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Hypnosis in Anaesthesiology
CORRESPONDENCE AN UNUSUAL COMPLICATION AFTER STELLATE GANGLION BLOCK
DANIEL C. MOORE
Seattle INTERMITTENT POSITIVE PRESSURE VENTILATORS AND THE BOSUN OXYGEN WARNING DEVICE
i
Sir,—We would like to draw the attention of readers to a serious danger that exists when the Manley intermittent positive pressure ventilator is used in conjunction with the anaesthetic machine fitted with a Bosun oxygen warning device. Drs. Hurter and Williams (1964) of the Orpington Hospital. Kent, have already drawn attention to this, but we feel that not enough publicity has been given to so serious a matter.
J. FRASER-JONES A. VIVIAN JENKINS E. THOMAS
Birmingham REFERENCE
Hurter, D. G., and Williams, D. (1964). The Bosun Device. Lancet, 2, 480. Correspondence.
BOOK REVIEWS Hypnosis in Anaesthesiology. An International Symposium held at the First European Congress of of Anaesthesiology of the World Federation of Societies of Anaesthesiologists, Vienna, Austria, September 5, 1962. Edited by Jean Lassner. Published by Springer-Verlag, Berlin, 1964. Pp. 51.
i
To listen to polyglot symposia is seldom, save to those with special linguistic abilities, a very rewarding experience. However, we can be glad that this symposium was held,, and that, thanks to Dr. Lassner, such an excellent English edition of its proceedings has been made available. The 16 participants, representing 12 countries from both sides of the Iron Curtain (something to be welcomed in itself), are all men of high repute in their special fields of psychotherapeutics and anaesthesia, and their contributions in this booklet are worthy of their reputations. Too many of the previous publications on the subject of hypnosis have tended to perpetuate beliefs in the mystioue of mesmerism; it is most refreshing to find that all the contributors unite in disclaiming magic, explain their aims and methods in simple language.
817
and, although convinced of the value of hypnotic techniques, recognize the dangers which may beset the path of the too-enthusiastic. Since these dangers are real, it may be valuable to mention them here. The late Dr. Stokvis (Holland) points out that unfortunate results may occur with patients of hysterical personality or impending psychosis, while Dr. Raginsky (Canada) emphasizes that, since the personal relationship between patient and doctor is much deeper when hypnosis is used, any mishandling of the situation may cause serious difficulties. Proponents of hypnotism would do well to bear in mind the following remarks by Dr. Antitch (Yugoslavia), "It is a wellknown fact that it becomes progressively easier to induce hypnosis with each repetition. It may become possible to induce it by a signal, even without the hypnotized person's knowledge or against his will. In this way, the initial legitimate use may pave the way *o possible abuse. There is also the danger of choosing a signal for the induction of hypnosis which may be encountered fortuitously." While there can be no doubt that the intelligent use of psychotherapeutic methods, in other words, of kind-
Downloaded from http://bja.oxfordjournals.org/ at Cornell University Library on July 26, 2015
S
Sir,—Dr. Magora's letter (Brit. J. Anaesth., (1964), 36, 601) states: "Only a small amount (about 1 ml of the total amount) was injected into another site when the patient moved." In reviewing his original article, neither I nor my partner can find any reference to the injection of "about 1 ml of the total amount." If only a total of 1 ml of lignocaine had been injected, then Dr. Magora's point is well taken. But more than 1 ml was injected. I still believe this reaction describes an epidural injection. There is no real proof that the 1 ml caused the complication—it could have been the other 9 ml.
We also have discovered that the use of the Manley ventilator renders the oxygen warning whistle inoperative, presumably due to a build up of pressure from the respirator back to the rotameter head during the expiratory phase. It appears that 3 lb. pressure is required for the efficient working of the Bosun whistle, and as there is a back pressure of l i lb. from the Manley ventilator during the expiratory phase, this renders the Bosun inoperative. It may be that other intermittent positive pressure respirators operated by the pressure of anaesthetic gases will produce similar undesirable results, although on testing the Barnet respirator we did not find this to be so. Further investigation with a view to rectification of a potentially most hazardous situation is urgently required. In view of the previous reliability of the Bosun device, and the reliance which anaesthetists may have adopted towards it, we hope you will give this letter maximum publicity. Yours faithfully,
818
BRITISH JOURNAL OF ANAESTHESIA
Effects of Anesthetics on the Circulation. Edited by H. L. Price and P. J. Cohen. Published by Charles C. Thomas, Springfield, Illinois, U.S.A. Pp. 308; 13 tables; $10.50. This book contains the proceedings of a conference on the circulatory effects of anaesthetics sponsored by the National Research Council and the New York Academy of Medicine and held in Washington, D.C., during May, 1963. Although entitled "Effects of Anesthetics on the Circulation" the text covers a much wider field. A substantial section is devoted to papers concerned with the normal mechanisms controlling the circulation. These papers in addition to describing work
carried out by the authors provide reasonably comprehensive reviews of recent activity in the fields under discussion. As such they present a wealth of useful data not readily available elsewhere. Unfortunately not all the chapters are so informative; despite the title a mere 500 words is used to provide information on cardiac output during anaesthesia and the approach is so vague and so parochial as to be of little value. Of the ten references quoted no less than eight refer to work done by the participants. It is surprising, to say the least, to find no mention of the pioneer work on cardiac output during anaesthesia by Johnson in Sweden and Prime and Gray in England. A critical analysis of the methods available is the least the reader is entitled to expect in a chapter headed "Cardiac output during anaesthesia" especially when it is claimed on the outer jacket that such a critique is included. For the readers seeking information about the effects of anaesthetics on the circulation this book is a disappointment, and those interested in clinical effects will be well advised to seek their information elsewhere. Nevertheless it can be recommended as a valuable source of information about the physiological regulation of the circulation and indeed from this aspect is well worth close study. As is often the case with proceedings of a symposium this volume shows signs of hasty editing. At least three systems of reference have been used; the. lists themselves are sometimes headed "References" and sometimes "Bibliography" for no obvious reason, and at least one asterisked chapter heading has no explanatory footnote. The production itself is excellent. The print is easy to read on good paper which is well bound. The diagrams, illustrations and photographs are very well produced and for the most part easily understood.
Printed In Great Britain by Jota Sbtrratt & Son, Park Road. Altrincham
/. P. Payne
Downloaded from http://bja.oxfordjournals.org/ at Cornell University Library on July 26, 2015
ness, humanity and understanding, can do much to lessen the tension and fears of the patient before and after operation, yet the members of the symposium were agreed that, with modern anaesthetic techniques, the use of hypnosis to achieve anaesthesia is seldom or never necessary or desirable in surgical practice, and it is difficult to argue with this statement. Anaesthetists may not need hypnosis, but they need to know about it, and this little book should be read by all in clinical practice. One criticism must, however, be made. The following statement reveals a state of affairs which should not be tolerated in any medical service: "Dental patients were purposely made anxious by disturbing behaviour on the part of the dentist and his assistants. These anxious patients could not be anaesthetized by nitrous oxide without increasing the percentage so as to create anoxia". This is contrary to the great canon of medical practice, "The patient first, last and all the time", or, as the ancients more elegantly expressed it, primum non nocere. M. H. Armstrong Davison
DANIEL C. MOORE
Seattle INTERMITTENT POSITIVE PRESSURE VENTILATORS AND THE BOSUN OXYGEN WARNING DEVICE
i
Sir,—We would like to draw the attention of readers to a serious danger that exists when the Manley intermittent positive pressure ventilator is used in conjunction with the anaesthetic machine fitted with a Bosun oxygen warning device. Drs. Hurter and Williams (1964) of the Orpington Hospital. Kent, have already drawn attention to this, but we feel that not enough publicity has been given to so serious a matter.
J. FRASER-JONES A. VIVIAN JENKINS E. THOMAS
Birmingham REFERENCE
Hurter, D. G., and Williams, D. (1964). The Bosun Device. Lancet, 2, 480. Correspondence.
BOOK REVIEWS Hypnosis in Anaesthesiology. An International Symposium held at the First European Congress of of Anaesthesiology of the World Federation of Societies of Anaesthesiologists, Vienna, Austria, September 5, 1962. Edited by Jean Lassner. Published by Springer-Verlag, Berlin, 1964. Pp. 51.
i
To listen to polyglot symposia is seldom, save to those with special linguistic abilities, a very rewarding experience. However, we can be glad that this symposium was held,, and that, thanks to Dr. Lassner, such an excellent English edition of its proceedings has been made available. The 16 participants, representing 12 countries from both sides of the Iron Curtain (something to be welcomed in itself), are all men of high repute in their special fields of psychotherapeutics and anaesthesia, and their contributions in this booklet are worthy of their reputations. Too many of the previous publications on the subject of hypnosis have tended to perpetuate beliefs in the mystioue of mesmerism; it is most refreshing to find that all the contributors unite in disclaiming magic, explain their aims and methods in simple language.
817
and, although convinced of the value of hypnotic techniques, recognize the dangers which may beset the path of the too-enthusiastic. Since these dangers are real, it may be valuable to mention them here. The late Dr. Stokvis (Holland) points out that unfortunate results may occur with patients of hysterical personality or impending psychosis, while Dr. Raginsky (Canada) emphasizes that, since the personal relationship between patient and doctor is much deeper when hypnosis is used, any mishandling of the situation may cause serious difficulties. Proponents of hypnotism would do well to bear in mind the following remarks by Dr. Antitch (Yugoslavia), "It is a wellknown fact that it becomes progressively easier to induce hypnosis with each repetition. It may become possible to induce it by a signal, even without the hypnotized person's knowledge or against his will. In this way, the initial legitimate use may pave the way *o possible abuse. There is also the danger of choosing a signal for the induction of hypnosis which may be encountered fortuitously." While there can be no doubt that the intelligent use of psychotherapeutic methods, in other words, of kind-
Downloaded from http://bja.oxfordjournals.org/ at Cornell University Library on July 26, 2015
S
Sir,—Dr. Magora's letter (Brit. J. Anaesth., (1964), 36, 601) states: "Only a small amount (about 1 ml of the total amount) was injected into another site when the patient moved." In reviewing his original article, neither I nor my partner can find any reference to the injection of "about 1 ml of the total amount." If only a total of 1 ml of lignocaine had been injected, then Dr. Magora's point is well taken. But more than 1 ml was injected. I still believe this reaction describes an epidural injection. There is no real proof that the 1 ml caused the complication—it could have been the other 9 ml.
We also have discovered that the use of the Manley ventilator renders the oxygen warning whistle inoperative, presumably due to a build up of pressure from the respirator back to the rotameter head during the expiratory phase. It appears that 3 lb. pressure is required for the efficient working of the Bosun whistle, and as there is a back pressure of l i lb. from the Manley ventilator during the expiratory phase, this renders the Bosun inoperative. It may be that other intermittent positive pressure respirators operated by the pressure of anaesthetic gases will produce similar undesirable results, although on testing the Barnet respirator we did not find this to be so. Further investigation with a view to rectification of a potentially most hazardous situation is urgently required. In view of the previous reliability of the Bosun device, and the reliance which anaesthetists may have adopted towards it, we hope you will give this letter maximum publicity. Yours faithfully,
818
BRITISH JOURNAL OF ANAESTHESIA
Effects of Anesthetics on the Circulation. Edited by H. L. Price and P. J. Cohen. Published by Charles C. Thomas, Springfield, Illinois, U.S.A. Pp. 308; 13 tables; $10.50. This book contains the proceedings of a conference on the circulatory effects of anaesthetics sponsored by the National Research Council and the New York Academy of Medicine and held in Washington, D.C., during May, 1963. Although entitled "Effects of Anesthetics on the Circulation" the text covers a much wider field. A substantial section is devoted to papers concerned with the normal mechanisms controlling the circulation. These papers in addition to describing work
carried out by the authors provide reasonably comprehensive reviews of recent activity in the fields under discussion. As such they present a wealth of useful data not readily available elsewhere. Unfortunately not all the chapters are so informative; despite the title a mere 500 words is used to provide information on cardiac output during anaesthesia and the approach is so vague and so parochial as to be of little value. Of the ten references quoted no less than eight refer to work done by the participants. It is surprising, to say the least, to find no mention of the pioneer work on cardiac output during anaesthesia by Johnson in Sweden and Prime and Gray in England. A critical analysis of the methods available is the least the reader is entitled to expect in a chapter headed "Cardiac output during anaesthesia" especially when it is claimed on the outer jacket that such a critique is included. For the readers seeking information about the effects of anaesthetics on the circulation this book is a disappointment, and those interested in clinical effects will be well advised to seek their information elsewhere. Nevertheless it can be recommended as a valuable source of information about the physiological regulation of the circulation and indeed from this aspect is well worth close study. As is often the case with proceedings of a symposium this volume shows signs of hasty editing. At least three systems of reference have been used; the. lists themselves are sometimes headed "References" and sometimes "Bibliography" for no obvious reason, and at least one asterisked chapter heading has no explanatory footnote. The production itself is excellent. The print is easy to read on good paper which is well bound. The diagrams, illustrations and photographs are very well produced and for the most part easily understood.
Printed In Great Britain by Jota Sbtrratt & Son, Park Road. Altrincham
/. P. Payne
Downloaded from http://bja.oxfordjournals.org/ at Cornell University Library on July 26, 2015
ness, humanity and understanding, can do much to lessen the tension and fears of the patient before and after operation, yet the members of the symposium were agreed that, with modern anaesthetic techniques, the use of hypnosis to achieve anaesthesia is seldom or never necessary or desirable in surgical practice, and it is difficult to argue with this statement. Anaesthetists may not need hypnosis, but they need to know about it, and this little book should be read by all in clinical practice. One criticism must, however, be made. The following statement reveals a state of affairs which should not be tolerated in any medical service: "Dental patients were purposely made anxious by disturbing behaviour on the part of the dentist and his assistants. These anxious patients could not be anaesthetized by nitrous oxide without increasing the percentage so as to create anoxia". This is contrary to the great canon of medical practice, "The patient first, last and all the time", or, as the ancients more elegantly expressed it, primum non nocere. M. H. Armstrong Davison