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421 20. Johnston, I. H., Gilday, D., Hendrick, E. B. Unpublished. 21. Walker, A. E., Adamkiewicz, J. J. J. Am. med. Ass. 1964, 188, 779. 22. Cohn, G. A. J. Neurosurg. 1964, 20, 784. 23. Davson, H., Hollingsworth, G., Segal, M. B. Brain, 1970, 93, 665. 24. Schurr, P. H., McLaurin, R. L., Ingraham, F. D. J. Neurosurg. 1953, 10, 515. 25. Marr, W. G., Chambers, R. G. Am. J. Ophthal. 1961, 51, 605. 26. Fitz-Hugh, G. S., Robins, R. B., Craddock, W. D. Laryngoscope, 1966, 76, 893. 27. Kinal, M. E., Jaeger, R. M. J. Neurosurg. 1960, 17, 81. 28. Martin, J. P. Br. med. J. 1955, ii, 467. 29. Beller, A. J. J. Neurol. Neurosurg. Psychiat. 1964, 27, 149. 30. Johnston, I. H., Rowan, J. O. ibid. (in the press). 31. Hayes, K. C., McCombs, H. L., Faherty, T. P. Brain, 1971, 94, 213. 32. Oldstone, M. B. A. J. clin. Endocr. 1966, 26, 1366. Reviews of Books Neurology of Ear, Nose and Throat Diseases CHARLES HAROLD EDWARDS, F.R.C.P., consultant physician, St. Mary’s Hospital, London. London: Butterworths. 1973. Pp. 305. E6. GENERAL practitioners not only provide the backbone to the National Health Service but also help to shape the work of hospital doctors by the manner in which they refer patients. Patients complaining of headache, giddiness, and facial pain are often referred to E.N.T. surgeons (or otorhinolaryngologists as they are called in the European Economic Community), and as a result much of these surgeons’ work has a medical flavour. The primary purpose of this book is to help E.N.T. surgeons to form a balanced view of the investigation and treatment of patients with acoustic neuroma, vertebrobasilar ischmmia, tri- geminal neuralgia, and other similar conditions which are usually considered to be the province of the neurologist or general physician. Dr Edwards is not seeking to produce budding neurologists, and he describes his material as no more than the simplest alphabet and his aim as purely clinical. But to be effective the Law needs to know the sort of thieves they are trying to catch, and surgeons need to know the runners in the diagnostic field if they are to give good advice to their patients and to the practitioners who refer them. Most of the book is clear and to the point and argument follows argument in an analytical and scientific manner that is stimulating to read. It is a pity that the author is occasionally long-winded: for instance, he sensibly thinks that it is bad if someone who is about to faint is not allowed to lie down, but you might be forgiven for not realising this when you read that environmental circumstances such as encumbrances in a bathroom and well-meaning bystanders may deprive the fainting subject of levelling of the heart and brain. However, it is churlish to criticise the occasional lapse in a book that is mostly easy to follow and which is full of nicely phrased comments on the clinical scene; " allergy next to injury must be the most uncritically blamed association in medicine "; and, speaking of the 10% of patients with anxsthesia dolorosa after injection of the gasserian ganglion for tic douloureux, " surgery has nothing whatever to offer them unless it be further sorrow ". There are chapters on some of the commoner symptoms to be met within medical practice such as pain in the head, face, and neck, disorders of balance, tinnitus and head noises, facial paralysis, dis- orders of speech, and other familiar problems. When seen in the busy practice or clinic, patients complaining of these symptoms often produce a sinking feeling in the doctor’s stomach, and the author’s clear account and common-sense approach to their management will help to cure this. The author is aware of current thinking on xtiology and treatment, but the soundness of theory is always tested by the acid of clinical practice, of which Dr Edwards has clearly had a lot. Clinical Application of Blood Gases BARRY A. SHAPIRO, M.D., assistant professor of anesthesiology, North-Western University Medical School, and medical director, division of respiratory therapy and associate director, North-Western Memorial Hospital. Chicago: Year Book. London: Lloyd-Luke. 1973. Pp. 210.$10; E5. THE worthy aim of maximising the audience, here in- tended to encompass both " critical care nurse " and " accomplished physician ", always poses problems. Dr Shapiro’s dilemma is apparent, for his didactic style, with exhortations to master one section before proceeding further, leaves him open to inevitable doubt as to the evidence for some of his didactic certainty, for he gives no references throughout his text. Much in this book is good, with clear practical advice, yet also much controversy is concealed. To most English readers ventilatory insuffi- ciency means not enough ventilation, but Dr Shapiro defines it as too much, or hyperventilation-a confusing difference which could lead to misunderstanding of literally lethal proportions. One senses that his experience is mainly with postoperative critical care, for the common medical emergencies where blood-gas estimations are invaluable, such as chronic bronchitis, cor pulmonale, pneumonia, and pulmonary oedema, receive scant attention. Thus he fails to stress the important differences between acute and chronic CO2 retention, and he omits entirely any reference to the invaluable delineation of the signifi- cance bands of in-vivo acid/base relationships described by Schwartz and his colleagues. Some of the statements on oxygen therapy are equally questionable, from the insistence on " shunt " or " dead space " as mechanisms of hypox- amiia, with little or no attempt to explain the far more ubiquitous ventilation/perfusion imbalance, to resurrection of the 1925 Lundsgaard hypothesis on recognition of cyanosis, ignoring modern investigations on the accuracy of detection of this sign or even the distinction between central and peripheral cyanosis. How can oxygen therapy " manipulate the ventilatory status " except by changing the arterial P02 sufficiently to effect chemoreceptor drive ? These criticisms are of little concern to the accomplished physician, for his experience will allow him to form his own judgment; but this book appears to cater principally for the nurse and paramedical technician, for it includes a brief description of cardiopulmonary physiology, of blood- gas electrodes, and of the gas laws, and a glossary of medical terms (where, strangely enough, respiratory failure is not defined in terms of blood-gas tensions). Regrettably, this book raises doubts as to the wisdom of the instruction in too many places for it to be recommended wholeheartedly to the uncritical student. Immunotherapy of Cancer in Man EVAN M. HERSH, M.D., JORDAN U. GUTTERMAN, M.D., and GIORA MAVLIGIT, M.D., department of developmental thera- peutics, University of Texas, M. D. Anderson Hospital and Tumor Institute, Houston, Texas. Springfield, Illinois: Charles C. Thomas. 1973. Pp. 141.$9.50. THE authors of this small book set out to provide " a review of the current status of immunotherapy in the context of advances of the past two decades ". The literature is vast, and the coverage is sensibly confined to a few topics. First, a chapter on immunological deficiency in cancer: the approach is critical, and the distinction between tumour-specific and non-specific immunodeficiency is a useful one. A section on tumour antigens follows, dealing with the cell surface and describing the factors that

Reviews of Books

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Page 1: Reviews of Books

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20. Johnston, I. H., Gilday, D., Hendrick, E. B. Unpublished.21. Walker, A. E., Adamkiewicz, J. J. J. Am. med. Ass. 1964, 188, 779.22. Cohn, G. A. J. Neurosurg. 1964, 20, 784.23. Davson, H., Hollingsworth, G., Segal, M. B. Brain, 1970, 93, 665.24. Schurr, P. H., McLaurin, R. L., Ingraham, F. D. J. Neurosurg. 1953,

10, 515.25. Marr, W. G., Chambers, R. G. Am. J. Ophthal. 1961, 51, 605.26. Fitz-Hugh, G. S., Robins, R. B., Craddock, W. D. Laryngoscope,

1966, 76, 893.27. Kinal, M. E., Jaeger, R. M. J. Neurosurg. 1960, 17, 81.28. Martin, J. P. Br. med. J. 1955, ii, 467.29. Beller, A. J. J. Neurol. Neurosurg. Psychiat. 1964, 27, 149.30. Johnston, I. H., Rowan, J. O. ibid. (in the press).31. Hayes, K. C., McCombs, H. L., Faherty, T. P. Brain, 1971, 94, 213.32. Oldstone, M. B. A. J. clin. Endocr. 1966, 26, 1366.

Reviews of Books

Neurology of Ear, Nose and Throat DiseasesCHARLES HAROLD EDWARDS, F.R.C.P., consultant physician,St. Mary’s Hospital, London. London: Butterworths.1973. Pp. 305. E6.

GENERAL practitioners not only provide the backboneto the National Health Service but also help to shape thework of hospital doctors by the manner in which theyrefer patients. Patients complaining of headache, giddiness,and facial pain are often referred to E.N.T. surgeons (orotorhinolaryngologists as they are called in the EuropeanEconomic Community), and as a result much of these

surgeons’ work has a medical flavour. The primarypurpose of this book is to help E.N.T. surgeons to form abalanced view of the investigation and treatment of patientswith acoustic neuroma, vertebrobasilar ischmmia, tri-

geminal neuralgia, and other similar conditions which areusually considered to be the province of the neurologistor general physician. Dr Edwards is not seeking to producebudding neurologists, and he describes his material as nomore than the simplest alphabet and his aim as purelyclinical. But to be effective the Law needs to know thesort of thieves they are trying to catch, and surgeons needto know the runners in the diagnostic field if they are togive good advice to their patients and to the practitionerswho refer them. Most of the book is clear and to the pointand argument follows argument in an analytical andscientific manner that is stimulating to read. It is a pitythat the author is occasionally long-winded: for instance,he sensibly thinks that it is bad if someone who is about tofaint is not allowed to lie down, but you might be forgivenfor not realising this when you read that environmentalcircumstances such as encumbrances in a bathroom andwell-meaning bystanders may deprive the fainting subjectof levelling of the heart and brain. However, it is churlishto criticise the occasional lapse in a book that is mostlyeasy to follow and which is full of nicely phrased commentson the clinical scene;

" allergy next to injury must be themost uncritically blamed association in medicine "; and,speaking of the 10% of patients with anxsthesia dolorosaafter injection of the gasserian ganglion for tic douloureux,"

surgery has nothing whatever to offer them unless it befurther sorrow ". There are chapters on some of thecommoner symptoms to be met within medical practicesuch as pain in the head, face, and neck, disorders ofbalance, tinnitus and head noises, facial paralysis, dis-orders of speech, and other familiar problems. Whenseen in the busy practice or clinic, patients complaining ofthese symptoms often produce a sinking feeling in thedoctor’s stomach, and the author’s clear account andcommon-sense approach to their management will help tocure this. The author is aware of current thinking on

xtiology and treatment, but the soundness of theory isalways tested by the acid of clinical practice, of whichDr Edwards has clearly had a lot.

Clinical Application of Blood GasesBARRY A. SHAPIRO, M.D., assistant professor of anesthesiology,North-Western University Medical School, and medicaldirector, division of respiratory therapy and associatedirector, North-Western Memorial Hospital. Chicago:Year Book. London: Lloyd-Luke. 1973. Pp. 210.$10; E5.

THE worthy aim of maximising the audience, here in-tended to encompass both " critical care nurse " and"

accomplished physician ", always poses problems.Dr Shapiro’s dilemma is apparent, for his didactic style,with exhortations to master one section before proceedingfurther, leaves him open to inevitable doubt as to theevidence for some of his didactic certainty, for he gives noreferences throughout his text. Much in this book is good,with clear practical advice, yet also much controversy isconcealed. To most English readers ventilatory insuffi-ciency means not enough ventilation, but Dr Shapirodefines it as too much, or hyperventilation-a confusingdifference which could lead to misunderstanding of literallylethal proportions. One senses that his experience is

mainly with postoperative critical care, for the commonmedical emergencies where blood-gas estimations are

invaluable, such as chronic bronchitis, cor pulmonale,pneumonia, and pulmonary oedema, receive scant attention.Thus he fails to stress the important differences betweenacute and chronic CO2 retention, and he omits entirelyany reference to the invaluable delineation of the signifi-cance bands of in-vivo acid/base relationships described bySchwartz and his colleagues. Some of the statements on

oxygen therapy are equally questionable, from the insistenceon

" shunt " or " dead space "

as mechanisms of hypox-amiia, with little or no attempt to explain the far more

ubiquitous ventilation/perfusion imbalance, to resurrectionof the 1925 Lundsgaard hypothesis on recognition of

cyanosis, ignoring modern investigations on the accuracyof detection of this sign or even the distinction betweencentral and peripheral cyanosis. How can oxygen therapy" manipulate the ventilatory status " except by changingthe arterial P02 sufficiently to effect chemoreceptor drive ?These criticisms are of little concern to the accomplishedphysician, for his experience will allow him to form hisown judgment; but this book appears to cater principallyfor the nurse and paramedical technician, for it includes abrief description of cardiopulmonary physiology, of blood-gas electrodes, and of the gas laws, and a glossary of medicalterms (where, strangely enough, respiratory failure is notdefined in terms of blood-gas tensions). Regrettably, thisbook raises doubts as to the wisdom of the instruction intoo many places for it to be recommended wholeheartedlyto the uncritical student.

Immunotherapy of Cancer in ManEVAN M. HERSH, M.D., JORDAN U. GUTTERMAN, M.D., andGIORA MAVLIGIT, M.D., department of developmental thera-peutics, University of Texas, M. D. Anderson Hospital andTumor Institute, Houston, Texas. Springfield, Illinois:Charles C. Thomas. 1973. Pp. 141.$9.50.

THE authors of this small book set out to provide " areview of the current status of immunotherapy in thecontext of advances of the past two decades ". Theliterature is vast, and the coverage is sensibly confined to afew topics. First, a chapter on immunological deficiencyin cancer: the approach is critical, and the distinctionbetween tumour-specific and non-specific immunodeficiencyis a useful one. A section on tumour antigens follows,dealing with the cell surface and describing the factors that

Page 2: Reviews of Books

422

determine the varying expression of tumour antigens.Methods for studying these antigens in man are discussed;the paucity of techniques is depressingly clear. In thethird chapter the authors consider specific examples oftumour immunity in man with particular reference to

leukxmias and lymphomas. The literature is often con-fusing here, with conflicting results reported from smallnumbers of patients with poorly standardised techniqueswhich are inadequately controlled. Doubts about the

specificity of carcinoembryonic antigens are expressed in asubsection on immunodiagnosis. The next chapter isdevoted to immunotherapy in animals: important advanceshave been made, but many of them are dependent on specialfeatures of laboratory animals that can never be reproducedin a human context. Some of the lessons learnt from suchstudies are, however, relevant to immunotherapy in man,described in the last section of the book: the most propi-tious circumstances for immunotherapy appear to be thosein which the tumour mass has already been reduced to aminimum (by other forms of treatment) in an immunologi-cally competent host. The clinical application of immuno-therapy is indeed " embryonic "-to quote from the

preface-and future developments are not easy-to predict.This account is simple and clear, but it will almost certainlysoon be out of date. There are hardly any references after1971 and there have been a number of important observa-tions since then.

Law and Ethics of A.I.D. and Embryo TransferEdited by G. E. W. WOLSTENHOLME and DAVID W. FITZ-SIMONS. Amsterdam: Associated Scientific Publishers.1973. Pp. 110. D.fl. 15.

TREATMENT of infertility in the male is progressing moreslowly than the decline in the number of children availablefor adoption, so unless there is some sudden change in thefrequency with which married couples determine to havechildren there could be an increasing demand for A.I.D.

Indeed a B.M.A. panel reported earlier this year on thedesirability of setting up accredited A.I.D. centres withinthe N.H.S. The potential demand for embryo transfermight be even greater, but so far work seems to be beingdirected towards the female equivalent of A.I.H., so theethical and legal problems may not be so urgent-providedthe procedure itself carries no medical problems for motheror child. A.I.D. carries with it many heavy responsibilities,and the doctors, lawyers, and moral philosophers at thisCiba Foundation Symposium have now added some rathermore fanciful ones to the list. We read about the purityof the records of the Registrar General, the responsibilitiesof the donor for his illegitimate children, the rights of theA.I.D. child to share in the estate of his biological father,and the duties to prevent half-sibling marriages, to science,and to the donor if an A.I.D. child develops an inheriteddisease. Faced with such responsibilities and uncertaintiesdoctors cannot be blamed for their reluctance to use A.i.D.,though some of the points raised were made to seem rathersilly when one participant pointed to a blood-group surveyamong 200-300 families which had incidentally revealedthat in 30% of children the apparent father could not havebeen the biological one. For those who like to readverbatim accounts of discussions between sharp minds withvarying backgrounds this book is full of interest, but readersmust not be disappointed to see more questions raised thananswered. How far should donor matching be taken, forexample ? One practitioner requires his donors to be ofabove average intelligence and gives semen from moreintelligent donors to less intelligent women, but not viceversa. What about the risk, remembering that the husband’sconsent to A.I.D. is not required in Britain, of abuse wereA.I.D. with an offer to match to be practised widely outside

the N.H.S.? A lot can be done to alter the status of theA.I.D. child by adjusting the definition of legitimacy (ordoing away with it) and by simplifying the adoptionprocedures in these special cases. But the medicolegalaspects still seem troublesome.

Viral and Mycoplasmal Infections of the RespiratoryTract

Edited by VERNON KNIGHT, M.D., professor of microbiologyand medicine, Baylor College of Medicine, Houston, Texas.Philadelphia: Lea & Febiger. London: Henry Kimpton.1973.$12.50; E5.60.

THE post-war years have seen a remarkable increase inour knowledge of the actiology of respiratory viral disease.This new book, by American authors, is a further additionto a rapidly expanding literature engendered by theseadvances. The book has four general introductory chapters,two of which are of special interest since they deal withairborne transmission and immunological responses at

mucosal surfaces-important subjects which rarely get thespace they deserve in books of this kind. In this sectionwill be found the expected account of laboratory diagnosticprocedures and, rather surprisingly, a chapter on inter-ferons (somewhat out of context since very little of it isconcerned with respiratory infection). The remainingchapters, which form the greater part of the book, dealwith the individual viruses or families of viruses that cause

respiratory viral disease. It is disappointing that many ofthese chapters are mere facsimiles of their counterparts ingeneral texts on medical virology with inadequate selectionand emphasis on information relevant to respiratory disease.The chapter on herpesviruses, for example, would be moreat home in a book on dermatology. The book as a wholeis well written, and has the pleasing feature that statementsin the text are substantiated by numerous tables and figurestaken from published work. It should prove useful to bothclinicians and virologists interested in these importantinfections.

Resuscitation of the Newborn Infant (3rd ed. St.Louis: Mosby. London: Henry Kimpton. 1973. Pp. 461.$26.95; £ 12.10).—This book has been expanded so muchthat only about a fifth is now concerned with resuscitation.A full account is given of the development of perinatalmedicine and its present practice. Dr Harold Abramsonand his team of thirty contributors write authoritativelyon topics as diverse as epidemiology and surgical emergencies.There are good practical advice and some useful tableswhich earn the book a place in the obstetric unit and thespecial-care nursery. In libraries it will be consulted

frequently by obstetricians, paediatricians, and all con-

cerned with the wellbeing of mothers and babies.

New Editions

Year Book of Neurology & Neurosurgery 1973. Edited byR. N. De Jong and 0. Sugar. Chicago: Year Book. London:Lloyd-Luke. Pp. 488.$15.50; E7.75.

Electronic Techniques in Ancesthesia and Surgery. 2nd ed.By D. W. Hill. London: Butterworths. 1973. Pp. 421. E7.

Essentials of Immunology and Microbiology. 2nd ed. of Essen-tials of Bacteriology. By Robert G. White and Morag C. Timbury.London: Pitman Medical. 1973. Pp. 390. £ 5.25, C3.50(paperback).

Year Book of Drug Therapy 1973. Edited by D. G. Friend.Chicago: Year Book. London: Lloyd-Luke. 1973. Pp. 426.$14.50; E7.25.