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post-operative staphylococcal infections in hair carriers thanin non-carriers, and in 3 cases the staphylococcus from thewound infection was of the same phage-type as that isolatedpreoperatively from the hair.The hair was a potential source of cross-infection, and

should be covered in patient and attendants during surgicalprocedures and the redressing of wounds.

Reviews of Books

Modern OphthalmologyVols. i and n. Editor: ARNOLD SoRSBY, M.D., F.R.C.S. London:Butterworths. 1963. Vol. i. Pp. 531. 130s. Vol. 11. Pp. 715.150s. Set of 4 vols. E24.

IN the evolution of clinical ophthalmology from a medicaleddy centred around a few ocular symptoms and signs-ofteninterpreted in terms of conjectural ideas of anatomy andphysiology-to what may now be described as the most exact ofclinical studies, many influences have been apparent. Amongthese the application of morbid anatomical knowledge duringthe past century was probably of greatest importance in

consolidating the foundations of a classification of oculardisease based upon manifest anatomical disorder. The

amplification of such knowledge permitted by the invention ofthe ophthalmoscope opened the door to the fruitful unionbetween histological conceptions of ocular disorder and thosederived from optical observation in vivo. By means of

biomicroscopy lesions can be displayed with an accuracyunrivalled in other branches of medicine; but equal precisionin aetiological classification its perforce, often lacking. Goodreason for this is apparent when one considers, for example,the comparatively early stage at which pathological disturbancescan be identified in the eye in relation to the obstacle whichthe " blood-aqueous barrier

"

presents to the appearance of

equally certain changes in the systemic circulation. The

peculiar problem of ocular inflammation exemplifies this

difficulty.Nevertheless the object of a reliable aetiological classification

of ocular disease remains constantly before the ophthalmologist,and the evidence on which it must be based gradually accrues.The task of bridging this gap, admirably begun in Systemic

Ophthalmology under the same editorship, is continued in thefour volumes of Modern Opthalmology, of which the first twohave now appeared. The first deals principally with the basicsubjects of anatomy, physiology, optics, and pharmacology insixteen sections contributed by British, Commonwealth, orAmerican authorities. A rigid separation of anatomical fromphysiological description has been commendably avoided; butthe important sections on embryology and comparative anatomyare given individual emphasis. The sections devoted to

physiology are comprehensive and lucid. That concerned withthe biochemistry of the eye is especially valuable in a work ofthis type. The chapter on optics is extensive, and here theclinician may feel that the detail in which mathematical opticsand lens forms are discussed is somewhat in excess of his needs.The limitations and advantages of systemically and locallyadministered antibiotics and sulphonamides form an importantpart of the chapter dealing with pharmacology which, inaddition to its section dealing with autonomic drugs, contains auseful survey of the value of steroids, hxmatological agents,enzymes, and anti-histamines in ophthalmological practice.The descriptions of examination methods are confined to

certain special methods-field examination, contact lenses,gonioscopy, tonometry, biomicroscopy, measurement of theaxial length of the globe, and electro-diagnosis. Space hasevidently not permitted the inclusion of more illustrations:these would be especially valuable to the student and generalclinician in the section dealing with biomicroscopy.Begun with a brief historical survey, and concluded by a

consideration of the problems of atiological diagnosis in

ophthalmology, this volume provides an excellent introductionto the clinical sections which follow.The first of these-systemic aspects-incorporates a new

edition of Systemic Ophthalmology in the series and has beenbrought up to date to cover those recognised general diseaseswhich underlie certain ocular disorders. The arrangement ofthe subject matter is unaltered. Minor additions and revisionsare apparent in most sections; but in that devoted to drugintoxications and chemical injuries the increasing hazards ofnew and complex drugs and industrial chemicals are recog-nised in an enlarged text. In this volume, then, oetiologicalclassification in respect of certain disorders is successfullypresented, and we look forward with interest to volumes 3 and4 in which topical ophthalmology is to be discussed as far aspossible in terms of xtiology.

EndocrinologyA. STUART MASON, M.A., M.D., M.R.C.P., consultant endocrino-logist, The London Hospital. London: Staples Press. 1963.Pp. 136. 36s.

Dr. Stuart Mason has done a useful service in writing thisvery short but comprehensive guide to the clinical managementof endocrine disorders. Everything that the ordinary physicianneeds to know is here in clear precise terms and without wasteof words. Inevitably, the advice given is dogmatic (there areno references); and the telegraphic style jars at times (" facialand trunkal obesity "). It is not a book for leisurely reading,but for quick reference, and perhaps for " cramming " beforefinals. For its size it is rather expensive, but a great deal ofinformation is packed into the space.

Thoracic Anaesthesia

Editor: WILLIAM W. MUSHIN, M.A., M.B., F.F.A. R.C.S., professorof anaesthetics, Welsh National School of Medicine. Oxford:Blackwell Scientific Publications. 1963. Pp. 695. 105s.

IN the revolution in anxsthesia in the past twenty-five years,three outstanding developments were the introduction of therelaxant drugs, the widespread use of endotracheal intubation,and the specialised techniques which have made major thoracicsurgery possible. But there has been an even greater revolutionin thinking; for the idea that the anaesthetist should cease to beprimarily a skilled technician and become a physician in thesurgical team has already been accepted, by anaesthetists at least.Medicine has therefore been an integral part of the F.F.A. R.C.S.examination right from its inception; and it is appropriate thatabout half this volume should deal with matters which are asmuch the province of the physician or surgeon as of theanaesthetist.The book begins conventionally with a discussion of the

problems of the open pneumothorax. The next sections containaccounts of the respiratory diseases amenable to surgery and ofthe preoperative assessment of respiratory function. The specialtests which can be applied to the assessment of lung functionbefore an operation are succinctly described; but though thebearing of the results of such tests on lung function are fullydescribed, space does riot permit discussion of the more difficultproblem of relation of degree of disability to the risk of lungsurgery. There are however in this, as in all the other sections,ample references for the serious reader to pursue these mattersfurther. Circulatory diseases are first discussed from the view-point of pathology and clinical investigation and in the succeed-ing chapter from the aspect of the assessment of circulatoryfunction. Here the anaesthetist (and almost everybody else) willfind all he needs to know about the pressures in the normal andabnormal cardiovascular system. Next, the anatomy of therespiratory passages and the thorax are described, with theirembryology. Subsequently, the physiology of respiration andthe circulation are discussed, and here the reader will findnot only the physiology of the normal but also that of hypo-thermia and the changes in respiratory function which arise asa result of thoracic surgery.

Professor Mushin himself deals with controlled respiration.The various tubes for endobronchial anxsthesia, in the designof which British anaesthetists have been so ingenious, are alsodescribed. Finally, technical aspects receive attention underthe headings of Control of Secretions, Anaesthesia for PeroralEndoscopy, Anaesthesia for Open Heart Surgery, and Hypo-

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thermia in Thoracic Surgery, all contributed by well-knownanxsthetists. The physiological approach continues in a dis-cussion of anaesthesia for the special problems of operations onthe lungs and respiratory passages (e.g., bronchopleural fistulaand sleeve resection). Postoperative care receives appropriateattention.The last two clinical chapters are concerned with the value of

interpretation of the E.C.G. and E.E.G. in thoracic surgery. Inaddition to the conventional elementary account of the electricalchanges observed, both these chapters contain much of specialinterest to anaesthetists in particular, the changes in the E.C.G.during anaesthesia which do not usually get attention in accountsof the subject. The volume ends with a description of thehistory of thoracic surgery and the development of positive-pressure respiration, artificial-respiration apparatus, and

oxygenators.In a preface, Professor Mushin notes how methods of

anxsthesia in thoracic surgery are still evolving, based onexperience with general anaesthesia for operations elsewhere inthe body. For this reason he feels that the thoracic anxsthetistshould have interests and activities wider than the limited areaof this book. For the same reason, and because he feels that a

specialty of thoracic anaesthesia must in the end be stultifying,accounts of techniques are in broad terms rather than minutedetail. The anaesthetist who wants’ a textbook which will tellhim exactly how to give an anaesthetic for a particular thoracicoperation will not find it here; and those who seek an encyclo-pedic review of this subject will likewise be disappointed. Onthe other hand, the anaesthetist with a broad interest will gaintremendously from reading this book; and we heartily commendit not merely to those who administer anaesthetics forthoracic surgery, and not indeed even to anxsthetists alone, butto all who would like an insight into the problems involved inoperating on and anaesthetising patients with intrathoracicdisease.

Year Book of General SurgeryEditor: MICHAEL DE BAKEY, B.S., M.D., M.S., professor of surgery,Baylor University College of Medicine, Texas. Chicago: YearBook Medical Publishers. London: Lloyd-Luke Medical Books.1964. Pp. 592. 64s.

THE incisive editing of Professor de Bakey and the main-tenance of the high standard of abstracting shown in previouseditions ensure a popular place for this volume. The belatedomission of the section on anxsthetics has left room for more

surgical articles, and the book contains abstracts of almost 500papers drawn mainly from the American literature. Despitethis wide coverage, the abstracts are not only sufficientlycomprehensive to give a satisfactory survey of the develop-ments in each field, but they are also sufficiently factual topresent adequately the contents of each paper. This approachleaves the reader free to form his own opinions and does notexpose him to the imbalance which sometimes results frombias in review articles. The editor is firm in his comments, andwhere his experience differs from that of an author it isexpressed clearly at the end of the article. It is only fair to saythat where his opinion concurs, agreement is expressed inequally forthright terms.At the beginning of the book there is a list of 525 selected

references in surgery. Some of these seem to be highlyspecialised, and the list could be pruned without much loss.The big advances in technique in cardiac surgery are offset

by the rather dismal accounts of the surgery of peripheralvessels. There is a notable absence of long-term studies ofmany of the large series of lower-limb arterial reconstructionswhich appeared in earlier Year Books. Most of the articles onperipheral vascular surgery show that the early vigour is nowtempered by a reappraisal of techniques.The papers on transplantation are fewer than might be

expected. They confirm the continued success of renal opera-tions and give some technical considerations on liver transplan-tation. The absence of reliable control of the immunologicalresponse remains a barrier to progress, and there is little hereto indicate further developments.

Advances in oesophageal surgery must be among the leastremarkable; but the lively debate on the surgical treatment ofpeptic ulceration continues. The claims for the new freezingtechriiques are more circumspect, and the papers on selectivevagotomy indicate that all is not well when complete divisionof these nerves is undertaken. Impressive results from gastrec-tomy continue to appear, while critical evaluation of vagotomyshows that its effects extend far beyond the stomach.

Mortality of Peptic Ulcer PatientsNorwegian Monographs on Medical Science. Prepared by KNUDWESTLUND, M.D., and JAN Riis, Oslo: Universitets Forlaget.1963. Pp. 110. N.Kr. 30.

THIS report was compiled from material of the UllevalHospital, Norway, and records total mortality-rates and post-operative complications among a group of 3662 peptic-ulcerpatients in the period 1917-39 traced either until death or to theanniversary of discharge in 1957. Cause-specific mortality-rates were used to study the association of peptic ulcer withother diseases and to search for late complications after surgicaltreatment. Only 3% of patients were lost from observation andnecropsy results were obtained in about 40% of the 1370 deaths.The monograph is well set out and much detailed information

is contained in the many tables. The mortality-rates of actual toexpected deaths were found to be moderately in excess of thosein the general population; gastric-ulcer patients fared less wellthan duodenal ulcer, but the difference in mortality largelydisappeared after surgical treatment. The pattern of the causeof death in ulcer patients showed, in general, only minordeviations from that of the general population, but many of thecorrelations explored are of interest; thus, a subnormal

mortality from gastric cancer was shown in unoperated duodenalulcer, suggesting that a correct diagnosis of duodenal ulcerimplies a reduced risk of neoplasm in this situation. No definiteabnormal mortality was found from coronary heart-disease, butthe suicidal risk was greater for both ulcer sites and was not

improved by operation. The study failed to disclose any latecomplications of ulcer surgery such as might influence theindications for operation.Many writers have reported that peptic-ulcer subjects are

more prone to certain diseases, and study of these associationsmay throw light on the pathogenesis of ulcer. Though the useof mortality as the index for association has the disadvantage ofgiving no information about non-fatal complications, such asanaemia or steatorrhoea, it does provide a basis for precisecomparison with the general population. Undoubtedly studiesof this type possess a special interest, and the Norwegian reportdeserves high praise.

The Genetics of Bacteria and their VirusesW. HAYES, M.B., SC.D., F.R.C.P.I., D.P.H., director of the MedicalResearch Council’s Microbial Genetics Research Unit, Hammer-smith Hospital. Oxford: Blackwell Scientific Publications. 1964.Pp. 740. 84s.

PERHAPS the most spectacular growth in any branch ofbiological science followed the discovery by Lederberg andTatum in 1946 of the existence of sexual recombination inEscherichia coli. Although fundamental work on transformationhad preceded it, this discovery opened the whole subject fordevelopment. Bacterial genetics and the related field of bacterio-phage genetics have had particular advantages, and have beenrapidly exploited to illustrate a number of important geneticalphenomena, from fine-structure genetic analysis to the inherit-ance of adaptive enzymes and drug resistance. With the

appearance of molecular biology as a separate discipline after1953, the two streams of thought merged into a torrent that hascarried everything before it. Genetics has been greatly changedby the impact. To quote the most obvious examples, almost allthat we know about the chemistry of mutagenesis or the

regulation of gene action comes from studies of bacteria andbacteriophages.

It is therefore necessary for every geneticist-whether he isworking with man, animals, or plants-to have some under-standing of microbial genetics. Some knowledge should also be

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acquired by medical bacteriologists, for without it they will beseriously handicapped in understanding important phenomenaincluding drug resistance or phage-typing. The acquisition ofsuch knowledge is becoming increasingly difficult. Bacterialand phage geneticists are emerging as a skilled group that carryout elegant experiments and tend to describe them in highlycompressed papers and reviews using their own esoteric

language. The outsider cannot easily find out what is going onin this charmed circle. From time to time the leading exponentsmake pronouncements about important conclusions on geneticcontrol and related problems, which are received by those out-side with awe and acclamation. But then rumours filter out thatthe experimental evidence on which the conclusions were basedis not as compelling as was first thought. Only those familiarwith the complexities are in a position to judge.

Dr. Hayes is well known as a clear thinker and lecturer, andhis book provides an excellent means of entry into the first levelof analysis of the subject. It is described as a fairly advancedtextbook designed to meet the requirements of postgraduateworkers who wish " to master the concepts of microbialgenetics and molecular biology well enough to be able to applythem to their own problems, to comprehend original papers andto assess future developments ". Clearly, a great deal of troublehas been taken to present the material in a simple and logicalfashion. There are some statements in the account of geneticsin higher organisms to which exception can be taken, and theaccount of measurement of mutation-rates will confuse somereaders. But in general there is no doubt that such a book wasneeded and that it will fulfil its purpose admirably. Jacob andWollman’s Sexuality and Genetics in Bacteria has had manyadherents, but Hayes’ account is more comprehensive and useful.The treatment is strictly academic, and practical problems

such as drug resistance are mentioned only in passing. Never-theless, it is to be hoped that at least the younger generation ofclinical bacteriologists will take the trouble to learn bacterialgenetics thoroughly. Postgraduate courses such as those

organised by Dr. Hayes at Hammersmith should be an essentialpart of their training. It is only in this way that clinical bacterio-logy can be revitalised for the benefit of its practitioners andmedical students. Sterility is admirable in its place, but can becarried too far. The barriers which have appeared betweenacademic and practical bacteriology must be broken down. Inorganising an excellent research unit Dr. Hayes has doneacademic microbiology in this country a considerable service,and in organising postgraduate courses and writing this book hehas likewise rendered medicine a service, of which full advantageshould be taken.

Dupuytren’s ContractureJ. T. HUESTON, M.S., F.R.C.S., F.R.A.C.S., hon. first assistant plasticsurgeon, Royal Melbourne Hospital. Edinburgh and London:E. & S. Livingstone. 1963. Pp. 123. 32s. 6d.

SINCE the publication of Skoog’s monograph in 1948, muchhas been written about various aspects of Dupuytren’s contrac-ture, and the time was ripe for a comprehensive review of recentwork on this puzzling disease. Mr. Hueston’s book fulfils thisneed, and, since it is based on a special study of Dupuytren’scontracture over the past ten years, he has himself many originalideas to offer.

After a historical introduction, the early chapters deal withthe incidence, aetiology, and pathology of the disease. Statisticalevidence supports the view that contracture is not (as Dupuy-tren and many others supposed) brought on by manual labour,but may in fact be related to chronic invalidism and decreasedhand activity. Included here is some interesting work on thepathogenesis of Dupuytren’s contracture by MacCallum andHueston, who conclude, from macroscopic and histologicalstudies, that the process arises in the superficial palmar tissues,and only secondarily involves the palmar aponeurosis itself-aview first held by Goyrand over a century ago. There followsa fascinating chapter on the Dupuytren diathesis, referencebeing made to Ling’s important study of the genetic factor.One must, however, disagree with the estimate of " a greater

1. J. Bone fit Surg. 1963, 45B, 709.

than 40 per cent. incidence of Dupuytren’s contracture in thehigher age groups ": this is certainly not the case in England orScotland, though it may apply to Australia where contracture iscommoner.

The practising surgeon will naturally turn to the last threechapters which deal with principles of management, details ofsurgical treatment, and the frustrating problem of recurrentDupuytren’s contracture. Here he will find plenty of good senseand sound advice. As Mr. B. K. Rank observes in a foreword," the timely indication, like the extent of surgery performed forDupuytren’s contracture, is not dictated by rules of thumb, butis based on an experienced assessment of each patient "; andthis expresses admirably what is, perhaps, the most valuableconclusion to be drawn from this book. The text is, with fewexceptions, accurate, and illustrated by excellent photographs,

Eduard Pernkopf Atlas of Topographical and AppliedHuman Anatomy

Vol. 1. Head and Neck. Editor: HELMUT FERNER, professor anddirector of the Anatomical Institute, University of Heidelberg;translated by HARRY MONSEN, associate professor of anatomy,University of Illinois College of Medicine, Chicago. Phila-delphia and London: W. B. Saunders. 1963. Pp. 356. z.

THIS beautifully produced work contains detailed, anatom-ically precise, and pictorially impressive drawings of speci-mens prepared by Pernkopf himself. This collection of illus-trations will be invaluable not only to anatomists but to others,particularly surgeons. We agree with Professor Ferner thatmost of the illustrations are outstanding works of art and that,in spite of their abundance of detail, they are very clear. The

accuracy of the labelling in general and of the finest details inparticular is unlikely to have been achieved in any other workon anatomy. Modern developments have necessitated theinclusion of some new material, such as the topographicalanatomy of the vessels of the brain in relation to arteriography,and there are also some new radiographs. The terminology isbased on the Nomina Anatomica 1961, but there has been someregard to current usage. The recent illustrations which havebeen added to Pemkopf’s original collection are well up tostandard.

Synopsis of Tropical Medicine (4th ed. London: Cassell.1963. Pp. 325. 15s.).-This synopsis by Sir Philip Manson-Bahr was prepared originally for use by medical officers of theBritish Armed Forces in the 1939-45 war, and the latest editionretains the essentially condensed, encyclopxdic, and therebydogmatic style. It is something of a relief to the reader of theclipped and otherwise economical prose that the author has

squeezed in some expressive phrases-" gun-washings " odour(of the skin in typhoid) and " white man big fever, black manlittle fever " (on immunity in malaria) are two examples. Thebook is concerned with the traditional European concept oftropical medicine, which means a catalogue of disorders moreor less peculiar to tropical countries and not therefore givenmuch attention in textbooks and teaching of general medicineat home. This remark may seem superfluous, but it might todaybe hard for the innocent abroad to understand why such com-mon tropical diseases as tuberculosis and infectious hepatitis arenot in the catalogue. Surprisingly, there is no mention ofchloroquine-resistant strains of Plasmodium falciparum, and forService medical officers the section on climatic disorders is

incomplete. Although nutritional diseases are not skimped, theaccent is presumably on disease to which white immigrants tothe tropics are susceptible, and this may explain why inheriteddisorders of the blood are barely mentioned. Since there is a

chapter on miscellaneous disorders of which some are ofobscure xtiology, it seems odd that infantile biliary cirrhosis(of India) has been included with nutritional diseases, andlatah and kuru with disorders related to climate. Within itsstated aims, and for those who seek potted and readily foundinstruction, this is an excellent book and-to the great credit of allconcerned in its production-unusually good value for money.Probably very few tropical physicians could equal the successof the author in compiling and condensing so vast an array ofinformation.