23 The B.S.I. sodium flame test is less sensitive than the bacterial penetration test. Theoretically there is a constant relationship between the sodium chloride and bacterial penetrations for a given filter at a given air velocity. Imperfections in the filter medium, undetectable by the sodium flame test, prove it inconstant in practice. We therefore tested filtration efficiency by both methods. This is illustrated by the Microflow filters after one year of clinical use and by the Williams filter which retained a low sodium chloride penetration even after 200 autoclavings. Their bacterial filtration efficiency deteriorated during these test periods, suggesting that minute cracks that allowed the passage of bacteria had developed. We would have missed these if we had relied solely on resistance testing or on the sodium flame test. Bryan-Brown9 advises daily autoclaving of the Williams filter; if his recommendation is followed, it could fail before the annual replacement of the

filter element suggested by the manufacturer. The Ohio and Pall filters allowed unacceptable sodium chloride penetrations, and bacterial filtration results confirmed that they are unsuitable for clinical use. Expiratory filters with acceptable low resistance and high

Reviews of Books

Systemic Lupus Erythematosus Major Problems in

Internal Medicine: vol VI. JAMES F. FRIES, M.D., and HALSTED R. HOLMAN, M.D., Stanford University School of Medicine. Philadelphia and London: Saunders. 1975. Pp. 199.

$14, ;9.25. THIS book will be of great significance to those who in their daily practice. Since its principal manifestations are in the skin, joints, blood, pleura, immune system, central nervous system, and kidneys, that means most clinicians. Dr Fries and Dr Holman present a mass of carefully arranged data from their own series of 187 patients with S.L.E. studied in great detail between 1969 and 1974. In any debate between "lumpers" (one disease) and "splitters" (several) these authors would be firmly on the side of the splitters, and this book will probably win the day for that view. Their extensive use of the computer to delineate subsets of this protean disorder commands first respect and then admiration. Even the ultimate subset, the individual patient, can form the centre of a whole study utilising all the data accumulated from the other patients, and thereby assist the physician in weighing benefits and clinical costs of management decisions. There are all degrees of all diseases-you can have a touch of cancer like an actinic keratosis or early rodent ulcer or be martyred by liferuining backache. These authors have demonstrated the truth of this axiom in s.L.E. Hitherto gloomy prognostications attached to this diagnosis must now be modified by their estimation of survival from the onset of multisystem disease of 80-95% at 10 years. Very valuable indeed are the correlations of individual manifestations with each other, and with prognosis. This is by far-ihe most useful part of the work. The benign nature of Raynaud’s syndrome and arthritis is confirmed, and the sinister significance of pleurisy and renal involvement is contrasted. The authors’ experience of centralnervous-system involvement seems to have been less unfortunate than many others, but few statistics are offered. The value of relatively simple and cheap investigations is proved, such as degree of anaemia, sedimentation-rate, and routine urinalysis. They show that renal biopsy is nothing like so sensitive and reliable an indicator of renal involvement as proteinuria-this observation alone would make the book worth writing. The section on therapy is less impressive, and this reflects the absence of well-controlled trials in their series, especially with regard to the effect of corticosteroids and/or immunosuppression, but their conservative approach to these

encounter S.L.E.

bacterial filtration efficiency must be used in clinical practice. In our tests, the Microflow filters reached these standards during prolonged use and the Williams filter, which failed after 200 autoclavings, warrants further investigation. We thank Miss A. Kehoe, Miss K. Gorman, and Miss L. Gleave for secretarial assistance.

Requests for reprints should be addressed

Bacteriology, Wright-Fleming Institute,

St

to H. G., Department of Mary’s Hospital Medical

School, London W2 1PG. REFERENCES 1. Br. med. J. 1973, ii, 625. 2. Holdcroft, A., Lumley, J., Gaya, H. Lancet, 1973, i, 240. 3. Holdcroft, A., Lumley, J., Gaya, H., Adams, D., Darlow, H. M. ibid. 1974,

ii, 25. Hellewell, J., Jeanes, A. L., Watkin, R. R., Gibbs, R. J. Anœsthesia, 1967, 22, 497. 5. Mitchell, N. J., Gamble, D. R. Br. med. J. 1973, ii, 653. 6. Lowe, D. Hosp. Engng, 1971, 25, 171. 7. Martin, J. T., Ulrich, J. A. Anesth. Analg. curr. Res., 1969, 48, 944. 8. Holdcroft, A., Lumley, J., Gaya, H., Darlow, H. M. Unpublished. 9. Bryan-Brown, C. W. Int. Anœsthesiol. Clins, 1972, 10, 147.

4.

agents accords with the results of recent large trials. In the absence of data the author’s construction of a "therapeutic index" must surely be spurious; for once they have let their computer run away with them. Despite this criticism they have interesting comments to make on management. They debunk the role of sunshine in provoking the disease. They recommend that any drug "employed chronically" before the development of the clinical syndrome should be suspect. All medications not strictly essential should be stopped during the initial evaluation because improvement may ensue. Procainamide, sulphonamides, hydralazine, some anticonvulsants, and practolol are important examples. The interesting absence of renal or neurological involvement in most such patients is noted, and it is suggested that the kidneys escape because the drug is nearly always stopped in time. They also assert the surprisingly good results of transplantation in terminal renal failure where the two-year kidney-survival rate is only slightly lower than that in renal transplantation registry data for patients with all diagnoses. This is a valuable work which will be referred to for many years to come.

Epidemiology in Medical Practice D. J. P. BARKER, M.R.C.P., M.F.C.M., University of Southampton, and G. ROSE, F.R.C.P., F.F.C.M., St Mary’s Hospital Medical School, London. Edinburgh: Churchill Livingstone. 1976. Pp. 140. £2.95.

THE study of disease among populations (a literal translation of "epidemiology") is unappealing to many doctors because it operates on a different time-scale to clinical medicine. The accurate diagnosis of population health problems is measured in months and years rather than the hours and days spent in reaching a diagnosis in an individual patient. Nevertheless epidemiology is an intriguing subject, needing a scientific expertise of its own to unravel the clues to establishing aetiology, and to ensure a fair balanced assessment of the efficacy of health services. This little book should do much to explain the subject, to arouse enthusiasm, and, most importantly, to clarify the situations where an epidemiological approach is required to answer a question. For an inherently mathematical subject the book is written with admirable clarity, and is liberally illustrated with topical and often provocative examples of common important health problems in Western society today. The first section is a description of disease in the community. It includes sources of information both from routine statistics and special surveys; methods of describing rates of disease and temporal and geographical trends; and shows the vital role which epidemiology plays in community

24

medicine, both in identifying major problems and in defining

seminomas, teratomas, and combined

The second section goes into greater technical detail of the methods used to investigate aetiology, and leading on from this discusses the evaluation of preventive measures. The final section, which will be of greatest interest to clinicians, shows how epidemiology contributes to patient care in matters such as establishing prognosis, screening for early detection of disease, and investigation of epidemics (ranging from the traditional infectious diseases to modern epidemics of problems such as drug abuse and even attempted suicide). The concluding chapter, on evaluation of medical services, shows how the achievements of health services can be measured and costed (using cost in a sense wider than mere finance), and thus how rational decisions on priorities depend on information of an epidemiological nature. Epidemiology is, in Dr Barker and Professor Rose’s words, the "intelligence service" of community medicine whose concern is the campaign to improve health. This book will prove very useful to medical students, teaching them the aims and methods of community medicine in a lively and easily digestible way. It is to be hoped that it will also be read by many clinicians who will appreciate the help it gives them in compiling an objective and scientific summary of their practice of medicine.

rarer

priorities.

Cancer of the

Lung

H. GUNTER SEYDEL, M.D., Albert Einstein Medical Center; ARNOLD CHAIT, M.D., University of Pennsylvania; and JOHN T. GMELICH, M.D., University of California. New York and Chichester :

Wiley.

1976.

Pp. 200. $27.75, £14.

Tms book is one of a series of monographs in radiology. There is a section on diagnostic radiology, but the book is intended primarily for radiotherapists, especially those in training. There are many illustrations and the text is short. The history, incidence, and aetiology of lung cancer are described briefly but well, and made interesting by the quotation of older as well as the most recent references. The chapters on pathology and diagnosis are longer and more detailed. Although there are brief chapters on chemotherapy and on the indications for surgery, radiotherapy is the only treatment described in detail, and a knowledge of the techniques of irradiation is required. The indications for radical and palliative radiotherapy are carefully discussed; the results of all forms of treatment are poor, and since most patients have locally advanced disease at the time of diagnosis, the authors stress the importance of considering the quality of survival rather than its length, when making this decision. There will not be many who find this book suits their purposes, but those who do will find it suits them very well.

Pathology of the Testis Edited by R. C. B. PUGH, F.R.C.PATH., Institute of Urology, London. Oxford: Blackwell. 1976. Pp. 487. /:18.50.

IN 1964 there was published a monograph, The Pathology Testicular Tumours, edited by Dr Pugh, which gave an illustrated account of almost 1000 cases of tumours referred to the Testicular Tumour Panel and Registry since its inception in 1958. This book presented the subject in a clear and concise manner and clarified confusion over nomenclature, in particular with respect to that used by the Armed Forces Institute of Pathology in Washington. Dr Pugh is to be congratulated on expanding that monograph, restricted as it was to testicular tumours, to provide a much more comprehensive book on testicular pathology. This has been done by thorough revision and updating and by the addition of several new chapters. In the section of the book still devoted to testicular tumours, data on some 3000 patients referred to the Panel between 1958 and 1973 are included. There is a useful introduction dealing with incidence, frequency, classification, and nomenclature (which has been further simplified). Other chapters cover

of

tumours as well as the interstitial-cell and Sertoli-cell malignant lymphomas, tumours, yolk-sac and other testicular tumours of childhood, miscellaneous tumours of epithelial type, and paratesticular tumours of connective tissue and muscle. Computer analysis has been possible for cases diagnosed in the 10 years 1958-67, and the results for the relative malignancy of these tumours are given together with a brief appendix on the statistical methods used. Among the new material in the book there is a comprehensive introduction dealing with the structure, function, and development of the human testis with studies of seminiferous tubules and chromosomes at meiosis. Other new chapters include those on congenital abnormalities, inflammatory conditions (including fungal and parasitic diseases), and a description of miscellaneous lesions some of which would have to be considered in the differential diagnosis of a tumour. In addition there is a thorough account of the comparative pathology of testicular tumours in animals, and the whole is enhanced by an authoritative chapter on the management of patients with tumours of the testis which should prove most useful for those responsible for the clinical management of these cases. The book is well illustrated throughout with numerous black-and-white photographs of gross specimens, photomicrographs, and electron micrographs. Dr Pugh has been ably assisted by his colleagues of the Testicular Tumour Panel and other experts, and they are to be congratulated on producing a clear and readable account of what to many is a

complex subject.

Chemotherapy Edited by J. D. WILLIAMS, A. M. GEDDES, K. HELLMANN, and T. A. CONNORS. London and New York: Plenum. 1976. /;26.46, $42, for each of 8 volumes.

WHAT can one say of this formidable undertaking, except that it exists? The Ninth International Congress of Chemotherapy was held in London last July, and this is a selection (about 50%) of the 1000 papers contributed to that gathering, which was,attended by workers from forty-nine countries. The last two volumes are on chemotherapy for cancer; the remainder, in order, are on Clinical Aspects of Infections, Laboratory Aspects of Infections, Special Problems in Chemotherapy, Pharmacology of Antibiotics, Penicillins and Cephalosporins, and Parasites, Fungi, and Viruses. There are no subject indexes, and type-faces and presentation are inconsistent; the price will send shivers down the spines of librarians. Pediatric Therapy 5th ed. Edited by HARRY C. SHIRKEY, M.D., Tulane University School of Medicine, New Orleans. St. Louis: Mosby. London: Kimpton. 1975. Pp. 1405.$34.50; /;27.65.

You may argue that the days of the multiauthor (117 in this case) textbook are over. Certainly, for an account of contemporary therapeutics one would consult the appropriate journals and not this book. Some of the contributions (management of asthma, hypertension, and the drug treatment of epilepsy and the nephrotic syndrome) seem to have been

written in the late 1960s. Nevertheless there is much to commend in this attractively presented and well-indexed volume. The sections written by Dr Shirkey on the fundamentals of drug therapy are humane and sensible. There is a delightful vital aid for providpicture of a rocking chair captioned "a ing love, fluids, and co-operative administration of drugs"the words of a doctor who understands children and parents. The chapter on eating problems is sane, and the treatment of play therapy should be read by anyone who considers this a suitable diversion for underemployed nurses-it is not. This is an expensive book but a good investment for a paediatric department library. Individual purchasers should not be deterred by the frequency of new editions. The important work will not date and recent advances are already dated. ...

Editorial: Ban the ban.

23 The B.S.I. sodium flame test is less sensitive than the bacterial penetration test. Theoretically there is a constant relationship between the sodi...
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