Postgrad Med J: first published as 10.1136/pgmj.29.336.497 on 1 October 1953. Downloaded from October 1953 SOMERVILLE: Mitral Stenosis: Selection of Cases for Mitral Valvotomy 497 for prompt treatment of sore throats or recurrences Secondly, to ensure an adequate check on any of limb or joint pains and on the importance of change in the cardiac status they may have penicillin cover for dental extractions if heart occurred; at follow-up clinical and radiological lesions persist. If sulphonamide prophylaxis has signs in the heart may be either more or less been started in hospital it should be continued for marked than they were in hospital and further at least another two years. Patients should attend advice on physical activity must be given. Thirdly, after-care clinics at regular intervals. Our own are to re-emphasize to the patients or their parents the seen at the third, sixth and twelfth month after dis- continued need for sulphonamide prophylaxis and charge and then once each year. These examina- prompt treatment of sore throats or limb or joint tions are of value for the following reasons. First, pains should they occur. to establish as far as possible whether there has been any fresh rheumatic activity; the occurrence BIBLIOGRAPHY of sore throats or limb andjoint pains is noted; the ABRAHAMS, D. G. (I949), Brit. Heart 7., II, 342. and 'American Heart Association Statement' (1953), Lancet, i, 285. haemoglobin, blood sedimentation rate weight BESTERMAN, E. M. M., and THOMAS, G. T. (I953), Brit. are recorded and a search is made for nodules. If Heart J., I5, 113. there is any question of present activity the patients TARAN, L., and SZILAGYI, N. (I947), Amer. Heart 3'., 33, 14. THOMAS, G. T., BESTERMAN, E. M. M., and HOLLMAN are re-admitted for assessment and treatment. A. (1953), Brit. Heart3'., 31, 29.

MITRAL STENOSIS: SELECTION OF CASES FOR MITRAL VALVOTOMY by copyright. By WALTER SOMERVILLE, M.D., M.R.C.P. Cardiologist, Thoracic Surgical Unit, Harefield Hospital. Assistant, Department of Cardiology, The Middlesex Hospital. Chief Assistant, National Heart Hospital.

When it became apparent that the stenosed I950; Harken, et al., 1950; Baker, et al., 1950) mitral valve could be treated by surgery, clinicians were applied to our first patients (Bedford, et al., immediately were faced with the problem of de- 1953). With experience, criteria were modified ciding which patients would benefit by operation. slightly, mainly towards including patients with http://pmj.bmj.com/ The more obvious indications were predicted from features which heretofore would have been re- the abnormal anatomy and physiology. Others garded as unfavourable or frank contraindications. were arrived at in time by the expedient of trial The current basis for selection, influenced to some and error. A number of important points are still extent by discussion with others interested in the subjudice. subject, but mainly by our observation and ex- It was soon evident that not every person with perience, is in close accord with the views expressed mitral stenosis was suitable for operation. Some recently by Baker and his associates (1952). The of the earlier cases were failures partly because of term ' mitral valvotomy' refers to splitting of the on October 2, 2021 by guest. Protected the newness of the technique of operating inside mitral valve commissures by finger or knife; it is the heart and partly because of clinical features synonymous with 'valvulotomy' and 'com- which today would have contraindicated operation. missurotomy ' used by other writers. In each of the first four cases, all fatal, reported by Bailey and his colleagues (I950), one or more of the following features were present: A very large Symptoms heart, mitral incompetence, advanced cardiac The main indication for mitral valvotomy is failure, gross left atrial enlargement and bronchiec- breathlessness attributable to mitral stenosis. This tasis. The unsuitability of each of these findings fact needs emphasis, for patients with mitral will be referred to later. stenosis may be breathless from other causes such The broad principles for selection laid down by as severe associated aortic valve disease or chronic the earlier workers in this field (Bailey, et al., lung disease. Postgrad Med J: first published as 10.1136/pgmj.29.336.497 on 1 October 1953. Downloaded from 498 POSTGRADUATE MEDICAL JOURNAL October I953 3 3 ;Ig 1 snap first second first sound sound sound 1' 4, ~thirdsod sound

I I

FIG. I.-Diagram of auscultatory findings in mitral stenosis (after Wood). A complete cardiac cycle is by copyright. depicted, commencing with the first heart sound and ending with the first heart sound of the succeeding cycle. The second sound is followed by the mitral opening snap, represented arbitrarily by a single line. If the two elements of the second sound are heard, they are shown as two columns in apposition, the heights and grading depending on which element is the louder. A diastolic murmur follows the opening snap, ending with a crescendo pre-systolic murmur which is also shown commencing the cycle. The numerals are grades of loudness, from i to 4 (loudest)-N is normal. The diastolic and pre-systolic murmurs are graded separately. The figure below the line represents the duration of the murmur, here grade 4 (from opening snap to first sound). The grading is assessed by auscultating at the apex for the first and third sounds, and pre-systolic and diastolic murmurs, if necessary with the patient lying on the left side; at the third left interspace for the second sound, and at the fourth left interspace close to the sternum for the opening snap. Aortic murmurs are entered verbally below the diagram. Fig. Ia represents the auscultatory findings in a patient suitable for mitral valvotomy. In Fig. ib the

signs of mitral incompetence are depicted. The third sound, later than the opening snap and without http://pmj.bmj.com/ its abrupt, sharp quality, is followed by a short diastolic murmur. Patients with this auscultatory pattern are unsuitable for valvotomy.

It is not always an easy matter to assess to what tions of severe mitral stenosis and are signs of extent a person is embarrassed by breathlessness. pulmonary congestion resulting from obstruction Many individuals are unable to explain their of blood flow from left atrium to left ventricle.

symptoms in their own words or they omit on October 2, 2021 by guest. Protected significant details because they are so familiar with Physical Signs of Mitral Stenosis and Pul- them. However, the majority know how far, or monary HTypertension for how long, they can walk at a brisk pace, whether The importance of distinguishing the types of they can keep up with their friends, travel to mitral stenosis likely to benefit by valvotomy has work or do their shopping or house work. Patients focussed attention on the other palpatory and should be encouraged to recount such everyday auscultatory signs which accompany the classical experiences for they provide a good assessment of mitral diastolic or presystolic murmur. In the the degree of incapacity and of the improvement ideal case the first heart sound is abrupt, loud and following operation; for these purposes they are snapping in quality, features which with the pre- more intormative than standard exercise tolerance systolic thrill are responsible for the characteristic tests. Orthopnoea, haemoptyses and attacks ofpul- . Direct of the exposed heart monary oedema awakening the patient from sleep and palpation within the left atrium during opera- or precipitated by effort are common manifesta- tion point to the fact that the first heart sound with Postgrad Med J: first published as 10.1136/pgmj.29.336.497 on 1 October 1953. Downloaded from October I953 SOMERVILLE: Mitral Stenosis: Selection of Cases for Mitral Valvotomy 499 these qualities is produced by the anterior leaflet common with sinus rhythm than auricular fibrilla- of the stenosed mitral valve when its texture is tion; it occurs whenever the left atrial pressure pliant and supple. Similarly the sharp additional exceeds about 35 mm. Hg. Hence, it follows sound which follows the second sound, the so- unusually strenuous exercise and may be the called mitral opening snap originates from this initial symptom responsible for drawing attention leaflet early in left ventricular diastole. The to the heart disease. Attacks of pulmonary oedema evidence is convincing that these two signs, the at rest are precipitated by , for example loud sharp first sound and the opening snap, are with terrifying dreams, or excitement, sexual inter- accompaniments of a mitral stenosis amenable to course, fever, thyrotoxicosis, pregnancy and valvotomy. When the mitral valve is predominantly parturition, and by certain drugs with an atropine- incompetent from retraction and deformity of the like action. leaflets and hence unsuitable for valvotomy, the Pulmonary hypertension in mitral stenosis may first sound invariably lacks the features mentioned be inferred from the physical sign of right ven- above (Brigden and Leatham, I953). tricular enlargement, a visible and palpable pulsa- The auscultatory signs of mitral stenosis can be tion over the third and fourth left interspaces close depicted conveniently by a diagram, a technique to the sternum. Rarely the enlarged pulmonary which is time-saving and at a glance gives to those can be felt in the second left interspace, and familiar with the system a comprehensive idea of just below it, the pulmonary valves produce a the most important auscultatory findings. The palpable when closing, heard through the symbols and grading used by Paul Wood (Fig. i) stethoscope as a loud second sound. The Graham are preferred to the more detailed scheme of Steell murmur of pulmonary incompetence may be Levine (I94). present when the pulmonary arterial pressure is The signs of mitral stenosis outlined above are very high. The electrocardiogram (Fig. 2) shows not of themselves indications for mitral valvotomy right ventricular hypertrophy and, with sinus because they can be present without symptoms and rhythm, the characteristic widened, notched P- may be discovered unexpectedly in the course of a mitrale. The radiological features are referred to routine medical examination. However, when pul- below. Pulmonary hypertension is confirmed andby copyright. monary hypertension is present symptoms are measured by cardiac catheterization. seldom absent and then the indication for surgical Cardiac catheterization has played an invaluable treatment is more secure. role in the investigation and explanation of the When the mitral valve is narrowed to a suf- haemodynamics of mitral stenosis. It has allowed ficiently severe degree, the blood pressure in the pulmonary arterial and capillary hypertension to be left atrium rises. The elevated pressure is re- interpreted in terms of symptoms and physical flected backwards through the pulmonary to signs. However, it is not an essential part of the the peripheral capillary vessels where the pul- investigation of mitral stenosis, and when the monary venous radicles commence and the indications for operation are clear-cut, we no flow catheterize the We restrict it to arterioles end. To maintain blood in face of longer patient. http://pmj.bmj.com/ this raised pressure, pulmonary arterial and right doubtful cases or where a discrepancy exists be- ventricular pressure must also increase. This has tween symptoms and physical signs. Sometimes been called passive pulmonary hypertension the physical signs ordinarily found with pulmonary (Wood, 1952). By a series of imperfectly under- hypertension are masked or attenuated by obesity, stood reflexes, certain patients with severe mitral chest deformity or other causes not always stenosis develop, in addition, an active constriction identifiable. In two instances cardiac catheteriza- of the pulmonary arterioles; the resulting in- tion demonstrated high pulmonary pressure in the creased resistance to blood flow causes a further absence of physical signs or electrocardiographic on October 2, 2021 by guest. Protected elevation of pulmonary blood pressure which may changes. then reach extreme levels. In the normal person physical exercise raises the Age pulmonary arterial and venous pressure but the The danger of activating the acute rheumatic increase is always within fairly well-defined limits. state by mitral valvotomy in young persons has The pulmonary hypertension of mitral stenosis fixed the lower age limit as 20, although occasion- exceeds these limits with exercise and is the most ally younger patients have severe mitral stenosis important factor governing the amount of exercise for which operation cannot be delayed. Suitable that can be taken without breathlessness. Ex- cases are uncommon over the age of 50. cessive elevation of the blood pressure in the pul- monary capillaries leads to haemoptysis or pul- Associated Valve Disease monary oedema and severe, often paroxysmal, Severe aortic valve disease or gross mitral in- dyspnoea. The latter distressing symptom is more competence disqualifies a patient for mitral Postgrad Med J: first published as 10.1136/pgmj.29.336.497 on 1 October 1953. Downloaded from 500 POSTGRADUATE MEDICAL JOURNAL October I953

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FIG. 2.-Electrocardiogram of patient with mitral stenosis on whom mitral valvotomy was performed successfully.. P-mitral is well shown in leads I and II. Pulmonary hypertension was also present and the tall R in Vi indicates right ventricular enlargement. - valvotomy. These lesions may be regarded as heart rhythm whether regular or irregular from contraindications when they are responsible for auricular fibrillation appears to have no bearing on clinical, radiological or electrocardiographic evi- the suitability for operation. Auricular fibrillationby copyright. dence of moderate to severe left ventricular en- in patient in the early 20'S or younger bespeaks largement. Mitral incompetence excludes the severea, rheumatic damage to the heart, a fact which patient when it causes a mitral systolic thrill and must be borne in mind when considering surgical murmur, left ventricular enlargement and great treatment. Older persons with auricular fibrilla- enlargement of the left atrium with or without tion have shown satisfactory improvement after expansion during ventricular systole. valvbtomy. The arrhythmia persists; we are not Mild aortic valve disease with little or no left aware of an instance of established auricular ventricular enlargement, or a mitral systolic mur- fibrillation reverting to sinus rhythm after mur without the other associations of mitral operation. incompetence, are not contraindications. Tricuspid incompetence may be an additional Embolism http://pmj.bmj.com/ sign of high pressure in the right ventricle and Previous emboli, systemic or pulmonary, have pulmonary artery. Then it is functional and re- been encountered in many patients who have later versible and a reflection of the severity of the undergone a successful valvotomy. The evidence disease, not a contraindication. This type of is strong, in fact, that operation diminishes or tricuspid incompetence may improve or disappear abolishes the tendency towards embolus formation. with the pre-operative medical treatment.. Or- Cardiac Failure

ganic tricuspid disease, stenosis and incompetence, on October 2, 2021 by guest. Protected may be disclosed by longstanding, intractable signs Paroxysmal dyspnoea is one of the cardinal of incompetence (prominent systolic pulsation in features of severe mitral stenosis and one of the the neck veins and liver) and can be confirmed by urgent indications for operation. The ease with pressure tracings in the right atrium and right which pulmonary congestion can be induced by ventricle. A limited personal experience suggests tachycardia has been referred to above. A patient that patients with this complication do poorly after in frank congestive (right ventricular) failure mitral valvotomy. should not be submitted for operation; he may Pulmonary incompetence (the Graham Steell respond well to medical treatment, however, and murmur) is the result of high pulmonary artery the case should be reassessed in his improved pressure and is appraised accordingly. state. It has been widely taught that intractable heart failure is evidence of advanced heart disease Heart Rhythm with widespread myocardial damage. Recent When the patient is suitable otherwise, the observations have shown that this is not always so Postgrad Med J: first published as 10.1136/pgmj.29.336.497 on 1 October 1953. Downloaded from October 1953 SOMERVILLE: Mitral Stenosis: Selection of Cases for Mitral Valvotomy 50S

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FIG. 3.-Radiographs taken before (A) and one year after (B) successful valvotomy for mitral stenosis. In by copyright. the post-operative picture, the pulmonary artery is much less prominent. and that active pulmonary hypertension which can Radiography be relieved by valvotomy is often the causative From what has been said about the clinical factor (Wood, 1953). indications and physical signs of the suitable case Mitral Calcification for mitral valvotomy it should be possible to Calcification of the mitral valve is best detected picture the radiographic features of the ideal case. by radioscopy with the patient turned slightly The cardiac shadow should be no more than towards the right oblique position. Extensive moderately enlarged; the cardio-thoracic ratio, calcification is seen without much searching, for it despite its obvious shortcomings as an accurate http://pmj.bmj.com/ stands out under the fluoroscope as a dense mobile measure of heart size, allows this permissible mass at the site of the mitral valve. Formerly it degree of enlargement to be expressed as not was our opinion that calcification of this degree greater than 6o per cent. The left atrial appendix would be an insuperable obstacle to valvotomy, is visible on the left cardiac border above the apart from the hazard of detaching a fragment into ventricular curve, by virtue of the left atrial en- the circulation. However, Mr. T. Holmes largement and of the adjacent infundibular (right Sellors has operated on a patient with gross ventricular) enlargement. The pulmonary artery calcification of this type who was otherwise suit- curve is more or less prominent; when the pul- on October 2, 2021 by guest. Protected able. The valve was split easily and the functional monary arterial pressure is greatly elevated this result was gratifying. No emboli were detached. curve is, as a rule, conspicuous. The aortic Nevertheless, extensive mitral calcification is knuckle is small or absent. Pulmonary venous usually a feature of severe, longstanding disease congestion causes a characteristic fan-shaped with incompetence, cardiac enlargement and other shadow radiating outwards from the hilar regions. unfavourable factors which contraindicate opera- The primary subdivisions of the right and left tion. The decision against operation seldom pulmonary may be dilated and super- depends on calcification alone. imposed on the pulmonary venous shadows. Less degrees of calcification in the form of dis- Pulmonary haemosiderosis does not appear to crete, opaque flecks which can be discovered often influence the operative result over a period of at after more or less diligent fluoroscopic search are least I8 months. Unless longer follow-up studies inconsequential and have no bearing on selection alter this impression, haemosiderosis should not be for operation. regarded as a drawback to surgical treatment. Postgrad Med J: first published as 10.1136/pgmj.29.336.497 on 1 October 1953. Downloaded from POSTGRADUATE MEDICAL JOURNAL October 1 95 3 Fig. 3a illustrates the typical radiographic The Middlesex Hospital under Dr. D. Evan appearances of a patient considered to be ideal for Bedford; mitral stenosis with sinus rhythm: for valvotomy. A good functional result was achieved. nine months frequent attacks of pulmonary Fig. 3b was taken one year after operation. oedema at night and with effort; exercise toler- ance reduced to less than 50 yds. walking. Associated Diseases Total thyroidectomy (Mr. R. Vaughan Hudson) Patients with mitral stenosis are often affected by was followed by complete freedom from symp- attacks of bronchitis from which permanent toms. Pattern of right ventricular enlargement residual changes in the lungs such as bronchiectasis in chest leads VI-6 disappeared. Myxoedema and emphysema may entail a reduced effort was controlled with small doses of thyroid tolerance. Therefore breathlessness in these extract. After three years, heart symptoms patients calls for careful appraisal, for when lung returned and mitral valvotomy was performed disease is the dominant factor it will not be im- with satisfactory results. proved by valvotomy. On the other hand, if the Pregnancy in patients with mitral stenosis does lungs have escaped detectable damage surgical not call for a different set of criteria for selection relief of mitral stenosis scems to leave the patient for operation. In the majority of instances they less susceptible to recurrences of lung infections. proceed to term uneventfully. Yet a sufficiently Pulmonary tuberculosis is seldom found with large number, usually in sinus rhythm, develop severe mitral stenosis, but if the indications for acute pulmonary oedema. The physical signs of valvotomy are otherwise clear-cut, there is no pulmonary hypertension in a pregnant woman with reason why it should not be performed. Recently rapid diminution in effort tolerance are a warning Mr. Holmes Sellors has operated successfully on a and indicate bed rest. If in spite of routine treat- girl with the tetralogy of Fallot and left upper ment with digitalis, sodium restriction and mer- lobe tuberculous cavitation, a left upper lobec- curial diuretics no improvement is apparent, or a tomy being followed immediately by a Blalock radiograph shows the vascular markings of pul- anastomosis. It would appear that equally en- monary venous congestion, then the danger of couraging results may be expected from surgical pulmonary oedema is great. This hazard mayby copyright. treatment for co-existing mitral stenosis and appear as early as the third calendar month or in pulmonary tuberculosis (Hill, 1952). the eighth month when the burden on the circula- pectoris occasionally complicates mitral tion is said to reach its peak. Pulmonary oedema stenosis, but there is little information on the is a specially terrifying experience for the pregnant effect of valvotomy on this symptom. In two woman and recurrences are common. Mitral instances where it was present no attacks have valvotomy may be life-saving under these circum- occurred since operation, two to six months ago. stances, allowing the pregnancy to continue and A third patient, a woman aged 49, had angina of later making the patient a fitter person to undertake effort for a year and a cardiac infarction five the responsibilities of motherhood. months before operation. Since valvotomy two Until more is known about the long-term re- months ago she has had one attack of at sults of mitral valvotomy, women who have been http://pmj.bmj.com/ rest. operated on successfully should not be encouraged The aggravating effect of uncontrolled thyro- to embark on repeated pregnancies. toxicosis on mitral stenosis has been referred to earlier. The severity of the cardiac symptoms Summary cannot be assessed until the thyrotoxicosis is The criteria for selection of patients with mitral treated. A course of thiouracil may alter the com- stenosis for mitral valvotomy are:

plexion of the heart disease in dramatic fashion; i. Breathlessness, pulmonary oedema and on October 2, 2021 by guest. Protected thyroidectomy, if preferred can then be carried haemoptyses resulting from mitral stenosis not out with safety. If mitral stenosis can still be from associated valve lesions or complications. blamed for symptoms and the indications outlined 2. Signs of the type of mitral stenosis amenable above are present, valvotomy should be performed. to surgery, namely a loud, abrupt first heart It will be recalled in this respect that 20 years sound and opening snap together with the murmur ago total thyroidectomy was in vogue for the of mitral stenosis. treatment of heart failure (Blumgart, et al., 3. Signs of pulmonary hypertension, namely 1933). The results were unpredictable and the palpable pulsation of the right ventricle, a loud method has fallen into disuse. Yet occasionally, palpable second sound and sometimes the Graham the distressing paroxysmal dyspnoea of mitral Steell murmur of pulmonary incompetence. stenosis can be improved or even abolished by Tricuspid incompetence may be an added sign of thyroidectomy. pulmonary hypertension; it has this significance Mrs. A. T. (B 69026), aged 45, admitted to when gross cardiac enlargement is absent. Cardiac Postgrad Med J: first published as 10.1136/pgmj.29.336.497 on 1 October 1953. Downloaded from October 1953 SOMERVILLE: Mitral Stenosis: Selection of Cases for Mitral Valvotomy 503 catheterization confirms pulmonary hypertension. 12. During pregnancy, if symptoms increase It no longer forms part of the routine investigation and pulmonary oedema develop3 in a patient and need only be performed when a discrepancy otherwise suitable for mitral valvotomy, the opera- exists between symptoms and signs. tion may be life-saving and allow successful de- 4. The most suitable age range is 20 to 50. livery later. The majority of pregnant women with 5. Severe aortic valve disease, tricuspid stenosis mitral stenosis do not require surgical treatment. and mitral incompetence should be absent, although mild degrees of these lesions are per- The patients referred to in this paper were under missible. the care of Dr. D. Evan Bedford in conjunction 6. The rhythm may be either regular sinus or with whom the observations were made. Many of auricular fibrillation. the views expressed were influenced by the teach- 7. Previous emboli, systemic or pulmonary, are ing of Dr. Paul Wood, whose chief assistant the not contraindications. Operation may prevent writer is at the National Heart Hospital. Mitral future emboli or lessen their frequency. valvotomy in all cases was performed by Mr. T. 8. Right ventricular failure should be absent, Holmes Sellors assisted by Mr. J. R. Belcher. although a patient in failure may respond to treat- BIBLIOGRAPHY ment and eventually become a candidate for BAILEY, C. P., GLOVER, R. P., and O'NEILL, T. J. E. (I950), operation. J. Thorac. Surg., ig, i6. from cardiac BAKER, C., BROCK, R. C., and CAMPBELL, M. (I950), Brit. 9. Gross cardiac enlargement med. Y., i, 1283. failure, severe associated valvular lesions or BAKER, C., BROCK, R. C., CAMPBELL, M., and WOOD, P. irreversible rheumatic muscular damage, contra- (1952), Ibid., i, 1043. BEDFORD, D. E., SELLORS, T. H., and SOMERVILLE, W. indicates surgery. (I953), To be published. should be controlled with BLUMGART, H. L., LEVINE, S. A., and BERLIN, D. D. (I933), io. Thyrotoxicosis Arch. intern. Med., Si, 866. thiouracil before mitral stenosis is assessed for BRIGDEN, W., and LEATHAM, A. (1953), Brit. Heart J., i5, 55. surgery. HARKEN, D. E., ELLIS, L. B., and NORMAN, L. R. (1950), i i. Repeated chest infections with residual per- Y. Thorac. Surg., I9, I.

HILL, I. (1952), Proc. R. Soc. Med., 45, 538. by copyright. manent. lung damage such as bronchiectasis or LEVINE, S. A., and HARVEY, W. P. (I949), 'Clinical Ausculta- tion of the Heart,' ist ed. pp. 145-I48. London: Saunders. emphysema sufficient to produce symptoms, make WOOD, P. (1952), Brit. med. Bull., 8, 348. valvotomy of dubious value. WOOD, P. (I953), Personal communication. http://pmj.bmj.com/ RADIOACTIVE ISOTOPES AN INTRODUCTION TO THEIR PREPARATION, MEASUREMENT AND USE by W. J. WHITEHOUSE and J. L. PUTMAN Both with the Ministry of Supply, Atomic Energy Research Establishment, Harwell With a Foreword by SIR JOHN COCKCROFT 440 pages 160 illustrations 50s. net on October 2, 2021 by guest. Protected

DISEASES OF THE HEART AND CIRCULATION by ALBERT A. FITZGERALD PEEL, D.M., F.R.F.P.S.(G) Physician for Diseases of the Heart, Victoria Infirmary, Glasgow; Medical Consultant, Department ofHealth Jbr Scotland and Ministry of Labour and National Service Recruiting Boards SECOND EDITION 496 pages 176 illustrations 35s. net OXFORD UNIVERSITY PRESS