James C. Eisenach, M.D., Editor.
By J. Schou. Lorrach, Alix Publishing Group, 1994. Pages: 104. Price: $18.00.
Idle moments are rare at an international medical meeting, especially one in Paris, France. The combination of a resolving coryza and a really nasty, rainy, cold spring day forced me to spend an extra hour or so in the scientific and technical exhibits rather than strolling the Tuileries gardens or the Champs Elysees. In the exhibit hall I found John Schou, a bearded giant of a man selling his own books. The challenge on the back cover was too much temptation for me, and I bought a copy to read on the return flight. He asks, "You call yourself an anaesthetist--do you really know what anaesthesia is?" If my answer is yes; he responds, "You know too much, read A Philosophical Approach to Anaesthesia and you will see how little you knew." If my answer is no and I don't care, he responds, "A difficult though widespread problem of how anaesthetists lost touch with anaesthesia." If I answer no but I am interested, he responds, "Finally a book for those who do not seek simple answers to complex questions. This book is for the stimulation of thought (but not attempting universal agreement) while opening up neglected topics of the anaesthetist's profession."
The book contains nine chapters and an epilogue in its 104 pages. It challenges our language and our science. Schou develops his iconoclastic philosophies in detail by showing that anaesthesia is not sleep (physiologic sleep); unconsciousness is not sleep. Anaesthesia has some similarities with sleep but shows important differences from natural sleep. He attempts to show that investigators (double-blind anesthetists) who believe only in therapies that have been proven in controlled clinical studies rarely will produce innovative progressive developments. Such individuals are able to follow the conventional track, blinded on one side by standards and guidelines and on the other side by the need to satisfy mathematical statistics (2 + 2 = 3.67+/-0.38, P < 0.05). The standard guidelines are of great comfort to the beginner in any medical specialty. Later, when the background has become clear and experience has been gathered, the standards inhibit the improvement of a practice that, in the meantime, has become too simplistic. Our patients, as much as they appear the same, vary in infinitely complex ways, and most standardized guidelines suffer from the lack of standardized patients. Schou develops this theme in greater detail with a fictional tale that places W. T. G. Morton and his discovery of anesthesia into the modern world. (What a way to celebrate the sesquicentennial of anesthesia!) Morton submits his manuscript to a journal. The editor rejects it but states that he will reconsider if the manuscript is extensively revised according to the recommendations of the reviewers. The revision is accepted for publication in an upcoming issue (1-2 yr later). Anticipating the delay, Morton submits an abstract to a scientific congress that has modified its program to present mostly refresher course lectures. His lecture is attended by six fellow lecturers, the two honorary chairpersons, and three others. Morton has established little, except to support his claim to be first. The intriguing paradox in the tale is that, in the era of high-speed telecommunications, news of an important discovery may take longer to reach the public that it did 150 yr ago when, from October 1846 to March 1847, the news had spread around the world and clinical "firsts" were reported from remote countries.
Schou describes the conceptual change from total cerebral depression produced by a single agent to the use of a variety of agents to achieve "balanced anaesthesia" and the pitfalls of the new concept. He then speculates on future theories of the mechanisms of anesthetic action on cerebral function and pronounces that we cannot come to grips with mechanisms because we have not properly disciplined our vocabulary. For example, the distinction between sedation and hypnosis is still hotly debated in the halls of organized anesthesiology. Schou offers a new definition of anesthesia that I do not find agreeable, thereby contributing to the problem rather than the solution. He invents a new word "dysthanasia," which means doing every high-priced procedure or test possible on a hopelessly ill, dying person in the intensive care unit.
Schou admits in the epilogue that his book "will be read by few and appreciated by yet fewer." He may be right, but I think that we must be constantly reminded that we do not know as much as we think we know and that much of what we know is wrong. I recommend the book for anyone who is willing to have his knowledge and actions challenged in a way that may open the door to a wider vision of our specialty of medicine.
A. H. Giesecke, M.D., Jenkins Professor of Anesthesiology, Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, Texas 75235-9068.