958

TREATMENTS RECOMMENDED, AND THEIR EFFECTS

brought immediate relief. Discontinuation of the sprayimmediately results in bed-wetting. So far, there have beenno side-effects. The personal benefits were obvious to themanagement of my company, who subsequently promotedme several times.About 1% of adults are bed-wetters,l and this socially

unacceptable feature can limit personal potential. Duringadolescence the hidden secret can lead to deepembarrassments and to awkward situations, and uponadulthood nocturnal enuresis can seriously affect the career,social life, and personal relationships. The spouse will needmuch empathy and patience, quite apart from the extra workof daily laundry. Hardly any of the GPs or medicalspecialists whom I consulted had experience with thetreatment of adult nocturnal enuresis. This often meant thatI was offered an experimental treatment. A patient with astrong desire to have the disease cured may go through adisturbing range of unsuccessful treatments; and, in myopinion, anything with a less than 50% success rate shouldbe excluded. For adults, only DDAVP at present meets thiscriterion.2.3Over the years, the intrinsic difficulties of nocturnal

enuresis have been compounded by the effects ofunsuccessful treatments. Psychiatric treatment changed mybehaviour, but improvement of my self image had to awaittreatment with DDVP.

REFERENCES

1. Gil Rushton H. Nocturnal enuresis: epidemiology, evaluation, andcurrently available treatment options. J Pediatr 1989; 114: 691-96.

2. Norgard JP, Pedersen ED, Djurhuus JG. Diurnal anti-diuretic hormonelevels in enuretics. J Urol 1985; 134: 1029-31.

3. Rittig S, Knudsen UB, Norgaard JP, Pedersen EB, Djurhuus JG.Abnormal diurnal rhythm of plasma vasopressin and urinary output inpatients with enuresis. Am J Physiol 1989; 256: 664-71.

BOOKSHELF

Teaching During Rounds: A Handbook forAttending Physicians and Residents

Donn Weinholtz, Janine Edwards. Baltimore: Johns HopkinsUniversity Press. 1992. Pp 127. Cl 1. ISBN 0-801843510.

In the hallway, after leaving Mrs Densen’s room, Dr Goffturned to Justine and good-naturedly scolded, "Six Anadin aday. You didn’t tell me that."Somewhat taken aback, Justine collegially jousted, "Well, she

told me that it was only occasional.""If she admits to as many as six," Goff explained, "she may

well be taking as many as eight or ten. And that could be thereason behind her ulcer."

There are plenty of such conversations, some quitelengthy, and apparently recorded from real life at LouisianaState University (using pseudonyms). They seem rathergrotesque, and I confess that I nearly spurned this little bookbecause of them. But Dr Weinholtz and Dr Edwards are

obviously born teachers and know what they are doing-their often banal illustrative dialogues are extraordinarily, ifirritatingly, memorable. In fact, they have written about anaspect of medical training which is strangely neglected byeducationalists despite its central importance. Whether thecourse be traditional or innovative, students sooner or laterfind their most vivid learning experiences on hospital wards.Yet ward teaching is inherently unstructured and full ofpitfalls, wasted time being one of the worst.Most clinicians are aware of tensions when faced with the

dual responsibilities of patient care and student teaching,especially when the two are combined at the bedside. Suchtensions are well articulated here, with practical advice onhow to resolve them. From the rather didactic approach, onehas the impression of long years of excellent and popularclinical teaching in a conventional medical school. But theauthors are not blind to the merits of active learning, andregret that so few clinical teachers cause students to gatherinformation for themselves. The roles and inter-

relationships of members of a typical US teaching hospitalteam are well described (UK readers may need an

American-English dictionary). So are the relative merits ofdifferent venues for clinical teaching: even the hallway is notneglected, though my favourite spot, sister’s office, is. Thebibliography includes important contributions from thehistory of clinical teaching, such as Romano’s 1941

discovery that patients may be upset by insensitive bedsideinstruction.

I was disappointed not to find clear condemnation ofinterminable ward rounds, which students still suffer inotherwise enlightened institutions. Surely it is time to

separate teaching from business rounds? It was amusing toread that one function of residents is to correct consultants’

teaching-another example of the authors’ sure grasp ofreality. Although it is unfashionable to say so, teachinghospitals still have a role in training future doctors, and Irecommend this modestly priced book for its commonsenseapproach to many aspects of hospital-based clinical training.Department of Medicine,Faculty of Health Sciences,Moi University,PO Box 4606 Eldoret, Kenya RICHARD GODFREY

959

Prospects for Antisense Nucleic Acid Therapy ofCancer and AIDS

Edited by Eric Wickstrom. New York: Wiley-Liss. 1991.

Pp 269. $69.95. ISBN 0-471568805.

Surgical practice is founded on a thorough knowledge ofanatomy and physiology--disciplines built up arduously byyears of dissection and experimentation. But the cuttingedge of medical science has penetrated into another stratum.Vesalius’s cadaver has been replaced by nucleic acids andproteins, his knife by enzymes, and his anatomical drawingsby gel electrophoresis. There were, of course, interveningsteps. Virchow’s revolutionary Cellular Pathology musthave seemed esoteric and recondite to the average doctor ofhis era. But no less a revolution in our comprehension ofdisease is taking place now. The first edition of Osler’sPrinciples and Practice of Medicine, published exactly onehundred years ago, is perceived today as an anthology ofhighly accurate descriptions of diseases, but almost devoidof any realistic approaches to therapy. During the 21 stcentury, current textbooks on molecular medicine will cometo be viewed in the same way.Even as this century draws to a close, the molecular

surgeons are whetting their figurative scalpels. Gene

replacement therapy is now a real possibility, but thedevelopment of methods to prevent the unwanted

expression of genes—eg, in virus infections and cancer-islagging behind. This subject is not, however, beingneglected, as shown by Eric Wickstrom’s text.

Antisense molecules are oligonucleotides that bind toRNA transcripts with exquisite specificity and prevent theirtranslation; they provide a precise means of inhibiting a geneproduct. Although some laboratory animal models havebeen reported, whether antisense therapy for human diseaseis feasible will remain uncertain for a long time. For cancer,the first difficulty is to ensure that appropriately targetedantisense oligonucleotides reach neoplastic cells in sufficientquantity to completely ablate translation of the relevantprotein. If this proves possible, the next task is to preventantisense molecules from interfering with the production ofthe same protein in normal cells. Tumour specificity couldbe achieved by targeting the molecular abnormalities thatcause tumours. Tumour-specific RNA targets include

c-myc intron sequences in some cases of Burkitt’s

lymphoma, the hybrid bcr-abl transcript in chronic myeloidleukaemia, and the transcripts of pathogenetically relevantviral genomes associated with the tumour. Alternatively,tumour specificity can be built into the delivery system-forinstance, with a retroviral vector in which expression ofantisense molecules is controlled by a tumour-cell-specificpromoter such as a-fetoprotein in hepatocellular carcinoma,or perhaps by a regulatory sequence derived from atumour-associated virus.

Since new transcripts are constantly produced,continuous exposure to antisense molecules is required tomaintain protein inhibition. But antisense therapy shouldnot be thought of as merely cytostatic. Inhibition oftranslation of a selected protein may, in some circumstances,lead to cell death. The inhibition of bcl-2 in follicular

lymphomas with 14:18 translocatons, for example, shouldinduce apoptosis. More prolonged, even permanent,inhibition of expression after short-duration exposure tooligonucleotide might also be possible by targeting DNAand preventing transcription.What is most exciting about this book, which will prove to

be of interest only to antisense aficionados, is theevidence that we can contemplate methods whereby

inappropriate gene expression can be rectified. It seems

likely that molecular therapy will emerge as a dominanttheme of the 21 st century.

Pediatric Branch,National Cancer Institute,National Institutes of Health,Bethesda, Maryland 20892, USA IAN MAGRATH

Butterworth’s Medico-Legal ReportsEdited by the Centre for Legal Aspects of Medical Practice,Cardiff Law School. London: Butterworth. 1992. Volumes 1-6.

/;25 each volume. ISBN 0-40644000X.

Butterworth, who publish the All England Law Reports,Halsbury’s Laws and Statutes, and other leading collectionsof reports, precedents, and textbooks, have now introduceda new series to take account of the burgeoning quantity ofmedico-legal litigation. The first six volumes are alreadyavailable in hardback and contain reports of earlier

decisions, not all of which can be found in mainstream lawreports.

Appropriately, the first case reported in volume 1 is that ofBolam vs Friern Hospital Management Committee (1957),in which the jury was directed that if a doctor undertook apractice thought proper by a responsible body of medicalopinion then that individual could not be found negligent.Bolam also dealt with the disclosure of risks arising fromtreatment-in this case, electroconvulsive therapy- andapplied the reasonably-competent-doctor test when

deciding how much information a physician was required togive when recommending a treatment. The test is that of theresponsible caring doctor as judged by his or her peers inthat field, and is one that has been endorsed by the House ofLords. However, in Sidaway (1985) a caution was issued tothe medical profession. Doctors must provide sufficientinformation to allow a patient to arrive at "an informedchoice". Whitehouse vs Jordan (1980) is also discussed. Theplaintiff was a brain-damaged baby; it was claimed that theregistrar in obstetrics had, during a trial by forceps,negligently pulled too hard and too long before deciding todeliver the baby by caesarean section. The plaintiff wassuccessful at trial but the decision was reversed on appeal.The House of Lords held-to the relief of the medical

profession-that the doctor concerned had exercised dueskill, care, and competence. It also informed lawyers anddoctors alike that an error of judgment may or may not benegligent depending on the circumstances.

I could find no underlying reasons behind the allocationof cases to different volumes. The second volume includesC vs S (the Oxford student who tried to restrain hisgirlfriend from having an abortion), Gillick, and R vsHallstrom, in which the "long leash" recall of patientsdischarged from mental hospital for compulsory renewal oftheir treatment was deemed neither lawful nor within the

scope of the Mental Health Act 1983. Many believe that theAct should be amended but the only response so far has beento shift long-term care from mental hospitals into the

community.Volume 3 contains a discussion of the celebrated case of

Wilsher vs Essex Area Health Authority. In this case, it wasclaimed that the negligent over-oxygenation of a prematurebaby caused retrolental fibroplasia, with subsequentblindness. The trial judge’s approach and thus his findingswere held to be unsatisfactory and the claim was sent back

960

for retrial. It was settled before the legal process could bere-run. Volume 4 reports the cases of two generalpractitioners who failed to treat adequately a small child whosipped boiling tea and whose throat and laryngeal injuriescaused near suffocation, together with permanent severebrain damage.Volumes 5 and 6 include Gardener vs Mounfield (a

successful claim for a non-diagnosis of pregnancy), Rance vsMid-Downs Health Authority (a claim for the upkeep andcare of a baby with spina bifida whom the mother claimedwould have been aborted but for the failure to diagnose hiscondition in utero), and the earliest of the cases known as"J". In this instance, doctors sought approval from theCourt for their decision not to treat a severely handicappedbaby, so that he could be allowed to die with dignity.These reports are well presented but are haphazardly

collected. They complement an already established seriesthat I have found to be excellent-namely, Medical LawReports. It is a pity for two such similar types of publicationto have to compete in a small sphere of legal activity, and onemust hope that this will provide the practitioner with afirst-class service.

15 Old Square,Lincoln’s Inn,London WC2A 3UH, UK DIANA BRAHAMS

Disorders of the Cervical SpineEdited by Martin B. Camins, Patrick F. O’Leary. Baltimore:Williams & Wilkins. 1992. Pp 628. c 115. ISBN 0-683014013.

Those who have had the experience of witnessing thetechnical wizardry of presentations given by Bill Fieldingwill immediately prick up their ears when they see that hehas written the introduction to this book. Double,asynchronous slide projection, interspersed with videosequences, a faultless delivery, and a wealth of clinical detailtempered with good common sense were the hall-marks ofthis man. Disorders of the Cervical Spine has just thosequalities; it is neither a quick read nor a textbook for thestudent but a balanced collection of chapters written in aninteresting and up-to-date form, beautifully illustrated withradiographs and line diagrams.Tutankhamen, we are told, had the first recorded cervical

laminectomy-admittedly, as part of the mummificationprocess. Osteotomy of the cervical spine is infrequentlydone, one surgeon reporting a single case, another corneringthe market and seeming to be heading for the record books.There is a description by Alan Crockard of how to deliver atranslocated odontoid peg without removal of the anteriorrim of Cl-if this is what interests you, then read on becausethere is a mine of information and a breadth of cervical

surgical experience that is second to none. The book is amust for the neurosurgeon and the orthopaedic surgeon,and for all those like myself who have difficulty persuadinghospital managers about the benefits of magnetic resonanceimaging.My only disappointment was a fleeting mention of the

so-called whiplash syndrome. This condition is commonand is the subject of millions of pounds of compensationpayments; I looked for it under many headings and found itto be absent. Overall, however, look no further for a treatiseon the disorders of the cervical spine.Department of Orthopaedic Surgery,Musgrave Park Hospital,Belfast BT9 7JB, Northern Ireland R. A. B. MOLLAN

Cystic dermoid.

This coronal computed tomographic scan shows a large mass in themedial compartment of the left orbit The globe (*) is displaced laterally.The mass contains two discrete components separated by a fluid level.Theupper half is a dense fluid, whilst the lower half is fatty in compositionSuch cysts are denved from ectodermal elements that are incorporatedinto the orbit during embryological development Erosion and remodellingof the orbital roof is charactenstic Taken from MRI and CT Atlas ofCorrelative lmagmg in Otolaryngology, by V M Rao, A E. Flanders, andB. M Tom (London Martin Dunitz 1992 Pp 383 E95 ISBN

1-853170372)

Selected Books: Public Health

Public Health & Preventive Medicine--13ili eeLn. John M. Last, RobertB. Wallace. East Norwalk: Appleton & Lange. 1992. Pp 1257. 75. ISBN0-838561829.

Economics, Medicine and Health Care-2nd edn. Gavin Mooney. NewYork: Harvester/Wheatsheaf. 1992. Pp 179.$29.99. ISBN 0-745010148.

Homelessness. A National Perspective. Edited by Marjorie J.Robertson, Milton Greenblatt London: Plenum Press. 1992. Pp 357.jC15.95. ISBN 0-306437899.

Homelessness-A Prevenfion-Onented Approach. Edited by Rene 1.Jahiel. Baltimore/London: Johns Hopkins University Press. 1992. Pp 409.43.ISBN 0-801843138.

Epidemiology in Context. Effectiveness of Health Care InterventIOns.Vinod Kumar Diwan. Stockholm: Department of International Health CareResearch, Karolinska Institutet. 1992. Pp 150. ISBN 9-162806211.

Passive Smoking. Edited by Joyce Epstein, Margareta Nilson-Giebel.London: Anglo German Foundation. 1992. Pp 185. jC15. ISBN 0-905492765.

Health Promotion: Disciplmes and Diversity. Edited by Robin Bunton,Gordon Macdonald. London: Routledge. 1992. Pp 240. 12.99. ISBN0-41505981X.

Promoting Health. a Practical Gulcle-2nd edn. Linda Ewles and InaSimnen. London: Scutari. 1992. Pp 280. cell.95. ISBN 1-871364737.

The Strategy of Preventive Medicme---Geoffrey Rose. Oxford: OxfordUniversity Press. 1992. Pp 138. 17.50. ISBN 0-192621254.

Assessmg Child Survival Programs-Edited by Joseph J. Valdez.Cambndge: Harvard University Press. 1992. Pp 247.$10.95. ISBN0-674049950.

Health Services Research: An Anthology-Kerr L. White.

Washington DC: Pan American Health Organization. 1992.$25. ISBN0-9275115346.