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However, when the fields of periocular hair-growthsuppression are widely spaced in early development,as in ocular hypertelorism, the superior point ofintersection between the two fields may occur loweron the forehead, resulting in a V-shaped midlinedownward projection of scalp hair-the widow’s peak.Fig. 1 illustrates this hypothesis.

COMMENT

We postulate that a widow’s peak is a secondaryminor anomaly, the consequence of a lower point ofsuperior intersection of the periocular developmentalfields of hair-growth suppression, allowing for a mid-line extension of scalp hair growth on to the fore-head. This could be the consequence of increaseddistance between the eyes-ocular hypertelorism-or of reduced size and/or shape of the developmentalfields of periocular hair-growth suppression, as

shown in fig. 1. The latter is the presumed explana-tion for the widow’s peak in individuals who havenormal intraocular distance. Examples of smaller

Fig. 3-Widow’s peak, presumably secondary to smaller fieldsof periocular hair-growth suppression in simians.

Cercopithecus albogularis Kolbi (left) and Symphangus syndactylus(gibbon) (right).

periocular fields of hair-growth suppression with aV-shaped downward projection of the scalp hair attheir upper median point of intersection are evidentin some simians (fig. 3).

Therefore, the detection of a widow’s peak shouldlead the clinician to measure for ocular hypertelorism,which if diagnosed as the more primary anomalywould indicate that the many syndromes in whichocular hypertelorism can be a feature should be con-sidered.4 More commonly, especially with slightdegrees of widow’s peak, the interpupillary distancewill be found to be within the normal range for ageand the widow’s peak may be interpreted as a normalvariant.

We thank Mrs Phyllis Wood for the illustrations and MrsMary Ann Harvey and Mrs Christine Hansen for secretarialassistance. We thank Williams and Wilkins Co. and theNational Foundation-March of Dimes for permission to pub-lish fig. 2. This work was supported by Maternal and ChildHealth Services, National Institutes of Health, and the NationalFoundation-March of Dimes.

Requests for reprints should be addressed to D. W. S.

REFERENCES

1. DeMayer, W. Neurology, 1967, 17, 961.2. Sedano, H. O., Cohen, M. M., Jr., Jirásek, J., Gorlin, R. J. J. Pediat.

1970, 76, 906.3. Furukawa, C. T., Hall, B. D., Smith, D. W. ibid. 1972, 81, 1117.4. Peterson, M. Q., Cohen, M. M., Jr., Sedano, H. O., Frerichs, C. T.

in Birth Defects: Original Article Series (edited by D. Bergsma);vol. VII (7), p. 122. Baltimore, 1971.

Reviews of Books

Medicine and Public Health in the People’sRepublic of ChinaEdited by JOSEPH R. QUINN, PH.D. Washington: UnitedStates Department of Health, Education, and Welfare.1973. Pp.333.

THE first in this series, commissioned by the FogartyInternational Center, dealt with the Soviet health pro-grammes since 1917. The latest one is intended to meetthe revived interest in matters Chinese in the UnitedStates, after the detente between China and America andthe " ping-pong " diplomacy. China has a great deal toteach and to demonstrate, especially to countries con-

fronted with similar problems. Whilst this book indicatesthe potential value of China’s example, it falls short of

fulfilling this objective since it is largely made up of biblio-graphical researches. Only two of the authors have visitedChina in the 1970s, but all of them have made China andChinese medicine a focus of their interest and study. Thebook whets the appetite, but fails to appease it.

The three main sections deal with Chinese medicinethrough the ages; health care and organisation since 1949;and the likely major health problems of today. In the

twenty-four years since the revolution attempts have beenmade to fuse the benefits of Chinese traditional andmodern Western medicine. Their combined benefits havebeen brought to the people by the " barefoot doctors

"

and the rural medical cooperatives supported by the

Western-type trained doctors in clinic and hospital. Allthis has not been without severe ideological struggle, acuteduring the " great leap forward " in 1958 and again in thecultural revolution of 1966.

Acupuncture and Chinese pharmacology are regarded byChairman Mao Tse-tung himself as " a great treasure-house. Efforts should be made to explore and then raisethem to a higher level ". The observers recording theirviews in this book recognise the essential pragmatism ofthe Chinese approach. From 1949 until about 1960

statutory laws were the basis of public-health admini-stration. An interesting chapter sets out the most importantdirectives of the Ministry of Public Health dealing withprevention and treatment, medical and public healthpersonnel, and the use of Chinese medicine materials.Fifty-four of the legal documents on public health are setout in note form in a fascinating mixture of health educationand communist party propaganda. Lately there has been adecline in the reliance on statutory instruments of thiskind. These laws and the basic type of health organisationwill be familiar to most practitioners of communitymedicine except for the influence of people’s communesproduction teams and the doctor/worker concept.The chapter on medical personnel and their training is

of particular interest, not least because it is written by oneof the authors who has recently visited China. Thosesuitable for formal medical education are chosen more bythe opinion of fellow workers in the communes than byacademic prowess. This, like the limitation of medicalcourses to a maximum of three years, is a recent develop-ment since the medical schools were reopened followinga three-year closure after the 1966 cultural revolution.

No book about China would be complete without onechapter at least on population, the country’s major healthproblem. The 1953 census is discussed since on it arebased all calculations of present population, estimated in aUnited Nations report of 1971 as almost 760 million.

However, projections over the next 10-15 years vary widely;

1129

the author of the chapter asks whether it is possible thatPeking will come out with an official series of populationstatistics and terminate the guessing game. Some of themost interesting points made in the book concern the

ideological acceptance of family planning and its imple-mentation. Marxist philosophy and the increasinglyobvious need to control population growth had to bereconciled. One cannot help wondering how appealingthe slogan " making love is a mental disease which wastestime and energy " would be in other parts of the world.There is some confusion about the four pests, one of the

major tenets of the eradication of communicable diseases.These are mosquitoes, flies, rats, and sparrows, though inone account the snail takes the place of the fly. Apart froma reference to the mobilisation of millions of people, themethods used are not detailed nor is the success or other-wise of such campaigns recorded. It is no surprise thattuberculosis, leprosy, and trachoma are expected to retaina high prevalence nor that the chief targets for eradicationare schistosomiasis, malaria, filariasis, kala-azar, andankylostomiasis (" the five most menacing parasiticdiseases ").

" Science for everyone, everyone a scientist " is cited asthe current research doctrine. The chapter on the Academyof Medical Sciences makes it clear that the People’sRepublic has taken matters a good deal further than LordRothschild. The Soviet influence was particularly evidentin medical research, as it was in the practice and teachingof medicine, in the early 1950s. There seems to be nodoubt that the cultural revolution disrupted some of theresearch establishments. Yet, despite allegations of thepursuit of personal fame and gain, some conventionalmedical research survives. On the other hand, the mostcelebrated new developments come not from academicinstitutes but from the medical schools and associated

hospitals-especially is this the case with regard to acu-puncture anaesthesia. Advances in cancer research andpreventive programmes against this disease are largelyattributed to the " mass-social-organisation model

adopted by the People’s Republic.Although this book is of absorbing interest, it still

leaves almost everything to conjecture. It is not easy toread, since so many authors inevitably cause repetition andinconsistency of style. Nevertheless, it does provide in onecompendium sufficient interest and background infor-mation for the reader who anticipates one day reading andassessing reports of health from sources within the People’sRepublic of China.

Spinal Cord Injuries, Comprehensive Managementand Research

Sir LUDWIG GUTTMAN, M.D., F.R.C.P., F.R.C.S., formerdirector, National Spinal Injuries Centre, Stoke MandevilleHospital, Aylesbury. Oxford: Blackwell Scientific Publi-cations. 1973. Pp. 696. E16.

ONE opens this long-awaited volume with an anticipationof considerable pleasure, and such anticipation is com-pletely fulfilled. This book will become a classic. SirLudwig created a new medical discipline when he broughtfresh insights and new basic concepts to the treatment andrehabilitation of paraplegics: he has been able to put theseideas into practice, has proved that they are right, and hasseen them accepted throughout the world.The book begins with the traditional sequence-

historical survey, anatomy and physiology of the vertebralcolumn and spinal cord, mechanisms and classification ofspinal injuries, and management of spinal fractures andgunshot wounds. There is then a full account of the

complications of spinal injuries. The sixth section on the

neurophysiological and clinical aspects contains a vast amountof fascinating research on the " physiology " of the isolated

spinal cord and autonomic nervous system and bringstogether many aspects of nervous integration and disinte-gration. The sections on respiration and bladder functionare specially valuable. The excellent chapters on rehabili-tation by work and sport might well have had a separatesection. The book ends with legal and statistical data, andan inspiring epilogue on the essence of rehabilitation.

Because this book will be consulted everywhere in theworld and because there will be further editions, it is rightto point out that a few sections could be expanded. Therecould be a fuller discussion of the disadvantages andpossible benefits of hand surgery in tetraplegics. In thesection on the spinal cord, it would be useful to include arather fuller discussion of the normal physiology of muscleand postural control. Considering the author’s greatpractical contribution to restoring control of trunk postureby developing unparalysed muscles, his discussion of theactions of individual trunk muscles is rather scanty,especially with reference to the prevention of late spinaldeformity in paraplegic children. His classification ofinjuries is anatomical rather than functional or mechanical.Probably, this is inevitable at the moment, but it underlinesthe difficulty in trying to correlate bony damage andneurological sequelx-yet this surely is an area where newinsights are slowly developing, linking the mechanism ofinjury with the degree of spinal damage. In initial treatmenthe rightly condemns widespread operative interference, butthere is an occasional indication for reduction and stabilisa-tion in the lumbar and cervical regions. He does notmention the use of halotraction and the image intensifierfor treatment of cervical spine-injuries. The discussion onturning beds is limited to one (admittedly very excellent)type, but there are others which have their uses and indi-cations. His discussion of mattresses, undersheets, wheel-chair cushions, and other means of distributing pressuremight also be expanded. The index will certainly requireamplification in the next edition.These are, however, only minor criticisms. Although the

book contains a vast amount of information it is easy toread, and the skilful interposition of clinical case-historiesto illustrate important points means that it is not just anencyclopaedia; it is a book to be read and re-read, and itshould certainly be in every university and hospital library.We must all be grateful to Sir Ludwig for undertaking thevast labour which writing this book must have entailed. Itis a fitting climax to his life’s work.

Nephrotic Syndrome of Quartan MalariaJOHN W. KIBUKAMUSOKE, M.D., F.R.C.P.E., D.T.M.&H., pro-fessor of clinical medicine, Makerere University, Uganda.London: Arnold. 1973. Pp. 116. 5::4.50.

ALTHOUGH an association between quartan malarialinfection and the nephrotic syndrome has long been

recognised, it is mainly during the past decade that itsnature has been elucidated. During this time ProfessorKibukamusoke has played a prominent part in the clinical,immunological, and morphological investigation of thisdisease in Uganda, complementing the work done in

Nigeria, and this book serves a useful purpose in assemblingthe mass of information which has been gained. After a

fascinating account of the historical and geographicalaspects, succeeding chapters deal with the clinical andlaboratory features of the disease, and include a wealth oforiginal data. Each chapter argues, with greater or lessercogency, the case for the likely though as yet unprovenhypothesis that the quartan malarial nephrotic syndrome isa form of soluble-complex nephritis. Unfortunately, thechapter on immunology is not matched in excellence bythat on biochemistry, which is brief and adds little to theunderstanding of the disease. It gives no data, for example,

1130

on the selectivity of proteinuria. The contribution byProf. M. S. R. Hutt is, in essence, a description of thepathological spectrum of the nephrotic syndrome as seenin Uganda, and its value would have been enhanced by theinclusion of a considerably expanded discussion of the

relationship with Plasmodium malariae infection, and greaterdetail of the electron-microscopic findings. The accom-

panying photomicrographs are not all of the high qualityrequired to emphasise details. The book is a pleasure toread, but the reader in search of new knowledge is left witha sense of incompleteness. This is perhaps because,although it comprises a series of informative essays onrelated subjects-including the immunological and patho-logical features, evidence for malarial xtiology, therapeuticresponse and prognosis-each is written in comparativeisolation. While this layout is an advantage to those usingthe book for reference, a final chapter giving clinico-

pathological correlations would have been a valuableaddition. The book contains a wealth of bibliography and,because of the relevance of its subject-matter not only totropical medicine but also to nephrology and immunology,it will appeal to a wide range of readers.

Mercer’s Orthopaedic Surgery7th ed. ROBERT B. DUTHIE, Nuffield professor of orthopxdicsurgery, Oxford University, and ALBERT B. FERGUSON, JR.,Silver professor of orthopedic surgery, University of

Pittsburgh. London: Arnold. 1973. Pp. 1236. E25.

THIS book weighs seven pounds and costs twenty-five- heavy on hand and pocket certainly-but since it is byfar the best and most complete single-volume Englishlanguage textbook on the subject, it must be regarded asone of the most rewarding specialist literary investmentson the market. Professor Duthie here collaborates withDr Albert B. Ferguson, himself the author of arguablythe first major textbook on pxdiatric orthopxdics. Thiscollaboration has resulted in three chapters being regroupedunder " children’s conditions ". Much rewriting andpruning has been done, and there are many new sections,the most outstanding being those on pain, joint lubrication,radiological interpretation of the hip in infancy, and thedetermination of inheritance. There is no major advancein the understanding, pathology, or reinterpretation ofdisease entities which is not recorded, and the end-of-chapter references are greatly increased. The classic

papers have been retained and a wise selection made fromthe international literature, with late 1971 publications notonly listed but referred to in the text. The authors have

sensibly concentrated on what they refer to as " core "material, and, while recording well-proven treatment andoperative procedures such as total hip prosthesis, haveavoided the trap of personal, present time, treatment

preferences which can so date a book on later reading.The 210 additional pages mostly represent the new advancesin the specialty, but there are many new and much clearertables, illustrations, photographs, and X-rays. The sectionon radiological interpretation has five new plates, wellchosen as interpretative examples. The last fourteen ofthese additional pages consist of a new chapter by DrPhilip Nichols on physical therapy and rehabilitation.While in no way detracting from their occasional but

scientifically unproven value, he gently and delightfullyputs the skids under those fanatically committed to thevalue of any one form of electrotherapy or ultrasound.His comments might be summarised by saying that, forwhatever reason, a hot skin makes a happy joint. The restof the chapter on rehabilitation is a timely reminder of thevery real help and contribution all the workers in this areaare making to speed total recovery. To take over, rewrite,and commit oneself to re-edit a major textbook is a work

of supererogation and is an ever-continuing labour: theresult advances the reputation of the well-praised earliervolumes.

The Developing Human

Clinically Oriented Embryology. KEITH L. MOORE, PH.D.,professor of anatomy, faculties of medicine and dentistry,University of Manitoba. Philadelphia and London: W. B.Saunders. 1973. Pp. 374. 511; E4.70.

THIS text has evolved from a set of illustrated notes whichDr Moore prepared for a course in medical embryology.It is a synopsis of human development and related informa-tion, trying at the same time to bridge the gap betweenembryology and adult anatomy, histology, pathology,obstetrics, paediatrics, and surgery. Thus it sets out to

give the student a base from which to develop his knowledgeand understanding. Another aim has been to use materialto emphasise important points, to discuss opposing views,and to summarise concepts and processes. Basic materialhas been set out in standard type, whereas what the authorconsiders to be less important information has been printedin small type or as footnotes. The text is concise, some of itin note form, and, in common with other textbooks ofembryology, pays too little attention to the developmentof function and to indicating clearly the relative incidenceof abnormalities of development. The book is well-pro-duced, reasonably priced, and contains a liberal supply ofillustrations, the vast majority of which are in black andwhite. In assessing the extent to which the author hassucceeded in his aims, one is left wondering whether, whenthe time available in a curriculum for teaching any onesubject is being curtailed, it is always the best way ofhelping students to provide them with increasingly shortertexts. A detailed text may go beyond the scope of a rudi-mentary course, but if a good student is to have his interestroused should he not be given more food for thought ?On balance, Dr Moore has achieved a measure of success inthis direction, and many students who cannot cope with amore detailed text will turn with gratitude to this book.

The Royal Army Medical CorpsREDMOND McLAUGHLIN. London: Leo Cooper. 1972.

Pp. 121. E2.10.

THE dangers, discomforts, and privations of even momen-tous campaigns cannot be adequately evoked by the mostgifted writer: and, paradoxically, the more sustained andrepeated they were, the duller any account of them becomes.Perhaps it is as well, for otherwise some regimental his-tories would be not too tedious, but too distressing, to read.None of the usual limitations, however, are in evidence inthe present book. Its author, lately retired from consultantsurgical practice, has researched his subject thoroughly,capturing its flavour as well as the details. To such anec-dotes as that which relates how Rommel was conductedround an R.A.M.C. unit, in an ill-defined no-man’s-land,by a British officer who " regarded him as a visitingPolish general ", are added many less familiar stories.There is even a reference to that unsung and little known

group of medical officers who served with the special forcesand operated, in both senses, behind the enemy lines.

(Perhaps it is wrong, however, to attribute to Guthrie in1815 the first successful emergency amputation at the hip.Another British Army surgeon, Broadrigg, and Larreyprobably anticipated him.) Till now the R.A.M.C. haslacked a concise, well-presented history. It deserved one,for, though born only seventy-five years ago, the Corpsinherited, and has added to, a proud tradition, and canjustly claim, as Kipling said of another youthful regiment:" We’re not so old in the Army List-But we’re not soyoung at our trade."