129 for perhaps 40 years, immeasuraelaborated recently in Professor Peter Mittler’s Research to Practice in tÌle Field of Handicap (see Lancet, 1976, i, 184). Professor Calnan has a lively sense of humour, and the book is in many ways a delight to read. Unfortunately his love of epigrams often leads to the enunciation of half-truths or even untruths-e.g., "Observations are always correct, conclusions rarely so". Similarly, we are treated to delicious slices of cynicism (e.g., under the heading Gamesmanship) which may be relished by the cognoscenti but could be taken with devastating seriousness by the novice to whom the book is ostensibly directed. The text was probably not subjected to criticism by members of its intended audience; it would have benefited greatly had this been done. One is disturbed too by numerous slips such as "Montagne." and "Rothchild" as well as by some slipshod grammar, especially when the sole reference under the section Writing is to a book of advice by Calnan and a coauthor. A serious criticism is of the organisation of the book. Its subtitle is the A-Z for Those Who Must, and the advice is arranged alphabetically under headings such as Advantages of Research (excellent), Analysis (poor), and Personnel (amusing). Apart from making it difficult for the reader to retrace half-remembered pearls of advice within the book (there is no index) and to find the references until you realise that these appear under the letter R, this device reveals only too clearly that the author has not followed his own precepts of thinking and re-thinking his ideas until they can be organised into a logical, coherent framework. Still this is an amusing book for a tedious train journey, a lazy hour on the beach, or times of depression when research is
daily practice, carried bly. A similar message
a
Reviews of Books
Nutrition in the A Text
for
Community
Public Health Workers. Edited
by DONALD
S.
MCLAREN, School of Medicine, American University of Beirut. London and New York:
Wiley.
1976.
Pp. 393. /;11.SO,$25.30.
PROFESSOR McLaren, editor and author of 4 chapters, his colleagues from the American University of Beirut who contribute a further 4 chapters, and the well-known authorities from less vexed countries who contribute the other 23 chapters, are to be congratulated on such a worthwhile production. The skill of the editor is seen in each chapter’s steady progression to produce a coherent and comprehensive review of applied nutrition. The book is divided into five sections-Nutrition at the Community Level, Malnutrition in the Community, Measures to Combat Malnutrition, the Role of Agencies, and Country Experiences. Cicely Williams’ foreword is a cogent expose of her teaching and forthright views, thus adding another valuable chapter. The publisher’s introduction states that the subject matter is frequently controversial-but evidence of controversy is hard to find. It is unfortunate that the subtitle should refer to public-health workers rather than community health workers, although even that title change would be insufficient since this is a book which should be read by those in ivory towers besides those in the field. A short chapter on physiological aspects of the subject such as nitrogen balance, would have been a helpful addition since all too often the worker has forgotten these things by the time he realises that nutrition is important. The national studies are well chosen, with work from the Caribbean, Ethiopia, India, the Philippines, the U.K., and the U.S.A. The United States study is a summary of the Ten-State Survey of 24 000 families, and demonstrates well the differences between socioeconomic and ethnic groups. The British chapter is more a review of the development of nutrition services and says little about nutritional problems in reference to socioeconomic groupings, immigrants, or the aged. The other studies are much franker about their countries’ problems, and the book greatly benefits from this approach. But why has Zambia been left out? Zambia’s recent national nutrition survey is reputed to have been large scale and expensive, yet to date no data seem to be available. Zambia also has an excellent national nutritional programme. The "protein myth" is well explained by Professor McLaren and hammered home elsewhere in the book by various data. In the Philippines the percentage adequacy of the mean daily percaput intake of protein is 93-5% whereas that of calories is 834%. With Indian preschool children there is a daily shortfall of 1% of protein but 41% of carbohydrate. However, the book does not explain why the myth of the "protein crisis" was perpetuated for so long and at such a great cost. This excellent book fills a long-standing gap and will be of very great use to every member of the health team who, though closely concerned with nutrition, is neither a biochemist nor a nutritionist. One
Way to Do Research
JAMES CALNAN. London: Heinemann Medical. 1976. Pp. 250
2.73. THE basic idea of this little paperback is a good one, but it does not quite come off. The book is addressed not to those whose main activity in life is (or will be) research, but to those who would like to conduct research or apply research method to their daily practice-physiotherapists, nurses, doctors without having had a research training. Professor Calnan emphasises that research requires rigorous mental discipline and is therefore valuable in itself; he also points out how fascinating it can be. Above all, research enhances the interest of
on
was
going badly. Comprehensive Psychiatry Care Edited
by
cester.
Oxford: Blackwell. 1976. Pp. 294.
A. A. BAKER, F.R.C.PSYCH.,
Coney Hill Hospital, ,(;6.75
Glou-
THE multidisciplinary team has been a feature of psychiatric clinical practice for several years. Some see it as a development which is capable of inspiring fresh ideas: others, the more cynical, regard it as a fashion behind which the helping process remains unchanged. This book goes a long way to reassure us that teamwork is indeed a major step forward, and one which presents a different challenge to each team member. The various chapters are written by experts representing several disciplines in the hospital setting, in primary health care, or subspecialties such as child psychiatry, mental handicap, and psychogeriatrics. It is of great interest to see the way in which tensions run through even a book such as this, written by those who clearly are keenly aware of the need for collaborative effort. In a team where traditional hierarchical medical authority has diminished, what really are the new roles of its members? How does the community psychiatric nurse relate to health visitors and social workers? What are the lines of communication which prevent the development of confusion? Each member of the team should find his or her own particular area of skill, one which overlaps with but yet is distinct from the others. The situation is summarised elegantly in Margaret Eden’s excellent chapter on social work, in which the intrinsic value and dignity of all social-work skills are clearly expounded-a point of view which those social workers who see casework as their entire role might do well to note. We are reminded that the essence of teamwork is mutual trust, contact, respect, and a willingness to acknowledge the limits of one’s own job. It is based on sharing-giving up some of one’s own power-and it requires generosity, humility, effective action, and fulfilled promises. This book inspires a fresh look at ways of working in mental health and rightly demands rigorous standards. We are told that it is relatively easy to set
things right within
a single team, but what are we going to do about the conflicts which may arise between two separate teams who meet rarely or only on theoretical issues? This book makes a challenge which must be met.
130
Beyond Normality The Predictive Value and Efficiency of Medical Diagnoses. ROBERT S. GALEN, M.D., and S. RAYMOND GAMBINO, M.D., Columbia University College of Physicians and Surgeons, New York. New York and London: Wiley. 1976. Pp. 8.
237.$16,
IN this book the usefulness of diagnostic tests is discussed in of their specificity, sensitivity, and predictive value. The presentation of these concepts is lucid, and numerous examples illustrate their importance in clinical practice. The influence of the prevalence of a disease on the predictive (diagnostic) value of a test is rightly stressed, and an excellent analysis is presented of the effect of combining several tests in parallel or in a series. Therefore it is a great pity that Dr Galen and Dr Gambino overstate their case by disregarding the limitations of their probabilistic model. It is, for instance, almost meaningless to discuss whether a test result in a patient suspected of rheumatoid arthritis is truly or falsely positive, because there is no independent way of establishing the truth of the diagnosis. The sensitivity of a test for the diagnosis of a syndrome is high if clinicians choose not to make the diagnosis when the test result is negative, and the specificity is high if they always make the diagnosis when the test result is positive. If the authors had appreciated this aspect of diagnostic reasoning, they would not have calculated the diagnostic value of a Q wave in the E.c.G. when the diagnosis of the patients in question was based partly on the E.C.G. findings. The probabilistic concepts which are explained so well in this book are important, but the diagnostic process also includes the non-probabilistic elements of pattern recognition and logical deduction which must not be neglected.
terms
Immunopathology of the Eye A. H. S. RAHI, M.D., and A. GARNER, M.R.C.PATH., Institute of Ophthalmology, University of London. Oxford: Blackwell. 1976.
Pp. 343./;11.30. THE postgraduate training of an ophthalmologist in every country is essentially a surgical one, so, not surprisingly, medical ophthalmology receives scant attention. Neurologists have hitherto carried the main burden of responsibility while the general physician has shown interest in the hypertensive and diabetic eye. The surgically trained ophthalmologist was therefore unprepared for the advent of a vigorous new interest in immunology, with its fresh techniques and new regimens for immunosuppression and immunotherapy. This wide gap between ophthalmologist and immunologist has now been efficiently bridged by this splendid new book by two pathologists in Prof. Norman Ashton’s department. There are 13 chapters presenting basic immune mechanisms and autoimmune disease concepts as they affect each tissue and layer of the eye. There are also chapters on immunology of ocular tumours, ocular involvement in systemic immune disorders, and principles of treatment. This monograph is a joy to read-clear, concise, academic, and practical. It is recommended to ophthalmologists ; to immunologists who are not conversant with eye disease ; to neurologists so that they learn the new language of immunology ; and to general physicians who help to support oph-
thalmologists. Chromosomal Aberrations in
readership. Local Anesthetics
BENJAMIN G. COVINO and HELEN London: Grune &
Stratton. 1976.
G. VASSALLO. New York and
Pp. 173.$13.50, /;7.
THIS is the first in a series on the scientific basis of clinical anaesthesia under the general editorship of Dr Richard J. Kit2 and Dr Myron B. Laver. Despite being in some respects a house publication of Astra Pharmaceutical Products, in whict organisation both authors direct departments, it providesa concise and up-to-date general account of local anaestheti< agents. Descriptions of the clinical uses of these drugs art superficial, and the main emphasis is on pharmacologica detail which is supported by a comprehensive bibliography Nevertheless the trainee anesthetist may find this a usefu book from which to gain knowledge to satisfy examiner: because the contents are made so accessible by their clear anc attractive
presentation.
Pathology Decennial 1966-1975 (New York: Appleton Century-Crofts. Hemel Hempstead: Prentice-Hall Intema tional. 1975. 7 vols).-The idea of reprinting review article that first appeared in the Pathology Annual series is not quitl as bizarre as it sounds because contributors have been give) the’chance to update their original contributions to late 1974 These new thoughts take the form of addenda; they have no been integrated into the text. The seven organ-system volume are on Gastrointestinal and Hepatic, Cardiovascular, Genita and Mammary, Pulmonary, Endocrine, Kidney, and Hematc logic and Lymphoid aspects. The volumes are available sepal ately, but the complete set costs £108.35.
New Editions Year Book of Medicine 1975-Edited by D. E. Rogers. Chicago: Year Book. London: Lloyd-Luke. 1975. Pp. 740.$21.50, 11.85.
Emergency Room Care-3rd ed. Brown. London: Quest. 1976. Pp.
By Charles Eckert. Boston: Little, 480.$17.50; /;10.50 (paperback
$12.50, £7.50).
Ophthalmology
R. BERGER, and H. SARAUX. Van Gorcum. 1975. Pp. 504. D.fl. 225.
J. FRANCOIS,
tion on autosomal anomalies contains a useful 25 pages on abnormalities of the eye in Down syndrome, but the descriptions of syndromes with no ocular manifestations are an irritation, and so are the lists of references to reports of unanimously negative findings. Again, in the 140-page section on sex-chromosome abnormalities, there is very little on ocular anomalies. The 2 pages of general conclusions in this section contain 11 lines summing up the ophthalmological manifestations, which are described as "somewhat reduced and of little specificity" —a waste of 138 pages? It is obviously useful to consider ocular abnormalities associated with chromosome syndromes in the context of other clinical manifestations, but the authors have been carried away by their enthusiasm, and the result is a book that contains a vast amount of superfluous material. The contents are well organised and attractively presented, but the whole concept is misguided. Stripped of its padding, this could have been a slim monograph, and, as such, it would have had considerably greater appeal to a necessarily limited
Assen, Netherlands:
THIS book is very expensive-and not just because of the unfavourable exchange-rate imposed on British readers. This is especially unfortunate because the book could have been produced at a quarter of its size, or less, and presumably much more cheaply. The title suggests a book for specialists, but the first part (of four) is an introduction to cytogenetics, and the information contained there can be found in any of a number of excellent elementary textbooks of genetics. The sec-
The Handling of Chromosomes-6th ed. By C. D. Darlington, and L. F. La Cour. Revised by L. F. La Cour. London: George Allen and Unwin. 1976. Pp. 201. /:6.
Syndromes-3rd ed. By Walter ]. Geeraets. Philadelphia’ Febiger 1976. Pp. 655.$45.
Ocular Lea and
Advances in Cardiology XXVII-Edited by John H. K. Basle: Karger. White Plains, N.Y.: Phiebig. Chichester:
Vogel,
Wiley. 1976.
I’p. 253. Sw.fr: 126;$48.50. Poison Detection in Human Organs-3rd ed. By Alan Curry Springfield, Illinois: Thomas. 1976. Pp. 356.$21.50.
daily practice, carried bly. A similar message
a
Reviews of Books
Nutrition in the A Text
for
Community
Public Health Workers. Edited
by DONALD
S.
MCLAREN, School of Medicine, American University of Beirut. London and New York:
Wiley.
1976.
Pp. 393. /;11.SO,$25.30.
PROFESSOR McLaren, editor and author of 4 chapters, his colleagues from the American University of Beirut who contribute a further 4 chapters, and the well-known authorities from less vexed countries who contribute the other 23 chapters, are to be congratulated on such a worthwhile production. The skill of the editor is seen in each chapter’s steady progression to produce a coherent and comprehensive review of applied nutrition. The book is divided into five sections-Nutrition at the Community Level, Malnutrition in the Community, Measures to Combat Malnutrition, the Role of Agencies, and Country Experiences. Cicely Williams’ foreword is a cogent expose of her teaching and forthright views, thus adding another valuable chapter. The publisher’s introduction states that the subject matter is frequently controversial-but evidence of controversy is hard to find. It is unfortunate that the subtitle should refer to public-health workers rather than community health workers, although even that title change would be insufficient since this is a book which should be read by those in ivory towers besides those in the field. A short chapter on physiological aspects of the subject such as nitrogen balance, would have been a helpful addition since all too often the worker has forgotten these things by the time he realises that nutrition is important. The national studies are well chosen, with work from the Caribbean, Ethiopia, India, the Philippines, the U.K., and the U.S.A. The United States study is a summary of the Ten-State Survey of 24 000 families, and demonstrates well the differences between socioeconomic and ethnic groups. The British chapter is more a review of the development of nutrition services and says little about nutritional problems in reference to socioeconomic groupings, immigrants, or the aged. The other studies are much franker about their countries’ problems, and the book greatly benefits from this approach. But why has Zambia been left out? Zambia’s recent national nutrition survey is reputed to have been large scale and expensive, yet to date no data seem to be available. Zambia also has an excellent national nutritional programme. The "protein myth" is well explained by Professor McLaren and hammered home elsewhere in the book by various data. In the Philippines the percentage adequacy of the mean daily percaput intake of protein is 93-5% whereas that of calories is 834%. With Indian preschool children there is a daily shortfall of 1% of protein but 41% of carbohydrate. However, the book does not explain why the myth of the "protein crisis" was perpetuated for so long and at such a great cost. This excellent book fills a long-standing gap and will be of very great use to every member of the health team who, though closely concerned with nutrition, is neither a biochemist nor a nutritionist. One
Way to Do Research
JAMES CALNAN. London: Heinemann Medical. 1976. Pp. 250
2.73. THE basic idea of this little paperback is a good one, but it does not quite come off. The book is addressed not to those whose main activity in life is (or will be) research, but to those who would like to conduct research or apply research method to their daily practice-physiotherapists, nurses, doctors without having had a research training. Professor Calnan emphasises that research requires rigorous mental discipline and is therefore valuable in itself; he also points out how fascinating it can be. Above all, research enhances the interest of
on
was
going badly. Comprehensive Psychiatry Care Edited
by
cester.
Oxford: Blackwell. 1976. Pp. 294.
A. A. BAKER, F.R.C.PSYCH.,
Coney Hill Hospital, ,(;6.75
Glou-
THE multidisciplinary team has been a feature of psychiatric clinical practice for several years. Some see it as a development which is capable of inspiring fresh ideas: others, the more cynical, regard it as a fashion behind which the helping process remains unchanged. This book goes a long way to reassure us that teamwork is indeed a major step forward, and one which presents a different challenge to each team member. The various chapters are written by experts representing several disciplines in the hospital setting, in primary health care, or subspecialties such as child psychiatry, mental handicap, and psychogeriatrics. It is of great interest to see the way in which tensions run through even a book such as this, written by those who clearly are keenly aware of the need for collaborative effort. In a team where traditional hierarchical medical authority has diminished, what really are the new roles of its members? How does the community psychiatric nurse relate to health visitors and social workers? What are the lines of communication which prevent the development of confusion? Each member of the team should find his or her own particular area of skill, one which overlaps with but yet is distinct from the others. The situation is summarised elegantly in Margaret Eden’s excellent chapter on social work, in which the intrinsic value and dignity of all social-work skills are clearly expounded-a point of view which those social workers who see casework as their entire role might do well to note. We are reminded that the essence of teamwork is mutual trust, contact, respect, and a willingness to acknowledge the limits of one’s own job. It is based on sharing-giving up some of one’s own power-and it requires generosity, humility, effective action, and fulfilled promises. This book inspires a fresh look at ways of working in mental health and rightly demands rigorous standards. We are told that it is relatively easy to set
things right within
a single team, but what are we going to do about the conflicts which may arise between two separate teams who meet rarely or only on theoretical issues? This book makes a challenge which must be met.
130
Beyond Normality The Predictive Value and Efficiency of Medical Diagnoses. ROBERT S. GALEN, M.D., and S. RAYMOND GAMBINO, M.D., Columbia University College of Physicians and Surgeons, New York. New York and London: Wiley. 1976. Pp. 8.
237.$16,
IN this book the usefulness of diagnostic tests is discussed in of their specificity, sensitivity, and predictive value. The presentation of these concepts is lucid, and numerous examples illustrate their importance in clinical practice. The influence of the prevalence of a disease on the predictive (diagnostic) value of a test is rightly stressed, and an excellent analysis is presented of the effect of combining several tests in parallel or in a series. Therefore it is a great pity that Dr Galen and Dr Gambino overstate their case by disregarding the limitations of their probabilistic model. It is, for instance, almost meaningless to discuss whether a test result in a patient suspected of rheumatoid arthritis is truly or falsely positive, because there is no independent way of establishing the truth of the diagnosis. The sensitivity of a test for the diagnosis of a syndrome is high if clinicians choose not to make the diagnosis when the test result is negative, and the specificity is high if they always make the diagnosis when the test result is positive. If the authors had appreciated this aspect of diagnostic reasoning, they would not have calculated the diagnostic value of a Q wave in the E.c.G. when the diagnosis of the patients in question was based partly on the E.C.G. findings. The probabilistic concepts which are explained so well in this book are important, but the diagnostic process also includes the non-probabilistic elements of pattern recognition and logical deduction which must not be neglected.
terms
Immunopathology of the Eye A. H. S. RAHI, M.D., and A. GARNER, M.R.C.PATH., Institute of Ophthalmology, University of London. Oxford: Blackwell. 1976.
Pp. 343./;11.30. THE postgraduate training of an ophthalmologist in every country is essentially a surgical one, so, not surprisingly, medical ophthalmology receives scant attention. Neurologists have hitherto carried the main burden of responsibility while the general physician has shown interest in the hypertensive and diabetic eye. The surgically trained ophthalmologist was therefore unprepared for the advent of a vigorous new interest in immunology, with its fresh techniques and new regimens for immunosuppression and immunotherapy. This wide gap between ophthalmologist and immunologist has now been efficiently bridged by this splendid new book by two pathologists in Prof. Norman Ashton’s department. There are 13 chapters presenting basic immune mechanisms and autoimmune disease concepts as they affect each tissue and layer of the eye. There are also chapters on immunology of ocular tumours, ocular involvement in systemic immune disorders, and principles of treatment. This monograph is a joy to read-clear, concise, academic, and practical. It is recommended to ophthalmologists ; to immunologists who are not conversant with eye disease ; to neurologists so that they learn the new language of immunology ; and to general physicians who help to support oph-
thalmologists. Chromosomal Aberrations in
readership. Local Anesthetics
BENJAMIN G. COVINO and HELEN London: Grune &
Stratton. 1976.
G. VASSALLO. New York and
Pp. 173.$13.50, /;7.
THIS is the first in a series on the scientific basis of clinical anaesthesia under the general editorship of Dr Richard J. Kit2 and Dr Myron B. Laver. Despite being in some respects a house publication of Astra Pharmaceutical Products, in whict organisation both authors direct departments, it providesa concise and up-to-date general account of local anaestheti< agents. Descriptions of the clinical uses of these drugs art superficial, and the main emphasis is on pharmacologica detail which is supported by a comprehensive bibliography Nevertheless the trainee anesthetist may find this a usefu book from which to gain knowledge to satisfy examiner: because the contents are made so accessible by their clear anc attractive
presentation.
Pathology Decennial 1966-1975 (New York: Appleton Century-Crofts. Hemel Hempstead: Prentice-Hall Intema tional. 1975. 7 vols).-The idea of reprinting review article that first appeared in the Pathology Annual series is not quitl as bizarre as it sounds because contributors have been give) the’chance to update their original contributions to late 1974 These new thoughts take the form of addenda; they have no been integrated into the text. The seven organ-system volume are on Gastrointestinal and Hepatic, Cardiovascular, Genita and Mammary, Pulmonary, Endocrine, Kidney, and Hematc logic and Lymphoid aspects. The volumes are available sepal ately, but the complete set costs £108.35.
New Editions Year Book of Medicine 1975-Edited by D. E. Rogers. Chicago: Year Book. London: Lloyd-Luke. 1975. Pp. 740.$21.50, 11.85.
Emergency Room Care-3rd ed. Brown. London: Quest. 1976. Pp.
By Charles Eckert. Boston: Little, 480.$17.50; /;10.50 (paperback
$12.50, £7.50).
Ophthalmology
R. BERGER, and H. SARAUX. Van Gorcum. 1975. Pp. 504. D.fl. 225.
J. FRANCOIS,
tion on autosomal anomalies contains a useful 25 pages on abnormalities of the eye in Down syndrome, but the descriptions of syndromes with no ocular manifestations are an irritation, and so are the lists of references to reports of unanimously negative findings. Again, in the 140-page section on sex-chromosome abnormalities, there is very little on ocular anomalies. The 2 pages of general conclusions in this section contain 11 lines summing up the ophthalmological manifestations, which are described as "somewhat reduced and of little specificity" —a waste of 138 pages? It is obviously useful to consider ocular abnormalities associated with chromosome syndromes in the context of other clinical manifestations, but the authors have been carried away by their enthusiasm, and the result is a book that contains a vast amount of superfluous material. The contents are well organised and attractively presented, but the whole concept is misguided. Stripped of its padding, this could have been a slim monograph, and, as such, it would have had considerably greater appeal to a necessarily limited
Assen, Netherlands:
THIS book is very expensive-and not just because of the unfavourable exchange-rate imposed on British readers. This is especially unfortunate because the book could have been produced at a quarter of its size, or less, and presumably much more cheaply. The title suggests a book for specialists, but the first part (of four) is an introduction to cytogenetics, and the information contained there can be found in any of a number of excellent elementary textbooks of genetics. The sec-
The Handling of Chromosomes-6th ed. By C. D. Darlington, and L. F. La Cour. Revised by L. F. La Cour. London: George Allen and Unwin. 1976. Pp. 201. /:6.
Syndromes-3rd ed. By Walter ]. Geeraets. Philadelphia’ Febiger 1976. Pp. 655.$45.
Ocular Lea and
Advances in Cardiology XXVII-Edited by John H. K. Basle: Karger. White Plains, N.Y.: Phiebig. Chichester:
Vogel,
Wiley. 1976.
I’p. 253. Sw.fr: 126;$48.50. Poison Detection in Human Organs-3rd ed. By Alan Curry Springfield, Illinois: Thomas. 1976. Pp. 356.$21.50.
