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could be prevented by naloxone, and hypotension producedby intravenous endorphin could be prevented by intravenousnaloxone administration.8,9 Furthermore, in rats and dogs,hypotension induced by endotoxin or haemorrhage can bereversed rapidly by intravenous naloxone. 11- IS sFrom the animal work one would not expect naloxone to

raise blood-pressure in patients with hypoadrenocorti-cotropism, because endorphin release would be suppressed.Presumably this accounts for the lack of response in the fourpatients with hypoadrenocorticotropism. Thus, our

preliminary findings support the contentions that naloxonemay reverse the effect of endorphins released in response tostress, that endorphins can lower. blood-pressure, and that ex-ogenous steroids (or hypoadrenocorticotropism) may sup-press endorphin release from the pituitary. 1,2,7- 10,16In the remaining patient who was unresponsive to naloxone

the hypotension was probably caused by chlorpromazine.Chlorpromazine can induce alpha-adrenergic blockade andmay directly depress myocardial contractility. 17- 19 Drug-induced depression of cardiac contractility would not berelated to release of endogenous opiates and should not res-pond to naloxone administration.’4,’s 5Naloxone has been used extensively in man and has few

side-effects; it has been given in doses as high as 10 mg in-travenously, 34 mg subcutaneously, or 1 g orally withoutadverse effects.20-24 In view of the safety of the drug, theresults of the present study and the brief report of a pressor ef-fect in a child with septic shock2s may justify administrationof naloxone for reversal of hypotension due to sepsis andpossibly other factors.We gratefully acknowledge the assistance of the house staff of The Brigham

and Women’s Hospital, Dr R. Wright, Dr V. Dzau, and Dr D. Geha. W. E. M.is in receipt of research career development award AM 00750 from the Na-tional Institutes of Health. The data have previously been presented inabstract form (Clin Res 1980; 28: 241 a).

Requests for reprints should be addressed to W. E. M., Brigham andWomen’s Hospital, 75 Francis Street, Boston, Mass. 02115, U.S.A.

REFERENCES

1. Wiesen M, Liotta AS, Krieger DT. Basal and stimulated release of immunoreactiveACTH, &bgr;-lipotropin, and &bgr;-endorphin from human anterior pituitary cells in vitro.Clin Res 1980; 28: 270A.

2. Guillemin R, Vargo T, Rossier J, Minick S, Ling N, Rivier C, Vale W, Bloom F.&bgr;-endorphin and adrenocorticotropin are secreted concomitantly by the pituitarygland. Science 1977; 197: 1367-69.

3. Mains RE, Eipper BA, Ling N. Common precursor to corticotropins and endorphins.Proc Natl Acad Sci USA 1977; 74: 3014-18.

4. Moberg GP. Site of action of endotoxins on hypothalamic-pituitary-adrenal axis. Am JPhysiol 1971; 220: 397-400.

5. Pur-Shahriari AA, Mills RA, Hoppin FG Jr, Dexter L. Comparison of chronic andacute effects of morphine sulfate on cardiovascular function. Am J Cardiol 1967; 20:654-59.

6. Evans AGJ, Nasmyth PA, Steward HC. The fall of blood pressure caused by in-travenous morphine in the rat and the cat. Br J Pharmacol 1952; 7: 542 - 52.

7. Laubie M, Schmitt H, Vincent M, Remond G. Central cardiovascular effects of mor-phinomimetic peptides in dogs. Eur J Pharmacol 1977; 46: 67-71.

8. Bolme P, Fuxe K, Agnati LF, Bradley R, Smythies J. Cardiovascular effects of mor-phme and opioid peptides following intracisternal administration in chloralose-anesthetized rats. Eur J Pharmacol 1978; 48: 319-24.

9. Lemaire I, Tseng R, Lemaire S. Systemic administration of &bgr;-endorphin: Potenthypotensive effect involving a serotonergic pathway. Proc Natl Acad Sci USA 1978;75: 6240-42.

10. Dashwood MR, Feldberg W. A pressor response to naloxone. Evidence for the releaseof endogenous opioid peptides. J Physiol 1978; 281: 30-31P.

11. Holaday JW, Faden AI. Naloxone reversal of endotoxin hypotension suggests role ofendorphins in shock. Nature 1978; 275: 450-51.

12. Faden AI, Holaday JW. Opiate antagonists: a role in the treatment of hypovolemicshock. Science 1979; 205: 317-18.

13. Faden AI, Holaday JW. Naloxone treatment of endotoxin shock: Stero-specificity ofphysiologic and pharmacologic effects in the rat. J Pharmacol Exp Ther 1980; 212:441-47.

14. Reynolds DG, Gurll NJ, Vargish T, Lechner RB, Faden AI, Holaday JW. Blockade ofopiate receptors with naloxone improves survival and cardiac performance in canineendotoxic shock. Circ Shock 1980; 7: 39-48.

15. Vargish T, Reynolds DG, Gurll NJ, Lechner RB, Holaday JW, Faden AI. Naloxonereversal of hypovolemic shock in dogs. Circ Shock 1980; 7: 31- 38.

16. Holaday JW, Law PY, Loh HH, Li CH. Adrenal steroids indirectly modulate mor-phine and &bgr;-endorphin effects. J Pharmacol Exp Ther 1979, 208: 176 -83.

17. Sakalis G, Curry SH, Mould GP, Lader MH. Physiologic and clinical effects of chlor-promazine and their relationship to plasma level. Clin Pharmacol Ther 1972, 13:931-46.

18. Dripps RD, Vandam LD, Pierce EC, Oech SR, Lurie AA. The use of chlorpromazinein anesthesia and surgery. Ann Surg 1955; 142: 774-85.

19. Gold MI. Profound hypotension associated with the use of phenothiazines. AnesthesAnalges 1974; 53: 844-48.

20. Martin WR, Naloxone. Ann Intern Med 1976; 85: 765-68.21. Jasinski DR, Martin WR, Haertzen CA. The human pharmacology and abuse potential

of N-allylnoroxymorphone (naloxone). J Pharmacol Exp Ther 1967; 157: 420-2622. Levine JD, Gordon NC, Jones RT, Fields HL. The narcotic antagonist naloxone

enhances clinical pain. Nature 1978; 272: 826-27.23. Grevert P, Goldstein A. Endorphins: Naloxone fails to alter experimental pain or mood

in humans. Science 1978; 199: 1093-95.24. Zaks A, Jones T, Fink M, Freedman AM. Naloxone treatment of opiate dependence. A

progress report. JAMA 1971; 215: 2108-10.25. Tiengo M. Naloxone in irreversible shock. Lancet 1980; ii: 690.

Reviews of Books

The Challenge of Urinary Tract Infections

A. W. Asscher, Welsh National School of Medicine, Cardiff. London:Academic Press. New York: Grune and Stratton. 1980. Pp. 209. ;CI5;$34.50.

A COMMON condition which can cause distress, which is a factor inthe cause of the renal failure in a fifth of patients entering dialysisand transplant programmes, and which, it is suggested, may in theend precipitate the terminal septicaemia of the geriatric patient,demands attention. This is what Professor Asscher sets out to do in aconcise, readable, and informative monograph, which will bothstimulate the reader’s interest and provide practical guidance inpatient care. There is a well-balanced selection of the vast literaturewhich has accumulated around the subject, but his researchcontributions, particularly the epidemiological studies ofbacteriuria in pregnant and non-pregnant women and in school-

girls, have added the perspective which a potentially lifelongcondition requires. For instance, the highlighting of the unstablebladder in women who void infrequently for a variety of trivialsocial reasons and have recurrent infections reminds us that habitsare formed early. For other, usually simple, reasons small girls mayalso void infrequently and have recurrent infections. It is unfor-tunate that some of the X-rays selected are perhaps more bizarrethan representative, and in general the captions for figures andtables do not seem to have received the same care as the main text; anumber are disappointingly uninformative, with terminology lessexact than Asscher himself advocates.The unsolved problems surrounding urinary infection, its diag-

nosis, management, and prognosis are a humbling statement of ourignorance despite much time, energy, and money expended on thesubject. Perhaps the fault lies in slow communication or acceptanceof progress, which this book should help to remedy. For theclinician, whether nephrologist, urologist, paediatrician, or familydoctor, there is much of interest and guidance and a useful set ofappendices.Paediatric Department,University College Hospital, London JEAN SMELLIE

Cholesterol, Children, and Heart Disease

An Analysis ofalternatives. Donald M. Berwick, Shan Cretin, Emmett B.Keeler. Oxford and New York: Oxford University Press. 1980. Pp. 399.18.

THE evidence that links cholesterol with ischaemic heart disease is

convincing, but to what extent lowering cholesterol levels in bloodwill prevent heart disease is still hotly debated. Doctors are used tohaving to make therapeutic decisions in the face of uncertainty. Thesame applies in preventive medicine, though a higher degree ofcon-

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fidence is rightly required before any intervention on a populationbasis is introduced. The authors, a paediatrician, a mathematician,and an expert in the provision of health services, examine criticallythe evidence for and against the introduction of preventive meas-ures, and then go on to compare, from the practical and economicpoint of view, three different approaches to prevention: mass popu-lation screening for cholesterol, screening of children at high riskbecause of a family history of premature ischaemic heart disease (tar-geted screening), or dietary intervention for a whole populationeither through the mass media or through school-based campaigns.The comparisons are based on analyses of cost-effectiveness.The authors succeed in making the text understandable to the

non-mathematician, and highly technical matters are banished tothe appendices, which will be comprehensible to statisticians, epi-demiologists, and health economists, but difficult for most phy-sicians. The chapters outlining the principles underlying studies ofcost-effectiveness, and describing and comparing the merits of thevarious preventive methods, demand more concentration from theclinician than he is used to give to descriptive clinical texts, but theeffort will be amply rewarded and the task is lightened by a clearstyle, common sense, and even a sense of humour.The book will appeal not only to those with an interest in the pre-

vention of ischaemic heart disease, but also to those concerned withother aspects of preventive medicine and health education and, inparticular, to the paediatrician concerned with measures applied tochildren to prevent disease in adulthood. The book is also recom-mended to those who are convinced that they have all the answersfor or against measures aimed at lowering cholesterol, because thethoughtful and critical approach of the book may lead them to recog-nise the complexity of the matter.

Institute of Child Health,London 0. H. WOLFF

Chronic Ear Disease -

Morwgraphs in Clmical Otolaryngology, vol. I!. Gordon D. L. Smyth, RoyalVictoria Hospital, Belfast. Edinburgh: Churchill Livingstone. 1980. Pp.225. f[5..

THE author of this volume is an academic surgeon who is interna-

tionally recognised for his contributions to the thorny subject ofchronic ear disease. He practises in Northern Ireland, where thewater and perhaps political barriers have ensured that most of hispersonal cases can be followed up for periods which must be theenvy of his less favoured colleagues elsewhere. This book is clearlya personal evaluation, drawing extensively upon his considerableexperience yet relating his conclusions to the opinions of otherotologists from every part of the world. The five sections deal withpathology, eradication, restoration of function, special problems intreatment, and finally, a look into the future. The prose is clear anddefinite, whilst the fairly simple diagrams amply illustrate salientpoints within the text.The problem of chronic suppuration from the ears, in both adult

and child, has been with us for over 150 years. Although the clinicalfeatures have long been recognised the aetiology and natural historyremains in doubt. Possible relationship with the now, all too com-mon, middle ear effusion is a favoured explanation, and this isthoroughly explored within this volume. Removal of potentiallydangerous middle ear disease or the production of a "dry" ear is nolonger the sole aim of the modern otologist, despite being possiblythe "best buy" for those working in overpopulated underprivilegedcountries. Almost half of this book consists of a detailed considera-tion of the most useful operative techniques designed to combineeradication of disease with restoration of function. There are few

otologists better fitted to express an opinion on these topics for,although his attitudes have changed with the passage of time, eachstep has been based upon a careful statistical evaluation of personalexperience. The reasons for abandonment or modification of, say,combined approach tympanoplasty in favour of mastoidectomywith obliteration of cavity and tympanic reconstruction, are clearlystated and supported by personally collected evidence.This book is in every way a highly successful monograph on the

"state of the art". My sole reservation is related to the potential

readership. The reputation of the author will ensure good sales, buthow many readers will appreciate the depth or subtlety of hisarguments, for this is a book by an otologist for otologists andshould not be considered "a plain man’s guide to the management ofchronic ear disease".

Institute of Laryngology and Otology,London D. F. N. HARRISON

SurgeryEdited by James 0. Robinson and Ashley Brown, St. Bartholomew’s Hos-pital, London. London: William Heinemann. 1980. Pp. 604. 27.50.

WHY do people undertake the long and difficult task of writinganother textbook of surgery "for the student and house surgeon"?.Presumably this particular group of authors from St.Bartholomew’s are aiming their book at their own undergraduatesand house officers; but to achieve wider success it must appeal toothers. I have shown the book to a random selection of our senior

surgical students (n=12, not broken down by age or sex) andalthough we all like its layout and clarity, they would not beprepared to pay 27.50, when cheaper (and more pocket-sized) textsare already available. Most chapters are very current, although "theadvances made in recent years" are often described only briefly, andwhy not, in what is basically an undergraduate text. It is good to seeradiotherapy given its rightful place in the treatment of manysurgical conditions, but the definitive chapter on radiotherapy wasconsidered by those critical students of mine to contain "far toomuch physics for us". The chapters on certain of the surgicalspecialties-e.g., the eye-are delightfully short and readable, butmight well need to be supplemented by other books to cover the fullundergraduate curriculum. The section on the locomotor systemlooks good to an untutored eye; and that on stoma care is mostwelcome. There are no photographs of clinical conditions, but thedrawings and diagrams are beautifully clear, and I could detect veryfew and very minor typographical errors. In conclusion: if this bookwas meant for me, then I would certainly buy it (or at least suggestthat our hospital library should buy it), but it is meant for medicalstudents, and my random sample has indicated that they would not.

Department of Surgery,City and University Hospitals,Nottingham. T. W. BALFOUR

The Vitamins in Medicine

Voll. Edited by Brian M. Barker and David A. Bender. London: WilliamHeinemann. 1980. Pp. 538. 25.

FIRST published in 1942, The Vitamins in Medicine was in its thirdedition by 1953 and highly regarded as a standard reference text onthe subject. Within the past twenty-seven years interest andresearch activity in this area has increased greatly, and regularlyrevised editions of this text would have been most valuable. Thefourth edition is therefore overdue and this first volume covers onlysome of the B vitamins and vitamins D and E-the remaining topicswill be covered in a second volume, to be published late in 1981.Almost a quarter of the book is allocated to one chapter on vitamin

D by D. R. Fraser. Many reviews of the literature on vitamin D havebeen published recently, but this one provides one of the bestbalanced and critical discussions of the literature up to 1977 by asingle author. Vitamin E is dealt with in twenty-four pages (J. S.Nelson and V. W. Fischer)-rather lightly for such a subject. Thecobalamins and the folates (I. Chanarin) take up a third of the text.Professor Bender writes an introductory chapter on

recommendations and intake and two others, on niacin and onvitamin B6, the latter with Dr Barker. Chapters on biotin andriboflavin (by S. P. Mistry and S. G. Flavell Matts, respectively)complete the volume.Some comparison with the third edition is inevitable. Of the

vitamins considered in this volume only biotin, the folates, andvitamins B6 and B12 are considered at greater length than in thethird edition. The reference lists at the end of each chapter are auseful source of further information. However, delays between

534

writing and publication have meant that there is almost no coverageof the literature after 1977; in most cases there is very little after1975. It is a pity because biochemical research in this area has beenmost active within the past decade and has made many aspects of thevitamins of increasing interest and relevance to clinicians as well asto research workers in medicine and related disciplines. Anillustration of how the book has been overtaken by events is thechapter on vitamin B6. Evidence published within the past fewyears about the role of this vitamin in the biosynthesis of collagencrosslinks helps to provide a biochemical rationale for some of thelesions observed in vitamin-B6-deficiency states and described in thechapter.

In summary, this first volume of the fourth edition lacks the detailand authority of Bicknell and Prescott’s third edition. This,together with the uneven quality of the contributions, tends toreduce the value of the book as a reference text, and I hope that thesecond volume will not show such deficiencies.

Strangeways Research Laboratory,Cambridge I. DICKSON

Radiotherapy Treatment PlanningMedical Physics Handbook, no. 7. R. F. Mould, Westminster Hospital,London & Bristol: Adam Hilger (in collaboration with the HospitalPhysicists Association). Distributed in N. and S. America by Hayden andSon. 1981. Pp. 204. D2.95;$31.

To most physicians radiotherapy planning is a mysterious processperformed somewhere in the depths of a large hospital. Patientsemerge neatly tattoed with gentian violet marks in the vicinity oftheir tumour. To the aspiring radiotherapist the process remains amystery well into his training. This is partly due to the considerabledifferences in planning technique used by radiotherapists not onlyin different centres but also within a unit.

Although this book forms part of a series for medical physicists itis eminently suitable for radiotherapists wishing to gain a furtherqualification. Dr Mould himself is a medical physicist whose maininterest is the treatment of cancer. After describing the hardware ofX-ray production and discussing the ways in which radiation ismeasured, he considers problems encountered in delivering ahomogenous dose to the tumour and surrounding areas. Thevarious factors affecting the radiation delivered from a singleisodose curve is described. This leads up to the use of multiple fieldsand the plans that they can produce. The chapters are well writtenand illustrated by very clear diagrams. The introduction of planningcomputers has made non-automated addition of isodose curvesobsolete in most departments. However the candidate for theF.R.C.R. examination is still expected to compose three-field plansrapidly, and this book provides adequate detail. As a manual ofpractical radiotherapy, however, there are some omissions. Forexample, adequate detail is not given on planning mantle fields forthe lymphomas or the inverted Y or J shaped fields for abdominaland pelvic lymph nodes. The deficiencies do not detract from itsuse as a simple but very valuable planning text for radiotherapists intraining and medical oncologists.

Ludwig Institute of Cancer Research,Addenbrooke’s Hospital, Cambridge. KAROL SIKORA

Immunology of ContraceptionCurrent Topics in Immunology Serzes. G. P. Talwar, All-India Institute ofMedical Sciences, New Delhi. London: Edward Arnold. 1981. Pp. 149.£13.50.

THE population of the world continues to grow at an alarmingrate. Guestimates vary from 4 - 2 to 6 billion (English, not American)by 2000 A.D. Since no present method of contraception is free fromproblems, some authorities, including the World Health Organisa-tion, have found the idea of immunological fertility control attrac-tive. Several groups have been engaged in research for a number ofyears, and the leader of the capable team, appropriately situated onthe Indian subcontinent, Professor G. P. Talwar, has been asked todescribe the fruits of these studies.

Disappointingly, the organisation of this book is awkward andrather confused. It begins well enough, with a brief discussion of theneed for a contraceptive vaccine, followed by a review of the im-munobiology of natural fertility and the effects of vasectomy.Several important aspects of the immunobiology of pregnancy areomitted-for example, the isolation of anti-HLA serum from

multiparous women and a discussion of the role of SPI (pregnancyassociated (3 glycoprotein). There is a detailed analysis of the effectsof hormones on pregnancy and on the immune response, and it isworth noting that the biological role of human chorionic

gonadotrophin is still unclear. The rest of the book describes theresults of immunological fertility control research, includinghazards and prospects. Here the book suffers from beingrepetitious, which the author might justify on the grounds of gettinghis message across. A simpler and more direct presentation of datawould have been more helpful.Some methods of fertility control, for which successful claims are

made, tax one’s credulity from an ethical and patient acceptibilitypoint of view (the injection of BCG into the testis, for instance).Others, such as immunisation against sperm-specific antigens, aretheoretically more attractive, but there is uncertainty about theirpotential long-term effects. Most space in this part of the book wasgiven, rightly, to immunisation against the subunit of humanchorionic gonadotrophin. Although this method has been suc-cessful on a limited scale, there has not yet been an extensive trial inwomen. The final chapter directs the reader’s attention to the mostpromising lines of research.

The style is somewhat exuberant and the English at timesidiosyncratic. The references are useful and up-to-date. It is possiblethat my mild but definite antipathy to this book stems from a feelingthat we should take especial care before we advocate immunologicalcontrol of pregnancy when we do not yet understand its normal im-

munobiology. Unfortunately, I do not feel that the book measuresup to the high standards set by some of its predecessors in the series,notably Immunodeficiency by Anthony Hayward, or that on HLAand H-2 by Hilliard Festenstein & Peter Demant.

Department of Paediatrics,St. Thomas’Hospital, London COLIN STERN

Alcohol Problems in Employment 1

Edited by Brian D. Hore, Withington Hospital, Manchester, and MartmA. Plant, University of Edinburgh. London: Croom Helm (in associationwith Alcohol Education Centre). 1980. Pp. 208. 14.95.

IN occupational health there has always been a doubt aboutwhether alcohol is a social problem with industrial connections inwhich the occupational physician can do little, or whether itdeserves the time and attention that would be spent by an occu-pational physician in working out a special programme. Doctors inindustry in the United States seem much more interested in theproblem than doctors in Britain. This is a persuasive book supporting the second point of view. It presents data from the UnitedStates, Norway, France, and Britain, and includes a chapter on alco-holism within the medical profession.There is no doubt that alcohol abuse in industry is widespread and

may well be the cause of industrial accidents. It is curious that withroad accidents the question of alcohol is always raised, whereas withindustrial accidents there seems to be a conspiracy of silence regard-ing the role of alcohol in its causation. The effect of alcoholism onthe efficiency of a company is even more difficult to measure.In places where heavy drinking is a problem there is a need for

organised advice. Industries in which alcohol is manufactured areobvious candidates for a specific programme. Where there is anindustrial physician employed in a factory then it is obviously partof his duty to detect the danger signs and make appropriaterecommendations. The main difficulty is that many industries haveno medical supervision.This book presents the facts very seductively. Every doctor in

industry should read it and adapt his policies according to theperceived extent of the problem.120 Temple Chambers,Temple Avenue, London ROBERT MURRAY