Book Review

Metabolic and Rheumatologic Disorders

Acid and Basics: A Guide to Understanding Acid-Base Disorders

N Engl J Med 1994; 331:955October 6, 1994

Article

Acid and Basics: A Guide to Understanding Acid-Base Disorders
By Jerome Lowenstein. 154 pp., illustrated. New York, Oxford University Press, 1993. $35 (cloth); $14.95 (paper). ISBN: 0-19-507572-2 (cloth)

With the plethora of pages devoted to acid-base disorders in the major textbooks of medicine and the useful formulas and mnemonics given in handbooks, it is a tribute to Jerome Lowenstein that the pedagogy of acid and base disorders seems more complete after the publication of his new book. Lowenstein has a flair for storytelling, and he targets medical students and young physicians. But his lucid explanations have a depth and sophistication that a much wider audience will enjoy.

Beginning with an entertaining historical overview of acids and bases, Lowenstein quickly reviews the relevant college-level chemistry and then elucidates in detail the physiology of acid-base metabolism. The basic chemistry is easy and hence covered quickly; the details of membrane-transport proteins, renal ammoniagenesis, and buffers are more difficult concepts and need more explanation. Lowenstein's style is Socratic and his approach mechanistic, engaging the reader with a question, then responding with an answer that appropriately acknowledges areas that are incompletely understood. Revealing the skill of an experienced teacher, Lowenstein marshals wonderful metaphors from fields ranging from cooking to electrical engineering to clarify his explanations and lead from simple concepts to complex ones.

The final chapters of the book deal with the four cardinal acid-base disorders, and these will be particularly useful to clinicians. The chapters on metabolic disorders are particularly strong, offering cogent discussions of the serum and urine anion gap, renal tubular acidosis, and chloride-responsive and chloride-unresponsive metabolic alkalosis. Perhaps owing to the author's training as a nephrologist, the discussions of respiratory disorders are briefer, but still effective.

If there is any shortcoming to Lowenstein's tour de force, it is that the “uninitiated and timid” whom he addresses in the preface are not given a clearer outline to aid them in deciphering acid-base disorders. The author eschews algorithms and formulas in his quest to elucidate the underlying pathophysiology. Many explanations are at a level of sophistication one might find in a biochemistry course. Although all this is clinically relevant, a more detailed way of approaching complex acid-base disorders would give readers a greater sense of mastery.

Ostensibly aimed at medical students and young physicians, Lowenstein's short and readable book forms a nexus between physiology and clinical problem-solving. It will be useful to all clinicians who seek an excellent review of this potentially vexing subject.

John Butter, M.D.
Dartmouth-Hitchcock Medical Center, Hanover, NH 03755