The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne

Book Reviews

A WAR OF NERVES: SOLDIERS AND PSYCHIATRISTS IN THE TWENTIETH CENTURY

By Ben Shephard. 487 pp., illustrated. Cambridge, Mass., Harvard University Press, 2001. $27.95. ISBN 0-674-00592-9.

knew from the quality of the writing and scholarship in the initial chapters of this book that it would be a pleasure to read, but I also realized it would be a challenge to review the book because of its scope and detail and the controversy the author provokes. Shephard begins, There is a compelling reason to take a much wider look at what has happened in the past: we are making a mess of this problem today and need to learn the lesson that, in treating the aftermath of war, good intentions are not enough. Shephard is a British writer who has produced historical and scientific documentaries for the BBC, including parts of the excellent series The World at War. Here he vividly presents the attempts of psychiatrists, neurologists, and psychologists who helped the military and civilian society treat or prevent the psychological breakdown of service members exposed to the horrors of war. The book focuses on Britain and America in World Wars I and II, then skips to a cursory look at Americas Vietnam War and its fallout up to the 1990s (with only a brief commentary on Korea). Shephard briefly covers the Falklands campaign and the Gulf War with its persistent syndromes. French and German problems and practices in the world wars provide short but informative contrasts. Shephard conveys the grim realities of war in striking vignettes of service members and patients. He captures concisely the personae of the shapers and movers of military psychiatry, including the few, such as Dr. William Rivers of World War I fame, who are known to general readers through literature or films. The book provides a fascinating account of the interplay of competing ambitions, clinical styles and interests, personal and institutional prejudices, and public opinion. Shephard succeeds in linking the undoubted successes and numerous disasters of military psychiatry with wider societal expectations and military and medical practices as they changed during the 20th century. One disaster was the U.S. screening program in the initial years of World War II. Shephards account left me simultaneously laughing and appalled, and I remembered the sad patient I had seen as a resident in 1968 whose thick chart for inadequate personality disorder began when he was rejected for military service because he was unable to urinate if others were watching. Alas, Shephard does not cite later observations and studies indicating that soldiers with substantial psychopathology could function well and even heroically in units with good leadership and comradeship. One provocative theme is the cultural shift from the traditionally Victorian masculine virtues of courage and selfdenial of emotional expression in the service of duty (what used to be meant by showing nerve) to the traditionally female virtues of free emotional expression and the giving and seeking of sympathy and care (which could lead to a pathologic case of nerves or nervous breakdown). This

theme culminates in the chapters, From Post-Vietnam Syndrome to PTSD and The Culture of Trauma, which will arouse anger in some readers and will reinforce the blind prejudice of others but should be read carefully and thoughtfully by all. Shephard acknowledges the real suffering of many veterans and the honorable intentions of those who created the diagnostic label and criteria for post-traumatic stress disorder and championed treatment and compensation programs for it. His sharp critique is founded on experience during and after the world wars. We have seen similar syndromes before, made similar mistakes, and have sometimes done better. We should also determine why many of the veterans with the worst histories of exposure do well without treatment. Shephard disproves many persistent myths that I hope will be dispelled by widespread reading of his book. He presents hard-learned lessons that are in perpetual danger of being forgotten. Shephard illuminates the struggles of the tough realist clinicians, in whose path I respectfully follow. In World War I and then starting from scratch again in World War II, the realists worked increasingly close to the battle, trying different but simple techniques to return many overstressed soldiers to duty in a period of hours to days. Those soldiers would have become psychologically disabled if they had been evacuated. The best realist clinicians educated unit leaders, general medical personnel, and chaplains to reduce the psychological and physiologic causes of stress-induced breakdown and to restore many stressed soldiers in their units, not in medical cots. I wish Shephard had included more historical details of that endeavor. The focus of 21st-century combat and operational behavioral health (stress control) is on primary and early secondary prevention at the unit and community levels. The same should be true of civilian programs of community mental health and management of psychological trauma, which grew out of the military experience. Better preventive interventions can greatly reduce the need for tertiary treatment of chronic cases far to the rear of combat or after the war. Shephard describes the many approaches to tertiary treatment masterfully, as he does numerous other topics of public interest. I hope the public response to A War of Nerves will encourage Shephard to finish writing the saga of postWorld War II military psychiatry (behavioral health). I know he can find more gold by panning deeper in streams he has just skimmed in this book, by exploring the well-studied Israeli experience, and by addressing the special problems of peace-keeping missions. Shephards account of the first half of the saga is a masterpiece, but the second half remains to be told. JAMES W. STOKES, M.D.
U.S. Army San Antonio, TX 78232

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BOOK R EV IEWS

GREAT FEUDS IN MEDICINE: TEN OF LIVELIEST DISPUTES EVER

THE

By Hal Hellman. 237 pp. New York, John Wiley, 2001. $24.95. ISBN 0-471-34757-4.

NUNDATED by medical journals, surrounded by news media with health and science reporters, bombarded with invitations to conferences, and ensnared in the World Wide Web, physicians and the public have come to expect medical discoveries and breakthroughs to appear constantly and to be incorporated instantly into clinical practice or further research. Hal Hellman, a writer of popular science, has provided a valuable service in his new book, Great Feuds in Medicine, revealing how difficult it can be to create and disseminate innovative medical information. Hellman has assembled 10 chapters in medical history, a series of contentious cases with some special drama or scientific interest to highlight the human enterprise of medical discovery. His stories cover a broad span of time, from the work of Harvey in the early 1600s to research on the human immunodeficiency virus in the 1980s, and an equally wide range of disciplines, including physiology, microbiology, neuroscience, psychiatry, and molecular biology. Most chapters tackle pivotal moments in medical thinking, when dramatic ideas or experiments transformed the field. After each such moment followed a time of discontent and upheaval, when challenges arose and information was dispersed, before the paradigm shifts and discoveries were accepted with broad consensus. Collectively, the vignettes illustrate the personal perils of being an explorer; medical researchers who aspire to greatness ought to have a thick skin. Before ascending to the pantheon of medicine, most of these heroes had to suffer through bitter attacks on their work and their character. Pasteur, Freud, Harvey, Bernard, Salk, Semmelweis each was prey to criticism, envy, competition, resistance, and dismissal before, with the passage of time, their contributions were accepted and acknowledged. The scientific process is revealed to be less pure and pristine than many imagine. Nationalist bias, professional entrenchment, institutional bureaucracy, religious sentiments, and cultural tradition all influence the development and adoption of medical knowledge, and thus have an impact at least as important as the scientific method itself. This is medical history as personal rivalry; hence, the feuds. Hellman relishes the anecdote, the off-hand comment, and the individual foible that make real people of these legendary heroes. Vanity, competitiveness, self-doubt, jealousy all these human frailties appear in great abundance. In some instances, this approach clearly enriches our understanding of seminal physicians, yielding insight into their ambition and brilliance. It is enlightening to be reminded that the acceptance or rejection of medical ideas frequently hinges on the personality of the individual researcher and on that of his or her competitors. The showmanship of medical discovery the ability to illustrate a point dramatically in public ceremony emerges as a lost art. Certain figures, such as Pasteur and Freud, prove so compelling that the controversy surrounding their discoveries extends into the historical assessment of their lives. Hellman notes how the feuds ignited by these men turned into battles among their various biographers and historians. How do differing opinions, conflicting data, disparate observations, contrasting philosophies, personal rivalries, and

pointed conjecture influence the growth of medical knowledge? This is the unspoken question underlying Hellmans book, and it is a critical one for understanding the way in which science and clinical practice evolve. The resolution of medical disputes is a fascinating and important process, and as Hellman shows, it is often governed by much more than cold, hard facts or data. Hellman provides interesting anecdotes that will capture the attention of a lay audience and build appreciation for human interaction in medical discovery. However, his method falls short of explaining how medicine changes over time, and his reliance on secondary sources means that there is little new information. The narration lacks the richness and depth favored by professional historians of medicine. Those seeking an introduction to the history of medicine will find the chapters readable and free of technical jargon. Yet the disputes Hellman chooses seem oddly petty personal but not intellectual and surprisingly devoid of the compelling drama created by real tensions in the scientific community. In relying on short case studies, Hellman misses an opportunity for tackling the broader meaning of dispute and debate as part of the scientific and medical process. The word feud connotes a bitter, festering, long-standing, and somewhat irrational quarrel an argument for the sake of an argument. In the long and colorful history of medicine, there have undoubtedly been many feuds. Some persist to this day. Great Feuds in Medicine serves up some of the most exciting disputes. These stories make for fascinating, if not entirely satisfying, reading. HAROLD J. BURSTEIN, M.D., PH.D.
DanaFarber Cancer Institute Boston, MA 02115

VEGETARIAN NUTRITION
(CRC Series in Modern Nutrition.) Edited by Joan Sabat. 551 pp. Boca Raton, Fla., CRC Press, 2001. $89.95. ISBN 0-8493-8508-3.

HIS book contains expert summaries of various aspects of plant-based, or meatless, diets. It provides not only ethical, moral, and religious viewpoints from different periods of history but also modern perspectives on health promotion and disease prevention. The editor, Joan Sabat, is a physician and nutrition specialist who for several decades has been a principal investigator in observational and intervention studies of health promotion among Seventh-Day Adventists. He has recruited an international group of authors and many of his colleagues at Loma Linda University for this collection. That the 26 contributors include only 2 physicians may indicate the need for this book, since the overall impression the book leaves is that vegetarian diets are safe, palatable, healthy, and at times curative. The material is presented succinctly, with good use of tables, and is referenced appropriately. Vegetarian diets may be classified as lacto-vegetarian, ovo-vegetarian, lacto-ovovegetarian, or vegan, respectively, if they include dairy products, eggs, both dairy products and eggs, or no animal products at all. The macrobiotic diet is an extremely restrictive vegetarian diet that is not nutritionally adequate and leads to malnutrition, especially in children. The books synopsis of growth studies involving children and adolescents who are vegetarians provides data on children from

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The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne

birth to 18 years of age. Lacto-ovo- or lacto-vegetarians, as most Seventh-Day Adventists are, have normal physical growth, whereas children who are vegans may have slower growth even if they are in good health. In a discussion of nutrients of concern in vegetarian diets, the authors conclude that appropriately planned vegan or lacto-ovo-vegetarian diets can be nutritionally adequate. There is concern about the adequacy of zinc intake in vegan women and about low intakes of vitamin B12 and iodine in vegans in general, but these needs can be met by fortified foods (such as breakfast cereal and salt). White and Asian vegan women may need to take calcium supplements in order to ensure that their intake is adequate, and those who live in northern climates may require vitamin D supplementation in winter, or year-round if they are elderly. Tables of health-promoting phytochemicals (beyond the traditional nutrients) provide information about the food and herbal sources of approximately 20 compounds, ranging from carotenoids to tocotrienols. The author of the chapter on phytochemicals recommends that whole foods rather than phytochemical supplements be consumed for the best protection against disease, since the safety and health benefits of concentrated extracts of fruits and vegetables with high levels of phytochemicals are unknown. The discussion of vegetarian diets in relation to the U.S. Dietary Guidelines and disease-specific guidelines (for heart disease, obesity, hypertension, diabetes, and cancer) concludes that these recommendations promote the eating of more unrefined grains, fruits, and vegetables and the reduction of the intake of saturated fat and cholesterol (present in all animal products and in no plants) a diet that overlaps with vegetarian eating patterns. The author of the chapter on dietary guidelines concludes that present knowledge suggests that diets rich in plant foods with small or minimal amounts of animal foods may be the remedy for modern life-style diseases. Dietary guidelines for vegetarians could be developed with the aim of promoting the consumption of a variety and abundance of plant foods; primarily unrefined and minimally processed plant foods; optional dairy products, eggs, or both; and a generous amount of water and other fluids. The concluding chapters on the historical context of vegetarianism and its relation to religion and spirituality are intriguing and provide new insights. Although the term vegetarianism was coined in the mid-1800s, the practice of abstinence from eating meat dates back, in Western society, at least to Pythagoras in southern Italy in the 6th century B.C. and to Zoroaster in Persia and Daniel in Babylon in the 7th century B.C. Prominent advocates of vegetarianism in America were Sylvester Graham, the leader of a 19th-century religious movement that called for temperance and the reform of health and hygiene practices, and John Harvey Kellogg, a 20th-century Seventh-Day Adventist who was trained as a physician and operated a SeventhDay Adventist Sanitarium in Battle Creek, Michigan. He developed meat substitutes and other vegetarian health foods, including the breakfast cereals that have immortalized the family name worldwide. ELAINE B. FELDMAN, M.D.
Medical College of Georgia Augusta, GA 30912
Book Reviews Copyright 2001 Massachusetts Medical Society.

N OTICES
Notices submitted for publication should contain a mailing address and phone number of a contact person or department. We regret we are unable to publish all notices received. Notices also appear on the Journals Web site (http://www.nejm.org). The listings can be viewed in their entirety or searched by location, month, or key word.

ST R U G G LE AGA IN ST ST R O K E

The International Symposium will be held in Dortmund, Germany, Oct. 35. Contact Maike Prager, KelCon-Keller Congress Organization, Ludwigstr. 2-6, D-63110 Rodgau, Germany; or call (49) 6106-8444-14; or fax (49) 6106-8444-44; or e-mail m.prager@kelcon.de.

T H E T H EO RY O F O B ST ET R IC ME D IC IN E

The course will be offered in London, Oct. 911. Contact Symposium Office, Div. of Paediatrics, Obstetrics & Gynaecology, IRDB, Imperial Coll. School of Med., Hammersmith Campus, Du Cane Rd., London W12 0NN, United Kingdom; or call (44) 20 75942150; or fax (44) 20 7594-2155; or see http://www.symposia.org.uk; or e-mail sympreg@ic.ac.uk.

G LO BA L FO R U M FO R H E A LT H R E S E A R C H

A conference entitled Forum 5: The 10/90 gap in health research: assessing the progress will be held in Geneva, Oct. 912. Contact GFHR, c/o WHO, 20 ave. Appia, 1211 Geneva 27, Switzerland; or call (41) 22 791-4260; or fax (41) 22 791-4394; or e-mail info@ globalforumhealth.org; or see http://www.globalforumhealth.org.

IN T E R N AT IO N A L S O C IET Y O F PA E D IAT R IC O N C O LO GY

The 33rd Meeting, subtitled Bone & Soft Tissue Sarcomas: Malignancy in the Adolescent, Immunomodulation and Cancer, will be held in Brisbane, Australia, Oct. 1013. Contact Intermedia Convention and Event Management, P.O. Box 1280, Milton, QLD 4064, Australia; or call (61) 7 3858-5580; or fax (61) 7 3858-5510; or see http://www.anzccsg.nch.edu.au/siop/; or e-mail siop2001@im.com.au.

C A R D IAC E LEC T R O P H YS IO LO GY

The 2001 NASPE/ACC Board Review Course will be held in Chicago, Oct. 1013. Contact North American Soc. of Pacing and Electrophysiology, 6 Strathmore Rd., Natick, MA 01760-2499; or call (508) 647-0100; or fax (508) 647-0124; or e-mail info@naspe.org; or see http://www.naspe.org.

10T H A N N UA L DYS P H AG IA R E S E A R C H S O C IET Y ME ET IN G

The meeting will be held in Albuquerque, N.M., Oct. 1113. Contact Karen Schmitt, International Meeting Managers, 4550 Post Oak Place, Suite 342, Houston, TX 77027; or call (713) 965-0566; or fax (713) 960-0488; or e-mail imm@meetingmanagers.com.

AU TO N O MIC N E RVO U S SYSTE M

The 12th International Symposium will be held in Palm Springs, Calif., Oct. 1114. Contact Anita Zeller, American Autonomic Soc., 5458 193rd St. W., Farmington, MN 55024; or call (651) 463-4119; or fax (651) 463-2009; or e-mail zeller.anita@mayo.edu.

THE JOURNALS WEB AND E-MAIL ADDRESSES:

For letters to the Editor: letters@nejm.org For information about the status of a submitted manuscript: http://www.nejm.org/papertrail To submit a meeting notice: meetingnotices@nejm.org The Journal s Web pages: http://www.nejm.org

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