TiPS -January 1992 [Vol. 131

also the major component of Part IV of the book, where the influ- ences of malnutrition on pharma- cokinetics (due to low serum albumin) and drug metabolism (due to low hepatic microsomal activity) are discussed. Unfortu- nately the effects on pharma- cology of the pathologies associ- ated with tropical diseases such as malaria and schistosomiasis are not mentioned. Genetic factors play their part, and the estab- lished examples of glucose 6-phos- phate dehydrogenase deficiency and acetylation polymorphism are described. More recent studies on the genetic basis of metabolism of the antimalarial proguanil under- line the importance of this area of research. Finally, chapters in Part V cover the parasitological diseases and there is a consider- ation of ‘new’ drugs for sickle-cell disease, malaria, leishmaniasis and trypanosomiasis.

However, in both the ‘tropical sections and the more traditional

pharmacology sections, many of the major advances of the last decade are not considered. The impact of molecular pharmacology and chirality on concepts of drug receptors, drug design and pharmacokinetics, and of gene amplification and P-glycoprotein on drug resistance, go un- remarked. The most recent refer- ence in the pharmacodynamic reading list is 1975. With a per- sonal interest in anti-infectives I found the sections on bacteria without fluoroquinolones, fungi without azoles, helminths without ivermectin and viruses without acyclovir to be sadly deficient. The section on systematic pharma- cology is extensive but areas of recent interest - NSAIDs, excit- atory amino acids, receptor sub- classes, platelet-activating factor, cholesterol and lipid control, the immune system - are either out- dated or missing.

To cover all this pharmacology in one volume is obviously a

43

demanding exercise; to remain up to date even more so. Publication can be slow. But some parts of this volume list reading matter as recent as 1988, by which date many of the above-listed omis- sions were well established. Additionally, even the novel tropical feature of the volume is littered with errors and inaccur- acies; to give just one example, Chagas’ (not Chaga’s) disease is not transmitted by blood-sucking bugs scratching the parasite into the skin (p. 246). It is good to see cultural, clinical and scientific issues relevant to the tropics con- sidered in a textbook for students of pharmacology in the tropics. It is sad that so much of the content is out of date. It is despicable that the cost is so high.

SIMON L. CROFT

London School of Hygiene and Tropicd Medicine, Keppel Street, London WClE 7HT. UK.

The enemy within Defeating Pain. The War Against a Silent Epidemic

by P. D. Wall and M. Jones, Plenum Press, 1991. $24.95 (300 pages) 1SBN 0 306 43964 6

Wall and Jones have addressed this unique volume to a broad audience that includes pain patients, physicians and other health professionals, and public policy makers. It is not, strict!y speaking, a scientific or medical book. The style and level are more akin to a work of investigative journalism.

Rather than a balanced, ob- jective and well-documented scholarly work about recent ad- vances in our understanding of pain mechanisms and manage- ment, this book is an expose of the ignorance and cultural forces that have led to a tragic paradox; that literally thousands of people are subjected to needless pain and suffering despite the fact that there have never been more effec- tive tools for treating their pain.

Wall and Jones tell us what the tools are, what the pain problems are and why the tools are not being used adequately. They briefly describe common clinical pain problems like headache, arthritis, bums, cancer and low back pain, and the full range of available treatments. They also discuss the training, or lack of it, among health professionals in pain management and, finally, they propose the mobilization of social resources to optimize pain treatment. In short, it is a battle plan for the conquest of pain.

Their treatment of the neural mechanisms underlying pain is well done and accurate, but it is very brief and selectively em- phasizes apparent paradoxes such as phantom limb pain and com- plexities such as the influence of attentional shifts. Although no mechanistic explanations of these phenomena are provided, the authors are content with the diffi- culties they pose for specificity theory. Wall’s interests in long- term changes in primary afferents and the spinal cord are apparent

in the amount of coverage these subjects receive.

Despite the crusading tone of the book, it is intelligent, acrvate and deeply compassionate. The text is aimed primarily at patients who have a chronic pain problem or may be fearfully anticipating the pain of labor or surgery. The book answers many of the com- mon questions that patients have but are reluctant to ask. In ad- dition, its broad scope and seam- less prose will make it both access- ible and informative to a wide audience of lay people and health professionals. Because the book is so broad in its scope and so short, no subject is covered in detail. However, the authors have done a good job of being both up-to-date and reasonably accurate. I believe most anyone could profit from reading this short gem of a book, including those who consider themselves experts in the field.

HOWARD FIELDS

&-urology Department, University of Cati- fornia Medical Center, ROCWI 7%. Box 0114,

San Francisco CA 94143, USA.