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Let us suppose that, as observed in animals after ovarianstimulation,’ AIO hardens the zona pellucida and thathardening is not uniform, then some weak spots may beformed through which the blastocyst may herniate. Suchhalf-hatched blastocysts, trapped partly inside and partlyoutside, could divide and form two separate embryos.8-lOMonozygotic twins thus originating by herniation will ofnecessity be dichorionic. Consequently, one would expectmore dichorionic than monochorionic monozygotic twinswith AIO than with spontaneous ovulation. In our series of

AIO, 54% (7/13) of the monozygotic twins were

dichorionic, compared with 37% after spontaneousovulation. Although this difference was in the expecteddirection, it was not statistically significant.

One could hypothesise that higher doses of ovulationinducers would not only induce more triplets but alsoincrease the rate of zygotic division. Conversely, the samephenomenon might arise with an enhanced maternal

susceptibility to these agents. In both instances, one wouldexpect the rate of zygotic division to be higher in triplets thanin twins. This difference was statistically highly significant(p<0’001) after AIO but not with multiple births afterspontaneous ovulation.Our results are in accord with those of Edwards et al,"

who also observed a higher-than-expected frequency ofmonozygotic twins after in-vitro fertilisation (frequency ofsplitting 1-33%). However, we do not agree with theirproposal that in-vitro conditions for embryonic growthmight predispose to monozygotic twinning. Since ovarianstimulation was used in the in-vitro fertilisation cases" andin our series, in which all oocytes except two (one set ofdizygotic triplets) were fertilised in vivo, it is AIO that

predisposes to zygotic division or an enhanced survival ofmonozygotic twins, rather than the in-vitro conditions.AIO seems to be the first identified biological mechanism

influencing the monozygotic twinning rate. Since

monozygotic twins after in-vitro fertilisation (frequency ofmalformations and perinatal complications, the increasedfrequency of monozygotic twinning after AIO is also

important in perinatal health care.

The EFPTS is sponsored by the Flemish Society of General Practitionersand the Flemish Society of Obstetrics and Gynaecology. We thank Prof FredHecht and Prof Ernest Meulepas for their remarks; Mrs Chris De Baere forassistance; Mr F. Shapiro (Syntaxis-Belgium) for editing; Dr C. Bockaert, DrA. Cammaert, Dr J. Caudron, Dr A. De Bruyn, Dr M. De Geest, Dr H. DeGezelle, Dr E. De Mot, Dr D. De Schryver, Dr P. Devroey, DrW. Flammee,Dr T. Hennay, Dr R. Heughebaert, Dr J. Leemans, Dr L. Londers, Dr A.Ooms, Dr J. Proost, Dr G. Onghena, Dr J. Rappe, Dr P. Santens, Dr J.Smolders, Dr L. Teughels, Dr K. Vanderheyden, Dr R. Van den Haute, DrM. Van Gysegem, Dr A. Van Parys, Dr M. Verpoest, Dr G. Verstraete, DrM. Vrijens, Dr R. Walchiers, Dr R. Weckhuysen, and Dr A. Yo Le Sian forinformation and material. This work was supported by grant no 3.0038.82from the Fonds voor Geneeskundig Wetenschappelijk Onderzoek, Brussels,Belgium.

Correspondence should be addressed to C. D.

7. Longo FJ. Changes in the zones pellucidae and plasmalemma of aging mouse eggs.Biol Reprod 1981; 253: 399-411.

8. Massip A, Van Der Zwalmen P, Mulnard J, Zwilsen W. A typical hatching of a cowblastocyst leading to separation of complete twin half blastocysts. Vet Rec 1983,112: 301.

9. Leroy F. Early embryology and placentation of human twins. In: Edwards RG, PurdyJN, Steptoe PC, eds. Implantation of the human embryo. London: AcademicPress, 1985: 393-405

10. Edwards RG. In-vitro fertilization and twinning. In: Parisi P, ed. Genesis of differentkinds of multiple births Proceedings of the fifth international conference on twinstudies. Acta Genet Med Gemellol (in press).

11. Edwards R, Mettler L, Walters D. Identical twins and in vitro fertilization. J In VitroFertil Embryo Trans 1986; 3: 114-17

REFERENCES

1. Lamont JA. Twin pregnancies following induction of ovulation: A literature review.Acta Genet Med Gernellol 1982; 31: 247-53.

2 Vlietinck R. Determination of the zygosity of twins. Leuven, Belgium: CatholicUniversity of Leuven, 1986. PhD thesis. Pp 126.

3. Derom C, Bakker E, Vlietinck R, et al. Zygosity determination in newborn twins usingDNA variants. J Med Genet 1985; 22: 279-82.

4 Schenker J, Yarkoni S, Granat M. Multiple pregnancies following induction ofovulation. Fertil Steril 1981; 35: 105-23.

5. Bulmer M. The biology of twinning in man Oxford: Clarendon Press, 1970.6. Boklage CE. The organization of the oocyte and embryogenesis in twinning and fusion

malformations In: Pansi P, ed. Genesis of different kinds of multiple births.Proceedings of the fifth international congress on twin studies. Acta Genet MedGemellol (in press)

Reviews of Books

Improving the Common Weal : Aspects of ScottishHealth Services 1900-1984

Edited by Gordon McLachlan. Edinburgh: EdinburghUniversity Press for the Nuffield Provincial Hospitals Trust.1987. Pp 635. 35. ISBN 0-852245513.

THIS collation of essays, produced in honour of the lateSir John Brotherston, was initiated by Sir John butcompleted by Gordon McLachlan after Sir John’s death in1985. Both Sir John and the Trust believed that an analysisof local events by those who participated in a period ofradical change would shed more light on the past andcurrent problems of the National Health Service than woulda more detached overview of UK services. The review ofScottish health services up to 1948 clearly benefits from SirJohn’s own earlier studies, and it is an editorial triumph thatnearly all of the other eighteen essays have been written byleaders in the particular field during the 1960s and 70s.Although the main purpose of the volume was not to

demonstrate differences between Scotland and the rest ofthe UK, inevitably the question is prompted as the sagaunfolds. One of the undoubted differences from Englandand Wales is the closeness of local clinicians and managers tothe centre of administration in St Andrew’s House-acloseness due partly to the absence of a regional tier andpartly to scale. As a result, it has been taken for granted bymost people in the health service, certainly until recently,that the centre belonged to them and was equally accessibleto all. In the 1960s and 70s, Sir John epitomisedpersonalised leadership from the centre; in his tireless driveto achieve an integrated medical profession-the initiativefor which he is probably best remembered by Scottishdoctors-he knew as friends most of the local leaders and,characteristically, many of the junior doctors also.But there is another factor, highlighted by Gordon

McLachlan in his prologue, that makes Scotland different.From the age of the Scottish Enlightenment in the 19thcentury, there has been an ethos of social concern, of thecommon weal, which has made concerted health care anatural outcome. The medical schools, which since theirinception had the leading role in providing medical care andwhose teaching hospitals were administered by the NHSfrom 1948 onwards, were an integral part of this movement.The Highlands and Islands Medical Service, set up in 1913,provided state subsidies for doctors and nurses and was runby a separate board. Even today, private medicine inScotland is still a fringe activity.

So has the common weal improved? Does this volumehelp us to understand the current problems of the NHS?The answer to both questions is "partly". Despite a

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relatively large and powerful health service, Scotland’s

ill-health remains greater than England’s. The incidence oftuberculosis in Scotland is twice that in England. Its rate ofbad housing is much higher. Sir John Brotherston had cometo believe that the UK model of the NHS was unsuited toScottish cultural, social, and business realities, and that therewas a better fit before the NHS was created. This book,although it provides no answers, is a disturbing testimony tohis belief; the current combination of an increase in privatepractice and a reduction in the role of the medical schools inproviding care conflicts fundamentally with Scottish cultureand tradition. The book should be read as it was intended, asa broad selection of vignettes that display a colourful canvasof the bad and the good. For those who believe, as did SirJohn, in constructive public involvement in health andmedical care, it is the stimulus that he wanted to findingnew ways-or very old ways&mdash;of improving the Scottishcommon weal.

Department of Community Medicine,University Medical Buildings,Aberdeen AB9 2ZD ELIZABETH RUSSELL

Intensive Care: A Concise Textbook

C. J. Hinds. London: Bailliere-Tindall. 1987. Pp 378. 14.95.ISBN 0-70201509.

IT is a major undertaking for a single author to produce atextbook on such a wide subject as intensive care, whichembraces almost every branch of medicine. Dr Hinds hasmade a brave attempt. Management of failure of all majororgans is discussed; and, in addition, there are sectionsdescribing common secondary complications in the

critically ill patient (infection, psychiatric disturbances, andpeptic ulceration), organisational aspects of the intensivecare unit, and acute poisoning.The book is intended as an introduction to intensive-care

medicine for doctors in training. In many ways, it willsucceed in this aim, in that it discusses both theory andpractice. However, the stated indications for specifictreatment tend to be vague and, although the book providesan overview of intensive-care medicine, it lacks the sort ofpractical detail that trainees need. In some places, it isdiscursive and packed with references; in others, notablycardiac failure, the coverage is superficial. In addition,presumably because of the time required to write a volumeof this type, some areas of discussion already show their age.The order in which the chapters appear is difficult to

explain; those dealing with the physiology and monitoring ofthe cardiovascular and respiratory systems are separated, bychapters on unrelated topics, from those discussing theclinical management of cardiovascular and respiratoryfailure. Not all intensivists will agree with some of Hinds’recommendations for treatment, particularly in respect ofmodes of ventilation.

Despite these criticisms, this book fills a gap. The

style of writing is uniform and readable, and the indexis comprehensive. Irrespective of background specialty,junior doctors undertaking training in intensive-caremedicine will find a wealth of information in its pages; andintensive-care nurses will also find it useful. So it deserves aplace on the unit bookshelf.

University Department of Anaesthesia,Leicester Royal Infirmary,Leicester LEI 5WW ALAN AITKENHEAD

A Textbook of Clinical OphthalmologyR. P. Crick and R. B. Trimble. Dunton Green, Sevenoaks:Hodder & Stoughton. 1987. Pp 440. /;29.50 (hardback); ISBN0-340376783. 15.00 (paperback); ISBN 0-340376805.

PUBLISHERS are insatiable. Already there are a dozensmallish textbooks of ophthalmology, all with seductivecovers and nice bright pictures. So a new author, keen toenter that crowded arena and leave his monument to

posterity, must somehow vary the menu and offer a newapproach. Little more than a year ago Calbert Phillipsoffered us his Basic Clinical Ophthalmology, which avoidedthe standard pattern, with emphasis on aetiology,presenting symptoms, and practice emergencies. Now MrCrick and Mr Trimble have covered similar ground, in whatis essentially a compendium of essays on aspects of

ophthalmology. The two largest contributions cover

common ophthalmic problems (sore, watery, blurry eyes,&c) and systemic ophthalmology (eg, endocrine, immuno-logical, and cardiovascular diseases); there are smallersections on drugs, refraction, regional disorders,examination techniques, and so on, that seek to fill the gaps.This pattern inevitably leads to omissions and overlaps, anda rather unbalanced diet. Thus, out of more than 400 pages,retinal detachment barely covers 2 Z pages of text in an early"diagnostic" section and another 2 in the penultimatesection on regional ophthalmology, and cataract fills 7 pagesof text in this early section, and 4 in the later one.The illustrations are excellent and profuse, the layout is

spacious, and the arrangement of the subject matter also hasits merits, but the book tries to satisfy too many needs. Likenearly all of its rivals it is recommended with equalconfidence to students, postgraduates, ophthalmologists,general physicians, and so on. General practitioners maywell find it a helpful reference book, with its emphasis onexternal diseases and the emergencies that come their way,but I suspect that those most likely to find value in this bookare the only groups to whom it is not specifically directed-paramedical personnel who see patients with oculardisorders. Harassed medical students need a textbook thatis more systematic and concise, and may find the style a littletoo flat and prolix to contain their interest.

3 Park Square West,London NW1 P. D. TREVOR ROPER

Childhood Asthma: Pathophysiology andTreatment

Edited by D. G. Tinkelman, C. J. Falliers, and C. K. Naspitz.New York: Decker. 1987. Pp 385.$107.50. ISBN 0-824777212.

THE editors set themselves a formidable task of

integrating, in a single volume, recent fundamental andclinical research with a comprehensive guide to investigationand management of asthma in childhood. In many respectsthey succeed and have produced a well blended set ofchapters that range from basic mechanisms to managementregimens. The detail in some chapters is remarkable andreflects the authority of the 23 contributors from around theworld, yet the book is well written with a consistent editorialstyle.There is an intelligible chapter on the origin, nature, and

role of various mediators in the development of asthma. Inthis area of burgeoning research interest there are alsoexcellent chapters reviewing the lung’s defence mechanismsand the role of lung injury in asthma. The lung-injury itemgoes comprehensively into macrophage, neutrophil, and

1240

eosinophil function and also discusses humoral anti-

protease mechanisms-their likely role and the effect ofanti-asthma treatment on them. There are useful chapterson the epidemiology of asthma and on the different

approaches needed in infants, children, and adolescents.Two interesting contributions review non-pharmacologicalforms of treatment and examine psychological aspects ofasthma in childhood.Of the few criticisms I have, the main one relates to the

detail contained in chapters dealing with investigation andtreatment: the practical guidance would have been

improved by a leavening of the authors’ own experience.There is also rather too much overlap between chaptersfor example, on the value of the history, examination, andchest radiology.The book is North American in outlook and the emphasis

on some treatment choices would be different in Europe.This does not detract, however, from its value. The

up-to-date blend of research and clinical practice should beof use to all physicians dealing with childhood asthma.

Respiratory Medicine Unit,City Hospital,Nottingham NG5 IPB D. J. SHALE

Cutaneous Abnormalities of the Eyelid and Face

An Atlas of Histopathology. Don G. Griffith, Stuart J. Salasche,and Donald E. Clemons. New York, Maidenhead: McGrawHill. 1987. Pp 367. 135. ISBN 0-070247951.

THIS colour atlas has been compiled by dermatologistsand ophthalmologists for anyone interested in dealing withdisorders of the eyelids or adjacent areas of the face. It hasbeen very carefully laid out with clinical photographs incolour, matched on each page with black-and-white histo-logical sections and with a succinct text describing thegeneral features of the disease as well as particular ones onthe face. The clinical photographs are fine and well

reproduced. The black-and-white micrographs can be rateda moderate success, the text accurate and appropriate.Dermatology classification has always been a nightmare,even from the time of Willan, but it is all there-fromeczema to lichen planus, Wegener’s granulomatosis to lipoidproteinosis, spider bites, and all sorts of other oddities thatmake one marvel at the ingenuity of the authors to havecollected them together. Tumours are very well repre-sented. There are several hundred references. A spot checkon 300 indicates only 29 emanating from outside the UnitedStates and all in English. The cost of this atlas-more ashame than a surprise-will discourage many of those whowould enjoy browsing through it.

Dermatology Department,Addenbrooke’s Hospital,Cambridge CB2 2QQ R. H. CHAMPION

Orthostatic Disorders of the Circulation

Mechanisms, Manifestations and Treatment. David H. P.

Streeten. New York, London: Plenum. 1987. Pp 272.$45.ISBN 0-306423227.

THIS monograph is unique in several ways. Itsummarises thirty years of original clinical observations byStreeten himself with the aid of eighteen collaborators atvarious times. We are presented with detailed accounts of169 patients with orthostatic oedema and 159 withorthostatic hypotension. Other recent works in this area areSir Roger Bannister’s Autonomic Failure, a typicalmultiauthor text, and Irwin Schatz, Orthostatic

Hypotension, a small monograph, but neither of these dealswith orthostatic oedema. Orthostatic disorders, with theircomplex diagnostic and therapeutic problems, are oftenpoorly dealt with in textbooks of general medicine.

Streeten’s book reflects scrupulous work in clinical sciencethat has not only contributed to better understanding ofphysiology and pathophysiology but has also led to betterrelief of patients’ discomforts. Thus it can be recommendedto medical students and family physicians as well as tospecialists. Naturally, close attention is given to Streeten’ssyndrome, which was described in The Lancet in 1972. Thesymptoms in this syndrome are caused byhyperbradykininism, which is a consequence of reducedkininase I activity. Streeten’s syndrome is the first exampleof an enzyme defect underlying an orthostatic disorder.As an up-to-date review, this book is suited to a broad

readership.Erasmus Universiteit,Rotterdam,Netherlands A. J. MAN IN ’T VELD

Management of Cardiac Arrhythmias-theNonpharmacologic Approach

Edited by Edward V. Platia. Philadelphia: Lippincott. 1986. Pp420.$55. ISBN 0-397507437.

SAD to say, very few physicians will think that they shouldread this book, yet it discusses the most common cause ofdeath and disability in the Western world. Too often

arrhythmias are badly managed by recourse to a Mrs Beetonstyle pharmacopoeia. In this volume Platia puts arrhythmiasin proper context and enumerates their many treatments.When drugs are not the answer, the solution may lie inimplantable devices, surgery, or non-surgical ablation.The work comes in two parts-the first on prevention and

the second on treatment. The scope is really too great for abook of this size and several chapters are unduly brief andrestricted: for example, the chapters on Bradyarrhythmiasand Pacemaker Therapy and on Cardiac Arrest and

Cardiopulmonary Resuscitation have insufficient material,and this is hard to understand when some items (such as thechapter on temporary pacemakers) might reasonably havebeen excluded. Even though the book is multiauthor theeditor has kept a firm grip on each chapter and was actuallyan author in 8 of the 17 chapters. The style is consistent andthere are few repetitions or contradictions. The volume isvery well illustrated, excellently indexed, and beautifullyproduced. Platia has attracted an exceptional team ofauthors.From my initial remarks it is clear that I recommend this

volume to all practising general physicians and cardiologists.All such should understand that cardiac arrhythmiasdemand vigorous, urgent, and expert attention. This is themessage of this new book.

Department of Cardiological Sciences,St George’s Hospital,London SW17 ORE A. JOHN CAMM

New Editions

Electrocardwgraphic Notebook.-5th ed. By M. Irene Ferrer. New York:Futura. 1987. Pp 162.$12.75.

Living with Drugs.2nd ed. By M. Gossop. Aldershot: Wildwood House.1987. Pp 242. 5.95.

Cash’s Textbook of Chest, Heart & Vascular Disorders forPhysiotheraptsts.-4th ed. Edited by P. A. Downie. London: Faber & Faber.1987. Pp 704. 10.95 (paperback).

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daily, including the night-time dose. Dosing may be more accurately calculatedas 3.5mg/kg every four hours. In cases of haematological toxicity, dosageadjustments are required. If the haemoglobin count falls below 7.5g/dl or theneutrophil count below 0.75 x 109/1 discontinue therapy. See Data Sheet. Children:No data available.Contra-indications, warnings, etc. Contra-indicated in those patients hypersensitiveto zidovudine and in those patients with abnormally low neutrophil cell counts orhaemoglobin levels. Anaemia (usually occurring after 6 weeks of therapy butoccasionally earlier) neutropenia (usually occurring at any time after 4 weeks’ therapy)and leucopenia (usually secondary to neutropenia) can be expected

to occur frequently in patients receiving Retrovir, therefore haematological 1should be carefully monitored. See Data Sheet for dosage adjustmrecommended that blood tests are performed at least every two weeks for thlmonths of therapy and at least monthly thereafter. Use with caution in papre-existing bone marrow compromise, hepatic or renal impairment. Dth.effects include nausea, headache, rash, abdominal pain, fever, myalgia, pavomiting, insomnia and anorexia. Experience of drug interactions with zidstill limited, therefore care should be taken in combining other drug relRetrovir. Patients should be cautioned about the concomitant use of self-admedications, especially chronic use of paracetamol. See Data Sheet.Basic NHS cost z143.25 for 100 capsules (PL3/0239).

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