Out of Print

OUT OF PRINT

THE LANCET LONDON:SAT URDAY, SEPT. 27, 1947

Out of Print THE war years have disciplined the shopper : when he cannot have what he wants he is usually glad to take what he can get. In the bookshop, however, he clings to the right of personal choice, waiting if peed be for the reissue of the work he seeks. Unhappily he must often wait. To the casual reader

this is an irritation, but for those who read to learn it may be a serious impediment, as Prof. SAMSON

implied last week. The general shortage improved sharing of resources ; the of one famous society with a large membership medical library has doubled since 1939. The libraries, however, are little better placed than the private purchaser ; and some report that readers, unable to borrow British books, are turning to the American counterparts. Even this supplementary source may WRIGHT1

has led to

be

for the Board of Trade has the import of books from all countries except by individual licence. It is, however, not yet known how serious the effect of this rule will be. Prospective purchasers of British books will be astonished to hear that, even excluding production by new publishers, the number of books printed is now greater than it was in 1939. The Ministry of Supply’s Paper Control grants to publishers a quota based on their trade in 1938-39 ; at the moment this quota is fixed at 70% by weight, plus 10% for export. Those concerned with the production and sale of books have called this a niggardly allowance,2 but by using thinner paper and adopting other economy measures they have made a given weight of paper serve for up to twice as many books as it did before the war. There is, however, substance in the suggestion that the year 1938-39, with war in the air, was one of trade depression which did not reflect the nation’s true appetite for reading. In any case it would not be easy to increase our supplies of paper; for the shortage of pulp, like that of food, is world-wide. Finland, once one of our chief suppliers, uses most of her wood for other purposes in reparation to Russia. Moreover, Finland, Sweden, and Norway, denied the coal resources of Germany, now burn in the grate wood that they would otherwise gladly export as pulp. The same story of world shortage can be told of esparto ; formerly obtained principally from Spain and North Africa, it is now imported in small quantities from Morocco. In the war years straw served as an expensive and less productive alternative ; this practice continues, but the paper industry fears that the Government may soon ban imports on even the present limited scale. Rag paper is, of course; little more than a memory. Even with unlimited pulp, few additional books could be made without reorganisation and further soon

curtailed;

announced

a

ban

on

concessions to the printing trade. The paper-mills working at about 70% of their mechanical

are

1. Lancet, Sept. 20, p. 449. 2. The Battle of the Books.

London.

1947.

471

capacity ; and this percentage could not be raised without further allocation of coal and chemicals. Increased paper production, if it could be used effectively, would certainly lower the cost of books ; for publishers, wishing to honour the claims of all their authors, can now order only small " runs " of each book, so the cost of setting the type cannot be spread over a large number of purchasers. Despite the of a adoption five-day week for printers, and despite a scarcity of metal often calling for the distribution of type which publishers would prefer to keep standing, printing difficulties are not the principal factor limiting output: this lies rather in the binding. The binding industry, overworked and neglected during the war, needs new machinery ; and for this it must look principally to the United States. But new machinery alone would not be enough : twothirds of those employed in the industry are women, and a further twenty thousand women are required. Finally, there is not enough cloth or boards for covers, It may be asked why publishers or even enough glue. do not remove at least this obstruction by satisfying themselves with. the paper covers beloved of the French. Here we touch bottom : folding the sheets is an expert task, and there are not enough skilled women to do the work by hand or machine. Why has the demand for books so greatly exceeded our production capacity ? There are a number of to continue and some more some causes, likely interest in reading ; the an enhanced ephemeral : raised school age ; a vast increase in the number of Government publications ; greater demand by overseas buyers ; and last winter’s fuel crisis which put back production by a full six months. Furthermore, books destroyed by bombing are being replaced ; and scientific books unrevised throughout the war years are being re-edited and eagerly bought. Publishers have been accused of diverting paper that might be used for educational books to more easily produced and profitable light literature. So far as medical books areconcerned this charge cannot be sustained. Most medical publishers deal only in scientific works, so with them there can be no question of diversion ; and those who engage in other forms of publishing point out that the profit to them is greater from a scientific than from another book, and that there is a better prospect of continued good sales from a wellchosen medical book than from other works. Any measure of censorship over the publisher’s choice of books would be regarded as retrograde and undesirable ; but a suggestion made by the Library Association at its meeting in Brighton last June deserves close attention. It is that a further 10% of paper should be allotted to the " Moberly pool," which was created to enable publishers to produce essential books. In some branches of learning, and not least in medicine, the delay in publication is as serious as the small number of books printed. After submitting his manuscript an author may have to wait three years before he sees his work in print ; and he is fortunate if the delay is no greater than eighteen months. During this time advances may prescribe revision or even rewriting of his script. In considering our needs at home, we should not overlook those of others. One famous medical publisher estimates that a third of his books are now sent overseas ; but he cannot satisfy more than

472 g

half the demand for the better-known books. The orders mostly come from Spain, Holland, France, Bel-

gium, Hungary, Czechoslovakia, Scandinavia, Poland, and Russia. When the war ended Swiss publishers made a determined effort to capture Germany’s trade in medical books. The attempt met with little success, for these reasons : an antipathy, especially in Scandinavia, to the German language and to Germany ; the long isolation of Germany which caused her to lag in the

march of progress ; and the destruction of the German pharmaceutical industry. To those who live in Britain it may not have occurred that in these days of proprietary medicines the sale of textbooks goes largely hand in hand with the sale of drugs ; for the books explain the use of complex preparations whose title and constitution vary from one country to another. We stand in peril of missing a great opportunity ; for to achieve friendship with other nations we must impress them not only politically but functionally. Each textbook sent to Europe is one more link with a neighbour; and from such beginnings grows

understandind.

A Cause of Failure in Sympathectomy ? THE most pressing of the many unsolved problems in the surgery of the sympathetic nervous system is the recurrence of symptoms, particularly after operations for Raynaud’s disease or arterial hypertension. A variable period of improvement is too commonly followed by a relapse. Often the malady present precludes the possibility of anything more than fleeting improvement after sympathectomy-structural disease of the affected organs may be far advanced, or by nature progressive, and to operate at all may be regarded as an error of judgment. But apart from this group, in which the pathology of the lesion is to blame, there are many cases in which a physiological or anatomical explanation is perhaps more

probable.

a time it seemed that the secret of success would be found in practising preganglionic section, but HAXTONhas recently drawn attention to his work on Prof. E. D. TELFORD’S patients, and the researches of others in the same field, which show

For

Raynaud’s disease the results of this preganglionic operation in the upper limb are no better than those of ganglionectomy. It would be of great interest if a comparable series of patients operated on by the 2 more radical sympathectomy practised by SMITHWICK 3 that in

could be studied in the same way. In both TELFORD’S and SMITHWICK’S operations precautions are taken to prevent regeneration, which is known to take place readily in the sympathetic system and is believed, by those who favour the anatomical explanation, to be the chief cause of recurrent symptoms after sympa-

thectomy.

It is hard to believe that

preganglionic

fibres from the lower end of the severed thoracic sympathetic trunk can make their way across a gap of several centimetres, and in an entirely new direction, to join the upper end of the divided trunk which has been turned upwards, ensheathed in a silk envelope, and buried in the muscle of either the front or the Some alternative pathway for back of the neck. 1. Haxton, H. A. Brit. J. Surg. 1947, 35, 69. 2. Smithwick, R. H. New Engl. J. Med. 1940, 222, 699. 3. Telford, E. D. British Surgical Practice, London, 1947, p. 472.

sympathetic impulses

sought, and in this accessory (intermediate) sym-

must be

issue SKOOG’ describes pathetic ganglia in the rami communicantes of the cervical and upper thoracic sympathetic trunk which may perhaps provide such a pathway. Such accessory ganglia have already been described in relation to the spinal nerves and rami communicantes, as SKOOG points out, but by decalcifying the skeleton of the cervical spine he has been able to dissect and section for microscopic study the cervical and upper thoracic nerves, and their connexions with the sympathetic chain, more completely than has been possible before. This study shows the surgeon how he will miss a few sympathetic ganglion cells and fibres in performing a sympathectomy; and it is unfortunately true that, because of the chemical mediation of nerve impulses, even a minimal amount of tissue which has escaped removal can vitiate the result of the operation. These intermediate ganglia are inconstant in number and position. If they are present in relation to the 2nd and 3rd thoracic spinal nerve-roots they are unlikely to be removed unless the spinal nerves themselves are excised. This is an essential step in SMITHWICK’S operation, which was designed to interrupt the minute nerve filaments which are regarded as extra rami communicantes connecting the sympathetic trunk to the spinal nerve medial to the main rami. It is possible that these additional rami carry fibres to or from the intermediate ganglia described by SKOOG, and that some of them even run inside the spinal canal. These researches may pointthe way to modifications in surgical technique which will make the late results of

sympathectomy

more

reliable.

Diet and Cirrhosis GREAT advances have been made in elucidating the metabolic processes associated with the liver in health and disease since ÛPIE and ALFORD’, and DAVIS and WHIPPLE, first noted the protective effect of diet in experimental chloroform poisoning. Among the main contributions of the last decade have been the striking additions to our knowledge of the absorption, utilisation, and transportation of fat, especially the work of BEST and his colleagues, together with the researches on the role of the thio-amino-acids and the studies of WHIPPLE and his group on the plasma proteins, with their concept of the " dynamic equilibrium " of the proteins. In this time also our ideas concerning the aetiology of cirrhosis of the liver have changed as a result of fuller appreciation of the postnecrotic sequelae of infective hepatitis and through the experimental production both of acute hepatic necrosis and of cirrhosis by dietetic means rather than by the action of toxic chemical agents. In turn the diet adopted in hepatic disease has altered from the classical liver-sparing one, relatively low in protein, to one providing an adequate and probably high intake of complete proteins, with or without vitamin supplements ; and more recently the active treatment of cirrhosis has given patients a longer survival period with partial or complete freedom from ascites and other manifestations of the condition. Fat circulates in the blood, and is present in the liver, as neutral fat (glycerides), phospholipids, and cholesterol esters, having been ingested, mobilised from