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Intradural Anesthesia in Genito-Urinary Surgery1
INTRADURAL ANESTHESIA IN GENITO-URINARY SURGERY' W. CALHOUN STIRLING
Washington, D. C. Received for publication August 22, 1924
In presenting this paper for your consideration, no attempt is made to add anything new in the way of anesthesia, but as Deaver says, "Even the most obvious things become impressive if repeated with sufficient· sincerity and frequency." On these grounds, I will present my own experience, as well as a brief survey of the literature on this subject. In reviewing this subject, one is forcibly impressed with the reluctance with which genito-urinary surgeons have adopted spinal anesthesia. Various objections have been advanced from time to time ac to the toxicity, high mortality, large per cent of failures, postoperative sequelae, etc., seen following the use of this anesthetic. That these objections are unfounded in a large measure has been my experience. This series comprises only 168 spinal anesthesias, but having given them myself, it is felt that some helpful deductions may be made. In reviewing the cause of death following operations on the genito-urinary tract, uremia has been termed '' Captain of the host of death" and accounts for at least 60 per cent of the deaths following prostatectomy. Chute says, '' The majority of deaths following enucleation of the prostate are due to inhalation anesthesia." Judd, in a recent paper emphasizes the hazardous risk in these patients, that they are more susceptible to cardio-renal and bronchial complications, 1 Read at the annual meeting of the American Urological Association, at Atlantic City, New Jersey, June 4, 1924.
535 THE JOURNAL OF UROLOGY, VOL. XII, NO,
5
536
W. CALHOUN STIRLING
such as myocarditis, hypertension, arterio-sclerosis, emphysema, etc. He also adds that a general anesthetic throws an extra burden on the eliminative organs that in many cases cannot be thrown off. He advises the use of sacral anesthesia combined with suprapubic field block, but reports at least 7 per cent of failures and that several patients complained of pain in difficult prostatectomies. This method of anesthesia has also been reported and used by Bransford Lewis, with fair results. Sacral anesthesia with infiltration of the suprapubic area has certain advantages, but is no less harmful than spinal anesthesia, and certainly does not give complete relaxation of the recti muscles. Kretschmer, in a recent discussion on ethylene gas, in operations on the urinary tract, calls attention to the shortcomings and contraindications to inhalation anesthesia. He confirms the results of others in the advantage of ethylene over nitrous oxid. It has the disadvantage of being easily diffused, and must be used with great caution in routine operations where an open cautery, etc., must be used. McNider has shown the toxicity of ether on the renal epithelium, in his work on dogs, causing a marked increase in the stainable lipoids on the loops of Henle. The 'thalein and blood chemistry findings also showed a marked deviation from normal after the anesthesia. The acid-base equilibrium of the blood is also deranged in ether narcosis, causing a depletion in the alkali reserve of the blood. Routine postoperative examinations of the urine in this series have failed to show any increase in albumen or casts, showing that the toxicity of novocaine on the kidneys can be disregarded. Caudal anesthesia has been used by me in 25 cases. It has given fair results, though it has been necessary to give either gas or ether in conjunction where deep manipulation or traction was necessary. The only severe reaction seen in this series was following the injection of 30 cc. of 1 per cent novocaine into the sacral canal. Despite the fact that the solution had been slowly injected, the patient went in collapse and required vigorous stimulation to restore her. This I have not seen occur with spinal
INTRADURAL ANESTHESIA IN SURGERY
':
537
anesthesia. Sacral anesthesia may be employed to advantage in perinea! prostatectomy, but it is not ideal for suprapubic work, since one does not derive complete anesthesia, with resultant muscular relaxation, unless local infiltration of novocaine is used in addition to it. This relaxation of the abdominal wall is essential when performing prostatectomy by the upper route, or for any intravesical operation. In spinal anesthesia the anterior nerve roots are blocked as well as the posterior ones, giving perfect relaxation, the muscles becoming flaccid, requiring little retraction. Nitrous oxid and gas in my experience has not given complete relaxation without ether. This combined form of anesthesia stimulates the cardiovascular system, respiration becomes hurried and the patient is rendered more or less cyanotic. This partial asphyxia as demonstrated by cyanosis, exerts a bad effect on the weakened heart muscle and impaired kidneys, which one expects to find in practically all of these old prostatics. With intradural anesthesia the heart is rested, respiration is slowed, the blood pressure drops moderately if the anesthetic is properly given, obviating excessive sponging as the operative field is usually fairly dry. I have not seen a case of bleeding as a result of the rise in blood pressure later, as claimed by some writers. Careful hemostasis at the time of operation has controlled this factor in my hands. The drop in blood pressure is usually temporary and has not been alarming in any of these cases. Respiration is usually slow and regular, though in cases where high anesthesia is desired, the respiration must be carefully watched and the patient told to breathe deeply and through the mouth. The chief disadvantage of spinal anesthesia has been the profound drop in blood pressure. This has been corrected, in a large measure, by giving the solution low in the spinal canal. The splanchnic areas are governed chiefly by the dorsal nerves, so that only a moderate drop in arterial tension may be expected, if the anesthetizing solution is kept away from these fibers. Smith and Porter, have shown very clearly the action of the solution on the spinal nerves of a cat, and are of the opinion that the bulk is more a factor in the upward diffusion than the
538
W. CALHOUN STIRLING
concentration. The anatomy, physiological action of the injected solution and the nerve distribution involved in spinal anesthesia, will not be discussed as it is thoroughly understood by this audience. There has been very little shock seen in any case in this series, as the nerve impulses from the operative field are prevented from bombarding the brain, by blocking the conductivity of the afferent nerves. I have had patients go through prostatectomies with no elevation of pulse rate or other evidence of shock. TOXICITY
In the past when cocaine and other highly toxic drugs were used in spinal anesthesia, some deaths were reported, just as there have been c3ises where cocaine was injected in operations on other parts of the body. Since novocaine and other nontoxic solutions have been in vogue, the mortality has been greatly reduced and as many as 7000 successful spinal anesthesias have been given with no mortality directly traceable to the anesthetic. Those using inhalation anesthesia speak of ether as if there were no deaths from its use. I have seen several patients die from ether and quote Chute who says, "We speak of spinal anesthesia as though inhalation anesthesia was without danger in these cases, while as a matter of fact the patients who die following prostatectomy, die chiefly as a result of inhalation anesthesia." In 3 cases it has been necessary to re-inject the patient, as the anesthesia was incomplete. This was done in every case where it was necessary to get surgical anesthesia, and no harmful results have been seen. DRUGS USED
Pure novocaine hydrochlorid crystals have been used exclusively in this report, and are put up in sterile ampoules, which hold enough spinal fluid to dissolve the crystals. The dosage varies from 100 to 120 mgm., depending on the weight and age of the patient. One centigram is given for each 5 kgm. body weight. All that is needed to give the solution is a 5 cc. Luer
INTRADURAL ANESTHESIA IN SURGERY
539
glass syringe, with a 20 gauge flexible needle, and a small hypodermic syringe to anesthetize the skin. An exact tenchique is required for success in this field. Its use may be condemned by those who are not familiar with the modus operandi, but with a little study and experience very little difficulty should be encountered in using it. INDICATIONS
Spinal anesthesia is indicated in all genito-urinary operations, especially below the umbilical region. I have used it on all operations of the genito-urinary tract, including nephrectomies, nephrorrhapies, prostatectomies, suprapubic lithotomies, external urethrotomies, closure of suprapubic fistulae, etc. Babcock uses it routinely for operations on the kidney and says he has never seen any ill effects from its use in this field. I rarely use spinal anesthesia for cystoscopies, as sacral block seems to work very well here. The oldest patient it was used on was eighty years old, the youngest six. I have not hesitated to use it on patients of any age, and have not seen any deleterious effects so far. The dosage is usually cut down somewhat, when used on the aged or young. CONTRAINDICATIONS
Nervous, prejudiced individuals do not take spinal anesthesia well, and complain at the slightest pain. It should not be used with patients having marked hypotension, unless measures are taken to combat a further drop in blood pressure. Patients with high arterial tension take it well, as do patients with heart lesions, as the heart is rested during the anesthesia. It is also well borne by patients with respiratory diseases requiring operative measures. It is not claimed that spinal anesthesia is the only anesthetic of choice in genito-urinary surgery, but just as there are indications for gas oxygen, ether, etc., I feel there is a field for this method of anesthesia not excelled by any other.
540
W. CALHOUN STIRLING TECHNIQUE
The technique is briefly as follows: With the patient sitting across the table, or lying on either side, the back is bowed well forward .and the interspace to be injected is located, using the iliac crests as a guide. For surgery of the upper abdomen, the second lumbar space is used. This will give anesthesia as high as the nipple line, other things being equal, and enables one to do a nephrectomy with ease. For prostatic and bladder work, the third, or preferably the fourth lumbar space is selected. The skin is sterilized, then anesthetized with novocaine. A 20 gauge flexible needle is slowly introduced until it can be felt piercing the dura, spinal fluid is then seen and enough collected in the ampoule to dissolve the crystals. Then from 10 to 15 cc. of spinal fluid is collected and discarded. The dissolved solution is then slowly introduced, aspirating fresh spinal fluid in the syringe several times, to make sure the needle has not moved. This is the most important procedure in the injection as it has been found if spinal fluid cannot be free.l y aspirated in the syringe, the needle is not properly placed and the anesthesia will be slight or absent. The needle is then withdrawn and the patient allowed to resume the recumbent position, with the head well supported on pillows. The Trendelenberg position is used if needed. One cubic centimeter of pituitrin is given just after the spinal puncture to aid in keeping the arterial tension from dropping unduly. One can usually count on an hour to operate, though it sometimes lasts as long as ninety minutes, the highest point of anesthesia being the shortest. Only 5 of these cases have complained of postoperative headaches, which passed off within forty-eight hours. No untoward sequelae have been seen in any case and the mortality has been nil. CONCLUSIONS
This report embraces 160 cases in which spinal anesthesia was used, and such uniformly good results have been obtained that its
INTRADURAL ANESTHESIA IN SURGERY
541
use as a routine anesthetic is strongly advocated in surgery below the costal margin. The mortality compares very favorably with any other anesthetic and the postoperative complications such as distension, nausea, and vomiting, have been markedly reduced. Fluids may be kept up before, during and after the operation, thus lessening the depletion of body fluids. The cardio-renal and respiratory systems, which in these conditions are already depressed, escape the additional burden which would be thrown on them by inhalation anesthesia, and thereby lessen the danger of uremia. REFERENCES CHUTE, A. L.: Spinal anesthesia in prostatectomy. Jour. Amer Med. Assoc., November, 1922, lxxix, no. 20, 1165. LABAT, GASTON : Regional Anesthesia. W. B. Saunders Co., 1924. BRANSFORD LEWIS, AND BARTELS, LEO: Caudal anesthesia in genito-urinary surgery. Surg., Gyn and Obst., Michigan, 1916. DEAVER, JoHN B. : Early diagnosis of the more common upper abdominal conditions. Boston Med. and Surg. Jour., June, 1914. KRETSCHMER, HERMAN L., and LUCKHARDT, A.: Ethylene gas in genito-urinary surgery. Jour. Urol., 1924, xi, 415. l'vlcNrnER, WM. D. B.: Naturally nephropathic animals, etc. Jour. Pharm. and Exper. Therap., December, 1922, xx, no. 5. SMITH, G. G.: Porter, spinal anesthesia in the cat. Amer. Jour. Physiol., July, 1915, xxxviii, no. 1. STIRLING, W. CALHOUN : Preliminary report on spinal anesthesia. Urol. and Cut. Rev., February, 1922, xxvi, 1. STIRLING, W. CALHOUN: Further report on spinal anesthesia. Va. Med. Monthly, December, 1923.
Washington, D. C. Received for publication August 22, 1924
In presenting this paper for your consideration, no attempt is made to add anything new in the way of anesthesia, but as Deaver says, "Even the most obvious things become impressive if repeated with sufficient· sincerity and frequency." On these grounds, I will present my own experience, as well as a brief survey of the literature on this subject. In reviewing this subject, one is forcibly impressed with the reluctance with which genito-urinary surgeons have adopted spinal anesthesia. Various objections have been advanced from time to time ac to the toxicity, high mortality, large per cent of failures, postoperative sequelae, etc., seen following the use of this anesthetic. That these objections are unfounded in a large measure has been my experience. This series comprises only 168 spinal anesthesias, but having given them myself, it is felt that some helpful deductions may be made. In reviewing the cause of death following operations on the genito-urinary tract, uremia has been termed '' Captain of the host of death" and accounts for at least 60 per cent of the deaths following prostatectomy. Chute says, '' The majority of deaths following enucleation of the prostate are due to inhalation anesthesia." Judd, in a recent paper emphasizes the hazardous risk in these patients, that they are more susceptible to cardio-renal and bronchial complications, 1 Read at the annual meeting of the American Urological Association, at Atlantic City, New Jersey, June 4, 1924.
535 THE JOURNAL OF UROLOGY, VOL. XII, NO,
5
536
W. CALHOUN STIRLING
such as myocarditis, hypertension, arterio-sclerosis, emphysema, etc. He also adds that a general anesthetic throws an extra burden on the eliminative organs that in many cases cannot be thrown off. He advises the use of sacral anesthesia combined with suprapubic field block, but reports at least 7 per cent of failures and that several patients complained of pain in difficult prostatectomies. This method of anesthesia has also been reported and used by Bransford Lewis, with fair results. Sacral anesthesia with infiltration of the suprapubic area has certain advantages, but is no less harmful than spinal anesthesia, and certainly does not give complete relaxation of the recti muscles. Kretschmer, in a recent discussion on ethylene gas, in operations on the urinary tract, calls attention to the shortcomings and contraindications to inhalation anesthesia. He confirms the results of others in the advantage of ethylene over nitrous oxid. It has the disadvantage of being easily diffused, and must be used with great caution in routine operations where an open cautery, etc., must be used. McNider has shown the toxicity of ether on the renal epithelium, in his work on dogs, causing a marked increase in the stainable lipoids on the loops of Henle. The 'thalein and blood chemistry findings also showed a marked deviation from normal after the anesthesia. The acid-base equilibrium of the blood is also deranged in ether narcosis, causing a depletion in the alkali reserve of the blood. Routine postoperative examinations of the urine in this series have failed to show any increase in albumen or casts, showing that the toxicity of novocaine on the kidneys can be disregarded. Caudal anesthesia has been used by me in 25 cases. It has given fair results, though it has been necessary to give either gas or ether in conjunction where deep manipulation or traction was necessary. The only severe reaction seen in this series was following the injection of 30 cc. of 1 per cent novocaine into the sacral canal. Despite the fact that the solution had been slowly injected, the patient went in collapse and required vigorous stimulation to restore her. This I have not seen occur with spinal
INTRADURAL ANESTHESIA IN SURGERY
':
537
anesthesia. Sacral anesthesia may be employed to advantage in perinea! prostatectomy, but it is not ideal for suprapubic work, since one does not derive complete anesthesia, with resultant muscular relaxation, unless local infiltration of novocaine is used in addition to it. This relaxation of the abdominal wall is essential when performing prostatectomy by the upper route, or for any intravesical operation. In spinal anesthesia the anterior nerve roots are blocked as well as the posterior ones, giving perfect relaxation, the muscles becoming flaccid, requiring little retraction. Nitrous oxid and gas in my experience has not given complete relaxation without ether. This combined form of anesthesia stimulates the cardiovascular system, respiration becomes hurried and the patient is rendered more or less cyanotic. This partial asphyxia as demonstrated by cyanosis, exerts a bad effect on the weakened heart muscle and impaired kidneys, which one expects to find in practically all of these old prostatics. With intradural anesthesia the heart is rested, respiration is slowed, the blood pressure drops moderately if the anesthetic is properly given, obviating excessive sponging as the operative field is usually fairly dry. I have not seen a case of bleeding as a result of the rise in blood pressure later, as claimed by some writers. Careful hemostasis at the time of operation has controlled this factor in my hands. The drop in blood pressure is usually temporary and has not been alarming in any of these cases. Respiration is usually slow and regular, though in cases where high anesthesia is desired, the respiration must be carefully watched and the patient told to breathe deeply and through the mouth. The chief disadvantage of spinal anesthesia has been the profound drop in blood pressure. This has been corrected, in a large measure, by giving the solution low in the spinal canal. The splanchnic areas are governed chiefly by the dorsal nerves, so that only a moderate drop in arterial tension may be expected, if the anesthetizing solution is kept away from these fibers. Smith and Porter, have shown very clearly the action of the solution on the spinal nerves of a cat, and are of the opinion that the bulk is more a factor in the upward diffusion than the
538
W. CALHOUN STIRLING
concentration. The anatomy, physiological action of the injected solution and the nerve distribution involved in spinal anesthesia, will not be discussed as it is thoroughly understood by this audience. There has been very little shock seen in any case in this series, as the nerve impulses from the operative field are prevented from bombarding the brain, by blocking the conductivity of the afferent nerves. I have had patients go through prostatectomies with no elevation of pulse rate or other evidence of shock. TOXICITY
In the past when cocaine and other highly toxic drugs were used in spinal anesthesia, some deaths were reported, just as there have been c3ises where cocaine was injected in operations on other parts of the body. Since novocaine and other nontoxic solutions have been in vogue, the mortality has been greatly reduced and as many as 7000 successful spinal anesthesias have been given with no mortality directly traceable to the anesthetic. Those using inhalation anesthesia speak of ether as if there were no deaths from its use. I have seen several patients die from ether and quote Chute who says, "We speak of spinal anesthesia as though inhalation anesthesia was without danger in these cases, while as a matter of fact the patients who die following prostatectomy, die chiefly as a result of inhalation anesthesia." In 3 cases it has been necessary to re-inject the patient, as the anesthesia was incomplete. This was done in every case where it was necessary to get surgical anesthesia, and no harmful results have been seen. DRUGS USED
Pure novocaine hydrochlorid crystals have been used exclusively in this report, and are put up in sterile ampoules, which hold enough spinal fluid to dissolve the crystals. The dosage varies from 100 to 120 mgm., depending on the weight and age of the patient. One centigram is given for each 5 kgm. body weight. All that is needed to give the solution is a 5 cc. Luer
INTRADURAL ANESTHESIA IN SURGERY
539
glass syringe, with a 20 gauge flexible needle, and a small hypodermic syringe to anesthetize the skin. An exact tenchique is required for success in this field. Its use may be condemned by those who are not familiar with the modus operandi, but with a little study and experience very little difficulty should be encountered in using it. INDICATIONS
Spinal anesthesia is indicated in all genito-urinary operations, especially below the umbilical region. I have used it on all operations of the genito-urinary tract, including nephrectomies, nephrorrhapies, prostatectomies, suprapubic lithotomies, external urethrotomies, closure of suprapubic fistulae, etc. Babcock uses it routinely for operations on the kidney and says he has never seen any ill effects from its use in this field. I rarely use spinal anesthesia for cystoscopies, as sacral block seems to work very well here. The oldest patient it was used on was eighty years old, the youngest six. I have not hesitated to use it on patients of any age, and have not seen any deleterious effects so far. The dosage is usually cut down somewhat, when used on the aged or young. CONTRAINDICATIONS
Nervous, prejudiced individuals do not take spinal anesthesia well, and complain at the slightest pain. It should not be used with patients having marked hypotension, unless measures are taken to combat a further drop in blood pressure. Patients with high arterial tension take it well, as do patients with heart lesions, as the heart is rested during the anesthesia. It is also well borne by patients with respiratory diseases requiring operative measures. It is not claimed that spinal anesthesia is the only anesthetic of choice in genito-urinary surgery, but just as there are indications for gas oxygen, ether, etc., I feel there is a field for this method of anesthesia not excelled by any other.
540
W. CALHOUN STIRLING TECHNIQUE
The technique is briefly as follows: With the patient sitting across the table, or lying on either side, the back is bowed well forward .and the interspace to be injected is located, using the iliac crests as a guide. For surgery of the upper abdomen, the second lumbar space is used. This will give anesthesia as high as the nipple line, other things being equal, and enables one to do a nephrectomy with ease. For prostatic and bladder work, the third, or preferably the fourth lumbar space is selected. The skin is sterilized, then anesthetized with novocaine. A 20 gauge flexible needle is slowly introduced until it can be felt piercing the dura, spinal fluid is then seen and enough collected in the ampoule to dissolve the crystals. Then from 10 to 15 cc. of spinal fluid is collected and discarded. The dissolved solution is then slowly introduced, aspirating fresh spinal fluid in the syringe several times, to make sure the needle has not moved. This is the most important procedure in the injection as it has been found if spinal fluid cannot be free.l y aspirated in the syringe, the needle is not properly placed and the anesthesia will be slight or absent. The needle is then withdrawn and the patient allowed to resume the recumbent position, with the head well supported on pillows. The Trendelenberg position is used if needed. One cubic centimeter of pituitrin is given just after the spinal puncture to aid in keeping the arterial tension from dropping unduly. One can usually count on an hour to operate, though it sometimes lasts as long as ninety minutes, the highest point of anesthesia being the shortest. Only 5 of these cases have complained of postoperative headaches, which passed off within forty-eight hours. No untoward sequelae have been seen in any case and the mortality has been nil. CONCLUSIONS
This report embraces 160 cases in which spinal anesthesia was used, and such uniformly good results have been obtained that its
INTRADURAL ANESTHESIA IN SURGERY
541
use as a routine anesthetic is strongly advocated in surgery below the costal margin. The mortality compares very favorably with any other anesthetic and the postoperative complications such as distension, nausea, and vomiting, have been markedly reduced. Fluids may be kept up before, during and after the operation, thus lessening the depletion of body fluids. The cardio-renal and respiratory systems, which in these conditions are already depressed, escape the additional burden which would be thrown on them by inhalation anesthesia, and thereby lessen the danger of uremia. REFERENCES CHUTE, A. L.: Spinal anesthesia in prostatectomy. Jour. Amer Med. Assoc., November, 1922, lxxix, no. 20, 1165. LABAT, GASTON : Regional Anesthesia. W. B. Saunders Co., 1924. BRANSFORD LEWIS, AND BARTELS, LEO: Caudal anesthesia in genito-urinary surgery. Surg., Gyn and Obst., Michigan, 1916. DEAVER, JoHN B. : Early diagnosis of the more common upper abdominal conditions. Boston Med. and Surg. Jour., June, 1914. KRETSCHMER, HERMAN L., and LUCKHARDT, A.: Ethylene gas in genito-urinary surgery. Jour. Urol., 1924, xi, 415. l'vlcNrnER, WM. D. B.: Naturally nephropathic animals, etc. Jour. Pharm. and Exper. Therap., December, 1922, xx, no. 5. SMITH, G. G.: Porter, spinal anesthesia in the cat. Amer. Jour. Physiol., July, 1915, xxxviii, no. 1. STIRLING, W. CALHOUN : Preliminary report on spinal anesthesia. Urol. and Cut. Rev., February, 1922, xxvi, 1. STIRLING, W. CALHOUN: Further report on spinal anesthesia. Va. Med. Monthly, December, 1923.