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valve-(2) in fig. 2—similar in principle to that used inRose et al.’s instrument. This does not give an exactlyconstant rate of fall, as the rate depends on the volume ofair in the cuff. The valve must therefore be adjusted by theoperator to suit the size of cuff he is using and his techniqueof applying it.When the cuff is being inflated, the moment when the

diaphragm chamber is full can be detected by a suddenincrease in the rate of rise in the manometer tube. This cangive a clue to the operator to the amount of zero displace-ment produced and- must therefore be eliminated. Inaddition, if the pressure is allowed to rise too quickly, themercury may not have time to fill the diaphragm chambercompletely.The flow of mercury up the manometer tube is therefore

slowed by means of a restriction--(9) fig. 1-between thereservoir and the tube. This is shown as a simple needle-valve ; but it was found in practice, by Dr. A. E. Bennett,of the department of clinical epidemiology and social medi-cine, St. Thomas’s Hospital, that this was liable to produceerrors by slowing the rate of fall of the mercury. A valvularrestriction, designed by Mr. R. Hayler, is therefore fitted tothe commercial model.The general appearance of the commercial form of the

instrument is shown in fig. 2 and its back view, with themechanism, in fig. 3.

It has been found that the extra volume of mercury inthe reservoir makes it liable to leak through the normal trap([10J in fig. 1) so a lever-operated valve ([1) in fig. 2) isfitted on the top of the reservoir. This valve must be closedwhen carrying the instrument, and opened before use.

PERFORMANCE

The design of the instrument does not eliminate digitpreference, but this is obscured and randomised in such away as to make its effects hardly appreciable. Bias is alsonot completely eliminated, as a zero shift of 0-60 mm. isnot sufficient to disguise an exceptionally low or exception-ally high blood-pressure, but again the effect of bias is verysubstantially reduced.

Although the distribution of displaced zeros is not strictlyrandom, owing to inevitable mechanical defects, it is nearlyenough so to prevent the observer having any idea of thezero displacement.The instrument has been extensively used by Dr. W. E.

Miall and his colleagues in the Medical Research CouncilEpidemiological Research Unit, Jamaica, by Prof. W. W.Holland and his colleagues of the department of epidemio-logy and social medicine, St. Thomas’s Hospital, and byother workers. An account of its performance has beengiven by Evans and Prior. S

Although the name " zero-muddler " originally used byGarrow has come to be in common use for this type ofsphygmomanometer, we have preferred the term " random-zero " as more suitable for a scientific instrument.We are indebted to Dr. W. E. Miall for drawing our attention

to this problem and for much helpful advice and criticism, forwhich we are also indebted to Dr. J. S. Garrow and Dr. G. A.Rose, and to Professor Holland and his colleagues. We areindebted to Mr. F. New for preparing fig. 1.The instrument is made and distributed by Messrs. Hawksley

and Sons Ltd., 12 Peter Road, Lancing, Sussex. Mr. R. Hayler,the managing director, has made many helpful contributions tothe final commercial design.

Requests for reprints should be addressed to B. M. W.,National Institute for Medical Research, Holly Hill, LondonN.W.3.

REFERENCES

1. Miall, W. E. Bull. int. epidem. Ass. 1966, 14, 71.2. Oldham, P. D., Pickering, G. W., Roberts, J. A. F., Sowry, G. S. C.

Lancet, 1960, i, 1085.3. Rose, G. A., Holland, W. W., Crowley, E. A. ibid. 1964, i, 296.4. Garrow, J. S. ibid. 1963, ii, 1205.5. Grimley Evans, J., Prior, I. A. M. Brit. J. prev. soc. Med. (in the

press).

Reviews of Books

A History of Bubonic Plague in the British Isles !J. F. D. SHREWSBURY, emeritus professor of bacteriology,

.

University of Birmingham. London: Cambridge UniversityPress. 1970. Pp. 661. E8.

THIS is a great work of scholarship for which we must begrateful. After a short account of the epidemiology ofplague the author analyses and discusses the records ofplague from 1348 until this century. He draws his materialfrom the chroniclers, the catalogues of ecclesiasticalappointments, and a wide range of memoirs and reports.The identity of historical disease in terms of bacteriologymust always have an element of guesswork in it" plague "," ague ", and " leprosy " may not have meant exactly whatthey do today. Professor Shrewsbury founds all his argu-ments on the assumption that plague occurs in man onlywhen a flea transmits the parasite from Rattus rattus; if thataccount suggests that fleas and rats were not abundant thtdisease is, by definition, not plague. However, although thi:is the usual origin of human plague the infection may Ixacquired in other ways ; and the natural history of aninfectious disease can change. There are some errors andinconsistencies. On p. 14 it is thought odd that Pepys didnot notice a murrain among the rats in the plague of 1665whereas on p. 4 the author points out that, because R. rattustends to die in secret places, it is unusual to observe a highdeath-rate among the rats. The epidemic which blightedKingsbury and other Somerset villages may well have beenmalaria, which persisted in those parts until the 19th century.Map 3 (p. 56) shows rivers as navigable which would notfloat a canoe except when in flood but omits others whichwere and are used for navigation, such as the Arun andCrouch. It is a pity that plague in the past hundred yearsgets such brief treatment, because living witnesses could befound only a few years ago. Professor Shrewsbury doubtsif the small outbreaks in East Suffolk early in this centurywere due to plague at all. There is no doubt that rats

(R. norwegicus) and rabbits in the tract between the Stourand the Deben were infected, presumably by rats in thegrain cargoes going up to Ipswich. Professor Shrewsburysuggests that some of the human deaths were due to

influenza and some to anthrax " acquired from beddingstraw". However, one experienced physician remarkedlater: " I have never before seen five out of six people in onehouse die of lobar pneumonia almost simultaneously and Iguessed it was due to something out of the ordinary ". Thebacteriologists who studied these events were able men andnot likely (as Shrewsbury suggests) to delegate work of thiskind to a technician (if, in 1910, they had technicians). Thedisease continued sporadically in the same district until 1918.No-one is likely to reopen this mine of facts, and futuregenerations will have cause to thank the author for hismonumental toil. The make-up of the book is excellent butthe index might be more comprehensive.

Mineral Metabolism in PaediatricsEdited by DOXALD BARLTROP, M.B., B.SC., M.R.C.P., D.C.H.,and W. L. B1:RLA."-J), M.B., D.c.H. Oxford: Blackwell ScientificPublications. 1969. Pp. 171. 55s.

THIS book consists of ten chapters based on the twelvescientific papers (and ensuing discussion) given at a Glaxosymposium held in London, in 1968. The book is wellproduced and the illustrations are of high quality. Thetopics range from a study of a variety of trace elements suchas chromium, selenium, molybdenum, manganese, andcobalt in human development by Dr. E. M. Widdowson, tostudies of potentially toxic substances such as fluoride,cadmium, and lead and the metabolic implications of

339

strontium-90 fall-out from nuclear explosions. There is a

chapter on children born into hoemochromatotic families andon zinc deficiency in malnourished children. A feature ofthe book is three chapters relating to five papers on vitaminD and calcium metabolism. The most directly clinicalinterest of the book lies in the two chapters on hypocalcse-mia and rickets in children, and pseudo vitamin-D-resistantrickets by Prof. A. Prader and Dr. A. Fanconi. There are244 references given chapter by chapter. These are usefulbut it seems a little unnecessary in one chapter to include 17references to papers by one of the contributors. The impli-cations of the material are wide ranging, and no one partici-pant could be familiar with such a diversity. Although themixture varies in quality it is palatable, lucid, and full ofinterest. This reflects credit on editors, contributors, andthose taking part in the discussion. Individual preferencesfor these varied chapters will differ, but the chapters onTrace Elements in Human Development and on Fluoride inBones and Teeth are of outstanding interest. This book is a" must " for every academic pxdiatric library and for every

metabolic and physiology department. It should be ofinterest to all paediatricians and can be highly recommended.

Paget’s Disease of BoneHUGH C. BARRY, B.SC., F.R.C.S., F.R.A.C.S., senior honoraryorthopxdic surgeon, Royal Prince Alfred Hospital, Sydney.Edinburgh: E. & S. Livingstone. 1969. Pp. 196. 80s.

A HUNDRED years after the initial observations made bySir James Paget and Sir Samuel Wilkes, Paget’s disease ofbone remains a mysterious condition of unknown aaiologywith a wide variation in incidence from country to countryand even within the same country. Mr. Barry first presentsthe history of the description of the disease and then dealswith its geographical and racial incidence. He has obtainedinformation about the diagnosis of incidental Paget’sdisease in all the admissions to Australian hospitals over aspecific period and found the incidence-rate to be generallyuniform in the different cities (1 case in about 670 admis-sions). Accounts of the clinical picture of the disease andits pathology are followed by a description of the skeletaldeformities and the medical aspects, including reference tometabolic studies. Other chapters review symptomatictreatment and the common complication-spontaneousfracture. The last chapter is on neoplastic changes in

Paget’s disease, and special reference is made to the rare

giant-cell tumours some of which may be surprisinglybenign. This book is a well-written and fully documentedexposition. The author has had wide experience in thetreatment of the complications-fracture and neoplasia-and his material is well presented. The production of thebook and the illustrations is excellent.

Management of the Injured PatientEdited by WILLIAM S. BLAKEMORE, M.D., and WILLIAM T.FITTS, M.D., professors of surgery, University of PennsylvaniaSchool of Medicine. New York: Harper & Row. 1969.

Pp. 370.$14.50.AT first sight this volume resembles many other text-

books on accident surgery: in fact it has several uniquefeatures, and a scope exactly defined by its title. The

monographs it contains are not, collectively or individually,comprehensive enough for an undergraduate: and not allare sufficiently orthodox for those seeking a higher quali-fication. But to the practising surgeon it will prove veryvaluable indeed. Each of five sections (fractures, soft-tissue wounds, burns, athletic injuries, and multipleinjuries) concludes with the report of a discussion amongseveral leading authorities. Some of the points whichemerge are enthusiasm for an unusual, but by no meansnew, sulphonamide (maphenide, ’ Sulfamylon ’) now beingused topically in the treatment of extensive burns, and the

surprisingly effective result of injecting, or even dividing,the posterior tibial nerve for causalgia after an os calcisfracture. The account of Volkmann’s contracture empha-sises that a significant arterial injury is seldom demon-

strated, and that any operation for its relief must free themedian nerve from " the clutch of the pronator teres

through which it passes ".

Encyclopaedia of UrologyVol. VII, Malformations. Berlin and New York: Springer-Verlag. 1968. Pp. 479. DM196; subscription priceDM156.

THE malformations section of the Encyclopcedia ofUrology is written by twelve American contributors.

J. A. Hutch and A. D. Amar write extensively on thevesicoureteric reflux. Various setiological factors are

discussed and the effects of reflux are considered in chronic

pyelonephritis and atrophic pyelonephritis. The indica-tions for medical and surgical treatment are well set out,and the authors stress that surgery is preferable in cases ofprogressive deterioration of the kidneys. Three operationsare well described in simple illustrations. Hutch and Amaralso write on anomalies of the ureter. V. F. Marshall andE. C. Muecke give a good review of congenital anomalies ofthe bladder, especially with regard to exstrophy of thebladder. Although functional reconstruction of the

bladder, bladder neck, and urethra is disappointing, theyfavour falling back on urinary diversion and cystectomywhen the conservative approach fails. J. J. Murphy andT. A. Tristan write about vesical-neck anomaly, and stressthe necessity for image intensification in voiding cysto-graphy. Keith Waterhouse writes well on anomalies of theurethra and pays special attention to posterior urethralvalves. There are other sections on anomalies of the male

genitalia, hypospadias, and anomalies of the female geni-talia which the urologist will find of special interest. Thesecases are usually referred to the gynecologist but oftenhave a serious renal anomaly on the same side as the mostserious mullerian-duct defect. The book is well producedand illustrated, and each chapter has a very full list ofreferences.

House-Dust Atopy and the House-Dust Mite Derma-tophagoides PteronyssinusR. VOORHORST, M.D., F. TH. M. SPIEKSMA, PH.D., and H.VAREKAMP, M.D., department of allergology, UniversityHospital, Leiden, Netherlands. Leiden: Staflen’s ScientificPublishing. 1969. Pp. 159. D.fl.25.

STARTING with Storm van Leeuwen in the early 1920s,Dutch workers have been prominent in investigations intothe source of the allergens of house dust. The Leiden

group has lately resolved the most puzzling aspect byidentifying the little-known acarine mite, Dermatophagoidespteronyssinus, as the major source of house-dust allergen;and their work is summarised in this book. A short intro-

ductory section is devoted to concepts of atopy and itscharacterisation by the presence of reaginic antibody (IgE).However, it is not correct to say that IgG antibody is

responsible for anaphylaxis in man: IgE is now accepted asthe homocytotropic antibody for atopy and anaphylaxisin man, whereas human IgG is heterocytotropic and

anaphylactic antibody for some animals. Many of theseworkers’ deductions on the specific allergenic content oftheir extracts and on the probable concentrations of specificIgE are based on intracutaneous tests with a three-pointlog-dose assay. The newer, serological methods formeasurement of specific IgE should clarify, and in all

probability confirm, at least some of these deductions.From comparative tests on a number of different house-dust extracts these workers concluded that house dustsfrom different sources contain a single major allergen,

340

present also in old kapok and old feathers. They founda direct relation between the allergenicity of house dustand factors such as low altitude, humidity (includingdamp houses and underground water-courses), and theautumn season-all conditions in which D. pteronyssinusflourishes. The main part of the book deals with the

origin of the allergenic factors in house dust. Micro-

organisms, moulds, human and animal dander, insects,and spiders were considered but none was a major allergen:extracts of mites such as Glycyphagtes domesticus, Tyro-phagus pwrescentiae, and Acarus siro were potently aller-genic in subjects sensitive to them, but were not corre-lated with house-dust extracts. D. pteronyssinus, however,correlated well with the potency of the dust, and its growthin poorly allergenic house-dust samples enhanced their

allergenicity. This mite, it seems, has been overlookedbecause the wrong entomological techniques were used;the mite swells and unfolds in lactic-acid solutions, thusmaking it identifiable. The culture of D. pteronyssinus,its taxonomy, morphology, ecology, and life cycle, andfactors influencing its growth are described. Humandander skin scales seem the best culture medium, togetherwith a small amount of yeast. Allergy to human danderitself has been neglected by other workers, but the Dutchgroup gives evidence of its allergenicity especially in hair-dressers. However, it is very much less potent thanextracts of D. pteronyssinus, and this, together with the factthat it is not normally present in large amounts, makes itunlikely to be of much clinical importance. Nevertheless,thousands of mites can live for several months on 250 mg.of human scales, and an individual sheds 05—1 mg. ofscales per day, much of this probably in bed.

Pathogenesis and Etiology of DemyelinatingDiseases

Edited by KRYSTYNA BURDZY and P. KALLOS. Basle and NewYork: S. Karger. London: Academic Press. 1969. Pp. 701. 3-1.80; E14 10s.

THIS supplement to the International Archives of Allergyand Applied Immunology includes the papers presented to aconference on the demyelinating diseases which was held inLocarno in June, 1967, together with an edited transcriptof the discussion. After an introductory clinical and his-torical commentary come three papers devoted largely tomorphology. The main part of the book is divided intothree sections which deal, in broad outline, with virologicalstudies, immunology, and, finally, a somewhat mixed bagof contributions upon topics as diverse as slow-virus dis-orders (e.g., kuru) on the one hand and cerebrospinal-fluidand tissue phospholipids on the other. The emphasis onvirology shows how clearly within the past few years theclimate of opinion concerning multiple sclerosis and theother demyelinating diseases has changed. Plainly manynow hold the view that the once-discredited viral hypothesisadvanced many years ago to explain the xtiology of multiplesclerosis may after all have much to commend it, especiallyif one is prepared to accept that this disease could representthe clinical expression of an abnormal immunological re-sponse to one or more viral infections. As is so often thecase in the published proceedings of symposia, much of thework has already been published elsewhere, and the papersare variable in scope and quality. But on the whole thisvolume is better than most, and its pages are enlivened bythe vivid and extensive reports of the discussion, whichseems to have been both frank and wide-ranging, even if attimes it reflects the entrenched and divergent views of someof the participants. Although the work presented herethrows no new light upon the setiology and pathogenesis ofdemyelinating processes, this book will be of real value toneuropathologists and to all of those whose interest in

multiple sclerosis and related disorders extends beyond theclinical care of patients.

Comparative Morphology of Hematopoietic Neo-plasms

Edited by CAROLYN H. LINGEMA.N and F. M. GARXER.Bethesda, Maryland: National Cancer Institute. 1969. Pp.365.$5.50.

THIS volume presents the papers given at a symposiumheld in March, 1968, at the U.S. Armed Forces Institute ofPathology, Washington, D.C. The hxmopoietic diseases offowls, mice and rats, guineapigs, cats, and dogs are all

briefly but effectively presented. What little is known aboutcorresponding diseases in fish, amphibia, reptiles, molluscs,and insects is described by Clyde J. Dawe; lymphosarcomashave been reported in several fish, including salmon andherring, and oysters apparently get something like a leu-kaemia. Dr. George Migaki reports on the hsemopoieticneoplasms found in cattle, sheep, goats, pigs, and horses;besides the more usual conditions thymomas are found inthis group of animals and mastocytomas have been foundin cattle and pigs. The editors with Dr. Raymond E. Reeddeal with the spontaneous hsemopoietic neoplasms of non-human primates. Most of the sections are well illustratedby black-and-white photomicrographs of typical tumours,and short bibliographies are appended to each chapter. Theinterest in animal tumours springs from the fact that some ofthem are transmissible by cell-free agents, and the hope isthat by studying them we may learn about human blood-diseases that may have a similar aetiology. Nomenclature

poses difficulties ; an animal disease described as a leukaemiamight well be named a reticulosis or lymphoma by a patho-logist used to human tissue changes. This difficulty is dealtwith by several contributors and should lead to better

understanding in the future. Another line of experiment thatcan be pursued in animals is the importance of geneticfactors. However, Henry Rappaport reasonably complainsthat, while we know much about the descriptive pathologyof these diseases, experimental pathology is largely confinedto rodents, and, while we undoubtedly owe a considerabledebt to workers in this field, he would like to see moreemphasis on experimental work in the future.

New EditionsAdvances in Immunology: vol X.-Edited by F. J. Dixon, Jr., and

Henry G. Gunkel. New York and London: Academic Press. 1969.Pp. 333.$15.00; f.,7.

The Nursing and Management of Skin Diseases.-By D. S.Wilkinson. London: Faber & Faber. 1969. Pp. 403. 22s. ; cloth 50s.

Lives of the Fellows of the Royal College of Surgeons of England,1952-1964.-By R. H. 0. B. Robinson and W. R. Le Fanu.Edinburgh: E. & S. Livingstone. 1970. Pp. 470. f.,6.

Ophthalmology: Principles and Concepts.-2nd ed. By F. W.Newell. Saint Louis: C. V. Mosby. London: Henry Kimpton.1969. Pp. 527.$15.50; C7.

Tumors of the Thyroid Gland.-By William A. Meissner andS. Warren. Washington, D.C.: American Registry of Pathology,Armed Forces Institute of Pathology. 1969. Pp. 135.$2.85.

Progress in Experimental Tumor Research: vol. XII-Editedby F. Homburger. Basle: S. Karger. London: AcademicPress. 1969. Pp. 176. DM 50;$12.00; C5.

The ABC of Acid-Base Chemistry.-5th ed. By Horace W.Davenport. Chicago and London: University of Chicago Press.1969. Pp. 119. 26s.

A Student’s Guide to Geriatrics.-2nd ed. By Trevor H. Howell.London: Staples Press 1970. Pp. 212. 45s.