- Email: [email protected]
CHRONIC PANCREATITIS
1106
obvious constituent of synovial fluid is hyaluronic, it is presumably in the synthesis of this polysaccharide that these cells are engaged. Also present in the synovial cells of both types are lysosomes, subcellular vesicles first shown by De Duve to consist of a lipoprotein membrane enclosing a mixture of several hydrolytic enzymes with little in common except optimal activity in the acid pH range of 3 to 5. Since these include powerful proteolytic enzymes which, in some tissues at least, can attack collagen and can certainly break down the protein-polysaccharide bond in chondromucoprotein, their participation in the pathogenesis of arthritis is extremely probable. In this context the studies of D. Hamerman with the electron microscope are especially significant. At the E.R.C. symposium he described finding in the lining cells of the synovium of rheumatic joints conspicuous electron-dense bodies much larger than lysosomes but probably derived from them, judging by their rich content of acid phosphatase. The precipitation of lead phosphate in the first stage of Gomori’s method for the display of this enzyme makes this a particularly suitable subject for electron microscopy. These studies of the ultra-structure of synovial cells suggest, therefore, that injury 10 joint structures may indeed be mediated by enzymes elaborated in the affected synovial cells. What leads in the first instance to the abnormality of these cells, as revealed by the electron microscope, is still obscure, but the results of Bitensky and her colleaguesI on the influence of antibodies to ascites tumour cells upon their lysosomal acid phosphatase imply that immune reactions on cell surfaces may be one method by which such lysosomal injury could arise. RENAL PAPILLARY NECROSIS AND PHENACETIN
THE frequency of renal papillary necrosis in Denmark is again emphasised by an account of 66 cases seen in four years in one department of medicine in Copenhagen. Harvald2 points out that only 5 of these were in patients with diabetes and only 8 in patients with obstruction of the urinary tract (his two " traditional " conditions associated with its occurrence). Of the other patients the largest group had had recurrent attacks of acute pyelonephritis, but of special interest was a group without any urological symptoms but with refractory anxmia found to be due to renal insufficiency from chronic pyelonephritis. Harvald was particularly concerned with the abuse of analgesic drugs, especially phenacetin : " most of our patients with papillary necrosis have consumed six tablets or more per day for over ten years". A few had reasonable grounds for this consumption (rheumatoid arthritis or osteoarthritis), but the majority gave vague explanations such as tiredness, feeling of insufficiency, over-exertion, or ill-defined headache. Harvald admits that the mechanism by which analgesics injure the kidneys remains obscuresLindwa113suggested that phenacetin may render the kidney more susceptible to infection. Papillary necrosis is less common in this country for perhaps two reasons. First, aspirin, and not phenacetin, is the main constituent of our headache powders 4 5; and, secondly, we may be more acutely aware of the minor 1. Bitensky, L. Brit. med. Bull. 1963, 19, 241. 2. Harvald, B. Amer. J. Med. 1963, 35, 481. 3. Lindwall, N. Acta radiol., Stockh. 1960, suppl. 192. 4. See Lancet, 1959, i, 84. 5. See ibid. 1960, ii, 858.
grades of pyelonephritis and the indefinite symptoms they produce. Thus the recognition of inapparent and subclinical pyelonephritis,6 and the purposeful investigation of indefinite symptoms possibly due to this or more overt chronic pyelonephritis,’ may lead to earlier recognition and treatment of infections, thus discouraging self-medication not only with phenacetin but with other analgesics too. It is surely too late to wait for the " comparatively unalarming symptomatology, either as attacks of acute pyelonephritis with excretion of papillary tissue or as a slowly progressing renal insufficiency."2 Lindwall3 found the changes of chronic pyelonephritis, often with acute exacerbations, in all the resected or postmortem kidneys of the phenacetin patients, while Harvald2 quotes Spuhler and Zollinger as finding a chronic interstitial nephritis which corresponds with Talbot’schronic interstitial infiltration in chronic ascendIt has already been shown4 how such a lesion can affect the blood-supply to the renal papillx.
ing pyelonephritis.
CHRONIC PANCREATITIS
THE
frequency of chronic pancreatitis may be much underestimated, because the main manifestations, such as a raised fasting level of serum-amylase or serumlipase, steatorrhoea, pancreatic calcification, and diabetes, are found only in well-established cases. Early, developing, mild, or atypical cases have been missed mainly through lack of specific tests of pancreatic function. Fitzgerald et awl. lay emphasis on the value of evocative enzyme tests in this connection. These workers investigated 53 patients with chronic pancreatitis by means of cholecystography, barium-meal examinations, tests for faecal occult blood, &bgr;-cell function tests (fasting bloodsugar levels and glucose tolerance), and straight X-rays to demonstrate pancreatic calculi. But they regard the secretin-pancreozymin test described by Howat 10 and elaborated by Burton et al. 11 as the most helpful of all tests in the diagnosis of early chronic pancreatitis, and as providing earlier information of pancreatic derangement than examination of the duodenal contents. 69 secretinpancreozymin tests were carried out on 40 patients with pancreatitis. The serum-amylase rose from fasting levels of 0-7-4-4 mg. per ml. (40-242 units) with a mean of 2-53 mg. per ml. (157 units) to 2-5-8-2 mg. per ml. (137-451 units) with a mean of 3-41 mg. per ml. (188 units). In normal control cases the serum-amylase rose from a fasting level of 0-5-1-9 mg. per ml. (28-105 units) with a mean of 1.3 mg. per ml. (72 units) to a peak post-stimulatory level varying from 0-6 to 2-6 mg. per ml. (38 to 137 units) with a mean of 1-5 mg. per ml. (84 units). In only 2 of Fitzgerald’s patients did the serum-amylase level fail to rise over 2-9 mg. per ml. (160 units) after stimulation-an accuracy of 95% for the test. This is an important finding, because fasting amylase and lipase levels are often normal in quiescent phases of pancreatitis, and may be raised in other diseases such as acute gallbladder disease and perforated duodenal ulcer and after
the administration of morphine-like narcotics.i2 Results from serum-lipase in the secretin-pancreo6. See ibid. 1959, i, 1265. 7. See ibid. 1961, ii, 89. 8. Talbot, H. S. J. Amer. med. Ass. 1958, 168, 1595. 9. Fitzgerald, O., Fitzgerald, P., Fennelly, J., McMullin,
J. P., Sylvester, J. B. Gut, 1963, 4, 193. Howat, H. T. Modern Trends in Gastro-enterology (edited by F. Avery Jones); p. 776. London, 1952. 11. Burton, P., Hammond, E. M., Harper, A. A., Howat, H. T., Scott, J. E., Varley, H. Gut, 1960, 1, 125. 12. Bogoch, A., Roth, J. L. A., Bockus, H. L. Gastroenterology, 1954, 26, 697. 10.
1107
zymin test were only occasionally of diagnostic value, and in this series reliance was placed on the amylase figures. The chief criteria, therefore, for diagnosis of pancreatitis in relation to enzyme tests were high fasting amylase (over 2-1 mg. per ml.) in the absence of other possible causes, and peak serum-amylase 2-9 mg. per ml. (159 units) or over at any time during the test. Another feature of pancreatic disease-enzyme dysfunction resulting in malabsorption-can be brought out by means of fat-balance studies, vitamin-A-acetate/vitamin-A-alcohol absorption studies, and triolein 131 and oleic-acid 1311 tests, but the diagnosis of pancreatic disease cannot be based solely on malabsorption of fat. The secretin-pancreozymin test may produce moderately severe but transient pain over the pancreatic area (indicating obstruction) and vomiting. After a suspected acute phase of pancreatitis the test is better avoided, and it is needed in advanced disease. Diagnosis is now possible when the acinar and islet tissues are only slightly damaged, and treatment can then be directed to preventing further pancreatic destruction. Medical treatment was used by Fitzgerald et al. in patients regarded as unsuitable for surgery, such as alcoholics, psychologically disturbed patients, and patients in a state of advanced malnutrition. The measures adopted were a low-fat, moderate-residue diet, replacement therapy with pancreatin, and, for the relief of pain, anticholinergic drugs, such as atropine, and smooth-muscle relaxants including glyceryl trinitrate. Surgical treatment was adopted in 27 of the Fitzgerald series of 53 patients. Generally, operation was reserved for those patients who did not respond to medical therapy, but with increasing experience surgery was offered to the majority. Sphincterotomy was the operation of choice, in view of the work of Doubilet and Mulholland.13 The procedure was essentially a meatotomy; in all patients who not
gave a positive secretin-pancreozymin test Fitzgerald et al. found a definite pancreatic lesion-usually sphincteric stenosis or some other obstruction. In most patients the ampulla was the site of blockage, indicated by the failure to pass a 3-5 mm. sound easily through it. An incision 1 cm. long in the ampulla displays the pancreatic duct. A retrograde pancreatogram may be made to demonstrate the patency of the pancreatic duct.14 15 Other procedures may be needed-removal of pancreatic calculi, drainage of
pancreatic abscess, hemipancreatectomy, or cholecystectomy. Many operations have been advocated for chronic pancreatitis, 16 11 but, in view of the morbidity that follows in their wake, even after sphincterotomy, extensive operations for non-malignant disease of the pancreas are be undertaken
lightly. descriptive name for the disease in many cases is chronic progressive pancreatitis-a disease which appears as a comparatively minor disturbance but over the years pursues a relentless course, punctuated by acute attacks,
not to
The
becoming more florid in its manifestations. Pain becomes more severe, and eventually complications, such as diabetes and steatorrhcea, arise. A condition such as this is more accurately described as " chronic progressive " rather than " chronic relapsing " pancreatitis.18 13. 14.
Doubilet, H., Mulholland, J. H. J. Amer. med. Doubilet, H., Poppel, M. H., Mulholland, J. 325.
15. 16.
Ass. 1961, 175, 177. H. Radiology, 1955,
64,
Bartlett, M. K., Nardi, G. L. New Engl. J. Med. 1960, 262, 643. Smith, R. in Recent Advances in Surgery (edited by Selwyn Taylor). London, 1959. 17. Lancet, 1960, i, 1282. 18. Tumen, H. J. Discussion on paper by Gambill, E. E., Baggenstross, A. H., Priestley, J. T. Gastroenterology, 1960, 39, 404.
BIRTH CONTROL
low-at world population in explosion, at our national struggle to house and educate our young or to save our lovely countryside from becoming one outsize housing-estate, at criminal abortion among the married and unmarried, or at the young wife, destitute of domestic help, childbound for years-the need to control conception if Man is to have room enough and food and any chance of leading a civilised life is undeniable. With Nature in flat opposition we need not expect control to be easy. In theory we have but to regulate our love-making; in practice we know that this, save for individuals, is no answer, and that if the daunting problem is to be solved at all it can be only through the widespread use of contraceptive devices. They are the only available counterpoise to our frightening success in exterminating major killing diseases and prolonging the expectation of life-and at present a by no means WHETHER
we
look
high
or
adequate one. For largely ineffective contraceptives there is little
to
be said. It would be very rash to suggest that either the world or the family are never the better for an unintended child; but, by and large, it is best that children should be at least not unwanted at conception. Accordingly we welcome a report1 on contraceptives which members of the Consumers’ Association may purchase as a supplement ? to Which? Which? has a reputation for devising fair and apposite efficiency tests for a wide range of recommended things and practices and for presenting its findings with lucidity and freedom from technical jargon. In every respect this report lives up to that reputation. It contains all that a married couple could wish to know about the anatomy and physiology of conception, how to encourage it, in outline, and how to control or discourage it, in detail. Methods as well as mechanical devices are considered, though these last occupy most of its pages. Apparatus has been examined for efficiency, durability, acceptability, harmfulness, and cost. Tests-for instance, of strength and permeability of condoms and of spermicidal power of allegedly sperm-killing ointments and pessaries-were drastic but not impossibly so, being often based on a draft British or an international standard. Condoms, as opposed to washable sheaths, come out badly and spermicides, in whatever form, very badly. Quality has little or no relation to price. Dates of manufacture seldom appear on rubber goods. Oral contraceptives, save for (often transient) immediate side-effects, easily win for efficiency on available evidence, though none of the twenty days must be missed and its long-distance innocence is not quite proved. C.A. makes the strong point that chemical contraceptives should be classed as " medicines " and the makers be required to state the contents; and the need for official control is underlined by Dr. Fraser in a letter on a later page of this issue. The findings in this report should stimulate manufacturers to do better and would-be birth controllers to choose more wisely. So informative and balanced an account might well be compulsory reading for medical students. It is a little sad to read: " You can go to your doctor, but not very many GPS have been trained in contraceptive techniques and you are likely to be sent on to a family planning clinic," especially as some such clinics are, it seems, actually run by manufacturers. 1.
Contraceptives. Published by the Consumers’ Association, 14, Buckingham Street, London, W.C.2. Pp. 96. 10s.
obvious constituent of synovial fluid is hyaluronic, it is presumably in the synthesis of this polysaccharide that these cells are engaged. Also present in the synovial cells of both types are lysosomes, subcellular vesicles first shown by De Duve to consist of a lipoprotein membrane enclosing a mixture of several hydrolytic enzymes with little in common except optimal activity in the acid pH range of 3 to 5. Since these include powerful proteolytic enzymes which, in some tissues at least, can attack collagen and can certainly break down the protein-polysaccharide bond in chondromucoprotein, their participation in the pathogenesis of arthritis is extremely probable. In this context the studies of D. Hamerman with the electron microscope are especially significant. At the E.R.C. symposium he described finding in the lining cells of the synovium of rheumatic joints conspicuous electron-dense bodies much larger than lysosomes but probably derived from them, judging by their rich content of acid phosphatase. The precipitation of lead phosphate in the first stage of Gomori’s method for the display of this enzyme makes this a particularly suitable subject for electron microscopy. These studies of the ultra-structure of synovial cells suggest, therefore, that injury 10 joint structures may indeed be mediated by enzymes elaborated in the affected synovial cells. What leads in the first instance to the abnormality of these cells, as revealed by the electron microscope, is still obscure, but the results of Bitensky and her colleaguesI on the influence of antibodies to ascites tumour cells upon their lysosomal acid phosphatase imply that immune reactions on cell surfaces may be one method by which such lysosomal injury could arise. RENAL PAPILLARY NECROSIS AND PHENACETIN
THE frequency of renal papillary necrosis in Denmark is again emphasised by an account of 66 cases seen in four years in one department of medicine in Copenhagen. Harvald2 points out that only 5 of these were in patients with diabetes and only 8 in patients with obstruction of the urinary tract (his two " traditional " conditions associated with its occurrence). Of the other patients the largest group had had recurrent attacks of acute pyelonephritis, but of special interest was a group without any urological symptoms but with refractory anxmia found to be due to renal insufficiency from chronic pyelonephritis. Harvald was particularly concerned with the abuse of analgesic drugs, especially phenacetin : " most of our patients with papillary necrosis have consumed six tablets or more per day for over ten years". A few had reasonable grounds for this consumption (rheumatoid arthritis or osteoarthritis), but the majority gave vague explanations such as tiredness, feeling of insufficiency, over-exertion, or ill-defined headache. Harvald admits that the mechanism by which analgesics injure the kidneys remains obscuresLindwa113suggested that phenacetin may render the kidney more susceptible to infection. Papillary necrosis is less common in this country for perhaps two reasons. First, aspirin, and not phenacetin, is the main constituent of our headache powders 4 5; and, secondly, we may be more acutely aware of the minor 1. Bitensky, L. Brit. med. Bull. 1963, 19, 241. 2. Harvald, B. Amer. J. Med. 1963, 35, 481. 3. Lindwall, N. Acta radiol., Stockh. 1960, suppl. 192. 4. See Lancet, 1959, i, 84. 5. See ibid. 1960, ii, 858.
grades of pyelonephritis and the indefinite symptoms they produce. Thus the recognition of inapparent and subclinical pyelonephritis,6 and the purposeful investigation of indefinite symptoms possibly due to this or more overt chronic pyelonephritis,’ may lead to earlier recognition and treatment of infections, thus discouraging self-medication not only with phenacetin but with other analgesics too. It is surely too late to wait for the " comparatively unalarming symptomatology, either as attacks of acute pyelonephritis with excretion of papillary tissue or as a slowly progressing renal insufficiency."2 Lindwall3 found the changes of chronic pyelonephritis, often with acute exacerbations, in all the resected or postmortem kidneys of the phenacetin patients, while Harvald2 quotes Spuhler and Zollinger as finding a chronic interstitial nephritis which corresponds with Talbot’schronic interstitial infiltration in chronic ascendIt has already been shown4 how such a lesion can affect the blood-supply to the renal papillx.
ing pyelonephritis.
CHRONIC PANCREATITIS
THE
frequency of chronic pancreatitis may be much underestimated, because the main manifestations, such as a raised fasting level of serum-amylase or serumlipase, steatorrhoea, pancreatic calcification, and diabetes, are found only in well-established cases. Early, developing, mild, or atypical cases have been missed mainly through lack of specific tests of pancreatic function. Fitzgerald et awl. lay emphasis on the value of evocative enzyme tests in this connection. These workers investigated 53 patients with chronic pancreatitis by means of cholecystography, barium-meal examinations, tests for faecal occult blood, &bgr;-cell function tests (fasting bloodsugar levels and glucose tolerance), and straight X-rays to demonstrate pancreatic calculi. But they regard the secretin-pancreozymin test described by Howat 10 and elaborated by Burton et al. 11 as the most helpful of all tests in the diagnosis of early chronic pancreatitis, and as providing earlier information of pancreatic derangement than examination of the duodenal contents. 69 secretinpancreozymin tests were carried out on 40 patients with pancreatitis. The serum-amylase rose from fasting levels of 0-7-4-4 mg. per ml. (40-242 units) with a mean of 2-53 mg. per ml. (157 units) to 2-5-8-2 mg. per ml. (137-451 units) with a mean of 3-41 mg. per ml. (188 units). In normal control cases the serum-amylase rose from a fasting level of 0-5-1-9 mg. per ml. (28-105 units) with a mean of 1.3 mg. per ml. (72 units) to a peak post-stimulatory level varying from 0-6 to 2-6 mg. per ml. (38 to 137 units) with a mean of 1-5 mg. per ml. (84 units). In only 2 of Fitzgerald’s patients did the serum-amylase level fail to rise over 2-9 mg. per ml. (160 units) after stimulation-an accuracy of 95% for the test. This is an important finding, because fasting amylase and lipase levels are often normal in quiescent phases of pancreatitis, and may be raised in other diseases such as acute gallbladder disease and perforated duodenal ulcer and after
the administration of morphine-like narcotics.i2 Results from serum-lipase in the secretin-pancreo6. See ibid. 1959, i, 1265. 7. See ibid. 1961, ii, 89. 8. Talbot, H. S. J. Amer. med. Ass. 1958, 168, 1595. 9. Fitzgerald, O., Fitzgerald, P., Fennelly, J., McMullin,
J. P., Sylvester, J. B. Gut, 1963, 4, 193. Howat, H. T. Modern Trends in Gastro-enterology (edited by F. Avery Jones); p. 776. London, 1952. 11. Burton, P., Hammond, E. M., Harper, A. A., Howat, H. T., Scott, J. E., Varley, H. Gut, 1960, 1, 125. 12. Bogoch, A., Roth, J. L. A., Bockus, H. L. Gastroenterology, 1954, 26, 697. 10.
1107
zymin test were only occasionally of diagnostic value, and in this series reliance was placed on the amylase figures. The chief criteria, therefore, for diagnosis of pancreatitis in relation to enzyme tests were high fasting amylase (over 2-1 mg. per ml.) in the absence of other possible causes, and peak serum-amylase 2-9 mg. per ml. (159 units) or over at any time during the test. Another feature of pancreatic disease-enzyme dysfunction resulting in malabsorption-can be brought out by means of fat-balance studies, vitamin-A-acetate/vitamin-A-alcohol absorption studies, and triolein 131 and oleic-acid 1311 tests, but the diagnosis of pancreatic disease cannot be based solely on malabsorption of fat. The secretin-pancreozymin test may produce moderately severe but transient pain over the pancreatic area (indicating obstruction) and vomiting. After a suspected acute phase of pancreatitis the test is better avoided, and it is needed in advanced disease. Diagnosis is now possible when the acinar and islet tissues are only slightly damaged, and treatment can then be directed to preventing further pancreatic destruction. Medical treatment was used by Fitzgerald et al. in patients regarded as unsuitable for surgery, such as alcoholics, psychologically disturbed patients, and patients in a state of advanced malnutrition. The measures adopted were a low-fat, moderate-residue diet, replacement therapy with pancreatin, and, for the relief of pain, anticholinergic drugs, such as atropine, and smooth-muscle relaxants including glyceryl trinitrate. Surgical treatment was adopted in 27 of the Fitzgerald series of 53 patients. Generally, operation was reserved for those patients who did not respond to medical therapy, but with increasing experience surgery was offered to the majority. Sphincterotomy was the operation of choice, in view of the work of Doubilet and Mulholland.13 The procedure was essentially a meatotomy; in all patients who not
gave a positive secretin-pancreozymin test Fitzgerald et al. found a definite pancreatic lesion-usually sphincteric stenosis or some other obstruction. In most patients the ampulla was the site of blockage, indicated by the failure to pass a 3-5 mm. sound easily through it. An incision 1 cm. long in the ampulla displays the pancreatic duct. A retrograde pancreatogram may be made to demonstrate the patency of the pancreatic duct.14 15 Other procedures may be needed-removal of pancreatic calculi, drainage of
pancreatic abscess, hemipancreatectomy, or cholecystectomy. Many operations have been advocated for chronic pancreatitis, 16 11 but, in view of the morbidity that follows in their wake, even after sphincterotomy, extensive operations for non-malignant disease of the pancreas are be undertaken
lightly. descriptive name for the disease in many cases is chronic progressive pancreatitis-a disease which appears as a comparatively minor disturbance but over the years pursues a relentless course, punctuated by acute attacks,
not to
The
becoming more florid in its manifestations. Pain becomes more severe, and eventually complications, such as diabetes and steatorrhcea, arise. A condition such as this is more accurately described as " chronic progressive " rather than " chronic relapsing " pancreatitis.18 13. 14.
Doubilet, H., Mulholland, J. H. J. Amer. med. Doubilet, H., Poppel, M. H., Mulholland, J. 325.
15. 16.
Ass. 1961, 175, 177. H. Radiology, 1955,
64,
Bartlett, M. K., Nardi, G. L. New Engl. J. Med. 1960, 262, 643. Smith, R. in Recent Advances in Surgery (edited by Selwyn Taylor). London, 1959. 17. Lancet, 1960, i, 1282. 18. Tumen, H. J. Discussion on paper by Gambill, E. E., Baggenstross, A. H., Priestley, J. T. Gastroenterology, 1960, 39, 404.
BIRTH CONTROL
low-at world population in explosion, at our national struggle to house and educate our young or to save our lovely countryside from becoming one outsize housing-estate, at criminal abortion among the married and unmarried, or at the young wife, destitute of domestic help, childbound for years-the need to control conception if Man is to have room enough and food and any chance of leading a civilised life is undeniable. With Nature in flat opposition we need not expect control to be easy. In theory we have but to regulate our love-making; in practice we know that this, save for individuals, is no answer, and that if the daunting problem is to be solved at all it can be only through the widespread use of contraceptive devices. They are the only available counterpoise to our frightening success in exterminating major killing diseases and prolonging the expectation of life-and at present a by no means WHETHER
we
look
high
or
adequate one. For largely ineffective contraceptives there is little
to
be said. It would be very rash to suggest that either the world or the family are never the better for an unintended child; but, by and large, it is best that children should be at least not unwanted at conception. Accordingly we welcome a report1 on contraceptives which members of the Consumers’ Association may purchase as a supplement ? to Which? Which? has a reputation for devising fair and apposite efficiency tests for a wide range of recommended things and practices and for presenting its findings with lucidity and freedom from technical jargon. In every respect this report lives up to that reputation. It contains all that a married couple could wish to know about the anatomy and physiology of conception, how to encourage it, in outline, and how to control or discourage it, in detail. Methods as well as mechanical devices are considered, though these last occupy most of its pages. Apparatus has been examined for efficiency, durability, acceptability, harmfulness, and cost. Tests-for instance, of strength and permeability of condoms and of spermicidal power of allegedly sperm-killing ointments and pessaries-were drastic but not impossibly so, being often based on a draft British or an international standard. Condoms, as opposed to washable sheaths, come out badly and spermicides, in whatever form, very badly. Quality has little or no relation to price. Dates of manufacture seldom appear on rubber goods. Oral contraceptives, save for (often transient) immediate side-effects, easily win for efficiency on available evidence, though none of the twenty days must be missed and its long-distance innocence is not quite proved. C.A. makes the strong point that chemical contraceptives should be classed as " medicines " and the makers be required to state the contents; and the need for official control is underlined by Dr. Fraser in a letter on a later page of this issue. The findings in this report should stimulate manufacturers to do better and would-be birth controllers to choose more wisely. So informative and balanced an account might well be compulsory reading for medical students. It is a little sad to read: " You can go to your doctor, but not very many GPS have been trained in contraceptive techniques and you are likely to be sent on to a family planning clinic," especially as some such clinics are, it seems, actually run by manufacturers. 1.
Contraceptives. Published by the Consumers’ Association, 14, Buckingham Street, London, W.C.2. Pp. 96. 10s.