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Reviews of Books

Ethical Issues In Family Medicine

R. J. Christie and C. B. Hoffmaster. New York: Oxford University Press.1986. Pp 190. L20.

THIS book by two Canadian family doctors starts with a definitionof family medicine that emphasises the doctor’s role in providingcomprehensive health maintenance and medical care-biological,behavioural, and social-to the entire family. It points out that manyissues regarded as clinical or medical are in fact ethical. Ethicalissues are seldom black and white. How, for example, should adoctor respond when a patient refuses a diagnostic X-ray? Whoshould decide? Advocates of patient autonomy would leave it to thepatient. Others would adopt a paternal or even authoritative lineand try hard to change the patient’s mind. The crux of the book isanalysis and discussion of such questions.Here is an example that illustrates the importance of the family

doctor’s knowledge of his patient. A 12-year-old girl is taken to theemergency department of a hospital with right-sided lowerabdominal pain. Appendicitis is diagnosed. The surgeon contactsthe family doctor as a matter of courtesy and says he proposes to doan immediate appendicectomy. The doctor, who has been

counselling the child’s mother and father because of marital

dysfunction, suggests that the symptoms might well be due to stressin the family. The operation is postponed and within 36 hours thesymptoms have subsided and the girl is discharged home. Anothercase history concerns a conspiracy of silence. An 83-year-old retiredfarmer has a prostatectomy which reveals a carcinoma. The surgeontells the family doctor that he is not going to tell the patient the truediagnosis. He agrees and so does the old man’s son. The authors listthe options and discuss in considerable detail the ethics of thisdecision and conclude that the family doctor should have rejectedthe surgeon’s decision not to inform the patient. A much moredifficult case history is of an unmarried woman in her early 20s whopresents with an episode of temporary blindness in her left eye. Thepossibility of multiple sclerosis arises. Should she be told of thispossibility or not? The authors discuss the question at length butcome to no firm decision.Other chapters discuss doctor-patient relationships, patient

autonomy, the family as patient, intervening in patients’ lifestyles,and difficult patients and doctors. The book identifies a host ofethical issues in family medicine and assesses the moral role of thedoctor. In addition it makes a strong case for the personal doctorwho will stick with his or her patients, however difficult, will copewith whatever problems they present, without fear of emotionalinvolvement, and will be sensitive to the effects of lifestyle onhealth. A fascinating book which adds a new dimension to familymedicine.

Whlckham Health Centre,Whickham,Newcastle upon Tyne ANDREW SMITH

Gastrointestinal and Hepatic Complications in PregnancyEdited by V. K. Rustgi, Stanford University Medical Center, andJ. N. Cooper, Georgetown University School of Medicine. New York:Wiley. 1986. Pp 289. f40.90.

OF the medical disorders associated with pregnancy,hypertension and diabetes have lately been attracting specialinterest. Gastroenterology has lagged somewhat behind in terms ofpublications and this book seeks to fill the gap. It begins with a clearaccount of the physiological effects of pregnancy on gastrointestinalfunction before proceeding to cover the major gastrointestinal andliver disorders that may be encountered during pregnancy. Itconcludes with a review of drug-induced jaundice with specificrelation to pregnancy, and a chapter on the fetal alcohol syndrome;

although the latter might be considered slightly out of place it is anappropriate recognition of a growing medical problem which canjustifiably be regarded as a complication of events occurring duringpregnancy.The emphasis of the book is on diagnosis and practical

management, and by and large it succeeds admirably. Not only is itfull of sensible and practical advice on how to diagnose and managegastrointestinal troubles in pregnancy but it is sufficiently wellreferenced to answer the questions that women with chronic diseasewishing to embark upon pregnancy are likely to ask. For example,physicians and obstetricians will often be asked about the risk ofpregnancy to both mother and fetus in a patient with inflammatorybowel disease, and the evidence is clearly and expertly reviewedhere. The book is not without faults. I question the need for a20-page chapter on endoscopy in the pregnant patient, particularlyif 14 pages of it are allocated to case histories of patients who haveundergone upper and lower gastrointestinal endoscopy. Apart froma dozen lines on the physiological effect of colonic function in theintroductory chapter there seems to be no mention at all of non-inflammatory disorders of the large bowel. Surely constipation, theirritable bowel syndrome, and haemorrhoids rate a mention?

Despite these criticisms the book has a great deal to commend it. Itdeserves a place in the library of every obstetrics department as wellas being a useful handbook for gastroenterologists or generalphysicians who are called upon to advise on medical problems inpregnancy.

Royal Hallamshire Hospital,Sheffield S 10 2JF DAVID TRIGER

Pulmonary Function Testing Indications andInterpretations

A Project of the California Thoracic SocIety. Edited by Archie F. Wilson,University of California School of Medicine, Irvine. Orlando, Florida:Grune and Stratton. 1985. Pp 353.$39.50.

Pulmonary Function Tests in Clinical and OccupationalLung Disease

Edited by Albert Miller, Mount Sinai School of Medicine. Orlando,Florida: Grune and Stratton. 1986. Pp 482.$67.00.

THE Rev J. Hutchinson first described the spirometer 140 yearsago. Since that time there have been enormous advances in our

ability to quantify many aspects of respiratory physiology but eventoday most clinicians are familiar only with simple spirometry andarterial blood gases. Modern chest physicians ought to understandthe indications and limitations of pulmonary function testing. Onlythen can they provide a service to colleagues that includes the abilityto measure the clinically important variables and, more

importantly, to interpret the findings in the light of the clinicalproblem. The temptation to associate disordered physiology withunderlying pathology is great and is to be resisted. Nevertheless,pulmonary function testing remains a cornerstone in the assessmentof the patient with a respiratory disease. Moreover, increasingpublic enthusiasm for physical fitness has stimulated interest intests of pulmonary (and cardiac) function under stress, and the effectof fitness training on exercise physiology.Despite all this interest (and ignorance) there are remarkably few

books whose primary aim is to help the chest physician chooseappropriate pulmonary function tests and interpret the findings.These two books have been released by the same publisher. Thefirst, edited by A. F. Wilson, is the result of a project by thephysiology committee of the California Thoracic Society. Thesecond, edited by A. Miller, perhaps by way of compensation,comes from Mount Sinai Medical Center in New York. They bothdiscuss the limitations of pulmonary function tests and the patternsof change observed in patients with respiratory disease; they bothhave chapters on the standard tests, including spirometry, lungvolumes, lung mechanics, gas transfer, and blood gases; and they

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both discuss the special problems of the assessment of children,occupational lung disease, sleep disorders, exercise, preoperativeevaluation, and bronchial provocation tests. Unfortunately theyboth leave out the important areas of chest wall physiology and thepulmonary circulation, but happily they both include sections onthe uses and problems of computer algorithms for the interpretationof results: as we suspected, there is still an important role for thedoctor. Wilson’s book has a more consistent style: each chapterstarts with the historical background and this is followed by a reviewof the methods for measuring each variable and then the indications,limitations, and controversies associated with each test. There areno photographs but graphs and line drawings are included whereappropriate. Miller’s volume is longer, printed on better qualitypaper, has better references, and includes many photographs butthere is considerable variation in style between chapters. Both booksfulfil their purpose admirably but I found the California offeringmore digestible; also I am slightly concerned when the "editor" of abook, even one as distinguished as Miller, writes more than half thechapters.Department of Medicine,Southampton General Hospital ANDREW PEACOCK

Speech and Language Evaluation in Neurology:Adult Disorders

Edited by J. K. Darby. Orlando, Florida: Grune and Stratton. 1985.$69.50.

Speech and Language Evaluation in Neurology:Childhood Disorders

Edited by J. K. Darby. Orlando, Florida: Grune and Stratton. 1985.$49.50.

FROM their titles, I had expected each of these volumes to addressprincipally the problems of evaluation of the individual withimpairment of language, and of evaluation of therapy. However, theeditor has used this opportunity to collect a wide range of chapterson distantly related topics, most of which are insufficiently welldone to warrant the space taken. For example, the "adult" volumecontains 40 pages on the anatomy of cerebral blood vessels, and thecauses and epidemiology of stroke, and the "childhood" volume astrange chapter on molecular genetics in speech and languagedisorders. To be fair, linkage analysis, for example, is rather welldone, but it is a strange volume in which to attempt to explain it,particularly when two principal problems that worryparents-delayed acquisition of language, and stuttering-are socursorily treated.Books about words tend to be wordy. "The nature and scope of

language intervention with children has metamorphosed fromfocussing solely on vocabulary and syntactic structure to

encompassing not only the structure and content of language butalso the child’s cognitive and social knowledge contributing to theuse of communication for social interaction. The introduction of

pragmatics to the child language literature in the mid-1970s has hadfar-reaching consequences on the conceptualisation of languageintervention." Translated, this means (I think) that "speechtherapy for children has changed; it is now more interested inhelping the child get the message across".The harsh truth is that we are still so far from understanding how

language is stored and communicated that virtually all research inthis field is observational and correlative. The most interestingobservation to date-that there is no difference in outcome for

aphasic patients treated by speech therapists as compared withvolunteers (David et al, J Neurol Neurosurg Psychiatry 1982; 45:957-6l)-is passed over in one sentence in these two volumes.

Department of Neurological Sciences,St Bartholomew’s Hospital,LondonECIA7BE ANTHONY HOPKINS

Retained Common Duct Stones

Edited by Roger W. Motson. Orlando, Florida: Grune and Stratton. 1985.Pp 150.$38.50.

THIS is a well conceived little book intended to provoke,stimulate, and update clinicians involved in the treatment of themany patients with gallstones. It is primarily aimed at surgeons inthe western world who are normally confronted with stones in thegallbladder (the majority) or the common bileduct. Reference ismade, however, particularly by the principal author, to the Asiaticproblem of recurrent pyogenic cholangitis associated with

intrahepatic stones, which is an almost completely different diseaseand much more difficult to treat.One might be tempted initially to think that little new has

happened in the area of retained common duct stones but carefulreading of the contents of this book will surprise most clinicians. Astrong plea is made by Motson for routine choledochoscopy and anincreased awareness of the normal appearance of the lower commonbileduct viewed in this fashion. Were this to be a routine procedure,it is claimed that the incidence of retained stones would be greatlyreduced. Good advice is given on the technique of choledochoscopyand on the various instruments available, their relative merits anddemerits. On the prevention of retained stones, careful operativecholangiography is emphasised and precision in technique clearlydescribed. This section is important and well worth reading even forexperienced surgeons, many of whom disdain the need for

choledochoscopy, except in the more difficult cases.On the therapeutic side, once stones have been identified in a

common duct after the original operation, the great range oftechniques to remove them is fully described in separate chapters.The chapter on the dissolution and flushing of retained stones is awell-balanced contribution clearly indicating from the worldliterature that only bile salts and mono-octanoin represent practicalapproaches to the dissolution of gallstones.The section on percutaneous removal of retained gallstones via

the T-tube tract is instructive; and the limitations of narrow,tortuous, and anteriorly placed T-tubes is emphasised. The place ofdilators and choledochoscope in this type of retrieval is carefullydetailed. Success rates in the most experienced hands with theseapproaches are impressive but it is emphasised that the learningcurve may be long. Newcomers to this technique are advised of theimportance of patient selection and the need for dilatation of T-tubetracts for this type of stone recovery in more than half the patients.Endoscopic sphincterotomy has an important role and a good

contribution is made on this subject by Adrian Hatfield. In the finalchapter on the surgical management of retained common bileductstones choledochoduodenostomy is favoured; it is a valuable

procedure certainly, but the claim on p 140 that it was associatedwith "a far better outcome and a lower incidence of various

postoperative sequelae than after either sphincteroplasty or

choledochojejunostomy" is difficult to grasp from the tables that areincluded. Overall, this is a valuable book which brings together agreat deal of practical information on a very important subject.Royal Infirmary,Glasgow G4 OSF C. W. IMRIE

Psychological Aspects of SurgeryAdvances in PsychosomatIc Medzczne, vol 15. Edited by F. G. Guggenheim.Basel: Karger. 1986. Pp 232. SF139; DM166;$59.25; ;(43.50.

SURGEONS are often surprised when a patient becomes severelydepressed after a major operation. The real surprise is that so fewseem to react to surgery in this way; and, on the evidence of recentwork, lesser degrees of psychological disturbance occur far moreoften than we have thought. Most surgeons have only a superficialknowledge of psychiatry and one of the refreshing aspects of thisimportant and timely book is that it is written in terms that all

doctors, not just psychiatrists, can understand.Operations can be grouped, firstly, into those aimed at conditions

that may have a large psychological component, such as impotence

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and morbid obesity; secondly, those that produce an obviousphysical defect, such as limb amputation and mastectomy; and,thirdly, those that are particularly stressful and complex, such ascardiac surgery and renal transplantation. All these areas are

covered, each chapter being written by an expert with experience ofassessing patients before and after each particular form of surgery.Appropriately, the first section of the book deals with

psychological issues common to many surgical patients andincludes a chapter on infants, children, and adolescents. There isuseful, practical advice on detecting, before operation, those patientsmost likely to have postoperative troubles and there is a critical lookat the assessment of the outcome of psychological intervention insuch people. The book is not just about psychological techniques,but includes all aspects of patient care: the chapter on postoperativedelirium is particularly useful in this regard, pointing out the role ofsuch factors as electrolyte imbalance, drugs, sepsis, and sleepdeprivation. Most of the twenty-one contributors come from theUSA but each chapter is extensively referenced from theinternational work.This excellent book can be strongly recommended to both

surgeons and psychiatrists, as well as social workers and seniornurses involved in the care of surgical patients. My only regret isthat it is so expensive for its size.

Department of Surgery,Royal Hallamshire Hospital,Sheffield S 10 2JF ALANJOHNSON

The Autoimmune Diseases

Edited by Noel R. Rose, Johns Hopkins Medical Institutions, and Ian R.MacKay, Walter and Eliza Hall Institute of Medical Research,Melbourne. Orlando: Academic Press. 1985. Pp 706.$85; ;E75.

THIS multiauthor book is small enough to carry in a briefcase butcontains over 700 pages. The editors’ stated aim is to provide bothphysicians and investigators with a deeper understanding ofautoimmune disease, and indeed the book has a wealth of usefulinformation and references. The opening chapter provides a

succinct and detailed review of genetics and autoimmunity, but theexpected chapter on immunoregulation does not materialisein chapter 2. Some information on current concepts of

immunoregulation is provided in the general introduction, but thisbackground should have been included in the main body of text.Despite the editors’ assertion that contributors were encouraged tofollow a common format, there is much variation in style andemphasis. This can readily be observed by comparing the chapterindexing, which has been designed to help the reader rapidly locateareas of interest. From Ian MacKay’s excellent review ofautoimmune liver disease it is clear that the aim of each chapter wasto cover historical background, classification, animal models,clinical features, histopathology, immunology, treatment, andfuture prospects. About half of the 25 chapters closely follow thisformat and most are excellent and up-to-date. Especiallyrecommended are those on systemic lupus erythematosus, mixedconnective tissue disease, scleroderma, Sjogren’s syndrome,thyroid disease, haematology, and diseases of the gut and liver.Those on diabetes mellitus, sperm, and testicular autoimmunitydeviate from the general style but are well written and makeinteresting reading. The flow of the book is spoilt by a minority ofchapters which are poorly written or do not conform to the editorialformat. Inevitably, these reflect the bias of the author rather thanthe perceived needs of the consumer. This causes a noticeableimbalance in the text and raises questions about editorial control.This is especially true of the items on adrenal, cutaneous, ocular,and renal disease, all of which deviate strikingly from the generalapproach. A disappointing section on rheumatoid arthritis focusesstrictly on the immunology and ignores clinical features andtreatment. Most autoimmune diseases are covered, but why excludeankylosing spondylitis, Still’s disease, and polyarteritis? Thechapter on cardiovascular disease and the discourse on

Autoimmunity of The Future could have given way to these.

There is undoubtedly a niche for a book like this. Had stricteditorial discipline been maintained, and had the exclusions beenincluded, this multiauthor edition might have received more thanmy 7507o vote of confidence.

Academic Department of Medicine,Royal Free Hospital,London NW32QG Q1k’EV EPSTEIN

Clinical Neuropsychiatry

Jeffrey L. Cummings, UCLA School of Medicine, Los Angeles,California. Orlando, Florida: Grune and Stratton. 1985. Pp 264.$44.50.

THE term neuropsychiatry carries different meanings in the USAand Britain. In the UK it is usually understood to cover conditionsand phenomena which lie at the border between psychiatry andneurology-chiefly the disorders of higher mental function causedby recognisable focal or generalised brain disease. By contrast, inAmerica, where psychiatrists have only just rediscovered the

importance of the brain after decades of being dominated bypsychoanalysis, it is an approach to all psychiatric conditions andnot merely a subspecialty with circumscribed terms of reference.This explains the wide scope of Dr Cummings’ book, in which heclasses anxiety, depression, schizophrenia, and delusions in thesame category of phenomena as aphasia, amnesia, or apraxia. To mymind such an approach gives a distorted view of psychiatry andultimately reduces the merits of the book.One more criticism before I mention the rositive features of this

volume: there is a tendency for lack of evaluation of the literature onsome topics. There are too many lists of reported causes of

psychiatric disorders but little to guide the reader as to thecommoner causes-eg, in a table of principal disorders withrecurrent psychoses 20 causes are listed, giving equal weight toschizophrenia (by far the commonest), cycloid psychosis (a doubtfulentity), migraine (a very rare cause if indeed it is a cause), and drug-induced flashbacks (which cannot be regarded as a psychosis at all).The best feature is a systematic account of the classical organic

mental phenomena-aphasia, alexia, &c. In fact, it is the bestaccount I have read in any textbook of psychiatry, neurology, orneuropsychology. Other chief merits of the book are conciseness oflanguage, comprehensive references, structure of the chapters andof the book as a whole, and clear formulation of difficult concepts.On balance, the merits clearly outweigh the demerits; 1

recommend it to students and practitioners of neurology andpsychiatry.Bethlem Royal Hospital,Beckenham,Kent J. CUTTING

New Editions

Monitormg for Drug Safety. -2nd ed. Edited by W. H. W. Inman. Lancaster:MTP Press. 1986. Pp 765. f85.Spinal In}ury.-2nd ed. By Davld Yashon. East Norwalk: Appleton-

Century-Crofts. 1986. Pp 546.$69.95.Clmical Management of Neurogenic Communicative Disorders.-2nd ed.

Edited by D. F. Johns. Edinburgh: Churchill Livmgstone. 1985. Pp 323. jE24Manual of Medical Care of the Surgical Patzent.-2nd ed. By S. Papper, G.

Rainey Williams. Edinburgh: Churchill Livingstone. 1985. Pp 256..C17.10Diabetes Mellitus-Diagnosis & Treatment.-2nd ed. By M. B. Davidson.

Chichester: John Wiley & Sons. 1986. Pp 589. f25.60.An Introducnon to the Psychotherapies.-2nd ed. Edited by Sidney Bloch

Oxford: Oxford University Press. 1986. Pp 285. f8.95 (paperback) £ 15 00.Mosby’s Medical Nursing Dictionary.-2nd ed. Edited by W. D. Glanze, er

al. Oxford: Blackwell Scientific. 1986. Pp 1563. ,E14.95.Lee McGregor’s Synopsis ofSurgicaIAnatomy.-12th ed. By G. A. G. Decker,

D. J. Du Plessis. Bristol: Wright. 1986. Pp 626. ,E12.50.Chemotherapy In Psychiatry. Revlsed and enlarged edition. By Ross J

Baldessarini. London: Harvard University Press. 1985. Pp 354. 21.25.Textbook of Work Physwlogy. 3rd ed. By Per-Olof Astrand, Kaare Rodahl

Maidenhead: McGraw-Hill. 1986. Pp 756. 38.95.