- Email: [email protected]
Acute Cardiovascular Management: Anaesthesia and Intensive Care. By Ream A. K. and Fogdall R. P. Published by J. P. Lippincott Co. Pp. 940; indexed; illustrated. Price £62.00.
BRITISH JOURNAL OF ANAESTHESIA
454
C. M. Conway
The Origins of Anaesthesia. By Sherwin B. Nuland. The Classics of Medicine Library. Published by Leslie B. Adams jr. Pp. 131; indexed; illustrated. Price $39.00. The aim of this beautifully produced volume is to relate the events leading up to October 16, 1846, when William Thomas Green Morton demonstrated the effectiveness of ether at the Massachusetts General Hospital. In order to review the variouis contributions the author has chosen to reproduce, in facsimile form, the various source articles of the time and, in addition, rounds off this dramatic presentation by recounting James Young Simpson's introduction of chloroform. Four key facsimile papers are reproduced which establish beyond doubt the basis of what led to modern anaesthesia. The author has brought under one cover, however, much more that is pertinent to the story of the beginnings of anaesthesia, ranging from pain relief in the Middle Ages
to Mesmerism. All combine to form a gripping and, at times, tragic account of the origins of our specialty. Many would claim, with some justification, that the greater part of the torrent of contemporary anaesthetic literature suffers from an ordinariness of presentation and lack of literary style only partially redeemed by its scientific value. Certainly, much of it is unlikely to be read 100 years from now with such enjoyment and intellectual stimulation as that provided by these few original papers of the last century. This in itself, if true, would be justification enough for the present publication. There is, however, another compelling reason to commend Dr Nuland's effort of compilation and commentary on the origins of anaesthesia. It is rare indeed for postgraduate trainees in anaesthesia nowadays to have more than a sketchy and inaccurate knowledge of their forebears and their labours. Some even give the impression that nothing of great relevance to their current practice happened in the pre-thiopentone age. The importance of knowing where we have been, as a guide to onward direction, seems to elude many. Even a cursory dip in this volume might just disabuse them of this mistaken view and enrich their appreciation forever of the specialty which claims their allegiance. The reviewer certainly hopes so; otherwise this splendid book will be condemned to the shelves and coffee tables of a few medical history buffs and not be, as it deserves, a well-thumbed and much appreciated account, in every teaching department which still has a library budget, of possibly the most dramatic milestone in modern medicine. D. Campbell
Acute Cardiovascular Management: Anaesthesia and Intensive Care. By A. K. Ream and R. P. Fogdall. Published by J. P. Lippincott Co. Pp. 940; indexed; illustrated. Price £62.00. The reader should not be misled by the title, into believing this book covers all aspects of cardiovascular management in intensive care. It does, however, deal comprehensively with the perioperative management of patients presenting for cardiac and vascular surgery. While it is a multi-author text, there appeared an overall consistency in the section dealing with clinical practice, reflecting perhaps the predominance of Stanford-based clinicians. For the purposes of review, the book can be divided into three sections. The first deals with physiology, pharmacology and monitoring, including a chapter on the assessment of cardiac catheterization data which would be read with benefit by anyone practising cardiac anaesthesia. The section on pharmacology was somewhat dated, as there was no discussion of calcium antagonists and the section on the cardiovascular effects of non-depolarizing neuromuscular blocking drugs seemed somewhat redundant on account of the cardiostability available with the current generation of blockers. The second section deals with clinical practice involving perioperative management of adult and paediatric cardiac surgery. The chapter on postoperative care of the adult cardiac patient was comprehensive and that on transplantation was also of interest, in view of the authors' considerable experience in this area. The more conservative cardiac anaesthetist would be encouraged by the fairly stringent criteria suggested for selection of patients suitable for pulmonary artery catheterization. The section is completed by chapters on anaesthesia for major vascular surgery. Description of anaesthesia for thoracic
Downloaded from http://bja.oxfordjournals.org/ at Emory University on August 18, 2015
Given that the current generation of anaesthetic machines are far from perfect, an important first task in planning for the future is to define our needs. Disparate views on this are presented in this book. In general, a more sober and more realistic approach is taken by the biomedical engineering contributors than by the anaesthetists. The engineers emphasize our great lack of understanding of normal physiological control mechanisms and the compounding of this problem by anaesthesia. They contrast the comparative simplicity of applying control theory to anaesthetic equipment with the great difficulty of controlling patient variables. Advanced technology will not remove from the anaesthetist the role of a decision taker. Improved methods of measurement and data processing will assist him by presenting information in an easily assimilated form. The microprocessor will also act as an automatic pilot or "cruise control"—the anaesthetist decides what to do, the machinery ensures that it is done. With our present body of knowledge, this is a better approach to the application of advanced technology than, for instance, the description given by one group of authors of fully automated closed-circuit anaesthesia. In their technique they have "closed the loop", but because in so doing they have used a large number of greatly simplified or empirical assumptions, their approach cannot improve our understanding of the problems or lead to better solutions. Even if their method appears to work, it takes us down a blind alley. The essential difference in approach between the clinical contributors and the technologists seems to this reviewer to be that the clinician tends to decide what it would be nice to do and assumes that technology must have a way of doing it. The technologist, however, says that before providing an answer he needs from the anaesthetist a far more detailed description of the problem. Any inherent imprecision in this description will of necessity constrain the efficiency of the solution. This book is not all about computers. There is a useful chapter by Rendell-Baker on the development of international standards for anaesthetic equipment, a discussion on how waste anaesthetic gases could be recycled, and several descriptions of newer methods available for gas flow measurement and control and for gas analysis. Possibly the most interesting chapter is the last one, entitled "What do we do until the future gets here". The message seems to be to put up with what you have—it works very well most of the time, there is little better available at present, and the sophisticated advances heralded in this book are probably a very long way off.
BOOK REVIEWS
455
aneurysm surgery was much appreciated by a reviewer with little experience of this area. The last section deals with miscellaneous topics, including coagulation, hypothermia and cardiac assist devices. The section is completed by a description of training in cardiac anaesthesia as practised at Stanford. I noticed with interest that the authors place their own text at the top of the reading list and in this reviewer's opinion, they may not be far wrong. J. C. Howie
Pediatric Anesthesia, Vols I and II. Edited by George A. Gregory. Published (1983) by Churchill Livingstone, London and Edinburgh. Pp. 1020; indexed.
Gordon H. Bush
Manual of Preoperative and Postoperative Care. By Dudrick, Baue, Eiseman, MacLean, Roweand Sheldon. Published by W. B. Saunders. Pp. 82; indexed. Price £27.25. This is the third edition of the Manual of Preoperative and Postoperative Care prepared by the Committee on Pre- and Postoperative Care of the American College of Surgeons. It is divided into four sections, covering basic problems in surgery, paediatric surgery, problems related to specific organ systems, and those relating to special categories of patients. It differs from the previous edition in that it reflects the evolving interests that have occurred in surgery within the past decade. The chapter on surgical nutrition has been expanded to include both enteral and parenteral nutrition, while the chapter on paediatric surgery has been expanded to four chapters dealing with the specific problems of paediatric surgical patients. Further chapters on preparation before operation, multi-systems failure and the problems
Downloaded from http://bja.oxfordjournals.org/ at Emory University on August 18, 2015
These two volumes of paediatric anaesthesia are edited by Professor George Gregory from the Department of Anesthesia, University of California, San Francisco School of Medicine, California U.S.A., who has invited 23 distinguished paediatricians and paediatric anaesthetists from the United States and Canada to contribute "their talents and clinical experience". The first volume of 550 pages is principally concerned with establishing basic embryological, physiological and anatomical principles upon which the techniques of paediatric anaesthesia are described in the second volume. The editor in the preface makes the valid point that, in recent years, a great deal of much valued information concerning physiological, pharmacological and pathological variables in infants and children has become available. However, because this knowledge is reported in paediatric, anaesthetic and surgical journals and textbooks, there is a need to collate this important information where it can be more readily found, "especially in the middle of the night"! Whilst there is no doubt that paediatric anaesthesia is now widely recognized as a valid subspecialty of anaesthetic practice, such an ideal is only to be applauded, and undoubtedly Professor Gregory has succeeded admirably. It is to be hoped that the busy practitioner and house officer will be consulting these texts, not in search of guidance on how to handle the particular clinical situation, but in how to present a coherent and informed report to the paediatric anaesthetic specialist. The differences between adults, and infants and children, are rightly continually being stressed. No-one who has read the chapters should be under any illusion that the response of the young patient compared with the adult to, for example, fluid requirements, drug dose, temperature regulation, cardiovascular and respiratory effects are modified considerably; these changes are well documented. Despite the recent increase in our knowledge of the effects of anaesthesia in infants and children, there is still a great deal of information to be obtained. It is to be hoped that some of the current concepts based on quoted adult or experiemental work will soon be replaced or modified by the results from paediatric research. The editor made a particular plea to his contributors to stress, among other items, aspects of physiology and embryology. The enthusiasm with which they have responded to this request has inevitably resulted in some imbalance and it could be asked whether more than 60 pages should be devoted to the renal system, whilst less than 20 pages cover the cardiovascular physiology and less than 30 pages the respiratory system. Similarly, while developmental metabolism and nutrition, and temperature regulation are most important aspects of the overall care of infants and children and the information presented is fascinating, the anaesthetic resident will need many hours of the midnight oil to
absorb the 145 pages devoted to these subjects. There is no doubt, however, that the academician and the specialist paediatric anaesthetist will revel in this mine of invaluable paediatric physiology. The accent certainly is aimed more at the medical approach to these problems and surgical aspects are not highlighted. How, for example, do the infant and child differ in respect of their metabolic response to surgery compared with the adult? The second volume will have great appeal to all practising paediatric anaesthetists and covers such topics as anaesthesia for the premature infant, which is currently much in vogue because of the achievements of neonatologists in improving the survival of extremely preterm infants, anaesthesia for congenital heart disease, thoracic surgery, neurosurgical procedures and all the other specialized branches of paediatric surgery. The final chapter deals excellently with paediatric intensive care and is accompanied by a list of 800 references. Paediatric practice in the U.K. appears to be very different in two aspects if one is to believe that "botulism is a relatively frequent cause of respiratory failure in infants". Fortunately also, thyrotoxic crisis has yet to be encountered in most paediatric intensive care units. A great deal of hard work by all the contributors, the editor and the publisher, has made these volumes easily readable and the clear print and good diagrams make them readily understandable. Inevitably, statements are made that do not have substantiation or which cannot be agreed. Thus, on p. 598 it is stated that "nitrous oxide is not without cardiovascular effects in preterm infants, decreases arterial pressure and can cause cardiac arrest". It would be interesting to know the basis on which this statement is made. Some paediatric anaesthetists will certainly question the advice that "it is usually not necessary to protect the airway with an endotracheal tube" for lacrimal sac washout, despite the assertion that the volume of fluid is very small. Doubts will also be expressed about the statement that "controlled ventilation results in rapid alveolarisation of the dye during bronchography". There are, incidentally, some minor typographical errors (Rees not Reece!), mislabelling of figure 11-13, and minor irritating colloquialisms, but on the whole the standard of proof reading is high. These small errors should not, however, be taken as any serious criticism on what is, and will remain for some time to come, a highly recommended textbook of paediatric anaesthesia. The major criticism will come from the resident anaesthetist who will find the price precludes these books from his library shelf.
454
C. M. Conway
The Origins of Anaesthesia. By Sherwin B. Nuland. The Classics of Medicine Library. Published by Leslie B. Adams jr. Pp. 131; indexed; illustrated. Price $39.00. The aim of this beautifully produced volume is to relate the events leading up to October 16, 1846, when William Thomas Green Morton demonstrated the effectiveness of ether at the Massachusetts General Hospital. In order to review the variouis contributions the author has chosen to reproduce, in facsimile form, the various source articles of the time and, in addition, rounds off this dramatic presentation by recounting James Young Simpson's introduction of chloroform. Four key facsimile papers are reproduced which establish beyond doubt the basis of what led to modern anaesthesia. The author has brought under one cover, however, much more that is pertinent to the story of the beginnings of anaesthesia, ranging from pain relief in the Middle Ages
to Mesmerism. All combine to form a gripping and, at times, tragic account of the origins of our specialty. Many would claim, with some justification, that the greater part of the torrent of contemporary anaesthetic literature suffers from an ordinariness of presentation and lack of literary style only partially redeemed by its scientific value. Certainly, much of it is unlikely to be read 100 years from now with such enjoyment and intellectual stimulation as that provided by these few original papers of the last century. This in itself, if true, would be justification enough for the present publication. There is, however, another compelling reason to commend Dr Nuland's effort of compilation and commentary on the origins of anaesthesia. It is rare indeed for postgraduate trainees in anaesthesia nowadays to have more than a sketchy and inaccurate knowledge of their forebears and their labours. Some even give the impression that nothing of great relevance to their current practice happened in the pre-thiopentone age. The importance of knowing where we have been, as a guide to onward direction, seems to elude many. Even a cursory dip in this volume might just disabuse them of this mistaken view and enrich their appreciation forever of the specialty which claims their allegiance. The reviewer certainly hopes so; otherwise this splendid book will be condemned to the shelves and coffee tables of a few medical history buffs and not be, as it deserves, a well-thumbed and much appreciated account, in every teaching department which still has a library budget, of possibly the most dramatic milestone in modern medicine. D. Campbell
Acute Cardiovascular Management: Anaesthesia and Intensive Care. By A. K. Ream and R. P. Fogdall. Published by J. P. Lippincott Co. Pp. 940; indexed; illustrated. Price £62.00. The reader should not be misled by the title, into believing this book covers all aspects of cardiovascular management in intensive care. It does, however, deal comprehensively with the perioperative management of patients presenting for cardiac and vascular surgery. While it is a multi-author text, there appeared an overall consistency in the section dealing with clinical practice, reflecting perhaps the predominance of Stanford-based clinicians. For the purposes of review, the book can be divided into three sections. The first deals with physiology, pharmacology and monitoring, including a chapter on the assessment of cardiac catheterization data which would be read with benefit by anyone practising cardiac anaesthesia. The section on pharmacology was somewhat dated, as there was no discussion of calcium antagonists and the section on the cardiovascular effects of non-depolarizing neuromuscular blocking drugs seemed somewhat redundant on account of the cardiostability available with the current generation of blockers. The second section deals with clinical practice involving perioperative management of adult and paediatric cardiac surgery. The chapter on postoperative care of the adult cardiac patient was comprehensive and that on transplantation was also of interest, in view of the authors' considerable experience in this area. The more conservative cardiac anaesthetist would be encouraged by the fairly stringent criteria suggested for selection of patients suitable for pulmonary artery catheterization. The section is completed by chapters on anaesthesia for major vascular surgery. Description of anaesthesia for thoracic
Downloaded from http://bja.oxfordjournals.org/ at Emory University on August 18, 2015
Given that the current generation of anaesthetic machines are far from perfect, an important first task in planning for the future is to define our needs. Disparate views on this are presented in this book. In general, a more sober and more realistic approach is taken by the biomedical engineering contributors than by the anaesthetists. The engineers emphasize our great lack of understanding of normal physiological control mechanisms and the compounding of this problem by anaesthesia. They contrast the comparative simplicity of applying control theory to anaesthetic equipment with the great difficulty of controlling patient variables. Advanced technology will not remove from the anaesthetist the role of a decision taker. Improved methods of measurement and data processing will assist him by presenting information in an easily assimilated form. The microprocessor will also act as an automatic pilot or "cruise control"—the anaesthetist decides what to do, the machinery ensures that it is done. With our present body of knowledge, this is a better approach to the application of advanced technology than, for instance, the description given by one group of authors of fully automated closed-circuit anaesthesia. In their technique they have "closed the loop", but because in so doing they have used a large number of greatly simplified or empirical assumptions, their approach cannot improve our understanding of the problems or lead to better solutions. Even if their method appears to work, it takes us down a blind alley. The essential difference in approach between the clinical contributors and the technologists seems to this reviewer to be that the clinician tends to decide what it would be nice to do and assumes that technology must have a way of doing it. The technologist, however, says that before providing an answer he needs from the anaesthetist a far more detailed description of the problem. Any inherent imprecision in this description will of necessity constrain the efficiency of the solution. This book is not all about computers. There is a useful chapter by Rendell-Baker on the development of international standards for anaesthetic equipment, a discussion on how waste anaesthetic gases could be recycled, and several descriptions of newer methods available for gas flow measurement and control and for gas analysis. Possibly the most interesting chapter is the last one, entitled "What do we do until the future gets here". The message seems to be to put up with what you have—it works very well most of the time, there is little better available at present, and the sophisticated advances heralded in this book are probably a very long way off.
BOOK REVIEWS
455
aneurysm surgery was much appreciated by a reviewer with little experience of this area. The last section deals with miscellaneous topics, including coagulation, hypothermia and cardiac assist devices. The section is completed by a description of training in cardiac anaesthesia as practised at Stanford. I noticed with interest that the authors place their own text at the top of the reading list and in this reviewer's opinion, they may not be far wrong. J. C. Howie
Pediatric Anesthesia, Vols I and II. Edited by George A. Gregory. Published (1983) by Churchill Livingstone, London and Edinburgh. Pp. 1020; indexed.
Gordon H. Bush
Manual of Preoperative and Postoperative Care. By Dudrick, Baue, Eiseman, MacLean, Roweand Sheldon. Published by W. B. Saunders. Pp. 82; indexed. Price £27.25. This is the third edition of the Manual of Preoperative and Postoperative Care prepared by the Committee on Pre- and Postoperative Care of the American College of Surgeons. It is divided into four sections, covering basic problems in surgery, paediatric surgery, problems related to specific organ systems, and those relating to special categories of patients. It differs from the previous edition in that it reflects the evolving interests that have occurred in surgery within the past decade. The chapter on surgical nutrition has been expanded to include both enteral and parenteral nutrition, while the chapter on paediatric surgery has been expanded to four chapters dealing with the specific problems of paediatric surgical patients. Further chapters on preparation before operation, multi-systems failure and the problems
Downloaded from http://bja.oxfordjournals.org/ at Emory University on August 18, 2015
These two volumes of paediatric anaesthesia are edited by Professor George Gregory from the Department of Anesthesia, University of California, San Francisco School of Medicine, California U.S.A., who has invited 23 distinguished paediatricians and paediatric anaesthetists from the United States and Canada to contribute "their talents and clinical experience". The first volume of 550 pages is principally concerned with establishing basic embryological, physiological and anatomical principles upon which the techniques of paediatric anaesthesia are described in the second volume. The editor in the preface makes the valid point that, in recent years, a great deal of much valued information concerning physiological, pharmacological and pathological variables in infants and children has become available. However, because this knowledge is reported in paediatric, anaesthetic and surgical journals and textbooks, there is a need to collate this important information where it can be more readily found, "especially in the middle of the night"! Whilst there is no doubt that paediatric anaesthesia is now widely recognized as a valid subspecialty of anaesthetic practice, such an ideal is only to be applauded, and undoubtedly Professor Gregory has succeeded admirably. It is to be hoped that the busy practitioner and house officer will be consulting these texts, not in search of guidance on how to handle the particular clinical situation, but in how to present a coherent and informed report to the paediatric anaesthetic specialist. The differences between adults, and infants and children, are rightly continually being stressed. No-one who has read the chapters should be under any illusion that the response of the young patient compared with the adult to, for example, fluid requirements, drug dose, temperature regulation, cardiovascular and respiratory effects are modified considerably; these changes are well documented. Despite the recent increase in our knowledge of the effects of anaesthesia in infants and children, there is still a great deal of information to be obtained. It is to be hoped that some of the current concepts based on quoted adult or experiemental work will soon be replaced or modified by the results from paediatric research. The editor made a particular plea to his contributors to stress, among other items, aspects of physiology and embryology. The enthusiasm with which they have responded to this request has inevitably resulted in some imbalance and it could be asked whether more than 60 pages should be devoted to the renal system, whilst less than 20 pages cover the cardiovascular physiology and less than 30 pages the respiratory system. Similarly, while developmental metabolism and nutrition, and temperature regulation are most important aspects of the overall care of infants and children and the information presented is fascinating, the anaesthetic resident will need many hours of the midnight oil to
absorb the 145 pages devoted to these subjects. There is no doubt, however, that the academician and the specialist paediatric anaesthetist will revel in this mine of invaluable paediatric physiology. The accent certainly is aimed more at the medical approach to these problems and surgical aspects are not highlighted. How, for example, do the infant and child differ in respect of their metabolic response to surgery compared with the adult? The second volume will have great appeal to all practising paediatric anaesthetists and covers such topics as anaesthesia for the premature infant, which is currently much in vogue because of the achievements of neonatologists in improving the survival of extremely preterm infants, anaesthesia for congenital heart disease, thoracic surgery, neurosurgical procedures and all the other specialized branches of paediatric surgery. The final chapter deals excellently with paediatric intensive care and is accompanied by a list of 800 references. Paediatric practice in the U.K. appears to be very different in two aspects if one is to believe that "botulism is a relatively frequent cause of respiratory failure in infants". Fortunately also, thyrotoxic crisis has yet to be encountered in most paediatric intensive care units. A great deal of hard work by all the contributors, the editor and the publisher, has made these volumes easily readable and the clear print and good diagrams make them readily understandable. Inevitably, statements are made that do not have substantiation or which cannot be agreed. Thus, on p. 598 it is stated that "nitrous oxide is not without cardiovascular effects in preterm infants, decreases arterial pressure and can cause cardiac arrest". It would be interesting to know the basis on which this statement is made. Some paediatric anaesthetists will certainly question the advice that "it is usually not necessary to protect the airway with an endotracheal tube" for lacrimal sac washout, despite the assertion that the volume of fluid is very small. Doubts will also be expressed about the statement that "controlled ventilation results in rapid alveolarisation of the dye during bronchography". There are, incidentally, some minor typographical errors (Rees not Reece!), mislabelling of figure 11-13, and minor irritating colloquialisms, but on the whole the standard of proof reading is high. These small errors should not, however, be taken as any serious criticism on what is, and will remain for some time to come, a highly recommended textbook of paediatric anaesthesia. The major criticism will come from the resident anaesthetist who will find the price precludes these books from his library shelf.