895

Fig. 2.

We have redesigned the cap using the principle of theexpanding collet, but the rest of the instrument remains asoriginally described by Crosby and Kuller.1 Fig. 1 shows thethree components of the redesigned cap and a cross-section ofit assembled; and fig. 2 compares it with the original cap. Thelower part of the cap (A) has a thin wall and is slit axially togive four flexible segments. When the screw B is tightened,the tapered plug C is drawn into the mating part of cap A,expanding the flexible segments radially to grip the inside ofthe body of the capsule at D. The rubber diaphragm E, as in

1. Crosby, W. H., Kuller, H. W. Amer. J. dig. Dis. 1957, 2, 236.

the original design, is trapped between the cap A and the bodyof the capsule D, and it is vented by a hole drilled longitudinallythrough the screw B. This ensures that the rubber membranemoves freely when suction is applied to the capsule. The firingmechanism, therefore, is the same as in the original design.We have used the modified apparatus 12 times, and the cap

has always remained in place and adequate biopsy has beenobtained. The new cap now withstands even inexperienced,and therefore often vigorous, injection of the radio-opaque dye.We also think that the modified apparatus consistently obtainsa larger piece of jejunal mucosa, thus permitting severalprocedures to be performed on one piece.The complete instrument will be manufactured under the auspices

of the National Research Development Corporation, 1, Tilney Street,London, W. 1, to whom inquiries should be addressed.

A. E. READM.D. Lond., M.R.C.P.

K. R. GOUGHM.D. Brist., M.R.C.P.

J. A. BONESB.SC. Brist.

C. F. MCCARTHYM.D. N.U.I., M.R.C.P.

Departments of Medicine andMechanical Engineering,

University of Bristol

Reviews of Books

Clinical Methods in Tropical MedicineBRIAN MAEGRAITH, M.B., D.PHIL., F.R.C.P.; C. S. LEITHEAD, M.B.,Liverpool School of Tropical Medicine, Liverpool. London:Cassell. 1962. Pp. 545. 30s.

IN this country, it is usual for the bird sitting on the tree tobe a sparrow: in the tropics it may be a sparrow or a canary ora particular type of sunbird; and several different birds may siton the same tree at the same time. Does the practitioner in thetropics have to consider every possibility ? Or can he restricthimself to the conditions found in the continent or even in the

part of the continent in which he is working ? He certainlyneeds a thorough grounding in clinical methods. If he is

fortunate, he will have studied as an undergraduate in thecountry in which he is going to work.Here the authors have decided that a wider approach is

necessary, and they have produced a book that will be usefuleverywhere-to the practitioner of tropical medicine in a

temperate country, who may see patients from all parts of theworld, as well as to the man in the tropics working in a morerestricted area. It will also be helpful to the graduate seekingadditional training in tropical medicine and wishing to revisehis knowledge of clinical methods.The book does much more than merely describe the special

methods required for tropical practice. It covers the whole

range of clinical medicine-history-taking, examination, andtechniques in the clinical sideroom. Its tropical bias is appliedby concentrating on examples from tropical medicine and bygiving a full description of tropical parasites. The standard isvery high and criticism can only be of emphasis, which is oftena matter of personal preference. A difficulty facing mostdoctors in parts where a language is spoken over only a smallarea is the use of the interpreter; this subject is mentioned, butno practical advice is given. In many countries shortage ofmedical man-power means that outpatients will have to befiltered through unqualified assistants for many years to come.Advice on the principles to be adopted would be of value tomany clinicians.The section on laboratory methods has been kept to a reason-

able length by referring the reader to other textbooks fordetails of the more difficult procedures; this practice mighthave been carried further. It is useful to have a description ofthe tapping of a hydrocele or an abdomen, though these pro-cedures are usually described more fully in books of minorsurgery; and anyone who can recall an embarrassing situationduring a funeral in an African village may look in vain for

advice on how to make a viscerotome work. The index is good.The book succeeds in covering a lot of ground succinctly

and at reasonable cost. A convenient size, it can be carried

easily for help in time of trouble in the tropics or for self-

improvement in public transport in this country.

The Physiology of EmotionsEditor: ALEXANDER SIMON, M.D., professor and chairman, depart-ment of psychiatry, University of California School of Medicine.Springfield, Ill. : Charles C. Thomas. Oxford: BlackwellScientific Publications. 1961. Pp. 248. 52s.

THERE is no adequate textbook on this subject: indeed, sorapid is its growth, and so large its literature, that much ofsuch a book would be outdated at once. One method of over-coming the difficulty is to invite leading scientists to meet andtalk, and then put their papers and discussions in a book likethis. The difficulty here is that there are many such symposia,particularly in the U.S.A., and the same people seem to spendmuch of their working lives going from one to another; so thereis bound to be redundancy. Nevertheless, this volume is a goodexample of its species and contains some excellent reviews anddiscussions, presented coherently with a central theme andprogressing from evidence to sane conclusion.Hoagland and Goldstein describe endocrine stress responses

in man. The efficacy of Hoagland’s contribution dependspartly on the massive detail of experimental work at theWorcester Foundation: and of Goldstein’s on his insight intothe way that the effects of adrenocortical and vitamin insuffi-ciencies depend on the particular activity of the nervous system,especially the sympathetic nervous system. Kety gives a shortand pithy review of the relation of stress to the catecholamines,and Beach a factual analysis of the physiological basis of matingbehaviour of mammals.A more sparkling brew is provided by Elkes, in which he

gives close attention to experimental work, mostly the excellentwork of the Birmingham school of neuropharmacology on themode of action of hallucinogenic drugs on the electrical

activity of the brain. He also proposes a complex and eleganthypothesis about how regional and local neuropharmacologicalevents and shifts of equilibrium can determine which patternin which complex neural lattices will dominate for the momentthe outflow of the stereotyped yet " highly organised patternsof activity which we know as affective behaviour ". Thus itbecomes apparent that the mere level of substance X (e.g.,adrenaline) in blood or a particular part of the brain is of littlesignificance without knowledge of concentration gradients,rates, or turnover, and without relating it to the activity ofother agents, such as the adrenocortical hormones or

acetylcholine.

896

Gerard’s short and witty essay on the role of moleculartraces in conditioning curiously does not mention Hyden’swork, and is so brief as to be little more than a few elegantasides on this subject. Grinker’s paper emphasises the diffi-culties of experimental human psychopharmacology, andillustrates the tendency of modern American psychoanalyststo mix into a heady conceptual cocktail the languages ofphysiology and psychoanalytical terms like " ego boundaries ".

Lastly, there is a curious symposium on the psychophysiologyof death, compounded of endocrinology, sea-sickness, voodoo,tales of sudden death due, it seems, to panic, and denial ofillness by those with brain tumours. This part of the bookreflects the frequent assumption in American biological sciencethat physiology and its related sciences have somehow provedthat no part or aspect of a human being survives the death of thephysical body. In fact, the accumulation of knowledge of brainfunction or of the relation of brain function to behaviour seemsunlikely to provide evidence of the existence or not of thehuman soul. The relation of mind to brain seems a problemlogically apart from those concerning behaviour or the structureand function of neurones.

Towards a Measure of Medical CareOperational Research in the Health Services. A Symposium.Contributors: J. 0. F. Davies, John Brotherston, NormanBailey, Gordon Forsyth, and Robert Logan. London: OxfordUniversity Press (for the Nuffield Provincial Hospitals Trust).1962. Pp. 91. 5s.

IN December, 1960, the Nuffield Provincials Hospitals Trustorganised a conference on operational research in the healthservices, and the papers presented then are now published witha foreword by Mr. Gordon McLachlan, secretary to the Trust.The four papers deal with some of the problems awaitinginquiry; with medical-care investigations in the health services;with the calculation of the scale of inpatient accommodation;and with the assessment of some methods used in studyingmedical care. The broad summary of conclusions put to theconference by its chairman, Prof. M. G. Kendall, was thatthere are widespread opportunities for the application of

operational research methods in studies of the National HealthService, at various levels of administration and including thedirection of possible modification of the service; that thereshould be periodic conferences of interested persons and someform of centralised information exchange; that the desirabilityof stimulating interest in operational research in health mattersshould be recognised; and that in view of the shortage of expertpersonnel there should be encouragement, in universities andelsewhere, towards the formation of operational research unitsto work in this field.

In his foreword Mr. McLachlan points out that the Trusthas in recent ’years encouraged development of operationalsociomedical research; and, observing that the objectives ofoperational research are essentially practical, he remarks thatthough there was almost complete agreement at the conferenceabout the need for developing techniques for measuring theeffectiveness of the various services which provide medical care,a real note of dissent was sounded by the question whether thecall to study the efficacy of present arrangements did notassume too much complacency with the whole basis of theNational Health Service. It is not easy to measure the efficacyof medical care, and the difficulty is perhaps greatest in relationto the work of the family doctor today.

The Human Pulmonary CirculationIts Form and Function in Health and Disease. PETER HARRIS,M.D., PH.D., M.R.C.P., senior lecturer in medicine, University ofBirmingham; DONALD HEATH, M.D., PH.D., senior lecturer inpathology, University of Birmingham. Edinburgh: E. & S.

Livingstone. 1962. Pp. 354. 70s.

IT is hard to realise that only a decade and a half have elapsedsince the first report from Cournand’s laboratory of a study ofpulmonary vascular pressures in heart-disease in man. Sincethen a vast body of knowledge and experience has beendeveloped in many cardiological centres throughout the world.

This book represents the experience and knowledge of a clinicalinvestigator and a pathologist from a distinguished school, andit should be read by every cardiologist as a model of scholarlyand critical thought in a rapidly developing subject. Theapproach to measurement of pressures down a long catheter isbased on sound physical and hsemodynamic principles withwhich all modern cardiologists should be, but are not always,familiar. The mathematical principles underlying vascular

distensibility, inertia, and impedance are lucidly explained,and the effort of detailed study will be well repayed.The discussion of the problems of structural change in the

lung vessels in different kinds of pulmonary hypertension isdetailed and fully documented; and the closing chapters arelargely devoted to the measurement of the complex relation-ships between ventilation and perfusion of the lungs applicableto the study of disordered pulmonary function. Mathematicaldetail is further elaborated in a series of useful appendices.

Right-heart catheterisation has now become commonplace,but for those who wish to undertake it the information con-tained in this book may be sufficient. It can be pre-dicted that Harris and Heath will become a laboratory bible forall research-workers in this field, and its study will be a " must "for all young cardiologists who wish to make their mark. Bothauthors are to be congratulated on producing a volume in whichpersonal experience is so well blended with a balanced appre-ciation of the vast literature. The careful reader will not onlyrealise the progress which has been made but will also

appreciate the penumbra of unsolved and confused problemswhich should be a challenge and a stimulus to further en-deavour in research.

Clinical ProcessAn Assessment of Data in Childhood Personality Disorders. E. KUNOBELLER, research director, Child Development Center, NewYork. New York: Free Press of Glencoe. London: MacmillanCompany of New York. 1962. Pp. 394. 75s.

THIS book makes an effective attack on a very difficult

subject: the formal recording of data relevant to the diagnosisand treatment of personality disorders in children. The usesand limitations of psychiatric records are discussed. Formalisedrecords are of real value when a team is working with a patient.In clinical psychiatry, however, when the recorder is alsoobserver and therapist, and many areas of information areindefinite, the statistical value of such records is doubtful.A method of evaluating the adequacy of data has therefore beenprovided.

All possible clinical information is discussed, with specialreference to its recordability. Methods of diagnosis and classi-fication of personality disorders are assessed, as are methods oftreatment and of recording response to treatment. In the finalchapters the value and application of recording methods areappraised. The appendix gives a guide to institutions intendingto adopt this method of recording and to the use of records forresearch.

This book is not of general interest, and some readers mayfind it hard to follow because of the strongly American style ofits text; but the expert will find it a very valuable contributionto the problem of making objective psychiatric records.The Facts of Life (A Family Doctor booklet published by

the British Medical Association, Tavistock Square, London,W.C. 1. 1962. Pp. 31. ls.).-Family Doctor’s excellent series ofshilling booklets has been joined by a new edition of " TheFacts of Life ", by Mr. Roger Pilkington, PH.D., which is alittle shorter than the old one and leaves out the chapter onheredity. The facts presented are those of reproduction, witha strong bias towards the bees (banana flies) and the birdsapproach, and human love and sex are discussed only brieflyin the last few pages. Many readers would like to know farmore about the physical and emotional changes of puberty andabout the emotional implications of sex in relation to themselvesduring their adolescent years, but the booklet does give somespace to every physical fact that should be known. Diagramsare not used, but there are small comic illustrations-again aquestionable asset in such instruction.