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Feb. 16, 1995

Dr. Diamonds remarks reect this concern. We have taken for granted that by and large, specialists who have trained longer, who are board-certied, and who learn from their experience provide the best care for patients with complex illnesses, but our crude measures of quality have yet to show striking benets of their care over that of generalists. The studies cited by Dr. Weinberger add to the meager evidence that in treating certain conditions, specialists outperform generalists. I called for better documentation of the benets of specialty care so that rational judgments could be made about the right proportion of specialists and generalists in managed care. As Dr. McAfee points out, one goal of the Patient Protection Act was to maintain appropriate referrals of patients

to specialists. I applauded this provision, but indicated that it was not very specic. Since the debate on health care reform began last year, many voices have become increasingly adversarial and shrill, and the remarks of Drs. Silverblatt and Zink are but two examples. Dr. Silverblatt, from a generalist platform, worries that specialists will resort to trickery and abuse of power. Dr. Zink, from a managed-care platform, scolds anybody who has not yet gotten the managed-care religion. Optimal care for patients will be achieved by the analysis of new information on quality of care, by cooperation, and by negotiation, not by intolerance. We must lower the decibel level. JEROME P. KASSIRER, M.D.

BOOK REVIEWS
LIVING
IN THE

SHADOW

OF

DEATH: TUBERCULOSIS

AND THE SOCIAL EXPERIENCE OF ILLNESS IN

AMERICAN

HISTORY

By Sheila M. Rothman. 319 pp. New York, BasicBooks, 1994. $25. ISBN 0-465-03002-5. Sheila Rothmans new book is an important contribution to the growing body of scholarly literature devoted to an understanding of the history of medicine from the patients perspective. With an approach that is self-consciously interdisciplinary incorporating medical anthropology and literary analysis, as well as medical history Rothman develops illness narratives to explore patients experiences with tuberculosis. Drawn from diaries and personal correspondence, these narratives are nely detailed descriptions of the lives of individual patients, tracing how the experience of illness is shaped by the interplay of medical, social, religious, and cultural forces. During the rst half of the 19th century, patients with tuberculosis typically considered themselves invalids whose principal responsibility was to improve. Improving meant reshaping virtually every aspect of ones life to combat the disease. An outdoor life was considered optimal for patients with tuberculosis, and many men jettisoned hopes of having professional lives, instead often embarking on lengthy sea journeys. Not surprisingly, assumptions about sex roles played a large part in these decisions, with womens domestic role making it less likely that they would engage in extensive travel. For both sexes, invalidism, with its call to balance every decision against its effect on ones health, became the dening characteristic of these patients lives. During the second half of the century, patients increasingly became health seekers who adopted a more aggressive approach to regaining their health. In contrast to the invalids, whose lives were based on the assumption of debility, the health seekers embraced a more vigorous lifestyle. Rothman provides interesting insights into the profound effect of these health seekers on the migration to and development of the West, especially Colorado and California. Rothman emphasizes that for both invalids and health seekers, physicians and medical institutions had a limited role. The illness narratives demonstrate that before the 20th century, patients controlled their own lives and medicine played a surprisingly modest part in the overall experience of illness. With the identication of Mycobacterium tuberculosis in 1882 and the demonstration that tuberculosis was contagious (throughout the 19th century many physicians believed it was

inherited), the disease and the patient became indistinguishable. Patients were placed in sanitariums, total institutions that exercised medical control and orchestrated (or tried to orchestrate) every aspect of a patients life. Rothman cogently argues that this medicalization sharply truncated the life experiences of patients with tuberculosis. As in all total institutions, a vigorous underground culture emerged, with forbidden parties, drinking, and sexual encounters, but the imposition of medical control dramatically limited the lives of patients in sanitariums. Although both the invalid and the sanitarium patient conated their disease with their identity, the invalid retained control over both, whereas the sanitarium patient ceded control to the physician. Rothmans work focuses on the patients experience and occasionally gets bogged down in details. Physicians remain in the background, and medical advances are described only in the light of their effect on the patients experience. Those seeking an account of medicines struggle with tuberculosis should consult Frank Ryans The Forgotten Plague: How the Battle against Tuberculosis Was Won and Lost (Boston: Little, Brown, 1993). Sheila Rothman has written a lucid and frequently moving account of what it meant to live with tuberculosis before the development of antibiotics. Her careful analysis forcefully underscores the interplay among medical, social, personal, and cultural forces that determines what it means to be sick with a particular disease in a particular time and place. As we struggle to respond to the renewed threat of tuberculosis, we need to be mindful of these inuences so that we can provide humane care for patients with tuberculosis, always distinguishing between the disease and the patient. Bronx, NY 10461 STEVEN C. MARTIN, M.D. Albert Einstein College of Medicine

VACCINES
Second edition. Edited by Stanley A. Plotkin and Edward A. Mortimer, Jr. 996 pp., illustrated. Philadelphia, W.B. Saunders, 1994. $159. ISBN 0-7216-6584-5. This book is a unique collection of information about what some now call vaccinology. Its 35 chapters include the epidemiologic and clinical studies leading up to the licensure of vaccines currently in use and pay some attention to newer approaches to vaccine development and to vaccines on the horizon. Since the rst edition, which appeared six years ago, there has been extensive addition and revision, reecting the rapid movement in this area of medical research. The authors were given a free hand in organizing their

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Vol. 332

No. 7

BOOK REVIEWS

477

chapters, which include a great deal of primary data that span a number of years and are thus very difcult to retrieve from the literature. In many chapters, the editors have chosen an effective combination of investigators those involved in the original development of the vaccine and those currently concerned with its regulation and implementation, such as physicians from the National Immunization Program at the Centers for Disease Control and Prevention. Unfortunately, the chapters are arranged in no discernible order. Two different approaches to the prevention of inuenza are discussed nine chapters apart. Differences of style and organization in the chapters are also evident. A clearer, more uniform template for the presentation of the data and a sterner editorial hand would have beneted the reader. The book is saved from these lapses of organization by the richness of the data and the experience and skills of the individual authors. Too little attention is paid to international aspects of vaccine use, immunization against parasitic diseases, newer adjuvant therapies, and the immunologic basis of vaccine development. Nevertheless, for readers with a research interest in vaccines this book is an invaluable reference. It should be the rst stop in investigations of the history of a vaccine, the potential for vaccine-associated illness, reports of vaccine failure, or indications for vaccine use. It contains information that extends well beyond what is available in the report of the Committee on Infectious Diseases of the American Academy of Pediatrics (Red Book; Elk Grove Village, Ill.: American Academy of Pediatrics) and the recommendations of the American Committee on Immunization Practices, which appear in the Morbidity and Mortality Weekly Report. For this reason, it should nd a place in the library of any inquisitive primary care physician. Nashville, TN 37232 PETER F. WRIGHT, M.D. Vanderbilt Medical Center

exploring medical history for the rst time. Each chapter tends to be self-contained; however, this approach adds needless repetition. For example, biographical material about Soranus of Ephesus appears in ve places in addition to a note at the end of the book. Unfortunately, the topical approach makes it difcult for readers to identify historical trends and relations among important areas. For example, neither the chapter entitled Narrative-Historical Overview nor the one entitled Spreading Knowledge gives a sense of the difculties encountered by obstetricians of the 19th century, who fought to make obstetrics and gynecology a recognized specialty alongside surgery and medicine and to make obstetrics a required part of the medical curriculum. Similarly, separate chapters on the menstrual cycle, amenorrhea, menopause, the premenstrual syndrome, dysmenorrhea, infertility, and sexuality give no sense that observations of all these clinical phenomena gave rise to the discovery of many hormones and to our understanding of hormonal regulation of the ovarian cycle and pregnancy. There is not enough expository material to lead readers from one pertinent area to the next. This book may be most useful to those who already know something about medical history and wish to explore a new area. The extensive chronologies and references will help these readers. Those looking for insight, however, may wish to supplement their reading with a textbook that deals with broader themes. Gainesville, FL 32610 DONALD CATON, M.D. J. Hillis Miller Health Center
OPTIONS

HIGH RISK PREGNANCY: MANAGEMENT

Edited by D.K. James, P.J. Steer, C.P. Weiner, and B. Gonik. 1318 pp., illustrated. Philadelphia, W.B. Saunders, 1994. $90. ISBN 0-7020-1575-X. This ambitious textbook covers the entire scope of clinical maternalfetal medicine. High Risk Pregnancy: Management Options distinguishes itself from other standard perinatology textbooks, such as MaternalFetal Medicine: Principles and Practice (edited by Robert K. Creasy and Robert Resnik. Philadelphia: W.B. Saunders, 1994), in presenting clinical information almost exclusively and omitting much basic-science information. Internationally recognized experts on the subject wrote most of the chapters. The books 73 chapters appear to be organized into four basic sections general obstetrics, medical complications of pregnancy, prenatal diagnosis and fetal disease, and management of labor and delivery although the sections are never listed. This is an important omission, since the editor states that all the contributors to each section were asked to give their preferred management in all areas of their section. All chapters contain boxed lists that in most cases provide adequate summaries of the material and that will facilitate use in clinical practice. I found a number of minor typographic errors in the book as well as one major error in a discussion of pheochromocytoma, in which beta-blockade was used when alpha-blockade was intended. The preface and back cover list a number of goals for the textbook. The rst is to be comprehensive. In fact, the editors have succeeded in covering all major topics, and most chapters are quite thorough. A few additions would have been helpful, including a more complete discussion of uterine and cervical abnormalities and a discussion of trauma in pregnancy. There is some overlap in topics, but this sometimes enhances the treatment of the subject. For example, a brief discussion of tuberculosis in a chapter on respiratory tract dis-

THE HISTORY

OF

OBSTETRICS

AND

GYNAECOLOGY

By Michael J. ODowd and Elliot E. Philipp. 710 pp., illustrated. New York, Parthenon, 1994. $125. ISBN 1-85070-224-1. It is difcult to summarize this book, because it is more than a history of obstetrics and gynecology and also less. History can be written in different ways and for different reasons. The authors never dene their goals, and this lack of denition affects much of the book. The book consists of 44 chapters, a section of short biographies, and indexes of names and subjects. Each chapter contains a short narrative on a particular topic, followed by a chronology of pertinent events and appropriate references. The rst two chapters put obstetrics and gynecology into historical perspective. They describe major changes in the medical management of pregnancy and of womens diseases from antiquity to the present. The remaining chapters deal with specic subjects for example, cesarean section, menorrhagia, and sexuality. The reasons for the inclusion of a particular subject, the space given to it, and its place in the sequence of chapters are not always apparent. For example, the chapter on information technology appears between the chapters on sexuality and urology. The chapter on laparoscopy is just one page shorter than the chapter on surgery. Some important topics are absent; no chapter deals with the physiology of pregnancy, even though clinicians have drawn extensively from this branch of science since the last half of the 19th century. The presentation of each topic is clear and easily grasped, an advantage for medical students and residents who may be

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THE NEW ENGLAND JOURNAL OF MEDICINE

Feb. 16, 1995

ease is followed by more thorough coverage in a chapter on infectious disease. The overlap is distracting in other places, as in a chapter on abdominal pain in which most of the information is covered in more detail elsewhere. The editors also tried to present a wide range of established management options. In this regard they were usually successful. Most chapters provide a balanced review of the topic and offer a defensible range of practice options. In a few chapters, the authors bias about accepted practice seems apparent, as in the chapter on testing of fetal well-being before labor and the chapter on fetal growth deciency. I found very few statements that are clearly erroneous. Most authors support their advice with appropriate data. A few authors, however, cite review articles, and others offer out-of-date references. A third goal of the textbook was to present practical information. There is little basic science or tangential clinical information. Most authors cite appropriate studies to justify their recommendations. By and large, the clinical approach is based on common sense and appropriate evidence. The editors intentionally enlisted contributors from many countries to provide a multinational perspective. I suspect that readers from the United States will have both positive and negative reactions to this approach. Some chapters contain terms and practices that are not common in the United States. Readers may fall prey to prejudice about the opinions of foreign experts and about data obtained outside the United States. For my part, I appreciated the diversity and found that the United Kingdom contributors were more likely to base their recommendations on evidence. My overall impression of this textbook is very favorable. There are a number of excellent chapters, including an outstanding review of fetal distress in labor. High Risk Pregnancy will be a valuable resource to a variety of practitioners, including upper-level obstetrics residents, maternalfetal medicine fellows, and practicing perinatologists, general obstetricians, and midwives. EMILY R. BAKER, M.D. DartmouthHitchcock Medical Center
IN DIAGNOSIS

Lebanon, NH 03756

THE FETUS

AS A

PATIENT: ADVANCES

AND THERAPY

Edited by Asim Kurjak and Frank A. Chervenak. 562 pp., illustrated. New York, Parthenon, 1994. $98. ISBN 1-85070558-5. Without question, the technological revolution of the past two decades has elevated the fetus to the level of the corecip-

ient of obstetrical health care. Thus, The Fetus as a Patient, edited by Asim Kurjak, M.D., and Frank A. Chervenak, M.D., is a timely look at the mysteries that cloak the world of the fetus. The editors have assembled a world-renowned group of researchers from the International Society of the Fetus as a Patient in an effort to review the fetal diagnostic and management techniques available to clinicians. The authors weave the chapters into a carpet from the four corners of the world and take the reader on a magic carpet ride through the historical events that have established the fetus as a patient entitled to care. These advances in fetal health care are highlighted by sections on new dimensions in fetal and placental imaging, antenatal assessment of the fetal condition, the role of Doppler ultrasonography, and fetal therapy. The cornerstones of the book cover such issues as the central role of the fetus as a patient in dening an ethical standard of care for fetal therapy, prenatal diagnosis of skin disorders, intrauterine growth retardation, sonoembryology, and three-dimensional ultrasonography. Nevertheless, the book is limited in scope and represents, at times, a compilation of personal research rather than a comprehensive overview of fetal health care. This is illustrated by the chapter Non-Directive Prenatal Genetic Counseling, in which the discussion of prenatal diagnosis is limited to postconception issues and fails to emphasize or recognize preconception counseling and alternative approaches to parenthood to help prospective parents avoid having a fetus with serious defects. Other chapters provide a comprehensive assessment of a selected fetal clinical condition, such as intrauterine growth retardation, but do little to guide clinicians through the complex tapestry of science and technology and their bedside applications. Other chapters, such as Transvaginal Evaluation of the Cervix, should have been left out, because they do not appear to apply directly to the management of fetal health care. In future updates, the editors should consider including chapters that focus on the legal issues confronting the fetal clinician, RH sensitization, and fetal risk management. In summary, The Fetus as a Patient is a brief but important glimpse into the world of the fetus. The thought of future editions of the book, which will expand on this initial effort, is enticing. Unfortunately, the book is too short and its coverage of fetal health care issues too brief. In a world that tends to focus on maternal rather than fetal issues, The Fetus as a Patient is an eloquent reminder that both issues are important. JEFFREY P. PHELAN, M.D., J.D. Pomona Valley Hospital Medical Center

Pomona, CA 91767

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