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The diagnosis lay between concealed accidental heemor-rhage and a twisted ovarian cyst complicating earlypregnancy. The possibility of an abdominal pregnancy wasconsidered, but rather discounted in view of the previouscurettage and absence of other signs.The patient was kept under observation for 24 hours,

but did not improve ; in fact, she became rather worse.operation was then decided upon, a diagnosis of twistedovarian cyst complicating early pregnancy having beenmade.On opening the abdomen a large rather thick-walled

cyst was seen almost filling the peritoneal cavity, whichalso contained a large amount of recent fluid blood and oldblood-clot. On extending the incision the cyst was seen toarise from the left broad ligament, which had been stretchedand lifted up, while the uterus-enlarged to the size of athree months pregnancy-was closely apposed on the rightside. On attempting to separate the cyst it was found tobe adherent to the abdominal wall in front and to theomentum and small intestine above and behind, and duringthis separation the anterior wall suddenly gave way and alarge quantity of liquor, followed by a living child, cameout. The gestation sac was then seen to be composedof a much stretched-out broad ligament anteriorly, whileposteriorly it had burrowed under and lifted up the caecumand mesentery of the small intestine ; the right colic arterywas running in the wall of the sac. The placenta washurriedly removed, and the sac packed with gauze andmarsupialised. During removal of the placenta there wasvery little bleeding, but there was considerable haemorrhagein the abdominal cavity, probably from a torn branch ofthe right colic artery.

After operation the patient was very collapsed and failedto respond to treatment, dying shortly after return to theward. The child, weighing 2 Ib., was quite normal andlived for 14 days.The so-called incomplete abortion, said Dr. Hunter,

for which the patient had been curetted was probablyan early ectopic gestation ; very possibly ruptureof the sac into the left broad ligament had occurredduring this manipulation. The associated hydramniosalmost excused the mistake in diagnosis, for evenwhen the cyst was exposed it was impossible to palpatethe foetus through its walls. To avoid a fatal resulthad been very difficult in view of the way in whichthe sac had displaced the mesentery and bowel.Perhaps incision of the sac, emptying of the contentsand immediate packing would have given the onechance of a successful result.

Dr. J. H. WiLLETT (Liverpool) said that he consideredit safer to leave the placenta, though recovery would-be tardy.

Dr. D. DOUGAL (Manchester) recalled a case offull-time ectopic pregnancy, in which the placentawas removed and the patient made a good recovery.

Dr. C. P. BRENTNALL (Manchester) described acase of abdominal pregnancy at four months.

Specimens and Cases.Dr. BRENTNALL showed slides illustrating an endome-

trioma of the anterior abdominal wall in a woman of37. The tumour was the size of a filbert and wasfirmly embedded in the rectus muscle. He said thathe had not found any recorded instance of a growthof this kind being situated so far from the uterus.The woman had had no previous operation, and thefact that the ovaries were not adherent suggested thatthey had not acted as an intermediate host for thespread of the tumour over the peritoneal cavity.There was no chocolate fluid in the tumour and theumbilicus was normal.

Dr. H. LErTH MURRAY (Liverpool) showed a speci-men of primary carcinoma of the appendix, emphasisingthe fact that such a growth might present itself asa very inconspicuous lesion.The PRESIDENT reported a case of labour obstructed

by a diverticulum of the rectum.Prof. BLAiR BELL (Liverpool) described two cases of

bilateral squamous-celled carcinoma of ovaries and

peritoneum, subsequent to vaginal hysterectomy forcarcinoma of the cervix, and to carcinoma of cervixtreated by radium.

Dr. J. W. BRIDE (Manchester) reported two casesof malignant disease in association with genitalprolapse.

Reviews and Notices of Books.SIR JAMES MACKENZIE.

The Beloved Physician, Sir James Mackenzie. ABiography. By R. McNAIR WILSON. London :John Murray. 1926. Pp. 316. 12s.

Dr. Wilson has written a readable biography ofone whom he loved as a man and whose genius headmired with whole-hearted enthusiasm ; and indeedMackenzie was one who deserved to inspire thesesentiments, for he was a good friend, a most helpfulteacher, and one who threw a flood of light upon thedark places.James Mackenzie, like many of his famous com-

patriots, came of good Highland farming stock. Hewas born at Scone and educated first at the PerthAcademy, where he wondered, as many at otherschools have done, why his teachers set so muchvalue on memory and so little on reason. He leftschool at the age of 15, when his boyish fancy wasone day attracted by the coloured jars in a chemist’swindow and he determined to become a chemist.Accordingly he was apprenticed, When, however,he came to work he was as much disillusioned withthe duties and with the gorgeous coloured jars as wasthe well-known Rosamond of Miss Edgeworth, andat the end of his apprenticeship he entered EdinburghUniversity as medical student. Soon after qualifyinghe became assistant in the firm of two medical menin Burnley, Dr. William Briggs and Dr. John Brown.This was in 1879, and in the course of his practicehe met with the case which was to determine hislife’s work. It was that of a young woman whodied from heart failure during labour, and Mackenzieasked himself whether, if he had had a wider know-ledge of heart affections, he could have foreseenand possibly averted the tragedy. So he took hundredsof tracings with a Dudgeon sphygmograph, andalso others of the venous pulse in the neck with afilament of straw stuck to the vein writing on smokedpaper, which crude device was followed in time by aningenious polygraph devised by himself. Years of studyconvinced him that every murmur of the heart wasnot necessarily a sign of disease, but that a heart inwhich a murmur was present could do its workperfectly well so long as it was not over-driven. Theoutcome of all these researches was, as every medicalman knows, the discovery of the conditions known asauricular fibrillation and heart-block.

Of the coming of the Burnley practitioner to London,of his welcome by the College of Physicians and theRoyal Society, of his success and honours, an accountmust be sought in Dr. Wilson’s pages. Here alsowill be found the reasons for Mackenzie’s dramaticresolve, when at the height of his fame, to give upLondon and go to St. Andrews, there to devote therest of his life to clinical research on the early symptomsof disease. The building in which the research wascarried on was called the St. Andrews Institute ofClinical Research, now known as the James MackenzieInstitute, and remains alike as a memorial to hisname and as a seat for the investigations which thebroad philosophy of his outlook made him feel to beimperative. Despite all the stress laid upon familyand personal history, both in institutional teachingand in private note-books, since clinical medicinebegan to be systematised some hundred years or moreago, the fact remains that the beginnings of diseaseprocesses did not receive until recently proportionalattention. In Mackenzie’s conception of an Institutedevoted to clinical investigation we see a formulationof the fundamental truth on which he insisted thatmedicine is a special branch of science dealing witha special group of phenomena, where the clinicalinvestigator must apply the methods which are

specially suitable for his purposes. It was essentialto this conception that the knowledge derived,mainly from general practice, by the watching ofill-health over a long course of years should be cate-gorised and tested, and along the lines thus suggested

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the work at St. Andrews is now proceeding. Itis one of the ironies of fate that soon after he went toSt. Andrews Mackenzie knew for a fact that he wasstricken with angina pectoris, and from this diseasehe died on Jan. 25th. 1925.A book which will interest not the medical man

alone, but also any intelligent layman. It is clearlyand often eloquently written, and good reasons aregiven for the striking title.

LA GRIPPE.

By Dr. PIERRE LEREBOULLET, Professeur agrege ala Faculté de Medecine de Paris, Médecin de

l’H6pital des Enfants Malades. Paris : Bailliereet Fils. 1926. Pp. 144. Fr.8.MOST of the books dealing with influenza are either

treatises on Pfeiffer’s bacillus or discussions of thatmedley of infections to which the layman has giventhis name. Dr. Lereboullet’s modest little volume isa refreshing clinical and pathological study. Pandemicinfluenza attacks the world with such extreme violenceand at such rare intervals that a new generation ofmedical practitioners is overwhelmed at a time whentheir experienced predecessors are unable to help them.Between pandemics it is next to impossible to obtainfirst-hand knowledge, and therefore we heartilycommend to medical students this excellent accountof a dreadful disease.

EPILEPSY.A Functional 31eittal Illness. By R. G. Rows,M.D. Lond., Pathologist and Medical Officer,County Mental Hospital, Prestwich, Manchester ;and W. E. BOND, M.R.C.S. Eng., L.R.C.P. Lond.,a senior medical officer to the Ministry of Pensions.London: H. K. Lewis. 1926. Pp. 138. 8s.

TIIAT older views on the nature of epilepsy havebeen to some extent modified by war experiences isdoubtless now a truism ; it can scarcely be questioned,at any rate, that types of epileptic phenomena thenoccurred with no little frequency which were muchless often encountered in ordinary civilian practice.Yet it would be erroneous to suggest that fits in whicha psychogenic factor was conspicuous had up to thetime of the war been unknown ; on the contrary, thevariety was fully recognised, if somewhat neglected.In a large proportion of war cases of epilepsy so obviousseemed the underlying psychological mechanism thatit was only natural that attempts should be made tounify all epileptic phenomena on that basis and to findin each and every manifestation of the condition theaction of a mental agent. The late Dr. R. G. Rowshas left on record his conclusions, based on abundantwar material, and his formulations are given in thebook without anything having been altered by hiscollaborator.

Briefly, it is Dr. Rows’s aim to demonstrate thatepilepsy is one and indivisible, and that behind itssimplest no less than its most complex exteriorisationlies the action of a mental factor. This factor is adisturbance of consciousness associated with an

emotional state ; " in every instance " this emotionalstate can be detected, and the phenomena of the fitare a reaction to express the emotion. This contentionis declared to be substantiated by a consideration of the"

meaning " of the movements in convulsions, and anattempt is made to support the argument on physio-logical grounds-viz., that the vasomotor-sympatheticsystem is implicated in fits and that its relation to theemotional sphere is acknowledged. Holding theseviews the authors treat their cases by " explanation,exploration, and re-education," and categorically statethat drugs " have no legitimate place in the treatmentof this or any other form of mental illness," unless asa temporary measure.While there is something to be said for the hypothesis

that disorders at the mental level are often enoughresponsible for somatic symptoms, the universalapplication of it to the phenomena usually calledepileptic, whatever their clinical type, raises moredifficulties than it settles. The authors slur over the

obvious hindrance to acceptance that resides in thecommonplace variety of infantile convulsions by sayingthat " attention must be given to the little controlover the emotions possessed by the child " ; what ofthe new-born infant, whose cortex may discharge forhours after injury in parturition ? What of Jacksonianepilepsy, which may for years be limited to oneparticular muscular group, as in epilepsia partialiscontinua ? We are convinced of the applicability ofthe authors’ conclusions to certain cases calledepileptic ; we are equally unable to find in them aplausible explanation of other types of the syndromethat come under the clinician’s notice daily.

DIAGNOSIS.A Manual of Normal Physical Signs. ByWYNDHAM B. BLANTON, B.A., M.A., M.D.,

, Associate in Medicine, Medical College of Virginia.London : Henry Kimpton. 1926. Pp. 215.12s.THERE is something to be said for a brief compilation

of the normal results of physical examination ofhealthy individuals such as is presented in this book.At the same time it must not be forgotten that thestep from the normal to the abnormal is an easy one,the normal percussion note in one region of thechest, for example, being abnormal when obtainedelsewhere, and therefore the complete divorce of thenormal from the abnormal is neither possible norlikely to be satisfactory. Dr. Blanton’s idea inpreparing his book, however, was to help the beginner,and for this purpose he introduces a chapter onsound and endeavours to deal with the subjects ofpercussion and auscultation on a physical basis. Thisattempt has not been very successful, and there arecertain errors in his book which render its valuefor beginners very doubtful. The right apex isdescribed as a normally dull thoracic area (p. 57), andinspiration in this same situation is said to be lessintense as compared with the left (p. 74). Theaccount of bronchial breathing is poor, no referencebeing made to the pause occurring between inspira-tion and expiration. Râles are classified as moistand dry, no mention being made of rhonchi (p. 79).When the circulatory system comes to be consideredthe third heart sound is given as prominent a positionas the more usual first and second sounds (p. 116),and this is bound to confuse the young student; noris the description of the method of obtaining thediastolic pressure lucid.

PEDIATRICS.

Diagnosis of Children’s Diseases. Third (German)edition. By Prof. E. FEER, Zurich. Translatedby C. A. SCHERER, M.D. London : J. B. Lippincott.1925. Pp. 551. 35s.THE third edition of Prof. Feer’s work, which has

achieved notable success on the continent, has nowbeen brought within reach of the English readerby the enterprise of Dr. Seherer. The book isintended to be a guide to diagnosis, and is notconcerned with systematic description or with treat-ment of diseases ; symptoms are described and thedifferential diagnosis of their possible causes isdiscussed in detail. Prof. Feer deprecates the tendencyto allow laboratory tests to supersede, instead of tofollow, thorough clinical examination of the patient,and the reader will be impressed throughout the bookwith the paramount importance of detailed clinicalobservation in this branch of medicine. The illustra-tions are numerous and include colour-plates of theexanthemata. As a supplement to the systematictext-books this work should be of great value tostudents and practitioners.

Dystrophien und Durehfallskrankheiten im Saug-lingsalter. By Prof. LEO LANGSTEIN. Leipzig:Georg Thieme. 1926. Pp. 207. M.14.THE principle underlying this work is that both

the dystrophies and diarrhoeas of infancy can be

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successfully treated by simple methods provided thatan accurate estimate of the clinical and setiologicalfactors is obtained. The book consists of two parts,dealing respectively with dystrophies and diarrhoeas.The classification and differential diagnosis of differenttypes are presented in a concise and lucid way andaccompanied by accounts of individual cases. Manyof these are illustrated by photographs and charts offeeding and weight. The method of treatment whichthe author advocates has the great advantage ofbeing extremely simple, consisting almost entirely inthe use of human milk, buttermilk, and diluted cow’smilk with added carbohydrate. It has also thepractical disadvantage that a large measure of itssuccess seems to depend upon the use of expressedhuman milk, which is not accessible to those whowork under less ideal conditions. Much emphasis islaid on the dangers of dehydration and the importanceof combating it ; curiously little is said about the useof intraperitoneal infusions in accomplishing this end.Careful attention to quantitative requirements andavoidance of overfeeding occupy a prominent placein the author’s regime. Prof. Langstein is impressedwith the extent to which practitioners are deterredfrom scientific treatment of these disorders by theconstantly changing stream of complicated methodswhich the literature of the subject presents. His bookwas written with the object of bringing the practitionerinto touch with the methods of diagnosis and treatmentof infantile malnutrition which are evolved from theexperience of pediatrists working in special institu-tions, and it may be recommended as a successfulattempt to simplify a complicated subject.

DIETETICS.What’s Best to Eat l By S. HENNING BELFRAGE,M.D. Lond., M.R.C.S., L.R.C.P. With a PracticalSupplement by LucY H. YATES, M.C.A. London :William Heinemann (Medical Books), Ltd. 1926.Pp. 199. 7s. 6d.

The Importance of Diet in Relation to Health. ThePeople’s League of Health Lectures. London :George Routledge and Sons, Ltd. 1926. Pp. 130.3s. 6d.

Food. Its Composition and Preparation. Secondedition, revised. By MARY T. DOWD and JEAND. JAMESON, Teachers of Household Science,Washington Irving School, New York. London :Chapman and Hall, Ltd. 1925. Pp. 177. 7s. 6d.

Dr. Belfrage is an ardent disciple of the " intestinalstasis " school, and his new book on dietetics thereforeowes a great deal to the teaching of Sir WilliamArbuthnot Lane. He sets out in some detail theprinciples of diet, attaching great importance to themineral salts and the vitamins contained in food. It isnot easy to follow exactly how the terrible poisonsalleged to be generated in intestinal stasis get intothe blood stream, as it is stated they do (p. 77), forin the first place the passage of absorbed foodstuffsto the liver is described (p. 72), and secondly thedetoxicating action of this organ in the case ofptomaine is carefully emphasised (p. 83). Theintelligent reader may well ask what is happening tothe liver when the poisons produced in intestinalstasis arrive. The answer that the liver cells getoverworked and break down is a mere speculation withlittle or no experimental proof. Naturally the listgiven of diseases caused or predisposed to by intestinalstasis is a long one, and the author also appears tobelieve that relative deficiencies in the vitamins offood " are very common and lead eventually to very,serious damage " (p. 26), a view which is not held bymost dietitians. Another point calling for criticism isthe sweeping recommendation of roughage " forchildren " from their earliest years (p. 75), since ithas been shown, for example, by G. F. Still, that,brown bread, coarse oatmeal, and the like, are frequentcauses of "

indigestion " and abdominal pain inchildren. The practical supplement of recipes andcooking is good, and it is a pity that the value of the

rest of the book is impaired by too one-sided anattitude to health and disease.The lectures delivered in 1925, under the auspices

of the People’s League of Health, have been publishedin book form. Of these lectures that by Sir D’ArcyPower on the history and geography of mankind’sfeeding habits is the most interesting, because itcontains almost the only new material which dis-tinguishes this book from many others publishedduring the last few months. Hippocrates is reputedto have said that all diseases commence in the stomach,and Sir D’Arcy Power’s lecture goes to show that ascivilisation has advanced this dictum has become morestrikingly true, although there are signs at the presentday of a reaction against our somewhat gross habits ofeating and drinking. The other lectures in thisvolume, on the general principles of diet by Dr.Leonard Hill, on vitamins by Prof. W. D. Halliburton,on infant feeding by Dr. H. Scurfield, on feeding andbreeding of cattle by Dr. M. J. Rowlands, and on foodpreservatives by Prof. W. E. Dixon, are consistentin their high standard of intelligent and balancedargument.The American school text-book is also characterised

by its well-arranged and well-balanced material. Theauthors approach the subject in a scientific manner,classifying, explaining, and describing food in itsraw and cooked state and dealing fully with theintermediate process. Its illustrations are excellent,but it suffers from the usual disadvantage of Americanbooks on diet in this country that many of the food-stuffs are not known ; even a glossary fails to getover the difficulty of the American colloquial terms.Modern advances in dietetics are, however, welldescribed.

JOURNALS.

JOURNAL OF INDUSTRIAL HYGIENE. October, 1926.disease and the Workmen’s Compensation Act isdealt with in the opening paper by Sir K. W. Goadby,a specialist medical referee. After describing theprocedure of the Act, he points out that compensationin 1924 cost industry double what it did in 1911.The cost per person in the mining industry in 1924was 56s. 2d. as compared with 8s. 7d. for factoryoperatives. Coal-miners accounted for over 90 percent. of all claims ; the claims for one disease alone,nystagmus, peculiar to them, being equal to all other >

claims for occupational diseases taken together.Claims for dermatitis increased from 270 cases in 1919to 709 in 1924. Incapacity for compensated diseaseis shown to be much greater than for compensatedaccidents.-Three articles follow by E. L. Middleton,dealing with three matters concerned with the cottonindustry. The first is weavers’ cough, a troublewhich breaks out in epidemic form from time to timein certain mills, and appears to be associated with theoccurrence of mildew upon the cotton threads. Thedisease is carefully described and case-histories are

given. The exact mould which causes trouble has notbeen isolated, nor have means yet been devised forabolishing moulds from weaving sheds. The secondsubject is that of dust in cotton-card rooms. Thisdust is known to cause a characteristic form ofspasmodic asthma after years of exposure. Detailsare given of samples of dust collected under varyingcircumstances. The constituent of the dust at faulthas not yet been determined. Further investigationis required. Meanwhile all dust generated in theearly processes of opening and carding cotton shouldbe carefully prevented from gaining access to theworkrooms. The third article deals with the presenceof mineral oils in the atmosphere of cotton-spinningrooms. The occurrence of mule-spinners’ cancer,which is ascribed to oil on the spinners’ clothes, addsinterest to this investigation. Samples of air weretaken in various positions in spinning-rooms and finedroplets of oil were found to be present. Herein maybe a possible explanation of the access of oil-to partsof the skin not exposed to oily surfaces, such as

machinery, nor in contact with saturated clothing.