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45 min, but in this case the exposed person received aninjection with a syringe previously used on a patient withHIV which was estimated to contain 100-200 gL ofblood.7Our patient had a substantial penetrating injury with freshblood from someone with AIDS and despite early treatmentwith zidovudine within 1 h of exposure she became infectedwith HIV. There are several possible reasons for thisinfection. The index patient was at the end-stage of herillness and therefore was likely, despite treatment withzidovudine, to have had a high titre of virus in her blood.8,9She was on treatment with zidovudine at the time of theincident and had been taking this agent for 18 months. It istherefore possible that this woman’s strain of virus wasresistant to zidovudine.1oThe virus from the health-care worker was substantially

less sensitive than those obtained from zidovudine-naiveindividuals. Although she had received zidovudine after theinoculation injury, the short duration of this treatment isunlikely to generate resistance.ll In the absence of virusisolation from the index patient, it is impossible to confirmthat transfer of resistant virus by inoculation injury tookplace but our results strongly suggest such an interpretation.Therefore the use of zidovudine prophylactically in thishealth-care worker might have been expected to beunsuccessful.

However, although prophylactic use of zidovudine maybe ineffective, its short-term use in otherwise fit individualsseems to be associated with, at worst, only minor reversibleside-effects.12 To date, no long-term adverse sequelae havebeen described. As data on successful prophylaxis cannot beobtained we would still offer zidovudine with fully informedconsent to health-care workers immediately after a specificincident involving known HIV-positive patients. If such apolicy is to be implemented, rapid access to confidentialcounselling facilities must be available at all times and isneeded to allay anxiety even if zidovudine is declined.Partners will often need to be seen also. Health-care workersmust be encouraged to report all such injuries promptly sothat at the very least baseline serum can be stored for

HIV-antibody testing, if necessary at a later date. Ifseroconversion does take place, an initial negative test will be

invaluable in confirming the source of infection and maybe of the utmost importance when compensation issuesarise.With the development of increasingly early medical

intervention in the course of HIV disease, prompt diagnosisand regular monitoring will allow administration ofantiretroviral and other therapies at the best time to prolonglife. The other important issue that this case highlights is theincreased risk to staff of doing emergency procedures onpatients with AIDS who are terminally ill. Our resuscitationpolicy now clearly states the importance of taking intoaccount the risk of HIV transmission whenever a decision ismade on the appropriateness of attempted resuscitation.

REFERENCES

1. Gill N, Heptonstall J, Porter K. Occupational transmission of HIV:summary of published reports, May 1992. PHLS AIDS Unit, CDSC,Colindale, UK.

2. Editorial. Needlestick transmission of HTLV-III from a patient infectedin Africa. Lancet 1984; ii: 1376-77.

3. Porter JD, Cruickshank JG, Gentle PH, et al. Management of patientstreated by surgeon with HIV infection. Lancet 1990; 335: 113-14.

4. Brun-Vezinet F, Ingrand D, Deforges L, et al. HIV-1 sensitivity tozidovudine: a consensus culture technique validated by genotypicanalysis of the reverse transcriptase. J Virol Methods 1992; 37: 177-88.

5. Jeffries DJ. Zidovudine after occupation exposure to HIV. BMJ 1991;302: 1349-51.

6. Looke DFM, Grove DI. Failed prophylactic zidovudine after needlestickinjury. Lancet 1990; 335: 1280.

7. Lange JMA, Boucher CAB, Hollak CEM, et al. Failure of zidovudineprophylaxis after accidental exposure to HIV 1. N Engl J Med 1990;322: 1375-77.

8. Ho DD, Moudgil T, Alam M. Quantitation of human immunodeficiencyvirus type 1 in the blood of infected persons. N Engl J Med 1989; 321:1621-25.

9. Coombs RW, Collier AC, Allain JP, et al. Plasma viremia in humanimmunodeficiency virus infection. N Engl J Med 1989; 321: 1626-31.

10. Rooke R, Tremblay M, Soudeyus H, et al. Isolation of drug-resistantvariants of HIV-1 from patients on long-term zidovudine therapy.AIDS 1989; 3: 411-15.

11. Larder BA, Darby G, Richman DD. HIV with reduced sensitivity tozidovudine (AZT) isolated during prolonged therapy. Science 1989;243: 1731-34.

12. Fahrner R, Beekmann SE, Zozia DE, et al. Safety of zidovudine (ZDV) aspost exposure chemoprophylaxis to healthcare workers (HCW) afteroccupational exposure to HIV. VIII International Conference onAIDS/III STD World Congress Amsterdam, 1992: PoC 4132.

BOOKSHELF

Torture and its ConsequencesEdited by Metin Basoglu. Cambridge: Cambridge UniversityPress. 1992. Pp 527. ,E55. ISBN 0-521392993.

Many of those who work with torture victims fear thatsome doctors and psychotherapists want to create an excitingnew discipline, torturology. The aim of Metin Basoglu’senterprise is to argue that a scientific approach to tortureneed not inevitably result in reductionist medicalising.Richard Mollica alludes to these tensions in a careful chapteron clinical care, noting that this is a field in need of a newscience. He writes that norms and measures generated forscientific investigations can only partly reproduce theessential inter-connectedness of human society and theextent to which individuals are embedded in their own

unique cultural, political, social, and family environments.

Several chapters focus on the physical and psychologicaleffects of torture. No clear correlations have yet emergedbetween types of torture and subsequent physicalpathology. That even the most vicious assaults may leavescars that are compatible with a bicycle accident is

problematic for asylum seekers who are pressed to provetheir story. I was puzzled by the omission of a review ofpsychosomatic symptomatology; this has a world wideprevalence, which one school interprets as stress-basedphysiological responses whilst another concludes that it ismerely a communication of the collective distress of

powerless and persecuted people.The debate about the psychological effects of torture is as

much framed by the mental set of professionals as byvictims. Many workers see torture as a wound for life,

1079

similar to rape or child abuse. To the extent that such beliefsbecome accepted and disseminated within popular culture,they will exert an influence on the meaning of trauma forvictims, shaping what they feel, how they communicate, andhow they seek help. There is a risk here of generatingself-fulfilling prophecies. Research into long-term effects isas much a study of social constructions of torture, which donot stand still, as it is of the individual fortunes of survivorsover time. Without minimising the seriousness of thesepractices, we must remember that all human experience isrelative; I have interviewed many who felt that torture wasnot the worst thing that had happened to them. It would bean affront to consider as permanently damaged theuncounted millions who reassemble their lives after torture.The chapter on the Jewish holocaust notes that the

suggestion that survivors have transmitted something totheir children has arisen from psychoanalytically orientedclinical studies; community based research has not tended tobear this out.A valuable review discusses the burgeoning literature on

post-traumatic stress disorder, with most authors agreeingthat its value is tempered by a restricted focus on subjectivemental life and an inability to encompass socio-culturalvariables. From the sections on treatment, includingmedication and psychotherapy, it emerges that there is noevidence to support one treatment over another. In my viewthe non-specific factors-providing a sympathetic ear,

allowing emotional expression, instilling hope for a betterfuture-are likely to be as important as any theoreticalapproach.

Torture and its Consequences reflects the preoccupations ofclinicians in western centres but there are also tellingcontributions from Argentina, South Africa, Pakistan, andthe Philippines. In South Africa, 24 000 children as youngas 12 were detained in 1985-89 without access to parents or

lawyers, and many were tortured. 83% of ex-detaineesreported some form of torture: beatings, electric shocks,near strangulation, and suspension. In the Philippines, theMedical Action Group documents that 102 health workerswere subject to extrajudicial killing, arbitrary detention, orother harassment in 1987-89 by military or para-militaryforces. In these settings the health professional who is

assisting victims is far more of a human-rights worker thanin the west. Doubts about the value of western psychiatriccategories are correspondingly more overt and the politicalstance of professionals is much more an issue. For areview of the ethics debate I would commend the BritishMedical Association’s recent and exemplary MedicineBetrayed.

I would have liked Basoglu to have broadened his focus toinclude contributions from sociologists and anthropologists.In the developing world, conflict-generating atrocity is

routinely taking place on a terrain of subsistence economies.What of those people who cannot imagine personal survivalif their way of life does not survive? What of the wounds thatembed themselves in whole societies and their beliefsystems? How do these systems adapt, recover, or die? Iendorse Prof Ron Baker’s point that a body of indigenouswritings about these questions exists but is rarely translatedinto western languages and published in the journals weread. Foucault wrote that the voice of the torture victim is awhisper. To hear it we must bend close.

Medical Foundation forthe Care of Victims of Torture,

96-98 Grafton Road,London NW5 3EJ, UK DEREK SUMMERFIELD

Carpal Tunnel Syndrome and Other Disorders ofthe Median Nerve

Richard B. Rosenbaum, Jose L. Ochoa. Boston, Massachussetts:Butterworth-Heinemann. 1993. Pp 358. 70/$135. ISBN0-750692294.

Carpal tunnel syndrome is not the disorder that it was adecade or two ago. It represents a new beast on the horizonof medicine that has grown not only in size but also in theway it looks. Why?The awareness by primary care physicians of the

symptoms of carpal tunnel syndrome has led to far moreaccurate and early diagnosis. What, besides the cleverphysician, has accounted for the increased prevalence of thisdisorder? Certainly the workplace has had a substantialimpact on carpal tunnel syndrome. Typing activities havechanged dramatically in the past decade with the advent ofcomputer terminals. The pressure required by a finger toestablish a keystroke on a computer keyboard is minusculecompared with what was previously required on manual andelectric-driven typewriters. The faster typing speeds thatcan now be accomplished place increased stress on thosestructures surrounding the median nerve. Have all thoseother manufacturing jobs that have been categorised asrepetitive changed dramatically in recent years? Mostdefinitely not. But the alacrity of employees in filing forcompensation has increased with time. In the USA alone,the cost of workers’ compensation claims from all conditionshas tripled in the past decade and shows little sign of abating.

For all these reasons, one should know as much as one canabout disorders of the median nerve. Do Dr Rosenbaumand Dr Ochoa give an accurate review of carpal tunnelsyndrome and its related conditions? Absolutely. The text iswell organised into short sections that provide the readerwith a synopsis of all the issues relating to carpal tunnelsyndrome. The writing has a refreshing cohesiveness thatsummarises over 2000 previous articles and manuscriptsinto one easily readable source. The only weakness is thediscussion about surgical treatment of refractory carpaltunnel syndrome. The price of this book is high but is wellworth paying for those who require contemporary andthorough data on this common condition. The binding onmy copy is certain to be well worn in the near future.

Department of Orthopedics,Brown University School of Medicine,Rhode Island Hospital,Providence, Rhode Island, USA ARNOLD-PETER C. WEISS

Cancer of the OvaryEdited by Maurie Markman, William J. Hoskins. New York:Raven. 1992. Pp 458.$156.50. ISBN 0-881679704.

Once a doctor has finished with examinations, the days ofsoaking up information in a sponge-like fashion can bewaved a cheery goodbye. Thereafter the busy clinicianlearns new facts either by quickly snatching digestiblepackets of information from journals or books or by a moreleisurely read of an article dedicated to some rare clinicalproblem that he has waited 20 years to see.

Cancer of the Ovary passes my test of valuable volumesand one need look no further than the contents page to see

why: short chapters with problem-related titles. There arechapters on secondary cytoreduction of ovarian

malignancies, palliative surgery, management of early stagedisease, and the role of radiotherapy in the management ofepithelial ovarian cancer. Discussion is also provided about

1080

well-defined and important non-therapeutic topics such ashistopathology, epidemiology, prognostic factors, and

radiological evaluation. Within each chapter, convenientsubsections with excellent tables and illustrations will guidethe reader.

Yet, this book is not perfect; its upbeat tempo leaves oneshort of breath and there are also some disappointingomissions. For instance, there is no chapter on what to do iffirst-line treatment fails. Despite these few reservations, Irecommend this book to all those who are specificallyinterested in the management of ovarian malignancies. Itshould be in every obstetrics and gynaecology departmentallibrary. Trainees and old lags would all benefit from quickdips into its pages. In short, buy it but do not settle into acomfortable chair and try to read it from cover to cover.

Royal Marsden Hospital,London SW3 6JJ, UK MARTIN GORE

Potassium Channel Modulators

Edited by Arthur H. Weston, Thomas C. Hamilton. Oxford:Blackwell. 1992. Pp 513. 79.50. ISBN 0-632030445.

The weakness of Potassium Channel Modulators is that it

provides vast amounts of factual information without anyeffort at integration into a comprehensible text. Admittedly,we all are made up of cells. But, to quote Bjom Folkow, whois among the last Mohicans of general physiologists "...although a modem jumbo jet compromises manyfold per sesophisticated components ... they remain a ’heap of junk’until assembled and trimmed to the perfect level ofcoordination that characterizes the flying wonder ...". Afurther thought that kept recurring while travelling fromcover to cover through this mass of observation on

potassium channel modulation was that sometimes it may bemore helpful to tell what we do not know than what we doknow. A chapter on this subject would be welcome in manybooks.The development of potassium-channel activators as

important tools for evaluating the role of these channels haspromoted research tremendously. Several potassiumchannels have now been defined; they constitute a family ofmembrane proteins which allow the conduction of

potassium currents in many different cell types. Some ofthese channel activators are now being considered as

candidates for several conditions ranging from angina andhypertension to asthma and impotence. Paraphrasing thediction "... Keine Liebe ohne Phosphor...", the ubiquityof potassium channels in the body underscores that neitherlife nor love can exist without potassium.The research presented in this book by 36 investigators

provides a database for those interested in ionic movementsat the cellular level. Within this field, molecular biologistsare attempting to express and transform ionic channels sothat pharmacologists can manipulate them in the patient.But the intended audience for this volume is not the generalphysician. The editors comment that "as pharmacologists,we make no apology that many of the chapters are concernedwith the mode of action of K-channel modulator drugs...".Apart from the first chapter (a synopsis on K +-channels)and a rather weak chapter on clinical aspects, this is the stuffonly for a happy few.

Academic Medical Centre/F4-264,Meibergdreef 9,1105 AZ Amsterdam, The Netherlands J. J. VAN LIE SHOUT

Selected Books: Orthopaedics

An Atlas of Osteoporosis.-J. C. Stevenson, M. S. Marsh. Carnforth:Parthenon. 1992. Pp 104. [38. ISBN 1-850703299.

Total Knee Arthroplasty.-Edited by James A. Rand. New York : Raven.1992. Pp 480.$162.50. ISBN 0-861679305.

The Back and Beyond : The Hidden Effects of Back Problems on YourHea/th.-Paul Sherwood. London: Arrow. 1992. Pp 252. jC6.99/$12. ISBN0-099928809.

Spinal Cord Dysfunction (Vol III): Functional Stimulation.-Editedby L. S. Illis. Oxford: Oxford University Press. 1992. Pp 360. 50. ISBN0-192619195.

Hip Arthroplasty.-RichardN. Villar. Oxford: Butterworth-Heinemann.1992. Pp 127. 40. ISBN 0-750607165.

Occupational Musculoskeletal Disorders.-Nortin M. Hadler. NewYork: Raven. 1992. Pp 287.$87.50. ISBN 0-881679593.

Lumbar Disc Disease.-2nd edition. Russell W. Hardy. New York:Raven. 1992. Pp 373.$156.50. ISBN 0-88167950693.

Bone Implant Grafting.-John Older. London: Springer Verlag. 1992.Pp 226. DM 290. ISBN 3-540197206.

Fractures and Dislocations (Vols I and //).-Ramon B. Gustilo,Richard F. Kyle, David Templeman. St Louis: Mosby. 1993. Pp 655 + 1285.$183. ISBN 0-815136404.

Managing Low Back Pain.-3rd edition. W. H. Kirkaldy-Willis,Charles V. Burton. New York: Churchill Livingstone. 1992. Pp 420. c6O.ISBN 0-44308789X.

A Simple Guide to Orthopaedics.-R. L. Huckstep. Edinburgh:Churchill Livingstone. 1993. Pp 450. 11.95. ISBN 0-44304385X.

Endpiece

"Egg-shell" calcification of the breast.

This type of benign calcification pattern is seen in multiple cystic lesionsof the breast. Taken from Imaging for Surgeons, by David Lisle, Ralph Ger.(London: Edward Arnold. 1993. Pp 296. £65.00. ISBN 0-340551704.)