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Reviews of Books

Endoscopic InterpretationNormal and Pathologic Appearances of the Gastrointestinal Tract. Michael0. Blackstone, University of Chicago, Illinois. New York: Raven Press.1984. Pp 575.$130.

AN endoscopist needs to be able not only to locate abnormalities inthe intestinal tract but also to interpret findings critically in the lightof what is known of normal variations in the appearance of the gut.The need for a well-thought-out atlas of gastrointestinal endoscopicappearances is well filled by this volume. It is an extremelyimpressive book that is a great credit to its author, the director ofgastrointestinal endoscopy at the Pritzker School of Medicine.There are five main sections on the oesophagus, the stomach andpylorus, the duodenum, upper gastrointestinal bleeding, and thecolon and terminal ileum. Each section starts with a helpful chapteron the techniques of examination and normal appearances, followedby one on appearances that vary from the normal but are of doubtfulclinical significance. Common abnormalities in each area are thensurveyed in detail, before the rare conditions. Indeed virtually everyconceivable lesion seen down an endoscope is dealt with. Thesection on upper gastrointestinal bleeding is particularly good, witha sensible discussion on the advisability, timing, and overallusefulness of endoscopic investigation. It also gives data from theauthor’s practice. _

The book is very well written, most of the endoscopicphotographs are of outstanding quality, and there is a

comprehensive and accurate index. All the chapters are heavilyreferenced up to 1983. The volume is more suitable for dipping intothan for reading from cover to cover, otherwise the reader comesup against considerable repetition both in the text and in thepictures. The author writes as superspecialist in a referral centre,and the range of cases that he sees is not typical of an ordinaryhospital. In general his advice on technique is sound, although he isfond of advancing his gastroscope "forcefully"-which could beunwise in inexperienced hands. One might also disagree with hisdisinclination to biopsy small gastric ulcers because of the lowchance of malignancy.My criticisms are minor. This splendid book should be looked at

and enjoyed by all gastrointestinal endoscopists. The price is

horrendous, but pressure should be put on the library to get a copy.

Department of Medicine,Basildon Hospital,Essex C. P. WILLOUGHBY

Immune Suppression and ModulationClrnrcs in Irrrrnurrologv and Allergy, vol 4, rro 2. Edited by Malcolm S.Mitchell, University of Southern California Medical Center, Los Angeles,and John L. Fahey, University of California, Los Angeles. Philadelphiaand Eastbourne: W. B. Saunders. 1984. Pp 451. fl2.50.

NINE of the eleven chapters in this book are concerned withimmunosuppression, either as a clinical objective or as an unwantedside-effect. Two chapters, one on interferon and the other oninterleukin-2, are about attempts to enhance immunologicalmechanisms of one sort or another. Presumably these two chaptersjustify the use of the word modulation. Since by definition

immunosuppression is a form of immunomodulation, I was andremain confused and irritated by the title of this book. Azathioprineis even referred to in a chapter heading as an immune-modulatingdrug. We are spared, fortunately, the term, biological responsemodifiers. Semantic quibbling, perhaps, but the use of words suchas immunomodulation is, I suspect, supposed to give the impressionthat immunologists are now in the business of fine tuning of theimmune response for clinical ends. They are not.Overall, this book presents a confused and confusing impression;

a series of uninspired and conventional reviews largely aboutimmunosuppression. The only relief that I could obtain was in anexcellent chapter about cyclosporin. It is hard to contain one’s

excitement when faced with such remarkable results. There are also

essays on the anti-mflammatory effects of steroids by a clinician, theeffects of doxorubicin on mice, the use of total lymphoid irradiationin rats and in man, and more besides. The chapter on interferon isbizarre. Much attention is drawn to its use for cancer treatment butits antiviral activity hardly gets a mention. Studies of the clinicalefficacy of interferon, we are told yet again, "are still in their

infancy". Most of the data are concerned with the effects of theinterferons on NK cells and not on the patients or their cancers.A little more attention to clinical data would have provided a more

convincing perspective for the whole book. For example, theaccount of the effects of cyclophosphamide in patients withmultiple sclerosis concentrates on its impact on OKT4/OKT8ratios, NK cells, and antibody and delayed hypersensitivityreactions but there is hardly a mention of the effects on the patientsor the lack of effects on the progress of their disease. The uneven

quality of the content may well be an accurate (but inadvertent)reflection of the present accomplishments and limitations of

therapeutic clinical immunology. Cyclosporin is the most excitingthing in this volume, perhaps the single most important advance inclinical transplantation for at least 20 years. But it is not enough toredeem an otherwise inadequate book.

Research Institute,Mane Cune Memorial Foundation,Oxted G. A. CURRIE

Taylor’s Principles and Practice of Medical Jurisprudence13th ed. Edited by A. Keith Mant, University of London. Edinburgh:Churchill Livingstone. 1984. Pp 415. L32

THIS thirteenth edition of Taylor’s Principles and Practice ofMedical Jurisprudence, appears just as its editor retires from a longand distinguished career as a forensic pathologist. Ever since it wasfirst produced by A. Swaine Taylor in 1865 to follow his Elements ofMedical Jurisprudence (1836) and Matutal of Medical Jurisprudence(1844), it has been a much respected source of forensic wisdom.

Professor Mant has radically changed the structure of this book.Apart from omitting the section on toxicology and pruning thehistorical references, he has made it a multiauthor book, to which hecontributes. This apparent effort to draw together the best advice inthe wide and constantly enlarging disciplines and subspecialties thatnow make up forensic medicine has to a large extent succeeded. Ifound the following sections particularly outstanding. That byBernard Knight outlining the development of the medicolegalsystem in England and comparing it with those in the United Statesof America and Europe gives much food for thought. The Englishlegal system is lucidly described by B. Hargrove, recorder of theCrown Court, in a way that most non-lawyers will understand. Therevision, by John Burton, of the late Gavin Thurston’s account ofdeath, its definition, and all it implies is excellent and it should beread by every newly qualified doctor. The laws relating to medicalpractice are well expounded by P. H. Addison, formerly secretary ofthe Medical Defence Union. David Paul’s very full account of the

medicolegal examination of the living, especially as regards thevarious forms of sexual assault, reflects his experience. BernardSims, one of the extremely few experts in this area, gives acomprehensive, masterly account of the development, applications,and importance of forensic odontology. David Bowen’s concise andup-to-date resume of abortion deals fully with both the law and thepathology, while James Cameron’s coverage of all aspects of infantdeaths includes sociological, psychiatric, and statisticalinformation. T. C. N. Gibbens’ account of forensic psychiatry, boththe legal and medical facets, is the best that I have read. Finally, PatToseland presents a much needed and informed discussion onforensic blood, breath, and urine alcohol determination; it is

contemporary and not over long.At L32 this latest Taylor is good value for money and every

practising or aspiring medicolegal practitioner should have it to

hand.

Department of Forensic Medicine,St George’s Hospital Medical School,London RL’FUS CROMPTON

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Clinical Geriatric PsychopharmacologyEdited by Carl Salzman, Massachusetts Mental Health Center andHarvard Medical School, Boston, Massachusetts. New York: McGraw-Hill. 1984. Pp 242. £26.25.

AT first sight this book does not inspire. The title, thoughaccurate, is unwieldy, the text is set in unattractive san-serif type,and there are no illustrations. Although the book seems to have beenpublished on the cheap it still costs over [,26.These initial impressions are unfortunate because the book is an

example of clinical pharmacology at its best. Some doubts have beenexpressed about the value of clinical pharmacology as a scientificdiscipline because much of the information derived from basicpharmacology has no special clinical relevance. Knowledge ofclinical pharmacology is nonetheless important in deciding whethersymptoms are appropriate for treatment by drugs or are in factcaused by them. This is particularly difficult in the elderly, and theassumption that one can extrapolate from experience with youngeradults is often sadly wrong. Carl Salzman, who has written eight ofthe ten chapters, and his colleagues have selected the importantinformation in pharmacology. that is relevant to the

psychogeriatrician. It is presented well. The format is also helpfulfor the clinician. A chapter on the treatment of "agitation andpsychosis" may not satisfy the diagnostic purists but in practicepsychiatrists are called on frequently to treat confused and deludedold people, who need to be managed quickly and effectively.Throughout the book there are practical tips on, for example, theeffects of anticholinergic drugs on dentures, the advantages ofgiving 95% oxygen before electroconvulsive therapy in elderlypatients, and ways of dealing with snoring. Clinical vignettes at theend of most of the chapters illustrate the importance of rationalprescribing.A nice balance is maintained between the practical use of

psychotropic drugs and their pharmacological properties. My onlyconcern is Salzman’s suggestion that methylphenidate and

amphetamine have a place in the treatment of apathetic andwithdrawn elderly people and that treatment of insomnia with lowdoses of barbiturates is still justified for in-patients.The book deserves a place in psychiatric libraries and the editor

and contributors can congratulate themselves on helping to makegeriatric psychopharmacology a respectable discipline.Mapperley Hospital,Nottingham PETER TYRER

Frontiers of Clinical Neuroscience

L’olll. Edited by Michael G. Ziegler, Umversity of California, San Diego,and C. Raymond Lake, Herbert School of Medicine, Bethesda, Maryland.Baltimore and London: Williams and Wilkins. 1984. Pp 521. £76.

As someone involved in biological research into psychiatric illnessbut working in association with a department of clinical

pharmacology which has a strong cardiovascular interest I

approached this book with great interest. It reviews noradrenalinein four sections: introduction and measurements; anatomy;physiology and function; and clinical aspects. Many of the authorshave been associated with the National Institutes of Health and aconsensus view seems to emerge from the book.The papers reviewing the anatomical and physiological aspects of

the noradrenergic systems cover a wide area and refer to both humanand animal experimental work. They provide a useful account ofcurrent understanding and form a good basis for the clinical section.From this point of view the book offers something that existingbooks do not, and it does this without excessive repetition. Alsovaluable is the chapter examining the use ofCSF noradrenaline anddopamine-&bgr;-hyroxylase as indicators of central noradrenergicfunction. In another chapter P. C. Rubin and J. L. Reid sound animportant warning note about the findings obtained in certaincategories of so-called "control" subjects.Perhaps surprising is the relative paucity of information

concerning adrenoceptors, particularly so in relation to theirdistribution in the central nervous system and their possiblerelevance for affective disorders, in which adrenoceptor

abnormality is the basis of one of the major biochemical theories. Infact the lack of a chapter solely on depressive illness is perhaps thegreatest omission in this book. It may have been left out because thefirst volume of the series, Neurobiology ofMoodDisorders, referred tothese aspects. Nevertheless, this omission may detract from theinterest this book should have for researchers into biological aspectsof psychiatric illnesses.As might be expected, the clinical section is allocated largely to

cardiovascular control and hypertension, and provides succinctreviews. There is also an interesting section related to the endocrinesystem, and here an opportunity may have been missed to discussthe use of hormone stimulation tests in the assessment of central

noradrenergic function.Overall I found this volume interesting and useful but I think it

will appeal primarily to those working in cardiovascular pharma-cology. Those interested in biological psychiatry may do well toexamine volume I in the series before making a final purchase.

Department of Psychiatry,Holywell Hospital,Antrim STEPHEN J. COOPER

Differential Diagnosis in Neuropsychiatry

Jeremy K. A. Roberts, University of Ottawa. Chichester and New York:John Wiley. 1984. Pp 377. £17; $25.50.

UNTIL recently the traditional rigid demarcation between

neurology and psychiatry has stranded British neuropsychiatry in astultifying limbo. There are now encouraging signs of a renaissance,with workers at the National Hospital for Nervous Diseases,London, well to the fore. Dr Roberts, the author of this book, is aproduct of this stable, although now translated to Ottawa. Hispedigree is discernible in his concept of neuropsychiatry not just asthe behavioural aspects of neurology but rather as an independentclinical specialty drawing on knowledge from both neurology andpsychiatry, yet possessing its own body of learning and expertise.The first six chapters deal in considerable detail with clinical

assessment, including history-taking, mental state evaluation,neurological examination, psychological testing, and the use ofspecial investigative techniques such as EEG, CT-scan, positronemission tomography, and nuclear magnetic resonance. The nextten chapters deal with the differential diagnosis of a variety ofsyndromes, symptoms, and behaviour patterns; these include

epilepsy, head injury, delirium, dementia and pseudo-dementia,aggression, falling attacks, altered consciousness, catatonia andstupor, sleep disorders, and disorders of perception.The final chapter contains sixteen case-histories which skilfully

illustrate the interaction of organic, psychological, and social factorsand the holistic approach required in the investigation andmanagement of patients with neuropsychiatric disorders. The bookconcludes with a useful glossary of terms and an adequate, but notoverwhelming, bibliography.The salient points of each topic are summarised in tables notable

for their clarity and comprehensive content. Thus there are tablesfor a wide spectrum of subjects-for example, the clinical features ofindustrial toxin poisoning, and the differential diagnosis ofdementia and pseudodementia, of psychogenic versus organicstupor, and of Wilson’s disease, Huntington’s chorea, and tardivedyskinesia. The text is also enhanced by some elegant line-drawingsdepicting various anatomical and clinical points.The authors’s thoroughness leaves little to criticise. Some of the

tabulated lists are over-inclusive and there are several misprints andone misaligned table (3.1). Insulinomas are not usually palpable,except at operation.This book fulfils admirably its avowed purpose as a diagnostic

manual. At the same time it imparts a good deal of information ofinterest to both neurologists and psychiatrists. It is of particularbenefit to trainees, but consultants will also find it a useful aid fordifficult diagnostic problems.Department of Psychiatry,Newcastle General Hospital,Newcastle upon Tyne K. DAVISON