James C. Eisenach, M.D., Editor

Wylie and Churchill-Davidson's A PRACTICE OF ANAESTHESIA, 6th Ed. Edited by Thomas E.J. Healy and Peter J. Cohen. Edward Arnold, London, 1996. Pages: 1,536. Price: $187.50.

Although this attractive volume is said to be a 6th edition, it has little in common with its predecessors. By my count, only one author (and neither of the two senior editors) made a contribution to the 5th edition. In addition, whereas editions 1 - 5 were written almost exclusively by physicians in the United Kingdom, this edition has an editor and multiple contributors from the United States.

The individual chapters are generally well-written and informative contributions from acknowledged experts; however, the editors appear not to have guided the chapter authors to achieve consistent breadth and depth. An entire chapter focuses on theories of narcosis and general anesthetic action, whereas the molecular mechanisms of local anesthesia, now studied at the gene sequence level, consume less than a page. Central nervous system monitoring consumed 53 pages, whereas spinal and epidural anesthesia were covered in only 7 pages. Other topics are needlessly repeated in several chapters.

There are other editing peculiarities. The chapter on autologous blood transfusion precedes the one on hemorrhage, blood volume, and oxygen transport. The chapter on cardiovascular pharmacology precedes rather than follows the chapter on cardiovascular physiology and pathophysiology.

The cardiovascular pharmacology chapter includes a figure depicting hemodynamic effects of catecholamines that does not include epinephrine! Milrinone is said to cause more vasodilation than amrinone; no reference is supplied, and a telephone call to the manufacturer confirms that they are unaware of a published study comparing the two agents in patients. Treatment for postcardiac surgical hypertension is described, treatment for the more vexing postcardiac surgical low-output syndrome is not. A fine chapter on cardiac physiology seems oriented to cardiologists rather than to physicians caring for critically ill surgical patients, because there is no mention of left ventricular failure occurring in association with cardiopulmonary bypass or sepsis, whereas ischemia, aging, valvular heart disease, and multiple types of cardiomyopathy are described.

There is an entire chapter on calcium and magnesium in anesthesia, yet little discussion of sodium or potassium in any chapter. The chapters on metabolism and nutrition make no mention of recent controversies regarding enteral versus parenteral nutrition in maintaining normal gut barriers to infection. The chapter on hemostasis and thrombosis recommends transfusion of platelets and fresh frozen plasma after ten units of blood, in disagreement with recent consensus development conferences in the United States.

In the several paragraphs on local anesthetic allergy, the fact that both positive intradermal reactions and true anaphylaxis probably occur more commonly with esters (particularly those metabolized to p-aminobenzoate) than amides is not mentioned. The chapter on inherited diseases and anesthesia lists procaine, chlorpromazine, and pancuronium with echothiophate and organophosphate insecticides as agents that can reduce cholinesterase activity iatrogenically. Surely, the first three agents are much less likely to result in misdiagnosis of cholinesterase deficiency than the latter two, as is pointed out in the chapter on neuromuscular transmission. In addition, contrary to the statement in the text, ester local anesthetics continue to be widely used (at least in the United States), particularly benzocaine, tetracaine (amethocaine), and 2-chloroprocaine. It also seems odd that there is no mention of the frequency with which the various cholinesterase alleles might be encountered in clinical practice.

The chapters on anesthetic management are good, but, again, include needless repetition, particularly when separate chapters cover pediatric and adult patients undergoing similar procedures.

In summary, Healy and Cohen produced an entirely new "Wylie and Churchill-Davidson" with only a superficial resemblance to prior editions. Although the individual chapters are generally well written and cover a contemporary list of topics, careful editing could have produced a more concise and useful work.

John, Butterworth, M.D.; Associate Professor and Vice Chairman for Research, Department of Anesthesia, Bowman Gray School of Medicine, Winston-Salem, North Carolina 27157-1009