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Anesthesia and Neurosurgery
British Journal of Anaesthesia 89 (1): 189±193 (2002)
Book Reviews Anesthesia and Neurosurgery (fourth edition). J. E. Cottrell and D. S. Smith. Published by Mosby, St Louis, Missouri. Pp. 784; illustrated. Price $110. ISBN 0-8151-0321-2. This is the fourth edition of a well-established and successful textbook of neuroanaesthesia. It is a multi-author text with contributions from 60 experts in their ®eld, mostly from North America. This edition retains the previously successful model of neurosurgeons and neuroradiologists contributing, along with neuroanaesthetists, to the sections dealing with the clinical management of speci®c conditions. All chapters have been updated, some have been dropped, and there are signi®cant contributions from new authors. The foreword notes that the neuroanaesthetist must learn to think, not just as an anaesthetist, but also as a neurologist and neurosurgeon. It might now be added that he or she must also think as an intensive care physician. An understanding of neuroanatomy, the patient's disease and symptoms, the relevant diagnostic procedures, the problems and technical aspects of the surgical procedure, the potential complications, and the postoperative management are essential to the safe practice of neuroanaesthesia. This text aims to educate the specialist in all these areas and, in general terms, it achieves that aim. The ®rst few chapters deal with the physiology and pathophysiology of brain metabolism, cerebral and spinal cord ¯ow, cerebrospinal ¯uid, the blood±brain barrier, and cerebral oedema. The chapter dealing with the pathophysiology of brain injury provides an overview of this dif®cult area in a style that is easily accessible. There is also a section providing a useful summary of the effects of anaesthetic agents and other drugs on various aspects of cerebral physiology. The sections dealing with monitoring techniques include neuroradiology, evoked potentials, other neurophysiological techniques, intracranial pressure monitoring, and transcranial Doppler ultrasonography. The chapter dealing with neuroradiology is a well-illustrated review of the subject and includes an introduction to modern techniques. Several of the ®gures are distant from their reference in the text and, although inevitable in a section with so many illustrations, it does mean that it is necessary to skip back and forth to gain the maximum bene®t from this excellent chapter. Other monitoring techniques are discussed in later chapters, but the inclusion of a separate chapter on cerebral oxygenation monitoring at this stage would have been helpful. The chapter dealing with intraoperative ¯uid management provides an excellent overview of the physiological principles and practical management and deserves a `stand alone' slot. However, the following chapter, dealing with the care of the acutely unstable patient, contains several areas that are dealt with elsewhere in the text. The sections dealing with speci®c clinical conditions are organized with one chapter covering surgical management, followed by a second discussing anaesthetic considerations. All areas of neurosurgical anaesthesia are covered, as would be expected in a text of this size. The general intracranial subjects are broken down into supratentorial masses, posterior fossa surgery, vascular conditions (including cerebral aneurysms, and arteriovenous malformations), and interventional neuroradiology. There is also an extensive section dealing with the medical and surgical management of occlusive cerebrovascular disease. There are separate chapters dealing with epilepsy surgery, paediatric neurosurgery, and neuroendocrine surgery. There are chapters
on the acute and elective management of spinal surgery, but the chapter on spinal cord injury appears later in the book. There is a short description of anaesthetic considerations for patients with neurological disease. The chapter dealing with postoperative and intensive care is well written and comprehensive, but the North American perspective does not perhaps re¯ect the higher pro®le of UK neuroanaesthetists in neurocritical care. This chapter covers most subjects in detail, but I would have preferred a separation between the description of routine postoperative care for elective neurosurgical cases and the intensive care management of critically ill patients. The details of postoperative management could have been included in the chapters dealing with speci®c conditions, but I accept that many will agree with the editor's approach of bringing these discussions together under a single umbrella. It is certainly helpful to have general issues, such as ventilatory support, haemodynamic and ¯uid management, sodium disorders and nutrition, covered as generic issues. The chapter on the management of severe head injury is an excellent review of the subject and is up-to-date and well referenced. The whole gamut of head injury management, from pre-hospital care to outcome, is comprehensively covered in this chapter. There is an excellent description of the medical management of head injury, including the management and monitoring of cerebral perfusion and intracranial hypertension, as well as coverage of general issues related to the intensive care management and monitoring of the injured brain. There follows an excellent, state of the art, review of the systemic complications of severe head injury. This is an area that is often not covered well in other textbooks of neuroanaesthesia and intensive care, and the editors are wise to have included this important area. Finally, there is a welcome chapter dealing with the many ethical considerations that arise in the management of patients with neurosurgical disease on the intensive care unit and the neurosurgical ward. The authors tackle this dif®cult area with sensitivity. However, there is no section dealing with brainstem death and management of the multiple organ donor; both are areas of clinical practice that are frequently encountered on the neurocritical care unit. Most areas of the principles and practice of neuroanaesthesia are covered by this book. Like most multi-author texts, it does suffer from some minor issues of style and repetition. For example, the management and monitoring of raised intracranial pressure is covered, to varying degrees, in at least four areas of the book. On the other hand, for full coverage of some subjects, it is necessary to look in more than one chapter. However, these observations do not detract from the book's major achievement in providing a comprehensive, up-to-date and clear account of the basic science, pathophysiology and clinical management that comprise the art of neuroanaesthesia. This is not a textbook that will be compulsory reading for general trainees but it will be an invaluable reference for those seeking specialist experience in neuroanaesthesia. It should be available in general departmental libraries for reference by trainees, and is a `must have' for departments of neuroanaesthesia. I suspect that most practising neuroanaesthetists will wish to own their own copy. M. Smith London, UK
Ó The Board of Management and Trustees of the British Journal of Anaesthesia 2002
Book Reviews
Critical Care Medicine: Principles of Diagnosis and Management in the Adult (second edition). Joseph E. Parrillo and R. Phillip Dillinger (editors). Published by Mosby, St Louis. Pp. 1770; indexed, illustrated. Price £140.00. ISBN 0323-012809. This impressive, 1770-page book weighs in at 3.78 kg. The weighty tome is the second edition of a text that seeks to provide an authoritative, comprehensive book aimed at practising critical care physicians. The goal was to produce the acknowledged standard in critical care medicine. While I do not understand what the goal of `acknowledged standard' means in the context of a textbook, this one certainly achieves its main aims. It has a very impressive cast of authors who represent authorities in their respective ®elds. The layout of the book is logical with the pharmacological and technical basis of the speciality preceding the disease orientated section. The range of topics is comprehensive. It is a de®nitive text. The book is relatively easy to read, and is clear and concise. The sections covering practical procedures are easy to follow and informative with relevant diagrams. Where controversy exists, the pertinent arguments are mentioned and referenced but without prolonged and turgid debate. This is clearly seen in the succinct discussion about the pulmonary artery catheter, or the `pros' and `cons' of percutaneous tracheostomy. In fact, throughout the book, I was impressed by the clarity of the discussion that managed to address issues without losing the reader in the detail. The diagrams throughout are clear, as are the photographs and other images. The echocardiography section is particularly impressive. At the end of each chapter, there is a list of key points, some of which are very useful summaries of the chapter with some real `gems', but others somewhat less informative. It is well referenced throughout and relevant papers are almost always listed. The index is easy to use and comprehensive. In general, the book is more than adequately detailed. An exception is in pharmacology where there are long lists of commonly used drugs which, in pharmacological terms, are lightweight. Clearly the intention is to provide a quick and easy guide to these drugs, not a pharmacopoeia. This is a very useful practical addition to the book but is somewhat out of kilter with the detail elsewhere. There are many outstanding chapters in this book but, in particular, the focused view of nosocomial infection is both interesting and practically relevant. Similarly, the chapter on diabetes is extremely good, as well as the discussion on ethics. It is probably unfair to highlight any individual chapters as the standard throughout is very high. De®ciencies are hard to ®nd, but obstetrics does not really feature, and I was surprised by the lack of reference to violent injury and trauma. There are several basic questions I would ask if I was out to spend £140.00 on a textbook, which I have answered below. 1. What do I personally want it for? As a reference textÐexcellent. As a resource book for the intensive care unitÐit is probably one of the best of its kind. As a revision textbookÐprobably too hard to read easily. As a manual in the intensive care unit for the problem at 02.00 h in the morningÐprobably too heavy, although it does have the practical information required. As one book to cover everythingÐit doesn't, but then none do. To look good on the book caseÐde®nitely. For bedtime readingÐonly if you have insomnia, but then who does read these books in bed except those taking examinations? 2. Does the intensive care unit I work in need one? De®nitely. 3. Would I recommend it? Yes. 4. Would I buy one myself? Yes. 5. Is it value for money? At £37.00 per kilo it is good value.
In conclusion, this is a very good textbook of critical care that would be an asset to any intensive care unit. It could be used by trainees working for examinations and by their seniors for continuing professional development or for reference. As an easy access manual, it is probably a little daunting, but would serve that function. The real test of the quality of a book is how long would it stay in the unit before it walked. The answer is, not long. This is one to secure. N. Soni London, UK Safe Retrieval and Transfer: the Practical Approach. The Advanced Life Support Group. Published by BMJ Books, London. Pp. 131; indexed, illustrated. Price £25. ISBN 0-72791583-5. There is a considerable number of published papers that demonstrate the risks associated with the interhospital transfer of sick patients. Unfortunately, with a national shortage of intensive care beds, the number of interhospital transfers shows no sign of reducing. This book provides a framework for safe transfer of sick patients and is written by a multi-professional group representing the Advanced Life Support Group. It is also the course manual for the Safe Transfer and Retrieval (StaR) course run by the same organization. The subject of effective patient transfer is not littered with entertaining anecdotes, and most readers are likely to want to be taken through the subject quickly and painlessly. The book is well laid-out with short chapters, many of which can be read in only a few minutes. Many readers might ®nd the style too didactic but, if seen as one safe method of achieving the desired objectives, this ceases to be a problem. The subject is covered comprehensively. Areas that are vital (and often neglected), such as effective patient packaging and stabilization, are given good coverage. Other areas are of relevance, but are unlikely to be utilized regularly by most transfer doctors e.g. radio voice procedure. Three-and-a-half sides are devoted to diagrams and text on the ®xation of tracheal tubesÐobviously one of the authors has bad memories of a tube displacement on a rainy motorway somewhere. Most of the content is predictable and well thought outÐunlike some multiauthor texts, the editors have ensured consistency. Wellestablished `ABC' type treatments form the mainstay of the guidelines. However, some areas touched upon are controversial, and it would be useful if they were highlighted as such for the less experienced reader. For example, it is suggested that not all critically ill patients necessarily need a doctor to transfer them from one hospital to another. It may be that the speci®c circumstances where this is appropriate are explained in the StaR course, but reading the book alone could cause problems. Also, the suggestion that the administration of steroids in spinal injury is mandatory will be questioned by some UK neurosurgical units. Overall, this book achieves its aims well, and adhering to the clear and well-presented guidelines will undoubtedly reduce the number of preventable adverse events during patient transfers by anyone that follows them. D. Lockey Bristol, UK
190
Book Reviews
Atlas of Hemo®ltration. R. Bellomo, I. Baldwin, C. Ronco and T. Golper. Published by W B Saunders, London. Pp. 106; indexed, illustrated. Price £29.95. ISBN 0702025046. Continuous renal replacement therapy (CRRT) has evolved over the years into a sophisticated therapy with many variations. Haemo®ltration has become commonplace on the intensive care unit, and its management is now computerized. While many critical care texts contain chapters on the background and therapeutic place of CRRT, few give a really simple `how-todo-it' guide. The authors of this book provide just that. Their stated aim is to give their patients the best chance of surviving, and they feel that assisting others to create an effective CRRT programme will help achieve this. The notion of simplicity is lost in the ®rst three chapters of the book. These give the background theory to CRRT which, although simple in concept, is dif®cult to describe simply. Even in these three chapters there is some overlap, with diffusion, convection and ultra®ltration being de®ned several times, the most straightforward description being in chapter 3. Chapters 4±12 regain the simple approach and describe the machines available for CRRT in some detail. The Prisma machine is used on our unit so we are most quali®ed to comment on this chapter. Essentially, it is a very honest summary of the machine, particularly of its advantages and disadvantages; the Prisma is indeed user friendly, but at a price. The recently introduced plasmapheresis facility for the machine is not mentioned but is newly available. If the same level of insight applies to the chapters on other machines, they are certainly fair. The following chapters are a motley collection on different aspects of haemo®ltration, such as paediatric renal replacement therapy and anticoagulation. The chapter on vascular access is towards the end of the book, a decision that seems rather strange since, before renal replacement therapy can be initiated, venous access must be established. The troubleshooting chapter is particularly useful. In it, common problems are described using case histories. The authors then discuss the problems, offering explanations and solutions. The problems highlighted are practical and common, and the solutions given based on experience and common sense. The chapter on nursing management is full of practical hints and addresses some important problems, such as heat loss, that are not covered elsewhere. This chapter also contains a description of how the authors teach others the techniques of CRRT. They use a resuscitation mannequin as a simple simulator for setting up haemo®ltration circuits. This adds reality to the teaching and is a useful tip. The principles behind changes in drug dosing with renal failure and CRRT are complex, but, nevertheless, their application is often relatively simple and easy to summarize. Because of this, the chapter on how to adjust drug dosage during CRRT was disappointing. One complex example is a table of drug sieving coef®cients: ®nding out how to use this table by reading the text is complicated. A summary table of increased or decreased doses would have been simpler and easier to interpret. There are also good reviews of this subject that are not even referenced. In fact, although there is much written on haemo®ltration, only a few of the chapters in this book quote references. More suggestions for follow up reading would have been useful. Our main disappointment with this book is its lack of visual impact. It is in black and white, which makes the sophisticated CRRT machines look like museum pieces. The cover is attractively colourful and atlases are usually in colour, which helps to provide detail and outline boundaries, but these details are missing from this atlas. Nevertheless, this is a useful book both as a teaching reference and as a ®rst-line troubleshooting guide. It is
a users' guide to haemo®ltration that will probably ®nd a place in every intensive care unit. J. A. Clayton and M. P. Shelly Manchester, UK The Year in Hypertension 2001. H. L. Elliott, J. M. C. Connell and G. T. McInnes. Published by Clinical Publishing Services, Oxford. Pp. 369. Price £49.50. ISBN 0-9537339-4-7. This very interesting and extensive review of over 190 articles on hypertension summarizes and puts into perspective articles published in 2000±2001, and includes relevant articles published over the last few years if they are important to the build-up of a clearer picture. The book does not address the issue of hypertension in surgical patients. However, it is highly relevant to perioperative medicine: advances in the understanding and management of hypertension are not always put into practice. As perioperative physicians, we are in a unique position to draw the attention of surgeons and general practitioners to the presence of hypertension that is either untreated or poorly controlled by present standards. In each section of the book a clear and concise introduction sets the scene, and relevant articles are commented on in a very clear manner. The section on clinical trials and guidelines includes comments on some meta-analyses of recent trials, and a detailed review of current guidelines. Reading this section makes one realize that many surgical patients remain inadequately treated by current standards. This section also includes published information, sometimes with preliminary results of major on-going trials. A number of trials focus on speci®c groups of patients, such as the elderly, and patients with diabetes or left ventricular hypertrophy. The second section deals with hypertension and other cardiovascular risk factors with particular reference to diabetes, interactions with lipid lowering drugs, and hormone replacement therapy. The third section focuses on hormonal mechanisms in hypertension, such as the role of the renin-angiotensin-aldosterone system, insulin resistance, and mineralocorticoids. The fourth section deals with practical issues including angiotensin II receptor antagonists, 24-h arterial pressure measurement, surrogate measures such as altered vessel wall properties, and ®nally, calcium channel blockers. An important observation is that in the long-term, elevated average arterial pressure correlates much better with left ventricular mass (an index of risk) than casual arterial pressure. The implication is that ambulatory arterial pressure measurement may be very useful in surgical patients to detect those with substantially raised average arterial pressure. Bearing in mind that the current goal in the treatment of hypertension is to decrease the level to 150/90 mm Hg in non-diabetics, there is still a long way to go. We are probably well placed to highlight the problem! For those interested in hypertension, this book offers a wealth of extremely useful, up-to-date information reviewed by experts; it broadens our understanding and helps us to grasp the most recent concepts and therapeutic advances. P. FoeÈx Oxford, UK Pediatric Anesthesia: Principles and Practice. B. Bissonnette and B. Dalens (editors). Published by McGraw-Hill, New York. Pp. 1618; indexed, illustrated. Price $195. ISBN 0-07-135454-9. Paediatric anaesthesia has made great advances over the past few years including having its own specialist journal. We now have a completely new textbook of over 1600 pages on this subject to add
191
Book Reviews
to our written armamentarium. This publication is a truly multinational collaboration with the two editors, Bruno Bissonnette (hailing from Canada) and Bernard Dalens (from France), and the other 143 contributors representing all continents, except Antarctica. It includes most of the acknowledged experts in the paediatric anaesthetic world. Whilst such a diverse authorship could lead to variations in style, the editors have, on the whole, managed to maintain a consistency to the book, although the constant use of metric rather than SI units is irritating to the European reader. The book is split into six sections, with the ®rst section dealing with both normal and abnormal human development. This includes a chapter on the development and evaluation of pain and the stress response, which is relevant, but the chapter on chronic and recurrent pain in children and adolescents is incongruous in this section. The second and third sections examine pharmacology of anaesthetic and analgesic agents, and anaesthetic management and techniques. This is followed by the section on special monitoring and resuscitation. The penultimate and largest section has the somewhat unwieldy title of `Surgical and Anesthetic Considerations of Procedures'. It is this section that will probably be referred to most in this book. For each particular surgical and anaesthetic subspecialty (e.g. cardiac, ophthalmic, neonatal), there are two chapters. The ®rst is by surgeons describing the presentation and surgical management of various conditions. This is then followed by the chapter on the anaesthetic management of these conditions by anaesthetists. In a number of the anaesthetic chapters, the authors have written the typical anaesthetic management of particular conditions in the form of tables, which are very easy to follow, in a stepwise manner: a good example being the chapter on the anaesthetic management of the neonate. As the surgical and anaesthetic sections are written by different authors, there is some avoidable duplication of information. The ®nal section of the book is entitled `Future of Pediatric Anesthesia'. The title is somewhat misleading as rather than describing a brave new world of paediatric anaesthesia, it addresses issues such as medicolegal and ethical subjects, education and training, and the use of computers and online services. There are many high quality greyscale illustrations (no colour), throughout the text. However, there is one glaring omission, which is surprising for a book of this size, and more so if it is to become the standard paediatric anaesthetic reference book. There is no section on syndromes and unusual paediatric diseases and their relevance to the anaesthetist. In fact, some conditions that are a particular challenge to paediatric anaesthetists, such as the mucopolysaccharidoses, which cause major airway problems, are not mentioned at all. This seems particularly odd as an advertising ¯yer for this book asserted that the book would include `a convenient, alphabetized section of every acute pediatric syndrome encountered worldwide, listing both precise instructions and quick reference information for each case'. In summary, although this is not a complete reference book, it does provide an excellent summary of current paediatric anaesthetic practice, which should be available in any department where children have anaesthetics. A. Bowhay Liverpool, UK
Shnider and Levinson's Anesthesia for Obstetrics (fourth edition). S. C. Hughes, G. Levinson and M. A. Rosen (editors). Published by Lippincott, Williams and Wilkins, Philadelphia. Pp. 690; indexed, illustrated. Price $129. ISBN 0-683-30665-0. The fourth edition of this classic textbook for obstetric anaesthetists comes 9 yr after the previous edition. Much has changed in the ®eld during this time, prompted by improvements in pharmacology and equipment, and recent advances in the understanding both of obstetric physiology and the effect of anaesthesia on pregnancy and delivery. Sol Shnider has died since the last edition and two eminent obstetric anaesthetists (Sam Hughes and Mark Rosen) have joined Gershon Levinson as editors. A host of internationally renowned authors have contributed, and although many of the contents and authors are the same as previous editions, there has been extensive reworking using up-to-date references. The book is comprehensive and organized into six parts. Part one covers maternal physiology and pharmacology. The topical issue of the effect of regional analgesia on the progress of labour is discussed. Analgesia for vaginal delivery is the topic of the second part. The new local anaesthetic drugs, ropivacaine and levobupivacaine are discussed, as are modern regimens such as low-dose local anaesthetic drugs, with or without adjuncts. Combined spinal epidural techniques and patient controlled epidural analgesia have been included as newly accepted regional techniques. The use of intrathecal and epidural opiates is now almost universal and considered routine. The anaesthetic management of obstetric complications is dealt with in part three. The options for Caesarean section are discussed as are the management of such disasters as major haemorrhage, amniotic ¯uid embolism, hypertensive disorders, and foetal problems. Mainstream general anaesthetic complications such as airway problems and gastric aspiration are included in part four. There is an up-to-date chapter on neurological complications of regional techniques and the management of post-dural puncture headache. A chapter on legal issues offers guidance concerning consent and complaints. Though obviously more interesting to American readers, it does have implications for clinical governance. Part ®ve is dedicated to non-obstetric disorders during pregnancy. This does not attempt to be a comprehensive encyclopaedia on how to manage any speci®c syndrome, but emphasizes the scienti®c background to various disorders and how these impact on pregnancy and anaesthesia. A whole chapter is reserved for the morbidly obese, pregnant patient. Anaesthetists in the UK are increasingly faced with such patients, many having altered anatomy and physiology necessitating modi®cations of techniques and equipment. Foetal problems are discussed in the ®nal part. This is too detailed for the UK anaesthetist, who is primarily responsible for the mother, but it helps to understand the concerns of other members of the team. This section includes information on problems caused by drug addicted mothers, who are becoming more common in the UK. The layout of the text is reader friendly and is accompanied throughout by useful illustrations, tables and many summary or recommendation boxes. The chapter sequence is logical and a bibliography appears at the end of each one. The index is comprehensive and it is easy to look up any queries. At US $129, this text is affordable and should be regarded as a comprehensive reference book that is a resource for the management of dif®cult or unusual cases. The book compares favourably with other high quality American textbooks of obstetric anaesthesia. It deserves a place on the shortlist when looking for the one tome to keep on the delivery suite. H. Gorton Leeds, UK
192
Book Reviews
Key Topics in Chronic Pain (second edition). K. M. Grady, A. M. Severn and P. R. Eldridge. Published by BIOS Scienti®c Publishers Ltd, Oxford. Pp. 212; indexed. Price £23.99. ISBN 1-85996-038-3. It is no mean feat to encompass the diverse features and management of chronic pain in 212 pages without being didactic, simplistic or super®cial. This book achieves this to a large degreeÐwith honours! It is the second edition of a popular book in a series with a succinct and successful format. The changes are those which re¯ect the evidence base of this speciality as determined by meta-analysis, informed review, randomized controlled trials (as far as such evidence exists) and consensus. The book is written in three parts: (i) assessment of evidence, history, examination and psychosocial factors; (ii) description of various chronic pain disorders with their features, treatment, mechanism and management; and (iii) various methods of treatment, including drugs, stimulation and invasive therapies, diagnostic and de®nitive methods, and surgical and psychological techniques. In general, the descriptions and management of the disorders agree with those in larger works and with recognized authorities. References are not given in the text, which may make this seem less authoritative, but certainly makes it easier to read. The chapters are small and sections within the paragraphs are short enough to be absorbed before the mind wanders. Technical terms are used sparingly and there is a glossary of acronyms at the beginning of the book. The authors are to be congratulated in that, although the text is terse with every phrase essential to the imparting of knowledge, it ¯ows clearly and the reader is drawn into the narrative, retaining interest. There are gems to be found in this book but, inevitably, there are also omissions, items that could or should have been omitted, and some with which I cannot concur. The gems include an excellent one and a half page chapter by Andrew Smith (who is the editor of the Cochrane Anaesthesia Review Group), which describes clearly and simply the various measurements of evidence-based medicine and how to measure them. There is Archie Cochrane's description of giving comfort to a dying soldier for whom no cure was possible, and his realization of the difference between suffering and pain. Under clinical governance, there is the acknowledgement that although there may occasionally be grounds for a patient's complaints, the process of complaining may be part of the presentation of the patient's disorder. It warns that an over-solicitous and apologetic response for an alleged de®ciency may reinforce the behaviour which aggravates the pain and disability. Statements such as `Pregnancy appears to be a risk factor for postpartum disc prolapse', and `central pain syndromes occur even in the absence of a spinal cord' made me smile.
There are omissions such as chronic dental causes of head pain, the use of cryothermy, the value of movement in conditions such as cervical spondylosis, the irreversible effects of botulinum toxin, and the consideration of anal pain. Even simple line diagrams would have made some aspects of physical therapy easier to understand. The index is inadequate in a book that seems to attempt to provide chapters which are suf®cient in themselves with cross-references to other sections. If, for example, one wishes to look up `stump pain', there is no entry although there are several entries for `phantom'. For `sympathectomy', one is diverted to `guanethidine'. If the trainee pain clinician wished to consult for an answer to shooting, numbing or burning pain, the index will not help. I dispute some of the information on sympathetic blockade. The addition of local anaesthetic to guanethidine in the i.v. regional technique may prevent the uptake of the guanethidine. The stellate ganglion is more usually found at the level of the seventh cervical vertebra; the somatic nerves do not have to be blocked during thoracic sympathetic block by the paravertebral approach; the lumbar sympathetic chain lies on the anterolateral aspect of the vertebral body rather than in the paravertebral gutter; and the hypogastric plexus does not have to be approached via the inconsistent space between the ®fth transverse process and the sacral ala. There is the theme throughout the book that pain disorders are diseases in themselves, having acquired an existence beyond that of an extension of the disease which initiated them. The primary aim is to alleviate the disability, and change the perception of the sensation that makes it so aversive. This is preferable to temporary pain relief which does nothing to alter the underlying disorder and may even render the victim more dependent on the various carers. Concurrent, however, is the acknowledgement that pain relief may have to be attempted to restore function and that even temporary relief for, say, a few weeks may be of value. The con¯ict between the ideal of transfer of the management of chronic pain to the subject and the more pragmatic chronic management of pain, is not resolved. The book is said to be designed for specialist registrars, general practitioners, nurses and physiotherapists, but this book has an even wider potential audience than this. The emphasis on evidence-based treatment makes it useful in formulating a treatment plan on ®rst consultation, or answering the question `whatever do I do now?' on later ones. The systematic organization of the chapters makes it ideal as a reference in the pain clinic. I have enjoyed reading it and I recommend it to almost any health professional. J. I. Alexander Bristol, UK
193
Book Reviews Anesthesia and Neurosurgery (fourth edition). J. E. Cottrell and D. S. Smith. Published by Mosby, St Louis, Missouri. Pp. 784; illustrated. Price $110. ISBN 0-8151-0321-2. This is the fourth edition of a well-established and successful textbook of neuroanaesthesia. It is a multi-author text with contributions from 60 experts in their ®eld, mostly from North America. This edition retains the previously successful model of neurosurgeons and neuroradiologists contributing, along with neuroanaesthetists, to the sections dealing with the clinical management of speci®c conditions. All chapters have been updated, some have been dropped, and there are signi®cant contributions from new authors. The foreword notes that the neuroanaesthetist must learn to think, not just as an anaesthetist, but also as a neurologist and neurosurgeon. It might now be added that he or she must also think as an intensive care physician. An understanding of neuroanatomy, the patient's disease and symptoms, the relevant diagnostic procedures, the problems and technical aspects of the surgical procedure, the potential complications, and the postoperative management are essential to the safe practice of neuroanaesthesia. This text aims to educate the specialist in all these areas and, in general terms, it achieves that aim. The ®rst few chapters deal with the physiology and pathophysiology of brain metabolism, cerebral and spinal cord ¯ow, cerebrospinal ¯uid, the blood±brain barrier, and cerebral oedema. The chapter dealing with the pathophysiology of brain injury provides an overview of this dif®cult area in a style that is easily accessible. There is also a section providing a useful summary of the effects of anaesthetic agents and other drugs on various aspects of cerebral physiology. The sections dealing with monitoring techniques include neuroradiology, evoked potentials, other neurophysiological techniques, intracranial pressure monitoring, and transcranial Doppler ultrasonography. The chapter dealing with neuroradiology is a well-illustrated review of the subject and includes an introduction to modern techniques. Several of the ®gures are distant from their reference in the text and, although inevitable in a section with so many illustrations, it does mean that it is necessary to skip back and forth to gain the maximum bene®t from this excellent chapter. Other monitoring techniques are discussed in later chapters, but the inclusion of a separate chapter on cerebral oxygenation monitoring at this stage would have been helpful. The chapter dealing with intraoperative ¯uid management provides an excellent overview of the physiological principles and practical management and deserves a `stand alone' slot. However, the following chapter, dealing with the care of the acutely unstable patient, contains several areas that are dealt with elsewhere in the text. The sections dealing with speci®c clinical conditions are organized with one chapter covering surgical management, followed by a second discussing anaesthetic considerations. All areas of neurosurgical anaesthesia are covered, as would be expected in a text of this size. The general intracranial subjects are broken down into supratentorial masses, posterior fossa surgery, vascular conditions (including cerebral aneurysms, and arteriovenous malformations), and interventional neuroradiology. There is also an extensive section dealing with the medical and surgical management of occlusive cerebrovascular disease. There are separate chapters dealing with epilepsy surgery, paediatric neurosurgery, and neuroendocrine surgery. There are chapters
on the acute and elective management of spinal surgery, but the chapter on spinal cord injury appears later in the book. There is a short description of anaesthetic considerations for patients with neurological disease. The chapter dealing with postoperative and intensive care is well written and comprehensive, but the North American perspective does not perhaps re¯ect the higher pro®le of UK neuroanaesthetists in neurocritical care. This chapter covers most subjects in detail, but I would have preferred a separation between the description of routine postoperative care for elective neurosurgical cases and the intensive care management of critically ill patients. The details of postoperative management could have been included in the chapters dealing with speci®c conditions, but I accept that many will agree with the editor's approach of bringing these discussions together under a single umbrella. It is certainly helpful to have general issues, such as ventilatory support, haemodynamic and ¯uid management, sodium disorders and nutrition, covered as generic issues. The chapter on the management of severe head injury is an excellent review of the subject and is up-to-date and well referenced. The whole gamut of head injury management, from pre-hospital care to outcome, is comprehensively covered in this chapter. There is an excellent description of the medical management of head injury, including the management and monitoring of cerebral perfusion and intracranial hypertension, as well as coverage of general issues related to the intensive care management and monitoring of the injured brain. There follows an excellent, state of the art, review of the systemic complications of severe head injury. This is an area that is often not covered well in other textbooks of neuroanaesthesia and intensive care, and the editors are wise to have included this important area. Finally, there is a welcome chapter dealing with the many ethical considerations that arise in the management of patients with neurosurgical disease on the intensive care unit and the neurosurgical ward. The authors tackle this dif®cult area with sensitivity. However, there is no section dealing with brainstem death and management of the multiple organ donor; both are areas of clinical practice that are frequently encountered on the neurocritical care unit. Most areas of the principles and practice of neuroanaesthesia are covered by this book. Like most multi-author texts, it does suffer from some minor issues of style and repetition. For example, the management and monitoring of raised intracranial pressure is covered, to varying degrees, in at least four areas of the book. On the other hand, for full coverage of some subjects, it is necessary to look in more than one chapter. However, these observations do not detract from the book's major achievement in providing a comprehensive, up-to-date and clear account of the basic science, pathophysiology and clinical management that comprise the art of neuroanaesthesia. This is not a textbook that will be compulsory reading for general trainees but it will be an invaluable reference for those seeking specialist experience in neuroanaesthesia. It should be available in general departmental libraries for reference by trainees, and is a `must have' for departments of neuroanaesthesia. I suspect that most practising neuroanaesthetists will wish to own their own copy. M. Smith London, UK
Ó The Board of Management and Trustees of the British Journal of Anaesthesia 2002
Book Reviews
Critical Care Medicine: Principles of Diagnosis and Management in the Adult (second edition). Joseph E. Parrillo and R. Phillip Dillinger (editors). Published by Mosby, St Louis. Pp. 1770; indexed, illustrated. Price £140.00. ISBN 0323-012809. This impressive, 1770-page book weighs in at 3.78 kg. The weighty tome is the second edition of a text that seeks to provide an authoritative, comprehensive book aimed at practising critical care physicians. The goal was to produce the acknowledged standard in critical care medicine. While I do not understand what the goal of `acknowledged standard' means in the context of a textbook, this one certainly achieves its main aims. It has a very impressive cast of authors who represent authorities in their respective ®elds. The layout of the book is logical with the pharmacological and technical basis of the speciality preceding the disease orientated section. The range of topics is comprehensive. It is a de®nitive text. The book is relatively easy to read, and is clear and concise. The sections covering practical procedures are easy to follow and informative with relevant diagrams. Where controversy exists, the pertinent arguments are mentioned and referenced but without prolonged and turgid debate. This is clearly seen in the succinct discussion about the pulmonary artery catheter, or the `pros' and `cons' of percutaneous tracheostomy. In fact, throughout the book, I was impressed by the clarity of the discussion that managed to address issues without losing the reader in the detail. The diagrams throughout are clear, as are the photographs and other images. The echocardiography section is particularly impressive. At the end of each chapter, there is a list of key points, some of which are very useful summaries of the chapter with some real `gems', but others somewhat less informative. It is well referenced throughout and relevant papers are almost always listed. The index is easy to use and comprehensive. In general, the book is more than adequately detailed. An exception is in pharmacology where there are long lists of commonly used drugs which, in pharmacological terms, are lightweight. Clearly the intention is to provide a quick and easy guide to these drugs, not a pharmacopoeia. This is a very useful practical addition to the book but is somewhat out of kilter with the detail elsewhere. There are many outstanding chapters in this book but, in particular, the focused view of nosocomial infection is both interesting and practically relevant. Similarly, the chapter on diabetes is extremely good, as well as the discussion on ethics. It is probably unfair to highlight any individual chapters as the standard throughout is very high. De®ciencies are hard to ®nd, but obstetrics does not really feature, and I was surprised by the lack of reference to violent injury and trauma. There are several basic questions I would ask if I was out to spend £140.00 on a textbook, which I have answered below. 1. What do I personally want it for? As a reference textÐexcellent. As a resource book for the intensive care unitÐit is probably one of the best of its kind. As a revision textbookÐprobably too hard to read easily. As a manual in the intensive care unit for the problem at 02.00 h in the morningÐprobably too heavy, although it does have the practical information required. As one book to cover everythingÐit doesn't, but then none do. To look good on the book caseÐde®nitely. For bedtime readingÐonly if you have insomnia, but then who does read these books in bed except those taking examinations? 2. Does the intensive care unit I work in need one? De®nitely. 3. Would I recommend it? Yes. 4. Would I buy one myself? Yes. 5. Is it value for money? At £37.00 per kilo it is good value.
In conclusion, this is a very good textbook of critical care that would be an asset to any intensive care unit. It could be used by trainees working for examinations and by their seniors for continuing professional development or for reference. As an easy access manual, it is probably a little daunting, but would serve that function. The real test of the quality of a book is how long would it stay in the unit before it walked. The answer is, not long. This is one to secure. N. Soni London, UK Safe Retrieval and Transfer: the Practical Approach. The Advanced Life Support Group. Published by BMJ Books, London. Pp. 131; indexed, illustrated. Price £25. ISBN 0-72791583-5. There is a considerable number of published papers that demonstrate the risks associated with the interhospital transfer of sick patients. Unfortunately, with a national shortage of intensive care beds, the number of interhospital transfers shows no sign of reducing. This book provides a framework for safe transfer of sick patients and is written by a multi-professional group representing the Advanced Life Support Group. It is also the course manual for the Safe Transfer and Retrieval (StaR) course run by the same organization. The subject of effective patient transfer is not littered with entertaining anecdotes, and most readers are likely to want to be taken through the subject quickly and painlessly. The book is well laid-out with short chapters, many of which can be read in only a few minutes. Many readers might ®nd the style too didactic but, if seen as one safe method of achieving the desired objectives, this ceases to be a problem. The subject is covered comprehensively. Areas that are vital (and often neglected), such as effective patient packaging and stabilization, are given good coverage. Other areas are of relevance, but are unlikely to be utilized regularly by most transfer doctors e.g. radio voice procedure. Three-and-a-half sides are devoted to diagrams and text on the ®xation of tracheal tubesÐobviously one of the authors has bad memories of a tube displacement on a rainy motorway somewhere. Most of the content is predictable and well thought outÐunlike some multiauthor texts, the editors have ensured consistency. Wellestablished `ABC' type treatments form the mainstay of the guidelines. However, some areas touched upon are controversial, and it would be useful if they were highlighted as such for the less experienced reader. For example, it is suggested that not all critically ill patients necessarily need a doctor to transfer them from one hospital to another. It may be that the speci®c circumstances where this is appropriate are explained in the StaR course, but reading the book alone could cause problems. Also, the suggestion that the administration of steroids in spinal injury is mandatory will be questioned by some UK neurosurgical units. Overall, this book achieves its aims well, and adhering to the clear and well-presented guidelines will undoubtedly reduce the number of preventable adverse events during patient transfers by anyone that follows them. D. Lockey Bristol, UK
190
Book Reviews
Atlas of Hemo®ltration. R. Bellomo, I. Baldwin, C. Ronco and T. Golper. Published by W B Saunders, London. Pp. 106; indexed, illustrated. Price £29.95. ISBN 0702025046. Continuous renal replacement therapy (CRRT) has evolved over the years into a sophisticated therapy with many variations. Haemo®ltration has become commonplace on the intensive care unit, and its management is now computerized. While many critical care texts contain chapters on the background and therapeutic place of CRRT, few give a really simple `how-todo-it' guide. The authors of this book provide just that. Their stated aim is to give their patients the best chance of surviving, and they feel that assisting others to create an effective CRRT programme will help achieve this. The notion of simplicity is lost in the ®rst three chapters of the book. These give the background theory to CRRT which, although simple in concept, is dif®cult to describe simply. Even in these three chapters there is some overlap, with diffusion, convection and ultra®ltration being de®ned several times, the most straightforward description being in chapter 3. Chapters 4±12 regain the simple approach and describe the machines available for CRRT in some detail. The Prisma machine is used on our unit so we are most quali®ed to comment on this chapter. Essentially, it is a very honest summary of the machine, particularly of its advantages and disadvantages; the Prisma is indeed user friendly, but at a price. The recently introduced plasmapheresis facility for the machine is not mentioned but is newly available. If the same level of insight applies to the chapters on other machines, they are certainly fair. The following chapters are a motley collection on different aspects of haemo®ltration, such as paediatric renal replacement therapy and anticoagulation. The chapter on vascular access is towards the end of the book, a decision that seems rather strange since, before renal replacement therapy can be initiated, venous access must be established. The troubleshooting chapter is particularly useful. In it, common problems are described using case histories. The authors then discuss the problems, offering explanations and solutions. The problems highlighted are practical and common, and the solutions given based on experience and common sense. The chapter on nursing management is full of practical hints and addresses some important problems, such as heat loss, that are not covered elsewhere. This chapter also contains a description of how the authors teach others the techniques of CRRT. They use a resuscitation mannequin as a simple simulator for setting up haemo®ltration circuits. This adds reality to the teaching and is a useful tip. The principles behind changes in drug dosing with renal failure and CRRT are complex, but, nevertheless, their application is often relatively simple and easy to summarize. Because of this, the chapter on how to adjust drug dosage during CRRT was disappointing. One complex example is a table of drug sieving coef®cients: ®nding out how to use this table by reading the text is complicated. A summary table of increased or decreased doses would have been simpler and easier to interpret. There are also good reviews of this subject that are not even referenced. In fact, although there is much written on haemo®ltration, only a few of the chapters in this book quote references. More suggestions for follow up reading would have been useful. Our main disappointment with this book is its lack of visual impact. It is in black and white, which makes the sophisticated CRRT machines look like museum pieces. The cover is attractively colourful and atlases are usually in colour, which helps to provide detail and outline boundaries, but these details are missing from this atlas. Nevertheless, this is a useful book both as a teaching reference and as a ®rst-line troubleshooting guide. It is
a users' guide to haemo®ltration that will probably ®nd a place in every intensive care unit. J. A. Clayton and M. P. Shelly Manchester, UK The Year in Hypertension 2001. H. L. Elliott, J. M. C. Connell and G. T. McInnes. Published by Clinical Publishing Services, Oxford. Pp. 369. Price £49.50. ISBN 0-9537339-4-7. This very interesting and extensive review of over 190 articles on hypertension summarizes and puts into perspective articles published in 2000±2001, and includes relevant articles published over the last few years if they are important to the build-up of a clearer picture. The book does not address the issue of hypertension in surgical patients. However, it is highly relevant to perioperative medicine: advances in the understanding and management of hypertension are not always put into practice. As perioperative physicians, we are in a unique position to draw the attention of surgeons and general practitioners to the presence of hypertension that is either untreated or poorly controlled by present standards. In each section of the book a clear and concise introduction sets the scene, and relevant articles are commented on in a very clear manner. The section on clinical trials and guidelines includes comments on some meta-analyses of recent trials, and a detailed review of current guidelines. Reading this section makes one realize that many surgical patients remain inadequately treated by current standards. This section also includes published information, sometimes with preliminary results of major on-going trials. A number of trials focus on speci®c groups of patients, such as the elderly, and patients with diabetes or left ventricular hypertrophy. The second section deals with hypertension and other cardiovascular risk factors with particular reference to diabetes, interactions with lipid lowering drugs, and hormone replacement therapy. The third section focuses on hormonal mechanisms in hypertension, such as the role of the renin-angiotensin-aldosterone system, insulin resistance, and mineralocorticoids. The fourth section deals with practical issues including angiotensin II receptor antagonists, 24-h arterial pressure measurement, surrogate measures such as altered vessel wall properties, and ®nally, calcium channel blockers. An important observation is that in the long-term, elevated average arterial pressure correlates much better with left ventricular mass (an index of risk) than casual arterial pressure. The implication is that ambulatory arterial pressure measurement may be very useful in surgical patients to detect those with substantially raised average arterial pressure. Bearing in mind that the current goal in the treatment of hypertension is to decrease the level to 150/90 mm Hg in non-diabetics, there is still a long way to go. We are probably well placed to highlight the problem! For those interested in hypertension, this book offers a wealth of extremely useful, up-to-date information reviewed by experts; it broadens our understanding and helps us to grasp the most recent concepts and therapeutic advances. P. FoeÈx Oxford, UK Pediatric Anesthesia: Principles and Practice. B. Bissonnette and B. Dalens (editors). Published by McGraw-Hill, New York. Pp. 1618; indexed, illustrated. Price $195. ISBN 0-07-135454-9. Paediatric anaesthesia has made great advances over the past few years including having its own specialist journal. We now have a completely new textbook of over 1600 pages on this subject to add
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Book Reviews
to our written armamentarium. This publication is a truly multinational collaboration with the two editors, Bruno Bissonnette (hailing from Canada) and Bernard Dalens (from France), and the other 143 contributors representing all continents, except Antarctica. It includes most of the acknowledged experts in the paediatric anaesthetic world. Whilst such a diverse authorship could lead to variations in style, the editors have, on the whole, managed to maintain a consistency to the book, although the constant use of metric rather than SI units is irritating to the European reader. The book is split into six sections, with the ®rst section dealing with both normal and abnormal human development. This includes a chapter on the development and evaluation of pain and the stress response, which is relevant, but the chapter on chronic and recurrent pain in children and adolescents is incongruous in this section. The second and third sections examine pharmacology of anaesthetic and analgesic agents, and anaesthetic management and techniques. This is followed by the section on special monitoring and resuscitation. The penultimate and largest section has the somewhat unwieldy title of `Surgical and Anesthetic Considerations of Procedures'. It is this section that will probably be referred to most in this book. For each particular surgical and anaesthetic subspecialty (e.g. cardiac, ophthalmic, neonatal), there are two chapters. The ®rst is by surgeons describing the presentation and surgical management of various conditions. This is then followed by the chapter on the anaesthetic management of these conditions by anaesthetists. In a number of the anaesthetic chapters, the authors have written the typical anaesthetic management of particular conditions in the form of tables, which are very easy to follow, in a stepwise manner: a good example being the chapter on the anaesthetic management of the neonate. As the surgical and anaesthetic sections are written by different authors, there is some avoidable duplication of information. The ®nal section of the book is entitled `Future of Pediatric Anesthesia'. The title is somewhat misleading as rather than describing a brave new world of paediatric anaesthesia, it addresses issues such as medicolegal and ethical subjects, education and training, and the use of computers and online services. There are many high quality greyscale illustrations (no colour), throughout the text. However, there is one glaring omission, which is surprising for a book of this size, and more so if it is to become the standard paediatric anaesthetic reference book. There is no section on syndromes and unusual paediatric diseases and their relevance to the anaesthetist. In fact, some conditions that are a particular challenge to paediatric anaesthetists, such as the mucopolysaccharidoses, which cause major airway problems, are not mentioned at all. This seems particularly odd as an advertising ¯yer for this book asserted that the book would include `a convenient, alphabetized section of every acute pediatric syndrome encountered worldwide, listing both precise instructions and quick reference information for each case'. In summary, although this is not a complete reference book, it does provide an excellent summary of current paediatric anaesthetic practice, which should be available in any department where children have anaesthetics. A. Bowhay Liverpool, UK
Shnider and Levinson's Anesthesia for Obstetrics (fourth edition). S. C. Hughes, G. Levinson and M. A. Rosen (editors). Published by Lippincott, Williams and Wilkins, Philadelphia. Pp. 690; indexed, illustrated. Price $129. ISBN 0-683-30665-0. The fourth edition of this classic textbook for obstetric anaesthetists comes 9 yr after the previous edition. Much has changed in the ®eld during this time, prompted by improvements in pharmacology and equipment, and recent advances in the understanding both of obstetric physiology and the effect of anaesthesia on pregnancy and delivery. Sol Shnider has died since the last edition and two eminent obstetric anaesthetists (Sam Hughes and Mark Rosen) have joined Gershon Levinson as editors. A host of internationally renowned authors have contributed, and although many of the contents and authors are the same as previous editions, there has been extensive reworking using up-to-date references. The book is comprehensive and organized into six parts. Part one covers maternal physiology and pharmacology. The topical issue of the effect of regional analgesia on the progress of labour is discussed. Analgesia for vaginal delivery is the topic of the second part. The new local anaesthetic drugs, ropivacaine and levobupivacaine are discussed, as are modern regimens such as low-dose local anaesthetic drugs, with or without adjuncts. Combined spinal epidural techniques and patient controlled epidural analgesia have been included as newly accepted regional techniques. The use of intrathecal and epidural opiates is now almost universal and considered routine. The anaesthetic management of obstetric complications is dealt with in part three. The options for Caesarean section are discussed as are the management of such disasters as major haemorrhage, amniotic ¯uid embolism, hypertensive disorders, and foetal problems. Mainstream general anaesthetic complications such as airway problems and gastric aspiration are included in part four. There is an up-to-date chapter on neurological complications of regional techniques and the management of post-dural puncture headache. A chapter on legal issues offers guidance concerning consent and complaints. Though obviously more interesting to American readers, it does have implications for clinical governance. Part ®ve is dedicated to non-obstetric disorders during pregnancy. This does not attempt to be a comprehensive encyclopaedia on how to manage any speci®c syndrome, but emphasizes the scienti®c background to various disorders and how these impact on pregnancy and anaesthesia. A whole chapter is reserved for the morbidly obese, pregnant patient. Anaesthetists in the UK are increasingly faced with such patients, many having altered anatomy and physiology necessitating modi®cations of techniques and equipment. Foetal problems are discussed in the ®nal part. This is too detailed for the UK anaesthetist, who is primarily responsible for the mother, but it helps to understand the concerns of other members of the team. This section includes information on problems caused by drug addicted mothers, who are becoming more common in the UK. The layout of the text is reader friendly and is accompanied throughout by useful illustrations, tables and many summary or recommendation boxes. The chapter sequence is logical and a bibliography appears at the end of each one. The index is comprehensive and it is easy to look up any queries. At US $129, this text is affordable and should be regarded as a comprehensive reference book that is a resource for the management of dif®cult or unusual cases. The book compares favourably with other high quality American textbooks of obstetric anaesthesia. It deserves a place on the shortlist when looking for the one tome to keep on the delivery suite. H. Gorton Leeds, UK
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Book Reviews
Key Topics in Chronic Pain (second edition). K. M. Grady, A. M. Severn and P. R. Eldridge. Published by BIOS Scienti®c Publishers Ltd, Oxford. Pp. 212; indexed. Price £23.99. ISBN 1-85996-038-3. It is no mean feat to encompass the diverse features and management of chronic pain in 212 pages without being didactic, simplistic or super®cial. This book achieves this to a large degreeÐwith honours! It is the second edition of a popular book in a series with a succinct and successful format. The changes are those which re¯ect the evidence base of this speciality as determined by meta-analysis, informed review, randomized controlled trials (as far as such evidence exists) and consensus. The book is written in three parts: (i) assessment of evidence, history, examination and psychosocial factors; (ii) description of various chronic pain disorders with their features, treatment, mechanism and management; and (iii) various methods of treatment, including drugs, stimulation and invasive therapies, diagnostic and de®nitive methods, and surgical and psychological techniques. In general, the descriptions and management of the disorders agree with those in larger works and with recognized authorities. References are not given in the text, which may make this seem less authoritative, but certainly makes it easier to read. The chapters are small and sections within the paragraphs are short enough to be absorbed before the mind wanders. Technical terms are used sparingly and there is a glossary of acronyms at the beginning of the book. The authors are to be congratulated in that, although the text is terse with every phrase essential to the imparting of knowledge, it ¯ows clearly and the reader is drawn into the narrative, retaining interest. There are gems to be found in this book but, inevitably, there are also omissions, items that could or should have been omitted, and some with which I cannot concur. The gems include an excellent one and a half page chapter by Andrew Smith (who is the editor of the Cochrane Anaesthesia Review Group), which describes clearly and simply the various measurements of evidence-based medicine and how to measure them. There is Archie Cochrane's description of giving comfort to a dying soldier for whom no cure was possible, and his realization of the difference between suffering and pain. Under clinical governance, there is the acknowledgement that although there may occasionally be grounds for a patient's complaints, the process of complaining may be part of the presentation of the patient's disorder. It warns that an over-solicitous and apologetic response for an alleged de®ciency may reinforce the behaviour which aggravates the pain and disability. Statements such as `Pregnancy appears to be a risk factor for postpartum disc prolapse', and `central pain syndromes occur even in the absence of a spinal cord' made me smile.
There are omissions such as chronic dental causes of head pain, the use of cryothermy, the value of movement in conditions such as cervical spondylosis, the irreversible effects of botulinum toxin, and the consideration of anal pain. Even simple line diagrams would have made some aspects of physical therapy easier to understand. The index is inadequate in a book that seems to attempt to provide chapters which are suf®cient in themselves with cross-references to other sections. If, for example, one wishes to look up `stump pain', there is no entry although there are several entries for `phantom'. For `sympathectomy', one is diverted to `guanethidine'. If the trainee pain clinician wished to consult for an answer to shooting, numbing or burning pain, the index will not help. I dispute some of the information on sympathetic blockade. The addition of local anaesthetic to guanethidine in the i.v. regional technique may prevent the uptake of the guanethidine. The stellate ganglion is more usually found at the level of the seventh cervical vertebra; the somatic nerves do not have to be blocked during thoracic sympathetic block by the paravertebral approach; the lumbar sympathetic chain lies on the anterolateral aspect of the vertebral body rather than in the paravertebral gutter; and the hypogastric plexus does not have to be approached via the inconsistent space between the ®fth transverse process and the sacral ala. There is the theme throughout the book that pain disorders are diseases in themselves, having acquired an existence beyond that of an extension of the disease which initiated them. The primary aim is to alleviate the disability, and change the perception of the sensation that makes it so aversive. This is preferable to temporary pain relief which does nothing to alter the underlying disorder and may even render the victim more dependent on the various carers. Concurrent, however, is the acknowledgement that pain relief may have to be attempted to restore function and that even temporary relief for, say, a few weeks may be of value. The con¯ict between the ideal of transfer of the management of chronic pain to the subject and the more pragmatic chronic management of pain, is not resolved. The book is said to be designed for specialist registrars, general practitioners, nurses and physiotherapists, but this book has an even wider potential audience than this. The emphasis on evidence-based treatment makes it useful in formulating a treatment plan on ®rst consultation, or answering the question `whatever do I do now?' on later ones. The systematic organization of the chapters makes it ideal as a reference in the pain clinic. I have enjoyed reading it and I recommend it to almost any health professional. J. I. Alexander Bristol, UK
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