1323

syndrome of hepatic coma was occasionally a chronic neuro-psychiatric disorder in patients with cirrhosis and an extensiveportal collateral circulation and that restriction of dietaryprotein resulted in dramatic improvement.In the discussion Dr. SHERLOCK emphasised her opinion

that elevated blood-ammonia levels after portacaval anasto-mosis were due to the coincident liver disease together withthe deviation of portal blood.Dr. W. VOLWILER (Seattle) commented that a group in

Denver had succeeded in reproducing the characteristicfeatures of impending hepatic coma by the intravenous infusionof large amounts of ammonium chloride in subjects withoutliver disease.

Dr. P. YouNG (Cincinnati) had found that blood introducedinto the stomach, thus reproducing the effect of gastro-intestinal bleeding, produced abnormal blood-ammoniacurves in patients with liver disease.

Some other Communications

Dr. 1. B. BRICK and Dr. L. KYLE (Washington) had investi-gated the effect of methyltestosterone in patients with liverdisease. Despite the recognised hazard of testosterone jaundice,there was no change in liver-function tests or hepatichistology in their patients.The application of needle biopsy to the diagnosis of primary

or secondary malignant hepatic lesions was described byDr. M. STAUFFER (Mayo Clinic), who had found that 83%of neoplasms were revealed by this method. These results,however, were achieved by taking multiple biopsies, oftenfrom a prominent tumour and with the help of frozensections.

The possibility that the recently described syndrome ofchronic idiopathic jaundice with unidentified pigment in theliver cells might be relatively common was raised by Dr. M.CAMPBELL (Minnesota). Together with Dr. J. CoE andDr. F. W. HOFF BAUER he reported three instances of thiscondition ; all were in elderly men, one of whom had retinitispigmentosa.Another congenital disorder of uncertain setiology had been

studied by Dr. 1. M. ROSENTHAL and Dr. H. J. ZIMMERMAN(Chicago) who described the onset of jaundice with tremor,ataxia, and scanning speech during childhood. As in cases

reported earlier, liver biopsy was normal, and it was con-cluded that this non-hoemolytic, non-obstructive icteruswas due to an inability of the liver cells to excretebilirubin.

Dr. A. L. SCHERBEL (Cleveland), described a patient withnormocholestersem.ic xanthomatosis, hepatic fibrosis, and

pulmonary cholesterolosis. Xanthomatous deposits had causedconjunctivitis and polyarthritis.

Dr. I. A. SCHAFER (Atlanta) and his colleagues (H. F. Eichen-wald, J. Mosely, J. 1. Karush, T. A. Asher, M. L. Candler, andG. R. Cooper) reported findings from an epidemic of infectioushepatitis in Kentucky. There was a high incidence ofmyalgia (56% of patients) and backache (36%) in the acuteepisode, and the persistence of symptoms or signs (52%)or abnormal laboratory findings (35%) a year after apparentrecovery was of interest.

Radioactive rose-bengal using 1311 had been applied toa study of liver function by Dr. C. H. BROWN (Cleveland).The uptake was recorded by a scintillator over the liver.In hepatic disease the uptake was reduced and excretion wasdelayed, but similar findings in obstructive jaundice reducedthe diagnostic value of the test.

Dr. D. MOLANDER and Dr. M. A. PAYNE (New York)found elevated levels of s.G.o. transaminase in patients withdecompensated cirrhosis, and abnormally high values alsooccurred in hepatitis and biliary cirrhosis.

Dr. A. G. BEARN (New York) discussed the place of dimer-caprol (BAL) in the treatment of Wilson’s disease. Some

patients showed a good response, and when the result wasless satisfactory he advocated a trial of larger doses continuedover a long period.

Dr. F. L. IBER, Dr. L. L. UZMAN, Dr. M. KNOWLTON, andDr. T. C. CHALMERS (Washington) considered that the affinityof the liver for copper in Wilson’s disease was due to an electro-phoretically distinct factor which they had demonstrated.They were unable, however, to identify this factor with

c oeruloplasmin.

Reviews of Books

Subphrenic AbscessH. R. S. HARLEY, F.R.C.S., consultant thoracic surgeonto the United Cardiff Hospitals. Oxford : BlackwellScientific Publications. 1955. Pp. 216. 35s.

BASED on 188 cases of subphrenic abscess from hos-pitals in or near London, this book examines thecondition from all angles. ,

The anatomy of the subphrenic region is discussed, andfive intraperitoneal and two extraperitoneal spaces are

described. This involves a clarification of the arrangementof the ligaments attached to the liver and their behaviourif the liver is separated from its normal relations by air orfluid. Most subphrenic abscesses occur on the right, andnearly all are intraperitoneal involving one space.90% of the abscesses were secondary ; perforated peptic

ulcers, appendicitis, or abdominal operations were associatedwith two-thirds. The bacteriological investigations gaveequal proportions of pure and mixed infection, and lessthan 10% were sterile. Staphylococcus aureus and strepto-cocci were responsible for " pure " infections, and in

" mixed "

infections, Escherichia coli was invariably present as well.Mr. Harley holds that infection spreads by a direct intra-peritoneal route and not by lymphatics, and he discussesthe various changes in intraperitoneal pressures that occurin different postures and during respiration. Pleural effusionwas recorded in 25% of the 188 cases, and is regarded asanalogous to oedema found in relation to an inflammatoryfocus.

Among the clinical features high fever, tachycardia, leuco-cytosis, and anaemia were common, but where the abscesswas chronic one or more of these signs was absent. The

radiological signs included immobility of the diaphragmoften associated with elevation, and sometimes with gasbelow it.

Drainage of the abscess should always be undertakenso as to avoid the pleural cavity and prevent collapse of thelung and total pleural infection. The incision differs accordingto the location of the abscess and the space involved, andonce drainage has been established the control of healingshould be observed by injection of lipiodol and radiography,so that the tube is not removed prematurely.The over-all mortality in the 188 cases was 40%-an

alarmingly high figure. Earlier diagnosis, followed by chemo-therapy and adequate drainage, now offers better prospects.

Mr. Harley has written a classic on the subject. Thecase analysis is detailed, the bibliography carefullyconsidered, and the opinions soundly based. It will besurprising if many of his views do not find a permanentplace in the textbooks of the future.

Asclepiades, his Life and WritingsTranslated by the late ROBERT 1VÍONTRAVILLE GREEN,M.D., emeritus professor of anatomy, Harvard MedicalSchool. New Haven, Connecticut: Elizabeth Licht.1955. Pp. 167.$6.

Asclepiades, who practised medicine in Rome in thegolden age of Cicero, Horace, and Virgil, was the mostimportant physician between Hippocrates and Galen,yet singularly little is known about him. Unhappilyalmost all his works have perished except for a fewfragments from which Dr. Antonio Cocchi wrote a

biography that was indifferently translated into Englishin 1762. The first part of this book consists of a newtranslation of this work. Thirty years later ChristianGottlieb Gumpert collected fragments of the writingsof Asclepiades and published them with his commentsin Weimar. Only one copy is extant and from it thepresent translation has been made.Many innovations have been attributed to Asclepiades.

He was the first to associate hydrophobia with the biteof rabid animals. He advocated walking in sand forparalysis, gave specific prescriptions of music for thementally ill, and used massage for muscle spasm as

well as dry steam and radiant heat.The translator, " a gentle scholar," did his work

well. Here is an excerpt:" The chief value of music, according to the opinion of

Asclepiades, is to be found in those diseases in which the mind

1324

is affected. Hence the minds of phrenitics, disturbed bydisease, are often restored to their own nature by a symphony.In the same way he teaches that a song should be employedin the treatment of mania. Caelius speaks thus they use alsomadrigals of pipes with varied modulations : one of theseis gay and excites those known to be insane from sorrow ;another is serious, injecting sternness, as in war, in those whoare affected with laughter or girlish giggling.’

"

Clinical Papers and Essays on PsychoanalysisKARL ABRAHAM, M.D. Translators : Hilda C. Abraham,M.D.. D. R. Ellison, M.A. London : Hogarth Press andInstitute of Psychoanalysis. 1955. Pp. 336. 25s.

IN 1927 when Karl Abraham’s Selected Papers werepublished as a volume in the International Psycho-analytical Library, Dr. Ernest Jones said that the bookcontained the whole of Abraham’s more important psycho-analytical work, except Traum und Mythus, and the studyof Amenhotep IV. In the ensuing quarter of a centuryAbraham’s reputation has increased, his pupils have intheir turn become prominent psycho-analytical teachersand theorists (though in the process they have divergedwidely from one another), and it has been for some timeobvious that psycho-analysts unable to read Germanneeded a satisfactory translation of those papers.Though less influential and important than those selected

in 1927, the papers nevertheless contain clinical observations,applications of psycho-analysis to biography and mythology,and some polemical or expository writings which are all ofvalue to students of this subject. It is fortunate that hisdaughter, herself a psychiatrist well versed in psycho-analysis,has been able to translate and edit these essays and articles.Among the more elaborate studies are the anthropologicallyingenuous but psycho-analytically original and inventivemonograph on Dreams and Myths (previously translated inthe Nervous and Mental Disease Monograph Series), andAbraham’s sympathetic and penetrating effort to understandthe psychology of the painter Giovanni Segantini.Abraham’s intellectual integrity and singlemindedness

are plain in these as well as in the other writings pre-sented in this volume. The translation is clear andstraightforward, though a few German idioms havebeen retained.

Uber den Einfluss der Schwangerschaft auf dieLungentuberkulose .

Dr. med. KLAUS OBMANN, Erfurt. Leipzig : GeorgThieme. 1955. Pp. 142. DM.25.

THE influence of pregnancy on tuberculosis is a subjectof lasting interest. This well-produced book recordsexperience at the clinic for the town and county ofJena in Eastern Germany.The greater part is occupied by the case-histories of 347

women with pulmonary tuberculosis during 531 pregnanciesbetween 1930 and 1952. Many of the histories are illustratedby the graphic method of Brauening and by radiographs.Relapse in the tuberculosis was commonest in the postpartumperiod, though it was by no means uncommon in the firstmonths of pregnancy. Patients who aborted spontaneouslyor whose pregnancies were terminated did better. On theother hand, suckling was thought to be beneficial.As for treatment, collapse therapy receives more emphasis

than chemotherapy. The author feels that termination of

pregnancy is not really treatment, and he favours strictlylimited indications for interference, though he is not againstit altogether.

Despite its satisfactory presentation of a great deal ofmaterial, the book seems outdated because it does nottake fully into account the great changes that chemo-therapy has produced.

Classics of Biology .’,.

AUGUST PI SuNEB. London: Pitman. 1955. Pp. 337.35s.

IT was an excellent idea to sketch the evolution ofseveral broad facets of biology and to illustrate themwith important milestones (reprints of original articlesfrom Aristotle to the present day).The subjects discussed are : matter and energy in life;

cell theory ; stimulus and excitation ; biocatalysts ; meta-

holism ; growth and reproduction ; germ-cells and soma ;form and dynamics of reproduction ; heredity ; individualand species ; preformation and epigenesis ; life on earth;geography and palaeontology ; causation and design ; reflexes,consciousness, and will; and, finally, the whole and its parts(holism, &c.).The reader obtains a bird’s-eye view of an extensive

field of evolution together with a running commentaryon the philosophic implications.

Cardiac Auscultation

Including Audao-visual Principles. J. SCOTT BUTTER-WORTH, M.D., associate professor of medicine, New YorkUniversity Post-Graduate Medical School; MAURICE R.CHASSIN, M.D., assistant professor of clinical medicine;ROBERT MCGRATH, M.D., associate professor of clinicalmedicine at the school. New York and London : Grune& Stratton. 1955. Pp. 105.$4.50.

WELL illustrated, written, and produced, this bookdescribes and demonstrates with clarity the findings ofauscultation. The phonocardiograms are perfectlysatisfactory. This should be a very valuable method ofteaching and is of course already used, in a less completeway, by many clinicians ; but, though in principle thebook is excellent, it cannot escape some criticisms.The outlook is rather too anatomical and would surely be

much improved for teaching purposes if there were morehaemodynamic principles. For example, it would be helpfulto explain the gap between the second heart-sound and theonset of a mitral diastolic murmur. The current view thatauricular and third heart-sounds are " filling sounds " is notmentioned, and gallop rhythm is said to occur almost invari-ably with heart rates of 100 or more, so that by this definitiononly summation gallop can be considered. Not many clinicianswould agree that an early diastolic murmur indicates pul-monary incompetence, rather than aortic incompetence, ifthere is no waterhammer pulse ; and the second sound inatrial septal defect is described as accentuated. Europeanprogress in auscultation since Laennec is largely ignored, andthe monaural wooden stethoscope is said to be still in commonuse in Europe.Each illustration is a single phonocardiogram without time-

marker or reference tracing. This aids clarity, but somevaluable clinical points are missed. The aortic and pulmonarycomponents of the second sound cannot be identified andthere is no description of the wide splitting of the secondsound in the pulmonary area which is so useful in the diagnosisof atrial septal defect and bundle-branch block. There is nomention of the retention of a normal aortic component, with adelayed or absent pulmonary component, in pulmonarystenosis.

The clinical side is therefore rather disappointing butthe discussion of the principles of hearing and thestethoscope is excellent.

Cardiovascular Surgery (Philadelphia and London:W. B. Saunders. 1955. Pp. 543. 89s.).-The proceedingsof the international symposium on this subject held at theHenry Ford Hospital, Detroit, last March, have been publishedunder the editorship of Dr. Conrad R. Lam. Those takingpart included Sir Russell Brock, Dr. Ian McMillan, and Prof.C. G. Rob.

Mechanisms of Microbial Pathogenicity (Cambridge:University Press for the Society for General Microbiology.Pp. 333. 25s.).-On April 19 and 20, 1955, the Society forGeneral Microbiology held its fifth symposium in London,and this is a record of the sixteen contributions. A bookof this kind can be neither complete nor homogeneous;for some contributors take the opportunity to develop theirown views, while others give a well-balanced review in whichtheir own work can be seen in proper perspective. Thesolution might be to give a general review of each aspect ofthe subject under discussion, and then to let the specialistswith divergent views have their say. Unfortunately the timelimit on most symposia forbids such comprehensive treat-ment. As this book was published before the symposiumwas held, the discussion could not be included, and contro-versial views must go unchallenged. The difficulty, therefore,for the general reader is to know what can be accepted asreasonably established and what is still hotly contested;but the specialist will find much that is stimulating.