191

Fig. 2.

In use, it has been found expedient to keep a threadedcurved triangular needle fixed in the needle-holder.

I am indebted to Mr. R. E. W. Fisher, of Gillette IndustriesT.tr).. for tffhmca.l fiSHistanfR.

GERALD OLLERENSHAWM.A., B.M. Oxfd

Gillette Industries Ltd.,Isleworth, Middx

A HEADLIGHT FOR GENERAL SURGERY

DENIS BROWNEF.R.C.S.

Hospital for Sick Children,Great Ormond Street,

London, W.C.1

IT is necessary in many operations to see deep intonarrow spaces. At a certain degree of depth andnarrowness this can only be done by means of a lightwhich originates in front of the surgeon’s eyes, andcoincides fairly closely with his line of sight. This, ofcourse, means a headlight, and after many attempts Ihave designed one which satisfies me. Its points are :

1. Brilliancy sufficient to compete with the intensityof ordinary main operating-lights, so that there is no needto darken the theatre.

2. An area of illumination intense in the centre,gradually fading out towards the edges. This corres-ponds to the visual consciousness of the surgeon, and isfar better than the clear-cut levelly illuminated field Iat first tried for. Any slight irregularities in the fieldof light will be found quite unnoticeable when working.

3. An approximately parallel beam. which remainswithout significant change in area or intensity on varia-tions in working distance. This can be attained onlyby a reflector system.

4. A beam which coincides with the line of sightclosely enough for all ordinary surgical work. The slightincrease in optical efficiency gained by looking througha hole in the mirror does not compensate for the loss ofperipheral vision.

5. A frame to hold the bulb which allows focusingaccurately and firm fixation when this is arranged.

6. An attachment to the head which is easily adjustedand which does not depend on that tight grip across theforehead which causes headache. The slight weight ofthe light is taken by an overhead band loosely held ateither end by a circular one.

7. An adjustment- for different types of work by afriction joint allowing the only movement necessary-that of up and down in the sagittal plane. (Mostheadlights have absurdly complicated and varied mount-ings.) This can easily be adjusted by a non-sterileassistant.

8. A bulb with an opaque-mirror backing over thefront two-thirds of the lens. This increases the lightsent backwards into the mirror and in addition stopsglare getting into assistants’ eyes.

9. A shield round the lower part of the mirror to preventglare into the surgeon’s eyes. It is possibly the lack ofthese last two devices which has caused the non-perforatedreflector type of light to be little used.

10. A battery, cheap and of large capacity, speciallyadapted to the bulb ; it is w orn on a belt round thewaist with an ordinary commercial switch on the flex,so that it can be put into action through the gown.The light can, of course, be run off the main by thosewho do not object to being tethered by a flex.The light is made by Messrs. Down Bros. of 32, New

Cavendish Street, London, W.l, to whom I am indebted forhelp in working out many details.

Reviews of Books

Breast Cancer and its Diagnosis and TreatmentEDWARD F. LEWISON, M.D., F.A.C.s., assistant professor ofsurgery, Johns Hopkins University School of Medicine.Baltimore: Williams & Wilkins. London: Bailliere,Tindall, & Cox. 1955. Pp. 478. 114s.

IN a foreword, Dr. Grantley Taylor admirably sumsup the importance of cancer of the breast to the wholeproblem of malignant disease. As he points out, our ideasof malignant disease " derive largely from observationsof breast cancer " ; and " breast cancer was the proto-type for the development and perfection of the conceptof the radical operation for cancer." The experimentalstudy of heredity in cancer has been chiefly carried outon cancer of the breast in mice. Again, cancer of thebreast is one of the few forms of cancer which has sofar responded to " therapeutic modifications of thehormonal environment." It is no wonder thereforethat many people feel that, if the exceedingly toughshell of the cancer problem is broken at the clinicallevel, it is likely to be through cancer of the breast.

This book assembles the known facts, with the emphasison the tradition of surgery, of the Johns Hopkins, andparticularly of Halsted. Thus, the first chapter givesan interesting account of the history of breast cancer,the culmination of which is the development of theoperation of radical mastectomy by Halsted. And thegreater part of the book represents the traditional surgicalpoint of view, given by a surgeon who obviously hasextensive knowledge and experience and has given muchthought to the practical problems involved.

Dr. Lewison has taken the lion’s share of the work, but hehas been helped by eight distinguished colleagues. The oneBritish contributor, Mr. R. S. Handley, has written anexcellent chapter on the surgical anatomy of the breast,in which he cleverly manages to give a dynamic twist to thesubject and to discuss the principles of breast surgery. Thisis the only part of the book in which the question whetherthe pectoralis major should be sacrificed in radical mastectomyis discussed : elsewhere this procedure, the main technicalcontribution of Halsted to breast-cancer surgery, is unquestion-ingly accepted. The book makes no reference to the classicalarticle by Gray on the lymphatics of the breast, which under-

i mines the traditional pathological arguments in favour ofroutine removal of the pectoralis major.

There is a very detailed account of " classical " radical

mastectomy, but in the chapter on hormonal treatment

only a bare mention (without any technical operative details)of adrenalectomy, and no discussion of the possible ways ofdestroying the pituitary influence. Diagnostic manoeuvresare fully described, and the importance of biopsy is properlystressed. The author rightly notes that palpation of thebreast should be carried out with the pulps of the fingers.

192

Many English books still advise that the breasts shouldbe palpated with the flat of the hand, though this advicestems from a wrong translation of Velpeau’s French.The book can be read as a whole, and not just as an

encyclopaedia. It may not give the reader a very originalpoint of view, but it achieves its object of summarisingthe main facts and the important questions about breastcancer, as an experienced surgeon sees them.

The Boke of ChyldrenTHOMAS PHAIRE. Edited by Prof. A. V. NEALE, F.R.C.P.,and H. R. E. WALLIS, M.D. Edinburgh: E. & S.Livingstone. 1955. Pp. 76. 7s. 6d.

PUBLISHED in 1545, this was the first book on poedia-trics ever written by an Englishman and one of theearliest medical books to be published in the Englishlanguage. At that time the world was beginning toemerge from the darkness of the Middle Ages : printinghad been invented a hundred years before ; andVesalius’s Fabrica had just appeared ; but books writtenby Avicenna and Galen were still in everyday use.

Phaire was born about 1510 probably in Norwich. Hewent to Oxford to study medicine and to Lincoln’s Inn tostudy law. He started to practise medicine about 1540and took his M.B. and doctorate at Oxford twenty years later.He was also a solicitor and Member of Parliament. He livedin Kilgerran in Pembrokeshire and died there in 1560.

This is an exact copy of the first edition with the originalspelling.

" The gut called of the latines rectum intestinum, fallethout at the foundament, and cannot be gotten in agaynewithout peine and labour." " Of smal pockes & measilles....The best and most sure helpe in this case is not to meddlewith anye kynde of medicines, but to let nature work heroperacion." Phaire says that the cause of ulceration of thehead is from sides of bacon or salt beef falling from the hooksin the ceiling. (Then, as now, accidents at work and in thehome were important.) The author’s credo is " Here to doothem good that haue most nede, that is to saye children."

The editors and publishers have earned our thanksby reprinting this book of quaintness and charm.

Somme de medecine contemporaineVol. 111. La thrapeutiqqte. Editors: Prof. ANnRELEMAIRE, Prof. GREGORIO MAEANON, Prof. JEAN LABARRE, Prof. ARVID WALLGREN. Nice : Les EditionsMedicales. 1955. Pp. 390.

THIS is the third volume of the Contemporary Medicineseries, prepared under the direction of the late ReneLeriche, which will be completed by a fourth volume onMedicine in Modern Life. In a foreword, Prof. AndreLemaire puts the case for more international " pooling

"

of methods of treatment, but he condemns those periodsof " inflation " which he thinks all active treatmentspass through.The early chapters on general subjects include a short but

interesting history of therapeutics by Prof. Jean La Barre.The rest of the book is divided according to the differentsystems of the body or different forms of treatment, rangingfrom phytotherapy to stomatology. Curiously enough thereis little mention of radiotherapy or radioactive isotopes.There is no index except for a list of authors with a short"

bio-bibliography " of each and a list of names quoted inthe text.

Social Casework in Marital ProblemsThe Development of a Psycho-dynaniie Approach. A

Stttdy by a Group of Caseworkers. London : TavistockPublications. 1955. Pp. 199. 15s.

Tms is an account by six caseworkers of the origins,development, and working of the Family DiscussionBureau, which is a child of the Family Welfare Organisa-tion Society and the Tavistock Clinic.The Bureau is rather like the Marriage Guidance Council

-but with a difference. Its caseworkers are not counsellorsor advisers but have had some training in the school of

analytic psychology, and have analytically trained psychia-trists immediately available for consultation. They endeavourto work out with marriage partners in difficulties the nature,psychological content, and origins of their emotional dis-

harmonies. If both partners are willing, each has his or herown caseworker, and the situation revealed is discussed bythe caseworkers and a psychiatrist in conference. Theexpectation is that many interviews will be needed in a givencase, though occasionally much good springs from a few oreven a single interview when the troubled partner has beenable to clear his own mind by talking to a receptive butuninvolved listener, who neither adjudicates nor takes sides.

Cases, both short and long, are used to illustrate the variousproblems, their working out, and the measure of success

achieved. Some attempt is made to assess statistically theresults of five years’ development and work.

The material is presented with modesty and candourand makes interesting and instructive reading.

Operative Dental Surgery7th ed. J. B. PARFITT, M.R.C.S., F.D.s.R.c.s., consultingdental surgeon, Guy’s Hospital; W. E. HERBERT,M.R.c.s., F.D.s. R.c.s., professor of dental surgery in theUniversity of London at the hospital. London : EdwardArnold. 1955. Pp. 524. 45.s.

BASED on lectures delivered at Guy’s Hospital byMr. Parfitt, this book first appeared just over thirty yearsago. Its scope, which was to give a concise account ofthe technical procedures of dental surgery with enoughtheoretical background to explain the underlying prin-ciples, has remained unaltered ; and there is no otherEnglish book which covers precisely the same rangeof subjects.

The chapters on filling materials and cavity preparationare good, but that on the uses of gutta-percha seems redundantin the present day, and a fuller account of the auto-polymeris-ing acrylic resins would be welcome. Crown and bridgeworkare dealt with adequately for all but the specialist. Anexcellent discussion of the pulpless tooth and " focal sepsis

"

will interest both doctors and dentists called upon to decidewhether or not dead teeth should be retained. The aetiologyof dental caries is oversimplified and there is no account. ofsome of the more recent work on this controversial and

perplexing subject.The chapter on local anaesthesia is somewhat disappointing;

considerable space is devoted to obtundents, which are

recognised to be of limited value, and the detailed accountof the preparation of procaine solutions in the surgery couldwell give place to further information about lignocaine. Morespace, too, could have been given to discussing the advantagesand disadvantages of the now almost ubiquitous

"

cartridge "

syringe, especially since it is in regular use by the studentsat the authors’ own hospital. Mercurochrome is advocatedas an oral antiseptic ; but the general opinion is that aqueoussolutions are useless, and solutions in alcohol or in acetoneare no more nor less effective than the solvents alone.Most of the many illustrations really help to clarify points

in the text ; and the radiographs are reasonably well repro-duced, with the exception of that showing the normalmouth.

Another edition of this valuable book will undoubtedlybe called for fairly soon, and the opportunity couldperhaps be taken to remove those parts of the text thatare becoming of less immediate interest to students anddental surgeons today.

Diseases of the Nervous System (5th ed. London:Oxford University Press. 1955. Pp. 996. 55s.).-To thestudents’ chagrin, successive editions of textbooks tend to getbigger ; but, despite the addition of much fresh material,the new edition of Sir Russell Brain’s book is a few pagesshorter than its predecessors. There is new material oncervical spondylosis, the Coxsackie viruses, inclusion-bodyencephalitis, acute haemorrhagic leucoencephalitis, toxo-

plasmosis, polymyositis, and neuropathy and myopathyassociated with carcinoma ; and Sir Russell has added asection on consciousness and unconsciousness to the chapteron the psychological aspects of neurology. The treatment ofmeningitis has been brought up to date with the latest advancesin chemotherapy, and recent developments in the treatmentof poliomyelitis and lead-poisoning are discussed. Compre-hensiveness and clarity have made Sir Russell’s boak a firmfavourite alike with students, with practitioners, and withneurologists.