Book Reviews Surg Neurol 395 1992;38:394-8

is included, but most information is redundant and contained in other areas of the book. The section on surgical anatomy and exposure makes up about 40% of the book, as well it should in a text for neurosurgeons on peripheral nerves. Unfor- tunately, this section is also one of the book's weakest parts. The chapter on brachial plexus exposure discusses the anatomy of the brachial plexus briefly and then, more thoroughly, dis- cusses the various approaches--anter ior , supraclavicular, in- fraclavicular, and posterior. The anatomical drawings, unfortu- nately, for such an involved exposure, are few and of only fair quality. This chapter should not be heavily relied upon, but is a good general overview. The chapter on surgical exposure of the nerves in the upper extremity is only a slight improvement. The anatomical drawings are improved, but the zigzag inci- sional approach to the upper extremity nerves, with its sharp corners, is to be decried. There is a good section on general principles concerning the ulnar and median nerve exposure in the palm, with the "line of Taleisnik" receiving emphasis. A section on the exposure of the digital nerves is very welcome because few major texts explain the nuances associated with their approach. The final two chapters, which concern the exposure of the lumbosacral plexus, the sciatic nerve, and the nerves of the lower extremity, are very well done, as one would expect from authors Benzel and Ducker. The anatomical drawings and incisional locations are well marked and very clear. Although many surgeons have little experience with such exposures as the Pfannenstiel infraperitoneal approach, this section could be used almost de novo to expose most of the structures listed. Some of the clinical material is contained in other chapters, but these two chapters present an excellent anatomical road map for the lower extremity.

Two chapters in the section on special considerations merit ment ioning-- those of Drs. Branch and Friedman concerning nerve tumors and restoration of extremity function, respec- tively. The chapter on nerve tumors is a good general overall view of these unusual tumors, and Table 1 presents a solid classification of them. The differences between schwannomas, neurofibromas, and plexiform neurofibromas are discussed, and the use of important operative adjutants, including magni- fication, the Cavitron ultrasonic aspirator and adequate proxi- mal and distal exposure, is emphasized. The use of nerve action potentials intraoperatively to identify functional fascicles is highly recommended during tumor resection, as well it should be. Other tumors, including malignant nerve tumors, meta- static tumors, lipomas, and ganglion cysts are also briefly dis- cussed.

Any neurosurgeon who deals extensively with peripheral nerve and plexus injuries recognizes that restoring function to a limb is paramount but often cannot be done by an operative procedure alone. The treatment of the "patients' dysfunction and not just their injured nerve" is the crux of Friedman's chapter. The use of physical therapy, orthotics, muscle and tendon transfers, and sensory retraining are highly recom- mended and can lead to excellent functional results. In addition to those adjuvant therapies, Friedman also emphasizes the sometimes excellent results with neurotization. Even if the nerve injury is such that motor control is unlikely to occur, i.e., ulnar nerve proximal to elbow or high median nerve, nerve grafts should be done just to restore critical sensory regions.

Many times, muscle or tendon transfers can provide the needed strength. Friedman's emphasis on the combination of all the above techniques is the most important point to be gleaned and should be noted by all involved in nerve injury care.

This book is of superior quality, with excellent authors and wonderful illustrations. It is not a book that an expert in peripheral nerve surgery would take to the operating room, but for anyone else it is an excellent beginning to a deeper knowledge concerning peripheral nerve surgery. It should al- most be considered required reading for medical students and should be read by all neurosurgery residents, especially those just beginning their training. It should definitely be included in any neurosurgical library because it provides a wonderful introduction to peripheral nerve surgery. Except for an occa- sional lapse in anatomical drawings and discussions, I highly recommend it to anyone invovled in the neurosciences, and it is obvious that the AANS has met its goal once again.

CHARLES E. RAWLINGS, III, M.D. Winston-Salem, North Carolina

Advances in Pain Research and Therapy. Volume 20: Pain Versus Man. Edi ted by F. Sicuter i , M . D . , L. T e r e n i u s , M . D . , L. Vecch ie t , M.D. , and C.A. Maggi , M.D . 320 pages. $90.00. N e w York : Raven Press , 1991.

Advances in pain research and therapy is a collection of 29 chapters describing a plethora of pain topics encountered in clinical scenarios and research. In the preface, the authors did not elaborate on their goals for this collection of chapters, leaving the reader to question the purpose of the inclusion of some chapters that are largely philosophic. Nonetheless, the layout of the chapters seems to flow reasonably well. The first chapters are a comprehensive historical perspective on pain, as well as a good overview of theories describing clinical situa- tions, all of which are well documented. Chapters like "Patho- physiological Mechanisms Operating in Reflex Sympathetic Dystrophy" written by W. J~nig showed the authors ability to succinctly lay out the complexities of the subject. This included both relevant discussion about nomenclature and the myriad of pathophysiological phenomena that were correlated with clinical componehts. Included, as in other better-written chap- ters, is a conclusion that suggested areas in which research may have a bright future. Little in this book elaborates on surgical contributions to pain control, and the number of chapters that generally allow crossover into guiding patient management are few. One notable exception to this is the chapter by Marie- Kristine Lombard et al entitled "Deafferentation Pain and the Opioids in the Dorsal Horn of the Rat Spinal Cord." This chapter outlines an animal model of neurogenic pain and the effect of rhizotomy on spontaneous spinal cord neuronal activ- ity. Its discussion led into the debate on the clinical usefulness of anticonvulsant medications in treating neurogenic pain and, additionally, the divergence of opinions on the usefulness of morphine in deafferentation pain. Other chapters such as that titled "Phantom Pain and Phenomenon After Amputation"

396 Surg Neurol Book Reviews 1992;38:394-8

present very limited data and omit any comparison or integra- tion of work by other notable authors (e.g., Melzack and his neuromatrix theory) [1,2]. A scant few chapters are accounts of clinical studies or laboratory basic research in animal models, which do little to integrate basic science and patient manage- ment. For example, the chapter entitled "Action of Antibiotics on Two Animal Models of Pain" is merely an animal laboratory study using subcutaneous application of antibiotics to control deafferentation pain. The author made no attempt in his discus- sion to integrate previous work using antibiotics in pain control [3].

The last third of the book is largely directed toward pain of head and neck distribution and is very well done. Specifically, there were some chapters regarding the role of serotonin in migraine syndromes, which American clinicians may find of value, especially with the impending availability of sumatriptin. Chapters such as "Humans Versus Pain: The Dilemma of Mor- phine," though well written, contained little new information and its humanitarian theme seems lost in a book with this title.

In general, this book contains a great deal of information that is both historic and current in the areas of pain research. As a work that describes areas of current pain investigation, it succeeds. I can find minimal evidence that the editors wove together the contributing authors' efforts into a unified presen- tation. As mentioned in the book's acknowledgments, the ori- gins of this book were the result of a workshop held in Italy in the spring of 1990. Though I do not have a reprint of the literature distributed at that meeting, one can suspect that this is largely a written collection of the presentations and could have benefited from both the editors' direction and selectivity.

KYLE JACKSON, M.D. Winston-Salem, North Carolina

References 1. Melzack R. Phantom limbs, Labat Lecture. Reg Anaesth 1989;14:208-11. 2. Melzack R. Phantom limbs. Sci Am 1992;April:120-6. 3. Gallagher J, Hamann W. Chronic neuropathic pain: aminoglycosides, periph-

eral somatosensory mechanisms and painful disorders. In: Atkinson RS, Ad- ams AP, eds. Recent advances in anaesthesia and analgesia. 1991.

Too Old For Health Care? Controversies in Medicine, Law, Economics, and Ethics. Edi t ed by R o b e r t H . B ins tock and S t e p h e n G. Post . 203 pages. $40 .00 (reg. $50.00) ha rdcover , $15 .16 (reg. $18 .95) pape rback . Ba l t imore : T h e J o h n s H o p k i n s U n i v e r s i t y Press , 1991. I S B N : 0 -8018- 4248-4 .

Surgical Neurology was not asked to review this book, but the editor purposely sought the book and purchased it, and having read it, feels constrained to write a short review.

It is written by a group of distinguished authors, all but two of whom are Ph.D.s, L.L.B.s, orJ.D.s. Physicians have written chapters in concert with Ph.D.'s.

There is a good foreword by former surgeon general of the United States Public Health Service, C. Everett Koop, M.D., which is a short version of his book, The Memoirs of America's Family Doctor [1]. He states:

Daniel Callahan, for example, is one who is more com- passionate and less rigid than his critics paint him. How- ever, I do disagree sharply when he defines rationing based on age alone.

Age is far too loose a criterion. Look at me. One of the main reasons I was rebuffed during my nomination to the office of surgeon general was because I was "too old." I was just a youngster of sixty-five.

The authors of this book, of whom there are 11, are distin- guished individuals, well acquainted with this health care field, and the subject is well covered in Chapter 2 by Jahnigen and Binstock, "Economic and Clinic Realities: Health Care for Elderly People." These authors very explicitly and thoroughly review the arguments for and against rationing of health care on the basis of age. They quote numerous percentage figures, which have become bywords since the computer has provided such a wealth of information to planners. As the authors of this chapter say, "Traditionally Western medicine has three simply stated clinical objectives: to cure where possible, to comfort when appropriate, and to care always."

In some of the chapters, the various cases that have been felt to be "landmark cases," such as the Quinlan case in 1976, the O'Connor case in 1988, and the Cruzan case in 1990, are thoroughly discussed, perhaps repetitiously.

There is a recurring theme in this book in several of the chapters to answser the proposals made by others who have spoken out in this field, including Governor R.D. Lamb, Daniel Callahan, Ann Daniels, and Robert Veatch. Although not much is made of his original observations, the publications by the late J. Fletcher were also of great importance in this area.

This entire book would have been improved by the submis- sion of the various chapters to the other authors so that repeti- tion and recurring arguments along the same line in different chapters could have been avoided.

Probably the best and most valuable summary of the whole subject is the ninth chapter by Harry R. Moody, Deputy Direc- tor of the Brookdale Center on Aging of Hunter College in New York, "Allocation, Yes; Age-Based Rationing, No." He clearly covers the Congressional actions that have been historic in this field, including the effort of Congress to pass the Cata- strophic Coverage Act, which would have taxed the elderly for the additional cost of Medicare. Although much of this chapter is quotable, a small portion of the conclusion is worthy of quotation.

What I mean to suggest by these examples is that philosophers, such as Callahan, Daniels, and others, who propose speculative ideas and theoretical models, can do us a service by stimulating public debate. Once the de- bate gets under way, however, it appears that the philoso- phers have little to contribute to the detailed resolution of problems. The very model of philosophical discourse today, even when it seems superficially practical, increas- ingly departs from the discourse of politics and practice. Philosophical discourse has long needed an adequate account of the importance of compromise in the real world of political action. As a result, philosophical dis- course is often lacking prudence or practical wisdom.