641 V’e thank Dr A. Voller for his help, and the Ministry of Overseas Development and the Medical Research Council for financial support.
Requests for reprints should be addressed to H. A. R. REFERENCES Voller, A., Bartlett, A., Bidwell, D. E. Trans. R. Soc. trop. Med. Hyg. 1976, 70, 98. 2. Voller, A., Bidwell, D., Bartlett, A. in Manual of Clinical Immunology edited by N. R. Rose and H. Friedman); p. 506. Washington, D.C., 1976. 3. Greenwood, B. M., Warrell, D. A., Davidson, N. M., Ormerod, L. D., Reid, H. A. Br. med. J. 1974, iv, 743. 4 Kochwa, S., Gitter, S., Strauss, A., de Vries, A., Leffkowitz, M. J. Immun. 1959, 82, 107. 5. Reid, H. A. Br. med. J. (in the press). 6. Reid, H. A. ibid. 1957, ii, 26. 7 Sutherland, S. K., Coulter, A. R., Broad, A. J., Hilton, J. M. N., Lane, L. H D. Med. J. Aust. 1975, i, 27. 1
Methods and Devices A SIMPLE AND INEXPENSIVE DEVICE FOR
POOLING CRYOPRECIPITATE R. GILLON
W. T. LOW
PETER JONES
Departments of Hœmatology and Medical Physics, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP CRYOPRECIPITATE therapy is still widely used for treatment in haemophilia A, especially in developing countries. We describe a method of pooling the contents of several packs by means of a simple vacuum box worked from an ordinary water tap and a Venturi pump.
Apparatus The
box used in Newcastle is made of 6 mm thick the top should be transparent, less expensive materials could be used. The box measures 28 (length) x 16 (width) x 7 (height) cm, and is covered with a closely fitting flanged lid (depth of flange 1.5 cm). Sponge rubber is glued around the flange to provide an airtight seal. A connector (stainless steel, brass, or plastic) is inserted into a 7 mm hole at one end of the box and held in place either by screws, or by an external nut, over rubber seals. Tubing runs from the connector, via a water trap, to a Venturi pump. A 4 mm C-slot at the other end of the box (duplicated in the flange) accepts tubing from the transfer pack. Sterile 0.9% saline solution is used to rinse the cryoprecipitate packs from a pack suspended above the apparatus via a Fenwal AE-7 double-ended transfer set. Fresh saline solution is used for each pool.
of Dick and Smithuses a vacuum chamber but obviates the need for a mechanical pump. It does not rely on a power source and may be ideal for home therapy when this has to be based on cryoprecipitate rather than lyophilised concentrate. With the method 10 packs can be pooled by aseptic technique in 5 minutes, after thawing. The saline rinse allows maximum recovery from the evacuated cryoprecipitate packs. The box, forceps, and the Venturi pump, water trap, and connected tubing are easily cleaned; the remainder of the apparatus is disposable. The device has been used in Newcastle for the past 5 years without any difficulties being encountered and has been supplied to associated haemophilia centres. Further details of construction are available from the department of hxmatology. ’
BX’e thank the staff of the University Department of and Teaching Aids Laboratory for help with the diagram.
vacuum
’Perspex’; although
Method A 600 ml transfer pack (Fenwal TA-1) is placed in the box, the tubing pressed into the C-slot, and the lid closed. The tubmg is clamped with a pair of Spencer Wells forceps and the pump turned on. The transfer pack coupler is inserted through one port of a cryoprecipitate pack and the tube undamped; cryoprecipitate is drawn into the transfer pack. After reclampmg, between 5 and 10 ml sterile saline solution is run into the cryoprecipitate pack via the second port and the pack is rinsed. The rinsing solution is then drawn into the transfer pack. The procedure is repeated until the desired dose of cryoprecipitate is attained. The transfer pack is then clipped off and the pooled cryoprecipitate is ready for intravenous-drip administration to the patient.
Discussion One of the drawbacks of cryoprecipitate is the need
to use
several individually donated packs to make up the correct dose of factor viii for the patient. Pooling in syringes is time consuming and unlikely to be aseptic. Alternative methods of pooling have been describedu2 but are either cumbersome or more expensive than the method we describe. Our method, like that
Photography
REFERENCES 1. 2.
Davidson, J. F., Muir, W. Lancet, 1968, i, 73. Dick, R., Smith, H. Gaz. Inst. med. Lab. Technol. 1973, 17, 384.
Reviews of Books The Child with Spina Bifida
,
ELIZABETH M. ANDERSON and BERNIE SPAIN. London: Methuen. 1977. Pp. 352. £ 7.50.
THE aim of this book is to give information on the functioning of the child with spina bifida and to make practical suggestions about how problems may be prevented or alleviated. It provides a wealth of clearly written facts and original data as well as a wide coverage of research, mainly on social and edu-
cational aspects. The section on medical aspects is clear but marred by errors. The section on the families is full of insight and common-sense recommendations. An excellent section on schooling gives details of difficulties in perception and poor manual skills. It describes the emotional immaturity, poor concentration, poor attainment, and apathy of many of these children. It analyses the problems encountered in reading, writing, and arithmetic and gives advice to teachers. It shows how help from parents and nursery-school experience may prevent some of the difficulties met in schooling. A special plea is made for exchange of information between doctors, teachers, and parents. The last section deals with the problems and needs of adolescents, which are becoming more pressing. The information in this book will be invaluable to all concerned with the provision of services for the children and young adults. It will also enable professionals to give a great deal more help with the day-to-day problems and so lighten the load on parents and others who have to care for children with spina bifida and hydrocephalus.
642
Spina Bifidii
Myopathies
Problems and Management. G. D. STARK, F.R.C.P.E., Royal Hospital for Sick Children, Edinburgh. Oxford: Blackwell. 1977. Pp.
JAAP BETHLEM, M.D., University of Amsterdam. Amsterdam. North-Holland. Philadelphia: Lippincott. 1977. Pp. 281. D.f1. 96,
192./:6.
$39.25.
THIS book reflects the experience which Dr Stark has gained a combined medical and surgical spina-bifida clinic in Edinburgh where the emphasis has been on a selective attitude to the treatment of patients with spina bifida. It is a welcome reaction to the surgical enthusiasm which followed the introduction of the Spitz Holter valve for the control of hydrocephalus. Unfortunately advocates for active treatment of spina bifida tend to ignore the irremediable defects which persist even after the hydrocephalus has been controlled and which are the cause of so much long-term disability. The author deals mainly with the assessment and medical aspects of the treatment of spina bifida, but he also considers the indiin
cations, limitations, and complications of surgical
treatment.
He begins with a section on the basic considerations, including the incidence and what is known of the aetiology. He then goes on to discuss clinical problems associated with myelomeningocele and affecting the lower limbs, bladder, bowel, and sexual functions, and associated malformations. There is a wealth of useful clinical advice about the management of all aspects of children with spina bifida. The production is excellent, the illustrations are good, and there is an extensive list of references. This book is intended for the community physician rather than the surgeon but any surgeon who has to deal with spina bifida ought to read this book, and so should every paediatrician and community physician who is involved in the management of children with spina bifida.
Dermatology Tutorials in Postgraduate Medicine: R. MARKS, M.R.C.P., and P. D. SAMMAN,
ALL those interested in neuromuscular disease will be familiar with the name of Jaap Bethlem, not only because of the many contributions which he has made to knowledge of this subject but also because of the excellence of his short introductory volume and atlas on muscle pathology (1970). They will turn to this new product of his pen with keen anticipation and will not be disappointed. In less than 300 pages Professor Bethlem gives a series of succinct yet comprehensive and wellreferenced commentaries upon most myopathic disorders. He deals successively with the muscular dystrophies, the congenital myopathies, those with abnormal mitochondria, myotonic disorders, periodic paralyses, glycogen and other storage diseases, disorders of muscle lipid metabolism, polymyositis and related disorders, endocrine myopathies, and other miscellaneous disorders. There are a few surprising omissions: paroxysmal rhabdomyolysis or myoglobinuria and myositis ossificans do not appear in the index (or in the book) and malignant hyperpyrexia gets only one line. However, these criticisms are minor because this is not a textbook but rather a simple short guide to the clinician who may not be wholly familiar with the subject. Although written in telegraphic style, the descriptions are generally clear and readable. Over ninety disease entities or syndromes are covered and to those who seek a short primer of current knowledge about the major disorders of skeletal muscle this compact volume will be most welcome. Not every expert will agree with all of the information provided or with the classifications proposed, but in general the volume can be warmly recommended. Persistent Pain
VI. Edited by F.R.C.P. London: Heinevol.
mann. 1977. Pp. 507.;11.50. ANYONE needing to sharpen his wits before combat with examiners would profit from this book, which comprises succinct reviews of the most important and fashionable topics in dermatology. It is predominantly British in authorship, and designed for M.R.C.P. candidates, but would not be fatal to North American residents, even if swallowed whole. C. D. Calnan writes on eczema, E. Cronin on contact dermatitis, M. M. Black a welljudged chapter on connective-tussue disorders, T. J. Ryan a thoughtful contribution on urticaria and vasculitis, and Harvey Baker an impeccable account of psoriasis. These chapters might be the highlights for the specialist, but pretty well the whole of dermatology is covered, so that the book would be an interesting and reliable guide for new registrars in dermatology, or for those contemplating a career in this specialty.
A Short Textbook of Medical Statistics AUSTIN BRADFORD HILL, D.SC., F.R.S. London: Hodder & 1977. Pp. 325. /:6.7S (paperback ;£3.45).
Stough-
Modern Methods of Treatment: vol. I. Edited by SAMPSON LIPTON, F.F.A.R.C.S., Walton Hospital, Liverpool. London: Academic. New York: Grune & Stratton. 1977. Pp. 272. 10.50;$20.50.
AN encouraging feature of medical publications in the 1970s has been the steady flow of well-produced books on the management of chronic pain. This concise book opens a series of five to six volumes on various aspects of pain. Subsequent volumes are planned every eight months in the hope of keeping the contents up-to-date, though the series as a whole will age between first and last volume. The standard of presentation and the scope of Dr Lipton’s book suggests that this should be a most attractive series despite the high cost. This book is directed at a wide readership, ranging from specialists to senior medical students. Many specialists will be familiar with certain chunks of text and diagrams which contributors have published elsewhere. The senior medical students would have benefited from a little more basic explanation in preference to the copious references which are a feature of some sections (despite the editor’s stated policy to the contrary). The name Sudeck is misspelled, a common trap. With a little more originality this could become a most valuable series.
ton.
THE subtle change in title and imprint should deceive nothis is the authentic "Bradford Hill", now in its tenth edition after forty successful years. Of an earlier edition Sir Austin said that, when illustrating a principle, "it clearly does not matter whether the reference is to 1935 (when I first wrote) or to this year of grace 1954". He was right, and over the years has properly been more concerned with the flesh and blood than with the modernity of the garb. Newcomers get a shorter book (the exercises and answers have been left out) but some bonuses, including two non-parametric methods (one is the Wilcoxon). A new table of random numbers seems unnecessary, but the simplified presentation of probability tables for t and 72 is a major advance. If whole sections seem unaltered this is because the book has stood the test of time and survived fierce competition in its later years.
New Editions
one :
Gyncecology: Essentials of Clinical Practice-3rd ed. By Thomas H. Green Jr. Boston: Little, Brown. London: Quest. 1977. Pp. 715. $17.50; £ 1.55 (paperback$12.50, £8.25). Behaviour and Adaptation
in Late
Life-2nd ed.
Edited
by Ewald W.
Busse and Eric Pfeiffer. Boston: Little, Brown. London: Quest. 1977.
Pp. 382.$17.50,£11.55 (paperback$12.50, ;£8.25).
Treatment of Neuromuscular Diseases (Advances in Neurology t’ol. XVII).—Edited by R. C. Griggs and R. T. Moxley. New York: Ra’ven 1977. Pp. 384.$31.20. Basic Human
Neuroanatomy.-2nd ed. By Craid
Watson. Boston:
Little, Brown. London: Quest. 1977. Pp. 141.$8.95; £ 5.95.
643
THE LANCET
Medical Education and the G.M.C. primary task of the General Medical Council, under the various Medical Acts from 1858 to 1958, is the supervision of undergraduate medical THE
education; and the pattern of that education has
undergone big changes during the past ten years. This modest revolution was partly the result of two reports published at the start of that decade-the decennial Recommendations as to Basic Medical Education (1967) and the report of the Royal Commission on Medical Education (1968). In 1973, in further pursuit of the true path, the G.M.C. decided to conduct a survey of basic medical education, the voluminous report! of which is published this week. The main aim of the survey was to discover what was happening in the medical schools: not only what curricular changes had been introduced or were being planned but also what difficulties the schools were experiencing in achieving their objectives. It is against the background of the 1967 recommendations and the views of the Royal Commission that this report has to be judged. The first of its two volumes compares student selection, curricula and assessment among different schools and gives a "profile" of each school. The second volume, which discusses the teaching of the disciplines, subject by subject, will probably be of greater interest to those who are now contemplating the state of medical education and the impact of its products on the community. The report provides a basis for speculation about how the G.M.C., whether in its present or any other form, sees its role in ensuring that medical education is subjected to all the necessary research, stimulation, and monitoring. In his introduction, the former chairman of the Council’s education committee, Sir JOHN BROTHERSTON, says that the Council’s task is to consider "where do we go from here?"; and since, as a matter of policy, the report contains no recommendations, this is obviously the key subject for speculation. The fact that the Government has promised legislation in the next Parliamentary session to implement some of the recommendations of 1 Basic Medical Education in the British Isles: the report of the G.M.C. Survey of Basic Medical Education in the United Kingdom and Republic of Ireland, 1975-76 London: Nuffield Provinical Hospitals Trust. 1977. Pp.
876 (in 2 vols).£14.
the Merrison report2 should be no excuse for postponing debate. The Council has much valuable work to do in stimulating discussion on the questions which face medical education today. The profession may still be clinging too tightly to what it sees as a traditional right to ensure that, as part of the self-regulatory process, it determines what should be taught to undergraduates. Nevertheless, there are indications that times are moving to a stage when, with the recognition and emergence of a Greater Health Profession, and with keener public awareness, pressures from without will compel action based on interests beyond those of the medical profession. An urgent duty lies with the profession, and particularly with the Council as its major self-regulating mechanism, to see how far it can encourage higher rather than merely "sufficient" standards and thus enhance the quality of care. There is no shortage of subjects for exploration. For instance, the relationship between groups in a subject where the profession has a major interest, such as clinical pharmacology, but where another non-medical group is also concerned, requires close analysis for mutual benefit. There are parallel issues in many of the preclinical and laboratorybased subjects, such as biochemistry, as well as in community health, medical statistics, and healthcare organisation. There are urgent questions about the promotion of health and health education. As a corollary, there must be a fresh look at the implications of the sociologists’ criticism of medical care as being based on a "medical" model of treatment, whereas the model needed for society has other facets hardly recognised in the teaching of medical students. The present G.M.C. has been experimenting with the technique of conferences as stimulators of debate on medical education: a programme of meetings on key questions might dispel the stuffiness which envelopes much of the subject, for it is hardly any secret, but it is significant, that much tact and caution had to be exercised in mounting the G.M.C. survey, in ensuring good responses from the schools, and in achieving publication of the results, albeit without comment. Indeed, such is the sensitivity of the position, doubts have been expressed about the use of the survey’s findings as a basis for the next decennial recommendations, particularly those which concern the teaching and assessment of students (whose views, unfortunately, were not sought during the survey). Despite this uneasiness, the information gathered in the survey, and the speculation its findings should promote, may lead to pressure for a similar study of graduate and continuing education. 2.
Report of the Committee of Inquiry into the Regulation of the Medical Profession. H.M. Stationery Office, 1975. See Lancet, 1975, i, 901, 969.
Requests for reprints should be addressed to H. A. R. REFERENCES Voller, A., Bartlett, A., Bidwell, D. E. Trans. R. Soc. trop. Med. Hyg. 1976, 70, 98. 2. Voller, A., Bidwell, D., Bartlett, A. in Manual of Clinical Immunology edited by N. R. Rose and H. Friedman); p. 506. Washington, D.C., 1976. 3. Greenwood, B. M., Warrell, D. A., Davidson, N. M., Ormerod, L. D., Reid, H. A. Br. med. J. 1974, iv, 743. 4 Kochwa, S., Gitter, S., Strauss, A., de Vries, A., Leffkowitz, M. J. Immun. 1959, 82, 107. 5. Reid, H. A. Br. med. J. (in the press). 6. Reid, H. A. ibid. 1957, ii, 26. 7 Sutherland, S. K., Coulter, A. R., Broad, A. J., Hilton, J. M. N., Lane, L. H D. Med. J. Aust. 1975, i, 27. 1
Methods and Devices A SIMPLE AND INEXPENSIVE DEVICE FOR
POOLING CRYOPRECIPITATE R. GILLON
W. T. LOW
PETER JONES
Departments of Hœmatology and Medical Physics, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP CRYOPRECIPITATE therapy is still widely used for treatment in haemophilia A, especially in developing countries. We describe a method of pooling the contents of several packs by means of a simple vacuum box worked from an ordinary water tap and a Venturi pump.
Apparatus The
box used in Newcastle is made of 6 mm thick the top should be transparent, less expensive materials could be used. The box measures 28 (length) x 16 (width) x 7 (height) cm, and is covered with a closely fitting flanged lid (depth of flange 1.5 cm). Sponge rubber is glued around the flange to provide an airtight seal. A connector (stainless steel, brass, or plastic) is inserted into a 7 mm hole at one end of the box and held in place either by screws, or by an external nut, over rubber seals. Tubing runs from the connector, via a water trap, to a Venturi pump. A 4 mm C-slot at the other end of the box (duplicated in the flange) accepts tubing from the transfer pack. Sterile 0.9% saline solution is used to rinse the cryoprecipitate packs from a pack suspended above the apparatus via a Fenwal AE-7 double-ended transfer set. Fresh saline solution is used for each pool.
of Dick and Smithuses a vacuum chamber but obviates the need for a mechanical pump. It does not rely on a power source and may be ideal for home therapy when this has to be based on cryoprecipitate rather than lyophilised concentrate. With the method 10 packs can be pooled by aseptic technique in 5 minutes, after thawing. The saline rinse allows maximum recovery from the evacuated cryoprecipitate packs. The box, forceps, and the Venturi pump, water trap, and connected tubing are easily cleaned; the remainder of the apparatus is disposable. The device has been used in Newcastle for the past 5 years without any difficulties being encountered and has been supplied to associated haemophilia centres. Further details of construction are available from the department of hxmatology. ’
BX’e thank the staff of the University Department of and Teaching Aids Laboratory for help with the diagram.
vacuum
’Perspex’; although
Method A 600 ml transfer pack (Fenwal TA-1) is placed in the box, the tubing pressed into the C-slot, and the lid closed. The tubmg is clamped with a pair of Spencer Wells forceps and the pump turned on. The transfer pack coupler is inserted through one port of a cryoprecipitate pack and the tube undamped; cryoprecipitate is drawn into the transfer pack. After reclampmg, between 5 and 10 ml sterile saline solution is run into the cryoprecipitate pack via the second port and the pack is rinsed. The rinsing solution is then drawn into the transfer pack. The procedure is repeated until the desired dose of cryoprecipitate is attained. The transfer pack is then clipped off and the pooled cryoprecipitate is ready for intravenous-drip administration to the patient.
Discussion One of the drawbacks of cryoprecipitate is the need
to use
several individually donated packs to make up the correct dose of factor viii for the patient. Pooling in syringes is time consuming and unlikely to be aseptic. Alternative methods of pooling have been describedu2 but are either cumbersome or more expensive than the method we describe. Our method, like that
Photography
REFERENCES 1. 2.
Davidson, J. F., Muir, W. Lancet, 1968, i, 73. Dick, R., Smith, H. Gaz. Inst. med. Lab. Technol. 1973, 17, 384.
Reviews of Books The Child with Spina Bifida
,
ELIZABETH M. ANDERSON and BERNIE SPAIN. London: Methuen. 1977. Pp. 352. £ 7.50.
THE aim of this book is to give information on the functioning of the child with spina bifida and to make practical suggestions about how problems may be prevented or alleviated. It provides a wealth of clearly written facts and original data as well as a wide coverage of research, mainly on social and edu-
cational aspects. The section on medical aspects is clear but marred by errors. The section on the families is full of insight and common-sense recommendations. An excellent section on schooling gives details of difficulties in perception and poor manual skills. It describes the emotional immaturity, poor concentration, poor attainment, and apathy of many of these children. It analyses the problems encountered in reading, writing, and arithmetic and gives advice to teachers. It shows how help from parents and nursery-school experience may prevent some of the difficulties met in schooling. A special plea is made for exchange of information between doctors, teachers, and parents. The last section deals with the problems and needs of adolescents, which are becoming more pressing. The information in this book will be invaluable to all concerned with the provision of services for the children and young adults. It will also enable professionals to give a great deal more help with the day-to-day problems and so lighten the load on parents and others who have to care for children with spina bifida and hydrocephalus.
642
Spina Bifidii
Myopathies
Problems and Management. G. D. STARK, F.R.C.P.E., Royal Hospital for Sick Children, Edinburgh. Oxford: Blackwell. 1977. Pp.
JAAP BETHLEM, M.D., University of Amsterdam. Amsterdam. North-Holland. Philadelphia: Lippincott. 1977. Pp. 281. D.f1. 96,
192./:6.
$39.25.
THIS book reflects the experience which Dr Stark has gained a combined medical and surgical spina-bifida clinic in Edinburgh where the emphasis has been on a selective attitude to the treatment of patients with spina bifida. It is a welcome reaction to the surgical enthusiasm which followed the introduction of the Spitz Holter valve for the control of hydrocephalus. Unfortunately advocates for active treatment of spina bifida tend to ignore the irremediable defects which persist even after the hydrocephalus has been controlled and which are the cause of so much long-term disability. The author deals mainly with the assessment and medical aspects of the treatment of spina bifida, but he also considers the indiin
cations, limitations, and complications of surgical
treatment.
He begins with a section on the basic considerations, including the incidence and what is known of the aetiology. He then goes on to discuss clinical problems associated with myelomeningocele and affecting the lower limbs, bladder, bowel, and sexual functions, and associated malformations. There is a wealth of useful clinical advice about the management of all aspects of children with spina bifida. The production is excellent, the illustrations are good, and there is an extensive list of references. This book is intended for the community physician rather than the surgeon but any surgeon who has to deal with spina bifida ought to read this book, and so should every paediatrician and community physician who is involved in the management of children with spina bifida.
Dermatology Tutorials in Postgraduate Medicine: R. MARKS, M.R.C.P., and P. D. SAMMAN,
ALL those interested in neuromuscular disease will be familiar with the name of Jaap Bethlem, not only because of the many contributions which he has made to knowledge of this subject but also because of the excellence of his short introductory volume and atlas on muscle pathology (1970). They will turn to this new product of his pen with keen anticipation and will not be disappointed. In less than 300 pages Professor Bethlem gives a series of succinct yet comprehensive and wellreferenced commentaries upon most myopathic disorders. He deals successively with the muscular dystrophies, the congenital myopathies, those with abnormal mitochondria, myotonic disorders, periodic paralyses, glycogen and other storage diseases, disorders of muscle lipid metabolism, polymyositis and related disorders, endocrine myopathies, and other miscellaneous disorders. There are a few surprising omissions: paroxysmal rhabdomyolysis or myoglobinuria and myositis ossificans do not appear in the index (or in the book) and malignant hyperpyrexia gets only one line. However, these criticisms are minor because this is not a textbook but rather a simple short guide to the clinician who may not be wholly familiar with the subject. Although written in telegraphic style, the descriptions are generally clear and readable. Over ninety disease entities or syndromes are covered and to those who seek a short primer of current knowledge about the major disorders of skeletal muscle this compact volume will be most welcome. Not every expert will agree with all of the information provided or with the classifications proposed, but in general the volume can be warmly recommended. Persistent Pain
VI. Edited by F.R.C.P. London: Heinevol.
mann. 1977. Pp. 507.;11.50. ANYONE needing to sharpen his wits before combat with examiners would profit from this book, which comprises succinct reviews of the most important and fashionable topics in dermatology. It is predominantly British in authorship, and designed for M.R.C.P. candidates, but would not be fatal to North American residents, even if swallowed whole. C. D. Calnan writes on eczema, E. Cronin on contact dermatitis, M. M. Black a welljudged chapter on connective-tussue disorders, T. J. Ryan a thoughtful contribution on urticaria and vasculitis, and Harvey Baker an impeccable account of psoriasis. These chapters might be the highlights for the specialist, but pretty well the whole of dermatology is covered, so that the book would be an interesting and reliable guide for new registrars in dermatology, or for those contemplating a career in this specialty.
A Short Textbook of Medical Statistics AUSTIN BRADFORD HILL, D.SC., F.R.S. London: Hodder & 1977. Pp. 325. /:6.7S (paperback ;£3.45).
Stough-
Modern Methods of Treatment: vol. I. Edited by SAMPSON LIPTON, F.F.A.R.C.S., Walton Hospital, Liverpool. London: Academic. New York: Grune & Stratton. 1977. Pp. 272. 10.50;$20.50.
AN encouraging feature of medical publications in the 1970s has been the steady flow of well-produced books on the management of chronic pain. This concise book opens a series of five to six volumes on various aspects of pain. Subsequent volumes are planned every eight months in the hope of keeping the contents up-to-date, though the series as a whole will age between first and last volume. The standard of presentation and the scope of Dr Lipton’s book suggests that this should be a most attractive series despite the high cost. This book is directed at a wide readership, ranging from specialists to senior medical students. Many specialists will be familiar with certain chunks of text and diagrams which contributors have published elsewhere. The senior medical students would have benefited from a little more basic explanation in preference to the copious references which are a feature of some sections (despite the editor’s stated policy to the contrary). The name Sudeck is misspelled, a common trap. With a little more originality this could become a most valuable series.
ton.
THE subtle change in title and imprint should deceive nothis is the authentic "Bradford Hill", now in its tenth edition after forty successful years. Of an earlier edition Sir Austin said that, when illustrating a principle, "it clearly does not matter whether the reference is to 1935 (when I first wrote) or to this year of grace 1954". He was right, and over the years has properly been more concerned with the flesh and blood than with the modernity of the garb. Newcomers get a shorter book (the exercises and answers have been left out) but some bonuses, including two non-parametric methods (one is the Wilcoxon). A new table of random numbers seems unnecessary, but the simplified presentation of probability tables for t and 72 is a major advance. If whole sections seem unaltered this is because the book has stood the test of time and survived fierce competition in its later years.
New Editions
one :
Gyncecology: Essentials of Clinical Practice-3rd ed. By Thomas H. Green Jr. Boston: Little, Brown. London: Quest. 1977. Pp. 715. $17.50; £ 1.55 (paperback$12.50, £8.25). Behaviour and Adaptation
in Late
Life-2nd ed.
Edited
by Ewald W.
Busse and Eric Pfeiffer. Boston: Little, Brown. London: Quest. 1977.
Pp. 382.$17.50,£11.55 (paperback$12.50, ;£8.25).
Treatment of Neuromuscular Diseases (Advances in Neurology t’ol. XVII).—Edited by R. C. Griggs and R. T. Moxley. New York: Ra’ven 1977. Pp. 384.$31.20. Basic Human
Neuroanatomy.-2nd ed. By Craid
Watson. Boston:
Little, Brown. London: Quest. 1977. Pp. 141.$8.95; £ 5.95.
643
THE LANCET
Medical Education and the G.M.C. primary task of the General Medical Council, under the various Medical Acts from 1858 to 1958, is the supervision of undergraduate medical THE
education; and the pattern of that education has
undergone big changes during the past ten years. This modest revolution was partly the result of two reports published at the start of that decade-the decennial Recommendations as to Basic Medical Education (1967) and the report of the Royal Commission on Medical Education (1968). In 1973, in further pursuit of the true path, the G.M.C. decided to conduct a survey of basic medical education, the voluminous report! of which is published this week. The main aim of the survey was to discover what was happening in the medical schools: not only what curricular changes had been introduced or were being planned but also what difficulties the schools were experiencing in achieving their objectives. It is against the background of the 1967 recommendations and the views of the Royal Commission that this report has to be judged. The first of its two volumes compares student selection, curricula and assessment among different schools and gives a "profile" of each school. The second volume, which discusses the teaching of the disciplines, subject by subject, will probably be of greater interest to those who are now contemplating the state of medical education and the impact of its products on the community. The report provides a basis for speculation about how the G.M.C., whether in its present or any other form, sees its role in ensuring that medical education is subjected to all the necessary research, stimulation, and monitoring. In his introduction, the former chairman of the Council’s education committee, Sir JOHN BROTHERSTON, says that the Council’s task is to consider "where do we go from here?"; and since, as a matter of policy, the report contains no recommendations, this is obviously the key subject for speculation. The fact that the Government has promised legislation in the next Parliamentary session to implement some of the recommendations of 1 Basic Medical Education in the British Isles: the report of the G.M.C. Survey of Basic Medical Education in the United Kingdom and Republic of Ireland, 1975-76 London: Nuffield Provinical Hospitals Trust. 1977. Pp.
876 (in 2 vols).£14.
the Merrison report2 should be no excuse for postponing debate. The Council has much valuable work to do in stimulating discussion on the questions which face medical education today. The profession may still be clinging too tightly to what it sees as a traditional right to ensure that, as part of the self-regulatory process, it determines what should be taught to undergraduates. Nevertheless, there are indications that times are moving to a stage when, with the recognition and emergence of a Greater Health Profession, and with keener public awareness, pressures from without will compel action based on interests beyond those of the medical profession. An urgent duty lies with the profession, and particularly with the Council as its major self-regulating mechanism, to see how far it can encourage higher rather than merely "sufficient" standards and thus enhance the quality of care. There is no shortage of subjects for exploration. For instance, the relationship between groups in a subject where the profession has a major interest, such as clinical pharmacology, but where another non-medical group is also concerned, requires close analysis for mutual benefit. There are parallel issues in many of the preclinical and laboratorybased subjects, such as biochemistry, as well as in community health, medical statistics, and healthcare organisation. There are urgent questions about the promotion of health and health education. As a corollary, there must be a fresh look at the implications of the sociologists’ criticism of medical care as being based on a "medical" model of treatment, whereas the model needed for society has other facets hardly recognised in the teaching of medical students. The present G.M.C. has been experimenting with the technique of conferences as stimulators of debate on medical education: a programme of meetings on key questions might dispel the stuffiness which envelopes much of the subject, for it is hardly any secret, but it is significant, that much tact and caution had to be exercised in mounting the G.M.C. survey, in ensuring good responses from the schools, and in achieving publication of the results, albeit without comment. Indeed, such is the sensitivity of the position, doubts have been expressed about the use of the survey’s findings as a basis for the next decennial recommendations, particularly those which concern the teaching and assessment of students (whose views, unfortunately, were not sought during the survey). Despite this uneasiness, the information gathered in the survey, and the speculation its findings should promote, may lead to pressure for a similar study of graduate and continuing education. 2.
Report of the Committee of Inquiry into the Regulation of the Medical Profession. H.M. Stationery Office, 1975. See Lancet, 1975, i, 901, 969.
