There were others that thought the good effect gained from a sea voyage was greatly overestimated, as no one could tell whether the patient was going to enjoy the voyage or lie in his cabin enduring the horrors of seasickness in addition to his invalidism due to tuberculosis. When one reflects upon the sickening scent due to the oil used on the engines, the impure air that we had to breathe during a storm when it was impossible to get out on deck, and all the portholes were closed and the ship swaying to and fro, and most every one you behold has an expression of uneasiness about his stomach, to say nothing of an occasional sea-fog, will make one very slow to prescribe this treatment until you have good reasons to believe that your patient is a good sailor, and that the sea will be smooth and the weather pleasant.

The mountain climate was thought to be contra-indicated in acute tuberculosis, catarrhal tuberculosis, laryngeal tuberculosis, in tuberculosis accompanied by great nervous irritability, and in patients with cavities. It was shown that when a patient went to the mountain climate there was at first a quickening of the respiration and circulation, and a decrease in blood-pressure, and often accompanied by great thirst; that the amount of urea excreted by the kidneys was decreased, while the amount of carbonic acid and water eliminated by the lungs was increased. But after remaining there for some time the normal amount of urea was excreted, the blood-pressure was increased, and the respiration and circulation decreased, and there was an increase in the measurement of the thorax of from one to three inches; and that there was a noticeable increase in the mobility of the thoracic walls, which was, no doubt, due to the greater physiological activity of the lungs and to a local empyema around the tubercular lesions.

As to the medicinal treatment, but little if any thing was added to the list of remedies already known.

Whether a tubercular patient should be allowed to marry or not is a question on which every one has his convictions; but in the light of our present knowledge of the nature of the infection of this disease, most every one will agree that it would be one of the greatest boons we have to rid our country of this dreadful scourge. If not law, then let public sentiment raise its voice against this practice, and maybe sense and not sentiment on the part of the contracting parties will assume its rightful sway, and all tuberculars will be regarded unmarriageable.

LONDON.

ANALGESIA FROM THE SPINAL SUBARACHNOID INJECTION OF COCAINE.*

BY J. GARLAND SHERRILL, A. M., M. D.

The ideal anesthetic would be a drug capable of producing unconsciousness, with freedom from pain and loss of reflex muscular contraction, without danger to life or disagreeable and annoying symptoms. Such an agent will scarcely be found, for any drug sufficiently powerful to render a patient even temporarily oblivious to external influences must of necessity be dangerous to life. No one who has used anesthetics frequently will deny their danger, or the frequency with which serious symptoms are observed during their administration. It is owing to the dangers incidental to general anesthesia that a number of different methods have been tried with the view of lessening the chances of fatality. Researches of this character have developed local anesthesia to a remarkable extent, quite a number of drugs having been used for this purpose. Recently the local use of cocaine has been extended to the spinal cord.

Dr. J. Leonard Corning, 1884-1885, was the first to demonstrate the possibility of cocainization of the cord. Prof. Bier, of Kiel, was the first to use the method in a surgical way, while Tuffier, of Paris, has brought the subject prominently before the profession. Murphy, Matas, Fowler, Morton, and others of this country have employed it quite frequently for surgery, and Marx has used it often in labor, giving a flattering report. The number of reported cases is at present quite large, yet insufficient to give an accurate idea of the danger or the value of this method for the relief of operative pain. That analgesia can be produced in this way has been clearly demonstrated. Strictly speaking, cocaine is not anesthetic, as the sense of feeling is not entirely abolished. The questions for the profession yet to determine are the dangers incident to its use, its feasibility, the indications and contra-indications for its employment, the best strength of solution, and the amount to be injected. That cocaine so used will ever displace the general anesthetics I do not believe, yet my limited experience, considered in connection with the

* Abstract of a paper read before the Kentucky State Medical Society, May, 1901.

reports of others, leads me to the conclusion that this method has a considerable field of usefulness. Let us consider the possible dangers from the injection into the spinal canal. First The shock of tapping the cord and injection of the cocaine. Simple tapping of the spinal subarachnoid space is usually a safe procedure, still Gumprecht (Deutsch Med. Wochenschrift, June 14, 1900) has collected seventeen cases from the clinics of Quincke, Furbringer, Lenhartz, Lictheisen, Kronig, Bull, and himself in which death has quickly followed lumbar puncture for diagnostic purposes, in which fatal termination could be attributed to no other cause than this apparently trivial procedure. It must be remembered, however, that these were cases of disease, either of the cord or brain, and in some cases, at least, tumors of the brain were present. It is quite probable, also, that the amount of fluid withdrawn had something to do with these fatalities. Where only a small quantity is withdrawn the shock will be slight. The depression from the injection seems to be proportionate to the dose of cocaine.

Second: The danger to the cord and centers in the medulla. Sicard has demonstrated that the toxicity of the cocaine injection increases as the injection is made higher in the cord. According to Tait, Sicard, and Cagleri, the spinal canal is accessible as high as the sixth cervical space. Depressive action upon the medullary centers is extremely unlikely to occur if the dosage of cocaine is small and the injection made in the lumbar region of the cord, or rather the cauda equina. I have made the injection successfully in the tenth dorsal space of a child of nine. If the patient remains in the sitting posture for one or two minutes after the injection is made, there will be little chance for the upper part of the cord or the medulla to be affected seriously. Nicoletti (see Therapeutic Gazette, November 15, 1900), on the basis of an experimental research, maintains that these injections cause no anatomical alterations of the nervous elements. If he is correct, and the effect on peripheral nerves leads us to think that he is, the danger of paralysis and late effect upon the cord is very remote. The danger of hemorrhage into the canal from injury to one of the spinal veins by the needle must be very slight, yet a case is recorded where such an accident has occurred. (Case of Heumberg.)

Third The action of cocaine upon the heart. Injected into the spinal canal the drug should be no more depressant or dangerous to the heart than a similar dose in another part of the body. A. M. Phelps reports a case of death from the local (not spinal) injection of thirty

minims of 2 per cent solution, and claims to have known two other deaths from the injection of a 10 per cent solution into the gums. Six tenths of one grain may then be assumed to be the smallest fatal dose. The amount of cocaine for safety, therefore, should be limited to three tenths or four tenths of a grain, which amount of an active drug will produce complete analgesia in parts below the diaphragm, or, according to Morton, as high as the face.

Fourth: The immediate danger of meningitis and myelitis from infection through the puncture under proper aseptic precautions should be rendered practically nil. The chief danger lies in the skin of the patient, which can not be rendered absolutely sterile. To avoid infection from this source a small incision is recommended to be made through the skin for the insertion of the needle. This I have found to be unnecessary. When we consider the frequent use of hypodermic medication, and the extreme rarity of resulting infection, it seems reasonable to conclude that thorough cleansing of the skin of the back as for any surgical operation will give a field devoid of danger. Carelessness in the technique may undoubtedly be productive of great harm, and no one should attempt spinal injection who is not familiar with practical asepsis. So far as I can learn, there have been up to this time no reports of infection through the puncture. The annoying and disagreeable symptoms that have been reported are by no means constant or certain. Rapid heart, nausea, vomiting, faintness, dizziness, pallor, sweating, cyanosis, and involuntary evacuations of the rectum have been noted during the analgesia. These symptoms appear with the nausea, and just prior to vomiting, and usually are not sufficient to annoy or cause alarm. Headache more or less persistent has occurred as an after-effect. Nausea appears in about 30 per cent of the eight hundred and three cases in which mention is made of the condition, and usually within fifteen minutes of the injection, but in a few instances it has occurred after the operation is concluded. It is usually slight, not persistent, and infrequently accompanied by vomiting. Headache appears to occur with about the same frequency. This can usually be relieved or prevented by the use of acetanilid, citrate of caffein, and bicarbonate of sodium. To counteract toxic symptoms, Marx recommends hydro-bromate of hyoscine just after the cocaine is administered, and nitro-glycerine with it or at the onset of nausea. Involuntary evacuations have occurred in only one of my cases, which I attribute to the fact that the rectum and bladder have been emptied. prior to operation. In fact, these patients received the same preparation

as for general anesthesia. The possibility of psychic pain will interfere with the efficiency of the method in very nervous individuals. Conversation regarding conditions met during the operation will, of course, be properly prohibited. The ability to converse with the patient will not ordinarily prove of especial value, although Rodman says he was materially assisted by the patient in the manipulation of a leg he operated upon by this method.

After every general anesthesia, especially for the more serious operations, the appearance of the patient is certainly indicative that he has been through a serious ordeal; moreover, some time must elapse before he regains full control of his faculties. That the shock of the general anesthetic, combined with that of the operation, tends to reduce the resistance of the patient to later dangers, such as sepsis, suppression of urine, bronchitis, pneumonia, etc., I firmly believe. The shock after even major operations done under spinal analgesia is very slight. One who has seen the ghastly and helpless appearance following prolonged anesthesia, and the bright, cheerful expression of the patient who has had the cocaine injection, is impressed by the marked contrast between the two conditions. This method of analgesia can be used in many cases in which a general anesthetic is especially dangerous, such as heart disease, bronchitis, or Bright's disease, with or without dropsy. These conditions, even with our present knowledge, offer a field for the use of cocaine. Old persons will certainly withstand the shock of an operation better under local than general anesthesia, and the interference with glandular activity, so frequent a sequence of general anesthesia, is not present. There is less disturbance of the lungs or heart; less interference with secretions; less shock; patient is conscious, and can give immediate notice of any ill feeling; after abdominal operations food and drink can be administered early without fear of nausea and vomiting, as the nausea occurs soon after the injection is given, and disappears promptly. A major operation apparently becomes a minor affair when done under cocaine. My experience leads me to favor this over general anesthesia in operations about the rectum and anus. This very sensitive part requires the most profound general narcosis to prevent resistance upon divulsion of the sphincter. I have divulsed under spinal cocainization from twelve drops of a 2 per cent solution, and operated for hemorrhoids and for fistula, without any resistance or complaint of pain upon the part of the patient. In fact, rectal cases have given me a very favorable impression of this method. Future cases may cause me to change my opinion in this