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Ministry without being referred to the association.The Minister had promised Parliament to do some-thing, and so he took one of the committee’s recom-mendations-the provision of a midwife for everyconfinement-a piecemeal action simply to satisfyParliament. It was absurd for the medical profes-sion not to have proper access to the local healthauthority. The proper way to tackle the maternalmortality problem was through the medical

profession.The New Scottish Maternity Service

Dr. J. B. MILLER (chairman of the Scottish Com-mittee) said that under the Scottish proposals everyparturient woman was to be provided with a completeservice. Each local authority framed its own schemeafter finding the views of the practitioners in thearea. It had now been agreed that the doctor on thematernity panel should undertake to make fiveexaminations, viz., three antenatal, one within twelvehours, and another within four weeks of delivery,but only to assist at the actual labour if he thoughtit desirable--on present experience the midwife wouldcall him in about once in four times-for which theinclusive fee would be 30s. or for insured women 25s.Should the woman enter hospital before labour set

in a, fee of 15s. was proposed. These terms, he said,were a great advance on anything they had got atpresent and were subject to revision after two years.It was a big opportunity for the general practitionerto keep on his domiciliary activity.

Dr. A. B. MURRAY (Banff) said there would be dis-appointment in his area where the normal confine-ment fee was E2 2s., not including antenatal work.- Dr. E. R. C. WALKER (Aberdeen) feared the

proposal was penalising the conscientious accoucheurwho wished to be present himself at a large proportionof confinements.-Dr. J. C. ARTHUR said that in anarea like Gateshead the Scottish proposals would putinto the practitioner’s hands probably twice thenumber of confinements he was now asked to attend;60 per cent. now went to the municipal clinics.- Dr. A. U. WEBSTER (Aberdeen) thought the schemewould undoubtedly give the doctor more to ’do, buthe would welcome it.

In reply, Dr. MILLER said that the proposals wouldnot affect well-to-do practices ; they only referred towomen who applied for maternity benefit. The two

years’ probationary period would show whether therewas a general desire on the part of practitioners inScotland to retain their midwifery work.

(To be continued)

REVIEWS AND NOTICES OF BOOKS

Health and a DayAddresses by Lord HORDER. London : J. M. Dentand Sons. 1937. Pp. 213. 7s. 6d.

THE dozen addresses here collected were given byLord Horder to varied audiences : his peers in theHouse of Lords ; a women’:; club ; listeners attunedto a series of broadcasts on national health ; Pilgrimsat lunch in New York ; laymen with a scientific biasattending the section of physiology of the British

Association, or a Friday evening discourse at the

Royal Institution ; and groups of students in Edin-

burgh and in London. Only three were actuallydelivered to doctors (though all will interest them) :of these the estimate of John Hunter might be classedas a stimulant, the plea for direct action in medicineas an alterative, and the essay on the clinician’sfunction as a purge. Lord Horder demandsan elimination of irrelevant and expensiveaids to diagnosis, a return to simplicity " with adash of courage and independence," to that bedrockof clinical medicine which should never have beenabandoned. Those who watched with him the birthand early growth of clinical pathology will enjoy hispicture of the incursion of this virile adolescent intothe sickroom, brusque and truculent, like a cuckoo

"ousting his more timid and gentle colleague fromthe latter’s legitimate sphere." Was medicine reallytaped at last ? "1 By no means ; some clinicians atleast kept their heads and showed that " the capacityto neglect is as important as the capacity to takenotice." It is not only in the rejection of unessentialmethods of investigation that a proper sense of valuesbecomes manifest. The " ability safely to omit "which Lord Horder regards as a sign of ripe clinicalacumen is also the mark of the expert in other fields,notably in oratory ; and no redundant phrase orflourish mars the prose, informal without beingcolloquial as befits the spoken word, which makesthese expositions of his ideas a pleasure to read andread again.

Treatment in PsychiatryBy OSKAR DIETHELM, M.D., Professor of Psychiatry,Cornell University Medical College, New York. NewYork : The Macmillan Company. Pp. 470. 17s.

SOBER descriptions of psychiatric treatment are asrare as sober notions of what it can achieve. Genuine

psychiatric treatment and psychotherapy are heldby some to be synonymous terms ; to others theformer means custody and drugs, and the lattermeans claptrap, and still another partisan groupinsists on somatotherapy as the only active andhonest means of treating the mentally ill. Sharpdistinctions are also drawn by protagonists of variousschools of thought-e.g., neurosis must be treatedcausally and psychologically ; psychoses, in contrast,must be treated expectantly or with palliatives.Advocates of this or that procedure seldom refrainfrom vilifying other methods, while making excessiveclaims for their own. A balanced account of whatcan be done to help the patient with psychologicaltroubles is seldom written, and when it does getwritten it often makes dull and sluggish reading ; thewise maxims (though constantly ignored in practice)read like platitudinous copybook staff ; the qualifiedstatements seem to argue pessimism and uncertainty ;the avoidance of jargon, speculation, over-zeal, andother particularist faults makes the thesis humdrum.

Prof. Diethelm’s book illustrates alike the meritsand the difficulties that attend a workman-likeattempt to set down the treatment given nowadaysin well-ordered psychiatric clinics. Although theauthor, disclaiming any originality for his book,states that it is based on the teaching and methodsof treatment of Adolf Meyer, under whom he workedfor ten years, it would be misleading to regard it ascharacteristic of any one school or point of view ; itsvirtue lies in its catholicity. The chapter headingsin the general part indicate this : study of personality,treatment in general, suggestion and hypnosis,psycho-analytic procedure, various psychotherapeuticprocedures (methods of Adler, Jung, Burrow, Rank andStekel, Dubois, Kronfeld), and distributive analysis

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and synthesis. Hydrotherapy, diet, drugs, occupa-tion, social care, exercises, and recreation likewisereceive attention, particularly in the more specialisedchapters dealing with individual reactions, such asschizophrenia, excitements and depressions, organicpsychoses, psychoneuroses, sexual difficulties, and

drug addiction. The matter is set forth clearly, ifrepetitively, with a sufficient attention to detail.The bibliography is unsatisfactory ; the case recordsare interesting, though they do not always convinceus of the success of the treatment. Although thereare warnings against ill-based hopes and promises,the problems of actual management are at timesslurred over. Such faults as these, however, are

trivial in comparison with the value of the work asa sensible statement of what good psychiatrists dofor their patients, in hospital or in private.

Source Book of OrthopedicsBy EDGAR M. BICK, M.A., M.D., Adjunct Ortho-pedic Surgeon, Hospital for Joint Diseases, NewYork. Baltimore : The Williams and WilkinsCo.; London : Bailliere, Tindall and Cox. 1937.

Pp. 376. 18s.

WHAT exactly is a " source book" ? In this casewe are told that it is " History, but not dead history.Valuable as a brief concise story of the evolutionof orthopedic surgery from earliest times to date.More valuable still as primarily a time-saving guideto the original sources of information...." At thispoint it is tempting to discuss the difference, if any,between history (presumably living) and merely" dead history." If there is a difference, it is in theway the subject is handled by the historian. Mostof us were brought up on 1066 and all that; a listof kings, scores of battles, maps of Western Europe,and then as we became more senior-of the wholeworld. An interminable string of facts--dead history,stone dead. Since those days G. M. Trevelyan’s" History of England has appeared, together withhis other great works ; no better examples could begiven of living history. The kings and the dates arestill there, but submerged in the splendidly flowingnarrative which explains how our nation grew andwhy at certain stages the people and their rulers didthings that are unthinkable to-day, and assignsto outstanding individuals their true place inthe great story. Such a book reads like a

romance.

Dr. Bick’s work, unfortunately, is very like theold-fashioned history book. He has been at greatpains to collect an astonishing amount of information,and to arrange it in an orderly fashion. But he givesus facts almost from first to last and fails to traceclearly the many phases of the evolution of ortho-paedic surgery. The chapters are arranged accordingto periods of time: primitive man, middle ages,renaissance, and so on. The modern period issubdivided into physiology, pathology, and methodsof practice. The result is that the complete historyof any particular condition or group of conditionshas to be sought in several chapters. Although thereare people who object to calling an injury or diseasean entity, yet there is no denying that a fracturesustained in the Ark during the storm must have beenvery like one occurring during an Atlantic crossingto-day, and it would have been better, perhaps, tohave given us a series of short self-contained histories,each centred on a particular condition, and showingthe gradual development of knowledge about itspathology and proper treatment.

The author’s preoccupation with detail makes thebook difficult to read. All the same we cannot butrecommend it, for it is a storehouse of information,likely to be of great value to the intelligent student.Dr. Bick has done orthopaedics a great service inproducing this book but he has not done full justiceeither to the subject or to himself, and we hopethat, if a second edition is called for, the book willbe rearranged in a more digestible and more trulyhistorical form.

Sick Children: Diagnosis and TreatmentA Manual for Students and Practitioners. Secondedition, revised. By DONALD PATERSON, B.A.Manitoba, M.D. Edin., F.R.C.P. Lond., Physician,The Hospital for Sick Children, Great Ormond.street; Physician for Diseases of Children, West.minster Hospital. London : Cassell and Co. 1937.Pp. 600. 12s. 6d.

THE call for a second edition of this usefulmanual has been made the opportunity for a fullrevision of the section dealing with the anaemias andfor amplication of that concerned with the diseasesof the new-born. The problem of allocation of spaceis always a difficult one in a manual of this type, andhas now been partly met by the use of small type forthe less common conditions. A number of tables anda particularly serviceable list of normal biochemicaland other data, compiled by Dr. W. W. Payne, havebeen added. The fact that Dr. Paterson’s approachto the subject is essentially clinical will be appreciatedby students doing their clerking and by busy practi-tioners. Others may perhaps feel that therapeuticsare dealt with a trifle uncritically, and that thereferences to the literature, provided in footnotes,hardly give sufficient prominence to pathology. Thebook is, however, well proportioned, and for its sizeand price contains a great deal of reliable information.For the most part this is clearly presented, and themany illustrations suitably selected and reproduced.Some sixty pages are devoted to the index.

Gabell’s Prosthetic DentistrySecond edition, revised and largely rewritten bvARTHUR G. ALLEN, L.D.S. R.C.S. Eng., DentalSurgeon to the London Hospital, and AssistantDirector of Dental Studies and Lecturer in DentalProsthesis at the London Hospital Dental School.London: Humphrey Milford, Oxford UniversityPress. Pp. 239. 12s. 6d.

THERE is perhaps no branch of dentistry whichcan confer so much satisfaction or dissatisfac-tion on mankind as the construction and fittingof dentures. Few of us who attain middle age escapethese aids. A sound knowledge of prosthetics is thusessential to the successful dentist. He must knowa certain amount of anatomy and physiology; heshould be a bit of an engineer and something of a

physicist and chemist, and above all a craftsman.Because it is so practical a subject there is a tendencyto decry text-books on prosthetics. But without asound knowledge of the underlying principles no

amount of digital dexterity will bring a dentistsuccess in this difficult branch of his art. When thisbook first appeared, in 1921, it was at once acclaimedas a most original contribution to dental prosthetics.Douglas Gabell was known as a stimulating teacher ona subject to which he had given a lifetime of study,and this book showed that as a writer he was equally

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gifted. His untimely death was a great loss to

dentistry and no doubt accounted for the lapse of15 years between the first and present editions. Inthat time many changes and improvements have beeneffected in dental prosthesis ; yet the foundationslaid by Gabell have remained practically unchanged.Students, and even practitioners, could consult theoriginal edition to-day with profit, and the skill withwhich Mr. Allen has accomplished his task of revisionjustifies his claim that the book still remains" Gabell " despite the extensive rewriting and

remodelling. The value of the book is that it is notonly practical but also sets out and explains in detailthe reasons for the various stages in making dentures.It is indeed one of the best books of moderate sizeon the subject which we have seen. It should beassured of a wide welcome with many furthereditions to keep green the memory of a greatteacher.

Diseases of the Nose and Throat

Fourth edition. By Sir STCLAIR THOMSON, M.D.,F.R.C.P., F.R.C.S., Emeritus Professor of Laryn-gology in King’s College Hospital; and V. E.NEGUS, M.S., F.R.C.S., Surgeon for Diseases ofthe Throat and Ear, King’s College Hospital.London: Cassell and Co. 1937. Pp. 976. 45s.

WE welcome a new edition of this outstandingtext-book. In the ten years which have elapsed sinceits predecessor appeared, laryngology has developedin various directions, but the size of the book hasbeen increased by only 33 pages, a result obtainedby rigid revision and by reducing the space formerlygiven to describing the technique of examination.In the production of this edition Sir StClair Thomsonhas had the collaboration of Mr. V. E. Negus and,as would be expected, endoscopic methods are nowfully treated in a separate chapter. The clinicalfeatures and diagnosis of laryngeal disease are fullyexplained, and the sections on tuberculosis andcancer are outstanding. The very varied methodsof treating cancer of the larynx are thoroughly dis-cussed ; the technique of the " window " method ofapplying radium is described, but the names ofHarmer and Finzi, the pioneers in this work, are notmentioned. A feature of the book is its references toalmost every known method of treatment, but onewishes that Sir StClair had used the great weight ofhis authority more often to indicate which methodhe himself prefers. Very many methods are thusgiven for the treatment of hay-fever withoutindication of the authors’ preference ; numerous

opinions on the efficacy, or otherwise, of activeimmunisation with pollen vaccine are quoted, butthe different methods of administration, "leisurely "and " rush " treatments, are not mentioned. In thesection on haemorrhage after tonsillectomy, theauthors lay insufficient stress on the gravity of thiscomplication ; they say that " some observersincline to the view that active local measures (spong-ing, packing, stitching the pillars) are difficult andalarming and may even encourage bleeding," withoutstating whether they agree with this opinion, whichmany hold to be a dangerous one. Suture of thepillars, according to the authors, should be done overa tightly rolled pad of iodoform gauze ; actuallythis is uncomfortable and soon becomes foul, whereassimple suture is very efficacious. The book coversthe ground very completely. There is scarcely anycondition, symptom, or method of treatment that isnot mentioned therein, and the work will retain itsplace as a classical British text-book.

Physiology in Health and DiseaseSecond edition. By CARL J. WIGGERS, M.D.,Professor of Physiology in the School of Medicineof Western Reserve University, Cleveland, Ohio.London : Henry Kimpton. 1937. Pp. 1124. 42s.

THE author,’s statement that he has been con-

tinuously engaged in the task of revision since theappearance of the first edition is borne out by theremarkable improvements effected. A work of thissize can only achieve perfection by degrees ; thedefects in the first text have been resolutely tackled.Much of the book has been remoulded, and every-where it has been brought up to date. A large pro-portion of the references to original literature, withwhich the text abounds, bear the date 1936, andthese are not merely addenda ; the work to which

they refer has been digested, and appears as partof the tissue of the book. The vigour of the revisionas well as the decisive manner of the writing give asingular air of vitality to the book; indeed the

English reader may find it at times a little over-

powering. It carries, as it were, an overload of fuelin the shape of recent work, and is kept afloat by thesheer strength of its driving force and the skill of itspilot. The reader would be well advised to pauseoccasionally and read at least some of the mono-

graphs and reviews which are generously quoted.In this way he will appreciate the full significanceof many of the paragraphs and avoid an overdoseof facts with but a superficial grasp of the principlesinvolved. Read in this way the book will be invalu-able to teachers and advanced students as a keyto physiological literature, while those engaged inclinical work will find the sections on applied physio-logy much to the point and easy to follow. Everytext-book has a bias, and the experienced seekerafter knowledge arranges his reading accordingly.The bias in this case is biophysical, and the principlesof electrocardiography and other bio-electric pheno-mena, which often puzzle the beginner, are clearlyexpounded. Much of Prof. Wiggers’s personal workhas had to do with the circulation of the blood,particularly its physical aspects, and the chaptersdealing with this subject are outstanding. The bookas a whole makes a definite contribution to the under-

standing of physiology. Probably its most importantcharacteristic is that it not only teaches, but providesthe means of learning, and yields more the more it isstudied.

The Control of Bovine Tuberculosis in Man

By NATHAN RAw, C.M.G., M.D., M.R.C.P., lateBritish Member of the International Committeeon Tuberculosis. London : Bailliere, Tindall andCox. 1937. Pp. 128. 6s.

Tms short monograph is based upon Dr. Raw’sown hospital and laboratory experience in the last30 years. This, he states in the preface, " comprisesthe care and treatment of over 7000 cases of pulmonarytuberculosis and of 2200 cases of non-pulmonary tuber-culosis." He regards tuberculous infection as so

widespread and so serious in certain groups that itis almost impossible to visualise its control and itsextinction except by vaccination of susceptible personsand animals. Although he accepts the general viewthat the human and bovine strains of tubercle bacilliare separate and distinct, he believes that the bovinestrain introduced into the human body in infancy orearly childhood may, after many years’ growth inits new tissues, undergo mutation and become a

human strain producing the usual lesions attributable

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to this strain. Dr. Raw acknowledges, however, thathe has had no opportunity of proving his theory, tthough he quotes some evidence in support of it.Moreover he is quite satisfied that the human,bovine, and avian strains when subcultured con-

tinuously for many years do not change their culturalcharacteristics. The immunising vaccine which headvocates is prepared from human strain culturesattenuated by subculture for 32 years without anyintermission until now they are avirulent and non-pathogenic ; unlike B C G they are killed by heatbefore use as a vaccine. This vaccine together withthe control of milk by pasteurisation are the principalweapons in the author’s armamentarium for eradicat-

ing bovine tuberculosis in man. Unfortunately thebook is rather scrappy and there is much repetition,not always with accuracy. The story of Koch at theInternational Conference at Washington is interest-

ing, as indeed must be all personal details of Kochto the present generation, most of whom did notknow him ; but it is a pity to tell the story threetimes in different parts of the book. Again, Dr. Rawappears to believe (vide p. 1) that all tuberculosis ofglands, bones, and joints and lupus is of bovineorigin, which is surely a -fallacy. The book is notfree from such inaccuracies, but it is interesting asthe expression of the point of view of an experiencedworker in tuberculosis.

EXAMINING BOARDS IN MEDICAL

SPECIALTIES

(FROM A CORRESPONDENT IN THE UNITED STATES)

To ensure that those physicians who claim to bespecialists shall in fact be qualified to do so thecouncil on medical education and hospitals of theAmerican Medical Association has been authorisedto express approval of certain examining boards inmedical specialties. The essentials for approvedexamining boards have been defined and include therequisites that the boards should be composed ofrepresentatives of national organisations of the

specialty, should be incorporated, should determinewhether candidates have received adequate prepara-tion, should provide comprehensive tests of theirability and fitness, and should certify the competenceof those who satisfy the requirements. Twelvebranches of medicine have been recognised as suitablefields for the certification of specialists : internalmedicine, surgery, paediatrics, obstetrics and gynoeco-logy, ophthalmology,’ otolaryngology, dermatologyand syphilology, neurology and psychiatry, urology,orthopaedic surgery, radiology, and pathology. Each

applicant for admission to the examination is requiredto present evidence that he has met standards in theway of general qualifications, professional education,and special training.

DERMATOLOGY AND SYPHILOLOGY

The first board to be accepted by the council wasthe American Board of Dermatology and Syphilology.The purposes of this body have been defined as

primarily to determine the competence of physicianswho specialise in dermatology and syphilology;secondly, to publish lists of physicians who have beencertified by the board, for the information of hospitals,medical schools, other physicians, and the lay public ;and thirdly, to improve the standards of practice ofdermatology and syphilology by investigation ofmedical school curriculums and by investigation andencouragement of adequate facilities for graduateinstruction in this specialty. Two classes of applicantsare recognised, the first consisting of physicians whohave limited their practice mainly to dermatologyor syphilology for ten or more years including aperiod of training satisfactory to the board, while thesecond comprises those who have practised dermato-logy and syphilology at least five years, includingtheir period of training. The latter group must havehad at least two full years of special training devotedexclusively to this specialty, including at least oneyear in a well-recognised clinic or as an assistant inthe private practice of a well-known specialist in thisfield. Applicants classed in the second group are

required to pass a written examination on clinicaland laboratory subjects, including cutaneous patho-logy, which are held simultaneously at stated intervalsin different parts of the country approximately twomonths before the oral examination. Applicantsin both groups are required to pass an oral, a clinical,and a laboratory examination which are conductedin a clinic or hospital ward where individual casesare discussed with each candidate. Under certaincircumstances the certificate may be revoked by theboard.

Similar requirements have been formulated forthe other boards so far organised, though somespecialties allow a wider latitude in qualificationsand examination than others. Boards have been

organised in all of the specialties mentioned as suitableby the council on medical education ; ten have been

already accepted by the council, and the other twoprobably will be as soon as they have met certainspecific requirements.

CRITICISMS OF BOARDS

These boards have not been organised, however,without some objections by qualified men. ThusDr. Bucy, who is secretary of the section on neurology,has made the criticism that their requirements tendto cast medical practice and medical research intotoo rigid moulds. He feels also that the certification,as so far developed, lays far too little emphasis onthe applicant’s possible research and too much onhis factual knowledge. These criticisms have beenanswered by Dr. Heyd, the retiring president of theAmerican Medical Association, and by Dr. Titus,who is secretary of the Advisory Board of the MedicalSpecialists and secretary of the Board on Obstetricsand Gynecology. Titus holds that the public hassuffered too long from too many self-styled specialistsand said that the boards are merely trying to makeavailable the facts regarding those who claim to bequalified for specialised practice. Furthermore, hestates that certain boards do not require a rigidlimitation of work to their specialty ; multiplecertification may be occasionally granted, and theBoard of Internal Medicine, for example, offersseveral routes by which applicants can be consideredqualified for certification. Dr. Boggs, in the presi-dential address read before the Association of AmericanPhysicians, also challenged the underlying philosophyof such certification and stated that since the trainingof the qualified internist may be obtained in a varietyof ways it is desirable, and in the public interest, thatindividuality should be encouraged rather thanreduced to one specific character.

It seems probable, in spite of these criticisms, thatthe organisation and functioning of the special boardswill continue. But there may be some modificationof their administration.