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Fig. 3-Radiographs of a very heavily calcified (-E -1- --) aorticvalve homograft after 65 months in situ.

A, horizontal view B; vertical view. Both x 1.1. The calcifiedaortic pillars extend upwards in A.

prepared as described: B.P.L. and freeze-drying 10%;ethylene oxide and Hanks’ solution 5.9%; B.P.L. andHanks’ solution 5-6%. In our series 21 of the 39valves showed ruptures or perforations. These 21 hadbeen in situ for 1-62 months (mean 32:18).

Freeze-drying has been shown to impair the tensilestrength of human pericardial strips, 16 aortic wall, andaortic valve cusps 17 and to produce visible cracks inhuman aortic valves. 18 While data on the effects ofethylene oxide, B.P.L., and irradiation are sometimesconflicting, adverse effects on tensile strength have, ingeneral, been described when the first two have beenused.

It is now evident that, the gentler the methodsemployed in the preparation of aortic-valve homo-grafts, the better. It is equally evident that sterilisationby ethylene-oxide gas followed by freeze-drying givesrise to results that fall far below the ideal. Ross 19

has, therefore, now abandoned this method of prepara-tion. The excellent results obtained by Barratt-Boyeset al.14 with their 16 " untreated " homografts, coupledwith the continuing impressive function 20 of Mur-ray’s 21,22 2 homografts inserted fresh into the

descending thoracic aorta 14 and 11 years ago andstill devoid of calcification, perhaps point the waytowards better and less rigorous methods of preparationof cardiac valves destined for transplantation.We thank Mr. D. N. Ross for help; and Mr. K. W. Twinn

and Mrs. Joy Taylor, of the physics department, Guy’s HospitalMedical School, for willing and skilful assistance with the radio-graphy.

REFERENCES

1. Ross, D. N.J. thorac. cardiovasc. Surg. 1964, 47, 713.2. Barratt-Boyes, B. G. Thorax, 1964, 19, 131.3. Davies, H., Missen, G. A. K., Blandford, G., Roberts, C. I.,

Lessof, M. H., Ross, D. N. Am. J. Cardiol. 1968, 22, 195.4. Pickering, B. N. Guy’s Hosp. Rep. 1966, 115, 105.5. Longmore, D. B., Lockey, E., Ross, D. N., Pickering, B. N. Lancet,

1966, ii, 463.6. Missen, G. A. K., Roberts, C. I. Unpublished.7. Eastcott, H. H. G., Holt, L. B., Peacock, J. H., Rob, C. G. Lancet,

1954, i, 1311.8. Flewett, T. H., Zinnemann, K. S., Oldfield, M. W. C., Shucksmith,

H. S., Dexter, F. ibid. 1955, i, 888.9. Schuster, S. R., Gross, R. E. J. thorac. cardiovasc. Surg. 1962, 43,

54.10. Brock, Lord. Thorax, 1968, 23, 249.11. Wesolowski, S. A. Evaluation of Tissue and Prosthetic Vascular

Grafts. Springfield, Ill., 1962.12. Urist, M. R., Adams, J. M. Ann. Surg. 1967, 166, 1.13. Smith, Judith C. Thorax, 1967, 22, 114.14. Barratt-Boyes, B. G., Roche, A. H. G., Brandt, P. W. T., Smith,

J. C., Lowe, J. B. Circulation, 1969, 40, 763.

15. Barratt-Boyes, B. G., Roche, A. H. G. Ann. Surg. 1969, 170, 483.16. King, M. H., Heimbecker, R. O., Trimble, A. S. Surg. Forum, 1967,

18, 119.17. Harris, P. D., Kovalik, A. T. W., Marks, J. A., Malm, J. R. Surgery,

St. Louis, 1968, 63, 45.18. Mohri, H., Reichenbach, D. D., Nelson, R. J., Barnes, R. W.,

Merendino, K. A. J. thorac. cardiovasc. Surg. 1968, 56, 546.19. Ross, D. N. Guy’s Hosp. Rep. 1969, 118, 5.20. Heimbecker, R. O. Ann. Surg. 1969, 170, 491.21. Murray, G. Angiology, 1956, 7, 466.22. Bigelow, W. G., Yao, J. K., Aldridge, H. E., Heimbecker, R. O.,

Murray, G. D. W. J. thorac. cardiovasc. Surg. 1964, 48, 333.

ADDENDUM

Since this report was completed 2 further excisedhomografts have been examined: one, removed at

65 months, showed + + + + calcification of pillars,annulus, and cusps (fig. 3); two cusps were perforated,while one of them showed tears at its free edge. Thesecond valve, excised after 54 months, showed + + —calcification of aortic pillars and annulus, but only + +calcification of cusps: despite clinical suspicion ofbacterial endocarditis, the cusps were intact.

Reviews of Books

An Introduction to Preventive Medicine

JOHN SIMPSON, M.D., M.R.c.P., D.P.H. London: WilliamHeinemann Medical Books. 1970. Pp. 237. 36s.

As our concepts of health and disease become more

complex, so the demands made on the medical professionand on the health services increase. As Dr. Simpson says:"

Society today requires a physician whose objectives areto conserve and improve health, to erect barriers to mal-function and disease and to extend the knowledge thatmakes these possible." This book outlines some of the

principal areas of knowledge with which a physician of thiskind should be familiar-apart, that is, from an essentialgrounding in the theory and practice of the medical sciences.The range of topics discussed is impressive. In twenty-fourbrief chapters the author deals with the historical develop-ment of preventive medicine, epidemiological and demo-graphic methods, data processing, trends in patterns ofmorbidity and mortality, the development and structure ofthe health-and-welfare services, and the provision of indi-vidual services (e.g., those for maternal and child care andfor rehabilitation). One chapter is devoted to a discussionof the factors involved in the spread and control of infectiousdiseases, but on the whole attention is concentrated on thehealth problems most relevant to developed countries-i.e.chronic diseases, accidents, addictive diseases, and mentalill-health. Two concluding chapters deal with the evolutionof international health organisations and the work ofW.H.O. The most helpful chapter is, perhaps, that onEnvironmental Hygiene, which examines how the environ-ment can adversely affect health; throughout it the authorshows a deep understanding of the relation between socialand economic development and the changing health needsof the community. The chapter begins with a descriptionof the traditional preoccupations of public-health workers-the purity of food and water and the efficiency of sewageand waste-disposal methods. It continues with a discussionof more modern problems, such as atmospheric pollution,radiation, noise abatement, and the complex relationshipbetween housing conditions and physical and mentalhealth; then follows a description of the problems ofinsect-borne diseases and vector control; and the chapterends with a detailed analysis of the effects of urbanisation.

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Few topics, however, are dealt with in such depth, and sothere remains some doubt about the author’s intendedreading public. This would be a stimulating book for thewell-read layman or for the doctor interested in extendinghis understanding of advances in medicine. As a textbook,however, it is inadequate. In Britain the teaching of socialmedicine is focused on two subjects-the theory and practi-cal application of epidemiological methods, and the assess-ment of medical-care needs in individual and community.Yet in this book epidemiological methods are dealt with in5 pages, and medical care is not considered separately,although references are made to the difficulty of assessingneed and demand and to the importance of health-servicesplanning. There is a separate chapter on the handling andprocessing of data, but again this does not do justice to thecomplexity of the subject. The book seems more a defini-tion of modern preventive medicine than a general intro-duction. The emphasis throughout is on general trends andformulating ideals, rather than on the solution of specificproblems. In a teaching course it would therefore be" supplementary " rather than " essential " reading. Butperhaps it is unfair to judge the book solely by its omissions,for much of it is very sound and informative. It shouldbe valuable background reading for more advanced studentsor for postgraduates.

Atlas of Surgical TechniquesPHILIP THOREK, M.D., F.A.c.S., F.i.c.s., clinical professor ofsurgery, University of Illinois. Illustrated by CARL T.LINDEN, former assistant professor of medical illustrations,University of Illinois. Philadelphia: J. B. Lippincott.Oxford: Blackwell Scientific Publications. 1970. Pp. 196.$22; Ell.

THIS is a book about the art and craft of surgery. The

style is simple and authoritative, and the illustrations are ofgood quality and easily understood. The format is such thattext and matching illustrations are placed on opposingpages, and the brief text and the numerous diagrams havebeen skilfully combined. This combination of skilled artistand experienced surgical teacher remains a most effectivemethod of instruction in operative surgery despite recentadvances with visual aids. Both the very wide experienceand the preferences of the author are reflected constantly inthe text. The operative procedures described are all withinthe scope of general surgeons and range from thyroid opera-tions and thoracotomy, gastro-oesophageal surgery, biliaryand intestinal surgery, and surgery of the spleen. Some

operations, such as anterior gastroenterostomy as a drainageprocedure in the surgery of duodenal ulceration, which areDr. Thorek’s personal preference, receive more attentionthan other procedures which are widely used. As mightbe expected, there are omissions, and urology and ortho-paedics are not covered. The trainee surgeon will find this avaluable manual as he develops his skills, whilst the experi-enced surgeon will enjoy the shared personal experience ofa master craftsman.

Diagnostic EnzymologyEdited by EUGENE L. COODLEY, M.D., F.A.C.P., F.A.C.C.,professor of medicine, Hahnemann Medical College, Phila-delphia. Philadelphia: Lea & Febiger. London: HenryKimpton. 1970. Pup.323.$12.50; E5 12s.

ALMOST forty years have elapsed since serum-alkaline-phosphatase measurements were introduced as an aid todiagnosis, during which time diagnostic enzymology hasgrown from a relatively minor to major subspecialty ofclinical biochemistry. Growth has been most rapid duringthe past two decades after introduction of serum trans-aminase measurements as a diagnostic and prognostic indexof cardiac infarction and hepatocellular damage. Today atleast fifty different enzymes are amenable to measurement-although only fifteen or so have established themselves

as valuable diagnostic tools in the average routine clinicallaboratory. Measurement of enzymes is subject to manydifficulties not experienced with simpler compounds; notleast of the problems is that of units. This derives from thefact that enzyme activity and not protein content is measured:and enzyme activity depends on the technique used.Attempts to produce uniformity in the units used to expressserum enzyme activity are being made by expert committeesin Britain and elsewhere; meanwhile the situation is con-fusing, and numerical values produced by a worker usingone technique may bear little relationship to those producedby another using a different procedure. It might have beenhoped, therefore, that in a book on diagnostic enzymologythe editor would have attempted to impose a measure ofuniformity of enzyme units upon his contributors-especially when they are dealing with the same enzyme. If

any such attempt was made in this book it does not show inthe finished product, which displays most of the disadvan-tages of multiple authorship-such as excessive repetitionand conflicting advice-with few of its merits. Individually,most of the chapters are a reasonable statement of currentpractice in diagnostic enzymology relative to the organsystem dealt with, and each contains an extensive biblio-graphy. If individual chapters had appeared as one of aseries of review articles in a journal, they would have beenhighly acceptable. Collected together as a monograph,they have little to recommend them.

Sympathomimetic DrugsDOMINGO M. AviADO, M.D., professor of pharmacology,University of Pennsylvania School of Medicine, Philadel-phia, Pennsylvania. Springfield, Illinois: Charles C. Thomas.1970. Pp. 613.$40.

THERE are a large number of sympathomimetic aminesnow available for investigative and therapeutic purposes,and a concise review of their pharmacology and indicationswould be welcomed by medical students and practitioners.Dr. Aviado attempts to supply such a book, and proposesa new classification for these compounds which, althoughof some value, is already out of date as a result of the intro-duction of compounds which selectively stimulate certainP-receptors but not others. In fact, Lands has suggested asubgrouping into (3a and P2 receptors, but this is notmentioned by Dr. A. M. Aviado, nor is practolol, thespecific (31-blocking drug, included. Although the book dealswith 61 sympathomimetic amines, only 8 are covered indetail. Unfortunately, general considerations of pharma-cology and chemistry follow these, rather than being dis-cussed at the beginning, and so it is difficult to obtain acoherent picture of the subject as a whole. Drug usagediffers in America and Britain in many respects, and somecompounds which are widely used in Britain receive rela-tively scant attention, and vice versa. This book may provea useful source of reference material on the well-establishedsympathomimetic drugs, but it is too expensive and is notsufficiently concise or up-to-date to be recommended tomedical students or general physicians.

Treatment or DiagnosisA Study of Repeat Prescriptions in General Practice. MiciL4ELBALINT, JOHN HUNT, DICK JOYCE, MARSHALL MARINKER, andJASPER WOODCOCK. London: Tavistock Publications. 1970.Pp. 182. 55s.

As with its well-known predecessor, The Doctor, HisPatient and the Illness, this latest book from " the Balintschool " is disturbingly helpful. Disturbing, because itforces general-practitioner attention to a common situationthat most of us avoid thinking about: and helpful, becauseit not only defines the problem but points towards at leasta partial solution. In the first part of the book, the results

966

are reported of a study of one thousand unselected patientsfrom ten general practices. 25% of these patients receiveda repeat prescription, and little else, from their doctors. Thestatistical analysis is claimed to show that the 18% ofpatients who received the same drug for more than sixmonths, " the long-repeat patients ", constituted a groupwith special characteristics-e.g., earlier marriage, greaterlikelihood of being widowed, separated, or divorced, andmore frequent but less intimate contact with the doctor.These findings led the group to formulate the hypothesisthat the balance between gratifications and frustrations inthe life of long-repeat patients is so unfavourable as to createin them a need for general-practitioner contact which posesfor the doctor difficult diagnostic and therapeutic problems,especially affecting his relationship with the patient. Theseproblems are illustrated by case-histories and searchingcommentaries in the second part of the book, which endswith a first-class and encouraging statement of conclusionsand suggestions by Dr. Balint himself. That this is a

scholarly reflective study of a situation that is part of everygeneral practitioner’s work is beyond argument. Whetherit will be read widely and acted on is another matter. Someof it is hard going, and the two parts, one statistical and theother clinical, do not always run easily in harness. But if agroup of general practitioners, seriously concerned about therepeat-prescription problem, were to study this book care-fully and test its hypotheses for themselves, they mightemerge less frustrated and more gratified about their re-lationship with a substantial and growing number of

patients.

Hospitals, Children and their FamiliesMARGARET STACEY, senior lecturer in sociology, UniversityCollege, Swansea; ROSEMARY DEARDEN, child psychiatrist,Glamorgan County Council; DAVID ROBINSON, research fel-low in sociology, University College, Swansea; and RoisiNPILL, research fellow in sociology, University College ofSouth Wales, Cardiff. London: Routledge & Kegan Paul.1970. Pp. 188. 50s.

THIS book is the report of an investigation into certainaspects of having children in hospital. Although the authorshad medical advice, there was no doctor in the team, andthe book is no better for the omission. The first object ofthe study was to see " what inhibitors, other than hospitalregulations ", stood in the way of parents living in with theirchildren or visiting more frequently. This was done byinterviewing a group of mothers who had roomed in atAmersham Hospital, and a comparable group who had not;but who might have been asked so to do. The resultsconfirmed what might have been deduced from an aca-demic exercise and a reading of S. R. Meadow’s paper onthe Captive Mother. It would seem preferable to providetrue unrestricted visiting combined with very elastic room-ingin facilities, and then allow parents to make what use ofthem they wish, rather than persuade them into a " liberal "regimen they do not always want. A second, and unrelated,investigation was to study the psychological and socialeffects of putting a child into hospital. Two hospitals, Xand Y, were studied, X having " a more liberal system thanY ". Elsewhere X is said to have " expectations of childrenwhich were much more restrictive, and the sanctions morepunitive than Y ", yet " in hospital X no nurses were everobserved threatening children. In hospital Y one out offive normals and six out of seven others were so threatened ".If the choice of hospitals sounds rather Dickensian, thechoice of children is equally unexpected. The group con-sisted of 32 children admitted for adenotonsillectomy. Ofcourse, the authors had to find a group which they couldassess before and after admission; but the indications fortonsillectomy are so varied and often so vague that thepatients are not always good representative examples. This

book will not be of great value to the average paediatricianwho is dealing with quite a different problem in wardswhich are progressively moving towards unrestricted visit-ing. One conclusion of the study is worth bearing in mind-that it is unwise to admit to hospital a child who hasrecently started school, as this proves most disturbing. Thebook is fairly easy to read though in places spoiled byjargon. Everything is " quantified " rather than measured,and the children have " interaction " rather than contactwith the nurses and their parents.

The Psychological Assessment of Mental and Physi-cal Handicaps

Edited by PETER MITTLER, M.A., PH.D., director, HesterAdrian Research Centre for the Study of Learning, Uni-versity of Manchester. London: Methuen. 1970. Pp. 857.E8.

MANY psychiatrists and social workers, says M. B.

Shapiro in a contribution to this book, regard the psycholo-gist " rather like the man who comes to read the gasmeter; he does not appear to be an applied scientist helpingthe clinic to do a day’s work ". This is a common attitudeto psychologists who specialise in behavioural abnormali-ties. In a brilliant introductory chapter H. Gwynne Jonessees the clinical psychologist’s task as the derivation ofhypotheses from what is already known about the patient,the selection of tests most suitable to investigate these ideas,the interpretation of results obtained in this way, and theclear communication of findings to colleagues. Thisapproach demands the discipline of experimental sciencecoupled with a certain sensitivity of subjective judgment-on the one hand scepticism and the search for other expla-nations, on the other a preparedness to form an opinion oninadequate evidence. Thirty-five British psychologistspresent here a comprehensive account of the theory andpractice of assessment in adults and children, including thedeaf, the old, the mentally subnormal, the maladjusted, andthe physically handicapped. There are chapters on generaltopics such as intelligence tests and personality assessment,but most of the contributions are from specialists describingtheir work as applied scientists assessing handicappedindividuals. The redefinition of the educational and clinicalpsychologist’s role as an applied scientist rather than atechnician is implicit in the contributions from J. E. Orme,discussing long-stay psychiatric patients, Moya Tyson onthe design of remedial teaching programmes, and J. L.

Gedye and E. Miller writing on automated testing systems.Inevitably, perhaps, the contributions are not equally clearor comprehensive, and the book lacks cohesion, despiteDr. Mittler’s admirable introduction, the final overview, andnumerous cross-references within chapters. Neverthelessit is a useful book for all those concerned with the psycho-logical assessment of handicapped individuals and for

colleagues who wish to understand what they are doing.

New Editions

Diagnosis and Treatment of Cardiac Arrhythmias. 2nd ed.By J. P. P. Stock. London: Butterworths. 1970. Pp. 271. 78:.

The Carbohydrates: vol. IIB. 2nd ed. Edited by Ward Pigmanand Derek Horton. New York and London: Academic Press.1970. Pp. 902.$22; E10 5s.

Clinical Hæmatology. 3rd ed. By R. D. Eastham. Bristol:John Wright and Sons. 1970. Pp. 201. 18s.

The Conquest of Deafness.-Revised ed. By Ruth E. Bender.Cleveland and London: Press of Case Western Reserve Univer-sity. 1970. Pp. 243.$7.50; 72s.