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Reviews of Books

Venous Thromboembolism

Jack Hirsch, Edward Genton, and Russell Hull, McMaster University,Hamilton, Ontario. New York & London: Grune & Stratton. 1981. Pp.335. 19.50,$29.50.

THE three authors are major contributors to recent advances ininvestigation and therapy of venous thromboembolism, and theirconsiderable knowledge of the condition is evident in this book inwhich they present the physician with guidelines for its diagnosisand treatment, including prophylaxis. Part I of the book deals withpathogenesis, risk factors (which are dealt with verycomprehensively), and clinicopathological correlations of venousthrombosis and pulmonary embolism. Part II, which concentrateson diagnostic techniques, prophylaxis, and treatment has an

especially valuable chapter on management of suspected venousthromboembolism in pregnancy. Part III contains chapters on allthe well known treatments, those on heparin and warfarin beingvery detailed. Lesser known agents such as snake venom and

dihydroergotamine, and the physical methods of prophylaxis arealso discussed. The chapter on diagnosis of venous thrombosis is 85 5pages long (one quarter of the book) and, as to be expected from thethrombosis group at McMaster University, the emphasis is on non-invasive methods of detection. Particularly well described are thetechniques of the various forms of plethysmography, isotope tests,Doppler ultrasound, phlebography, and angiography. Therationale for the use of each test is incorporated into the descriptionof well-designed schemes of management of the various situationswhich may confront the physician.The book contains an exuberant, and in some areas perhaps

excessive, number of line-diagrams, often complex, but fortunatelyaccompanied by good explanatory legends. The text itself is notreferenced, but at the end of each chapter is a bibliographycategorised so that it is easy to find appropriate papers for furtherreading on any given topic. The book refers briefly to the authors’new approach to secondary prophylaxis of venous thrombosis withadjusted moderate-dose subcutaneous heparin in place of warfarin,but the results have only since been published (N Engl J Med 1982;306:189); they show that, compared with warfarin, heparin reducesthe incidence of bleeding but does not alter the risk of recurrentthromboembolism.There are obviously points of contention, such as the choice

between treating or monitoring the progression of established calfvein thrombi, and the place of haematological investigations in theprediction of and diagnosis of venous thromboembolism stillremains to be delineated. On the whole this volume is a usefulreference work, and its bibliographies are helpful if further detailsare required. I recommend that it be incorporated into existinglibrary stock.

University Department of Clinical Surgery,Royal Infirmary, Edmburgh G. C. DAVIES

Diagnosis and Management of Acute PoisoningAlexander Proudfoot, Royal Infirmary, Edinburgh. Oxford: Blackwell.1982. Pp. 236. [,7.50.

THIS book was written primarily for doctors working in accidentdepartments and medical units. The advice contained in the

introductory chapters, on the diagnosis of poisoning and the generalprinciples of its management, is first class, based as it is on theimmense experience of the world-renowned Edinburgh RegionalPoisoning Treatment Centre. The remaining sections summarisethe clinical features and treatment of overdosage with the commondrugs, chemicals, and plants likely to be encountered in the UnitedKingdom. Each section is followed by one or more well-chosen up-to-date references. There seems, however, little point in citing "inpress" references without mentioning the journal in which thepaper is due to appear.Junior doctors want practical and unambiguous advice from a

book such as this, which is generally what Dr Proudfoot gives. On

occasions, however, he is too dogmatic (such as in his advocacy ofn-acetylcysteine over oral methionine in the treatment of

paracetamol poisoning). On other occasions he is unclear as to whatshould be done. He states that treatment for cimetidine overdose is

unnecessary, but then states that a good urine output be ensured. Itis also not clear whether patients should have an abdominal X-rayafter gastric lavage for iron poisoning to see if any tablets remain. Afurther source of confusion is the repeated referral to tablet numbersrather than dose of drug ingested, even when the drug in question isavailable in different dosage strengths. A pocket-sized book such asthis cannot be comprehensive and this does lead to some

inconsistencies-for example, metoprolol is included in the indexbut not timolol.These criticisms are minor and the book is a pleasure to read, well

produced, and inexpensive. It should be readily available to all thosewho have to treat poisoned patients.Poison Unit,Guy’s Hospital,LondonSEI9RT P. CROME

Illustrated Encyclopaedia of DermatologyLionel Fry, Fenells T. Wojnarowska, St Mary’s Hospital, London, andParvin Shahrad, Luton and Dunstable Hospital, Bedford. Lancaster:M.T.P. Press. 1981. Pp. 561. 19.95.

I RATE this book highly for its clear text but not so highly for itsphotographs, some of which are dim and drab. In dermatologyblack-and-white is not beautiful, and I hope that this book willblossom into colour in its next edition; the senior author’s ownillustrated guide (Dermatology; An Illustrated Guide, Update Books,1978) shows how effective colour photographs can be. Havingfound some of the pictures baffling myself, I asked several otherdermatologists to have a look. Even the most experienced were hardpressed to recognise some common disorders which they see often intheir clinic. This is a pity, since otherwise the book is very suitablefor the "general practitioner and primary physicians with a specialinterest in this field" for whom it was written.The volume is strongly bound and nicely laid out. The main

disorders are presented alphabetically, so reading straight throughthe book demands some mental agility, jumping as one does fromacanthosis nigricans to acne to amyloidosis; but this arrangementdoes make it easy to look up individual conditions as they crop up inthe surgery. The approach is methodical and sound, and the degreeof detail given is right for a keen general practitioner, who willbenefit particularly from the paragraphs on differential diagnosiswhich always face up to the real difficulties and suggest ways ofresolving them clinically.There are also many line-diagrams. Those which show the usual

distribution of a particular eruption on the skin surface are clear andhelpful; those which present the sex ratio of the diseases as lines ofsmall male and female dolls seemed useful at first, but after lookingat nearly fifty of these diagrams, each occupying about a quarter of apage, I began to tire of them. I feel that this book with its

straightforward sensible text will help general practitioners andperhaps those taking up dermatology. Some may already own asmall colour atlas of dermatology and will be able to work well withthe two in harness.

Department of Dermatology,Royal Infirmary, Edinburgh J. A. SAVIN

Basis and Development of ReproductionBasic Reprodzictive Medicine, vol. 1. Edited by David Hamilton, Universityof Minnesota, and F. Naftolin, Yale University School of Medicine.Cambridge, Massachusetts: M.LT. Press. 1981. Pp. 174. 15.75.

THIS volume is the first in a five-volume series concerned with

reproductive medicine. The audience for which it is, primarilyintended is stated to be students, presumably medical. If this is sothen the format is somewhat "old-fashioned" in that it displays a"discipline" rather than an "integrated" approach to teaching. Thefirst section deals with the genetics of sex development and is well

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written but contains such a wealth of factual detail that an

undergraduate might not appreciate it until the clinical applicationof such knowledge has become apparent. At the other extreme thedescription of the physiological and psychological aspects of sexualdevelopment and function is somewhat simplistic and is

accompanied by half-page drawings of dubious value with regard totheir anatomical and physiological content. The section on

development of the reproductive tract is similar to that found inmany standard textbooks and one page of drawings is taken from abook published in 1956.The chapter describing the development of adult reproductive

function is useful but overlaps in some details with other chapters;that describing puberty and adolescence is short, clear, and useful,though drawings of a sun and moon on one of the figures to indicateday and night seems a little too basic. -

I doubt that this book will readily appeal to medical studentsbecause it is too detailed, but it is useful for those studying forspecialist examinations in obstetrics and gynaecology or moresenior colleagues who wish to refresh their ideas concerning currentthoughts about genetic sex and mechanisms controlling puberty andfertility. The list of contents of future volumes leaves me with theimpression that, with judicious pruning, this series could becondensed into a useful single volume for the intending specialist.M.R.C. Human Reproduction Group,Princess Mary Maternity Hospital,Newcastle upon Tyne TOM LIND

The Biology of Cholesterol and Related Steroids

N. B. Myant, Hammersmith Hospital, London. London: WilliamHeinemann, 1981. Pp. 910. 1:45.

IN the seventy years that have elapsed since Anitchkow producedlesions in the aortas of rabbits by feeding them cholesterol, thenumber of papers published on the biology and pathology ofcholesterol has swelled to unmanageable proportions. In The

Biology of Cholesterol and Related Steroids Dr Myant has attempted,single handed, a critical review of the present state of our

knowledge. The book is unnecessarily long, the same subject matterbeing covered under several different headings. Myant shows signsof exhaustion in three chapters, in which the presentation is

perfunctory and repeated much of what can be found elsewhere inthe book; these chapters are those on the distribution of sterols innature, the epidemiology of plasma cholesterol, and theintroduction to disorders of cholesterol metabolism. I found chapter13 on cholesterol and atherosclerosis, out of date and sadly lackingin critical insight, but then one is always a harsh judge in one’s ownspecialty. I also found that throughout the book attributions of workare often not clear, and apparently authoritative statements aremade on some controversial topics without references being given.These are my criticisms, but they are insignificant compared with

the enormous amount of material that Myant has assembled that isof value to medical scientists, cell biologists, and biochemists. Earlychapters cover chemistry, analysis, and biosynthesis of sterols, butthereafter the approach is more biological and medical. There is aparticularly illuminating section on regulation of sterol synthesis,and the section on measurement of rate of synthesis of cholesterol inanimal tissues contains much good advice for experimenters. Thelow density lipoprotein (LDL) receptor pathway in cultured cellsand its role in whole body regulation of LDL levels in normalsubjects and in type II hyperlipoproteinaemia are criticallydiscussed. An excellent account is given of the genetics andmetabolic basis of type III hyperlipoproteinaemia. Metabolism ofthe plasma lipoproteins is discussed in the chapter on plasmacholesterol and includes an interesting account of the exchangebetween plasma free cholesterol and red-cell-membrane cholesterol;in a separate chapter Myant describes the effects of sterols onmembrane function.The book is reasonably up to date, with references extending up to

1980; it is a book to have on one’s shelf for frequent consultation,but its price may be a serious disincentive.

Department of Chemical Pathology,University of Aberdeen ELSPETH B. SMITH

Diagnosis and Management of Stroke and TLAsClinical Practice Series. Edited by John S. Meyer, Baylor College of Medi-cine, and Terry Shaw, Veterans Administration Medical Center,Houston, Texas. Menlo Park: California. Addison-Wesley. 1982. Pp. 318.$24.95.

PuBLIC debate amongst stroke specialists engenders more argu-ment than agreement, reflecting a greater prevalence of opinionthan of knowledge. A clear and authoritative guide for non-experts,who treat most cases of stroke, would be very desirable. This volumein the Clinical Practice series has been conceived with obvious care.That its style may appeal more to American readers, with points ofimportance abstracted into a wide left hand margin, is no criticismsince the book is American. The problem with such presentations isthat the annotation reflects the particular interests of author oreditor and presupposes that the reader is of like mind. Which leadsto the question of who the reader may be and, perhaps, to the key tothis book’s loss of purpose. Though said to be for primary-carephysicians, the book is more often a review than a fount of practicaladvice and only with effort on the part of the user would it serveeither GP, who may retain responsibility for managing up to half ofall strokes, or general physician, who may treat half of the rest. But itis not in all chapters a source book either, since many reference listsare limited and others heavily dependent on authors’ own bibli-ographies. Many statements in the book must therefore be taken on’their own authority, which may be acceptable since many of the con-tributors are authorities in their specialty.Early chapters review the association between ageing and

cerebrovascular disease before discussing more relevantly, the

recognised risk factors for stroke (with emphasis on Framinghamand occasional reference to other surveys) and the differential

diagnosis of stroke, but barely mentioning the non-vascular lesionsthat may present with stroke-like syndromes. There is no excuse forillustrative CT scans to be less than exemplary. This is equally trueof the ECGs, which are sometimes beyond discernment, but thecriticism cannot be made of angiograms, since none accompany thesection on angiography. Barnett’s chapter reads as a clear statementof the problems that complicate medical management of transientischaemic attacks (TIA) (and of some solutions). It is a pity that thetable (p. 154) showing possible benefits from platelet anti-

aggregants has its values confused by the text.The two chapters on surgical management are, as expected, more

forthright, a quality that sometimes uneasily accommodates impar-tial reporting of surgical outcome. Chapter nine, on cardiologicalconsiderations, leaves the disconcerting impression that "light-headedness", for which several cardiac causes are given, is not

distinguished from TIA. Sections on physical and speech andlanguage rehabilitation complete the exposition.

It should not always be a fault in a book if grounds are more easilyfound for criticism than acclaim. Management of stroke is one of thegreatest challenges in medicine today: with its diverse presentation,stroke is never without interest. If this volume, which is not unread-able, presents this view to neurologists and geriatricians who havestill to discover it, it will yet be worthwhile.

Department of Neurology,Charing Cross Hospitaland Medical School T. J. STEINER

New Editions

Aging and Mental Health.-3rd ed. By Robert N. Butler and Myra I. Lewis.London: Year Book Medical Publishers. 1982. Pp. 483. ;E12.1981 Year Book of Cancer.-Edited by R. W. Cumley and R. C. Hickey.

London: Year Book Medical Publishers. 1981. Pp. 502. 31.50.Anesthesia In Otolaryngology and Ophthalmology.-2nd ed. By John C.

Know. Hemel Hempstead. Prentice/Hall. 1982. Pp. 278. ,E19.90.1981 Year Book of Orthopedics.-Edited by Mark B. Coventry. London:Year

Book Medical Publishers. 1981. Pp. 456. ,E27.1981 Year Book of Urology.-Edited by J. Y. Gillenwater and S. S. Howards.

London: Year Book Medical Publishers. 1981. Pp. 356. f25.50.Surgery of the Alimentary Tract.-Vol. II-Stomach. 2nd ed. By R. T

Shackelford and G. D. Zvidema. Eastbourne: W. B. Saunders. 1982. Pp. 705.f49.Surgery of the Alimentary Tract.-Vol. III-Colon. 2nd ed. By R. T

Shackelford and G. D. Zvidema. Philadelphia and Eastbourne: W. BSaunders. 1982. Pp. 634. 49.