It is now about one year and a half since Bier, of Kiel, Germany, announced to the profession that he had found a new method of anesthesia, consisting of injections of cocain into the subarachnoid space of the spinal cord1. His methods were promptly put to the test by various obstetricians, gynecologists and surgeons, and to-day the whole surgical world is agog to learn the indications for the use of this method, its limitations and its special field. The original supposition was that it was

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... licable to cases demanding a limited field of work and the practice of the early operators was to confine it to operations upon the lower extremities. This was gradually extended to include operations within the pelvis, the line of analgesic demarcation being drawn at the umbilicus. This naturally led to the conclusion that the special field for its application was embraced in the three departments of obstetric, gynecologic and genito-urinary surgery, together with the general surgery of the lower extremities. Further experience with the method and with the use of larger doses has extended to the regions of the body in which surgical work can be done under this method of anesthesia until it includes all parts, both superficial and deep, from the tip of the toes up to and including the breasts. The head, neck and upper extremities are outside its sphere, and probably will always remain so. It would seem, therefore, to be a matter of special pleading to insist that gynecology has any special claim on the method for its particular use. and yet there are reasons for insisting that it has in this departmenta special indication. We know that after an injection of the cocain, the analgesic effect begins in the toes and gradually extends up the lower extremities, the extent of its complete analgesic influence depending on the amount of the drug used. It has been thoroughly established, however, that the dosage necessary to produce anesthesia as high as the umbilicus is perfectly safe; its action is prompt and the unpleasant effects are not severe. Tuffier began his extension of the work from the lower extremities to the trunk of the body by operations, first on the perineum, then on the rectum, extending it Read in a general discussion of Anesthesia by Lumbar Punc- [ill]ure before the Section on Obstetrics and Gynecology of the New York Academy of Medicine, Oct. 25, 1900. 1. Bier performed his first operation under medullary analgesia Aug. 16, 1898, and published a report of his first six cases in April, 1899. We now know that J. Leonard Corning, of New York, devised this method and put it on a practical basis in 1885. gradually to the bladder, ureter, to vaginal hysterectomies, appendectomies, hernias, and finally gastroenterostomies. Encouraged by his success in these regions, he has extended the field of operation to the kidneys and even to operations on the breast. To secure surgical anesthesia in these latter regions it is not necessary to make the injection any higher than the fourth space in the lumbar region, but it is necessary to use larger doses. On Sept. 27 last, I had the privilege of seeing Dr. Neven, one of Turner's assistants, remove a small fibroid tumor from the right breast, the patient showing no signs of pain, either during the incision or the sewing up of the wound. In this instance three cubic centimeters of a 2 per cent, solution of cocain were used. Seven minutes after the injection the incision was made and the entire operation completed in about twenty minutes. There was no vomiting in this case, but the respirations were excited and sighing in character. Profuse perspiration came on during the operation, and when the woman was raised up on the table for the purpose of applying the dressing and bandage, she became extremely faint and limp, and asked for water. The faintness was not, however, greater than under similar circumstances after the use of ether or chloroform. Hot black coffee was used in this case as a stimulant. In addition to the increased dosage, it is possible that the line of anesthesia can be carried higher up the body by a forcible injection of the cocain. In my own experience, the first case in which I used it was subjected to this method; that is, the piston was shoved home quickly and the fluid was suddenly and forcibly injected. In that case, although the operation was a vaginal hysterectomy, the tests that were applied showed that the line of analgesia extended above the breast line ; and it was remarked at the time that undoubtedly an operation in that case could have been performed on the breast as painlessly as on the uterus. At the Lariboisière Hospital it is the custom of both Dr. Tuffier and his assistants to inject the cocain slowly and steadily. Whether there was headache following the large dose of cocain in the breast case just mentioned I was unable to learn, but the other phenomena-nausea, vomiting, sweating, chilly sensations and general depression-were not so pronounced as in a case of vaginal hysterectomy for epithelioma of the cervix done on the same day by Dr. Lyot, another of Turner's assistants, with only 1/6 grain of cocain. It has doubtless been the observation of all of us that in many instances a small dose of morphin administered hypodermically will be followed by serious nausea, vomiting and headache, while a larger dose in the same patient will not be attended by any of these distressing symptoms. It is quite possible that the same rule will apply to the dosage of cocain in these spinal injections. Indeed" in conversation with Tuffier in the early part of this month, he expressed himself as inclined to think that the rule Downloaded From: http://jama.jamanetwork.com/ by a RYERSON UNIVERSITY LIBRARY User on 06/15/2015