By Patrick D. Wall and Ronald Melzack. Edinburgh, Churchill Livingston, 1999. Pages: 1,152. Price: $275.00.

Since the first edition in 1984, the Textbook of Pain  has been the  textbook of pain for clinicians and researchers, assembling together concise reviews by the best people in the field to discuss pain, suffering, and analgesia comprehensively. The current edition follows the pattern of a 5-yr cycle for renewing and updating (and, as in many such texts, enlarging) the previous edition. This book, like its predecessors, succeeds marvelously, and should be in the library of any clinician or investigator with a major emphasis on the study and treatment of pain.

The book is organized into three sections: Basic Aspects, Clinical States, and Therapeutic Aspects. Authorship of each of the 68 chapters reads as a “Who’s Who” in pain research and treatment, and the editors have done an outstanding job of twisting arms to gather such a group together to write concise and up-to-date information and of editing these for fair consistency of style. There is obvious redundancy throughout the text, as one would expect, because it would be unusual (although perhaps not unpleasant) to sit down by a fire on a few winter evenings and read the book from cover to cover.

I considered the section Basic Aspects, just over 400 pages, to be the most successful in the text. Perhaps this reflects my bias as a clinical and laboratory investigator in the field. The concise, timely, and clearly written material in Peripheral & Central Systems, Psychology, and Measurement should be required reading for all clinicians who treat patients with chronic pain and read the literature about new treatments. Although Peripheral & Central Systems is a superb overview of the complex and plastic anatomy and physiology of pain transduction, it was the Measurement section that I particularly enjoyed. How can one make sense, for example, of the myriad of reports about new therapies in the preclinical and clinical literature in our own anesthesia journals without first understanding how pain is assessed in animals and humans, what the pitfalls are, and what predictive value, if any, these simple tests have for complex clinical pain phenomena? This small section about pain measurement includes brief chapters by authorities and creative thinkers who have defined this field, including Ronald Dubner, Patrick McGrath, Richard Gracely, and Ronald Melzack.

The next section, Clinical States, is a collection of 28 chapters comprising more than 500 pages, divided basically by “where it hurts.” Thus, the chapters are divided into Soft Tissue, Joints and Bones, Deep and Visceral Pain, Head, Nerve and Root Damage, Central Nervous System, and Special Cases. This organization, although somewhat distracting in that a patient may have multiple sources of pain, the pathophysiology of which cannot be easily determined and earmarked into some of these categories, succeeds in providing a handy way to find rapidly the most salient topic related to a particular patient or presumed disease process. The disparity in writing style and organization is greatest in this section, reflecting more likely the disparity in maturity of the study and science of pain mechanisms in these different areas.

The last section, Therapeutic Aspects, is a collection of 21 chapters comprising more than 400 pages, divided by major therapeutic approaches: Pharmacology, Surgery, Stimulation, Physiotherapy, Psychotherapy, and Special Cases, including pain in children, cancer pain, peripheral neuropathic pain, and prevention of disability due to chronic musculoskeletal pain. The small section (less than 130 pages) about pharmacology is superb, and the initial chapter by H. J. McQuay and R. A. Moore, “Methods of Therapeutic Trials,” although reflecting the clear bias of these authors, is a wonderful framework and clear elucidation of how one should design pain trials as an investigator and how one should interpret them as a reader. Other chapters about nonnarcotic analgesics, psychotropic drugs, opioids, local anesthetics, and sympatholytics were wonderful and complete descriptions of the pharmacology of these agents, their clinical use and flow diagrams used in their application to chronic pain, and the uncertainty in some cases and variability in all cases of response to therapy. Other outstanding chapters included Patrick Wall’s fascinating description of the placebo and the placebo response and the thoughtful organization of the chapter “Peripheral Neuropathic Pain: An Approach to Management” by Howard Fields, Ralf Baron, and Michael Rowbotham.

What is there not to like about this book? Very little. It is, as indicated, encyclopedic, which makes it very big (more than 1,500 pages), heavy, and expensive. It is a multiauthored text, which I thought not at all to be distracting because one would not read this as a novel in any case. There are just a few color plates, placed at the beginning of the book, and these are not of good quality. Although the text would have been enhanced by the use of color, it would have so much increased cost that I agree with the editors’ choice that it would not be worth it.

In summary, this fourth edition of Wall and Melzack’s classic text remains the authoritative and comprehensive review of pain and analgesia. It should be in the library of every department of anesthesiology, and, although it is very big and expensive, I believe it belongs on the shelf of any laboratory or clinic studying and treating patients with pain.