743

work. They should acknowledge in the manuscript allfinancial support for the work and other financial or personalconnections to the work.

Reviewers

External peer reviewers should disclose to editors anyconflicts of interest that could bias their opinions of themanuscript and they should disqualify themselves fromreviewing specific manuscripts if they believe it appropriate.The editors must be made aware of reviewers’ conflicts ofinterest to interpret the reviews and judge for themselveswhether the reviewer should be disqualified. Reviewersshould not use knowledge of the work, before its

publication, to further their own interests.

Editors and staff

Editors who make final decisions about manuscriptsshould have no personal financial involvement in any of theissues they might judge. Other members of the editorialstaff, if they participate in editorial decisions, should provideeditors with a current description of their financial interests,as they might relate to editorial judgments, and disqualifythemselves from any decisions where they have a conflict ofinterest.

Published articles and letters should include a descriptionof all financial support and any conflict of interest that, in theeditors’ judgment, readers should know about.

Editorial staff should not use for private gain theinformation gained through working with manuscripts.

BOOKSHELF

The Making of a Doctor

Medical Education in Theory and Practice. R. S. Downie,B. Charlton. Oxford: Oxford University Press. 1992. Pp 203.22.50. ISBN 0-19262136X.

Recent excavations at the Asclepion have shown noevidence that Hippocrates and his team were carryingbleeps. This is the first conclusive evidence that medicinehas changed; it is now much more effective. We can cureinfections, take out gallbladders, blast away stones, anderadicate tumours. Everybody wants some of the action andpatients ask that this will be given politely, quickly, and freeof complication. Managers require that this action shall takeplace without increasing the budget. There is a danger thatmedicine will become a patching-up service, forgetting itsadditional role as a positive promoter of health. Theremarkable thing is that there are still queues of recruits atthe medical schools to join the battle. Is it certain that newdoctors will be equipped to meet these pressures andparadoxes?Change is fashionable, and medicine as a reflection of

society is expected to change also. Yet before turning themedical course on its head, it is worth remembering thatmillions of satisfactory consultations between doctor andpatient are taking place every year. Is there really a need for adramatic metamorphosis? R. S. Downie and BruceCharlton argue strongly that there is. The whole medicalcourse is rotten and this particular tree of knowledge willsoon collapse. Medical student selection is arbitrary, thepreclinical course is irrelevant, the clinical course is a kind of"careers fair" of short visits to departments, and thehousemanship is pure graft. The authors suggest gradualbut sweeping changes to the UK medical course.

Their suggestion for more adventurousness in medicalstudent selection is interesting although somewhat

worrying. A conservative profession should look at thefigures from the medical defence organisations and GeneralMedical Council before changing selection procedures. Themain legal complaints against the medical profession areerrors of omission-failure to visit, failure to refer, andfailure to reach a correct diagnosis. The GMC proceedingsalso suggest a failure to cope-alcohol, sex, drugs, and fraud.

If we are going to select for good communication skills,conscientiousness, and robustness of personality, this is

unlikely to be detected by A levels or interview. Wouldpersonality tests or a two-day assault course be morereliable? (By the way, what happened to the results of thesinister test inflicted on us as entrants to Newcastle medicalschool in 1963?)Downie and Charlton believe that the preclinical

curriculum should concentrate on a core of informationessential for clinical practice rather than the presentinformation overload approach. They also suggest thatmuch of the time in preclinical work should be dedicated to aparticular student project to teach scientific method. Theymake no mention of information technology or managementskills as essential inputs into this phase. Computer-assistedlearning could be an efficient way for some students to learnthe "core" information. Certainly, time vacated in thepreclinical course could be occupied with other interestingactivities. Instead of academic occupational health lectures,let students accompany someone in their daily work routinesand invite their critical assessment of the health implicationsof their way of life. Instead of adding clinical presentations tothe end of the study of a system, bring it forward so thatpreclinical learning projects are built around the patient.Downie and Charlton suggest more arts involvement in a

preclinical course-perhaps they could study a novel asproject work.

In the clinical phase, short visits to departments musthave some function in acquainting the clinical student withthe diversity of medicine. Downie and Charlton are right insaying that this approach can be overdone, and personalemulation or "modelling" cannot take place with such shortimpersonal exposure. A return to the clinical clerkship maybe the ideal; a student would be attached to particular firmsor general practices for longer intervals to absorb the ethosand to become a part of the clinical team. Improvement inthe preregistration year cannot be achieved without asubstantial amount of money. The recent allocation of 50%of resources for training posts to the postgraduate deans isone way of forcing improvement, but it is not a magicsolution and does not increase the total cash available.

Perhaps the final year at medical school could become a

744

junior house-officer year, extending the time of training inpractice without the need for substantially increasedresources.

The importance of a close-knit peer group as a means oflearning, criticism, and professional development isunderestimated as an important factor in learning. Whatexactly is the "core" of medicine as a profession if somepeople are going to unravel DNA replication mechanismsand others to unravel the conflict in former Yugoslavia?Perhaps the medical course content is irrelevant and themost important thing is to allow doctors to develop in acontrolled environment. Hippocrates could not have

envisaged the diverse consequences of his initiative.

Clinical Oncology Unit,University of Bradford,West Yorkshire BD7 1 DP, UK DENNIS PARKER

In-situ hybridization: a practical approachEdited by D. J. Wilkinson. Oxford: IRL Press at OxfordUniversity Press. 1992. Pp 210. 30. ISBN 0-199633282.

In biological and clinical laboratories across the globemolecular biology is the order of the day. Since theintroduction of in-situ hybridisation in 1969, manydifficulties have had to be overcome in working outappropriate methodology, but the technique is nowestablished as a powerful research and diagnostic tool. Thedetection of specific nucleic acid sequences-RNA, viralDNA, or chromosomal DNA-at a cellular and sub-cellularlevel has many important applications in medicine. Analysisof the spatial and temporal regulation of expression ofindividual genes is a crucial step towards understandingtheir physiological and pathophysiological roles. In-situdetection of viral sequences provides insight into the

pathology of viral infections and is enabling us to understandseveral human diseases that were previously cloaked inmystery-eg, the role of Epstein-Barr virus in Hodgkin’sdisease. The detection of chromosomal DNA sequences has

many applications, including mapping of the genome andrapid analysis of chromosomal rearrangements.How does the apprehensive clinical investigator get to

grips with the technology and become one of the elite "club"of practitioners in this art? There was a time when the onlyanswer was to mix with the long hair and sandal brigade toacquire precious and tattered photocopies of magicalprotocols and formulations. Do we still need to becomesorcerers’ apprentices to acquire this technology? Thereductionist view is that a recipe book is all that is required.The truth is that such skills lie somewhere between sorceryand cookery; success with in-situ hybridisation comes frommixing of the two.The popular IRL Press Practical Approach series is a

diverse set of specialised manuals for molecular biology andbiochemistry. This new volume aims to explain anddemonstrate the basics, not to professional molecularbiologists but to less skilled investigators who need a soundpractical knowledge of available techniques. This bookprovides a valuable summary of what is possible with today’stechnology, how to go about setting the methods up, andwhat the limitations of these techniques are. Step-by-stepprotocols are aided by concise explanations of the theoryunderlying each procedure. Wilkinson has achieved

consistency from his contributors in both depth andpresentation of topics, which range from basic investigativeprocedures to more state-of-the-art techniques.

The notion underpinning this reference text is that anabsolute beginner can make a practical start, while the moreexperienced molecular biologist will fmd some new

methodological approaches. Readers who plan to cut theirmolecular teeth with this book will do well to bear in mind

that, while they are provided with an adequate startingprotocol, successful results will require continuous fine-tuning. Herein lies the sorcery of in-situ hybridisation.

Department of Clinical Chemistry,University of Birmingham,Birmingham B15 5 2TT, UK ANN LOGAN

Infection in Surgical Practice

Edited by Eric W. Taylor. Oxford: Oxford University Press.1992. Pp 422. ,E60. ISBN 0-192620231.

Do you know the difference between a disinfectant and an

antiseptic, or that postoperative infection costs the UKbetween 100 million and C200 million annually, or that1 % is the aim and 2 % the limit of acceptability for infectionfollowing clean surgery? The first chapter gives you all thefacts needed for an informed discussion of preoperativeshaving, skin preparation solutions, drape materials,duration of hand scrub, use of drains, and gloveperforations. Historical background, defmitions (except,surprisingly, of the word nosocomial), theory, and

practicalities then follow, ending with an economist’s viewabout the value of infection reduction. I found two

unexpected desert island choices in this section: an excellentanalytical approach to scoring systems-in general and forsepsis in particular-and a superbly succinct chapter oncytokines, the cellular biology of wound (non-)healing, andmultiple organ failure syndrome.The larger second part of the book considers surgical

infection by surgical specialty and organ, but also includeschapters on gunshot and war surgery, AIDS,postsplenectomy infection, infection in intensive care units,and selective gut decontamination. Sampling these 20chapters reveals several shortcomings. Some (eg, accidentand emergency, breast infection) are too comprehensive(including management of seal bites!), while others providegood theoretical coverage but fail to give up-to-date practicaladvice. For instance, the discussion on postsplenectomyinfection omits any reference to the newer 23-valent

pneumococcal vaccine. The orthopaedic chapter is verylight on the raison d’etre of this book-infection-and is fullof ex-cathedra dogma. Although some of the best chaptersare dogmatic, these are well argued and substantiated bycontemporary references. I commend especially the

chapters on war surgery, pancreatitis, and AIDS.Areas of controversy which receive scant if any debate

include eusol, high-technology (and expensive) dressingmaterials, choice of decontaminating peritoneal lavagesolutions, suction-versus-passive closed drainage systems(open drains are rightly condemned), fungal septicaemia,and the ill-fated monoclonal endotoxin antibody. Thehigh-table pedigree of the publishing house mightreasonably be expected to confer immunity against howlerssuch as it’s for its, effect for affect, diverticulae fordiverticula, and abcess. Surgical fallibility extends beyondthe operating table.

Watford General Hospital,Watford WD1 8HB, UK JOHN MEYRICK THOMAS

745

Chiropractic: History and Evolution of a NewProfession

Walter I. Wardwell. St Louis: Mosby. 1992. Pp 352. 29.ISBN 0-801668832.

Walter Wardwell is an emeritus professor of sociologywho has devoted years of observation and study to themarginal healing profession of chiropractic. He is a carefuland scholarly analyst and brings to his descriptive inquiry anunusual depth of knowledge derived from his experience as alifelong client of chiropractic. That fact does not seem tohave influenced his objectivity. He neither scornfully rejectsnor naively accepts what he has learned; he simply offers acool and critical scrutiny of his subject.

Chiropractic was established in an era when modemmedicine and its awesome technology had not yetdeveloped. It appealed to a constituency wary of ordisappointed by the regular medical establishment.

Claiming both physiological and therapeutic authenticity,chiropractic has survived and flourished. Wardwell

recognises that "since many diseases are self-limiting,puzzling as to cause or prognosis, unpredictable, andintractable, the value of any therapeutic intervention is

problematic. Hence the therapist often receives unearnedcredit or blame for the outcome". Patients and physiciansknow that, despite the failure to validate claims of efficacy,there are real benefits from chiropractic manipulations inseveral musculo-skeletal conditions. Yet the orthodoxmedical establishment remains hostile.Wardwell notes, drily: "Ideally, reason, science, and logic

should govern health behavior, but they do not." From hisobservations in the US, where he estimates that there arenearly 50 000 practitioners and perhaps 25 million clients,chiropractic’s future seems assured. And in the UK, similarassurance may be drawn from chiropractic’s royalimprimatur: Princess Diana is the patron of the Anglo-European College of Chiropractic in Bournemouth. Theloyalty of millions of patients leads Wardwell to believe thatchiropractic will neither disappear nor be absorbed into themainstream of medicine. Because of this loyalty, and thelegal acceptance into insurance payment schemes, hebelieves the chiropractors "... will evolve slowly into a’limited medical’ status comparable to dentists, podiatrists,optometrists and psychologists".Yale University School of Medicine,New Haven, Connecticut 06511, USA GEORGE A. SILVER

A History of HypnotismAlan Gauld. Cambridge: Cambridge University Press. 1992.Pp 738. /;75. ISBN 0-521306752.

Hypnosis is steeped in mystery, misconception, andmisinformation. Some practitioners would argue that thisvery mystique, together with the expectations that go with it,is an essential component of the art. Many of my colleagueswere unaware of my interest in the subject until thepublication of our first Lancet paper (1984; ii: 1232-34).Now, some of the most erudite members of our professionavoid eye contact with me for fear of my casting some sort ofspell on them-a good example of the powerful folkloresurrounding the subject.Dr Gould charts the history of hypnosis from its early

beginnings with F. A. Mesmer in the 1770s to the presentday. He gives an interesting and detailed account of the

major contributors up to the first world war, sprinkling thetext with case histories and anecdotes. It soon becomes

apparent that the subject baffled these early workers just as itdoes those of today. Unfortunately, he skips the era from thefirst world war to the 1960s entirely because, he says, thisperiod has been dealt with by previous authors. Even thetime from the 1960s onwards is dealt with in much lessdetail. Nevertheless, for those who want a complete historyof the early phase of hypnotism, this book is well worthreading.A History of Hypnotism will not teach interested readers

how to do hypnosis, although the historical background toany subject is always useful. The technique is almost

impossible to learn from any book and is much better

acquired by attending a good practical course. It is

surprisingly easy for anybody to hypnotise just aboutanybody else; and, paradoxically, this can be one of thegreatest drawbacks of hypnotism in medicine. The verysimplicity of hypnosis often leaves practitioners flounderingwhen they try to master the really difficult part of thetechnique-ie, its therapeutic application. This aspectrequires hours of practice and endless modifications

according to the patient’s needs.

Department of Medicine,University Hospital of South Manchester,Manchester M20 8LR, UK P. J. WHORWELL

Selected Books: Nephrology

Toxicology of the Kidney-2nd edn. Edited by Jerry B. Hook, Robin S.Goldstein. New York: Raven. 1992. Pp 572.$144. ISBN 0-881678856.

Autoimmunity in Nephritis-Edited by F. W. Ballardie. Switzerland:Harwood Academic. 1992. Pp 140. 17. ISBN 3-718651955.

Renal Physiology (vols 1 and 2)-Edited by Erich E. Windhager.Oxford: Oxford University Press. 1992. Pp 1184 and 2516. 120. ISBN0-195060067.

Moving Points in Nephrology (Series: Contributions to Nephrology102)-Edited by G. M. Berlyne, S. Giovanetti. Basel: Karger. 1992. Pp 270.SFr 246/DM 295/107/$197. ISBN 3-80555642X.

Atlas of Genitourinary Tract Infections-Marrin J. Wood, W. EdmundFarrar. New York: Gower. 1992. Pp 128.$87.50. ISBN 1-563755548.

Endpiece

Chronic idiopathic intestinal pseudo-obstruction (CIIP).Patients who present with symptoms and signs of an obstructive ileus,

yet who have no physical evidence of obstruction at laparotomy, are saidto have pseudo-obstruction. If no motility disorder can be found then Cl I Pis deemed idiopathic and results from either smooth muscle myopathy orintestinal neuropathy. Taken from Normal and Disturbed Motility of theGastrointestinal Tract by André J. P. M. Smout and Louis M. A.Akkermans (Petersfield. Wrightson Biomedical. 1992. Pp 313. £26.50.

ISBN 1-871816157 )