External diameter must be 1.1 m.m.; the internal diameter, 8 m.m. It must be solid, so as not to bend when it comes in contact with the vertebral column. Its end must have short bevel. I employ a 2 per cent solution of cocain. This solution must be sterile and recent; old solutions must be discarded. This is important. The fluid injected must be carefully sterilized. I prepare my solutions as follows: The solution is exposed to a temperature of 80° C. in water bath for fifteen min

Cornu bulbularis.

3

utes, then it is kept in a temperature of 38° C. for three hours; it is again brought to a temperature of 80° C.; then allowed to cool to 38° C. This operation is repeated five or six times in succession. It assures a perfect sterilization; the anaesthetic properties of the cocain are not altered.

"The operative technique is as follows: The patient is in the sitting posture, both arms carried forward. The field of injection is thoroughly asepticized. Locate the iliac crests. An

imaginary line connecting these two crests passes through the fourth lumbar vertebra. By injection beneath that line you penetrate the medullary canal. As soon as you have located with the left index finger this spinous process, tell the patient to bend forward so as to make a big bag. This bending forward causes a separation of 1.5 c.m. between the vertebra on which you have your index finger and the subjacent vertebra. Then it is always wise to tell the patient, I am going to stick you with a needle; you will feel some pain, but do not move.' Make the injection with the right hand. I insert the needle to the right of the vertebral column, about 1 c.m. from the line of

the spinous process. The needle goes through the skin, through the subcutaneous cellular tissue, through the lumbar aponeurosis, through the muscles of the sacro-lumbar region, and penetrates the limellar space, and it at last penetrates the spinal canal. As soon as the needle is in the subarachnoid space it meets no resistance, and from it escapes a clear yellow fluid. This fluid is the cerebro-spinal fluid, and escapes drop by drop. The surgeon must never inject a solution of cocain before he has seen the cerebro-spinal fluid escape. After he has seen this fluid escape through the needle, he attaches to the needle a syringe containing 1 c.c. (15 minims) of a 2 per cent

solution of cocain. The injection is made slowly; it should be completed in one minute. The dose injected should not exceed 15 milligrams of cocain. I always employ a 2 per cent solution. The injection terminated, I rapidly remove the needle and close the needle puncture with sterilized collodion. Note the precise minute at which the injection is terminated, and then wait. The patient can be questioned as to the subjective sensation

which he experiences. After a certain lapse of time, which in our observations varied according to the subjects, from about four to eight or ten minutes, the patient would complain of a tingling sensation and numbness of the feet. This numbness extends to the legs. You can now begin to operate. Gradually a sensation to pain and heat disappears. Contact sensation persists. Toward the last the motor system may be affected.

From four to ten minutes after the injection analgesia is usually complete. Most often it extends to the thorax; occasionally to the axilla. It is not an approximate analgesia; it is complete, it is absolute; so much so that in a thigh amputation we asked the patient to elevate his stump that we could better secure the vessels. In the course of the operation the patient, when questioned, would say that he felt only a sensation of contact. One of my patients could hear me saw his femur, and told my assistant that he could not tell whether I was sawing his femur or the table. While doing a vaginal hysterectomy one of my patients felt that something was giving away when the uterus was being removed, but she experienced no pain. In the course of a lumbar nephrectomy the patient, at the close of the operation, asked us if we were not going to begin the operation soon.

"The duration of analgesia is from one to one-and-a-half hours It has always allowed me sufficient time to complete the most laborious surgical intervention. The position which the patient is made to assume during the course of the operation does not at all modify the analgesia. I have thus always been able to employ that posture best suited to the operative procedure. Like under general anesthesia, I have operated in the inclined posture and in the left lateral posture.

"The following incident may happen in the course of the puncture: In subjects whose spinal column is deviated, as in scoliosis, the line of the spinous process can only be found with difficulty, and owing to the fact that the vertebral laminæ have lost their normal relations, the puncture may be difficult. This obstacle, however, can be overcome by patience on the part of the operator. If the needle strikes against a vertebral lamina, change the direction of its point, either upward or downward, but do not pull it back and forth. This pulling back and forth along the blunt needle may succeed in breaking it. The better thing to do is to remove the needle. Make another puncture higher or lower. The solution must be injected in the subarachnoid space. There is only one sign which permits us to affirm that the needle is in the cavity. I mentioned this sign before; it is the escape of cephalo-rachidian fluid. If blood escapes through the needle, it may be fluid blood, or it may be blood with an admixture of cerebro-spinal fluid. As to the nature of the blood, we cannot decide by simple inspection.

We repeat the puncture, and we will not inject until we have seen two or three drops of pure cephalo-rachidian fluid escape. Can this method of anesthesia be productive of any accident? I do not know, but, basing my opinion upon personal observation, I can affirm that I never have seen a serious accident. Usually the patients complain of epigastric weight, a feeling of epigastric coldness. They are anxious; they are nauseated; emesis is frequent. These accidents are very frequent. I have noticed emesis 50 times in 63 operations; the vomit is mucous or bilious; it is not abundant; it yields readily to the injection of ice. Headache occurs more frequently than emesis. In twothirds of the cases it is mild headache, a simple heaviness. It disappears on the day following the operation. It can, however, be a very severe headache, provoking insomnia, and disappearing only at the end of forty-eight hours. I have noticed profuse sweats, some dilation of the pupils, some shaking of the limbs, some rapidity of the pulse. All these accidents have disappeared twenty-four hours after the operation. In 15 cases I noticed an evening elevation of temperature on the day of the operation. This elevation occurred in the absence of any operative complications. On the next day the temperature was normal. In forty patients I noticed a chill after from ten to fifteen minutes. Among my patients there were 39 males and 24 females. They varied in age from 12 to 69 years. Sex and age seem to have no influence on this method of anesthesia. I would consider children and hysterical individuals as being poor subjects for this method of anaesthesia. I consider it well to put a simple compress over the patients' eyes. Some of my patients object to being blindfolded."

I report the following cases from my clinic in the City and County Hospital:

CASE 1.—Mr. J. B., City and County Hospital, aged 52 years. Ischio-rectal abscess. Injection of 10 minims of 2 per cent solution of hydrochlorate of cocain in the subarachnoid space just below the fourth lumbar vertebra. The needle was easily introduced and a few drops of cerebro-spinal fluid passed; about one minute was used to inject the cocain. The opening was closed with sterile cotton and collodion. Sphincter was dilated and fistula opened. Flaps were brought from the side of the nates to cover some denuded surface, and at first he complained of a little pain, which soon disappeared. Patient was nauseated