1130

different degrees of response to specific stimuli. A

neurogenic influence could prime for a response, and agenetic or other influence then determine the clinicaloutcome. For mechanical, genetic, or other reasons themirror image joint appears likely to respond with clinicallyapparent inflammation, although there is no reason tobelieve that the process of mirror imaging of inflammatoryresponses is specific to the joint alone.

We thank the Arthritis and Rheumatism Council, the British TechnologyGroup, and Perstorp Pharma (Sweden) for financial support. B. L. K. is aDista research fellow.

Correspondence should be addressed to B. L. K., Arthritis and

Rheumatism Council Research Building, London Hospital Medical College,London El 2AD.

REFERENCES

1. Hench PS, Rosenburg EF. Palindromic rheumatism. Arch Intern Med 1947; 73:293-321.

2. Solis-Cohen S. Angioneurotic manifestations in and around joints, frequentlymistaken for gout and rheumatism. Trans Coll Phys Philadelphia 1911, 33: 309-11.

3. Halls JT, Fallahi S, Hardin JG. Small joint involvement: a systematicroentgenographic study in rheumatoid arthritis. Ann Rheum Dis 1986; 45: 327-30.

4. Buckland-Wright JC, Clark GS, Walker SR. Erosion number and area progression inthe wrist and hands of rheumatoid patients: a quantitative microfocal radiographicstudy. Ann Rheum Dis 1989; 48: 25-29.

5. Thompson M, Bywaters EG. Unilateral rheumatoid arthritis following hemiplegia.Ann Rheum Dis 1962; 21: 370-77.

6. Glick EN. Asymmetrical rheumatoid arthritis after poliomyelitis. Br Med J 1967; iii:26-29.

7. Kennedy JL, Alexander IJ, Hayes KL. Nerve supply of the human knee and itsfunctional importance. Am J Sports Med 1982; 10: 329-35.

8. Freeman MAR, Wyke B. The innervation of the knee joint: an anatomical andhistological study in the cat. J Anat 1967; 101: 505-32.

9. Halata Z, Groth H. Innervation of the synovial membrane of the cat knee joint capsule.Cell Tiss Res 1976; 169: 415-18.

10. Mapp P, Kidd B, Merry P, Gibson S, Polak J, Blake D. Neuropeptides are found innormal and inflamed synovium. Br J Rheumatol 1989, 28 (suppl 3): 8.

11. Grondblad M, Konntinen YT, Korkala O, Liesi P, Hukkanen M, Polak J.Neuropeptides in the synovium of patients with rheumatoid arthritis andosteoarthritis. J Rheumatol 1988; 15: 1807-10.

12. Langford LA, Schmidt RF. Afferent and efferent axons in the medial and posteriorarticular nerves of the cat. Anat Rec 1983; 206: 71-78.

13. Schaible H, Schmidt RF, Willis WD. Spinal mechanisms in arthritis pain:enhancement of responses of tract neurons in the course of inflammation. In:Schmidt RF, Schaible H, Vahle-Hinz C, eds. Fine afferent nerve fibres and pain.Weinheim: VCH Publishers, 1987: 399-409.

14. Nakamura M, Ferreira SH. A peripheral sympathetic component in inflammatoryhyperalgesia. Eur J Pharmacol 1978; 135: 145-53.

15. Woolf CJ, Wall P. Relative effectiveness of C primary fibres of different origins inevoking a prolonged facilitation of the flexor reflex in the rat. Neuroscience 1986; 6:1433-42.

16. Koizumi K, McBrooks. The integration of autonomic system reactions. Ergen Physiol1972; 67: 1-68.

17. Livingston WK. Pam mechanisms. New York: Macmillan, 1943.18. Jancso N, Jancso-Gabor A, Szolcsanyi J. Direct evidence for neurogenic inflammation

and its prevention by denervanon and by pre-treatment with capsaicin. Br JPharmacol 1967; 32: 138-51.

19. Foreman JC. Peptides and neurogenic inflammation. Br Med Bull 1987; 43: 386-400.20. Holzer P. Local effector functions of capsaicin-sensitive sensory nerve endings:

involvement of tachykinins, calcitonin gene-related peptide and other

neuropeptides. Neurosci 1988; 24: 739-68.21. Gibson SJ, Polak JM The neurochemistry of the spinal cord. In: Polak JM, ed.

Immunocytochemistry: modern methods and applications. 2nd ed. Bristol: Wrightand Sons, 1986: 360-90.

22. Hertfort RA. Extended sympathectomy in the treatment of chronic arthritis. J AmGeriatr Soc 1957, 5: 904-15.

23. Levine DJ, Dardick SJ, Roizen MF, Helms C, Basbaum AI. Contribution of sensoryafferents and sympathetic efferents to joint injury in experimental arthritis.

J Neurosci 1986; 6: 3423-29.24. Levine DJ, Clark R, Devor M, Helms C, Moskowitz MA, Basbaum AI. Intraneuronal

substance P contributes to the severity of experimental arthritis. Science 1984; 226:547-49.

25. Devellier P, Weill B, Renoux M, Menkes C, Pradelles P. Elevated levels of

tachykinin-like immunoreactivity in joint fluids from patients with rheumaticinflammatory diseases. N Engl J Med 1986; 314: 1323.

26. Charl LA, Ladd J. Local oedema and general excitation of cutaneous sensory receptorsproduced by electrical stimulation of the sensory nerve in the rat. Pain 1976; 2:25-34.

27. Denko CW, Petricevic M. Sympathetic or reflex footpad swelling due to crystalinduced inflammation in the opposite foot. Inflammation 1978; 3: 81-86.

28. Levine DJ, Dardick SJ, Roizen MF, Basbaum AI, Scipio E. Reflex neurogenicinflammation: contribution of the peripheral nervous system to spatially remoteinflammatory responses that follow injury. J Neurosci 1985; 5: 1380-86.

29. Kidd B, Mapp P, O’Higgins F, Merry P, Claxson A, Blake D. Contralateral effects ofexperimental monoarthritis. Br J Rheumatol 1989; 28 (suppl 3): 8.

Reviews of Books

Handbook of Renal-Independent CardiacGlycosides: Pharmacology and ClinicalPharmacology

Norbert Rietbrock and Barry G. Woodcock. Chichester: EllisHorwood. 1989. Pp 340. ;[54. ISBN 0-745806406.

EVERY book has its Hippocrene. In this case the fountainof inspiration first sprang in 1930, with a paper by SydneySmith entitled "Digoxin, a New Digitalis Glucoside" (]Chem Soc 1930; i: 508-10). The central thesis of this book isthat digoxin, now the most popular choice of cardiacglycoside in many countries, including the UK and theUSA, does not deserve its popularity. The authors arguethat the fact that digoxin is cleared almost completely by thekidneys constitutes a major disadvantage, and that

glycosides which are mostly metabolised in the liver,exemplified by digitoxin, should in all cases be preferred.These glycosides they call renal-independent-an unwieldyterm derived by direct translation of the German wordnichtnierenpflichtige.

This debate has been in progress for some years, but neverhas the case been so clearly argued or so well presented, atleast on behalf of the prosecution. In comparing the twotypes of glycoside the authors draw on a striking simile fromRoger Jelliffe, who has been a consistent advocate of

digitoxin in the USA. They liken digoxin to a windsurfer,short in length (ie, of short half-life) and easy to manoeuvre,but susceptible to the vagaries of the wind (ie, changing renalfunction) and requiring constant attention if a straightcourse is to be maintained and the mudflats of toxicityavoided. They contrast this with an image of digitoxin as abarge, long and cumbersome, but stable in the face ofvirtually anything on the Beaufort scale. They might havemore realistically compared it to a supertanker-not evenHurricane Hugo could blow the digitoxin vessel much offcourse. The authors support their contention by comparingthe reported rates of intoxication for digoxin (about 20%)with those for digitoxin (about 5%). In taking this utilitarianstand they do less justice to the question of the relativeseverity and duration of toxicity in the individual: oneshould remember that supertankers have a much greaterdisplacement than windsurfers and can take many miles inwhich to lose way.

There are other points on which the case for the defence isrepresented less vigorously than it might be. For example,although the authors discuss the measurement of plasmaglycoside concentrations, they do not lay emphasis on thedifficulties presented by digitoxin compared with digoxin.Nor do they sufficiently stress, in dealing with differences indrug interactions between these two glycosides, that themost common interaction (via potassium depletion due todiuretics) would be expected to occur equally with digitoxinand digoxin. Nor do they point out that there is greatervariation in the size of the barge one has to sail (ie, theeffective dose) for the glycosides which are metabolised thanfor those which are excreted unchanged, and that it maytherefore be more difficult to predict the size of bargerequired for a particular waterway (ie, patient).

In 1979 the West German Transparenzkommission beimBundesgesundheitsamt published a list of glycosideformulations available in Europe. The list included 170formulations of cardiac glycosides, either alone or in

1131

combination with other drugs. The current British NationalFormulary lists 5. This reflects the different ways in whichcardiac glycosides are used in different countries. It wouldclearly be to everyone’s advantage if a more logical approachto the choice of cardiac glycoside were to emerge fromreviews of the kind offered here by Rietbrock and

Woodcock. Perhaps we should be trying to identify thosepatients in whom we should prefer digoxin and those inwhom we should prefer digitoxin, rather than debatingwhich one to use in all cases.

Finally, two misprints, one serious and one amusing,which merit attention. First, the authors write that

hypocalcaemia enhances the actions of cardiac glycosides(my italics). They mean hypercalcaemia. Hypocalcaemiablunts their actions. Second, in the course of a historicalintroduction the authors say that dropsy derives from aGreek word <7u8crcoB)/, which, if it existed, would bepronounced sudsoaps. I shall now be unable to imagine MrsMacStinger, described in Dombey and Son as "... a widowlady, with her sleeves rolled up to her shoulders, and herarms frothy with soap-suds and smoking with hot water",without the added features of a severe dropsy and a glass offoxglove tea at her elbow.

MRC Clinical Pharmacology Unit,Radcliffe Infirmary,Oxford OX2 6HE J. K. ARONSON

Eternal Fixation and Functional BracingEdited by Richard Coombs, Stuart A. Green, and AugustoSarmiento. Rockville: Aspen/London: Orthotext. 1989. Pp 419.$125.00. ISBN 0-951418602.

A FEW years ago surgical fixation of fractures was

regarded as a meddlesome intervention to be used rarely andonly in specific situations. The pendulum has now swung sofar that one has to seek justification for conservative

management for most long-bone fractures. A wide range oftechniques of fracture fixation by internal and externalmeans has gained currency in recent years. The mainproblem is not when to operate but which device to use.

In this book the small section on functional bracing isimportant in that it serves to remind readers that fracturescan heal with minimal support and excellent preservation offunction. The larger part is devoted to external fixation.Inevitably with 94 contributors from seventeen countriesthere is variable standard of presentation and some overlapbut overall the standard is high. Every aspect of externalfixation is covered, ranging from the historical to the

psychological. The biomechanical chapter by Chao and Arofrom the Mayo Clinic is particularly noteworthy. Theversatility of external fixation is illustrated by its use not onlyin the management of fractures but also in limb lengthening,correction of deformity, and arthrodesis of joints. Manyappliances are described, from simple single-bar devices tomore complex but more versatile multiple-bar assemblieswith varying degrees of rigidity. A defect of the book is thatthere is no information regarding the relative merits of thesedifferent systems and no indication of the cost or where theymay be obtained. A most interesting contribution is thesection by Ilizarov, who, working in relative isolation inRussia, has produced an original apparatus. At first sight itlooks rather bulky and cumbersome, consisting of a series ofrings that completely encircle the limb, but in practice it hasproved exceedingly adaptable and is rapidly gaining

popularity in many centres. This is the first detailed accountby Ilizarov in English of his methods, and for this and manyother reasons this book will be of great interest to all

orthopaedic surgeons, particularly those who deal withtrauma.

Princess Margaret Rose Hospital,Edinburgh EH 10 7ED J. CHALMERS

Surgical Audit

Alan Pollock and Mary Evans. London: Butterworths. 1989. Pp167. 20.00. ISBN 0-407008233.

AUDIT is in fashion-a buzz word flaunted by politicians,promulgated by Royal Colleges, and picked-at bycommittees. It shares a lot with teenage sex. Thoseconcerned expect to be doing it, but the majority are notentirely sure what’s involved or how to do it. The result,behind the public posturing, is an unhappy confusion.The principle of audit is simple enough-honest review

of the effectiveness of providing health care. It is the practicethat confuses, and that confusion arises largely from thedisparate nature of different branches of audit. The means ofauditing the competence of a consultant, a patient’s qualityof life, adequacy of services, cost of procedures, and use ofoperating theatres have very little in common. It is thedetails of this patchwork of tasks that Alan Pollock and MaryEvans address. Their title is somewhat misleading, sincethey actually cover a wide range of the tasks that requireaudit, most of which are not specific to surgery. This broadview includes not only chapters on economic audit (length ofstay, cost containment) and outcome audit (includingmishap, malpractice, patient satisfaction, and quality of life,but also the audit of publications and, contentiouslyperhaps, the audit of ethics including human

experimentation. The book is predominantly structured as areview of the work of others, and is widely referenced. Whatit does not do is help with the difficult practicalities of settingup audit, judging severity of illness, rationing resources,determining priorities, and deciding how extensive and howcomprehensive computerisation should be. Nor does itaddress the costs of audit in time and equipment.Nevertheless, it is an invaluable source-book and, in an areawhere most publications make dull reading, it is an

entertaining exception, worth the attention of the interestedclinician and essential reading for members of district auditcommittees.

St Thomas’ Hospital,London SEl 7EH A. E. YourlG

CT and Sonography of the Acute AbdomenR. Brooke Jeffrey, Jr. New York: Raven. 1989. Pp 295.$122.50.ISBN 0-881675067.

THE author interprets the term acute abdomen with atouch of poetic licence since not all the conditions that hedescribes are acute abdominal emergencies; some, rather,are acute conditions affecting the abdomen. The book isorganised into eight chapters. The first five deal with thesolid organs, the last three with the gastrointestinal tract, thepelvis, and the retroperitoneum. This division into organsor compartments is perhaps unavoidable but, in

the evaluation of blunt abdominal trauma, compart-

1132

mentalisation seems to me especially false and

unrepresentative of the way such patients present.Dr Brooke Jeffrey concedes that the text reflects the

institutional. bias of the University of California, SanFrancisco, and there were occasions when the overall

imaging strategy did not equate with my own. Rather than acomparison of the two established sectional imagingtechniques, we are offered the imaging strategy of hisdepartment, with its ready access to CT machines. Scantattention is paid to the place of sonography, and this is

particularly obvious in the section on hepatic trauma. I donot take issue with the author’s choice of primary imagingtechnique; but less generously equipped centres continue touse sonography for the assessment of abdominal trauma andhe should have addressed the limitations of the techniquerather than dealing with it so dismissively. However, todwell on this would be unfair to the book, which is

extensively and beautifully illustrated with many examplesof the different appearances of common conditions.

Frequently there are comparative CT and ultrasoundimages with comparable slices-a feature often missing inbooks on CT and ultrasound. Moreover, the imagesinvariably compare high-quality ultrasound with high-quality CT.

Although its organ-based construction means that it doesnot consider the contribution of extra-abdominal disease tointra-abdominal symptoms (lobar pneumonia and testiculartorsion to name but two), and although the didactic

approach to imaging strategy means that certain imagingtechniques are ignored when a brief consideration wouldhave provided completeness, this is a very good book thatdeserves a place in any radiology library.Radiodiagnostic Department,Plymouth General Hospital,Plymouth PL4 7JJ P. A. DUBBINS

Addiction-Substance Abuse and DependencyN. W. Imlah. Wilmslow: Sigma Press. 1989. Pp 182. 14.95.ISBN 1-850580588.

Dr Imlah’s book mirrors the prevailing confusion aboutaddiction. Its curious mixture of clinical anecdote and

shifting opinion seems to be all things to all men. There areno references or bibliography and the text is full of

contradictions--eg, on adjacent pages we are told thatevidence of "brain damage resulting from cannabis use [is]dubious" and that cannabis "combines ... dangers ofalcohol and tobacco". The chapter on cannabis omits theinfluential Indian Hemp Commission report of 1894 but isotherwise good, and the chapter on alcohol is excellent.

There is a strong selective bias throughout the bookwhereby evidence for a less alarmist approach to drugs isheld to be tendentious or simply omitted while all evidencefor greater concern is held to be incontrovertible. For

example, when Imlah’s figures for the Japaneseamphetamine epidemic are analysed, it turns out that only1 % of amphetamine addicts become mentally disordered,which would make amphetamines considerably safer thanalcohol. Yet the Japanese episode is asserted to "illustratethe speed a drug craze can overtake a society, and thedevastating results ...". In his argument for moreenforcement he cites Malaysia’s capital penalties but omitsthe fact their drug addiction rate (125 000 registered among11 million) is thirty times England’s. Rotterdam and

Liverpool’s low HIV rates are contrasted with the disastrousfigures in New York and Edinburgh but the author fails toanalyse why this might be. Worse, he inaccurately reportsthat syringe exchanges are unsuccessful, when Governmentresearch revealed that well-run exchanges, such as those inLiverpool and Cleveland Street, London, are helpful. Hegives an intelligent analysis of "maintenance", but does notdiscuss the paradox whereby prohibition seems to beassociated with increased drug-taking and slight relaxationof drug controls with reduced drug-taking (as exemplifiedby domestic consumption of cannabis in the Netherlandsafter de-facto decriminalisation). A puzzlingly large numberof major developments and writings of the last few decadesare ignored-such as supervised naltrexone and the culturalcontrol of drug misuse.Norman Fowler, a politician who is prepared to grasp

nettles, is deservedly praised for his anti-AIDS initiativesand yet Imlah questions the priority given by the AdvistoryCommittee on Misuse of Drugs to the HIV pandemic. Is hesaying better dead than intoxicated? The high hopes of theforeword and preface are not borne out, and the book isdisappointing.Halton General Hospital,Runcorn WA7 2DA JOHN MARKS

Anaesthesia Databook: a Clinical Practice

Compendium

Rosemary A. Mason. Edinburgh: Churchill Livingstone. 1989.Pp 529. 24.95. ISBN 0-443041202.

FROM the title I expected a series of facts and figures, drugdoses, equipment manufacturers, circuitry classificationformulae for gas flow, formulae for estimating endotrachealtube sizes in children, and so on. What Dr Mason hasactually produced is a book of manageable size foranaesthetists to carry round in the briefcase or keep in theback of the car as a ready reference. Her aim was to provide atext that lies "between the standard textbook and the

specialist monograph". There are four sections-the first onmedical disorders that present anaesthetic problems, the laston anaesthetic emergencies, and the intervening two onpreoperative and perioperative pharmacology.

Books of this sort are apt to come out as an unhappyamalgamation of a standard textbook of anaesthesia and astandard textbook of medicine. Dr Mason seems to haveavoided this pitfall. The medical and emergencies sectionsare clearly written. The English is concise with 1-4 pages foreach subject and assumes just about the right amount ofknowledge, with key references given at the end of eachsubject. Conditions are arranged in alphabetical order.What spoils the book are the pharmacology sections,consisting largely of drugs with their key features listed innote form and a lot of wasted space. She cannot do justice tothe drugs in this way, and in a book that is not meant forbeginners there was no need to list agents such as morphine,fentanyl, or phenoperidine (which most anaesthetists useevery day) so as to tell us they are respiratory depressants.

This is a useful book to have around-somewhat akin toKatz’s Anaesthesia and Uncommon Diseases, and in manyways superior-but it would have been better without thepharmacology.University Department of Anaesthesia,Royal Liverpool Hospital,Liverpool L69 3BX I. T. CAMPBELL