16

samples had shifted to the right relative to control. The effectwas concentration dependent. At the end of the experiment,pH had dropped because of glycolytic metabolism by anequal amount in both treated and control samples. Thedifferences in ODCs could therefore not be attributed simplyto a Bohr effect. 5

Intracellular DPG levels were, however, consistentlyhigher in BWA827C treated samples than in controls. Thecompound-induced improvement in DPG levels relative tocontrol reached a maximum of between 2 and 3 x 1 0 - 3 mol/l.After two weeks, control values had generally fallen from aninitial value of around 5 to <0 - 5 x 10 -’ mol/1, at which timelevels were 2 x 10- mol/1 in the presence of BWA827C.

In an experiment to examine the effect of BWA827C onintracellular adenosine triphosphate (ATP) levels, the ATPconcentrations were 2 - 07 (&plusmn;0 . 18)x 10- mol/l(with 3 x 10-3mol/1 BWA827C) and 2-13 (&plusmn;0-06)x 10-3 mol/i (control).There is no evidence, therefore, to suggest that the rise inintracellular DPG is obtained at the expense of ATP levels.These results were obtained with small (1-5 ml) volumes of

blood stored at 4&deg;C. The effect of BWA827C on P50, pH,DPG, and ATP levels in whole units of stored blood has alsobeen investigated and will be reported later.

DISCUSSION

The novel compound BWA827C is one of a series beingstudied for its ability to shift the ODC of haemoglobin to theright. The compound is also able to reduce the fall in DPGlevel which occurs when blood is stored in anticoagulants.6Reduced DPG levels cause a considerable left-shift of theODC and a reduction in the capacity of the stored blood todeliver oxygen. This capacity is not fully restored for severaldays after transfusion and patients with coronary arterydisease or cerebrovascular disease are particularly at risk fromthe transfusion of large quantities of stored blood.8 Themedia currently used for the liquid storage of blood have beendeveloped to maintain red-cell ATP, which is related to post-transfusional cell survival, at the recognised expense of a lossof DPG, and the simpler, practical procedures for

maintaining DPG levels militate against the conservation ofATP.9 The simple addition of BWA827C to CPDA blooddoes not have this disadvantage and may be preferable to theother effective, but more complex, techniques.1O Thereforethe potential of treating stored blood with agents of this type,in addition to their systemic applications, is beinginvestigated.Correspondence should be addressed to R. M H.

REFERENCES

1. Perutz MF, Poyart C Bezafibrate lowers oxygen affinity of haemoglobin Lancet 1983,ii 881-82.

2 European patent application no. 83104086.03. Beddell CR, Goodford PJ, Stammers DK, Wootton R Species differences in the

binding of compounds designed to fit a site of known structure in adult humanhaemoglobin Br J Pharm 1979; 65: 535-43

4 Nygaard SF, R&ouml;rth M An enzymatic assay of 2,3-diphosphoglycerate in blood. J ClinLab Invest 1969; 24: 399-403.

5 Wranne B, Woodson RD, Detter JC Bohr effect: Interaction between H+, CO2 and2,3DPG in fresh and stored blood. J Appl Physiol 1972; 32: 749-54.

6 Sugerman HG, Davidson DT, Santi Vibul AB, Delivoria-Papadopoulos M, Miller LD,Oski FA The basis for defective oxygen delivery from stored blood Surg Gyn Obstet1970, 131: 733-41.

7 Valeri CR, Hirsch NM. Restoration in vivo of erythrocyte adenosine triphosphate,2,3-diphosphoglycerate, potassium ion and sodium ion concentrations following thetransfusion of acid-citrate-dextrose-stored human red blood cells. J Lab Clin Med1969, 73: 722-33.

8 Woodson RD. Physiological significance of oxygen dissociation curve shifts. Crit CareMed 1979; 7: 368-73.

9. Beutler E, Meul A, Wood LA. Depletion and regeneration of 2,3 diphosphoglycericacid in stored red blood cells. Transfusion 1969; 9: 109-14

10. Valeri CR Blood banking and the use of frozen blood products Cleveland, Ohio: CRCPress, 1976.

Reviews of Books

Vascular SurgeryA Comprehensive Review Edited by Wesley S. Moore, University ofCalifornia School of Medicine, Los Angeles, California. New York andLondon: Grune and Stratton. 1983. Pp 994.$89.

IN 1982 the American Board of Surgery and Thoracic Surgerystarted an examination in order to grant Certification of SpecialCompetence in General Vascular Surgery, the aim being to improvestandards of peripheral vascular surgery in the United States. Thistextbook is designed to accompany a postgraduate course forcandidates preparing for this examination and therefore everychapter ends with questions designed for self examination. Thisoutstanding textbook gives much more than the basic knowledgerequired for a certificate of competence. Each chapter manages to bevery comprehensive and erudite without sacrificing clarity of

expression. Some textbooks of vascular surgery start by describinginvasive and non-invasive investigations in detail then go on tochapters on specific conditions which repeat the investigationsdescribed in the first half. This pitfall is avoided here, so althoughthe book looks smaller than some of its contemporaries, it contains aremarkable amount of information.

Angiography is described by J. De Angelis, and illustrated bymany excellent radiographs. Vascular laboratory investigations andnon-invasive measurements are equally well clearly described byJ. D. Baker. I was sorry that the chapter on upper extremity vasculardisease, by H. I. Machleder, was entirely without illustrations anddid not discuss the various operations designed to relieve subclavianocclusion and upper limb ischaemia. These operations are describedin an earlier section by C. G. Rob and P. C. Podore, but withoutdiscussing the indications. I particularly enjoyed W. F. Barker’shistorical section, the chapter on haemodynamics, by R. E. Zierlerand D. E. Strandness, and that on non-atherosclerotic vasculardisease by J. M. Porter, L. M. Taylor, and G. M. Bauer. These arepersonal preferences. Other first-class chapters, each written byexperts, include those on aneurysm of the aorta and iliac arteries

(E. S. Crawford and C. Stowe), peripheral artery aneurysm(J. E. Connolly), aorto-iliac occlusive disease (J. A. Mannick, A. D.Whittemore, and N. P. Couch), lower limb occlusive disease (F. J.Veith and coworkers), vascular trauma (M. 0. Perry), and

extracranial cerebrovascular disease (W. S. Moore and W. J.Quinones-Baldrich). Even for those who, thankfully, no longer haveto take examinations, the questionnaire at the end of each chapteradds interest and stimulation. This book is an important addition tostandard textbooks of peripheral vascular surgery.Department of Surgery,Lewisham Hospital,London D. NEGUS

Practical Paediatric RadiologyS. von W. Hilton, D. K. Edwards, and J. W. Hilton, University ofCalifornia Medical Centre, San Diego, California. Philadelphia andEastbourne: W. B. Saunders. 1984. Pp 619. f64.50.

WRITTEN for general radiologists occasionally practising paedi-atric radiology and for paediatric radiologists well versed in rarediseases but sometimes removed from the more common paediatricproblems, this book consists of chapters related to specificconditions-stridor, cough and fever, heart murmur, abdominalpain, vomiting, diarrhoea, bloody stools, constipation, gastro-intestinal haemorrhage, limp, child abuse, urinary tract infection,and enuresis. Each of these chapters follows a set pattern. An intro-duction, discussion of the clinical features, and an extensive list ofdifferential diagnoses of the condition precede an account of theclinical and radiological features of three or four of the commonerdisorders presenting with the symptom being considered. The bookthus covers most of the common problems presenting in childhood.There are contributions from guest authors who are well known

paediatric radiologists.In general the text is clear, unambiguous, and sensible. Frequent

reference is made to computed tomography, ultrasound, and isotope

17

scans, and a pathway of investigation is given for each clinicalproblem. The radiographic illustrations are excellent. There is

considerable repetition of clinical features, but an advantage of thisis that the causes of a particular symptom are put into perspectiveand not related only to the diseases seen in the radiology depart-ment. The lists of differential diagnoses provide a useful referencepoint. I do not agree with the recommendation that all childrenshould undergo intravenous urography and micturating cysto-urethrography for their first urinary tract infection. There isevidence that the intravenous urogram could be replaced,particularly in the younger child, by the ultrasound scan, which isvery efficient as an initial screen. The value of ultrasonography inrenal disease was not given sufficient emphasis.Overall the book is of excellent standard and does emphasise the

clinical and radiological features of common diseases seen by thepaedtatric radiologist. The chapter on the court testimony in casesof non-accidental injury and that on radiation effects in children arealso of interest and practical value to the paediatric radiologist. Ihave no hesitation in recommending this book for the library of bothgeneral and paediatric radiologists.Department of Paediatric RadIOlogy,Royal HospItal for Stck Children,Edinburgh G. M. A. HENDRY

Cardiovascular Disease in the ElderlyDevelopments m Cardwvascular Medicine. Edited by F. H. Messerli,Ochsner Climc. Boston and The Hague: Martinus Nilhoff. 1984. Pp 347.$52.50; Dfl 169.

THIS useful addition to the many books on cardiovascular diseasein the elderly is well laid out and discusses all the appropriateproblems that are likely to be faced by the physician who is inattendance on or advising the elderly patient with heart disease.Good use is made of tables but the text is not disrupted by numerousECG or X-ray plates, a common fault in this type of book. Theeditor and his authors have imparted a large amount of commonsense and practical advice in their writing. The important conceptsthat the patient is a patient first and an elderly patient second, andthat the underlying pathology in any heart condition should bemanaged in the light of the patient’s activities as well as currentthoughts on that particular ailment, come over strongly in thechapters on the management of heart failure, hypertension, andcoronary artery disease. The book provides sufficient references toenable the reader to pursue a topic in more detail without swampingthe text with them; in fact it is quite clear that the advice given stemsfrom the practical experience of the writer. This book greatly helpsphysicians with an interest in geriatric medicine and practitionerswith large numbers of elderly patients under their care.

Victoria Geriatric Unit,Glasgow J. L. C. DALL

Developmental NeuropsychiatryEdited by Michael Rutter, Institute of Psychiatry, London. Edinburgh:Churchill Livingstone. 1984. Pp 632. 40.

CHILD psychiatry needs a volume similar to Lishman’s OrganicPsychiatry, a work which summarises what is known about thevicissitudes of the developing brain and their expression in theemergent person. Such is Professor Rutter’s pre-eminence in hisspecialty that this book will be bought by title, sight unseen, by mostlibraries catering for postgraduate psychiatrists, in the confidentexpectation of meeting that need. However, the book is a collectionof essays by a very distinguished panel of authors from severaldisciplines trying in their various ways to provide a succinct surveyof research findings, "empirical issues", and conceptual andmethodological issues on a variety of child-related topics. They tendtherefore to address their peers, looking for debate, rather than theirstudents, who are looking to them for guidance.The book’s five sections are broadly indicative of the subject

matter but Brain Traumata and Disorders: Psychological Sequelaecontains two thoroughly workmanlike chapters on poisoning inchildhood and specific medical syndromes, which are neither

developmental nor neuropsychiatric. However, Rutter’s ownchapter on head injury, written with Chadwick and Shaffer, is

brilliantly both. Section II, The Measurement of Brain Functionand Dysfunction, is extremely useful and important and shows howbooks like this do contain chapters which are likely to becomerequired reading, for example, that on neurometrics. Section III ison Hyperkinetic/Attentional Deficit Syndrome, an area ofconsiderable dispute between British and American schools of childpsychiatry. The subject is worked over in considerable detail. InRutter’s cool and rational chapter he sifts through his sources andmarshalls his arguments well. The differences at issue seemirrational and attitudinal, more in the area of polemics. Clinicians,no doubt aware of "the sort of child you mean by hyperkinetic",look on breathlessly and still somewhat helplessly while the

indefatiguable continue their pursuit of the indefinable. Section IVis on Learning Disabilities and is written mainly by psychologists,who discuss difficulties in learning to read and their remediation.The section is very interesting and will be useful to students ofpsychiatry, but there is nothing about the wider problem of childrenwho find it hard to learn anything, or about those whose skillsdeteriorate. Section V is an essay by Rutter on Issues and Prospectsin Developmental Neuropsychiatry.Perhaps the book is disappointing because we need someone of

Rutter’s erudition and abundant energy to provide an authoritativestatement about what can be relied on now to guide clinical practice.Given the continuing explosive increase in the volume of researchpapers being produced, academics have a responsibility to provideclear and unambiguous opinion based on a sensible and constructivesynthesis of previous work. Instead all too often we are faced with afine balance of the evidence and the recurrent formula that not

enough is known and more research is needed-universal truismswhich really describe man’s position vis a vis science for the whole oftime. In his prefatory remarks Rutter notes the curious separationbetween child and adult neuropsychiatry. This separation is duepartly to the weakness of the discourse and shortage of distinguishedchild psychiatric practitioners suitably trained and interested, andpartly to paediatric neurologists and neuropsychologists of widervision annexing these territories.

Child and Adolescent Psychiatry,University of Manchester DAVID C. TAYLOR

Gastrointestinal EndoscopyAdvances m Diagnosis and Therapy, vol 1. Eclited by P. R. Salmon,University College, London, School of Medicine. London: Chapman andHall. 1984. Pp 278. &pound;17.50.

THIS book, the first in a proposed series, is based on lecturesdelivered at three recent meetings convened by the editor andentitled "Growing Points in Endoscopy". The aim of the volume isto highlight important advances in gastrointestinal endoscopy, andthe contributors are well-known international experts. There arefour main sections-intestinal bleeding, problems in the

oesophagus, peripapillary disorders, and inflammatory boweldisease-and a final short chapter on the role of the pathologist vis-a-vis developments in colonoscopy. Unfortunately, although theintention in producing this book was undoubtedly worthy, theresult is disappointing. Most of the chapters are either accounts of aparticular author’s own series of patients, or represent highlyindividual, and sometimes dogmatic, views of the topics covered. Isuspect that the polarised opinions expressed in, for example,chapters 3 and 5-both of which deal essentially with endoscopiccontrol of variceal bleeding-account for their curious but possiblydiplomatic separation by a section on laser photocoagulation inintestinal haemorrhage. The reader who is looking for an objective,reasonably comprehensive, and recent review in any particular areais likely to feel let down. In this context, the book suffers from theusual problem of the genre in that it is clear that most of thecontributions were prepared about three years ago and more recentdevelopments in many of the areas covered will already be familiarto the discerning reader. Most of the bibliographies extend only to1981, which limits the book’s value as a reference source. Many ofthe monochrome illustrations of endoscopic photographs are

unhelpful and might as well have been omitted; some of the X-raysare poorly reproduced, and figure 15.9 is magnificently upside-down.

18

In summary, a disappointing volume which combines the worstaspects of an elephant’s pregnancy and a Chinese meal: too long inthe gestation and leaving me, at least, unsatisfied after thoughtfuldigestion.Medical Unit,BasildonHospital C. P. WILLOUGHBY

Principles of Paediatric Pharmacology

George Maxwell, University of Adelaide, Australia. London: CroomHelm. 1984. Pp 407. &pound;22.50.

THIS book is one of several on paediatric pharmacology likely tobe published in the next few years, a forecast based on "inside"information. The subject remains somewhat in its infancy.However, our profession is realising that children are not "littleadults" in relation to drug therapy any more than in relation todisease problems and prevention; and publishing houses are everkeen to probe potentially rewarding market areas. I think that thisbook will meet the needs of paediatricians, general practitioners,and pharmacists, but only to a limited extent.

Its scope is broad and covers most of the background material onewould expect-principles of drug action, drug handling processes,pharmacokinetics and pharmacodynamics, specific pharmacologicalprinciples relating to different periods of childhood fromintrauterine life to adolescence, ethical considerations, and clinicaltrials. The major part of the book takes a systematic approach todrugs, giving details of the relevant physiology and information onuse, actions, drug handling, and adverse effects.So what are its limitations? These necessarily reflect my views of

what the intended readership wants rather than the extent to whichthe volume falls short of the author’s aims. Problems inevitably arisewhen pharmacology and therapeutics are separated. For the

clinician, a combined approach is usually necessary and booksaimed at covering one or the other in isolation usually leavefrustrating gaps in content and clinical relevance.

Since the volume does not limit itself to principles of pharmacol-ogy, I would have liked a section on medication compliance andtherapeutic drug monitoring, but these are clearly therapeuticaspects. In addition, despite good physiological backgrounddescriptions, there are no similar outlines on pathophysiology,which sometimes makes it difficult for the reader to understand theexact role of the drugs described. Moreover, for individual drugs,there is no consistency as to which of the following items arediscussed: use, action, absorption, distribution, elimination, andadverse effects. This inconsistency is found in most pharmacologybooks and probably relates to the still not inconsiderable gaps in ourknowledge of the pharmacology of commonly used drugs in

children.The author has achieved his aim of outlining principles of

paediatric pharmacology, but these occupy only a small part of thewhole volume. The remainder reads like many other pharmacologytexts, except that in this case there is a degree of paediatric emphasisto the text.

Department of Clinical Pharmacology,Children’s Hospital,Birmingham GEORGE RYLANCE

Doing Right

Everyday Medical Ethics. Solomon Papper, Umversity of OklahomaHealth Sciences Center. Boston: Little, Brown. London: Quest. 1983. Pp148.$16.50.

As the subtitle indicates, this is a book dealing with clinicalmedical practice rather than with the major medicolegal problemssuch as abortion, euthanasia, and genetic engineering. Dr Papper’squalification for his task is three-fold. He is not only a physician anda teacher but also a long-standing patient. It is this last qualificationwhich, no doubt, prompts such an observation as "The X-Ray tablemay be terribly cold first thing in the morning" and his protest at theloss of dignity involved in a patient having his history taken whilstin a state of undress. It may also have increased his awareness of therisk of careless talk in lifts and corridors being overheard by patientsand relatives.This is a practical, down-to-earth book covering ethical problems

in preventive medicine, research, administration, and medical

education, as well as those involved in relationships with medicalcolleagues and other health professionals. But Papper is at his bestwhen dealing with relationships with patients. The chapter on TheUndesirable Patient is particularly good. He describes five

categories of patient who tend to receive a less-than-enthusiasticwelcome from the doctor. There is the socially undesirable, such asthe alcoholic and the unkempt; the attitudinally undesirable, such asthe patient who thinks he knows best; the physically undesirable,such as the patient who has no organic illness or who fails to respondto treatment; the circumstantially undesirable, such as the patientwho arrives late; and the distractionally undesirable, the patientwho does not fit in with the interests of the unit. Dr Papperemphasises the need for honesty and humility, and is not ashamed toadmit his own mistakes. He recommends that when a doctor doesmake a mistake, this should be pointed out to him and whereappropriate an apology should be expected.The book is easy to read and contains a great deal of good common

sense. It has doubtless all been said many times before.Nevertheless, it is a subject on which all doctors need frequentreminders; probably never more so than today. It could be read withprofit by every resident during his or her first appointment, andannually thereafter. Most doctors would agree with all Papper says.The great problem is how to maintain this standard in practice,when other things like getting on, getting done, and getting off seemso much more important. A student once asked the author: "Whendid you learn to put the patient first?" He thought for a moment andthen said he did not know. From various clues in the book, there islittle doubt that he inherited a religious tradition whose practicalapplication is summarised in The Golden Rule.

48 Victoria Street,Aberdeen AB9 2PL DAVID SHORT

Health Policy and the National Health Service

Judy Allsop, Polytechnic of The South Bank, London. London and NewYork: Longman. 1984. Pp 324. 6.50.

ALTHOUGH the focus of this book is the National Health Service,it is much more than simply another analysis of a state system ofhealth care. Judy Allsop’s point of departure is to put the NHS intothe wider frame-work of health policy, looking closely at

socioeconomic and political factors that affect the provision ofhealth care by examining several important themes and showinghow the possibilities for change are constrained by the structure ofpower in decision-making. The themes she emphasises range fromthe search for control in the NHS, the dilemmas in expenditure andresource allocation, the growing burden of dependent groups and,finally, the current tendency to look to the privatisation of healthservices for answers. These are the policy issues discussed in thefirst half of the book. The second part, called controversies in health

policies, looks more broadly at the social basis of ill-health. Inreviewing British policy, Allsop concludes that governments haveso far failed to act positively upon the overwhelming evidence of thestrong relation between social conditions and ill-health, and thatthis failure is reflected in preventive health policies which focus onchanging individual behaviour but do not take the broader viewnecessary to ameliorate avoidable risks to health. Policies for

prevention and the NHS and its users receive careful attention. Thefinal part of this section looks at some of the contemporary critiquesof health care, their concern encapsulated by A. Wildavsky’s phrase"doing better and feeling worse". Here are brief discussions on thestrengths and weaknesses of different critiques, which range fromthe left focus on professional dominance and the medicalisation ofhealth care, to the radical right, which proposes a change in fundingfor the NHS, and more private investment.What I particularly liked in this book was the last section, which

comprised of excerpts from thirty-three different documents datingfrom E. Chadwick’s prescription for public health written in 1842to a 1981 DHSS study on unemployment and health. These adddepth and force to the issues under discussion. Although the book iswritten primarily for students, I think that anyone interested inhealth policy will find it illuminating and gain some insight from it.

Evaluation and Planning Centre,London School of Hygiene and Tropicat Medicine GILL WALT