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V. M. REZNIK AND OTHERS: REFERENCES

1. Conley SB, Flechner SM, Gilbert R, Van Buren CT, Brewer E, Kahan BD. Use ofcyclosporine in pediatric renal transplant recipients. J Pediatr 1985; 106: 45-49.

2. Tejani A, Butt KMH, Khawar MR, et al. Cyclosporin experience in renal

transplantation in children. Kidney Int 1986; 30: S35-43.3. Van Buren CT. Cyclosporine: progress, problems and perspectives. Surg Clin N Am

1986; 66: 435-49.4. Bennet WM, Norman DJ. Action and toxicity of cyclosporine. Annu Rev Med 1986;

37: 215-24.

5. Kahan BD, Flechner SM, Lorber MI, Jensen G, Golden D, Van Buren CT.Complications of cyclosporine therapy. World J Surg 1986; 10: 348-60.

6. Bennett JA, Christian JM. Cyclosporine-induced gingival hyperplasia: case report andliterature review. J Am Dent Assoc 1985; 111: 272-73.

7. Wysocki GP, Gretzinger HA, Laupacis A, Ulan RA, Stiller CR Fibrous hyperplasiaof the gingiva: a side effect of cyclosporine A therapy. Oral Surg 1983; 55: 274-78.

8. Bencini PL, Montagnino G, Sala F, De Vecchi A, Crosti C, Tarantino A. Cutaneous

lesions in 67 cyclosporin-treated renal transplant recipients. Dermatologica 1986;172: 24-30.

9. Bencini PL, Montagnin G, Crosti C, Sala F, De Vecchi A. Acne in a kidney transplantpatient treated with cyclosporin A. Br J Dermatol 1986; 114: 396-97.

10. Palestine AG, Nussenblatt RB, Chan C. Side effects of systemic cyclosporine inpatients not undergoing transplantation. Am J Med 1984; 77: 652-56.

11. Johnson JP. Acquired craniofacial features associated with chronic phenytoin therapy.Clin Pediatr 1984; 23: 671-74.

12. Lefebvre EB, Haining RG, Labbe RF Coarse fades, calvarial thickening andhyperphosphatasia associated with long-term anticonvulsant therapy. N Engl JMed 1972; 286: 1301-02

13. Simmons RG. Social and psychological posttransplant adjustment In Kutner NG,Cardenas DD, Bower JD, eds. Rehabilitation and the uremic renal disease patient.New Jersey: Spectrum Publications Inc, 1985: 85-97.

14. Korsch BM, Fine RN, Negrete VF. Noncompliance in children with renal

transplants. Pediatrics 1978; 61: 872-76.

Reviews of Books

Medical Evaluation of the Surgical Patient

Edited by Robert J. Bolt. New York: Futura. 1987. Pp 440.$64.ISBN 0-879932651.

INTERNISTS (physicians) in the USA are being askedincreasingly frequently by surgeons to "evaluate the

patient’s medical condition" before operation. This

development reflects both the threatening medicolegalclimate and the growth of the geriatric population. Althoughthis book is concerned mainly with the assessment of patientfitness for anaesthesia and surgery, only two of the

twenty-odd contributors are anaesthetists. However, totheir credit, most of the internist contributors avoid makingrisk-benefit judgments on the matter, being content tocomment on various medical conditions likely to present insurgical patients, and to recommend appropriate medicalmanagement thereof.

Chapter 2, Informed Consent: Complication Prevention,written by two psychiatrists, makes excellent sense even tothose of us practising in less litigious climates. Chapter 11,Reducing the Risk of Infection in Surgical Patients, offersadvice of worth to both surgeons and anaesthetists-

especially the latter, who are nowadays frequently calledupon to administer antibiotics by the intravenous routeduring an operation. In chapter 5, the pregnant patientpresenting for incidental surgery is discussed, but nomention is made of severe hypertension in pregnancy, nor ofthe expectant mother presenting for neurosurgery (bleedingintracranial berry aneurysm). Table 2 on page 71

incorrectly shows maternal pH decreasing rather thanincreasing in pregnancy. There is a tendency to

typographical error: glaring examples include holothane,pentazocaine, benzodiazepam, and enflurine. The chapteron Prophylaxis of Thromboembolic Disease cites a

dauntingly large number of references but the result issometimes confusing. In the item on Hematologic andHemostatic Considerations before Surgery I would takeissue with the statement on p 409, that "a hemoglobinconcentration of 8 G/dl. (with appropriate increase incardiac output) is more than sufficient to supply oxygendemands". Most, if not all anaesthetic techniques at thedisposal of the anaesthetist, including regional anaesthesia,have the potential to lower the patient’s cardiac output,sometimes dramatically. The author’s bias is no doubtinfluenced by the relatively greater dangers of transfusingblood in the United States, as outlined in the originalreference cited. A further mild criticism of this otherwise

excellent and provocative chapter is the small size of printused in the featured algorithms.

In summary, despite the dearth of anaesthetic input andinsight, the occasional typographical error, and the variationin the quality and style of writing typical of multi-authortexts, this inexpensive book with its generous bibliographydeserves close study by trainee surgeons and anaesthetists. Itwill also be of value to physicians who are frequentlyconsulted on such matters, to surgeons (especially theoccasional ill-informed "cutter" who plagues theanaesthetist by consistently presenting patients for

operation without proper "work-up"), and to consultantanaesthetists.

Department of Anaesthesia,University of Nottingham JOHN W. DOWNING

America’s Health in the Balance: Choice or Chance?

Howard H. Hiatt, New York: Harper and Row. 1987. Pp 252.$18.95. ISBN 0-06039068.

THE United States spends nearly 11 % of gross nationalproduct on health care-three times more per head thanBritain-but the health outcomes produced by this vastexpenditure are less than impressive in terms of infantmortality, life expectancy, and access to care. This book,written by a physician, is an excellent review of the problemsof the United States health care market and it offers some

stimulating solutions, in part based on his experience of theBritish National Health Service, to the rationing dilemmasthat face all health care systems. It is divided into 13 chaptersin four sections. The first section examines health care inAmerica. Hiatt claims that 37 million Americans haveneither private health insurance nor access to State healthbenefits and that, although there are fewer children in theUSA than in the 1960s, more of them live in poverty wherethey generate the health problems of tomorrow. He arguesthat rationing has been part of medical practice since itsbeginnings, even though the labels in the past were morediscreet, and that "privatisation" and "competition" maycreate at least as many problems as they resolve.

In looking for lessons from abroad, Hiatt examinesCanada, China, and Britain and, although some aspects ofhis coverage are perhaps incomplete, he provides a nicereview of the essentials of these systems. This comparativeanalysis is the basis for the author’s proposals to improve theUS health system-the use of prevention, provided it is costeffective; increased support for biomedical research,provided it is scientific and uses social science inputs inconjunction with medicine and statistical expertise;

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increased investment in technology assessment; and greaterequality in access to health care.The thrust of this stimulating book’is that health care

should be rationed by design rather than by accident. Hiattrecognises that health policy is determined by social valuesand that any changes must be undertaken carefully if

productive doctor-patient relationships are not to be

damaged.Whilst the structure of the US health care system is

different from that of Britain, its problems are very similar.Resources are scarce and have to be rationed, and it isessential that the rationing process is explicit and informedby data on the cost-effectiveness of competing therapies.This book is essential reading for doctors and policy makers.Let us hope that it will convince more of them that theeconomic dimension of health care cannot be ignored ifresources are to be used efficiently.

Centre for Health Economics,University of York,York YO1 5DD ALAN MAYNARD

Clinical Aspects of Inner Ear Deafness

Ernst Lehnhardt. Berlin: Springer-Verlag. 1986. Pp 172.

DM148. ISBN 3-540161309.

THIS monograph is an outstanding reference work upondeafness arising from disease affecting the hair cells of thecochlea and the spiral ganglion. The text assumes a highdegree of knowledge and its main value must be for- theotological specialist. The published work has been

extensively reviewed to provide a detailed section on eachpathological process giving rise to inner ear dysfunction.The evaluations are critical-for example, Lehnhardt

expresses reservations about autoimmune deafness in viewof the lack of basic research in this area-and the conciseresumes of controversial subjects include one on the

aetiology of acute unilateral sensory hearing loss anddeafness in the aged (viral or vascular?). He also identifiesareas for future research. The reference list occupies about aquarter of the entire book and provides a valuable source ofup-to-date information for clinicians and research workers.

National Hospitals for Nervous Diseases,Queen Square,London WC1N 3BG LINDA LUXON

Neurological Skills

A Guide to Examination and Management in Neurology. MichaelHarrison. London: Butterworths. 1987. Pp 132. 15. ISBN0-407013601.

THE mysteries of neurological diagnosis strike fear intothe hearts not only of medical students but also of manyclinicians. The central premise of this book is that "accuratediagnosis and rational management can be achieved

routinely by no more than the careful application of basicclinical skills". Harrison sets out to make these skillsaccessible to the non-neurologist in a concise and clearmanner. A basic knowledge of neuroanatomy is assumed,and reference to standard texts is made at the end of eachchapter.The first section, in which we are guided through the

complexities of history-taking and examination, is a delightto read. A clear explanation is given of each component of

the neurological test battery, and this is well supported byline drawings and illustrations. Common pitfalls in testmethods and in the interpretation of tests are drawn to ourattention. Eponymous signs cause much confusion in

neurology, but here they are always described in the contextof their place in everyday neurological diagnosis.

In the second section, various common presentingsymptoms are dealt with. The emphasis is neurological, andit would be wise to remember that there are many othercauses of, for instance, loss of consciousness, than thosementioned here. Flow charts are much used, and aregenerally helpful. The third and shortest section deals

briefly with some common neurological conditions. Thissection would not suffice as an alternative to a standardtextbook of clinical neurology.

This- book has been written primarily for medicalstudents. I can recommend it also for MRCP candidates,and it will have a place on my own bookshelf.

Department of Geriatric Medicine,University of Manchester K. J. FULLERTON

Neonatal NeurologyCurrent Reviews in Paediatrics 3. Malcolm Levene. Edinburgh:Churchill Livingstone. 1987. Pp 262. /;25. ISBN 0-443034249.

DURING the past 10 years our understanding of neonatalcerebral disorders has increased apace,- largely because oftechnological innovations such as real-time ultrasound butalso because of the increasing survival of "at risk" infantsin neonatal intensive care units. Much of this new

development has not yet reached standard textbooks, yet anunderstanding of conditions such as periventricularleucomalacia and periventricular haemorrhage is essentialfor every neonatal and paediatric resident. This book, one ofa small series, aims to fill the gap. The style is direct and veryreadable, though the topics selected reflect very much themain interests of the author. The opening chapter, withexcellent photographs, briefly illustrates some techniques ofneurological examination but does not really tell the juniordoctor how to evaluate all the responses that may be elicited.Cerebral bloodflow and intracranial pressure and the

techniques for measuring them are covered in the secondand third chapters, but the relevance of this to the doctor"studying for the MRCP" is doubtful, since these

techniques remain, regrettably, research tools.The middle five chapters are the book’s strength;

liberally illustrated, they cover intracranial and

periventricular haemorrhage, hydrocephalus, ischaemic

lesions, and birth asphyxia. The recently published work isextensively reviewed, and Levene never leaves the reader indoubt as to what he thinks or would do. The diagnosis andtreatment of neonatal convulsions is well covered and thebook finishes with a short account of neonatal hearing lossand methods for early screening-but curiously nothing onvisual loss and its assessment.As an update or add-on to current paediatric neurological

texts, this little volume succeeds admirably and will be wellreceived by the growing army of budding neonatologists.However, the buyer should not be misled by the title intobelieving that it is a comprehensive primer on neonatalneurology.

Department of Child Health,University of Liverpool RICHARD COOKE