Dr John Dickinson (1832-1863): The man behind the bird.

The surgeon/naturalists Dr John Kirk, Dr Charles Meller and Dr John Dickinson, associated with the Zambezi Expedition (1857-1864) under the leadership of Dr David Livingstone are, like him, credited with the discovery of new species' of birds. A raptor, Falco dickinsoni, is named after Dr John Dickinson. Dickinson, born in the north east of England, trained in medicine in Newcastle upon Tyne. He volunteered to join the Universities' Mission to Central Africa and arrived as part of a second group to join Bishop Frederick Mackenzie, then attempting to build a Mission in Magomero, on the Shire Mountain Plateau in modern Malawi. Livingstone and Mackenzie had sown the seeds of disaster for the first UMCA venture while Dickinson was on his way to Central Africa, and his one meeting with Livingstone was trigger to a chain of events that threatened the whole expedition. Shortly after Dickinson's arrival in Magomero, Bishop Mackenzie and a fellow traveller, Reverend Henry de Wint Burrup, died. Magomero was abandoned and the remaining missionaries retrenched in Chibisa's Village on the River Shire. There, where Dickinson did most of his bird collecting, on 17 March 1863, he died of blackwater fever. Livingstone and Kirk were present at the burial. A marble cross at Chikwawa in Malawi is marker to the event that occurred on the day of Dr John Dickinson's 32nd birthday.

The King's anaesthetic.

King George VI underwent an operation for pneumonectomy in September 1951. Part of the operation anaesthetic record has survived. With conjecture, on a typical scenario of a 55-year-old male undergoing pulmonary resection for carcinoma in the early 1950s and other facts in the public domain, the King's anaesthetic has been reconstructed to give an approximation of the events that in the last few months of his life caused his speech to change from that achieved by his personal voice coach and recently portrayed on celluloid in the film 'The King's Speech'. The popularity and success of the film 'The King's Speech' brought to mind that King George VI died of bronchogenic carcinoma, a result, not recognised at the time, of the cigarette smoking habit that is a prominent feature of the story in celluloid.

The big ideas of Edgar Alexander Pask (1912-66).

Edgar Pask worked before, during and after World War II with the anaesthetist Robert Macintosh. Both were ranking officers and engaged in work with the Royal Air Force Physiological Laboratories at Farnborough, then in the charge of Dr Bryan Matthews. Pask submitted as a Doctorate Thesis a compilation of much of the experimental work in which he was the main subject, most of the data being acquired while he was unconscious. Experiments in which the Farnborough Team were engaged form a central core to the Thesis and relate to the development of life jackets. The information is well known and has been widely publicized, along with most of the biography of Pask. However, some extreme physiological experiments, again with Pask as the test subject and which probably were not conducted at Farnborough, are less well known but in their own way even more extraordinary. The theme in common is Pask's ideas to use the anaesthetized state and the properties of anaesthetic agents as surrogates to the extreme situations Royal Air Force pilots were subject to in modern warfare. There is no purpose to detract from Pask's ideas and selfless heroism by digressions into parallel processes conducted by the opposing Oberkommando der Luftwaffe (OKL) research establishments, but it is evident these were known and had shocked the Farnborough Team (including Pask) before revelation at the Nuremberg War Crimes Trials.

Anesthesia for thoracoscopic surgery.

Anesthesia for thoracoscopy is based on one lung ventilation. Lung separators in the airway are essential tools. An anatomical shunt as a result of the continued perfusion of a non-ventilated lung is the principal intraoperative concern. The combination of equipment, technique and process increase risks of hypoxia and dynamic hyperinflation, in turn, potential factors in the development of an unusual form of pulmonary edema. Analgesia management is modelled on that shown effective and therapeutic for thoracotomy. Perioperative management needs to reflect the concern for these complex, and complicating, processes to the morbidity of thoracoscopic surgery.

Endobronchial tubes - a case for re-evaluation.

An endobronchial tube (Macintosh-Leatherdale) was used to secure the airway for a tracheal resection and end-to-end anastomosis. This lung separation device enabled insertion of both a fibreoptic bronchoscope and a tube exchange catheter. These were required after the trachea was transected and re-anastomosis proved surgically difficult. The airway exchange catheter allowed for jet ventilation and later a tube change when an emergency occurred. Options and management issues for tracheal surgery and lung separators are discussed. A case is made for a re-evaluation of endobronchial tubes both as a useful conduit for modern airway instruments and as an alternative to small double-lumen tubes for the increasing population of obese patients weighing > 100 kg, requiring thoracic surgery.

Anaesthesia for laparoscopic urological surgery.

Laparoscopy for urological surgery is a relatively recent surgical innovation. Some centres have substantial experience of single operations, but very few have experience with a comprehensive range. Our programme began with nephrectomy and pyeloplasty, and has expanded to provide for a living related kidney donor programme and for other procedures usually conducted open. Recently, it has included prostate and bladder cancer surgery. The learning curve and implications for anaesthesia are described on the basis of the experience of one anaesthetist with 124 patients. Perioperative care issues, in common with other abdominal laparoscopic procedures, relate to operating positions, the consequences of carbon dioxide under pressure in the abdomen and postoperative analgesia. There is only a small requirement for regional anaesthesia supplementation and invasive analgesia. The corporate laparoscopic cholecystectomy experience was used as the foundation for anaesthesia and to delineate specific organ system issues and any interventions. Significant differences were found in the spectrum of the urological patient population and comorbidity, notably renal function or dysfunction, and complications.

Local anaesthesia and sedation for rigid bronchoscopy for emergency relief of central airway obstruction.

We report three experiences that illustrate the use of local anaesthesia for rigid bronchoscopy. All patients were acute emergencies, with life-threatening central airway problems. Instruments were inserted after the airway was anaesthetised using a technique that owes much to mid 20th Century methods for inserting endobronchial blockers. There is discussion about requirement to preserve and conserve self-ventilation and the securing of compromised central airways without the aid of neuromuscular blocking agents. Historical aspects of bronchoscopy are reviewed. Concomitant sedation reduced the unpleasantness of the experience in a way that in the past could only be dealt with by careful attention to the humanitarian elements of detail. Problems of oxygenation were ameliorated by periodically superimposing intermittent jetting with a Sanders injector fed from the oxygen pipeline. A need for developing and refining topical and other local anaesthetic techniques for rigid bronchoscopy is anticipated with the expansion of services for tracheo-bronchial stenting and lasering.

Pain disaggregation theory--statistical nonsense or a pointer to a paradigm for quantum nociception?

BACKGROUND: The various patterns of patients' experience of treated acute post-thoracotomy pain exemplify the phenomenon of disaggregation. The intent in this study was to define a theory of disaggregation with a hard-wired neuroanatomical model of thoracotomy pain. METHODS: In order to distinguish the disaggregated nociception conducted along one of three possible pathways, the vagus, the phrenic and, in this study, the intercostal nerves, data from 143 patients undergoing thoracic surgery, and that from two previously conducted studies of multimodal analgesic regimens, were reviewed. The values of one subjective outcome measure (verbal rating score) at different stress levels-at rest, on raising the arm, and on coughing (dynamic pain scores)-were used to construct individuals' charts (pain profiles) of the progress of pain relief over time. These were batched, and analysed using statistics of summary measures. RESULTS: This was a crude exercise in the handling of redundant data, but there is a suggestion that it is possible to distinguish a disaggregated route by an effect of a treatment on a mass of nociception. CONCLUSIONS: This information could underpin a paradigm of quantum nociception, and has potential to quantify aspects of analgesia practice and current and future neurophysiological theories of pain. Prospective studies are warranted.

Anaesthesia and tracheobronchial stenting for central airway obstruction in adults.

In the last decade, stents suitable for the management of tracheobronchial stenoses and obstruction have evolved from bulky prostheses requiring tracheal resection to small devices that are self-expanding and can be inserted using fibreoptic techniques. The experience base for this review is more than 100 patients between 1989 and 2001 who have been anaesthetized for stent insertion. Early cases required rigid bronchoscopy for the routine of insertion. Anaesthetic techniques have evolved from those that were designed and developed for laser surgery in the central airways. The advent of modern devices now extends the variety of anaesthetic management techniques that can be used. But the original one, based on the requirement for use of a rigid bronchoscope, is best for dealing with complications and extracting problem stents. The most frequent complication of the processes of stent insertion has been respiratory failure because of carbon dioxide retention, consequent on obstruction with secretions in the area of the carina. The nature of central airway problems suggests that anaesthesia induction, management and teaching should not be founded on the conventional model-base of upper airway obstruction.

Total spinal anaesthesia in association with insertion of a paravertebral catheter.

An association between intercostal nerve block and the development of a total spinal is rare. Usually, subarachnoid injection is considered to have followed intraneural placement or inadvertent entrance into a dural cuff extending beyond an intervertebral foramen. We report a patient that followed injection of local anaesthetic into a paravertebral catheter sited at surgery in the thoracic paravertebral space of a patient undergoing thoracotomy. This was a life-threatening event that occurred on two occasions before the definitive diagnosis was made. It is considered likely that the paravertebral catheter entered an intervertebral foramen and the tip perforated the dura.

Post-thoracotomy analgesia.

Pain relief has come a long way in 20 years. Many aspects of the relief of pain of thoracic surgery must be rationalized and modernized to meet the demands placed on services and subject to new dynamics. To place the present state of practice and knowledge in the context of an anticipation that such attitudes will impact on and, ultimately, drive services for relief of pain, the key issues of safety, defining and measuring quality, and giving value for money must be addressed. Rationing is the impetus; the exercise to be conducted by those interested in the field of thoracic pain relief is to recognize that not all patients can have or require five-star services and gold standard techniques but are entitled to an equally high quality and measure of pain relief. Newer drugs, such as clonidine, ropivacaine, and modified local anesthetics, are on the horizon; old drugs, such as ketamine, are being revisited. Their place in the field will become apparent only if the ways that outcome measures are presented are more uniform and standard. Disaggregation analysis, pain profiling, a revisitiation of respiratory restoration factor, and optimization modeling are suggested ways forward to meet the clinical and organizationally holistic population forces being generated on the cusp of the third millennium. Increasingly, we live in a world defined by guidelines and protocols. The challenge is ensuring that these measure up to the watchwords--effective, safe, affordable.

Implications of a tracheal bronchus for adult anaesthetic practice.

The problems posed by tracheal intubation in the presence of a tracheal bronchus in adults are exemplified with three case histories. The anomaly has been categorized into three types on the basis of its potential to cause problems when attempting intubation. Suggestions are given for ways of securing the airway that are safe and less likely to result in obstruction and hypoxia.

Management of complications of tracheal surgery--a case of dehiscence.

We report a case of tracheal stenosis in a patient with immune thrombocytopenia who presented 4 yr after splenectomy. The 20-yr progression of the stenosis and management, including resection, is charted. The period after resection was complicated by wound infection, surgical emphysema, mediastinitis and dehiscence of the anastomosis of the trachea. The management of patients with tracheal lesions is discussed, but concentrates on airway care after tracheal resection when complications developed. A laryngeal mask airway was used to stabilize an uncuffed tracheal tube at the site of dehiscence.