216 BRITIStl JOURNAL OF PLASTIC SURGERY

The most promising application of the method is the study of the local circulation in regions of skin and tissue, and this may therefore become a useful research tool for studying the problems arising in plastic surgery. In the case of tubed skin pedicles the clearance rate does not appear to be affected by the environmental conditions, and with care in checking possible sources of experi- mental error reasonably consistent experimental results have been obtained and a programme of clinical studies has been carried out with automatic equipment designed to reduce the tedious work involved in recording large numbers of observations.

The results of clinical studies which relate directly to the practical aspects of plastic surgery are summarised. The circulation rates in first, second, and third stage pedicles have been measured, and as a result of experience already gained it is apparent that a considerable saving of time can be achieved by the application of the experimental results obtained with ~*Na clearance measurements, and it is reported that some operations can now be completed in a few weeks instead of months. In cases where an inadequate circulation was demonstrated, it could be accounted for by some abnormal condition, which could usually be corrected before any permanent damage had been suffered by the pedicle. Studies are proceeding to provide data on problems relating to the post-operative care of pedicles and flaps, and various clinical tests are being compared with the sodium clearance measurements.

Biochemical investigations are reported in the fifth group, and these cover a wide range of materials and isotopes. Experiments with penicillin labelled with I~C and with 3;S, and with vitamin Bxz labelled with ~~ a~Pj and ~C are in hand to study the site and mode of action of these substances of intense biological activity. Recent work with carbon isotopes confirms that the carbon dioxide of a tissue is in a dynamic state and is continually exchanging with the carbon dioxide of other tissue and the body fluids.

In the study of protein metabolism, plasma protein metabolism, and fat synthesis~ stable and radioactive isotopes have been used, but as several ~C-labelled compounds are now available in this country with high specific activities the bulk of the work has been done with this isotope. Multiple tracing techniques using more than one label have been used in immunochemistry to make sure that the label is not transferred from one compound to another, and so far studies have been confined to proteins labelled with ~3~I, a.,p, and ~S. Stable tr'N has been used in chemical pathology in studies in porphyria, and up to the present almost all isotope work has been carried out on cases of congenital porphyria.

The symposium closes with three articles of particular interest to anyone who wishes to start work with radioactive isotopes. The problems associated with the production of labelled compounds, particularly those containing ~C, on a commercial scale are considered, and some indication of the cost involved in producing compounds to meet special requirements is given.

The precautions recommended for handling radioactive materials are set out to meet the needs of users in the different fields, the conditions which exist at the tracer and research levels being separated from those at the high-activity, therapeutic level. The nature of the hazards, the maximum permissible doses and contamination levels, and suggested disposal of waste are given in convenient paragraphs for reference. Representative types of monitoring and handling equipment are illustrated and their limitations pointed out.

Finally, some details are given of the production and supply of the medically important radioisotopes, including their relevant physical properties and the chemical forms usually available.

A. N. B.

L e T r a i t e m e n t C h i r u r g i c a l d e la D i v i s i o n V61o-pala t ine C o n g ~ n i t a l e . By D o c t eu r

P IER~ DUMAS. Pp . 86, wi th 5 i l lustrat ions. (Paris : Librai r ie A m e t t e . 1952.)

This is an account by a member of the Clinique d'Orthop~die et de Chirurgie Infantile of the treatment of cleft palates in the Clinic at Lyon for the last twenty years. The author reports the result of 209 operations by Professor Guilleminet. He describes ho~- the technique which was originally based on Veau has been steadily modified in succeeding years, and demonstrates improved results in the patients treated. Unfortunately only 6o per cent. of the patients have been followed up, so that there is a limited amount of clinical material available for estimating speech.

Briefly the modifications in technique are that hammular process fracture is now carried out in every patient, that metal has been abandoned in the " suture musculaire," and that bipedicle flaps are employed whenever possible instead of the Veau type of flap. The ideal age of operation is considered to be between fifteen and twenty months. Extensive employment of up-to-date chemotherapy contrasts strongly with old-fashioned an,~sthesia in which chloroform is preferred to ether. It is surprising that there is only one fatality in 2o9 patients, a case of death by hyperthermia pallida.

With regard to speech training, the author agrees that the parents are the best trainers in the early years, but a qualified speech therapist is employed if there are faults in speech after 4 or 5 years of age. The role of the orthodontist is appreciated but not enlarged upon.

BOOK REVIEWS 217

The results of treatment are fully set out in tables, and the speech results would clearly have been much improved if the anatomical results had been better. For instance, in the soft palate clefts of forty-seven patients treated, there were total breakdowns in ten, partial in eight, and smooth union in only twenty-three of the patients. Speech was perfect in seventeen of twenty-seven patients followed up.

It is a pity that we cannot have a uniform description of speech results like those given by \Vardell, since the reader finds it difficult to differentiate between the standards set, as " perfecb" " excellent," " good," and " normal."

This is not a book that will advance the science of cleft palate surgery in Britain, but is of interest in that it demonstrates the progress that can be made in a French provincial clinic by adopting certain modifications in technique.

R . B .

D i e B e h a n d l u n g d e r P s e u d a r t h r o s e n . By ALFRED NIKOLAUS WITT, Obera rz t des

Staatl. O r thop . Versehr t enkrankenhauses , Bad Tolz . Pp. 212, with 328 i l lustrat ions.

(Berl in : Wai te r De Gruy te r & Co. 1952.)

Primarily of value to the orthop,xdic surgeon, this book develops in detail the indications for and the practise of reduction, immobilisation, and fixation of fractures involving bones in the upper and lower extremities. The free use of radiographs ahd line drawings serve to provide one with a visual appreciation of the methods employed in the treatment of individual cases. The main interest in this book, in so far as the plastic surgeon is concerned, lies in the importance the author stresses in ensuring an adequate skin cover prior to undertaking the procedures which he advocates.

It is clear that the author has considerable experience in his specialty. The text of his book is practical and well presented, though the bibliography, while it is relatively complete, is reserved for the last few pages.

Although the value of this book to the plastic surgeon is limited, there can be little doubt that it will prove acceptable to those interested in this specialised branch of surgery.

W. D. M.