Splanchnic Analgesia.

By J.W. COSTELLO, M.B., Ch.B., Napier Hospital.

In the following series of eight cases of upper abdominal operations, the general condition of the patients was such that everything that could be done to diminish shock was of primary importance, and it was thought that in splanchnic analgesia this to a large extent would be eliminated in addition to conferring other advantages on the patient.

With the permission and helpful assistance of Dr. J. Allan Berry I was enabled to use this method of anæsthesia for some of his cases in an attempt to reduce the shock, heart strain and post-operative distress to a minimum, with results that would suggest its suitability for use over a much wider range of cases.

As with every form of local anæsthesia the physical condition of the patient must be considered, as well as the fact that it is impossible in most cases to prevent certain sensations caused by traction on the peritoneum or mesentery which although not described as painful by the patient are such as to cause apprehension. The fear of pain together with the somewhat awesome sights and sounds of the operating theatre, would appear often to more than counter-balance the advantages of the local nerve-blocking in the prevention of shock, even when the operation is preceded by liberal injections of morphine and hyoscine, and for this reason most of the cases were given a light ether anæsthesia throughout—from one to one-and-a-half ounces per hour was all that was required to keep them in a quiet sleep, from which they would occasionally waken sufficiently to talk to the anæsthetist. Complete relaxation of the abdominal muscles and the absence of any straining or forcible breathing were maintained for periods varying between 1¼ and 1¾ hours, after which any further anæsthesia required had to be obtained by increasing the amount of ether used. On return to the ward consciousness was recovered in from 5 to 20 minutes, the pain in all cases seemed to be somewhat less than after general anæsthetics, and there was a remarkable freedom from vomiting or nausea. In most cases the chief difficulty was to persuade the patients that they were unable to go back to a full diet on the first or second day after operation.

TECHNIQUE.—The patients are prepared by giving liberal quantities of glucose and fluids and sufficient sod. bicarb. to render the urine alkaline, for 24 to 48 hours before operation. At least an hour before leaving the ward they are given 1–6 to 1–8 gr. Morphine and 1–150 to 1–250 gr. hyoscine, according to their condition, and this dose is repeated, if the first is well tolerated, just before being taken to the theatre. Blood-pressure and pulse record are made before starting the splanchnic injections which consist of 25 to 30 c.c. 1 per cent. novocain with 5 to 10 minims adrenaline on either side of the body of the twelfth thoracic and first lumbar vertebra, according to the method described by Labat. With the patient on his side and a pillow to keep the vertebral column straight, a perpendicular line is dropped to meet the last rib at a distance of 7 c.m. from the mid-line and a lumbar puncture needle inserted at an angle of 45 degrees with the sagittal plane of body till it comes in contact with the body of the first lumbar vertebra—the point of the needle is then withdrawn and raised till it can be felt passing just tangentially to the anterior surface of the vertebral body. It is then pushed in 1 c.m. further, and 15 to 20 c.c. of the solution injected slowly. The syringe should be aspirated before and at intervals during the injection to be sure the needle is not in a blood vessel. If the point of the needle is in correct position very slight pressure is needed, the weight of the piston being almost sufficient to diffuse the solution through the loose tissues surrounding the coeliac plexus. The needle is then withdrawn till the point is in the subcutaneous tissues and reintroduced in a similar way till it just grazes the anterior surface of the second lumbar vertebra, it is then pushed in 1 c.m. further and 10 to 15 c.c of the solution injected—the process is then repeated on the other side. The danger of penetrating some of the large vessels is not great if care is taken to keep the point of the needle in contact with the body of the vertebra and to pass it not more than 1 c.m. further once it is felt to graze the anterior surface—with a little practice on the cadaver the necessary landmarks can easily be acquired.

After these injections there occurred in all cases a pronounced fall in blood-pressure and a degree of collapse that at times seemed rather alarming, but when turned on their backs and kept quiet for 10 to 15 minutes, during which time the abdominal wall was injected, all the cases made a rapid recovery and the operation was not started till the blood-pressure was rising again.

The initial shock of the splanchnic injections was minimised by slow injection and keeping the temperature of the solution at 100 degrees F. In some cases the use of more adrenalin in the splanchnic injection and less in the abdominal wall seemed to lessen the disturbance also. Never more than a total of 15 to 20 minims adrenalin was used for all the injections. The abdominal wall is then anæthetised with from 60 to 80 c.c., ½ per cent. novocain on either side—the injections being made in two layers—into the muscles and subcutaneously. The former can be made either into the lateral border of the rectus or along the costal margin and down to the iliac crests on both sides beneath the deep fascia covering the oblique muscles; of the two the latter is no more difficult and gives a wider area of relaxation. By the time the injections are completed, 20 to 30 minutes from starting, the patient is recovering from the first shock of the injection and full anæsthesia of the abdominal wall and abdominal contents is present. Whilst making the splanchnic injections a light third degree anæsthesia is preferable, as even with the minimum of scratching of the bone of the vertebra it is a painful process, described as the most painful part of the whole operation by two patients who had no general anæsthesia at all. As soon as the posterior injections are completed the anæsthetic can be stopped till the abdomen is opened.

The following is a record of the cases:—

(1) Male, 60, shepherd. Abdomen tensely distended with hydatids. History suggestive of heart failure for several months past—marked signs of pressure on thoracic organs—dullness and many coarse creps. both bases—liver at upper margin of fourth rib on inspiration—heart lying almost transversely with apex 2 inches outside nipple in fourth space. X-ray not suggestive of any hyatids in thorax.

Throughout the operation the patient insisted on having his head raised sufficiently to see what was going on and his interest in the number of cysts of all sizes being washed out of his abdomen was only diverted by an occasional mouthful of brandy. At the end of 1½ hours after starting the operation, just before closing the abdomen, a firm pull on the liver with the hand between it and the diaphragm caused no comment, except that it made him feel a little sick.

He returned to the ward with a strong steady pulse of 99 which had fallen to 85 by the evening and the general condition of the patient was very good till about midnight, when he collapsed while attempting to sit up in bed. The pulse recovered for a few hours and then failed rapidly, death occurring about 18 hours after the operation. The condition of the patient was so good for 12 hours after the operation that the sudden collapse seems to be more due to the effect of the patient’s efforts to sit up, on a heart already labouring under some extreme changes of pressure, rather than to the shock of the operation.

(2) Male, 47, railwayman. Extensive carcinoma of pylorus with marked cachexia and general debility. He had a complete anæsthesia and relaxation for 1½ hours, during which time a partial gastrectomy and wide dissection of the glands in mesentery was done. The first ether was given whilst closing the peritoneum  which was a difficult one to approximate in the upper part of the wound. He was fully conscious a few minutes after return to the ward, with a strong pulse, between 70 and 80, there was no vomiting, restlessness or abdominal tension, and the patient was up and eating well a week later. He was discharged 15 days after the operation in rapidly improving condition; ten months later he reported himself to be fit and working harder than at any time during the past 8 years.

(3) Female, 60. Diagnosed as extensive carcinoma of the stomach—marked emaciation, and heart sounds weak—tic-tic rhythm and frequent extra systoles, response to effort poor, three million reds, 45 per cent. Hb. Kept under observation for several months and decided to be inoperable, till test-meals and a slight improvement in her general condition threw some doubt as to whether the condition was carcinoma. Operation showed two chronic ulcers with extensive infiltration of the stomach wall. Ulcers were excised and gastro-enterostomy performed. The patient was kept under light ether most of the time, but was allowed to become conscious one hour after the operation started; she had no complaint to make except to want a drink. Fully conscious and feeling well 10 minutes after return to the ward, she never vomited, nor had any nausea—there was moderate distension of the abdomen for several days, beyond which very little discomfort was complained of. She was discharged feeling very well three weeks after the operation.