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Salmonella-specific antibodies in reactive arthritis. J Infect Dis 1991;164: 1141-48.

6. Calm A, Goulding N, Brewerton D. Reactive arthropathy followingsalmonella vaccination. Arthritis Rheum 1987; 30: 1197.

7. Isomaki O, Vuento R, Granfors K. Serological diagnosis of salmonellainfections by enzyme immunoassay. Lancet 1989; i: 1411-14.

8. Mäki-Ikola O, Viljanen MK, Tiitinen S, Toivanen P, Granfors K.Antibodies to arthritis-associated microbes in inflammatory jointdiseases. Rheumatol Int 1991; 10: 231-34.

9. Granfors K, Jalkanen S, Lindberg AA, et al. Salmonella

lipopolysaccharide in synovial cells from patients with reactive arthritis.Lancet 1990; 335: 685-88.

10. Mäki-Ikola O, Yli-Kerttula U, Saario R, Toivanen P, Granfors K.Salmonella-specific antibodies in serum and synovial fluid in reactivearthritis. Br J Rheumatol 1992; 31: 25-29.

11. Gaston JSH, Life PH, Granfors K, et al. Synovial T lymphocyterecognition of organisms that trigger reactive arthritis. Clin ExpImmunol 1989; 76: 348-53.

12. Brewerton DA. Causes of arthritis. Lancet 1988; ii: 1063-66.13. Granfors K, Jalkanen S, Mäki-Ikola O, Toivanen P. Bacterial antigens in

reactive arthritis: studies on yersinia- and salmonella-triggeredarthritis. In: Lipsky PE, ed. Proceedings of the Second InternationalSimmons Center Conference on HLA-B27 related disorders. NewYork: Elsevier Science Publishing (in press).

14. Granfors K, Jalkanen S, von Essen R, et al. Yersinia antigens insynovial-fluid cells from patients with reactive arthritis. N Engl J Med1989; 320: 216-21.

15. Viitanen A-M, Arstila TP, Lahesmaa R, Granfors K, Skurnik M,Toivanen P. Application of polymerase chain reaction andimmunofluorescence techniques to the detection of bacteria in

yersinia-triggered reactive arthritis. Arthritis Rheum 1991; 34: 89-96.16. Keat A, Thomas B, Dixey J, Osborn M, Sonnex C, Taylor-Robinson D.

Chlamydia trachomatis and reactive arthritis: the missing link. Lancet1987; i: 72-74.

17. Schumacher HR Jr, Magge S, Cherian PV, et al. Light and electronmicroscopic studies on the synovial membrane in Reiter’s syndrome.Immunocytochemical identification of chlamydial antigen in patientswith early disease. Arthritis Rheum 1988; 31: 937-46.

18. Wordsworth BP, Hughes RA, Allan I, Keat AC, Bell JI. ChlamydialDNA is absent from the joints of patients with sexually acquiredreactive arthritis. Br J Rheumatol 1990; 29: 208-10.

19. Hammer M, Zeidler H, Klimsa S, Heesemann J. Yersinia enterocolitica in

the synovial membrane of patients with yersinia-induced arthritis.Arthritis Rheum 1990; 33: 1795-1800.

20. Lahesmaa-Rantala R, Granfors K, Isomaki H, Toivanen A. Yersiniaspecific immune complexes in the synovial fluid of patients withyersinia-triggered reactive arthritis. Ann Rheum Dis 1987; 46:

510-14.21. Unanue ER, Allen PM. The basis for the immunoregulatory role of

macrophages and other accessory cells. Science 1987; 236: 551-57.22. Jalkanen S. Leucocyte-endothelial cell interaction and the control of

leucocyte migration into inflamed synovium. Springer Semin

Immunopathol 1989; 11: 187-98.23. Repo H, Leirisalo-Repo M, Koivuranta-Vaara P. Exaggerated

inflammatory responsiveness plays a part in the pathogenesis ofHLA-B27 linked diseases—hypothesis. Ann Clin Res 1984; 16: 47-50.

24. Granfors K, Ogasawara M, Hill JL, Lahesmaa-Rantala R, Toivanen A,Yu DTY. Analysis of IgA antibodies to lipopolysaccharide in

yersinia-triggered reactive arthritis. J Infect Dis 1989; 159: 1142-4725. Mäki-Ikola O, Hill JL, Lahesmaa R, Toivanen A, Granfors K. IgG and

IgA responses against porins in yersinia-triggered reactive arthritis.Br J Rheumatol (in press).

26. Inman RD, Chiu B, Johnston MEA, Vas S, Falk J. HLA class I-relatedimpairment in IL-2 production and lymphocyte response to microbialantigens in reactive arthritis. J Immunol 1989; 142: 4256-60.

27. Viner NJ, Bailey LC, Life PF, Bacon PA, Gaston JSH. Isolation ofyersinia-specific T cell clones from the synovial membrane andsynovial fluid of a patient with reactive arthritis. Arthritis Rheum 1991;34: 1151-57.

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patient with post-infectious salmonella arthritis. Scand J Rheumatol1990; 19: 350-55.

29. Stieglitz H, Fosmire S, Lipsky P. Identification of a 2-Md plasmid fromShigella flexneri associated with reactive arthritis. Arthritis Rheum 1989;32: 937-46.

30. Mäkela PH, Hovi M, Saxen H, Valtonen M, Valtonen V. Salmonella,complement and mouse macrophages. Immunol Lett 1988; 19: 217-22.

31. Duncan RL Jr, Morrison DC. The fate of E coli lipopolysaccharide afterthe uptake of E coli by murine macrophages in vitro. J Immunol 1984;132: 1416-24.

32. Munford RS, Hall CL. Detoxification of bacterial lipopolysaccharides(endotoxins) by a human neutrophil enzyme. Science 1986; 234:203-05.

BOOKSHELF

Research Issues in Human Behavior and SexuallyTransmitted Diseases in the AIDS Era

Edited by J. N. Wasserheit, S. 0. Aral, and K. K. Holmes.Washington, DC: American Society for Microbiology. 1991.Pp 391.$48. ISBN 1-555810635.

Genuine interdisciplinary approaches to the control ofhuman immunodeficiency virus (HIV) and other sexuallytransmitted diseases are long overdue and this multi-author"monograph" is an attempt to bring biomedical andbehavioural scientists around the same table to address someof the problems. The book grew out of two US conferencesrun by the National Institute of Allergy and InfectiousDiseases in 1989 and 1990, which aimed to define abehavioural research agenda for sexually transmitteddiseases and HIV. How far have the authors succeeded? It is

refreshing to see one book, amidst a pandemic of new textson the topic, which places HIV in the context of othersexually transmitted diseases and attempts to bring it withinthe bounds of our existing knowledge of epidemiology andcontrol. It serves to remind us that old principles can beapplied to new problems. The inclusion of chapters fromestablished disciplines such as ethnography, social

psychology, and social marketing, to name but a few, leavesthe reader in no doubt that we should not be surprised thatincreased knowledge alone fails to lead to changed sexualbehaviour; and that there is much to be learned from

studying the influence of beliefs, cultural norms, andsocioeconomic climate on the spread of sexually transmitteddiseases in the developed and the developing world alike.Time, perhaps, for the policy-makers to rethink their focuson quantitative research and to remember the contributionthat good qualitative research can make to policy-makingand intervention.

So far so good: here is much food for thought. Where thebook falls down, as with so many multi-author texts, is in thestriking variability in the quality of contributions; repetition;a tendency for some basic epidemiological parameters, suchas incubation period and transmission probabilities, to begiven different definitions and values in different parts of thetext; and a plethora of behavioural taxonomies and models.These failings may present an impenetrable maze forstudents new to the discipline. In places, more could bemade of research achievements during the HIV epidemic,particularly in our understanding of sexual behaviour. Butreaders are correctly reminded of the hitherto limitedevaluation of outcome and effectiveness of investment inbehavioural interventions, and the need to apply establishedand rigorous scientific methods to the assessment of futureprogrammes. Among the many papers there are some veryworthwhile contributions, particularly from the editorsthemselves. Largely because of the different styles andapproaches the book lacks sufficient cohesiveness to providethe definitive text in its professed goal of "defining a

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behavioral research agenda", but it does open an importantdialogue and should remind researchers that a great deal canbe learned from established disciplines. If the editors

thereby save us from slowly retracing past steps and

relearning basic lessons of old their book will make a usefulcontribution.

Academic Department of Genitourinary Medicine,UCMSM, Middlesex Hospital,London W1 N 8AA, U K ANNE M. JOHNSON

Epidemiology of Peripheral Vascular DiseaseEdited by F. G. R. Fowkes. Berlin: Springer-Verlag. 1991. Pp366. DM 225/80.50. ISBN 3-54019696X.

At last! It is refreshing to see a book devoted to theepidemiology of peripheral arterial disease. The title is alittle misleading because venous disease and all of the lesscommon vascular disorders are ignored: this book is aboutatherosclerosis, and its effects on peripheral arteries. Itderives from a symposium held in 1991, so the contributionsare reasonably up to date. Within its self-imposed limits, therange of topics included is impressive, even though coverageis occasionally superficial (for example, only 4 pages aredevoted to diabetes mellitus compared with 7 on

personality). On the other hand, some aspects of undoubtedimportance such as lipids, cigarette smoking, hypertension,fibrinogen, and cardiovascular outcome are covered quiteextensively. Perhaps it is time to pay even more attention tolipids and lipoproteins. The generally held impression thatcigarette smoking is the only risk factor for arterial diseasereadily amenable to control is incorrect. It should not be toosurprising to find that what is bad for coronary arteries isalso bad for arteries elsewhere.

I was particularly encouraged to see a chapter on carotidartery disease, even though it only applies to symptom-freepatients with detected disease in the bulb. Though oftenconsidered the preserve of neurologists this part of thecirculation, just like the coronary arteries, is connected to therest of the body and should not be considered in isolation.Hopefully, the trend towards compartmentalisation can bereversed. Fowkes’ collection of papers is a good start and Ihope it will encourage clinicians of various specialties to takemore notice of the blood supply to their favourite organs.Vascular disease should not be treated by vascular surgeonsalone.

Division of Vascular Surgery,University of Washington Schoolof Medicine,

Seattle, WA 98195, USA D. EUGENE STRANDNESS, JR

Primary Health Care and PsychiatricEpidemiology

Edited by Brian Cooper and Robin Eastwood. London:Tavistock Routledge. 1992. Pp 357. 50. ISBN 0-415070732.

General practice is now recognised to be the specialty inwhich the greatest number of psychiatric patients are seenand treated. This fact has taken some time to sink into theminds of many mental-health workers who are wedded to

hospital practice, but has long been of interest to

epidemiologists and planners of mental-health services.This book represents, somewhat tardily, the maincontributions of the first international scientific meeting onthe subject, held in Toronto in 1989. 58 contributors from12 countries describe the methodological problems in

identifying mental disorder, surveys of the prevalence of

different conditions, referral patterns to specialist services,and research implications. General practice is described as afield laboratory by the editors in their preface, but the bookis intended to be read by many more than laboratoryspecialists; public health physicians, community and socialworkers, as well as general practitioners will find much ofinterest.To synthesise these disparate contributions is no easy task

but the editors have done well to minimise overlap andprevent repetition. The subject could almost have beenpatented in the UK, primarily because of the pioneeringwork of Michael Shepherd and his collaborators. Since 1959it has spread across the world, unevenly but unerringly, likeripples on an irregularly shaped pond. The authors showthat we now have an international structure (although it stillneeds some scaffolding from eastern Europe) of generalpractice psychiatry that can serve both as a comparator forsurveys and as a baseline for measuring change. I would nowlike to see us forge ahead; to find ways of measuring not justhow much and what types of psychiatric disorder are seen ingeneral practice, but also how to marshal the delivery of ourservices to improve mental health throughout wholecommunities. To date we have conspicuously failed; bookslike Primary Health Care and Psychiatric Epidemiology showus where and how to make waves, instead of ripples.St Charles’ Hospital,London W10 0 6 DZ, UK K PETER TYRER

Biopsy Interpretation of Lymph Nodes

Steven H. Swerdlow. New York: Raven. 1992. Pp 401.$1101[99.70. ISBN 0-881678406.

It is said that the British and the Americans are a peopledivided by a common language. Nowhere has this dictumbeen more apparent than in the nomenclature of

lymphoreticular disease. The Working Formulation was anattempt to bridge this gap but, as Steven Swerdlow reports,was flawed from the outset and has proved less than durable.In this book, he gives a fair account of the main lymphomaclassifications but clearly favours, and subsequently follows,the functional classifications of Lukes and Collins and ofKiel. The book confines itself, almost exclusively, to

lymph-node pathology-an understandable, but not

entirely logical, approach to lymphoreticular disease.Detailed protocols for the handling of biopsies are

presented, with guides to the use of immunohistochemistry,genotyping, and cytogenetic analysis for accurate diagnosis.Nevertheless, the author correctly emphasises the centralrole of morphology in the interpretation of lymph-nodebiopsies: "without well fixed histologic sections and withouta firm knowledge of lymph node histopathology one cannotpractise diagnostic hematopathology no matter how manyspecial studies have been performed".One of the charms of Swerdlow’s book is his lack of

dogmatism, an unusual attribute in such a work; mostlymphoreticular pathologists seem to follow the preceptthat, although they may be wrong, they must never showdoubt. This lack of dogmatism will certainly appeal to manyreaders but may be considered a disadvantage by non-experts looking for an unclouded (if not unbiased) opinion.The book is well illustrated, mainly in black and white butwith eight colour plates; the photographs are mainly of goodquality and the author sometimes indicates the fault in thosethat are not (I wonder if his technical staff appreciate thisunusual honesty?). It should be noted that the selection andlayout of the illustrations are not conducive to their use as a

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wallpaper-matching type of bench book. Nevertheless,Biopsy Interpretation of Lymph Nodes will appeal to anyonewith a special interest in lymphoreticular pathology andshould be on the bookshelves of all pathology departmentswith trainee staff. It is well referenced and I have alreadyfound it a useful guide when dealing with unusual anddifficult biopsies; I expect my copy to be well used over thecoming months.

University Department of Pathology,Southampton General Hospital,Southampton S09 4XY, UK DENNIS H. WRIGHT

Practical Management of Pain2nd edition-Edited by P. Prithvi Raj. St Louis: MosbyYearBook. 1992. Pp 1096. /;115.50/$170.50. ISBN 0-815170122.

Myofascial Pain and Dysfunction: The TriggerPoint Manual, vol 2. The Lower Extremities

Janet G. Travell and David G. Simons. Baltimore: Williamsand Wilkins. 1992. Pp 607. 70/$93. ISBN 0-683083678.

Though Practical Management of Pain dwells mainly onthe relief of chronic pain, there are substantial chapters onthe treatment of acute pain. The expansion in size of thissecond edition is testimony not only to the burgeoninginterest in the relief of various kinds of pain but also to ourrapidly advancing scientific knowledge about its origins.Anaesthetists run many pain clinics and undertake most ofthe invasive procedures, such as nerve blocks, that may bedecided upon by the groups of clinicians from variousspecialties who work together in those clinics. It thereforecomes as no surprise that 46 of the 77 authors are

anaesthetists and that nerve blocks feature strongly, ratheroverwhelming the contributions of a solitary hospicedirector, a pharmacist, a nurse, and a few physicians,surgeons, and psychiatrists. Nevertheless, this proportionalrepresentation is probably a true reflection of the

backgrounds of the specialists who work in

multidisciplinary pain relief clinics. The book is perhapsmore accurately described as down-to-earth than as

practical-with the exception of a fascinating chapter on theunusual problems of providing pain relief in space. Its pricewill probably mean that it is used more as a library referencethan a workbench guide.

Myofascial Pain and Dysfunction, by contrast, is aninvaluable and practical guide that should not leave theclinic. This second instalment deals with the lower trunkand legs (as some of us call lower extremities); like the firstvolume, which dealt with the head, upper trunk, and arms, itis a work of remarkable scholarship and clarity. Somereaders may find it strange to so divide the body into upperand lower reaches but the authors make out a convincinganatomical case. Besides, without such subdivision the taskmight never have been attempted, let alone completed. Ameasure of the amount of effort involved is the passage of noless than 9 years between publication of the two volumes.Together they will repay the attention of all clinicians whomanage pain, but particularly those anaesthetists whoconcentrate almost exclusively on "pain-busting" nerveblocks and fail to appreciate the importance ofmusculoskeletal trigger points in chronic pain. Thesewell-illustrated books provide a key to locate the commontrigger points and to promote a better understanding of painof extraneural origins. Curiously, the authors do not refer topainful enthesiopathy, a condition in which even those withfirm views about the origins of pain (nervous activity vs

muscle tension) may express uncertainty, but nerve

entrapment between muscle planes is addressed. Generalunfamiliarity with trigger points is reason enough to giveboth "Trigger Point Manuals" a prominent place in painclinics to ensure that they are readily available for reference:it should not be forgotten that many techniques to relievemusculoskeletal pain are noninvasive and can easily berepeated without fear of complications.Pain Relief Centre,Frimley Park Hospital,Surrey GU16 6 5UJ, UK J. G. HANNINGTON-KIFF

The Healer’s Power

Howard Brody. New Haven/London: Yale University Press.1992. Pp 311. 18.95/$32.50. ISBN 0-300051743.

There are some who claim that creativity flourishes inadversity: perhaps so, for here is a book with an intellectualenergy, literate style, and sturdy originality that wouldsurely never have flowered in the crowded, cosy bed ofBritish medicine. In the USA, where the health-care crisisdwarfs the UK’s home-grown variety, primary-carephysicians languish at the base of a rich heap. HowardBrody, ethicist, philosopher, and professor of familypractice, comes up fighting.

His subject is the analysis of physician power as it affectsmedical ethics. He proposes that physicians must learn toshare power with their patients, own it (admit and use itopenly), and aim it. Aimed power is power directed to theservices of "the patient’s life plan". He analyses the

previously unconsidered power component of several classicmedical ethical dilemmas and has hard words for all parties.The chapters on Care versus Work, Informed Consent, ThePower to Determine Futility, and The Rescue Fantasystand out, peaks in a lofty range. But Brody’s recipe forcircumventing the unethical nature of the physician asgatekeeper, Power and Cost Containment, I found

unconvincingly tortuous. UK general practitioner fund-holding will not be so delicately defanged.Brody suggests that physicians have social, cultural, and

charismatic power over their patients. And "Aesculapianpower", the power of knowledge-an irreducible, structuralfeature of training and professionalism. Put simply, thedoctor usually knows best. Brody believes the principles ofrespect for autonomy and beneficence can never make the

physician-patient relationship "doctor-proof ’. "I would askthe defenders of the legalistic model precisely how the powerequality between physician and patient that they seek couldbe achieved in practice." But he has no intention ofdefending medical paternalism and aims to build on the newmedical ethics, not to bury them. Hence the theme of hisbook, that physicians must understand and share theirpower. The antipaternalist revolution has yet to unsettleEuropean medical practice but, in the UK at least, all thenecessary preconditions are now in place. It will be a stormyjourney for all of us. We could not wish for a wiser guidethan this book.

Middleton Lodge,New Ollerton,Newark NG22 9SZ, UK K MICHAEL LOUDON

New Editions

Child Psychiatry and the Law-2nd edn. Edited by Dora Black, StephenC7?//</ and Jean Harris Hendriks. London: Gaskell/Royal College ofWotfkind, and Jean Harris Hendriks. London: Gasketl/Roya) Cottege ofPsychiatrists. 1991. Pp 200. :00. ISBN 0-902241419.

Accidents and Emergencies-2nd edn. Norman G. Kirby. Oxford:Oxford University Press. 1991. Pp 480. /;14.95. ISBN 0-192630008.