Spinal anesthesia—Volume control technique

SPINAL ANESTHESIA-VOLUME TECHNIQUE* RICHARD

CONTROL

B. STOUT, M.D.

MADISON, WISCONSIN

M

UCH interest has been aroused by recent deveIopments in spinal anesthesia, but there still exists considerable skepticism on the part of many surgeons as to its reliability and safct\. . A technique has been developed at the .lackson CIinic \vhich makes possible a definite control of the height of anesthesia on the hod!- Lvithout the introduction of an> substance other than novocaine into the spinal canal. This technique also prevents the \\-ide variations in blood pressure and the nausea, \.omiting and related discomforts which frequently occur Ivith most of the methods nou- in general LlSt’.

Corning, a neurologist, first attempted to relies-e the pain of a cliseased spine in 1885 by injection of a solution of cocaine. Quincke, in 1891, n-as the first to withdra\\ spinal fluid I~\- lumbar puncture; Bier in 1899 successfulI>. injected cocaine into the spinal c*nnaI, and Tait and Cngleri in 1899 used intradurnl injections of cocaine for surgical anesthesia; the method enjoyed a brief popularity but \vas soon abandoned because of’ frequent disnsterous results. \C:ith the discover>- of the less toxic drugs, sto\.aine I~\- Fournenu in 1904 and novocninc I),y Einhorn in 1905, spinal anesthesia \vns :igain attempted 6). Braun and others lvith mow f:i\,orable results. In America Babcock and Labat ha\.e been for years the foremost exponents of the method and ha\,e reportecl several thousand cases, with an extremely Ion morbidity. and mortality. The majokt?; of
popularized spina anesthesia through the routine prophylactic use of ephedrine, which adds greatly. to the safet). of the method, together \vIth gravitation of light and heav>- soIutions of no\ocaine first suggested b\- Barker in rgo- to control the extent ok anesthesia. hIan,of the recorded accidents with spinal anesthesia have been clue’ to an inadequate understanding of the h>drodynamics of the spina fluid and of the technical procedures in\-ol\.ed. Lack of preparation to meet the emergencies that may arise ha\.eadded an occasional fatalit\ . The majority of deaths have been amon< patients mor’ibund at the time (of operation, and undoubtedI>would ha1.e occurred \vith any form of anesthesia. Against these ma\. be counted many patients \vho h;~vc silt-\ ived major surgery uncler spinal anest hesia, for Lrhom an>- other for-n1 of anesthesia probably wouIcI h:l\.e t)een fatal.

No\ocaine in solution, Fvhen introcluced into the spinal canal, is rapidI>- absorbed b,v ner1.e tissue and bIocks the passage of sensor\ ~ or motor stimuli. \2’hen it i< diffused upkvard in the dural Lxnal to :I for the perfotmance of lex.el necessary a large proportion of abdominaI surgery, the spinal nerx-es that suppI>. motor stimulation to the sympathetics b>, \va> of the white rami communicantes arc paral!.zecl, causing \.asodilntion and a fail in blood The extent of this fa11 in blootl pressure. pressure has been found to hold ;I direct proportion to the extent of sympathetic, paralysis, lvhich in turn ma?- be gauged I~?- the height of anesthesia on the body. The Trendelenburg position \vas frrst used to combat this fall in bloocl pressuw and is stii1 being used routinel?by Rab-

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American

Journal

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cock and Labat without other stimuIation. This causes bIood to gravitate to the brain cerebra1 anemia in spite and prevents

JUll, 1gzg

Anesthesia

off and the sympathetics regain contro1. Ephedrine admirably fuIfilIs the foregoing requirements. Its use in spinal anesthesia

^^I.

\

\\

FIG. I. Diagram showing extent of sympathetic paraIysis compnrcd with IevcI of anesthesia on body. Sympathetics are vasoconstrictors, while parasympathetics (broken lines) are vasodilators. Anesthesia to &vi& involvcs paraIysis of all sympathetics and maximum faII in blood pressure which may be prevented by maximum prophylactic dose of ephedrine. Anesthesia to umbilicus invoIves paralysis of about half of sympathctics, therefore half maximum dose of ephedrine is given. Perinca anesthesia does not cause sympathetic paralysis, hence no ephedrine is given.

of the genera1 vascuIar reIaxation, but aIIows stagnation in the dependent portions of the body and anemia in the uppermost. The Trendelenburg position in most instances wiI1 suffice to save the patient from death by cerebra1 anemia, but the occasiona1 case of severe myocardia1 damage allows stagnation to such an extent that emergency cardiovascuIar stimulation may become necessary. AdrenaIin has been used for this purpose, but its action is so fI eeting that repeated injections are necessary and the patient’s vascuIar instabiIity often becomes a source of concern to the anesthetist. A more desirabIe procedure is the prophyIactic administration of some peripherally acting vascuIar stimuIant which wiI1 maintain a norma vascuIar tone over the entire body until the anesthesia wears

was introduced by OckerbIad and DiIIon in 1927. They first gave it oraIIy after the bIood pressure had faIIen IO per cent of its original Ievel and Iater hypodermicaIIy. Its prophyIactic use before induction of the spinal anesthesia was then tried with such favorable results that it has become the method of choice. VOLUME

CONTROL-THEOKY

In a series of 600 cases in the Jackson CIinic, we have found it possibIe to produce a spina1, or intradura1 radicular bIock anesthesia, which can be accurateIT controlIed as to the height of anesthesia on the body. This technique does not invoI\-e the introduction of any foreign substance other than novocaine into the spinal cana1, and its success depends upon an understanding of the hydrodynamics of

the spinal fIuid rather than the effect of gr:r\ itv upon light or hen\.)- solutions of no\.ocaine. Nothing has been introduced to prex.ent difYusion of the drug lvithin the spinal canal as it is possibIe, \vith an understanding of the ph\-sical principles go\.erning this difI’usion, to control it accur:lteIy enough for practica1 purposes. In ;I rex.iew of physical chemistry certain princ+pIes governing diffusion of cr>-stalloids in soIution will be found, which, Mhen applied to spinal anesthesia, form the basis of a method to control the extent of diffusion of novocaine in the spina cana1, and hence the height of anesthesia on the body. I; I’\VAKD

EXTENSION

OF

ANLSTHESI.4

I. 7‘he upward e.utension - proportional to the speed of difusion of tbe novocaine in.jected into the q~inal canal. The diffusion rate of a crystalloid in a preponderantI)aqueous soIx.ent is constant Lvhen the temperature of the solutheir proportionate x-olumes and tions, amount of concentrations, and the mechanicoI agitation are kept constant. 2. It is incersely proportional to the rate f)j ,fisation of nozxjcaine /Iv nerve tissue. Dif‘usion of a crystalloid in an aqueous soI\.ent proceeds at a definite rate unti1 its concentration is uniform throughout the soI\.ent. Complete diffusion may be pre\,ented by- the early retno\-aI of the difl‘using crystaIIoid from the soIvent. Thus genera1 anesthesia is prevented by the rapid fixation of novocaine from the spin71 fluid by nerve tissue, and the extent of diffusion is Iimited bJ- the rapidity of lixrtion. The rate of fixation, as observed cIinicaII~, is practically constant, therefort, the rate of diffusion must be varied to produce a \,ariation in the extent of resultant IcveI of or the diffusion xnesthesia. 3. It is direct&- proportional to the volume (!f’,Jluid injected. The larger the voIume of fluid injected, ;111 other factors remaining constant, the

higher wiI1 the anestheskl extend as a direct result of increased \-olume dispIacement and increased mechanical agitation which :tcc.eIernte the rate of ditfwsion of the injected nolwcainc. 4. It is direct&- proportional to the speed (!f in,jection. The morerapid theinjection thefilsterthe up\vard difl’usion of the anesthetic agent, due to increased mechanic:11 agit:ltion. 3. It i.s inverse&r proporlionai to the cerebrospinal jluid pressure. The diffusion of an)- two liquids under pressure is slower than under decreased pressure. U:hen unmeasured qu:\ntities of cerebrospinal ffuid are allowed to escape, the pressure is reduced an unkno\\-n amount and diffusion will proceed to a higher Iex.eI, proportional to the decrease in intraspina1 pressure, and the anesthetist is unable to predict the resultant le\,eI of anesthesia. 6. It is direct(v proportionul to the speciJic gravity oj the solution. Increasing the specific gra\.itJ. of the soIution by use of Iarge amounts of no\-ocaine will increase the rate of diff’usion by increase of mass and hence inertia oi the heal.\injected solution. It more novocaine is injected than is required to saturate the nerve tissue to the desired Ie\.eI, diffusion wiI1 continue until ail the novocaine is fixed or absorbect from the spinal fIuic1, thus producing :I higher Ie\.cI of anesthesia than desired. 7. It depends upon the position (!f the patient’s body* when there existr a difference the solution in specific gravity- between in,jectcd and the spznal Juid. Gravitation of a concentrated solution of no\-ucaine to the tip of the dural can4 \\-ill produce anesthesia of the perineum of concentrated onIy, as \viII gra\ itation no\-ocsinc to the dorsal or cerx.icodors:ll curves produce segmenta anesthesia of abdomen and thorn:;. The the upper Trendelenburg position assumed during or immediately after injection of nox,ocaine will accelerate the rate of upward cIifYusion while Foaler’s position xi11 retard it.

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American

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Anesthesia

the certainity of producing anesthesia to any definite IeveI on the body as desired, As previousI\- mentioned, ephedrine is we were abIe to predict with a fair degree a peripherally acting vascuIar stimulant of accuracy the extent of the fall in blood pressure to be expected. The prophyIactic dose of ephedrine was then varied in direct proportion to the degree of vasodiIation expected. This has resulted in a much greater vascular stabiIitx during anesthesia with less nausea, \-omrting and physical discomfort to the patient. 60 The proper timin g of the prophyIactic dose of ephedrine has also been found to be an important factor in maintainence as is illustrated by of blood pressure 0 Figure 2. If the spinal anesthesia is induced before absorption of the ephedrine has started, \rascular tension is reduced to such an extent that absorption takes pIace slo~vlg, if at all, and stimuIation by adrenalin becomes necessary. It has been noted that the greatest faI1 in blood pressure, in spite of the prophyIactic dose of ephedrine, occurs in hyperbvhich, when properly administered, wilI tensive cases with scIerosis. The explanation may be offered that whiIe the periphmaintain a norma vascular tone over the eral vessels may be palpably scIerotic, the entire bodsr unti1 the anesthesia wears splanchnic \.essels are rarely as markedIy off and the sympathetics regain contro1. so. As ephedrine is a peripherally acting If the anesthetic agent is diffused to such vasoconstrictor, its stimulation in sclerotic a 1eveI that all the sympathetics are cases is relatively ineffective, and as the paralyzed, a maximal fall rn blood pressure Iess scIerotic splanchnic \.esseIs dilate will occur, while if only a portion of the with onset of anesthesia a great faII in sympathetics are paralyzed, a proportionis usuaIl\experienced. blood pressure ately Iess se\-ere faI1 will occur. In the This suggested the use of larger doses of absence of any method to definitely ephedrine or the addition of a small dose contro1 the height of anesthesia, when of adrenalin. The Iatter therapy has been using novocaine crystals dissolved in spinal used successfuIIy in the few cases met with fluid, the degree of faI1 in blood pressure in this series. Patients \vith functiona or to foIIow could not be predicted. A uniform essentia1 hypertension (not encountered in prophyIactic dose of i’x grain of ephedrine this series) wouId on a theoretica basis is commonly used, supplemented by the be given a small dose of ephedrine. HypoTrendeIenburg position, adrenalin, or more tensive patients ma>: be given an increased ephedrine as the occasion seems to demand. o\;er dose of ephedrine which \vill raise their presThis is a definite improl-ement sure to a safe Ieve during the anesthesia. previous methods, hotvever, nausea, vomitThe most important factors in I-olume ing and minor variation of blood pressure contro1 technic of spina anesthesia are: continue to occur when the anesthesia the aspiration of accurately measured extends higher than the costal margin. volumes of spinal fluid used as a solvent With the development in the Jackson for graded doses of no\-ocaine, and the CIinic of volume control technique and BLOOD

PRESSURE

CONTROL

NI \5

Sr~,ts

VOL.

VII,

No.

I

Stout-Spinal

Anesthesia

American

.lourn:~l <,I Surgyrv

61

reinjection of the spinal fIuid novocaine at a constant measured rate solution tvithout loss of fluid during the manipula-

and the condition of the patient during operation. Preparation of the patient for operation

tion. This is facilitated bj- the use of small caliber (22 gauge) spinal puncture needles which minimize fluid loss and avoid postpuncture leakage and cord trauma. Of equal importance is the properly timed prophylactic administration of ephedrine in amounts direct117 proportional to the height of anesthesia to be produced, varied also according to the size of the patient and his \,ascular condition. A careful record should be kept of all factors \-aried under control, the extent of the anesthesia produced and its duration, the patient’s genera1 condition, and any with medication during the operation, graphic blood pressure and puIse records. These records must be studied and coma fuII realization of the pared to obtain effect of variation of any given factor upon the resultant Ievel of anesthesia

under spinal anesthesia includes at least t\vent>.-four hours of rest in bed, adequate h\-dration, and the usual laboratory and ph\-sical esamin~~tions.Thefollo~~in~standardized routine orders arc carried out in the preparation of all patients for major operations: I. Fluids should be forced to at Ieast 3500 C.C. during twent>--four hours preceding operation. 2. Thorough cleansing enema on wening before operation. 3. Ten grains of sodium barbital by mouth one and one-half hours preceding operation. 4. Pantopon, grain ItI, and scopolamine, one hour by hypodermic grain l i.i0, before operation. 5. Stop up patient’s ears and co\.er eyes, keep room quiet.

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The technique shown in Table I wiI1 produce anesthesia to the indicated Ievels in the average adult weighing 130 pounds.

VoIumes, novocaine and ephedrine dosage must be increased proportionately for Iarge individuars and decreased for smaIi ones. Ephedrine dosage is varied from that prescribed in the tabIe in cases of hypotension and hypertension. Any severe faII w\;rthin five or ten in bIood pressure ’ minutes after injection of the novocainespinal fluid solution means that an insufficient prophyIactic dose of ephedrine was given or that the intraspina1 injection was made too soon after the ephedrine was given. If th e injection is made five minutes or more after a sufficient dose of ephedrine has been injected intramuscularly, this faII wiI1 not occur.

Anesthesia TECHNIQUE I.

Record

bIood

pressure

on

graphic

chart. 2. Prepare surgica1 fieId, cover with sterile towel, strap towel down with adhesive straps. 3. With the patient in the right lateral position, back bowed out, knees up, neck flexed, and steadied by an assistant, the back and upper buttock is thoroughly scrubbed with ether and aIcoho1, dried and painted with 3 per cent tincture of iodine. 4. Inject ephedrine intramuscularly in buttock noting time of injection. (For dosage see TabIe I.) Massage site of injection thoroughIy. Ephedrine is not given when perinea1 anesthesia onIy is desired. 5. After paIpation of a convenient Iumbar interspace (usually the second or third) produce IocaI ischemia by firm pressure of the thumbnai1 for ten to twenty seconds. Then quickIy introduce a za-gauge spinal puncture needle through bIanched area which has been rendered temporarily anesthetic by pressure. Continue introduction of needle sIowly through interspinous ligament into dural sac, which is recognized by a sIight snap and subsequent Iack of resistance. Novocaine skin infiltration may be used if so desired. 6. Remove stylet of spina needle. When fluid is seen weIImg up into hub of needIe, quickIy attach syringe without 10~s of fluid and sIowIy aspirate the required voIume of fluid. (See TabIe I for volume.) Detach syringe and quickly replace styret. 7. Attach another needIe to syringe and transfer spina fluid to ampule of novocaine crystaIs (For dosage see Table I). DissoIve crystaIs by barbotage, aspirate solution into syringe, detach needle and express any air bubbles. 8. Five minutes after ephedrine was injected, remove stylet from spins1 needle, quickly attach syringe and inject soIution at a rate of I C.C. in five seconds without barbotage. 9. SpinaI needle is then withdrawn, stiI1 attached to syringe, and with a steriIe

sponge held over the site of puncture, the patient is pIaced in position for operation. IO. BIood pressure readings are taken

of the novocaine in the nerve tissue by that time. The IeveI of anesthesia may be raised if the TrendeIenburg position is taken sooner. If too Iarge a dose of no\-oCaine has been used, complete absorption takes a longer time and TrencIeIenburg position in ten minutes may aIIon gravitation of the unabsorbed remainder, thus raising the Ievel of anesthesia on the trunk. A competent anesthetist shouId be with the patient throughout the operation and attend to his menta1 and physical comfort. Blood pressure and pulse rate are recorded at frequent intervaIs. Pantopon or morphine may be administered during the operation if the preoperative sedation is deemed insuffrcient.

and recorded whiIe draping the operative field, and the patient is told that he may expect :I sensation of numbness to foIIow shortIT. I I. The level of anesthesia is determined by pin-prick fix-e minutes after

Ephedrine and adrenalin in ampuIes should be kept read\for h>-podermic injection in case any considerable faI1 in bIood pressure shouId occur. Ephedrine suIphate in ampules contain(,LilIy) and ing lti grain in I C.C. solution novocaine crystaIs in ampuIes containing 100 or 200 mg. (Metz) hn\re been used throughout this series of cases. Luer-Lok 2 C.C. and 3 C.C. syringes and 22 gauge spina puncture B-D Erusto point ha\ e been needles w+th 4s’ bevel

injection and recorded. Operation is then aIIowed to proceed. After ten minutes the IeveI of the table may be changed (Fowier’s or TrendeIenburg) to suit the convenience No change in IeveI of of the surgeon. anesthesia resuIts, which indicates fixation

found most satisfactory. They may be cIeaned by rinsing in distiIIed Lvater, wrapped in a towel with gauze sponges, gIoves and powder, a file and a Iifter for the ampuIes, and autoclaved for twenty minutes at 20 pounds pressure. Several

FIG.

5.

AccurateIy injection.

timed intraspina1 iNotc wrist watch.)

novoc:~ine

6-I

Americ:ln

Journal

oi Surgery

Stout-Spinal

such sterile outfits are alwa?-s kept on of novocaine crystals, hand. Ampules ephedrine and adrenalin are kept in small covered cups immersed in 70 per cent aIcoho1 until used. INDICATIONS FOR

AKD SPINAL

CONTKAINDICATIONS ANESTHESIA

which has long been Spinal anesthesia, recognized as the safest anesthesia for use in cases \I-ith se\.ere pulmonary, cardiac, renal or hepatic complications, is certainly the safest anesthesia to use in the average case. The extent to which spina anesthesia can be utilized in surgery is limited only by the anesthetist’s skill and experience, and probably in the near future will ahnost compIeteIy repInce inhalation anesthesia. Hypotension, which in the past LV~S a forma1 contraindication to spina anesthesia, may now be successfully overcome by the judicious use of ephedrine. Dehydration, which is a contraindication to surgery, may be effectuaIIy overcome by the subcutaneous or intravenous administration of fluid. COMPLICATIONS

OF

SPINAL

ANESTHESIA

The most common immediate compIication of spinal anesthesia is a slight to moderate faI1 in blood pressure, usually accompanied by nausea and occnsionaIIy vomiting when systoIic pressure faIIs below 8j mm. L$:hen due to an insufficient prophy attic dose of ephedrine, nausea may be relieved b\- the injection of 2 or 3 minims of adrenalin which quickly restores the bIood pressure to its former IeveI. Nausea, caused by too vigorous mesenteric traction, is usually accompanied by a sIight faI1 in bIood pressure which quickly regains its former Ie\-e1 with cessation of the nausea when the traction is stopped. StimuIation by adrenaIin in this case wiI1 raise the bIood pressure but &II not relieve the nausea. Adequate incision and gentIe handIing obviate this difIicuIty. Psychic nausea is unaccompanied by a faI1 in bIood pressure and may be pre\-ented by avoiding the

Anesthesia clatter of instruments, loud conversation, and noises which might disturb a conscious patient. Even a nervous patient may be comfortably carried through a major operation if sufhcient preoperative sedation has been given, or if the anesthetist wiI1 keep the patient’s mind off the operation by means of an interesting conversation. in the Convulsions are reported Iiterature to ha1.e followed injection of novocaine into the \-enous pIesuses around the cord. CarefuI lumbar puncture and the administration of IO grains of sodium barbita1 by mouth one and one haIf hours preoperatively will prevent this occurrence. Respiratory and cardiac failure have been reported with the higher anesthesias, but have not been encountered in this series. Of great interest in this connection is the work of Jonnesco and of Koster who have produced general surgical anesthesia, by the intradural injection of nowcaine and neocaine, permitting operations on the head, neck and thorax, without the occurrence of respiratory or cardiac failure. This may be due to gravity keeping the reIativeIy heavy solution of no\-ocaine confined to the posterior position of the spina cana as it diffuses cephalud, thus anesthetizing the sensory roots onI?- at the higher IeveIs. This may be duplicated by the injection of coIored novocaine soIution into a saline-fiIIed horizontal glass tube. Postanesthetic headaches nna~\’ occur, due to withdrawa or Ioss of Iarge amounts of spinal fluid, either at the time of puncture or Iater through a gaping puncture wound made by a large needIe. NeedIes of 22 gauge with a short beve1 obviate this difficuIty. When perinea1 or intradura1 caudal anesthesia has been induced for some minor procedure, such as cervica1 cauterization, circumcision in the aduIt, or c?stoscopy, headaches, due to Ieakage of spma1 fluid through a smaI1 but unhealed puncture in the durn, have foIIowed when the patient was immediateIy ahowed up and about. These headaches have been avoided by requiring bed rest for at Ieast tweIve hours.

hleningismus, lvhich is the result of the iniection of a sterile irritant into the spina c:lnnI, may follow the use of imperfectly cleansed svringes or needIes. hleningitis is due to contamination of solutions, syringes or needles. Transient paresthesias are reported to occur, USUalI) being limited to the perineum or legs, and are usually caused b>trauma to the net-\-e roots I,?- a large calibre long beveled neecllc. F-\ILC:I
TO

OBTAIN

AUESTIIES1.A

Alost authorities on spinal anesthesia, particularI>De Takats, admit a failure to obtain anesthesia in j or 6 per cent of their cases. T\vo explanations of failure ma!. be ofFered. First, that the injection of no\-ocaine second, \vas estrndural, idosyncrac;v novocaine. The first to explanation seems to be the most likeI>as in 4 cases in this series, after complete failure to produce anesthesia, a second injection w-as made by the same operator and a satisfactor\anesthesia was obtained. These failures were undoubtedly due to slight mox.ement of the needle after successful puncture and \vithdravxI of the fluid, the tip of the needle I\-ing partialI) or wholly outside the dural canal during iniection. 13ENEFITS

OF

SPINAL

the absence of sympathetic inhibitory stimuli. The abdominal walls may be retracted uplvard with only slight traction,

AKESTHESIA

Relaxation of the abdominal wall, which is mow complete than that obtained under any other anesthesia, is appreciated by the surgeon in any case, but especially so in cases of ruptured viscera, such as gangrenous a ruptured appendix or perforated gastric or duodenal ulcer. The necessa? surgical procedure may be carried out, without disseminating infective material throughout the surrounding peritoneum, b>- fighting the Iabored respiratory efForts of an “ether patient” and forcibl!packing away distended intestines. The intestines under spinal anesthesia are contracted, owing to preponderance of \.agus or parasvmpsthetic tone in

and the entire abdominal ca\ it) Ill a J be inspected before any manipulation. This condition of “abdominal silence” is :I revelation to the surgeon not accustomed to spinal anesthesia, and has been termed a “surgical paradise” 6~. a recent con\.ert to the method. Spin:11 anesthesia constitutes an eRecti\-e bIock to pain originating in the operative field and hence removes this possible causative factor in the production of shock. Surgical shock has not occurred in this series of cases. There is little or no postoperati\.e nausea, \-omiting or distention, therefore, less strain on the suture line. This results in less pain in the region of the incision and less chance of occurrence of postoperative hernia. Paralytic ileus has been oxrerc‘ome by the use of spinal anesthesia to interrupt the reflex s?-mpathetic inhibition of peristaIsis which characterizes this condition. Postoperative respiratory complications occur one seventh as frequently as after inhalation anesthesia. No demonstrable damage to the liver or kidney has ever followed spina anesthesia. The patient is able to take fTuicIs and food before, during and immediately after an operation. Catheterization has thus been much less frequent in this series of cases than after ether anesthesia. The burdens of the nursing staff are lightened considerabI?as patients after

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Amrrican

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to their rooms operation are returned conscious, cheerfu1 and co6perative. The appreciation of the patient, who has previously had an ether anesthesia, demonstrates that from his viewpoint the method is commendabIe.

4. Volume tion

anesthesia, when skiI1fuIIy I. SpinaI administered, provides complete absence of pain, complete relaxation, and faciIitates the rapidity and ease with which any surgical operation may be performed. 2. Con\-alescence surgery perafter formed under spinal anesthesia is attended by far fewer complications and enjoys a definiteI!lower mortaIity rate than after inhaIntion anesthesia. 3. Spinal anesthesia is rapidI>- growing in fax-or and in time GIL be used more than inhalation anesthesia.

control

of spina

600

satisfactory nique

stance

and

has

and

reliable.

\v\re are

to any

able

desired than

for induc-

has been proved

to

Ie\-eI

to the other

technique

anesthesia

cases,

resorting

CONCLUSIONS

JULY,1929

Anesthesia

With

this

produce

on the

introduction novocaine

used

in

unusuaIIy tech-

anesthesia

body

without

of any into

sub-

the spinal

canal. ad5. The properIS; timed prophylactic ministration of ephedrine, in amounts directIy proportional to the height of anesthesia to be produced, wil1 maintain a vascuIar tone during anesthesia which cIoseIv approximates the patient’s normal. I &h to thank Dr. R. H. Jackson and his associates of the Jackson Clinic for their coSperation and encouragement in the application of this technique to general surgery.

BIBLIOGRAPHY

of

T. BAKOM, VV. \\‘. Spinal ;incsthcsia, :I study about i~,ooo inductions. Penn. :\I. J., ~6: 303, 1922. 2. BAIKOCK, \v. IV. The technic of spinal :tnesthcsi:t. N. Ihrk M. J., I: 697-702, 1914. 3. B.mcocr<, \I~. VV. Spinal mcsthcsi:c; :m cspericncc of twenty-four ,vems. AM. J. S~RC., n. s. 5: $7,~ $77, 1928. .+, BARKER, A. E. Clinic:d

expcricnces with spin;11 an:& gesia in ioo c:~scs. Brif. ;ZI. J., I : 665-674, 1907. 5. BIIX, A. Vcrsuchc uber cocxinisrun: dcs Ruchenmnrks. Dcutsche Ztschr. j. Cbir., 5 I : 36 I, , Xqcj. 6. BRAU~, II. Quoted by king, J. J. Local Anesthcsi:i, etc. N. I’., IIocber, 1926, p. 7. 7. CHEU, I\. K., and S(xr~~or, C. F. Action of cphcdrinc. J. I’burmucol. (“+ Esper. T/map., 24: 339, 1925. 8. CORNINc,

J. I.. Spin:tI mcsthcsia :rnd local medication of the cord. N. yo’o,-k M. J.. 12: 483. 188;. DESPLAS and XIILMX. Shock producing repu&ion of spinnl :tncsthcsin, is it justified? Presse m&l., 26: 23+-236, 1918. DE TAKATS, G. Low1 Ancsthesi:t. Phila., Saunders, i928. EINI-IOKX. Quoted by King, J. J. Local Anesthesia, etc. N. Y., Hocber, 1926, p. 7. EVANS, C. H. Possible compIic:ttions with spinal mwsthesin. AM. J. SURC., n. s. 5: 581-594, 19~8. Spinal Anesthesia. N. Y., Hoeber, 1929. FWJRNEAU, E. Stovnine, xwsthesique lowI. Bull. d. SC. $x~rmacol., to: 141-148, 1904. Jous~sco, T. Technic for intr:tspinal gencralizcd :inesthcsi:~. Pwsse m&l., 31: 145, 1926. I
9.

IO. I I. 12.

13. 14. I j.

16. LAI~~T, G. Elimimition of dxngcrs of spinal :tnrsthcsi;i. AM. J. SUM;., n. s. 5: 625-633, 1928. 17. ~~.~~KOWITZ, J., and C~\IP~
L__

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