Book reviews

BOOK REVIEWS

The Medical Annual 1967. 85th year. Editors Sir RONALD BODLEY SCOTT and R. MmMES WALKER. John Wright & Sons Ltd. 52/-.

In 1958 when the 76th issue with its new format and welcome change from an alphabetical arrangement of the entire contents to the eminently more readable method of giving the review of the year's work under sections in alphabetical order, the importance of a subject by the editors could be gauged by the number of pages allotted to it. I t is sad to report that, al though first class editors come and go, the two Cinderellas, paediatrics, still listed under children's diseases and orthopaedic medicine, still suffering from the misnomer of chronic rheumatic diseases, have not yet attained their majority. One still has to forage for information on paediatrics outside its actual section, but a golden rule is to look for it at the end of a section e.g. nutrition, and vitamins, radiotherapy, public health.

In the paediatric section the new syndrome of acute encephalopathy following an U.R.I. with death from cerebral oedema in 48 hours is noted. The intravenous administration of urcvert is not mentioned but has proved life-saving in the reviewer's experience. The inquiry into the decline in breast-feeding carried out by Callaghan and Brown (1966) in the Rotunda receives honourable mention and to counter any charge of paediatric pre- judice, the same is accorded to Fegan for his injection-compression technique for varicose veins practised by him for 13 years during which time he has produced the slim feminine silhouette which has made Dublin the fashion centre of the world.

In the other Cinderella section the impression continues to be fostered that the main problem is rheumatoid arthritis which takes up 80% of the allotted ten pages. One wonders what the M.R.C., having weighed the steroids on a faulty balance, will make of the con- clusion that aspirin can produce a higher excretion of renal tubular cells than an equal dose (3.6 G. per day) of phenacetin. Those on the other hand who continue to control rheumatoid arthritis with steroids will learn with advantage that the proper rate of with- drawal of prednisolone is 1 mg. daily every 3 months. The problem of the arthritides with persistently low serum uric acid levels has at last been solved.

As regards the remaining treasure in this carefully selected r~sum6 of the world literature with index to match, where else could be found between two covers such varying information by reliable authorities as the A.C.T.H. treatment of Bell's palsy, the subclavian steal syndrome with self-explanatory diagrams, the immediate treatment and prophylactic follow-up of a pulmonary embolism, the r61e of hypokalaemia in cardiac arrest in diabetic acidosis and the life-saving result of early replacement, the biochemical aspects of depression with the action of MAOL and the tricyclic anti-depressants, the association of inadequate and antisocial personality in adult life with behaviour disorders in childhood, that 30% of the cases of Cushing's syndrome are due to tumour with the 17-OCHS tests to dis- tinguish them from hyperplasia of the adrenal cortex and so on and so on, with the results that false gods are tumbled and even new substitutes like serum iron are shown to have very human vagaries.

The high-lights are as usual the special articles with the inevitable "Towards a calculus of Medicine" or "Computer Inc." and the down-to-earth comments of the compilers of the sections such as that of Bignall " that asthma treatment should be aimed at relieving distress and not solely at improving certain measurements of the complex mechanisms of respiratory function."

The print is easy on the eye, the paper the kind one loves to touch, the illustrations, some in colour, of an exceptionally high standard especially the radiographs. Whether one is a clinical teacher, or one of the hundreds of underprivileged lone learners, this Manual continues to represent countless man hours devoted to the production of easily assimilable pabulum for the conscientious medical s tudent--and aren ' t we all?

JOHN MOWBRAY.

Post-Gastrectomy Nutrition. A Glaxo Symposium. Lloyd-Luke, London. 20/-.

This is an account of the proceedings of a symposium which took place in November 1966 under the Chairmanship of Dr. Avery Jones. The last few years have seen an increasing volume of work on nutritional disturbances following partial gastrectomy. It was a useful idea to bring together workers in this field for discussion. There were eight papers mostly concerned with various aspects of the deficiencies of iron, B12 and folate. Two communications were presented on gastrectomy and bone disease. Apart from these formal papers, this publication gives the discussions in detail and these are particularly revealing to those interested in this subject.

Progressive B12 deficiency is now well established as a late complication of partial gastrectomy. Hoffbrand reviewed the evidence from various centres, including Dublin, and his paper was followed by a fascinating discussion on the aetiology of this deficiency. Alteration of the bacterial flora as a possible factor was discussed at length, but finally the main opinion favoured the view of the cause being inadequate secretion of intrinsic factor. I t was generally agreed that folate deficiency, which is much less common, is related

37

38 IRISH JOURNAL OF MEDICAL SCIENCE

to dietary intake rather than to alterations in the structure or function of the gastro- intestinal tract.

Iron deficiency, the commonest following gastrectomy, was discussed fully by McLean Baird, Turnbull and Callender. The mechanism of its development appears to be multi- factorial and iron absorption studies are not easy in these patients.

Booth described the findings in 10 cases of post-gastrectomy osteomalacia. Plasma vitamin D-like activity was practically absent in these cases. Vitamin D absorption studies were normal, and lack of vitamin D in the diet was likely to be the important factor.

Ellis presented data on the advantages of vagotomy over gastrectomy, pointing out that it is the "most physiological approach we have to date for the surgical treatment of duodenal ulceration".

Finally the symposium ended with discussions of the whole problem of post-gastrectomy deficiencies and how they may be prevented. J. Alexander Williams put forward the idea of a "post-gastrectomy tablet" containing iron, B12, folic acid calcium and vitamin D. This proposal was not well received and the general feeling at the meeting was in favour of regular review of these patients with haematological tests. P . B . B . GATENBY.

Surgery for Acquired Mitral Valve Disease. By F. HENRY ELLIS, Jr., M . D . W . B . Saunders Company. 1967.

This is an excellent book. The development of mitral valve surgery over the last twenty years illustrates in a very special way the combined effort which is necessary to modern medical advance. Major contributions have been made by cardiology, surgery, anaesthesia, radiology, physiology, haematology, engineering and other disciplines. It is right, therefore, that Dr. Ellis should have called on six of his colleagues to make contributions on such special aspects as haemodynamics, radiology, pathology and the clinical picture.

His own contribution is dearly and succinctly written. He has used the outstanding experience of the Mayo Clinic in this field to present a complete account of the surgical problem. At the same time he does not fall into the trap of attempting to explain in print what can only be understood by working in the operating theatre.

The book is primarily written for the cardiac surgeon--to whom it must be indispensable ---but it should also be of great interest to anyone dealing with any aspect of surgical heart disease. The cardiologist, or radiologist will find his own sections brief and summary, but the presentation will help him to understand the overall surgical problem. There is a wealth of information for anyone dealing with extracorporeal circulation problems.

Techniques for inserting prosthetic valves are now well established, but the problems associated with the long term prosthesis are still serious--particularly thrombo-embolic complications. One welcomes Dr. Ellis's sane approach to this problem. Closed mitral valvotomy, though largely a palliative operation, is still the major weapon in the surgical treatment of mitral stenosis. Where prosthetic replacement is necessary it is reserved until no other treatment can control the situation.

Finally, it is rrice to record that the excellent chapter on clinical aspects of mitral disease was contributed by Dr. Daniel Cormolly of the medical section of the Mayo Clinic, who graduated at U.C.D. and interned at the Mater Hospital, Dublin.

EOIN O'MALLEY.

The Genetics of Gastro- Intestinal Disorders. By R. B. McCo~r~Lr.. Oxford Universi ty Press. 70/-.

This is one of a series of monographs on medical genetics. I t deals wi th the influence of heredi ty in pr imary a l imentary t r ac t disorders as well as some conditions which present wi th symptoms referable to the gastro-intestinal t ract .

By combining his personal experience wi th an exhaustive review of relevant l i terature, Dr. MeConnell has produced a detailed and scholarly treatise. A mult i tude of conditions, ranging from hare lip to imperforate anus, are included and appropriate emphasis is given to those in which the role of heredi tary factors is well established.

The mode of presentat ion presupposes some knowledge of principles of h u m a n genetics ; a glossary is, however, included for those who m a y be unfamiliar with genetic terminology. A useful summary of topics discussed is appended a t the end of each chapter .

This book should have special appeal for gastro-enterologists and medical geneticists. The bibl iography of almost 1,100 references will prove especially valuable to research workers in these fields.

JOSEPH ~r

Arteriography--Principles and Techniques. By JOSEPH CURRY and WILLAI%D J , I-Iowr.A~D. Publ ished by W. B. Saunders & Co. s 18s.

This book has boon produced b y two authors who work in a communi ty hospi tal in the Uni ted States. In i t they review their entire experiences wi th ar ter iography and in a comprehensive tex t cover all aspects of this subject, The opening chapter is devoted to a review of the equipment and mater ia l and includes such topics as catheter materials

BOOK REVIEWS 39

and film changers. In discussing the question of anaesthesia the au thors favour a general anaesthet ic for young children and apprehensive adults . They fail to ment ion the slight d isadvantage of some of the modern anaesthet ic agents such as halothane in which there m a y be a fall in blood pressure with result ing difficulty in punctur ing the vessel. Fur thermore they raise the quest ion of steroid pre-modieation particularly in cerebral s tudies which they believe is a prophylactic measure to prevent cerebral oedema. They do, however, admi t t ha t steroids m a y cause an increased risk in venous thrombosis. The use of an injection of 1% procaine to prevent arterial spasm particularly in tbe brachial ar tery is stressed. A s t rong point is made t h a t ar ter iography should not be carried out wi thout hav ing readily available a vascular surgeon or a neurosurgeon to deal with any of the complications which m a y arise. They comment on the interest ing phenomenon of laminar flow which was recently reported by Fox and Hugh. In discussing the t iming of radiographs particularly in peripheral ar ter iography the use of radio-isotopes is ment ioned to assess t rans i t time. The au thors favour the use of the axfllary approach in a number of conditions, the sl ight d isadvantages being the proximi ty to the braehial plexus bu t the danger of spasm with subsequent ischaemia involving the h an d is for tunately less.

At ten t ion is drawn to the danger of recoil movement when using an end hole catheter for demons t ra t ing the arch of the aorta. When carrying out a rch aor tography it is suggested t h a t an electrocardiogram and a defibrillator should be constant ly available. The au thor s ' approach te abdominal aor tography in general is no t favourable to the t r ans lumbar method and they say t h a t t hey have only used it three t imes in the past three years. They employ the t ransfemoral Seldinger approach, retrograde femoral injection, or an axillary approach.

I n view of the fact t ha t complications, some t ransient and some serious and more prolonged, can occur after these procedures, it has been felt t h a t the usual ward notes failed to give a record of these events and on this account a specially designed record sheet has been used by the authors . To some extent this m a y have been init iated by the ra ther widespread medical legal a t t i tude which is more common in the Uni ted States, b u t it is felt t h a t this is a wise decision. Hence before the pat ients leave the x-ray depa r tmen t after completing the examinat ion there is a pe rmanen t record of the clinical and neurological findings.

I t is interest ing to notice t ha t polyethlene catheters are preferred to teflon catheters as the former hold their curves m u c h more satisfactorily. I n general in approaching the examina t ion of the great vessels of the neck and also the intraeranial vessels the authors ' approach is to carry out a general examinat ion of the aortic arch and subsequent ly to carry out selective catheterisat ion of the carotid and all vertebral vessels. In an effort to overcome reactions to the dyes used in angiography steroids have been employed in some cases, as also has low molecular dextran, bu t the final decision as to the values of these substances has yet to be determined. While some workers in the field of carotid angiography like to use the long sleeve teflon needles the authors in this case are keen on selective catheterisation.

Renal angiography is well covered and well illustrated. An essential preliminary is routine injection of the abdominal aorta. I n 25% of the cases multiple aberrants are present. There are m a n y good examples of selective angiograms in cases of tumour , aplasia, hydronephrosls to ment ion bu t a few conditions. I n the investigation of hyper- tension of renal origin the au thors ment ion the problems of es t imat ing renin from the renal vein. There are a number of i l lustrations of art~rio-sclerotic lesions involving the coeliac and mesenteric arteries while reference is made to the visualisation of the marginal a r tery of D r u m m o n d in some of these cases. Finally there is a chapter devoted to pos t -mor tem arteriography.

I n s u m m a r y this is an excellent book, well i l lustrated and has an up-to-date and extensive bibliography. I t can be recommended without hesi ta t ion to every radiologist or surgeon working in this field.

D. F. CAI~TWELL.

Cardiac Pathology. By ROBERT LANNIGAN. London : But terworth . s 16s. This is the first appearance of this short textbook on "Cardiac Pathology" and is

primari ly addressed to post graduate s tudents and practising pathologists who presumably do not have the s tandard larger work to hand.

This is a concise work of less t h a n 400 pages and with the exception of a chapter on cardiac physiology and one on hear t disease in childhood all fourteen chapters are from the pen of Dr. Larmigan who is senior lecturer in pathology a t the Universi ty of Bi rmingham. One wonders why a section on the embryology of the heart has not been included.

The au thor ' s morphological background is quite evident th roughout the tex t which is amply il lustrated including electron microphotographs. The book is noteworthy for a terse style giving the impression of a series of lecture notes and is admirably suited to a work of this size making for clarity and emphasis on impor tan t points.

The ability to condense wi thout deleting is ably shown by Cameron in his chapter


on cardiac diseases in childhood. As in m a n y works in which it is essential to describe all conditions which come under the umbrel la of the title it is probably inevitable t ha t some would receive less a t ten t ion t h a n others. This reviewer would have preferred more informat ion on Chromosomal abnormalities, and also noted the lack of information on the familiar incidence of sub-valvnlar aortic stenosis and the failure to ment ion the gross cardiac changes seen in some eases of the moscowitcz syndrome.

These are small points and it m u s t be clear t ha t this book makes its appearance as a sound and welcome addit ion to the specialised works in pathology.

S. F. CA]~AL~E.

Communicable and Infectious Diseases. By FI~A~LI~ H. ToP. 5th Edition. $21.00.

Owing to rapid changes in t he rapy and in the incidence of certain of the infectious fevers i t has been found necessary to produce the fifth edition of this book a t a shorter interval (since its immediate predecessor) t han for any previous edition.

New chapters on malaria, infectious encephalitis, Coxsackie and Echo virus infections have appeared and other chapters have been revised, e.g., p r imary atypical pneumonia now appears as myeoplasmal pneumonia . Several contr ibutors have been replaced, the total now being twenty-five.

There are two sections in the book. The first one deals wi th general considerations applicable to communicable diseases. Included in this section are excellent chapters on t he rapy preventat ive and therapeut ic . At t imes the mater ia l appears too simplified. However, th is is explained in the glossary a t the end of the book by the s t a tement t h a t individuals who are members of paramedical disciplines or employed in them use this book as a reference.

The second section deals wi th communicable and infectious diseases classified by common portal of entry. Regarding the problem of which diseases to include and omit in th is section there seems to be no definite policy. There is no ment ion of arboviruses and only a short reference to yellow fever. I n these days of rapid travel one would expect reference to cholera. On the other h a n d there are excellent articles on malaria and smallpox. Viral dysentery now considered the commonest cause of mild gastroenterit is is only ment ioned in the differential diagnosis of bacillary dysentery and under specific viruses (about one fifth of the epidemics). There is no chapter on such ill-defined con- dit ions as epidemic vertigo a l though these are commonly seen in practice. Myeoplasmal pneumonia should perhaps be re-ti t led mycoplasmal infection as not all cases develop pneumonia . I t is perhaps surprising to find this chapter under the sub-section diseases due r viruses.

I n spite of these criticisms the book is clearly wri t ten and beautifully illustrated. I t is a good reference book for practi t ioners interested in infectious diseases, resident medical s taff entering fever hospitals and those in the paramedical disciplines but perhaps no t the consul tant in this speciality. As regards its value to readers on this side of the Atlant ic it is refreshing to find numerous references to Bri t ish l i terature including Pickle 's book on Epidemiology in a Country Practice. I n fu ture editions one would hope to find a more detailed index, so impor tan t in a book used as a reference in medical practice.

l ' i . G. NELSON.

Disorders of the Respiratory Tract in Children. Edited by E. L. KE~DIG, Jr . Saunders Co. 1967. s 2s.

This is the first serious a t t e m p t to provide an authori ta t ive up- to- the minu te volume of universal appeal on wha t have steal thi ly produced the mos t common and difficult problems in paedia t r ics - - the respiratory diseases.

Professor Kendig, Medical College of Virginia, who has devoted his professional life to this field, has called on the services of twenty-seven contr ibutors from Maryland 's J o h n Hopkins to Tennessee 's Vanderbilt , and as a balance one from London, England.

Their magnum opus is certainly comprehensive. The funct ional basis of respiratory pathology for the higher ma themat ic i ans amongs t us is relieved by simple s ta tements such as tha t , in general, rhinorrhoea and hoarseness are indicative of the onset of a non-bacterial infection, while for the paediatric registrar there is a table giving the dimensions and code number of t racheos temy tubes for various ages. For both and their fellow-students, the consul tants , there is a chapter on laryngotracheo-bronchit is which serves as a dramatic and climactic reminder of the ex ten t to which the viral hordes, crowded into another table, have become the modern menace, being the actiolo- gical agent of this potential s trangler in 85% of cases. The i l lustration of the "mis t t e n t " in this connection is also a perfect example of the clarity with detail achieved th roughout this book which combines so well the visual aid with the pr in ted word. As regards the m a n y roentgenograms one m u s t with a t inge of malice quote f rom the foreword: "As clinicians we should not a t t e m p t to become roentgenologists. On the other hand the paediatr ician should utilize the roentgenogram as another laboratory method to become a bet ter clinician".

BOOK REVIEWS 41

For t h e pu r i s t s t he r e is a de l igh t fu l c h a p t e r on bronchio lo t i s w h i c h is t he m a i n r ea son for hosp i t a l admi s s ion du r ing t h e f irst y e a r of life, for t h e c h a u v i n i s t a n a c k n o w l e d g m e n t t h a t Enge l a n d l~ewns in E n g l a n d were t h e first to d i s t i ngu i sh i t f r o m b r o n c h o p n e u m o n i a in 1941, a n d for t he f ami ly doc to r who in a ve ry real sense s t a n d s in t he f ron t r a n k o f paed ia t r i e i ans a comfor t i ng s t a t e m e n t t h a t i t is s o m e t i m e s imposs ib le to m a k e a d i f ferent ia l d iagnosis , t h a t a l t h o u g h t h e prognos is is u s u a l l y excel lent , a t t h e first s ign o f s e c o n d a r y bac ter ia l in fec t ion a b road s p e c t r u m an t ib io t ic s h o u l d be e m p l o y e d in t h i s p r i m a r i l y v i ra l condi t ion .

The re is a s a l u t a r y con f i rma t ion o f t h e fac t t h a t t h e n a s a l a n d accessa ry s inuses are p r e s e n t in comple te or p r ecu r so ry fo rm a t b i r th , a n d t h a t t h e m a x i l l a r y a n t r a a re suff ic ient ly p n e u m a t i s e d to be i nvo l ved in y o u n g in fan t s . T h e c h a p t e r s on chronic a n d r ecu r r ing cond i t ions a re first class, t h a t on a s t h m a , ou t o f w h i c h ch i ld ren do not genera l ly grow, in pa r t i cu la r .

T h e e leven sect ions compr i s ing s i x t y - s e v e n chap t e r s a re p r e s e n t e d in a f o r m a t wh ich compe l s one to r ead on so t h a t e v e n t h e m o s t cri t ical rev iewer m a y be p a r d o n e d for fa i l ing to see t he flaws, i f t h e r e a re a n y . T he references a re i n n u m e r a b l e , t h e i ndex cons i s t s o f 43 pages a n d th i s b o o k ' s v i t a l s t a t i s t i c s are 10~" b y 6u b y 1�89

All t h o s e in t e re s t ed in paed ia t r i c s shou l d inves t in th i s book i f t h e y can af ford i t - - a n d even i f t h e y c a n ' t !

JOHN MOWBRAY.

A Short Textbook of Microbiology. B y D. C. TURK a n d I . A. PORTER. E n g l i s h Un ive r s i t i e s Press . s

I t is r e m a r k a b l e h o w a d e q u a t e l y t h e medica l a spec t s o f microbio logy, i nc lud ing bacter iological , viral , f unga l a n d p ro tozoa l arc covered b y t h i s l i t t le book in 270 pages . I n a s ea r ch for omiss ions few were found: in serology t h e ca tegor ies o f immunog lobu l i n s , I gG etc . , a re n o t g iven , no r a re t h e c o m p l e m e n t c o m p o n e n t s C ' I etc. The def in i t ions a n d desc r ip t ions are crisp, luc id a n d brief, one wou ld fear to t h e p o i n t of over simplif ica- t ion, b u t t h i s is ra re ly so. I n t h e sec t ion on h y p e r s e n s i t i v i t y t h e role o f t i s sue f ixed a n t i b o d y t h o u g h impl ied is n o t def in i te ly s ta ted , a n d in desc r ib ing s t aphy locoagu la se i t is n o t m a d e clear t h a t t h e " r e a c t i n g f ac t o r " is p rov ided b y p l a s m a .

S y s t e m a t i s t s will criticise t h e u s a g e s Staphylococcus citreus, Streptococcus pneumoniae a n d Streptococcus viridans.

A n e x a m p l e o f c la r i ty in def in i t ion is seen in dea l ing w i t h bac te r ia l food po i son ing whe re t h e cl inical f ea tu res o f t h e t h r e e c o m m o n t y p e s a re c o n t r a s t e d in a m a n n e r a s s u r i n g r e t en t ion .

J. D. i~CKEEVER.

Practical Dermatology. B y GEORGE M. LEWIS a n d CLAYTON E. WHEELER. W . B . S a u n d e r s & Co., Ph i l ade lph ia . 3rd Ed i t ion . s 7s. 6d.

Th i s is t h e 3rd ed i t ion of a c o m p e t e n t a n d i n s t ruc t i ve t e x t book of d e r m a t o l o g y . I t is i n e v i t a b l y increas ing in size w i t h each edi t ion, b u t t h e increase in we igh t is due to t he l ay ing d o w n of ac t ive t i s sue r a t h e r t h a n to t h e depos i t i on o f s u b c u t a n e o u s fa t . The re is a g rea t ly e x p a n d e d c h a p t e r on t h e bas ic sc iences in re la t ion to d e r m a t o l o g y which s u m m a r i s e s t h e a d v a n c e s in our knowledge o f t h e a n a t o m y a n d phys io logy o f t he skin . The re is also a n e x t e n s i v e fo rmu l a ry . Basical ly , t h e book cons i s t s o f s o m e 660 pages , a l m o s t one t h i rd o f w h i c h are t a k e n up w i th b l ack a n d whi t e p h o t o g r a p h s . All t h e c o m m o n , a n d m a n y rare , d i seases a re dea l t wi th ; t he r e is a welcome e m p h a s i s on t he sk in m a n i f e s t a t i o n s of s y s t e m i c diseases . To cover s u c h a large a m o u n t o f der- m a t o l o g y in a re la t ive ly l imi t ed space a n e c o n o m y of words is necessa ry . Th i s h a s been ach i eved b y a r a t he r s t acca to s ty le o f express ion , b u t in no place is accu racy sacrif iced to b rev i ty . T h e pho tog raphs , w h i c h are one o f t h e m a i n f ea tu r e s o f t h e book, are all in b l ack a n d whi te a n d are o f a n e x t r e m e l y h i gh s t a n d a r d . T h e y r ep roduce e x a c t l y w h a t t h e y are m e a n t to i l lus t ra te . T h e book is p r o b a b l y a l i t t le too de ta i led for a med ica l s t u d e n t , b u t will p rove va luab le to a genera l p rac t i t i one r who w a n t s to keep a b r e a s t o f r ecen t d e v e l o p m e n t s in t he d iagnos i s a n d t r e a t m e n t o f sk in diseases . I t s g rea t e s t va lue , however , will p robab l y be as a h a n d y book of reference a n d v a d e m e e u m for t h e b u s y c o n s u l t a n t . H e will f ind especia l ly usefu l t he b ib l iog raphy a d d e d to t he e n d of each chap t e r .

F . O. MEENAN.

Anticancer Agents. B y FRANCES E. KNOCK. Chas. C. T h o m a s , Il l inois. $15.50.

Dr . K n o c k out l ines t h e pe r spec t ives in cancer resea rch a n d t h e a p p r o a c h to t r e a t m e n t for a s t a r t , conc lud ing t h a t t h e bas ic app roaches to cancer t h e r a p y are e s sen t i a l ly surgical or chemical . R a d i o t h e r a p y is to be r ega rded as a f o r m of chemica l approach , because o f i t s ionis ing effects in t h e t r e a t e d t i ssues . The pos i t ion o f Lase r b e a m s a n d h y p o - or h y p e r t h e r m i a is less c lear ly definable.

T r e a t m e n t b y su rge ry a n d surgica l p rocedures i nvo lved in a d m i n i s t e r i n g a n t i e a n e e r a g e n t s accord ing ly receive a chap te r , fol lowed b y a co r r e spond ing c h a p t e r devo ted t o


radiation. Within so short a compass the principles of t rea tment must of necessity receive rather more emphasis than details; but there are interesting observations recorded in the tex t and the paragraphs on the prevention of iatrogenic spread of cancer in the surgical section are thought-provoking, especially in the centenary year of Lister's first publications on antiseptic surgery. The analogy is there for those prepared to see. The later chapters of the book, which is very well produced, are devoted mainly to the chemotherapeutic approach to cancer, with a short reference to the immunological at tack on the disease.-The agents covered in some detail, alkylating agents, sulph-hydryl inhibitors, antimetabolites, antibiotics, alkaloids and retine, are naturally discussed in relation to cell metabolism with the expected reference to their influence on D.N.A. and proteins, especially those of the cell nucleus.

The most pleasant feature of these chapters is the basic approach to the problems involved, providing an insight to the mechanism of action, necessarily somewhat technical but simplified, The use of steroids and hormones is discussed separately and these, which probably represent the most successful chemically-defined agents in cancer t reatment , are perhaps least understood as to their mode of action. One must conclude tha t there is much empiricism in cancer chemotherapy, despite the energy and financial expenditure which its development has demanded. Nor can it be otherwise, until more study has been devoted to the biological characterisation of turnouts, especially the naturally-occurring spontaneous cancers of man.

This book is moderately comprehensive ~nd informative of the present state of our knowledge, although the postscript states unashamedly: "This book is not finished. No satisfactory finish can be writ ten until cancer is prevented or cured".

R. A. Q. O'MEARA,

A Synot~sis of Ophthalmology. By J . L. C. ~&RTI~-DoYLE. Bristol, John Wright & Sons. 25]-.

This small book was first published in 1951. This is its th i rd edition. There is a great dcal to be said in favour of the compact, simple text-book in specialised subjects, for use of the undergraduate and as a reference foranyone in general practice. Of such books on the eye, this is undoubtedly one of the very best. As an example of its usefulness, the chapter on ocular signs of general disease could hardly be surpassed, having regard to the limits imposed by condensation and brevity, The alphabetical list of syndromes is clear and readable almost at a glance. Not everyone, however, would sgree in calling Sareeldosis a very rare disease.

I t is difficult to keep new editions of short text-books as brief as in the first edition; this thi rd edition is longer by twenty-one pages than the second, but it is still remarkable for the condensation of its material and the economical use of good English.

~ATR~CK DWYER JOYCE.

Clinical Pathology of the Serum Electrolytes. By F. W. SUN~ERMAN and F. W. SUI~DERNIAN~ Jr. Martin C. Thomas, Springfield, Illinois. $24.50.

During the past few years many advances have been made in understanding the clinical pathology of the serum electrolytes and, with the development of rapid techniques for measuring them and the possibility of treating their aberrations successfully, these matters have descended from the realms of theory to present the practising physician with problems relating to biochemical situations for which his training has fll prepared him and to the use of powerful remedies whose dangers he may not fully understand.

All the information which he is likely to require is provided in a volume recording the proceedings of a seminar on the Serum electrolytes in clinical medicine held under the auspices of the Association of Clinical Scientists in Washington D.C. The contributions of more than fifty authorities in the field have been edited by Dr. F. W. Sunderman and Dr. F. W. Sunderman, Junior. Their book, which is attractively produced, is divided into two sections. The first describes methods of measuring the various electrolytes clearly and simply, points out the likely sources of error in the techniques and deals with the clinical implications of abnormal results. The second is a full discussion of the physiological and pathological principles involved in electrolyte disorders resulting from disease.

The bibliography and index are both comprehensive and even at its relatively high price this book is recommended.

DOUOLAS E. MELLOI~.

Current Diagnosis. Ed. by H. F. Conn, R. J . Clohecy, R. B, Conn. Philadelphia, W. B. Saunders & Co. s 13s 8d.

A doctor who had called Sir William Fergusson in consultation quizzed him regarding prognosis.

"Weel, men, it 's a verra obscure case," the celebrated surgeon replied, "and I 've just noticed tha t those verra obscure cases seldom do verra weel."

Today when the florid clinical pictures of the nineteenth century are tess common we

BOOK REVIEWS 43

are perplexed more and more by "verra obscure cases", but diagnosis--due to develop- ments in radiology, clinical pathology, endoscopy and needle biopsy--has reached a degree of precision tha t would have astonished 1%rgusson. A consequent problem in dealing with particular cases is the selection of the appropriate tests, keeping in mind economy and the avoidance of unnecessary discomfort to the patient. The magnitude of this problem increases yearly in direct proportion to the increasing variety of ancillary diagnostic methods.

I t is not by any means an abnegation of bedside medicine to think tha t in a book entitled Current Diagnosis these ancillary methods might be expected to receive detailed attention, especially as so many excellent medical text-books are already available. The editors of this newcomer, however, have conceived differently and their 286 authors give us definitions followed by clinical descriptions and, when applicable, brief sections on laboratory diagnosis. The only difference, indeed, from the traditional medical textbook is a negative one: the absence of morbid anatomy and therapeutics. I t should be added tha t there are chapters on obstetrics and gynaeeology, burns and aural infections.

As in most books of multiple authorship the performance is uneven. The account of the clinical features of peripheral arterial disease, to cite an example, is excellent but many contributions are undistinguished.

Current Diagnosis is intended as a reference book to be consulted by the physician with the problem case. How many problems it will solve is, I regret to say, open to conjecture. Adrenal insufficiency and pyelonephritis are dealt with in a practical and helpful way but the pre-senile dementias receive mere mention. The muscular dystrophies are disposed of, mainly in tabular fashion, in four pages, whereas three and a half pages are devoted to Tietze's syndrome. Congestive heart failure and ischaemie heart disease are compressed into a page and half and four pages respectively; congenital heart disease expands over thirty-six pages. Yet, when it comes to the point the congenital heart poses the problem which will be referred for solution by a cardiologist.

I do not think that this book, in its present form, fulfils the purpose implied in its title. As a reference book it is certainly inadequate and inferior to many standard text- books. I t s subt i t lc--A Biennial Volume of Clinical Diagnostic Methods and Evaluation appears to indicate tha t it is not to be ephemeral In the circumstances, perhaps, the editors and publishers should seriously reconsider whether ancillary methods should not receive the maximum of space and clinical details the minimum.

J. B. Lr~o~s.

The, Pharmacologic Principles of Medical Practice. By JOHN C. KRA•TZ and C. ffELLEFlV CARR. E. and S. Livingstone Ltd., Edinburgh and London, 1965. 6th Ed. s 18s.

This valuable book now in its sixth edition, has been reprinted 15 times since it was first published in 1949. I t has also appeared in Spanish and Portuguese editions. In about 1,000 pages it deals with a wide range of pharmacological agents, including anti- infective drugs, hormones, vitamins, antihistamics and many substances having stimulating, or inhibiting actions on the central nervous system and periferal receptors. I t considers drugs for the prevention, diagnosis and t rea tment of disease and embraces pharmacy, pharmacognosy, toxicology, therapeutics, posology and materia mediea, each a specialised field in itself. While medical practice prescribes how and when a drug should be used, the object of this book is to consider which drug is preferable and more especiially why it is so. This lat ter question is considered where possible at a cellular, metabolic or enzyme level taking advantage of the most recent advances i~ medical research.

The authors draw attention to the fact tha t considerable changes have been made in the layout and contents of the book since the last edition in 1961. Many drugs no longer in general use have merely been mentioned in the new edition leaving space for a fuller t rea tment of over 100 new drugs not mentioned previously.

The historical approach to the subject is evident throughout the book and there are many interesting and sometimes amusing anecdotes concerning the early discoveries of drug properties, which make the book all the more readable. In this respect the discoveries of the anaesthetic proper ty of nitrous oxide and of the pharmacological effects of adrenaline and digitalis are described in a most engaging manner. Chapters are devoted to the topical questions of alcoholism, drug addiction and the smoking habit in relation to health.

Each of the 59 chapters of the book is preceded by a topic outline indicating major mat ters discussed accompanied by page numbers. This is particularly useful as the general index at the end of the book could be more comprehensive.

When one considers tha t over 30,000 new chemicals are isolated or synthesised yearly and tha t many on screening are found to have some pharmacological actions, it is clear tha t in addition to the Pharmacopeia, there is a need for a book which will draw at tent ion to the more promising of the new drugs and where common pharmacological actions exist in a group of drugs to suggest which might be the most reliable in a given set of circumstances. Few drugs are devoid of occasional unpleasant, or even dangerous side, effects and these must be weighed carefully against possible benefits derived from their-


use. A bet ter understanding of the basic principles underlying the use of a particular drug may be of service in this respect,

The authors acknowledge the help of 25 medical and scientific specialists who accepted sections of the n~nuscr ip t for review and criticism. The final product of this thorough preparation is a very informative, readable and attractively planned volume which must be highly commended.

R. P. KERI~AN.

A Pocket Medicine. 5th Edition. By G. E. BEAUMONT. Publishers : J. & A. Churchill Ltd. 20/- .

This pocket book contains basic essential facts for the medical s tudent in his clinical years. Being of a handy size he will find it useful as a quick reference during travel and between lectures. I t will simplify his reading of the larger textbooks. The information is presented in a clear, concise and accurate manner and this book would be a very useful companion during the immediate pre-examination days for revision. I t is strongly recommended to the s tudent as an aid to medicine. The busy G.P. wanting to brush up his medicine will find it useful as a week-end refresher on the subject.

A. SMYTH.

Radioactivity in Man. Second Symposium. By G. R. MENEELY and S. M. L~DE. Illinois : C. C. Thomas. $24.50.

The book is divided into seven main categories, namely : Potassium and Body Composition ; Cobalt Metabolism ; Iron i~etabolism ; Miscellaneous Topics ; Metabol- ism of Fission Products ; Social and Industrial Aspects of Interrml Radioisotope Burdens.

Representatives from 16 different countries contribute to this well-compiled and documented volume of approximately 600 pages. Emphasis is laid on the improved techniques and sensitivity of counters in achieving bet ter accuracy and a reduction in the dose of radioactive substances administered to patients. Recordings of open discussion following most of the papers elucidate the m ~ y problems workers in this field experience.

Special interest is shown in whole body counting with particular reference to instru- mentat ion and its location.

This book covers many aspects of the different usages in n ~ n of radioactive substances. I t should be read by all those specifically concerned in this field, but should also hold some interest for those whose studies with radioactive isotopes are limited.

M. J. O'HALLORAN.

A Guide to Medical and Surgical Nursing. By E. R. D. BENDALL and E. RAYBOULD. H. K. Lewis & Co. Ltd., London. 25/-.

This book illustrates clearly the aims of modern nursing education, the integration of theoretical subjects with each other and practical nursing experience and the encouragement of an alert and enquiring approach. I t s tarts with two good introductory clmpters including excellent sections on pain and loss of privacy and goes on to describe observations, t rea tment and care classified under the various systems of the body. Detailed nursing techniques are assumed to have been learnt already (this was the aim of the authors ' previous book Basic Nursing} but general principles are clearly indicated and the suggestions for further reading at the end of each chapter are an encouraging addition.

Avoidance of repetition aids economy and style, but calls for a fuller index tlmn is provided. The line diagrams are good, with the exception of two (13 and 14) which could be misleading in the chapter on the circulatory system. The book itself is well bound and attractively presented and could be of benefit to even the most senior medical man.

PETER F. ROE. JUDITH M. CHEVASSE, R.G~N.

Diuretic Therapy. An appraisal of diuretic drugs. Edited by A~THUE C. DEG~AFF, M.D. and ALA~ F. LYon, M.D. The C. V. Mosby Company, St. Louis, 1965. $3.50.

The modern diuretic drugs consti tute one of the most important ~dvanees kn~ t reatment . This is particularly t rue of those drugs which r~ay be administered orally. Because of the unfailing rapidity with which new members of this group appear on the market the practising physician is presented with a serious dilemma in selection. I t is generally realised tha t while a diuretic may be an extremely useful form of therapy i t has also many hazards. The difficulty of the physician is not made easier by the often exaggerated claims for a new product. The danger lies not in the claim tha t it is a more efficient diuretic, but rather tha t its manufacturers tell us t ha t they have succeeded in eliminating, or partially eliminating the metabol ic disturbances set in train by the drug 's predecessors on the market. A critical and objective appraisal of the diuretics

BOOK REVIEWS 45

n o w ava i lab le to u s is t i m e l y a n d one feels t h a t a n y phys ic i an who p e r u s e s t h i s sho r t m o n o g r a p h o f fo r ty -one pages will be g ra t e fu l indeed to t h e a u t h o r s a n d to t h e publ i shers . I n c o n t e n t i t cons i s t s o f n ine a r t ic les pub l i shed in t h e American Heart Journal d u r i n g 1964 a n d 1965. I n add i t i on t h e r e is an i n t roduc t i on on t h e gene ra l pr inciples o f d iure t ic t h e r a p y in re la t ion to rena l p h y s i o l o g y and a s u m m a r y . T h e l a t t e r is p robab ly t he p a r t o f t h e m o n o g r a p h wh i ch will appea l m o s t s t r ong l y to t h e ave rage reader .

One m i g h t join i s sue on t h e r a t h e r d o g m a t i c i n t e r p r e t a t i o n o f t h e si te o f ac t ion in t h e r ena l t u b u l a r s y s t e m a n d also on t h e m o d e of ac t ion in t h i s s y s t e m a t t r i b u t e d to t h e v a r i o u s d iure t ics b y t h e a u t h o r s . Few, however , would quar re l w i t h the i r clinical a n d me tabo l i c a s s e s s m e n t o f t h e v a r i o u s d iure t ics . Mercuria ls , th laz ides , sp i ronolac tone , t r l a m t e r e n e a n d e t h a c r y n i e ac id a re all dea l t w i t h i nd iv idua l ly a n d we a re p rov ided w i t h a v e r y reliable guide in t h e m a t t e r o f se lect iou o f t h e s e d iure t ics in t h e va r i ous p r o b l e m s of oedema . The re is a s a l u t a r y a d m o n i t i o n n o t to over look t h e benef i t s o f me rcu ry , especial ly in t h e r ap i d d iures i s wh i ch is r equ i r ed in severe conges t ive fai lure. Of pa r t i cu la r i m p o r t a n c e is t h e r e m i n d e r o f t h e fac t t h a t t h i s old and well t r ied d iure t ic does n o t c ause a n excess ive loss o f p o t a s s i u m . The clinical a n d me tabo l i c s imi la r i ty in t h e r e s u l t s o b t a i n e d b y i n t r a m u s c u l a r m e r c u r y and oral e t h a e r y n i c ac id are clearly ind ica t ed .

T h e th l az ides receive a v e r y sens ib le appra i sa l . H a v i n g i s s u e d t h e expec t ed w a r n i n g r e g a r d i n g hype rg lyeaemia , h y p e r n r i c e m l a , a n d h y p o k a l e m l a t h e c o n t r i b u t o r s c o m e d o w n f i rmly on t h e side o f t h e th i az ides as t h e m o s t su i t ab le m ~ i n t e n a n c e d iure t ics in t h e a v e r a g e case. One is pa r t i cu l a r l y re l ieved to r e ad t h e w a r n i n g r ega rd ing com- p l acency in t h e u se o f th iaz ide p r e p a r a t i o n s in wh ich i n a d e q u a t e a m o u n t s o f p o t a s s i u m are i nc luded by t h e p roduce r s a n d f u r t h e r m o r e we are g iven p rac t i ca l sugges t i ons as to t h e p rov i s ion o f a n a d e q u a t e p o t a s s i u m i n t ake for p a t i e n t s m a i n t a i n e d on t h e s e drugs . T h e twofo ld benef i t s o f sp i rono lac tone a n d t r l a m t e r e n e u s e d in c o m b i n a t i o n w i th t h e thic~zides is e m p h a s i s e d , viz. , in t h e f irst place as a n a d j u v a n t in r e f r ac to ry oeden~a a n d in t h e second place t h e a d d i t i o n o f t h e s e two d r u g s will d i m i n i s h t h e ka lure t ic , or p o t a s s i u m los ing effect o f t h e th laz ides .

T h e s t a t e m e n t t h a t e t h a c r y n i c acid is t h e m o s t power fu l oral d iure t ic avai lable m i g h t n o w be cha l l enged b y t h o s e w h o are fami l ia r w i t h f r u semide . F r u s e m i d e (Lasix) is n o t cons ide r ed in t h i s m o n o g r a p h , b u t S t u a r t a n d E d w a r d s f r o m t h e rena l u n i t o f t h e S y d n e y H o s p i t a l have shown t h a t t h e r e is v e r y l i t t le to choose b e t w e e n t h e s e two d rugs . The per iod o f ac t ion a n d t h e m a g n i t u d e o f d iures is is v e r y s imi la r in b o t h cases as a r e also t h e me tabo l i c effects. / % i t h e r d r u g is a ser ious pobas s inm loser and each h a s t h e a d v a n t a g e o f s igni f icant ly a d e q u a t e a c t i o n in t h e p r e sence o f m o d e r a t e , or even severe r ena l insuff ic iency. I n d e e d i t wou l d a p p e a r t h a t t h e ma in ind ica t ions for u s i n g f ru semide or e t h a c r y n i c ac id a re (a) a s a n a l t e r n a t i v e to i n t r a m u s c u l a r me rcu r i a l d iure t ics whe re r ap id r e s p o n s e is r equ i red or (b) as m a i n t e n a n c e d iu re t i c s in c a se s o f o e d e m a which a re c o m p l i c a t e d b y chronic r ena l insuff ic iency. Whi le t h i s m o n o g r a p h is m a i n l y conce rned w i t h o e d e m a as i t a r i ses in ca rd iac d i sease t h e p r o b l e m s o f t h e neph ro t i c s y n d r o m e a n d h e p a t i c c i r rhos is do n o t go neg lec t ed .

A pub l i c a t i on s u c h as t h i s h a s b e e n a n e e d for s o m e t ime . W e n o w have i t in a shor t , clear p rac t i ca l and i n t e r e s t i ng fo rm and i t m u s t be r e c o m m e n d e d to all who u s e diuret ic , t h e r a p y in the i r da i ly clinical work . W . F . O 'DwYsR.

Cellular Concepts in Rheumatoid Arthritis. B y C. A. L. STEPHElqS a n d A. B. STANFIELD. C. C. T h o m a s , Il l inois. $14.75.

I n F e b r u a r y 1964 a s y m p o s i u m in m e m o r y of t h e la te Dr . W. P a u l Ho lb rook was he ld in t h e U n i v e r s i t y of Ar izona . T he pane l o f d i s t i n g u i s h e d con t r i bu to r s d i s cus sed cel lular concep t s in r h e u m a t o i d a r th r i t i s u n d e r t h e c h a i r m a n s h i p o f Dr . Wi l l i am D a m e s h e k a n d the i r de l ibera t ions h a v i n g been recorded are now pub l i shed in p e r m a n e n t form. T h e v o l u m e is well p r o d u c e d a n d t h e l e t t e rp ress embe l l i shed w i t h i n s t r u c t i v e m i c r o p h o t o g r a p h s .

T h e f irst c h a p t e r s t resses t h e d y n a m i c cha rac te r o f connec t ive t i s sue a n d t he cellular c o n t r i b u t i o n to t he b i o syn t he s i s o f col lagen, g r o u n d s u b s t a n c e a n d b a s e m e n t m e m b r a n e . The r e semb lance be t ween t h e depos i t i on of col lagen b e n e a t h b a s e m e n t m e m b r a n e in r h e u m a t o i d a r th r i t i s a n d t h e s imi la r p rocess wh ich c a n be obse rved on t h e surface o f f ib rob las t s is clearly d e m o n s t r a t e d . T he n e x t chap t e r dea ls w i th t h e t e chn ique of t i s sue cu l tu re a n d t h e o p p o r t u n i t y w h i c h i t a f fords of obse rv ing t h e ac t iv i t ies o f s ingle cells l iv ing u n d e r cont ro l led cond i t ions , whi le t he t h i r d one is a m a s t e r l y review b y Dr . D a m e s h e k of t h e c o n t r i b u t i o n w h i c h t h e concep t o f a u t o - i m m u n i t y can m a k e to t h e u n d e r s t a n d i n g o f t h i s a n d t h e o t he r so called a u t o - i m m u n e disorders . Dr . E u g e n e B a r n e t t follows w i th a chap t e r on a n t i n u c l e a r fac tors in r h e u m a t o i d a r th r i t i s a n d L .E . He h a s been able to produce , b y i m m u n i s a t i o n , an t i bod i e s in mice wh ich clear ly r e semble t hose f o u n d in ce r t a in cases o f t he se d isorders . Dr . E d w i n Osgood t h e n p roposes a well conce ived a r g u m e n t t h a t r h e u m a t o i d a r t h r i t i s is a n express ion n o t o f a u t o - i m m u n i t y , b u t of w h a t he calls c r o s s - i m m u n i t y . Th i s is t h e abi l i ty o f an t ibod ies to reac t w i th chemica l s u b s t a n c e s imi lar to, b u t n o t necessa r i ly ident ica l wi th , t h e a n t i g e n wh ich h a s p rovoked t h e m . T he n e x t con t r ibu t ion is a n o t h e r beau t i fu l ly i l lu s t r a t ed


paper on tissue culture investigations in rheumatoid arthrit is by Dr. A. B. Stanfield and others and it is followed by a discussion on certain factors related to the induction of auto-immunity and of auto-immune lesions.

Some of the concepts discussed in this volume are complicated and it is a measure of the ability of the contributors tha t they can discuss them without recourse to the neologisms or the contorted language which make tedious the interpretat ion of so many modern contributions to knowledge. D . E . MELLON.

The Lymphecytes. By MICHAELW. ELV~S. London : Lloyd-Luke. 1966. 50/-.

For long perd~, the small lymphocyte became for many years the cynosure of contro- versial eyes. Clarity dawned with the realisation tha t lymphoeytes do not form a uniform population. Bone marrow cells morphologically indistinguishable from small lymphocytes may take part in erythropoiesis--and possibly in granulopoiesis. Lymphocytes in lymphatic nodes and vessels do not serve an haemopoietic function but form a defensive barrier by carrying "immunological memory". Lymphocytes of the two populations are to be found in circulating blood. The life expectancy of one group is measured in hours, of the other in many years ; but both are waiting to be called on, to develop and differentiate or to proliferate and fabricate. Elves, one of the foremost workers on lymphocyte transformation, reviews in this monograph the present state of our knowledge of these enigmatic cells. His references run to 777 ; three-quarters of these were published in the last decade, half of them since 1960. Two rather bizarre but relevant papers have slipped through the net : In considering the possible role of the lymphocyte in erythropoiesis the case of reticular dysgenesia described by O. M. de Vaal and V. Seynhaeve (1959, Lancet, 2, 1123) is worthy of consideration ; no lymphoetes were seen in thymus, spleen or marrow where myeloid cells were also absent but formation of erythroblasts and megakaryoeytes was not disturbed. I t has been established tha t the constant steam of long-lived cells through the thoracic duct is accounted for by recirculation, the lymphocytes passing from blood to lymph through the endothelial cells of the post-capillary venules in the lymph nodes. But the possibility of lymphaticovenous communications has also arisen with obvious problems concerning the barrier function of lymphocytes : by injecting air into a cervical node (presumably into a lymph sinus) 3. J . Pressman and M. B. Simon (1961, Surg. Gynec. Obstet., 113, 537) found air in the veins and lymphatics leaving the node and inferred that the node contains numerous openings between lymph sinuses and veins!

The lymphocytes participate in inflammation and repair, in ant ibody production and the homograft reaction ; if there is a doctor (spare-part surgeons excepted) whose daily bread is not buttered by these thaumaturgic cells, he has no need to savour this opsonie collation. C . S . BREATKNACH.

The Birth of Language. By S. KASTEIN and B. TRACE. C. C. Thomas, Illinois. $6.75.

The greater portion of this b o o k - - P a r t I I - - i s the story of an American family ; more especially The Stery of Jean. Joan ' s birth was premature by three months and one week. J=Ier parents were already aware of the high risk of retrolental fibroplasia and this knowledge proved to be disturbing almost to the point of rejection. They had to wait eighteen weeks for reassurance tha t the dreaded eye disease had come and gone without leaving any residual eye damage. Nonetheless, only some eleven years later, at the close of 1964, could it be said of Joan that "for the first t ime there was no indication whatsoever tha t this eleven year old girl was in any way different from any other child her age". Seven years earlier, the difference had been great indeed with many and frequently recurring pat terns of behaviour which were both baffling and alarming ; but in the following year (I958), Joan ' s basic problem had for the first t ime been correctly diagnosed as (and I quote) "a dysfunction of the central nervous system and receptive language disorder". After years of unremitting effort, i ts t rea tment was now complete. Wri t ten as it is by Joan ' s mother, this document does not confront the reader with a great deal of professional terminology, yet it provides all the details of the case with a lucidity which one would expect from a professional recorder.

Mrs. Kastein, Speech Pathologist, Columbia Presbyterian Medical Center, New York, whose help was eventually sought in the diagnosis and t rea tment of Joan's problem, has contributed Parts I and I I I . There is a wealth of information to be gleaned here for anyone concerned with the evaluation of and therapeutic approach to children with communication disorders.

This book should prove of considerable value to the various professional workers to whom anxious parents may turn for advice and guidance. Combined with adequate personal contact and counselling, it will most certainly be a means of enabling them to acquire a bet ter understanding of what must be for many an altogether baffling problem.

A small point, but one which could cause some confusion of thought if read at random, is the inaccuracy in the date given on page 43. This should, it seems, read "June, 1957" (and not 1956 as stated). I t is, in fact, subsequently corrected at the beginning of Chapter 7. S.K.

BOOK REVIEWS 47

Cecil-Loeb Text-book of Medicine. Ed. by P. B. BESSON and W. McDERMOTT. 12th edition. W. B. Saunders and Company, Philadelphia and London.

In its 12th edition this volume maintains the standard of excellence which has made it the best-known of the larger text-books of medicine in the English language. The subject is treated so widely and with a degree of detail that makes it more suitable for the post- graduate student (including mature doctors) than for undergraduates.

There is an unusually large number of new contributors and sub-editors; in consequence some sections have been almost re-written; the entire type seems to have been re-cast with more lines to a page and despite new additions it is shorter and more easily handled than its predecessor.

Incidentally, one of the editors (P. B. B.) is now a "Yank at Oxford", but whether his appointment to the Nuffield professorship is to be looked upon as reversal of the direction of the brain-drain, or as a manifestation of the peripatetic Osier tradition is problematical.

J. B. LYONS.

Thymic Tumours. By J. F. HALE and E. F. SCOWEN. Lloyd-Luke. 30s. The thymus appears to have an immunological role, but the precise significance of the

known association of thymoma with certain diseases--myasthenia gravis, Cushing's syndrome, S.L.E., bone-marrow hypoplasia, hypogrammaglobulinaemia, polymyositis (and very rarely rheumatoid arthritis, Sjogren's syndrome and scleroderma)--is by no means clear. The incidence is highest in myasthenia gravis and, paradoxically, myasthenic patients who have a tumour are unlikely to benefit from thymectomy. Indeed, cases have been described in which the first muscle weakness post-dated the removal of a thymic tumour.

That the details regarding thymoma in text-books of neurology are surprisingly meagre will be confirmed by reference to those by Sir Francis Walshe, H. Houston Merritt, and Lord Brain which include the above facts and give widely varying figures of incidence; even the chapter on myasthenia gravis in Disorders of Voluntary Muscle (ed. Walton) contains just one paragraph on thymoma. Drs. Hale and Scowen's monograph is based on 64 cases of thymic tumour: 53 had myasthenia gravis and one of these had S.L.E. too; 4 had bone-marrow hypoplasia; in 7 there was no associated disease. Although their youngest patient was a girl of twenty-two they found thymoma uncommon under thirty and a similar sex incidence. Benign tumours caused no symptoms and were detected radiologically.

They discuss the prognosis, incidence of malignancy and therapeutic management; they explain that the x-ray features of the series (which a colleague has described in a separate publication) are outside their terms of reference. Their book is significant and informative; its practical value would have been enhanced by incorporation of the radiological study.

J. B. LYONS.

.4 Manual of Tropical Medicine. By HUNTER, FRYE and SWARTZWELDER. W. B. Saunders Company, Philadelphia and London. Fourth Edition, i966. s 9s. 6d.

This is the fourth edition of a book originally issued during World War I[ to meet the needs of the Armed Forces of the United States working in tropical and subtropical regions. The authors aim to supply precise and detailed instruction as technical assistance in the attack on disease in the tropics and for the training of physicians and other health personnel in the recognition, treatment and control of disease. Each section of the work is by a specialist contributor, of whom there are forty. All but one is an American and the closest present contact with the tropics is that of the contributor from the Panama Canal Zone.

In essence the book is a comprehensive manual for those posted abroad to foreign par ts- - throughout the emphasis is on prophylaxis, laboratory recognition and Public Health control of communicable disease; the very stuff to give the troops. As such, inev- itably the title is taken as virtually synonymous with Communicable Diseases of Tropical Regions. A short section on Diseases of Nutrition, less than 3% of the text, is almost the only exception. Ill-health in the indigenous people is of importance to the authors only insofar as it might be communicated to the visitors. Thus the whole subject of neoplastic disease amongst tropical dwellers is not considered here, neither is there any account of diabetes, endocrine disorders, central nervous disease, or cardio-myopathies as encountered in tropical communities. The authors have drawn a line and made no effort to be clinically comprehensive. Such limitations may very properly be imposed and this comment is made merely to indicate that the manual is comprehensive only within this framework.

Comprehensive and authoritative it certainly is and it would be difficult to fault the precision and the detail of instruction for the recognition of communicable disease and for its control--from virus invasion to the many disease vectors, and from helminth infestation to the toxicity of pesticides. Approximately half the text deals with infection; the section on Arthropods of medical importance covers more than one hundred pages. A substantial part is devoted to medically significant wild life from snakes to spiders and from crocodiles to ticks.


A section on laboratory diagnostic methods gives practical details which should supply complete operational direction for a tropical diseases health centre, or laboratory. No medical officer serving abroad, no specialist seconded for work in the tropics, could afford to be without a text such as this, and for such visitors it should prove to be invaluable.

This manual of tropical medicine can be warmly recommended as a reference book for a wide range of investigational methods, as a comprehensive and precise guide to communicable disease around the globe (a tropical diseases gazetteer is included in the appendix) and as affording sufficient clinical detail to direct medical staff towards minimis- ing the hazards of tropical life and raising standards of health. Printing and production are of the high quality to be expected from the publishers, while the illustrations are generally of value and sometimes excellent.

ALAN THOMPSON.

Surgery of the Ear. By G. E. SHAMeAUGU. W. B. Saunders Co. Ltd. s 10s. This book was first published in 1959 and was at once recognised as an important

contribution to otology. Because of the substantial gains in otologic surgery and in particular surgery under the operating microscope a large part of the text for this second edition has been rewritten.

Although mainly concerned with surgery it deals quite fully with all aspects of otologyo For example, such subjects as the developmental anatomy of the ear and the mechanics of hearing are given extensive coverage.

The chapters on conventional radiological examination and on the tomography of the temporal bone are perhaps a little too detailed for a text-book on surgery but they are a mine of information and should be most useful for reference. It is shown that tomography is of extreme value in the diagnosis of acoustic neurinornas when the osseous changes produced by the mass growing inside the internal auditory canal are still quite minimal and impossible to detect by conventional radiography.

The section devoted to tympanoplasty is particularly good. The various techniques are described in detail and the illustrations are most helpful. These operations designed to improve hearing in various types of middle ear lesions are largely replacing the old classic radical mastoidectomy. The late results of tympanoplasty may be disappointing and the author rightly states that all patients undergoing this type of operation should be instructed not only in the possibility of failure, but in the likelihood that more than one operation may be required.

The chapters on the surgery of otosclerosis are perhaps the best in the book. The description of the various surgical techniques is meticulous and the illustrations are numerous and unusually clear. This section like some of the other chapters is prefaced by a historical note and it is interesting to learn that as far back as 1890 Miot reported a series of 200 stapes mobilization operations and that he used a method very similar to the operation revived 62 years later by Rosen. Stapedectomy with wire loop on compressed gelfoam is the method preferred by the author. He is careful to point out all the difficulties of the operation and how they may be overcome. The technique and results of the stapes operations have improved and indications for the classic fenestration of the horizontal canal have narrowed very considerably, but despite this a full chapter is given to this operation.

The author prefers local anaesthesia with adequate pre-operative sedation for nearly all temporal bone operations on adults. This would not be the usual practice in this country even though on the average there is nearly always less bleeding with local anaesthesia.

There is a very interesting chapter devoted to facial nerve decompression and repair. In Bell's palsy opinion is still divided between those who oppose decompression in any case and those who, like the author, believe that in selected cases decompression favours earlier and more complete recovery.

Acoustic neurinoma receives a chapter to itself and a full description is given of the new transtemporal bone microsurgical method for removing this type of tumour. This is of particular use for all small tumours and appears to have a very brief convalescence compared to the traditional posterior fossa operation. However, most otologists would prefer this type of tumour to be dealt with by a neurosurgeon.

The medical and surgical aspects of M~ni~re's disease receive detailed attention and in this chapter there is a useful differential diagnosis of vertigo. Less than 5 to 10 per cent. of patients with M~ni~re's disease require surgical intervention. When surgery is required the author prefers Cawthorne's horizontal canal labyrinthotomy.

The book is beautifully produced and is very easy to read. It is difficult to recommend it too highly.

DESMOND KENNEDY.

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