Book Review

Iatrogenic Neurology

N Engl J Med 1998; 339:931September 24, 1998

Article

Iatrogenic Neurology
Edited by José Biller. 530 pp., illustrated. Boston, Butterworth–Heinemann, 1998. $110. ISBN: 0-7506-9840-3

Iatrogenic disease is an important topic. It is often neglected despite compelling evidence of its frequency in published accounts and clinical experience. Paradoxically, interested parties outside medicine cite published estimates that 5 to 10 percent of hospital days and of hospital costs might be due to iatrogenic conditions, although those within medicine often dispute this claim.

The central nervous system, peripheral nerves, and skeletal muscles are uniquely vulnerable tissues. Their intolerance of metabolic change, sensitivity to toxins, and vulnerability to anatomical disruption lend critical importance to the opinions of neurologists and neurosurgeons in consultation. This book is aimed at them, and they should find it especially valuable.

As the editor, Biller conducts readers on a tour of common and uncommon iatrogenic disorders of the peripheral and central nervous systems, as well as selected disorders of skeletal muscle. Although most of the authors are neurologists, contributors also include several specialists in associated fields, especially neurosurgery and radiology, adding considerably to the depth of the discussions of the adverse consequences of invasive procedures. Since the book is intended primarily for audiences knowledgeable about neurology, it calls for general familiarity with clinical neuroanatomy, neurophysiology, and the manifestations of neurologic disorders. However, it should also be useful for those in related surgical and nonsurgical fields. Most chapters review the relevant pathophysiology and anatomy, making the more specialized topics accessible.

Half the book is devoted to complications of invasive procedures, including diagnostic and interventional radiology and cardiovascular, spinal, and cranial surgery. The discussions include succinct summaries and numerous illustrations of particular presentations and approaches to their initial management. The chapters on lumbar puncture, anesthesia, and problems encountered in the critical care unit are especially helpful because they summarize material that is not easily available elsewhere. Appropriately for this audience, the chapters on procedures stress the recognition of neurologic complications rather than the intricacies of management, since the latter are more appropriately covered in other publications.

The remainder of the book deals with common and uncommon manifestations of drug toxicity. These manifestations are divided between particular clinical presentations or systems (e.g., disorders of movement, of peripheral nerves, and of muscles) and classes of drugs (e.g., anticoagulants, thrombolytic drugs, chemotherapeutic agents, and vaccines). The references are copious, up to date, and deep, averaging 200 per topic. Many references from fields not normally encountered by the clinician, such as toxicology, are included. Particularly strong are the chapters on drug-induced optic neuropathies and vestibulocochlear disorders, which summarize obscure information. This section contains a number of lessons drawn from clinical experience — for instance, the patient's awareness of the symptoms of ototoxicity from erythromycin and unawareness of them with aminoglycosides, the unexpected toxicity of topical agents, cryptic presentations of akathisia, and the often overlooked syndrome of stimulant withdrawal. Where appropriate, the book acknowledges the additive effect of multiple procedures or drugs on a patient during a single encounter, such as the complex effects of angiography, vascular surgery, and myriad medications on a patient with delirium.

Not surprising in a book of this breadth, there are a number of idiosyncratic positions and the occasional use of nonstandard abbreviations. The book emphasizes disorders in adults, not those in children, and complications of pregnancy are omitted. However, outweighing those omissions are the thoughtful nature of the reviews, the depth of experience represented by the authors, and the sensitivity to controversy. The authors maintain an unacknowledged but consistent position: iatrogenic conditions are like most other diseases — much is known, and much is yet to be discovered.

Inevitably, a book with this title will be used by nonclinicians for other purposes. Whether used in litigation, risk management, or peer review, this material will be particularly germane. The contributors have avoided drawing unwarranted conclusions about the causes of injury and have also avoided making prescriptive recommendations for prevention, though they do not shy away from clearly outlining prophylactic measures when such measures are known. This approach adds to the balance of the work by avoiding blame, making it clinically valuable, and potentially aiding the interaction among clinicians who share, through one intervention or another, a focus on the nervous system.

Hamilton Moses, III, M.D.
Partners HealthCare System, Boston, MA 02199