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BRITISH MEDICAL JOURNAL 5 JANuARY 1980 35
Medicine and Books Br Med J: first published as 10.1136/bmj.280.6206.35 on 5 January 1980. Downloaded from
Aquestion ofnutrition
Inequality in Society Series. "Prevention of Handicap and the Farmers and their wives, by contrast, have very low mortality
Health of Women." Margaret Wynn and Arthur Wynn. rates from these diseases. The inference is that good nutrition
(Pp 247; £9 95.) Routledge and Kegan Paul. 1979. increases resistance to many diseases, including cancer, and
poor nutrition lowers resistance. Research into what members
Margaret and Arthur Wynn have travelled widely and dug of the armed Forces and their wives eat, and then changing it,
deeply into regional and national statistics from many countries would be an easy way of testing the hypothesis.
to try to find out why the perinatal mortality rate and the The book ends with the Spastics Society's resolution at a
incidence of handicapped children in the British Isles are so public meeting last year. It calls upon the Government to
high. The causes, it turns out, are manifold and the answers improve services for pregnant women and unborn babies,
much more complex than recent controversy among paedia- create first-class maternity units with special and intensive care
tricians about perinatal facilities in hospitals would suggest. facilities for the newborn in every health area, finance further
There seem to be two main problems: babies of low birth research into the cause and prevention of handicap, and start a
weight, and babies with malformations of the central nervous campaign for the health education of women. All laudable
system such as spina bifida and anencephalus which arise in the objectives but, on the evidence presented in this book, measures
first trimester of pregnancy. The latter occur so much more to improve the nation's diet would seem an immediate priority.
often in children of Irish mothers that they are thought of as a ANDREW SMITH
"curse on the Celts." Popular belief that diseased potatoes
might be responsible foundered when investigations disclosed
that white bread with fewer added vitamins than in the rest
of the UK has supplanted potatoes as the staple food of the Rights and wrongs for doctors
lower socioeconomic groups in Eire.
Emigration to the USA breaks the curse: as soon as the Decision Making in Medicine: thepractice ofits ethics. Ed Gordon
Irish take to the indigenous diet there their incidence of brain- Scorer and Antony Wing. (Pp 211; £6 50.) Arnold. 1979.
damaged infants falls to normal levels. This suggests dietary
deficiency as a likely cause. The Wynns cite epidemics of Perhaps it is the fate of all books on medical ethics that they
malformed babies during food shortages in other countries. should be disappointing. Disappointment stems fromexpectation
The first well-documented one occurred after the siege of being unfulfilled and hopes being frustrated. But it is unfair to http://www.bmj.com/
Paris in 1870. There was another in Boston duringthe depression expect too much by craving for certainty where none can be had
of the early 1930s and several in European countries occupied in the difficult task of deciding what is right and what is wrong
bythe Germans inthe last war and in German cities immediately conduct. There is need for a great deal ofthought to be given to
after it ended. The common factor in all these epidemics was this. Medical knowledge, skills, and power have so increased
shortage of food. In Oslo during the German occupation in the and will increase that the serious questions are how these tools
1940s the effects of food shortage were counteracted by vitamin shall be used, and there is even the question of whether some
supplements. Vitamins were given to 700 pregnant women of them should be used at all. The science can be taken for
who then produced exceptionally few low birthweight babies. granted; the uses of science in medicine, however, are not to be on 5 October 2022 by guest. Protected by copyright.
In Zaragossa, a rural province of Spain, poor peasant women determined within the scientific canon, but outside it in ethics.
have a lower incidence of brain-damaged children than many We have emerged from the era of jejune belief that science has
areas ofthe UK. No need ofvitamin supplements there, because the capacity to solve all our medical problems. Hence any book
their traditional diet is rich in them. In Sweden intensive showing evidence of consideration of acceptable medical
dietary education, which emphasises the importance of vitamins behaviour is welcome.
for the health of future babies, has been part of the school The book's title and subtitle are somewhat misleading. Many
curriculum since the war. This is reinforced by the district of the contributors simply describe the problems arising in all
midwives whom young women consult about contraceptive kinds of medical practice. But often there is no subsequent
advice. Sweden has the lowest perinatal mortality rate in the analysis giving reasons why the writer prefers one course of
world and a very low incidence of handicapped children, which action to another. This, of course, is extremely difficult to do
suggests cause and effect. but it would have made the book more valuable. It is about
The authors, one of whom is a statistician, analysed the decision-making, so the title says, and it is about practice, for the
mortality rates of different countries and different socio- The reader therefore expects an answer to the
economic groups in the same countries in considerable detail subtitle says so. this author think that I ought to do when
and they have come up with some surprising correlations. They question, "What does in ?" And he does not get
include the following. Populations with a high death rate from faced with ethical problems medicine ofthe rather
cancer in middle age have more malformed babies. Middle- it; even so, that may be a general criticism subject
aged women in lower socioeconomic groups in Scotland have a than of this particular book. from the Christian point of view,
very high death rate from cancer, and a very high proportion of The contributors all write is not stoutly pro-
their babies are malformed. Members of the British armed but the fact emerges only gradually and it
Forces and their wives have the highest mortality rates for claimed. It is therefore a book of Christian ethics applied to
cancer, above average rates for diseases of the digestive and medicine; that needs to be kept in mind in the reading, because
cardiovascular systems, and high death rates from all causes. it explains some of the assertions and dogma, with most of
36 BRITISH MEDICAL JOURNAL 5 JANUARY 1980
which I personally agree. But unsupported dogma is not good Durban one out of every 100 patients on the medical ward
enough for a sceptical audience who do not share similar beliefs suffers from typhoid; it accounts for 1-500 of all paediatric
and preconceived ideas which are not explicitly argued. A admissions. Shouldn't this major communicable disease be
sermon is not a substitute for ethics as moral science. So this is a prevented? Amoebiasis, tapeworm, schistosomiasis, ascariasis Br Med J: first published as 10.1136/bmj.280.6206.35 on 5 January 1980. Downloaded from
restatement ofone moral position, leaving most ofthe others out abound. And rheumatic fever flourishes, with a prevalence
of account or giving them only brief mention. That would not rate for heart disease of 6-9 per 1000 in African schoolchildren.
matter if the dogmatic base were declared unequivocally. There is no proper discussion ofthe reasons for such disturbing
Allowance could then be made for statements such as "reserva- statistics, but in his introduction Adams alludes briefly to
tion of sexual intercourse until marriage is the key to lasting malnutrition, overt and subclinical, and the part this might
happiness and personal fulfilment"-a tenable view for some, play in predisposing to infection.
but by no means all. contributors feel This book is not meant to deal comprehensively with tropical
The editors and deeply that there is a or subtropical medicine. It is essentially a companion, full of
decline in standards of morality and they want doctors to be wise and thought-provoking observation. It is a collection of
"educated in the knowledge of the former truths which gave hints and clues to the causes of disease that should delight any
wisdom and strength to the medical profession and bred epidemiologist. How good of Professor Adams to have passed
confidence in their patients." But former truths need argument on to us the benefits of his experience.
and support and are no longer self-evident. My major criticism R HOFFENBERG
of this book is that it does not face the fact and the challenge to
its basic principles: too often, it asserts rather than debates. Yet
it is worth reading, for it has a case to make which is in the Designed for the Continent
mainstream ofwestern Christian thought as applied to medicine.
PHILIP RHODES Atlas of Rectoscopy and Colonoscopy. 2nd edn. Peter Otto and
Klaus Ewe. Translated by B Clowdus. (Pp 110; $5390.)
Springer. 1979.
Disease in Southern Africa Most surgeons would probably agree with Dr Otto and Dr Ewe
that proctoscopy and sigmoidoscopy are largely self-taught, and
A Companion to Clinical Medicine in the Tropics and Subtropics. would welcome publication of a comprehensive atlas to help
E B Adams. (Pp 210; £8.) Oxford University Press. 1979. those with limited experience recognise characteristic endo-
scopic appearances in patients with colorectal problems. This
Professor E B (Barry) Adams retired recently from the chair of book is written for students, surgeons, dermatologists, gynae-
medicine in the University ofNatal, and A Companion to Clinical cologists, paediatricians, and general practitioners-an ambitious
Medicine in the Tropics and Subtropics is a distillation of his and somewhat unrewarding task in the context of British
experience of disease in Southern Africa over a period of medicine today, but no doubt relevant to the Continental system
roughly 25 years. Strictly speaking Natal is not tropical, but of health care for which the atlas was clearly designed.
many diseases of central Africa are found there and Professor There are three approximately equal parts to the book. The
Adams has had sufficient personal experience to write with first is devoted to a description of history taking, physical
authority about most of them. He has also included many examination, and endoscopic technique including colonoscopy.
conditions that are definitely not confined to tropical countries There is little here that cannot be found in current textbooks
which-because of racial (genetic or cultural) and particularly of colorectal surgery. In particular, the description of colono-
socioeconomic factors-differ profoundly in presentation, scopy and polypectomy is certainly inadequate for anyone http://www.bmj.com/
course, and management when they affect Africans. attempting these procedures without previous experience. In
Some of the difficulties of clinical practice in Natal emerge the second part ofthe book the authors describe diseases that are
from the first chapter on neurological disease: the frequent later illustrated in the atlas section and also suggest appropriate
lack of a proper history; the inappropriateness of our customary treatment. This section may be useful for students, but the
tests of intelligence; our inability to assess dysphasia, dysarthria, content is inadequate for British surgeons in training and in
or circumlocution in a foreign unintelligible language; the several respects the treatments described do not accord with
elicitation of plantar responses in patients who wear no shoes current practice in Britain. It would be unusual, for instance, to
and have grossly thickened skin over the soles of the feet. find a surgeon (or patient) here who approved of injecting on 5 October 2022 by guest. Protected by copyright.
Patterns of disease also differ: multiple sclerosis is yet to be phenol in oil into a haemorrhoid instead of above it and, while
described in a black African; migraine, lumbar discs, carpal there is brief reference to the use of "banding," neither maximal
tunnel syndromes, and Parkinson's disease rarely affect them. anal dilatation nor cryotherapy are mentioned. The text of both
This variation of disease prevalence and pattern is what I these sections clearly betrays its German origin. The use of
find so intriguing when I contrast Adams's experience in curious words (what is a "knot" ?) and a ponderous English
Natal with British medicine. Such diversity must contain clues translation will not appeal to the British reader-even if he is
to aetiology and pathogenesis. What dictates the relative freedom familiar with the notoriously inaccurate terminology ofcolorectal
from atheroma in blacks, and why are strokes common among surgery. is far the best
them but myocardial infarcts rare ? In a population prone to Thecolour atlas itselfcompletes the book and by
hypertension heart failure is a common sequel, but myocardial part of it. Each plate is accompanied by a brief description and
infarction is not-why? And what is the basis of congestive commentary on the lesion illustrated. The colour photographs
cardiomyopathy, which accounts for a quarter of all heart are well chosen, technically satisfactory, and, with the help of
disease, 9800, of the sufferers being black (African) ? The im- the descriptive text, can easily be interpreted-though this
portance of these observations has obviously not escaped would sometimes be easier if the orientation was more clearly
Adams; in fact, he highlights these differences wherever indicated on the illustration. The colonoscopic photography is
possible and wisely refrains from too much speculation to technically less satisfactory but, as the authors have illustrated
explain them. most common higher lesions in their sigmoidoscopic series, this
Another message emerges from the book-the frequent is no great disadvantage. This section, though not comprehen-
occurrence of diseases that are preventable, that should not sive, would interest the trainee surgeon in the United Kingdom
exist in such a wealthy and up-to-date country. Tetanus still and perhaps be of value to those who work in isolated circum-
takes its toll of neonates, older children, and adults; why has stances who are confronted by an unfamiliar colorectal problem.
no proper immunisation programme been introduced? In It is a pity that the atlas section-which is the most likely one
BRITISH MEDICAL JOURNAL 5 JANUARY 1980 37
to appeal to the British reader-occupies only 40 of the book's medicosocial problems of developing countries. Subsequent
110 pages. As a whole, the book is marred by inaccuracies and experience in emergency war surgery led him into disaster
omissions in the text which must reduce its value to surgeons management and to high office in the medical division of the
or general practitioners in training in the United Kingdom. International Committee ofthe Red Cross. Now, in four concise Br Med J: first published as 10.1136/bmj.280.6206.35 on 5 January 1980. Downloaded from
General surgeons and those with a special interest in colorectal chapters, Dr Spirgi reviews disaster management, disaster
surgery will enjoy the photographs. planning, training in disaster management, and mass casualty
ADAM LEWIS care. One of the main problems of international disaster relief
is that all too often it is uncoordinated, inappropriate, and,
sadly, usually too late. The mismanagement by donor countries
is often compounded by mismanagement in the affected country.
Turned and unturned stones To overcome this problem Dr Spirgi outlines the role of a
national disaster committee which would be responsible for
Renal Calculus. Leslie N Pyrah. (Pp 370; $49.) Springer. 1979. predisaster planning and preparedness (including disaster
prevention). After a disaster this committee would assess the
Hardlyanissue ofany urological journal goes by without a paper needs created in terms of medical care, food, clothing, and
on some aspect of stone disease, perhaps the oldest and still the shelter, and would be in a position to assess the national
most perplexing ofall urological problems. This makes it all the resources, and to call on specific international aid.
more amazing that one author could cull from published work An important aspect of disaster management is to provide
and from his own vast clinical experience such an extensive and adequate training in basic life support not only for doctors, but
succinct account of the present state of affairs. for paramedical teams and for the lay public. Following the
Few of us could quote an experience with over 500 patients disaster impact, initial casualty management is dependent on the
with stone followed for a minimum of 10 years and many for surviving members of the community, who must be familiar
20 years. Leslie Pyrah, ex-professor of urology in Leeds, can with the assessment and support of vital functions rather than
do just this. This is a splendid book that I cannot help but be the more traditional first-aid measures. Many would endorse Dr
proud of owning. The contents are arranged in such a way as to Spirgi's emphasis on the need for compulsory life support
invoke maximum interest, and there is a short historical note at training in secondary schools.
the beginning of many sections. The first chapter on the The final chapter on mass casualty management emphasises
epidemiology of urolithiasis is fascinating because it correlates the critical importance of triage, and explains that triage is not
changes in lifestyle and diet with incidence of stones. Mr Pyrah just the assessment and sorting of the injured according to the
discusses the classical theories of stone formation-simple severity of the injuries, but should also be applied according to
crystallisation, crystallisation on an organic colloidal material, or the benefit that can be expected from available medical treatment
the presence of inhibitor substances that stop us all from freely at the time. Once again, the need for delayed primary closure of
forming stones. He also reviews all the possible underlying any missile wound is stated. Dr Spirgi has encompassed the
mechanisms, both congenital and acquired, and the biochemical In this small monograph and I commend it as an
factors. These include such rarities as xanthinuria and whole range of disaster planning, that will be of interest to
cystinuria. introduction to disaster management
Above all, this is a clinical text that tells us just when to all doctors. P E A SAVAGE
attempt to pull a stone out of the ureter with a basket and when
it is safe to leave a small stone in the kidney. I was pleased to see
that the blood and urine tests for patients with stones are as
simple today as they were 10 years ago-and, sadly, often about http://www.bmj.com/
as useless in the vast majority of patients. I, for one, have yet Super for someone
to discover a previously undiagnosed patient with cystinuria by
routinely looking for cystine in the urine. Although there is a Monographs on Endocrinology. Vol 13. "Vitamin D: Metabolism
wealth of instruction on how to remove stones, I could not find and Function." H F DeLuca. (Pp 80; $16.) Springer. 1979.
any indication of Mr Pyrah's favourite surgical approach to the
kidney. One ofthe major advances in operative stone removal is Motoring correspondents in the popular Sunday papers often
the use within the kidney of a cystoscope, paediatric resecto- begin their review of the latest offering from Turin or Long-
scope, or even a specially designed nephroscope. The use ofthese bridge with a highly improbable but moderately long story on 5 October 2022 by guest. Protected by copyright.
instruments, which is not discussed by Mr Pyrah, has gone a having only tenuous links with the motor trade. This may be
long way to make his section on partial nephrectomy for stone because the only new features ofthe car under consideration are
redundant. technical innovations of interest only to, or within the com-
The urological world owes a debt to this much respected prehension of, the enthusiast. To hold the interest ofthe general
author and would do well to heed his words of wisdom. reader is a more difficult task because his demands are more
RHWHITAKER prosaic: "Will it hold the wife, kids, dog, and mother-in-law,"
or, light years further down the aspirational scale, "Will it pull
the birds ?" Undeniably, Professor DeLuca's book on vitamin D
has a good deal less sex appeal than the latest Ferrari, but being
Coping with calamity £21 200 cheaper is quite an attraction. Even so, the analogy
with the motoring correspondent remains: is it a book for the
Guidelines general reader or the enthusiast ? one who has been
Disaster Management: Comprehensive for Disaster It is a beautifully written monograph by
Relief. Edwin H Spirgi. (Pp 118; Sw frs 34.) Hans Huber. 1979. concerned with many of the fundamental advances in this
subject. As one would expect, it is an authoritative review but
One of the fascinations of disaster planning is that it covers one with a feel for the temporal perspective of the vitamin D
almost the full range of human activity-from the detailed story. This is well illustrated by the first chapter, which sets out
clinical management ofa few victims after a road accident to the the historical aspects ofthe growing awareness ofthe nature and
mass casualties and sociopolitical consequences of major natural function of the vitamin. I found this fascinating reading, not
disasters affecting thousands of men, women, and children. least because of the amazing intellectual ability of the early
Dr E H Spirgi graduated from Basle and, during his post- workers such as Mellanby, McCollum, and Steenbock, who,
graduate work as a general surgeon, became interested in the with only a rudimentary understanding ofthe nature ofvitamins,
38 BRITISH MEDICAL JOURNAL 5 JANUARY 1980
were none the less able to construct hypotheses about structure Together with nine other contributors, she discusses the "gut
and function which subsequently proved largely correct. reaction" of neuroimmunology. Dare we believe the presence
The first third of the book describes the structure of the of jejunal mucosal antigens to measles in multiple sclerosis, to
various vitamin D metabolites and reviews the factors exerting poliovirus in amyotrophic lateral sclerosis, and to herpes virus
a controlling influence on their production. This is extremely in progressive muscular atrophy ? Br Med J: first published as 10.1136/bmj.280.6206.35 on 5 January 1980. Downloaded from
well done, providing as it does considerable detail while remain- Whereas Cleave or Burkitt might ponder the use of a holy
ing intelligible to the non-biochemist. The next section considers bran to bind and eliminate noxious substances from the intestine,
the action of vitamin D on the target organs: intestine is dealt Cook et al actually claim clear evidence of clinical improvement
with in considerable detail but the sections on bone, kidney, and in motor function, speech, skilled acts, and the abolition of
muscle are rather brief-perhaps reflecting the extent of our fasciculation in amyotrophic lateral sclerosis from the use of
ignorance in these areas. Although the references are com- antiviral agents capable of removing antigen from the jejunal
prehensive and up to date I came away from this section with a mucosa. In a chapter devoted to myasthenia gravis, much play
feeling that more could have been made of it by providing an is made ofthe fact that a single electroplax cell from the electric
overview of the problems facing investigators. Thus much of organ of the eel, Electrophorus electricus, contains some 2 x 1011
the work on renal actions of vitamin D is dismissed on technical nicotinic acetylcholine endplate receptors similar to those of the
grounds, and yet there is an opportunity here to put this in some skeletal muscle of less startling individuals. It is also suggested
sort ofperspective so that the interested reader is better informed that the antigenicity of the ionophore protein may be as
should he wish to go back to the source material. A minor important in the aetiology of myasthenia as that of the endplate
criticism is that a review of the interrelationships in the calcium receptor.
homoeostatic system precedes this section on target organ A social reviewer was once sued for writing, "I have already
function rather than being placed in a later co-ordinating role. described Lady So-and-So's dress." Do I describe the im-
The final section dealing with the clinical use of vitamin D peccable quality of the photomicrographs, the excellent tables,
and its metabolites consists of only two and a half pages and clear prose, and thought-provoking text ? A minus factor is the
can do little more than draw attention to the diseases with which careless compilation ofthe names and initials ofthe contributors.
an abnormality of vitamin D has been implicated. Perhaps it is Even so, each chapter contains some worthwhile comment.
the brevity of this last chapter that highlights the dilemma of Not all the work has been reproduced in other centres. Thus
this book and brings us back to the motoring metaphor: at Pertschuk et al in an honest discussion on viral antigens of the
whomis the book aimed ? As a text for the undergraduate in his jejunal mucosa emphasise that difficulties in tissue handling
physiology and biochemistry courses it is superb, if, that is, he have meant that some of their exciting results as yet lack
needed such a comprehensive understanding of vitamin D confirmation by other workers. In this regard, the emphasis
structure and function. For those clinicians wishing to develop laid on detailing the experimental techniques throughout the
an interest in metabolic bone disease it is an ideal introduction volume is a welcome departure from the all-too-brief discussion
to the basic physiology, but I wonder how many will be un- more usually available. Progress in Neurological Research is not
familiar with this data and would they not be better served with designed for the student, but for the interested scientific
something more clinically orientated ? For those already working graduate this is a satisfying yet speculative volume on the ever
in the specialty much ofthe data will be well known but the size developing subject of clinical neuroimmunology.
and nature of this monograph precludes an in-depth critique
of some of the more contentious topics. E M R CRITCHLEY
I thought that this was a super little book but I just wish I
knew for whom it was intended. References
DAVID J HOSKING
Clinical Neuroimmunology, ed P 0 Behan and S Currie. Volume 8 in the http://www.bmj.com/
series Major Problems in Neurology. London. Saunders, 1978.
2 Clinical Neuroimmunology. Ed F Clifford Rose. London, Blackwell, 1979.
The continuing debate
Progress in Neurological Research: with particular Reference to Contributors
Motor Neurone Disease. Ed Peter 0 Behan and F Clifford Rose.
(Pp 232; £16.) Pitman Medical. 1979. ANDREW SMITH is a general practitioner and a lecturer on 5 October 2022 by guest. Protected by copyright.
This is the third book by Behan-Rose Productions on Clinical in family medicine at the University of Newcastle upon
Neuroimmunology. On this occasion the title is different' 2 but Tyne.
there is a similar panoramic sweep of lymphocytic behaviour, PHILIP RHODES is postgraduate dean of medicine at the
myelin disruption, persisting viral infections, serological University of Newcastle upon Tyne.
changes, clinical considerations, and experimental models before R HOFFENBERG is Professor of medicine at the Uni-
zooming in on the principal theme of motor neurone disease. versity of Birmingham.
The presentation, alas, is not entirely free from camera wobble.
For a resurrected Bernard Shaw, Progress in Neurological ADAM LEWIS is a consultant surgeon at the Royal Free
Research would provide a most fruitful source from which to Hospital, London.
update his satire on Almroth Wright's immunology as depicted R H WHITAKER is a consultant urologist at Adden-
in The Doctor's Deilemma. Beneath the cloak of scientific brooke's Hospital, Cambridge.
respectability, the most exciting and fantastic hypotheses are
garishly displayed. Thus the book begins with the postulate P E A SAVAGE is a consultant surgeon at Queen Mary's
thatthepresenceofevanescentsubstrates-T (andB)lymphocyte Hospital, Sidcup, Kent.
interaction modulation factors-with a half-life measured in
nano-seconds and neutrino-like properties, can divert lympho- DAVID J HOSKING is asenior lecturer and honorary con-
cytes from their Calvanistic predestination to selected sites sultant physician at University Hospital, Nottingham.
into alien tissues where they can cause autoimmune reactions. EMRCRITCHLEYis a consultant neurologist at Preston
ThenameofDrFlorenceNidzgorski, unit director, Department Royal Infirmary.
of Neuroscience, the Long Island College Hospital, Brooklyn,
New York surely conjures forth an ideal Shavian heroine.
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