315 This is the sort of thing which will happen to such a man over his long case : , " Then the main points you have found here are weakness and shortness of breath for three months, pallor" purpura, universal enlargement of lymph-nodes, and the spleen enlarged to the level of the umbilicus."-" Yes." " That is correct. Now please discuss the diagnosis."- " It might be pernicious anaemia." " Oh ! Does a patient with pernicious anaemia have a - spleen like this ? "-" No." " Or enlargement of the lymph-nodes ? "-" No."’ 4’Or purpura ? "-" No." " Well then, suppose we think of something else."-" It might be thrombocytopenic purpura." " Oh ! Does such a patient have enlarged lymph-nodes ? " -" No." " Or a spleen like this ? "-" No." "Well now, what else have you to suggest ? It might be acholuric jaundice." " Oh ! Has this patient ever been jaundiced ? "— " No." " And in acholuric jaundice are the lymph-nodes enlarged ? "-" No." "And does purpura usually occur ? "-" No." And so the bell rings and the candidate has never even mentioned leukaemia ! Here he is up for an honours examination, having had forty minutes to take the history, elicit the signs, and think about the diagnosis. Does he suppose that blood diseases will be sorted out for him by technicians who do blood-counts ? f Clinical medicine has not begun to dawn on such a man. How can a censor possibly consider him fit to advise another doctor who calls him in consultation over a case ? f He would make the problem all the more confused. THE VIVA If you survive until the first viva remember that specimens and photographs are used mainly as pegs upon which to hang questions. Thus a photograph of a patient with obvious acromegaly evokes questions on gigantism, basophilism, chromophobe adenoma, and suprasellar cyst. You must know the clinical features, pathology, and treatment of all such syndromes. Equally you must be prepared to interpret radiographs, electro- cardiograms, blood-counts, and other laboratory reports. When shown a museum specimen in the viva you should identify the organ and follow this up with a description of the size, shape, and colour of the patho- logical lesion. The diagnosis should always come last ; otherwise if you come to the wrong conclusion, you will inevitably lose everything. When it comes to describing the colour of the normal organs of the body most men are singularly bad. It is scarcely possible to persuade a candidate in a viva to say that the suprarenal cortex is golden-yellow, the medulla slaty-grey, and the normal thyroid red-brown. But scattered through examination scripts one sees such confusing descriptions as " the colour of a daffodil, an iris, a rose, a marigold, or a plum." FUN FOR THE CENSOR Does a censor ever get any fun at all out of the examina- tion ? I like to think so. One candidate, I am told, wrote: " examination of the fundus reveals papal cedema," and another " it is said that the face of a cretin is like that of a constipated owl, but perhaps this is a, slight exaggeration." An examiner is occasionally privileged to give an extra mark to a candidate with exceptional powers of human understanding, such as the man who said of the treatment of insomnia-" an attractive and agreeable marriage partner is advocated by many." At one time a question’ was asked on anthrax, but it is not recorded whether an extra mark was given for the statement that " in the case of an out- break of anthrax the animal must be burned or buried alive and the woolsorter must be boiled." Neither do we know what marks were allotted to the man who wrote " in scarlet fever the patient should be strictly isolated and should have connexion with no-one except the nurse." . Sometimes, I understand, a number of examination scripts contain a remarkable answer which can only have come from a whole class of men having misunder- stood a lecturer. -The famous example is that in answer to a question on the treatment of haematemesis, where countless candidates said the patient must be given oyster soup. This was traced to a lecturer lately imported from Glasgow who had told them to give the patient " ice to suck." One cannot dismiss this subject without quoting the statement of a very earnest candidate who obtained good marks throughout a whole exam.- " in hypoglycaemia it is possible by the judicious use of adrenaline to restore the patient sufficiently towards consciousness that he can swallow himself." In the final viva be prepared for questions on the history and classical literature of medicine. On the whole the censor of today despairs of meeting a really erudite candidate. One hot summer, during, the July examination, one of them kept asking, who was the author of An Essay on the Shaking Palsy. No answer was forthcoming, and in the end the President is said to have remarked kindly that in this modern age one could not expect to meet a candidate who had read anything beyond a textbook. In the words of a past president, himself a master of erudition, " it is a bleak prospect." ’ Reviews of Books Textbook of Obstetrics GILBERT I. STRACHAN, M.D., F.R.C.P., F.R.C.S.,- F.R.C.O.G.., professor of obstetrics and gynaecology, University of Wales, obstetrician and gynaecologist, Cardiff Royal Infirmary. London : H. K. Lewis., 1947. Pp. 732. 45s. ALTHOUGH the British Isles are provided with a goodly number of textbooks of obstetrics, and thereby with a great diversity.of opinions, it is some few years since a new author made his appearance. We will state forthwith, that Professor Strachan’s book is_a good book-comfort- ably orthodox, pleasantly written with a scattering of superlatives to give emphasis in safe places, bountifully illustrated with over 300 illustrations and 3 colour plates, and really well produced with clear type and (for these days) surprisingly good paper. Throughout it shows his conviction of the evils of what he terms too early interference and of the urge to interfere with even the normal course of labour. There are nine sections, each of which is much sub- divided, and the subdivisions are not numbered. The arrangement is unusual and leads occasionally to odd sequences. Of much greater importance, however, is the fact that no less than 275 pages-over a third of the total-are given to description of the normal. This is a great accomplishment. Probably the first two sections are the best in the book. The student receives detailed instruction in the preparation of the patient for, and the conduct of, a normal labour, and there is an excellent description of the objects and application of postnatal care. The third section, of only 36 pages, is concerned with the newborn child and its ailments. Although written by the paediatrician to the department, it cannot be said to be notably better than similar sections in other obstetric textbooks. Condensation to this extent is always difficiilt. In the treatment of gonorrhoea in pregnancy, local treat- ment of the infected sites is advised, and in that of con- cealed accidental haemorrhage the author gives the impression that he has just failed to be courageous enough to exclude caesarean section. No fewer than six different methods of treatment are described for the management of placenta praevia, and some of these, surely, are now discredited. -- The assessment of contracted pelvis is essentially sound, and Caldwell and Molloy’s classification is criticised. The estimate of the value, and lack of value, of external pelvi- metry is definite and fair, but Professor Strachan’s views on the results of trial of labour are gloomy. The student receives excellent instruction on the management of the occipito-
Transcript
315
This is the sort of thing which will happen to such aman over his long case : ,
" Then the main points you have found here are weaknessand shortness of breath for three months, pallor" purpura,universal enlargement of lymph-nodes, and the spleenenlarged to the level of the umbilicus."-" Yes."
" That is correct. Now please discuss the diagnosis."-" It might be pernicious anaemia."
" Oh ! Does a patient with pernicious anaemia have a- spleen like this ? "-" No."
,
" Or enlargement of the lymph-nodes ? "-" No."’4’Or purpura ? "-" No."" Well then, suppose we think of something else."-" It
might be thrombocytopenic purpura."" Oh ! Does such a patient have enlarged lymph-nodes ?
"
-" No."" Or a spleen like this ? "-" No.""Well now, what else have you to suggest ? It
might be acholuric jaundice." .
" Oh ! Has this patient ever been jaundiced ? "—" No."" And in acholuric jaundice are the lymph-nodes
enlarged ? "-" No.""And does purpura usually occur ? "-" No."
And so the bell rings and the candidate has nevereven mentioned leukaemia ! Here he is up for an honoursexamination, having had forty minutes to take thehistory, elicit the signs, and think about the diagnosis.Does he suppose that blood diseases will be sorted outfor him by technicians who do blood-counts ? f Clinicalmedicine has not begun to dawn on such a man. Howcan a censor possibly consider him fit to advise anotherdoctor who calls him in consultation over a case ? f Hewould make the problem all the more confused.
THE VIVA
If you survive until the first viva remember thatspecimens and photographs are used mainly as pegsupon which to hang questions. Thus a photograph ofa patient with obvious acromegaly evokes questionson gigantism, basophilism, chromophobe adenoma, andsuprasellar cyst. You must know the clinical features,pathology, and treatment of all such syndromes. Equallyyou must be prepared to interpret radiographs, electro-cardiograms, blood-counts, and other laboratory reports.When shown a museum specimen in the viva you
should identify the organ and follow this up with a
description of the size, shape, and colour of the patho-logical lesion. The diagnosis should always come last ;otherwise if you come to the wrong conclusion, you willinevitably lose everything. When it comes to describingthe colour of the normal organs of the body most men aresingularly bad. It is scarcely possible to persuade acandidate in a viva to say that the suprarenal cortex isgolden-yellow, the medulla slaty-grey, and the normalthyroid red-brown. But scattered through examinationscripts one sees such confusing descriptions as " thecolour of a daffodil, an iris, a rose, a marigold, or a plum."
FUN FOR THE CENSOR
Does a censor ever get any fun at all out of the examina-tion ? I like to think so. One candidate, I am told,wrote: " examination of the fundus reveals papalcedema," and another " it is said that the face of a cretinis like that of a constipated owl, but perhaps this isa, slight exaggeration." An examiner is occasionallyprivileged to give an extra mark to a candidate withexceptional powers of human understanding, such as theman who said of the treatment of insomnia-" anattractive and agreeable marriage partner is advocatedby many." At one time a question’ was asked on
anthrax, but it is not recorded whether an extra markwas given for the statement that " in the case of an out-break of anthrax the animal must be burned or buriedalive and the woolsorter must be boiled." Neither dowe know what marks were allotted to the man whowrote " in scarlet fever the patient should be strictly
isolated and should have connexion with no-one exceptthe nurse."
.
Sometimes, I understand, a number of examinationscripts contain a remarkable answer which can onlyhave come from a whole class of men having misunder-stood a lecturer. -The famous example is that in answerto a question on the treatment of haematemesis, wherecountless candidates said the patient must be givenoyster soup. This was traced to a lecturer lately importedfrom Glasgow who had told them to give the patient " iceto suck." One cannot dismiss this subject withoutquoting the statement of a very earnest candidatewho obtained good marks throughout a whole exam.-" in hypoglycaemia it is possible by the judicious use ofadrenaline to restore the patient sufficiently towardsconsciousness that he can swallow himself."
In the final viva be prepared for questions on thehistory and classical literature of medicine. On thewhole the censor of today despairs of meeting a reallyerudite candidate. One hot summer, during, the Julyexamination, one of them kept asking, who was theauthor of An Essay on the Shaking Palsy. No answerwas forthcoming, and in the end the President is said tohave remarked kindly that in this modern age one couldnot expect to meet a candidate who had read anythingbeyond a textbook. In the words of a past president,himself a master of erudition, " it is a bleak prospect."
’
Reviews of Books
Textbook of ObstetricsGILBERT I. STRACHAN, M.D., F.R.C.P., F.R.C.S.,- F.R.C.O.G..,professor of obstetrics and gynaecology, University ofWales, obstetrician and gynaecologist, Cardiff RoyalInfirmary. London : H. K. Lewis., 1947. Pp. 732. 45s.
ALTHOUGH the British Isles are provided with a goodlynumber of textbooks of obstetrics, and thereby with agreat diversity.of opinions, it is some few years since anew author made his appearance. We will state forthwith,that Professor Strachan’s book is_a good book-comfort-ably orthodox, pleasantly written with a scattering ofsuperlatives to give emphasis in safe places, bountifullyillustrated with over 300 illustrations and 3 colourplates, and really well produced with clear type and(for these days) surprisingly good paper. Throughoutit shows his conviction of the evils of what he terms tooearly interference and of the urge to interfere with eventhe normal course of labour.
There are nine sections, each of which is much sub-divided, and the subdivisions are not numbered. Thearrangement is unusual and leads occasionally to oddsequences. Of much greater importance, however, isthe fact that no less than 275 pages-over a third of thetotal-are given to description of the normal. This isa great accomplishment. Probably the first two sectionsare the best in the book. The student receives detailedinstruction in the preparation of the patient for, and theconduct of, a normal labour, and there is an excellentdescription of the objects and application of postnatalcare. The third section, of only 36 pages, is concernedwith the newborn child and its ailments. Althoughwritten by the paediatrician to the department, it cannotbe said to be notably better than similar sections inother obstetric textbooks. Condensation to this extentis always difficiilt.
In the treatment of gonorrhoea in pregnancy, local treat-ment of the infected sites is advised, and in that of con-cealed accidental haemorrhage the author gives the impressionthat he has just failed to be courageous enough to excludecaesarean section. No fewer than six different methods oftreatment are described for the management of placentapraevia, and some of these, surely, are now discredited.
--
The assessment of contracted pelvis is essentially sound,and Caldwell and Molloy’s classification is criticised. Theestimate of the value, and lack of value, of external pelvi-metry is definite and fair, but Professor Strachan’s views onthe results of trial of labour are gloomy. The student receivesexcellent instruction on the management of the occipito-
316
posterior position, and emphasis is rightly put on the timeof interference. Whereas Kjelland’s forceps do not getfavourable mention, articles of such dubious value as thelaminaria tent, the gum-elastic bougie, and the solid rubberbougie for use in the induction of abortion and labour aregiven a place:The book concludes with a section on the casualties of
childbirth, and a practical account, by Dr. Robert Drummond,of:1?lood-transfusion..The criticisms that can be offered are few and unim-
portant in relation to the vast bulk of the work, whichreceived too little praise at the beginning of this review.
The Acute Infectious FeversALEXANDER JOE, M.D., F.R.C.P.E., medical superintendent,City Hospital, Edinburgh. London : J. & A. Churchill.1947. Pp. 276. 18s.
Dr. Joe’s book, based on his experience as clinicianand teacher in London and Edinburgh, is primarilyintended to help the student and young doctor in solvingthe everyday problems posed by the common fevers.The author has succeeded in his aim: the clinicaldescriptions are clear, the discussions on diagnosisadequate, and the sections on prevention and treatmentfull. From the teaching aspect, the half-tone reproduc-tions of photographs, as usual, are not uniformly success-ful : those portraying the pock diseases are very good,but those illustrating measles are but indifferent guidesto the student. Dr. Joe is, throughout, conservative inhis views and cautious in their expression : in scarletfever most fever clinicians now deprecate the use of thedouche-can for flushing the fauces, however gently,because of the danger of infecting the eustachian tubeand thus the middle ear. While the reliability of thecough-plate in the diagnosis of pertussis is perhapsoverestimated, the postnasal swab, of greater value ininfants and young children who cannot cobperate, isnot mentioned.- But such are small points which do notdetract from the merits of the book.
A Synopsis of Anaesthesia .
J. ALFRED LEE, M.R.(3.S., D.A., consultant anaesthetist,Southend General Hospital. Bristol: John Wright.1947. Pp. 254. 12s. 6d.
A GREAT deal of work has gone into the preparationof this book ; and although it is only of pocket size itcontains a wider range of factual information thanmany textbooks of ansesthetics. Some statements willnot be accepted everywhere. For instance, the main-tenance of an adequate respiratory exchange with carbondioxide and oxygen is given as the first treatment of" ether convulsions "-the old term being retained inpreference to the current one of convulsions during anaes-thesia. A rise in blood-pressure and a heart-rate slowedto 50 is also regarded as a normal response to cyclo-propane, while the use of such high concentrations asmentioned’in connexion with cardiac arrhythmias hasfew advocates today. In the main, however, this bookwill be found to be’ a reliable source of reference and aquick means of revision.
’
A Textbook of Dietetics
(2nd ed.) L. S. P. DAVIDSON, M.D., F.R.C.r., professorof medicine, University of Edinburgh ; 1. A. ANDERSON,M.B., lecturer in clinical chemistry, University of Aberdeen.London : Hamish Hamilton Medical Books. 1947.Pp. 517. 21s.
,
THE -first edition of this book in 1942 rapidly estab-lished it as one of the soundest and clearest treatises inthis field. The second edition lives up to this reputationand the general practitioner and general physician willprobably find it the most useful work on dietetics nowin circulation. The fundamentals are treated withcommendable clarity, and dietetic therapy with lustycommon sense. Sections from the previous edition havebeen brought up to date and new sections have beenadded on parenteral therapy, the treatment of starvation,the use of folic acid, and food policy’during the war.The authors pay an instructive tribute to the scientificguidance so largely responsible for the success of thispolicy. Professor Davidson might also have remarked
that a wider appreciation of the teaching in this bookwould have saved the invalid rationing committee,of which he is a distinguished member, much unneces-sary work, and also economised the time of our legislators.
The Child-bearing YearsC. SCOTT RUSSELL, M.A., F.R.C.S.E., M.R.C.O.G., assistantdirector, department of obstetrics and gynaecology,University of Manchester. Oxford : Blackwell. 1947.Pp. 88. 7s. 6d.
AMONG the educational books now available for thelay woman it is pleasant to find one of outstandingmerit and suitability. Mr. Scott Russell offers thewoman of average education a good survey, of thephysiology of childbearing, menstruation, and the meno-pause. Contained in these chapters is also a shortdescription of relevant pathological conditions, and hemust be congratulated on his skill in describing thesewithout playing into the anxiety of his reader. Manyof the sections contain just the type of information thatwomen require, and this is given in a direct and sensibleway.
It is perhaps a pity that in the chapter on breast feedingthe emotional advantages to mother and child receiveno mention. For both mother and child breast-feedingis invaluable as a means of education in intimacy andloving. With natural easy mothers suckling is indulgedin simply ; but the neurotic woman may all tooeasily lose this natural way of breaking down herbarriers if these facts are not pointed out to her.
An Introduction to Bacteriological Chemistry(2nd ed.) C. G. ANDERSON, PH.D., DIP.BAOT., formerlyLewis Cameron teaching fellow, University of Edinburgh.Edinburgh : E. & S. Livingstone. 1946. Pp. 500.’ 20s.
ALL living cells have the same basal biochemistry, andfor this reason bacteria can be used for the rapid andeconomical assay of a wide range of biologically importantsubstances such as amino-acids and vitamins. Bacterialenzymes are capable of performing almost every possiblebiochemical reaction, and we now know that severalbacterial toxins, such as the ex-toxin of Clostridium welchii,are enzymes. These are among the many reasons why allstudents of bacteriology should know something of thechemistry of micro-organisms. The present edition ofthis excellent book contains a new chapter on theantibiotics and a fresh presentation of the facts aboutgrowth factors. General subjects such as enzymes andcolloids and adsorption are followed by a much largersection on the metabolic habits of bacteria, and finallythere is a clear explanation of modern views on immuno-chemistry. It should be said that only an elementaryknowledge of organic chemistry is needed to find the wayin this expanding field of study.
Human EmbryologyBRADLEY M. PATTEN, professor of anatomy, Universityof Michigan. London: J. & A. Churchill. 1946. Pp. 776.45s.
THIS is one of the best textbooks on human embryologyproduced in recent years. Original in style, arrangement,and illustration, it is unusually attractive to read andentirely up to date. The illustrations are well producedand clarify those aspects of development which thestudent often finds most difficult. The sections dealingwith the functional significance of developing structuresare somewhat of an innovation, though perhaps unneces-sarily detailed in the case of the central nervous system.The story of development is carried well into postnatallife, and developmental defects receive detailed treat-ment. It is pleasant to see the sections on developmentof general tissues, such as bone and muscle, placed earlyin the book, instead of being relegated to an odd chapterat the end as so commonly happens. A few points forcriticism no doubt arise.-e.g., no reference is made toosteoclasts in bone growth ; the magnification of manyof the photomicrographs and illustrations of reconstruc-tion models is not stated ; and there are a few loosephrases, such as the description of the ventral nucleusof the thalamus as " a conscious and relay centre." Butthese are small blemishes in a book of exceptionaloriginality and accurate detail.
