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the most striking ones discussed are those for thedetermination of the carbon dioxide pressure in theblood and alveolar air, and those concerned with thedetermination of the reaction of the blood in exercise.

IThe report, expressing the considered and agreedstatement of 11 members, all of whom have workedon various branches of the subject, should prove veryvaluable, and provide some solid ground for furtherprogress. The subject is not treated in great detail,the object of the report being merely to present thecurrent opinions held in this country.

" ROYAL OCTAVO."

lir. S. P. Vivian has lost no time in introducing aninnovation into the General Register Office for whichall students and librarians will bless him. The firstinstalment of the Registrar-General’s StatisticalReview of England and Wales 1 for the year 1921 hasjust appeared in " royal octavo " instead of " foliofoolscap." It is the statutory duty of the Registrar-General to collect and publish in the intervals betweenone census and another such information as will besthelp central and local authorities, and in order to doso effectively he has now divided the tables hithertopublished together into two sections of (1) medicalstatistics, (2) civil statistics-each section to be issuedwhen ready without waiting for the other. Thepresent volume consists of those tables, contained inthe old index, which had a medical interest, suitablyrearranged. It also comprises the annual figures ofthe notifications of infectious diseases hitherto separ-ately published. We must not wait for a formalreview of the volume to say how much the innovationand the handy form are appreciated.

NEW WORK ON RENAL SECRETION.

PHYSIoLOGISTS have long been divided into twocamps, those who believe that the excretion of urinecan be explained entirely on the basis of filtrationand reabsorption, and those who consider that inorder to explain it, it is necessary to add to filtrationand reabsorption secretion by the tubules. In thecurrent Biclletin of the Johns Hopkins Hospitalappears an article by E. K. Marshall, jun., and J. L.Vickers, entitled the Mechanism of the Eliminationof Phenolsulphonephthalein by the Kidney-a proofof Secretion by the Convoluted Tubules. Theseinvestigators have set out to throw light on thedifficult subject of renal secretion. In their paper thewriters briefly summarise the existing evidence thatfavours the secretory theory of urinary excretion underthe following headings : (1) Investigations by histo-chemical methods indicating an accumulation ofvarious urinary constituents or foreign substancesin the cells of the tubules ; (2) the classical experi-ments of Nussbaum on the amphibian kidney ;(3) the finding of various granules and vacuoles in thecells of the convoluted tubules ; (4) attempts todetermine the site of elimination of various substancesby injuring certain parts of the kidneys and noting theeffect of this damage on elimination. The experimentsperformed on dogs by the writers, dealing with theelimination of phenolsulphonephthalein by the kidney,and described in their paper, appear to lend addi-tional support to the view that in urinary excretionthere occurs an active secretion as well as a filtrationand reabsorption in the kidney. They found thatif phenolsulphonephthalein is injected into a dog, theanimal is killed shortly afterwards, the distribution ofthe phthalein in the blood and other tissues of the bodybeing studied, the kidneys will be found to contain anabnormally high concentration of that substance. Inorder to be sure that elimination of the urine hadceased during the experiment the spinal cord wasdivided at the atlanto-occipital junction, eliminationof the urine ceasing when the blood pressure fell below

1 New Annual Series. No. 1. Tables, Part I. Medical.H.M. Stationery Office. 1923. 15s.

40 mm. The concentration of phthalein in the varioustissues of the body was then determined, and it wasfound that on occasions the kidneys contained as

much as 35 per cent. of the total amount of phthaleininjected, although they made up only about 0-6 percent. of the total body-weight. The concentrationof phthalein in the kidneys was invariably foundto be many times greater than the concentration inthe blood or any other tissue. As no urine flowedfrom the ureters during the experiments the phthaleinmust either have been concentrated in the renal cellsor transferred through these to the lumen of thetubules. Evidence strongly points to the former ofthese two possibilities having occurred. In longi-tudinal sections of the kidney the phthalein was madeevident by a brilliant yellow colour, and it could beeasily seen that the yellow colour was almost entirelyconfined to the cells of the convoluted tubules, andthat it was absent from the lumen. It will, therefore,appear that the phthalein had been specifically takenup from the blood by the cells of the convolutedtubules. Presumably after storing in these cells it wasslowly given out in the urine.

These interesting experiments are undoubtedly avaluable contribution to the physiology of urinaryexcretion. They furnish sufficiently strong evidencethat the processes which have been designatedfiltration, reabsorption, and secretion all play a r6lein the elimination of the urine, and that filtration andreabsorption alone cannot account for the phenomenonof urine excretion.

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INFECTIOUS MONONUCLEOSIS.

ACCORDING to Dr. Warfield T. Longcope/ of thePresbyterian Hospital. New York, who records tencases which he has observed in the course of the last13 years, the terms " infectious mononucleosis,"" glandular fever," and " acute benign lympho-blastosis " have been applied to a symptom-complexwhich, though not very common, is sufficientlyfrequent to be of importance, both from the practicaland theoretical standpoint. The clinical course

presents a fairly uniform picture. The disease

usually occurs in young adults or adolescents. Manyof the patients, as is exemplified in Dr. Longcope’sseries, have been medical students or young physi-cians. The onset is gradual, with malaise, headache,and irregular fever. Pharyngitis, tonsillitis, or

tracheitis may be initial manifestations. Rarely thefirst sign of the disease is an enlargement of thecervical lymph glands : as a rule, the glands do notbecome enlarged till a few days later. The enlarge-ment is sometimes confined to the cervical glands,but frequently the axillary, inguinal, epitrochlear,and possibly the bronchial glands become involved.In some cases the spleen becomes enlarged and tenderduring the first week. By the seventh day themononucleosis is well marked ; it increases until theeighteenth day, when it gradually subsides con-

currently with a fall in the temperature and a

disappearance of the glandular enlargement. Con-valescence is rapid and uneventful. The disease hasbeen mistaken for tuberculosis, typhoid, Hodgkhi’sdisease, and leukaemia. while in a few cases syphilishas been suspected, but there is no evidence thatinfectious mononucleosis is at all related to any ofthese diseases. From leukaemia, to which it bearsthe closest resemblance, it is distinguished by theearly and marked enlargement of the lymph glands,the absence of anaemia and purpura, and the histo-logical and biological characteristics of the mono-nuclear cells, the predominant type of which issomewhat larger than the small lymphocytes andcontains oval or reniform nuclei, usually withoutdefinite nucleoli. Whether infectious mononucleosisis identical with the glandular fever described byPfeiffer cannot be decided until epidemics of infec-tious mononucleosis are reported or until cases ofglandular fever are described in which the blood

1 American Journal of the Medical Sciences, December, 1922.

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picture differs essentially from that in infectiousmononucleosis. Although a few specific infectionssuch as typhoid, pertussis, malaria, Malta fever, andpossibly tuberculosis, and intoxications such as thosedue to arsphenamine and carbon tetrachloride mayproduce a mononucleosis, the increase in the mono-nuclear cells in these cases is not very great, and is ofteninsignificant compared with the considerable mono-nucleosis encountered in the condition under discus-sion. The setiological agent is unknown. AlthoughBlaedorn and Houghton. who found spirilla andfusiform bacilli in smears from the tonsils in three oftheir four cases, are inclined to regard the disease asa form of Vincent’s angina, the clinical appear-ances in the throat do not correspond to thepicture of Vincent’s angina.

MENTAL HOSPITALS ADMINISTRATION:A NEW MENTAL TREATMENT BILL.

THE recommendations of the Committee on theAdministration of Public Mental Hospitals, whichwere set forth in full in THE LANCET of August 12th,1922, have been incorporated in a letter addressed tothe visiting committees of these hospitals by SirFrederick Willis, as chairman of the Board of Control.The most encouraging feature of his letter, apart fromthe cordiality with which the Board endorses therecommendations, is the incidental reference to theprovisions of a Mental Treatment Bill which it isproposed to introduce this coming session. Facilitiesfor the early treatment of cases of incipient mentaldisorder without certification are to be anticipated,and some enabling provision for after-care ; it isintended also to include a clause whereby the com-bination of local authorities for any purpose, such asresearch or laboratory accommodation, may beregularised, while another clause will legislate for theco-option upon visiting committees of speciallyqualified persons who are not members of the localcouncil. For the rest, the Board, in detailingthe recommendations, have wisely discriminatedbetween those which could be adopted withoutinvolving heavy financial commitments, and thosefor which it is manifestly inopportune to pressin these lean years. Nine out of the fifteen recom-mendations are regarded as in the former class.The suggestions as to the classification of patients

with some regard to former surroundings, as to theposting of notices calling attention to the right ofpatients to send unopened letters to certain authorities,and the provision of letter-boxes for this purpose, areapproved and passed on without comment. Therecommendation that the superintendent shall be amedical practitioner, preferably with a diploma inpsychological medicine, and not without generalhospital experience, is warmly endorsed by the Board,who emphasise, in addition, the importance of insistingon high medical attainments and personal qualities,on organising ability, and on an appreciation of theuse of laboratory adjuncts to treatment. Elsewherein the letter the Board record their opinion that muchmore extensive use should be made in the ordinaryroutine of laboratory and other modern methods ofdiagnosis and treatment. Following a suggestionmade, the Board have arranged for a small advisorycommittee to be at the disposal of any visiting com- z,mittee who may desire to consult them in regardto the filling of vacant posts, which should be adver-tised. The appointment of a consultant staff to amental hospital has the strong approval of the Board,who note with gratification that at most institutionsthe services, at any rate, of a dental surgeon arealready available. With regard to assistant medicalofficers, the recommendations of the Committee dono more than reiterate the need for increased staffand for the provision of opportunities for study leave,emphasised by the Board in a circular addressed tovisiting committees on March 3rd, 1920. In thiscircular the probable causes of the dearth of suitableapplicants for these posts were outlined, the desirabilityof providing for the more effective treatment upon

modern lines of recoverable cases insisted on, and thenecessity for affording facilities to raise the standardof training for existing and future medical officersexplained. As to the employment of patients, thequestion of authorising payment to patients doinguseful work is under consideration ; it is agreed thatevery endeavour should be made to provide patientswith suitable occupation and to arouse their interest.Again, the Board agree that the importance of after-care can scarcely be over-estimated. and suggest thatwithout waiting for the proposed legislation, voluntaryeffort in this respect should be encouraged-forexample, by the formation of local branches ofthe Mental After-Care Association. The uniformly vsympathetic attitude of the Board is well shown bythe trivial nature of the only reservation made inforwarding the recommendations. While they agreeas to the importance of drawing the attention offriends and relatives of patients to their powers(under Section 79 of the Lunacy Act, 1890) to makeapplication for the discharge of a patient, theyconsider that this should be done in the rules as tovisitation rather than by means of notices in thewaiting-rooms as suggested. Arrangements for thevisiting of patients by responsible people speciallyauthorised by the local authority, as well as greaterfacilities for visits from friends and relatives, are

also among those alterations which could be effectedwithout much expense and with great advantageto the confidence felt by the public in mental hospitaladministration. Recommendations affecting the dailycomfort of patients, such as the arrangements fordaily toilet and the number of hours spent in bed,are specially commended to visiting committees.As to the suggestions which would involve heavier

expenditure, the limitation of the size of hospitals to1000 beds, and the adoption of the pavilion systemof buildings, need not, it is said. arise unless thebuilding of a new institution or the enlargement ofan existing one is contemplated. The remainingrecommendations in this category deal with thenursing service and the dietary, and are beingconsidered by special committees appointed by theBoard of Control ; a further communication willembody the results of these deliberations. The Boardare giving careful consideration to the revision of thedefinition of " seclusion," as suggested by the Com-mittee. Sir Frederick Willis’s letter concludes withan appreciation of the helpful spirit, in which therecommendations of the Committee were drafted.Indeed, most of them cover points which the Boardhave for some time been pressing upon the notice oflocal authorities. It is noticeable also how closelythey coincide with the demands made at the Conferenceof Medical Superintendents and Representatives ofLocal Authorities called together in January, 1922.We commented favourably on these and on the reportof the Committee on Administration of MentalHospitals when they were first issued, and need nowadd only our conviction that public confidence inthe Board of Control will be greatly strengthened bytheir evident anxiety to use for the advantageof the patients under their care every particle ofthe present public interest in mental hospitaladministration.

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Sir Charles Ballance will deliver a short appreciationof the Life and Character of the late Mr. Hunter Todto the members of the Otological Section of the RoyalSociety of Medicine to-day (Friday) at 5 P.M.

Report 2 of the Industrial Fatigue Research Board,issued to-day, deals with atmospheric conditionsin cotton - weaving. It establishes the fact thatoperatives are exposed to atmospheric conditionswhich are physiologically unsatisfactory, althoughit does not dispose of the question whetherconditions causing discomfort necessarily result inill-health.

1 THE LANCET, 1922, i., 188 and 243 : ibid., 1922, ii., 343.2 H.M. Stationery Office. 2s.