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General Anaesthesia
416
BOOK REVIEW General Anaesthesia (2nd edition, 1965.) Volume 1: Basic Principles, 676 pp. Volume 2: Clinical Practice, 672 pp. Edited by Frankis T. Evans and T. Cecil Gray. Published by Butterworth and Co. Ltd., London. Price £5 5s. per volume.
Downloaded from http://bja.oxfordjournals.org/ at University of Michigan on July 12, 2015
When monographs axe new, comprehensive, and written by research workers, they are unlikely to be challenged within their own fields by a multi-author textbook; but monographs can present a one-sided, perhaps transatlantic, viewpoint; they may be relatively expensive, and of course there are still too few of them available. If there seems to be no intrinsic reason why large textbooks should not be successful, there are at any rate several stringent requirements: suitably-qualified authors; rapid passage through the press; and, most important of all, an extrem:ly demanding and critical, almost dictatorial, editorship to ensure evenness and thoroughness. Laudable effort on the part of all concerned in the present work should not be discounted by too severe criticism, but on the criteria just mentioned the success of the new General Anaesthesia is only partial. Volume I starts with the historical background to modern anaesthesia, but there is undue compression of the last four decades and the final sentence of advice, "primum non nocere", is of certain clinical importance but of remote historical interest. Curiously, the patient's name is the only one not mentioned in the caption to the illustration of the first successful use of ether by Morton (nine more or less involved persons were said to be present). Perusal of the following chapter on anatomy made this reviewer feel that it was high time for an authoritative teaching body to commission an anatomist to write an acceptable set of anatomy notes for anaesthetists, which could be distributed among examination candidates, thus freeing their minds for attention to other more essential and rapidly changing fields. The use of such statutory notes, combined with a number of dissecting-room demonstrations as examination time approached, would make it unnecessary to include (and only for the sake of completeness?) short "anatomies for anaesthetists" in most textbooks of general anaesthesia. The "Physiology of Respiration" is a generally satisfying review of the subject; but the examination candidate will not find an adequate account of ctrebrospinal pH changes and intracranial chemoreceptors, or of pulmonary ventilation-perfusion disturbances. Cardiovascular physiology is handled effectively, but here again omissions are obvious: it is not emphasized that many circulatory effects of chemoreceptor activation are due to the associated respiratory stimulation. This section, not written by an anaesthetist, is marred by a brief and uneven account of the cardiovascular effects of anaesthetics—for some years now there has been factual evidence that cyclopropaneinduced hypertension occurs at normal arterial carbon dioxide tensions. The cerebral bloodflow studies mentioned (which overlap with other sections) are those of the Glasgow group alone.
"Neurological Principles in Anaesthesia" is vast, detailed, and comprehensive. There is much to praise and little to offset (except perhaps the undue number of footnotes referring to the author's previous reviews of the work of others). This seems a more than adequate account for the examinee. The "vertical" concept, that anaesthesia affects higher and lower centres sequentially, is disposed of, but this example is unfortunately not followed by some other authors in the present volumes. The term "neurology of general anaesthesia" is a curious innovation. Useful accounts of acid-base, water and electrolyte balance, blood storage and transfusion, and cholinesterase and its variants, are presented subsequently. Pre- and postoperative drugs are considered by a pharmacologist, who includes some statements surprising to most anaesthetists: "atropine may depress respiration (p. 398) . . . morphine sensitizes chemoreceptors . . ." (perhaps true, but established experimentally?); "morphine takes second place to pethidine as pre-operative medication". There is no mention of the butyrophenones and associated drugs, about which early doubters are having to change their minds. The science of pharmacology does seem to be divisible into two rather separate disciplines: that of "description", which is quite likely to be effectively taught by interested clinicians, and a more basic involvement with the factors upon which drug actions really depend—uptake and distribution, structure/activity relationships, and receptor characteristics—fields merging into molecular biology. "The Pharmacology of Inhalation Anaesthetics" extends to 73 pages, and is interestingly presented and essentially up-to-date; if the worker in the field notices one or two references quoted out of context, then this scarcely detracts from a very adequate teaching story. An expectedly high standard is reached in the account of intravenous anaesthesia (which, although substantially clinical, is sited in Volume I). "The Influence of Anaesthesia on the Electrocardiogram" impresses greatly by its reflection of a close and discerning contact with anaesthetized patients. As anticipated, "Neuromuscular Block" is also outstanding; perhaps some readers will doubt the permanence of several of the present concepts in this field, and look forward to a greater unity based on simplicity. "Medical Gases is a mine of not-easily-obtained information, and the author (a clinical anaesthetist) must be congratulated for an effort which any engineer would be hard pressed to equal. A condensed "Principles of Anaesthetic Apparatus" and "Methods of Measurement" (this last item is not modern and occasionally misleading) completes Volume I. The second volume begins with a bri;f consideration of pre-operative respiratory and cardiovascular assessment. The reader may be reminded that this is a physician's viewpoint by the implication that extrasystoles are harbingers of ventricular fibrillation in patients with a history of coronary thrombosis. "Methods of Investigation of Pulmonary Function" starts very adequately, but finally disappoints (because of publication delays?) by an incomplete coverage of modern methods of arterial blood gas analysis.
BOOK REVIEW
Induced hypotension is considered very fairly, but there are some brow-raising statements in "Anaesthesia and Analgesia for Neurosurgery". Bilateral thoracic tractotomy (as usually performed) is surely not equivalent to thoracico-lumbar sympathectomy in its effects on arterial pressure (or sympathetic vasomotor control), and should it be generalized that the main blood loss during craniotomy occurs during closure of the incision? There is a rather personal chapter on anaesthesia for genito-urinary surgery, and sections on ophthalmic and obstetrical anaesthesia. "Reactions to Trauma, and their Significance" is considered quite basically, although a little imagination is required to accept fully the author's descriptions of traumatically-induced hypotension during surgical operations. Endocrine disorders, and their anaesthetic management, arc considered in some detail; this section should be helpful to the examination candidate, but it is surprising to see cholinergic drugs included in a table of adrenaline antagonists, and disappointing to find no mention of blood volume expansion to oppose the loss of circulating vasoconstrictors immediately following removal of a phaeochromocytoma (it is a very theoretical premise to suggest instead a trial of different vasoconstrictors). The recommendation to give sodium chloride pre-operatively to thes: patients is not clarified. A brief chapter on anaesthesia in the diabetic patient is effectively to the point. A section on dentalchair anaesthesia should b : of great practical value, but only if this practice is condoned. Aspects of Anaesthesia in Infants and Neonates" is excellent but it is difficult to understand why separate authors were chosen for this and the preceding "Principles and Practice of Paediatric Anaesthesia". A comprehensive account of anaesthesia in the difficult patient includes an ambiguous comment that oxygen may have to be restricted to ensure spontaneous respiration in the patient with severe respiratory disease. The 34 chapters of this volume are completed with a highly practical section on anaesthetic emergencies, a treatise on equipment sterilization, and considerations of immediate postoperative care, physiotherapy, respiratory insufficiency, and artificial respiration. There is a concise chapter on oxygen therapy which seems of real value, while hyperbaric oxygen receives its due. Hypnosis is evaluated in an apparently fair and unbiased way. The book ends with medico-legal considerations of anaesthesia—well worthy of inclusion. These weighty volumes, throughout which can be discerned a sprinkling of printing and numerical errors, are not for the impatient reader, full as they are of discursive comment; but for the examination candidate who has the time, they provide a substantial foundation of knowledge; useful to anaesthetists of both cultures, indispensable probably to neither; essential for the departmental library, but at the price unlikely to be so regarded by th: individual. R. A. Millar
Downloaded from http://bja.oxfordjournals.org/ at University of Michigan on July 12, 2015
There follow chapters on congenital heart disease (29 pages), and blood and fluid transfusion (no mention of low molecular weight dextran). Premedication, and its evaluation, is considered discursively, critically, and interestingly, albeit rather inconclusively. A section on basic techniques of anaesthesia is full of common sense; but th: extremes of caution and recklessness are reached in regard to halothane where it is stated that it should not be used with tubocurarine, and that concentrations b:low 5 per cent produce minimal effects on the cardiovascular and respiratory systems. There is also an old chestnut, liable to raise a groan at clinical meetings—". . . no complications of any kind . . .", in reference to intravenous tribromoethanol. "Techniques of Endotracheal Anaesthesia" is full of detailed practical information and is a most impressive account, although without much consideration of the sometimes dramatic circulatory changes associated with this routine manoeuvre. The latter two sections might be termed "very British" by our North American friends, with their recommendation of carbon dioxide as an aid to nitrous oxide-oxygen-ether inductions or for blind nasal intubation, and in the comment that 500 mg thiopentone alone can be given for blind intubation (how many present-day anaesthetists, observers only in pre-relaxant times, can recall the purple patient and the anaesthetist poised, awaiting the cough which was sometimes all too long delayed?). "Can be done" is rather different from "recommended"; the old days were sometimes not so good. An account of the clinical application of relaxant drugs is as outstanding as expected. The advocacy of the nitrous oxide/relaxant technique is persuasive, of course, but surely there are many factors other than the relaxants which have turned modern anaesthetists toward a more detailed knowledge of physiology and pharmacology. "Hypotensive anaesthetists" will be especially unlikely to change their ways in face of the not-so-occasional and unintentional rude awakenings of patients anaesthetized only with nitrous oxide and oxygen. There follow sections on anaesthesia in abdominal and cardiothoracic surgery, and on heart-lung machines. Hypothermia is considered very fully. In spite of the vast literature on the subject (or is it because of uncritical special pleading and repetitive publication?) there remains a great deal of woolly speculation about the clinical us: of hypothermia. Uncontrolled series abound, comparisons of one technique of inducing hypothermia with another are confused by attendant alterations in general clinical management, etc. Surely more substantial evidence is required before it is fair to accept that "pulmonary overventilation is obviously undesirable" in the hypothermic patient? Do we know that the shift to the left of the oxygen dissociation curve causes hypoxia without knowing the relevant tissue Po,?
417
BOOK REVIEW General Anaesthesia (2nd edition, 1965.) Volume 1: Basic Principles, 676 pp. Volume 2: Clinical Practice, 672 pp. Edited by Frankis T. Evans and T. Cecil Gray. Published by Butterworth and Co. Ltd., London. Price £5 5s. per volume.
Downloaded from http://bja.oxfordjournals.org/ at University of Michigan on July 12, 2015
When monographs axe new, comprehensive, and written by research workers, they are unlikely to be challenged within their own fields by a multi-author textbook; but monographs can present a one-sided, perhaps transatlantic, viewpoint; they may be relatively expensive, and of course there are still too few of them available. If there seems to be no intrinsic reason why large textbooks should not be successful, there are at any rate several stringent requirements: suitably-qualified authors; rapid passage through the press; and, most important of all, an extrem:ly demanding and critical, almost dictatorial, editorship to ensure evenness and thoroughness. Laudable effort on the part of all concerned in the present work should not be discounted by too severe criticism, but on the criteria just mentioned the success of the new General Anaesthesia is only partial. Volume I starts with the historical background to modern anaesthesia, but there is undue compression of the last four decades and the final sentence of advice, "primum non nocere", is of certain clinical importance but of remote historical interest. Curiously, the patient's name is the only one not mentioned in the caption to the illustration of the first successful use of ether by Morton (nine more or less involved persons were said to be present). Perusal of the following chapter on anatomy made this reviewer feel that it was high time for an authoritative teaching body to commission an anatomist to write an acceptable set of anatomy notes for anaesthetists, which could be distributed among examination candidates, thus freeing their minds for attention to other more essential and rapidly changing fields. The use of such statutory notes, combined with a number of dissecting-room demonstrations as examination time approached, would make it unnecessary to include (and only for the sake of completeness?) short "anatomies for anaesthetists" in most textbooks of general anaesthesia. The "Physiology of Respiration" is a generally satisfying review of the subject; but the examination candidate will not find an adequate account of ctrebrospinal pH changes and intracranial chemoreceptors, or of pulmonary ventilation-perfusion disturbances. Cardiovascular physiology is handled effectively, but here again omissions are obvious: it is not emphasized that many circulatory effects of chemoreceptor activation are due to the associated respiratory stimulation. This section, not written by an anaesthetist, is marred by a brief and uneven account of the cardiovascular effects of anaesthetics—for some years now there has been factual evidence that cyclopropaneinduced hypertension occurs at normal arterial carbon dioxide tensions. The cerebral bloodflow studies mentioned (which overlap with other sections) are those of the Glasgow group alone.
"Neurological Principles in Anaesthesia" is vast, detailed, and comprehensive. There is much to praise and little to offset (except perhaps the undue number of footnotes referring to the author's previous reviews of the work of others). This seems a more than adequate account for the examinee. The "vertical" concept, that anaesthesia affects higher and lower centres sequentially, is disposed of, but this example is unfortunately not followed by some other authors in the present volumes. The term "neurology of general anaesthesia" is a curious innovation. Useful accounts of acid-base, water and electrolyte balance, blood storage and transfusion, and cholinesterase and its variants, are presented subsequently. Pre- and postoperative drugs are considered by a pharmacologist, who includes some statements surprising to most anaesthetists: "atropine may depress respiration (p. 398) . . . morphine sensitizes chemoreceptors . . ." (perhaps true, but established experimentally?); "morphine takes second place to pethidine as pre-operative medication". There is no mention of the butyrophenones and associated drugs, about which early doubters are having to change their minds. The science of pharmacology does seem to be divisible into two rather separate disciplines: that of "description", which is quite likely to be effectively taught by interested clinicians, and a more basic involvement with the factors upon which drug actions really depend—uptake and distribution, structure/activity relationships, and receptor characteristics—fields merging into molecular biology. "The Pharmacology of Inhalation Anaesthetics" extends to 73 pages, and is interestingly presented and essentially up-to-date; if the worker in the field notices one or two references quoted out of context, then this scarcely detracts from a very adequate teaching story. An expectedly high standard is reached in the account of intravenous anaesthesia (which, although substantially clinical, is sited in Volume I). "The Influence of Anaesthesia on the Electrocardiogram" impresses greatly by its reflection of a close and discerning contact with anaesthetized patients. As anticipated, "Neuromuscular Block" is also outstanding; perhaps some readers will doubt the permanence of several of the present concepts in this field, and look forward to a greater unity based on simplicity. "Medical Gases is a mine of not-easily-obtained information, and the author (a clinical anaesthetist) must be congratulated for an effort which any engineer would be hard pressed to equal. A condensed "Principles of Anaesthetic Apparatus" and "Methods of Measurement" (this last item is not modern and occasionally misleading) completes Volume I. The second volume begins with a bri;f consideration of pre-operative respiratory and cardiovascular assessment. The reader may be reminded that this is a physician's viewpoint by the implication that extrasystoles are harbingers of ventricular fibrillation in patients with a history of coronary thrombosis. "Methods of Investigation of Pulmonary Function" starts very adequately, but finally disappoints (because of publication delays?) by an incomplete coverage of modern methods of arterial blood gas analysis.
BOOK REVIEW
Induced hypotension is considered very fairly, but there are some brow-raising statements in "Anaesthesia and Analgesia for Neurosurgery". Bilateral thoracic tractotomy (as usually performed) is surely not equivalent to thoracico-lumbar sympathectomy in its effects on arterial pressure (or sympathetic vasomotor control), and should it be generalized that the main blood loss during craniotomy occurs during closure of the incision? There is a rather personal chapter on anaesthesia for genito-urinary surgery, and sections on ophthalmic and obstetrical anaesthesia. "Reactions to Trauma, and their Significance" is considered quite basically, although a little imagination is required to accept fully the author's descriptions of traumatically-induced hypotension during surgical operations. Endocrine disorders, and their anaesthetic management, arc considered in some detail; this section should be helpful to the examination candidate, but it is surprising to see cholinergic drugs included in a table of adrenaline antagonists, and disappointing to find no mention of blood volume expansion to oppose the loss of circulating vasoconstrictors immediately following removal of a phaeochromocytoma (it is a very theoretical premise to suggest instead a trial of different vasoconstrictors). The recommendation to give sodium chloride pre-operatively to thes: patients is not clarified. A brief chapter on anaesthesia in the diabetic patient is effectively to the point. A section on dentalchair anaesthesia should b : of great practical value, but only if this practice is condoned. Aspects of Anaesthesia in Infants and Neonates" is excellent but it is difficult to understand why separate authors were chosen for this and the preceding "Principles and Practice of Paediatric Anaesthesia". A comprehensive account of anaesthesia in the difficult patient includes an ambiguous comment that oxygen may have to be restricted to ensure spontaneous respiration in the patient with severe respiratory disease. The 34 chapters of this volume are completed with a highly practical section on anaesthetic emergencies, a treatise on equipment sterilization, and considerations of immediate postoperative care, physiotherapy, respiratory insufficiency, and artificial respiration. There is a concise chapter on oxygen therapy which seems of real value, while hyperbaric oxygen receives its due. Hypnosis is evaluated in an apparently fair and unbiased way. The book ends with medico-legal considerations of anaesthesia—well worthy of inclusion. These weighty volumes, throughout which can be discerned a sprinkling of printing and numerical errors, are not for the impatient reader, full as they are of discursive comment; but for the examination candidate who has the time, they provide a substantial foundation of knowledge; useful to anaesthetists of both cultures, indispensable probably to neither; essential for the departmental library, but at the price unlikely to be so regarded by th: individual. R. A. Millar
Downloaded from http://bja.oxfordjournals.org/ at University of Michigan on July 12, 2015
There follow chapters on congenital heart disease (29 pages), and blood and fluid transfusion (no mention of low molecular weight dextran). Premedication, and its evaluation, is considered discursively, critically, and interestingly, albeit rather inconclusively. A section on basic techniques of anaesthesia is full of common sense; but th: extremes of caution and recklessness are reached in regard to halothane where it is stated that it should not be used with tubocurarine, and that concentrations b:low 5 per cent produce minimal effects on the cardiovascular and respiratory systems. There is also an old chestnut, liable to raise a groan at clinical meetings—". . . no complications of any kind . . .", in reference to intravenous tribromoethanol. "Techniques of Endotracheal Anaesthesia" is full of detailed practical information and is a most impressive account, although without much consideration of the sometimes dramatic circulatory changes associated with this routine manoeuvre. The latter two sections might be termed "very British" by our North American friends, with their recommendation of carbon dioxide as an aid to nitrous oxide-oxygen-ether inductions or for blind nasal intubation, and in the comment that 500 mg thiopentone alone can be given for blind intubation (how many present-day anaesthetists, observers only in pre-relaxant times, can recall the purple patient and the anaesthetist poised, awaiting the cough which was sometimes all too long delayed?). "Can be done" is rather different from "recommended"; the old days were sometimes not so good. An account of the clinical application of relaxant drugs is as outstanding as expected. The advocacy of the nitrous oxide/relaxant technique is persuasive, of course, but surely there are many factors other than the relaxants which have turned modern anaesthetists toward a more detailed knowledge of physiology and pharmacology. "Hypotensive anaesthetists" will be especially unlikely to change their ways in face of the not-so-occasional and unintentional rude awakenings of patients anaesthetized only with nitrous oxide and oxygen. There follow sections on anaesthesia in abdominal and cardiothoracic surgery, and on heart-lung machines. Hypothermia is considered very fully. In spite of the vast literature on the subject (or is it because of uncritical special pleading and repetitive publication?) there remains a great deal of woolly speculation about the clinical us: of hypothermia. Uncontrolled series abound, comparisons of one technique of inducing hypothermia with another are confused by attendant alterations in general clinical management, etc. Surely more substantial evidence is required before it is fair to accept that "pulmonary overventilation is obviously undesirable" in the hypothermic patient? Do we know that the shift to the left of the oxygen dissociation curve causes hypoxia without knowing the relevant tissue Po,?
417