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SPINAL ANÆSTHESIA IN ABDOMINAL SURGERY.
579
ligatured stump of the vein ; this thrombosis is have made, or will make, the surgeon refuse them a mainly due to the stagnation of the contained blood, general anaesthetic and excision-operation. They can and for this reason is much more likely to be lightly safely be cured of varicose veins by the injection adherent than when it occurs secondarily to endo- treatment, given cautiously with fewer injections at a thelial damage. It is from this stagnation thrombus sitting and longer intervals between sittings. Their that pulmonary emboli occur after operative measures. own opinion is that almost a new lease of life is thereby Fourthly, statistics show that as far as the risk to the patient is concerned it is certain that the chance of embolus occurring after injection treatment is many times more remote than in cases which have undergone In any operation the various forms of operation. involving the ligature of a varicose vein the danger of embolus is never entirely absent, and the incidence is higher than the general incidence of post-operative emboli. If the theoretical danger of pulmonary emboli is to deter us from the treatment of varicose veins, the danger must be given much greater consideration in discussing operative than in discussing injection
given them. In fact, with the growing confidence of doctors and public in the treatment and its results, all but one of the above types of varicose vein patients will
become rare, instead of
as
now, common ; for the
practice of early injection of varicose veins so soon as they appear will become universal. This, however, will often mean injection of quite small varicose veins in " quite young girls "-to Prof. Young’s I am, Sir, yours faithfully, dismay. H. M. HANSCHELI. Weymouth-street, W., March 9th, 1929.
treatment.
Fifthly, the failures of injection treatment are mustered against the method. The method is new, its
employment has been largely experimental, and technique often halting, and I do not doubt that there have been failures. In my own experience, and I know this is confirmed by that of many others, I have yet to see a case in which I failed to achieve its
SPINAL ANÆSTHESIA IN ABDOMINAL SURGERY. To the Editor of THE LANCET.
SIR,—A hasty statement of mine in your issue of thrombosis and sclerosis of the veins with corre- Feb. 16th concerning the action of gravity and sponding relief of symptoms. Failure in this respect is " diffusion " was severely criticised by Prof. Pannett, certainly due to faulty technique. Similarly, with and as I clearly recognised that the wording was proper technique, the local lesions which are sometimes both unscientific and calculated to mislead, I thought seen, can be reduced to negligible proportions. that in the circumstances the most graceful, if perhaps Applying similar arguments to operative methods, it not the most sensible thing to do, was to publish will be admitted that failure is not unheard of and an admission of error in your following issue. But sepsis not unknown. I find that Mr. Percival Cole (same issue, p. 468) is Sixthly, Prof. Young calls in question the efficiency so obviously of the same opinion as myself as to the of the method in cases which he considers really clinical findings and makes the same mistake in the require treatment. Clinical experience of injection unscientific use of the word " diffusion " that I make treatment shows here that the functional results no apology for re-entering the discussion and offering obtained are as good as those obtained from ideal what I believe to be the correct solution of the operations, and cosmetically much better, to say problem. nothing of the fact that the treatment has been I am still of the opinion that gravity being a ambulatory. constant is the least important factor in this discussion, I will conclude by quoting the sentences from the and there is no better way of describing the probable annotation to which Prof. Young has taken exception. progress of novocaine in the theca than by saying " diffuThis treatment is so simple, so effective, that it has that there is a progressively slow downward novocaine it comes a sion " of until to natural extincon ousted almost completely the treatment by operation the whole, it can be said that the injection methods now tion by absorption at a certain level proportional generally adopted are suitable for routine use. The risk is to dosage. Referring to the glass-tube experiment, less than operation and the results are better. Prof. Pannett states that these results cannot be The facts as here stated are strictlv accurate and based applied to the human body and gives as his reason the obstructions which the solution encounters in on experience, and since surgery is a practical art, they its downward course. He misses altogether the prime are not likely to be gainsaid by purely theoretical factor which differentiates this experiment from a considerations. similar one in the body-viz., the rapid absorption by I am, Sir, yours faithfully. the tissues of the novocaine and the resulting progresREGINALD T. T. PAYNE. PAYNE. March 6th’ Harley-street, W., sive diminution in the specific gravity of the descending fluid. Referring to the body, he states (your issue of Feb. 9th, p. 276) :To the Editor of THE LANCET. " There is no danger at all of the solution flowing up too SIR,—Everyone with any extensive first-hand high and causing dangerous paralysis. There are large of the actual ...
REGINALD
experience operation of the " injection " margins of safety in the small size and small dose of novoof varicose veins, and of its results, will unhesitatingly caine solution and in the fact that the anaesthetic is quickly support Dr. Christopher Howard and Sir Sidney diminished in strength as it trickles upwards, partly because Alexander in their disposal of Prof. Archibald Young’s it becomes fixed by the nerve-roots, partly because of the rapid absorption which takes place from the spinal canal." objections to that treatment. To the category of otherwise healthy patients If he will allow me I will paraphrase this statement suitable for the injection treatment-viz., those and add considerable meaning to it :who unshakably (and I think very reasonably) When the solution is injected owing to rapid dilution connect their pain, fatigue, discomfort. and unsightli- and absorption of novocaine, there is a progressive diminuness with their leg varicose veins, whether these be tion in the specific gravity of the descending fluid, this very varicose or not ; and those with varicose ulcers ; results in a progressive retardation of the descent and a and those (not few) whose varicose veins have recurred consequent increased opportunity for novocaine to be after one, or more, excision-operation ; and those, absorbed, untilthe specific gravity of the advancing column often quite young men and women, rejected for some so nearly approaches that of the cerebro-spinal fluid that results in the complete absorption of novocaine at a service or other on account of varicose veins, though, stasis constant level proportional to dosage. as often happens, these veins had so far caused no discomfort or disability ; I would add, also from my It will be noted that Prof. Pannett makes use of own practice, one more, " not otherwise healthy "the expression " trickles upwards." It was in response viz., those middle-aged or even old patients whose to this invitation and in opposition to this conception activities are curtailed and life made uncomfortable that I left the rigid confines of physical science and by reason of varicose veins, but whose age and general used the term" diffusion." Gravity then, although its state of health-e.g., more or less chronic bronchitis- action is obvious in the early stage as shown by its
580 the underside in the lateral were " rhetorical," as the sentence in his original position, progressively loses its hold on the descending paper seems plain enough : " During the time that solution and will never take us to the required level these 200 patients were dealt with over 7000 cases of unless the dose is adequate to stay the course. many and various forms of arthritis and allied I therefore offer the following theory for criticism. conditions passed through the hospital(my italics). The accomplishment of spinal analgesia falls into three Mr. Pavey-Smith now desires to cancel the 7000 and to substitute instead accurate numbers of the various natural divisions:conditions with which he is dealing. This is certainly 1. Block across the lower lumbar and sacral nerves for more
immediate effect
short
operations
on
on
the
satisfactory.
perineum, &c.
Interval-the lowest-small dose 5-10 cg. 2. Block across the root of the cauda equina, thence involv-
ng the roots of the first lumbar and lower thoracic nerves, for operations on the legs, testis, and lower abdomen. For both these divisions no postural arrangement of the body is necessary, the patient lying horizontal, but slight inclination of the body favours paralysis of the upper segments of the rectus muscle. For unilateral operations reinforcement can be obtained by placing the patient on the affected side and keeping him thus during the induction period. Interval L 1, L 2, average dose 10-12 cg.
I i
Splanchnic block-up to
the fourth thoracic nerve-roots little beyond. This requires an inclination of the body sufficient to overcome the dorsal curve, the actual angle being unimportant provided that this condition is fulfilled, though it ought not to be excessive. The level reached is dependent upon the amount of the dose used; this amount should be proportional to the probable size and therefore absorptive power of the nerve-roots in an individual case. Every dose owing to rapid dilution, absorption, progressive diminution in specific gravity, retardation of descent, increased opportunity for absorption, ultimately attains stasis and the novocaine is completely absorbed at a 1 evel proportional to the amount of the dose. Interval L 1, L 2. Dose, 10-12 cg. ; in some big men more. In the event of partial failure a second dose isadministered, the amount of such dose to be proportional to the deficiency of the result.
3. and
a
.
Mr. Pavey-Smith gives 2333 cases of all forms of arthritis admitted. Analysing these one finds that roughly 20 per cent. of acute and subacute rheumatism show tonsillar sepsis, but that in other forms of infective arthritis only 8 per cent. were subjected to operation, 1 per cent. being cured and 4 per cent. obtaining benefit. In one only of some hundreds of cases of osteo-arthritis did the condition of the tonsils warrant interference. With these more exact figures one still finds that in arthritis, with the exception of rheumatic fever, tonsillar infection plays but a very small part. I should like to congratulate Mr. Pavey-Smith on his conservative policy when dealing with this disease. I am, Sir, yours faithfully, H. WARREN CROWE. March 5th, 1929. London, W.,
No amount of inclination will bring a small dose to a high level, except in the case of a secondary dose, because previous saturation favours its progress. Barbotage results in distributing novocaine below "
"
the site of an intended block and should never be used. The above theory is not only in accordance with all clinical findings, but in my opinion reconciles the conflicting views recently expressed in your columns.-I am, Sir, yours faithfully. W. HOWARD JONES, M.B., B.S. Lond., W. HOWARD Anaesthetist to Charing Cross Surgeon Anæsthetist March llth, 1929. Hospital. To the Editor
of THE LANCET. SIR,-Your correspondents have raised the question of the spread of fluid in the spinal theca. The Saccharine Corporation and MM. Poulenc Freres were so obliging some years ago as to carry out at my suggestion experiments in regard to the density and diffusibility of solutions employed for spinal injection. According to the reports, which I shall be pleased to send to anyone interested, diffusion was extremely slow and may be in practice disregarded. Gravity may come into play to some extent, even if a light solution is used (the 10 per cent. stovaine in saline is often supposed to be as light as the cerebro-spinal fluid), but the fact is, that experiments tell us very little of what happens in the living subject, for various physical, anatomical, and physiological complications are added ; and one may depend upon the practical result, which is, in my experience and that of many others, that a patient may be put into the Trendelenburg position as soon as an injection of stovaine in saline has been given. I am, Sir, yours faithfully, London, N.W., March 8th, 1929.
OPERATING FOR APPENDICITIS. To the Editor
may I endeavour to clear up one or two apparently doubtful points ? In the first place, the cases from which these statistics were compiled were divided into cases operated upon while infection was still confined to the appendix, and " the remainder," which included local abscess, local and general peritonitis. In estimating the ultimate mortality, some slight allowance must admittedly be made for the risk of interval removal, but if sufficient time (about three months), is allowed for infection to subside, then this added risk should be almost negligible. In my lecture, I dwelt on the possibility of refusal of the patient to undergo interval appendicectomy after expectant treatment had tided him over the crisis, but I believe it is exceptional for subsequent operation to be refused-the memory of recent illness and the fear of recurrence are too vivid. At any rate, we must assume that patients are more or less
J. D. MORTIMER.
TONSILLECTOMY IN CHRONIC ARTHRITIS. To the Editor
of
of THE LANCET. SIR,—In reply to Prof. Grey Turner,
THE LANCET.
reasonable, and according to
beliefs, endeavour to
tion of Battle’s incision. I purposely refrained from mentioning it, as the sooner it falls into oblivion the better it will be for abdominal walls. I am not conversant with Rutherford Morison’s " oblique muscle-cutting incision," but, personally speaking, its strongest recommendation would be to know that Prof. Grey Turner uses it himself. Mr. Davies-Colley raises one or two points to which I should like to refer, particularly in connexion with operation when infection is localised to the right iliac fossa. Ignoring the high mortality of interfering cases between the third and fifth days (over 9 per cent.), the risk of complications and sequelae is considerable. When infection is localised efficient protection of the infected area by packing may require very wide exposure in order to avoid breaking down adhesions to the anterior abdominal wall. Infection of this extensive wound, which commonly occurs, is prone to result in incisional hernia. As Mr. Davies-Colley suggests, anxiety to leave structures in situ may prohibit closure of the appendix stump, and as drainage is usually required, the formation of a faecal fistula is encouraged. When once localisation has occurred, general peritonitis is only likely to follow if a subsequent abscess
conclusions,
SIR,—It is rather surprising that Mr. Pavey-Smith should now state that the figures of his hospital admissions from which I drew certain
our
pilot them through an illness with the minimum of risk, in the hope that they will continue to follow our advice, and the arguments for interval appendicectomy are certainly clear and weighty. I heartily applaud Prof. Grey Turner’s condemna-
in localising
*
ligatured stump of the vein ; this thrombosis is have made, or will make, the surgeon refuse them a mainly due to the stagnation of the contained blood, general anaesthetic and excision-operation. They can and for this reason is much more likely to be lightly safely be cured of varicose veins by the injection adherent than when it occurs secondarily to endo- treatment, given cautiously with fewer injections at a thelial damage. It is from this stagnation thrombus sitting and longer intervals between sittings. Their that pulmonary emboli occur after operative measures. own opinion is that almost a new lease of life is thereby Fourthly, statistics show that as far as the risk to the patient is concerned it is certain that the chance of embolus occurring after injection treatment is many times more remote than in cases which have undergone In any operation the various forms of operation. involving the ligature of a varicose vein the danger of embolus is never entirely absent, and the incidence is higher than the general incidence of post-operative emboli. If the theoretical danger of pulmonary emboli is to deter us from the treatment of varicose veins, the danger must be given much greater consideration in discussing operative than in discussing injection
given them. In fact, with the growing confidence of doctors and public in the treatment and its results, all but one of the above types of varicose vein patients will
become rare, instead of
as
now, common ; for the
practice of early injection of varicose veins so soon as they appear will become universal. This, however, will often mean injection of quite small varicose veins in " quite young girls "-to Prof. Young’s I am, Sir, yours faithfully, dismay. H. M. HANSCHELI. Weymouth-street, W., March 9th, 1929.
treatment.
Fifthly, the failures of injection treatment are mustered against the method. The method is new, its
employment has been largely experimental, and technique often halting, and I do not doubt that there have been failures. In my own experience, and I know this is confirmed by that of many others, I have yet to see a case in which I failed to achieve its
SPINAL ANÆSTHESIA IN ABDOMINAL SURGERY. To the Editor of THE LANCET.
SIR,—A hasty statement of mine in your issue of thrombosis and sclerosis of the veins with corre- Feb. 16th concerning the action of gravity and sponding relief of symptoms. Failure in this respect is " diffusion " was severely criticised by Prof. Pannett, certainly due to faulty technique. Similarly, with and as I clearly recognised that the wording was proper technique, the local lesions which are sometimes both unscientific and calculated to mislead, I thought seen, can be reduced to negligible proportions. that in the circumstances the most graceful, if perhaps Applying similar arguments to operative methods, it not the most sensible thing to do, was to publish will be admitted that failure is not unheard of and an admission of error in your following issue. But sepsis not unknown. I find that Mr. Percival Cole (same issue, p. 468) is Sixthly, Prof. Young calls in question the efficiency so obviously of the same opinion as myself as to the of the method in cases which he considers really clinical findings and makes the same mistake in the require treatment. Clinical experience of injection unscientific use of the word " diffusion " that I make treatment shows here that the functional results no apology for re-entering the discussion and offering obtained are as good as those obtained from ideal what I believe to be the correct solution of the operations, and cosmetically much better, to say problem. nothing of the fact that the treatment has been I am still of the opinion that gravity being a ambulatory. constant is the least important factor in this discussion, I will conclude by quoting the sentences from the and there is no better way of describing the probable annotation to which Prof. Young has taken exception. progress of novocaine in the theca than by saying " diffuThis treatment is so simple, so effective, that it has that there is a progressively slow downward novocaine it comes a sion " of until to natural extincon ousted almost completely the treatment by operation the whole, it can be said that the injection methods now tion by absorption at a certain level proportional generally adopted are suitable for routine use. The risk is to dosage. Referring to the glass-tube experiment, less than operation and the results are better. Prof. Pannett states that these results cannot be The facts as here stated are strictlv accurate and based applied to the human body and gives as his reason the obstructions which the solution encounters in on experience, and since surgery is a practical art, they its downward course. He misses altogether the prime are not likely to be gainsaid by purely theoretical factor which differentiates this experiment from a considerations. similar one in the body-viz., the rapid absorption by I am, Sir, yours faithfully. the tissues of the novocaine and the resulting progresREGINALD T. T. PAYNE. PAYNE. March 6th’ Harley-street, W., sive diminution in the specific gravity of the descending fluid. Referring to the body, he states (your issue of Feb. 9th, p. 276) :To the Editor of THE LANCET. " There is no danger at all of the solution flowing up too SIR,—Everyone with any extensive first-hand high and causing dangerous paralysis. There are large of the actual ...
REGINALD
experience operation of the " injection " margins of safety in the small size and small dose of novoof varicose veins, and of its results, will unhesitatingly caine solution and in the fact that the anaesthetic is quickly support Dr. Christopher Howard and Sir Sidney diminished in strength as it trickles upwards, partly because Alexander in their disposal of Prof. Archibald Young’s it becomes fixed by the nerve-roots, partly because of the rapid absorption which takes place from the spinal canal." objections to that treatment. To the category of otherwise healthy patients If he will allow me I will paraphrase this statement suitable for the injection treatment-viz., those and add considerable meaning to it :who unshakably (and I think very reasonably) When the solution is injected owing to rapid dilution connect their pain, fatigue, discomfort. and unsightli- and absorption of novocaine, there is a progressive diminuness with their leg varicose veins, whether these be tion in the specific gravity of the descending fluid, this very varicose or not ; and those with varicose ulcers ; results in a progressive retardation of the descent and a and those (not few) whose varicose veins have recurred consequent increased opportunity for novocaine to be after one, or more, excision-operation ; and those, absorbed, untilthe specific gravity of the advancing column often quite young men and women, rejected for some so nearly approaches that of the cerebro-spinal fluid that results in the complete absorption of novocaine at a service or other on account of varicose veins, though, stasis constant level proportional to dosage. as often happens, these veins had so far caused no discomfort or disability ; I would add, also from my It will be noted that Prof. Pannett makes use of own practice, one more, " not otherwise healthy "the expression " trickles upwards." It was in response viz., those middle-aged or even old patients whose to this invitation and in opposition to this conception activities are curtailed and life made uncomfortable that I left the rigid confines of physical science and by reason of varicose veins, but whose age and general used the term" diffusion." Gravity then, although its state of health-e.g., more or less chronic bronchitis- action is obvious in the early stage as shown by its
580 the underside in the lateral were " rhetorical," as the sentence in his original position, progressively loses its hold on the descending paper seems plain enough : " During the time that solution and will never take us to the required level these 200 patients were dealt with over 7000 cases of unless the dose is adequate to stay the course. many and various forms of arthritis and allied I therefore offer the following theory for criticism. conditions passed through the hospital(my italics). The accomplishment of spinal analgesia falls into three Mr. Pavey-Smith now desires to cancel the 7000 and to substitute instead accurate numbers of the various natural divisions:conditions with which he is dealing. This is certainly 1. Block across the lower lumbar and sacral nerves for more
immediate effect
short
operations
on
on
the
satisfactory.
perineum, &c.
Interval-the lowest-small dose 5-10 cg. 2. Block across the root of the cauda equina, thence involv-
ng the roots of the first lumbar and lower thoracic nerves, for operations on the legs, testis, and lower abdomen. For both these divisions no postural arrangement of the body is necessary, the patient lying horizontal, but slight inclination of the body favours paralysis of the upper segments of the rectus muscle. For unilateral operations reinforcement can be obtained by placing the patient on the affected side and keeping him thus during the induction period. Interval L 1, L 2, average dose 10-12 cg.
I i
Splanchnic block-up to
the fourth thoracic nerve-roots little beyond. This requires an inclination of the body sufficient to overcome the dorsal curve, the actual angle being unimportant provided that this condition is fulfilled, though it ought not to be excessive. The level reached is dependent upon the amount of the dose used; this amount should be proportional to the probable size and therefore absorptive power of the nerve-roots in an individual case. Every dose owing to rapid dilution, absorption, progressive diminution in specific gravity, retardation of descent, increased opportunity for absorption, ultimately attains stasis and the novocaine is completely absorbed at a 1 evel proportional to the amount of the dose. Interval L 1, L 2. Dose, 10-12 cg. ; in some big men more. In the event of partial failure a second dose isadministered, the amount of such dose to be proportional to the deficiency of the result.
3. and
a
.
Mr. Pavey-Smith gives 2333 cases of all forms of arthritis admitted. Analysing these one finds that roughly 20 per cent. of acute and subacute rheumatism show tonsillar sepsis, but that in other forms of infective arthritis only 8 per cent. were subjected to operation, 1 per cent. being cured and 4 per cent. obtaining benefit. In one only of some hundreds of cases of osteo-arthritis did the condition of the tonsils warrant interference. With these more exact figures one still finds that in arthritis, with the exception of rheumatic fever, tonsillar infection plays but a very small part. I should like to congratulate Mr. Pavey-Smith on his conservative policy when dealing with this disease. I am, Sir, yours faithfully, H. WARREN CROWE. March 5th, 1929. London, W.,
No amount of inclination will bring a small dose to a high level, except in the case of a secondary dose, because previous saturation favours its progress. Barbotage results in distributing novocaine below "
"
the site of an intended block and should never be used. The above theory is not only in accordance with all clinical findings, but in my opinion reconciles the conflicting views recently expressed in your columns.-I am, Sir, yours faithfully. W. HOWARD JONES, M.B., B.S. Lond., W. HOWARD Anaesthetist to Charing Cross Surgeon Anæsthetist March llth, 1929. Hospital. To the Editor
of THE LANCET. SIR,-Your correspondents have raised the question of the spread of fluid in the spinal theca. The Saccharine Corporation and MM. Poulenc Freres were so obliging some years ago as to carry out at my suggestion experiments in regard to the density and diffusibility of solutions employed for spinal injection. According to the reports, which I shall be pleased to send to anyone interested, diffusion was extremely slow and may be in practice disregarded. Gravity may come into play to some extent, even if a light solution is used (the 10 per cent. stovaine in saline is often supposed to be as light as the cerebro-spinal fluid), but the fact is, that experiments tell us very little of what happens in the living subject, for various physical, anatomical, and physiological complications are added ; and one may depend upon the practical result, which is, in my experience and that of many others, that a patient may be put into the Trendelenburg position as soon as an injection of stovaine in saline has been given. I am, Sir, yours faithfully, London, N.W., March 8th, 1929.
OPERATING FOR APPENDICITIS. To the Editor
may I endeavour to clear up one or two apparently doubtful points ? In the first place, the cases from which these statistics were compiled were divided into cases operated upon while infection was still confined to the appendix, and " the remainder," which included local abscess, local and general peritonitis. In estimating the ultimate mortality, some slight allowance must admittedly be made for the risk of interval removal, but if sufficient time (about three months), is allowed for infection to subside, then this added risk should be almost negligible. In my lecture, I dwelt on the possibility of refusal of the patient to undergo interval appendicectomy after expectant treatment had tided him over the crisis, but I believe it is exceptional for subsequent operation to be refused-the memory of recent illness and the fear of recurrence are too vivid. At any rate, we must assume that patients are more or less
J. D. MORTIMER.
TONSILLECTOMY IN CHRONIC ARTHRITIS. To the Editor
of
of THE LANCET. SIR,—In reply to Prof. Grey Turner,
THE LANCET.
reasonable, and according to
beliefs, endeavour to
tion of Battle’s incision. I purposely refrained from mentioning it, as the sooner it falls into oblivion the better it will be for abdominal walls. I am not conversant with Rutherford Morison’s " oblique muscle-cutting incision," but, personally speaking, its strongest recommendation would be to know that Prof. Grey Turner uses it himself. Mr. Davies-Colley raises one or two points to which I should like to refer, particularly in connexion with operation when infection is localised to the right iliac fossa. Ignoring the high mortality of interfering cases between the third and fifth days (over 9 per cent.), the risk of complications and sequelae is considerable. When infection is localised efficient protection of the infected area by packing may require very wide exposure in order to avoid breaking down adhesions to the anterior abdominal wall. Infection of this extensive wound, which commonly occurs, is prone to result in incisional hernia. As Mr. Davies-Colley suggests, anxiety to leave structures in situ may prohibit closure of the appendix stump, and as drainage is usually required, the formation of a faecal fistula is encouraged. When once localisation has occurred, general peritonitis is only likely to follow if a subsequent abscess
conclusions,
SIR,—It is rather surprising that Mr. Pavey-Smith should now state that the figures of his hospital admissions from which I drew certain
our
pilot them through an illness with the minimum of risk, in the hope that they will continue to follow our advice, and the arguments for interval appendicectomy are certainly clear and weighty. I heartily applaud Prof. Grey Turner’s condemna-
in localising
*