Denis Williams

Colposcopic assessment of the accuracy of cervical cytology screening.

Two hundred asymptomatic women in a general practice were screened both cytologically and colposcopically for evidence of cervical intraepithelial neoplasia. The prevalence detected by cytology alone was 5%, but the prevalence detected by cytology and colposcopy together was 11%. None of the larger lesions of cervical intraepithelial neoplasia (affecting more than two quadrants of the cervix) was associated with negative cytology. The false negative cytology rate for smaller lesions was 58%. The clinical importance of the smaller lesions that were not accurately detected by cytology screening is unknown. As these lesions affected 6% of the screened population further studies of their clinical course are urgently required. Local destructive treatment in such cases may represent considerable overtreatment. If these lesions prove to be clinically important, however, the results of this study predict an increasing epidemic of preinvasive and invasive disease of the cervix.

New Orientations in Epilepsy

of yesterday, and may be the discarded fallacy of to-morrow. Methods, like men, must establish their own grading. Above all things it is important that the relation of confidence between the doctor and his patient should not be disturbed. The patient should look on his doctor as an individual whom he has chosen to help his own individual needs, as a man of power who can invoke State assistance and command State resources, never as an official at the end of an office string. For this relationship to be maintained it is essential that private practice should be encouraged rather than driven into the hands of the small group of charlatans who would still exist to prey on the stragglers of a society in which all reputable doctors were perforce full-time employees of the State. In matters of decisive concern to the individual-his health, his house, his legal affairs, his money-it is essential that each man should be free, if he so desires, to seek advice from an expert of acknowledged position and integrity, chosen by himself. Only when such a body of experts is available, as a standard for comparison and as a Court of Appeal in doubt or difficulty, can a Government service be wholly efficient or command complete confidence. It is clearly in the interests of a State medical service that the men who work within it, and the men whose wisdom or whose contributions to science have earned them a position in which they are sought as second opinions, should be the same.

Cerebral Embolism Following Contusion of Heart

Damage to the heart resulting from non-penetrating blows to the chest wall is not rare, and several series of these cases have been recorded (Barber, 1944; Bright and Beck, 1935; Kahn and Kahn, 1929; Warburg, 1940; Hawkes, 1935; Arenberg, 1943; Sigler, 1945). The heart and pericardium, lying close behind the chest wall, are very vulnerable to severe blows in the region of the praecordium, but generally any damage which may be caused is mild and not recognized. In children and youths, however, there is perhaps a greater chance of cardiac trauma than in adults, because the heart is behind a resilient sternum and can be the more easily compressed against the spinal column. Although many cases of cardiac damage have been described we have not been able to find a case recorded in the literature in which a 3

Temporal Lobe Epilepsy

My subject is temporal lobe epilepsy as such-that is to say, the disturbances experienced by the patient and observed by others when there are stereotyped intermittent disturbances of feeling, behaviour, or consciousness resulting from disorder of the temporal lobe of the brain. Except in an incidental way the electroencephalographic correlates of the clinical disorders will not be described, the nature of the pathological lesions responsible will be ignored, and the predisposing or immediately precipitating causes will be discussed only in passing. Neither will this account of temporal lobe epilepsy become anecdotal, I hope, for there can be no branch of medicine in which the elaborate and often bizarre experiences of patients lead to purposeless and discursive description of the event. Rather I will try to distil from the clinical notes of many patients who suffer from temporal lobe epilepsy some pattern of disturbed function related to the disorder of brain which may

Book Review: Epilepsy and the Law – a Medical Symposium on the Current LawEpilepsy and the Law – a Medical Symposium on the Current LawFenwickP & E (eds) pp 88£9 ISBN 0-19-922022-0 London: RSM Services1985

explanatory line drawings and these would perhaps be more helpful if they were correlated more closely with the excellent radiographs. A few of the illustrations are rather dark. In the demonstration of varices relaxation of the oesophagus is important but over distension may actually make varices less obvious. This is a useful book which is recommended to consultant radiologists as an indication of the high standard that may be obtained, as well as to trainees. There is a useful list of references. F J BRUNTON Consultant Radiologist Southampton General Hospital

TEXTBOOK OF NEUROLOGY

on visual teaching, which was so widely followed during the period between the wars. Since this is not a mere catalogue of methods, it seems a pity that the technical section was not also treated on historical lines. Past mistakes and enthusiasms often give an insight into present difficulties, especially in an empirical subject such as this. The impression is given of a cri de ctur from one who has mastered the art in all its intricacies, knows the part a museum still has to play in medical education, and is not impressed by glossy superficial montages of the contemporary exhibition type. The great medical museums probably reached their zenith in the second decade of this century, when morbid anatomy was a prime concern of heads of teaching departments and of the leaders in medicine and surgery. To-day the focus of attention has moved to other rapidly extending fields of inquiry and the museum has tended to become a nostalgic tradition. The young technician is quick to realize that such patiently acquired skills no longer attract the attention they merited in the past, and the trained preparator is becoming extinct in consequence. It is to be hoped that this book will revive interest in medical museums and help them to meet the challenge of the times.

THE CEREBRAL CORTEX

blood vessels. The fourth section, on systemic biochemical factors in the causation of atherosclerosis, is in some ways the most stimulating. A. L. Lehninger gives a masterly summary of present views on lipid metabolism, and R. G. Gould writes on the control of steroid metabolism. Ancel Keys summarizes his well-known views on the important part which diets with a high fat content play in the causation of atherosclerosis. The last section is concerned with the lipoproteins and the evidence that they are involved in the production of atherosclerotic changes in vessels. The causation of atherosclerosis appears to be almost as difficult to unravel as that of cancer. In both cases we seem to be confronted with a jigsaw puzzle of which some parts are missing, some pictures appear twice in slightly different forms, and others seem to come from an entirely different set. It is to be hoped that soon someone with a more than usually observant eye will be able to see the whole picture. It is clear that no one so far has caught more than a glimpse of a part of it. This monograph shows that failure will arise from lack neither of effort nor of interest. It can be strongly recommended to those interested in the question of the causation of atherosclerosis. It does not include the clinical syndromes arising as a result of atherosclerotic changes in vessels. E. J. WAYNE.

Repetitive Auricular Flutter

SIR,-Attention has been drawn by Dr. Peter Stradling (Nov. 6, 1948, p. 832) and Dr. Bertram Mann (Nov. 20, p. 917) to the practitioners duty and delay in the diagnosis of phthisis. As one who has been specially interested in this condition I make the following comments with the hope that useful knowledge may be added for those who write such articles and have no sustained experience of general practice. X Rays.-Hopelessly overworked departments have been the rule in most areas visited, and they are usually under-staffed; since the State Service came into being chaos has prevailed. How can one therefore send cases up-other than to a mass x-ray unit-for a host of suggested symptoms without considerable sifting ? Shortage of films is another factor. Cough.-Where this is found to be due to disease of the upper respiratory system, chronic bronchitis or heart failure, smoking to excess with or without alcohol, or secondary to acute infections, x-ray examination is not recommended unless the cough persists with other signs or symptoms. When one considers the huge numbers of cases of bronchial catarrh in the English climate, this can hardly be regarded as pathological; no x-ray examination is suggested for these. Dyspnoea and laryngitis are so common in non-tuberculous conditions that other causes should be eliminated first. Some four patients with tuberculous laryngitis have been seen in my practice in twenty-two years, two before the chest condition was diagnosed. Of the many pneumonias, a similar number proved to be due to phthisis. Lassitude.-For every case found to be tuberculous in origin many hundreds are due to other conditions, especially functional causes. Haemoptysis.-Whilst this indicates x-ray examination, many other conditions such as neoplasm, mitral disease, bronchiectasis, papilloma of bronchus, and acute bronchitis are commoner causes by far. Pain in the chest, pleurisy, loss of weight, anorexia, and anaemia, while being symptomatic of tuberculous disease, so commonly occur in other conditions as often to rule it out without further thought. Ischio-rectal abscess, erythema nodosum, and phlyctenular conjunctivitis have become so increasingly rare for a number of years in my practice that as signs they seem remote compared with the commoner features. P.U.O. cases have mostly proved blanks to all investigations. Very few cases of influenzal and recurrent febrile chills have been found to be tuberculous. Before condemning the practitioner in the delay of diagnosis of phthisis we must remember that there are other illnesses which take up his time. Any cough unaccounted for by multitudinous other causes and which persists for 2 to 4 weeks is investigated for phthisis by any reasonably modern or ancient competent family doctor, especially when accompanied by wasting, night sweats, and haemoptysis. Far too many criticisms are levelled at the family doctor by. those who are quite ignorant of prevailing conditions of general practice, and what is more have no prolonged practical experience of this branch of medicine.-I am, etc., Hove, Sussex. J. HARTSILVER.