BOOK REVIEWS

7"he Common Bile Duct. By CLARENCE ft. SCHEIN, WILLHELM Z. STERN, HAROLD G. JACOBSON. Published by Charles C. Thomas, Illinois.

Three contributors, two Radiologists and a Surgeon, have produced this excellent mono- graph based on their experiences in the Albert Einstein College of Medicine of the Yeshiva University, New York. It is divided into three main sections namely Operative Cholan- giography, Biliary Endoscopy and Choledocholithotomy.

This book opens with a brief but concise historical note. There is a fascinating illustration of operative cholangiography as practised in France during the 1940 era. It shows a Radiologist enclosed in a metallic chamber underneath the operating table, who aided with a Flouroscopic screen, could observe the dye in the biliary system and take spot films, most important he was able to communicate with the Surgeon using a microphone, but happily this method is not longer employed but it does at least highlight a point well made in this book, that active co-operation between the Surgeon and Radiologist is essential in this particular field. The technical details are well covered in the third chapter. The Authors favour the use of hypaque as a contrast media but could perhaps pay a little more detail to the quantities used. Reference is made to the rare accounts of pancreatitis occurring as a complication. There then follows an extensive series of Radiographs illustrating the varying anatomical appearances seen. The Authors make particular reference to the value of the lateral view as well as the antero-posterior view. In discussing percutaneous transhepatic cholangiography the Authors recommend that this be carried out, either in the x-ray department or on an operating table, but insist, in the case of the former, that direct surgical exploration should be carried out immediately after the procedure. They describe the use of a needle but mention the great value of using a fine polythene tubing which can be threaded over the needle and in general is more satisfactory. The decided advantages of image intensification and television are adequately stressed as it helps to confirm the site of the needle and therefore alerts one to the disadvantages of a vascular injection or an injection into the hepatic parenchyma. As a routine for this procedure the Authors recommend 20 cc of dye with films in the P.A. oblique and lateral projections. Regarding Theatre technique, the use of a modern, more powerful, mobile apparatus gives a greater clarity in the radio- graph. The standard plywood tunnel is described but possibly a description of some of the other modifications of this technique, such as a long linen sleeve with multiple films might have been mentioned. The Authors do incidentally mention that they have tried polaroid film but have found this unsatisfactory.

As regards the operative cho!angiography, the most satisfactory approach described is direct injection into the cystic duct which in many ways is preferable to injection into the gallbladder. To carry out this they use the multifenestrated cannulae of Fourres and Mallet-Guy. Great stress is laid upon the correct siting of the T.Tube as, if the insertion is made too high, the upper limb may enter one of the hepatic ducts and partially obscure the other. There are numerous illustrations of the various appearances seen after T.Tube cholangiography. There is an interesting list of misadventures including the occurrence o f air bubbles, mal-position, foreign bodies such as surgical instruments and perhaps the most common of all, the use of too much rather than too little dye.

The question of protection for the staff is stressed, the Surgeon and Theatre nurse should always wear a lead apron. The difficulties of differentiating between the presence of air bubbles and calculi is stressed. Regarding the appearances at the lower end of the bile duct the problems of interpreting the differences between spasm of the sphincter of Oddi and organic stenosing papillitis is mentioned. The former may be due to the instrumentation and the use of serial films usually helps to clear up this problem. There are a number o f examples of the reversed C sign which occurs in pancreatitis.

Biliary endoscopy is adequately described and is obviously a supplementary examination particularly valuable for examination of the ampullary end of the common bile duct. The procedure should take no more than five minutes and cameras are now made to be attached to this apparatus. It is stressed that under no circumstances should this be carried out i f there is coexisting pancreatitis. The text ends with a comprehensive account of all the surgical aspects of the biliary tree. Stress is made that an adequate exposure should be made and the various methods of clearing the common bile duct are mentioned including such methods as, manipulation by compression, scooping the duct, irrigation, forceps extraction and the use of Bakes dilators. The text finally closes with a comprehensive and up-to-date bibliography. The only small criticism which I have to offer is that, exclusion of some of the numerous illustrations would perhaps cut the cost, without detracting from the value of the book to bo th Surgeon and Radiologist.

D. F. CANTWELL.

Aspects o f Medical Virology. BRITISH MEDICAL BULLETIN, 23, 2 (May, 1967). Medical~ Department, The British Council. 30/-.

In spite of its title it is, at first sight, difficult to relate the great majority of the articles in this issue of the British Medical Bulletin with the practice of clinical Medicine. In his

387

388 IRISH JOURNAL OF MEDICAL SCIENCE

introduction Professor M. G. P. Stoker remarks: "Admittedly the most spectacular advances have concerned molecules rather than patients, but it is the molecules which cause the diseases and,. in. the long run,. papers in the,, Journal . . . . . o f Molecular Biology may contribute" as much to medicine as those m The Lancet. Th~s, of course, is an overs~mphficatlon and an example of the trend which may perturb many virologists whose interests lie in the diagnosis and the epidemiology of virus infections. By concentrating on molecules we may be in danger of forgetting the diseases and we are now fast ap0roaching the situation where, all credit to the molecular biologists, virus chemotherapy is just around the corner, but we still know little of the actual disease processes which we hope to be in a position to cure. So rapid and spectacular have been the advances in virology in the past fifteen years tha t we have gone from peak to peak, but we know little more now of what goes on in the valleys than we did then. To give only one example: paralytic poliomyelitis is now all but conquered and we certainly have the means of controlling it, but we still do not know how the virus gets from the gastro-intestinal tract to the central nervous system. Again, the correlation between the multitudinous respiratory viruses and the clinical syndromes which they cause is merely in its infancy. The article by D. A. J. Tyrrell on "Common Colds and Related Diseases", while a masterly summary of what is known, shows how far we still have to go. When chemotherapy becomes a practical proposition we shall be faced with a tremendous diagnostic challenge in relating the causative virus to its appropriate chemotherapeutic agent.

Nonetheless, all this having been said, this number provides exciting reading and, in all fairness, does give pointers to the medical future. Those who are not familiar with recent work may well be surprised at how much is known of virus replication. The articles by Appleyard on the "Chemotherapy of Virus" and by Wildy, Watson and Shedden on "Non-structural Proteins of Viruses of Vertebrates' ' will repay close study by those interested in the treatment of virus infections. It is pointed out that antibody is not the major factor in recovery from a viral infection, a point made also by Waterson, Pennington and Allan in "Virulence in Newcastle Disease Virus" when they state: "Recovery from a first infection with a virus probably depends scarcely at all upon antibodies, and the final disappearance of virus may be caused by its eclipse into cells rendered immune, probably by infection". While one might quibble at the use of the word " immune" in this context, this thesis brings up to date what has been postulated by several workers over the years, and re-inforces the concept, for which there is considerable evidence, that antibody is of value only in the prevention of virus infection--and, of course, in retrospective diagnosis. More interesting, however, is the discovery, referred to in these papers and with profound implications for the future, that viruses, in their replication, depend on newly synthesized enzymes not normally present in the cell. Until now it had always been accepted that the growth of new virus particles was so intimately bound up with, and so dependent upon, the processes of the cell itself that it was impossible to inhibit one without also interfering with the other. If this is not so, then we now have a theoretical basis on which to proceed, and progress will undoubtedly be far more rapid than many now seem to think. Indeed, it is ironic that, already, drug resistance is emerg.ing as a problem. In any event we must crawl before we can run and the prospects for wrus prophylaxis are far better than for therapy--another reason for far more intensive study of the epidemiology of virus diseases, particularly in general practice.

The article by H. G. Pereira and R. C. Valentine "Morphological and Antigenic Sub- Units of Viruses" shows how new knowledge of where antigenic structures are located on the virus particle may open the way to new approaches to the study of the roles p.layed by the different virus components during the course of infection, and may in time gwe us an inkling of what is the precise significance of the different serological tests which are already in use. Two papers by Cooper and Subak-Sharpe deal with the genetics of viruses, and Macpherson on "Viral Oncogenesis" and Stanley on "Reoviruses" bring one up to date in the difficult field of virus induced tumours. Martin on "Replication of Small R N A Viruses" describes the interaction of both viral constituents (RNA and protein) in the production of mature virus, and speculates that the result of even moderate inhibition of the synthesis of either of these may be a severe interference with the production of mature virus. Fraser in "Defective and Delayed Myxovirus Infections" discusses these in some detail and points to the possible practical applications in so far as, if the processes involved in abortive infections of the cell with influenza virus were understood, it might become possible to do this deliberately in human infections. Stamp writes of "Scrapie and its Wider Implications", points to its similarity with Kuru in New Guinea, and goes on to discuss the possibility that several encephalitie diseases of man, the cause of which is at present unknown, may be due to similar slowly acting agents which may be viruses, al though this remains to be proved.

Two articles with more immediate clinical interest are "Smallpox and Vaccinia" by Bedson and Dumbell and "Rubel la" by McCarthy and Taylor-Robinson. The first of these deals with rapid diagnosis of smallpox which nowadays, in the absence of widespread vaccination, is more necessary than ever. The authors point out that smallpox is not infec- tious during the incubation period which makes the task of public health authorities engaged in control so much easier, but comment on the high morbidity in nurses and doctors. Many will be interested, in view of recent controversies which have so clouded the issues,

BOOK REVIEWS 389

in the statement that " . . . there is general agreement that the risks of primary vaccination are least in the first two years of life." McCarthy and Taylor-Robinson, in speaking of congenital rubella, make the interesting point that, as only IgG antibodies can cross the placenta, the foetus may be exposed for some time to the action o f virus without the possible protection afforded by the IgM antibodies, produced first but unable to cross the placenta, to the maternal tissues. This concept should probably, however, be read in conjunction with those articles mentioned earlier in this review. The authors discuss also subclinical attacks and show that it is certainly possible that these may contribute to the congenital rubella syndrome.

Finally, in "Viral Multiplication in vitro in relation to Pathogenesis", Kingsley Sanders makes a strong plea for the use of the more modern methods now available in the re- investigation of the pathogenesis of viral disease. As might have been gathered from the remarks made at the outset, this plea is heartily endorsed by your reviewer.

There is so much material in this number that one can really only mention the articles which it contains. Not the least important is the introduction by Professor Stoker, who devotes just enough space to "helper" viruses to make one wish for much more. As he states, it has always been assumed that the adaptation of viruses to grow in abnormal hosts arose from mutation and selection. This may not be so but may, in some instances at least, be due to the action of a "helper" virus in the culture; for example, adenoviruses will only grow in green monkey cells if these are also infected with SV40 virus. It seems that the two viruses are mutually dependent, and that each complements a defect in the other. The implications of this for the production of live virus vaccines are obvious, and it would seem that in future the strains used in such vaccines must be more critically evaluated. q-he presence of SV40 virus in some batches of Salk vaccine shows that this applies to killed, as well as attenuated, vaccines.

It is difficult to recommend this number too highly. It is well balanced, the articles are authoritative and should open up new avenues to many readers. It is not easy reading, but the results will repay the labour involved. It is always exciting to get a glimpse of the future.

P. N. MEENAN.

Cellular Biology of Myxovirus Infection, (Ciba Foundat ion Symposium). By G. E . W . WOLSTENHOL~IE and J. K ~ m ~ . J . A . Churchill. 60/-

I t is with a feeling of considerable exci tement tha t one greets a new Ciba Foundat ion publication whether this be one of the short Study Group reports or the proceedings of one of the Symposia which have contr ibuted so much to the high regard in which the Founda t ion is held in the scientific and particularly in the medical world. Both have set an exceptionally high s tandard in their presenta t ion of recent work- -au thor i ta t ive yet a t the same t ime with a compactness and succinctness not of ten achieved in published conference reports. The present volume is a report of a Sympos ium on myxovi ruses held in London in February, 1964, Perhaps the mos t effective t r ibute one can pay to it is t ha t it is still in 1967 well worth buying.

The myxovi ruses have for the last twen ty years been in the forefront of virological research and for a very good reason. Of all the h u m a n pathogenic viruses they are probably the easiest to manipula te in the laboratory. Inevi tab ly therefore they have come to be regarded as models the examinat ion of which m a y serve to i l luminate the whole field of virology. The group is one which has undergone start l ing changes in its boundaries in recent years. Originally defined, on the basis of the capacity to adsorb to mucoprote in receptors on the surfaces of red cells, to include the influenza viruses, the closely related fowl plague and Newcastle disease viruses, the m u m p s virus and later the para-influenza viruses, the group has now been ex tended to include all viruses resembling these in electron microscopic morphology even if t hey are outside the scope of the original definition. In this way it now includes the measles, respiratory syncytial , d is temper and rinderpest viruses and almost includes, though these are at the m o m e n t in a taxonomic ante-chamber, the Bi t tner agent and the Rous sarcoma, avian erythro- blastosis, Gross leukaemia, infectious tracheobronchitis of chickens and rabies viruses.

The common morphological features on the basis of which the group is a t present defined a r e - - t h e presence of a nucleocapsid possess inghel ica lsymmetry i .e . the subuni ts or eapsomeres of which are disposed in helical array around the viral nucleic acid, the whole being enclosed in an envelope derived to a considerable ex ten t from the membrane of the hos t cell and which m a y or m a y not possess 'spikes' by which the virus adheres to the red cell surface. All the myxovi ruses are RNA viruses i.e. t hey contain ribonucleic acid as their sole nucleic acid. In conformity with current t rends it would seem not illogical to ex tend the boundaries of the group to embrace the tobaccomosaic virus, which is also an RNA virus with helical symmetry , though it does not possess a capsid. At the m o m e n t the problem of extending it to include I)NA viruses with helical sym- m e t r y does not arise since none of these have so far been discovered.

As defined in this way the myxov i ruses fall into two quite dist inct biological groups dis t inguished by their size, the rigidity of the envelope, the diameter of the internal nucleoprotein i.e. the nucleocapsid, the capacity to produce f i lamentous forms and to

390 IRISH JOURNAL OF MEDICAL SCIENCE

produce incomplete virus, the site of virus synthesis in the cell--whether this is in the cytoplasm or the nucleus, the capacity for genetic ineraetion, particularly the capacity for recombination or hybrid formation and the degree of dependence on the host cell nucleus for replication. These properties and their biological significance are the subject of several of the contributions to the symposium. The contributions whichdealwith them are of great intrinsic interest, particularly to those involved in virological research. At the same time they raise fascinating issues of more general biological importance viz: the mechanism of self-assembly of viral capsids and by implication of biological self- assembly processes in general, the function of the viral envelope and its possible relation- ship to antigenic variation and why, though all are RNA viruses, myxoviruses which appear to replicate in the nucleus should be highly susceptible to Actinomyein D which inhibits the synthesis of RNA on a DNA template while those which appear to multiply in the cytoplasm are not.

The Symposium also presents material which is of more direct medical interest in communications on the heterogenecity of A2 (Asian) viruses in respect of their capacity to combine with antibodies and with mucopretein receptors, on the nature and quality of the ant ibody response to the influenza virus, on the antigenic and immunogenie properties of disrupted influenza viruses and on the cellular and humeral factors involved in the defence against influenza virus infection.

Of these papers all of which deal with the fundamental aspects of immunity against influenza two are of particular interest: In one of these Fazekas de St Groth and R. G. Webster consider the immunological implications of the doctrine of Original Antigenic Sin proposed initially by Francis and Davenport. This doctrine expresses the fact that individuals who have in early life been exposed to an influenza virus will on any subse- quent exposure respond with the production of antibody with a specificity directed particularly towards the virus initially experienced. The fact t ha t the reviewer is not in complete agreement with the conclusion tha t this phenomenon can only be satisfactorily explained on a selective theory of ant ibody production with selection operating at a subcellular level through the currently fashionable mechanism of derepression does not detract from the originality and interest of the communication. Undoubtedly of most practical importance is the contribution by Davenport, Hennessy, Dreehser and Webster on 'Analytical, serological and clinical experiences with the haemagglutinating subunits of influenza virus.' This communication presents convincing evidence that the antigenic variation which has bedevilled the prophylaxis of influenza and which has in the last resort b3en the basis of our repetitive experience of this uncomfortable disease is due, not to muta t ion of the virus to a new antigenic type, but to a rearrangement, in individual strains, of a limited number of antigens in such a way that some which are prominent in one strain are concealed in another. I t is on this possibility and on our capacity to exploit it tha t we must base the future effective control of influenza.

In their preface the Editors record the part icipants ' and Foundations ' regret that serious illness prevented the at tendance of Dr. Alick Isaacs. As a result the Symposium contained no contribution on interferon the discovery of which was Dr. Isaacs' out- standing contribution to virology. I t is a sad postscript to this comment to have to note Dr. Isaac's death in January last at the early age of 45 less than a year after his election to Fellowship of the Royal Society.

FREDERICK S. STEWART.

Endocrine Surgery in Human Cancer. (Second edition). By PAVL JURET. Charles C. Thomas, Springfield, Illinois.

This book is a translation from the French edition of Paul Juret , chief of the endocrine laboratory of the Inst i tut Gastav Roussy, Villejuif, France. The title is perhaps mis- leading, as it is predominantly concerned with cancer of the breast and prostate, with very brief mention of endocrine surgery in cancer elsewhere in chapter 10. The basis for endocrine gland ablation in cancer, of course, is the proven concept of hormone-depen- dence and most work has been concerned with those tissues (mammary and prostatic) which are normal hormonal target cells.

The book deals with all aspects of endocrine surgery in these two conditions, including literature review (approximately 1,000 references), pros and cons of surgery, method of selection of cases, comparative results of surgical versus other acceptable approaches to therapy and also an account of the various methods of securing endocrine ablation including medical, irradiation and surgical procedures. There are also detailed accounts of methods of management of pat ients following surgery. To select any individual chapter for especial mention is always difficult and demonstrates reviewer bias, but I would recommend chapter 2, in which the place of adrenaleetomy is diseussed.

The subject matter, while it is dealt with extremely fairly, cannot in the words of Dr. Jure t "claim to have escaped any personal view and [it] would be mendacious to deny the unavoidably subjective character of the sequences of t rea tment . . . . " (p. 258). This is a very honest statement, as the disadvantages and the views of antagonists are fuily expressed. Nevertheless, to quote again from Dr. Juret, "endocrine surgery seems to have

BOOK REVIEWS 391

success fu l ly p a s s e d t he t e s t o f t i m e [and] t h e t h e r a p e u t i c a l va lue o f t he se ope ra t ions is now u n q u e s t i o n e d b y i m p o r t a n t a n d expe r i enced oncologis t s" . (p. 257).

P r e s e n t a t i o n o f d a t a is clear a n d r ead i ly u n d e r s t a n d a b l e . Pub l i c a t i on is, o f course, impeccab le . The t r a n s l a t o r s a re to be c o n g r a t u l a t e d on t h e c la r i ty o f t he t e x t a n d to be fo rg iven for t h e occas ional ' New ' word wh i ch appea r s , for e x a m p l e ' a n t i b i o t h e r a p y ' (p. 84). Al l i n t e r e s t e d ac t ive ly in cance r t h e r a p y m u s t be deep ly i ndeb t ed to Dr. J u r e t a n d h i s co l labora tors for col lect ing a n d s i f t ing t h e m a n y r ecen t o b s e r v a t i o n s in th i s r ap id ly e x p a n d i n g field.

JAMES G. DEVLIIV.

Chemotherapy of Disseminated solid Tumors. ]By F. J . ANSFIELD. Charles C. T h o m a s , Springfield, Il l inois.

W h e n I saw t h a t t he a u t h o r o f th i s book was F. J . Ansf ie ld o f Madison , Wiscons in , I felt i t w o u l d be m o s t l ikely t h a t t h e f luo r ina t ed p y r i m i d i n e s wou ld ge t v e r y p r o m i n e n t m e n t i o n . I-Iaving r ead t h e book I feel t h e t i t le shou l d be s o m e t h i n g s u c h as " T h e Place o f F luo rourac i l in Cancer C h e m o t h e r a p y " . T h e book is v e r y well i l l u s t r a t ed w i t h pho to s a n d x - r a y s before a n d a f te r t r e a t m e n t a l m o s t in all cases w i t h f l u o r o u r a c i l - - n o w you see it, n o w y o u don ' t . I o f t en m a r v e l a t t h e wonde r fu l r e s p o n s e s i l l u s t r a t ed by m a n y a u t h o r s in t h e case o f large necrot ic , avascu l a r - l ook ing t u m o u r s .

Ans f i e ld is one of t he o p t i m i s t s in t h e field. However , he obv ious ly h a s a v e r y ba l anced o p t i m i s m , b u t I feel t h a t s o m e o n e no t fami l ia r w i t h t h e t r ue p lace o f d r u g s in cancer c h e m o t h e r a p y m i g h t ge t a false i m p r e s s i o n o f the i r va lue . The c h a p t e r s b a s e d on d r u g eva lua t ion , p a t i e n t selection, t h e r a p e u t i c p rocedure s c o n c e n t r a t e on all of t h e s e m a i n l y as s e fe r r ed to f iuorouraci l . I a m s u r p r i s e d to no te t h a t he u s e s f luorodeoxyur id ine b y r t r~ igh t I .V. in jec t ion a t d~sage o f 30 m g m / K g m / d a y s ince m o s t o f u s now prefe r t h e c o n t i n u o u s I .V. or I .A. in fus ion w h i c h m e a n s a dosage o f 1 m g m / K g m / d a y . Th i s is a v e r y i m p o r t a n t cons idera t ion w h e n u s i n g such a n expens ive d rug .

O t h e r d rugs , viz a lky la t ing agen t s , a c t i n o m y c i n D, m i t h r a m y c i n , m i t o m y c i n , vclbe , h o r m o n e s a re g iven a d e q u a t e if b r ie f m e n t i o n .

I n t h e m a n a g e m e n t o f a d v a n c e d b r ea s t c a r c i n o m a in t h e f irst five yea r s p o s t - m e n o - p a u s e it su rp r i ses m e to see t h a t f luorouraei l t a k e s first p lace in m a n a g e m e n t i.e. even before h o r m o n a l t h e r a p y . I feel a d r e n a l e c t o m y or h y p o p h y s e c t o m y shou ld be g iven f irst cons ide r a t i on a t t h i s s tage . I t is m y exper ience t h a t r e s p o n s e s can be p roduced , b u t I p r e fe r to u se h o r m o n a l t h e r a p y fol lowed b y a lky l a t i ng a g e n t s before go ing on to f luorouraci l . R i g h t l y he s t r e s se s t h e po t en t i a l o f f luor ina ted p y r i m i d i n e s in gas t ro in t e s t i - na l c a r c i n o m a where s ignif icant benef i t is f o u n d in a b o u t ½ of p a t i e n t s .

T h e d a n g e r in sma l l ser ies is i l l u s t r a t ed b y his ana lys i s in l ung ca r c inoma of r ad i a t i on v e r s u s r a d i a t i o n -bFluorourac i l - - - the m e a n su rv iva l be ing 6 a n d 22 m o n t h s respec t ive ly , b u t w h e n a s t u d y c o m p a r i n g t h e l a t t e r to c y t o x a n - b r a d i a t i o n was carr ied ou t t h e m e a n su rv iva l o f p a t i e n t s g iven r ad i a t ion -k f luo rou rae i l was on ly 5.7 m o n t h s .

Tes t i cu l a r t u r n o u t s r ep r e sen t t h e one g roup where o the r d r u g s t a k e precedence . The re is l i t t le d o u b t o f t he va lue o f a e t i n o m y e i n D a n d m i t r a m y c i n in se lec ted cases here .

As r e g a r d s inoperable o v a r i a n c a r c i n o m a where m o s t o f u s ge t such encou rag ing r e su l t s w i t h a lky l a t i ng a g e n t s a g a i n f luorouraci l is se lec ted as t h e f irst line o f a t t a c k . The r ev i ewer ' s exper ience here does n o t s u p p o r t t h i s point . I~owever , t h e n u m b e r o f cases t r e a t e d b y Ansf ie ld (300) is m o s t convinc ing . For w h a t k i n d o f r eade r is t h i s book sui table? T h e size s u g g e s t s it a s a h a n d y guide to t h e p h y s i c i a n i n t e r e s t e d in t h e sub jec t . However , such s t r e s s is la id on t h e m o r e tox ic k i n d o f d r u g s t h a t I feel it shou ld be r e s e r v e d for t h e special is t , who , I m i g h t add, shou ld h a v e as m u c h e n t h u s i a s m for f l uo r ina t ed p y r i m i d i n e s as h a v e t h e au t ho r s .

JAMES J. FENNELLY.

Backache Relieved ; Through New Concepts of Posture. B y W. H . FA~RNI. I l l inois : Char les C. T h o m a s . $5.50.

Ci t ing a n I n d i a n tribe, t he Bihil , as a n example , t h e au tho r , a C a n a d i a n o r thopaed ic su rgeon , c la ims t h a t backache a n d sciat ica are u n k n o w n in t h e jungle . Th i s he a t t r i b u t e s to the i r s p o n t a n e o u s a n d u n t u t o r e d a d o p t i o n of " m e t h o d s o f r e s t a n d locomot ion t h a t c losely a p p r o a c h t he mechan i ca l idea l" . W es t e rne r s , however , s ince Grecian t imes h a v e a d u l a t e d t h e soldier a n d t he m i l i t a r y s t ance ha s become a false i d e a l

I t is e a sy to agree w i t h t h e l a t t e r p a r t of t he thes is . T h a t t h e r a m - r o d s t ance o f a soldier a t a t t e n t i o n is unphys io log ica l is p roven a n n u a l l y b y g u a r d s m e n fa in t ing on p a r a d e a n d cer ta in exercises be loved of phys ica l i n s t r u c t o r s a re p r o b a b l y h a r m f u l r a t h e r t h a n beneficial .

The re is m u c h to be said for a r e l axed p o s t u r e howeve r s lo th fu l i t m a y appear . M a n y , w i th re l ieved consciences, will we lcome Mr. F a h r n i ' s ins i s tence t h a t to sprawl c rossways in a n e a s y cha i r w i th knees s l u n g ove r t h e a r m of t he cha i r is n o t on ly comfor tab le b u t a d v a n t a g e o u s .

B u t to r e t u r n to his i n t r i gu ing c l a im t h a t backache is u n k n o w n to t he Bihi l t r ibe i t m u s t be sa id t h a t his a r g u m e n t s are a d v a n c e d in a m o s t unsc ient i f ic fashion . He does n o t tel l u s h o w m a n y sub jec t s h a v e been obse rved nor for h o w long. F a v o u r a b l e f ac to r s

392 IRISH JOURNAL OF MEDICAL SCIENCE

such as climate, absence of obesity and regular exercise are not considered. Fur ther- more, certain of the postures which he extols are by no means confined to the Bihil. Squatt ing during leisure hours is common among miners in Wales and England, and Irish i t inerants and gypsies everywhere carry their babies si t t ing on the hip bone.

I f Mr. Fahrn i ' s s ta tement is co r rec t - -and the explanat ion is no t merely tha t the stoical Bihil do not complain of back-pain because of exposure to worse i l ls--his views deserve more elaborate and scientific expression. J . B . LYO:CS.

The Use of Diagnostic Ultrasound in Brain Disorders. By C. C. GROSSMA~. C. C. Thomas, Illinois. $9.00.

This small monograph is based on material presented at Fr iday morning seminars on encephalography and diagnostic u l t ra-sound conducted by Dr. Grossman a t the Presbyter ian Universi ty Hospital in Pi t tsburg. The importance of ul t ra-sound as a non- t raumat ic diagnostic tool is now generally rccognised especially with reference to the A-scope technique and the parameters of its usefulness have been fairly well defined. The advantages , considering the vulnerabi l i ty of brain cells, vascular hazards in the elderly and the discomfort connected with injection of opaque media into the cerebral circulation are obvious. This technique is adequate ly described for an intelligent grasp of the subject.

Emphasis , however, has been placed on the B-ocan technique, or ultra-sonic tomography of the brain. Al though the monograph is s ta ted to be primarily for physicians who have no special familiari ty with medical electronics or engineering, there are few, even among neurologists or neurosurgeons, with a wide experience of this technique. Many technical problems exis t in connection with linear and compound (sector and circular) scanning and interpretat ion is difficult.

Al though these techniques m a y offer a great deal in the future the subject is in its infancy and as the author himself points out some aspects of the material presented in the monograph inevitably may prove to be of t ransient value.

M:CHA~L WALDRO~¢.

Glaucoma in Ophthalmic Practice. By W. LEYnHECXER. Churchill, London, 1966. 21/-. This is an excellent authori tat ive and practical s u m m a r y of the modern managemen t

of glaucoma. I t is writ ten as a short guide for the practising ophthalmologist and shows how to diagnose and t reat glaucoma in daily practice. The me thods he describes as those "which have stood the tes t of m y own experience".

The au thor continues: "The progress of simple glaucoma is generally as good as the surgeon who t rea ts it and this little book a t t emp t s to show how this t r ea tmen t can be carried out ". There is no extended discussion of theory, etc., h u t twenty-two excellent basic references are given.

Par t I (19 pages) describes clinical types of glaucoma. Par t I I (42 pages) describes methods of examination, including gonioseopy, provocative tes ts , etc. Par t I I I (11 pages) describes medical t r ea tmen t and supervision of the pat ient in pr imary glaucoma, including advice to pat ients and the mean ing of pressure regulation. Par t IV (10 pages) deals with indication for and choice of operation. Par t V (2 pages) describes common errors i n practice.

There is a useful index. The tone is dogmatic with emphas is on the practical avoidance of loss of vision due

to glaucoma. The au thor ' s views are well known in stressing the destruct ive effects of small rises

in intraoeular pressure over long periods of t ime. While he does not ignore the possible importance of local pathology in the optic nerve the emphasis on rise m pressure is a little out of step with current t rends in these islands. The excellent practical diagnostic approach in a short s u m m a r y of his longer handbook no doubt makes this inevitable.

The possibility of recognising a high normat ive pressure wi thout nerve damage migh t be included in fur ther editions in order to avoid the possibility of prescribing unnecessary t rea tment . Ocular hypertension is not ment ioned as such and the au thor s ta tes on page 3 : "The opposite conception 'hyper tens ion without glaucoma' is out-dated. In this condition glaucoma is certainly present , bu t the damage due to the pressure rise has not yet become evident ." In fact, diagnosing glaucoma where it is not present will be difficult if the information contained in this book is used. Nonetheless, if in doubt it is bet ter to observe rather t h a n to t rea t pressures only slightly above normal, e.g. 24 ram. Hg.

This is the best available compact accounb of everyday diagnosis and t r ea tment of pr imary glaucoma.

G. EVERARD ~EWSOI~.

Hysteria and Related Mental Disorders. By D. W. ABSE. John Wright & Sons Ltd. 42/-. This book features an approach to psychological medicine t h a t is different to the

general run of t ex t books on the subject, based on the belief t ha t an adequate s tudy of hyster ia can open the gateway to the whole field of psychological medicine.

BOOK REVIEWS 3 9 3

Fol lowing a de ta i led a c c o u n t o f t h e p sycho-pa tho logy , s y m p t o m s and s igns , d iagnos i s a n d t r e a t m e n t of hys t e r i a b a s e d on t h e a u t h o r ' s exper ience whi ls t work ing in t h e U n i t e d K i n g d o m a n d Ind i a du r i ng 1942-1946 a n d s u b s e q u e n t l y in Amer i ca , he h a s a c c u m u l a t e d a v a s t a m o u n t o f clinical ma te r i a l . A p p a r e n t l y t h e incidence o f h y s t e r i a is h i g h a m o n g s t y o u n g m a l e s in Ind ia , a n d it was f rom the s t u d y of th i s ma t e r i a l t h a t t h e a u t h o r deve loped his a p p r o a c h to t h e whole field o f psychologica l medic ine . H a v i n g t r e a t e d hys t e r i a in detai l as a d isease en t i ty , he t h e n d i scusses t h e differential d iagnos is a n d i l lus t ra tes wi th cases t he i m p o r t a n c e o f recognis ing t he organic disease t h a t p r e s e n t s w i t h a n hys t e r i ca l over lay a n d is so f r e q u e n t l y m i s sed . T h e r e is a ve ry good sec t ion on sch izophren ia a n d i ts d i agnos i s f r o m hys te r i a , b u t w i th r e cen t r e sea rch on t h e ae t io logy of schizophrenia , s u g g e s t i n g t h e b iochemical fac tor , or d i s t u rbed m e t a b o l i s m , n o t all would agree wi th t h e thes i s t h a t the re can be a t r a n s i t i o n f r o m hys t e r i a to sch izophren ia , or t h a t n e u r o s e s develop into p sychoses . I n t h e chap t e r s on h y p n o i d s t a t e s a n d mul t ip l e persona l i t i es t h e a u t h o r leans heav i l y on F r e u d and p s y c h o a n a l y t i c a l t e c h n i q u e s a n d in t e rp re t a t ions , pa r t i cu la r ly in t he case o f t h e housewife wi th t he two persona l i t i e s " B e t t y a n d E l i z a b e t h " .

T h e sec t ion on p s y c h o t h e r a p y a n d t r e a t m e n t o f h y s t e r i a is ba sed aga in on p s y c h o a n a l y s i s which l imi ts i t s u se fu l ne s s a n d m u s t h a v e l im i t a t i ons in genera l hosp i t a l p sych ia t r i c pract ice. W i t h i n t h e t e r m s of reference t h e a u t h o r h a s m a d e a w o r t h whi le c o n t r i b u t i o n to psych ia t r i c l i t e ra ture . H e ha s a p l e a s a n t f lowing s tyle wh ich is e a s y to r e ad a n d t he m a n y de ta i led case records serve to ho ld t h e r eade r ' s a t t e n t i o n . T h e s t a n d a r d o f p roduc t ion is w h a t one h a s come to expec t o f t h e pub l i she r s a n d the re is a n e x t e n s i v e b ib l iography a n d a sub jec t a n d a u t h o r index , t h a t m a k e i t va luab le a s a b o o k of reference. I t c an be r e c o m m e n d e d to all t r a i n e d p s y c h i a t r i s t s a n d t h o s e s t u d y i n g for h igher qual i f icat ions .

J o ~ P . M~,LG~E.

A b*ynopsis of Rheumatic Diseases. BY D. N. GeLDInG. J o h n W r i g h t & Son, Bris tol 30/- .

I n r e cen t yea r s T idy ' s Synops i s o f Medicine ha s been rep laced b y smal l v o l u m e s b y d i f ferent a u t h o r s deal ing w i t h each spec ia l ty separa te ly . Th i s book is one o f t he sho r t e s t - - u n d e r 200 pages a n d it is p l e a s a n t to see t h a t a n I r i sh g r a d u a t e h a s b e e n chosen to cover t h e subjec t . He does so m o s t sa t i s fac tor i ly , c o n f o r m i n g to t he s t a n d a r d s t y l e - - v e r y c o m p r e s s e d a n d wi th mu l t i p l e sub -head i ngs a n d no i l lus t ra t ions , or references . T h e a p p r o a c h is v e r y u p - t o - d a t e b o t h w i t h r ega rd to d iagnos i s a n d t r e a t m e n t a n d the re is a no t i ceab le absence o f unrea l i s t i c (bu t t rad i t iona l ) m a t e r i a l t h a t t e n d s to be carr ied over f r o m earl ier t e x t books. T h i s is a n exce l len t e x a m p l e of t h e Synops i s s e r i e s - - w h i c h ca t e r pa r t i cu l a r ly for t he p o s t - g r a d u a t e rev is ing for e x a m i n a t i o n , a l t h o u g h m a n y earlier a n d la te r in the i r careers will f ind it h i g h l y in fo rma t ive .

J. G. KIRKER.

Genetics in Medicine. B y J . S. THOMPSON a n d M. W . THOraPSO~. L o n d o n , W. B . Saunder s . £2 12s. 6d.

T h i s book of u n d e r 300 p a g e s is w r i t t e n by a h u s b a n d a n d wife f r o m t h e Medica l School o f t he U n i v e r s i t y of Toron to . T he pceface s t a t e s t h a t it a i m s m a i n l y a t t he med i ca l s t u d e n t . I n s ty le it is l ively w i t h good pr in t ing , n u m e r o u s d i a g r a m s a n d t e s t ques t i ons , b u t it r equ i re s a n equa l ly h i gh s t a n d a r d o f a le r tness a n d c o n c e n t r a t i o n f r o m the reader . I n pa r t i cu l a r each page s e e m s to i n t roduce f resh t echn ica l t e r m s a n d a g lo s sa ry o f 200 of t h e s e conc ludes t h e book. As a n i n t r o d u c t i o n it s hou ld se rve t h e k e e n a n d scient i f ical ly m i n d e d s t u d e n t well, b u t i t is n o t for t h e slow or casua l , no r does it se t ou t to be a re ference book for t he c l inician c o n f r o n t e d wi th a pa r t i cu l a r gene t i c p rob lem.

J. G. KIRKER.

Oral Ant~d~abetic Therapy 1956-1965. W i t h pa r t i cu la r r e fe rence to To lbu~amide (Orinase) . BY H. A. TUCKER, M . D . C . C . T h o m a s .

T h e second pa r t o f t he t i t le is s ignif icant , for t he a u t h o r is a m e m b e r o f t h e med ica l d iv is ion o f t h e U p j o h n C o m p a n y . He p r e s e n t s a n a n n o t a t e d b ib l iog raphy compi led f rom records m a i n t a i n e d in t h e l ib ra ry o f t h a t C o m p a n y a n d t h u s p rov ides a r ap id re ference to 1,706 pape r s on oral an t id iabe t i e t r e a t m e n t pub l i shed before t h e e n d of 1963. T h e r e is a n i n d e x b y sub jec t a n d one b y a u t h o r . T he sub jec t i n d e x h a s 132 re fe rences u n d e r or inase a n d one unde r ch lo rp ropamide , a n d none u n d e r p h e n f o r m i n (or dibot in) . P e r h a p s t h e t i t le shou ld have r e a d - - " O r i n a s e T h e r a p y in D i a b e t e s Mel l i tus" .

M. I . D~uRY.

Essentials of Automatic Ventilation of the Lungs. BY A. R . HUIffTER. L o n d o n , J . A. Churchi l l . 16/-.

T h i s l i t t le bookle t o f e i g h t y pages g ives a br ie f cove rage to all a spec t s of art if icial v e n t i l a t i o n o f t he l ungs in s imple t e r m s , excep t ven t i l a t i on in n e o n a t a l a n d paed ia t r i c p rac t ice .

The book s t a r t s wi th e l e m e n t a r y i n f o r m a t i o n on a i rways , t ubes , t r a c h e o s t o m i e s a n d

394 IRISH JOURNAL OF MEDICAL SCIENCE

continues to describe simple means of providing artificial ventilation. The later chapters on the characteristics of mechanical ventilators and the descriptions of commonly used ventilators arc well done though Dr. Hunter ' s classification may be difficult to follow.

There is a good clinical guide as to how a patient is established on a ventilator using the Radford nomogram, which is inetuded in the t ex t and listing all the complications which may arise. This is followed by details of assessing the adequacy of ventilation by blood gas analysis which important aspect is well covered. Valuable information is incorporated in this chapter. Simple monitoring of mechanically ventilated patients such as pulse and blood pressure charting and regular chest x-raying got no mention. Food and fluid balance, control of infections, suction of the lungs, communication, general nursing care and sedatives (for which Dr. Hunter recommends phenoperidine) are briefly, but adequately covered. Early feeding and daily electrolyte balancing are hardly stressed enough.

There is practical information on sterilisation techniques, means of humidification and speaking valves to fit Radford t racheostomy tubes.

This booklet is highly recommendable as a guide to any doctor, or nurse who may be entrusted with the care of artificial ventilation, or to anyone who is interested in a complete summary of this expanding and exciting branch of anaesthesia.

The sketches are good and the references many. -It is agreeably presented, though I have noticed printing errors. I t is wisely published as a booklet, thereby keeping down the cost. MICHA~.L F. CU~TIN.

Treatment of Inoperable Cancer. BY WINr'RIED I-IERBERGER. John Wright and Sons, Ltd. 42/-.

The management of advanced malignant disease is probably best carried out, ff at all possible, in the pat ient 's home ra ther than in an institution, as most people, especially the elderly, are happier when in familiar surroundings. The work, accordingly, usually falls to the lot of the family doctor, and, depressing though it is, is frequently, in a way, rewarding. To minimize a pat ient 's sufferings, both physical and mental, may call for skill, judgment , tac t and sympathy of a high order and demand the highest qualities, professional and personal, from the medical a t tendant . Dr. Herberger has obviously had considerable experience of these cases and his book is intended mainly for the benefit of practitioners who are called upon to cope with them. I-Ie very rightly lays considerable stress upon the general management of the patient and although he mentions and describes a number of so-called "Cancer t rea tments" he is not very enthusiastic about any of them, as can be readily understood. The book is quite well t ranslated and reason- ably easy to read. F . J . HENRY.

Respiratory Function in Disease. An Introduction to the Integrated Study ofrthe Lung. by D. V. BATES, M.D. and 1%. V. CHRISTIE, M.D. W . B . Saundcrs and Co. Ltd. £5 8s. 6d.

Bates and Christie is a title tha t will come easily to the mind and to the tongue, when one discusses lung disease and it will be easy to quote. The mat te r contained in this volume makes it well worth quoting.

The first eighty pages or so are devoted to the description of the methods available for the investigation of lung function, the significance of the information produced by them and hence the changes effected by disease. This is not al together easy reading. I t needs close attention, but such a t tent ion and study are well repaid in the information as to lung function which can so be acquired. I do not think tha t any physician who wishes to speclalise in diseases of the lungs could need more information on the essentials of pulmonary investigation than is here so lucidly produced for him.

From page 128 to the end, this book is a condensed textbook of disease of the respiratory system, with case histories showing the application of the methods described in the earlier part to the problems presented by the diseases described in the latter part. Naturally it is not a complete tex t book of these diseases, but there is so much valuable information stripped to the bare bones, tha t any s tudent could learn much from it.

The authors undoubtedly combine the best of two worlds. They work in Canada, have worked in England and have not neglected the important work of the U.S.A. I t is to me particularly pleasing to note the use made of the work of Moran Campbell, who has done so much to bring laboratory methods to the bedside and unite the worlds of physiologist and physician. In the section on bronchiectasis I regret the failure to recognise the importance of Whitewell 's work. ~Ie is just quoted, but I feel tha t here as in other tex t books, his paper on the pathogenesis of bronchieetasis does not receive the a t tent ion it deserves.

The book is what one would expect from the house of Saunders. I t is beautifully produced on glazed paper and with no misprints tha t I noticed. The reproductions of radio-graphs are inevitably somewhat uDsatisfactory, but are be t te r t~an the average. There is a very good bibliography and the general index is adequate. The double

dumn lay-out makes for quick reading, and the price is remarkably low for such a work. cordi~,lly recommend it. BRENDAN O'BI~IEN.