parently minor points have been spoken of before, but their importance is, we believe, sufficient justification for their repetition.

New Technic Employed by the Authors in the Administration of Procain for Kidney Operations. As a preliminary the patient is given purgation the day before operation. This allows a comfortable night without disturbance. Sodium bicarbonate is administered by mouth in 30 grain doses or per rectum in a 5 per cent. solution. Fluids are given freely up to one hour before operation.

One hour before operation the patient is given % of a grain of morphine dissolved in 2 c. c. of 50 per cent. chemically pure magnesium sulphate solution after the method of Gwathmey. This is repeated in 30 minutes and a third injection is given just as the patient starts for the operating room, or 300 grain of hyoscine and % of morphine is used.

Upon arrival the patient is taken directly to the anesthetic room and a special nurse assigned to be present until the surgeon is ready to proceed. All evidences of haste, flurry or active preparations are shut out. When all is ready for the administration of the anesthesia the patient sits on the table with feet on a support. The hands rest on the knees or on the shoulders of an attendant, who sits in front of the patient. The back is bent slightly forward and the head lowered, This position throws the bony parts concerned into most prominence and is maintained while the first part of the anesthesia is given. It can be administered with the patient lying on the opposite side, but this is not so suitable.

We have long been under the impression, from clinical observation, that adrenalin added to local anesthetic adds greatly to its toxicity without adding any material benefit

whatever. Those who advocate its use believe that it is not rapidly absorbed. This opinion is differed with strongly by D. Murray Lyon of the University of Edinburgh (Jour. of Experimental Medicine, December 1, 1923, Vol. XXXIII, No. 6, page 655), who states: "The impression seems to be widely prevalent that adrenalin, given subcutaneously, causes little general effect and its action is quite uncertain. This view is probably based on the blanching of the skin which is seen around the site of injection, and on the fact that adrenalin causes vasoconstriction of some vessels. But the spectacular relief from disturbing symptoms that occurs in asthmatics within a few minutes after a hypodermic injection of a minute dose of adrenalin has been given, is in itself evidence that absorption by this route is rapid and satisfactory. It is suggested that absorption can take place freely by lymphatic channels."

"

Emil Mayer (Jour. of the American Medical Assn., March 15, 1924, Vol. 82, page 876) states: And it seems probable that adrenalin was a contributing factor in many of the deaths recorded." The statement that "animals bear larger doses of procain when small doses of epinephrin are injected simultaneously into the veins" is not based on animal experimentation, at least no experiments are quoted.

Leo Schmidt (Göttingen Thesis, 1919) states that the fatal action of subcutaneous and intravenous administration of adrenalin in guinea pigs has a very uniform foundation. The cause of death is always to be found in lung hemorrhages, perhaps with the additional action of a lung edema, which leads to death by suffocation without striking individual variation in susceptibility from a definite, sufficiently sharply defined border dose.

with which they come in active contact. This action they possess in common with many other active substances, even with the physical action of water upon protoplasm. Their intense selective affinity for nerve substances is particularly characteristic. They

them particularly toxic to the central nervous system."

Thus, we see that both the local anesthetics and epinephrin have a special affinity for the nervous system. When injected intravenously into experimental animals in toxic

doses they produce nervous symptoms, excitement, convulsions, central paralysis and, finally, death by respiratory or cardiac paralysis. Epinephrin is 450 times more toxic than procain for experimental animals.

Meeker and Frazer (Jour. of Pharmacology and Experimental Therapeutics, Vol. 22, No. 5, December, 1923, "In certain. regions absorption is more rapid than in others, for example, in the sacral canal and on each side of the vertebral column, a fact which accounts for a great likelihood of toxic manifestations in paravertebral and sacral anesthesia. Injections should be made cautiously if strong solutions are used about the head, pharynx and sacral canal. No doubt the incidence of reactions to local anesthetics would be greatly reduced were it possible to dispense entirely with adrenalin. We would even take issue with Braun's contention that local anesthetics should be compatible with adrenalin and maintain that the drug replacing procain for local anesthesia should be either more powerfully anesthetic in proportion to toxicity or less toxic in proportion to anesthetic power, making adrenalin unnecessary. Starting at a point a little below the 12th costo-vertebral angle and about 2 cm. from the midline a long wheal is raised by the injection of 1 per cent. procain. This infiltration extends from the original point to the level of the 8th rib. A point opposite the spine of the 7th dorsal vertebra and 2 cm. from the midline is selected. A carefully tested needle is then inserted until it strikes the angle formed by the lamella on that side and the transverse process, it is then pushed over the edge of the bone and the point deflected inward, the needle being again inserted for a distance of about 1 cm. This brings the point of the needle into the area occupied by the merging nerve roots. Suction is put upon the syringe to make sure

that the point of the needle is not in a blood vessel and then 2 or 3 c. c. of 1 per cent. procain solution is injected into the region. This is repeated at the 9th, 10th, 11th and 12th dorsal vertebræ. The angle formed by the 12th rib and the vertebral column is filled quite thoroly, both superficially and deeply with the solution, all injections taking their origin from the original wheal. The patient is then placed on the opposite side in a comfortable lying position. Injections are made into the skin, subcutaneous and muscular tissues of the entire loin with 1 per cent. procain. All of these injections take their origin in the preliminary wheal, so that the only pain the patient feels is one needle prick at the beginning of the infiltration.

It is very important to avoid pain in the

administration of the anesthesia because the average patient will be much more cooperative if this is successfully given. It is hard to convince the patient that no pain will result from a cutting operation if the administration of the procain is particularly uncomfortable. It has been our custom not to give more than 150 c. c. of 1 per cent. procain (1.5 gr.) or its equivalent.

It has always been possible for us to proceed as soon after the completion of the injection as it was possible to get the patient in position and properly prepared and draped.

When we approach the intervertebral foramen, care must be used not to exercise too much pressure, as it is at this point that toxic symptoms with absorption of the drug may occur. Neither is it a necessity to have the fluid penetrate the foramen or reach the nerves as pressure at the sill of the foramen seems sufficient to produce the desired anesthesia.

Seff in his work on Paravertebral Anesthesia in Pulmonary Conditions states that

care should always be used when our needle is close to the bony structures involved, as the periosteum is often hypersensitive. Raising and lowering the needle alternately at the sill of the intervertebral foramen assures a better distribution of the anesthetic and is important. In the vicinity of the 12th nerve lying as it does below the rib and having a tendency to spread, should receive a little more anesthetic than the nerves above.

The successful carrying out of this technic should give us a complete anesthesia of the posterior lateral and enough of the anterior abdominal wall to allow any of the modern kidney incisions to be made. It is rarely possible to obtain a complete middle line anterior anesthesia unless the nerves of the opposite side are also blocked. In addition to the abdominal wall, we should also obtain a peritoneal and abdominal anesthesia as well. When we reach the renal pedicle, particularly if tension is placed upon it, we are likely to elicit pain. Pain in this area can always be overcome by mildly infiltrating the connective tissue about it. As in all regional procedures it is difficult to anesthetize against pulling and we must, therefore, proceed at all times with great

care, handling all structures gently. Speed

must at all times give way to gentle and careful manipulation. Where we have to deal with a large mass, the patient may notice some tugging, and if such a procedure is found necessary, a mere whiff of ether may aid, but as a rule the presence of the cone with an ether odor is sufficient.

It may be well to repeat that the anesthetized areas should be tested out before we start on an operation. It is also advisable not to ask the patient if he feels pain. If it is present he will promptly communicate that fact to you. If he is asked regarding

sensation he is prone to become hypersensitive. An eminently wise precaution that should not be overlooked is the screening off of the field of operation from the patient's view. The well nurtured patient often expects to experience pain and, this being so, one finds that painful sensations are often absent when the manipulations of the surgeon are invisible to the patient. The presence of a physician or a welltrained nurse to keep the patient's mind diverted from the operative field is a most valuable asset in this technic, as in other local or regional procedures.

The method which we have described seems to have several advantages over the older ones. In fat or heavily muscled individuals it is extremely difficult to locate the rib at the point usually recommended, on account of the fact that there is a tremendous amount of tissue between it and the skin. By the method described above, however, it is always possible to locate the angle formed by the transverse process and the lamella of the vertebra and that allows the injection to be made in the proper place in all cases.

It is considered particularly important to conduct the entire injection with only one prick of the needle. The patient imme

diately feels that he will be carried thru without pain and the fact that the injection is practically painless serves as a tremendous psychologic boost.

Description of Cases.

Our series of cases is not large, but it is very encouraging. Tabulation of them follows:

Operations upon the kidney under paravertebral anesthesia are practical and in general give the patient much less shock than that suffered from any type of inhalation anesthesia. This type of anesthesia is

absolutely indicated in cases with lung disease of any description.

Two of the cases operated upon are worthy of more complete mention. A brief résumé of the histories follows:

Case I.-J. F. O. R. Mamaroneck, L. I. History No. 253387. Married. Admitted Feb. 23, 1924. Discharged Feb. 25, 1924.

Patient was first admitted February 23, 1924, for cystoscopy and pyelography and discharged February 25th. At this time he complained of pain in his right side and a tumor in his right kidney region. Patient had scarlet fever and measles in childhood, and pneumonia at age of 25 without evident complications. Gonorrhea at 17 with one swollen testicle. Family history irrelevant. Patient's symptoms began one month before admission with sudden pain in right side which caused him to go to bed. It was only relieved by morphine. At this time he had an acute tonsillitis and was given diphtheria antitoxin. First examination of urine two days later showed it to be full of pus. Repeated urine examinations showed much pus at times with exacerbations of entirely clear urine. He has had intermittent fever for one week. White blood count 30,000, then 26,000, later 12,000. On admission patient shows slightly enlarged tonsils but no inflammation. There is a large palpable right kidney which is tender. Cystoscopy: instrument passes without difficulty, vesical fundus shows a moderate degree of patchy cystitis. Right ureteral orifice somewhat congested.

ether

Only fair, re- Poor

inforced with 3 I ether Fair Excellent

No shock No shock

15 days 15 days

Excellent Excellent

The trigone is slightly reddened. No. 6 French catheters pass to both kidney pelves without obstruction. Right specimen shows cloudy urine, no urea, no p. s. p. in 15 min. with many w. b. c. and some epith. Left specimen clear, urea 2 mgrs. per 1. p. s. p. appeared 4 min. with 9% excretion in ten minutes. There were a few epthelial cells on the left side.

Second Admission: March 6, 1924. History No. 253570. Patient reentered hospital for nephrectomy as advised at his first admission. His entire family have low blood pressure, usually around 100, systolic. Urine on admission was amber, specific gravity 1020, acid clear, with no albumin or pus. Three days after operation urine showed some pus and bacteria, but has been free from pus since. Patient was prepared for paravertebral anesthesia with the usual purgation and the administration of 3 doses 1/8 gr. of morphine in 2 c. c. of 50% magnesium sulphate solution given at 30 minute intervals begun one and one-half hours before operation, thus giving the patient 3/8 grs. of morphine sulphate.

Nephrectomy was performed March 7, 1924 (right). With the patient in semi-sitting posi tion, usual injections made blocking 8th, 9th, 10th, 11th and 12th thoracic nerve at the point of exit from the spine. Superficial and deep infiltration was made in the quadrangular space over the kidney region. Usual kidney incision exposed the rather large fluctuating kidney which was separated without much difficulty, the ureter tied off low down and kidney removed. The anesthesia was successful except while stripping the peritoneum from the kidney. He complained of some pain almost