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BOOK REVIEW fever, vasculitis of the polyarteritis or malignant hyperten- sion type. Does race, age, or sex alter prognosis? One . - cannot learn the answer from this book.

One also gets little hint of common concerns in the management of the 10-20-year disease-duration chronic lu- pus patient: cataracts, atherosclerosis with ischemic cardio-

The Clinical Management of Systemic Lupus Erythematosus. Peter H . Schur, editor. New York, Grirne & Strattoti, 1983. 290 pages . Illustrated. Indexed. $39.50.

My first response, on being asked to review this book, was "Why another book on lupus?" In this era of information overload, and of a new rheumatology text every year, what difference could there be in a new monograph? In fact there is a difference, and this book, while it has flaws, has a tone that is unique and interesting.

First, the basic facts: this is a short, multiple- authored book. I t has overview chapters at the beginning and the end, and chapters on serologic immunology and immunopathology. The rest of the chapters are organized by organ system. The final overview chapters are on manage- ment. References in most chapters are as recent as 1982 and in many chaptcrs are organized into a standard footnote-type reference and a second, general. bibliography. The index is scanty. It doss not do justice to what is actually in the.text.

The authors constitute a Who's Who of Americans working in the field of lupus. There is the expected amount of repetition, particularly concerning general or common symptoms, serologic abnormalities. and therapeutic ap- proaches: in the latter there are even contradictions (Zvaifler and Kogers handle psychosis differently; Rothfield says aspirin doesn't cause renal dysfunction, while Decker says it does [Decker is right]). As advertised, the book is very clinically oriented, with a clear "how to" and "why" approach; i t is thus helpful for the clinician.

Some chapters present, extremely lucidly, concepts at the front lines of contemporary knowledge. I would cite. for their excellence, Winchcster's review of immunogenet- ics. Reichlin's of serology, and Provost and Dorc's of dermatologic aspccts. In the latter chapter, however, the reproductions of what once must have been excellent photo- graphs arc poor. Othcr chaptcrs review, fairly and complete- ly, Contemporary knowlcdgc. ZiLic's chapter on gastrointcs- tinal manifestations does this particularly well. The basic bias of the book is immunologic; there is little attention given to mechanisms of inflammation, hormonal aspects of the disease, prostaglandin system mediation of blood flow (for instance. in discussion of renal function), and other phcnom- ena.

What is missing in this book? The epidcmiology of lupus is almost ignored, though Winchester briefly mentions race. Contemporary interest in sex hormones is not men- tioned. yery serious, though uncommon, management prob- lems are mentioncd superficially or not at all: severe system- ic hypertension, pulmonary hypertension, chronic dementia, infection in the immunocompromiscd host, evaluation of

- . myopathy and stroke, spontaneous tendon ruptures, and diverticulitis in the under-40 age group. Osteoporosis and dialysis are discussed; in discussing osteonecrosis, Stevens makes the rather surprising implication that core decompres- sion of bone is a trivial procedure of proven value. The possibility that different patient populations, rather than different treatments, may account for differences among results from one clinic to the next is not considered.

There are some editorial annoyances. There is not a uniform manner of presentation from chapter to chapter. Some chapters present tabular data as percentage occur- rences with no descriptions of the patient populations from which the data arc drawn and no references; with detective work, the reader can locate the original references. but this is an unnecessary burden. Other chapters clearly indicate the sources of the tables.

There are also some editorial delights: Reichlin pre- sents a nice Boolean logic diagram (without the diamonds, squares, and circles that frighten so many people) of serolog- ic evaluation in the collagen diseases; Koffler and Bie- secker's graph of "Mechanisms of Tissue Injury in SLE" may be the funniest chart I have ever seen in a medical text. I have already made a slide of it. and I intend to use it shamelessly.

Why is this book unique? Almost every chapter has been written in the following format: What is the problem? What data exist to solve the problem? What data do not exist and, therefore, what must we guess at? What is the author's personal opinion (clearly labeled as personal opinion)? The opinions also support my prcjudiccs: that mixed connective tissue disease is not a distinct entity (Provost and Dore), that central nervous system-lupus consists of many diseases (Zvaifler).

The format provides a forum for the authors to explain why, in 1983, not every question is answerable, and it provides the thoughtful clinician, to whom the book is prcsumably addressed, an opportunity to understand the thinking behind the reasoning and to feel more comfortable in his or her own uncertainty. Thc subtlcty of the argumcnts may be missed by medical students or clinicians who want superficial answers to simply posed questions. Although these answers can be found, those who seek only those answers will miss the value of this book.

Michael D. Lockshin. MD The Hospitul f o r Special Si irgeq N e ~ s York. N Y