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475 venous and arterial blood are mixed in the left ventricle and only an anastomosis between the systemic and pulmonary circulations-i.e., a Blalock or Potts opera- tion—will allow the blood to enter the lungs and so relieve the cyanosis. Possibly there is one other group in whom a shunt type of operation must be carried out - those with such extensive pulmonary atresia that direct attack is impracticable. Between these two groups of cases, in which the indications for either a shunt operation or valvulotomy are fairly precise, there lies a large number in which the decision may be difficult. Where a surgeon is more experienced in arterial anastomosis, he will naturally find himself treating most of his patients in this way. Others will favour the direct relief afforded by valvu- lotomy, and as they gain greater experience in its execution will find more cases to which it can be success- fully applied. A recent report by Brock is particularly illuminating. Of his first 223 cases of pulmonary stenosis, 112 were treated by anastomosis and III by direct operation ; but in the first 50 there were 2 direct opera- tions and 48 anastomoses, whereas in the last 50 there were 36 direct operations and only 14 anastomoses. Of these 14, 5 were cases in which a direct operation could not be done for reasons stated above. The direct relief of pulmonary stenosis seems, therefore, to be technically possible in about two-thirds of the cases. It is certainly an attractive solution, since it largely restores to normal the mechanics of the heart, adds no new strain, and does not call for an artificial ductus with its potential risk of infection. Nevertheless only continued close study of patients treated by these alternative techniques will establish their relative values. 7. Brock, R. C. Ann. Surg. 1952, 136, 63. 8. Out of Step. JOSEPH TRENAMAN. London : Methuen. 1952. Pp. 223. 21s. GETTING INTO STEP THOSE of us who find irksome even the mild regimen- tation of contemporary civilian life will readily sympathise with the soldier who is " out of step." Usually he is a young man who finds that soldiering does not agree with him and that the consequences of kicking over the traces of discipline can be more unpleasant in the Army than in civil life. He may have wanted to be a driver, not an infantryman ; if he could not be a driver he wanted to transfer to the Navy or the Mercantile Marine. He, and his like, find it hard to conform. They have not learned to swallow small injustices, and they almost inevitably run foul of the authority of the orderly room ; and their " crimes " may range from personal neglect (" dirty rifle ") to absence without leave. Sometimes their offences, though still not of a kind to get them into real trouble in civil life, are more serious and may vary from making Donald Duck noises on parade to throwing a bucket of whitewash over the regimental sergeant-major. In 1941 the Army established at Pontefract a camp at which the training was to be-" specially framed with a view to reclaiming young soldiers from a career of crime and converting them into good soldiers." Mr. Joseph Trenaman, who shared in the educational side of the venture. has described 8 the men who came to the camp, and how they fared there. Physically the men were weaker, feebler, and more ill-nourished than the ordinary run of young soldiers. They were a little below the average level in innate intelligence, but not obviously subnormal ; emotionally they were immature. For the most part they came from poor and overcrowded homes. Only some 14% had been apprenticed to a ,.killed trade in civil life, and many had been in police trouble there ; 36% had been convicted of indictable offences: before joining the Army. But Trenaman believes that parental neglect was the " probable major factor’’ responsible for delinquency, with psychopathic "tates a poor second. Among the minor factors he lists, in order, physical deficiency, poverty at home, broken home, and invalid parents. Sir Cyril Burt, who con- tributes a stimulating preface to the book, does not like the term " psychopathic." It was a label bestowed by the psychiatrists who saw the men ; but, as Burt says, different psychiatrists interpret the term in different ways. Not all the men were enamoured of the new venture. It would have been overoptimistic to have expected otherwise. Some made it plain that they took a poor view of this latest outcropping of reforming zeal. The Glasgow youngster was probably not alone when he wrote across one of the early questionarv forms, " none of your bissness." But the important thing is that the method seemed to bring results. The records of these lads were much better after treatment in the unit than thev had been before. 1. Brit. med. Bull. 1952, 8, no. 2-3. ISOTOPES IN BRITAIN DURING the late war British scientists heard with admiration-and not a little envy--of the remarkable developments in America as radioactive isotopes became available for biological research. These developments flowed directly from the brilliant work by American physicists in setting up cyclotrons and the first chain- reacting pile. After the war came a period when the United States with great generosity provided British workers with supplies of isotopes and information about the technique of their use in biological research. But these supplies were necessarily limited and could not in any case include the shorter-lived isotopes. It was therefore a great relief when the pile at Harwell came into action and home supplies were to be had. Now a wide range of isotopes can be obtained by British workers, and in addition Harwell carries on a thriving export trade. With several years’ experience now behind them, British workers can give a good account of themselves, as is shown by an issue of the British Medical Bulletin devoted to this subject.’ A comprehensive review of this sort provides an opportunity for assessing the value of this fascinating and still novel application of physics to biology and medicine. The tale of what has so far been achieved has to be set against a background of the many technical problems that had to be overcome before any results at all were possible. Although nearly all isotopes are now prepared by neutron bombardment of suitable material in the pile, the actual production and isolation of each one involves an individual problem if material of the desired specific activity is to result. Isotopes are only useful to the biologist if they are present in the chemical form which he requires. For this reason the radiochemical centre at Amersham was set up. Here the necessary chemical manipulations can be carried out on highly radioactive substances ; the compounds which the centre can supply include some forty labelled withC14. In the subsequent handling of radioactive materials stringent precautions are needed, according to the type of radiation and the half-life of the isotope concerned. In the measurement of radioactivity in tissues or whole organs there are many pitfalls for the unwary. The research-worker has to adjust himself to the new habits of thought required for the interpretation of experiments involving isotopes. He first has to become used to the idea that all his measurements are subject to an inevitable (but always calculable) error due to the random nature of atomic disintegrations, over and above any errors which may result from his manipulations. Then he must realise that his measurements only enable him to follow the fate of a small parcel of labelled atoms, introduced into his biological preparation at a particular time ; rapid passage of a batch of labelled atoms through a given organ does not necessarily mean that large
