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What made spinal anesthesia different from general anesthesia?
International Congress Series 1242 (2002) 159 – 162
What made spinal anesthesia different from general anesthesia? Carlos Parsloe Hospital Samaritano, Rua Conselheiro Brotero 1486, 01232-010, Sa˜o Paulo, SP, Brazil
Abstract At the time of the introduction of spinal anesthesia in 1898, general anesthesia was far from being an innocuous procedure. Respiration was spontaneous and the patients were under constant threat of asphyxia. Abdominal relaxation was poor, with the bowels protruding from the abdomen. Surgeons had to operate in haste. Postoperative nausea and vomiting were common and intense and the recovery period was prolonged, customarily with postoperative pulmonary complications. The death rate attributed to general anesthesia with chloroform was of the order of 1:1000 to 1:2000. Patients under spinal anesthesia were conscious and able to converse and drink, while feeling no pain. The most important characteristic was the complete abdominal relaxation with a quiet abdomen and quiescent bowel. As a result, for the first time surgeons were able to operate without strict consideration of time. The contrast was in favor of spinal anesthesia. D 2002 Elsevier Science B.V. All rights reserved. Keywords: Spinal; General anesthesia; Advantages; Disadvantages; Abdominal relaxation; Postoperative complications
A series of statements from several sources were selected to describe the impact of the introduction of spinal anesthesia into surgical practice. When the discovery of general anesthesia with ether was announced at the French Academy of Sciences, the physiologist Flourens made this warning [1]: ‘‘L’e´ther qui oˆte la douleur, oˆte aussi la vie, et l’agent nouveau que vient d’adque´rir la chirurgie est a` la fois mervelleux et terrible’’ (Ether, which kills pain also kills life, and this new agent, recently introduced into surgery, is at the same time wonderful and terrible). Flourens was the first physiologist to study the action of general anesthetics and later introduced ethyl chloride.
E-mail address: [email protected] (C. Parsloe). 0531-5131/02 D 2002 Elsevier Science B.V. All rights reserved. PII: S 0 5 3 1 - 5 1 3 1 ( 0 2 ) 0 0 7 2 2 - 7
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C. Parsloe / International Congress Series 1242 (2002) 159–162
The panorama of general anesthesia, ca. 1898, could be described as follows: spontaneous breathing with air, common respiratory obstruction and asphyxia, lack of abdominal relaxation with protruding bowels interfering with surgery. The surgeons had to operate in haste for fear of respiratory and cardiac arrest. Postoperative nausea and vomiting were usual and intense; mortality and morbidity were high with stated mortality from chloroform on the order of 1:1000 to 1:2000. At Martin Kirschner’s [2] clinic in Heidelberg, as described in his textbook of surgery in 1940, the anesthetizer was forbidden to start anesthesia without a special ‘‘narcosis tray’’ containing all instruments and necessary means for anesthesia and to combat its accidents. No mention of how to administer anesthesia but instructions to combat its expected accidents! The introduction of spinal anesthesia was an example of a global achievement as stated by Forgue and Basset [3]: ‘‘L’ide´e fut ame´ricaine. La re´alization chirurgicale fur allemande. Il est permis de dire que la me´thodisation fut francß aise’’ (The idea was American. The surgical realization was German. It can be said that the standardization was French). Corning had a ‘‘lucky failure,’’ as stated by Fink [4], which prevented the patient’s death since he had injected an overdose of cocaine. Bier had the audacity of innovation and of acting as the first volunteer but Tuffier was the enthusiast who explored the potentiality of spinal anesthesia and proceeded to standardize it. By 1900, Tuffier could report 125 cases and by 1901 a total of 400 cases. He progressively elevated the level of spinal anesthesia operating on the abdomen, the kidney and the breast. He used a fine, short bevel needle and a slow injection of the local anesthetic. He also described the proper site of lumbar puncture at the vertebral intersection of a line, between the two iliac crests, later called Tuffier’s line. Tuffiers performed his first spinal anesthesia for the treatment of pain from a leg sarcoma. His second spinal was for surgery and is worth reproducing: ‘‘Subarachnoid cocaine in a young girl with sarcoma of the thigh. Full anesthesia in 5 min, in 2 min the sarcoma was removed and another 5 min for hemostasis and suture’’ [5]. He remarked: ‘‘haste is unnecessary since anesthesia lasts for one hour.’’ Until this observation, the surgeons needed to be fast in order to prevent severe complications and even death with general anesthesia. Hopkins, who went from New York to Paris to observe Tuffier’s demonstrations, gave the first eyewitness report. ‘‘To be able to converse with a patient during the performance of a hysterectomy, the patient all the while evincing not the slightest indication of pain (and even being unable to tell where the knife was being applied) was certainly a marvel, and was well worth crossing the Atlantic to see’’ [6]. A nurse who was operated for panhysterectomy and appendectomy left this report [7]: ‘‘Lumbar puncture at L2 – L3. Stovaine 3%, 1/2 dram. I slept at short intervals during the operation. I was given by hypodermic injection 1/100 gr. nitroglycerin and 1/6 gr. morphin, and at intervals small quantities of brandy and water by mouth. After the operation I drank lemonade to the health of the doctors. I had no unpleasant after-effects from the analgesia.’’ Babcock stated the following opinion: ‘‘In most cases spinal anesthesia enables me to operate entirely free from the worry and the watchfulness associated with etherisation by an untrained assistant’’ [8]. It was Maisonnet [9] in 1936 who described the epitome of spinal anesthesia: ‘‘Silence abdominal complet, absence de la pousse´e intestinale’’ (complete abdominal silence, absence of intestinal protrusion). He added: maintenance
C. Parsloe / International Congress Series 1242 (2002) 159–162
161
of consciousness, lack of postoperative nausea and vomiting, and what seemed the utmost advantage, it requires no ‘‘assistant anesthetist.’’ Forgue and Basset [3] wrote a comprehensive book on spinal anesthesia after making a report for the 1928 surgical congress. They were able to collect over 200,000 cases. Among many suggestions for the safety of the procedure they stated: ‘‘Le mot fait image et est bien justifie´: c’est le silence abdominal’’ (the word is well justified: the abdominal silence). Also: ‘‘La suppression de l’aide-anesthe´siste’’ (no need for the assistant anesthetist). And: ‘‘Avec la rachi, l’ope´rateur lui meˆme fait l’anesthe´sie: cela precise la technique et fixe la responsabilite´’’ (With a spinal the surgeon himself performs the anesthesia: this offers precision and fixes the responsibility). The simplicity of spinal anesthesia was clearly described by Monod [10] in his 1937 book: ‘‘elegant and precise, by means of a single injection it provides in a few minutes anesthesia of the lower part of the body.’’ Forgue and Basset [3] perhaps went to the extreme to affirm the advantages of spinal anesthesia: ‘‘If you wish to use spinal anesthesia for infra-umbilical operations only, all you need to do is skin asepsis and injection of the anesthetic; all the rest is superfluous.’’ Victor Pauchet, a major proponent of regional anesthesia, gave his Olympian view: ‘‘I do not give anesthesia. I trust it to a trained assistant. It is easy to find one.’’ ‘‘My interns perform it well after one or two months practice.’’ His preeminence certainly made him a favorite person for aspiring surgeons to wish to become his assistants. His pupil, Gaston Labat, was the most noteworthy and helped Pauchet prepare the 3rd edition of his textbook on Regional Anesthesia [11]. Pauchet did make recommendations for the comfort of the patient under spinal anesthesia: ‘‘Eyes covered, cotton on the ears, a person talks to the patient on any subject, excepting the operation being performed.’’ Sir Robert Macintosh made a concise statement, which well describes the main difference between spinal anesthesia as performed by surgeons or by anesthetists: ‘‘For the surgeon, the spinal ends with the injection of the local analgesic. For the anaesthetist, the spinal begins with the injection of the local analgesic’’ [12]. August Bier did not seem to be an enthusiast of spinal anesthesia, perhaps because he suffered a severe prostrating headache after Hildebrandt’s failed attempt to administer him a spinal anesthetic. During the process, Bier suffered considerable loss of spinal fluid and had to remain in bed for 9 days. Postspinal headache, the main disadvantage of spinal anesthesia, became well known from the very beginning, with the first volunteers, Bier and Hildebrandt.
References [1] T. Keyes, History of Surgical Anesthesia, Schumans, 1948. [2] M. Kirschner, Tratado de Te´cnica Operatoria General y Especial. Translated into Spanish from the German edition. Editorial Labor, 2da edn. 1940. Barcelona, Madrid, Buenos Aires, Rio de Janeiro. [3] E. Forgue, A. Basset, La Rachianesthe`sie, Masson et Cie E´diteurs, Paris, 1930. [4] B.R. Fink, The First ‘‘Spinal’’ Anesthesia, A Lucky Failure, The History of Anesthesia, Third International Symposium, Wood Library Museum of Anesthesiology, Park Ridge, Illinois, 1992. [5] T. Tuffier, Compt. Rend. Soc. Biol. (Paris) 51 (1899) 882. [6] G.S. Hopkins, Anesthesia by cocainization of the spinal cord, Philadelphia Medical Journal 6 (1990) 864. Quoted by B.R. Fink. History of Local Anesthesia, in: M.J. Cousins, P.O. Bridenbaugh (Eds.), Neural
162
[7] [8]
[9] [10] [11] [12]
C. Parsloe / International Congress Series 1242 (2002) 159–162 Blockade in Clinical Anesthesia and Management of Pain, J.B. Lippincott Company, Philadelphia, Toronto, 1980, pp. 3-18. J.T. Gwathmey, Anesthesia, D. Appleton Company, New York, London, 1914, p. 581. W.W. Babcock, Spinal Anesthesia with Report of Surgical Clinics, Surg. Gynecol. Obst. 15 (1912) 608. In: L.H. Maxson (Ed.), Spinal Anesthesia, J.B. Lippincott Company, Philadelphia, London, New York, Montreal, 1938, p. 608. J. Maisonnet, Manuel Pratique D’Anesthe´sie Chirurgicale, Gaston Doin et Cie, Paris, 1936. R. Monod, L’Anesthe´sie en Pratique Chirurgicale, 1937. V. Pauchet, G. Labat, P. Sourdat, R. de B. D’Ormony, Anestesia Regional, Translated into Portuguese, Editora Guanabara, Rio de Janeiro, 1937. R.R. Macintosh, Personal communication, circa 1950.
What made spinal anesthesia different from general anesthesia? Carlos Parsloe Hospital Samaritano, Rua Conselheiro Brotero 1486, 01232-010, Sa˜o Paulo, SP, Brazil
Abstract At the time of the introduction of spinal anesthesia in 1898, general anesthesia was far from being an innocuous procedure. Respiration was spontaneous and the patients were under constant threat of asphyxia. Abdominal relaxation was poor, with the bowels protruding from the abdomen. Surgeons had to operate in haste. Postoperative nausea and vomiting were common and intense and the recovery period was prolonged, customarily with postoperative pulmonary complications. The death rate attributed to general anesthesia with chloroform was of the order of 1:1000 to 1:2000. Patients under spinal anesthesia were conscious and able to converse and drink, while feeling no pain. The most important characteristic was the complete abdominal relaxation with a quiet abdomen and quiescent bowel. As a result, for the first time surgeons were able to operate without strict consideration of time. The contrast was in favor of spinal anesthesia. D 2002 Elsevier Science B.V. All rights reserved. Keywords: Spinal; General anesthesia; Advantages; Disadvantages; Abdominal relaxation; Postoperative complications
A series of statements from several sources were selected to describe the impact of the introduction of spinal anesthesia into surgical practice. When the discovery of general anesthesia with ether was announced at the French Academy of Sciences, the physiologist Flourens made this warning [1]: ‘‘L’e´ther qui oˆte la douleur, oˆte aussi la vie, et l’agent nouveau que vient d’adque´rir la chirurgie est a` la fois mervelleux et terrible’’ (Ether, which kills pain also kills life, and this new agent, recently introduced into surgery, is at the same time wonderful and terrible). Flourens was the first physiologist to study the action of general anesthetics and later introduced ethyl chloride.
E-mail address: [email protected] (C. Parsloe). 0531-5131/02 D 2002 Elsevier Science B.V. All rights reserved. PII: S 0 5 3 1 - 5 1 3 1 ( 0 2 ) 0 0 7 2 2 - 7
160
C. Parsloe / International Congress Series 1242 (2002) 159–162
The panorama of general anesthesia, ca. 1898, could be described as follows: spontaneous breathing with air, common respiratory obstruction and asphyxia, lack of abdominal relaxation with protruding bowels interfering with surgery. The surgeons had to operate in haste for fear of respiratory and cardiac arrest. Postoperative nausea and vomiting were usual and intense; mortality and morbidity were high with stated mortality from chloroform on the order of 1:1000 to 1:2000. At Martin Kirschner’s [2] clinic in Heidelberg, as described in his textbook of surgery in 1940, the anesthetizer was forbidden to start anesthesia without a special ‘‘narcosis tray’’ containing all instruments and necessary means for anesthesia and to combat its accidents. No mention of how to administer anesthesia but instructions to combat its expected accidents! The introduction of spinal anesthesia was an example of a global achievement as stated by Forgue and Basset [3]: ‘‘L’ide´e fut ame´ricaine. La re´alization chirurgicale fur allemande. Il est permis de dire que la me´thodisation fut francß aise’’ (The idea was American. The surgical realization was German. It can be said that the standardization was French). Corning had a ‘‘lucky failure,’’ as stated by Fink [4], which prevented the patient’s death since he had injected an overdose of cocaine. Bier had the audacity of innovation and of acting as the first volunteer but Tuffier was the enthusiast who explored the potentiality of spinal anesthesia and proceeded to standardize it. By 1900, Tuffier could report 125 cases and by 1901 a total of 400 cases. He progressively elevated the level of spinal anesthesia operating on the abdomen, the kidney and the breast. He used a fine, short bevel needle and a slow injection of the local anesthetic. He also described the proper site of lumbar puncture at the vertebral intersection of a line, between the two iliac crests, later called Tuffier’s line. Tuffiers performed his first spinal anesthesia for the treatment of pain from a leg sarcoma. His second spinal was for surgery and is worth reproducing: ‘‘Subarachnoid cocaine in a young girl with sarcoma of the thigh. Full anesthesia in 5 min, in 2 min the sarcoma was removed and another 5 min for hemostasis and suture’’ [5]. He remarked: ‘‘haste is unnecessary since anesthesia lasts for one hour.’’ Until this observation, the surgeons needed to be fast in order to prevent severe complications and even death with general anesthesia. Hopkins, who went from New York to Paris to observe Tuffier’s demonstrations, gave the first eyewitness report. ‘‘To be able to converse with a patient during the performance of a hysterectomy, the patient all the while evincing not the slightest indication of pain (and even being unable to tell where the knife was being applied) was certainly a marvel, and was well worth crossing the Atlantic to see’’ [6]. A nurse who was operated for panhysterectomy and appendectomy left this report [7]: ‘‘Lumbar puncture at L2 – L3. Stovaine 3%, 1/2 dram. I slept at short intervals during the operation. I was given by hypodermic injection 1/100 gr. nitroglycerin and 1/6 gr. morphin, and at intervals small quantities of brandy and water by mouth. After the operation I drank lemonade to the health of the doctors. I had no unpleasant after-effects from the analgesia.’’ Babcock stated the following opinion: ‘‘In most cases spinal anesthesia enables me to operate entirely free from the worry and the watchfulness associated with etherisation by an untrained assistant’’ [8]. It was Maisonnet [9] in 1936 who described the epitome of spinal anesthesia: ‘‘Silence abdominal complet, absence de la pousse´e intestinale’’ (complete abdominal silence, absence of intestinal protrusion). He added: maintenance
C. Parsloe / International Congress Series 1242 (2002) 159–162
161
of consciousness, lack of postoperative nausea and vomiting, and what seemed the utmost advantage, it requires no ‘‘assistant anesthetist.’’ Forgue and Basset [3] wrote a comprehensive book on spinal anesthesia after making a report for the 1928 surgical congress. They were able to collect over 200,000 cases. Among many suggestions for the safety of the procedure they stated: ‘‘Le mot fait image et est bien justifie´: c’est le silence abdominal’’ (the word is well justified: the abdominal silence). Also: ‘‘La suppression de l’aide-anesthe´siste’’ (no need for the assistant anesthetist). And: ‘‘Avec la rachi, l’ope´rateur lui meˆme fait l’anesthe´sie: cela precise la technique et fixe la responsabilite´’’ (With a spinal the surgeon himself performs the anesthesia: this offers precision and fixes the responsibility). The simplicity of spinal anesthesia was clearly described by Monod [10] in his 1937 book: ‘‘elegant and precise, by means of a single injection it provides in a few minutes anesthesia of the lower part of the body.’’ Forgue and Basset [3] perhaps went to the extreme to affirm the advantages of spinal anesthesia: ‘‘If you wish to use spinal anesthesia for infra-umbilical operations only, all you need to do is skin asepsis and injection of the anesthetic; all the rest is superfluous.’’ Victor Pauchet, a major proponent of regional anesthesia, gave his Olympian view: ‘‘I do not give anesthesia. I trust it to a trained assistant. It is easy to find one.’’ ‘‘My interns perform it well after one or two months practice.’’ His preeminence certainly made him a favorite person for aspiring surgeons to wish to become his assistants. His pupil, Gaston Labat, was the most noteworthy and helped Pauchet prepare the 3rd edition of his textbook on Regional Anesthesia [11]. Pauchet did make recommendations for the comfort of the patient under spinal anesthesia: ‘‘Eyes covered, cotton on the ears, a person talks to the patient on any subject, excepting the operation being performed.’’ Sir Robert Macintosh made a concise statement, which well describes the main difference between spinal anesthesia as performed by surgeons or by anesthetists: ‘‘For the surgeon, the spinal ends with the injection of the local analgesic. For the anaesthetist, the spinal begins with the injection of the local analgesic’’ [12]. August Bier did not seem to be an enthusiast of spinal anesthesia, perhaps because he suffered a severe prostrating headache after Hildebrandt’s failed attempt to administer him a spinal anesthetic. During the process, Bier suffered considerable loss of spinal fluid and had to remain in bed for 9 days. Postspinal headache, the main disadvantage of spinal anesthesia, became well known from the very beginning, with the first volunteers, Bier and Hildebrandt.
References [1] T. Keyes, History of Surgical Anesthesia, Schumans, 1948. [2] M. Kirschner, Tratado de Te´cnica Operatoria General y Especial. Translated into Spanish from the German edition. Editorial Labor, 2da edn. 1940. Barcelona, Madrid, Buenos Aires, Rio de Janeiro. [3] E. Forgue, A. Basset, La Rachianesthe`sie, Masson et Cie E´diteurs, Paris, 1930. [4] B.R. Fink, The First ‘‘Spinal’’ Anesthesia, A Lucky Failure, The History of Anesthesia, Third International Symposium, Wood Library Museum of Anesthesiology, Park Ridge, Illinois, 1992. [5] T. Tuffier, Compt. Rend. Soc. Biol. (Paris) 51 (1899) 882. [6] G.S. Hopkins, Anesthesia by cocainization of the spinal cord, Philadelphia Medical Journal 6 (1990) 864. Quoted by B.R. Fink. History of Local Anesthesia, in: M.J. Cousins, P.O. Bridenbaugh (Eds.), Neural
162
[7] [8]
[9] [10] [11] [12]
C. Parsloe / International Congress Series 1242 (2002) 159–162 Blockade in Clinical Anesthesia and Management of Pain, J.B. Lippincott Company, Philadelphia, Toronto, 1980, pp. 3-18. J.T. Gwathmey, Anesthesia, D. Appleton Company, New York, London, 1914, p. 581. W.W. Babcock, Spinal Anesthesia with Report of Surgical Clinics, Surg. Gynecol. Obst. 15 (1912) 608. In: L.H. Maxson (Ed.), Spinal Anesthesia, J.B. Lippincott Company, Philadelphia, London, New York, Montreal, 1938, p. 608. J. Maisonnet, Manuel Pratique D’Anesthe´sie Chirurgicale, Gaston Doin et Cie, Paris, 1936. R. Monod, L’Anesthe´sie en Pratique Chirurgicale, 1937. V. Pauchet, G. Labat, P. Sourdat, R. de B. D’Ormony, Anestesia Regional, Translated into Portuguese, Editora Guanabara, Rio de Janeiro, 1937. R.R. Macintosh, Personal communication, circa 1950.