Reviews and notices of books

The Biology of Cancer. A New Approach the fact that this appears a bit odd on the face of it, one P. R . J . Burch. 2 3 0 ~ 160 mm. Pp. 452. Illustrated. 1976. may conclude also that we move in predestined grooves-a Lancaster: MTP. f11.50. genetically determined tram rather than a bus. Therefore. a KUHN (1970) has made us familiar with the idea that occasion- ally an advance in understanding comes from a new look, a reversal of or a radical shift in the tenets of established or ‘normal’ science. Newtonian gravitational theory, Einsteinian relativity theory and the Crick-Watson ‘breakthrough’ to the double helix are all examples of what Koestler called ‘sleep walking’ followed by a sudden switch of view and a new concept. The trouble about Kuhn’s work is that it has made us self-conscious. On the one hand, those who have long been concerned with a field may come to feel on inadequate grounds that they have gained a particular insight which qualifies them to claim a revolution; on the other hand, lesser mortals charged with criticism or analysis are afraid to be adverse lest they condemn something the future will show to be revolutionary.

These things pass through my mind as I plough my way across the broad fields of Professor Burch’s magnum opus. Here, in great and often overwhelming detail, is a new and revolutionary look at cancer. Though modest to a certain degree, Burch clearly thinks that he has achieved a Kuhnian switch; I for my part doubt this, hut am fearful that my doubts will be held against me when in the future Burch’s reasoning proves, against the run of my feelings, to be sound.

Burch’s book is like much of Marx’s writing-there is such a wealth of evidence and dialectic (in the best sense of that word) that one can almost draw any conclusions one wishes. As with Marx, there is a century of work ahead just to disprove the numerous hypotheses he erects. Very briefly, and I am sure the author will say inaccurately, he postulates central control of growth (through the ‘immune’ system), and that the initiation of malignancy is a defect of control which has its origin in a mutation by DNA ‘strand switch’ within this central mechanism. Malignancy develops because of the inability of normal negative feedback to recognize and deal with a group of wild peripheral cells which are ‘cognate’ of the stimulus provided by the aberrant central messengers. One is pre- disposed to malignancy in its clinical form by a weakness in or absence of a surveillance system to suppress the forbidden clones so generated. From there it is an easy step to say that there is a genetic predisposition to cancer, based upon the insufficiency of protection and that malignancy expresses itself only in those with such genetic predisposition. Hence bronchial carcinoma is not caused by smoking cigarettes; it manifests itself in those who have a genetic predisposition both to smoking and poor immunological surveillance. The prevalence and incidence of cancer in various communities are then analysed to show that patterns of malignancy are compatible with the view that there is genetic determination and thereafter stochastic (‘random’) emergence of the disease.

Both the masses of data that Professor Burch brings together and his erudition are impressive. Yet a t this point the shadow of another scientist-philosopher looms large. All Professor Burch’s evidence marshalled here is confirmatory; indeed, he shows an occasional rather cavalier attitude towards exceptions and a casual approach to the approximations needed to make his argument persuasive. Karl Popper (1959) would count this an intrinsic weakness because in his view the strength of a theory is its ability to resist and explain departures and the fertility of a hypothesis is its power to suggest critical experi- ments which can confute it. Though Professor Burch rightly pleads in his final chapter for a theoretical medicine analogous to theoretical physics (and one might say theoretical astronomy), Popper does not figure in his bibliography, nor are there many links between his proposals and the biological experiments which would be required to test them. Instead, concept is piled on concept and theory on theory until there exists a somewhat rickety superstructure analogous to what Chagarff (1974) in a moment of acidie called the ‘Tower of Babble’.

The extent of the arguments in this book tends to drag the reviewer on. I shall limit myself to one other comment. The superstructure of ideas to which I have just referred has given rise to inappropriate publicity on cancer of the lung. Professor Burch, in championing the cause of predisposition, implicitly negates free will and says in effect that if you are going to get lung cancer, smoking is something you do as well. Apart from

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conscious-decision to stop smoking is well-nigh futile. Marxian predestination again, unpalatable to most of us and certainly an argument to laissez-faire approach in terms of public health reform.

This is not to say (and here I am, as I indicated, hedging my bets) that Professor Burch has not done us a great service in at least three ways. First, and least, his collection of information will provide a magnificent archive. Secondly, and more important, he has pleaded with us to take a different look at the phenomenon that we call cancer and which is the central motive of much of the surgical life. Maybe we are wrong to continue to chip away at cancer cells as if they were infecting organisms or a dry rot which can be relieved by radical excision; in but a few years surgical treatment of malignancy will be as dead as the dodo. It is always refreshing to be reminded of one’s own professional obsolescence. Finally, and here he has the greatest part of my support, his appeal for theoretical analysis should not fall on the deaf ears of a wholly pragmatic profession. We do need theories; surgeons tend to be repelled by them, but as surgical science increasingly infiltrates practice a theoretician such as Professor Burch at our elbow may help to direct our critical knives. I t would be a great pity if his en- thusiasm, undoubted grasp and leaps of potential insight were to be dismissed because of the frequent looseness and com- plexity of his reasoning. Let us only hope there are experi- mental biologists-some of whom are doubtless surgeons- who will design critical experiments to test the Burchian views. Until then, his theme might be:

‘I have spread my dreams under your feet; Tread softly, because you tread on my dreams’.

H. A. F. DUDLEY

References CHAGARFF E. (1974) Building the Tower of Babble. Nature

KUHN T. (1970) Structure of Scientific Revolutions. Chicago

POPPER K. (1959) The Logic of Scientijk Discovery. London,

(Lond.) 248, 776-777.

University Press.

Hutchinson.

Plastic Surgery Continuing Education Review Donald M . Greer jun. 215 x 140 mm. Pp. 155. 1975. New York: Medical Examination. $10. THIS is one of a series of hooks whose purpose is to provide a refresher course by means of a series of questions to which are given the answers and, in each case, an up-to-date reference. In all, there are over 400 questions covering the various aspects of plastic and reconstructive surgery and including basic physiological and pathological problems and with a section on anaesthesia.

On the whole the questions are well chosen and interesting. The references are mostly to the American and British literature, and altogether the book gives quite a good summary of many of the day-to -day problems in plastic surgery.

I. F. K. MUIR

Hand Surgery J. Edward Flynn et al. Second edition. 255 x 175 mm. Pp. 712+ xoii. Illustrated. 1975. Baltimore: Williams & Wilkins. $48.50. IN the second edition of Hand Surgery all the sections have been revised and brought up to date. In the first edition there were 58 contributors from both sides of the Atlantic, while in the present edition there are 59, 21 of whom are new contributors.

In the reviewer’s opinion, the second edition is a vast improvement on the first, both in content and style. It is an excellent work of reference and well merits a place in the library of plastic and orthopaedic surgeons whose particular interest is the hand.

DONAL BROOKS

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