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a plastic airway. Some expansion of thelungs may occur with each puff of oxygen,in a very flaccid infant a slight amount ofair may enter the stomach.The few babies who fail to respond are

immediately intubated with a Portsmouthtube, which has a shoulder to limit inser-tion. The face mask is replaced by anadapter which fits the endotracheal tubeand venturi suction removes any fluid: aninner tube is sometimes used for this pur-pose. The lungs are then ventilated byintermittent positive-pressure puffs, onlya few being needed to stimulate regularbreathing. In very severe asphyxia withbradycardia this procedure is used im-

mediately and maintained in all cases wherethe heart is beating until rhythmic respira-tion is established.

This apparatus has been used suc-

cessfully in cases of cardiac arrest in babies.Artificial inflation of the lungs oxygenatesthe blood during external cardiac massage.The apparatus also meets the need for

venturi suction and oxygen in patients whoare recovering from an anxsthetic in thehome, or in hospital wards with no

resuscitation facilities.I am greatly indebted to British Oxygen Co.

(in particular Mr. J. E. Tatham), who havemade the apparatus for me and from whom itcan be obtained.

D. J. MACRAEM.D. Edin., F.R.C.S.E., F.R.C.O.G.

The Mothers’ Hospital,London, E.5 Fig. 1. Fig. 2.

Reviews of Books

Trauma to Nerves in Limbs

JAMES E. BATEMAN, M.D., F.R.C.S.(c). Philadelphia and Lon-don : W. B. Saunders. 1962. Pp. 453. 98s.

THE functional disability which results when a peripheralnerve is damaged is often out of all proportion to the originalinjury and may interfere disastrously with the patient’s way oflife. Treatment is necessarily prolonged and, even after monthsof waiting, the final results are rarely perfect and often dis-appoint both surgeon and patient. If such cases are not to

linger forgotten in physiotherapy departments, the surgeonwho undertakes their care must have patience and enthusiasm,a detailed knowledge of peripheral surgical anatomy, a preciseand meticulous operative technique, facilities for thoroughinvestigation and aftercare, and a wide repertoire of secondarycorrective procedures if the nerve fails to recover. The authorof this timely book is such an enthusiast. During the pasttwenty years he has cared for 2500 cases of peripheral nerveinjuries, and the book is the product of this experience. It isthus extremely practical; and it is also comprehensive,including all aspects of nerve trauma.The surgical anatomy of the peripheral nerves is particu-

larly well described, with clear original drawings. The typesof injury, the pathological changes involved, the methods ofclinical investigation, and the diagnostic assessment of dam-age are fully discussed and well illustrated. Then follow thegeneral techniques of repair, and further chapters deal withthe operative problems related to individual nerves, and thesupporting measures required during the postoperative phase.The results to be expected from treatment and the assessmentof the residual disability will be of great value to those con-cerned with the medicolegal aspects of trauma. The recon-structions available for residual paralysis are next discussed;and finally the author goes beyond his title and includes

chapters on neural pain, peripheral neurovascular disorders,

denervations for joint pains and spasticity, and peripheralnerve tumours.

A curious omission is the absence of any note of Dr.Bateman’s past or present appointments or even his address.Any doubts of his competence, however, are dispelled by theexcellence of his work; whether as practical manual or book ofreference, it is thoroughly recommended to all interested intrauma.

Hare Lips and Their TreatmentA. B. LEMESURIER, M.D., F.R.C.S.(c.), late surgeon-in-chief,Hospital for Sick Children, Toronto, Canada. Baltimore:Williams & Wilkins Co. London: Bailliere, Tindall, & Cox.1962. Pp. 169. 56s.

THIS book is devoted to a surgical technique-a methodof repairing hare lips which Dr. LeMesurier modestly disclaimsinventing, but which universally bears his name and for thedevelopment of which, from Hagedorn’s original description in1892, he deserves full credit. He first wrote about it in 1949and published further details in 1952 and 1955. Many plasticsurgeons adopted the technique, for it had obvious advantages;the quadrilateral flap transposed extra tissue into the lowerpart of the lip giving a natural pout, while the scar crossingthe lip margin was brought to the midline, thus allowing anormally shaped Cupid’s bow to be constructed. Above all, thetechnique was adaptable; cleft lips vary enormously in theirdegree, and methods which give good results in one child may beunsuitable for another. But the effect of the Le Mesurier

operation can be precisely calculated in every case and the exactmeasurements and shape of the incisions and flaps worked outin advance for best results.The book is based on a series of 1444 patients with hare lips

of all kinds, more than half of whom the author dealt withpersonally over a period of 19 years. It illustrates impressivelyhow a single technique with the merit of adaptability can bepolished and perfected in the hands of one surgeon with

adequate clinical material. It has always been a technique forthe specialist and not for the occasional operator on hare lips,

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but now that every facet has been explored and every modifica-tion explained in the fullest detail, it seems that almost anyoneafter carefully reading this book could close a cleft lip success-fully. The postoperative results, many with follow-up photo-graphs taken in early adult life, are extremely good for all

varieties of cleft. Poor results can be obtained by Le Mesurier’smethod, but those who study this work will realise that they aremost often due not to the technique itself but to its mis-

adaptation by the surgeon. The main criticism has been thatthis method of repair tends to make the lip too long. This is

particularly apparent in some of the bilateral cases in which themucosa from the lateral parts is advanced below the prolabium.But no-one has yet devised the perfect repair for bilateral clefts,and the results illustrated here compare favourably with thoseachieved by most other methods.

In some ways, it is true to say that the book has appearedten years too late. Many who struggled to fit the method asoriginally described to individual cases would have valued thefull descriptions of the various applications. Inevitably too,others have published modifications and improvements whichhave many supporters, but the book takes little note of them,although most are listed in the references. But whether one is adevotee of his method or not, Le Mesurier’s writing is full of thewisdom of great experience, and all who deal with these caseswill welcome his book.

Medicine and the Navy: 1200-1900Vol. IV 1815-1900. CHRISTOPHER LLOYD, F.R.HIST.S., pro-fessor, Royal Naval College, Greenwich; JACK L. S. COULTER,F.R.C.S., late captain, Royal Naval Medical School. Edinburgh:E. & S. Livingstone. 1963. Pp. 300. 50s.

WITH this volume, Professor Lloyd and Surgeon CaptainCoulter have completed the survey which the late SurgeonCommander Keevil began. The years with which its periodopens have certain parallels with modern times, since theArmed Forces, expanded during the Napoleonic Wars (theNavy in 1814 was larger than it is today), were being pro-gressively reduced. Yet developments in gunnery and marineengineering ensured that the efficiency of the Fleet increased,even though its size diminished.This was an era of scientific advances too. Some were made

by such men as Darwin and Huxley, whose names are stilllinked with those of H.M.S. Beagle and H.M.S. Rattlesnake:others by those who, with Sir John Franklin, took smallvessels like Erebus and Terror through the Arctic ice. Strangelyenough, the Navy contributed relatively little to medical andphysiological research, perhaps because of the subordinatestatus of its surgeons and the inequities under which theylaboured. (Thomas Wakley was moved to protest about oneparticularly obnoxious order, and his demonstration culmin-ated in his being struck by a Bow Street runner. His attemptto have the constable committed for assault failed, but theoffending regulation was withdrawn.)

Regrettably, it was also the day of the convict ships whichcarried men and women to Australia, four or five hundred ata time, under battened hatches. The death-rate among thesehuman cargoes was often as high as 20% or 30%. This wasan inevitable result of a contract system which paid for thecarriage of a convict " dead or alive," but the situation

improved when the Admiralty assumed responsibility forpenal transportation.The scope of a volume which has -io deal with all these aspects

of Naval medicine, as well as such matters as the Crimean Warand the evolution of the Naval Hospitals, is much wider thanthat of its predecessors. Yet it is as painstakingly compiled,and it is a worthy conclusion to a unique and very valuablestudy.

The Health of Older PeopleETHEL SHANAS, Cambridge, Mass.: Harvard University Press.London: Oxford University Press. 1962. Pp. 250. 48s.

THIS book is a study of the health needs of older people inthe United States. In 1957 nearly 2000 people over sixty-fivewere interviewed in different parts of America by members of

the National Opinion Research Centre of the University ofChicago. The study was confined to old people living at home,and excluded all those in any kind of institution. To thisextent it is not representative of the total problem of the aged,but within her chosen limits the author’s claim to give a fairpicture seems well supported.The subjects of the survey were by no means all sick, infirm,

or indigent, as those who think of old people en masse areperhaps too ready to assume. More than half of those inter-viewed considered themselves fit and troubled their doctors

very little. The proportion in poor health, however, increasedwith age, and 1 in 5 of those over seventy-five reported them-selves as " very sick." Some of those who were unfit did notdemand much attention from their doctors, believing that theiraches and pains were an inevitable consequence of old age.Very few hesitated to call their own doctors for fear of thecost. Two-thirds paid their own doctor’s bills; over halfwere able to meet their own hospital expenses, at least forshort illnesses. Almost all were anxious about longer illness,however, and about half were in favour of comprehensiveGovernment health insurance to meet it.

The attitude of younger generations towards their elderswas also studied. No evidence was found that aged parentswere often rejected by their children, and many were receiv-ing financial aid or personal care from them. The old peoplepreferred, where possible, to remain independent, but liked tolive near enough to their children and grandchildren to be ableto see them often.

To the medical reader this book reveals both the strengthand the weakness of purely sociological research. The studiesof the mental attitudes and the social circumstances of theindividuals interviewed are extremely well done, and presentfacts which may well influence American domestic policy inthe future; but the medical information, being based entirelyupon what the subjects said about themselves, is inevitablyrather unsatisfactory.

Handbook for Medical Officers of Schools on Schooland Communicable Diseases

13th ed. Issued by the Medical Officers of Schools Associa-tion. London : J. & A. Churchill. 1962. Pp. 112. 10s. 6d.

THE first edition of this handbook appeared in 1885. It hasbeen regularly brought up to date in succeeding editions andhas extended its scope in step with increasing knowledge ofchild and adolescent health. The new edition has been pains-takingly revised and remodelled by an editorial committeewhich includes not only medical officers to some of the publicschools but also doctors from the Ministry of Health and chelocal-authority school health services. In consequence, thoughit has special value as a guide for those in charge of boardingschools, every doctor in any branch of school health workshould find it useful.

Most of the space is given to notes on communicable diseaseswhich concentrate on the control of spread rather than ontreatment. The school M.o. has no easy task in steering be-tween exclusion and quarantine measures which would be sosevere as to disorganise the work of the school and less string-ent policies which might carry too much risk of spreadinginfection. Any action in the face of an epidemic involves thetaking of some calculated risks, and the information given inthe handbook wisely avoids the dogmatic and provides thebasis on which appropriate action may be taken. The uncom-mon infections are also included; and it is interesting to findQ fever and tetanus among them. As the authors point out,the increase in travel abroad among children of school age is a

strong indication for including certain " non-British " infec-tions.

Since there are many small boarding schools whose medicalofficers are G.P.’s giving only a small part of their time to thework, a handbook such as this could profitably give guidanceon the preventive aspects of the subject. The section ongeneral hygiene is adequate if read in conjunction with the

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official publications listed by the authors. It is perhaps a pitythat the short section on medical services in a residential schooldoes not also contain a list of recommended official publica-tions and other books. And, in spite of the fact that the lasttwo-thirds of the book give communicable diseases in alpha-betical order, it would have been worth numbering the pagesand providing an index. These points, however, detract butlittle from the very real worth of the only volume of handysize on this subject.

Advances in Rheumatic Fever 1940-1961MAY G. WiLSON, M.S., emeritus professor of clinical pediatrics,Cornell University Medical College. New York and London:Harper & Row. 1962. Pp. 249. 96s.

FEW doctors in the world can match Dr. Wilson’s experi-ence of rheumatic fever. It extends over two generations ofpatients, and her previous monograph in 1940 concerned

patients seen since 1916. Since then a number of papers basedon this initial series of over 1000 patients have been published.This second record-an interesting and controversial book-brings the story up to date and adds data on other patientsseen since 1940. Students of rheumatic fever will read thisbook with great respect.

One of Dr. Wilson’s theses is that rheumatic fever is geneti-cally predetermined. This concept is at first sight difficult toreconcile with the decreasing prevalence of rheumatic fever inrecent decades. Dr. Wilson’s own experience supports thisdecline, but she suggests that what has been observed is areduction in the relapse-rate and in the death-rate. Thereader infers (without evidence) that the rate for first attacksis unchanged. Her evidence for inheritance of rheumaticfever is set out again; it rests on family studies, especiallythat of 1954 (with Dr. M. D. Schweitzer) of the families ofknown rheumatic subjects and of controls. The parents in291 families were subdivided into various mating types accord-ing to the history of rheumatic fever in the parent or hisimmediate relatives. The number of occurrences of rheumaticfever in the children was almost exactly what would have beenexpected if the disease were determined by a single autosomalrecessive gene. But the diagnosis of rheumatic fever in thesechildren was based to some extent upon the " clearance

angle " as an index of heart involvement. Although in anotherpart of the book Dr. Wilson gives an impressive validation ofthis radiological sign, not many cardiologists would rely uponit to this extent.

Dr. Wilson has interesting things to say about the group-Ap-haemolytic streptococcus. While not discounting its import-ance in causing relapses, she does not think it is the only micro-organism which may be concerned, and she finds no clearevidence that it is necessarily implicated in first attacks. Thisleads her to serious criticism of those who believe that penicil-lin must be given for all streptococcal sore throats and as astreptococcal prophylaxis, irrespective of infection, in thosewho have-had an attack of rheumatic fever, although she sup-ports its use in the treatment of sore throats or the carrierstate in rheumatic-fever subjects.

Another chapter deals with the pathology of rheumaticfever, including the new knowledge which has come from studyof atrial biopsies, without shedding much light on whetherAschoff bodies in the myocardium of patients with clinically" inactive " disease really mean that the disease is active afterall. On p. 209 there is a potentially dangerous misprint ofmethyl salicylate for acetylsalicylate in a regimen of oraltreatment.

Dr. Wilson’s other main controversial thesis is that rheumaticfever can be cured and heart damage prevented by a short,early, and intensive course of prednisolone in doses of 50-100 mg.a day for seven days. What she has in mind is illustrated bythe one colour plate in the book. Different colours indicatethe change from an initial inflammatory to a subsequentreparative phase, with " irreversible damage " occurring onlyin the first 51/2 weeks. Even allowing for artistic licence and

simplification, it is hard to get this to tally with the conceptof one week’s treatment completely suppressing irreversibledamage. Nevertheless, convincing individual case-reportsare cited in favour of this regimen, whose benefits are com-pared with the pre-steroid treatment of rheumatic fever. Someof the evidence for prevention of cardiac damage is againderived from " clearance angle " data. Nevertheless, this

regimen, Dr. Wilson writes, is such that " the results obtainedwith short term hormone therapy in patients treated earlyindicate that controls are obviously not essential and at presentnot justified". Surely, in few therapeutic situations is theremore need for controlled clinical trial.

Resuscitation and Artificial HypothermiaV. A. NEGOVSKII, translated by BASIL HAIGH, M.B. London:Pitman Medical Publishing Co. 1963. Pp. 314. 90s.

THIS volume gives a very real insight into Soviet experi-mental medicine and its application to therapeutics. It isconcerned basically with the treatment of cardiac arrest pro-duced by haemorrhage. It is not surprising, therefore, thatintra-arterial blood-transfusion is the first measure to bediscussed. Negovskii appreciates that this measure may not besatisfactory in every case and that cardiac massage may alsobe needed. Internal cardiac massage receives its share ofattention and it is interesting to read of external cardiac mas-sage under the title of the Maas-Koenig method, a techniquewhich was apparently practised in Russia before 1928. Rever-sal of fibrillation by chemical and electrical methods is alsodiscussed. It is recognised that cardiovascular resuscitationalone is insufficient and the various problems of artificial venti-lation of the lungs in the resuscitation of the exsanguinatedanimal are treated at some length. The biochemical changesin the brain during resuscitation and recovery are considered.The question of brain damage as a result of circulatory arrestis also discussed. The effect of hypothermia in prolonging thelethal period of anoxia was investigated. This was found tobe of some value, but the induction of mere " hibernation "

by the administration of a " lytic cocktail " did not commenditself.

In the last main section the clinical application of the com-bined method of resuscitation described by the author,mainly intra-arterial blood-transfusion, cardiac massage,defibrillation, and artificial respiration, in various clinical

situations, is discussed, with a large number of illustrativecases. The books ends with a considerable bibliography inwhich, for the convenience of those who do not read Russian,the references to Soviet literature are separated from those tojournals published in English or other Western Europeanlanguages. It is a pity that the book has no index.Many Western readers will find this book unusual, even in

its English translation. In its presentation of material, seriousstatistical analysis has no place; on the other hand, the detailin which the experimental work is described makes it quiteeasy for anyone who wishes to check the statistical significanceof the data to do so for himself. The whole volume in factis reminiscent of some of the early classics of medical litera-ture, like the work of Crile on shock. For these reasons wecommend this volume, but with the caveat that the fly-leafstates that the Russian text was published in Moscow in1960 and few of the references are later than 1957.

This Island Now (London : Hogarth Press. 1963. Pp. 103.10s. 6d.).-Last year Prof. G. M. Carstairs’ Reith lecturesstimulated lively discussions in press, pub, and parlour.Unfortunately discussion tended to concentrate on what he hadto say about teenagers and sex, and his other, no less important,observations and ideas were neglected. Publication will nowgive thoughtful readers an opportunity to reconsider thelectures as a whole. In his introduction to the book, ProfessorCarstairs himself recommends to their attention as recurringthemes the sudden acceleration in the rate of social change andthe interplay of scientific observation and analysis with theflights of creative imagination.