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without waiting for signs of recovery, and it was of

paramount importance to prevent stiffness, which wasalways possible, by early motion ; nerve-splintage wasnot the equivalent of fracture-splintage in this respect,and the joints must be moved 2-3 times daily. Thoughearly operation was essential, this did not extend toactual primary suture, for in many cases the damagewas not finally delimited until a few weeks had elapsed,while with time the originally frayed epineurium hyper-trophied and became more capable of taking sutures ; in

securing early delayed suture, skin-grafting was of muchimportance in closing the original wound.

The- vexed question of whether regular electricalstimulation could prevent muscular degeneration whileawaiting recovery after suture had been settled by theexperimental observations of Guttmann and by theclinical findings obtained at Oxford. Galvanism wouldalways maintain muscle volume, or nearly so, thoughit would not make up for the shrinkage occurring beforetreatment was begun ; so it was impossible to start tooearly. Though animal experiments corresponded to adaily treatment of several hours’ duration, in clinicalpractice it was enough to give a short session providedthat this was done every day and not merely on alternatedays. It was best to use the largest possible current,with short duration to avoid the painful electrolyticchanges under the skin that followed a slow regulating-device like the mercury metronome ; 100 contractionsat a session was sufficient, using three groups of 30 stimuliwith 3 minutes’ rest between each group ; the treatmentwas continued until the muscle could act against gravity,when active exercises and faradism were substituted.When this stage was reached some confusion in re-educa-tion was common because of lack of sensory discriminationand the imperfect control of independent movement inthe digits. Occupational therapy was here of great valuein aiding mobility and muscle-power, and in helping therecovery of tactile discrimination when the mediannerve was involved ; in the latter case patients oftentended to use their 4th and 5th fingers for fine work ifnot induced to do otherwise.

Lastly, Professor Seddon recalled the various compen-satory devices available for imperfect recovery, such asselective redevelopment of other muscles and operationssuch as tendon-transplantation or arthrodesis. He madea plea for peripheral nerve injuries to be given the sameplace in peace as in war, and pointed out that in nobranch of trauma were the methods of physical medicineso important to the final result. There was a good deal tobe said for ridding outpatient departments of their manyhopeless cases and concentrating their resources on thosethat would most benefit from close attention.

Dr. W. RiTCHiB Russiij6 stressed the need for teachingthe patient to perform his own passive movementsthrough a full range and not allowing him to leave itto the masseuse. In all cases, especially in civilians,there should be a periodic assessment of the socialposition of the patient from the point of view of the func-tion attained and the wisdom or otherwise of continuingtreatment ; here the clinician and the social workercould usefully collaborate, for these patients had toreadjust their former ambitions.

Mr. J. ELLIS mentioned the individual constitutionaldifferences in the liability to fibrosis and stiffness, associ-ated with differences in the degree of vasomotor disturb-ance, which tended to be greater also with the heightof the lesion.

Prof. J. Z. YouUNG, F.R.S., thought that one of thefactors that prevented wasting in passive movement wasthe maintenance of full length ; experimentally, galvaniccontraction against resistance completely prevented anyshrinkage taking place.

Dr. F. S. CoOKSBY wondered whether it might not beadvisable to rest the part at the first reappearance ofactive muscular contraction for fear of disturbing thereconnexion of the nerve-fibres with the motor end-plates.He allowed patients to treat themselves at home with asimple apparatus based on a 60-volt high-tension batteryand found that the more intelligent could easily managethis while remaining at work.

Professor SEDDON, in reply, agreed that self-treatmentat home was possible with a foolproof galvanic machine.Rehabilitation was encouraged by retraining at vocationalcentres at the earliest possible stage, and he believed in

explaining fully to the patient the probable durationof treatment and final disability. He confirmed the’increased tendency to stiffness with high lesions and thenecessity for hard work by the physiotherapist in thesecases ; there was an enormous tendency to stiffness inpainful irritative partial lesions, - and these should betackled by relieving pain by exploration or even sym-pathectomy’at an early date. There was no doubt’thatmuscles wasted more extensively if allowed to shorten,and recent experimental work in Australia indicatedthat paralysed muscles were best treated electrically if’kept on the stretch-a feature which had been attributedby Dr. P. BAUWENS during the discussion to the main-tenance of a higher tension within the muscular envelopeand the squeezing-out of oedema fluid. ,

Reviews of BooksAnaesthesia in Operations for GoitreSTAIdLEY ROWBOTHAM, M.D., D.A., anaesthetist to the Royal.

Free Hospital, Charing Cross Hospital, and the RoyalCancer Hospital. Oxford : Blackwell Scientific Pub-lications. Pp. 104. 12s, 6d. ’

THE few surgeons who still insist on the right to directthe anaesthetic as well as the operation would do wellto read Dr. Rowbotham’s book. Here is displayed thegreat amount of clinical detail and judgment involvedin anaesthesia for goitre operations alone. The methodsdescribed have gradually evolved through an accumu-lation of experience in large thyroid clinics, and nobodyis better qualified to describe them than the author,who for .years was Joll’s anaesthetist at the Royal FreeHospital. He does not stint the reader. It is refreshingindeed to find that before discussing the anaesthetictechnique to be employed he gives brief but sufficientdescriptions of the clinical and pathological features ofthe patient’s disease. There is a good chapter on theexamination of the patient by the anaesthetist; the latteris so often at a loss how to interpret the preoperativeclinical features, ill so far as the anaesthetic method isconcerned, that this is one of the most helpful parts ofthe book. Both local analgesia and general anaesthesiaare described, but emphasis is rightly laid on pointswhich the author has himself found significant. He is astaunch advocate of endotracheal intubation and favourssubcutaneous injection for haemostasis. The acerbityand dogmatism which characterise discussions on intuba-tion for thyroid operations leave the inexperiencedanaesthetist and surgeon a little bewildered, and the factthat intubation is the routine method advocated bysomeone as experienced as Dr. Rowbotham, for reasonsclearly stated, will be noted in centres where a goitreoperation is a rarity. The book concludes with a descrip-tion of postoperative complications and their treatment-important for the anaesthetist because on him may fallthe onus of the immediate treatment. The text is wellillustrated and the work as a whole is a credit both toauthor and publisher.

Principles of Human Physiology (Starling)(9th ed.) C. LOVATT EVANS, D.SC., LL.D., F.R.C.P., F.R.S.,Jodrell Professor of Physiology, University College,London. London: Churchill. Pp. 1155. 36s.

THIS is the only surviving British textbook which makesmore than a superncial attempt to present at once physio-logy and the scientific method of its development. Thelatter is well documented by references which do not over-look the European literature, and a degree of historicalperspective is preserved which becomes - ever more

valuable, as the years pass. For the Brst time we aregiven a series of historical introductions, which are

modestly referred to by the author, but which must havecost much time and trouble.The first question about the new edition of any scientific

textbook is whether it is up to date, but that is nowbecoming tempered by anxiety as to whether it has sunkto the level of a report on the latest football results. Manyresults have been incorporated in this edition of " Star-ling" without changingjts balance or stifling the thoughtswhich pass from writer to reader. The more closelyphysiology sticks to its origins’ in -the laboratory, theless systematic -4t appears as a whole, and this book is-therefore no revat.ion-of the subject to be digested at...

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a sitting. Its interest lies in its contact with the actualas distinct from the theoretical, and in its accounts ofdetail and experiment. It is a book to be studied by allwho take physiology- seriously-not so much for theknowledge it imparts as for the idea it conveys of howknowledge is acquired. In the last two editions ProfessorLovatt Evans seems to have felt less tied down to’theoriginal format, and the result is a better illustrated andmore modern work. The section on the central nervoussystem is remarkably original for a textbook treatmentand emphasises the fundamental processes of the con-duction and transmission of excitation. In all the othersections the basic principles and a clear account ofmodern methods are skilfully combined.

A Food Plan for IndiaRoval Institute of International Affairs. With a foreword

bv Prof. A. V. HILL. London: Oxford UniversityPress. Pp. 63. 3s. 6d.

THE anonymous authors of this plan calculate thatin 1953 the food requirements of India will be about25 % more than is produced at present, and they seekto bridge this gap. They concentrate on five measuresfor increasing food-production-the use of fertilisersand manures, the improvement of water-supplies anderosion control, the use of improved varieties of seed,the control of seed-borne diseases and of seed pests,and the control of malaria. They also put forwarda modest scheme for training as agricultural officialssome 25,000 Indians of the N.c.o. class on demobilisationfrom the Forces. They make no attempt, however, torelate the Indian food shortage to the general world

position, or to tackle the vast social problems on’whosesolution the lasting amelioration of conditions in Indiadepends. While the measures they do propose are

necessary, they are so obvious and so limited in scopethat it is doubtful how far it is useful to publish themwhile so much of greater importance is omitted. Indeed,many of these- measures are already being taught topeasant cultivators at present in the army, and havetherefore been accepted in principle by the governmentof India. But no mention is made of the difficultvof ensuring that food produced in India today actuallyreaches the consumer at a price he can afford to pay.Hoarding and the rocketing of food prices were amongthe chief causes of the 1943 famine in Bengal, andthe remedy for such evils lies in extensive social change,including government control of all stocks of food.Again, the present system of fragmentation and sub-division of the land until the holdings become too smallfor economical cultivation is a major barrier to improvedagriculture. Little mention is made of this, or of thepeasants’ cooperative movement which is attackingthis problem at its roots. There is no word about thewidely recognised necessity for some form of collectivefarming. And finally, the authors ignore the probablerepercussions on the agrarian system of widespreadindustrialisation, which is bound to come in the nearfuture, and which may, more than any other singlefactor, relieve the present appalling pressure on the land.The food crisis in India is so large a part of the general

world food shortage that it must be considered as partof the world problem. In the circumstances, this academicreport has an air of unreality.

New Inventions

AN AUTOMATIC PNEUMOENCEPHALO-GRAPHIC APPARATUS

THE object of Osborne’s " automatic pneumo-encephalograph" 1 is tle simultaneous replacement ofcerebrospinal fluid (c.s.F.) by gas. Unfortunately hisapparatus was found to be unsatisfactory because C.s..persistently flowed through the upper needle. Theapparatus here described (fig. 1) works well, is easilymanaged, and retains the advantages of diminished dis-

,

_ * . .UOIlll 1 U r V

for thepatient tduringand afterthe opera-tion.Double

rachio-centesisis per-formedin twosuitableinter-spaces.About 10c.cm. ofC.S.F. isallowedto run off.Rubbertube A

(f ig. 2)is con-

nected tothe lowerneedlewith a’ Record ’needleadaptor.1. Osborne,R.L.Arch.Newrol.Psyckiat.1944, 51,405.

The two-way tap, B, enables C.s.F. to pass into capillarymanometer c or graduated tube D. The c.s.F. pressurehaving been taken, tap B is turned to allow the fluid torun into u. Tap G is then turned on, and rubber tube Kis immediately connected to the upper needle. Mercurydrops into graduated tube F, thus producing a partialvacuum at H which ensures flow of fluid through thelower needle. As tube F fills up, air is displated throughthe cotton-wool filter i and so into the upper needle witha pressure indicated by the small mercury manometer E.Absence of pressure rise in E indicates an air leak. Thetrap J catches any C.S.F. which may leak through theupper needle. Once the operation has been started,filtered air automaticallytakes the place of outflowingc.s.F. In this way the desiredamount of air can be intro-duced.

Obstruction the lowersystem is im- -

mediately _K ,revealed by ’=(S*cessation of J.flow into D, ,and in the -"’ Ba...upper - system Aby mounting pressure in manometer E.

The c.s.F. pressure can bechecked at any time. Bymeans of the tap L, normallykept closed throughout theoperation, the negative pres-sure in D and H can bereduced. It is helpful, whenoperating, to keep the appa-ratus at a level below thatof the lower needle.The apparatus is mounted

on a light wooden frame.It is easily assembled anddismantled. Only parts A, B, c, I, J, and K need besterilised. In practice, sterilisation of B and c is a refine-ment, because, their internal volume being small com-pared with that of A, backflow of the c.s.F. into thepatient is practically impossible.The apparatus is obtainable from Down Bros. Ltd.

Runwell Hospital,Nr. Wickford, Essex.

M. B. BRODY, M.D. Sheff., D.P.M.T. C. HALL, M.S.R.