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of the bones and there was calcification of ligaments andmuscular attachments. It seems possible that fluorosis, bycausing extensive osteosclerosis of the skeletal thoraciccage and calcification of some supporting tissues, hasresulted in such rigidity of the chest as to impair respira-tion and oxygenation thus producing the circumstancesrequired for the development of clubbing of the fingers.This is consistent with the fact that in the group of personsunder study clubbing was not seen in children, was lesscommon in those aged 20-40, but was frequently found inthose over 40. This corroborates the view that thecumulative effect of ingestion of excessive fluorine overmany years has its major effects on the bones of olderpeople.5The bony abnormalities described here arose in persons

who had been consuming water containing 5 p.p.m. (ormore) of fluorine for many years. The findings have nobearing on individuals who drink water fluoridated tocontain around 1 p.p.m. of fluoride-a procedure whichhas been clearly shown to reduce greatly the incidence ofdental caries 6 is areas where the water contains much lessthan this amount. The osteosclerosis found in subjects inthe survey does, perhaps, support the view that in theselesser amounts fluorine consumed over many years may bebeneficial to older people by reducing the incidence ofosteooorosis.

M. C. LATHAMO.B.E., B.A., M.B. Dubl.

D.T.M. & H., M.P.H. Harvard

Department of Nutrition,Harvard University

School of Public Health,665, Huntington Avenue, Boston,

Massachusetts 02115, U.S.A.

5. Shortt, H. E., McRobert, G. R., Barnard, T. W., Nayar, A. S. N.Ind. J. med. Res. 1937, 25, 553.

6. Ast, D. B., Fitzgerald, B. J. Am. dent. Ass. 1962, 65, 581.7. Bernstein, D. S., Guri, C. D. Post-grad. Med. 1963, 34, 407.

Reviews of Books

Recent Advances in GastroenterologyEditors: JOHN BADENOCH, D.M., F.R.C.P., consultant physician,United Oxford Hospitals; BRYAN N. BRooKE, M.D., M.CHIR.,F.R.C.S., professor of surgery, University of London at St.George’s Hospital Medical School. London: J. & A. Churchill.1965. Pp. 381. 65s.

- THIs authoritative and readable volume is the joint work ofphysicians, surgeons, biochemists, and geneticists, who present,not a systematic treatise, but an exciting series of essays onsubjects in which progress has been striking. In selecting theircontributors the editors have shown fine judgment, and theircollaborators speak with the authority that derives from expertknowledge. The part played by heredity in gastroenterologicaldiseases and the application of new physiological knowledge togastric and duodenal ulcer are ably dealt with by Dr. R. B.McConnell, and the role of immune mechanisms in the initia-tion or perpetuation of chronic inflammatory lesions of theintestinal tract is admirably reviewed by Prof. K. B. Taylor.Dr. M. Atkinson writes with authority on disorders of theoesophagogastric junction; the metabolic effects of vagotomyand gastroenterostomy receive impartial consideration, whichis particularly welcome with the recognition of an increasingproportion of measurable defects after both procedures. Thechapters on protein-losing enteropathy by Dr. A. M. Dawsonand on intestinal malabsorption Dr. C. C. Booth are particu-larly good, and Dr. N. F. Coghill’s information on ileostomymanagement is of great practical value. The irritable-colon

syndrome-perhaps the commonest of alimentary disordersand, until recently, the least understood-has shared in theadvances provided by the introduction of manometric andradio-telemetering devices, and the present situation is wellsummarised by Dr. S. C. Truelove. Prof. Sheila Sherlockrelates bilirubin metabolism to the various types of jaundice in a

chapter which is a model of clarity. The final sections of the bookdeal with the biochemistry of liver failure, the surgery of portalhypertension, and the investigation of pancreatitis.

Gastroenterology2nd ed. Vol. III. HENRY L. BOCKUS, M.D., emeritus professorof medicine, University of Pennsylvania Graduate School ofMedicine. Philadelphia and London: W. B. Saunders. 1965.

Pp. 1352. 210s.

HOT on the heels of the publication of the second edition ofthe second volume (that is to say, a year later) comes the thirdvolume of " Bockus ". Once again, in this completely rewrittenedition, Dr. Bockus has drawn on what he calls " our officialfamily (past and present) of the gastrointestinal division of theGraduate School of Medicine " who have written the greaterpart of the book. For over twenty years this has been thestandard authoritative work on gastroenterology: in itsrejuvenated form its pre-eminence is unlikely to be challenged.The third volume deals with gastrointestinal parasites, the liverbiliary tract, and pancreas, and secondary gastrointestinal dis-orders. Medical librarians, no doubt with melancholy reflec-tions on the mounting cost of medical books, will neverthelessfeel bound to buy it.

Hallux Valgus, Allied Deformities of the Forefoot andMetatarsalgia

’ H. KELIKIAN, M.D., associate professor of the department ofbone and joint surgery, North-Western University MedicalSchool, Chicago. Philadelphia and London: W. B. Saunders.1965. Pp. 503. 136s. 6d.

IN the middle of the last century, Volkmann, speaking of thedeformity now known as hallux valgus, complained that " thehandbooks of surgery pass over it mostly in silence ". Muchhas since been written to redress the balance, but probably nomonograph has ever treated the subject at the length and in thedetail accorded it by this American book. Part of the volumedoes relate to various disorders of the lesser toes, Freiberg’sdisease, Morton’s metatarsalgia, and the like; but more thanhalf is devoted to valgus deformities of the great toe. Sixchapters discuss their aetiology and pathology, and seven more,different techniques for correction.On the strength of this work alone, the author’s views

must command respect. It is interesting to find that he

supports a traditional view, recently unfashionable, of thecause of the deformity, and blames unsuitable footwear. Whenadvising on treatment he distinguishes between cases in whichthe deformity is a simple one and those complicated by second-ary changes which have made the metatarsophalangeal jointstiff or painful. For the first group, Dr. Kelikian has foundSilver’s operation the most useful: this is an intra-articularprocedure which releases adductor tension on the lateral side ofthe joint, and reinforces the medial capsule. When an arthritishas developed, fusion or a Keller’s resection is advised. Dr.Kelikian feels there is also a definite place for a restrictedexostectomy in the treatment of aged patients.

In this book for the specialist among orthopaedic specialists,the surgeon who has to deal as well with many other deform-ities would welcome a summary at the end of each chapter, anda rather more didactic style throughout.

Experimental Physiology (7th ed. Edinburgh: E. & S.

Livingstone. 1965. Pp. 244. 37s. 6d.).-This is a modern

edition, with a new editor, Dr. B. L. Andrew, of a book byProf. G. Bell which first appeared in 1936. It begins with briefdescriptions of the " black box " as well as the smoked-papervariety of apparatus, and then goes on to describe the perform-ance of class experiments suitable for medical students. In thecourse of time the explanation of the findings may change, andthe apparatus used to demonstrate them may become morerefined as well as more expensive, but it is interesting that theexperiments nevertheless remain basically those which havebeen in use for many years-illustrating how difficult it is tobe original in dealing with a large class of students, a smallstaff, and a limited budget. This book is what it sets out to be-practical.