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Reviews of Books

Introduction to PhysiologyVol. IV. HUGH DAvSoN, University College and King’s College,London, and M. B. SEGAL, St. Thomas’ Hospital, London. Lon-don : Academic Press. New York: Grune & Stratton. 1978. Pp.621.11.80;$24.30.

WITH the publication of this volume, Dr Davson and DrSegal complete the fourth lap of their six-lap marathonthrough physiology. Their industry can inspire nothing butawe. In thoroughness and in minutiae of documentation theyeasily outdo such single-author textbooks of the subject as

exist. The multiauthor handbooks cannot produce such uni-formity of succinctness and detail. But their treatise is no in-troduction. It is for the professional or would-be professional,who knows already that the many neatly balanced accountshere do not mean that all accounts are now closed, and whoneeds detailed documentation of the past to guide him into thefuture. The student of human physiology may find the textmore cat-oriented, and even decerebrate-cat-oriented, than herelishes. For instance, a limb supporting the weight of the bodyis said to exhibit "simultaneous contraction of both extensorsand flexors operating at the joints" (p. 9). Cats cannot fullyextend their knees; they do not stand around, but are built forlying in wait, springing out, and sleeping afterwards. Man hasborrowed the herbivorous trick of standing with largelyrelaxed musculature, for browsing or for queueing. Much ofthe work collated here and concerned with the neural controlof movement and posture is highly complex, and general prin-ciples are far to seek. This volume describes the substrate fromwhich these principles have to grow.

Behavioural Treatment of Obsessional States

H. R. BEECH and M. VAUGHAN, University of Manchester. Chi-chester and New York: Wiley. 1978. Pp. 189.0.50.

THIS is a detailed review in which the authors first give aconcise and accurate account of the obsessional disorders, thenexamine the published evidence on the effectiveness of behav-ioural treatment. Although they concede that some of the newtypes of treatment, especially modelling exposure and responseprevention, are promising, they are so highly critical that theyrisk discarding evidence that would satisfy most researchworkers and therapists. Dr Beech and Dr Vaughan are, how-ever, properly critical of the inadequacies of many of the as-sessment procedures which have been used in determining theeffectiveness of these methods, and their objection to "thought-less empirical pursuit" is well-taken. They consider the evi-dence on the effectiveness of desensitisation, satiation training,thought-stopping, and self-regulation to be incomplete and un-convincing. Few people would claim that the value of thesemethods had been demonstrated satisfactorily-but theseauthors also harshly reject, prematurely, and on inappropriatecriteria, methods that are acknowledged to be, and are pre-sented as, experimental techniques (e.g., satiation training);however, when the experimental methods are recommendedfor routine clinical use, their objections are fully justified. Intheir comprehensive and thoughtful assessment of the best de-veloped procedure, modelling and response prevention, theauthors persistently opt for the pessimistic interpretation. Theglass is always half-empty; never half-full-hence, they layemphasis on the contradictory evidence about whether thetreatment method produces improvements in mood, withoutpaying sufficient attention to the large and significant changesin compulsive behaviour that often are produced by the pro-cedure. Similarly, they repeatedly express doubts about thelong-term stability of the improvements observed after thetreatment, whereas the evidence available is reassuring

(although inevitably confounded by the provision of boostersessions). At present there is no practical and ethical alterna-tive that permits the collection of satisfactory follow-up data.High standards of criticism are all to the good, but they shouldnot be so unrealistic as to rule out the possibility of collectingacceptable evidence. Beech’s and Vaughan’s severe assessmentwould have benefited from the inclusion of more of the steadilyaccumulating and encouraging information from independentresearch teams, and fuller acknowledgement of the contribu-tions made by Dr V. Meyer and his colleagues at the MiddlesexHospital would have been fitting. This fluent and clearlywritten book is recommended as a detailed and thoughtful,albeit unjustifiably conservative and severe, assessment of pres-ent knowledge on the subject.

Mitral Valve ProlapseROBERT M. JERESATY, University of Connecticut, U.S.A. NewYork- Raven. 1978. Pp. 264.$28.60.

IN the eighteen years that mitral-valve prolapse has beenrecognised it has been variously named and has caused intenseinterest; it has now become the subject of a monograph. In hisuseful historical introduction the author discusses the various

guises under which mitral-valve prolapse had previously beendiagnosed, and he shows convincingly how the successive clini-cal reports by Reid and Barlow in 1961 led to our presentknowledge. Their clinical, phonocardiographic, and electrocar-diographic suggestions have been amply confirmed by for-

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tunate coincidental developments in angiocardiography andechocardiography. The wider implications of the syndrome, itspathological background, the possibility of its causal or non-causal relationships to a number of other disorders, and thevexed question of associated chest pain, all receive carefulattention. There is a judicious blend of Dr Jeresaty’s own dataand data quoted from others, and a bibliography of some 400articles. The illustrations strengthen the text and help to jus-tify the appearance of this material as a book instead of as anextended review in a journal. It is helpful to have data col-lected in book form, to provide a useful starting point for anyfuture work, as well as for better understanding by those inter-ested in this syndrome. The importance of mitral-valve pro-lapse has increased as the incidence of rheumatic mitral-valvelesions has declined, especially in those parts of the worldwhere high-technology medicine can be practised-which iswhy Jeresaty’s monograph is timely. It reads easily enough foranyone who wants to learn more about the disorder to dip intoit, and it will for some years be a helpful, but not exhaustive,work of reference for those whose needs are more extensive.

The Biological Importance of Bile Salts

Frontiers of Biology, Vol. 47. G. A. D. HASLEWOOD, -Universityof London: Amsterdam and New York: North-Holland Publish-

ing Co. 1978. Pp. 206. D.fl. 125;$53.75.

THE series to which this publication belongs aims at present-ing current concepts of fundamental issues important in bio-logy. Professor Haslewood, renowned for his work on the bio-chemistry of bile-salts within the animal kingdom, surveys allthat is known about bile-salts. Written more for the non-

specialist than the specialist, the text is comprehensive ratherthan detailed; but there are sufficient up-to-date and importantreferences to enable the reader to pursue any topic in greaterdepth. The book covers the nature and function of bile, bilechemistry, the biosynthesis of bile-salts, and the importance ofbile-salts in human physiology and disease. It is, however, inthe section devoted to the distribution of bile-salts in the ani-mal kingdom that Professor Haslewood comes into his own.This chapter contains a great deal of information which willbe unfamiliar to many readers, who will be fascinated by theevolutionary pattern of bile-salts. It is surprising how much isknown and yet, as this monograph indicates, there are many

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important gaps in our understanding of the comparative bio-chemistry of bile-alcohols and bile-salts. In the final chapterthe author speculates about the relevance of bile-acid bio-chemistry to concepts of vertebrate evolution. Can these mole-cules shed light on evolutionary senescence? What is the evolu-tionary significance of the primitive bile-acids formed bychildren with biliary atresia? Why is it that cholic acid hasbeen evolved separately by every vertebrate group? An appen-dix contains new data on bile acids and alcohols which havenot appeared in previous classifications of the different animalspecies. This book, written in a relaxed, almost chatty style,will be read with much enjoyment and benefit by many biologi-cally and medically oriented scientists who wish to remain incontact with a rapidly evolving area of biochemistry and physi-ology.

Current Themes in PsychiatryRAGHU N. GAIND, Glly’S HOSpital, arid BARBARA L. HUDSON, Uril-RAGHU N. GAIND, Guy’s Hospital, and BARBARA L. HUDSON, Uni-versity of Oxford. London: Macmillan. 1978. Pp. 400. D2.

THIS book is the first of a series on contemporary psychi-atric themes and is based on lectures given to senior psychi-atrists during a course held at Bexley Hospital in Kent. Thecourse and the series are a tribute to the enthusiasm and energyof Dr Gaind, and these spill out frequently in the pages ofthis book even though his direct contribution is small. Twenty-nine authors write on subjects as varied as multiple-choicequestions in psychiatry, the prognosis of severe neurosis, andthe treatment of psychopaths, the only common feature of thecontributions being their connection with clinical psychiatryand their topicality. The freshness and informality with whichmany of the chapters are written make them more readablethan those in weightier volumes. Pride of place must go to thelate Peter Scott’s account of the psychiatry of kidnapping andhostage-taking, in which his personal experience of the Spa-ghetti House and Balcombe Street sieges is used to good effectin explaining the apparently irrational behaviour of terrorists.Elsewhere there is a reasonable balance between contributions.Reviews of drug treatment are matched by ones of non-phar-macological healing; behavioural techniques for marital prob-lems are coupled with chapters on psychotherapeuticapproaches, and there are interesting accounts of psychiatricproblems in general practice and the psychiatry of chronicphysical illness. These are interspersed with chapters on lat-erality in psychiatry, classification of psychiatric disorders,sleep, anxiety, and psychosurgery, but many of these havebeen published in similar form elsewhere. Not all the contribu-tors reach the same standard. There is also unnecessary over-

lap between subjects and a tendency by many authors to ignorework done outside the United Kingdom. This is a pity, for thebook is clearly and attractively set out, contains few errors,and is comprehensively indexed. As the first member of theseries the book deserves qualified approval, but there is scopefor improvement in later volumes.

Recent Advances in Community Medicine

Vol. I. Edited by A. E. BENNETT, St. George’s Hospital MedicalSchool. Edinburgh: Churchill Livingstone. 1978. Pp. 278. 15.

MANY of the more recent medical specialties owe their ori-gins to special techniques of investigation and treatment whichset the practitioners apart and make it incumbent on them tokeep up to date. Community medicine is different. It was calledinto being to perform functions which seemed more importantto politicians and social reformers than to many other doctorswho, failing to see community physicians plumbing a particu-lar orifice with a particular instrument, wondered aloud whothey were and what they did. The morale and status of thespecialty is low. The appearance of this series is something ofan event for those involved in the specialty. This first volumesets out to show that there is indeed a strong scientific base to

the subject and much of importance and interest in it to therest of the medical profession; these should help to put com-munity medicine’s tail up again. The topics covered includethe history of the subject and the training in it, health econom-ics, environmental factors and disease (diet, minerals in drink-ing water, air pollution, and smoking), the epidemiological useof data (mortality, hospital diagnoses, adverse drug reactions),disablement, vaccination, and multiphasic screening. The bookis well presented, readable, and stimulating. The contributionsare of variable quality, some of the reviews are a little partisan,and from the statement that whooping-cough is a rare disease,one deduces that the book has been in preparation for sometime. Community physicians will want to read a lot of thebook, while clinicians will find much in it to interest themwhich is less accessible elsewhere-for example, the reviews ofsmoking-induced disease, vaccination and diet and ischxmicheart-disease.

Guide to Pulmonary Medicine

Monographs in Family Medicine, Vol. Edited by DONALD P.TASHKIN and STANLEY M. CASSAN, University of California, LosAngeles. New York and London: Grune & Stratton. 1978. Pp.368.$18.50;12.

THIS volume is the first of a series of monographs which ismeant to form a comprehensive reference textbook for familyphysicians, presumably in North America. The structure ofthis book is similar to that of many reference textbooks on pul-monary disease. The book begins with concise and informativeaccounts of the anatomy and histology of the lung, pulmonaryphysiology, and acid-base balance, although occasionally therequirements of brevity lead to statements which are not fullysupported by the text. The inclusion of a small paragraph onoxygen therapy in the section on blood-gases is unfortunate,because this subject is dealt with later in a far more precise andfar less dangerous manner, with an explanation of the prob-lems of oxygen therapy as well as the benefits. The illustrationsare clear and helpful, but this is not the case with the repro-duction of the radiographs in the chapter on the interpretationof the chest X-ray. However, the discussion of the interpre-tation of chest X-rays is excellent and contains a considerablequantity of information. The chapters on bronchoscopy andinhalational therapy are too brief to be useful to interestedreaders and are unnecessary for the average family practi-tioner. The remainder of the book deals with clinical aspectsof respiratory disease. The arrangement of this section is poor,chapters on single diseases such as asthma coming well beforethose on symptoms (dyspnoea, haemoptysis) and clinical andradiological presentation (pneumothorax and pleural effu-

sions). This disorganisation reduces the readability of the bookand makes it difficult to use as a reference textbook, althoughthe index is adequate. The criteria for further investigationand treatment are not always in accord with views held inEurope, where the value of the treatment sections will belimited by the transatlantic difference in the availability ofpharmaceutical preparations. The clinical, pathological, andradiological criteria for the diagnosis of chronic pulmonaryobstructive disease are expressed clearly, and the treatment ofthe condition is well outlined. There are several other chapterswhich will be of value to general practitioners and hospitalphysicians alike, but their content can be found in a consider-able number of similar, better books.

New Editions

Duke-Elder’s Practice of Refraction.-9th ed By David Abrams.

Edinburgh: Churchill Livingstone. 1978. Pp. 204. /:11.Human Growth After Birth.-3rd ed. By David Sinclair. Oxford.

Oxford University Press. 1978. Pp. 246. 3.95.Energy Balance & Obesity in Man.-2nd ed. By J. S. Garrow.

Amsterdam and New York: Elsevier/North-Holland. 1978. Pp. 243.Dfl.123.$53.50.Manual of Emergency Pediatrics.-2nd ed. Edited by Robert },t

Reece. London: Holt-Saunders. 1978. Pp. 721. 10.75 (soft cover).