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immunity, contacts have acquired immunity throughspread of the vaccine virus, and the spread of thevaccine virus has prevented the spread of wild virulentvirus. Wild virus can no longer be recovered fromsewage in Sweden, and is only rarely recovered inthe U.S.A.12 Up to now, this disappearance of wildstrains coupled with a largely immune population hasresulted in 10 years of almost complete herd immunity.But during this time, vaccination-rates have fallenand each successive cohort of children has more non-immunes. Thus in Houston in 1969, at ages 3-4

55% and 5-14 40% lacked antibodies to type 3, andfor the age group 1-4 years 40 % were doubly ortriply susceptible.3 Similarly in Scotland in 1970,only 50 % of children aged 3-5 years had tripleimmunity, and 16 % were doubly or triply suscept-ible 2u3 Both studies were on children from lowsocioeconomic groups: however, although the immunestatus would probably be better in higher socio-economic groups, it could well be worse among othersamples of low socioeconomic groups. The patternrevealed by these serological surveys recalls the

position in New York in 1917 before the epidemicwhich resulted in 11,000 cases of paralytic polio-myelitis : a largely immune population of adults withan increasing proportion of susceptibles rising to

perhaps 90% in the 1-3 year age-group. Presumably,there had been a virtual absence of poliovirus of oneparticular type for nearly 6 years. Although we havenot reached such a high figure of non-immunes, itis possible that our present apparent herd immunityis due in no small part to the disappearance ofvirulent strains of poliovirus. However, such strainsare still lurking in the U.S.A. and the U.K. and mayoccasionally spread among groups of non-immunesto produce sharp epidemics before they are containedby vaccination (e.g., the Christian Science School,U.S.A.,4 and the epidemic in 1970 at Staphorst inHolland 14). Another danger would be the intro-duction of virulent strains from foreign countrieswhere polioviruses still circulate. In exceptional cases,especially if we allow the immunisation gap to grow,it might be possible for a virus to spread more rapidlythrough a population than it could be contained bymass use of oral vaccines. It is perhaps significantthat the outbreak at the Christian Science Schooloccurred in October, at what would have been

regarded as very late for the poliomyelitis season, sothat spread of the virus was slow. Similarly, theStaphorst epidemic caused by type-1 poliovirusoccurred in March.Once Man has interfered with the natural spread

of a virus, interference must be continued. Ifimmunisation gaps are allowed to occur throughneglect by politicians, doctors, and the public, theconsequences may be more serious than has beenthought.

REFERENCES

1. Sabin, A. B. Am. J. Hyg. 1951, 54, 275.2. Reid, D., Bell, E. J., Grist, N. R. Lancet, 1973, ii, 899.3. Melnick, J. L., Burkhardt, M., Taber, L. H., Erckman, P. N.

J. Am. med. Ass. 1969, 209, 1181.4. Centre for Disease Control. Morbid. Mortal. 1972, 21, 365.

5. Peart, A. F. W. Can. J. publ. Hlth, 1949, 40, 405.6. Addair, J., Snyder, L. H. J. Hered. 1942, 33, 306.7. Horstmann, D. M. Ann. N. Y. Acad. Sci. 1955, 61, 956.8. Lavinder, C. H., Freeman, A. W., Frost, W. H. Publ. Hlth Bull.

Wash. 1918, 91, 1.9. Paffenbarger, R. S., Bodian, D. Am. J. Hyg. 1961, 74, 311.

10. Sabin, A. B. in Perspectives in Virology (edited by E. Pollard);p. 90. Minneapolis, 1961.

11. Wyatt, H. V. J. infect. Dis. 1973, 128, 802.12. Wallis, C., Melnick, J. L. Bull. Wld Hlth Org. 1967, 36, 219.13. Reid, D., Grist, N. R., Bell, E. J. Symp. Eur. Ass. Polio, 1972, 13,

35.14. Bykerk, H. ibid. p. 27.

Reviews of Books

Textbook of Paediatrics

Edited by JOHN 0. FORFAR, M.D., F.R.C.P., F.R.C.P.E., pro-fessor of child life and health, University of Edin-burgh ; and GAVIN C. ARNEIL, M.D., PH.D., F.R.C.P.,

F.R.C.P.E., professor, department of child health, Univer-sity of Glasgow. Edinburgh : Churchill Livingstone. 1973.Pp. 2115. 19.50.

By any standard this book must be hailed as an im-portant and major achievement. At over 2100 pages it isthe first large comprehensive British textbook of paedi-atrics. It costs more than its American rivals, but theuser gradually becomes aware that it is more extensivethan its rivals and usually better. Do such large textbookshave a place in modern medicine? Many people prefer toconsult a recent authoritative monograph for detailed in-formation rather than the necessarily less detailed andless up-to-date section of a large textbook. However, noteveryone knows the best monograph to consult, not alllibraries have all monographs, and not all doctors haveeasy access to a well-stocked library. For most doctorscaring for children this book will be a valuable referencework. It does not aim to instruct the doctor how best totackle the problems of children and families who comewith headaches, recurrent coughs, and behaviour problems ;and there is not a lot about health and development. Itis mainly about disease and disorders, and it deals withthem well. Though it is geared towards hospital practice,it does devote lengthy sections to community and socialaspects of paediatrics.More than seventy authors have contributed to the book.

They include some, but not all, of the acknowledged UnitedKingdom experts on individual subjects, and some, butnot all, of the best writers and communicators. Most ofthe contributors are Scotsmen, which is understandablein a book edited from Edinburgh and Glasgow and is a

recognition of the contribution the Scottish departmentshave made to British paediatrics. Nevertheless occasionallyone wishes that the editors had stopped scouring thelocal hills for undiscovered talent and used their per-suasive powers to capture writers from across the border.The success and future of this book will depend upon

the speed with which new editions emerge. There are fewthings more exasperating than out-of-date expensive text-books. Even now some sections are short of recent refer-ences. There are a number of small omissions and mis-takes which readers should pass on to the editors forcorrection in future editions. The layout, tables, andillustrations are generally excellent. It is a good and easybook to use. Unfortunately, the section on psychomotorand intellectual development is not so well presented.Several of the pictures are indistinct and have been re-produced more clearly in other books. The chapter on

786

practical procedures would be more useful if there hadbeen more diagrams. X-ray pictures are reproduced on80 pages of high-grade paper at the back of the book.This section may be helpful to students revising radi-

ology, but it is tedious for the regular user.The editors, Professor Forfar and Professor Arneil

have written some very long sections themselves in addi-tion to the many small bits they have had to fill in. Theyare to be congratulated on a most excellent start to avaluable venture.

Gastrointestinal Disease

Edited by MARVIN H. SLEISENGER, M.D., professor, de-partment of medicine, University of California Schoolof Medicine, and JOHN S. FORDTRAN, M.D., professor ofmedicine, University of Texas Southwestern Medical

School, Dallas. Philadelphia and London: Saunders.1973. Pp. 1659.$37.50 fl5.95.

THis book is extravagant to the point of self-indul-gence. One senses that the editors determined not to allowconsiderations of space and economy to restrict or modifytheir desire to offer a detailed and pictorial account of thegut and its diseases to anyone with the cash and the

strength to carry this book’s 3.8 kg. away. Dr Sleisengerand Dr Fordtran wisely exclude the liver, and the mouthand tongue have been mislaid, but almost everything elseis there. The flag of scientific accuracy is nailed to themast in the foreword: "Description of clinical disease ...is authoritative only insofar as the facts will permit.Statements are documented and uncertainties emphasized".This laudable ideal is usually maintained, but the bookcontains a good sprinkling of unsubstantiated assertions,though the 57 authors have tried hard to produce accurateas well as clear and helpful accounts of their subjects-and have often succeeded brilliantly.The first part of the book deals exclusively with gas-

trointestinal function, diseases only being brought in toillustrate recognisable abnormalities. These are well-con-structed chapters, and, like the whole book, excellentlyillustrated with carefully chosen and well-reproducedradiographs and endoscopic colour photographs. Emphasisis properly placed here, and in the later clinical chapters,on disordered function as a cause of abdominal symptoms,and Thomas P. Almy is allowed to spread himself in dis-cussing the relationship of stress to gastrointestinal disor-ders (self-indulgence here reaching the point of repeatingfacts, opinions, and anecdotes already seen in chapter 1).When ten pages are allotted to the psychosomatic theoryof peptic ulcer, it is surprising to find no mention of suchknotty clinical problems as duodenal diverticula, rectal

prolapse, halitosis, sore tongue, or hiccup. Little commentis made on endoscopic ampullary cannulation for biliaryand pancreatic disorders, and Yersinia enterocolitica is notmentioned as a cause of acute ileitis. Gastroenterology ismuch stronger on physiology and diagnosis than it is on

therapy, and this book reflects that sad situation. Theuse of American proprietary names will baffle most Brit-ish readers and, although the F.D.A. has so far pre-vented any first-hand experience of metoclopramide in theU.S.A., some mention of this interesting drug should havebeen made.

Omissions apart, this book is a remarkable and inval-uable compendium of facts about the gastrointestinaltract. The saddest feature is that its clear and excellentillustrations are not always matched by its literary stan-dards. What does one make of the sentence "Operativemortality approaches 70 per cent when emergent surgeryis required to control variceal bleeding; therefore, prog-nosis for surgically decompressing the portal bed is

optimal as an elective procedure"’ When this book reaches

its second edition-as it deservedly will—the editors ’.’. II

find that clarity is improved if their contributors "eallowed 20% less space and if Sir Ernest GOBB er ::

required preliminary reading.

Experience with AbortionA Case Study of North East Scotland. Edited byGORDON HOROBIN, assistant director, Medical ResearchCouncil Medical Sociology Unit, University of Aber-deen. London : Cambridge University Press. 1973. Pp379. ,67.

FACTS about abortion in all its aspects are relativ-elvscarce considering the numbers of terminations carriedout lately. The experience described here was gained inAberdeen by a study which began in 1966 and involvedobstetricians and gynaecologists, psychiatrists, and soci-

ologists. It is appropriate that the study was done in a

city known for the high standard of its health serviceand where progress towards Sir Dugald Baird’s "fifthfreedom" started over thirty years ago. The geographicalsituation of the city, its size and population, and the

presence of appropriate university departments and theM.R.C. Sociology Unit with members interested in the

problems inherent in unwanted pregnancy and in abor-tion provided a unique opportunity. Many will have pre-conceived ideas about the attitude in Aberdeen to abor-

tion, but it may surprise readers to find that abortion is

certainly not available on demand and that doctors’ atti-tudes vary considerably. For abortion, patients in Aberdeendepend almost solely on the National Health Service. Thecontributors, besides the editor, are Jean Aitken Swanand Colin Farmer (sociologists), K. John Dennis andIan McGillivray (gynaecologists), and Vivien Edward,Colin McCarce, and Peter C. Olley (psychiatrists). Theintroduction describes the interdepartmental approach, thequestions which interested the investigators, and the wayin which they set out to answer them. The chapter on theepidemiological background gives information about preg-nancies, abortion-rates, and the details of the women re-ferred for termination. Then follow the indications fur

termination, methods, utilisation of hospital beds, and

follow-up. There are other chapters on married and singlewomen, social and psychological characteristics, psychiat-ric follow-up, and psychiatric assessment. The book end,with two thoughtful chapters, one on decision-making in

therapeutic abortion and one of conclusions. The bookcontains a lot of information and a formidable series oftables which are clearly set out, however, and summarisethe impressive fund of information gained from the

study. The book is written with the interests of differentgroups of readers in mind, avoiding undue specialist andtechnical phraseology. The contributors stress that this isa limited study from one area, but there will be a fewinvolved with patients seeking or undergoing terminationin whatever capacity who will not find that they havecommon experience and problems with the investigatorsSome of the findings concerning, for example, repeatedunwanted pregnancy and the acceptance-rates in relationto social class are disturbing. The need to relate medicaltreatment to the social situation of the patient is stronehsupported. LTnfortunately the number of patients who re-quested referral by their general practitioner but wereturned down is unknown but otherwise the study ’? re-

markably comprehensive. This is quite an expensive bock.but it is excellent value considering the amount of workwhich must have preceded its publication. It should te eessential reading for all those whose work or conscienceinvolves them in the care and consequences of unwa".’e1 1

pregnancy, illegitimacy, abortion, sterilisation, or the f’:C c-lems of uncontrolled fertility.

787

THE LANCET

Prognosis and Pathology in AcuteGlomerulonephritis

THE old description of acute glomerulonephritis asan acute disease from which most patients recoveris now recognised as a misleading oversimplification.Attention has been focused particularly upon twoproblems-the questionable concept of acute

glomerulonephritis as a disease entity, and theclinical course of pathological patterns that may beencountered. Pathological and immunological ad-vances are central to the new understanding of

glomerulonephritis. BLACK, using a respectablecardiological precedent,2 has pointed out that threeseparate and distinct questions are relevant to theanalysis of a clinical case of glomerulonephritis:what type of pathological process is at work, whatstructural damage is it causing, and what disturbanceof function is it producing ? Specialisation inmedicine has led to radically different concepts of" glomerulonephritis " among workers trying to

resolve these different problems. In its strictest

sense, of course, the term belongs to the pathologist,and implies inflammatory change within the

glomerulus. Difficulties arise because clinicianshave applied the term to a group of clinical featuresand, to the uninitiated, acute glomerulonephritishas become a well-defined disease. That " glomerulo-nephritis " may pursue one of several clinicalcourses has long been known 3,4; but it has nowbecome clear that the pathological changes lumpedtogether under the same heading are also hetero-

geneous. Unfortunately, the association betweenclinical picture and histological appearance is not aclose one, and we have to be very careful in definingterms when we speak of glomerulonephritis.The clinical stereotype of acute glomerulonephritis

is of an acute illness characterised by haematuria,1. Black, D. A. K. Br. med. J. 1970, ii, 315, 387.2. White, P. D. Heart Disease; p. 259. New York, 1944.3. Longcope, W. T. J. clin. Invest. 1936, 15, 227.4. Ellis, A. Lancet, 1942. i, 1, 34, 72.

hypertension, and oedema after a streptococcalinfection. Some of these features may be missing,and some additional abnormalities may be present.A number of syndromes may be concealed withinthis diagnostic category.’- CAMERON,5 adopting thecommendable term acute nephritic syndrome, recog-nises several subgroups. In addition to the classic

syndrome he distinguishes a group which earlybecomes anuric or oliguric, a group which presentswith isolated haematuria, and a fourth group inwhich the syndrome is secondary to a systemicdisease such as Henoch-Schonlein purpura or

collagenosis. In the first and third groups the out-come is usually favourable, but patients with earlyanuria/oliguria seldom do well. A particularly knottyproblem is presented by a fifth group which show somefeatures of the nephrotic syndrome; many of themprogress to chronic disease. Undoubtedly, analysisof a large enough group of patients would yieldother clusters of features representing

" acute

nephritic syndromes ".Discussion of the pathological, as opposed to the

clinical, varieties of acute glomerulonephritis is

hampered by a different terminology which yieldsdifferent diagnostic categories. Additionally, therehas been a regrettable lack of consensus in thecriteria adopted for such classification. This is

particularly perplexing for the clinician, who needsto know how far a given lesion is associated with aparticular clinical course. The most recent, and oneof the most thorough, attempts to match the twohas been made by a group of French workers. 6 In65 patients presenting with acute proteinuria,hypertension, and haematuria, the expected mixedbag of appearances was seen. Most patients showedan increase of cells in the mesangial region, with"

humps" lying on the epithelial side of the

glomerular basement-membrane. These humps areof great interest. Usually they are associated withdeposition of immunoglobulin (IgG and the piCglobulin component of complement) 7,8; it is

tempting, therefore, to ascribe both the pathologicalpicture and the clinical condition to soluble antigen/antibody complex deposition within the kidneywith the induction of secondary glomerular damage.But this hypothesis has drawbacks. A minority ofpatients show &bgr;lC deposition without IgG. It wouldbe difficult to accept the presence of antigen/antibodycomplexes in the absence of antibody. Of course,antibody may possibly be present in amounts whichare undetectable by the comparatively crude tech-niques of immunofluorescence; or "(-globulin may beconcealed by steric covering by &bgr;lC, Alternatively,5. Cameron, J. S. in Renal Disease (edited by D. A. K. Black); p. 295.

Oxford, 1972.6. Hinglais, N., Garcia-Torres, R., Kleinknecht, D. Am. J. Med.

1974, 56, 52.7. Michael, A. F., Drummond, K. N., Good, R. A., Vernier, R. L.

J. clin. Invest. 1966, 45, 237.8. Fish, A. J., Herdman, R. C., Michael, A. F., Pickering, R. J.,

Good, R. A. Am. J. Med. 1970, 48, 28.