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In Their Hands Edited by Javed Siddiqi Thieme, New York, USA, 2002 ISBN 1-58890-083-5 (The Americas) ISBN 3-13130-031-0 (Rest of World) £50.00
This is a beautiful book but one that raises a number of questions for me. Javed Siddiqi states in his prologue that ‘the diversity of human emotions expressed with and in our hands is legion’. He cites examples of paintings and sculptures in which the hands are the focal point for all the spiritual intensity and sentiment in the work, and mentions with diffidence the exhibition at which his photographs of hands were exhibited alongside hand sculptures by Rodin. And the photographs in this book, without doubt, are beautiful.
Siddiqi asks whether the hand is enslaved to the brain or the brain to the hand. The answer to him is obvious. He takes the hands of surgeons and places them in such a way that they are imbued with shadows, the fingers curved so that every crease and fold intensified. These hands, the pictures say, are special hands. See the drama, sense the hidden history that saturates every cell. See how I have captured every barely perceptible line, each one a testament to a scene of intensity as the surgeon delved into the very essence of humanity, played god with a scalpel, changed the life, the very thoughts of a fellow being. These hands, are profound hands and they are more than the sum of their parts. They are the hands of surgeons. From this picture the reader can obtain a glimpse of the surgeon’s soul.
To which response is - well, no. Neurosurgeons do indeed explore terrifying territory on a daily basis. They operate on nerves and the brain itself, in ways that demand total accuracy, finesse and complete authority. Imagine the overwhelming sense of awe that comes from observing the miraculous beauty of the human body, realising that the flaws within it can never be fully understood, and then taking a knife to it anyway. Imagine the type of person who holds that power and retains the humility to use it wisely. Then try to encapsulate that in one moment of time, with one disembodied portion of the body, in two dimensions. A photograph of a hand is a decontextualised fragment that can only tease the viewer with a hint of the whole human being. I found as much, if not more, of interest in the facial portraits of the neurosurgeons at the back of the book as I did in the hand images. And, anyway Siddiqi is cheating. These are images only of the hands of surgeons. Take a photograph of my hand, with a dark background, artistically lit and stylistically arranged, and it will look as striking as any of the hands in this book. As a scientist, postulating metaphysical nuances in neurosurgeons’ hands, Siddiqi really ought to have a control group of non-neurosurgically adept hands against which to compare the metaphysical nuance level. (I’m joking!)
A hand really is only a tool. It is a slave of the brain, even if evolved before the brain as Siddiqi states. Without my hands, I still exist. Without my mind my hands are nothing. Surely in the work of a surgeon this is more, rather than less, true. The hand has to act as an extension of the instruments and obey every last demand of the surgeon. During surgery the hand is encased in latex, not even visible. It is, in fact, less of a canvas for the history or personality of the person to which it is attached than would be the case for almost any other profession. My father was a carpenter, and I can look at his hands and see a palimpsest of his life, scars and callouses that show that his existence had been hard and eventful. All the surgeons I know have flawless hands. The hand must be sensitive to respond, through their gloves, to the tissue beneath them. More information is gained for the movements and substance of a surgeon’s hand than from its surface. In a photograph it is a mere symbol. If in real life that symbol trembles, that is when the observer learns something.
In any case, doesn’t it diminish a person to assume that their profession is what gives greater meaning to their image? If the hand is indeed a unique element of individuality, then surely a person’s profession must be the least part of it? Yes, the character of a person may drive the career that they choose, but surgeons are also poets, lovers, warriors and friends. Many potential neurosurgeons have ended up as accountants, the aesthetic value of their hands in no way diminished as a consequence. As a surgeon you may massively impact on the life of a person by operating on his or her spinal cord, but as a human being your influence, whether healing or destructive, ranges far more widely and profoundly. Surgeons’ hands - surgeons themselves - are not imbued with mystical qualities just because their work involves the human nervous system. Any assumption that they are borders dangerously on arrogance. The ‘healing touch’ is not the province solely of the medical profession. This book almost diminishes its own message by taking neurosurgery as a foundation, slapping on an extra layer of profundity where none is needed. Rodin didn’t only sculpt the hands of physicians. Buy this book as a volume of elegant photographs, but don’t take its message seriously!
Ms Sadie Maskery
The Museum, The Royal College of Surgeons of Edinburgh, UK
Surgical Management of Pain Edited by Kim J Burchiel Theime, Germany, 2002 ISBN 3-13-125981-7 £199.00
Pain is a ubiquitous factor in medical practice. Often its mechanisms are poorly understood and treatment very much ad-hoc. Nonetheless the majority of patients do well. The focus of this book, however, is the small number of patients who have chronic severe debilitating pain. The many facets of the book focus on why a small percentage of patients with particular disorders, develop chronic pain syndromes, what is the anatomy and physiology of these syndromes and what are the theoretical based, predominantly surgical, treatments for specifically recognised syndromes. The five sections of the book cover basic considerations (such as the physiological anatomy of nociception pathophysiology of chronic neuropathic pains, central pain and central nervous system mechanisms in pain modulation): part 2 - Fundamentals in pain medicine; part 3 - Specific pain syndromes; part 4 - Surgical procedures (this encompasses aspects of peripheral nerve stimulation, spinal cord stimulation, motor cord stimulation, deep brain stimulation, intrathecal opoids, neuro-ablative procedures including dorsal root ganglionectomy, dorsal rhizotomy, sympathectomy, myelotomy, cordotomy, and thalamotomy amongst others); part 5 - At the forefront of pain surgery (sections on functional imaging of pain, technological innovations in spinal cord stimulation, innovative intrathecal analgesics, encapsulated cell inserts for pain surgery, intrathecal chromaffin cell grafts for cancer pain).
Kim Burchiel, an emminent American neurosurgeon who specialises in surgical management of pain syndromes, edits the book. The contributors include predominantly Americans but also Australians, Europeans and Canadians. The contributing authors are a real who’s who of pain, anatomy, physiology and management. The foreword by Bjorn Meyerson is a succinct, yet comprehensive overview of the topic and a cogent argument as to why the existence of this book is required. Kim Burchiel in his preface outlines what his vision of the book is and why he has adopted the style of presentation. His decision to format the book as a series of chapters with an independent review by authors with perhaps contradictory or more expansive viewpoints, is one of the particular strengths of the book. In essence, for each topic one gets two overviews of current considerations and practice. The format is identical to that used in the journal Neurosurgery and as Burchiel has stated in his preface, on occasions the commentaries by the experts are more valuable than the contributing paper!
Overall, this is a 992 page book with excellent references, diagrams, content and general presentation. It is certainly very expansive in its scope and as such will have a very wide appeal to anaesthesiologists, physicians, neurologists as well as neurosurgeons. As the management of pain becomes a larger part of medical practice and indeed a specialty in its own right, the need for an encyclopaedic core text which is up-to-date such as this, is cogent. Burchiel asks where this book will stand in the future compared with classics such as Whyte and Sweets Pain: its mechanisms and neuro-surgical control, Pain and the neurosurgeon (1969) and Neurosurgical treatment of persistent pain (1989). In my opinion this volume will remain a worthy successor to these major texts and certainly for the next few years, and probably beyond, be the standard authoritative work in its field.
I would consider this an obligatory purchase for neurology and neurosurgery departments, departments of anaesthesiology as well as general medical libraries.
Despite its length and complexity it was a delight to review and undoubtedly this opinion will be shared by many clinicians world-wide.
Professor Ian Whittle
Western General Hospital, Edinburgh, UK
Core Topics in General and Emergency Surgery Second Edition Edited by Simon Paterson-Brown W.B. Saunders, UK, 2002 ISBN 0 7020 2589 5 £61.99
This is an outstanding series of books for specialist surgical practice. Its popularity can be gauged by this second edition appearing only 4 years after the first. This particular volume has been enhanced considerably by the introduction of clear evidence-based practice led by a splendid first chapter by Rigby and Michaels on that specific topic. Key papers, intended for further reading, are marked by small scalpels in the margins which is novel and surprisingly useful. Sadly not all chapters reflect an exhaustive background of reading to give current guidelines in surgical practice.
Many of the chapters do present a sound pathophysiological background to their topics. The chapters on DVT prophylaxis and treatment (Hamilton) and sepsis and intensive care management (Everitt and Rowlnads) are good examples. The majority of chapters present specific surgical emergency core topics and are of high calibre. Most of the gastrointestinal emergencies fall into this category: perforations of the upper GI tract (Gatley); non-variceal GI bleeding (Steele); pancreaticobiliary (Powell and Sirirwardena) and colonic (Ash Kanani and Munro) emergencies, as well as two commonsense and readable chapters by the editor - early assessment of acute abdomen, and acute conditions of small bowel and appendix (Paterson-Brown). More pithy but nonetheless important topics include patient assessment (de Cossart), perioperative management (Bennett) and surgical nutrition (Heys, Eremin and Broom). The managers amongst the potential readership will enjoy the chapter on outcomes and health economics but its hard going for the uninitiated.
Other chapters presented a rather dull textbook approach - abdominal hernias (Bennet and Kingnorth), whilst others presented topics with passion, and relatively poor detail and references rather than being evidence based - anorectal (Grace) and paediatric (Spitz and Sugarman) emergencies but McWhinnie does bring some respect to day case surgery.
Overall the book is well edited but chapter style could have been more standardised. The authors are all appropriate and their chapters are well delivered and readable with useful radiographs and figures, although there are too many tables in the chapter on abdominal trauma (Boffard).
Anyone in current surgical practice will value this useful book, particularly those taking examinations or those examiners who develop question cards. This is modern emergency surgery as it is currently practised and is all essential knowledge. The editor asked me to donate the book to the College after reviewing it. As I have just joined the Inter-Collegiate Examination Board I’m not sure I will!
Professor David J Leaper
North Tees General Hospital, Stockton on Tees, UK