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We describe the 11th case of bioterrorism-related inhalational anthrax reported in the United States. The presenting clinical features of this 94-year-old woman were subtle and nondistinctive. The diagnosis was recognized because blood cultures were obtained prior to administration of antibiotics, emphasizing the importance of this diagnostic test in evaluating ill patients who have been exposed to Bacillus anthracis. The patient's clinical course was characterized by progression of respiratory insufficiency, pleural effusions and pulmonary edema, and, ultimately, death. Although her B anthracis bacteremia was rapidly sterilized after initiation of antibiotic therapy, viable B anthracis was present in postmortem mediastinal lymph node specimens. The source of exposure to B anthracis in this patient is not known. Exposure to mail that was cross-contaminated as it passed through postal facilities contaminated with B anthracis spores is one hypothesis under investigation.

Medical Oncology is designed to be a "single comprehensive source of information for the practitioner and trainee and to serve as a platform on which to build new information," say the editors in their preface. For the most part they have achieved their goal, for this is a well-organized, well-written text on medical oncology. The editors have assembled a group of contributors who are well known in their fields of endeavor and have written their assignments in a cogent, clear, and succinct manner. The text has three main parts: "Basic Principles," "Specific Neoplasms," and "Supportive Care." "Basic Principles" is the platform one needs to be conversant with in order to build new information. This major area is subdivided into sections on the biology, etiology, and systemic effects of cancer and principles of patient management and clinical evaluation of new cancer therapies. These sections are excellent but by their nature difficult

This superbly organized, well-written text is divided into six main divisions. Part one is entitled "Cytological, Histological, and Functional Basis for a Modern Classification of Lymphomas." This section includes a description of the physiological condition of the various types of normal lymphocytes and correlates their function with their histomorphological condition. There are many excellent photomicrographs clarifying the author's word picture. The second division is a short chapter on the "Methodological Prerequisites for the Differential Diagnosis of Lymphomas." This is strictly for the pathologist, as it outlines various staining techniques to point out important differences in making a histological diagnosis as practiced in Dr Lennert's laboratory. Part three is "Classification of Non-Hodgkin's Lymphoma." This section and the next, "Histopathology and Diagnosis of Non-Hodgkin's Lymphoma," will be of most interest to the clinician. A short historical overview and comparisons of the various classifications are the main focus of the short chapter on

The Politics of Cancer is a 600+ page political statement. Starting from the premises that a high percentage of cancers are caused by exposure to environmental agents and that the latent period between exposure and clinical cancer is 15 to 20 years, Dr Epstein discloses major and minor carcinogenic experiences in the workplace, the personal environment, and the general environment. This overwhelming, ubiquitous exposure to one or more carcinogenic agents is the cause of immeasurable avoidable suffering. The proliferation of carcinogenic agents in the future and the uncontrollable use of known carcinogenic agents are leading to an explosion in the incidence of cancer. This scenario must be changed. The cause of cancer has been defined. That cause is man-made or man-controlled, and so must be removed. Past obstacles have been a greedy, crass industry and an inept government. An aroused citizenry with enforceable regulations over possible, probable, potential, or definite

• Paroxysmal supraventricular tachycardia developed in two infants with structurally normal hearts and no evidence of ventricular preexcitation. In both infants, the onset of the arrhythmia was associated with the presence of an indwelling jugular venous catheter in the body of the right atrium. Repeated episodes of the arrhythmia occurred while the catheter remained in place. Restoration and maintenance of sinus rhythm could only be achieved after withdrawal of the catheter. (AJDC1984;138:474-475)

• The epidemiology, significance, and clinical consequences of influenza in the hospital setting were studied in a prospective surveillance of adults in an acute-care hospital during the 1986-1987 influenza season, specifically searching for cases of nosocomial influenza. A total of 43 cases of influenza A were identified; 17 cases occurred among working hospital employees, 14 cases occurred among patients in the emergency room or clinics, ten were community-acquired cases among hospitalized patients, and two cases were nosocomially acquired. The nosocomial influenza attack rate was 0.3 per 100 hospital admissions. Both cases of nosocomial influenza were associated with secondary pneumonias and prolongation of hospital stay. These cases might have gone unrecognized in the absence of an influenza surveillance program. A potential reservoir of infection was the health care providers caring for the hospitalized patients. Further systematic influenza surveillance is needed to assess the global medical and economic impact of nosocomial influenza on hospitals, rather than simply relying on reports of institutional outbreaks. (Arch Intern Med1988;148:113-116)

PLASMAPHERESIS has been accepted as an effective treatment for the immediate control of hyperviscosity syndrome. However, routine methods of blood withdrawal in this entity are fraught with many technical difficulties. Recently, we treated a patient with multiple myeloma and hyperviscosity syndrome who demonstrated many of the clinical problems associated with plasmapheresis and suggest a method by which these problems can be circumvented. Report of Case A 66-year-old white man was admitted to the hospital for evaluation of his increasing confusion. He had been transferred from an outlying hospital where he had been admitted with anemia and upper respiratory tract infection. There was no history of bleeding, visual symptoms, or dyspnea. On admission, the patient was very confused. Temperature was 38.3 C (101 F). Pertinent physical findings were distended retinal veins, S 4 gallop, and diffuse pulmonary rhonchi. Drawing blood was extremely difficult because of rapid clotting. A bone marrow examination

During the past several months there have been several excellent books published on oncology. This latest volume is nonetheless a welcome addition to those that have preceded it.Clinical Interpretations and Practice of Cancer Chemotherapylimits its approach to the drugrelated aspects of the treatment of cancer. Dr Greenspan's presence is strongly felt, as he authored or coauthored seven of the 31 chapters that make up the text. His approach emphasizes past clinical experience backed by a scientific background in explaining therapeutic decisions. At times one feels that one is standing at the bedside with Greenspan deliberating over a patient's treatment. The other authors are well known in their fields and perform their tasks admirably. Following Greenspan's historical introduction on cancer chemotherapy, chapters dealing with the basis of polychemotherapy, the molecular biology of the anticancer agents, the mathematical interpretation of tumor growth kinetics, the basis for adjuvant chemotherapy, and the

Dr Chabner has edited an excellent text. His objective was "to provide a comprehensive and detailed examination of the preclinical and clinical pharmacology of the anti-neoplastic drugs." He has accomplished his objective. However, the detail and sophistication of the presentations will limit his readers to the most serious students of this aspect of medical oncology. The book is divided into two sections. The first deals with the role of neoplastic drugs, chemical and cellular pharmokinetics, cell kinetics, and the late complications of chemotherapy. The second discusses specific drugs or classes of drugs. Although there is not a set pattern for each chapter that explores a drug or class of drugs, the author usually covers chemistry, mechanism of action, cellular pharmacology and metabolism, pharmokinetics, drug interactions, and toxicity of that particular agent or class of agents. Clinical studies when mentioned are kept to a whisper. The 21 chapters cover 445 pages

• Pyomyositis is an acute bacterial infection of skeletal muscle. It is a common disease in the tropics; fewer than 50 cases of pyomyositis have been reported in the continental United States. Most patients are healthy males, although the disease has been reported in diabetics and in the immunocompromised. This article presents the first detailed known reported case of pyomyositis in a patient with the acquired immunodeficiency syndrome;Staphylococcus aureuswas the etiologic agent. (Arch Intern Med1988;148:1608-1610)

The curtain of depression is rising on the cancer drama. Although many scientific and emotional events will surely recur before the green curtain of hope will totally replace that purple curtain of sorrow and despair, progress is being made. One of the attitudes that is changing and adding to that change is evidence that cancer is not an "inevitable" disease. As has been the case with other "malignant" diseases like tuberculosis and rheumatic fever, mechanisms can and will be identified, removed, or frustrated before the end result, an incurable malignancy, has developed. A method of tracking down these inciting or promoting agents is epidemiological study. The text presents mortality statistics of specific cancers. These mortality statistics are studied from many vantage points. The evaluation of cancer mortality in relationship to age, sex, color, marital status, geographical area, urbanization, social and economic status, and origin of birth are all looked at

THE use of flucytosine (5-FC) as an alternative to amphotericin B in the treatment of cryptococcal meningitis has recently been advocated. 1,2 Although physicians have been counselled to watch for the toxic effects of flucytosine on the kidney, liver, and bone marrow, emphasis has been placed on the ease of administration, good diffusion, and relative lack of toxicity of flucytosine as contrasted with amphotericin B. 1,2 We report a case of aplastic anemia that resulted from flucytosine therapy. Report of a Case A 59-year-old man with diabetes mellitus was transferred to the hematology service of the Veterans Administration Hospital, Bronx, NY, for evaluation of pancytopenia. The patient, a weekend pigeon feeder, had been well until August 1970, when he was admitted to this hospital because of headache, nausea, and vomiting. Cerebrospinal fluid culture disclosed Cryptococcus neoformans . The patient was treated with a total dose of 1,455 mg of amphotericin B.

Lung Cancer: A Comprehensive Treatise is a well-defined and -organized although at times wordy monograph on the subject. The impetus to develop this publication came from the four editors, who are members of the chest oncology group at the University of Chicago Medical Center. In addition to those four editors, 27 chapters, 39 contributors, and 452 pages constitute this publication, all of which seem excessive. The treatise is divided into four major divisions: "Basic Principles" (of cancer diagnosis and treatment), "Non—Small Cell Lung Cancer," "Small Cell Lung Cancer," and "Supportive Care." The areas where the subject matter appears the least disciplined and restricted are in the chapters on "Basic Principles." Information is presented that may not have much application to the specific understanding of lung cancer and its diagnosis and treatment. However, such subjects, which include a two-page chapter on the multimodality approach; a chapter each on pathology and biology

A three-year epidemic of legionnaires' disease in a hospital was dramatically curtailed following hyperchlorination of the potable water supply. The hypothesis that potable water was the source for the outbreak was further supported by isolation ofLegionella pneumophila(the agent of legionnaires' disease) from the hospital water supply, observation that a sudden upsurge had occurred in the number of cases following a peculiar manipulation of the hospital water system, and documentation of a 30-fold increase in concentration of organisms in the water when this manipulation was artificially recreated. Thus, potable water may be an important source of epidemic legionnaires' disease and continuous hyperchlorination a method of control. (JAMA1985;253:1412-1416)

In the closing years of the 19th century, William Halstead opened the door to modern-day therapy of carcinoma of the breast. His description of the radical mastectomy was rapidly accepted by the medical profession and vigorously applied to this dread disease. Shortly thereafter radiation therapy was introduced for the treatment of this malignancy. Over the succeeding years, changes in operative procedure and radiotherapeutic approach, ablative and additive hormonal therapy, and more recently chemotherapy have been added to the physicians' armamentarium. Unfortunately the rightful place of each of these modalities alone or in combination has not been defined adequately. Confusion as to the most effective application of these procedures still exists in the minds of many clinicians. Moore and his associates seek to end this confusion by outlining their program for the treatment of this disease. Experience at the Peter Bent Brigham Hospital from 1954 to 1963 forms the basis of

Allopurinol [4-hydroxypyrazolo(3,4-d)pyrimidine], a potent inhibitor of xanthine oxidase, was given orally to patients with leukemia and lymphoma in whom marked hyperuricemia was present or was to be expected as a result of cytolytic therapy. There was a decrease in serum uric acid in each patient, and a decrease in urine uric acid excretion in each of the ten patients in whom it was measured. This was accompanied by only a moderate increase in urinary oxypurines and no evidence of renal, hematologic, gastrointestinal, or hepatic toxicity.

The Seventh Canadian Cancer Conference held at Honey Harbor, Ontario in June 1966 must have been informative and stimulating to all who attended. The proceedings are faithfully recorded in this volume and maintain a level of excellence from the first to the last presentation. The discussion was divided into five sections; each represented a major field of inquiry into the cancer problem with subject matter confined almost entirely to the preclinical level. The first section is entitled "Cell Proliferation." Three authors presented their concepts of the properties, controls, and mitotic rate of the normal and neoplastic cell. Of special interest to the oncologist and hematologist would be Doctor Bruce's discussion of spleen cell assay, as a means of evaluation the effect of specific chemotherapeutic agent upon hematopoetic and "lymphoid" (his word) tissue. For those interested in immunology there is a discussion of the stimulating effects of antigens upon "lymphoid" tissue.

With the clinical application of nitrogen mustard's (mechlorethamine hydrochloride) activity on lymphomatous tissue vaguely realized, the medical strategy for the controy of cancer was born. During the subsequent three decades, innumerable drugs have been tested and a handful have perculated through multifarous evaluations to find useful clinical applications. The principles regarding the application of these drugs on a clinical basis and their relationship to surgery, radiation therapy, and, more recently, immunology, developed slowly. Paced by Skipper's work on the cell kinetics of L 1210 mouse leukemia and Bruce's work on drug cell cycle activity, a lava flow of principles guiding medical oncology has begun. In 1962, the European Organization for Research into Cancer Treatment (OERTC) was founded as an agency to coordinate work in 16 European institutions. This monograph represents the first session of the 1968 meeting of OERTC which was devoted to a teaching seminar for clinicians. The chapters

The clinical course of a patient with acute granulocytic leukemia was complicated by disseminated mucormycosis, which initially appeared as indurated skin nodules and pneumonia. This is the first description of cutaneous vasculitis as a dermatologic manifestation of mucormycosis.

Although not large in content, this monograph is large in purpose; it attempts to cover five fields that relate to the laboratory diagnosis of cancer. In just 97 pages (including 29 pages of references), the reader is briefed on chromosomal, chemical, immunological, histological, and physical methods available in the presumptive diagnosis of cancer. The major advantage of this book is the excellent bibliography with appropriate review articles cited at the end of each chapter. The lack of depth in any single topic and rather uneven coverage of subjects are principal drawbacks. As with any text dealing with fields of vigorous activity, subject matter may become dated rapidly. This has occurred with the material on Australia antigen. This book may be of some value to the clinician wishing a short statement concerning the present position of a given laboratory test as it is related to the diagnosis of cancer. Usually a

Moore has summarized a great deal of material in this well organized text. He covers all major sites of human cancer, as well as devoting chapters to "Terms," "Carcinogenesis," "Childhood Tumors," "Chemotherapy," and "Reporting of End Results." A chapter on radiotherapy is absent. Each section dealing with tumors of a specific organ is subdivided into subject matter concerned with Incidence, Etiology, Pathology, Natural History, Diagnosis, Preventive Measures, and Treatment Principles. The bibliographies at the end of each chapter are adequate. The major problem facing the author of a synopsis is to present a wide enough spectrum of material to embrace his chosen topic, maintain enough specific material to be informative, and still keep it reasonably concise. This is especially difficult in a field as vast as clinical cancer. A method employed in condensing this amount of material is listing, and Moore uses this method effectively. Yet, in places it is

In recent years, a great deal more of the energies and moneys of scientists and institutions interested in cancer have been focusing on leukemia in its variegated forms. This intensified search-for-understanding is undertaken with far-ranging vision. Researchers seek beyond control and cure of human leukemia, searching out paths that will provide insight into other forms of human malignancy. This symposium held in December 1966, under the auspices of the Leukemia Society of America, reflects the intensive pursuit of oncologic knowledge that occupies many scientific disciplines. The symposium opens with a discussion of epidemiological considerations of the leukemia problem. Five papers on various aspects of viral investigation follow. Dutcher initiates the viral section with a chronological review of viral-induced malignancies and concludes with a discussion of problems faced by those trying to show that human leukemia is a viral disease. Dmochowski surveys what part ultrastructural studies are playing in the