944

pneumothorax may result from Pneumocystis cariniiinfection in patients with AIDS.

Surgical experience differs between London schools,which might be because of local shortages of suitablepatients for teaching. An overall reduction in surgicalexperience might arise from a deliberate policy, which maybe appropriate for a subject that is becoming morespecialised and (perhaps more suitably) postgraduate. Onthe other hand, the parallel, unwelcome reduction in

familiarity with practical procedures suggests that thedecrease in experience of students was unplanned. Therewas no indication that the reduction in practical experiencewas because students were instead receiving more trainingand supervision.

Attention has been focused on London, which contains29% of UK medical students and 25% of the population.The lesser clinical experience at schools in Scotland andNorthern Ireland, compared with those in England andWales, may be explained by the smaller population availableto its students (20% of UK medical students and 10% of thepopulation).The general decrease in experience of medical students

that we report here, coupled with moves toward a less factualand less detailed curriculum, makes imperative a radicalimprovement in the much criticised pre-registration year asthe final phase of basic medical education.ll Therecommendation of the British General Medical Council-acore course with options-is likely to yield doctors with lesscomprehensive clinical knowledge and experience thandoctors practicing today. Conversely, they should be better

able to reason, enquire, and learn from their experience,provided that they have adequate postgraduate training withcloser supervision.

The survey of the 1981 cohort was funded by the Economic and SocialResearch Council and the survey of the 1986 cohort by the LeverhulmeTrust.

REFERENCES

1. Chantler C. Service increment for teaching and research. BMJ 1992; 305:71-72.

2. Dean M. London perspective: Too many medical beds? Lancet 1992; 339:170-71.

3. Dean M. London perspective: Teaching hospitals running out of patientsand cash. Lancet 1991; 338: 874-75.

4. Smith J. London’s health care again. BMJ 1992; 304: 1646-47.5. McManus IC, Richards P. An audit of admission to medical school: 1.

Acceptances and rejects. BMJ 1984; 289: 1201-04.6. McManus IC, Richards P, Maitlis SL. Prospective study of the

disadvantage of people from ethnic minority groups applying tomedical schools in the United Kingdom. BMJ 1989; 298: 723-26.

7. Jolly BC, Macdonald MM. Education for practice: the role of practicalexperience in undergraduate and general clinical training. Med Educ1989; 23: 189-95.

8. Lockwood DNJ, Goldman LH, McManus IC. Surgical dressers: thetheatre experience of junior clinical students. Med Educ 1986; 20:216-21.

9. Wakeford RE. Undergraduate students’ experience in ’peripheral’ and’teaching’ hospitals compared. Ann R Coll Surg Eng 1983; 65: 274-77.

10. Lockwood DNJ, Goldman LH, McManus IC. Clinical experience ofclerks and dressers: a three-year study of Birmingham medicalstudents. Proc R Soc Med 1986; 79: 38-42.

11. Richards P. Educational improvement of the preregistration period ofgeneral clinical training. BMJ 1992; 304: 625-27.

BOOKSHELF

There is Nothing More I Can Do

An Introduction to the Ethics of Palliative Care. David Jeffrey.Penzance: Patten Press. 1993. Pp 96. 5.95. ISBN1-872229115.

Patients expect that doctors who care for them will do noharm. Many also assume that on graduation from medicalschool doctors take the Hippocratic oath. A further

assumption is that all doctors possess faultless insight. If adoctor is accused of being less than honest with a patient or,more specifically, of not disclosing prognosis, he is often saidto be denying patient autonomy. Yet the real difficulty maybe that he is just lacking in insight. Doctors’ and patients’agendas frequently differ. Medical tradition still holds thatthe doctor knows best and that the patient must be protectedif not from reality then at least from facts. This protection issometimes provided without efforts to establish the patient’sreal wishes. The teaching of communication skills is nowpart of the undergraduate medical curriculum. Does thisemphasis reflect a modem interpretation of the notion of "agood bedside manner" or is it a return to medical

paternalism? Our aim must be a more ethical and equitablepartnership of care with our patients.

Quality of life has become a catch phrase in the

management of cancer. If it can be measured and to someextent maintained, then much can be justified. It has beenthought of as a measure of the difference at any particulartime between an individual’s expectations and experiences.

With increasing competition for limited resources,discussion of treatment options with a patient or relativemay turn into a cost-benefit analysis. Palliative care has beendefined as the active total care of patients whose disease is nolonger responsive to curative treatment. Listening to

patients and controlling their physical, psychological, social,and spiritual symptoms are the cornerstones of modempalliative care. If curative and palliative treatment could begiven in parallel, the ethical dilemmas of transition from oneto the other would be less problematical. Why the

dichotomy between curative and palliative? There are manyconditions, for instance diabetes mellitus, where thetreatment is always palliative.Advance directives or living wills are favoured by some

and feared by many. David Jeffrey argues that the presenceof a living will may be of some help in influencing a doctor’sdecisions, but says that to resort to such a device in palliativecare is a sad reflection on the quality of the doctor-patientrelationship. Dislike of advance directives or living willsseems to conflict with the notion of patient autonomy.Patient autonomy in the face of vulnerability, advancingdisease, and impending death is a curious phenomenon. Arevulnerability and autonomy mutually exclusive? Advancedirectives might allow patients a more objective opportunityat a less vulnerable time. In the USA the 1991 Self-Determination Act requires that all patients be informed onadmission to hospital of their right to refuse treatment and tomake an advance directive. Thin partitions may divide

945

active voluntary from passive euthanasia. Some observersclaim that the right to self-determination could conflict witha doctor’s autonomy. Perhaps society needs to encourage itscitizens to adopt advance directives to limit interventionsthat are judged not only economically wasteful but alsoinhumane. Explicit rationing, and the inevitable publicdebate, would also help resolve the conflict between thegood of society and that of the individual.Recent court cases in this country have served to

encourage debate on the ethical and legal issues involved incaring for patients with incurable disease. The inappropriateuse of drugs, including opioids, to hasten death by somedoctors might make a few patients reluctant to discuss theirpain. Dying in pain, being afraid to admit it, or even to talkabout it may be worse than being dead. Why do patientshave to be dying before being offered effective analgesia forthe control of their pain? The reluctance to use opioids forchronic pain other than pain from advanced malignantdisease has led to an unfortunate association between

morphine and death. The process of dying is part of thehuman condition; there is much that can be done to ease it.But, although we have the means, their wider applicationdemands a change in attitudes on the part of society and themedical profession. "There is nothing more I can do" isanathema to good palliative care. The ideas discussed in thisbook could be applied to all partnerships of care.

Department of Palliative Medicine,Division of Oncology,St Thomas’s Hospital,London SE1 7EH, UK W. M. O’NEILL

Nasopharyngeal Carcinoma

C. Andrew van Hasselt, Alan G. Gibb. Hong Kong: ChineseUniversity Press. 1992. Pp 286. /;40. ISBN 9-622015425.

Even though nasopharyngeal carcinoma is thecommonest tumour found in south China, it exerts a

fascination out of all proportion to its prevalence. Thisdisease raises many questions that involve a wide range ofdisciplines; and to the occidental, it is a disease from exoticparts. Nasopharyngeal carcinoma arises almost in the centreof the head, presents late, and may spread to produceintracranial, ophthalmological, otological, rhinological, orneurological symptoms; or it may present as metastaticdisease of the neck. Until the advent of the electron

microscope in the 1960s, it was not even certain whether itwas carcinoma, sarcoma, or lymphoma. These tumours aredifficult to locate and thus to diagnose, although modemimaging has improved this obstacle dramatically;nevertheless, they are hard to reach surgically.Nasopharyngeal carcinoma was one of the first tumours

for which epidemiologists hoped to pinpoint a cause becauseof its strange geographic distribution. Was its highprevalence in Canton, especially among the fisherfolk, aresult of environmental or genetic factors? Early studiesshowed that the prevalence diminished sharply, though notcompletely, as Cantonese were separated by distance andtime from south China. Visions that one of the exoticconstituents of dried fish, a dietary staple of that region,would be the sole causal agent proved simplistic; co-factors,such as trace minerals in drinking water, became important.Almost inevitably, the Epstein-Barr virus has been

implicated, and yet are we any closer to a solution? Despiteintense international study, the cause remains elusive.The editors of this volume have brought together a

formidable group of local Hong Kong talent to review what

was known about the disease in 1991. In a well writtenhistorical article, Gibb suggests that the disease was evenknown to the ancient Egyptians. The book is strong onimaging techniques. Good practical advice is given abouttherapy, including the use of traditional Chinesemedications as adjuncts to western medicine. The section onepidemiology is weak.

For the surgeon, the nasopharynx has become moreaccessible during the past decade, but radical en blocresection remains a technician’s dream, except for smalltumours that are cured by radiotherapy anyway. Thecombined efforts of the surgeon, the immunologist, and thegeneticist are gradually bringing an explanation and curativetreatment of this disease closer. The topic is beguiling tomany disciplines. Is it too much to hope that, as the toolsbecome more powerful in all branches, they will continue tocollaborate?

This book has something in it for those from all

disciplines who work in the field. The contributors givegood practical advice and it will serve as an excellent generalreference work-the illustrations are superb, which is

especially important for histopathologists and radiologists.Any book in which Alan Gibb has a hand will contain goodeducational material; Gibb imaginatively demonstrated thetechnique of stapedectomy and the dffficulties of a floatingfootplate by using congealed fat floating on top of tepid gravyin an oval sauce bowl. This book does not let him down.

Department of Otolaryngology,Toronto Hospital,Toronto, Ontario M5G 2C4, Canada PETER W. ALBERTI

Sickle Cell Disease

2nd edition-E. R. Serjeant. Oxford: Oxford University Press.1992. Pp 631. 65. ISBN 0-192622323.

The socio-economic and geographic perspective of bothphysicians and their patients must affect their attitudes toperceived needs in sickle cell disease (SCD). These prioritiesare incredibly diverse, not only between continents but alsowithin any one country, because of the funds available to

patients and their families for treatment and the skills of theirphysicians. Attitudes and therefore priorities in SCD

probably relate to the time during which the sickle gene hasbeen present in a country. For instance, it is rarelyencountered in northern Europe and so is thought to be atropical disease, whereas in southern Europe it is common.The epidemiology of the sickle gene is well reviewed bySerjeant who corrects the common misconception that thisgene is limited to black men and women; in fact, it isdistributed widely among the peoples of southern Italy,northern Greece, southern Turkey, Saudi Arabia, and India.The aims of any SCD programme must include the

prevention and management of its complications. Schemesshould provide neonatal screening, adult screening, andprenatal diagnosis to allow informed decision taking inchildbearing, as well as the hunt for a cure. From a Europeanperspective, sub-Saharan Africans must focus on ensuringthat their blood supply is free from transmissible viruses andthey should provide prophylaxis for infants againstpneumococci and for all against malaria. Yet, when my SCDchildren go to Africa, there is no penicillin prophylaxis andthey are assured that its use is not important. Pneumococcalsepsis is an important cause of infant death among patientswith SCD in northern Europe and the USA, while it is rarecompared with deaths from gastroenteritis and malaria inGhana and Nigeria. This tension between priorities results

946

in these children and their families receiving contradictorymedical advice.The search for a cure has taken on quite different aspects

depending on the country. Americans have adoptedhydroxyurea, a powerful chemotherapeutic agent, to inducefetal haemoglobin production. Many patients will have adiminution of their clinical symptoms with hydroxyureatreatment, but we do not yet know whether this is caused bythe rise in fetal haemoglobin or by some other factor, such asan associated reduction in white cell count or increase inerythrocyte mean cell volume. Europeans, meanwhile, ledby two groups in Belgium, have now done nearly forty bonemarrow transplants for SCD. Most of the recipients havesurvived, now cured of their illness. With a cost of

approximately C40 000 for each transplant it is interesting tonote how limited the discussion has been about the ethics of

transplants and their clinical indications. In sub-SaharanAfrica, patients must be hoping that the developed world isworking on a cheap anti-sickling agent that would solve theirdifficulties. Little work is being undertaken to find such anagent, despite the birth of around 250 000 childrenworldwide annually with a major haemoglobinopathy.

Doctors and health-care planners must appreciate theglobal size of the SCD population. A broad debate is neededto determine the main clinical questions requiring a

solution-eg, can hypertransfusion regimens and bonemarrow transplantation stop progression of organ damageincluding major cerebral vessel occlusion and chronic renalfailure. We need to break free from anecdotal one-offtreatments and develop coordinated programmes to

investigate new therapies. All patients with SCD shouldhave access to centres of excellence.

Department of Haematology,Central Middlesex Hospital,London NW10 7NS, UK K SALLY C. DAVIES

Cytokines in Health and Disease

Edited by Steven L. Kunkel, Daniel G. Remick. New York:Marcel Dekker. 1992. Pp 584.$185. ISBN 0-824786483.

Why should anyone want another heavy book oncytokines, especially at a time when research is moving sofast? The answer is because Kunkel and Remick haveproduced a well-organised, comprehensive text that

provides a firm basis of knowledge in this increasinglycomplex field. Whether you are seeking a detailed account ofthe structure and function of interleukin 8 or the role of this

cytokine in pulmonary injury, the information is easy tofind.The contents cover a wide range of topics: from AIDS to

inflammation, from fibroblasts to haematological stem cells,and from viral infections to septic shock. I particularlyenjoyed the chapter on cytokine networks in skin disease,which discusses the role of different cytokines in severalcommon conditions such as atopic dermatitis, mycosisfungoides, psoriasis, and allergic contact dermatitis.

Cytokine profiles in individual diseases are beginning toshow patterns that may have therapeutic implications.Placebo-controlled, double-blind trials of cytokines andtheir soluble receptors are now needed to test rapidlyemerging hypotheses. For those who require a good grasp ofthe cytokine field, this book will be an excellent basicreference.

Department of Immunology,John Radcliffe Hospital,Oxford OX3 9DU, UK H. M. CHAPEL

Selected Books: Obstetrics & Gynaecology

Bai/lière’s Clinical Obstetrics & Gynaecology-Prostaglandins.-Edited by M. G. Elder. London: Baillière Tindall. Pp 908. 27.50. ISBN0-702016942.

Baillière’s Clinical Obstetrics & Gynaecology-The Immune Systemin Disease.-Edited by G. M. Stirrat, J. R. Scott. London: Bailliere. 1992.Pp 391. 27.50. ISBN 0-702016349.

Baillière’s Clinical Obstetrics & Gynaecology-AssistedReproduction.-Edited by L. Hamberger, M. Wikland. London: Bailliere.1992. Pp 391. £27.50. ISBN 0-702016330.

Large Loop Excision of the Transformation Zone-A Practical Guideto LLETZ.-Edited by Walter Prendiville. London: Chapman & Hall. 1992.

Pp 168. 60. ISBN 0-412462400.

Immunological Obstetrics.-Edited by Carolyn B. Coulam, W. PageFaulk, John A. McIntyre. New York: W. W. Norton. 1992. Pp 887.$75.ISBN 0-393710114.

Survival of the Weakest : A Christian Approach to Extreme

Prematurity.-John Wyatt, Andrew Spencer. London: Christian MedicalFellowship. 1992. Pp 36. 2. ISBN 0-906747260.

The Human Placenta.-Edited by C. W. G. Redman, I. L. Sargent,P. M. Starkey. Oxford: Blackwell Scientific. 1993. Pp 598. 85. ISBN0-632027215.

Hormones and Fetal Pathophysiology.-Edited by Jorge R.

Pasqualine, Robert Scholler. New York: Marcel Dekker. 1992. Pp 808.$185.ISBN 0-824786513.

Endpiece

Acrodermatitis chronica atrophicans.

This skin lesion (seen here as a blueish-red discolouration with

atrophy on the sole of one foot) is a late (stage III) manifestation of Lymeborreliosis. Its course is typically chronic and progressive, and there maybe additional sclerotic changes Women usually predominate and themedian age of onset is 64 years. First recognised in 1975 from Lyme,Connecticut, USA the causal agent (Borrelia burgdorferi) was onlyfinally identified in 1983. The disease is transmitted by Ixodes dammmior related Ixodid ticks. Taken from Aspects of Lyme Borreliosis, edited byK. Weber, W. Burgdorfer. (Berlin. Springer Verlag. 1993 Pp384.E88.50.ISBN 3-540556281.)