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doi: 10.1097/ALN.0000000000000002
Reviews of Educational Material

Anesthetic Uptake and Action. By Edmond I Eger, II, M.D. Philadelphia, Williams & Wilkins, 1974. Pages: 383. Price: $18.47 (used).

Tyler, Patrick D. B.A.

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As I read the introduction to Dr. Edmond Eger’s classic text Anesthetic Uptake and Action, my mind drifted to a recent conversation with a friend. We had been discussing the PBS period drama Downton Abbey, which depicts an aristocratic British household during the early 20th century. One of the show’s main draws is the fascinating relationship between the aristocrats and the servants, a hierarchy that we can scarcely imagine in the modern Western world. The show follows the characters over many years and eventually, with global changes such as World War I, the social order shifts and buckles. As cracks appeared in the walls and plaster fell from the ceiling, my friend remarked on how easy it was to picture the benefits of overturning this society in favor of a new world. “But when old things fall by the wayside,” he asked, “have we also lost something in the process? If so, what’s been lost, and does it matter?”
Anesthetic Uptake and Action, most recently published in 1974, is a vintage almost 40 years in fermenting. It would be easy for today’s anesthesiologist to dismiss it as a dusty relic from the past, like the bygone hierarchy at Downton. “Sure, Dr. Eger’s text is a classic, the whole basis for our understanding of volatile anesthetics,” that modern person might say, “but the knowledge can be just as easily gained, with updates, from Miller’s Anesthesia, or the Barash text.” But can it? And what would be lost?
Foremost would be the story of a big idea. Uptake is foundational science, to be sure; yet, like Downton, it is also a compelling drama. Through its pages, the reader experiences firsthand the story of Eger stumbling upon a key, turning it in the lock, and discovering many of the fundamental principles of anesthesia behind the door. These principles include the effect of inflow rate on the movement of volatiles in the anesthetic circuit and lungs, the notion that end-tidal gas reflects concentration in the brain, and the minimum alveolar concentration. This book is, in many ways, the story of those and many other discoveries, and Eger makes it possible for the reader to follow along. For example, he does not just discuss the anesthetic circuits available, he discusses each type of circuit, rules for constructing a functional circuit, and how different successful combinations affect concentrations of carbon dioxide, rebreathed gases, and inflow efficiency. For any equation, the derivation is almost always included in the footnotes, and I frequently found myself with a paper and a pen, substituting equations (2), (3), and (4) into (5) and solving for some variable to produce equation (1). These exercises deepened my understanding of the basic concepts and their interrelationships in a way that was both practically valuable and intellectually satisfying.
Furthermore, there is something to be said for reading original source documents. As an example: Judging by many texts published today, one would think that the concept of “third spacing” (i.e., the notion of a Bermuda triangle outside the intravascular and interstitial spaces into which effective circulating volume disappears) was an established medical fact on par with cardiac contractility or absorption atelectasis. But the original tracer studies that inspired the theory are methodologically flawed; subsequent, more rigorous tracer studies failed to support the initial papers.1 Although there are no such concerns about Dr. Eger’s work, I submit that the foundations of our specialty deserve the same serious consideration, if only to follow these ideas back to their roots and run our fingers through the soil. The health of the tree and a sense of its development are best acquired by examining the base and trunk, not the leaves.
And from the standpoint of a pure bibliophile pleasure, this book has soul, in a way that more-modern textbooks do not, the kind that can only be instilled by a man with erudition and wit. In his discussion of the minimum alveolar concentration, he exhorts the physician to “temper his ministrations” to the elderly, lest he gas an unwitting pensioner into hypotension and dysrhythmia. The graphs and diagrams recall an earlier, simpler time when patients were hand ventilated for entire procedures and vital signs were monitored by looking at the patient. The reader can almost picture Dr. Eger chuckling to himself as he added the “No Swimming” sign into one of the illustrations of the hydraulic model, a wry grin returning as he summarized that brilliant analogy as “simple pipes and puddles we have just waded through.”
So, why return to this old book now? Beyond the practical relevance of its content, Uptake is, in its own way, new to our time. We live in an age obsessed with the efficient, practical, technical, in which deep intellectual consideration of abstract ideas can feel passé. There is some vapor contained in the pages which makes the basic concepts of our specialty feel intoxicating again, that induce awe in the reader. After reading it, I wonder: What “advanced” agent will become our cyclopropane and what technique our entire-procedure hand ventilation? How will new diagrams appear such that trainees see the present ones as belonging to our simpler time? Who will make this generation’s foundational discoveries, and what will be their stories?
In an interview conducted by the Wood Library Museum, Dr. Eger describes how, after a lecture by one of his mentors, he was moved to read T.A.B. Harris’ The Mode of Action of Anaesthetics. Despite the fact that Mode was “wonderfully wrong” in most instances, Eger points out that the book was “full of ideas, attempts to think about and not display things in a cookbook fashion.” Eger was stimulated by this reading to “evolve [his] own thoughts,” which ultimately led to the data presented and concepts developed in Anesthetic Uptake and Action. In reading Dr. Eger’s book, I found myself in a similar position: surrounded by (wonderfully right) ideas that challenged and enabled me to think more deeply about some of the foundational concepts of anesthesia. I hope you will consider engaging this relevant, absorbing text yourself—you will enjoy it. And perhaps you will even be the one to find the next key, turn it in the lock, and open the door.
Patrick D. Tyler, B.A.
, Northwestern University, Feinberg School of Medicine, Chicago, Illinois. pdt@fsm.northwestern.edu
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Reference

1. Jacob M, Chappell D, Rehm M. The ‘third space’—Fact or fiction? Best Pract Res Clin Anaesthesiol. 2009;23:145–57

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