801

The trial has shown that subcutaneous calcium

heparin in a dosage of 5000 units 8-hourly can safelyreduce the high incidence of deep-vein thrombosis afteran acute stroke. We are extending the trial to assess theeffects of preventing deep-vein thrombosis on the rate ofmobilisation of patients and on the mortality from pul-monary emboli.

We thank Dr J. M. K. Spalding and Dr A. A. Sharp for their helpand advice in setting up the trial, Mr G. J. Draper for advice on statis-tics, and Dr L. Wollner, Dr R. A. Griffiths, and Dr G. Wilcock forpermission to study their patients.

Requests for reprints should be addressed to S. T. McCarthy, TheCowley Road Hospital, Oxford OX4 1XB.

REFERENCES

1. Warlow, C., Ogston, D., Douglas, A. S. Lancet, 1972, i, 1305.2. Denham, M. J., James, G., Farran, M. Age Ageing, 1973, 2, 207.3. International Multicentre Trial Lancet, 1975, ii, 45.4. Morris, G. K., Mitchell, J. R. A. Br. med. J. 1977, i, 535.5. Warlow, C., Beattie, A. G., Terry, G., Ogston, D., Kenmure, A. C. F.,

Douglas, A. S. Lancet, 1973, ii, 934.6. Handley, A. J. ibid. 1972, ii, 623.7 Kakker, V. V., Nicolaides, A. N., Renny, A. N., Friend, J. T. G., Clarke, M. B.

ibid. 1970, i, 540.8. Oxbury, J. M., Greenhall, R. C. D., Grainger, K. M. R. Br. med. J. 1975,

iii, 125.9. Yates, F. JlR. statist. Soc. 1934, suppl. no. 1, p. 217.

Reviews of Books

Rational Management of DiabetesHABEEB BACCHUS, M.D., Loma Linda University School of Medi-cine. Baltimore: University Park Press. Lancaster: M.T.P. 1977.Pp221.$16.50, £11.75.

THIS is a well presented, readable, and interesting book thatdescribes the best North American practice in the managementof diabetes mellitus. Oral hypoglycaemic agents are dismissedas being of very limited value in the treatment of the maturity-onset patient. Most European physicians would claim that sul-phonylureas, at least, have a place in the diabetic armamentar-ium ; but Dr Bacchus presents reasoned arguments for hisviews, and without one direct reference to the UniversityGroup Diabetes Program. This apart, the opinions expressedwill in general be familiar to the British reader. Bacchus optsfor "split-dose" insulin (a combination of short and intermed-iate acting preparations given twice daily) in the treatment ofmost insulin-dependent patients, and he rightly dismisses pro-tamine zinc and ultralente insulins as having no place in themodern treatment of diabetes. This book confirms the impres-sion that American practice is moving away from the once-daily insulin regimens and that it is now closer to British prac-tice in this respect. The key to the rational management ofdiabetes is a detailed understanding of intermediary metabo-lism and its control and the disturbances that are present indiabetes, and almost a third of the book consists of up-to-dateand clear reviews of these topics. Almost every chapter beginswith a valuable theoretical section. The chapters on acute andlong-term complications are outstanding; that on aetiology, andthe section on classification and diagnosis, are less satisfactory.The section on the management of the patient undergoing sur-gery is disappointing and, despite a first-class pathophysiologi-cal introductory section, that on the pregnant diabetic issketchy. There is a useful chapter on hypoglycaemic syn-dromes, part of which demolishes the fad of "pseudohypo-giyca-mia." The chapters on diabetes in childhood and on Per-spectives on the Clinician’s Approach to Diabetic Manage-ment, are sound and helpful. Bacchus’ strict classification ofdiabetes into two clearly defined clinical types certainly sim-plifies treatment but does not allow for the variability of pres-

entation and the occasional overlap between the two extremesof the clinical spectrum. His classification does not recognisethe intermediate-onset patient of average weight, who is

usually aged 35-55, is not ketotic, does not respond to diet, yetwho does not seem to demand immediate treatment with insu-

lin ; but then this is the group of patients for whom sulphony-lureas are most commonly used in Britain. Bacchus providesa mass of tables, equations, and formulae to calculate quanti-ties of fluid, electrolytes, and insulin. Formulae like these canserve as guidelines, but in view of the rapidly changing meta-bolic milieu in the diabetic patient, particularly in ketoaci-dosis, it would be unwise to follow these instructions too

rigidly. This is a very well written and, for the most part,sound review that will be of interest to all physicians con-cerned with the care of diabetic patients. The index is well pre-pared and, although a number of the references are old, mostimportant recent publications are noted.

Biological Effects of Microwaves

STANISLAW BARANSKI, Institue of Aviation, Warsaw, and PRZE-MYSLAW CZERSKI, National Research Institute of Mother andChild, Warsaw. Stroudsburg, Pennsylvania: Dowden, Hutchin- 10son. 1976. Pp. 234.$15.25,/:9.

IN 1976 it was widely reported that the U.S.A. had com-plained to the U.S.S.R. about microwave radiation directed atthe U.S. Embassy in Moscow. This followed several years ofrumour and speculation about the purpose and extent of theirradiation and an alleged high incidence of mysterious ill-nesses affecting U.S. diplomatic personnel. What made theaffair distinctly curious was that, on the figures released by theState Department, the Americans seem to have been protestingabout intermittent exposures that were below the limits of theU.S. exposure standard by a factor of about 300. This bizarreexample highlights the very wide range of world opinion about"safe" exposure levels for microwave radiation. One of themost valuable features of this monograph is the authoritativeaccount of and informed comment on the major national expo-sure standards. These can differ by up to 3 or 4 orders of mag-nitude, and much of this disparity has come about by the verydifferent safety factors used in deriving permissible exposuresfrom the observed biological effects. In their discussion of thisthese Polish authors differentiate between three possibleapproaches: no discernible effect (U.S.S.R.); no change infunctional efficiency (Poland, Czeckoslovakia); no irreversiblechanges (U.S.A., U.K., and other countries). They also pointout to people using microwave ovens conforming to theemission limits of the U.S. and of the British Standards Insti-tute would be regarded as being safe under both Polish expo-sure regulations and those of the U.S.S.R. The authors seemleast at home in their selection and treatment of material inthe chapters devoted to physics and engineering concepts andto the physical interactions of microwave radiation with tissue.Even so, they make valuable observations about the limitationsand oversimplifications involved in mathematical and physicalmodelling. They are much more fluent and convincing whendealing with experimental biological effects and in discussingepidemiological studies. Their ability to consider documentsand research papers in the original languages adds authorityto their review of other people’s work. The book seems to havebeen delayed in translation or publication because considera-tion of work reported later than 1973 is limited to brief com-ments in the final chapter. It would have been useful to havehad some discussion of medical applications of microwaves(e.g., diathermy) and of the possible synergistic effects whenmicrowaves are used in conjunction with ionising radiations.This is an important book, strongly recommended to anyoneinterested in microwave bioeffects and hazards. Comparedwith other monographs on the subject, it is very readable, withthe occasional asides and personal views affording valuable in-sights.

802

Child PsychiatryModern Approaches. Edited by MICHAEL RUTTER, F.R.C.PSYCH.Institute of Psychiatry, and LIONEL HERSOV, F.R.C.PSYCH., Beth-lem Royal and Maddstey Hospitals. Oxford: Blackwell. 1977. Pp.1024. 21.50.

CHILD psychiatry has undergone several metamorphosessince its infancy in the 19th century. It began with paediatricobservations, became attached to neurology, submerged for atime in various psychoanalytic theories, was administrativelyclaimed by adult psychiatry, education, and social services, butis at last emerging as a true medical entity. This book consistsmainly of review articles of research and thinking in this newclinical discipline. The contributors are generally connectedwith work done over the past 15-20 years in the children’s

department of the Maudsley Hospital, London. The bookoffers a confirmatory statement of the existence of child psychi-atry. However, it is also an essential source of references tocurrent thinking and research. It is difficult to select from somany contributions (there are 41), but the chapters on individ-ual differences, genetics, and antisocial conduct seem particu-larly important to the new thinking about early identificationand prevention of at least some child psychiatric problems.There are helpful accounts of adoption, diagnostic appraisal ofdisturbed children, psychological testing, and language dis-orders. The book is less helpful on treatment-with a fewexceptions, notably the management of disturbed adolescents,mentally handicapped children, and behaviour modification.Antidepressants are handled cautiously: there is a categoricalstatement, in the chapter on enuresis, that tricyclics should notbe given to children younger than 4 years, and the chapter onhyperactive children states that imipramine may not be givento children younger than age 12, except for enuresis. The bookshows evidence of haste in production. There are numerousmisprints and occasionally unhappily worded phrases, and inat least two places text seems to have been omitted. Overallthis book can, however, be warmly recommended as a refer-ence source and an authoritative statement of current thinkingin most aspects of child psychiatry.

Doing Better and Feeling Worse

Health in the United States. Edited by J. H. KNOWLES, M.D. NewYork: Norton. 1977. Pp. 287.$9.95 (paperback$3.95). York: Norton. 1977. Pp. 287.$9.95 (paperback$3.95).THIs book is the result of deliberations on the state of medi-

cine in America by twenty doctors, economists, and politicaland social scientists. Nelson Rockefeller, chairman of the Com-mission on Critical Choices for Americans, invited Dr Knowlesof the Rockefeller Foundation to coordinate this inquiry. Thecommon theme is similar to that of T. McKeown’s Role ofMedicine, A. L. Cochrane’s A Question of Quality, and evenIvan Illich’s Medical Nemesis. Aaron Wildawsky (RussellSerge Foundation) concludes: "According to the Great Equa-tion, Medical Care equals Health. But the Great Equation isWrong. More available medical care does not equal betterhealth ... Most of the bad things that happen to people areat present beyond the reach of medicine". This is the dilemma,coupled with the rising expectations of American (and other)societies, that the authors discuss at length and unanimouslyagree upon. As Walsh McDermott (Cornell University) puts it:"Today’s often repeated cliche that what the physician doeshas relatively little influence on health is more correctly statedthat what the physician does has relatively little influence onthose indicators of health that are largely irrelevant to whathe does".The nineteen chapters cover a wide range of subjects-from

increased "medicalisation" of American society, ethics, thecontribution of technology, primary care, relationshipsbetween government, consumer, and provider, to specific caregroups, such as the mentally ill and children, and to researchneeds and health finance. There is some overlap betweenchapters, and several chapters analyse the major problems fac-

ing the American health "industry": Few references are givento other countries, but issues such as national health insur-ance, private medicine, training for primary care, and methodsof financing research and medical education are of interest toall involved in health-care policy. This book is neither a

defence of medicine nor an attack on it: rather it is a critical

analysis of what medicine should be achieving. Several con-tributors make the point that we have reached a half-way stageof development. While many major advances have been madethese advances are very limited compared to what could bedone. The need for major changes in life-style does comethrough in this book, though perhaps not as forcibly as else-where. Daniel Callahan (Institute of Society, Ethics and the ’

Life Sciences) says that two social realities bedevil the task ofaltering people’s expectations. "The first is the almost total

breakdown of the ethical distinction between ’need’ and ’desire’ in our culture. The second, closely related to the first, is the continuing utopian lure of technology, the lure whoseeffect is to thwart any attempt to place limits on medical aspir-ation". Of the increasing costs of health care Lewis Thomas(Memorial Sloan-Kettering Cancer Centre) writes: "If our so-ciety wishes to be rid of the diseases, fatal and non-fatal, thatplague us the most, there is really little prospect of doing soby mounting a still larger health-care system at still greater

’

cost for delivering essentially today’s kind of technology on alarger scale". Eli Ginzberg (Columbia University) continuesthis theme: "... while the health-care system is responsive tothe most urgent needs of most of the population, there is noprospect whatever, no matter how much money we invest in Iit, for the system to serve as broad support for the host of illsthat already beset modern man and that may well multiply in the years ahead. In consuming over 8 per cent of the gross Inational product the health-care system is crowding the mar-

’gins of family and public income, and we should consider care-fully what we are likely to buy if we increase our expenditureto any significant degree".

These quotes reflect the flavour of this impressive collectionof essays. Nothing new is in this book but what is said is saidwell and said with the authority of those who shape opinionin the United States. But why does not the message get acrossto the public, professions, and governments? Despite whatMcKeown, Cochrane, and Illich-and now this highly res-

pected group-have said little notice is taken at the opera-tional level.

Manual for Disaster Relief Work

MURIEL SKEET, British Red Cross Society. Edinburgh: ChurchillLivingstone. 1977. Pp. 412. £ 12.

TRAINING for catastrophes can be basic or particular. Per-sonnel who may have to deal with crises as different as a hurri-cane in the tropics or a flood in near-arctic conditions, mustbe well versed in the general problems of rescue and survival.Those preparing for nuclear disasters require other, and veryspecific, skills. This manual makes a praiseworthy attempt toserve both groups. Such an encyclopaedic approach has inevi-tably led to the inclusion of some material which seems too eso-teric for any common emergency. It is not an exclusively medi-cal book, but the clinical features of actinomycosis are listedin detail, and there is a two-page list of fifty-eight arthropod-borne viruses. The notes on gunshot wounds feature instruc-tions for "fabricating a sizeable vein graft", though it is easierto imagine circumstances in which the text would be consulted,to no avail, upon the moot point as to whether T.A.B. vaccina-tion is dangerous when an epidemic has already broken out.There is a wealth of most valuable information in the book;some of it not easily to be found elsewhere. The best sectionsare those dealing with the urgent, elementary aspects of reliefwork. Future editions would be enhanced by a less academicapproach, and by references to past disasters and the lessonsto be learnt from them.