Book Review

The Pericardium: A comprehensive textbook

N Engl J Med 1997; 337:866September 18, 1997

Article

The Pericardium: A comprehensive textbook
By David H. Spodick. 464 pp., illustrated. New York, Marcel Dekker, 1997. $165. ISBN: 0-8247-9316-1

Spodick's The Pericardium is not only first-rate but also humbling. Written with considerable literary craftsmanship, this book reaffirms that Spodick is one of our preeminent “pericardiologists.” Each richly detailed section reveals the breadth of the author's experience and knowledge.

The organization of the book deserves comment. Spodick points out in his foreword that each chapter and subsection can stand alone, so that a limited clinical question can be answered without seeking information at several sites. This approach necessitates some overlap and repetition, but I did not find it annoying; after all, repetition is learning. In each section fundamental points are set off in italics, and key points are listed at the end of each chapter. These useful devices permit quick review and reinforce what has been read. I believe they represent the author's attempt to overcome a tendency to produce a blizzard of facts at the expense of key information.

As with any complex work, there are negatives. The most glaring is the omission of all references within the text. With a touch of arrogance, Spodick explains that “the reader must necessarily concede the benefit of the doubt for both knowledge and bona fides.” He says, further, that “in this day of ready recourse to computer searches, the literature on any subject can be exhaustively accessed quite rapidly.” In my experience, most physicians (especially those with $165 to spend on a book) do not yet know how to access Medline effectively. When I read part of this book during a recent transoceanic flight, my long experience with Medline was useless. Time and time again, Spodick asks us to accept complex and erudite statements without documenting them. For example, we learn that

whether from infection, vasculitis, irritation by tumor cells, or other pathogenetic agents, pericardial inflammatory responses are mediated by cytokines, like tumor necrosis factors and interleukins. These formidable substances nearly always also inflame the subpericardial myocardium, but curiously, spare the coronary arteries and veins.

At the end of the chapter there are references to nine works (two by Spodick), but none of them hint at the extensive research related to this statement. In chapter 13, on pulsus paradoxus, we learn that

the left atrium is normally tightly clasped by the locally specialized parietal pericardium, often preventing penetration of fluid behind it. Thus, the left atrium sometimes continues to abut lung tissue and is variably subject to negative pulmonary inspiratory pressure. . . . This is the mechanism favoring inspiratory right-to-left shunting through an atrial septal defect or patent foramen ovale during tamponade.

Interesting, but where can I read more about how this was documented? The eight references at the end of the chapter give no clue.

In dealing with echocardiography and Doppler examination in cases of effusion and tamponade, Spodick exhaustively lists signs but studiously avoids grading them in importance. In fact, the title of Table 10.3 includes the parenthetical statement that these signs are of “varying sensitivities and specificities.” This approach does not give the reader enough information about which of these signs is most reliable clinically. The book's illustrations, moreover, are not as carefully prepared as the text. In some cases an arrow or two would have made an image much clearer. For example, if the reader is unfamiliar with the appearance of the inferior vena cava and hepatic veins on a subcostal echocardiogram, the unlabeled Figure 11.9 will do little to enlighten him or her. In general, the echocardiograms were adequate and interesting, but of only average quality.

In summary, I believe this is an important book whose strengths are its writing, its currency, and the vast experience the author shares so lucently. Reading it has revitalized my interest in pericardial disease and enhanced my own clinical practice. I believe most physicians interested in the pericardium will have the same positive experience and that many of them will be inspired to learn to use Medline.

Nelson B. Schiller, M.D.
University of California, San Francisco, Medical Center, San Francisco, CA 94143