groan; if, however, they are asked whether they are in pain, they will
generally reply that there is an unpleasant sensation, or that they feel
sick. Occasionally they may vomit, the face becomes pallid, and
sweat breaks out on the brow. But in the greater number of cases
everything passes olQF peacefully; even in very great interference,
such as disarticulation of the hip- joint; it will be exceptional if
there is any slight evidence of shock.

In rare cases the remedy seemed to fail, but I now believe this
was due to slight impatience and because one did not wait long
enough. I have then had recourse to a suggestive narcosis, that
is, a few drops of ether have been poured on to a mask and placed
before the patient's face. The operation can then almost without
exception be commenced and accomplished painlessly. It is
only in very rare cases, with highly excitable patients, that I have
been obliged to induce general narcosis.

After-effects.

For most cases the anesthesia is so perfect that there is no dis-
turbance, even in prolonged operations. At the same time, it is
advisable to at once utilize the time when anesthesia has been
induced, as it varies in duration. Sometimes, at the end of forty-
five minutes, the patient is observed to become rather restless and
to groan, although this is frequently only due to a strong feeling of



Digitized by



Google



24 Kt'STER: SPINAL ANESTHESIA

sickness and a desire to vomit. But on an average, at the end of
an hour and a half the action of the anesthetic will be over, and
the patient will begin to experience genuine sensations of pain.

As a rule, after the cessation of the anesthesia the patients
feel perfectly well and accept the nourishment offered them with
considerable appetite. Some, who at the same time experienced
motor paralysis — as already mentioned, only a very small number —
assert that they still feel a sensation of weakness in their legs, which,
although it does not prevent their walking, makes them limp a
little'. After a few hours the power of movement is completely
restored. Still, it is noteworthy that sensation more quickly
returns to the normal than does the capacity of movement.

With regard to the ill effects which accompany lumbar anes-
thesia, the principal one is headache, which in the first 200 cases
appeared in about 14 per cent. This can become very violent
and last several days, so that the patients suffer intensely. We
possess, however, an excellent remedy for it by the renewed
puncture of the dural cavity and drawing off about 10 c.c. of fluid,
as first recommended by Chaput.* This method acts like magic.
Directly after the operation the patients declare that their heads
now feel completely relieved; the pain has disappeared immediately.
This was the case in March with a boy of nine, who before had
suffered severely, but directly after the puncture became bright and
in good spirits. This method has only failed in one case. The
patient in question was a man of about thirty, who had been oper-
ated on for hemorrhoids. He had previously suffered from severe
headaches and was very ill the day of the operation. A renewed
puncture, made the following morning, brought him no relief.
The pain lasted with varying violence for six days, and was not
relieved by pyramidon, which is highly recommended in such
cases as a curative remedy; it was only at the end of this time
that the pain became milder and gradually disappeared.

A second case is also worthy of note : A man of thirty-five had
been castrated because of sarcoma of the testicle. As he also
suffered from headache, which increased in violence, a lumbar

^ Centralblatt f. Chirurgie, 1906, Nr. 26.



Digitized by



Google



Kt'STER: SPINAL ANESTHESIA 25

puncture was performed at the end of two days. The fluid drawn
out looked cloudy and contained diplococci. Nevertheless, the
headache disappeared at once, and recovery took place without
any further disturbance.

Before we pursued this method of treatment we once saw a
case the symptoms of which could only be described as aseptic
meningitis. There was violent sickness, together with stiffness
of the neck, severe headache, and sensibility to touch of the spinous
process of the cervial segment of the vertebral column. But at
the end of foiu: days the disturbance disappeared spontaneously.
Having regard to the previous observation, one cannot help
presuming this might have been more rapidly and surely overcome
by means of lumbar puncture.

Henking in the report of our first 1 60 cases refers to a number
of after-effects which we seldom meet, thanks to a more perfect
technique. The following cases are among them:

A boy aged twelve was operated on for purulent epi typhlitis;
six days later epileptiform spasms appeared, which affected first
the right and then the left side of the face and gradually extended
to the upper extremities. The boy was completely dominated by
them; every movement brought on a spasm. Recovered after a
repuncture.

In another case, that of a man aged twenty-eight, twelve hours
after the injection great restlessness appeared, which became
almost maniacal and persisted for sixty hours. It then disappeared
after a large dose of morphine; but the headache continued for six
days longer. Here, also, in all probability, a lumbar puncture
would have proved effectual more rapidly.

Once, at the end of fourteen days, paralysis appeared which
persisted for three weeks; paralysis of the bladder and rectum
occurred twice, and also disappeared at the end of eight to ten days;
finally, paresis of one leg was observed once.

Fever has only occurred once, on the day of the injection.

On the other hand, we have only once seen slight pneumonia
after an operation for epityphlitis, in which, as a matter of fact,
general narcosis was also employed. It ran its course in two days.



Digitized by



Google



26 kCster: spinal anesthesia

There was no doubt it was a case of embolus. We may, therefore,
conclude from our observations that lumbar anesthesia is a pro-
tection against the frequent and dangerous postoperative pneu-
monias. This opinion is in marked contrast to many obsen'a-
tions in which pneumonia is frequently referred to; for example,
at the Breslau Clinic it is asserted that pneumonia has not
decreased at all under lumbar anesthesia. But when one reflects
that the majority of postoperative pneumonias are due to the
aspiration of phlegm or saliva during profound narcosis, one must
conclude that similar results cannot follow operations performed
during complete consciousness. I consider, therefore, that the
prevention of pneumonia through aspiration is one of the most
powerful arguments in favor of spinal anesthesia.

The question as to whether in spinal anesthesia there is a
possibility of its causing degeneration of the spinal cord, even after
the lapse of years, may be touched upon here. This form of local
anesthesia has already been practised for nearly eight years, and
the most varied drugs have been employed, without a single case
of subsequent illness having been reported in literature; so we
may look forward calmly and confidently, without anticipating the
appearance of any. As novocaine especially is proved to be more
certain in its action, and as acute disturbances of a threatening
nature are manifestly of the rarest occurrence, we may confidently
assert that in the future neither early nor late processes of degenera-
tion need be anticipated. Consequently, I have not hesitated to
resort to spinal anesthesia several times with the same person.
Thus, in one case of novocaine anesthesia I have employed it five
times on a man aged sixty-five, without so far any apparent harm
resulting.

Statistical Observations.

Up to April ist of this year lumbar anesthesia in my clinics
has been induced 290 times, of which 208 cases were men and
82 women. The youngest individual who submitted to this
treatment was a child aged five years; the oldest was a man of
seventy-seven. There was no noteworthy difference perceptible
in the behavior of the two sexes; but age, on the other hand.



Digitized by



Google



KCSTER: 6PINAL ANESTHESIA ^'J

made a certain difference. With children the small operation is
always particularly easy, because of the wide opening between
the vertebrae. Consequently, they suflFer so little from the
simple prick that in the children's portion of my clinic,
they have a great preference for this remedy in operations, as
contrasted with general narcosis. Children, when brought into
the operating room, nearly always beg for a "Pieks'* (prick),
and detest the "little cap," as they call the narcosis mask. Spinal
anesthesia is a great advance in the struggle to combat and avoid
the operative pain of a wound. It is also of the greatest assistance
to us when making examinations of the pelvic organs and of the
abdominal cavity, especially in the cases in which pain or reflex
muscular contraction augments the difficulty of the examina-
tion. The method appears to be less dangerous than general
narcosis, as it does not immediately threaten life, and also does
not induce any serious after-eflfects; pneumonia in particular,
caused by inhaling irritating substances — i. e., pneumonia by aspira-
tion — appears to be entirely prevented. The method does not, as
a rule, aflfect the health by any means as much as general narcosis;
so that it can be employed without danger even in the cases of
weak, delicate, and suffering people, and those who are afflicted
with severe disorders of the internal organs — the kidneys, heart,
etc. It is, therefore, worthy of the most comprehensive regard
and development.

I shall rejoice if my address is the means of extending the
field of this method of operative surgery, and procuring for it a
wider range of usefulness than has hitherto been the case in
America.



Digitized by



Google



23 DISCUSSIO!^



DISCUSSION.

Dr. Thomas W. Huntington, of San Francisco.

In opening the discussion upon the excellent paper by Professor
Kiister, I wish to say that in entering upon the work described by the
reader, I believe that no person ever employed spinal anesthesia with
greater unwillingness or with more doubt as to its legitimacy than myself.
I appreciated what seemed the great risk in approaching so important
a structure as the spinal canal by the prescribed method. Urged,
however, by my associates and influenced materially by the experience
of colleagues, I concluded two years ago to give it a fair test. We
engaged in the undertaking systematically and for a time employed
spinal anesthesia whenever it was applicable in adults. We have never
attempted it in eariy childhood, for obvious reasons. My observations
are closely in accord with those of the reader, with one or two possibly
essential differences.

The drug of our choice has been tropococaine instead of novocaine,
and have used as a solvent the spinal fluid, employing from 2 to 4 c.c.
of the spinal fluid for this purpose.

We have come to think that this method of administration is of ver\'
great moment. Rarely have our cases suffered from headaches or ner\^e
disturbances, while in our earlier efforts with cocaine these were not
uncommon and were sometimes exceedingly annoying. Without
exception there has been satisfactory anesthesia below the point of
administration. Patients lie passively during operation and have been
free from all the terrors which were depicted so brilliantly by those who
have decried the method without extensive experience.

The one thing which has impressed us most, the thing which has
convinced me that spinal anesthesia has come to stay, is the postoperative
comfort of the patient. Go to the bedside of patients operated upon
from two to four hours previously and you will find them lying com-
fortably, some taking their meals as usual, some sleeping, and none of
them suffering from postoperative vomiting. Shock is greatly minim-
ized and in ordinary cases it is unnecessary for nurses to hover over the
patients in an effort to relieve distress.

I believe this one feature is sufficient to convince the person with
experience that we have in spinal anesthesia a means of eliminating post-
operative distress, discomfort, and pain, which is perhaps superior to
all other anesthetics.

Personally, I am willing heartily to endorse spinal anesthesia when
properly conducted.



Digitized by



Google



SPINAL ANESTHESIA 29

Dr. a. T. Bristow, of Brooklyn.

Some three or four years ago I did about fifty operations at the County
Hospital under cocaine anesthesia. I have had no experience with any
of the other narcotics, but I would like to detail my experience in these
cases. In the first place the patients suffered, as a rule, a good deal from
headache; this was extremely persistent and severe, lasting in one case
for three weeks. Vomiting also was frequent. Then, again, I was not
always sure of my anesthesia. In two-thirds of the cases it was satis-
factory, while in one-third it was most unsatisfactor}\ In operations
on the cord for varicocele, etc., I got practically no anesthesia. I had,
moreover, a series of six cases of postoperative insanity I reported at
the time. Professor Kiister has suggested a similar case of his own in
which a maniacal condition existed after spinal anesthesia. In six of
these cases, after the use of spinal anesthesia, the patients developed
illusions of persecution which lasted from two to three weeks. One
man, an electrician, got the idea that the hospital was running electric
currents into him to destroy him. Another said that his relatives were
seeking to poison him. They all ultimately recovered.

I was not so unfortunate as to have any paralysis or infections. For
one thing, I invariably, before introducing the needle, make a slight
puncture with the scalpel, in order to avoid passing the needle through
the infected layer of skin.

The cases of mania were most interesting to me, and so far as I know,
after having made inquiry in New York, I am the only surgeon who has
had such cases.

Dr. Schmieden, of Bonn (by invitation).

It is my intention to add but a few words to the paper under discussion
on '* Liunbar Anesthesia," and that is with reference to the indication
as observed at Bier's clinic.

As you know. Bier has spared neither time nor effort to perfect the
method in every direction. Yet he had often been the verj' one to
condemn too geat enthusiasm, which can only hurt even the best of
causes. The extension of the field of application must keep pace with
the progress of the technique, but must not precede the same. We want
to use lumbar anesthesia only where it is absolutely safe.

We know very well that occasionally lumbar anesthesia may be ex-
tended up to the shoulders, but we do not at present advise this for
practical purposes. W'e use it in hernias and all operations below
Poupart's ligament (rarely in the case of laparotomies). In the back
one can well go up somewhat higher. Hence, we do all operations upon
the kidneys under lumbar anesthesia.

From the foregoing you will see that the field of application is suffi-



Digitized by



Google



30 DISCUSSION

ciently large as it is. Everything that lies below the limits stated is
operated upon, almost without exception, under lumbar anesthesia at
Bier's clinic.

The technique is progressing from year to year and we still hope to
make many improvements, and have no doubt that in the end Bier's
prognostication of a brilliant future for lumbar anesthesia will be
realizd.

Dr. Willy Meyer, of New York.

Regarding this method, I would say that the same certainly has not
been very extensively used on this side of the Atlantic, since the first
enthusiasm following its introduction rolled by. There must be reasons
for this. I believe they are threefold: First, that surgeons soon realized
that spinal anesthesia also has its dangers; second, the unsettled
condition that arose from the uncertainty as to the proper drug to be
used; third, that general anesthesia in America has been continuously
improved and its dangers reduced, partially by using safer anesthetic
drugs, partially by employing specially trained narcotizers in nearly
all its hospitals, thus doing away with the dangers arising from entrust-
ing this important work to the youngest man on the staflF.

Yet I believe that spinal anesthesia has its clear indication. Per-
sonally, I have used it in some 70 cases since 1900, employing cocaine
(with or without paranephrine), tropacocaine, adrenalin, stovaine, and,
at the special request of Dr. S. J. Meltzer, of New York, sulphate of
magnesia. The physiological effect of the latter in its various appli-
cations on the human subject certainly is a wonderful discovery. But
if used for spinal anesthesia it produces temporary paralysis of bladder
and rectum, which is a concomitant effect, and this in certain cases,
e. g,, hypertrophy of the prostate or stricture of the urethra, may give
surgeon and patient a great deal of trouble. In view of this, I hardly
think we are justified in recommending its general use for spinal anes-
thesia.

Novocaine, which was so warmly endorsed by Trendelenburg, of Leip-
zig, two years ago, and has again today been highly recommended by
Professor Kiister, is the only drug I have not tried. Lately, I have
resumed the use of tropacocaine, which is half as poisonous as cocaine.
I had abandoned it for a while on acount of two deaths. The cause
was, as I later ascertained, exaggerated sterilization of the solution, which
I presume split the drug. Tropacocaine is made from tropine, a
fractionation product of atropine and hyoscyamine. Today, tropa-
cocaine as well as stovaine are to be had in the market properly sterilized,
ready for use, and put up in the extremely convenient ariston ampulla?,
which for me constitutes a reason in favor of its use.



Digitized by



Google



SPINAL ANESTHESIA 3I

Personally, I believe spinal anesthesia to be distinctly indicated
in very old patients, diabetics afflicted with gangrene, many cases of
urinary surgery, especially old prostatics, and in all cases complicated
with chronic heart or lung trouble.

I think it is our duty to recognize that we have today three different
useful methods for painless operating: General anesthesia, local
anesthesia, and spinal anesthesia, each one of which has its indication.
If local anesthesia be impossible and the dangers of general anesthesia
are greater than those of spinal anesthesia, the latter should be employed.
But, generally speaking, I believe it will be a good plan, as far as surgical
work in this country is concerned, to Umit the use of spinal anesthesia
to such cases in which it is strictly indicated, at least for the present.

Dr. George E. Brewer, of New York.

I would like to ask Professor Kuster if he can give us an idea of the
statistics, the mortality following this procedure, gathered from his
own experience and that of his colleagues in Europe. The reason I
ask this is that after the first enthusiasm regarding spinal anesthesia had
passed, at one of the Congresses in Paris a number of reports were made,
and it was commuted from these that the mortality was something
like I in 500. That is one of the reasons why it has not been used more
extensively in this country. I have made it a rule never to employ it
unless I felt that the administration of a general anesthetic was accom-
panied by a greater risk than i in 500.

Dr. Willis G. MacDonald, of Albany.

Before closing this discussion on lumbar anesthesia, I should like
to present to the Association in a general way some personal experience
and observation with relation to its employment.

I returned early in August, 1900, from a trip abroad, during which I
visited a large number of clinics in Germany, Switzerland, and France.
Just at this time, that of the Paris International Medical Congress,
lumbar anesthesia was attracting wide attention, particularly in the Paris
hospitals. I had the pleasure of observing its employment on several
occasions by some of the most skilful surgeons. Purchasing the then
most approved apparatus, I approached the employment of the method
with some considerable enthusiasm. During the first year I employed
lumbar anesthesia in not far from 60 cases out of a total of 1000 or more
anesthesias. During this time a i or 2 per cent, solution of cocaine was
employed, but never in a maximum dose. Several postoperative com-
plications in the way of severe headaches, prolonged vomiting, and
disturbed mind were observed, together with symptoms of considerable
shock and not infrequentiy cocaine poisoning.



Digitized by



Google



32 DISCUSSION

In the succeeding years we have used this plan of anesthesia with a
progressively decreasing frequency and have employed all of the sub-
stitutes for cocaine which have been advocated, including eucaine, sto-
vaine, and novococaine. While in the use of some of these latter agents
the disagreeable manifestations associated with the employment of the
remedy have been less frequent, yet, nevertheless, they have from time
to time been sources of great anxiety.

I am familiar with the newer preparations and methods which have
been recently presented, and saw a death occur from the administration
of two-thirds of a bottle of solution identical with that which has been
passed about the Association this morning.

There can be no doubt but that lumbar anesthesia is an agent of some
considerable value. Time is not afiforded for a general discussion of
the indications for its use, which I believe to be limited, and that this
form of anesthesia in no way is to be employed as a general substitute for
ether or chloroform.

The question of anesthesia is largely a matter of personal equation,
depending to a considerable extent upon the personnel of the clinic and
the geographical surroundings. There can be no question but that in
America general anesthetics are employed at this time with greater skill
than in any other country of the world, except perhaps England, and
that surgery is becoming awakened to the usefulness of the specially
trained and skilled anesthesist now so frequently employed in our hos-
pitals and private practice.

It appears to me that in this relation, that is, of the employment of
IcKal and lumbar anesthesia, we Americans are not alone given to all
of the fads.

Professor E. Kuster. In reply to the question of the gentleman
who spoke last, I wish to state that a certain number of deaths have been
obsened after nearly all the drugs hitherto employed for lumbar anes-
thesia. The most dangerous anesthetic we have found to be cocaine,
already described by me; however, all other drugs are more or less
dangerous, even stovaine, which was so highly recommended at one
time. The autopsy findings in the case reported by Fritz Konig have
shown that stovaine may produce acute degeneration of the cord, result-
ing in death. No such experience has as vet been reported in connection
with novocaine, although this latter drug has been verj- extensively
useil. Of course, this does not prove that unfavorable results may not
still occur, \*et there seems to be no ground for such apprehensions.



Digitized by



Google



CONTINUOUS PASSIVE HYPEREMIA IN DELAYED

UNION OF FRACTURES AND IN HASTENING

THE CONSOLIDATION OF FRACTURES.

By JOHN B. ROBERTS, M.D.,

PHILADELPHIA.



Ten or eleven years ago I reasoned that physiological processes
made it probable that delayed union in fractures could be success-
fully treated by engorging the fragments of bone with venous blood.
This I determined to eflfect by applying a rubber bandage moder-
ately firmly around the limb above the seat of fracture. I reported
an instance of delayed union of the tibia and fibula so treated to
the Section on General Surgery of the College of Physicians of
Philadelphia in 1897' and mentioned the subject elsewhere about
the same time.*

When the report was made the patient had worn the bandage for
nearly three and a half months. It was used after waiting for
two months for imion after resection of a fracture of the tibia and
fibula, which had remained ununited for five months. The band-
age was applied around the lower part of the thigh, and was worn
day and night just tight enough to make the foot and leg blue and
swollen from venous engorgement. The skin beneath the bandage
was kept in good condition by occasional bathing with alcohol and
the use of a short cotton bandage beneath the rubber one.

The treatment with continuous hyperemia was supplemented by