533

SILICONE RUBBER IN SURGERY

TUBING to be left in situ should ho non-toxic andhave suitable physical properties. The urgent need forthis is well known to surgeons. In particular, the growingfrequency with which short-circuiting operations are

performed within the central nervous system makes it

increasingly important to find the ideal tube for neuro-surgery.

’Polythene’ and ordinary rubber are the materialsusually chosen, but each has disadvantages. Therelative stiffness and tendency to straighten make

polythene tubes of sufficient bore liable to cause pres-sure necrosis. The types of rubber commonly usedoften cause an acute meningeal reaction and a stormyconvalescence.

Silicone rubber has the advantage of being veryflexible and easily manipulated, and it can of course bedrawn to the bore and wall-thickness that circumstances

require. We have observed no obvious change in its

physical characteristics after 40 sterilisations in thetheatre autoclave at 255°F and a pressure of 171/2 lb.to the square inch. In addition, its surface, like itssubstance throughout, is water-repellent : it is " non-wettable." This property suggested to us that anypotentially toxic ingredients in it would diffuse out

slowly, if at all.

In six operations nine silicone rubber tubes have beenintroduced and left permanently in position. These

operations were ventriculo-cisternostomies of various

types and one in which drainage of a conus medullarissyrinx into the cerebrospinal fluid around the caudaequina was effected. One patient, with hydrocephalus,died suddenly elsewhere 1 month after operation ; andat necropsy the brain and tubes showed no inflammatorychanges. The other five made satisfactory progress,without either obstructive or meningeal reactions, in the2 weeks following operation. In two of them there wasa temporary low-grade fever in the 3rd postoperativeweek, and although in one the cerebrospinal fluid wasnormal to analysis, in the other there were signs ofreaction (a maximum pleocytosis of 75 leucocytes perc.mm. with 80 mg. of protein per 100 ml.). But after

follow-up periods ranging from 6 months to 2 months allfive patients are now well.

These observations are early. The technical advantagesof silicone rubber are important. The later behaviourof these tubes and of the tissues in which they lie arebeing followed.We are indebted to the Dunlop Rubber Co., Ltd., Cambridge

Street, Manchester, 1, for providing silicone rubber tubes toour specification.

STEVENS DIMANTM.B. Melb., F.R.C.S.

Chief assistant

Department of Neurosurgery,The Royal Infirmary,

Manchester, 13

Reviews of Books

An Introduction to Pathology2nd ed. G. PAYLING WRIGHT, D.M., F.R.C.P., professorof pathology, Guy’s Hospital Medical School, Universityof London. London: Longmans, Green. 1954. Pp. 636.40s.

Professor Payling Wright’s scholarly presentation ofthe principles of his subject is so readable that it willbe easily understood by the undergraduate. But it willalso be of value to the postgraduate, and the teacherwill find in it much to stimulate him and, indeed, tolearn. When a book is intended mainly for students whoare beginning their clinical training, any addition mustbe clearly justified, and in this second edition ProfessorPayling Wright has added 67 pages. This increase ismainly due to two useful new chapters.One of these deals with the principles of inflammation in

allergic reactions, and gives an excellent concise account ofwhat must be a puzzling subject to most students. It is

perhaps a pity that more space could not have been givento changes in naturally occurring diseases such as tuberculosis,rheumatism, and nephritis. The introduction to the mecha-nism of anaphylaxis and the explanation of the concept of"

allergen," as distinct from that of a "

primary irritant," isan admirable and lucid expositioxx of the subject.The other new chapter describes the effects of irradiation

on the tissues-a subject of growing importance in view of itsincreasing use as a method of’ therapy for malignant diseases.The short section on atomic-bomb effects will stimulateinterest.

This is a book for the reader who wishes to think andto pursue further the many stimulating points whichemerge from the text, but the student looking forclassified lists with which to prepare himself rapidly foran examination will be disappointed. The production oftext and illustrations is good and the small increase inthe price of this edition seems reasonable.

Donovanosis(Granulorna Inguinale, Granuloma Venereum.) R. V.RAJAM, M.S., F.R.C.P.E., director, venereal diseases depart-ment, Government General Hospital, Madras ; P. N.RANGIAH, M.D., associate professor of venereal diseases,Madras Medical College. Geneva : World Health Organi-sation. 1954. Pp. 72. J08.

THE causative organism of the disease which in thiscountry is usually called " granuloma inguinalo" was

first described forty-nine years ago by Major CharlesDonovan, who was then professor and physician at theMadras Medical College and the associated hospital. Itis therefore fitting that this comprehensive review ofthe subject, sponsored by the World Health Organisation,should be prepared by his successors.The disease is practically unknown in this country but is

endemic in considerable areas of Asia, Africa, and America,and in Northern Australia. It is a chronic disease oflow infectivity, but generally believed to be transmitted

venereally.This excellent detailed account by Professor Rajam

and Professor Rangiah owes much to their experience.They include a full bibliography and 37 useful illustrationswhich should be of great value to those without access toclinical material.

It is satisfactory that antibiotics now produce prompthealing and cure in many cases which in the past wouldhave been regarded as hopeless.

A Catalogue of Incunabula in the Wellcome HistoricalMedical Library

F. N. L. POYNTER, B.A., F.R.S.L., F.1..A., librarian.London: Oxford University Press. 1954. Pp. 160. 50s.

THE collection here described in detail has been builtup by purchases made during the past fifty years. Thesevolumes were not collected primarily as examples ofearly printing but for their contents, for the late SirHenry Wellcome had always in view the object of makingavailable to students of the history of medicine theoriginal texts which are the basis of their study. It washis ambition to obtain wherever possible the first, or atleast a very early printed, edition of every medical workof any consequence.The condition of these volumes is, in most cases, excellent,

and a large proportion, which are duly noted, retain in finestate their original bindings of wooden boards and old leatherwith clasps. Their immediate provenance and the names of

previous owners have been recorded wherever this informationcould be discovered. The nucleus of the collection lies inthe volumes acquirsd from three famous private libraries thatof’ William Morris, Dr. J. F. Payne, and Kurt Wolff. Theearliest was printed in 1467. The catalogue is well illustratedand is a graceful volume. It is a pity that a short descriptionof each item could not be provided, but instead a referenceis given to the book in which the best description can befound.

Many will be surprised at the size and character of thecollection. It is a thrilling occasion when a, bibliophile

534

is allowed to visit the strong-room in which it is housed.Its importance is indicated by the fact that more thana hundred of these books are not to be found in thecollection at the British Museum. Here are riches indeedfor the medical historian ; but they represent only asmall, if important, part of the wealth of medical literaturewhich Wellcome brought together in London. Thecomplete catalogue of the Wellcome Historical MedicalLibrary, which contains over 200,000 printed books andpamphlets, as well as 5000 manuscripts and about100,000 autograph letters and other signed documents,is now in preparation.

The Alkaloids -

Chemistry and Physiology. Vol. IV. Editors : R. H. F.MANSKE and H. L. HoLMES. New York : AcademicPress. 1954. Pp. 357.$8.50.

THE first three volumes of this treatise have alreadybeen reviewed (Lancet, 1951, i, 33 ; 1952, ii, 274 ; 1954,i, 83). Vol. iv, which completes the chemistry section ofthe work (except for a chapter on miscellaneous alkaloidsto be included in vol. v, the pharmacological section),contains thirteen monographs written on much the samelines as those in previous volumes, and-like them-welldone.

Nine are concerned with isoquinoline alkaloids, ranging incomplexity from the simple substituted tetrahydro-isoquino-lines found in " mescal buttons " (Anhalonium lewinii) and afew other plants, as described in the first of two monographscontributed by L. Reti, to the complex bisbenzylisoquinolinesdescribed by M. Kulka. One of the editors, R. H. F. Manske,is author or part author of seven of the monographs, the firstof which is on the biosynthesis of isoquinolines. Manske

points out that though the exact mechanism by which a plantcell elaborates an isoquinoline is not yet known, it is possibleto envisage a series of reactions, which could occur underphytochemical conditions and should result in biosyntheses.Of the four remaining monographs two are contributed byManske on the cularine group of three alkaloids, yielded bycertain species of Corydalis and Dicentra, and on the C(-naph-thaphenanthridine alkaloids, better known perhaps as thechelidonine group. The volume closes with two monographson groups of alkaloids in which the nuclear structure is stillundetermined-the Erythrophleum alkaloids dealt with byG. Dalma, who first isolated several members of this group,and the alkaloids of Aconitum and -Dep7M.MtM species onwhich E. S. Stern contributes a comprehensive and criticalsurvey.

Several of the monographs include notes on pharma-cology, and in the case of papaverine (belonging to thebenzylisoquinoline group) A. Burger provides a moredetailed statement, discussing also a few of its derivativesand some of its numerous analogues which chemistshave synthesised in the hope of improving on thetherapeutic properties of papaverine.

Operationen am OsophagusProf. Dr. R. NissEN, director of the surgical universityclinic, Basle. Stuttgart: Thieme. 1954. Pp. 161. DM. 72.

RECENT developments in the surgery of the oesophagushave stimulated the interest of all surgeons, who nowrealise that something can be done to help patients withdisorders of this structure. The descriptions of operationson the oesophagus have usually been confined to originalarticles : in the standard textbooks accounts are oftensketchy and sometimes out of date. Professor Nissen,who, with Sauerbruch, has seen many of the pioneerprocedures in this field, has now produced a work inwhich the operations are all described and freelyillustrated.

A section on anatomy contains a good description of theblood-supply, and is followed by an account of the generalprinciples of technique. The final chapters deal with specialoperations, including the various methods of restoring con-tinuity after total gastrectomy. Considerable-and perhapsunnecessary-space is given to antethoracie reconstructionof the oesophagus. Operations on hiatus hernia are fullydiscussed with special attention to replacement of the

oesophago-gastric junction at or below the level of the dia-phragm. The section on carcinoma of the oesophagus is

comprehensive, though less attention is paid to the right-

sided approach than might bo expected. Palliative by-passprocedures are described, and Berman’s method of using aplastic tube is given in full. Indeed, there can be few methodsthat the author has overlooked, judging by the list of namesand procedures mentioned.

The book is essentially technical ; indications andresults are barely discussed, and there are no references;but within these limits it is admirable. The line and half-tone illustrations, which number nearly 150, are extremelygood.

The KidneyA Ciba Foundation Sympo8ium arranged jointly with theRenal Association. Editor for Renal Association : A. A. G.LEWIS, B.sc., M.D. Lond., M.R.C.P. Editor for CibaFoundation : G. E. W. WOLSTENHOLME, o.B.E., M.A.,M.B., assisted by JOAN ETHERnsrctTON. London : J. & A.Churchill. 1954. Pp. 333. 32-s.

THIS book is an account of the proceedings at aninternational symposium on the kidney arranged jointlyby the Ciba Foundation and the Renal Association, andheld in London in July, 1953. It displays the aspects ofrenal physiology and pathology in which research hasbeen most active in recent years.The sections on renal pathology describe the two modern

techniques of micro-dissection of single nephrons and of

aspiration biopsy of the kidney. Recent interest has beenfocused more on the functional aspects of individual units ofthe kidneys than on the organs as a whole. The three

chapters on renal clearance describe the wide statisticalvariation in the function of single nephrons, and another isconcerned with the biochemistry of the tubular cell.The popularisation of the flame photometer is largely respon-

sible for recent interest in the problems of electrolyte excretion,and the related subject of acid-base balance. This book

gives an excellent account of advances in this field. Clinicianswill be interested in the sections concerned with acute renalfailure, but will be disappointed in the almost completeneglect of glomerulonephritis and pyelonephritis. This is,however, a subject in which few spectacular advances havebeen made of late.

This book will be of great value to renal physiologistsand pathologists, and to clinicians who are particularlyinterested in the functional aspects of the kidney inhealth and disease. The verbatim reports of discussionsbetween the participants in the conference, at the endof each section, show that doctors can disagree&mdash;<;an behighly critical indeed-without rancour.

Synopsis of Forensic Medicine and Toxicology (3rded. Bristol : John Wright& Sons. 1954. Pp. 180. 12s. 6d.).-These pages of condensed forensic material include aremarkable amount of useful information. The student willbe grateful to Dr. E. W. Caryl Thomas for so much in sucha small compass, and the general practitioner for an easyreference to his forensic responsibilities. The book is notintended for experts, for it contains small inaccuracies andolder forensic fallacies that might incur damaging cross-

examination if used in evidence. But on the whole it is a

worthy member of the useful students’ synopsis series, a greatdeal shorter-and a lot cheaper-than some of its shelf-fellows.

Atlas of Congenital Anomalies of the Heart andGreat Vessels (2nd ed. Springfield, Ill. : Charles C. Thomas.Oxford : Blackwell Scientific Publications. 1954. Pp. 202.97s.).--Written descriptions of congenital abnormalities ofthe heart are not always easy to follow. The atlas by Dr.J. E. Edwards and his colleagues at the Mayo Clinic has

largely met this difficulty. The first edition was publishedsix years ago ; the second edition includes most of the originalmaterial, considerably expanded. It consists largely ofbeautifully produced illustrations, many in colour, of individualcases. Thirty examples of different disorders are given.Each case-record starts with a short general description,which is followed by photographs and diagrams of the

heart-specimen, electrocardiograms, radiographs, and a briefhistory and clinical account. The publishers and thoseresponsible for the illustrations, as well as the authors, areto be congratulated on this valuable work, which shouldcertainly be read (or, more correctly, looked at) by everyoneinterested in this fascinating subject.