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Reviews of Books

Lipoproteins, Atherosclerosis and Coronary ArteryDisease

Metabolic Aspects of Cardiovascular Disease, vol. 1. Edited by N. E. Millerand B. Lewis, St Thomas’s Hospital Medical School, London.Amsterdam: Elsevier/North Holland. 1981. Pp. 232.$33.75; Dfl.69.

READERS of The Lancet are well placed for following the

protracted and often lively debate on the role of

hypercholesterolaemia and other hyperlipidaemias in the aetiologyof coronary artery disease. The apparent reduction in deathsattributable to coronary artery disease recently observed in severalcountries, including Australia and the U.S.A. but not Great Britain,has fanned the flames of this controversy. Some protagonists viewthe North American experience as the direct outcome of preventivemeasures widely adopted in the U.S.A. throughout the past twodecades, including an attempted reduction in saturated animal fatconsumption and an increase in polyunsaturates. Others, equallywell motivated, point to the lack of proof concerning the efficacy ofdietary change in reducing the incidence of coronary artery diseaseand emphasis the possible hazards associated with a reduction ofserum cholesterol, including a rise in the incidence of malignancy.The intensity of the argument which spills daily into the mediamakes this comprehensive but compact book both timely andwelcome.Twelve essays provide a thorough review of current concepts and

knowledge on the interrelation between lipoproteins andatherosclerosis. The physiology of lipoproteins and the disorderedmetabolism thought to underly the atheromatous process are

reviewed in some detail in the opening section, which also gives anexcellent account of the HDL story. The evidence for a causativerole for lipoproteins in atheroma formation is considered togetherwith the possible mechanisms involved. It is, however, the finalsection which will hold most interest for the clinician faced with the

problem of what to advise his patients and their families. Here arediscussed both the management of hyperlipidaemia and the resultsof published trials in both primary and secondary prevention ofcoronary artery disease. This section is extremely well done andillustrates the almost insuperable difficulties of getting an answer tothe diet-heart controversy from the conventional therapeutic trial.The volume is well produced and for the most part well written. It

may not provide the categorical answers we seek but the reader willbe substantially better informed and in a stronger position toevaluate the often emotional arguments which the subject of dietaryprevention of atherosclerosis seems to engender.

Department of Medtcine,General Hospital, Birmingham B. L. PENTECOST

Immunology of Cardiovascular Disease

Basic and Clinical Cardiology, vall. Edited by Maurice H. Lessof, Guy’sHospital Medical School, London. New York: Marcel Dekker Inc. 1981.Pp. 431. [44.

THIS bookte-views the work which has shown that immunologicalprocesses play an important role in some cardiovascular diseases.The twelve chapters are by nineteen authors, ten of whom work inthe U.K. and four of whom are immunologists. About a third of thebook discusses possible immunological mechanisms incardiovascular diseases, a third deals with specific cardiovasculardiseases and their associated immunological defects, and theremainder contains long reference lists. The three main chaptersprovide an elementary introduction to immunology (A. M.Denman), a review of cardiovascular involvement in connectivetissue diseases (Lessof & E. G. J. Olsen), and a description of onestudy on the post-cardiac injury syndrome in children (M. Engle,W. A. Gay, J. B. Zabriskie, & L. B. Senterfit). Other topics coveredinclude infections and cardiovascular disease, (such as rheumaticfever and Chagas’ disease) vasculitic diseases, cardiac allograftrejection in man, and immunological mechanisms in blood-vessel

injury.The principal value of this book is that it gives the newcomer to

each of these areas an outline of clinical and experimental workwhich he can then follow up. However, the reference lists includeonly a handful of papers published after 1979, and five chapters arelimited to work published before the end of 1978.The major weakness of the book is that too much space has been

given to hypothetical discussions of possible immunologicalmechanisms, and the reader will find it hard to extract many wellsubstantiated conclusions. To some extent this may be because the

subject is still at an early stage, but our ignorance about possibleimmunological mechanisms in diseases has been somewhat maskedin this book by an excess of redundant and unrelated information,much of it unconnected with cardiovascular disease. For a book

costing over ;[40, the production is poor (both print and figures).Nonetheless, it should enjoy a wide readership amongst seriousstudents of immunology and cardiology.Department of Immunology,Royal Postgraduate Medical School,London C. J. F. SPRY

Progress in Diseases of the Skin

Vol. 1. Edited by Raith Fleischmajer, Mount Sinai Medical Center, NewYork. New York and London: Grune and Stratton. 1981. Pp. 280.$39.50.

I HOPE that further volumes in this series are as successful as thisone in providing the reader with concise summaries of progress indiseases of the skin. The book, written for the specialist, will be ofhelp not only to the dermatologist but also the pathologist,immunologist, and biochemist. The text is well balanced, eachchapter is of similar length, and most chapters are comprehensivelyreferenced.The chapters are written by experts in the topic concerned. Some

chapters deal with basic cutaneous events such as keratinisation,collagen-its structure and function, and interactions at the dermal-epidermal junction, whereas other chapters discuss relevant

developments in other disciplines. These include the role ofprostaglandins in immunological responses, lysosomes in skin

disease, immune complexes, lymphokines, and the interaction ofT-lymphocytes with the epidermis. Two chapters relate to specificdiseases (porphyrias and necrotising cutaneous vasculitis) anddiscuss new ideas on their aetiology, classification, and treatment.The last chapter summarises in 22 pages the use of retinoids inclinical dermatology. Retinoids are probably the most excitingtherapeutic advance in dermatology since the corticosteroids, andG. Peck gives a good account of the recent laboratory and clinicalstudies which assess the value of this drug.The book is easy to read and, although dogmatic in parts, many

authors take a critical approach so that the reader can understandthe future avenues along which the subjects discussed in this firstvolume may develop. My only criticism is that the black-and-whitepictures are not of the highest calibre, but this in no way detractsfrom my conclusion that all dermatology departments should buythis book.

Department of Dermatology,General Infirmary, Leeds W. J. CUNLIFFE

An Outline of Modern PsychiatryJennifer Hughes, Royal South Hants Hospital, Southampton. Chichesterand New York: John Wiley. 1981. Pp. 211. ;C9.75 (hardback); 6.75(paperback). -

Dr Hughes has written a book which she feels would have satisfiedher needs when she began training in psychiatry-her needs being"a short book which clearly summarised current knowledge of thesubject and was easy to use for reference or revision". In the pastfive years a number have been written in lecture-note form. Theycover the basics of the subject mainly for medical students. This is

°the first which is expressly for those beginning postgraduatetraining.

It covers general psychiatry and most of the special topics verybriefly, but rehabilitation is not included. The layout is excellent;

718

one can see at a glance what information is contained in each

chapter. The reference list at the end of each topic includes some ofthe most relevant publications. As promised in the preface there is a"very detailed index". The disappointing feature is that often thetext is no more informative than the index-for example, in the text,galvanic skin response (GSR) and Beck depression inventory areonly listed as possible measurements in certain circumstances,without information on how they are used or how their findings areinterpreted. The useful glossary would be much more so if exampleswere included, and these need not take up much space. Similarly,the case-histories used to illustrate major categories of diagnosiswould be more helpful if accompanied by a very short discussion ofthe cases and their treatment.Much has been sacrificed because of the need for brevity, but

sometimes at the expense of clarity. One example is the descriptionof indications for ECT, which leaves me with the impression thatECT is the treatment of choice in all the cases of depressive illnessand not, as I believe the author intended, only under thoseconditions which preclude less invasive forms of treatment. I thinkthat the deliberate omission of "explanatory detail" limits theappeal of the book. Explanatory detail is necessary to most traineesstarting off in psychiatry unless they have had a rigorous training asundergraduates, and certainly such detail is essential for the latter.However, this book may be useful for those just about to takepostgraduate examinations.

Department of Psychiatry,St James’s University Hospital,Leeds - SUSAN SHAW

Health and Wealth

An International Study of Health-care Spending. Robert J. Maxwell.Lexington, Massachusetts: Lexington Books (D. C. Heath & Co.). 1981.Pp. 179. 14.95.

FOR more than a decade, rising health costs in most developedcountries have stimulated research into health care expenditure.Much of this research has been inward looking, with little attentiongiven to experience of other countries. In large part this has beendue to the enormous difficulty in making comparisons acrosscountries in the absence of an up-to-date agreed standard format forthe relevant financial data. Robert Maxwell has not only succeededin providing readers with reliable information on health careexpenditure for ten developed countries, but will also undoubtedlysucceed in providing a major stimulus to researchers in this field toexamine more closely the provision of health care in countries otherthan their own.The greater part of the book is taken up by the presentation of

health care expenditure figures for the ten countries in Europe(including the U.K.) and North America. Particularly valuable isthe four-part breakdown of total health care expenditure. Thisapproach not only provides a valuable check on the accuracy of thefigures, but also presents the reader with a view of health careexpenditures from four quite distinct perspectives. Thus, after ahelpful chapter on methods, sources, and definitions, and anexcellent general background chapter on total health care

expenditure, Maxwell proceeds to break down expenditure in theten countries in four different ways-the sources of finance; thecontrol and administration of health care institutions and agencies;the resources purchased for use in health care; and what healthservices are provided. The availability and comparability of the datavary considerably in these four approaches and Maxwell is careful toexplain both in the text and the tables the limitations of the datapresented. He goes further than the mere presentation of

information, however, and he proceeds to analyse the data and drawconclusions. Possibly because there is inadequate space in thisvolume to present the detailed expenditure information as well as todraw conclusions likewise based on detailed argument, this aspect ofthe book is not entirely successful. The analysis of the expendituredata by itself is sometimes not adequate to support the conclusionsdrawn by Maxwell. In particular, his apparent preference forsystems with public financing but not government ownership andcontrol requires far greater justification than he provides. On the

other hand, there can be no disputing his data and conclusions asregards the administrative costs of insurance. He concludes that:"insurance modes of financing, whatever their merits, do addsubstantially to administrative costs." This book should be read byanyone with an interest in health care expenditure and health caresystems-including those in the British Government who

contemplate altering the existing form of NHS finance. They willfind little justification for moving to an insurance scheme.

University Department ofCommunity Medicine,

Usher Institute,Edinburgh S. R. ENGLEMAN

The Family Doctor

His Life and History. Ronald Gibson. London: Allen & Unwin. 1981. Pp.214..E9.50,

THIS is the story of one distinguished doctor’s forty years or morein general practice. It is more than that, for it also gives a fresh lookat the development of the National Health Service from one whotook part in much of the political and medicopolitical infightingsince 1948. Politicians are regarded warily. Aneuran Bevan isdescribed by the author as being undoubtedly the greatest Ministerof Health, yet his preference for the less forceful Kenneth Robinsonis very obvious.

Quite a lot of the appeal of this interesting and well-written booklies in simple nostalgia for the leisurely, if not richer, days of DrFinlay and James Herriott: "When I went into practice in the 1930s,complete with wife and one child, I had an income of about 600 ayear. This enabled us, with intermittent and sometimes involuntarydonations from both our families, to retain a cook, two maids, anursemaid and a gardener once a week". We are taken into a worldwhere young Dr Gibson, as he then was, was expected to have aclean car and a "natty" suit and, with his wife, play a prominent partin church and local society, and where an appearance at the Mayor’sBall was absolutely essential. Many younger doctors, particularlythose practising in our inner cities, will not be in a position to arguewith the statement that "the duke and dustman look much the samewithout their clothes on". Nor, on their calls are they likely to be"admitted by a butler to ... a sweeping staircase, vast bedrooms andnurses in attendance night and day". These differences, however,will not come between the reader and the warm humanity thatpermeates the pages of this interesting and entertaining book. Fromamidst the anecdotes, what comes across most strongly, particularlyin the parts not dealing with politics, is a picture of a caring,

’ conscientious, efficient and, above all, enormously hardworkinggeneral practitioner.143 Cranley Gardens,London N10 SAG GEORGE MORRIS

New hdiUons

The Penguin Gurde to Supplementary Benefas.-4th ed. By Tony Lunes.London: Penguin Books. 1981. Pp. 319. 2.50.

The Year Book of Diagnostic RadIOlogy 1981.-Edited by Walter M.Whitehouse. London: Y. B. Medical Pubhshers. 1981. Pp. 480..t.30.50.Atlas o/OMAoaM &<rry.&mdash;2nd ed. By Louise A. Goldstem & Robert C.

Dickerson. London: Y. B. Medical Pubs. 1981. Pp. 654. 75.The Lung & its Disorders 111 the Newborn Infant.-4th ed. By Mary Ellen

Avery, Barry D. Fletcher, and Roberta G. Williams. Philadelphia andEastbourne: W. B. Saunders. 1981. Pp. 367. 26.

The Gynecology of Childhood & Adolescence.-2nd ed. By John W. Huffman.C. John Dewhurst, Vincent J. Caprano. Eastbourne: W. B. Saunders. 1981.Pp 588. L40.

The Neonate with Congenital Heart Disease.-2nd ed. By Richard D. Rowe.Robert M. Freedom, and Ali Mehnzi Philadelphia and Eastbourne: W. BSaunders. 1981. Pp. 716. 25.25.

Esserrtzals of the Neurologic Exammation.-2nd ed. By Elliott L. Mancall.Philadelphia: F. A. Davis. 1981. Pp. 228.$13.75.Medical Parasitology.-Sth ed. By Edward K. Markell and Marietta Voge

Philadelphia and Eastbourne: W. B. Saunders. 1981. Pp. 374. 15.

Microbiology for Dental Students. -3rd ed. By T. H. Melville and C. RussellLondon. Wm. Heinemann, 1981. Pp. 394. D2.50.