DisastersThe Public Health Consequences of Disasters,edited by Eric K. Noji, 468 pp, with illus, $59.95,ISBN 0-19-509570-7, New York, NY, Oxford Uni-versity Press, 1996.

To increase our awareness of the sig-nificant human losses associated with di-sasters throughout the world, the UnitedNations declared the 1990s the Inter-national Decade for Natural Disaster Re-duction (IDNDR). As part of the re-

sponse to the United Nations initiative,editor Dr Eric Noji, with 15 other con-tributors, has developed a major refer-ence text on public health and disas-ters.

The Public Health Consequences ofDisasters is a significant update to the1989monograph by the Centers for Dis-ease Control and Prevention (CDC) onthe same subject. As with the earliermonograph, many of the contributorshave had extensive medical and publichealth experience related to recent di-sasters in both national and internationalsettings while serving as physician-sci-entists or public health professionalswithin the CDC.Following the approach used by Dr

Michael Gregg, who served as editorand contributing author of the 1989 CDCmonograph and who provides the fore-word to this text, Dr Noji divides the20-chapter book into four main sections:general issues, geophysical events,weather-related problems, and human-generated problems.While 15 of the chap¬ters provide additional and more currentinformation on topics previously cov¬

ered, new chapters present timely and au¬thoritative information on other impor¬tant issues, such as environmental health,mental health, epidemiologiemethods usedto study disasters, and descriptions ofacutesituations affecting large civilian popula¬tions (complex emergencies).The introduction and first two chap¬

ters, which cover the nature and gen¬eral characteristics of disasters and therelatively new field of disaster epide¬miology, are well written by Dr Nojiand provide an excellent primer to therest of the text. Noji indicates that thepublic health reviews throughout thetext emphasize an epidemiologie ap¬proach and present a common theme:that the public health consequences of

disasters can be eliminated or greatlyreduced by implementing effective pre¬vention and control measures. I foundthat these stated objectives were defi¬nitely achieved. Readers will most cer¬tainly want to venture beyond the in¬troductory sections, however, since thefollowing chapters have something foreveryone.Having served as an environmental

epidemiologist in a state health depart¬ment for almost 15 years, I was par¬ticularly interested in learning moreabout the natural and human-made di¬sasters that have occurred throughoutthe United States and their impact onhuman health. I was not disappointed.Many authors provide comprehensivereviews ofmajor national disasters thatfrequently occur, such as floods, torna¬does, hurricanes, and earthquakes, andthe associated mortality and morbiditypatterns. They also provide importantrecommendations and practical advice,such as known health risk factors asso¬ciated with specific disasters or avail¬able educational materials (for example,CDC pamphlets on specific disasterssuch as hurricanes and floods). I wasfascinated by Dr Peter Baxter's reviewon volcanoes, as I learned that there arenumerous volcanoes in the westernUnited States, Alaska, and Hawaii. Twovolcanoes, Mauna Loa in Hawaii andMount Rainier in Washington, are in¬cluded on IDNDR's listing of "DecadeVolcanoes,"which require special study.The health threats associated with vol¬canoes are well covered, with a specialfocus on lessons learned from the 1980Mount St Helens eruption. For thosewith an interest in international health,several chapters, such as reviews by DrMichael Toole on complex emergenciesand Dr Ray Yip on famine, provide ex¬cellent insights into the devastating pub¬lic health consequences associated withrecent international disasters.Although Dr Noji states in the intro¬

duction that the book cannot cover allareas of emergency response and pre¬paredness, I would have enjoyed seeingsome review of terrorist emergencies(for example, the 1995 Oklahoma Citybombing) and transportation disasters(eg, airline crashes). Dr Edwin Kil-bourne's chapters on hot and cold envi¬ronments give excellent practical ex¬

amples of how normal seasonal eventscan result in significant public healthemergencies. My one suggestion is thatthe chapter on cold environments be ex¬

panded in the future to include potential

adverse effects related to blizzards andother snow emergencies. As I read No-ji's chapter on earthquakes, I noted thatentities considered undermorbidity andmortality could also apply to nonearth-quake emergencies, such as the collapseof buildings due to acts of terrorism. Amajor strength ofthe book, in fact, is theapplicability ofmedical and public healthinformation and recommendations fromany given chapter to other areas.Many physicians at the local level will

find this book directly relevant to theirpractices. Specific chapters, particularlythose on flooding, hurricanes, tornadoes,and hot and cold environments, will cer¬tainly increase practicing physicians'level of awareness of potential healththreats for their patients due to nor¬

mally recurring events in certain high-risk areas. For other physicians, publichealth professionals, and all others whohave an interest in the medical and pub¬lic health implications, The Public HealthConsequences of Disasters is an out¬standing desk reference. I recommendit wholeheartedly and without reserva¬tion. It is a fascinating book, which willserve as an authoritative source of in¬formation for many years to come.

James N. Logue, DrPH, MPHPennsylvania Department of HealthHarrisburg

Edited by Harriet S. Meyer, MD, Contributing Editor;Jonathan D. Eldredge, MLS, PhD, University of NewMexico, Health Sciences Center Library, Journal ReviewEditor; adviser for new media, Robert Hogan, MD, San

VesaliusThe Panorama of Vesalius: A 'Lost' Design FromTitian's Studio, by G. S. Terence Cavanagh, lim-ited edition, 9x16 in portfolio includes 14 sepia-printed plates on heavy Folio Antique paper, andone 20-pp pamphlet, $275, ISBN 0-937543-54-3,The Sacrum Press/Emeritus Books (145 WoodhavenRidge, Athens, GA 30606; 706-546-0378), 1996.

..

. few disciplines are more surelybased on the work of one man than isAnatomy on Vesalius.1Andreas Vesalius of Brussels is ac-

claimed for three towering publications:Tabulae anatomicae sex of 1538, Dehumani corporisfabrica libri septum of1543 and 1555, and the Epitome of 1543.With the brashness of Icarus, yet bornealoft on wings of genius, he penned thepreface to the Fabrica: "I am awarethat by reason ofmy age\p=m-\Iam at pres-ent twenty-eight years old\p=m-\myeffortswill have little authority, and that, be-cause of my frequent indication of thefalsity of Galen's teachings, they willfind little shelter from the attacks ofthose who were not present at my ana-tomical demonstrations."Cavanagh's full folio size recreation of

the original artwork of the 14 Vesalian

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From The Panorama of Vesalius, plates I-XIV.

muscle men of the second book of theFabrica is not only a tribute to theheights of beauty but also a great tech¬nical achievement. I'm sure that theidealistic Cavanagh spent a consider¬able sum for these stunning reproduc¬tions, in the same way that the artistCalcar paid from his own pocket forsome of the Vesalian output.This review will not consider the

substance or technique of the landscapebackgrounds to these figures; I leavethat task to others who know moreabout art. However, I agree with Cava¬nagh that the landscapes give a sense ofreality and perspective to these mag¬nificent anatomical figures. Far fromthe "Dance ofDeath" that Putscher (asquoted by Cavanagh) named the en¬semble composition, here is a celebra¬tion of muscular organization and coor¬dination. Cavanagh points out the "goodmarching order" and "splendid effect."Viewing these figures, I hear not onlytriumphant martial strains, but alsomelodious ballet music. By all means,this is an "admirable vision," recallingthe poem of Paine:

Beyond the last horizon's rim,Beyond adventure's farthest quest,Somewhere they rise, serene and dim,The happy, happy Hills of Rest.2Much speculation surrounds the de¬

sign and engraving of this work. Kemp3credited Calcar with the Vesalianmuscle men. Petrucelli4 reported Vasa-ri's contemporary support (1568) of Cal¬car as the artist of the illustrations ofthe Fabrica, but not the Tabulae ana-tomicae. Guerra5 supported the ideathat Calcar was the designer andda Forli the engraver. My superficialhistorical knowledge tells me that thisgreat glory should perhaps be shared byboth men, but surely the greatestmeritshould go to the designer, Jan Stephanvan Calcar. Wershub6 also mentions"the best printer," Oporinus of Basel.Thankfully, it is not within the missionof this review to solve the problem.

In the Venesection Epistle of 1539, Ve¬salius wrote: 'WTierefore, if there are op¬portunities ofobtaining bodies, and ifJanStephan—the most illustrious painter ofour time—does not refuse his services, Ion my part will by no means shun thetask."7 There is no question in my mindthat Vesalius, with his passion for cor¬rectness in anatomy, was involved in theorganization and presentation of themuscle men. It is my opinion that Ve¬salius advised the artist how to proceed,perhaps even choreographing the fig¬ures himself. Muscles are seen in action,strutting, performing amachine ofmusclethat only God could create.

"Vesalian muscle men"

In plate I of the portfolio, a lateralprojection, the muscle man is marching.The dissection is superficial, with ex¬cellent muscle demonstration. Plate IIis an anterior view with removal of skinand superficial fat. Here the muscle manis perhaps praying.There are problems with plate III.

According to Vesalius, it "demonstratesthe anterior view of the body, and itdiffers from the first plate of the musclesin that it shows the muscles of the fleshymembrane (membrana carnosa) and alsoseveral of the facial muscles" [FabricaII:26:i]. Richardson and Carman8 bril¬liantly laid bare the subtleties of Ve-salius's Latin style and vocabulary, cau¬tioning that "even a minor slip here can

easily distort a careful piece ofresearchor exposition and turn it into error oreven absurdity." That said, I confess tonot understanding this "fleshy mem¬brane." Saunders and O'Malley9 consid¬ered it to be the deep fascia. Or shouldwe follow Kemp,3 who places this ana¬tomical entity "above themajormuscles"?I venture, without any assurance, thatit is perhaps the epimysium, the innomi¬nate fascia covering the external ob¬lique muscle.

In plates IV through VIII, Vesaliuspresents anterior views of the deepmuscles of the human body, some ofwhich are removed for better demon¬stration of the underlying layers. In plateV, the rectus abdominis reaches theclavicle, and a nonhumanmuscle is shownat the anterior neck. Why? I agree withO'Malley10 that these "errors" may havebeen purposely executed to highlightthe differences between the Vesaliandemonstrations and the prevailing Ga¬lenic dogma combined with animal dis¬section. A similar "mistake" occurs inplate VI, where the scalenus anteriormuscle is extended below its insertionon the scalene tubercule of Lisfranc onthe upper surface of the first rib. PlatesIX through XIV demonstrate the deepand superficial musculature of the back.I strongly advise every medical doctor

and researcher to buy these Vesalianmuscle men and to hang them in his orher office. Every medical library shouldalso own this striking portfolio. After all,we would then be the proud possessorsof a limited edition of the "most impor¬tant of all illustrations in the history ofmedical science"3; "its greatly admiredplates are still a delight to behold."11Vesalius died in October 1564 and was

buried on the beautiful Greek island ofZakinthos (Zante) in the Ionian Sea. Ifhe but knew of the continuing rape ofgross human anatomy in our days,12surely he would be turning over in hisgrave! Perhaps Vesalius was not onlycommenting on his own times when hewrote, "As things are now taught in theschools, with days wasted on ridiculousquestions, there is very little offered tothe spectators that could not better betaught by a butcher in his shop."

John E. Skandalakis, MD, PhDEmory University School of MedicineAtlanta, Ga

1. Singer C. The Evolution of Anatomy. London,England: Kegan Paul, Trench, Trubner; 1925:111.2. Paine AB. The Hills of Rest. In: Hill CD, ed. TheWorld's Great Religious Poetry. New York, NY: Mac-millan; 1954:328.

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3. Kemp M. A drawing for the Fabrica; and some

thoughts upon the Vesalius muscle-men. Med Hist.1970;14:277-288.4. Petrucelli RJ II. Giorgio Vasari's attribution of theVesalian illustrations to Jan Stephan of Calcar: a fur-ther examination. Bull Hist Med. 1971;45:29-37.5. Guerra F. The identity of the artists involved in Ve-salius's Fabrica. Med Hist. 1969;13:37-50.6. Wershub LP. Urology From Antiquity to the 20thCentury. St Louis, Mo: Warren H Green; 1970:187.7. Underwood EA. Calcar,Wesel, and Vesalius. BMJ.1945;1:381-382.8. Richardson WF, Carman JB. On translating Ve-salius. Med Hist. 1994;38:281-302.9. Saunders JB deCM, O'Malley CD. The IllustrationsFrom the Works of Andreas Vesalius of Brussels.Cleveland, Ohio: World Publishing; 1950:96.10. O'Malley CD. Andreas Vesalius ofBrussels 1514\x=req-\1564. Berkeley: University of California Press; 1964:165.11. O'Rahilly R. Commemorating the Fabrica of Ve-salius. Acta Anat. 1993;148:228-230.12. Skandalakis JE. The rape of anatomy. Am Surg.1980;46:197-200.

Error and JudgmentDesign Paradigms: Case Histories of Error andJudgment in Engineering, by Henry Petroski, 207pp, $44.95, ISBN 0-521-46108-1, paper, $18.95,ISBN 0-521-46649-0, New York, NY, CambridgeUniversity Press, 1994.

This book demonstrates the value fail-ure has in achieving success. Written byan engineer, the chair of the DepartmentofCivil and Environmental Engineeringat Duke University, it illustrates prin-ciples as important to the successful prac-tice of medicine as they are to engineer-ing. The book comprises case histories ofengineering failures, dating back to thefirst century BCE. The most dramatic ex-amples are bridges that collapsed andships that sank; the most recent is the1981 collapse of an interior walkway of alarge Kansas City, Mo, hotel in whichmore than 100 people died. The impor-tance of the case histories, aside fromtheir historical interest and the beautyof nature that the physical principles re-veal, resides in the author's analyses ofthe way in which failure occurred, andhow, in retrospect, failure made a uniquecontribution to eventual success.How is this related to medical prac-

tice? Petroski's analytic style is similarto that used by expert physicians inreviewing cases that have had adverseor unintended outcomes, ie, failures. By

meticulously reviewing hidden assump¬tions, false premises, unwarranted gen¬eralizations, and untested hypotheses,the crucial error and its ripple effect areexposed. The process of discovery hasvalue for all who are involved in it; theynow have an increment of practical in¬sight theywould not otherwise have had.Major similarities between engineeringand medical errors include: how a seriesof past successes can turn out to be fail¬ures with long latent periods; how mis¬leading a purely mathematical analysiscan be in the real world; and, most im¬portantly, how the most successful prac¬titioners are those who have made them¬selves the most knowledgeable aboutfailures.Pathologists learn early in their ca¬

reers to make a friend of failure. Manyclinicians traverse a similar learningcurve, but others have a different view."The operation was a success, but thepatient died" is a common aphorism,which attempts to deny the existence ofjudgmental or technical error. The medi¬cal procedure that has the most in com¬mon with the analyses in Design Para¬digms is the autopsy.While the autopsyis by no means the only effective form ofmedical case review, it is clearly in thefront rank of such analyticmethods. The

"... errors are valuable, even es¬

sential, opportunities ..."

autopsy is unequaled in its ability to re¬veal how farbeyond our grasp perfectionresides. The value added by the autopsy,as an informative medical procedure, hasbeen the subject ofextensive discussionsand debate,14 but often these consist oftheoretical and abstract arguments,which practice-oriented physicians findeasy to ignore. That is one reason whythis book, exceedingly concrete and defi¬nitely situated in the real world, is so

important for physicians to read.A seminal contribution by Dr Lucían

Leape has initiated a radical change in

the way that we view error in medicine.5As a result, rational discussions of errorare becoming acceptable in civilized medi¬cal discourse. In this new paradigm, er¬rors are symptoms of flawed systems,not personal failures. Instead of ignoringerrors, or pretending they don't exist, itshould be recognized that errors are valu¬able, even essential, opportunities to cre¬ate systems that function better in pa¬tient care. While no one would deny thatthereare somemajordifferencesbetweenbuilding bridges and managing sick pa¬tients, many important similarities un¬derlie Petroski's failure analysis andLeape's error analysis. Physicians whoread this book will deepen their under¬standing of the indispensable role errorhas in the world they inhabit, and theymay discover a rationale for reevaluat-ing the autopsy's contribution to contem¬porary medical practice.

Dwight K. Oxley, MDHCA-Wesley Medical CenterWichita, Kan

1. Lundberg GD. College of American PathologistsConference XXIX on restructuring autopsy practicefor health care reform: let's make this autopsy confer-ence matter. Arch Pathol Lab Med. 1996;120:736-738.2. McManus BM, Wood SM. The autopsy: simplethoughts about the public needs and how to addressthem. Am J Clin Pathol. 1996;106(suppl 1):S11-S114.3. Anderson RE, Hill RB, Key CR. The sensitivity andspecificity of clinical diagnostics during five decades:toward an understanding of necessary fallibility.JAMA. 1989;261:1610-1617.4. Landefeld CS, Chren MM, Myers A, et al. Diagnosticyield of the autopsy in a university hospital and a com-

munity hospital. N Engl J Med. 1988;318:1249-1254.5. Leape LL. Error in medicine. JAMA. 1994;272:1851\x=req-\1857.

TobaccoSmoke and Mirrors: The Canadian TobaccoWar,by Rob Cunningham, 361 pp, with illus, paper, $25CAN, Ottawa, Ontario, International DevelopmentResearch Centre (order from Renouf, 5369 Canotek,Ottawa, Ontario, K1J 9J3), 1996.

Smoking is, as the old saying goes, amajor cause of statistics. That is prob-ably one reason Rob Cunningham be-gins his book on a more personal note,tracing the struggles of individual smok-ers: Julie Laperle, a 16-year-old Quebecgirl who began smoking at the age of 12and now smokes two to three packs a

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