SPINAL SUBARACIINOID INJECTIONS.
—This method of producing anfesthesia was first resorted to by J. Leonard Corn ing, of New York. It consists in the in jection of a solution of cocaine into the subarachnoid cavity. This soon acts upon the spinal centres and ganglia, and the whole or lower half of the body be comes analaesic b • The needle should be of gold or plati num, from three inches and a half to four inches in length, and the bevel of the point should be short. It should be provided with a small steel nut, sliding freely upon the needle and fixable at any point of its length by a set-screw. When the needle is finally within the spinal canal, this nut is pressed against the skin and fixed in place so as to prevent any further entrance of the needle. The needle is left in, situ until anwsthesia supervenes, and is then withdrawn. The most rigid asepsis is enjoined. It is preferable to puncture between the sec ond and third lumbar vertebrea, as this causes the anwsthetic to arrive at the cord more quickly, and in a more concen trated condition than when introduced lower down. Corning notes that tbere bits been a singular immunity from fatality until now—but this will not go on indefinitely, and there should be a concerted effort by the invocation of every known precaution to keep the mortality as low as possible.
While, as stated, the point of introduc tion is a space between the fourth and fifth lumbar vertebne, one-half inch from the median line, the patient occu pying a sitting position, in some cases of spinal deformity it has been impossible to insert the needle at this point. Injec tions have been made between the sixth and seventh cervical vertebrtn. The fluid should never be injected except when the cerebro-spinal fluid. is flowing from the needle, and it should always be injected slowly, requiring from forty to • sixty seconds.
The symptoms as described by Mur phy (Jour. Amer. Med. Assoc., Feb. 9, 1901) are as follow: First there is a sen sation of heat passing over the entire body, then that of thirst, followed in a few minutes by nausea, which may last for ten minutes. Preceding the vomiting there is increased rapidity of pulse, pal lor, and respiration. These symptoms last for a few minutes usually, but are in some cases very marked and make stimu lation necessary. Murphy thinks that
hyoscine hydrobromate, / 1, 200 grain, and nitroglycerin, 7„0 grain, are the best stimulants under the circumstances. The analgesia usually appears in from 3 to 10 minutes, though sometimes it may be delayed from 20 to 30. It usually be gins in the feet and gradually ascends, though in rare instances it may first ap pear as a band around the body and then descend. And in rarer instances still it has been known to ascend from the level of the injection and involve the upper extremities, the neck, and face.
The post-operative symptoms are: Headache, lasting several hours to sev eral days; more or less prolonged vomit ing; vertigo and some ataxia in gait, which may persist for some days; rise of temperature. Coma and delirium have been observed. Mental exaltation fre quently so. Failure to obtain analgesia after the employment of this method is ascribed by Murphy to faulty technique or personal idiosyncrasy. Alcoholism exposes the patient to be unfavorably affected.
Bier, of Kiel (Deutsche Zeitschrift fiir Chirurgie, Apr., '99), first anms thetizes the region for the puncture by Schleich's plan of infiltration. IIe then injects within the meningeal cavity a few drops of a dilute solution of cocaine, introducing frona '/„ to 1/, grain.
Four cases in which the method was used for major operations. A slightly larger quantity of cocaine was used than recommended by Bier CA grain- of co caine), but the effects produced were practically the same, complete anws thesia following in every case and last ing sufficiently long for the completion of the operations, the longest of which lasted fifty minutes. Tlie operations per formed were a Pirogoff amputation of the foot for carcinoma; amputation of the leg and extirpation of the inguinal glands for melanosarcoma of the calca neum; removal of an extensive skin car cinoma in the region of the knee and en larged inguinal glands; and resection of the knee for tuberculosis. Sensation re turned a short time after the completion of the operation, and there were no seri ous after-effects in any case. Seldowitsch (Centralb. f. Chin, vol. xxvi, p. 1110, '99).