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Reviews of Books

The Leukaemic Cell

Edited by D. Catovsky, Royal Postgraduate Medical School, London.Edinburgh: Churchill Livingstone. 1981. Pp. 281. all 9.

THE cell characterisation of leukaemias is an area where theintensive study of small numbers of patients by experienced investi-gators has been very rewarding. Although most of the methodsdescribed in this work are not yet widely applied in day-to-daydiagnostic haematology, several have been of key importance inincreasing our understanding of the leukaemias. For this reason thebook will interest many more than those intending to set up thetechniques. Dr Catovsky’s introductory "overview" is also a

summary of the salient findings which have emerged from the tech-nology described by his team of authors, all of whom give details ofmethods and the findings that can be expected by the use of thesemethods.

Cytochemical techniques, which are "bread and butter" to

haematologists, are described succinctly, with some good colourillustrations. Assay of terminal transferase, also of immediate

practical value, is given its own chapter. (Other biochemicalmarkers, some mentioned briefly by the editor, will no doubt findtheir way into the repertory in due course.) Haematologists areincreasingly turning to trephine biopsies for information, but thecontribution on marrow histology from Rolf Burkhardt, whosefindings are based on myelotomy (drill biopsy) rather than Jamshidineedle biopsy, may raise a few eyebrows. The larger biopsy canevidently be useful in a variety of situations. Electron microscopymay seem a remote science to those who have no personalexperience of it, but the combination of ultrastructural,cytochemical, and immunological methods has provided crucialinformation unobtainable by other techniques, and the presentationby Breton-Gorius and colleagues is clear and well illustrated. It is,however, the study of membrane markers, for which GeorgeJanossy is a natural exponent, which arouses most interest andchallenge. The reader is led by the hand through the theory and thepractice of standard techniques and introduced to new ones whichare not likely to be followed in any other than highly specialisedlaboratories. This is a particularly.valuable contribution. DonaldMetcalfe’s description of semisolid culture techniques is a usefuldistillate. Chromosomal studies which, as yet, offer limited

practical assistance but which seem poised for a step forward, andglucocorticoid receptors-still something of an unknown

quantity-are the subject matter of the two other chapters. Cellkinetics do not find a place except in passing in the introduction butthe choice of topics may be regarded as being representative of theimportant growth areas. It will pay the reader who has gone throughthe book to return to the editor’s overview, which is

characteristically enthusiastic, well referenced, and personalised.Department of Haematology,General Infirmary, Leeds J. A. CHILD

Advances in Perinatal Medicine

Vol. 1. Aubrey Milunsky and E. A. Friedman, Harvard Medical School,and Louis Gluck, University of California, San Diego. New York andLondon: Plenum Press. 1981. Pp. 438.$35.

THIS new series is meant to "serve as a catalyst and critical forumforthe needs of all those interested in optimal pregnancy outcome".Its first volume is a collection of eight articles each written by one ortwo contributors, most of whom are from the United States. Theeditors point out that, since previous technical innovations inperinatal care have led to problems such as retrolental fibroplasiaand bronchopulmonary dysplasia, there is a need to assess new

:echniques carefully, and to justify scientifically changes in clinicalPractice. I am sure all would agree with these sentiments.The first chapter is therefore disappointing in that it gives a

raited account of the physiology and treatment of apnoea, with theheater part of the treatment described being for the term infant andder child. Most of the rest of the volume is more relevant and, in

particular, chapters on intrauterine growth retardation, and oncomplications and management of breech presentation, are

balanced accounts and good reviews of the literature. It is refreshingto see some old obstetric guidelines being re-stated, such as the needto take as much, if not more, care with a breech presentation inmultiparas, compared with primiparas. It is also refreshing toread that not all breech presentations in the United States wouldnecessarily be delivered by caesarean section, but that the case forsuch delivery of the pre-term breech is strong.Chapters on perinatal damage to the developing brain and on

ultrasound in pregnancy are a good reflection of current thinking. Itis surprising, however, to see that although the aetiology and earlydiagnosis of intraventricular haemorrhage are stressed, the

advantages of ultrasound over CT scanning for making this

diagnosis are not mentioned. The book ends with two chapters forthe future. The first of these, an attempt to describe the effects ofuterine contractions on the fetal cranium, discusses how techniquesof engineering structural analysis are used to investigate the bio-mechanics of fetal head moulding; while the second describes aclinical study of the effect of uterine pressure on the fetal cranium.Both are complicated chapters which make one think, at times, thatone is reading an engineering textbook, but they draw some fairlysimple conclusions, such as "pre-term skull bones behave differentlyfrom the skull bones of more mature infants", and "the forces on theskull of a foetus presenting by breech are considerable". Presum-ably as the engineering model becomes more precise and furtherinformation is acquired, the conclusions drawn will become moresubstantial.The book is well produced and has an excellent bibliography and

good illustrations. It is a useful source of reference for the specialistworking in perinatal medicine, be they obstetricians or paedia-tricians. However, it is not sufficiently coherent or comprehensiveto attract the majority of these specialists. One is left wondering,firstly, whether the editors planned the book and then chose thecontributors, or vice versa, and secondly, what sort of a mixture oftopics the second volume will contain.

Institute of Obstetrics and Gynaecology,Hammersmith Hospital, London M. G. ELDER

Maternal and Fetal Medicine

New Techniques and Concepts in Maternal and Fetal Medicine. Edited byHarold A. Kaminetzky and Leslie Iffy. London and Toronto: VanNostrand Reinhold. 1980. Pp. 390. ;E22.15.

THE twenty-nine papers related to pregnancy and perinatalmedicine are based on presentations made at the yearly IgnatzSemmelweis seminars, established in 1975. The topics rangewidely, from physician education, and health care planning andcosting, through sociological studies of teenage pregnancy, andinduced abortion in Hungary, to more technical subjects such as theanatomy and physiology of the uteroplacental circulation and theassessment of fetal lung maturity. Gynaecologically oriented topicsinclude four studies of aspects of ectopic pregnancy, while

neonatology is represented by papers on resuscitation of the new-born and group B streptococcal infection. Particularly stimulatingare those papers which deal with controversial areas such asantenatal diagnosis; the clinical value of intrapartum and antenatalfetal heart rate monitoring, and aggressive neonatal management;caesarean section; and the management of premature labour andruptured membranes. I especially enjoyed a lucid evaluation of themanagement of hypertension in pregnancy, which emphasises therelatively low risk of non-proteinuric pregnancy-associated hyper-tension and concludes that the only effective treatment of

fulminating proteinuric pre-eclampsia is delivery, with hydrallazineand an anticonvulsant as stopgap measures. All the papers are

extremely well constructed and written in a fluent and readablestyle, which seems to be due to rewriting by Mrs Margot Stickley,who is given the credit for improving the manuscripts. Theconsistency of style greatly eases the task of jumping from one topicto a very dissimilar one.Each paper has an extensive list of important references, so that

the whole volume acts as a useful starting point for further reading.

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The book is well produced and well presented, with a clear typeface,and refreshingly free from serious misprints. Altogether an

enjoyable and worthwhile publication which should find a place inevery library and would also be a worthwhile personal buy forperinatologists.Department of Obstetrics and Gynaecology,St Mary’s Hospital, London PHILIP STEER

Lasers in Medicine

Vol. I. Edited by Hans K. Koebner, Laser and Electro-Optik, Munich.Chichester and New York: John Wiley. 1981. Pp. 274. ,E39.50.

IT is a pleasure to read this well illustrated book on the wideapplications of lasers in medicine. ENT surgery is one of the fewspecialties in which the benefits of the COz laser have beenestablished and are generally accepted. B. E. Hoeksema andG. G. M. van Overbeek are very cautious but are nevertheless able toconvince the reader that the COz laser allows procedures to be donethat would otherwise be very difficult. The Russian authors seem tohave vast experience with the use of different laser systems. Thetreatment of skin malignancies by local destruction is controversialsince it is only during follow-up that one can tell whether or not theprocedure was radical. The endoscopic use of lasers to coagulateupper gastrointestinal haemorrhages is widely accepted and needsno further comment.The contributors on the use of the C02 laser in thoracic, general,

and plastic surgery have obviously been so carried away by theirenthusiasm for this new instrument that they forget to be critical.Accidents, near accidents, or morbidity caused by the COz laser arenot mentioned. The claim that the use of the COz laser woulddecrease the peroperative spread of tumour cells has not beensubstantiated by sound data in this book or anywhere else. Theauthors also forget to mention that precision surgery is difficult withthis "no touch" instrument. The use of the COz laser for many ofthe procedures discussed is certainly controversial and probablyunnecessary. For instance, I would not advise anybody to try it forhand surgery, a face-lift, or a neck dissection.The contribution on laser acupuncture is not backed by scientific

data verifying the value of this work. The use of the neodymium-YAG laser in the bladder, as described by A. Hofstetter, lookspromising and opens new avenues for the treatment of small bladdertumours. The lack of controls makes E. Mester’s conclusions aboutthe beneficial effect of the laser on wound healing debatable. Thereport on neurosurgery with the COz laser is clear but the work isstill in a very preliminary stage. T. Oshiro gets astonishing resultswhen treating chromatic macules with the ruby laser; however, heshould stress the strict patient selection and in depth knowledge ofphotodermatology required to obtain these results.Every medical investigator using lasers should have access to this

book, as an update of knowledge in the field. Novices in the use oflasers should read it very cautiously and critically and shouldcertainly not embark on many of the procedures described withoutadequate preparation and above all good indications for the use ofthe instrument.

Department of Surgery,Academisch Ziekenhuis Gronmgen,Netherlands R. C. J. VERSCHUEREN

The Experimental Foundations of Modern ImmunologyWilliam R. Clark, University of California, Los Angeles. Chichester andNew York: John Wiley. 1980. Pp. 372. 9.30,$21.80.

TEXTBOOKS nowadays come in two main kinds. There are multi-author books which sacrifice the benefits of uniform style andpresentation to those of having every section written from first handknowledge, and single author books that make the reverse sacrifice.Dr Clark’s belongs in the second category and the sacrifices he hasmade are not trivial. His own interest is evidently concentrated onstudies of immunoglobulin structure and genetics and of the majorhistocompatibility complex (MHC) and its role in the induction ofthe immune response. The chapters dealing with these topics arelong and carefully written. They are illustrated by accounts ofrelevant experimental work accompanied by the reproduction from

the published literature of much detailed data. For example, one canfind the entire nucleotide sequence coding an immunoglobulin lightchain. In general these sections of the book can be warmlyrecommended to the prospective reader though it is possible, evenhere, to cavil at occasional omissions. Thus, in an otherwise com-prehensive account of the MHC, the G locus of H-2 is still given asseparate from the S locus although both are mouse C4; and, some-what surprisingly, the whole topic of disease association with HLAhaplotypes in man is ignored, as indeed is all work on humanimmune response genes. Nevertheless, the account is very good andincludes much recent work brought together in an easily accessibleform.The remainder of the book does not maintain this high standard.

It shows too often the stigmata of deriving from secondary sourcesand declines on occasion to unacceptable levels of accuracy. Hereare a few examples. There are not lymphatic vessels wherever thereare blood vessels. The absence of afferent lymphatic drainage in,say, the anterior chamber of the eye or the hamster cheek pouch isafter all the anatomical basis of their immunologically privilegedstatus. There are, however, normally both lymphocytes and macro-phages in afferent lymph and the latter are believed to play animportant role in bringing antigen to lymph nodes. Not little but agreat deal is known about the biochemistry of the leucotriene, SRS-A, and the "platelet activating factor" of mast cells gets no mentionas a mediator of immediate hypersensitivity reaction. The "so-called" LE cell is an in-vitro phenomenon and is not normally foundin vivo either in blood or in bone marrow. The errors in the sectionon the alternative complement pathway are too numerous to list,The nadir is reached with the chapter on immunity to infection,whose nine pages do no justice to one of the most important aspectsof immunology. It is simply not true that immunisation againstdiseases caused by bacteria (the exotoxin producers apart) and fungihas been more successful than immunisation against viral diseaseand that the T cell response to influenza virus does not crossreactbetween different influenza A viruses. The discussion of interferonomits its action in activating NK cells. Immunity to protozoa andhelminths gets no mention at all.As a current account of the molecular biology of the "afferent

limb" of the immune response this book has considerable merit, as acomprehensive treatise on immunology it does not. It is a pity thatClark did not restrict the text to those parts of the field where he canwrite with authority. If it were not for Ivan Roitt’s excellentEssential Immunology I might reasonably conclude that it is no

longer possible to write adequately about the whole of immunology.Certainly this book shows how difficult the task has become.

Mechanisms in Tumour Immunity Unit,Medical Research Council Centre, Cambridge P. J. LACHMANB

Neural Blockade

Clinical Anesthesia and Management of Pain. Edited by M. J. Cousins.Flinders Medical Centre, Adelaide, and P. 0. Bridenbaugh, University ofCincinnati Medical Center, Ohio. Philadelphia: Lippincott. London.Harper and Row. 1980. Pp. 749. 62.

ALTHOUGH this book was edited in Australia and the UnitedStates of America (surely a publisher’s nightmare), the editors havesucceeded magnificently, and this book is the most important toarrive on the nerve-blocking scene since the launch of the influentialSeattle books nearly thirty years ago by John Bonica and DanMoore. Perhaps it is a sign of the times that there are 39 contributorsbesides the contributing editors. The first part deals with basicpharmacology and physiology, the second with techniques, and thelast with the management of chronic pain. Throughout, there is agood balance of theory and practice. Undoubtedly, the outstandingfeature of this book is the high standard of the illustrations whichstand out clearly on the glossy paper used. This kind of quality mustbe paid for and the editors and publishers are to be congratulated fordaring to produce a sumptuous book in these austere times. Mostestablished anaesthetists will wish to possess a copy of this book

despite its high price.

Pain Rehef Clime,Frimley Park Hospital, Surrey JOHN HANN1NGTO.KIFf