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large molecules to escape into the interstitial fluid (fig. 1). Themost important molecule that accumulates within the tissuesis fibrinogen. This polymerises to form insoluble fibrincomplexes that are not broken down because of inadequatefibrinolytic activity within both the blood and the tissue fluid.The fibrin deposited around the capillary forms a barrier (fig.2) to the passage of oxygen and other nutrients which sustainthe cells of the epidermis. This leads directly to cell death andulceration.At an early stage this process may be reversed by reducing

the venous pressure by surgery or elastic stockings andenhancing the fibrinolytic activity of the cells with drugs. Ifunchecked, however, the deposition of fibrin within the skinresults in irreversible fibrosis and permanent tissue damagewhich makes the ulceration resistant to all our present formsof treatment.

REFERENCES

1. Adams EF. The genuine works of Hippocrates. London: Sydenham Press. 1849.2 Burnand, KG, O’Donnell TF, Lea Thomas M, Browse HL. Relationship between

postphlebitic changes in the deep veins and results of surgical treatment of venousulcers. Lancet 1976; i: 936-38.

3. Gay J. On varicose disease of the lower extremities. The Lettsonian lectures of 1867.London: Churchill, 1868.

4. Spender JK. A manual of the pathology and treatment of ulcers and subcutaneousdiseases of the lower limbs. London: Churchill, 1868.

5. Ludbrook J. The analysis of the venous system. Berne: Hans Huber, 1972.6. Homans J. The aetiology and treatment of varicose ulcers of the leg. Surg Gynaecol

Obstet 1917; 24: 300-11.7. De Takats G, Quint H, Tillotson R, Crittendon PJ. The impairment ofthe circulation

in the varicose extremity. Arch Surg 1929; 18: 671-66.8. Blalock A. Oxygen content of blood in patients with varicose veins. Arch Surg 1929; 19:

898-905.9. Holling HE, Beecher HK, Linton RR. Study of the tendency to oedema formations

associated with incompetence of the valves of the communicating veins of the leg.Oxygen content of the blood contained in varicose veins. J Clin Invest 1938; 17:555-61.

10. Fontaine R. Remarks concerning venous thrombosis and its sequelae. Surgery 1957; 41:6-17.

11 Blumoff R, Johnson G. Are arteriovenous shunts present in varicose veins? Paperpresented to the Society of Academic Surgeons, 1976.

12 Dickson Wright A. The treatment of indolent ulcer of the leg. Lancet 1931; i: 457-60.13. Schanzer H, Peirce EC. A rational approach to surgery of the chronic venous stasis

syndrome. Ann Surg 1982; 195: 25-29.14. Piulacks P, Vidal Barraquer F. Pathogenic study of varicose veins. Angiology 1953; 4:

59-100.

15. Pratt GH. Arterial varices. A syndrome. Am J Surg 1949; 77: 456-60.16. Brewer AC. Arteriovenous shunts. Br Med J 1950; ii: 270.17. Haimovici H, Steinman C, Caplan LH. Role of arteriovenous anastomosis in vascular

disease of the lower extremity. Ann Surg 1966; 164: 990-1002.18. Guis JA. Arteriovenous anastomosis and varicose veins. Arch Surg 1960; 81: 299-308.19. Lindemayr W, Loefferer O, Mostbeck A, Partsch H. Arteriovenous shunts in primary

varicosis: A critical essay. Vasc Surg 1972; 6: 9-14.20. Hehne HJ, Locher JT, Waibel PP, Fridrich R. Zur Bedentung arteriovenoeser

anastomosen bei der primaeren Varicosis und der chronischvenoesen Insuffizienz.Vasa 1974; 3: 396-98.

21. Landis EM. Microinjection studies of capillary blood pressure in human skin. Heart1930; 15: 404-53.

22. Pappenheimer JR, Soto Rivera A. Effective osmotic pressure of plasma protein andother quantities associated with capillary circulation in the hind limb of cats anddogs. Am J Physiol 1948; 152: 471-91.

23. Whimster 1. Cited by Dodd H, Cockett FB. The pathology and surgery of the veins ofthe lower limb. Edinburgh: Churchill Livingstone, 1956.

24. Burnand KG, Whimster IW, Clemenson G, Lea Thomas M, Browse HL. Therelationship between the number of capillaries in the skin of the venous ulcerbearing area of the lower leg and the fall in foot vein pressure during exercise. Br JSurg 1981; 68: 297-300.

25. Burnand KG, Clemenson G, Gaunt J, Browse NL. The effect of sustained venoushypertension in the skin capillaries of the canine hind limb. Br J Surg 1981; 69:41-44.

26. Shirley HH, Wolfram CG, Wasserman K, Mayerson HS. Capillary permeability tomacromolecules: stretched pore phenomenon. J Physiol 1957; 190: 189-93.

27. Pietra GG, Szidon JP, Leventhal MM, Fishman AP. Haemoglobin as a tracer inhaemodynamic pulmonary oedema. Science 1969; 166: 1643-46.

28. Beard RC. MS thesis, Cambridge University, 1982.29. Leach RD, Browse NL. Lymph fibrinogen in long and short term venous hypertension

in the hind limb of the dog. Br J Surg 1981; 68: 354.30. Burnand KG, Whimster I, Naidoo A, Browse NL. Pericapillary fibrin deposition in the

ulcer bearing skin of the lower limb-The cause of lipodermatosclerosis and venousulceration Br Med J (in press).

31. Browse NL, Jarrett PEM, Morland M, Burnand KG. Treatment of liposclerosis of theleg by fibrinolytic enhancement: a preliminary report. Br Med J 1977; ii: 434-35.

32. Burnand KG, Clemenson G, Morland M, Jarrett PEM, Browse NL. Venouslipodermatosclerosis: treatment by fibrinolytic enhancement and elastic

compression. Br Med J 1980; 280: 7-11.33. Hopkins NFG, Rhodes CG, Spinks T, Jones T, Jamieson CW. Position emission

tomography in venous ulceration. Br J Surg (in press).

Reviews of Books

Clinical Hypertension and HypotensionEdited by Hans R Brunner, Hospitalier Universitaire Vaudors, Lausanne,and Haralambos Gavras, Boston University School of Medicine, Boston,Massachusetts. New York and Basle: Marcel Dekker. 1982. Pp. 322.Sw. Fr. 188.

SOME may be surprised to learn that there has been only one bookon clinical aspects of hypertension since the last edition of

Pickering’s monograph in 1968. Advances in the area have been thesubject of several symposia and proceedings but reviews have beenconfined to chapters in textbooks and journals. Hypertension is socommon that physicians can hardly fail to read or hear something onthe subject every week. But occasionally it helps to take stock of newideas and treatment to see them in perspective. With this in mind,two distinguished workers, Brunner and Gavras, one from each sideof the Atlantic, have collaborated to edit a multiauthor book. Theresult is a well-presented, readable book of twenty chapters byacknowledged experts with a gift for lucid writing.After a word on patient assessment, there are six chapters dealing

with secondary hypertension. The discussion of renal arterystenosis puts emphasis on identification of the patient with curablehypertension, but few in the U.K. will feel able to follow theserecommendations. The diagnosis and management of phaeo-chromocytoma is described with the authority that comes from widepersonal experience. There is also a whole chapter on oral

contraceptive hypertension.The middle section of the book covers essential hypertension and

includes a detailed chapter, by Heusler, on the neurogenic control ofblood pressure. Brunner and Gavras are careful not to postulate thecause of hypertension but simply present the data, leaving thereader to ponder. Some workers may be aggrieved because theirwork is not mentioned, but this is inevitable with a subject that is sowidely investigated.The rest of the book deals with treatment of special forms of

hypertension, including hypertensive emergencies. The stickyproblems of borderline blood pressure and hypertension in theelderly are thoughtfully written, and there is a stimulating chapteron pregnancy, although the use of intravenous magnesium salts forimpending eclampsia would be considered unusual in Britain. Thebook closes with a chapter on orthostatic hypotension, a conditionwhich is still poorly understood and notoriously difficult to manage.Reading about hypertension is unexciting at times, simply

because ofa sense ofdeja vu, but this is a reliable book which shouldfind a place in every medical library. It contains almost a thousandreferences, which are re-listed alphabetically at the end. It will be ofvalue to all physicians but unfortunately too expensive for me torecommend a personal copy,.Department of Medicine,Weymouth and District Hospital,Dorset PETER DOWN

The PituitaryClinical Endocrinology 1. Butterworths International Medical Reviews.Edited by Colin Beardwell, University Hospital of South Manchester, andGary L. Robertson, University of Chicago. London and Boston:Butterworths. 1981. Pp. 337. L1350 (subscription price LID.OO).

THE pituitary gland may no longer be the conductor of theendocrine orchestra, but it retains a special fascination forendocrinologists which continues to increase as its mysteries areunravelled. This book attempts to review some of the advances in

understanding and practice which have been brought about over thepast 20 years as a result of basic research and improved methods ofinvestigation and treatment.Three chapters cover pituitary tumours. R. Fahlbusch writes

from his extensive and successful experience of 737 operations forpituitary adenoma from 1970-80. He is controversial only in statingthat there is no dispute that large prolactin-secreting adenomasaccompanied by visual disturbance must be treated surgically,

246

particularly since the results are poor and bromocriptine mayreduce tumour size considerably. G. E. Sheline writes clearly aboutradiotherapy, emphasising that there is a difference betweenfunctional and mass effect. He reviews the results of conventionalexternal irradiation as well as those of a-particle and proton-beamtherapy but does not mention interstitial irradiation. C. Beardwellreviews drugs for suppressing both pituitary and adrenal

hyperfunction as well as hormone replacement for patients withtreated pituitary tumours. R. A. Vigersky describes functionaldisorders of the hypothalamopituitary axis, particularlyamenorrhoea induced by weight loss, exercise, and stress, andfunctional hyperprolactinaemia, though as he says the latter may bedue to a very small tumour undetectable by current methods. Drug-induced hyperprolactinaemia is covered by S. M. Shalet in hischapter on iatrogenic hypothalamopituitary disease which is mainlyabout the hormonal effects of cranial irradiation for pituitary and,increasingly, non-endocrine disease. Gonadotropin-releasinghormone and its analogues, including their remarkable

antireproductive effects and the recent work on the potential ofpulsatile low-dose infusions in the treatment of infertility, aredescribed by S. J. Nillius. Other chapters contain authoritativeaccounts of vasopressin function based on advances in radio-immunoassay, ectopic hormone production, structure-activityrelationships of posterior pituitary hormone analogues, and

extraction, purification, and synthesis of anterior pituitaryhormones, including the use of genetic engineering techniques.The editors have coordinated the contributions of their British,

American, and European authors, so that there is very little overlapand a high standard of literacy, marred only by the occasionalinfelicity (e.g., emergent situations instead of emergencies).Omissions are few and minor, and high production standards, largeprint, and generous use of subheadings make for easy reading. Thebook can be recommended to all with an interest in the pituitary.Department of Medicine,Westminster Hospital, London A. J. ISAACS

Rheumatic and Metabolic Bone Diseases in the ElderlyD. F. Giansiracusa, University of Massachusetts, Worcester, and F. G.Kantrowitz, Harvard Medical School, Boston. Lexington,Massachusetts: Collamore Press. 1982. Pp. 229.

THE elderly constitute a dominant part of a rheumatologist’spractice, and rheumatic problems are an important feature indisorders of the elderly as seen by family practitioners, generalphysicians, and geriatricians. Indeed with the particular problemsthat exist in the elderly one could make a case for combined clinicsconducted by geriatricians with rheumatologists, just as

rheumatologists do with orthopaedic surgeons, paediatricians, orchiropodists. It was therefore with interest that I started to read thisbook, particularly since its aim, according to both the fly-leaf andthe preface, is to concentrate on practical problems. It is reasonableto begin with a chapter on the ageing of the immune system, althoughthe 3112 sides seem to indicate how little is known. The chapter onlaboratory tests does add a geriatric dimension to such items assedimentation rate. However the next chapter, on amyloidosis, ishalf devoted to amyloid arthropathy and does not mention renalamyloid or the management of the disease in general. Thisimbalance sets the trend for most of the book. There is a whole

chapter on systemic lupus erythematosus and drug-induced lupusbut, except for a very few lines, one could read this in isolation asbeing about SLE in general and drug-induced lupus in particular,since over half is allocated to this interesting but easily avoidedsyndrome. A chapter on rheumatoid arthritis, adequate so far as itgoes, is shorter than that on SLE. Lumbar spondylosis receivesscant attention, rather less than Forestier disease (ankylosingvertebral hyperostosis). Cervical spondylosis is not covered

properly and spinal stenosis not at all. Soft tissue rheumatismreceives inadequate coverage as regards clinical signs, symptoms,and management. The problems of the acromioclavicular joint aregiven scant attention. The sections on medication and on metabolicbone diseases are more useful.

Overall I found this book disappointing; not only does it fail toanswer the problem-oriented questions that arise in looking after

elderly patients with rheumatic disease, but the authors also do notcover adequately the areas which they claim to in their introduction.However, one has to admit that it is one of the few texts availableconcerning rheumatic diseases in the elderly.Department of Rheumatology and Rehabilitation,University College Hospital, London M. L. SNAITH

Biocultural Aspects of Disease

Edited by Henry Rothschild and Charles F. Chapman, Louisiana StateUniversity Medical Center. London and New York: Academic Press.1981. Pp. 653. £ 43;$65.

THIS is not a conventional geographical pathology text but avaliant attempt by some twenty contributors, from different

disciplines, to produce a readable account of the relation betweendisease and ethnicity. It deals not only with genetic backgrounds butalso cultural, environmental, nutritional, and other factors.Previous works have concentrated on single ethnic groups-e.g.,Jews or Blacks; here the scope is wider, with an admission of bias toethnic groups important in North American society. The Irish arescarcely mentioned, and I reget the omission of the Australoids (amost interesting ethnic group).The discussion of the vexed question of "race" takes into account

problems in semantic ambiguity and controversial sociopoliticalclimates; "ethnic group" is the preferred term for socially definedpopulations. There is philosophical discussion of changing patternsin the history of concepts of disease; of relation between culture,biology, and medicine; and of genetic polymorphism, especially inblood and HLA groups, haemoglobins, enzymes, and proteins.Kuru, Burkitt’s lymphoma, and nasopharyngeal cancer exemplifythe value of recent multidisciplinary approaches. Denis Burkittoutlines the geography of disease, including, of course, those relatedto constipation. The biology of senescence is discussed in depth.The Black Death profoundly altered mediaeval social

institutions, Napoleon’s Russian campaign led to continuingdecline of French power in Europe, while the plague of Athenschanged the course of the Peloponnesian War. Thus are disease andhistorical events related.Ten reports of varying depth and complexity relate to different

ethnic groups. Each reader will have his personal preference; Ienjoyed most those on Latin America and Black Africa. LatinAmerican trypanosomasis and pinta are considered; malaria andmeasles appeared only after agriculture permitted population build-up. Despite a high incidence of zoonoses among Amerindians, theirdomination by invaders resulted largely from introduced Europeandiseases. The low index of physical quality of life in Black Africa isassociated with many serious arthropod-borne diseases, includingmalaria (with its association with sickle-cell genes) and otherprotozoal, viral, filarial, and sewage and water borne diseases.Cholera became important only after 1970, but schistosomiasis hasalways been a major cause of disease and still affects 34 millionpeople. Traditional medicine thrives and remains to be integrated.This impressive book contains a wealth of information and food

for thought but it is expensive for students and junior doctors.Perhaps a shortened, paperback version might be considered.

University Pathology Department,Western Infirmary,Glasgow A. T. SANDISON

New Editions

Parent-Infant Bonding. -2nd ed. by M. H. Klausandj. H. Kennell. London:Year Book Medical Pub. 1982. Pp. 314. f13.50.Short Textbook of Surgery.-5th ed. By S- Taylor and L Cotton. Sevenoaks:

Hodder & Stoughton. 1982. Pp. 631. f7 .45.Anatomy for Surgeons, Vol. IIL-3rd ed. By W. Henry Hollinshead. London:

Harper & Row. 1982. Pp. 878. f56.Personality Disorders-Diagnosis & Managemenr.-2nd ed. By John R. Lion.

Baltimore and London: Williams & Wilkins. 1982. Pp. 592. 26.75.An Introduction to Electrocardiography.-6th ed- By Leo Schamroth. Oxford:

Blackwell. 1982. Pp. 317. f7.80.Year Book of Neurology & Neurosurgery 1982.-Edited by R. N. De Jong,

R. D. Currier and O. Sugar. London: Year Book Medical Pub. 1982. Pp. 499.$45; ;E25.