Charles S. Lieber. 579 pages. New York: Plenum; 1992. $89.50.

The single-authored medical text has been pronounced dead; few challenge a "do not resuscitate" order. Many wistfully recall when such a text could shape and personify a discipline. Osler, Joslin, Wintrobe, Werner, and Hurst have all been tackled by multiple authors and it is difficult to play the game by the old rules. Thus, I was delighted to receive Lieber's Complications of Alcoholism. Although 18 collaborators are credited, the book is his. He is the sole or co-author on all but 6 of the 18 chapters. He has certainly defined the field of complications of alcoholism over the past several decades; his book differs from current textbooks that tend to be limited to symposia proceedings or handbook formats.

My initial enthusiasm was tempered by the realization that authors tend to perceive reviewers in the manner that trees look down on dogs. Nevertheless, to err is canine, and my views follow. Luckily, I loved the book.

Alcohol abuse has been around at least since Noah parked his ark, raised grapes, made wine, and passed out in his tent (Genesis 9:20-21). The field has become eclectic and has exceeded the scope of a single author. Even the Gordon Scientific Conference on Alcohol has split into two groups. The neurobiologist and behavioralist meetings now alternate with the metabolic and nutritional meetings. The book tends to slight the former but could well be required reading for the latter, despite that most references are current only through 1989, with a few references cited from 1991.

Most textbooks, including this one, are dated by the time of publication. In addition, Lieber's book does not cover the entire field. Why did I like it? First, the level of intellectual rigor is refreshing in an era of 10-year computer searches. Concepts are traced from their intellectual beginnings and references from previous centuries are cited where appropriate (for example, Hippocrates as well as Thomas, an 1898 source in chapter 16; Heberden and a 1772 source in chapter 12). Second, the chapters are well-integrated, refer to one another, and avoid repetition. Third, the clinical lessons derived from science come often enough to keep the clinician as well as the investigator interested.

The world according to Lieber has its center in the liver. Chapter 1 is "Metabolism of Ethanol" and chapter 2 is "Acetaldehyde and Acetate." Chapter 7 deals directly with alcohol and the liver. The now (in)famous schematic of the hepatocyte is found here in several versions. Each version has been mercifully abbreviated from the one that brought many a medical school class to its collective knees. That slide of intermediary metabolism was initially condensed to a series of wall flip-charts and subsequently to an 1100-page book entitled Principles of Biochemistry. One looks in vain for a simple table comparing the various enzymatic pathways of ethanol metabolism to acetaldehyde in terms of the Michaelis constant, maximum velocity, and relative contribution to ethanol metabolism in humans. Nevertheless, the reasons for the difficulty of the task are all present.

Nowhere is the "hepatocentric" focus of the book more apparent than in the juxtaposition of chapters 9 and 10. The former, "Immunologic Reactions in Alcoholic Liver Disease" by Parometto, is the extent of the immunology presented despite an increasing amount of information on the immunologic implications of ethanol ingestion. Inclusion of such a chapter, including infectious complications of alcoholism with new data on the acquired immunodeficiency syndrome, could be of great benefit to the clinician. The latter chapter, "Alcohol and the Digestive Tract," inches eloquently down the gut. The chapter ends with several pages on the colon, although the only proven colonic complication of ethanol is hemorrhoids (mediated by portal hypertension).

Chapters 3, 4, and 5—"Alcohol Hormones and Metabolism," "Ethanol and Lipid Disorders," and "Effects of Ethanol on Amino Acid and Protein Metabolism"—constitute a small course in endocrinology and metabolism caused by the ubiquitous action of ethanol and its metabolites. The clinical implications of ethanol on sexual function, carbohydrate metabolism, coronary artery disease, and brain wasting are cogent. Similarly, chapter 6, "Ethanol-Drug Interactions," provides a short course in clinical pharmacology and a sobering list of potential pitfalls for the prescribing clinician.

Chapter 8 by Lindenbaum on the hematologic system was one of my favorites. Figure 12, a diagnostic approach to anemia in the alcoholic, should be in the little black book of all housestaff. Clinical "pearls" come with increasing frequency in the latter part of the book, including chapter 12 by Friedman on cardiovascular effects, chapter 13 by Martin and Peters on skeletal effects, chapter 14 by Victor on the nervous system, and chapter 16 by Epstein on the kidney. Lieber and colleagues contributed chapter 11 on the pancreas, chapter 15 on mutagenic effects and fetal alcohol syndrome, chapter 17 on nutrition, and the final chapter on biological markers of alcoholism, an area of great clinical promise. Here, as elsewhere in the book, I disagree with Lieber's conclusions. Nevertheless, the process of reading the book was akin to spending nights arguing areas of reasonable doubt in the area of alcohol studies with "the master." Is this not what the best of medicine and the scientific process is all about?