogs, nor to the discovery of insulin inlarge quantities in tissues other than the pancreas.These observations are very difficult to explain if theclassical theory as to the action of insulin be adopted.It must, of course, be borne in mind that " no otherorgan or tissue can replace the pancreas as the sourceof this hormone in the animal body."

There is a very brief description of the main methodsfor the preparation of insulin, together with a shortaccount of its chemical properties. Then follows adetailed account of the metabolism of the depan-creatised dog treated by dietetic means and withinsulin. This ground is very familiar, and manyreports on the subject have been published, but it isinteresting to read the views of one of the originalinvestigators on the question, and these are summedup in one of the later chapters. The mechanism ofthe action of insulin is discussed at some length, butthis subject is, of course, an unsatisfactory one, andup to the present no definite statement as to theaction of insulin can be made. The final chapterdeals with methods of assay, and consists mainly of asummary of the recent publications of the Standardisa-tion Committee of the Health Section of the League ofNations.

This monograph is of great value in that it givesthe general reader an opportunity of hearing the

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views of one who has been associated with work oninsulin from its beginning. The volume is certainlynot a complete summary of the literature on thissubject, as many important researches by Europeanworkers are omitted, yet, as Prof. Macleod states," if undue weight may appear to be given to the workwhich has gone on under my own supervision, it ishoped that this will be pardoned on the ground thatotherwise it would have been impossible for me toprepare the monograph."

DISORDERS OF NUTRITION AND GROWTH IN CHILDREN.

Clinique M édicale des Enfants : : Troubles de laivutrition et de la Croissance. By P. NOBÉCOURT,Professeur de Clinique Medicale des Enfants à laFaculte de Médecine de Paris. Paris : Masson etCie. 1926. Pp. 404. Fr.36.

THE third volume of Prof. Nobecourt’s notable.system of children’s diseases is on the same lines as itspredecessors, detailed clinical accounts of individualpatients being followed by a discussion of the con-ditions which they exemplify. This volume is perhapsthe most attractive of the series.

The first part of the book is devoted mainly to thedifferent types of hypotrophy in children ; the casesdescribed are illustrated by excellent photographs andby radiograms of the hand and carpus, the develop-ment of ossification centres being taken as one

of the most useful points of distinction between thedifferent types of retarded growth. The varyingdegrees of hypothyroidism, and the effect of syphilisin diminishing growth, are fully discussed in theirrelation to hypotrophy. The question of staturalhypertrophy is approached in the same way, withspecial reference to the r6le of the endocrine organs.The author recognises three main types : the Hutineltype with delayed puberty and a subsequent staturenot greatly in excess of the normal; acromegaly ; andhypertrophy of stature with precocious puberty.The cases of obesity which Prof. Nobécourt describesare of remarkable interest, as is his discussion of theproblem of their pathogenesis. He is convinced thatmany cases of obesity in children are wrongly attri-buted to diminution of pituitary secretion, and are ofcerebral origin ; when found in association with apituitary tumour they are the result of neural lesionscaused by pressure on the tuber cinereum or surround-ing parts of the brain. This view is supported byevidence which he brings forward of obesity occurringas a sequela of encephalitis, also resulting from lesionsof this locality. A few chapters are devoted to theclinical features and treatment of diabetes ; some

of these were written before and some after theintroduction of insulin treatment. Non-diabeticacetonsemias are also discussed, and attention isdrawn to the meningeal reaction which may accom-pany them, and the alterations which they producein the cerebro-spinal fluid.

This volume further establishes Prof. Nobécourt’s" Clinique Medicale " as one of the most importantworks on paediatrics, and will give both pleasure andinstruction to all who are interested in problems ofgrowth and of endocrine function.

NEMATODE WORMS.A Synopsis of the Families and Genera of Nematoda.By H. A. BAYLIS and R. DAUBNEY. London :Trustees of the British Museum. 1926. Pp. xxxvi.+ 277. 10s. 6d.

ZOOLOGY is essentially a science of classification,and this is no less true for the more economic branchesthan for the purely scientific. Without classificationwe are unable to apply effectively our knowledge ofbiology and preventive measures, and although tothe true biologist the name of an animal is merelya label, without a systematic knowledge of these nameschaos would result. This is particularly true of the

round worms, over 600 genera of which are describedand classified in the present work. It is unfortunatethat the authors have stopped at genera, as theabsence of species considerably reduces the value ofthe book to the general zoologist and the medical man.A genus is often an artificial collection of species basedon some arbitrarily chosen morphological detail; andwhile the authors on the whole have avoided theobvious pitfall they have often been compelled to writea diagnosis of a genus containing a single species-a task of great delicacy and sometimes questionablevalue, as such a species is often proposed on accountof its differences from other genera rather than on itsown intrinsic characters.

The classification of the " worms " has received agreat amount of attention in recent years, but in mostcases only the parasitic forms have been considered.Baylis and Daubney believe, however, that a moreaccurate system should include all nematodes, free-living or parasitic, without regard to their habitat.The adoption of this plan has in their hands led tosome curious anomalies, although there can be nodoubt that it gives a sense of perspective to the studyof the purely parasitic forms, and a sense of perspectiveis a valuable adjunct in all the branches of economicbiology.As the last word has yet to be written on systematic

helminthology, few students of the nematodes willagree with everything in this volume, but many willagree with most, and all will welcome the addition ofsuch a concise synopsis to their library shelves.

PUBLIC HEALTH ENGINEERING.

The Principles of Public Health Engineering. ByEARLE B. PHELPS, B.S., Professor of SanitaryScience, College of Physicians and Surgeons,Columbia University. New York : The MacmillanCompany. 1925. Pp. 265. 12s. 6d.

THIS book, in spite of a title not particularly attrac-tive to medical men, will be found to make interestingreading. It is intended for the health officer with littleknowledge of engineering, and for the sanitary engineerwhose understanding of the public health objectiveof his efforts is usually vague. The author, a

chemical biologist who has become a sanitarian, iswell equipped for his task. The scope of the work islimited to a few problems-viz., ventilation andatmospheric pollution, water-supplies, sewerage,pasteurisation, lighting, refuse disposal, and insectcontrol. In each of these subjects the fundamentalprinciples involved, and their application to the needsof society, are discussed in relation to modern scientificinvestigation and engineering practice. The treat-ment is perhaps more satisfactory on the scientificthan on the practical side, but even practical issuesare dealt with more thoroughly than is customary inthe ordinary text-book on public health. Interest isenhanced by the exposition of the results of investiga-tions by the author and other workers on sanitationin America, which compensate for the somewhatastonishing meagreness of the references to Englishand other European observers in a branch of medicinewhich we have been accustomed to regard as peculiarlyour own.

This book should be read by every medical officer ofhealth and teacher of hygiene, and it may also berecommended to civil engineers whose work bring?them into contact with problems of sanitation.

JOURNALS.

QUARTERLY JOURNAL OF MEDICINE.—The Julynumber contains the following articles : The Effecton Renal Efficiency of Lowering the Blood Pressurein Cases of High Blood Pressure, by Charles Reid.Certain renal efficiency tests, such as the estimationof blood-urea and non-protein nitrogen and the urea-concentration test, were made upon patients suffering