Ten Years Experience with Spinal Anesthesia at San Quentin Prison
L. L. Stanley, MD
Then “I trust that I will be pardoned for injecting the personal element into this recital of my experience with spinal anesthesia, but I feel that a narrative will probably be of more interest than a purely scientific treatise of the subject.
In 1913 I received the appointment as Resident Physician at the State Prison and the duty devolved upon me to care for over two thousand men, unaided excepting by two doctors who were serving terms for violations of the law.
This was quite a responsibility for one just having finished a year's internship in a large hospital, where the only surgical procedure he was allowed to do unassisted was a circumcision.
But at San Quentin there was much work to be done and it devolved upon me to do it. Before my time, surgeons were called in from San Francisco to operate, but such an arrangement did not prove satisfactory.
My first emergency appendectomy was performed with fear and trepidation with an ether anesthetic administered by one of the inmates. The patient survived.
Encouraged by this success, other operations were attempted and the patients came along surprisingly well. But it was difficult to depend upon the anesthetic administered by the prison help as operations of graver nature were performed. One anesthetist would purloin any alcohol which might be about and would imbibe freely of it before he administered the ether. Another had little regard for safety and occasionally gave too much.
With these difficulties to contend with it became necessary to do without an anesthetist and because of these the use of spinal anesthesia was begun.
The first case was given 1½ grains of tropococain intraspinally for the purpose of stretching the sciatic nerve. The anesthetic was perfect and the result was good. Encouraged by this, other operations were performed and it was not long before the alcohol purloining anesthetist was dispensed with entirely.”1
Now Dr. Stanley described a series of 1185 spinal anesthetics performed by a single proceduralist (acting as both anesthesiologist and surgeon) from 1913 to 1923. General anesthesia was administered; for all procedures below the diaphragm, a spinal anesthetic was performed, including appendectomy (175 cases), herniorrhaphy (287 cases), and hemorrhoidectomy (199 cases). He prepared his own ampules of local anesthetic (90–180 mg of tropococain or procaine), the crystals of which were diluted with the patient's cerebrospinal fluid. After injection, the patient was placed in the Trendelenburg position to facilitate spread of the hyperbaric solution. The anticipated duration of the spinal anesthetic was approximately 1 to 2 hours.
Undoubtedly, Dr. Stanley would be pleased that the surgeon was no longer responsible for performing the anesthetic and relieved of the “extra worry and care imposed in looking to the progress and effect of the anesthetic.” He would likely be amazed at the improvements in equipment, local anesthetics, and adjuvants that allow longer surgery and provide postoperative analgesia. However, he would also be surprised that spinal anesthesia is no longer the anesthetic of choice for abdominal surgery because of the advances in general anesthesia. (It is important to note that deep ether anesthesia was required to achieve adequate muscle relaxation for abdominal wall closure. This depth of anesthesia was associated with atelectasis, pneumonia, and cardiovascular collapse.)
There are several results within Dr. Stanley's series that are noteworthy as they foreshadow recent events and ongoing issues. A careful review of the list of procedures reveals “removal of testicle- 2” and “replacement of testicle- 1,” suggesting a wrong-side surgery. In 2004, the Joint Commission initiated the Universal Protocol to prevent wrong-person, wrong-site, and wrong-procedure events. However, a Wrong Site Surgery Summit was held in 2007 to address concerns raised about the continued increase in wrong-site surgery cases. At a rate of 8 to 10 new cases per month, wrong-site, wrong-procedure, and wrong-patient operations remain the most frequently reported sentinel event in the Joint Commission database, despite introduction of the Universal Protocol. Active involvement of the patient and empowerment of the team to “speak up” for patient safety and the introduction of a surgical checklist (http://www.jointcommission.org/standards_information/up.aspx) have been demonstrated to reduce these errors (and decrease mortality) without introducing procedural delays. Given that “ordinarily no hypnotic is given the prisoners before the operation,” it would seem that had a Universal Protocol been followed, this wrong-side surgery would not have occurred.
Dr. Stanley reports 2 deaths within his series, 1 of which involved an equipment malfunction. The patient was undergoing laparotomy for severe gastric hemorrhage. During resection of the ulcer, the patient suffered respiratory collapse. A pulmotor (a respiratory-assist device) was applied but the patient's condition worsened and he died intraoperatively. A year later, when the pulmotor was inspected, it was determined that a tank of carbon dioxide had been substituted for oxygen. Anesthesia delivery systems have made it increasingly more difficult to administer the wrong gas or volatile agent. In the event this should occur, sensors/monitors will alert the provider. Nevertheless, the danger associated with infrequently used equipment was highlighted early in the practice of our specialty.
The shortage of medications, including perioperative drugs, has significantly affected patient care in the last 2 decades. Shortages may be attributable to lack of raw materials, manufacturing issues, or discontinuation/interruption of production.2 It is interesting that Dr. Stanley also reported a shortage in what he considered a “mission critical drug,” tropococain: “since the war tropococain has been unobtainable and it has become necessary to use procaine. This is not so satisfactory as the effects do not last as long.” Because of the ongoing concern regarding impending shortages or outages of perioperative medications, anesthesiologists are urged to develop institutional management guidelines as well as collaborate with the Food and Drug Administration and the American Society of Healthcare Pharmacists. Although tropococain is no longer a mission critical drug—defined as a medication that without which, patient care would be adversely affected—both lidocaine and bupivacaine are classified as such (at least at the Mayo Clinic).
Finally, as illuminating as Dr. Stanley's series is, it would likely not be published today, because his human subjects were prisoners. He could not have foreseen the atrocities conducted by Nazi physicians during World War II that led to the Nuremberg code in 1947. The code provides 10 Directives for Human Experimentation, the first of which is that “the voluntary consent of the human subject is absolutely essential.” The current Department of Health and Human Services' policy for Protection of Human Subjects limits research involving prisoners to investigations that “study the possible causes, effects, and processes of incarceration and of criminal behavior” and “evaluate conditions affecting prisoners” (such as hepatitis or drug addiction) or “practices which may improve health or well-being” (http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.html#subpartc). A comprehensive, but not exhaustive, search on studies involving prisoners, which were published in Anesthesia & Analgesia, yielded only 3 additional articles: a follow-up to the current study reporting on 4674 spinal anesthetics over 25 years at San Quentin,3 an investigation of factors affecting spread and level of epidural anesthesia,4 and an evaluation of the antiemetic effect of metoclopramide (in which subjects received metoclopramide then fed and administered apomorphine).5 None of these methodologies meet criteria for approval under the Department of Health and Human Services' policy for research involving prisoners.
Over the last 90 years, advances in equipment and medications have enhanced applications of spinal anesthesia, while the introduction of practice protocols has improved safety. Few of us have practiced under the circumstances described in Dr. Stanley's article. He concluded, “spinal anesthesia was employed ten years ago at San Quentin because of necessity and with continued use it has become the anesthetic of choice.” We must commend him for his pioneering spirit, which sought from the beginning to improve patient care and optimize outcomes.
Dr. Terese T. Horlocker is the Section Editor for Regional Anesthesia for Anesthesia & Analgesia. This manuscript was handled by Dr. Steven L. Shafer, Editor-in-Chief, and Dr. Horlocker was not involved in any way with the editorial process or decision.
Name: Terese T. Horlocker, MD.
Contribution: This author wrote the manuscript.
Regional anesthesia has come to stay. —William J. Mayo
I have become comfortably numb. —Pink Floyd