The technique of the lumbar puncture is not as simple as might be supposed. In stout individuals the spinous proc esses are difficult of palpation, and even in cases where there are not consider able fat a patient that was very nervous when placed in a direct posture would throw the muscles into snch rigidity as to render it almost impossible to fix the point of the spinal process. Unless the lumen of the needle had become oc cluded in its passage through the soft parts, cerebro-spinal fluid flows without any difficulty. In some cases aspiration either with the syringe that is being em ployed or a special suction will still more facilitate the outflow of the cere bro-spinal fluid. It is well to allow a full minute for the injection, thus giv ing ample time for the solution to thoroughly mix with the cerebro-spinal fluid. The solution should be freshly prepared with a menstrnum of sterilized water and boiled for a minute be fore using. It is believed that a, con centrated solution of a definite quantity will not produce disagreeable symptoms any more than the same dose in a di luted solution, and that the effect will last longer. Analgesia is present in the soles of the feet from 1 to 5 minutes, and in from 5 to 15 minutes extends to the umbilicus. In no personal ease did it fail to reach the umbilicus when the solution proved at all effective; in 2 cases it reached to the vertex. In none of the cases did the analgesia subside below the umbilieus under 27 minutes. The amount of cerebro-spinal fluid pres ent in each case has probably direct hearing, upon the extent of the anal g.esia. With a reliable solution it is be lieved that a. failure to produce anal gesia depends upon the failure to intro duce the solution into the spinal cord. In the greater number of cases disagree able features were present, among. them being vertigo, nausea, vomiting, head ache, chills, elevation of temperatu-re .and increased pulse-rate, pallor, cold sweat, and involuntary urination and defecation. The case of Turner, in which death occurred, was found, upon a post-mortem examination, to have been affected with cardiac and puhno nary lesions. In some personal ca.ses there were even heart-murnmrs present, and in one case there was gangrene of the lungs, but no harm supervened. Insensibility to the surgical procedure is not all that should be required of an ideal ancesthetic, and, on the other hand, -such features as the knowledge by the patient of what is taking place around and the perception of the gravity of the operation are to be distinctly avoided. A further trial and conscien tious study of a large collection of eases is required to ascertain the danger that may accompany employment of this form of anmsthesia. G. R. Fowler (Phila. Med. Jour., from Med. News, .Jan. 5, 1901).
In obstetrical and gyncological cases the following technical points are im portant: 1. Sur,gical cleanliness in all things and a fresh, aseptic solution of .cocaine, full strength. The method of sterilization used at the present time is to raise the temperature of the solution (in small bottles) to SO° C. for one hour ,on two. successive days. 2. The needle need not be longer than 7 centimetres and should be kept sharpened. 3. A nurse should stand at patient's head when the puncture is made to keep the back arched forward. A case was re cently reported in this city of a patient suddenly sitting upright and breaking the needle. 4. During an operation the patient's ears should be kept closed with cotton and the eyes covered with a towel or cloth.
The results, as far as they go, would tend to support the view that spinal anrestliesia is not very dangerous, ex cept perhaps to the child itt utero.
When it produces disag-reea.ble symp toms, they are usually transient. In the labor cases it usually retarded progress. Finally, the anresthesia it produces is for a fairly definite period of time without affecting consciousness and with full control of the voluntary muscles.
From a study of these cases the use of the lumbar puncture in multiparfe would seem to be less called for than inhalations of chloroform. The results obtained from its use in primiparm were also not very encouraging, but when good results can be obtained in a few cases the experiments should be con tinued.
In instrumental deliveries, when ur gency is required and the patient is not of a very nervous temperament, the spinal narcosis seems to meet every in dication. The delivery would be much facilitated by the patient's aid, which is not obtained under general narcosis, and the dangers of retained placenta and post-partum Immorrhages are lessened.
It is doubtful if the puncture will ever replace general narcosis in abdominal operations. In vaginal eceliotomy and minor gymecological work it seems to have its greatest field of usefulness, and will, it is believed, come more in vogue as its merits are more fully observed and understood. N. J. Hawley and F. J. Taussig, (Med. Record, Jan. 19, 1901).
It is contra-indicated in children and in nervous and timid patients, particu larly women; also in operations de manding muscular relaxation, such as those for the reduction of fracture and dislocation, and in cases of difficult and prolonged laparotomy. In women, par ticularly those who are young and nerv ous, lumbar amesthesia is not satisfac tory, as it is so liable in such subjects to give rise to intense discomfort and a very rapid pulse. and to be followed by obstinate vomiting and severe and pro longed headache. It should only be used in female patients who are calm and free from timidity, and in cases in which general anmsthesia is contra indicated. Chaput (Bull. et Mai. de la Soc. de Chin de Paris, Apr. 30, 1901).
Conclusions based on fifty cases of spinal analgesia: 1. Cocaine is far more satisfactory than cocaine. The latter is less potent, more evanescent, the areas of analgesia are frequently "patchy," having the pain-sense retained all around them and not being so complete below definite levels. The cocaine pro duces no more unpleasant after-effects than eucaine, and is decidedly more re liable. 2. -Analgesia to the level of the diaphragm can be depended upon in all cases where a moderate dose of a potent solution of cocaine has been introduced by lumbar puncture. In some the anal gesia is sufficient for operation on the upper extremities. 3. Complete anal gesia—including, the eyes, month, and throat—has occurred. It does not en tail more severe after-effects than when the lower extremities only are involved. 4. The preparation of the patient as for a g,eneral ant:esthetic diminishes all tbe unpleasant effects of cocaine and eueaine and often prevents them altogether. 5. By moderate doses of bromides before the injection the initial vomiting is fre quently avoided and the liability of headache lessened. 6. In neurotic pa tients there are often hysterical symp toms directly following the completion of the injection, but. as a rule, in a few moments a calm follows and the patient lies perfectly still. 7. Initial nausea and vomiting often occur soon after the puncture, but last only for a moment or two, and usually do not recnr during the operation. As consciousness, as well as the muscular power, is preserved, the danger of the introduction of the vomi tus into the longs is practically nil. S.