Book rewiews
Schaller, K. F., ed. Color Atlas of Tropical Dermatology and Venerology. Berlin, Heidelberg, New York: Springer-Verlag, 1994. 303 pp., index, 601 color figures. Springer-Verlag GmbH and Co. KG, Ticrgartenstrasse 17, D-69121 Heidelberg, Germany. Price DM 198.00.
This superb atlas from Springer-Verlag has been produced by Professor K F. Schaller and a small group of colleagues, mainly from Hamburg in Germany. There are 303 pages, with index, and no fewer than 601 figures in color, illustrating a wide range of dermatological and vencreological conditions found in the tropics, with a degree of clarity and color quality which will be difficult to surpass. The aim of this atlas, as the Preface emphasizes, is ". . . to provide clear guidance and a source of quick and easy reference for all physicians dealing with patients suffering from exotic skin diseases and for medical staff working in tropical and sub-tropical regions. It is not designed to replace the numerous excellent textbooks on tropical diseases and dermatology, but rather to supplement and complement them in a practical way."
The main chapter headings include: Viral Diseases of the Skin, Rickettsial Diseases, Bacterial Dermatoses, Endemic Treponcmatoses, Sexually Transmitted Diseases, Superficial Fungal Dermatoses, Deep Mycoses, Protozoan Dermatoses, Helminthic Dermatoses, Dermatoses due to Arthropods, Venomous Animals, Dermatoses due to Malnutrition, Maculopapulosquamous Dermatoses, Vesiculobulbous Eruptions, Connective Tissue Disorders, Urticaria, Erythema Multiforme and Drug Eruptions, Diseases of the Skin Appendages, Diseases Due to Physical Agents, Naevoid Conditions, Benign Skin Tumors, Malignant Skin Tumors and Miscellaneous Dermatoses. The succinct descriptive text alongside each set of color pictures will be valuable, but the great potential of this publication almost certainly lies in the unusually high quality and visual impact of the color pictures (the vast majority of which are from Professor Schaller's own collection), and which will surely be of great practical value in the identification and diagnosis of diseases due to infectious organisms, parasites, venomous animals and genetic, nutritional, chemical and physical factors. The Editor and his colleagues, and the publishers, are to be congratulated on the production of a color atlas of exceptional quality, which deserves wide circulation, not only in the tropics, but also in other parts of the world where patients may present with exotic dermatological and vencreological diseases. -A. Colin McDougall
Misra, R. S. Leprosy; a Reference Guide for Medical Practitioners, Programme Managers and Leprosy Workers. New Delhi: Concept Publishing Company, 1993. Hardbound, 353 pages, color and black and white illustrations, index. Available from Concept Publishing Company, A/15-16 Commercial Block, Mohan Garden, New Delhi, India 110059.
This 352-page book is intended for leprosy control workers and planners ofleprosy control programs. There are 17 distinguished contributors in addition to Professor Misra, 4 Brazilian, 1 from the U.K., the remainder from India.
Early in the book the point is made that leprosy is at a turning point. Leprosy has three dimensions: 1) medical, 2) public health, and 3) socioeconomic. These three facets have to work together in close unison if any leprosy control program is to be successful.
Throughout the book there are extensive tabulations of prevalence and new case detection rates in various leprosy-endemic areas with emphasis on India, which has the largest number of cases in the world. Details of various Indian control programs, targets, achievements by year of operation, etc., are given, some at the state and district levels.
Much of the information is aimed at an Indian reader. As an example, in discussing health education for early detection ofleprosy, Dr. A. B. Hiramani lists personnel who may be utilized for delivering health education. The list includes health workers, family members, etc., and members of the Manila Mandels. A half page later the reader learns that Mahila Mandels are ladies clubs.
There is an unusual collection of 26 appendices covering everything from the organizational charts of the NLEP to case loads of voluntary organizations operating in India to a listing of the major leprosy journals.
The book contains a vast amount of information relating to leprosy control activities in India. It should prove of considerable value to those working in these programs or planning to set up such programs elsewhere. -RCH
Van Parijs, Luc G. and Abraham, Betsy . Teaching Tools for Health Professionals. Leuven, Belgium: TAMILEP, 1993. Softbound, 275 pp., black and white illustrations. ISBN: 90-9006496-6. Available to all health professionals free of charge from: Teaching and Learning Materials, The Leprosy Mission, 80 Windmill Road, Brentford, Middlesex TW8 OQH, U.K.
"The purpose of this book is to provide busy health professionals with a guide to the selection and use of seven of the most widely available and effective tools for teaching. The book also provides an understanding of the principles of teaching and learning that are relevant for using those tools.
"The authors have distilled the essentials of their subject from their own deep and resourceful experiences as teachers, from the hundreds of learners they have worked with and from the vast literature that exists, much of which is not accessible to the people who need it the most.
"The most difficult task a teacher has to do is teaching a topic that seems simple, but is not, and which most people think they understand, but do not. The use of teaching tools is such a topic. Some may take the first step, try to understand and know they don't know, but are reluctant to admit it and often impatient to learn. This impatience may result in yet another superficial and hurried attempt to learn in a few minutes that which takes serious study.
"It is likely that you have taken the first step. If this is so, I urge you to read the Introduction and Section One. They will help you immensely to understand why you should choose specific tools for specific teaching tasks. Section Two will help you to understand how the tools can be used most effectively.
"The effective practice of a profession depends on competence in the use of the 'tools of the trade.' For those who have to teach, but do not enjoy it, and for the many who want to teach, but fear that they do not know how to use the tools available for teaching, this book will be invaluable." -Foreword by Dr. Felton Ross
Yawalkar, S. J. Leprosy for Medical Practitioners and Paramedical Workers. 6th edn. Basel: CIBA-GEIGY Limited, 1994. Softbound, 140 pp., many color and black and white illustrations. Available from CIBA-GEIGY Ltd., Basel, Switzerland.
This edition is dedicated to the late "Dr. R. H. Thangaraj who lived for the causes of leprosy," and who co-authored the first four editions of this textbook, first published in 1986.
As the author states in his Preface, "Leprosy, one of the major public health problems of the developing countries, is well known for the strong stigma associated with it. The treatment of leprosy sufferers throughout history is one of the darker examples of man's inhumanity to man. In spite of the considerable enlightenment and information about leprosy available today, the fear and prejudices regarding leprosy and the leprosy patient remain to a large extent ingrained and persistent. This is therefore still one of the most trying diseases that man has to endure.
"The principle of reducing the load of infection in society, to break the chain of infection, is the cornerstone of leprosy control work today. It implies early diagnosis and early adequate drug treatment to make the patient non-infectious. In 1982, the World Health Organization recommended multidrug therapy (MDT) regimens for the treatment of patients with leprosy. MDT is now recognized as the key to the control and eradication of the disease.
"A considerable number of patients first consult general practitioners and keep away from leprosy centres because of the stigma, shame and fear associated with this disease. The cooperation of medical practitioners is therefore essential for leprosy control. The purpose of this monograph is to provide basic information on leprosy and its treatment. New chapters on physiotherapy and plantar ulcers have been added to the fifth and sixth editions, respectively. It is hoped that the monograph will be of practical value, especially to medical practitioners, medical students and paramedical workers, and that it will stimulate their interest in the subject."
Again in this edition, Professor Yawalkar has produced a remarkably succinct, lavishly and clearly illustrated, authoritative monograph on leprosy. It should prove highly useful, and Professor Yawalkar is again to be congratulated. -RCH
Chatterjee, B. R., ed. Leprosy; Etiobiology of Manifestations, Treatment and Control. Jhalda, India: Leprosy Field Research Unit, 1993. Hardbound, 590 pp., illustrations in black and white and color.
"A reference book for graduate- and postgraduate-level researchers, teachers and students of leprology, for medical men engaged in treatment and management of leprosy, and for planners and administrators of leprosy control/containment programs. Contains writings on all aspects of the leprosy problem dealt with from a basic biological point of view from active scientists, teachers and practitioners in the laboratory, clinic/ hospital/field, and from nodal agencies involved in leprosy control-product of extensive literature research of work done all over the world, with citation of 1657 published papers, 180 black and white and 12 color illustrations, 69 figures and graphs, 79 tables and 7 flow diagrams.
"The hard-bound book has been published by the Leprosy Field Research Unit, Jhalda 72302, India, in October 1993 and printed on art paper at The Statesman Commercial Press, Calcutta. The text material of the book runs 590 pages and is priced at 1200 Rupees, US$90, 60£ Sterling. Postage and handling within India costs 40 Rupees, while the cost of overseas air parcel and handling runs to almost 10% of the basic price.
"Checks, drafts, etc., covering the basic price, postage and handling costs are to be made out to "Leprosy Field Research Unit," and mailed to Leprosy Field Research Unit, P.O. Jhalda, 723202, West Bengal, India."-From the book announcement.
This is an authoritative textbook of leprosy. It bears the unmistakable style and encyclopedic knowledge of the editor, containing opinions which are not always "mainstream," but guaranteed to be stimulating. The list of contributors is very impressive, making up a highly respected group of international authorities in the field.
Within the first two chapters of the book, on epidemiology and bacteriology and both authored by the editor, attention-getting suggestions and comments are made that 1) Mycobacterium leprae could perhaps attain growth-competence if it were cultivated with another, growth-competent microorganism. 2) Dapsone treatment is associated with increased disabilities clinically. 3) Type 1 reactions are part and parcel of active disease. 4) The incubation period of leprosy is 6-24 months, but there may be a latent (infected but asymptomatic) period of many years before the disease becomes apparent. 5) M. leprae may have already been cultivated as a soft-walled or wall-deficient L-form which may later become typical acidfast rods.
Almeida contributes a brilliant, thoughtprovoking, and out-spoken chapter on the quantitative aspects of drug resistance in leprosy. If one accepts the many, all reasonable, assumptions made, the mathematics lead to the conclusion that sulfone resistance is uncommon. Taken to the extreme, the author concludes that both primary and secondary dapsone resistance consist of". . . little more than artefacts of the mouse foot-pad test, with questionable relevance to patients." Most clinicians who cared for sulfone-resistant lepromatous patients in the years before clofazimine became available can attest to the non-artefactual nature of the bacteriologically progressive disease in compliant patients taking sulfones.
Rook provides an excellent overview of the immunology of leprosy, concluding with the candid statement that the ". . . immunology of leprosy remains as confusing as ever. There are now too many possible explanations."
Excellent, succinct chapters are contributed by de Vries on the relationship between HLA and leprosy type, by Saha and Chakrabarty on complement, by Bharadwaj on seroepidemiology, and by Sengupta and Sinha on monoclonal antibodies.
Chatterjee authors a chapter entitled "Immunopathogenesis of Leprosy-Facts and Artefacts." In an admittedly uninhibited interpretation of published findings he concludes: 1) Neural colonization by M. leprae is a secondary event which is driven by the immune response. 2) All clinical cases of leprosy are borderline and are in a perpetual state of reaction, silent or "noisy." 3) The role of T suppressor cells is in controlling DTH and type 1 reactions.
Stanford contributes a fascinating chapter on environmental mycobacteria. The greater a person's poverty the less his possessions and the greater his contact with his environment, including the mycobacteria in it.
Ramanujam writes an authoritative chapter on clinical aspects, and Bhutani and Yawalkar provide two excellent chapters on differential diagnosis. A chapter is included on complications of leprosy by the late A. B. A. Karat.
Chatterjee's views on therapy are unconventional, thought-provoking, and in places likely to be erroneous by conventional thinking. "If killing M. leprae could cure leprosy, our job would be much easier." ". . . while killing of bacilli will be an important target, the most important objective of leprosy treatment and management will have to be prevention of reaction, neuritis, and deformity." Neither the killing of persisters nor disposing of killed bacilli are achieved by chemotherapy. Most would disagree with the theory that dapsone actually acts, not on the bacilli, but by means of the host's defenses. Even more would disagree with the assertion that low-dose dapsone is preferable clinically to conventional doses. The evidence that low-dose dapsone is immunostimulatory and "high"-dose dapsone is immunosuppressive to the host does not seem as strong as the evidence for a conventional mechanism of action of dapsone in inhibiting folate synthesis in the bacilli, a mechanism which is accepted to require the maximum tolerated concentration of drug to achieve the maximum inhibition of the bacterial enzyme and thus the maximum benefit to the host.
Ramu contributes a masterful chapter on reactions. It points out that Ramu observed the beneficial effect of chloroquinc on erythema nodosum leprosum (ENL) in 1959, and that Roche, Convit, et al. first used corticosteroids (ACTH) in reactions in 1951. Colchicine is recommended for ENL.
Palande authors excellent chapters on nerve surgery and reconstructive surgery of deformities. Srinivasan contributes two very well written chapters on plantar ulcers, providing well-deserved emphasis to this very important complication of the disease.
Chatterjee authors the chapter on control and eradication of leprosy. Several important observations are made regarding multidrug therapy (MDT). Post-MDT surveillance is suffering with regard to the detection of relapses and the care of deformities. There is an air of complacency once the intensive phase of the MDT campaign is over. The importance of propaganda is in increasing the number and proportion of self-reporting cases. The importance of a successfully treated, non-deformed leprosy patient restored to normalcy in his community, and the willingness of neighborhood doctors and health care workers to treat leprosy as a disease like any other are the two most powerful tools in health education in leprosy.
Noordeen outlines the WHO strategy for eliminating leprosy as a public health problem by the year 2000.
Mittal discusses the national strategy for the elimination of leprosy in India. In districts of the country with a leprosy prevalence of 5% or more and with an inadequate leprosy infrastructure, primary health care workers were put in charge of the leprosy work. Cash incentives were offered patients for collecting drugs, for completing treatment on time, and for reporting another new case of leprosy. The experience with this approach has not been satisfactory and the current plan is to have MDT delivered by separate workers supported by funding from the World Bank. So far the prevalence of the disease has almost been halved due to the release of patients from treatment after MDT is completed, but there are still approximately 450,000 new cases detected annually and this figure has not changed as yet. It is planned that by the year 2000 leprosy services will be totally integrated with the General Health Services in India.
Chatterjee concludes the book with a chapter entitled, "Anti-oxidants, Meny Bergel, dapsone, and down-grading of Hansen's of bacterial clearing when used as a corndisease." The author feels that ". . . lowponent of a multidrug regimen compared to dose dapsone never got a fair trial." From the rates of bacterial clearing in multidrug the literature he concludes that dapsone in regimens which do not contain dapsone.- currently conventional doses slows the rate RCH