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Reviews and Notices of Books.SOCIAL INSURANCE, WHAT IT IS AND WHAT IT

MIGHT BE.

By ALBAN GORDON, B.Sc., F.C.S. London :Fabian Society and George Allen and Unwin,Ltd. 1924. Pp. 150. 6s.

THIS excellent exposition of the whole subject ofsocial insurance is timely, because the differences ofview between the medical profession and the approvedsocieties in respect of the working of the NationalInsurance Acts are coming almost immediately underthe scrutiny of a Royal Commission : in a still bettersense it is timely, for it is an earnest attempt to look farahead, and foresight at any date is opportune. Allpolitical parties have placed social insurance in theforefront of their programmes, but the promises havecarried little conviction, for many of the politicianshave not grasped the principles which must underlieall schemes, so that they have been unable to explaineither why they think certain developments desirable,or how they propose to mould affairs in the future.Mr. Gordon’s book should be instructive to those whoare called upon to take active leadership, and shouldalso inform the public upon those essential factswhose comprehension is necessary if legislativeproposals are to be criticised with intelligence, andeither helped to fruition or relegated to obscurity inaccordance with their merits.The book is divided into two parts, of which the

first sets out the subjects appropriate for insurance,analysing the treatment which they receive at thepresent ; while the second consists of a scheme for theunification of social insurance, where the necessity,indicated in the first part, is assumed for the coördi-nating and supplementing of existing diverse systems.The need for a national scheme of health insurance isnot discussed, and indeed it has been abundantlyproved, but so has the justice of some of the com-plaints against the working of the methods as we nowknow them ; for no one can deny the inadequacy ofthe benefits provided by the National Insurance Act,the overlapping of the thousands (literally) ofseparate bodies involved, the neglect of preventivemeasures in disease, and the lack of personal touch inadministration. The grounds for these complaintsare set out here, and analysed, with the inference thatthe working of the approved societies, viewed fromthe broad national aspect of the prevention and cureof sickness, is proving a failure. Full credit is given tothe societies for bringing the Act into operation, andfor arduous and anxious labour in carrying-on throughthe first 11 years of national insurance, and it is

suggested that many of the failures and anomalieswould have been avoided had the original qualification ,for an approved society remained a membership of5000 at least, the multiplicity of small societies havinghopelessly damaged the scheme. And at this pointin the book a short but revolutionary proposal, as asolution of the main obstacle to efficient action anddevelopment, is put forward succinctly. In Mr.Gordon’s words, " A simple and efficacious solution liesready to hand-reraove medical benefit from theInsurance Act altogether," because the prevention ofthe incidence of illness and its prompt treatmentupon recognition do not form a logical section of anyorganisation taking charge of sickness benefit anddisablement benefit; for these are self-contained cashaffairs, can depend on an actuarial basis, and can berestricted to persons paying contributions-none ofwhich holds good for what is implied by medical benefit.Perhaps if the insurance committees, speciallycreated for the purpose of administering medicalbenefit in every county and county borough, hadworked in accordance with the original designs of theAct, and had taken a large share in the handling oflocal sanitary affairs, the position that we are nowin would have been less critical, but while thesecommittees confine their activities to the disbursing of

monies and the scrutiny of prescriptions, the cost atwhich the country is for their maintenance seemsinexcusable. While the insurance committees functiononly in such a manner medical benefit remainsmuch as it was before the Act-that is to say, it hasbecome the rendering of service by individual practi-tioners to their insured patients, for these extremelybusy men with little machinery by which to obtainthe services of specialists or the accommodation ofinstitutional treatment for their charges, cannot dealboth with the mass of existing disease and be respon-sible for the early diagnosis of such maladies as, forexample, tuberculosis and venereal disease. More-over, medical benefit as at present devised has beenonly directed to a limited section of the working class,and the position of the average middle-class householdremains unaffected by the Act, though this class isquite unable to afford such a draft upon its resourcesas is implied by a major operation or a lingering illness.The scheme to meet the circumstances, which forms

the second part of the book, is a brave attempt to lookahead, based upon a supposition that the need forprofound alteration in our system of social insuranceis proved; it is put forward tentatively as a way,and not as the only way of dealing with what isterm.ed " the slimy mess of the Poor-law" and thecurse of unemployment. The basis of this compre-hensive scheme for national social assurance assumesthat the risks of sickness, unemployment, accident,widowhood and orphanhood, indigent old age, andpremature death can be provided for by insurance,and can all be administered in one comprehensivescheme, a State national minimum of insurance beinginsisted on as a corollary to wage minimums and assupplementary to measures for the prevention ofdestitution. Such compulsory insurance is based inthe scheme upon local territorial units, and gradedwith relation to maintenance of a reasonable standardof existence, while the scheme throughout providesfor the prevention of the risks which it proposes tocompensate. The contributions from employer andemployed, foming the gross income, are to besubsidised, it is proposed, not only from the CentralExchequer, but from the local rates, the last sumsimplying merely a diversion of the existing Poor-lawrate. The insurable matters being thus provided for,schemes for medical benefit-i.e., for the publichealth of the country-would fall into their logicalplace to be administered by the public health authori-ties, full cooperation being insured between themedical practitioner and the State officials, medicaland lay.

This is an excellent little book.

CLINICAL STUDIES IN EPILEPSY.

By DONALD FRASER, M.D., F.R.F.P. & S. Glasg.,Consulting Physician, Royal Alexandra Infirmary,Paisley. Edinburgh: E. and S. Livingstone.1924. Pp. 240. 7s. 6d.THERE is no disease of which the causation is more

obscure than epilepsy. The object of Dr. Fraser’sbook is to bring together reports of a number of casesof different varieties of the disease in the hope thatfrom their discussion some hint of the pathogenesisof epilepsy may emerge. His arguments are basedon the work of Hughlings Jackson, and he quotesJackson’s words again and again with implicitconfidence. This attitude of reliance on a great teacherhas led, however, to a fault in the book-a lack ofprecision in the author’s own views on the nervousmechanisms at work in epileptic manifestations.In one of the citations (p. 21) there occurs the phrase,"

epilepsies in the scientific sense-that is, they dependon discharges beginning in some part or parts of thecortex cerebr," and later on (p. 67) Dr. Fraser’scomment, " This hypothesis of a discharging lesionis a very convenient one, though what takes placein the highest levels is, we believe, not a dischargeof energy alone but a deprivation of it, leading touncontrolled discharge from lower and subordinatecentres." But surely this distinction is vital, for on

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it depends whether we regard epilepsy as the result ofirritation or of inhibition of the highest centres, andour views of causation will vary accordingly. The

hypothesis which looks upon the epileptic attack asa release phenomenon, consequent upon an inhibitionof the highest centres, is the one which is the mostsatisfactory, and although various chapters of thisbook are imbued with it, it is a pity that it is notstated with more insistence. The hypothesis isapplicable to all the psychic and motor disturbances-aphasia, amnesia, fugues, loss of consciousness,mania, convulsions, and twitchings-described in theinteresting case-reports ; it may be applied also tothe negative sensory phenomena-e.g., temporaryscotomata-and its application to the positivesensory disturbances, though less easy, is not

impossible. Vaso-constriction, if the possibility of itsoccurrence in the cerebral vessels be granted, aftordsa satisfactory cause of cortical inhibition, and it isthis theory that the author supports ; he arguesstrongly in its favour, and sees its causal agent insome toxin allied to histamine. The chapter devotedto the effects of " the cerebro-spinal reflex " is lessconvincing. The main interest of the book lies,and is meant to lie, in the case-reports, and here isfood for much thought.

Dr. Fraser reproaches British neurologists with thefact that the writings of Hughlings Jackson havenever been published collectively, and it may be hopedthat at least a representative selection of his paperswill be brought together before long.

PATHOLOGICAL TECHNIQUE.Eighth edition. By FRANK BURR MALLORY,A.M., M.D., Pathologist to the Boston CityHospital; and JAMES HOMER WRIGHT, A.M., M.D.,S.D., Pathologist to the Massachusetts GeneralHospital ; Assistant Professor of Pathology,Harvard Medical School *’ London and Phil-

adelphia : W. B. Saunders Company. 1924.

Pp. 666. 32s. 6d.THIS work has long ago established itself as a

popular and reliable manual of pathological technique. I

For this, the eighth, edition several sections have beenadded or rewritten by various collaborators, and thewhole book has been thoroughly revised. While thegeneral level of the different sections is high, some,notably that dealing with histology, are outstanding.Should any omissions be considered advisable infuture editions, the pages dealing with animalinoculations might well be sacrificed. In its presentform this chapter is a poor substitute for practicaldemonstrations, and is not up to the standard of therest of the book. We can recommend this volume asone which few laboratory workers can afford to ignore.

MODERN METHODS OF TREATMENT.

By LOGAN CLENDENING, M.D., Assistant Professorof Medicine and Lecturer in Therapeutics, MedicalDepartment of the University of Kansas. London :Henry Eimpton. 1924. Pp. 691. 45s.WE welcome this book as a rational and straight-

forward exposition of the present-day outlook ontreatment. Singular skill is shown in the apportion-ment of its true value to each of the methods at ourcommand. It is remarkably free from. that type oftraditional treatment which is often described butseldom used ; on the other hand, it is no less free fromthe over-enthusiasm, of the specialist. Further, therationale of treatment is well explained on a physio-logical basis. The section on drugs contains unusuallylittle dross. The first half of the book, consisting of440 odd pages, is on the

" Methods used in Treatment,"of which space 140 pages are devoted to drugs.Dietetics, in the same part of the book, fills nearly onehundred pages and gives thoroughly practical hints.The various methods of treatment described in the restof this section of the volume, such as the production ofartificial pneumothorax, transfusion of blood, gastriclava,ge, are given with sufficient detail to make them

of definite value to the man who is called upon tocarry them out. In the second portion of the book,entitled the "Application of Therapeutics to Picu1arDiseases,"the facts mentioned in the earlier portion arecollected and applied. The diagrams are well chosen,many of them being pictorial descriptions of thestages of the processes used. The pictures of Sippy’s 1method of treatment for gastric ulcer will fix it in thememory in a way which no written account or table offigures could achieve. Agglutination, as shown inanother series of pictures, becomes a simple pheno-menon to understand. Prof. Clendening’s reason forgiving no section on antipyretics is interesting-" because the treatment of fever, per se, is a relic ofsome other age of treatment." But is he right, orat any rate in accord with modern notions, when hesays that " fever is the reaction, probably defensiie,of the body to infection " ? We should not, it is true,rashly interfere with a raised temperature, but feveris now generally believed to throw a strain on ratherthan to defend the bodily mechanism. The bookcontains a sufficient amount of episode and historyto make it pleasant reading. There is a slip in con-nexion with Thomas Dover, who is said to haverecommended his powder in 1762. Dover died in1742. Generally, this volume deserves high praise;it is so well balanced that it is suitable both as a text-book and as a work of reference, a standing to whichfew books attain.

AIDS TO PSYCHIATRY.

By W. S. DAWSON, M.D. Oxf., M.R.C.P. Lond.,D.P.M., Senior Assistant Medical Officer, MaudsleyHospital. London : Bailliere, Tindall and Cox.1924. Pp. 309. 4s. 6d.

- IN the " Aids " series any approach to uniformityof size must mean that specialised subjects will receivefuller treatment than can be afforded to " medicine "

and " surgery " in the volumes with correspondingtitles. In this consideration lies the only adversecriticism which this volume is likely to receive. It is,in fact, a text-book differing little in size and scopefrom several well-known works on the same subject:the difference in bulk is counter-balanced by the useof small type and comparatively thin paper. Thestudent who supposes that he need learn the wholecontents of this volume for his qualifying examinationwill, no doubt, be erring on the right side, and themistake will stand him in good stead in the future.The arrangement is on orthodox lines, with a

commendably simple classification of varieties ofinsanity: indeed, a warning is needed that in practicecases cannot easily be relegated to any of these simplecategories, and sometimes not at all. There is anexcellent chapter on treatment, a full discussion onall the important legal bearings of mental disorder,and a particularly complete chapter on mentaldeficiency, in which a simplified series of tests ofmental age is given-a feature of the utmost practicalvalue. Psycho-analysis is treated with due impar-tiality, and there is a valuable section on the Theoriesof the Neuroses (one would rather have said"

Hypotheses "). At its extremely moderate price thisbook is likely to achieve great popularity.

L’ALIMENTATION NATURBLLE CHEZ L’ENFANT.

By Dr. MONTEUUIS. With a Preface by Prof.NOBECOURT. Paris : A. Maloine. 1923. Pp. 278.Fr.8.THIS posthumous work of the late Dr. Monteuuis

conveys an appeal to French mothers to eschewmethods of feeding based on caloric requirements,and to return to the older habits of diet consistingof more natural and less " industrialised " foodstuffs.The author’s principal contention is that the quali-tative value of the various cereals is the important

1 The death of Prof. B. W. Sippy was announced on

August 15th at Chicago in his fifty-eighth year. He had beensince 1906 professor of medicine in the Rush Medical College.

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factor, and that this varies according to their modeof preparation ; white bread is regarded as a nationalperil. The work consists largely of recipes, andshould provide an extremely varied dietary forchildren.

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INFECTION AND RESISTANCE.

Third edition. By HANS ZINSSER, M.D., Professorof Bacteriology and Immunity, Harvard Univer-sity, &c. New York: The Macmillan Company.Pp. 666. 24s. ’

THE literature on immunity has reached suchenormous dimensions that it may be doubted whetherany one man is fully conversant with it. Only byexceptional industry is it possible to cope with theflood of modern publications on the subject, and atrained and critical intelligence is needed to divide thewheat from the chaff and to estimate the true value ofrecorded observations. Under these circumstancesa small dogmatic text-book on immunity becomesalmost an impossibility, while a more ambitious workmay defeat its ends by leaving the student in a state ofhopeless bewilderment. Dr. Zinsser follows a middlecourse with skill and success. His book contains amine of information, which is developed clearly andlogically and with commendable fairness and modera-tion. Opposing points of view are faithfully recorded,and though the author’s personal opinions are never inany doubt, the student is placed in the position to formhis own conclusions. For this edition the work hasbeen revised and partly rewritten, and it may bethoroughly recommended as a trustworthy guide toa difficult subject.

INSTRUMENTS AND APPLIANCES FOR OPERATIONS.

Second edition. By Lieut.-Colonel CASTOR. Re-vised by Lieut.-Colonel CONNOR, I.M.S. Calcutta :Thacker, Spink and Co. 1924. Pp. 34. Is. 6d.

THIS little pamphlet describes the requirementsfor a satisfactory small operating theatre, whetherimprovised or permanent, and the essential outfit.Lists of the instruments required for various commonoperations follow, with a few notes as to dressings andthe position of the patient during operation. It isall very good and to the point. We would only offerone criticism-there is not really any such organ asthe esophagus, nor was there even when -ZEsopanticipated the present authors by also advising theuse of a pair of long-bladed forceps in a case of severedysphagia.The book is well arranged, and would be of real

use to anyone who has to select instruments foroperations. ’

HIPPOCRATES. if

Hippocrates and His Successors in Relation to thePhilosophy of Their Tirrae. Being the FitzPatrickLectures for 1921-1922. By R. 0. Moorr,M.D. Oxf., F.R.C.P. London: Longmans, Greenand Co. Pp. 171. 6s.

Dr. Moon’s admirable lectures should be read inconjunction with the Translation of Hippocratesnow appearing in the Loeb Classical Library. Thetwo first lectures deal with Hippocrates in relationto the philosophy of his time and give an excellentaccount of the various systems of philosophy whichaffected his opinions-both those schools, such asthat of Pythagoras, which existed in pre-Hippocratictimes, and those, such as that of Democritus, whichwere contemporaries of Hippocrates. The last twolectures deal with post-Hippocratic schools ofmedicine and philosophy. With regard to Pythagoras,Dr. Moon points out that the Greek idea of the soul i

being a Harmony " seems to have originated from IPythagoras in connexion with Medicine," and he goeson to quote from Plato’s Phaedo a remark ofSimmias the Pythagorean, in which he argues that Iour soul is a kind of temperament and attunement

of the warm and the cold, the moist and the dry,when they are mingled with one another well andin due proportion. Dr. Moon further quotes from" Greek Philosophy " by J. Burnet, who says that" Health means just being in tune, and disease arisesfrom undue tension and relaxation of the strings ;even now we speak of tonics in medicine as well asin music." We might remark in this connexion thatin.the Greek musical scale the tonic was not as wecall it, the beginning and the final of the scale, butthe middle note of it, and they called it uc77. Theintense Greek feeling for the mean in everything mayhave been the reason why they placed their tonicin the middle.

JOURNALS.

BRITISH JOURNAL OF OPHTHALMOLOGY. September,1924.-M. L. Hepburn : Classification of Diseases ofthe Choroid. The writer points out the classificationof inflammatory diseases of the choroid alone under26 different headings, as is done in the American" Encyclopaedia of Ophthalmology," is totally unjusti-fiable. Mr. Hepburn’s own classification is underfive heads : (1) Inflammatory, (2) vascular, (3)degenerative, (4) congenital, and (5) new growths.The paper is all too short-we could do with moreexamples, and especially with illustrations of eachclass. Some controversial matter is included-viz.. theinclusion of retinitis pigmentosa as a choroidal diseaseof vascular origin and the objection to treatingmacular affections as a class by themselves.-W. G.Laws describes a rare form of retino-choroiditis,possibly associated with pituitary dysfunction. Fourcases are cited in which this association occurred.They were characterised by an acute onset with muchinflammatory change in the optic nerve head andretina, widespread but always superficial and there-fore possibly secondary lesions of the choroid, a self-limited course, and recovery with relatively goodvision.-C. -L. Preziosi discusses the electro-cauteryin the treatment of glaucoma. This paper advocatesthe use of the electro-cautery in lieu of the trephinein performing a sclerectomy for glaucoma. The chiefadvantages claimed are : (1) simplicity of technique;(2) impossibility of injuring deep structures ; and(3) the slowness with which the anterior chamberis emptied, reducing the risk of heamorrhage. Iridec-tomy is not performed, which the writer claims is anadvantage, but which may be the opposite.-E. R.Chambers, of Bristol, gives the notes of a case ofparalysis of divergence in encephalitis lethargica.In connexion with the recent epidemic he -has seensix similar cases within a few weeks. There has beena difference of opinion as to the existence of thiscondition. Sir George Berry, we note, holds thatall these cases are really instances of spasm ofconvergence and that the so-called centre fordivergence in the brain does not exist (cf. Trans.Ophth. Soc., 1901, p. 268).JOURNAL OF THE ROYAL ARMY MEDICAL CORPS.-

The first paper in the Journal for August was deliveredby Lieut.-Colonel J. A. Anderson before the WarSection of the Royal Society of Medicine in April.He explains the new motive of the sanitary specialistin the army, concerned rather with health and itspromotion than with disease and its prevention. Heconsiders that there was too much thought in olddays of infectious diseases and their prevention tothe exclusion of all else : but was it not the work ofthe pioneers in this field that nearly extinguishedtyphoid and undùlant fevers, and, by reducing illness,left officers with fewer cases to treat, and thus hasgiven them time now to spend on diminislrng thelesser ailments of the men ?-The first part of CaptainJ. S. K. Boyd’s Parkes’ Memorial Prize Essay on theProphylaxis of Malaria appears in this number. Itpromises to be a clear and well-balanced account ofthe problem.-Major C. M. Finny reports the case ofa soldier in the Gordon Highlanders, who, runningin an inter-regimental cross-country race, twistedhis left foot inwards three miles from home, and, as