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may describe as a " chill " or

" influenza." Theremay be a variable interval between such a chill andthe onset of the neuritic symptoms. These usuallybegin as sensations of numbness and tingling in thetoes and fingers, followed by marked motor weaknessin all four limbs. Soon the facial muscles becomeaffected, and this observation, combined with, later,the occurrence of trunk muscle weakness, serves toindicate the correct diagnosis. Sensation is dulledover the distal portions of the extremities, but thesensory loss is usually much less marked than themotor loss. Apart from other forms of peripheralneuritis, the condition may simulate Landry’sparalysis and acute ascending myelitis at the outset.The peripheral distribution of the symptoms, thedisordered sensation, and the presence of facialparalysis are the chief points which would lead tothe diagnosis of acute infectious polyneuritis. Thecerebro-spinal fluid shows no definite change.

Mr. LEYLAND ROBINSON said that the disease inone of Dr. Johnson’s cases might be associated witha transfusion of whole blood which had been carriedout for post-partum haemorrhage two weeks beforethe onset of the neuritic symptoms. Polyneuritis wasrecognised as a rare complication of parturition anddue to pregnancy toxsemia (pernicious vomiting) orpuerperal septicaemia, both of which could be excludedin this patient. The clinical features so closelyresembled the type seen in France during the war asto suggest a common aetiology, and although the donorgave no history of neuritis, he had served in Franceand might be a carrier of the disease. The patienthad subsequently become pregnant and had been ’’,delivered by Ceesarean section at full term ; pregnancy ’’,and the puerperium were uneventful. I

Mr. G. P. NEWBOLT read a note on four cases of lfIntestinal Obstruction Caused by Gall-stones.

Three of the cases were women, all of whomrecovered, one case was a male, who died. The z,

symptoms were those of intestinal obstruction. ’,Faecal vomiting with intermissions was present.Constipation was not absolute and there was notmuch abdominal distension. The patients were allstout and elderly, one woman weighing 19 st. Thechemical examination of the last stone removed wasthat of a typical gall-stone.

Mr. G. C. E. SrmMPSON said that he had seen twocases of this condition, both in women. One, aged 70,died of pneumonia after operation. In the other casegall-stones were diagnosed, but the vomiting passed soinsensibly into the vomiting of obstruction that somedays were lost; in the latter case on exploration theadhesion of the gall-bladder to the duodenal anglewas seen and two stones were felt firmly impactedlow down in the common duct. Presumably thefistula first formed in the initial severe attack, theonly attack accompanied by jaundice, six monthsbefore the big stone passed, and gave rise to obstruc-tion. Operation on the biliary region had not yetbeen undertaken.

Dr. C. 0. STALLYBRASS read a paper * on the recentoutbreak of

Encephalitis Lethargica.Having referred to the past history of the disease,he stated that whilst it was not new its pandemicextension was a new feature. As the disease spreadthere had been observed in France, Italy, &c., a

tendency to evolve from a type presenting depressionof function to one exhibiting exaltation of function ;instead of palsies, lethargy, and somnolence, therewere involuntary movements, delirium, and sleepless-ness. In Liverpool, in 1921, 81 per cent. of the caseswere of the first type. In the winter 1922-23 aconsiderable outbreak involving over 100 cases

occurred and only 52 per cent. were of the first type.The delirium was usually occupational. Alteration intype was accompanied by increased fatality as wellin the lethargic as in the over-active type ; age-incidence was identical in both types. A definite

* See also THE LANCET, Oct. 27th, p. 922.

history of contact with a preceding case was foundin 9 per cent. of the cases. Dr. Stallybrass describedfour abortive cases. The virus he regarded as a

variable one, which at times exhibited markedmalignancy and increased pathogenicity, as at Derby,Rudduvoorde, and, probably, at Miilheim.

Dr. A. G. GULLAN stated that he had first seencases of encephalitis lethargica at the end of 1919,when they were of the lethargic type, and thoughthey were not paralysed the patients lay motionlessin bed, were only roused with difficulty, and spoke ina monotonous, toneless voice. The only interest thepatients took was, that in a feeble voice, they asked" whether they were going to recover." He agreedthat the expressionless face was the most charac-teristic symptom of the disease, both in the lethargicand in the restless varieties. In 1922 he saw a con-siderable number of cases of the excited form inwhich choreic movements, wakefulness, and in someinstances occupational delirium were present. Dr.Gullan stated that his mortality was considerablylower than that given for the whole of Liverpool ;at the present time he had a case of the lethargic typein his wards which gave a previous history of trauma.

Reviews and Notices of Books.PATHOLOGICAL PHYSIOLOGY OF INTERNAL DISEASES.

By ALBION WALTER HEWLETT, M.D., B.S.,Professor of Medicine, Stanford Medical School.London and New York: D. Appleton and Co.1923. With 151 illustrations. Pp. 765. 35s.THE proper understanding of the normal functions

of the body and of the manner in which they maybecome deranged in disease is the basis of scientificmedicine. To keep abreast of recent work in physio-logy, biochemistry, immunology, and the like is,however, by no means easy, and implies leisure forreading and access to literature which the generalpractitioner is rarely fortunate enough to enjoy.Prof. Hewlett’s book meets the demand so oftenexpressed for a critical and reliable guide to modernpathological physiology. Dealing with the circulation,digestion, metabolism and its disturbance, fever, thederangement of respiration, renal function, infection,the blood, the nervous system, and the endocrineorgans, he describes the functional changes broughtabout by disease and discusses their causation. Hedoes so in a clear and readable manner, avoidingcontroversy when possible and presenting a definitepoint of view. The reader is presented with a clearand concise picture of disease, and an adequatebibliography is appended to each chapter for thebenefit of those who may desire to extend their readingto the original sources. As is only to be expected in asubject of such dimensions, certain of the sections aremore satisfactory than others, but on the whole thebook is well balanced throughout, and may be confi-dently recommended to students and practitioners alike.

CHRONIC INTESTINAL STASIS-A RADIOLOGICAL STUDY.

By ALFRED C. JORDAN, C.B.E., M.D., M.R.C.P.Oxford Medical Publications. London : HenryFrowde and Hodder and Stoughton. 1923.Pp. 230. 25s.ALIMENTARY delay, or constipation in its widest

sense, is of immense importance to human well-being, and the radiologist-to whom the viscera arenot the sealed book that they are to others-is in abetter position than most to make exact observations.In his preface, Dr. Jordan says,

" I have attempted togive an ordered account of chronic intestinal stasis.I have found it a difficult task, so interwoven are theeffects of stasis. There is unavoidable repetition, andI hope my readers will forgive this, especially as therepetition is more apparent than real and is, in fact, apresentation of the subject from many aspects." Tothis volume Sir Arbuthnot Lane contributes a

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" foreword," so that we know from the start we arereading the work of a, follower of the doctrines of Lane.Those who wholeheartedly accept these doctrines will,no doubt, find the study completely satisfying.

Dr. Jordan is safest and best when he is examiningthe intestinal viscera almost wholly from the point ofview of the skilled radiologist. Thus, following hisbrief summary of the developmental causes of" stasis," he proceeds to deal with the intestinal tractunder the chapter headings of the Large Intestine inChronic Intestinal Stasis ; the Pelvic Colon in Stasis ;the Peristalsis of the Large Intestine; Colitis;Diverticulitis ; the Ileal Kink ; Ileal Torsion ; theUndescended Caecum; the Appendix. All of theseconditions are well described and appear to the readerto be really close to his subject. A good case is madeout for including studies of duodenum and stomach.In regard to cardiospasm, no doubt " stasis " may beone of its causes, although treatment on the linesrecommended by the author will, we think, notalways be successful. Dr. Jordan would have usbelieve that chronic intestinal stasis will cause suchvaried conditions as chronic mastitis, certain formsof blindness, disseminated sclerosis, epilepsy, aorticaneurysm, fibroid phthisis, gall-stones, glycosuria,Dupuytren’s contraction, and cancer. Now intestinaldisorders are common, while a number of the diseasesenumerated are relatively uncommon. Some of theillustrations given are very striking, and the associa-tion of two apparently unrelated conditions is oftencurious and suggestive ; but it must be rememberedthat the citation of a number of cases in which thesediseases were present and associated with intestinalderangement is not in itself proof.

Radiological technique has reached a high degreeof precision, but even now the illustrations so obtained Iare difficult to interpret. In spite of the carefullynumbered and lettered descriptions, some of themwill leave the reader with an open mind. It would,perhaps, be better if in a later edition Dr. Jordanenlarged the book in the direction of making ita complete work on radiological investigation ofthe intestinal tract alone, or confined it rigidlyto advancing proofs of the correctness of Lane’shypothesis. In either sphere his experience wouldbe welcome and carry weight.

EXERCISE IN EDUCATION AND MEDICINE.Third Edition. By R. TAIT MCKENZIE, M.D.,LL.D., late Major, R.A.M.C. ; Professor ofPhysical Education and Director of the Depart-ment, University of Pennsylvania. London:W. B. Saunders Company. With 445 illustrations.Pp. 601. 24s.ALL those who are interested in physical work,

whether educational or gymnastic, have grown accus-tomed to look forward to reading anything from thepen of Tait McKenzie. The rare combination ofphysician, sculptor, and university professor hasqualified him to produce a standard work on thesubject which he has made particularly his own.The book is divided into two sections, the first ofwhich is devoted to exercises in education, and thesecond to exercises in medicine. The first part givesa most comprehensive survey of the subject, anddeals largely with history, comparing the systems ofgymnastic education in vogue in various countrieswith admirable precision and clearness. It is mainlyin these pages that the value of the combination ofmedical man and sculptor is so clearly shown. It isperhaps unfortunate that more reference has notbeen made to the attempts that are now being madethroughout our national schools to pay serious atten-tion to the physical fitness of the children attendingthem ; for, although the system is still in its infancy,it has made such rapid strides as to be worthy ofcomment. At the same time, it cannot be deniedthat the perusal of the account given of educationalgymnastics in other countries is, in places, inclinedto till the British reader with an envious admiration.More particularly will this be the case amongst those

who have had the opportunity of seeing the author’smagnificent work in his own University at Philadelphia.A glance through the titles of the 17 chapters in

this section of the book shows at once its compre-hensive scope, since even the physical education of theblind and the deaf-mute is given full consideration.The chapter devoted to the physical education ingirls’ schools and women’s colleges places the prosand cons of this much-debated subject with greatclearness, and a careful study of these pages by thosewho have joined in the acrimonious discussion of thissubject would speedily clear the ground for a moreready settlement of divergent views. In the sectiondealing with exercises in medicine the author changeshis r6le from that of the sculptor and scholar to thatof the medical practitioner. He has, of course, foundit impossible entirely to separate treatment by exercisefrom treatment by other physical means ; and acertain amount of consideration has been devoted totreatment by massage, though other methods, such aselectrical treatment, have received but passingmention. One of the outstanding features of treat-ment by exercises prescribed by the author is thefrequency with which his patients are instructed tocarry out certain stated movements. Almost thewhole field of physical therapeutics is covered by thebook. Its title may lead to the impression that it isonly intended for the masseur-gymnast and physical-therapist. It is to be hoped that others, too, will studyits pages. There can be few medical men who wouldfail to derive much practical help therefrom in the-treatment of patients.

BIOLOGICAL TECHNIQUE.H anãbuch der biologischen Arbeitsmethoden. Heraus-gegeben von Geh. Med.-Rat. Prof. Dr. EMiLABDERHALDEN, Direktor des Physiologischen.Instituts der Universitat Halle a. d. Saale.Abt. IV., Teil 3, Heft 2, Lieferung 106,Blutuntersuchungen. Berlin und Wien: Urbanund Schwarzenberg. 1923. Pp. 514.Tms number of the " Handbuch der biologischen

Arbeitsmethoden," now appearing under the editor-ship of Prof. Abderhalden, will be of particular-interest to students of the blood. Each of the sevensections is written by an authority who has himselfcontributed to the sum of knowledge on his subject,and, in consequence, all contain matter not availablein any previous handbooks. But little attention isgiven to theoretical considerations ; the whole purpose-of the work is practical, and the details of all theprocedures described are fully and clearly set forth.The first two sections will be of least interest to.’workers in this country ; in the former Hamburger,of Groningen, describes an accurate method forestimating the fragility of the red cells, which is.undoubtedly a great advance in technique on Widal’s:original method, but has the disadvantage of requiringrather elaborate specially made apparatus ; in thelatter Reiss, of Frankfurt-am-Main, describes the-newer methods of refractometry of the serum. I&-the third section Kleinmann, of Berlin, goes veryfully into the theory and practice of colorimetry andnephelometry; this is a most valuable contribution.Fahraens, of Stockholm, in the fourth section dealswith the suspension stability of the red cells ; thissubject, interesting though it be academically, offers.little promise of useful clinical application, and has.attracted little attention in this country. It isinteresting to note that the first true observation onthis matter was made by an Englishman, or rather-Briton-Hewson-who in 1772 demonstrated that the-formation of a " buffy coat" depended upon sinking othe red cells before clotting had occurred. The-author points out the fact, not usually recognised,that diminution of the suspension stability dependsnot upon retardation of clot formation, but is due to-the clumping of the red cells, the fall of the cells beingthe more rapid the larger the clumps formed. In thefifth section Degkwitz, of Munich, details a number ofprocedures applicable to the study of the blood.

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platelets, and in the sixth and seventh Schelcht, ofDuisburg, and Frank and Seeliger, of Breslau,respectively have collected and fully described a largenumber of histological procedures of the greatest valuein the study of the blood and haematopoietic systems.

THE EXAMINATION OF PATIENTS.

By NELLIs B. FOSTER, M.D., Assistant Physicianto the New York Hospital; Associate Professor ofMedicine at Cornell University College of Medicine.London and Philadelphia: W. B. SaundersCompany. 1923. Pp. 253. 18s.

Dr. Nellis Foster is familiar to many readers inthis country as the author of a number of penetratingstudies and illuminating lectures on clinical medicine.His new book will be greatly appreciated by those whoprefer an account of the everyday methods of oneskilled physician to the generalities of the ordinary

I’text-book. Dr. Foster here records his routine in theexamination of patients, and the precision of hiswriting, the thoroughness of his method, and hiscritical but sympathetic attitude to recent advances,make his book a most valuable one to all thoseengaged in general practice. We do, however, feel thatthe book loses a great deal through the omission toinclude descriptions of the clinical examination of theblood and lymphatic systems and of the urine. Wecan imagine the practitioner turning to this volumein a hundred difficult situations, and receiving thegreatest service from the author’s description ofexamination of a cardio-vascular, gynaecological, orneurological condition. But should his patient beone with a grave anaemia, or an obscure splenicenlargement, he will not get the same assistance. Wehope that future editions may see these omissionscorrected.

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LOEB CLASSICAL LIBRARY.

Hippocrates. Vol. II. With an English Translationby W. H. S. JONES. London : Heinemann. 1923.Pp. 336. 10s.A REVIEW of the first volume of this edition of the

text, with a translation of the Hippocratic Corpus,appeared in our issue of Sept. 8th. This volumecontains the following treatises : Prognostic, Regimenin Acute Diseases, The Sacred Disease, The Art,Breaths, repi uo-Mf, Law, Decorum, Physician(Cap. 1.), and Dentition. The Introductory Essayscontain, amongst others, one upon Ancient Nursing,derived from information contained in the treatisesEpidemics, Regimen in Acute Diseases, and Decorum,from which it appears that the nursing was carried outby a pupil-i.e., by someone more or less fully trained.Another essay deals with the subject of AncientMedical Etiquette, or rather Medical " Good Form,"the information being derived from the treatises TheOath, Law, The Physician, Decorum, and Precepts.

Perhaps the most interesting treatise in this volumeis that upon The Sacred Disease, which, mutatismutandis, might have been written by Erasmus. Thewriter considers that no one disease is more divine thananother,

" all are divine and all human. Each has anature and power of its own; none is hopeless or

incapable of treatment." The term " Sacred Disease "apparently includes not epilepsy alone but any con-vulsive affection-e.g., the writer’s description of thedisease in cattle and goats seems to refer to hydatidof the brain (p. 169). Two other notable treatises arethose entitled Law and Decorum. Mr. Jones suggests,with great probability it seems to us, that these twotreatises, and possibly Precepts as well, deal withmatters discussed and only known to medical men whobelonged to a guild or secret society. Thus the lastsentence of Law ends as follows : " Holy things areshewn to holy men ; to the profane it is not lawful toshew them until these have been initiated into the ritesof knowledge." In Precepts V. a genuine physician iscalled " one made a brother." The expression " Holythings for holy persons " is a common religious formula,and we may point out that it has survived to this day,with a slightly different application, in the Eastern

Liturgies, such as those of Chrysostom and Basil, whereat the Elevation the priest says : " The Holy thingsare for the holy " (rà. éí-YLU To2s (i-yiot5), while in theWest we find the same phrase, " Sancta Sanctis," inthe Mozarabic and Gallican Liturgies,. Although thelatter is not now in use, the former is daily saidin the Cathedral of Toledo.

JOURNALS.BRITISH JOURNAL OF OPHTHALMOLOGY. — The

original articles in the October number are physio-logical. The Blood Pressure in the Eye and itsRelation to the Chamber Pressure is the title of anarticle by Priestley Smith, in which many problemsare discussed, such as the self-adjusting equilibriumof pressure inside and outside the retinal veins, thevenous pulse and its relation to finger pressure, &c.The author is one whose researches are always valu-able. The second article is by H. Herbert on thePectinate Ligament in its Relation to Chronic Glau-coma. The anatomy of the ciliary region is still a

subject about which complete certainty has not yetbeen cstabhshed. In this article the scleral spuidiscovered by Prof. Thomson, of Oxford, on whichhis " pump action " theory is founded, is criticisedas not having been found in the eyes examined byHerbert. According to Herbert there are strikinganatomical variations in the mode of attachment ofthe longitudinal fibres of the ciliary muscles, sometypes involving a greater predisposition to glaucomathan others.-The November number is a clinicalone. The first article by W. Barrie Brownlie andH. Neame calls attention to a risk that attends uponthe ordinary operation of advancement of a rectusmuscle. A case is given in which an advancementoperation was followed in a few months by theappearance of an implantation cyst of the iris andciliary body. In spite of a large iridectomy, whichincluded all the anterior wall of the cyst, its recur-rence was inevitable, and ultimately the eye had tobe excised. Such a disaster as this, though of courseextremely rare, ought to be a warning to all operators.The position of the cyst, as determined by patho-logical examination, suggested that the needle carry-ing one of the sutures was passed too deeply, andtraversed the anterior part of the ciliary body at itsjunction with iris root and pectinate ligament. Theadvancement operation had not been performed bythe author of the article, but he charitably remarks," Who will say conscientiously that he has never lefta suture in the deep ciliary region or even deeper ? "A case of cyst of the sclera following upon an advance-ment operation was reported in 1921 by C. Gouldenand M. H. Whiting at a meeting of the Ophthalmo-logical Society, and in the discussion that followedMr. Cyril Walker spoke of a cyst following an advance-ment operation which projected both externally andinternally. In this case, however, the growth stoppedspontaneously. To avert such a disaster as is herenarrated it is necessary not only to avoid penetratingtoo deeply into the sclera with the needle, but also tokeep the overlying conjunctiva well out of the wayso as to mitigate any risk of it being carried into thewound along with the needle. Sanford R. Giffordwrites of intra-cisternal injections in the treatmentof luetic atrophy, and J. J. Keegan of the techniqueand reaction of intracranial bichloride injections.The latter author admits that the constancy andseverity of the immediate reaction from the injectionsmake this a rather heroic procedure. Nevertheless,the first author reports improvement of vision in fivecases, the best results being obtained in early caseswith relatively good central vision, at least in oneeye, and with little evidence of other nervous involve-ment. The fourth article in this number, by A. W. S.Sichel and A. R. Fraser, reports a case of hemianopiaas the sole clinical feature in untreated secondarysyphilis.

The Medical Clinics of North America are publishedbi-monthly, and the price of a year’s issues, which comprisea complete volume, is 55s.