Care distillation of empirical research find¬ virtue only to the small-minded, and

Enterprise-Health this book should appeal to all who con¬

ings from the commission's own techni¬
For-Profit Enterprise in Health Care, edited by cal studies and other published work. sider themselves above such trifles. In¬
Bradford H. Gray (Committee on Implications of deed, there is good reason why the IOM
For-Profit Enterprise in Health Care, Institute of These chapters represent by far the
best treatment of the subject available committee equivocates on certain key
Medicine), 556 pp, $47.50, Washington, DC, Na- in print today. The writing is clear, free issues. The question of the proper role
tional Academy Press, 1986.
of jargon, and even eloquent. The com¬ of for-profit enterprise in health care is,
No issue in health care is more contro- mission's conclusions and recommenda¬ after all, as much a philosophical as an
versial than the role of profit-making tions in the last chapter of Part I are empirical economic one. Nowhere is this
enterprise. It is a widely held percep- artfully presented and contain some point better made than in the open
tion that growth of investor-owned busi- surprises. The commission found, for exchange of letters between two com¬
ness ventures will fundamentally example, that for-profit health care en¬ mittee members, Arnold Relman, MD,
change way the health care is provided terprises generally have higher costs, editor of the New England Journal of
and financed in the United States in charge higher prices, and appear to be Medicine, and Uwe Reinhardt, PhD,
coming years. Some argue that an in- less efficient than theirit not-for-profit the silver-tongued economist from
creased business presence will bring counterparts. Although uncovered no Princeton who introduces Part II of the
needed discipline to health care mar- evidence that proprietary facilities pro¬ report. It is worth the price of the book.
kets long characterized by excessive vide lower-quality health care, it did Bruce Stuart, PhD
costs and inattention to consumer find that such facilities are less accessi¬ The Pennsylvania State University
wants. Others fear the loss of traditional ble to the poor and uninsured and, with University Park
and a few notable exceptions, eschew any
community-oriented providers pos-
sible deleterious effects on access and commitment to medical education and Cancer Surgery
quality of care. There is no shortage of research.
Cancer of the Face and Mouth: Pathology and
rhetoric on either side but surprisingly The committee's policy recommenda¬
little in the way of supporting empirical tions run the gamut from safe and pre¬ Management for Surgeons, by Ian A. McGregor
and Frances M. McGregor, 615 pp, with illus, $175,
evidence. dictable (ie, that governments should New York, Churchill Livingstone Inc, 1986.
squarely address the indigent care
that Medicare should con¬ This "atlas" of orofacial surgery is
".. .
for-profit health care enter¬ question, tinue to fund hospital capital expenses, described by the authors as reflecting
prises generally have higher costs, and that tax-exempt bonding should be their personal experience in the treat-
charge higher prices, and appear to retained for not-for-profit hospitals un¬ ment of benign and malignant lesions. It
be less efficient than their not-for- til something better comes along) to the is a "how I do it" book. The emphasis is
profit counterparts." innovative and somewhat bizarre (in¬ on the practical excision of malignancies
cluding a recommendation to use tax of various kinds, sites, and sizes, affect-
This book is the second Institute of receipts from investor-owned health ing the face, facial structures, oral cav-
Medicine (IOM) study of the for-profit care companies to pay for indigent care). ity, and salivary glands, but not the
phenomenon. (The New Health Care for A strong consensus is voiced against pharynx, larynx, thyroid, or parathy-
entrepreneurship. At one roids. Reconstructions by grafts and
Profit: Doctors and Hospitals in Com- physician
a
petitive Environment, published in point the committee recommends devel¬ flaps mirror the authors' experience.
opment of "physician compensation sys¬ There are no data on the outcome of the
1983, was the first.) And it specifically
addresses the question ofwhat is known tems that break the link between the procedures, morbidity and mortality
empirically about differences between their decisions physicians make in treating rates, or the number and kind of secon-
not-for-profit and proprietary health patients and the rate of return dary procedures required.
they earn on investments in their medi¬ The authors emphasize the impor-
providers\p=m-\hospitals particular—on cal practices" 162). This would appear
in
tance of experience\p=m-\thesurgeon "with
such dimensions as cost and prices (p
be a clear indictment of fee-for-serv- for it"\p=m-\ratherthan published
charged, the willingness to offer uncom- to medicine. But the committee is able
a nose
data. One can sympathize with this atti-
pensated services, and the quality of ice to finesse this conclusion and target tude; however, the "nose" can also be an
care. An IOM committee chaired by
Walter McNerney with representatives concern instead on physician invest¬ errant guide, as is depicted by the pho-
of major viewpoints on the subject com¬ ments in large capital equipment pur¬ tographs (on p 366) of radical surgery
missioned 14 studies to aid in this en¬ chases and ownerships in health facili¬ for extensive malignant melanoma.
deavor. These studies appear as Part II ties. Pathology is included in the title, but,
as stated in the preface, "from the view¬
of the report. Their appeal is primarily
to health services researchers rather "A strong consensus against point of the surgeon rather than the
pathologist." In my opinion, the
. . .

than a lay readership. physician entrepreneurship."

Part I consists often chapters written
by IOM staff. Herein is presented a
Edited by Harriet S. Meyer, MD, Contributing Editor;
adviser for software, Robert Hogan, MD, San Diego.
This is not the only instance where
semantic gymnastics are used to cover
over seeming contradictions. But con¬
sistency, as Emerson noted, may be a
pathology is inadequate, because often
it is not related to prognosis or even
modifications of the surgical proce¬
dures.
Management of patients, such as pre-
operative preparation, postoperative

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 diets, and counseling and rehabilita¬
tion, is not covered, except in general,
nonspecific terms (chapter 11).
The authors' personal view of pub¬
lished data is stated in the preface: "the
surgeon makes little use of them, 'nu¬
merical presentations of such matters as
incidence rates and cure rates,' in his
clinical practice because they are rarely
applicable to the management of the
individual patient." Because of the au¬
thors' rejection of numbers, there are
puzzling incomplete statements. For ex¬
ample, in chapter 7 on the ear, the
incidence of tumors affecting the ear is
noted to be different from that of the
face—true, but no data are provided.
This atlas has about 600 black-and-
white illustrations and photographs,
the majority of which are excellent.
There are many serial illustrations that
clarify, stepwise, the surgical proce¬
dures. The artist, Ian Ramsden, de¬
serves great credit for the drawings.
There is much that is not covered in
the book. Again, there are no data on
morbidity, mortality, nursing care, re¬
habilitation, lengths of palliation, cure
rates, and functional results.
The posture of the plastic surgeon
predominates. Recent techniques de¬
veloped by oral surgeons are not men¬
tioned. Only a general discussion of
radiation therapy is included, and
chemotherapy (in contrast to an adver¬
tisement of the book) is dismissed in a
few paragraphs on page 345. Topical
chemotherapy is limited to a single in¬
definite sentence on page 64.
Chemosurgery is neither mentioned
nor indexed. There are no roent-
genograms, computed tomographic
scans, or tomograms. A majority of
references provide support for one or
another technical procedure. Chapter
23 (upper alveolus and palate) has but a
single reference, despite the complex
surgical topography of this area.
In brief, this is a beautifully illus¬
trated "how I do it" book related to
neoplasms of the face and oral cavity.
However, it should be subtitled "Atlas of
Surgical Techniques," not "Pathology
and Management."
George E. Moore, MD, PhD
Denver General Hospital
Pulmonary Circulation
The Human Pulmonary Circulation: Its Form
and Function in Health and Disease, by Peter
Harris and Donald Heath, 702 pp, with illus, $140,
New York, Churchill Livingstone Inc, 1986.
The third edition of The Human Pul-
monary Circulation: Its Form and
Function in Health and Disease by
Peter Harris, MD, and Donald Heath,
MD, is a classic textbook dealing with
all aspects of pulmonary circulation,
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including developmental anatomy,
structure-function relationships, funda-
mental concepts related to pressure and
flow, and the pathology, clinical pre-
sentation, and treatment of common
(chronic bronchitis and emphysema)
and less common (dietary pulmonary
hypertension) pulmonary diseases.
Since the last edition in 1977, the
authors have updated all their chap-
ters and references, although the
number of references is relatively small
and selective, and added a new, impor-
tant chapter on the pulmonary
endothelial cell.
In particular, the chapters on the
structure and function of vascular
smooth muscles, primary pulmonary
hypertension, pulmonary veno-occlu-
sive disease, and portal and pulmonary
hypertension are state-of-the-art. The
chapter on pharmacology of the pulmo-
nary circulation is complete and reflects
the many controversies still extant in
this area. The use of prostaglandins and
leukotrienes to control pulmonary cir¬
culation is explored. The light and elec¬
tron microscopy photographs that are
scattered liberally throughout the book
are top quality. There is an appendix
with a mathematical analysis and for¬
mulae derivations for pulsatile flow and
measurement of blood volume as well as
a left ventricular dye-curve for the
calculation of mean pulmonary transit
time.
As with all books, however, there are
some disappointments. The intended
audience is not defined in the foreword
to this or the last edition. From my
perusal of this book I would guess it is
intended for pulmonologists, cardiolo¬
gists, and pathologists with research
interests in the pulmonary circulation.
There are a few areas of interest to the
clinician, ie, vasodilator treatment of
primary pulmonary hypertension. The
sequence of chapter topics does not
seem logical; for example, although
some of the earlier chapters (6 through
9) deal with such basic physiological
concepts as pressure, flow, flow distri¬
bution, and resistance, ventilation-per¬
fusion relationships are not discussed
until chapter 41. There are several fac¬
tual errors. For example, in the pulmo¬
nary embolism chapter (40), the authors
state that, "Drugs intended for oral use
are sometimes dissolved in a medium
containing talcum or starch particles.
..." This statement is incorrect, be¬
cause drugs intended for oral use (ie,
pills or tablets) contain talc and micro-
crystalline cellulose. These inert sub¬
stances are used to mold and bind the
pills.
There are also some unusual (for an
American) uses of the English lan¬
guage. Valvular, as in "mitral valvular
disease," becomes "valvar." During an
excellent explanation of the dampening
phenomenon (chapter 6) as related to
pressure measurements, the authors
allude to "this spring and weight sus¬
pended in a jar of treacle," thus motivat¬
ing this reviewer to hurry to his dictio¬
nary to find that "treacle" is another
word for molasses.
The book is 649 pages long excluding
the appendix. It is eminently readable,
although not at one sitting. The price of
$140 is rather steep. However, this is a
classic textbook on a complex and fas¬
cinating subject and is an excellent
source book for those interested in the
physiology and biology of the pulmo¬
nary circulation.
Frederick L. Glauser, MD
Medical College of Virginia/McGuire
Veterans Administration Hospitals
Richmond
Neuromuscular Diseases
A Clinician's View of Neuromuscular Diseases,
by Michael H. Brooke, ed 2; 388 pp, with illus,
$44.50, Baltimore, Williams & Wilkins, 1986.
Nine years have elapsed since the
publication of the first edition of this
book, and many ofthe changes that have
occurred in the field of neuromuscular
diseases are included in this new edi-
tion. However, the format remains the
same, and the new, somewhat expanded
version is even better than the original.
This textbook describes the major
neuromuscular diseases, exclusive of
peripheral neuropathies, that produce
muscle weakness in children and adults.
The disorders covered include motor
neuron diseases, disorders of neuro-
muscular transmission, muscular dys-
trophies and myotonias, inflammatory
and metabolic myopathies, and congeni-
tal muscle diseases. An introductory
chapter describes the general approach
to diagnosis based on symptoms and
signs and provides many helpful clues
that Dr Brooke has garnered through
years of experience. A new section deal-
ing with exercise, muscle energetics,
and various stress-testing techniques
introduces and provides the foundation
for the chapter on metabolic myopa-
thies.
The book has ample illustrations, and
those dealing with muscle histopathol-
ogy are particularly helpful. The refer¬
ences are abundant and many from 1985
are included.
The title of the book and the preface
state clearly that clinicians are the tar¬
get readers, and Dr Brooke's aim is
true. The descriptions of the bedside
findings are detailed and accurate. The
author's extensive experience with
these disorders is evident as the dilem¬
mas of differential diagnosis and the
nuances of various treatments are de-