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or experimentally ; he presumed that it meant

hyperglycaemia progressing beyond normal limits.If there were several conditions producing " diabetes "there must be varying prognosis and treatment.It was already possible to distinguish certain clinicaltypes of hyperglycaemia which were not diabetesmellitus. It was impossible at the acute stage todistinguish between cellulitis causing glycosuriaand mild diabetes complicated by cellulitis. Manycases of hyperthyroidism had difficulty in dealingwith sugar. If a patient was mistakenly given adiabetic diet and insulin, not being really diabetic,his blood-sugar might show a suspiciously "diabetic "curve. On an ordinary diet he would show normalcurves. It was unsafe to assume that a persontook a normal amount of carbohydrate by choice;healthy people rarely took above 300 g. of carbo-hydrate a day and many people only took 100 g.An increase of carbohydrate often abolished post-prandial glycosuria. Such cases of mistaken diagnosisaccounted for reports of the cure of diabetes. If £they were given insulin the sugar-tolerance curve

was made very much worse. The curve was highin most cases of spontaneous hypoglycaemia. A personwho tolerated large doses of insulin was not necessarilya diabetic.

Dr. T. C. HUNT mentioned the prognosis of hyper-glycsemic glycosuria as seen in a number of untreatedand treated adult cases. Of the untreated, about athird got better and only a half got worse. Of treatedcases about 30 per cent. got worse. The factorsaffecting prognosis might be found in causation orcourse. Of the improved cases only a few wereoverweight or neuropathic, and nearly 70 per cent.were over 50 years of age. Of those who did notimprove, a third were overweight, a half were

neuropathic, and the majority were under 50. If the

glycosuria were noticed in the course of an infection

the outlook was usually good ; if it were noticed

during mental shock, the patient seemed not to doso well. An onset associated with dyspepsia wasfound in some cases ; biliary drainage in two of thesehad revealed an associated external pancreaticdisorder, but, on the whole, stimulation of the externalsecretion did not affect the internal secretion.

DISCUSSION

Dr. RONALD JoNES described experiments he haddone on pituitary hyperplasia in hyperglycaemia,which he did not regard as significant. Injection ofextracts produced no change in the blood-sugar ofdogs or patients. There seemed in fact to be no,

such thing as a pancreatropic hormone.Dr. E. P. PouLTON asked for details of the patients

subjected to deep pituitary irradiation, and observedthat Joslin had examined severely shocked mencoming back from the front line and had never foundglycosuria. Perhaps people reduced their carbo-

hydrate because there was a pernicious doctrinegoing about that carbohydrates were no good.

Dr. LEYTON recalled a fat patient who used todevelop hypoglycaemia when normal saline was

injected. Some people had very poor power ofstoring carbohydrate throughout their lives, and thetitle had been chosen to exclude these stationaryhyperglycsemias. The sugar-tolerance test had beenabandoned by him as a diagnostic measure, exceptfor purposes of exclusion. X ray therapy had onlybeen used in cases of basophilism.

Dr. WILLMORE observed that his pensioners hadall been normal before the war and had developeddiabetes during or soon after it.Dr. HIMSWORTH said that all over the world since1900 there had been a progressive change in diet,in the direction of decrease of carbohydrate andincrease of fat.

REVIEWS AND NOTICES OF BOOKS

Treatment of Acute PoisoningBy H. L. MARRIOTT, M.D., M.R.C.P. Lond.,Resident Medical Officer, Middlesex Hospital;Assistant Physician, Miller General Hospital,Greenwich. London : Published for the Middlesex

Hospital Press by John Murray. 1935. Pp.45. 5s.

THE idea of treating a case of acute poisoningconjures up for most of us nightmares of stomach-pumps, of long lists of poisons and their antidotes,of home-made emetics and antidotes, and of the

indications and contra-indications of gastric lavage.It is curious that such anachronisms as are embodiedin the standard accounts of this important branch ofmedicine have apparently satisfied the inquirerfor many decades, especially when it is realised thatfor long carbon monoxide has held pride of place amongthe causes of accidental or suicidal poisoning, at anyrate in this country and in America.Dr. Marriott in this monograph strikes at the roots

of the worn-out doctrines repeated from text-bookto text-book and builds a new and rational conceptbased on the treatment of several hundred patientsat the Middlesex Hospital. He has assumed reason-

ably enough that even if the identity of the poisonis known, the antidote is either not remembered oris not at hand. The principles underlying the

successful treatment of acute poisoning are found inthe three questions which the medical attendant shouldput to himself in every case: Is the patientasphyxiated or suffering from poisoning by a gas tIf the poison was not gaseous, how did it enter thebody ? 7 Is life endangered by coma, dehydrationor dechloridation, pain, or delirium, and convulsions 7It is a measure of the success of Dr. Marriott’s-elucidation of these matters that the substance of his-

principles could be condensed into small compass,for of all branches of medicine, this is one in which the-physician is called to deal with a desperate emergencywith little time to think and even less to look upreferences. But here is not merely a reconstructionof indications ; there is supplied, with chapter andverse, the exact technique of the various procedures.to be used by the physician. Furthermore, theauthor has devised a new method of gastric lavagewhich if adopted as a routine should save many apatient recovered from his poison from death throughbroncho-pneumonia. Medicine is already indebtedto Dr. Marriott and his collaborator, Dr. A. Kekwick,-for the method of blood transfusion by the dripmethod which he published in our columns last year-(THE LANCET, 1935, i., 977) and which has rapidlygained general recognition as the method of choice insuitable cases. We now have to thank him for awork which reduces to order and reason a sectionof medicine hitherto disorderly and irrational.This manual is a landmark in the literature ofthe therapeutics of poisoning.

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Diseases of the Chest

By J. ARTHUR MYERS, M.D., Professor of Medicine,Preventive Medicine, and Public Health, MinnesotaMedical School. New York : National MedicalBook Co. Inc. London: H. K. Lewis and Co.Ltd. 1935. Pp. 385. 13s.6d.

A GENERATION ago tuberculous infection was

considered to be almost universal by the time adultyears were reached, and a positive tuberculin reactionwas only considered important in quite young children.Prof. Myers takes up an entirely different position.He argues that as the dangerous reinfection typeof tuberculosis can only occur after the tissues havebeen altered by the primary infection, all positivereactors should be kept under careful observation.In such cases an X ray film of the chest should bemade at least every year and preferably every sixmonths on persons after the age of 10 years. Heim-beck’s observation that amongst young nurses it is

mainly those who have escaped a childhood infectionwho became ill with pulmonary tuberculosis doesnot fit in with Prof. Myers’s theory, and it is a pitythat this work is not even referred to. Until moredefinite evidence is brought forward to show thattuberculous disease is less prone to affect those whoescape childhood infections, the expenditure of thevery large sums of money, which would be requiredto keep some millions of healthy positive reactorsunder medical supervision, does not seem justifiable.The remainder of the first section of the book dealswith the physical signs and symptoms and treatmentof pulmonary tuberculosis; the advantages of

early treatment by artificial pneumothorax are

stressed and the indications for the various proceduresof thoracic surgery are clearly given.

Non-tuberculous diseases of the chest are the

subject of the second part of the book. Both serumtreatment and artificial pneumothorax receive favour-able mention in the treatment of lobar pneumonia ;in the latter procedure not more than 200 to 300 c.cm.of air should be introduced at a time; two or

more refills may be necessary at intervals of 12 to24 hours.In the discussion of the treatment of bronchiectasis,

empyema, and pulmonary abscess, conservativemeasures are first described, but the indications forsurgical intervention are also given and a brief accountof the methods used. Diseases due to mould-likebacteria, true moulds, and yeast-like fungi are dealtwith in a short but adequate chapter illustrated byseveral skiagrams of these rare diseases. The conclud-

ing chapter on diseases due to inhalation of dust

brings into association such ill-assorted conditionsas hay-fever and silicosis. The book is well illustratedand has a full index as well as a bibliography, mainlyAmerican, at the end of each chapter.

Painful and Dangerous Diseases of the EarBy R. R. WOODS, M.B., F.R.C.S.I., Surgeon inCharge of the Ear, Nose, and Throat Department,Sir Patrick Dun’s Hospital, Dublin. London :Humphrey Milford, Oxford University Press.1936. Pp. 188. 15s.

A DIFFICULTY which confronts the specialist in ateaching hospital is to decide how best to impart auseful knowledge of his subject to the future prac-

titioner. If he attempts to cover the whole of thespecialty in the limited time available, the instructionis likely to be superficial and allows far little dis-crimination between matters of clinical importanceand those with which the general practitioner is rarelyconcerned.Mr. Woods has written this book to fill the gap

between the larger manuals of otology, which containmuch material of interest only to the specialist, andthe student’s handbooks, which tend to treat essentialsubjects with insufficient detail. He has fulfilled hisintention most admirably, and has produced a lucidaccount of the common forms of suppurative diseaseof the ear, for his plan amounts essentially to a

description of these affections. We could have wished,however, that more consideration had been given tothe important point of when to operate in acutemastoiditis. Mr. Woods does say that " it is inadvis-able to operate on a case of mastoidism, for the courseof the disease after operation may be stormy," buthe fails to emphasise the fact that operation for acutemastoiditis is rarely necessary in the first week orten days from the beginning of the otitis, that aproportion of these cases recover without operation,and that the course after over-early operation islikely to be tempestuous. We have seldom read aclearer exposition of the intracranial complications ofaural disease, while the short final. chapter on thecerebro-spinal fluid is most valuable. It is wise tohave made no attempt to describe details of the

major operations, but an account of their after-treatment would have been helpful. There are some

good illustrations in the text, and 24 colouredpictures showing the otoscopic appearances of variousconditions of the drum.We recommend this book to the practitioner

who wishes to gain a sound knowledge of the moreimportant forms of aural disease that he is likely toencounter.

1935 Year Book of the Eye, Ear, Nose, andThroat

’

By E. V. Z. BROWN, M.D., Professor of Ophthal-mology, and Lo-uis BOTHMAN, M.D., AssistantProfessor, University of Chicago ; GEORGE E. SHAM-BAUGH, M.D., Clinical Professor Emeritus ; ELMERW. HAGENS, M.D., Assistant Clinical Professor;and GEORGE E. SHAMBAUGH, Jr., M.D., ClinicalInstructor of Otolaryngology, Rush Medical Collegeof the University of Chicago. Chicago : The YearBook Publishers; London : H. K. Lewis and Co.,Ltd. Pp. 638. 10s. 6d.

THIS issue of the Year Book, which consists asusual of abstracts from the current literature, disclosesthis year no notable advances or striking new methodsbut gives evidence of great activity in the explorationof the fields covered by these specialties, and par-ticularly of research into the intricate physiology ofboth the hearing and balancing functions of the

labyrinth. The abstracts are well chosen and wellwritten and, as in former years, shrewd editorialcomments on the more important of these add totheir value. The editors plainly show their dislikeof early operation in acute mastoiditis. They quotestatistics from an article in an English journal of91 cases, in 73 of which the duration of the otitismedia varied from two to eight days ; of these casesfive died from meningitis, one developed suppurativeparophthalmia, and the average time of completehealing with a dry ear was ten weeks ; and they very

434

properly point out that these figures would be verymuch improved if operation were delayed, when theduration to complete healing is normally about threeweeks. This is a convincing argument against earlyoperation in acute otitis, but we believe that theeditors are not correct in thinking that early operationis practised frequently in England. A number ofarticles dealing with malignant disease of the throatand its treatment by surgery, diathermy, and radia-tion are summarised, and are a useful guide to thepresent position of the treatment of these conditions.Indeed, the Year Book, with its very full index, is amost valuable book of reference to the newest work.

1. Commoner Diseases of the SkinBy S. WILLIAM BECKER, M.S., M.D., AssociateProfessor of Dermatology in the University of

Chicago. New York: National- Medical BookCo. Inc.; London: H. K. Lewis and Co., Ltd.1935. Pp. 283. 13s. 6d.

2. Common Skin DiseasesThird edition. By A. C. ROXBURGH, M.D., F.R.C.P.,Physician in charge of the Skin Department, andLecturer on Diseases of the Skin, St. Bartholomew’sHospital. London: H. K. Lewis. 1935. Pp. 377. 15s.

1. THE claim advanced by the author that " inten-sive study of functional diseases in all fields of medi-cine has tended to clarify and simplify the study ofdermatology," does not solve or appreciably lightenthe many problems of the therapist, although it

opens up new avenues for research.This is not a book for beginners. A knowledge ofhistology is presumed, for no microscopic appear-ances, even of the fungi, are portrayed. A discursivestyle is adopted throughout, , headings and sub-

headings are avoided, and the aim appears to be tointerest rather than instruct. The subject matteris considered in 26 chapters. The first is given tothe care of the skin and scalp, in which the authorstresses the differences of response of the ichthyoticand the seborrhoeic person. The second chapterdiscusses the complexities of the eczema-dermatitisgroup, under the general heading, Toxic Dermatosesof Epidermal Origin, and succeeds in presentinga fairly comprehensible picture of this still somewhatobscure reaction. Infantile eczema is included inthis section, and the paragraphs on differential

diagnosis, prognosis, and treatment are models of

brevity and succinctness. " Stasic " (‘1 static) ulcersof the leg afford the author an excellent opportunityof proving his originality. " Most of our patientswith leg ulcers do not have varicose veins, and mostof those being treated for varicose veins do nothave leg ulcers." Aphorism or epigram-the state-ment will be substantiated by all who have hadmuch experience in the O.P. clinic, and are not theslaves of text-book assertion. Chapter V., which isconstantly referred to in the rest of the text, is

essentially a monograph on the neurodermatoses,which evidently have been especially studied by theauthor. A diagrammatic representation of his con-clusions (facing p. 64) will provide the reader withmuch food for thought, and a commonsense planon which to base his treatment of an increasinglyfrequent epidermal syndrome. The following twochapters extend this field of functional skin diseaseto a degree which to those graduating from theschools of Hebra or Unna may appear somewhat

dangerous. Pruritus ani, and pediculosis vulvae,pediculosis capitis, dyshidrosis (surely a retrogradestep ?), and " neurotic " excoriations are all includedand given pride of place in this group. Beginners

who come across this work should beware of adoptingtoo literally opinions, which to the seasoned observerseem more conjectural than convincing. Succeedingchapters on the papulo-squamous eruptions, physical(e.g., light produced) dermatoses, vascular, pyogenic,mycotic, and parasitic diseases follow more orthodoxlines. A chapter on the " skin in industry " and anappendix of simple formulae conclude a volumewhich will prove of value to the more advancedstudent or teacher of an increasingly importantbranch of medicine.

2. The practitioner will find in this book, whichhas achieved three editions in as many years, all theinformation he is likely to need on the practical sideof dermatology, and more than he is likely to beable to apply in therapeutics. The illustrations areexcellent, and have been increased in number. Anew feature, and one that must have given theauthor much labour, is the duplication of all pre.scriptions in metric as well as in apothecaries’ weightsand measures. It is one which is certain to appealto the continental reader, and maybe, render atranslator’s task less difficult. The addition of a

paragraph on gold dermatitis, now supplied, wasbadly needed, for it is probably one of the mostfrequent if not the most troublesome of all drugeruptions at the present time. As an introductionto the study of dermatology there is no better manualin the English language.

Prescription Writing and FormularyThe Art of Prescribing. By CHARLES SOLOMON,M.D., Assistant Clinical Professor of Medicine,Long Island College of Medicine. London : J. B.

Lippincott Company. 1935. Pp. 351. 21s.

NEARLY every text-book of prescribing publishedin the last thirty years has deplored the habit ofusing ready-made formulae, particularly those dis-

pensed in compressed form as tablet, pills, and soforth. It has been reiterated that if the physicianis to be independent of the complex pseudo-mysteriesof the drug factory, he must be able to write a pre-scription, with the implication that the educationof the medical student is defective, in so far as itrelates to prescription writing. Dr. Solomon evi-

dently subscribes to this opinion, and has preparedthis volume with a view to providing a sound scientificbasis for prescription writing. The work is indeedwonderfully complete. The introductory chapterincludes a brief account of the history of the pre-scription, a discussion of a number of importantpractical considerations, and a useful review of methodsof administration. The second part contains every-thing anyone need know about prescription writing,including dosage and incompatibility. The rest ofthe book consists of a formulary which contains avery large number of prescriptions of the more

commonly used drugs. These are arranged systema-tically according to the therapeutic effect expectedof the drugs, and are printed both in Latin and inEnglish. The author is careful to point out thatthey are not intended to be set or standard pre-scriptions, but rather to illustrate the simplicity ofrational prescribing. At the same time, the youngpractitioner will find in them a comprehensive sourceof information. To add to the usefulness of theformulary, an index of prescriptions according to

symptoms and diseases has been included, as wellas a general index. The book as a whole perhapscontains too much information for the needs of themedical student, but should prove a handy workof reference for the practitioner.