1152 REVIEWS AND NOTICES OF BOOKS.

REPORT OF THE ST. ANDREWS INSTITUTE FOR

CLINICAL RESEARCH, ST. ANDREWS, FIFE.Vol. 1. Oxford Medical Publications. London :Henry Frowde and Hodder and Stoughton. 1922.Pp. 208. 10s. 6d.

THE St. Andrews Institute for Clinical Research wasfounded by Sir James Mackenzie, now its honorarydirector, with a view to the prevention of thosediseases that are common among the people of thiscountry. To achieve that object it is obviouslynecessary to know the life-history of such diseasesfrom onset to termination, and, as the generalpractitioner is the only type of individual withopportunity for such continuous observation, theInstitute has enlisted the cooperation of all thepractitioners in the town of St. Andrews. To aid andsupport them the Chandos professor of physiologyand the Bute professor of anatomy in the Universityof St. Andrews are attached to the medical staff,while the Institute has further at its disposal a

consulting surgeon and a consulting ophthalmologist,as well as a laboratory provided with expert chemist,bacteriologist, and radiologist. The volume beforeus is part of the outcome of the first year ofwork at the Institute. The first article contains anaddress on clinical research by the honorary director,in which he justifies the enterprise to good purpose,while giving a warning against immediate expecta-tion of results. Sir James Mackenzie deals in

another article with the theory of disturbed reflexesin the production of symptoms of disease, and alsocontributes an article on prognosis. The remainingeight articles, some of which have appeared insubstance in our own columns, are the result ofpatient and comprehensive investigations by variousmembers of the staff, beginning with Dr. AndrewRowand’s article on the Present State of MedicalKnowledge regarding the Diseases Common amongthe People, and ending with Prof. David Waterston’sObservations upon Cutaneous Sensation.Although the objects of the Institute are now

widely known, the methods adopted there are noteasy of apprehension to superficial study, and all thosewhose previous education and bent have been centredrather upon evidences of advanced disease will dowell to peruse with care this first volume of theSt. Andrews results. The work may be regarded as anew chapter in contemporary medicine, the sequel towhich should throw light upon problems that dailyconfront the doctor in his work.

THE MECHANICS OF THE DIGESTIVE TRACT.

By WALTER C. ALvAREZ, M.D., Assistant Professorof Research Medicine, George Williams HooperFoundation for Medical Research, University ofCalifornia Medical School. New York : Paul B.Hoeber. 1922. Pp. 192.$3.50.THIS fascinating and stimulating book will be

welcome, and should have a considerable vogue inthis country. The author is evidently widely readin his subject, is an able critic and a scholarly writer,and has made his book a real digest of much recentinformation. The volume reflects great credit on theapplication of physiological principles and methodsof investigation to practical problems of medicine.With many of the conclusions we disagree, while atonce admitting that the author has made out hiscase cleverly, indeed so cleverly that there is a dangerof his leading the inexpert to follow him where theyshould not. The book is based on Dr. Alvarez’s ownwork on the metabolic gradients in the alimentarytract ; his thesis is that the passage of peristalticwaves in a certain direction is due to the fact thatthere is a metabolic gradient in that particulardirection, the wave passing from a point of highmetabolic rate, high contraction frequency, highsensitivity to drugs, to a point where all these mani-festations are lower. Reversal of peristalsis impliesreversal of the gradient. There is a certain amount of

experimental evidence for this theory, but it appearsto us that to a very great extent it is merely a re-statement of what actually happens. The " gradients ’rof the stomach present a complicated picture, and wethink Dr. Alvarez’s conception will prove to be toosimple. He appears to underrate the nervous control.and then complicates the position in a re-statement ofwhat actually occurs by saying that the influence otthe nerves is exerted on the gradient. But, right orwrong, his theories cannot help but prove stimulating,and we much prefer such a book to a dull conventionalwork within which no fault and no inspiration is tobe found. A bibliography of 456 recent papers willprove valuable to other investigators.

JOURNALS.BRITISH JOURNAL OF OPHTHALMOLOGY. May,

1922.-The principal interest of this number ispathological. Mr. Foster Moore records an unusualcase of renal retinitis. The patient was watched andhis fundus condition carefully recorded at intervalsduring seven years. At first the usual changescharacteristic of the disease were noted, and therewas a rather small retinal detachment below in eacheye. After seven months all the fundus changes wereretrogressing, the detachments had disappeared, andthe patient was extraordinarily improved in health.After fifteen and a half months there was no trace ofalbumin in his urine, though the blood pressure wasstill 190 mm. During the war he was working over-time in a small-arms factory. Seven years after firstbeing seen he died of uraemia, the retinitis having com-pletely subsided and leaving comparatively slightsigns. This case of a man of 42 who survived foran exceptionally long time after the onset of retinitisis of interest as bearing on the prognosis in these cases.- Mr. Humphrey Neame records a case of tuberculousiridocyclitis and parenchymatous keratitis of the lefteye, associated with tuberculosis of the conjunctivaof the right eye, and tuberculous lymphadenitis.Figures of the pathological conditions present areincluded.

IN the JOURNAL OF THE ROYAL ARMY MEDICALCORPS for May, Capt. Alexander Mearns, R.A.M.C.,discusses the chronic effects of inhalation of suf-focating gases, chlorine, phosgene, chlor-picrin, andtrichloromethylchloroformate. He notes that theseeffects may appear either during convalescence aftera severe gassing in the field, or during prolongedexposure to low concentrations of noxious gases,during work, for example, in gas factories. One classof case is purely functional, and occurs particularlyamong the lightly gassed ; it is a definite gas neurosis,presents the signs and symptoms of the effort syn-drome, and is best treated in a high oxygen chamber,but its severity depends on the instability of thepatient. The organic change in the lungs shown inanother groupof cases maybe fibrotic, emphysematous,or bronchitic. The fibrotic variety has an insidiousonset with dyspnoea on exertion and orthopnoea atnight, a dry cough, perhaps heamoptysis and loss ofweight ; respiration is shallow, as the movementsof the diaphragm are much restricted, and there isperibronchial fibrosis and hypertrophy of the rightheart. These all resemble the changes in pneumo-koniosis. The emphysematous type is generally aconsequence of the other varieties, but may at timesitself arise somewhat acutely. The bronchitic typemay so closely simulate pulmonary tuberculosis asto require X ray and laboratory examination fordifferentiation. Gassing is by some authors heldto predispose to tubercle ; Achard’s experiments onguinea-pigs seem to indicate the contrary, and amongthe cases of gas-poisoning quoted in the literatureonly some 2 per cent. developed tubercle, and evenin the cases which seemed decisive the possibility oflatent tubercle cannot be excluded. Captain Mearnsconcludes that the inhalation of gas has an extremelysmall influence on the occurrence of tubercle of thelung.