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A SINGLE-OPERATOR TECHNIQUE FOR FIRST-TRIMESTER CHORION BIOPSY
1340
G, of each patient). Within each individual, however, analysis of cell viabilities, irrespective of whether the cells were incubated alone (A) or with the various ricin-A-chain/TG combinations (B-G), revealed no significant difference. DISCUSSION
With the successful conjugation of the autoantigen thyroglobulin to free ricin A chain by means of the heterobifunctional reagent SPDP we have produced a stable TG-ricin immunotoxin. Preincubation of PBM from patients with autoimmune thyroid disease with the immunotoxin produced a dramatic but highly selective abolition of the TG autoantibody response. No such suppression of TG autoantibody synthesis occurred when the cells were preincubated with TG alone or ricin A chain alone. In addition no alteration in total immunoglobulin or thyroid microsome autoantibody synthesis was observed, whatever the preincubation conditions used. Clearly, therefore, conjugation of an autoantigen with the A chain of ricin toxin can provide an immunotoxin which may have the capacity selectively to delete only B lymphocyte clones that recognise the specific autoantigen. The ability selectively to delete autoreactive B cell clones has important implications for the therapeutic manipulation of the aberrant immune response in patients with autoimmune diseases that are autoantibody-mediated and in which the antigen to which the antibody is made is characterised. These preliminary observations in vitro demonstrate that such an approach is feasible, though clearly in-vivo studies are now required. Such studies are now being carried out in an animal model of autoimmune thyroid disease in our laboratory. This work was supported by grants from the Wellcome Trust and the Medical Research Council. We thank Dr J. A. Forrester (Chester Beatty Institute, London) for providing the ricin and Dr B. M. J. Foxwell and Mr J. A. G. Bremner Jr (Imperial Cancer Research Fund, London) for their help in preparing the A chain. Miss A. Berry’s secretarial help is much appreciated.
Correspondence should be addressed to A. M.
Methods and Devices A SINGLE-OPERATOR TECHNIQUE FOR FIRSTTRIMESTER CHORION BIOPSY
C. H. RODECK K. H. NICOLAIDES
J. M. MORSMAN C. MCKENZIE
Harris-Birthright Research Centre for Fetal Medicine, Department of Obstetrics and Gynaecology, King’s College Hospital Medical School, London SE5 C. M. GOSDEN
J. R. GOSDEN MRC Clinical and Population Cytogenetics Unit, Edinburgh THE
possibility
of first-trimester
prenatal diagnosis has
stimulated the development of a multiplicity of methods for taking chorion biopsies. Ultrasound-guided transcervical passage of an endoscope with direct-vision aspiration ofvilli2 has been successful, but it is a relatively complex technique, and teaching it can be difficult. We describe here a simpler ultrasound-guided method.
Equipment The equipment (see figure) consists ofa17 cm 16-gauge malleable silver cannula (Downs Surgical plc). One end has a Tucker valve with ostium to control suction pressure, and a standard Luer fitment. A flexible blunt stainless-steel obturator is passed down the cannula, allowing this to be bent without kinking and facilitating introduction through the internal os. A standard mucus aspirator with trap is connected to the cannula and to a theatre suction pump. A high-resolution real-time scanner (ADR, Squibb Medical Systems) is essential, and both 3’5MHz and 5 MHz probes may be needed. A lower-power dissecting microscope is at hand to identify chorionic villi.
M. G.
REFERENCES
JH, McGregor AM, Hall R. Pathogenesis, diagnosis and management of Graves’ disease. Clin Surg Int 1983, 6: 127-39. 2. Hershman JM, Givens JR, Cassidy CE, Astwood EB. Long-term outcome of hyperthyroidism treated with antithyroid drugs. J Clin Endocrinol 1966; 26: 803-07. 3. Strakosch CR, Wenzel BE, Row VV, Volpé R. Immunology of autoimmune thyroid diseases. N Engl J Med 1982; 307: 1499-507. 4. McGregor AM, Petersen MM, McLachlan SM, Rees Smith B, Hall R Treatment and the autoimmune response in Graves’ disease. J Mol Med 1980; 4: 119-27. 5. Davies AJS, Crumpton MJ. Experimental approaches to drug targeting. Cancer Surveys 1982; 1: 347-559. 6. Vitetta ES, Krolick KA, Miyama-Inaba M, Cushley W, Uhr JW. Immunotoxins: a new approach to cancer therapy Science 1983; 219: 644-50. 7. Olsnes S, Pihl A. Toxic lectins and related proteins In: Cohen P, van Heyningen S. eds. Molecular actions of toxins and viruses. Amsterdam: Elsevier, 1982: 51-105. 8. Krolick KA, Villemez C, Isakson P, Uhr JW, Vitetta ES. Selective killing of normal or neoplastic B cells by antibodies coupled to the A-chain of ricin. Proc Natl Acad Sci 1980; 77: 5419-23 9. Trowbridge IS, Domingo DL. Anti-transferrin receptor monoclonal antibody and toxin-antibody conjugates affect growth of human tumour cells. Nature 1981, 294: 171-73. 10. Thorpe PE, Mason DW, Brown ANF, Simmonds SJ, Ross WCJ, Cumber AJ, Forrester JA. Selective killing of malignant cells in a leukaemic rat bone marrow using an antibody-ricin conjugate. Nature 1982; 297: 594-96. 11. Thorpe PE, Ross WCJ. The preparation and cytotoxic properties of antibody-toxin conjugates. Immunol Rev 1982; 62: 119-58. 12. Volkman DJ, Ahmad A, Fauci AS, Neville DM. Selective abrogation of antigenspecific human B cell responses by antigen-ricin conjugates. J Exp Med 1982; 156: 634-39. 13. Feldt-Rasmussen U. Purification of human thyroglobulin for radioimmunoassay and testing by ultracentrifugal analysis and immunoelectrophoresis. J Immunol Methods 1. Lazarus
1978; 21: 295-303. 14. Olsnes S, Pihl A Different biological
of ricin, a 3121-26. 15. Weetman AP,
toxic
properties of the two constitutent peptide chains protein inhibiting protein synthesis. Biochemistry 1973; 12:
McGregor AM, production by an action on
39-45.
Hall R. Methimazole inhibits accessory cells. Clin Immunol
thyroid autoantibody Immpathol 1983; 28:
16-gauge silver cannula and obturator for first-trimester ultrasoundguided aspiration biopsy of chorionic villi. Procedure With the patient in the lithotomy position the vulva, perineum, vagina, and cervix are cleansed and the patient is draped. A Sim’s speculum is inserted and gentle traction is exerted on the cervix with a tenaculum. No analgesia or sedation is needed. With the patient’s bladder moderately full, the uterus is scanned, and the number of embryos, the heart rate, and the gestational age (by measurement of crown-rump length3and gestation sac volume4) are determined. Chorionic villi are recognised by their characteristic echogenicity. Before 10 weeks’ gestation they are found all around the gestation sac, and the implantation site cannot be accurately defined. After 10 weeks the placenta can usually be located, since most of the extraplacental villi have degenerated to form chorion laeve. The cannula and obturator are bent appropriately and passed through the cervix with one hand, while the operator holds the ultrasound transducer in the other. The cannula is highly echogenic and is easily guided between gestation sac and uterine wall into an area rich in villi. An assistant steadies the tenaculum, removes the obturator, and attaches the mucus extractor. A vacuum of up to 750 mm Hg is induced, and the tip of the cannula is moved to and fro by a
few millimetres. On the ultrasound screen chorionic villi may be entering the cannula. After 15-20 s the cannula is withdrawn under continuous sunction. Physiological saline is aspirated from a gallipot, and this, together with the tissue in the cannula, enters the trap; the contents are examined under the microscope. seen
1341 At the end of the procedure the fetal heart rate is checked and any bleeding through the cervix is noted (there usually is none).
Results 40 patients had biopsy specimens taken between 7 and 12 weeks’ gestation-32 before termination of pregnancy and 8 for diagnostic reasons (fetal sexing in X-linked diseases, 5; haemoglobinopathies,
2; and chromosome analysis, 1). Chorionic villi were obtained in 36 (90%). The estimated weight of chorion was 10-30 mg, but the samples sometimes contained decidual debris, which was carefully separated under the microscope. All 4 failures were in termination patients; 3 were among the earliest attempts, and 1 of these had a blighted ovum. Lack of a microscope accounted for the 4th, more recent, failure (no 17). In the last 23 consecutive patients, chorionic villi were obtained in all (100%). The fetal heart rate was normal at the end of each procedure, and slight bleeding was noted in 5 patients. Of the 8 diagnostic patients, 6 have normally continuing pregnancies; 2 had terminations because the fetal sex was male, but the pregnancies had progressed normally for 2 weeks after biopsy. In addition, planned termination was delayed by 4 days in 2 patients, and the fetus was alive immediately before aspiration curettage. There were no intrauterine deaths or spontaneous abortions.
Comment
decidual fragments may be present, and careful separation by means of microscopy is essential to avoid maternal contamination. The silver cannula has a number of advantages. It can be fashioned to the desired shape which it then retains after removal of the obturator; this, together with its echogenicity on the ultrasound screen, means it can be accurately placed and guided. Still finer control is achieved by the operator performing the ultrasound guidance himself; precision is enhanced, damage is diminished, and the assistant need not be skilled. The safetv of the method needs further assessment in continuing pregnancies.
J. M. M. and C. M. are supported by MRC grant no 8209273 CA. We thank Prof D.J.WeatheraII and Dr J. Old, of Oxford University, for car ryng out the DNA analysis on the haemoglobinopathy patients.
Correspondence
Reviews of Books Brain Tumours in the
Young
Luis V. Amador, Northwestern University Medical School Chicago. Springfield, Illinois: Charles C. Thomas. 1983. Pp 900.$125.
THERE has been a need for an authoritative text on childhood brain tumours for some time and on the whole this book should fill it. Most of the thirty-two lavishly illustrated chapters have been written by neurosurgeons and neuroradiologists working in the United States. In addition to chapters on individual tumours and evaluation of patients, there are sections covering epidemiology, psychosocial problems, the physiology and management of raised intracranial pressure, anaesthesia of children undergoing surgery for brain tumours, hydatid disease and tuberculosis, endocrinology, and chemotherapy and radiation therapy. There is an excellent chapter on neuropathology, which I found most useful. I highly recommend the chapters on hydatidosis and tuberculosis, which are good personal accounts by authors (from Argentina and India, respectively) with wide experience of their subject. A major problem with this book is repetition. The first chapter covers the epidemiology of brain tumours and, although some of the terminology is confusing, why should it be necessary to repeat statistics at length in subsequent chapters on specific tumour types? The excellent chapter on pathology is clearly written and well illustrated; yet authors on individual tumours repeat much of this information. And despite 300 pages of neuroradiology (some of it repetitious in itself), the chapters on neoplasms of the cerebral hemispheres contain 18 pages on investigation. This book could have been shortened considerably, with consequent lowering of its price. The second fault with this book may be due to the time it takes for publication. The chapter on endocrinology has no references after 1976. Consequently there is little if any mention of endocrine problems following the treatment of medulloblastoma, a major area of interest in the past seven years. Chemotherapy and radiation therapy of childhood brain tumours are dealt with in some 30 pages. There was possibly little to say about chemotherapy at the time the chapter was written, but the dose of vincristine, which is given as 1 - 5 mg/m2, should have been qualified by the point that the maximum dose is 2 mg. One of the most frustrating problems to manage postoperatively is ventriculo-peritoneal shunt infections, so I looked forward to being
to
C. H. R.
REFERENCES 1. Rodeck
CH, Morsman JM. First trimester chorion biopsy. Br Med Bull 1983; 39:
338-42. 2. Rodeck
CH, Morsman JM, Gosden CM, Gosden JR. The development of an improved trimester microsampling of chorion Br J Obstet Gynaecol (in press). Robinson HP. Sonar measurement of fetal crown-rump length as a means of assessing maturity in the first trimester of pregnancy. Br MedJ 1973; 4: 28-31. Robinson HP. Gestation "sac" volumes as determined by sonar in the first trimester of pregnancy. Br J Obstet Gynaecol 1975; 82: 100-07.
technique for first
3.
This simple quick technique yields biopsy specimens of chorionic villi in the first trimester with a high degree of reliability. However,
should be addressed
4.
enlightened about its natural history and management; but 1 could find no mention of it in the index and in relevant chapters. Apart from the reservations expressed above, I would recommend this textbook to large libraries; I doubt if there are many individuals or departments able to afford$125. Department of Oncology, BristolRoyal Hospital for Sick Children
A Guide to Gastrointestinal
A. OAKHILL
Motility
Edited by James Christensen, University of Iowa, and David L. Wingate, London Hospital Medical College. Bristol and Boston: Wright/PSG. 1983. Pp 253. £ 25.
AFTER many years in the doldrums, interest in gastrointestinal motility, both in laboratory animals and in health and disease in man, has revived. As so often, this revival is due to the arrival of new techniques, such as electrophysiological methods for the study of smooth muscle activity, and neuropharmacological techniques for the investigation of the multitude of neurohormonal stimuli that affect (and sometimes afflict) the gut. This book is a review of the current state of the art; in this area it is not surprising that much of the literature cited is old, but newer work published up to 1982 is included. The first two chapters discuss in detail the innervation and smooth muscle of the gastrointestinal tract. Inevitably, much of the work described here has been done on mammalian rather than human tissue. Individual chapters then discuss in depth the motility of the oesophagus, stomach, small intestine, biliary tract, and colon. There is some inconsistency in presentation, with variable emphasis on mathematical models, microscopy, and animal anatomy and physiology, though probably no more than would be expected in a multiauthor book and after allowance has been made for the extent to which different parts of the gut have been investigated. There is some overlap between early and later chapters, regrettable in a book which is not cheap at £ 25 for 250 pages. I found the "short-notes" format of the chapter on methodology irritating. In future editions this section could be profitably extended, re-written, and placed earlier in the book, and an attempt made to edit out later repetition. Finally, in the same format, there is a synopsis of clinical syndromes. The classifications of these is odd and the emphasis sometimes inappropriate. For example, there are separate sections for idiopathic vomiting and pyloric stenosis, but the irritable bowel syndrome, surely the motility disorder par excellence, is given two lines, and rumination nearly half a page.
G, of each patient). Within each individual, however, analysis of cell viabilities, irrespective of whether the cells were incubated alone (A) or with the various ricin-A-chain/TG combinations (B-G), revealed no significant difference. DISCUSSION
With the successful conjugation of the autoantigen thyroglobulin to free ricin A chain by means of the heterobifunctional reagent SPDP we have produced a stable TG-ricin immunotoxin. Preincubation of PBM from patients with autoimmune thyroid disease with the immunotoxin produced a dramatic but highly selective abolition of the TG autoantibody response. No such suppression of TG autoantibody synthesis occurred when the cells were preincubated with TG alone or ricin A chain alone. In addition no alteration in total immunoglobulin or thyroid microsome autoantibody synthesis was observed, whatever the preincubation conditions used. Clearly, therefore, conjugation of an autoantigen with the A chain of ricin toxin can provide an immunotoxin which may have the capacity selectively to delete only B lymphocyte clones that recognise the specific autoantigen. The ability selectively to delete autoreactive B cell clones has important implications for the therapeutic manipulation of the aberrant immune response in patients with autoimmune diseases that are autoantibody-mediated and in which the antigen to which the antibody is made is characterised. These preliminary observations in vitro demonstrate that such an approach is feasible, though clearly in-vivo studies are now required. Such studies are now being carried out in an animal model of autoimmune thyroid disease in our laboratory. This work was supported by grants from the Wellcome Trust and the Medical Research Council. We thank Dr J. A. Forrester (Chester Beatty Institute, London) for providing the ricin and Dr B. M. J. Foxwell and Mr J. A. G. Bremner Jr (Imperial Cancer Research Fund, London) for their help in preparing the A chain. Miss A. Berry’s secretarial help is much appreciated.
Correspondence should be addressed to A. M.
Methods and Devices A SINGLE-OPERATOR TECHNIQUE FOR FIRSTTRIMESTER CHORION BIOPSY
C. H. RODECK K. H. NICOLAIDES
J. M. MORSMAN C. MCKENZIE
Harris-Birthright Research Centre for Fetal Medicine, Department of Obstetrics and Gynaecology, King’s College Hospital Medical School, London SE5 C. M. GOSDEN
J. R. GOSDEN MRC Clinical and Population Cytogenetics Unit, Edinburgh THE
possibility
of first-trimester
prenatal diagnosis has
stimulated the development of a multiplicity of methods for taking chorion biopsies. Ultrasound-guided transcervical passage of an endoscope with direct-vision aspiration ofvilli2 has been successful, but it is a relatively complex technique, and teaching it can be difficult. We describe here a simpler ultrasound-guided method.
Equipment The equipment (see figure) consists ofa17 cm 16-gauge malleable silver cannula (Downs Surgical plc). One end has a Tucker valve with ostium to control suction pressure, and a standard Luer fitment. A flexible blunt stainless-steel obturator is passed down the cannula, allowing this to be bent without kinking and facilitating introduction through the internal os. A standard mucus aspirator with trap is connected to the cannula and to a theatre suction pump. A high-resolution real-time scanner (ADR, Squibb Medical Systems) is essential, and both 3’5MHz and 5 MHz probes may be needed. A lower-power dissecting microscope is at hand to identify chorionic villi.
M. G.
REFERENCES
JH, McGregor AM, Hall R. Pathogenesis, diagnosis and management of Graves’ disease. Clin Surg Int 1983, 6: 127-39. 2. Hershman JM, Givens JR, Cassidy CE, Astwood EB. Long-term outcome of hyperthyroidism treated with antithyroid drugs. J Clin Endocrinol 1966; 26: 803-07. 3. Strakosch CR, Wenzel BE, Row VV, Volpé R. Immunology of autoimmune thyroid diseases. N Engl J Med 1982; 307: 1499-507. 4. McGregor AM, Petersen MM, McLachlan SM, Rees Smith B, Hall R Treatment and the autoimmune response in Graves’ disease. J Mol Med 1980; 4: 119-27. 5. Davies AJS, Crumpton MJ. Experimental approaches to drug targeting. Cancer Surveys 1982; 1: 347-559. 6. Vitetta ES, Krolick KA, Miyama-Inaba M, Cushley W, Uhr JW. Immunotoxins: a new approach to cancer therapy Science 1983; 219: 644-50. 7. Olsnes S, Pihl A. Toxic lectins and related proteins In: Cohen P, van Heyningen S. eds. Molecular actions of toxins and viruses. Amsterdam: Elsevier, 1982: 51-105. 8. Krolick KA, Villemez C, Isakson P, Uhr JW, Vitetta ES. Selective killing of normal or neoplastic B cells by antibodies coupled to the A-chain of ricin. Proc Natl Acad Sci 1980; 77: 5419-23 9. Trowbridge IS, Domingo DL. Anti-transferrin receptor monoclonal antibody and toxin-antibody conjugates affect growth of human tumour cells. Nature 1981, 294: 171-73. 10. Thorpe PE, Mason DW, Brown ANF, Simmonds SJ, Ross WCJ, Cumber AJ, Forrester JA. Selective killing of malignant cells in a leukaemic rat bone marrow using an antibody-ricin conjugate. Nature 1982; 297: 594-96. 11. Thorpe PE, Ross WCJ. The preparation and cytotoxic properties of antibody-toxin conjugates. Immunol Rev 1982; 62: 119-58. 12. Volkman DJ, Ahmad A, Fauci AS, Neville DM. Selective abrogation of antigenspecific human B cell responses by antigen-ricin conjugates. J Exp Med 1982; 156: 634-39. 13. Feldt-Rasmussen U. Purification of human thyroglobulin for radioimmunoassay and testing by ultracentrifugal analysis and immunoelectrophoresis. J Immunol Methods 1. Lazarus
1978; 21: 295-303. 14. Olsnes S, Pihl A Different biological
of ricin, a 3121-26. 15. Weetman AP,
toxic
properties of the two constitutent peptide chains protein inhibiting protein synthesis. Biochemistry 1973; 12:
McGregor AM, production by an action on
39-45.
Hall R. Methimazole inhibits accessory cells. Clin Immunol
thyroid autoantibody Immpathol 1983; 28:
16-gauge silver cannula and obturator for first-trimester ultrasoundguided aspiration biopsy of chorionic villi. Procedure With the patient in the lithotomy position the vulva, perineum, vagina, and cervix are cleansed and the patient is draped. A Sim’s speculum is inserted and gentle traction is exerted on the cervix with a tenaculum. No analgesia or sedation is needed. With the patient’s bladder moderately full, the uterus is scanned, and the number of embryos, the heart rate, and the gestational age (by measurement of crown-rump length3and gestation sac volume4) are determined. Chorionic villi are recognised by their characteristic echogenicity. Before 10 weeks’ gestation they are found all around the gestation sac, and the implantation site cannot be accurately defined. After 10 weeks the placenta can usually be located, since most of the extraplacental villi have degenerated to form chorion laeve. The cannula and obturator are bent appropriately and passed through the cervix with one hand, while the operator holds the ultrasound transducer in the other. The cannula is highly echogenic and is easily guided between gestation sac and uterine wall into an area rich in villi. An assistant steadies the tenaculum, removes the obturator, and attaches the mucus extractor. A vacuum of up to 750 mm Hg is induced, and the tip of the cannula is moved to and fro by a
few millimetres. On the ultrasound screen chorionic villi may be entering the cannula. After 15-20 s the cannula is withdrawn under continuous sunction. Physiological saline is aspirated from a gallipot, and this, together with the tissue in the cannula, enters the trap; the contents are examined under the microscope. seen
1341 At the end of the procedure the fetal heart rate is checked and any bleeding through the cervix is noted (there usually is none).
Results 40 patients had biopsy specimens taken between 7 and 12 weeks’ gestation-32 before termination of pregnancy and 8 for diagnostic reasons (fetal sexing in X-linked diseases, 5; haemoglobinopathies,
2; and chromosome analysis, 1). Chorionic villi were obtained in 36 (90%). The estimated weight of chorion was 10-30 mg, but the samples sometimes contained decidual debris, which was carefully separated under the microscope. All 4 failures were in termination patients; 3 were among the earliest attempts, and 1 of these had a blighted ovum. Lack of a microscope accounted for the 4th, more recent, failure (no 17). In the last 23 consecutive patients, chorionic villi were obtained in all (100%). The fetal heart rate was normal at the end of each procedure, and slight bleeding was noted in 5 patients. Of the 8 diagnostic patients, 6 have normally continuing pregnancies; 2 had terminations because the fetal sex was male, but the pregnancies had progressed normally for 2 weeks after biopsy. In addition, planned termination was delayed by 4 days in 2 patients, and the fetus was alive immediately before aspiration curettage. There were no intrauterine deaths or spontaneous abortions.
Comment
decidual fragments may be present, and careful separation by means of microscopy is essential to avoid maternal contamination. The silver cannula has a number of advantages. It can be fashioned to the desired shape which it then retains after removal of the obturator; this, together with its echogenicity on the ultrasound screen, means it can be accurately placed and guided. Still finer control is achieved by the operator performing the ultrasound guidance himself; precision is enhanced, damage is diminished, and the assistant need not be skilled. The safetv of the method needs further assessment in continuing pregnancies.
J. M. M. and C. M. are supported by MRC grant no 8209273 CA. We thank Prof D.J.WeatheraII and Dr J. Old, of Oxford University, for car ryng out the DNA analysis on the haemoglobinopathy patients.
Correspondence
Reviews of Books Brain Tumours in the
Young
Luis V. Amador, Northwestern University Medical School Chicago. Springfield, Illinois: Charles C. Thomas. 1983. Pp 900.$125.
THERE has been a need for an authoritative text on childhood brain tumours for some time and on the whole this book should fill it. Most of the thirty-two lavishly illustrated chapters have been written by neurosurgeons and neuroradiologists working in the United States. In addition to chapters on individual tumours and evaluation of patients, there are sections covering epidemiology, psychosocial problems, the physiology and management of raised intracranial pressure, anaesthesia of children undergoing surgery for brain tumours, hydatid disease and tuberculosis, endocrinology, and chemotherapy and radiation therapy. There is an excellent chapter on neuropathology, which I found most useful. I highly recommend the chapters on hydatidosis and tuberculosis, which are good personal accounts by authors (from Argentina and India, respectively) with wide experience of their subject. A major problem with this book is repetition. The first chapter covers the epidemiology of brain tumours and, although some of the terminology is confusing, why should it be necessary to repeat statistics at length in subsequent chapters on specific tumour types? The excellent chapter on pathology is clearly written and well illustrated; yet authors on individual tumours repeat much of this information. And despite 300 pages of neuroradiology (some of it repetitious in itself), the chapters on neoplasms of the cerebral hemispheres contain 18 pages on investigation. This book could have been shortened considerably, with consequent lowering of its price. The second fault with this book may be due to the time it takes for publication. The chapter on endocrinology has no references after 1976. Consequently there is little if any mention of endocrine problems following the treatment of medulloblastoma, a major area of interest in the past seven years. Chemotherapy and radiation therapy of childhood brain tumours are dealt with in some 30 pages. There was possibly little to say about chemotherapy at the time the chapter was written, but the dose of vincristine, which is given as 1 - 5 mg/m2, should have been qualified by the point that the maximum dose is 2 mg. One of the most frustrating problems to manage postoperatively is ventriculo-peritoneal shunt infections, so I looked forward to being
to
C. H. R.
REFERENCES 1. Rodeck
CH, Morsman JM. First trimester chorion biopsy. Br Med Bull 1983; 39:
338-42. 2. Rodeck
CH, Morsman JM, Gosden CM, Gosden JR. The development of an improved trimester microsampling of chorion Br J Obstet Gynaecol (in press). Robinson HP. Sonar measurement of fetal crown-rump length as a means of assessing maturity in the first trimester of pregnancy. Br MedJ 1973; 4: 28-31. Robinson HP. Gestation "sac" volumes as determined by sonar in the first trimester of pregnancy. Br J Obstet Gynaecol 1975; 82: 100-07.
technique for first
3.
This simple quick technique yields biopsy specimens of chorionic villi in the first trimester with a high degree of reliability. However,
should be addressed
4.
enlightened about its natural history and management; but 1 could find no mention of it in the index and in relevant chapters. Apart from the reservations expressed above, I would recommend this textbook to large libraries; I doubt if there are many individuals or departments able to afford$125. Department of Oncology, BristolRoyal Hospital for Sick Children
A Guide to Gastrointestinal
A. OAKHILL
Motility
Edited by James Christensen, University of Iowa, and David L. Wingate, London Hospital Medical College. Bristol and Boston: Wright/PSG. 1983. Pp 253. £ 25.
AFTER many years in the doldrums, interest in gastrointestinal motility, both in laboratory animals and in health and disease in man, has revived. As so often, this revival is due to the arrival of new techniques, such as electrophysiological methods for the study of smooth muscle activity, and neuropharmacological techniques for the investigation of the multitude of neurohormonal stimuli that affect (and sometimes afflict) the gut. This book is a review of the current state of the art; in this area it is not surprising that much of the literature cited is old, but newer work published up to 1982 is included. The first two chapters discuss in detail the innervation and smooth muscle of the gastrointestinal tract. Inevitably, much of the work described here has been done on mammalian rather than human tissue. Individual chapters then discuss in depth the motility of the oesophagus, stomach, small intestine, biliary tract, and colon. There is some inconsistency in presentation, with variable emphasis on mathematical models, microscopy, and animal anatomy and physiology, though probably no more than would be expected in a multiauthor book and after allowance has been made for the extent to which different parts of the gut have been investigated. There is some overlap between early and later chapters, regrettable in a book which is not cheap at £ 25 for 250 pages. I found the "short-notes" format of the chapter on methodology irritating. In future editions this section could be profitably extended, re-written, and placed earlier in the book, and an attempt made to edit out later repetition. Finally, in the same format, there is a synopsis of clinical syndromes. The classifications of these is odd and the emphasis sometimes inappropriate. For example, there are separate sections for idiopathic vomiting and pyloric stenosis, but the irritable bowel syndrome, surely the motility disorder par excellence, is given two lines, and rumination nearly half a page.