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which might have contributed to the acute myocardialdeterioration.Even in the absence of coronary artery disease,

myocardial ischaemia may occur during profoundhypoxaemia or hypotension. Certainly, in case 1,hypoxaemia was a prominent early feature although it wasrapidly corrected. In neither case did the provision of anadequate arterial oxygen tension reverse myocardialdepression. Although hypotension occurred in both cases, itwas prolonged only in case 2 and thus is unlikely to havebeen the sole cause of the myocardial depression. Similarly,although acidosis might impair myocardial contractile

function, in neither case was there significant prolongedacidosis and both continued to show evidence of myocardialdepression long after acidosis had been corrected. Thus it ismost unlikely that the observed myocardial dysfunction wasa consequence of underlying heart disease or of themetabolic and vascular abnormalities that may accompanyanaphylaxis.Human and guineapig hearts contain mast cells which

release histamine on immunological and pharmacologicalchallenge.8 Anaphylactic challenge of guineapig heartresults in the release of histamines, leucotrienes,prostaglandins, and thromboxane.9.1O These exert a negativeinotropic effect on the heart and reduce coronary blood-flow.10 The human heart contains HI and Hz receptors andtheir stimulation in vitro results in an initial tachycardia andincreased contractility followed by myocardial depression."Further, histamine is a potent coronary vasoconstrictor inpatients with coronary artery disease."

Anaphylaxis in man can produce arrhythmias, infarction,and angina.3 Fisher has suggested, however, that only in thepresence of pre-existent cardiac disease is the heart a majorfactor in cardiovascular dysfunction.z Where cardiacfunction has been assessed during anaphylaxis, no evidenceof contractile failure has been identified. We have nowobserved myocardial contractile depression due to

anaphylaxis in patients without underlying heart disease.Although rare, myocardial depression with anaphylaxis maybe profound, life-threatening, and unresponsive to

conventional therapy. Our study emphasises the efficacy ofintra-aortic balloon counterpulsation in the short-term

support of patients with reversible myocardial depression.This is the first report of its use in anaphylactic shock.

Correspondence should be addressed to R. F. R.

REFERENCES

1. Fisher M, More DG. The epidemiology and clinical features of anaphylactic reactionsin anaesthesia. Anaesth Intensive Care 1981, 9: 226-35.

2. Fisher M. Anaphylactic cardiovascular collapse: Clinical observations on

pathophysiology and treatment. Anaesth Intensive Care 1986; 14: 17-21.3. Wasserman SI. The heart in anaphylaxis. J Allergy Clin Immunol 1986; 87: 663-66.4. Beaupre PN, Roizen MF, Cahalan MK, Alpert RA, Cassoria L, Schiller NB.

Haemodynamic and two dimensional transoesophageal echocardiographic analysisof an anaphylactic reaction in a human Anaesthesiology 1984; 60: 482-84

5. Silverman HJ, Van Hook C, Haponik EF. Haemodynamic changes in human

anaphylaxis. Am J Med 1984; 77: 341-446. Nicolas F, Villers D, Blanoeil Y. Hemodynamic pattern in anaphylactic shock with

cardiac arrest. Crit Care Med 1984; 12: 144-45.7. Fisher MM The diagnosis of acute anaphylactoid reactions to anaesthetic drugs

Anaesth Intensive Care 1981, 9: 235-418. Levi R, Chenouda A, Trzeciakowski JP, et al. Dysrhythmias caused by histamine

release m guinae pig and human hearts. Klin Wochenschr 1982, 60: 965-71.9 Graver LM, Roberston DA, Levi R, Becker CG, Weskler BB, Gay WA.

IgE-mediated hypersensitivity m human heart tissue: Histamine release andfunctional changes. J Allergy Clin Immunol 1986, 77: 709-13.

10. Machado FRD, Assem ESK, Ezeamuzle IC Cardiac anaphylaxis. Part II the role ofprostaglandins, thromboxanes and leucotrienes m C.A Allergol Immunopathol1985, 13: 335-50

11. Bristow MR, Ginsburg R, Harrison DC. Histamine and the human heart the otherreceptor system. Am J Cardiol 1982; 49: 249-51.

12. Kalsner S, Richards R. Coronary artenes of cardiac patients are hyperactive andcontain stores of amines a mechanism for coronary spasm. Science 1984, 223:1935-37.

Reviews of Books

Chronobiology and Psychiatric Disorders

Edited by A. Halaris. New York: Elsevier. 1987. Pp 339.$49.50ISBN 0-444012168.

MANY biological functions have a circadian rhythm.Chronobiology is the study of these rhythms and the"biological clocks" that control them. Circadian functionsinclude the cycles of sleep and wakefulness, feeding anddrinking, and body temperature, and the output of cortisoland other hormones. Severe depressive disorders haveseveral features that suggest an abnormality in thesefunctions. These features include clinical phenomena suchas early morning waking and diurnal variation in mood; andbiochemical phenomena such as changes in the diurnalrhythm of cortisol production. In some affective disordersthere is also a longer cycle of changing mood and behaviour,seen most clearly in rapid cycling manic-depressivedisorders and in the seasonal depressive disorders.Observations such as these have led to the suggestion thatone of the basic pathological changes in severe affectivedisorder is a disturbance of the control of circadian rhythms.The editor and 28 authors of this book have written fifteen

chapters, each of which is a comprehensive review of anaspect of the research into circadian rhythms in affectivedisorders. The topics include: circadian patterns of

noradrenergic transmission in healthy people and depressedpatients; rapid-eye-movement sleep and temperatureregulation in affective disorder; diurnal changes in theefficiency of performing tasks; rhythms of cortisol in

depressed patients and healthy people; circadian rhythms ofbrain serotonin; and seasonal depressive disorders. Manyintriguing observations are described, of which only twoexamples can be given here. Lithium salts, which stabilisethe mood fluctuations of manic-depressive patients,interfere profoundly with circadian rhythms of a widevariety of plants and invertebrates. Sleep patternsresembling those of depressed patients develop whenhealthy people are restricted to bed for 60 hours anddeprived of any activity. The second observation suggeststhat changes in sleep in depressive disorders could besecondary to the reduced activity that is part of theseconditions.

Although much of the content of the book is directed tothe idea that a disorder of biological rhythm is a centralfeature in affective disorders, other points of view are notneglected. For example, von Zerssen rejects the idea that thecircadian phenomena observed in depressive disorders arecaused by an abnormality of a pacemaker, and suggestsinstead that they are due to the influence of a normalpacemaker on whatever separate abnormality accounts fordepressive disorder.

This book can be recommended to general medicalreaders as well as psychiatrists for its up-to-date reviews.These bring together aspects of two of the most intriguingpuzzles of human biology-the nature and purpose ofcircadian rhythms, and the basis of normal mood regulationand its breakdown in manic depressive disorder.

University of Oxford Departmentof Psychiatry,

W’ameford Hospital,Oxford OX3 7JX M. G. GELDER

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Duchenne Muscular DystrophyOxford Monographs on Medical Genetics No 15. Alan E. H.Emery. Oxford: Oxford University Press. 1987. Pp 315. ,(:35.ISBN 0-192615564.

Emery has aimed this monograph at "all those involved inthe field who are not necessarily experts". He has succeededand I wholeheartedly recommend this book to all clinicians,scientists, and members of the caring community involvedwith Duchenne dystrophy. Clinical aspects of the disease arewell covered, reflecting the author’s extensive personalexperience, and there is a good section on differential

diagnosis, particularly with respect to the other X-linkeddystrophies. The chapters on the biochemistry and

pathogenesis of Duchenne dystrophy are excellent reviewsof an enormous literature and form a good starting place forthose new to the field.As one would expect from a clinical geneticist the chapters

on genetics, counselling, and prevention are detailed, lucid,and informative. The chapter on molecular biology is one ofthe highlights of the book. It deserves a much wideraudience for it describes with great clarity many of theprinciples of the new genetics. Emery noted that theisolation of the Duchenne locus was on the horizon and hereviews the background leading to this up to 1986. It is areflection of the speed of development in this area that onChristmas Eve 1987 a paper by Kunkel’s group appeared inCell (1987; 51: 919-28) describing the identification of theDuchenne gene product. They named this 400 kD proteindystrophin; it represents approximately 0-002% of totalskeletal muscle protein. This discovery heralds a new era inthe study of Duchenne dystrophy and it should proveparticularly helpful that the mouse mdx dystrophy modelappears to represent the same genetic disorder. In the nextcouple of years an enormous number of papers are going toappear as a result of these latest developments and I lookforward to seeing them reviewed critically in the secondedition of this excellent monograph.Department of Neurology,Radcliffe Infirmary,Oxford OX2 6HE DAVID HILTON-JONES

Davey and Lightbody’s The Control of Disease inthe Tropics

A Handbook for Physicians and other Workers in Tropical andInternational Community Health, 5th edition. Edited by D.Stevenson. London: H. K. Lewis. 1987. Pp 509. 12(paperback). ISBN 0-718604954.

CONTRIBUTIONS to disease prevention by the LiverpoolSchool of Tropical Medicine have during nearly 100 yearsbeen substantial. This book, which was originally based onpublic health lectures held there, came about because "mosttextbooks on the subject of disease in the tropics have beenwritten from the clinical point of view". Sixteen yearselapsed between the fourth edition and this one. During thistime, smallpox has been eliminated as an endemic disease,but "must still be mentioned both as a historical exampleand in case it comes back" (is this really necessary?), whilenew diseases including AIDS have appeared, and newpatterns of disease have emerged.The bulk of the text deals systematically with diseases

associated with low standards of personal and publichygiene (cholera takes pride of place), proximity and contactinfections (headed by smallpox), infections borne by insectsand other vectors (arboviruses), and infections from othervertebrates. The opening chapters deal with economic and

social aspects of disease, communicable disease (many termsare clearly defined) including some control measures, andcontrol of community-wide disease. Welfare services, familyhealth (which includes vaccination programmes), healtheducation, water supplies, disposal of human and animalwastes, the housefly, housing, nutrition, and vital statisticsthen follow, and the final chapter looks to the future(changes in ways of living and patterns of disease).Appendices deal with such varied topics as vaccinationcertificates, mosquito dissection, snail collection,meteorological observations, measurement of the chlorinecontent of water, and conversion factors.

This is not, therefore, just another book for the

community health worker about drains and purer watersupplies. I have a few criticisms. The text offers someinformation (albeit scanty) on clinical presentations,diagnosis, and chemotherapy; although a knowledge of thelatter is required in, for example, the implementation ofvertical eradication strategies, these aspects are probablybest left to the clinical books, including those devoted toprimary health care. Nutrition is underplayed; control ofcommunicable disease is seriously hampered when diet isinadequate, and a mere 13 pages on this topic out of 509 issimply unacceptable. Infective agents, including viruses andbacteria, are all referred to as parasites; this is somewhatunorthodox. Nonetheless, the volume does represent thecrystallised wisdom of more than 30 years and like its

predecessors it will be widely read by vast numbers of those,at many levels, who are devoted to the task of reducing theravages of human disease and suffering throughout the thirdworld. It represents excellent value for money.

Hospital for Tropical Diseases,St Pancras Way,London NW1 OPE G. C. COOK

Psychopharmacology: the Third Generation ofProgress

Edited by Herbert Y. Meltzer. New York: Raven Press. 1987.Pp 1780.$180. ISBN 0-881672734.

TOMES are back in fashion and this is one of severalreferenced texts that have broken the C 100 barrier. It is thethird edition of the American College of Neuro-

psychopharmacology handbook, previous volumes havingbeen published in 1968 and 1976. The aim is ambitious-tointegrate molecular biology, neuroscience, pharmacology,and clinical practice. Not surprisingly, however, the

impressive team of 271 contributors assembled by the editoris too large to work in unison. This does not matter, for thebook is primarily a work of reference for the psycho-pharmacologist. It is both a review and a revue; the editor,with his colleagues Joseph Coyle, Erwin Kopin, WilliamBunney, Kenneth Davis, Charles Schuster, Richard

Shader, and George Simpson, brings on a troupe ofvirtuosos who briefly command the stage before the showmoves on.

Recent developments in psychopharmacology, both

speculative and substantial, are well described, includingelectron microscopical and pharmacological evidence forinteraction of aminergic systems, the latest imagingtechniques identifying brain receptors, a whole section onthe exciting field of neuropeptides, viral and immune

hypotheses of schizophrenia, the latest on panic disorder,and a new section on the psychopharmacology of eatingdisorders.

However, it is as a reference text that this book will be

390

judged primarily. Here it comes out well. The index is

comprehensive without being overwhelming and mostchapters are well referenced for those who wish to follow upindividual questions.

For the past few weeks I have carried this book aroundwith me at the back of my car and each time I have hadoccasion to refer to it for a specific problem in clinical andresearch practice I have found the relevant pages quicklyand easily and, in most cases, obtained the answer I had beenlooking for. Although there is an inevitable emphasis onAmerican work this also reflects the balance of researchendeavour in pharmacology. Unfortunately, althoughEurope and the Commonwealth are still flush with usefultheories and ideas, it is only the North Americans who seemto have the resources to put these into practice. Despite itsprice this book is likely to prove essential to any researchworker in psychopharmacology and can be heartilyrecommended.

Mapperley Hospital,Nottingham NG3 6AA PETER TYRER

The Management of Motor Neurone DiseaseEdited by G. M. Cochrane. Edinburgh: Churchill Livingstone.1987. Pp 104. 4.95 (paperback). ISBN 0-443036942.

OF the relentless incurable illnesses, motor neuronedisease is amongst the most wretched. While its

management burdens all concerned, Dr G. M. Cochraneand his colleagues show that it is still possible to giveconstructive and welcome advice. This admirable bookletbased upon considerable experience gained at MaryMarlborough Lodge, a disabled living research unit inOxford, has been written on behalf of the Motor NeuroneDisease Association. The text clearly summarises what littlewe know of the malady and describes in a frank and realisticmanner the emerging problems-both physical andemotional-from early through to the terminal phases of thedisease. All chapters are impressive, but that which dealswith conveying the diagnosis is memorably wise andcompassionate. Cochrane’s philosophy-that "the right toknow as much as possible is so strong that the burden oftruth lies with the physician who decides not to tell. It isuncertainty about diagnosis that leads to despair"-shouldpersuade the most reactionary of traditionalists who in thepast elected never to tell. Short chapters are replete withpractical and useful suggestions, from orthoses to opiates,and the final section on bereavement confirms that the art ofmedicine persists even when science has withered. While theremarks are primarily intended for family doctors and theircolleagues, I suspect that the booklet will have a much widerand equally appreciative readership of patients, their

families, and their neurologists.48 Wimpole St,London W1M7DG GERALD STERN

Reproductive Genetics and the LawSherman Elias and George J. Annas. Chicago/London: YearBook Medical/Wolfe. 1987. Pp 323. /;32.00. ISBN 0-

815130627.

THE seeds of public disquiet over meddling with humanreproduction, first sown by Aldous Huxley and laternourished by Nazi atrocities, have now blossomed intowidespread debate as a consequence of advances inmolecular biology and obstetrics. It might seem curious thatthe media often seen more concerned with geneticengineering and the rights of the fetus than with suchmatters as impending global starvation and nuclear

annihilation. Nevertheless, society is entirely correct inconfronting the dilemmas presented by reproductivegenetics, which sooner or later will have to be tackled bylegislators.Those embarking upon this thankless task would be well

advised to use this concise and accurate overview as a

starting-point. Roughly half of the text provides a

comprehensive and realistic review of the basic principlesand practicalities of genetic screening, prenatal diagnosis,and noncoital reproduction. The remainder of the book isconcerned with legal precedents raised by controversial anddifficult subjects such as wrongful birth, surrogacy, andsterilisation of the handicapped. The authors include detailsof judgments reached in relevant cases with balancedobjective commentaries, supplemented by practicalguidelines, which might be incorporated in future

legislation. Elias and Annas have drawn on their extensiveknowledge of obstetrics and health law, respectively, toprovide a highly readable and stimulating account of anethical and legal minefield. In so doing, they have managedto avoid the turgid verbiage much loved by the legalprofession. Inevitably many of the citations and soberingtales of litigation relate to North America, but these wellwritten pages will be read with benefit in any country where

malpractice insurance premiums are generating alarm.Department of Child Health,Leicester Royal Infirmary,Leicester LEI 5WW 1. D. YOUNG

Coronary AngioplastyBernhard Meier. Orlando: Grune and Stratton. 1987. Pp 279.$49.50. ISBN 0-808918925.

CORONARY angioplasty is one of the most rapidlydeveloping techniques in contemporary medicine. It wouldbe difficult enough to produce a multi-author work on thesubject, and this solo text is something of a personaltriumph.The book covers the history of angioplasty followed by

sections on equipment and technique, the mechanism ofangioplasty, indications (including special situations such asunstable angina and acute infarction), the assessment ofresults, complications, recurrence of stenosis, and newmethods that may be of importance in the future. Itconcludes with some 500 references including workpublished in 1987. The book is well indexed and there is nodifficulty finding the relevant section. It is lavishlyillustrated with beautiful reproductions of coronaryangiograms. Only in the section on equipment and

technique does one feel that the subject has not been dealtwith comprehensively. This is hardly surprising in such arapidly changing area. Dr Meier points out that there isbound to be some personal bias in such a text. This is notnecessarily unhealthy, and it is not prominent.Many British cardiologists and radiologists will have

attended Meier’s excellent angioplasty course in Geneva.One returns with a certain euphoria that only subsides whenpractical difficulties are encountered in the catheter

laboratory. To some extent the same effect may be expectedafter reading this book. The only satisfactory way to learnthe technique is in the catheter room with an experiencedoperator. Nevertheless, this text is so good that it deserves tobe in the library of every hospital with a catheter room.

Sheffield Cardio-thoracic UnitNorthem General Hospital,Sheffield S5 7AU G. D. G. OAKLEY