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The Device

This consists of two parts-an adhesive rim of stomahesiveto which is fused a transparent plastic cover (see figure). Thecover, which defines a closed chamber positioned over thewound, has entry and exit ports for supply of the irrigatingfluid and escape of the fluid and wound exudate, respectively.The transverse ribs of the chamber improve flexibility andallow a thin plastic material to be used without the chambercollapsing onto the wound during irrigation. The entry portaccommodates a standard intravenous giving set. The exit portis connected to a drainage bag which can be emptied througha tap. One bag may therefore be used throughout the life-spanof the device.

Use of the DeviceAfter the wound and its surroundings have been sampled for

bacteriological examination they are cleaned in the usual way.The parchment backing from the stomahesive is then peeledoff and the chamber positioned over the area of breakdown.Sutures adjacent to the area of dehiscence need not beremoved.

Three precautions aid successful use. Firstly, the bondbetween stomahesive and skin may be improved if the peri-phery of the base is taped with ’Micropore’. Secondly, the pa-tient should lie quietly in bed for 2-3 h after application of thedevice; after this time, he may move about freely within rea-son. Thirdly, irrigation is delayed for 4 h, since rapid irrigationbefore this may lift off the stomahesive base and result in leak-

age. Irrigation is carried out with the patient lying in bed orsitting in a chair. It may be continuous or intermittent, usuallythree times daily, until discharge lessens and the appearanceof the wound improves. The rate of irrigation is controlled bythe drip set, and the effluent evacuated from the drainage bagafter each irrigation. Handling of infected material is thereforekept to a minimum, and material for bacteriological examina-tion can be obtained from the effluent or by swabs of thewound through the exit port. Between periods of irrigation,the entry and exit ports may be spigoted so that the patientmay walk about. The device remains in place for 2-4 days oruntil leakage precipitates its removal. The aim is to keep thedevice in place until the wound is clean, non-offensive, andrequires no more than one dressing daily. On the whole, pa-tients have found this form of dressing both convenient andcomfortable.

It is not intended to discuss the fluids which may be used for

irrigation; stomahesive has however been tested against a

range of antiseptic solutions to ensure that these will not dis-turb its bond to skin.

Advantages of Device1. Provision of a closed system for irrigation of the infected

wound.2. Reduction of exposure of the purulent wound and in-

fected dressings to the atmosphere, and elimination of thehandling of contaminated material.

3. Prevention of maceration of surrounding skin by soggydressings.

4. Elimination of unpleasant smell.5. Possibility of inspection of the wound without removal of

the chamber.6. Provision of a system for the assessment of topical anti-

septics and antibiotics in the eradication of sepsis and promo-tion of wound healing.

7. Reduction in nursing time.

We thank Squibb Surgicare Ltd. for their help in the production ofthis device.

Requests for reprints should be addressed to: S. W., Department ofCardiothoracic Surgery, Hammersmith Hospital, DuCane Road, Lon-don W12 OHS.

Reviews of Books

The Philosophy of Medicine

The Early 18th Century. LESTER S. KING. London: Harvard Uni-versity Press. 1978. Pp. 291. 12.25.

IN order to understand medicine today one has to knowsomething of the basic medical sciences. In order to understandmedical thought in the 17th and early 18th centuries, whichwas based on natural philosophy, one has to know somethingabout the philosophical schools of that period, and the waythey influenced and were influenced by medical theory andpractice. In this book, the author guides us through the

changes in philosophy that took place. Thus, he discusses theconcepts of nature, of soul, mind, and body, and of substantialform, and traces the development of iatromechanics and iatro-chemistry ; he illustrates these concepts and their relevance tomedical thought by a critical examination of a large numberof authorities, including Robert Boyle, Boerhaave, Sydenham,and Thomas Willis, and other less familiar names such as Bab-lot, Maupertius, Blondel, and Malebranche. These strands arebrought together in three excellent chapters on the process ofexplanation, the cause of disease, and rationalism and empir-icism. Dr King, who was professor of pathology at the Univer-sity of Illinois and senior editor of the Journal of the Ameri-can Medical Association, is a distinguished medical historianand authority on this period of medical history. By going backto the original Latin sources he has produced a very scholarlywork. He has written it with the aim that it should be under-stood by anyone interested in the medicine of that period, evenif they have not had formal training in philosophy. It is a mea-sure of the lucidity of his writing that he has succeeded. It is,nevertheless, not an easy book to read because, to most doc-tors, it covers largely unfamiliar territory. Reading this bookwill be like being taken through a region one knows slightly byan expert guide who repeatedly shows one things one has nevernoticed, or half-noticed without realising their significance. Ifthere is tiredness at the end of the journey, there will also bea sense of achievement, of greater understanding, and of re-spect for the authorities of the past. The journey may be aneffort but a worthwhile one, and one that should be made byanyone interested in medicine in the 17th and early 18th cen-tury. The footnotes are excellent and the production and print-ing are exceptionally fine.

Beyond the Magic Bullet

BERNARD DIXoN. London: Allen & Unwin. 1978. Pp. 249. .SO.BERNARD Dixon trained as a microbiologist, became a

deputy editor of World Medicine, and is now Editor of NewScientist. This career is reflected in his book, for it is lucidlywritten and it is concerned with demonstrating the present andlikely future failure of continuing belief in "specific setiolo-gy"-a term denoting a relatively simple relation betweencause and effect in the genesis of disease. The idea gained enor-mous impetus from the successes of bacteriology towards theend of the 19th century, when a single agent could be seen tocause and identifiable disease. In tracing the doctrine of speci-fic xtiology, Dr Dixon draws on some slightly doubtful inter-pretations of medical history, though here he has probablybeen constrained by the need to compress his argument. Hethen considers the rise of bacteriology in the hands of Pasteur,Koch, and Ehrlich (a section handled briefly and well). Thisapproach to disease was further vindicated by the recognitionof vitamin deficiencies, endocrine disorders, and genetic abnor-malities, as well as by psychosurgery (an inclusion which seemsa little strained, though the generality of the theme is reason-ably established). The next step in the argument is obviouslyto show that the total belief in specific aetiology is erroneous.

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"This does not mean that specific aetiology is untrue. It does

suggest that the notion is simplistic, and that much more needsto be taken into account in delineating the essence of disease".The quotation shows why the book may be a disappointmentto clinicians: it points to the gulf between theory and practice.The clinician, seeing the variations of human disease, evenwhen a primary agent is operating and identifiable, scarcelyneeds this reminder. The medical textbooks too are diffuse and

difficult, even nebulous in their sections on aetiology, patho-logy, clinical patterns, and treatment. There is little evidencein them of "simplistic" approaches, as any medical undergra-duate struggling with all the uncertainties will avow. The bookproceeds with now familiar criticisms of high-technologyMedicine, the failures of teaching hospitals, the unnecessaryprescription of drugs for trivial ailments, the improper use oflaboratory services, and the inadequacy of Medicine to deal ef-fectively with grief and psychological disorders. All this isfashionable and right-up to a point. Yet there are morethings in health and disease than have been dreamed of inmedical philosophy. The role and value of Medicine in society,until recently unquestioned, are now far from clear. Dr Dixonfollows the trail of doubts as others have done, though his eyecatches a few unfamiliar details along the route. But thebook’s important theme somehow escapes the depth of treat-ment it merits. The reader hopes for bread and yet, if he is notactually given a stone, there is the same pabulum as before.That may be no fault of the author’s, for the future of Medi-cine is indeed a formidable subject to which many people, in-cluding, fortunately, an increasing number of doctors, are put-ting their minds. Those who have fallen behind in the debatewill find this book helpful in describing the present state ofplay-though it is the view of a commentator who has not

played the game. If, as many believe, Medicine must increas-ingly accept that.its prime function is to maintain healthrather than treat disease, this idea has, for doctors, been morefully explored by Thomas McKeown in The Role of Medicine. tThere he showed that the determinants of health were mainlynutrition, hygiene, and the control of numbers of people, onwhich conventional medical care had had little influence. Heillustrated the difference between social action and medicalaction. More important perhaps was the distinction betweenhealth care and medical care. The fact that doctors are ofteninvolved with health care should not obscure the differenceswhich are arising between cure and care, between maintenanceof health and its restoration when lost. General practice isgroping after a rapprochement; and, to a lesser extent, so arehospital doctors, medical educators, and many others. But,except by implication and inference, Dr Dixon does not

sharpen these developing ideas and break new ground. Never-theless he has charted the old ground from a fresh viewpointof specific aetiology and its now demonstrable failure to meetpresent needs. It is, however, doubtful whether specific xtiol-ogy ever had such a hold on medical practice as he believes.

Clinical Embryology

R. G. HARRISON, University of Liverpool. London and New York:Academic Press. 1978. Pp. 250. 4.80;$9.35.

THIS latest addition tQ the series, Monographs for Studentsof Medicine, is a logical extension of the author’s originalTextbook of Human Embryology, now out of print. Onceagain the aim has been to present embryology in a way thatfacilitates the comprehension of human development andassists the understanding of human anatomy. This new volumeis bound to compete with professor M. J. T. FitzGerald’sHuman Embryology: A RegionalApproach (Lancet, May 27, p.

1. McKeown, T. The Role of Medicine: Dream, Mirage or Nemesis? London,1976. See Lancet, 1977, i, 352.

1134) which is mainly an adjunct to an undergraduate coursein human anatomy, the subject being presented by region withemphasis on normal morphogenesis; there is little attention

paid to the development of function, and malformations aretreated briefly. By contrast, Professor Harrison’s new book,although designed principally for preclinical students, perhapscaters better for postgraduate students such as those studyingfor the primary F.R.C.S. examinations. His text is slightlylonger but the illustrations are fewer and not as good. The textis presented in the more traditional way, by system. Descrip-tions of morphological features are brief in order to makespace for those of function. Emphasis on the clinical relevanceof embryology has been achieved by a section on clinical rela-tionships at the end of each chapter. Another useful feature isthe information on the incidence of the malformations de-scribed. The times of developmental events have largely beenomitted "since they mostly occur in the first eight weeksanyway". This is a weakness because knowledge of timing isimportant in the consideration of the possible role of terato-genic factors in the production of abnormalities such as in theeye, ear, brain, heart, limbs, palate, kidneys, gonads, andexternal genitalia. No author can hope to produce a book thatsatisfies the needs of every preclinical course, but as was thecase with Professor FitzGerald’s book, this one is most wel-come for its readable, concise text, appropriate for the majorityof medical schools.

Atlas of Clinical AnatomyR. S. SNELL, George Washington University, School of Medicine.Boston: Little, Brown. London: Quest. 1978. Pp. 530.$24.95;/;16.25.

Gross Anatomy Dissector

R. S. SNELL, George Washington University School of Medicine.Boston: Little, Brown. London: Quest. 1978. Pp. 358.$9.95;£ 6.50.

THE atlas, organised by region into eight sections, contains384 illustrations, most of which are original colour drawingsbased on specially prepared dissections. At the beginning ofeach section colour photographs show the surface features ofthe region. Within each section the anatomy is presentedsequentially, starting at the surface and proceeding stepwise tothe deeper structures. The illustrations and the labelling aregenerally clear, but the colours are vivid, and although thedrawings are adequate for their purpose, there is a certain lackof finesse in the style of the drawings. A particularly useful fea-ture of the atlas is the text accompanying each picture, whichindicates briefly some of the abnormalities and diseases whichmay affect the structures depicted. As Professor Snell pointsout, medical students are students of medicine, not of ana-tomy, and they should be reminded of the practical applicationof their knowledge of the normal structure of the body. Stu-dents who use this atlas will be left in no doubt that anatomyis the rock on which the increasingly complex edifice of clinicalmedicine has been built. The Gross Anatomy Dissector, whichis meant to be used with the atlas, is issued in limp covers withspiral binding, and the regions of the body are presented in thesame order as in the atlas, to which frequent reference is made.

. The introduction gives practical advice on the technique of dis-section and the proper use of dissecting instruments. Nextcome comprehensive instructions for the dissection of the

thorax, abdomen, pelvis, perineum, the upper and lower limbs,head and neck, and the back, although this sequence need notbe adhered to. Students are encouraged to familiarise them-selves, by palpation, with the salient landmarks of each partbefore they start the dissection, and the necessary skin inci-sions are shown in photographs of the region. The text is pro-fusely illustrated by clear line-drawings based on the equiva-

506

lent illustrations in the atlas; indeed, the Gross AnatomyDissector is virtually an atlas in its own right. Professor Snellgives no indication of the number of hours which would berequired in the dissecting room to follow this guide in toto. Itis likely that some anatomy departments would be unable toprovide the necessary time within the restrictions imposed bythe type of medical curriculum which is fashionable at present.

The Newborn BabyS. C. L. SHORE, Groote Schuur Hospital, M. P. KEET, Universityof Stellenbosch, and V. C. HARRISON, University of Cape Town.Cape Town : Juta. 1978. Pp. 540. R19.50.

THIS work, by three well-known South African poediatri-cians with a special interest in neonatal medicine, is writtenmainly for medical students. The authors hope that the bookwill be of use also to nurses, general practitioners, and otherdoctors. It deals not only with the common disorders of thenewborn period, but also with perinatal statistics, perinatalphysiology, growth and development, infant feeding, intensivecare, neonatal drugs, and neonatal surgery, and contains morethan 200 figures, some in colour. Sometimes the emphasis isuneven. For example, 115 pages are given to congenitaldefects, but only 14 to "respiratory distress"; and twins, poly-cythxmia, and thrombocytopenia receive too little attention.Some statements are open to challenge. Is it really advisableto resuscitate the asphyxiated infant in the head-down posi-

- tion? Is it true that pneumomediastinum is unlikely to causecomplications? Does the perinatal mortality of infants born towomen with diabetes exceed 33% if the mother is deliveredafter 38 weeks? Apart from these criticisms, this is a good,comprehensive introduction to neonatal medicine.

Principles and Practice of Child PsychiatrySTELLA CHESS and MAHIN HASSIBI. 1978. London and NewYork: Plenum, 1978. Pp. 500, 12.60;$24.

THE authors wrote this book for those intending to

become child psychiatrists, but it is doubtful whether there isenough detail for such students. Cerebral dominance isdismissed in a single paragraph, and the effects of a fatherlesshome on future development-rates in a mere page and a half.There is, however, certainly enough detail for the general-psy-chiatrist-in-training, who will find this a well written, up-to-date American textbook into which a modern, research-oriented view of the whole of child psychiatry is successfullycompressed. Dr Chess is well known for her research on theNew York longitudinal study of temperament. Here she

emerges as a perceptive and undogmatic clinician as well as acapable researcher.’ Her conclusions are usually based onresearch data, and references are given to recent research find-ings in both Britain and the United States. After a historicalaccount of the subject there are separate chapters on normaldevelopment and theories of development; the second sectiondescribes disorders of behaviour and the assessment of the

child, and the last 300 pages discuss issues in classification andthen give an account of various syndromes. The chapter onclassification gives five different schemata; unfortunately, noneof these is followed in the chapters on the individual syn-dromes. Although the book is easy to read, one is conscious ofbeing taken through a vast terrain at high speed. A longer textwould probably have been easier to write, as well as more re-warding to read. There are occasional errors. The evidence fora genetic component in human intelligence does not rest en-tirely on Cyril Burt’s work, dementia prxcox was not so

named because the adolescent syndrome resembles senility,and The Way of All Flesh is not a vivid portrayal of innatechildhood wickedness.

A New Approach to Medicine

Principles and Priorities in Health Care-JOHN FRY. Lancaster:M.T.P. 1978. Pp. 154. 6.95.

JOHN Fry’s contribution to the literature of primary care iswell known. It is based on a wide experience of the discipline,ineticulous record-keeping of his clinical work for more thana quarter of a century, and an extensive knowledge of systemsof health-care in other countries. In this book he presentsbriefly and clearly a summary of his work and outlines someof the changes in primary care that have occurred in his life-time. There is no doubt that his most valuable contribution tomedicine has been the demonstration of the natural history ofmany common disorders and it is this that forms the basis ofmost of his conclusions. The popular image of medicine todaytends to be one of spectacular advances involving complextechnological procedures, which have either just been discov-ered or are just about to be. John Fry points out how seldomit is emphasised that there are few diseases that are "curable"and many that are self-limiting. It is an unexciting messagecompared with news concerning "breakthroughs" but it needssaying now as never before. We are not yet nearly critical

enough about the cost-effectiveness of many medical proced-ures ranging from computerised tomography to what is nowknown as "informal" psychotherapy. Dr Fry points out thatwe tend all the time to "over-investigate, over-operate, andover-treat". He illustrates these points with examples and asksmany questions that must be answered before medicine canbecome-as it must-more rational and less expensive. Thereare two main criticisms of the book: the title and the style. Thetitle suggests that the author is proposing new and radicalsolutions to the problems of health-care, and the reader maysense a disappointment when such promise is not fulfilled. Fewof the author’s conclusions are controversial today althoughthey might have seemed so a few years ago. This is partlybecause his views are so well known that they have alreadybecome familiar, even although they have not always beenacted on; it is also partly a consequence of his style. Brevityand plain English are always virtues in medical writing, buthere they are observed to such an extent that the book reads

, like summaries or lecture notes, almost as if the author is veryslightly bored with having to say it all again. And, indeed, itis true that those who have followed the mainstream of litera-ture on general practice over the last twenty years will find thecontents of the book largely familiar, although it has the meritof pulling everything together under one cover. To those notfamiliar with the author’s work the book serves as an excellent

summary of the work of a general practitioner whose energyis prodigious and whose greatest virtue is his profound andsolid common sense, a virtue not to be despised.

New Editions

External Infection of the Eye.-2nd edition. By Helena Biantovs-kaya Fedukowicz. New York: Appleton Century Croft. London: Pren-tice Hall. 1978. Pp. 283. 18.35.

Psychiatry Examination Review.-2nd ed. By William M. Easson.New York: Arco. 1978. Pp. 149.$8.

Renal Histopathology.-2nd ed. By Robert Meadows. Oxford:Oxford University Press. 1978. Pp. 544. 30.Acid-Base Regulation: Its Physiology, Pathophysiology, and the In-

terpretation of Blood-Gas Analysis.-2nd ed. By Edward J. MasorotefpreMtMM of Bloo-Gas Analysis.—2nd ed. By Edward J. Masoroand Paul D. Siegel. London & Philadelphia: Holt-Saunders. 1978. Pp.169./;6.75.

1978 Year Book of Obstetrics & Gynecology.-Edited by Roy M.Pitman and James R. Scott. London: Year Book’Medical Publishers.1978. Pp. 480.18.Medical Malpractice Law.-2nd ed. By Angela Roddey Holder.

London: Wiley. 1978. Pp. 562. [,17.60.Guide to Surgical Terminology.-3rd ed. By Francis Coleman.

New Jersey: Medical Economics. 1978. Pp. 397.$11.80.Dermatology.-An illustrated guide. 2nd ed. By Lionel Fry. Lon-

don : Update. 1978. Pp. 164. £ 6.50.$19.00.