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Reviews of Books

Acute Renal Failure: Diagnosis and ManagementROBERT C. MUEHRCKE, M.D., F.A.C.P., clinical associate pro-fessor of medicine, University of Illinois College of Medicine,Chicago. Saint Louis: C. V. Mosby. London: HenryKimpton. 1969. Pp. z 19.75; E8 18s.

OVER the past fifteen years the team of renal physiciansat Illinois University, which includes Dr. R. M. Kark, Dr.H. Mattenheimer, Dr. C. L. Pirani, and Dr. V. E. Pollak,has made major contributions to the understanding of mostforms of renal disease. Much of this work has been based onpercutaneous renal biopsy, a method first used by others,but which the Illinois group firmly established as a usefuldiagnostic tool that carries little risk in experienced hands.Dr. Muehrcke, a member of the Illinois team, has done avaluable service in recording his extensive experience ofacute renal failure. There is a real need for such a book, forthe management of acute renal failure has been revolution-ised by modern methods of treatment, yet no comprehen-sive monograph exists on this subject. Unlike some writerson acute renal failure, Muehrcke does not confine himself tothe syndrome known as " acute tubular necrosis " butfollows the more logical course of considering all forms ofrenal disease in which renal function suddenly fails regardlessof the supposed lesion-a more helpful approach for theclinician, who frequently finds it difficult to distinguishacute tubular necrosis from other forms of renal failure. Theresulting book has many excellent features, especially thehistorical section in which the author emphasises the valu-able early contributions of W. T. Councilman on acute in-terstitial nephritis and E. G. L. Bywaters on acute tubularnecrosis, the very full pathological descriptions, and acopious bibliography. The sections on pathogenesis andtreatment are also good, but less detailed. The book con-tains many fascinating and detailed case-reports. Some ofthese are excellent, although several patients had morenumerous renal biopsies than are usually considered neces-sary for diagnosis and treatment; a patient with arsine-induced tubular necrosis underwent renal biopsy six times.One irritating feature of this book, which it shares withsome others from the U.S.A., is the illogical and almostcomplete replacement of the word " urea " by " BUN "(blood-urea-nitrogen). Urea values can be obtained fromBUN by multiplying by 2-14, but why should urea aloneamong nitrogenous compounds be designated by its nitro-gen content? Sometimes this usuage can be confusing; thestatement " elevated BUN levels have no damaging effect tobody tissue and are insignificant in producing the toxicuremic clinical features " leaves the reader with the uneasysuspicion that the biological properties of urea can somehowbe distinguished from those of its nitrogen content.

The BiocratsGERALD LEACH. London: Jonathan Cape. 1970. Pp. 317.35s.

IF we wake up one day to a trend in biology or medicinewhich we do not like, have never agreed to, and cannoteasily reverse, whom should we blame ? The " biocrats ",says Mr. Leach, reserving this ugly term for a key group ofworkers who do not contribute to debate and decision

making " because they are walled up by their own expertiseand attitudes, and do not listen to those outside their narrowconfines "; and the mass media, he adds, for thinking insensational headlines instead of providing perspective to thetechnical side of biomedicine. Certainly we could not blameMr. Leach (who is science correspondent of the Observer),for he has written a balanced, informative, and deliberatelynon-sensational account of those areas, present and future,

where medical advances and social and economic prioritiesare at odds. No newspaper editor should allow the terms" gene " or " test-tube baby " to appear in a headline untilhe and his staff have thoroughly digested what Mr. Leachhas to say. But the communications media are not the onlyagencies to be found wanting in the face of 20th-centurychallenges such as transplantation surgery, artificial organs,and fetal medicine. He concludes that " traditional medicalethics " are an anachronism; but he bases this conclusion onthe arguable notion that the conduct of most doctors is

governed by inflexible principles-for example, that lifemust be preserved, or death postponed, at all costs. Thebook follows a logical sequence from population control andcontraception, through genetic counselling, intrauterinediagnosis, and fetal repair, to congenital defects, and right onto the expensive business of replacing organs in later life.In the two chapters on birth control it is difficult to knowwhom to cast in the role of biocrat; these pages seem out ofplace. His estimate of 200,000 abortions (legal and illegal)in the first year of the Abortion Act is likely to be toohigh, and he gives no justification for it. At the other end ofthe lifespan, Leach rather surprisingly makes no mention ofgerontology. Might not those who enthusiastically advocateresearch with chemicals which could be used, unselectively,to slow down the ageing process create more far-reachingsocial problems than those who are working with, forexample, man/mouse hybrids in tissue culture or in-vitrofertilisation ? The inherited defect caused by the recessivegene of large effect is one very difficult problem which theauthor tackles well. Screening for recessive mutant genesand selection of a non-carrier mate for those who bear such

genes would lower the prevalence of severe handicaps inchildren; but future generations may curse us for passingon to them a gene pool considerably more abnormal thanour own. Leach condemns present attitudes to the care ofthe baby with spina bifida because he concludes that adecision to treat by early surgery is almost universal, butthat necessary support for the handicapped survivor and hisfamily is not provided on a sufficiently large scale. However,as correspondence in our columns in 1968 revealed, opinionon the merits of immediate surgery is nowhere near

unanimous. In the end the debate is really about priorities." Families accept that they cannot buy everything theywant; we must realize that the same is true of our lives andhealth as a total community." Perhaps, he concludes," medicine should help us live more fully and spend less inaverting our deaths. Medicine in crisis cannot do both tothe full. In the end this is the biggest choice we have toface."

Our Future SelvesCare of the Elderly. NESTA ROBERTS. London: George Allen& Unwin. 1970. Pp. 159. 30s.

THE fact that in the next 25 years there will be one millionmore people aged 75 or over makes the plea for more com-prehensive and flexible services for old people, which is thetheme of Miss Roberts’ book, a timely one. She gives abrief history of the growth of present services in Britain,from the Poor Law Commission of 1832 to the green-paperof 1968. The development of the National Old People’sWelfare Council since its foundation in 1940 is described indetail. The second part of the book covers particular aspectsof present services for the old-training of staff, preparationfor retirement, domiciliary services, accommodation whereold people can be independent, homes for those who needresidential care, clubs and arrangements for visiting oldpeople, geriatric medicine. Miss Roberts alternates a briskrelation of facts with appeals for more constructive help andsympathy. Her most effective appeal is probably in hertitle. However, it is difficult to see how the book will interestthose not already involved in care of the elderly.

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In the Service of Old AgeANTHONY WHITEHEAD, deputy medical director, PrestwickHospital, Manchester, and consultant psychiatrist, Man-chester Northern Hospital. Harmondsworth: PenguinBooks. 1970. Pp. 160. 5s.

CARE of the elderly mentally ill (psychogeriatrics) con-stitutes a major medical problem in the U.K., which is

likely to reach its peak, in terms of actual numbers, withinthe next twelve years. The resources to deal with it areslender and inadequate. This paperback describes a systemat Severalls Hospital, Colchester, which maintains a largenumber of old people fairly successfully in the community,reducing the number of inpatients by making a reasonablyefficient use of limited resources of money and manpower.It describes in detail hospital staff working in the com-munity, coordination of community services, day care, theemergency service (a scheme originated at Severalls), andboarding-out. It will be of great value to all concernedwith the welfare of the elderly, including hospital doctorsof all specialties, general practitioners, social and welfareofficers, members of hospital committees, and patients andfuture patients. One of Dr. Whitehead’s special pleas is fora service which is based on the patient’s own needs. Thewriting is lucid, the approach modest and sympathetic.Some repetition is inevitable because the subject-matter ofthe various chapters overlaps, and the book is based onprevious published papers. No-one reading this book canremain complacent, excusing himself for doing nothing toimprove the care of the elderly on the ground that theresources are insufficient.

Physical Principles of Ultrasonic DiagnosisPETER N. T. WELLS, University of Bristol and United BristolHospitals. New York and London: Academic Press. 1969.Pp. 282. 80s.

THIS is a book by a physicist and written in the languageof physics. It lives fully up to its name and starts straightoff into a description of the physical and mathematicalproperties of wave motion. As the author rightly pointsout, the subject lies between the three disciplines of physics,engineering, and medicine. Attempts to bridge all three arenow more than ever necessary with the recent rapid growthin the importance of medical sonar. It is hardly an intro-duction suitable for the complete beginner in its clinical

uses, and a fair knowledge of electronics is needed to makeit comprehensible throughout to the average doctor; but itwill serve as an important reference guide. Besides a goodbibliography the book includes a useful glossary and a listof generally accepted mathematical symbols. This book ischiefly remarkable for its review of future possible develop-ments and a description of the technical difficulties alreadyencountered in subjects as complicated, for example, asacoustic holography. It is an informative and thought-provoking work.

Drink, Drugs and DrivingH. J. WALLS, B.SC., PH.D., formerly director of the Metro-politan Police Forensic Laboratory, and A. R. BROWNLIE,M.A., LL.B., solicitor, Supreme Courts, Edinburgh. London:Sweet & Maxwell. 1970. Pp. 190. 30s.

THE Road Safety Act 1967 has now been in operation forrather more than two years, so that a book such as this,which gives the scientific and legal background in a con-venient and easily assimilable form, is especially welcome.Dr. Walls, as director of the Metropolitan Police Labora-tory, was much involved in the long period of preparationand the early stages of enforcement of the Act, so he speakswith authority. Both he and Mr. Brownlie have the gift ofclear and interesting exposition, in simple language, of anoften tangled subject. The subject is, however, so wide,that it is impossible, even for authors to speak with authority

on all aspects of it, and this sometimes leads to uncriticalacceptance of somewhat doubtful or inconsistent views.For example, on p. 40, the conclusion of T. A. Loomis andT. C. West that " the severely intoxicated person is not themain public hazard ... but rather the person in a moderatestate of intoxication " is quoted with approval. But,later on, they quote with equal approval the Grand Rapidssurvey, which showed clearly that severely intoxicateddrivers were a major source of accidents, because, althoughthey were less numerous, their liability to accident was verygreatly increased. It is a pity indeed that the Road ResearchLaboratory’s estimates which showed the actual proportionof all accidents attributable to alcohol at various blood-levels (by simple calculation from the Grand Rapids figures)were not also quoted. It is also a pity that breath analysis asa substantive test, with all its convenience for all parties, isdismissed on the basis of a rather superficial survey of theliterature, and unpublished researches in Home Officelaboratories. These, however, are relatively minor criticismsof a generally reliable and informative handbook. The de-tailed consideration of the technical problems of identifica-tion, handling, and analysis of blood specimens is especi-ally useful; and there is a full discussion of the statistics oferror. The short chapter on drugs other than alcohol showsclearly the troubles in store for us if driving under theirinfluence ever becomes common. The extreme difficulty ofdetection and analysis, compared with alcohol, would makeproof of an offence almost impossible. The five chapters onthe legal aspects of drink and driving are a useful guidethrough the twists and turns of the defences, which, fortu-nately, do not normally concern the medical profession.

Manic-Depressive IllnessGEORGE WINOKUR, A.B., M.D., professor of psychiatry, PaulaJ. Clayton, B.S., M.D., assistant professor of psychiatry, andTHEODORE REICH, M.D., B.SC., C.M., Washington UniversitySchool of Medicine, St. Louis, Missouri. St. Louis: C. V.Mosby. London: Henry Kimpton. 1969. Pp. 186.$6.50;59s.

THIS book is divided into three parts. Part i is largely areview of previous epidemiological, genetic, and clinicalstudies on affective disorders, including manic depression.The authors conclude from their highly selected reviewdata that neurotic and psychotic depressions are xtiologic-ally and phenomenologically separate. Going beyond theneurotic-psychotic dichotomy they present some evidencethat psychotic depression may itself be divided into twomutually exclusive categories-manic depressive (bipolar)psychosis and depressive (unipolar) psychosis. Althoughsome of the 300 or so references cited in the text are morerecent, there is no mention of R. E. Kendell’s 1968 book, TheClassification of Depressive Illness. This important workoffers the most conclusive evidence to date that a classifica-tion of depressive typologies based on a dichotomy ortrichotomy concept is a gross oversimplification. Instead,Kendell advocated a continuum model, with most casesfalling between the psychotic-neurotic poles and showingmixed features. This view, which fits the clinical facts muchbetter, is steadily gaining ground. Part II is the best sectionof the book and comprises a prospective study of sixty-one" rigorously defined " manic-depressive (bipolar psychosis)probands and their immediate families. Especially com-mendable are the clinical descriptions of manic and depres-sive episodes and various associated syndromes; these areamply illustrated by case-material. From the family studies,which are also well documented, the authors emphasise thecausal importance of genetic elements. Proceeding fromthe general to the specific they argue that the major con-tribution to manic depressive disease seems to be from anX-linked dominant kind of gene. They support this bydescribing one family, several members of which pre-sented with mania and colour-blindness of the protan type;

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this type of colour-blindness is inherited via an X-linkedrecessive gene. The locus for the colour-blindness gene isknown to be on the short arm of the X chromosome.Winokur and his co-authors presume that the locus for anX-linked dominant gene in manic-depressive disease wouldbe located in the same place. These findings are undoubtedlyimportant, but they are likely to be only a part of the story.Part ill reviews various biological and, somewhat perfunc-torily, psychological theories about the xtiology of affectivedisorders, including manic depressive (bipolar) psychosis,and discusses their treatment. One surprising statement isthe recommendation that amphetamine, either alone or withspecific antidepressants, be used in patients who are

maximally depressed in the morning; few British psychia-trists would agree with this. This book promulgatesan extreme constitutional and specific genetic viewpointof manic-depression. However, despite this bias it is avaluable reference work. It will provide provocative readingfor psychiatrists generally, and especially for registrarsreading for the D.P.M.

Trends in Clinical PathologyEssays in Honour of Gordon Signy. Association of ClinicalPathologists. London: British Medical Association. 1970.

Pp. z7.50; 60s.THIS volume of essays by colleagues is in celebration of

Gordon Signy’s twenty-five years’ editorship of the Journalof Clinical Pathology. Since Signy is a Londoner and hasspent all his working-life in London, it is not surprisingthat most of the contributors to this volume are alsoLondoners. The essays are of two types-those that discusstIends in policy and administration of a branch of clinicalpathology, and those that concern the special interest of thecontributor. Of the first type the essays of Dr. E. K.Blackburn and Prof. J. V. Dacie on hxmatology, Prof. N. F.Maclagan on chemical pathology, Prof. Keith Simpson onforensic medicine, and Dr. G. H. Tovey of Bristol on theblood-transfusion service are of topical interest; Prof. R. J.V. Pulvertaft’s essay on pathology in developing countriesalso comes into this group. Of the special contributionsthose of Dr. Rosemary Biggs on problems of hasmostasis,Dr. J. A. Dudgeon on medical virology, Prof. A. C. Lendrumon the relation between fibrin and hyalin (with first-classillustrations), and Prof. N. H. Martin on molecular defenceare worth reading by any doctor-clinicians and pathologistsespecially. Volumes of this type are of most interest to

specialists and those who know the person being honoured;but the general medical reader will benefit from browsingthrough this collection of essays.

Ultrastructure of Synovial Joints in Health andDisease

FEROZE N. GHADIALLY, M.D., PH.D., D.SC., M.R.C.PATH. pro-fessor of pathology, University of Saskatchewan, andSuBiMAL Roy, M.D., PH.D., assistant professor of pathology,All India Institute of Medical Sciences, New Delhi. London:Butterworths. 1970. Pp. 186. E5.

THIS beautifully produced book should be in everylibrary. The text occupies the left-hand page and theelectron micrographs the right throughout the book, whichgives a pleasing appearance, although one still often has toturn over a number of pages for reference to the appropriateillustration. There is a good deal more illustration (190photomicrographs) than text, which occupies only 25%of the chapters. The work is mainly that done while theauthors were in Sheffield, and it is an advantage to have itbrought together in one volume with comparison with theviews of other workers. The opening two chapters dealwith the normal appearance of synovial membrane andarticular cartilage and subsequent ones with the pathologyof osteoarthrosis, traumatic arthritis, hsemarthrosis, andrheumatoid arthritis. Each chapter is set out in the same

pattern passing from naked-eye and light-microscopicchanges in the synovial membrane and articular cartilageto ultrastructural changes in the synovial intima, sub-

synovial tissue, and articular cartilage, and finishing with asection on the implication of the ultrastructural changes.This consistent pattern enables easy reference, quite apartfrom the adequate index and useful bibliography at theback. No reference is made to scanning electron micro-scopy, so that the information this technique has given onthe structure of the layers and surface of articular cartilageand the synovium is absent. For instance, the surface ofarticular cartilage is described as " remarkably smooth ",whereas scanning electron microscope studies from London,Leeds, and Strathclyde have demonstrated that its surfaceis undulating and that this is highly significant in terms ofthe lubrication mechanism. There is much more detail inthis volume than will be required by the routine pathologist,but any clinician or pathologist with a special interest injoints, as well as the electron microscopist, will want to seethis book on his own shelf as well as that of the library.

Immunology and DevelopmentClinics in Developmental Medicine, no. 34. Edited by M.ADINOLFI. London: Spastics International Medical Publica-tions. 1969. Pp. 187. 63s.

THIS book, intended for pxdiatricians, biologists, immu-nologists, and others, contains six monographs coveringdivers fields, not obviously related. The concept that

ontogeny recapitulates phylogeny underlies this book, but,as Dr. J. H. Humphrey says in the preface, this has not yetbeen shown to be applicable to the immune response.Discussion is confined to specific immunity, includingcomplement-non-specific immunity functions have littleconsideration. The mechanism of generation of diversity,which forms the basis of recognition and so of specificimmunity, is considered in a sophisticated and very theoreti-cal way by Dr. D. W. Talmage. In contrast, Dr. J. R.Hobbs provides a pragmatic account of the more severeimmunity-deficiency diseases. This is, perhaps, the mostuseful practical review and source on this topic; it is veryup to date, but the use of the unsatisfactory classification ofthe dysgammaglobulinasmias into types I to n and theomission of the clinical relevance of a range of less extremeabnormalities are, perhaps, unfortunate. Dr. R. B. McCon-nell gives a similarly practical account of the use of antibodyto prevent fetal damage resulting from rhesus incompatibi-lity. The monographs by Hobbs and McConnell will be ofgreat use to clinicians. Dr. W. D. Billington deals morebroadly with the fascinating field of immunological relation-ships between mother and fetus. Dr. M. Adinolfi (who, aseditor, has achieved an excellent presentation) describeswith Dr. C. B. S. Wood the wide range of immunityfunction the fetus can achieve, including the effect ofsuch environmental factors as infection. Dr. L. W.Clem and Dr. G. A. Leslie provide a very valuable reviewof phylogeny, which, to use Dr. Humphrey’s words, recordsthe loss of the hagfish’s special status as the negative hero ofthe phylogeny of immunity; they deal in detail with struc-ture and chemistry but one would have liked even more ofthe work on the immunity functions in invertebrates. Isthere an element of recognition of self at this stage ? Thisbook contains excellent matter for all those at whom it isaimed, and it can be recommended as reliable and forward-looking.

New Editions

Pediatric Surgery.-3rd ed. Edited by Orvar Swenson. NewYork: Appleton-Century-Crofts. London: Butterworths. 1970.Two vols. Pp. 1507. S45; E20.

Synaptic Transmission.-2nd ed. By Hugh McLennan. Phila-delphia and London: W. B. Saunders. 1970. Pp. 178.$17.80; E7 9s.