Full Chapter Handbook of Clinical Anesthesia Seventh Edition Barash Paul G Cullen MD Bruce F Stoelting MD Robert K Cahalan MD Michael K Stock MD M Christine Ortega MD Rafael PDF

Handbook of Clinical Anesthesia
Seventh Edition Barash Paul G Cullen

Md Bruce F Stoelting Md Robert K
Cahalan Md Michael K Stock Md M
Christine Ortega Md Rafael
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SEVENTH EDITION
HAND B O O K O F
Clinical
Anesthesia
LWBK1191-FM-i-xiv.indd 1 1/11/13 9:05 PM

SEVENTH EDITION
HAND B O O K O F
Clinical
Anesthesia
Paul G. Barash, md Michael K. Cahalan, md
Professor Professor and Chair
Department of Anesthesiology Department of Anesthesiology
School of Medicine School of Medicine
Yale University School of Medicine The University of Utah
Attending Anesthesiologist Salt Lake City, Utah
Yale-New Haven Hospital
New Haven, Connecticut M. Christine Stock, md
Professor and Chair
Bruce F. Cullen, md Department of Anesthesiology
Emeritus Professor Feinberg School of Medicine
Department of Anesthesiology Northwestern University
School of Medicine Chicago, Illinois
University of Washington
Seattle, Washington Rafael Ortega, md
Professor
Robert K. Stoelting, md Vice-Chairman of Academic Affairs
Emeritus Professor and Past Chair Department of Anesthesiology
Department of Anesthesia School of Medicine
School of Medicine Boston University
Indiana University Boston, Massachusetts
Indianapolis, Indiana

Acquisitions Editor: Brian Brown
Managing Editor: Nicole Dernoski
Marketing Manager: Lisa Lawrence
Production Editor: Priscilla Crater
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Design Coordinator: Stephen Druding
Compositor: Aptara, Inc.
7th Edition
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.

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Copyright © 2009 by Wolters Kluwer Health/Lippincott Williams & Wilkins, 2006, 2001 by
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1993, 1991 by J.B. Lippincott Company.
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Printed in China
Library of Congress Cataloging-in-Publication Data
Handbook of clinical anesthesia / [edited by] Paul G. Barash . . . [et al.]. — 7th ed.
p. ; cm.
Includes bibliographical references and index.
Summary: “The Handbook of Clinical Anesthesia, Seventh Edition, is a companion to the parent
textbook, Clinical Anesthesia, Seventh Edition. This widely acclaimed reference parallels the
textbook and presents content in a concise outline format with additional appendices. The
Handbook makes liberal use of tables, graphics, and clinical pearls, to enhance rapid access of
the subject matter. This comprehensive, pocket-sized reference guides you through virtually every
aspect of perioperative, intraoperative, and postoperative patient care.”—Provided by publisher.
ISBN 978-1-4511-7615-5 (alk. paper)
I. Barash, Paul G. II. Clinical Anesthesia.
[DNLM: 1. Anesthesia—Handbooks. 2. Anesthetics—Handbooks. WO 231]
617.996–dc23 2012051809
Care has been taken to confirm the accuracy of the information presented and to describe
generally accepted practices. However, the authors, editors, and publisher are not responsible for
errors or omissions or for any consequences from application of the information in this book and
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remains the professional responsibility of the practitioner; the clinical treatments described and
recommended may not be considered absolute and universal recommendations.
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and dosage set forth in this text are in accordance with the current recommendations and prac-
tice at the time of publication. However, in view of ongoing research, changes in government
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Some drugs and medical devices presented in this publication have Food and Drug
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bility of the health care provider to ascertain the FDA status of each drug or device planned for
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LWW.COM

For All Students of Anesthesiology

CONTRIBUTING AUTHORS
The authors would like to gratefully acknowledge the efforts of the con-
tributors to the seventh edition of the textbook Clinical Anesthesia.
Saint Adeogba, MD Jan Ehrenwerth, MD

Shamsuddin Akhtar, MD John H. Eichhorn, MD
Michael L. Ault, MD, FCCP, James B. Eisenkraft, MD
FCCM Matthew R. Eng, MD
Douglas R. Bacon, MD Alex S. Evers, MD
Gina C. Badescu, MD Ana Fernandez-Bustamante,
Dalia Banks, MD, FASE MD, PhD
Honorio T. Benzon, MD* Lynne R. Ferrari, MD
Christopher M. Bernards Scott M. Fishman, MD
Marcelle E. Blessing, MD Lee A. Fleisher, MD
Michelle Y. Braunfeld, MD Michael A. Fowler, MD, MBA
Ferne R. Braveman, MD Kevin Friede, BA
Brenda Bucklin, MD J. Sean Funston, MD
Asokumar Buvanendran, MD Tong J. Gan, MD
Levon M. Capan, MD Steven Gayer, MD, MBA
Louanne M. Carabini, MD Kevin J. Gingrich, MD
C. Richard Chapman, PhD Kathryn E. Glas, MD, MBA
Amalia Cochran, MD Loreta Grecu, MD
Edmond Cohen, MD Jay S. Grider, DO, PhD
Christopher W. Connor, MD, Dhanesh K. Gupta, MD
PhD Steven C. Hall, MD
C. Michael Crowder Matthew R. Hallman, MD
Marie Csete, MD, PhD Tara Hata, MD
Anthony Cunningham, MD J. Steven Hata, MD
Armagan Dagal, MD, FRCA Laurence M. Hausman, MD
Albert Dahan, MD Jeana E. Havidich, MD
Steven Deem, MD Thomas K. Henthorn, MD
Timothy R. Deer, MD Simon C. Hillier, MB, ChB
Stephen F. Dierdorf, MD Robert S. Holzman, MD
Karen B. Domino, MD, MPH Harriet W. Hopf, MD
François Donati, MD, PhD Terese T. Horlocker, MD
Michael B. Dorrough, MD Lucy S. Hostetter, MD
Randall O. Dull, MD, PhD Robert W. Hurley, MD, PhD
Thomas J. Ebert, MD, PhD Michael P. Hutchens, MD, MA
vii

viii Contributing Authors
Adam K. Jacob, MD Glenn Ramsey, MD

Girish P. Joshi, MBBS, MD, Kevin T. Riutort, MD, MS
FFARCSI G. Alec Rooke, MD, PhD
John P. Kampine, MD, PhD Stanley H. Rosenbaum, MA, MD
Jonathan D. Katz, MD Meg A. Rosenblatt, MD
Sandra L. Kopp, MD William H. Rosenblatt, MD
Catherine Kuhn, MD Richard W. Rosenquist, MD
Arthur M. Lam, MD, FRCPC Aaron Sandler, MD, PhD
Jerrold Lerman, MD, FRCPC, Barbara M. Scavone, MD
FANZCA Katie Schenning, MD, MPH
Jerrold H. Levy, MD, FAHA, Jeffrey J. Schwartz, MD
FCCM Harry A. Seifert, MD, MSCE
Adam D. Lichtman, MD Aarti Sharma, MD
J. Lance Lichtor, MD Andrew Shaw, MB, FRCA, FCCM
Yi Lin, MD, PhD Benjamin Sherman, MD
Larry Lindenbaum, MD Nikolaos J. Skubas, MD, FASE
Spencer S. Liu, MD Todd J. Smaka, MD
David A. Lubarsky, MD, MBA Hugh M. Smith, MD
Stephen M. Macres, PharmD, MD Terry Smith, PhD
Gerard Manecke, MD Karen J. Souter, MB, BS, FRCA
Joseph P. Mathew, MD Bruce D. Spiess, MD, FAHA
Michael S. Mazurek, MD Mark Stafford-Smith, MD, CM,
Kathryn E. McGoldrick, MD FRCP (C), FASE
Sanford M. Miller, MD Andrew F. Stasic, MD
Timothy E. Miller, MB, ChB, Randolph H. Steadman, MD
FRCA David F. Stowe, MD, PhD
Peter G. Moore, MD, PhD Wariya Sukhupragarn, MD
Michael J. Murray, MD, PhD, Santhanam Suresh, MD
FCCM, FCCP Christer H. Svensen, MD, PhD,
Charles D. Nargozian, MD DEAA, MBA
Steven M. Neustein, MD Paul C. Tamul, DO
Marieke Niesters, MD Stephen J. Thomas, MD
Erik Olofsen, MSc Merriam Treggiari, MD
Charles W. Otto, MD, FCCM Ban C.H. Tsui, MSc, MD,
Frank Overdyk, MD, FCCM FRCP(C)
Nathan Leon Pace, MD, Mstat J. Scott Walton, MD
Paul S. Pagel, MD, PhD Mary E. Warner, MD
Ben Julian Palanca, MD, PhD Denise J. Wedel, MD
Albert C. Perrino, Jr., MD Paul F. White, MD, PhD,
Andrew J. Pittaway, FRCA FANZCA
Mihai V. Podgoreanu, MD Scott W. Wolf, MD
Wanda M. Popescu, MD Cynthia A. Wong, MD
Karen L. Posner, PhD James R. Zaidan, MD, MBA
Donald S. Prough, MD

PREFACE
Welcome to the 7th Edition of the Handbook of Clinical Anesthesia. The

Handbook fulfills the requests of health care providers to have the
essential information contained in the parent textbook, Clinical
Anesthesia in a more ‘portable format’. Even with the advent of per-
sonal computers, smart phones and tablets, the Handbook continues
to have a vital role.
Dr. Robert Stoelting has shepherded the Handbook from its incep-
tion in 1991 to this, his final edition. Each of the Editors personally
thanks him for the time and effort and more importantly serving as our
role model.
This edition of the Handbook contains a new chapter on
Laparoscopic and Robotic Surgery. In addition, the Appendices on
Electrocardiography and Pacemakers/Implantable Defibrillators are
presented in a new graphic interface to improve reader comprehension
of these important subjects. Further, approximately twenty percent of
the Chapters are written by new contributors to the parent textbook.
We would like to acknowledge the contributors to the textbook
Clinical Anesthesia. Although the Handbook of Clinical Anesthesia is the
product of the editors, its chapters were developed from the expert
knowledge of the original contributors, reorganized and rewritten in a
style necessary for a text of this scope. We also thank our administrative
assistants—Gail Norup, Ruby Wilson, Deanna Walker, and Mary
Wynn. We would like to thank our editors at Lippincott Williams &
Wilkins-Wolters Kluwer, Brian Brown and Lisa McAllister, for their
commitment to excellence. Finally, we owe a debt of gratitude to Nicole
Dernoski—Managing Editor at LWW, Chris Miller—Production
Manager at Aptara, Lisa Lawrence—Marketing Manager at LWW
whose day-to-day management of this endeavor resulted in a publica-
tion that exceeded the Editor’s expectations.
Paul G. Barash MD
Bruce F. Cullen MD
Robert K. Stoelting MD
Michael K. Cahalan MD
M. Christine Stock MD
Rafael Ortega, MD
ix
LWBK1191-FM-i-xiv copy.indd 9 1/12/13 2:39 PM

CONTENTS
Contributing Authors vii

Preface ix
SECTION I Introduction to
Anesthesiology
1 The History of Anesthesia 1

2 Scope of Practice 7
3 Occupational Health 15
4 Anesthetic Risk, Quality Improvement, and Liability 29
SECTION II S cientific Foundations

of Anesthesia
5 Mechanisms of Anesthesia and Consciousness 39

6 Genomic Basis of Perioperative Medicine 50
7 Basic Principles of Clinical Pharmacology 65
8 Electrical and Fire Safety 80
9 Experimental Design and Statistics 94
SECTION III Anatomy and Physiology
10 Cardiac Anatomy and Physiology 99

11 Respiratory Function in Anesthesia 112
12 The Allergic Response 129
13 Inflammation, Wound Healing, and Infection 139
14 Fluids, Electrolytes, and Acid–Base Physiology 154
15 Autonomic Nervous System: Physiology and Pharmacology 179
16 Hemostasis and Transfusion Medicine 204
xi

xii Contents
SECTION IV nesthetic Agents, Adjuvants,

A
and Drug Interaction
17 Inhaled Anesthetics 227
18 Intravenous Anesthetics 252

19 Opioids 271
20 Neuromuscular Blocking Agents 290
21 Local Anesthetics 310
SECTION V reanesthetic Evaluation and

P
Preparation
22 Preoperative Patient Assessment and Management 325

23 Rare Coexisting Diseases 347
24 The Anesthesia Workstation and Delivery Systems for Inhaled
Anesthetics 370
SECTION VI Anesthetic Management
25 Commonly Used Monitoring Techniques 387

26 Echocardiography 405
27 Airway Management 417
28 Patient Positioning and Potential Injuries 434
29 Monitored Anesthesia Care 441
30 Ambulatory Anesthesia 456
31 Office-Based Anesthesia 469
32 Nonoperating Room Anesthesia (NORA) 482
33 Anesthesia for the Older Patient 496
34 Epidural and Spinal Anesthesia 508

Contents xiii
SECTION VII nesthesia for Surgical

A
Subspecialties
35 Peripheral Nerve Blockade 535

36 Anesthesia for Neurosurgery 553
37 Anesthesia for Thoracic Surgery 580
38 Anesthesia for Cardiac Surgery 597
39 Anesthesia for Vascular Surgery 621
40 Obstetrical Anesthesia 637
41 Neonatal Anesthesia 658
42 Pediatric Anesthesia 674
43 Anesthesia for Laparoscopic and Robotic
Surgeries 696
44 Anesthesia and Obesity 711
45 The Liver: Surgery and Anesthesia 730
46 Endocrine Function 749
47 Anesthesia for Otolaryngologic Surgery 770
48 Anesthesia for Ophthalmologic Surgery 780
49 The Renal System and Anesthesia for Urologic
Surgery 792
50 Anesthesia for Orthopedic Surgery 823
51 Transplant Anesthesia 842
52 Trauma and Burns 858
53 Emergency Preparedness for and Disaster Management of
Casualties from Natural Disasters and Chemical, Biologic,
Radiologic, Nuclear, and High-Yield Explosive (Cbrne)
Events 890

xiv Contents
SECTION VIII erioperative and

P
Consultative Services
54 Postanesthesia Recovery 903

55 Critical Care Medicine 918
56 Acute Pain Management 942
57 Chronic Pain Management 964
58 Cardiopulmonary Resuscitation 982
APPENDICES
A Formulas 1003
B Atlas of Electrocardiography 1009
C Pacemaker and Implantable Cardiac Defibrillator
Protocols 1041
D American Heart Association (AHA) Resuscitation
Protocols 1057
E American Society of Anesthesiologists Standards,
Guidelines, and Statements 1078
F The Airway Approach Algorithm and Difficult Airway
Algorithm 1095
G Malignant Hyperthermia Protocol 1097
H Herbal Medications 1100
Index 1109

Introduction to
Anesthesiology I
S E C T I O N
C H A P T E R
1
The History of Anesthesia
Although most human civilizations evolved some method for dimin-

ishing patient discomfort, anesthesia, in its modern and effective
meaning, is a comparatively recent discovery with traceable origins
dating back 160 years. (An epitaph on a monument to William T. G.
Morton, one of the founders of anesthesia, reads: “Before whom in all
time Surgery was Agony.”) (Jacob AK, Kopp SL, Bacon DR, Smith
HM. The history of anesthesia. In: Barash PG, Cullen BF, Stoelting RK,
Cahalan MK, Ortega R, Stock MC, eds. Clinical Anesthesia.
Philadelphia: Lippincott Williams & Wilkins; 2013: 1–27.)
I. ANESTHESIA BEFORE ETHER. In addition to limitations

in technical knowledge, cultural attitudes toward pain are often
cited as reasons humans endured centuries of surgery without
effective anesthesia.
A. Early Analgesics and Soporifics (Table 1-1)

B. Almost Discovery: Clarke, Long, and Wells
1. In January 1842, William E. Clarke, a medical student, may
have given the first ether anesthetic in Rochester, NY, for a
dental extraction.
2. Crawford Williamson Long administered ether for surgical
anesthesia to James M. Venable on March 30, 1842, in
Jefferson, GA, for the removal of a tumor on his neck.
Long did not report his success until 1849 when ether
anesthesia was already well known.
3. Horace Wells observed the “analgesic effects” of nitrous
oxide when he attended a lecture exhibition by an itinerant
“scientist,” Gardner Quincy Colton. A few weeks later, in
January 1845, Wells attempted a public demonstration in
Boston at the Harvard Medical School, but the experience
was judged a failure.
1
LWBK1191_C01_p01-06.indd 1 1/4/13 9:01 PM

2 Introduction to Anesthesiology
T a b l e 1 - 1 Early Analgesics and Soporifics
Mandragora (soporific sponge)

Alcohol
Diethyl ether (known in the 16th century and perhaps as early as the
8th century)
Nitrous oxide (prepared by Joseph Priestly in 1773)
C. Public Demonstration of Ether Anesthesia. William Thomas

Morton Green was responsible for the first successful public
demonstration of ether anesthesia. This demonstration, which
took place in the Bullfinch Amphitheater of the Massachusetts
General Hospital on October 16, 1846, is memorialized by the
surgeon’s statement to his audience at the end of the procedure:
“Gentlemen, this is no humbug.”
D. Chloroform and Obstetrics
1. James Young Simpson, a successful obstetrician of
Edinburgh, Scotland, was among the first to use ether for
the pain relief in obstetrics. He became dissatisfied with
ether and encouraged the use of chloroform.
2. Queen Victoria’s endorsement of obstetric anesthesia
resulted in acceptance of the use of anesthesia in labor.
3. John Snow took an interest in anesthetic practice soon after
the news of ether anesthesia reached England in December
1846. Snow developed a mask that closely resembles a
modern facemask and introduced a chloroform inhaler.
II. ANESTHESIA PRINCIPLES, EQUIPMENT, AND

STANDARDS
A. Control of the Airway
1. Definitive control of the airway, a skill anesthesiologists
now consider paramount, developed only after many
harrowing and apneic episodes spurred the development
of safer airway management techniques.
2. Joseph Clover, an Englishman, was the first person to
recommend the now universal practice of thrusting the
patient’s jaw forward to overcome obstruction of the upper
airway by the tongue.
B. Tracheal Intubation
1. The development of techniques and instruments for intu-
bation ranks among the major advances in the history of
anesthesiology.
LWBK1191_C01_p01-06.indd 2 1/4/13 9:01 PM

The History of Anesthesia 3
2. An American surgeon, Joseph O’Dwyer, designed a series
Introduction to Anesthesiology
of metal laryngeal tubes, which he inserted blindly between
the vocal cords of children having diphtheritic crises.
3. In 1895 in Berlin, Alfred Kirstein devised the first direct-
vision laryngoscope.
4. Before the introduction of muscle relaxants in the 1940s,
intubation of the trachea could be challenging. This chal-
lenge was made somewhat easier, however, with the advent
of laryngoscope blades specifically designed to increase
visualization of the vocal cords.
5. In 1926, Arthur Guedel began a series of experiments that
led to the introduction of the cuffed tube.
6. In 1953, single-lumen tubes were supplanted by double-
lumen endobronchial tubes.
C. Advanced Airway Devices. Conventional laryngoscopes
proved inadequate for patients with difficult airways. Dr. A. I. J.
“Archie” Brain first recognized the principle of the laryngeal
mask airway in 1981.
D. Early Anesthesia Delivery Systems. John Snow created ether
inhalers, and Joseph Clover was the first to administer chloro-
form in known concentrations through the “Clover bag.”
Critical to increasing patient safety was the development of a
machine capable of delivering calibrated amounts of gas and
volatile anesthetics (also carbon dioxide absorption, vaporiz-
ers, and ventilators).
E. Two American surgeons, George W. Crile and Harvey
Cushing, advocated systemic blood pressure monitoring dur-
ing anesthesia. In 1902, Cushing applied the Riva Rocci cuff
for blood pressure measurements to be recorded on an anes-
thesia record.
1. The widespread use of electrocardiography, pulse oximetry,
blood gas analysis, capnography, and neuromuscular
blockade monitoring have reduced patient morbidity and
mortality and revolutionized anesthesia practice.
2. Breath-to-breath continuous monitoring and waveform
display of carbon dioxide (infrared absorption) concentra-
tions in the respired gases confirms endotracheal intuba-
tion (rules out accidental esophageal intubation).
F. Safety Standards. The introduction of safety features was
coordinated by the American National Standards Institute
Committee Z79, which was sponsored from 1956 until 1983
by the American Society of Anesthesiologists. Since 1983,
representatives from industry, government, and health care
professions have met as the Committee Z79 of the American
Society for Testing and Materials. This organization establishes
LWBK1191_C01_p01-06.indd 3 1/4/13 9:01 PM

voluntary goals that may become accepted national standards

for the safety of anesthesia equipment.
III. THE HISTORY OF ANESTHETIC AGENTS

AND ADJUVANTS
A. Inhaled Anesthetics. Fluorinated hydrocarbons revolution-
ized inhalation anesthesia (halothane in 1956, methoxyflurane
in 1960, enflurane and isoflurane in the 1970s, desflurane in
1992, and sevoflurane in 1994).
B. Intravenous Anesthetics. Thiopental was first administered
to a patient at the University of Wisconsin in March 1934
followed by ketamine (1960s), etomidate, and most recently
propofol.
C. Local Anesthetics. Amino esters (procaine in 1905, tetracaine)
were commonly used for local infiltration and spinal anesthe-
sia despite their low potency and high likelihood to cause aller-
gic reactions. Lidocaine, an amino amide local anesthetic, was
developed in 1944 and gained immediate popularity because
of its potency, rapid onset, decreased incidence of allergic
reactions, and overall effectiveness for all types of regional
anesthetic blocks. Since the introduction of lidocaine, all local
anesthetics developed and marketed (mepivacaine, bupiva-
caine, ropivacaine, levobupivacaine) have been of the amino
amide variety.
D. Opioids are used routinely in the perioperative period, in the
management of acute pain, and in a variety of terminal and
chronic pain states. Meperidine, the first synthetic opioid, was
developed in 1939 followed by fentanyl in 1960 and sufentanil,
alfentanil, and remifentanil. Ketorolac, a nonsteroidal antiin-
flammatory drug (NSAID) approved for use in 1990, was the
first parenteral NSAID indicated for postoperative pain.
E. Muscle relaxants entered anesthesia practice nearly a century
after inhalational anesthetics. Curare, the first known neuro-
muscular blocking agent, was originally used in hunting and
tribal warfare by native peoples of South America. Clinical
application had to await the introduction of tracheal intuba-
tion and controlled ventilation of the lungs. On January 23,
1942, Griffith and his resident, Enid Johnson, anesthetized
and intubated the trachea of a young man before injecting
curare early in the course of an appendectomy. Satisfactory
abdominal relaxation was obtained, and the surgery proceeded
without incident. Griffith and Johnson’s report of the success-
ful use of curare in a series consisting of 25 patients launched a
revolution in anesthetic care. Succinylcholine was prepared by
LWBK1191_C01_p01-06.indd 4 1/4/13 9:01 PM

The History of Anesthesia 5
the Nobel laureate Daniel Bovet in 1949 and was in wide inter-
national use before historians noted that the drug had been
synthesized and tested in the early 1900s. Recognition that
atracurium and cis-atracurium undergo spontaneous degrada-
tion by Hoffmann elimination has defined a role for these
muscle relaxants in patients with liver and renal insufficiency.
F. Antiemetics. Effective treatment of patients with postoperative
nausea and vomiting (PONV) evolved relatively recently and
has been driven by incentives to limit hospitalization expenses
and improve patient satisfaction. The antiemetic effects of
corticosteroids were first recognized by oncologists treating
patients with intracranial edema from tumors. Recognition of
the role of the serotonin 5-HT3 pathway in PONV has led to a
unique class of drugs (including ondansetron in 1991) devoted
only to addressing this particular problem.
IV. ANESTHESIA SUBSPECIALTIES

A. Regional Anesthesia. The term “spinal anesthesia” was coined
in 1885 by a neurologist, Leonard Corning, although it is likely
that he actually performed an epidural injection. In 1944,
Edward Tuohy of the Mayo Clinic introduced the Tuohy
needle to facilitate the use of continuous spinal techniques.
In 1949, Martinez Curbelo of Havana, Cuba, used Tuohy’s
needle and a ureteral catheter to perform the first continuous
epidural anesthetic. John J. Bonica’s many contributions to
anesthesiology during his periods of military, civilian, and
academic service at the University of Washington included
development of a multidisciplinary pain clinic and publication
of the text The Management of Pain.
B. Cardiovascular Anesthesia. Many believe that the successful
ligation of a 7-year-old girl’s patent ductus arteriosus by
Robert Gross in 1938 served as the landmark case for modern
cardiac surgery. The first successful use of Gibbon’s cardiopul-
monary bypass machine in humans in May 1953 was a monu-
mental advance in the surgical treatment of complex cardiac
pathology. In 1967, J. Earl Waynards published one of the first
articles on anesthetic management of patients undergoing
surgery for coronary artery disease. Postoperative mechanical
ventilation and surgical intensive care units appeared by the
late 1960s. Transesophageal echocardiography helped to fur-
ther define the subspecialty of cardiac anesthesia.
C. Neuroanesthesia. Although the introduction of agents such as
thiopental, curare, and halothane advanced the practice of anes-
thesiology in general, the development of methods to measure
LWBK1191_C01_p01-06.indd 5 1/4/13 9:01 PM

brain electrical activity, cerebral blood flow, and metabolic rate

put neuroanesthesia practice on a scientific foundation.
D. Obstetric Anesthesia. Social attitudes about pain associated
with childbirth began to change in the 1860s, and women
started demanding anesthesia for childbirth. Virginia Apgar’s
system for evaluating newborns, developed in 1953, demon-
strated that there was a difference in the neonates of mothers
who had been anesthetized. In the past decade, anesthesia-
related deaths during cesarean sections under general anesthe-
sia have become more likely than neuraxial anesthesia-related
deaths, making regional anesthesia the method of choice.
With the availability of safe and effective options for pain
relief during labor and delivery, today’s focus is improving the
quality of the birth experience for expectant parents.
V. PROFESSIONALISM AND ANESTHESIA PRACTICE

A. Organized Anesthesiology. The first American medical anes-
thesia organization, the Long Island Society of Anesthetists,
was founded by nine physicians on October 6, 1905. Members
had annual dues of $1.00. One of the most noteworthy figures
in the struggle to professionalize anesthesiology was Francis
Hoffer McMechan. He became the editor of the first journal
devoted to anesthesia, Current Researches in Anesthesia and
Analgesia, the precursor of Anesthesia and Analgesia, the oldest
journal of the specialty. Ralph Waters and John Lundy, among
others, participated in evolving organized anesthesia.
B. Academic Anesthesia. In 1927, Erwin Schmidt, a professor of
surgery at the University of Wisconsin’s medical school,
encouraged Dean Charles Bardeen to recruit Dr. Ralph Waters
for the first American academic position in anesthesia.
C. Establishing a Society. The New York Society of Anesthetists
changed its name to the American Society of Anesthetists in
1936. Combined with the American Society of Regional
Anesthesia, the American Board of Anesthesiology was orga-
nized as a subordinate board to the American Board of
Surgery in 1938, and independence was granted in 1940. Ralph
Waters was declared the first president of the newly named
American Society of Anesthesiologists in 1945.
LWBK1191_C01_p01-06.indd 6 1/4/13 9:01 PM

C H A P T E R
21
Scope of Practice
Medical practice, including its infrastructure and functional details, is

changing and evolving rapidly in the United States (Eichhorn JH,
Grider JS. Scope of practice. In: Barash PG, Cullen BF, Stoelting RK,
Cahalan MK, Ortega R, Stock MC, eds. Clinical Anesthesia. Philadelphia:
Lippincott Williams & Wilkins; 2013: 28–60). Traditionally, anesthesia
professionals were minimally involved in the management of the many
components of their practice beyond the strictly medical elements.
I. ADMINISTRATIVE COMPONENTS OF ALL

ANESTHESIOLOGY PRACTICES
A. Operational and Information Resources
1. The American Society of Anesthesiologists (ASA) provides
extensive resource materials to its members regarding prac-
tice management (www.asahq.org) (Table 2-1).
2. These documents are updated regularly by the ASA through
its committees and House of Delegates.
3. The Web site for the Anesthesia Patient Safety Foundation
(www.apsf.org) is useful in promoting safe clinical practice.
B. The Credentialing Process and Clinical Privileges
1. The system of credentialing a health care professional and
granting clinical privileges is motivated by the assumption
that appropriate education, training, and experience, along
with an absence of an excessive number of adverse patient
outcomes, increase the likelihood that the health care pro-
fessional will deliver high-quality care.
2. Models for credentialing anesthesiologists are offered by
the ASA.
3. An important issue in granting clinical privileges, especially
in procedure-oriented specialties such as anesthesiology, is
whether it is reasonable to grant “blanket” privileges (i.e.,
the right to do everything traditionally associated with the
specialty).
C. Maintenance of Certification in Anesthesiology
1. Anesthesiologists certified as diplomats by the American
Board of Anesthesiology after January 1, 2000, are issued
a “time-limited” board certification valid for 10 years. A
formal process culminating in the recertification of an
7
LWBK1191_C02_p07-14.indd 7 1/4/13 8:57 PM

T a b l e 2 - 1 Practice Management Materials Provided

by the American Society of
Anesthesiologists
The Organization of an Anesthesia Department

Guidelines for Delineation of Clinical Privileges in Anesthesiology
Guidelines for a Minimally Acceptable Program of Any Continuing
Education Requirement
Guidelines for the Ethical Practice of Anesthesiology
Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-
Resuscitate Orders or Other Directives that Limit Treatment
Guidelines for Patient Care in Anesthesiology
Guidelines for Expert Witness Qualifications and Testimony
Guidelines for Delegation of Technical Anesthesia Functions for
Nonphysician Personnel
The Anesthesia Care Team
Statement on Conflict of Interest
Statement on Economic Credentialing
Statement on Member’s Right to Practice
Statement on Routine Preoperative Laboratory and Diagnostic
Screening
anesthesiologist for an additional and then subsequent

10-year intervals is designated Maintenance of Certification
in Anesthesiology (MOCA).
2. The MOCA program introduced in 2000 is subdivided into
four components or modules that include professional stand-
ing, lifelong learning and self-assessment, cognitive examina-
tion, and practice performance assessment and improvement.
D. Professional Staff Participation and Relationships
1. Medical staff activities are increasingly important in
achieving a favorable accreditation status from The Joint
Commission (JC).
2. Anesthesiologists should be active participants in medical
staff activities (Table 2-2).
E. Establishing Standards of Practice and Understanding the
Standard of Care
1. American anesthesiology is one of the leaders in establishing
practice standards that are intended to maximize the quality
of patient care and help guide anesthesiologists make diffi-
cult decisions, including those about the risk–benefit and
cost–benefit aspects of specific practices (Table 2-3).
2. The standard of care is the conduct and skill of a prudent
practitioner that can be expected at all times by a reason-
able patient.
LWBK1191_C02_p07-14.indd 8 1/4/13 8:57 PM

Scope of Practice 9
T a b l e 2 - 2 Examples of Anesthesiologists as
Participants in Medical Staff Activities
Credentialing
Peer review
Transfusion review
Operating room management
Medical direction of same-day surgery units
Medical direction of postanesthesia care units
Medical direction of intensive care units
Medical direction of pain management services and clinics
T a b l e 2 - 3 Materials Provided By the American

Society of Anesthesiologists Designed
To Establish Practice Standards
Standards (Minimum Requirements for Sound Practice)

Basic Standards for Preanesthesia Care
Standards of Basic Anesthetic Monitoring
Standards for Postanesthesia Care
Guidelines (Recommendations for Patient Management)
Guidelines for Ambulatory Surgical Facilities
Guidelines for Critical Care in Anesthesiology
Guidelines for Nonoperating Room Anesthetizing Locations
Guidelines for Regional Anesthesia in Obstetrics
Practice Guidelines
Practice Guidelines for Acute Pain Management in the Perioperative
Setting
Practice Guidelines for Management of the Difficult Airway
Practice Guidelines for Pulmonary Artery Catheterization
Practice Guidelines for Difficult Airway
Practice Parameters
Pain Management
Transesophageal Echocardiography
Sedation by Nonanesthesia Personnel
Preoperative Fasting
Avoidance of Peripheral Neuropathies
Fast-Track Management of Coronary Artery Bypass Graft Patients
LWBK1191_C02_p07-14.indd 9 1/4/13 8:57 PM

a. Failure to meet the standard of care is considered mal-

practice.
b. Courts have traditionally relied on medical experts to
give opinions regarding what the standard of care is and
whether it has been met in an individual case.
3. Leading the Way. Anesthesiologists have been very active
in publishing standards of care (see Table 2-3).
4. Practice Guidelines. A practice guideline has some of the
same elements as a standard of practice but is intended
more to guide judgment, largely through algorithms.
a. Practice guidelines serve as potential vehicles for helping
to eliminate unnecessary procedures and to limit costs.
b. Guidelines do not define the standard of care, although
adherence to the outlined principles should provide
anesthesiologists with a reasonably defensible position.
5. JC standards focus on credentialing and privileges, verifi-
cation that anesthesia services are of uniform quality, con-
tinuing education, and documentation of preoperative and
postoperative evaluations.
6. Review Implications. Another type of regulatory agency is
the peer review organization, whose objectives include issues
related to hospital admissions, utilization, and quality of care.
F. Policy and Procedure
1. An important organizational aspect of an anesthesia
department is a policy and procedure manual.
2. This manual includes specific protocols for areas men-
tioned in the JC standards, including preanesthetic evalua-
tion, safety of the patient during anesthesia, recording of all
pertinent events during anesthesia, and release of the patient
from the postanesthesia care unit (PACU).
3. A protocol for responding to an adverse event is useful
(Anesthesia Patient Safety Foundation Newsletter,
2006:21:11, www.apsf.org).
G. Meetings and Case Discussion
1. There must be regularly scheduled departmental meetings.
2. The JC requires that there be at least monthly meetings at
which risk management and quality improvement activities
are documented and reported.
H. Support Staff. There is a fundamental need for support staff
in every anesthesia practice.
I. Anesthesia Equipment and Equipment Maintenance.
Compared with human error, overt equipment failure rarely
causes critical intraoperative incidents. The Anesthesia Patient
Safety Foundation advocates that anesthesia departments
develop a process to verify that all anesthesia professionals are
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Scope of Practice 11
trained to use new technology being introduced in the operat-
ing room.
1. Service. Equipment maintenance and service may be pro-
vided by factory representatives or in-house engineers.
2. Replacement of obsolete anesthesia machines (10 years
often cited as the estimated useful life) and monitoring
equipment is a key element in a risk-modification program.
J. Malpractice Insurance
1. Occurrence means that if the insurance policy was in force
at the time of the occurrence of an incident resulting in a
claim, the physician will be covered.
2. Claims made provide coverage only for claims that are
filed when the policy was in force. (“Tail coverage” is
needed if the policy is not renewed annually.)
3. A new approach in medical risk management and insur-
ance is advocating immediate full disclosure to the victim
or survivors. This shifts the culture of blame with punish-
ment to a just culture with restitution.
K. Response to an Adverse Event
1. Despite the decreased incidence of anesthesia catastrophes,
even with the very best practice, it is statistically likely
that an anesthesia professional will be involved in a major
anesthesia accident at least once in his or her professional
life.
2. A movement to implement immediate disclosure and apol-
ogy reflects as shift from the “culture of blame” with pun-
ishment to a “just culture” with restitution. Laudable as the
policy of immediate full disclosure and apology may
sound, it is recommended for the anesthesia professional to
confer with the involved liability insurance carrier, the
practice group, and the facility administration before pur-
suing this policy.
II. PRACTICE ESSENTIALS

A. The “job market” for anesthesia professionals is being influ-
enced by the number of residents being trained, the geo-
graphic maldistribution of anesthesiologists, and marketplace
forces as reflected by managed care organizations and the real
and potential impact on the numbers of surgical procedures.
B. Types of practice include academic practice, private practice
in the marketplace, private practice as an employee, practice as
a hospital employee (rather than subsidize an independent
practice), practice for a management company, and practice in
an office-based setting.
LWBK1191_C02_p07-14.indd 11 1/4/13 8:57 PM

C. Billing and collecting may be based on calculations according

to units and time, a single predetermined fee independent of
time, or fees bundled with all physicians involved in the surgi-
cal procedure.
1. All practices should have detailed compliance programs in
place to ensure correct coding for services rendered.
2. Billing for specific procedures becomes irrelevant in sys-
tems with prospective “capitated” payments for large num-
bers of patients (a fixed amount per enrolled member per
month).
3. The federal government has issued a new regulation allow-
ing individual states to “opt out” of the requirement that a
nurse anesthetist be supervised by a physician to meet
Medicare billing requirements.
D. Antitrust Considerations
1. The law is concerned solely with the preservation of com-
petition within a defined marketplace and the rights of
consumers.
2. The market is not threatened by the exclusion of one phy-
sician from the medical staff of a hospital.
E. Exclusive service contracts state that anesthesiologists seeking
to practice must be members of the group holding the exclu-
sive contract.
1. In some instances, members of the group may be termi-
nated by the medical staff without due process.
2. Economic credentialing (which is opposed by the ASA) is
defined as the use of economic criteria unrelated to quality
of care or professional competency for granting and renew-
ing hospital privileges.
F. Hospital Subsidies. Modern economic realities may necessi-
tate anesthesiology practice groups to recognize that after
overhead is paid, patient care revenue does not provide suffi-
cient compensation to attract and retain the number and
quality of staff members necessary.
1. A direct cash subsidy from the hospital may be negotiated to
augment practice revenue to maintain benefits while increas-
ing the pay of staff members to a market-competitive level.
2. The ASA’s Washington, DC, office maintains lists of con-
sultants to help anesthesiologists and groups dealing with
hospital subsidies.
III. EVOLVING PRACTICE ARRANGEMENTS

A. Even though the impact of managed care plans has waned
somewhat, various iterations still exist and have ongoing
impact on anesthesiology practice.
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Scope of Practice 13
B. Prospective Payments. In this arrangement, each group of
providers in the managed care organization receives a fixed
amount per member per month and agrees, except in unusual
circumstances (“carve-outs”), to provide care.
C. Changing Paradigm. There is an emerging trend for private
contracting organizations to tie their payments for profes-
sional services to the government’s Medicare rate for specific
CPT-4 codes.
D. Pay for performance is the concept supported by commercial
indemnity insurance carriers and the Centers for Medicaid and
Medicare Services to reduce health care costs by decreasing
expensive complications of medical care.
1. Accountable Care Organizations were created by the
Patient Protection and Affordable Care Act that was signed
into law in 2010. To ensure the importance of preoperative
care of the surgical patient in these provisions, the ASA is
advocating a “surgical home” model of care.
2. Management Intricacies. The complexities of modern
medical practice have spawned management consultants
that offer their services to anesthesiology group practices.
IV. Health Insurance Portability and

Accountability Act
A. Implementation of the privacy rule of the Health Insurance
Portability and Accountability Act (HIPAA) creates significant
changes in how medical records and patient information are
handled. Under HIPPA, patients’ names may not be used on
an “operating room (OR) board” if there is any chance that
anyone not directly involved in their care could see them.
B. Electronic Medical Records (EMR). Basic EMR implementa-
tion has been problematic for practices (e.g., expense, obvious
savings, acceptable software), but true electronic anesthesia
information management systems have been even more diffi-
cult to implement.
V. EXPANSION INTO PERIOPERATIVE MEDICINE,

HOSPITAL CARE, AND HYPERBARIC MEDICINE
A. Formalized preoperative screening clinics operated and
staffed by anesthesiologists may replace the historical practice
of sending patients to primary care physicians or consultants
for “preoperative clearance.”
B. Anesthesiologists may become the coordinators of postopera-
tive care, especially in the realm of providing comprehensive
pain management.
LWBK1191_C02_p07-14.indd 13 1/4/13 8:57 PM

VI. OPERATING ROOM MANAGEMENT

A. The current emphasis on cost containment and efficiency
requires anesthesiologists to take an active role in eliminating
dysfunctional aspects of OR practice (e.g., first-case morning
start times).
1. Anesthesiologists with insight, overview, and a unique per-
spective are best qualified to provide leadership in an OR.
2. An important aspect of OR organization is materials man-
agement.
B. Scheduling Cases
1. Anesthesiologists need to participate in scheduling of cases
because the number of anesthesia professionals depends
on the daily caseload, including “offsite” diagnostic areas.
2. The majority of ORs use block scheduling (preassigned
guaranteed OR time with an agreed cutoff time), open
scheduling (first come, first serve), or a combination.
3. Computerization will likely benefit every OR.
C. Preoperative Clinic. Use of an anesthesia preoperative evalua-
tion clinic usually results in more efficient running of the OR
and avoidance of unanticipated cancellations and delays.
D. Anesthesiology Personnel Issues. In light of the current and
future shortage of anesthesia professionals, managing and
maintaining a stable supply promises to dominate the OR
landscape for years.
E. Cost and Quality Issues
1. Health care accounts for approximately 14% of the US
gross domestic product, and anesthesia (directly and indi-
rectly) represents 3% to 5% of total health care costs.
2. Anesthesia drug expenses represent a small portion of the
total perioperative costs, but the great number of doses
administered contributes substantially to the aggregate
total cost to the institution.
a. Reducing fresh gas flow from 5 to 2 L/min whenever
possible would save approximately $100 million annu-
ally in the United States.
b. More expensive techniques and drugs may reduce indi-
rect costs (e.g., propofol is infusion more expensive but
may decrease PACU time and reduce the patient’s nau-
sea and vomiting).
c. For long surgical procedures, newer and more expensive
drugs may offer limited benefits over older and less
expensive longer acting alternatives.
d. It is estimated that the 10 highest expenditure drugs
account for more than 80% of the anesthetic drug costs
at some institutions.
LWBK1191_C02_p07-14.indd 14 1/4/13 8:57 PM

C H A P T E R
3
Occupational Health
The health care industry has the dubious distinction of being one of the
most hazardous places to work in the United States (health care is sec-
ond only to manufacturing in the number of occupational illnesses and
injuries sustained by their workers (Katz JD, Holzman RS. Occupational
health. In: Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Ortega R,
Stock MC, eds. Clinical Anesthesia. Philadelphia: Lippincott Williams
& Wilkins; 2013: 61–89).
I. PHYSICAL HAZARDS
A. Anesthetic Gases
1. Concerns about the possible toxic effects of occupational
exposure to inhalational anesthetics have been expressed
since their introduction into clinical practice.
2. Several studies testing for chromosomal aberrations, sister
chromatid exchanges, or changes in peripheral lympho-
cytes have found no evidence of cellular damage among
clinicians exposed to the levels of anesthetic gases that are
encountered in an adequately ventilated operating room
(OR).
3. Nitrous oxide exposure is a special situation as this gas can
irreversibly oxidize the cobalt atom of vitamin B12 to an
inactive state. This inhibits methionine synthetase and pre-
vents the conversion of methyltetrahydrofolate to tetrahy-
drofolate, which is required for DNA synthesis, assembly of
the myelin sheath, and methyl substitutions in neurotrans-
mitters. At adequate clinically used concentrations of
nitrous oxide, this inhibition could result in anemia and
polyneuropathy. As with the halogenated hydrocarbon
anesthetics, these effects with nitrous oxide have not been
demonstrated in adequately scavenged ORs with effective
waste gas scavenging.
B. Reproductive Outcomes
1. There is no increased risk of spontaneous abortion in stud-
ies of personnel who work in scavenged environments
where waste gases were scavenged.
2. It is likely that other job-associated conditions (e.g., stress,
infections, long work hours, shift work, radiation exposure)
15
LWBK1191_C03_p015-28.indd 15 1/4/13 8:08 PM

Another random document with
no related content on Scribd:
OUR SERMON.
In adopting this heading for a series of articles, which will be
continued as occasion offers, we are very far from intending to
startle our readers with a rush of theological disquisition. In proof of
our sincerity, and as an earnest of the gist of our discourses, we
have chosen as a standing text, or motto, the golden rule of “peace
and goodwill to all men;” but while we leave intact the functions of
the divine, it is our business, as we conceive it to be our duty, to
sermonize on the morals of trade, the social relations of every-day
life, and even the proprieties which enhance every species of
domestic enjoyment.
A right understanding of the relative duties of master and man, or
of employer and the employed, yields to no subject in importance;
peculiar incidents, induced by a rapidly increasing population, the
tendency of commercial wealth to accumulate in masses, and its
employment under the familiar term “capital,” through the agency of
individuals, in the construction of great works, constitutes, however,
an era in the Building trade to which former periods bear no very
strict analogy. In offering our humble opinions upon actuating causes
and their effects, be the subject what it may, we will never lose sight
of our text; we shall make use neither of angry words nor
denunciations; peace is too lovely to our minds, and charity too
imperative to be abandoned; we would dispel the darker and sterner
passions, giving every brother full credit for good intentions, and
assign occasional deviations from the path of right rather to
misfortune than intention. Whatever the class of men addressed or
dealt with, this, we are convinced, is the best and only true policy. It
may be very well for any one to talk of their anger being aroused, or
their indignation excited, and so on, and under such pleas to vent
abuse, imprecate a thousand vengeances, and the like, but, depend
upon it, fear is less to be relied on than love; we would win a child to
our love, not deter it by frowns and coercion;—we would have a
thousand friends rather than a single enemy.
Who has not heard of the tale of the traveller, upon whom the sun
and wind essayed their power? These elements, as the fable puts it,
were at issue as to which was superior, and agreed to rest the
decision upon the effect they should produce upon the first wayfarer.
Well, first the wind fell to work, and blew with all his might, to compel
the subject of their experiment to throw off his cloak, but the more
vehemently the man was assailed, the closer he wrapped the
garment about him; in turn the sun made trial of his power, and
genial warmth soon accomplished what the bluster of the ruder
element had made more and more difficult. So in human policy the
kindly glow excited by generous sentiments and actions will succeed
where threats, force, and even punishments have failed. The human
heart has no such obduracies but that charity will overcome them.
It is a part of our present purpose to refer to practical benevolence
of this nature, and it will be found in an extract from the Leeds
Mercury, given in another part of our paper, on the subject of the
treatment of workpeople, by Sir John Guest, at Merthyr Tydvil, and
the Messrs. Marshall, of Leeds. These, thank God, and for the
honour of our country, are not solitary instances. These gentlemen
stand not alone in the practice of that soundest principle of Christian
political economy which instructs the rich to dispense of their
abundance for the benefit of their poorer brethren. We have Master
Builders in every department, proprietors of large works and
establishments, whose names we could hold up to the admiration of
their craft and country, but we will not do this violence to their
unobtrusive merit, neither will we invite invidious comparisons by
such selections; we would rather hold up these Christian duties for
common emulation, and call upon all to “go and do likewise.”
We open, then, our exhortations to Masters, because we know
that the first impulse of benignant power must originate with them;
kindness from them may be likened to the sun in its influence, and
most surely will it be returned with usurious interest “into their basket
and their store.”
Who ever saw the good father of a family putting firm faith in virtue
and honour, and regulating his household by their dictates, failing to
raise up virtuous, amiable, and honourable citizens? or, to put the
case stronger, who ever knew the man that acted upon opposite
principles succeed in sowing any thing but vice and discord? Depend
upon it, then, the same principles and rules apply in business, from
the overseer of the smallest undertaking to the governor of a nation.
Fatherly solicitude for those under our care, or for whom we bear
any responsibility, is as solemn and sacred a duty as the fulfilment of
contracts or engagements; nay, it is the first of duties between man
and man.
On the other hand, as to the workman,—fidelity—and more, the
same generous kindness towards his master is required, as that he
would receive; in fact, “to do unto others us you would be done by,”
is the great and universal secret of social happiness.
It is with this view of relative duties that we deem it of as much
importance to engage ourselves in giving good counsel to our craft,
as in enlightening them on principles of science pertaining to their
several callings; for of what avail will it be to a man to possess all the
knowledge of his art, if his heart be corrupt, or continue under vicious
influences? Away with, as dross, all the ability of the engineer,
architect, master builder, or workman, if the man be not endowed
with moral excellence. What are beautiful designs, imposing
structures, mechanical skill, or ingenious artifice in workmanship,
without a mind and heart in harmony with the superior inspirations
which virtue alone bestows? This, this indeed must come first as the
base of the pyramid. In any other case the pyramid may be there,
but it topples, leans, or lies on its side; the same inherent beauty
may exist, but its position and action are superadded elements of
deformity. Oh, how beautiful the human mind when lit up and guided
by the impulses of virtue! how terrible and loathsome when passion
and gaunt sensuality have their sway!
Guard, my beloved countrymen, against avarice, envy, malice;
avoid contentions; be moderate in the desire of gain; repine not at
another’s success in life, or the distinctions he may attain to; cast all
rancorous suggestions far from your heart; contend not in any unholy
spirit of craving competition; “live, and let live,” is a maxim which we
conjure you at all times to observe.
In times of commercial depression, aggravate not your own or
another’s suffering; these, like seasons of sickness and malady,
must and will have their recurrences, and they will recur more
frequently, and press more grievously, where brotherly love and
charity, the great preventative and remedy of human ills, are
neglected. Let none imagine it his privilege to be exempt from these
obligations; let us not, because we see a neighbour unmindful of his
duties in any of the multifarious walks of life, think ourselves justified
in departing from our superior policy; neither must we judge and
condemn; inflict, if you will, pains and penalties on yourself, but you
have no right to do so on another.
Pardon us, good brothers of our building fraternity, and you who
do us the favour to lend an ear to our counsellings, if we thus seek to
engage your attention, and offer our well-meant importunings.
Should your approving suffrages incite a continuance of our
vocation, it will be our ambition to discuss the relative duties of the
stations you respectively fill—master, apprentice, or workman; father,
brother, son, or husband; neighbour or friend; and to do as we have
now done, namely, try to improve each and all, and in doing so,
promote, in some degree, the cause of human happiness.
TREATMENT OF WORK-PEOPLE BY
THEIR EMPLOYERS.
In an article under this head it was mentioned that the
parliamentary inquiry into the payment of wages in goods had
shewn, that there are persons extensively engaged in manufactures
of various kinds, who feel that the employment of bodies of
workpeople involves a degree of responsibility to care for their
general well-being, and who act on that conviction in a manner
highly creditable to themselves, and conducive to the excellent
object they have in view. These employers are of opinion that to
regard as a machine a man whose skill or industry assists them to
maintain their own families in respectability, is altogether unchristian,
and that by viewing workpeople in such a light, they would deprive
themselves of some of the finest opportunities of usefulness, and of
cementing the bonds of society.
Of course, as the intention in moving for a committee of the House
of Commons was to expose grievances, it was not likely that any
examples of conduct distinguished for its humanity would be found in
the pages of the report. As we remarked, however, when formerly
writing on the subject, illustrations of this kind might be obtained by
any one from our own neighbourhood. We had only last week the
pleasure of visiting an extensive range of school buildings just
erected on the best principles, in connection with Messrs. Marshall’s
mill at Holbeck. In that suite of rooms there are between 300 and
400 children under daily instruction, independent of about 160 boys,
who work half-time at the factory, and are at school either in the
morning or afternoon of every day; the same gentlemen have also
instituted girls’ and infant schools (which are situated elsewhere),
and a night school, attended by young men and women from the
mill, whose improvement in conduct as well as attainments, in
consequence of this arrangement, is spoken of as highly gratifying.
In the several schools every thing seems to be done to promote the
comfort of the young, and to cultivate habits of cleanliness and
decorum, as well as to impart an excellent plain education.[2] Plans
for affording the means of recreation to the adult workpeople have
also been devised in connection with these buildings; and all
manifests that a sincere interest is felt by the members of the firm in
the welfare of every class in their employ.
The principal example of attention to the interests of workpeople
which came under the notice of the parliamentary committee, was
that of Sir John Guest and Co., at their iron and coal works, Dowlais.
These works, which were established from thirty to forty years since,
“in an isolated place on the top of a hill,” in Glamorganshire, have
now a town around them (Merthyr Tydvil), and nearly 5,000 persons
are employed by this firm alone. In the first instance, great difficulty
was experienced by the workpeople in procuring the means of
lodging, but in the course of time this was removed by the erection of
a large number of cottages at the expense of the company, and by
the people being encouraged to build dwellings for themselves. The
cottages belonging to the firm are stated to be low-rented,
convenient, well built, well drained, and the taking of them is quite
optional with the workpeople; while the granting of loans to steady
men to build cottages for themselves has been pursued to a
considerable extent, and has been found to attach them to the place,
to keep them from the ale-house, and to produce and confirm in
them a feeling of independence.
The amount of each individual’s wages at this extensive
establishment is settled every Friday evening, and the whole of the
hands are paid on the morning of Saturday; shewing that a large
number of workpeople is no barrier to the early payment of wages if
employers are determined to adopt that highly beneficial practice.
Nearly twenty-four years ago, Sir John Guest and his partners
recognised the responsibility which attached to them as employers
by erecting large schools, near the works at Dowlais, chiefly for the
education of the children of their workmen, but (like Messrs.
Marshall) not confined to them. There are at present about 220 girls
and 250 boys under instruction, the children being admitted at the
age of six, and usually remaining until thirteen years old. The
teachers are well paid, and the whole expenses of the schools are
defrayed by the workpeople and employers together, in the following
manner:—Twopence in the pound is stopped every week “for the
doctor” from the wages of every one in the works, of which 1½d. is
appropriated to provide medical attendance for the families of the
workmen, and the remainder goes towards the support of the
schools. Each child is also expected to pay one penny a week, and
whatever is wanting to make up the amount incurred in maintaining
the educational establishments is contributed by the company. In
connection with the schools, it is worthy of notice that Mr. Evans, the
manager at Dowlais (from whose evidence our facts are drawn),
expressed before the committee a strong conviction, as the result
both of his own observation for above twenty years, and of the
statements of colliers themselves, that for a collier to put his child to
work in the pits very young is decidedly bad economy; instead of
gaining, the family loses by it in the long run, while the unfortunate
victim of error or cupidity becomes decrepit and unfit for work when
individuals of the same age are in possession of mature strength.
Very few of the children taught in the schools at Dowlais become
colliers, the greater number being qualified for employment as
carpenters, smiths, and, in some instances, even book-keepers. “We
derive very great advantage,” says Mr. Evans, “from having children
in the works who have been educated there; they are of great use to
us.” Here, then, is a proof to masters who have not yet exerted
themselves for the elevation of the families dependent on them, but
are disposed to do so, that such a course is not only beneficial to
others, but brings a reward to every one who adopts it. The medical
attendants on the workpeople at Dowlais consist of three regular
surgeons and a dispenser, whose services are remunerated chiefly
by the money stopped from the wages. In 1827 a fund for the relief
of the sick and aged was formed, one penny in the pound being
stopped every week to furnish the necessary supply for the wants of
those who are thus unable to provide for themselves; this fund is at
the disposal of a committee, elected yearly by all the contributors.
From the peculiar circumstances of the district, when the works of
Sir John Guest and Co. were established, and for many years after,
it was desirable and even needful that the firm should afford their
workpeople the means of obtaining the necessaries of life by
maintaining a shop on the premises. In 1823, however, they closed
it, but once again opened it at the request of the men in 1828. On the
act against truck shops being passed in 1831, the workmen were
called together and desired to state whether they wished the store
belonging to the firm still to be continued. The votes were taken by
ballot, and thirteen only were given for the discontinuance; but as
there was not perfect unanimity, the company thought it best that the
shop should be finally closed at that time; and the increase of
population having had the usual effect of attracting private
individuals to supply the wants of the community, the only result of
this step was to shut up an establishment where the labouring
classes were always sure of buying good articles at a moderate
price. The accommodation being no longer necessary, we think the
company’s decision was a wise one.
It is gratifying to find that no loss whatever has been entailed on
Sir John Guest and Co. by all the beneficial regulations adopted by
them on behalf of their workpeople. On the contrary, “by the
education of the people,” Mr. Evans states, “we have gained more
than we have spent upon them.” And this gentleman expressed
himself as feeling certain that if a similar system were extended over
the manufacturing and mining districts of the whole country, it would
prove the cheapest and most effectual mode of benefiting both the
working classes and employers, and consequently society at large.
Of course, the details of the system at Dowlais, or at any other
establishment of which an account is before the public, are not
essential to its being adopted with advantage in other parts of the
country, though the success which has attended those plans gives
them a title to careful consideration; the thing to be desired is, that
each employer should ask himself how far he can adopt the
principle, and then carry into operation the dictates of his own
judgment and conscience.—Leeds Mercury.
[2] The ventilation of the new school-rooms appears to be

remarkably effective—a point of great importance where so many
individuals are for three hours at a time congregated together.
The playground also is being extremely well laid out.
Reviews.
Temples, Ancient and Modern, or Notes on Church Architecture. By
William Bardwell, Architect. London: Fraser & Co., and
Williams.
Mr. Bardwell, in the Preface to this work, states his object to be
—
“To endeavour to excite among architects a spirit of inquiry such
as cannot fail to prevent a repetition of those improprieties the
existence of which in our public edifices has so long afforded subject
for complaint and matter for criticism;” and “to put an end to that
inconsistency which is the cause of error,—namely, the tyranny of
custom and the caprice of fashion: which, while they compel the
modern architect to copy in little and with meaner materials the
sublime works of revered antiquity, indulge a laugh at his expense,
because his reproduction fails to excite those sensations of pleasure
and admiration which are inseparable from a contemplation of the
original.”
Passing over the first three chapters of the work, which, although
they contain much excellent matter of opinion, to which all may
subscribe, do nevertheless open a door to controversy, and this it is
our desire to avoid,—we come to Chapter IV. This is headed “Errors
in the details of late-erected Churches, a connected series of critical
observations;” and has for its object, by stringing together a number
of critiques from the Gentleman’s Magazine and other sources, to
call attention to the prevalent errors of past design, and to enunciate
correct principles for future practice. We quite agree with Mr.
Bardwell, that “notwithstanding the querulous tone in which the
writers have occasionally indulged, the extracts contain many hints
that may be permanently useful;” and would wish that the spirit of a
following paragraph could be always borne in mind by the critic and
reviewer. “The legitimate object of criticism,” says our author, “is to
improve the future, rather than to cast ill-natured censure upon the
past.” However, we cannot take exception to Mr. Bardwell’s
discharge of his duty. He has most appositely given these extracts
through a whole chapter, and placed them in admirable order for
study and profitable reflection. No one can read through this chapter
attentively without being impressed with a desire to contribute his
part to the rectification of such errors as are therein pointed out—it
will awaken many to an active investigation where other modes of
expression or remonstrance would probably fail.
In Chapter V. Mr. Bardwell enters into the great question that
awaits us at every approach to a comprehensive study in
architecture—the origin. Speculation on this point is in its nature
endless; but it is highly gratifying to feel occasionally that we are
thrown in the way of facts, and such it is the province of this chapter
to treat us to. With a little prefatory matter in the way of an assault
upon the hitherto deemed orthodox authorities on such subjects, and
upon the principle of adherence to rule and precedent, and upon the
little fables of an inventive tradition, assigning to this accident or that
the origin of this or that feature, plan, and style, we come to the
“burden of the book,”—Temples; and have a most interesting
dissertation on those of ancient character, or on what we may more
aptly term sacred edifices, memorials, or monuments.
“An altar of turf or of stones, stones of memorial, such as that set
up at the grave of Jacob’s beloved Rachel, the great stone near the
oak at Shechem, Absalom’s Pillar, Jacob’s Bethel, Samuel’s
Ebenezer, the Gilgal, or circle of stones, of Joshua; a heap of
unhewn stones, the Pandoo Koolies, of Hindostan, the numerous
pillars set up by the Phœnician merchants, on the shores of the
Mediterranean, in France, in Sweden; and in Great Britain, circles
and rows of huge stones, like those of Stonehenge, Abury, &c.;
cromlechs and logan stones, a portable ark, or tabernacle, were the
first sacred monuments. Next came the pyramid, a cylinder, whether
a cippus or a column; a cubical block, with a particular member
superadded to the regularity of mathematical proportions. A sphere
and a tetrahedron; and last succeeded a vase covered with a flat lid,
and adorned with various sculptures from the vegetable and marine
world.”
Thus Mr. Bardwell connects with religion the first memorable and
permanent efforts of Building Art—sacrifice he shows to have been
associated with, and to have guided the workings of, the first
builders, from the “primeval altar of little more than a raised hearth,
built generally of unhewn stones,” to the “column or stone pillar of
mystic character—‘And Jacob rose up early in the morning, and took
the stone that he had put for his pillow, and set it up for a pillar, and
poured oil upon the top of it; and he called the name of that place
Beth-El.’” “The Greeks also erected pillars which they called
‘Baitulia,’ evidently derived from Beth-El, involving the same mystery,
and both supposed to be symbols of the Divine Presence.”
Chapter VI. increases in interest, and is devoted to the Temple of
Ammon.
“The Temple of Ammon, the remains of which archæologists, for
many powerful reasons, agree are extant in the enormous pile
known as the Temple of Karnac, is by far the most extensive, as well
as the most ancient, of the Theban edifices; properly belonging to
the whole period of the monarchy, and may with propriety be termed
the Temple of the Pharaohs, the majority of whom, in succession,
more particularly such as are celebrated in history, contributed their
efforts to its enlargement and magnificence. From numerous
authorities it seems clear that Ham, the son of Noah, the Amun,
Ammon, or Osiris of the Egyptians, must be considered as the
original founder of Thebes, or the city of Ammon, as his son
Mizraim, Misor, or Menes, was by common consent the founder of
Memphis; so that the temple of Ammon or Ham was, in all
probability, originally named from its founder, like the Temple of
Solomon at Jerusalem.”
We cannot take our readers along with us as we would by quoting
largely from this interesting chapter, nor will we presume to dispose
of the work by this brief and imperfect notice; it deserves much more
at our hands; it is written with an enlarged feeling, and a genuine
spirit of devotion to the sublime art upon which it treats; it is erudite,
and occasionally profound; but we must take our leave of it for the
present, concluding with another extract from the same chapter.
“The remains of Karnac are about 2,500 feet from the banks of the
Nile, on an artificial elevation, surrounded by a brick wall, about
6,300 yards in circuit. The chief front of the temple (the western) is
turned towards the river, with which it was connected by an alley of
colossal crio-sphinxes, leading down to the bank of the river. Here
the devotee would land who came from a distance to the shrine of
Ammon, and with amazement and a feeling of religious awe would
he slowly walk along between the majestic and tranquil sphinxes to
the still more magnificent propylæ of the building. This colossal
entrance is about 360 feet long and 148 high; the great door in the
middle is 64 feet high. Passing through this door-way, he would enter
a long court, occupied by a row of pillars on the north and south
sides, and a double row of taller pillars running down the middle.
These pillars terminated opposite to two colossal statues in front of a
second propylon, through which, after ascending a flight o’ twenty-
seven steps, we enter the great hypostyle hall, which had a flat stone
roof, supported by one hundred and thirty-four colossal pillars, some
of which are twenty-six feet in circumference, and others thirty-four.
The width of this magnificent hall (for the entrance is in the centre of
the longest side) is about 338 feet, and the length or depth 170 feet.
The centre column supported a clere-story, in which were small
windows. Four beautiful obelisks mark the entrance to the adytum,
which consists of three apartments entirely of granite. The centre or
principal room is 20 feet long, 16 wide, and 13 feet high. Three
blocks of granite form the roof, which is painted with clusters of gilt
stars on a blue ground. Beyond this are other porticos and galleries,
which have been continued to another propylon at the distance of
2,000 feet from that at the western extremity of the temple.”
English Patents for 1841. By Andrew Pritchard, M.R.I., &c.

Whitaker and Co., London. 2s. 6d.
We had commenced the selection of a list of patents from this
excellent compendium, with the intention of laying before our readers
all those pertaining to the Building Art, but found that we should have
to reprint nearly the whole of the book; so comprehensive is the
range we have chosen, and so ingenious the class we have the
honour to serve. Of 441 patents herein entered, by far the largest
proportion are as we have stated; and we can only, therefore, refer
to the work itself. Besides the above list of patents, there is
appended a copy of Letters Patent, an abstract of the Registration of
Designs Act, and a notice respecting its operation, concluding with a
useful Index, which shews at one glance what you would refer to.
The value of such a work as this is not to be estimated. All persons
intending to take out patents should look over its pages, as it may
save much trouble and expense. We know of many who would have
been great gainers had they had such a guide at their elbows.
MISCELLANEOUS.
There is a consideration which entitles architecture to a decided
pre-eminence amongst the other arts. It is itself the parent of many
separate professions, and requires a combination of talents and an
extent of knowledge for which other professions have not the
smallest occasion. An acquaintance with the sciences of geometry
and mechanical philosophy, with the arts of sculpture and design,
and other abstruse and elegant branches of knowledge, are
indispensable requisites in the education of a good architect, and
raise his art to a vast height above those professions which practice
alone can render familiar, and which consist in the mere exertion of
muscular force. From these considerations it appears there is some
foundation in the very nature of architecture for those extraordinary
privileges to which masons have always laid claim, and which they
have almost always possessed—privileges which no other artists
could have confidence to ask, or liberty to enjoy.—Ency. Brit., Vol.
XIV., p. 280.
Alison on French Architecture.—In France we find that public
works have been reared at an expense not exceeding that of edifices
of little or no excellence in our own country, even although the
charges of building are not materially different in the two countries.
So true it is, that the most essential elements in architectural beauty
—genius and taste in the architect, are beyond the power of mere
wealth to command—that it is not money to construct beautiful
edifices, but the mind to conceive them, which is generally wanting.
It would seem, therefore, that it is the pure taste and noble
conceptions of the artists of Southern Europe, rather than in any
great excellence in the materials at their command, or the wealth of
which they have the disposal, to which we must ascribe their
remarkable superiority to those of this country.
Devonshire House, Piccadilly.—The additions and alterations
which are being made to this fine old mansion, the residence of His
Grace the Duke of Devonshire, are proceeding rapidly, and will add
considerably to the extent as well as to its internal arrangements. Mr.
Decimus Burton is the architect, and Messrs. Woolcott and Son are
the contractors, for these works, which will yet take many months to
complete. The Duke is for the present staying at his princely abode,
Chatsworth.
Church Extension.—There are now twelve new churches
building, or about to be commenced, in various parts of the
metropolis; one in the Kent-road, in the parish of St. George,
Southwark; one in the parish of Paddington; another on the site of
the Old Broadway Chapel, Westminster; a large church, with a lofty
Gothic tower, in which a musical peal of bells is to be placed, in
Wilton-square, Knightsbridge; three in Bethnal-green parish, and a
church in St. Pancras parish. Sites have been chosen for a new
church in the Waterloo-road district of Lambeth parish; another in St.
Botolph Without, Aldgate, in the county of Middlesex; and a third in
St. George’s-in-the-East. The new parish church of St. Giles’s,
Camberwell, building on the site of the old edifice, which was
destroyed by fire, is progressing rapidly, and will be a noble and
spacious edifice. The new church at Paddington will be a great
ornament to that neighbourhood. The University of Durham has
granted 400l. towards the erection of a new church at South Shields.
It is intended to build a new Roman Catholic Church in the eastern
part of the metropolis. The site chosen is a large piece of ground on
the south side of the Commercial-road, and it is expected that the
total cost of the edifice and the purchase of the ground will not fall
short of 30,000l.
NOTICES.
To Advertisers.—This first impression of Five Thousand is
reserved for sale in London and the large Provincial Towns. The next
impression of five thousand will be stamped, so as to pass post-free,
and will be circulated gratuitously on the 7th of January, 1843,
amongst that number of the nobility, gentry, clergy, professional men,
and principal tradesmen, all over the United Kingdom, according to a
list which has most generously been placed at our disposal for that
purpose by a friend. It is important, therefore, to advertisers that they
should seize the opportunity thus afforded them of a special and
select notification of their business among a class of such
importance. It may be affirmed, indeed, that a circulation of this
character and amount is superior to one of four times the number of
copies dispersed at random, in the ordinary way of sale. Additional
advertisements, therefore (if sufficient in number) will be inserted in a
Supplement to accompany this gratuitous circulation, as well as the
future sale, and should be sent to the Office at latest, on Thursday,
the 5th of January. The charge for advertisements in the Supplement
will be 15s. per quarter column, 1l. 10s. per half column, and so on;
smaller advertisements according to agreement. To insure more
attention to the Supplement, as well as to secure an additional
circulation for it, it will contain matter of interest as to the progress of
the first impression, correspondence, and the like. Our prospects
hitherto have been so far gratifying as to give us confidence that the
whole number of 20,000 copies of the Precursor will be disposed of!
To our Readers.—As we do not choose to trust our own

judgment on a subject in which so many are interested besides
ourselves, and as it is so easy to obtain an opinion by which we may
be guided, we think it right in this place to invite attention to our
views on the subject of the future character of “The Builder.” Before
a month shall have elapsed, at least 20,000 numbers of this paper
will, in all probability, have been circulated, and will have passed
under the review of twenty times that number of readers. They, and
in particular our Building friends, will have made up their minds as to
whether “The Builder” is a work to be encouraged—it certainly is
not our desire to attempt to force the point, although we would use a
little “gentle violence” to develope the evidence—and this we may be
supposed to be doing now. We have said that there are two parties
to this, as to every other question—the public and ourselves. It is not
for us to tell the public that they know nothing of their own wants,
and to attempt to force them into the belief that such a paper as “The
Builder” is absolutely necessary, but unless we had taken this step
on our own responsibility, the question would have remained
undetermined. What we would ask of the Building public then is—Do
you wish to have a periodical devoted to your interests, as we
propose? and whether would you have it a Magazine and Advertiser
simply, or as a Newspaper conjoined? In the former case it might be
weekly or monthly, in the latter it must necessarily be weekly. As to
the price and size: If a Magazine and Advertiser of twelve pages of
the size of our present number, we should say 3d. the number,
stamped 4d.; if a Newspaper of sixteen pages, we do not think it
could be less than 6d. Every body has seen the Illustrated London
News, and allowing for difference in the character of the illustrations
(those in “The Builder” being devoted entirely to art and science),
you will be able to judge of the appearance which the latter will
present. We are only anxious to undertake no more, or, no less, than
can reasonably be expected to be carried out. If it should appear
from experience of the working that more can be accomplished, we
shall most gladly acknowledge and act upon it, by either enlarging
the paper, or reducing the price. But we still think that to conjoin the
character of a Magazine and Newspaper, and at the cost of one to
give the advantages of both, will be to study the true economy of our
cause.
The readers, therefore, have much of the settlement of the
question in their own hands—even to the influencing of the
advertisers. All advertisers look for papers of large circulation, and
as advertisements are a great means of support to a newspaper, it is
evident that the more “The Builder” is supported by the mere
reader, by so much the more does it stand a chance of support from
advertisers. We venture, therefore, to speak in this business as
though we were ourselves less concerned in its issue than we really
feel to be—and we urge upon our honoured fellow-craftsmen to
make this paper their own. Let it be a sign or standard of union.
We do not ask to have subscriptions forwarded, but we would
respectfully request to be favoured by an immediate intimation front
all parties as to their willingness to subscribe, and which they would
prefer, a Magazine alone, or Magazine and Newspaper.
We trust it will be considered that we are pursuing a
straightforward and ingenuous course, willing to be guided by
circumstances, rather than to seek to force or control them, or to
stake upon our own presumptuous judgment that which a prudent
and discreet man would say should be left to the decision of the
common voice and experience.
Pardon us if we once more urge you to rally round “The Builder.”
ADVERTISEMENTS.
BAZAAR PANCLIBANON, 58, BAKER-STREET, PORTMAN-
SQUARE.—KITCHEN RANGES, STOVE GRATES, FURNISHING
IRONMONGERY.—The stock of this vast establishment has been
renewed, with an extensive selection of every description of
domestic furniture, usually found in the ironmongery department.
Every requisite for the Kitchen, in Copper, Iron, or Tin, of first-rate
qualities, the prices being marked in plain figures, for READY
MONEY. Kitchen ranges and cooking apparatus upon approved
principles, including useful and modern improvements. The higher
class of goods comprises an enlarged assortment of register and
stove grates, in steel and black metal, with fenders and fire-irons to
correspond, suitable to drawing and dining rooms, libraries, halls,
and chambers, in various styles of ornamental embellishment now in
vogue, and of improved modes of construction, calculated to insure
safety with economy.
A very large assemblage of baths, of sound make, and adapted to
all purposes of health and comfort; comprehending shower, plunge,
and vapour baths; those proper to the nursery, with hip, foot, and
knee baths, and peculiar shapes convenient for embrocation; among
these enumerated, are varieties fitted with practical improvements
for the ready application of this valuable resource to the invalid, or in
cases of sudden indisposition.
A commodious saloon has been added to receive a new stock
containing Appendages to the tea table, including papier maché and
iron tea trays of great beauty of design, and tasteful display of
ornament. Tea and coffee urns and coffee machines of the best
quality, of London make, comprising every useful improvement in
those articles.
Tea services in Britannia metal, of superior quality, and in
considerable variety of shape and pattern. A costly display of plain

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Handbook of Clinical Anesthesia

Seventh Edition Barash Paul G Cullen

ROBBINS amp KUMAR BASIC PATHOLOGY 11th Edition Vinay

Emergency Neurology 2nd Edition Sara Lahue Md Morris

Berne Levy Physiology 8th Edition Bruce M. Koeppen Md

Calcium Signaling Md. Shahidul Islam

On Call Neurology On Call Series 4th Edition Mayer Md

Herzog’s CCU Book Eyal Herzog Md

Gout, 1e 1st Edition Naomi Schlesinger Md

Ophthalmology 5th Edition Jay S. Duker Md

LWBK1191-FM-i-xiv.indd 1 1/11/13 9:05 PM

LWBK1191-FM-i-xiv.indd 3 1/11/13 9:06 PM

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Library of Congress Cataloging-in-Publication Data

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LWBK1191-FM-i-xiv.indd 5 1/11/13 9:06 PM

Saint Adeogba, MD Jan Ehrenwerth, MD

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Adam K. Jacob, MD Glenn Ramsey, MD

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Welcome to the 7th Edition of the Handbook of Clinical Anesthesia. The

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Contributing Authors vii

1 The History of Anesthesia 1

SECTION II S cientific Foundations

5 Mechanisms of Anesthesia and Consciousness 39

SECTION III Anatomy and Physiology

10 Cardiac Anatomy and Physiology 99

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SECTION IV  nesthetic Agents, Adjuvants,

17 Inhaled Anesthetics 227

18 Intravenous Anesthetics 252

SECTION V  reanesthetic Evaluation and

22 Preoperative Patient Assessment and Management 325

SECTION VI Anesthetic Management

25 Commonly Used Monitoring Techniques 387

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SECTION VII  nesthesia for Surgical

35 Peripheral Nerve Blockade 535

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SECTION VIII  erioperative and

54 Postanesthesia Recovery 903

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Although most human civilizations evolved some method for dimin-

I. ANESTHESIA BEFORE ETHER. In addition to limitations

A. Early Analgesics and Soporifics (Table 1-1)

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T a b l e 1 - 1 Early Analgesics and Soporifics

Mandragora (soporific sponge)

C. Public Demonstration of Ether Anesthesia. William Thomas

II. ANESTHESIA PRINCIPLES, EQUIPMENT, AND

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2. An American surgeon, Joseph O’Dwyer, designed a series

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voluntary goals that may become accepted national standards

III. THE HISTORY OF ANESTHETIC AGENTS

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IV. ANESTHESIA SUBSPECIALTIES

SECTION II S cientific Foundations

SECTION IV nesthetic Agents, Adjuvants,

SECTION V reanesthetic Evaluation and

SECTION VI Anesthetic Management

SECTION VII nesthesia for Surgical

SECTION VIII erioperative and

T a b l e 2 - 1 Practice Management Materials Provided

T a b l e 2 - 3 Materials Provided By the American