739

often involved in this way than branches of the othermain vessels. It is claimed therefore that the

predominant role which tradition assigns to theanterior descending branch of the left coronary.artery in the tragedy of coronary thrombosis is

unwarranted, and that the right branch plays analmost equally important part. It is believed thatthe misconception arises out of the greater difficultyin dissecting adequately the tortuous right branches,and in opening them without dislodging a thrombus.Also it is asserted that infarction of the posteriorwall of the ventricle will be found more often if thiswall is carefully incised. The findings of these

investigators, if confirmed, will destroy the claims ofthe anterior descending artery to be known as the"

artery of sudden death," or "the artery of coronaryocclusion."

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MEDICAL TREATMENT OF CATARACT.

FROM time to time we hear of claims to restorethe transparency of a partially opaque crystallinelens by means of medical as opposed to surgicaltreatment. The measures that have been advocatedare, first, local application of a non-irritating nature-e.g., Dor’s drops, containing compounds of iodine.and calcium, and the calcium alkaline iodide ointmentwhich had some vogue about eight years ago.1 Wehear little of this ointment now, and may conclude-that it has not fulfilled the expectations that it atone time aroused. Secondly, there is the subconjunc-tival injections of some irritant such as cyanide ofmercury with the object of causing hyperaemia of theciliary body and so an alteration in the nutrition ofiihe lens. Lieut-Colonel Henry Smith, of Indian fame,has long been an advocate of this treatment, whichhowever is attended by pain so great that localanaesthesia is insufficient and morphia has to be used.In Smith’s practice, nevertheless, a single subcon-junctival injection of 20 minims of 1 in 5000 neutral- cyanide of mercury is often sufficient to clear up anincipient opacity of the lens. But the loss of trans-parency thus overcome is not apparently associatedwith any definite opacities " beyond occasional blacksand-like particles in the periphery in the earlystages." 2 Without such definite opacities it is notusual to diagnose cataract at all.

Thirdly, there is the treatment advocated byDr. A. E. Davis, of New York,3 by injections of "lens.antigen." The theory on which he works is thatcataract is due to certain substances contained in theblood which are toxic to the lens alone (cataractpatients are often quite healthy in all other respects)These toxins can be counteracted by the action of" antibodies called forth by the injection into the Isystem of a substance derived from the broken downlenses of animals-" lens antigen." The theory is sofar plausible that it is widely admitted that the

ordinary form of senile cataract is not a local diseasebut is probably dependent on some defect of generalmetabolism. Dr. Burdon Cooper, of Bath, who hasfor many years been working on the chemical changesinvolved in the cataractous process, is inclined totake this vein. 4 In practice the treatment by dailysubcutaneous injection is very prolonged and is

apparently not without some risk of "

anaphyllaxis "

in case of intermission. On the other hand, accordingto Davis, the prospects of arrest or amelioration inearly cases are good. Of 243 incipient subeapsular

1 See THE LANCET, 1924, i., 700.2 Trans. Ophthalmol. Soc., 1928, xlviii., 91.

3 Ibid., 1925, xlv., 186; Amer. Med., 1932, xxxviii., 27.4 Doyne Memorial Lecture for 1922, Brit. Jour. Ophthalmol.,

1922, vi., 410.

cataracts treated by him as many as 98, or 40 per cent.,improved, and in an equal number of cases the processwas arrested. To estimate the importance of thesefigures it would be necessary to compare them withuntreated cases watched through equal periods oftime.

Mr. W. S. Duke-Elder sums up the matter thus 5 :" It is true that in some early cases of acute cataract (true

diabetic, traumatic), when the process has not progressed toactual coagulation of the proteins of the lens, transparencymay be recovered by controlling the exciting conditions ;it is also true that in all cataracts variations appear to occurdue to changes in the fluid traffic and alterations in therefraction of the unstable lens ; but it is as certainly truethat an organic opacity once formed is immutable. Coagu,-lation of protein is an irreversible chemical change."It would perhaps shorten future controversy if theadvocates of the medical treatment of cataract admitthe soundness of the above dictum and if, on the otherhand, their critics can give us a clinical test by whichto distinguish those opacities which are merelytemporary from those which are "organic." Mean-time Mr. Duke-Elder’s advice holds good, that whileit is reasonable to attack and eliminate any excitingcause that is known or suspected, the only legitimatemethod of treatment is operative removal of the lens.

THE PSYCHIATRIC ASPECTS OF GASTRO-

ENTEROLOGY.

OuR American colleagues give to the word"

psychiatry " a wider significance than we do, as

shown in an address to the American Gastro-Entero-logical Association by Dr. Adolf Meyer,6 in which hediscusses the relation between the part-function andthe total-function of the patient as expressed in symp-toms. Functional or structural stomach disturbance

may result from local disorder, from the influence ofother organ complexes, or from conditions of the

personality functions. Thus arises the question of

understanding what disturbances of the gastro-intestinal tract can be part of emotional states andtopical experiences-mentally integrated processescalling for a knowledge of personality implications.Facts and situations are involved concerning whichthe student and physician should acquire as adequatetraining as about infections, poisons, and functionalclashings or inhibitions, and Meyer believes that it ispossible to understand the role of the so-called mentalfactor in the simpler and more easily managedconditions without going into problematic and pro-tracted types of psychotherapeutic treatment. Fromhis wide experience he is able to give practical adviceto the physician on the elucidation of the patient’semotional difficulties. He gives a warning, for exam-ple, against precipitating antagonism by questionswhich the patient has to deny in order to save hisface ; one has to prepare the ground on which he canreally find an incentive to seek aid, instead of blockingthe way to further discussion. Here Meyer puts hisfinger upon the fact, already well known to those whoare accustomed to investigate the mental difficultiesof sick people, that some physicians have easy accessto intimate histories that are a closed book to others.The physical examination of patients has been

systematised so that the experience of ages is at thedisposal of every student ; on the other hand, thestudent or practitioner with the temperamentalqualities that give insight into mental factors andfacilitate their discovery has an initial advantage overhis fellows which experience increases. Yet he would

5 Recent Advances in Ophthalmology. London. 1929, p. 299.6 Amer. Jour. of Surg., March, 1932, p. 504.

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sometimes be tempted to yield up this advantage,for it carries with it the difficulty of conveying hisfindings to his colleagues or of having their significancerecognised. Meyer’s paper is an attempt to equalisematters and, in his own words, " to lead the physicianwho is almost exclusively taught to study parts of theorganism and their functions to take an interest alsoin the total-function of the person."

FLORENCE NIGHTINGALE’S LATER WORK.

THE energy with which Florence Nightingalecarried through her plans for the reform of nursing inthe British Army is the chief theme of her latestbiographer.l Those acquainted with the compara-tively cloistered life of nurses to-day will find it

interesting to be reminded how fiercely the founderof modern nursing strove against the restrictions oflife in a Victorian home. " To be nailed to a continu-ation and exaggeration of my present life," she wrote," without hope of another, would be intolerable tome." Her sense of frustration expressed itself in lowspirits and irritability, and the consternation pro-voked by these symptoms has been depicted elsewhereby Mr. Lytton Strachey, in the imagined comment ofher friends : "What could be the matter with dearFlo " By dwelling on early obstacles Miss Willis isable to show how powerful was the driving force withwhich Florence Nightingale launched herself into thefield of reform when once the barriers were down. Shedraws a character full of vigour, ruthless to herselfand others in her determination to accomplish thetask of the moment, and with a grasp of practicaldetail almost passionate.

" I think what I have feltmost," she wrote at one point, " ... is the not havingone single person to give me one inspiring word oreven one correct fact,"-rather as though she mighthave dispensed with the inspiration. The book is a

complete biography, and Miss Willis makes some

attempt to analyse the human and religious motiveswhich lay at the root of so much activity; herconclusions are interesting since they have a bearingon the vocational attitude towards nursing at thepresent time. She considers that in a religious ageonly a religious motive could justify a young womanin breaking away from custom. " God had to be

brought into it," Miss Willis writes ; " His call alonecould justify such unusual conduct." But she regards

Florence Nightingale as having been essentially a

free thinker who brought in God, unconsciously, as afigurehead, " because the impulse to do this or that... came with such overpowering strength that shecould think of no other source than God from whomit could have come." Many will be found to combatthis view of her character, but it is one which providesample grounds for speculation ; the book is writtenclearly and concisely, and well documented. MissWillis, in a foreword, confesses to owing much toSir Edward Cook’s biography of Florence Nightingale.

HYPERGLYCÆMIA AND SKIN DISEASES.

A PAPE]ET 1 by Prof. G. Rost, of Freiburg, read atthe last annual meeting of the British Association ofDermatology and Syphilology, should be studied byall interested in the inter-relations of metabolism and

dermatology. The author has a concise and simplestyle, and the reader will have no difficulty in appre-ciating the points raised and the difficulties encoun-

1 Florence Nightingale. By Irene Cooper Willis. London:George Allen and Unwin, Ltd. 1931. Pp. 255. 7s. 6d.

1 Brit. Jour. Dermat. and Syph., 1932, xliv., 57.

tered, even if he be lacking in both biochemical anddermatological knowledge. The method describedfor administering glucose in estimating tolerance

(i.e., intravenously instead of by mouth), and thereasons for so doing, will arouse general attention.Rost states that he never found hyperglycaemia inacne, seborrhoeic eczema, furunculosis and other

pyodermias, toxic dermatitis, carcinoma, or tuber-culosis cutis. The same is true of eczema in a generalsense, though he qualifies this observation by advisingthat a tolerance test should always be done whereeczema does not respond to ordinary treatment. Onthe other hand, he urges that every patient with inter-triginous dermatitis should be submitted to the test,.and mentions that cases of psoriasis often exhibit a"

pathoglycsemic "

curve. Hypoglycaemia, which isprobably an equally important abnormality, is not

infrequently associated with so-called " flexuraldermatitis," and in practice it is found that this.common symptom, especially in children, diminisheswith an increased carbohydrate administration.

While admitting that hyperglycaemia is a rarityin urticaria P. Chevalier 2 says he has tried insulinempirically in a case of apparently incurable chronic,urticaria with excellent results. The patient, a

woman of 32, had suffered from the disease for fiveyears, the attack seeming especially to follow

ingestion of fatty foods. Five units of insulin (Byla)’were given subcutaneously night and morning, witha little sugar simultaneously, and after a few daysthere was complete cessation of the pruritus, no-

matter what foods were allowed. A slight recurrence,after taking greasy foods, also cleared up when asecond and similar series of insulin injections wasprescribed. Another young woman, afflicted since-childhood with the same disease, appears to have beencured in eight days, but she too was subject to minorremissions. It cannot be supposed that every caseof chronic urticaria will respond favourably to insulininjections any more than we should hope that otheropotherapeutic remedies, such as thyroid, recom-

mended in the past, will always prove successful.It is well known too that whole blood, milk, and otherprotein complexes producing a greater or lesser degreeof " protein shock " will sometimes relieve the

symptom. Chevalier does not state that any of thesehad been used in the two cases he reports. We aretherefore left in doubt about his claims, and onlyrecord the treatment for possible trial in intractablecases.

WE regret to announce the death on Monday lastof Dr. George M. Robertson, the distinguished psychia-trist and physician-superintendent of Morningside.

WE also have to record the death of Mr. RushtonParker, professor of surgery in the University ofLiverpool.

‘

2 Paris Méd., 1932, No. 3, p. 54.

MOORFIELDS EYE HOSPITAL.-This institution(the Royal London Ophthalmic Hospital, City-road, E.C.}reports a surplus on last year’s working of JB285, not-withstanding that the increase of beds since 1930 from122 to 152 had sent up the expenditure by ,s6500. Thisincrease has been met by augmented income, chiefly fromlegacies. During the year .816,537 was raised for rebuildingthe out-patients’ department, and King Edward’s Fund hasmade an offer on behalf of an anonymous donor of a poundfor every pound up to 26000 for the building fund providedthat the hospital can raise an additional ,s6000 before nextAugust.