Book Review

Clinical Toxicology

N Engl J Med 2001; 345:1648-1649November 29, 2001

Article

Clinical Toxicology
Edited by Marsha D. Ford, Kathleen A. Delaney, Louis J. Ling, and Timothy Erickson. 1168 pp. Philadelphia, W.B. Saunders, 2000. $125. ISBN: 0-7216-5485-1

Medical toxicology, which encompasses the pathophysiology, diagnosis, and treatment of clinical problems related to poisoning and drug intoxication, has in the past decade become an established subspecialty with demonstrated breadth and depth of knowledge. Medical toxicologists treat patients with acute drug overdoses, as well as those poisoned by industrial chemicals, native or exotic snakes, wild mushrooms, herbs, and alternative medical products. Medical toxicologists are emergency physicians, internists, pediatricians, occupational physicians, clinical pharmacologists, specialists in laboratory medicine, nurses, and clinical pharmacists. They direct poison-control centers, drug-detoxification centers, research units in clinical pharmacology, and public health agencies.

Medical toxicology is now recognized as a subspecialty by the American Board of Medical Specialties, and since 1994, over 200 physicians have successfully completed the certifying examination administered by the American Board of Emergency Medicine. Training in medical toxicology requires a two-year postgraduate fellowship after the completion of a residency in a primary specialty such as emergency medicine or pediatrics. The training program includes direct patient care, consultation to poison centers and evaluation of cases at the centers, rotations in occupational medicine, and course work in clinical pharmacology, pharmacokinetics, and the medical management of exposure to hazardous chemicals.

Such a large and diverse field calls for comprehensive textbooks to summarize existing knowledge and address areas of consensus and controversy. Twenty-five years ago, there were only two widely recognized sources of information for the management of poisoning: Clinical Toxicology of Commercial Products, by Gosselin et al. (Baltimore: Williams & Wilkins, 1976), and Dreisbach's Handbook of Poisoning (Los Altos, Calif.: Lange, 1977). With increasing knowledge of medical toxicology and the growth of the subspecialty, it is no surprise that there are now four large textbooks of medical toxicology (Goldfrank's Toxicologic Emergencies [Stamford, Conn.: Appleton & Lange, 1998]; Clinical Management of Poisoning and Drug Overdose, edited by Haddad et al. [Philadelphia: W.B. Saunders, 1998]; Ellenhorn's Medical Toxicology: Diagnosis and Treatment of Human Poisoning [Baltimore: Williams & Wilkins, 1997]; and Bryson's Comprehensive Review in Toxicology [Rockville, Md.: Aspen, 1989]), as well as more than a dozen handbooks and quick reference guides, a computerized CD-ROM data base (POISINDEX), and on the horizon, data bases that can be downloaded to hand-held devices. (A recent perusal of an on-line bookstore netted more than 300 titles in toxicology and poisoning, from The Five Minute Toxicology Consult and Small Animal Toxicology to The Toxicology of Contact Sensitivity and Hamilton & Hardy's Industrial Toxicology.)

On this playing field, a new textbook of medical toxicology will naturally be measured against its competitors. Does it add depth to the knowledge base? Does it represent the consensus of leading clinical toxicologists? Is the book readable, with discussions that are consistently high in quality? And a very important question, especially for the toxicologist in training or the nonspecialist in search of specific information: Is the book well organized and easy to consult?

These thoughts were on my mind as I examined Clinical Toxicology. The editors, all nationally recognized medical toxicologists, have assembled an impressive list of contributors, who together provide a fairly comprehensive approach to the diagnosis and treatment of acute poisoning and drug overdose. The book is divided into sections covering the principles of management, the bedside approach to patients with typical complications such as hyperthermia and cardiovascular instability, and — the largest section — the diagnosis and treatment of poisoning caused by 100 specific substances or categories of substances. Within each chapter in this section, the material is organized according to a standard format, covering pharmacology, pathophysiology, clinical presentation, differential diagnosis, laboratory studies, treatment, and expected sequelae. My postgraduate fellows have given it a thumbs up for accessibility and readability.

Although I found the book's organization pleasing and many of its chapters excellent, the quality and depth of the individual chapters vary, and a few are less than impressive. I was disappointed that there is no chapter on the evaluation of occupational exposure to chemicals and that the special aspects of poisoning in children and elderly persons are not covered. In some cases, serious typographical errors were overlooked during proofreading (e.g., millimoles per liter instead of milligrams per liter, in the chapter on acetaminophen). There is also some redundancy; for example, atropine poisoning is discussed in at least three chapters, two of which are devoted to poisoning by plants. Tables listing the causes of QT-segment prolongation appear in more than one chapter, with inconsistent information. And, as is often the case with large textbooks, locating the definitive discussion of a topic by using the index proved to be frustrating. Also, I found the quality of the book's production wanting. The tables, in particular, are poorly laid out, with small type; large empty spaces, which make it difficult to follow the text across a row; and insufficient use of shading, indentation, or other means of indicating subcategories. However, these disappointments were tempered by a number of superb entries, such as Kulig's exposition of the controversies surrounding gastrointestinal decontamination.

The question is, who is the audience for this book? Is it nonspecialists looking for a quick answer while treating a patient in the emergency department? The audience is more likely to be toxicologists or clinicians in training who want a digestible summary of the literature and a list of useful references. Ford et al. have produced an impressive book that will certainly find a place on the bookshelves of clinical toxicologists and poison-control centers, as well as in the reading rooms of residency-training programs. However, the book will probably not be as useful for nonspecialists, who are advised to seek consultation from a medical toxicologist or a poison-control center for assistance in managing a case of acute poisoning.

Kent R. Olson, M.D.
University of California, San Francisco, CA 94143-1369