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Reviews of Books

Biopsy Pathology of the Small Intestine

Biopsy Pathology Series. F. D. LEE and P. G. TONER, GlasgowRoyal Infirmary. London: Chapman and Hall. 1980. Pp. 188.

12.THIS superbly illustrated volume on histological and elec-

tron microscope studies of the small intestine and duodenumwhich contains excellent photomicrographs is also informative,and its recommendation of morphometric assessment of biopsyspecimens is generally accepted for academic studies. Thereare, however, a few deficiencies. The evidence that collagenoussprue represents another potentially refractory form of coeliacdisease is not convincing. Moreover, the brief reference to thegluten challenge test gives no histological detail, and there isno mention of the valuable technique of brush cytology formalignant tumours of the duodenum. The Cronkhite-Canadasyndrome is not discussed although interpretation of duodenaland jejunal histological appearances in such a case presentdiagnostic difficulties. Inflammatory erosions distinct from fociof superficial erosions or epithelial defects are not describedamong the histological features of duodenitis, although care-fully documented studies in the literature illustrate their occur-rence. Unfortunately, and probably because of the time factorin publication, new and important observations on lymphocytecounts in intestinal epithelium in relation to unit length ofmuscularis mucosa, recent morphometric studies, and raisedIgE cell counts as a feature of food allergy are not included.Also, photomicrographs 4-22 and 4-23 are confused. Exceptfor these points, this is a book that will be enjoyed by both gas-troenterologists and pathologists.

Department of Pathology,General Hospital, Birmingham HENRY THOMPSON

Heart Disease

A Textbook of Cardiovascular Medicine. Edited by EUGENEBRAUNWALD, Harvard Medical School. Philadelphia and London:BRAUNWALD, Harvard Medicai School. Phitadelphia and London:W. B. Saunders. 1980. Pp. 1943. ;[40.00.

THIS splendid successor to Friedberg’s classic textbook com-bines the standard virtues with quite unusual readability. Nodoubt this owes something to the fact that twenty-two of theforty-four contributors come from one institution (Harvard),and to Braunwald’s extensive personal involvement through-out all four parts. These, comprising fifty-five chapters, arewritten with a strong clinical bias but with more than ade-quate coverage of the scientific basis to satisfy all except thosewith the most highly specialised interests. For them, the com-mendably up-to-date bibliography provides rapid entry to therelevant literature, with only a hint of under-representation ofnon-American sources here and there. Authoritative and suffi-

ciently comprehensive this work most certainly is, and its placeas a standard source of reference is assured. The index runs to106 pages. The lucid expositions of examination techniquesand findings in part I, such as that on coronary arteriographyby G. G. Gensini, will prove invaluable to the cardiologist intraining. Part n, which deals with abnormalities of circulatoryfunction, is perhaps the least cohesive, but the managementadvice therein, and that in parts III and iv (which deal withspecific cardiovascular diseases and their relationship withother diseases and disorders), is definitive in the light of pres-ent knowledge. Maybe subsequent editions will offer clear

guidance on the need for infective endocarditis prophylaxis inthose with only soft, apical, late systolic murmurs and on whatconstitutes severe (surgical) aortic stenosis in the symptomlesspatient. A nice balance is maintained between established factor practice--digitalis is good treatment for heart failure (theevidence for useful inotropy is paraded)-and a forward look,e.g., at appropriate surgical solutions to the problem of end-stage heart failure (the artificial heart). R. W. Wissler’s admir-ably concise description of atherogenesis is followed by the

chapter by R. I. Levy and M. Feinleib which contains a suc-cinct account of plasma-lipid typing and its problems, someoptimism about the reversibility of atherosclerosis, and unequi-vocal dietary advice. Congenital heart disease is dealt with asit is seen in adults as well as in childhood, and the essential in-formation for genetic counselling is clearly presented. Thereare remarkably few obvious errors and omissions, dubiousstatements, and descriptions of practices which differ acrossthe Atlantic. The list of indications for coronary arteriographymay seem too wide to European readers. Important mechanismsof cardiac uraemia and hyponatraemia seem to be ignored andmicroscopic haematuria is undervalued in the diagnosis of in-fective endocarditis. Ambulation on the fifth day after myocar-dial infarction seems inconsistent with the healing timetable ofthe lesion. Where thumps are concerned, the praecordium maybe a better target than the sternum. Multiple echoes can beobtained from anterior mitral leaflets free of calcium; theLVIDs may be the most valuable measurement in aortic reflux;and hyperventilation should surely be listed amongst the dif-ferential diagnoses of chest pain. Not all the figures and photo-graphic reproductions are of the highest quality. None is incolour. But the quality of the paper makes the book a joy tohandle. Its weight poses problems for the reader but may pro-vide an effective alternative to chaining it to the library wall.

Regional Cardiac Unit,Papworth Hospital, Cambridge. D. W. EVANS

The Practice of CardiologyEdited by R. A. JOHNSON, E. HABER, and W. G. AUSTEN,Massachusetts General Hospital, Boston. Boston: Little. Brown.London: Quest. 1980. Pp. 1179.$72.50; 42.05.

MODERN textbooks tend to come in two sizes-the large referencetome, which is almost impossible to carry, or the student’s

handbook, designed to fit into a pocket. The Practice of Cardiology isa refreshing change. It fits into the briefcase, yet contains all theinformation essential for the practice of modern cardiology. Writtenby a team from the Massachusetts General Hospital it consists of acollection of essays that cover all the practical aspects of diagnosisand management. The book has been written for clinicians and iswell organised for that purpose. The second refreshing aspect of thisbook is that it is well written, and the authors are not afraid toidentify themselves and their opinions. The personal pronoun isused frequently as is the present tense. All this makes for easierreading and clarity. The chapters on arrhythmias, pacemakers,different sorts of valve replacements, and the value of variousdiagnostic techniques are very good. Common dilemmas of moderncardiology, such as when to operate, are discussed lucidly. Thepictures and diagrams are excellent, and nearly all the chapters havea good reference list. I have only a few minor criticisms. The phrase"cardiomyopathic syndrome resulting from coronary arterydisease" (abreviated to CM-CAD in the text) is used widely. Surely,if the word cardiomyopathy is to have any meaning it must bereserved for heart muscle disease of an unknown origin. Coronaryartery disease can obviously cause heart failure if sufficient

myocardium is destroyed, but it is confusing to call this myocardialdestruction a cardiomyopathy. Similarly, I find it difficult to

understand why the Goodwin and Oakley classification for

cardiomyopathies (hypertrophic, congestive, and restrictive) is notused more frequently. The terms used in this book are confusing:hypertrophic non-dilated, dilated, and non-hypertrophic non-

dilated cardiomyopathies describe the same diseases. The subject isclouded further when hypertrophic non-dilated cardiomyopathy isreferred to as idiopathic hypertrophic subaortic stenosis in the text(it has been admitted at last by an American publication thathypertrophic cardiomyopathy is the best term for this condition).Congenital heart disease is dealt with in two sections: those

frequently encountered in infants and young children, and thosewhich may present in adolescents. However, there is no mention ofsequential chamber localisation for the analysis of complexmalformations in the neonates. An attempt is made to broaden the

scope of the book by including good reviews of rheumatic fever,endomyocardial fibrosis, and Chaga’s disease. Naturally the range

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of drugs referred to is less than a European might be used to. Thenewer calcium antagonist drugs are mentioned in the text, butclearly they are not yet used as widely in North America as they arein Europe. In summary this excellent textbook has much torecommend it over the larger volumes available and it is probably ,ideal for registrars training in cardiology or for the general physicianwho is inquisitive about modern cardiology.Cardiac Department,John Radcliffe Hospital, Oxford JOHN SANDERSON

Topical Reviews in Radiotherapy and OncologyVol. 1. Edited by T. J. DEELEY, Velindre Hospital, Cardiff. Bris-tol : John Wright 1980. Pp. 274. 13.50.

THE wide range of subjects in this volume reflect perhaps asmuch Dr Deeley’s interests as much as their current impor-tance. Some topics are of immediate research interest, such asthe chapter on hypoxic cell sensitisers, whilst others, such asthat on carcinoma of the oesophagus, are excellent surveys ofthe literature. However, the quality of the contributions is veryvariable and this detracts from the general value of the book.The most successful chapters are those in which very specifictopics have been considered. The late G. A. Edelstyn has pre-sented a very comprehensive summary of the current situationon the diagnosis and management of breast cancer but has in-troduced an alternative method of staging which seems to beunnecessarily confusing when we already have the U.I.C.C.and various American nomenclatures. Also, no mention ismade of the technique of conservational surgery combinedwith implantation of radioactive sources which is excitingmuch interest internationally. Although his discussion of thesurgical aspects of carcinoma of the oeophagus is skimpy, M.Pearson gives a good survey of the topic by his account ofits epidemiology, prognostic factors, and diagnosis and ther-apy. W. M. Sutherland provides an interesting and somewhatalarming account of the errors that may occur in radiotherapytreatments; these are largely due to the human element and itis not surprising that the introduction of calculators intro-duced new errors. Other chapters are less successful and onoccasion of little value; subsequent volumes may benefit frommore consistency regarding format and content. Despite thedeficiencies mentioned, there is much of interest in this book.

Department of Clinical Oncologyand Radiotherapeutics,

Addenbrooke’s Hospital, Cambridge N. M. BLEEHEN

Health Care and EpidemiologyEdited by W. W. HOLLAND, St Thomas’s Hospital MedicalSchool, London, and LucIEN KARHAUSEN, Commission of theEuropean Communities, Brussels. Boston: G. K. Hall. TunbridgeWells: Pitman Medical. 1980. Pp. 268.$20; 13.

THE urgent need to apply epidemiological techniques in

planning health-care services in the United Kingdom and else-where in Western Europe makes a book with an emphasis onthe development and evaluation of health care most desirable.The title, impressive list of contributors, eminent editors, andsponsorship by the Commission of the European Communitiesall suggest that this is a pivotal book in this important field.The articles make up a coherent whole written in an attractive

style, with no hint whatever that some contributors are notwriting in their native languages, although the tendency torepetition inherent in this type of production has not been eli-minated. Each chapter contains a helpful summary and anextensive list of references and further reading, whilst some ofthe later chapters, describing particular disease registers, pro-vide fascinating information in a most useful, concentratedform. The emphasis upon population screening may be under-standable but is unnecessarily intrusive. There is welcomestress on the need to apply epidemiological findings in thedetermination of strategies for health-care services, but the

book places greater emphasis upon the difficulties than upontheir solution. The specialist reader may find it too great aneffort to search for valuable information among much that is

familiar, whilst the health-service planner will conclude thatthe book is too remote from day-to-day problems to be of prac-tical value. There are insufficient volumes on basic epidemiolo-gical techniques for either the general reader or the post-graduate student to dismiss this one, but both would be welladvised to examine it carefully to ensure that it meets their needs.

Croydon Area Health Authority,Park Lane, Croydon J. STUART HORNER

Principles and Practice of Sex TherapyEdited by SANDRA R. LEIBLUM, Rutgers Medical School, andLAWRENCE A. PERVIN, Rutgers University. London: TavistockPublications. 1980. Pp. 408. [16.

Harold Lief of Philadelphia, who did much to establish thespecialty of sexual medicine, considers the expert or specialistin sex therapy to be a psychotherapist who is able to use a var-iety of therapeutic approaches and to choose from amongstthese methods of intervention that fit the circumstances in a

given clinical situation. This excellent and well constructedbook takes stock of the many approaches used-behaviouraltherapy of different sorts (such as sensate focus and systematicdesensitisation) cognitive therapy, the use of imagery, para-doxical intervention, group methods, conjoint marital therapy,social skills training, and, to a lesser degree, conventional psy-chodynamic psychotherapy. Factors leading to the varyingdegree of successes are discussed, and causes of the lack of suc-cess are critically examined. The development of the art of sextherapy is described in the introductory chapter which givescredit to the major contributors to this field and deals with theenormous progress made in the post-Masters and Johnsondecade. Each chapter in the other four sections starts with anintroductory commentary, presumably by the editors. Sex-drive problems are dealt with by Leslie LoPiccolo in a mostrevealing and thoughtful manner. The section dealing withfemale sexual disorders includes group therapy of anorgasmicwoman. In the chapter on vaginismus the vaginal dilator isattributed to Hegar, although it is usually the cervical dilatorswhich are attributed to him. In the section on male sexualdisorders the nuances and complexities of erectile dysfunctionare particularly well discussed. The final section, on sexualproblems of particular populations, includes sexual counsellingand coronary heart disease, which should be read by all phys-icians and general practitioners dealing with this very commonproblem; the approach advocated could prevent much unhap-piness. The book ends with "a statement of the Art", its

achievements, areas that need critical review, and where devel-opments are needed. It is strongly recommended for all whohave an interest in this sex therapy, especially general prac-titioners and gynaecologists, who will get an idea of what psy-chologists and psychotherapists have to offer patients withsexual problems.

Department of Obstetrics and Gynaecology,University of Manchester MAX ELSTEIN

Medicine Out of Control

The Anatomy of a Malignant Technology. RICHARD TAYLOR,Melbourne: Sun Books. 1980. Pp. 278. /;4.95.

Richard Taylor is a self-confessed member of the dissidentminority which calls for a proper appraisal of new methods ofinvestigation and treatment before they are introduced widely.In a well-researched synthesis of current medical knowledgeand application of care he attacks the Western medical estab-lishment on a wide front; a difficult task which he accom-plishes with overall success. The message is intended for thelay reader as well as for health workers. He admits that therehave been truly spectacular advances in the treatment of some

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diseases but claims that the effect of modern medical practiceon mortality and disability from the commonly occurring dis-eases of man has been greatly oversold. A wide range of dis-eases, from tuberculosis and rheumatic fever to respiratorysyncytial virus infections, are closely related to adverse socialand environmental factors, and planners in developing coun-tries should aim for adequate nutrition, proper housing, sani-tary engineering, and ecological manipulation, and should notbe carried away by the razzamatazz of Western medicine. Thesaga of iatrogenesis makes sad reading-pink disease (mercurypoisoning), smallpox (variolation), subacute myelo-optic neur-opathy (’clioquinol’), vacuolar encephalopathy (hexachloro-phane), asthma deaths (high-dose isoprenaline sprays), retro-lental fibroplasia (oxygen)-are but a few of the tragediessome of which could with care have been avoided. Thalido-mide, practolol, and high-dose isoprenaline sprays were neversanctioned by the United States Food and Drug Administra-tion. Deaths from complex diagnostic procedures are said to beon the increase, and the low incidence which is reported fromspecial units may not be achieved elsewhere (e.g., coronaryangiography). The theme develops. There is no point in in-creasing the use of resources and, therefore, costs, if this doesnot lead to increasing benefit to the patient. CAT scanning(which has led to "cat fever") is good, but how good we do notknow yet. Taylor attacks and provides figures for unnecessarysurgery ("acute remunerative surgery"); he complains aboutsuperspecialisation, which leads to the multidisciplinaryapproach, which has the disadvantage that no one physicianthen assumes responsibility for the patient. Pregnancy andchildbirth have become diseases, and obstetricians can turn anormal childbirth into a technological nightmare by interfer-ence. "People" have become "patients" and are screened fordisease, a costly exercise, not without risk, and, with rareexceptions, of unproven value. Many new methods of diagnosisand treatment are introduced prematurely without full evalua-tion, but, paradoxically, the onus of proof has been shifted tothose who doubt. Taylor claims that social, economic and en-vironmental factors are of primary, not secondary, importancein the cause of most disease which affects us today. Significantimprovement in health care is unlikely to occur through con-tinued enlargement of diagnostic and therapeutic services. Heattacks vested medical interests and blames the fee-for-servicefor much of medicine’s ills; all told the picture Taylor paintsis an appalling indictment of the medical scene. Perhaps so-ciety has given doctors too much power which they use lesscritically than they should, and there may be much wrong withmedicine, yet it has its good side which is given only passingreference. The book makes valid criticism of the shortcomingsof modern medical practice, but does less justice to the manydoctors who try to help individual patients, often unselfishly,without fee-for-service considerations. Sometimes no cleartreatment has yet been established, nor is cost-effectivity theonly yardstick for a caring profession.General Practitioner,Stockton-on-Tees, Cleveland AUBREY COLLING

Somatic Selection and Adaptive Evolution

On the Inheritance of Acquired Characters. By E. J. STEELE,London: Croom Helm. 1979. Pp. 91. /;8.9S.

Dr Steele, an Australian immunologist now working in Tor-onto, has an original and intriguing hypothesis. Like manybiologists he senses strongly that the neo-darwinian hypothesisof evolution by natural selection acting on random genetic vari-ation is an inadequate explanation for the speed at which evolu-tionary change can occur. Dr Steele feels that there must besome lamarckian modification of the germ-cell line in re-

sponse to environmental experience. As an immunologist he isfamiliar with the difficulties of explaining how an individualanimal is capable of producing specific antibodies to such anenormous variety of antigens. He outlines the current view

that this depends on a high rate of somatic mutation in B lym-phocytes, with rapid cloning of whichever cells succeed in pro-ducing the specific antibody in response to the antigenic stimu-lus. He cites one study in rabbits which indicated that suchsomatic mutation after antigenic stimulus could be transmittedby both sexes (though not in simple mendelian fashion), indi-cating that the mutation in a B cell had been incorporatedsomehow into the germ-cell line. He suggests that the vectorcould be endogenous RNA virus. He extends the idea to othertissues, suggesting that a somatic mutation (for example, onepermitting detoxification of a noxious chemical in the liver)could spread to adjoining cells. He speculates that there mightbe some such mechanism in the brain, and notes the implica-tions this would have for the evolution of behaviour in Homo

sapiens. The book is fun to read, and the reader unfamiliarwith modern developments in immunology will learn muchabout them quite painlessly. The central idea, however, seemsat present to rest on flimsy evidence. The author sees clearlythat experiments need to be repeated extensively, the criticalexperiment being to breed from animals before and after theyhave been exposed to a specific antigenic stimulus. I suspect DrSteele is "up a gum-tree", but I enjoyed reading his book andwill await with interest the outcome of further experiments onthe genetic transmission of somatic mutation for variable sitesin immunoglobulin chains.

M.R.C. Clinical Genetics Unit,Institute of Child Health, London C. O. CARTER

Willis’s Oxford Lectures

KENNETH DEWHURST, Linacre College, Oxford. Oxford: SandfordPublications. 1980. Pp. 182. [9.00.

Thomas Willis (1621-1675) was born in Great Bedwyn,Wiltshire but grew up, was educated, and spent most of his lifein Oxford. As soon as he became a bachelor of medicine in1646 he started to practise and also developed research inter-ests, which profited by his association with William Petty(1623-1703), Robert Hooke (1635-1703), Richard Lower

(1631-1691), and the Hon. Robert Boyle (1627-1691). Theycarried out experiments and dissections, became interested inbiochemistry, and catalogued books on natural philosophy.Willis described the use of Peruvian bark or quinine in thetreatment of quartan fevers. His "spirits of piss" was made bydistilling dung mixed with urine from a "sound man thatdrinks wine". Despite such grotesque concoctions, or perhapsbecause he maintained strict secrecy concerning these for-

mulas, his practice flourished. The Archbishop of Canterburywas so impressed with his ability that he invited him to prac-tise in London, which he did from 1667 until his death. LikeWilliam Harvey, he was able to combine harmoniously a largeand even Royal clinical practice with the tireless energy of askilful research worker. This highly entertaining book recap-tures the life and times of an Oxford Restoration medical

genius and records for us the 34 Latin lectures he delivered onsuch topics as sleep, wakefulness, colic, arthritis, sleepwalkers,lethargy, nightmares, coma, vertigo, paralysis, melancholia,mania, stupidity, and, of course, the cerebrum. His concept ofa cerebral circulation allowed him to speculate on a chemicalimbalance in different parts of the brain and to attemptexplanations of various psychiatric disorders. He would cer-tainly have enjoyed today’s speculations on chemical neuro-transmitters. The author undertook the painstaking basicresearch for this labour of love as a senior Wellcome researchfellow, and the Wellcome Trustees are to be commended fortheir support of a worthwhile project, admirably brought tofruition as a Wellcome Centenary commemorative publication.Henry Wellcome would have been very proud of the endeav-our. This edition is limited to 750 copies.

Department of Medicine,Royal Northern Hospital,London D. GERAINT JAMES