CURRENT MEDICAL LITERATURE.

The New General Spinal Analgesia of Jonnesco.

Thomas Jonnesco, of Bucharest, Roumania (The British Medical Journal, November 19, 1909), gives a very complete description of his new method of general spinal analgesia, which was first described by him at the Congress of the International Society of Surgery in Brussels, in September, 1908. There are two points of novelty in the method: (1) The puncture is made at a level of the spinal column appropriate to the region to be operated upon; (2) An anesthetic solution is used which,

with the addition of strychnine, is tolerated by the higher nervous centers. Jonnesco prefers stovaine, but states that tropacocaine or novocain are equally efficacious, and, with the addition of strychnine, equally harmless.

The solution is prepared by introducing the necessary quantity of stovaine into a glass tube with a rubber stopper, which is sterilized in the autoclave. Dissolve 5 to 10 cg. of neutral strychnine sulphate in 100

grams of sterilized (not distilled) water in a glass-stoppered bottle previously sterilized; if 5 cg. of strychnine are used, I c.c. of the solution will contain one-half mg.; if 10 cg., I c.c. will contain I mg. The weaker solution is used for the upper, the stronger for the lower puncture. The strychnine takes a little while to dissolve. Add a syringeful, or I c.c., of the solution of strychnine to the tube of stovaine, shake well to dissolve the salts.

The apparatus used in making the spinal injection is the ordinary Pravaz syringe holding I c.c., and the usual needle for lumbar puncture, previously sterilized by boiling. The needle must have a point cut rather

squarely, for since the arachnoid space is relatively small, if the point of the needle be oblique, it is possible that part of the opening might go through the dura while part remains outside-such a condition would give only incomplete results.

Jonnesco indicates four points in the spine at which the puncture should be made in order to obtain an analgesia of the region to be operated upon, but for practical purposes he reduces this to two sites, namely, (1) an upper dorsal puncture between the first and second dorsal vertebræ,

which produces perfect and deep analgesia for the segment of the body comprising the head, the neck and upper limbs; (2) a lower or dorsolumbar puncture made between the twelfth dorsal and first lumbar vertabræ, which produces perfect analgesia of the whole abdomen and lower segment of the body. Figures 1, 2, 3, will show the anatomical landmarks and the method of performing the upper puncture. Figure 4 shows the position for the lower puncture.

Jonnesco says the position of the patient after injection is a very important one so far as insuring analgesia of the region to be operated

upon is concerned. If you want analgesia of the head and neck with the high dorsal injection, the patient is made to lie on his back; if the operation is to be on the throat the head should be a little raised; if on the face or skull he should lie horizontally; if on the upper limb or the thorax, he should remain sitting for two or three minutes and then lie on the back with the head, neck and thorax bent slightly forward. If after three or four minutes the analgesia of the head or of the neck is not complete,

the patient's head should be lowered below the level of the body for three or four minutes. With the lower puncture, if the viscera of the upper abdominal region (liver, stomach, spleen, pancreas, kidneys, etc.) are to be operated upon, the patient assumes a sitting position for two or three minutes and then lies on the back, with the head, neck and shoulders

Fig. 4.

raised. If the analgesia is incomplete after five or six minutes, put the patient in the Trendelenburg position for a few minutes and then return him to the sitting position. If the operation is on the lower abdominal region (pelvis, perineum, external genital organs) or on the lower limbs, the patient remains in the sitting position for five or six minutes and then lies on his back with the upper part of the body, head, neck, and thorax raised and bent forward.

Doctor Jonnesco has used his method in a number of cases with great success, and his words deserve attention. His conclusion regarding his method are well worth reproduction. They are as follows:

I. The fundamental principles in spinal analgesia are that puncture of the arachnoid may be performed at all levels, and that to the anesthetic, whether stovaine, tropacocaine or novocain, strychnine should be added.

2. Puncture of the arachnoid at whatever level is harmless, and the fear of pricking the cord unfounded; even if it happens, it is not harmful. 3. Medio-cervical puncture is useless and dangerous; mid-dorsal puncture is difficult and useless; superior dorsal puncture between the first and second dorsal vertebræ, and dorso-lumbar, between the last dorsal and first lumbar vertebræ are easy, and suffice to obtain analgesia of all regions of the body.

4. The addition of neutral strychnine sulphate to the anesthetic preserves the full antiseptic power of the solution, and at the same time neutralizes its injurious action upon the bulb. Thanks to this addition, superior spinal analgesia can be performed without danger.

5. Among known anesthetic substances, stovaine, tropacocaine and novacain seem to be the best; any of them may be used with the addition of strychnine.

6. The strychnine and the anesthetic substance need not be sterilized, a process which would destroy some of their properties.

7. The water used for making the solution must be sterilized but not distilled.

8. The injection should consist of I c.c. of solution, the amount of strychnine and anesthetic substance being varied.

9. The technique is simple, requiring only a Pravaz syringe and the usual needle for lumbar puncture.

IO. There are no contraindications for general spinal anesthesia, which always succeeds if the liquid penetrates into the arachnoid cavity, and if the dose of the anesthetic is sufficient.

II. General spinal anesthesia is absolutely safe; it has never caused death, nor produced any important complications, early or late.

12. General spinal anesthesia is infinitely superior to inhalation anesthesia. Owing to its simplicity, it is within the reach of all, and as there is no contraindication it may be employed with any patient. As it can be performed by the surgeon himself it does away with the attendance of a person often inexperienced, and never responsible.

13. In operations on the face, or the throat, where analgesia by inhalation is difficult and often incomplete, spinal analgesia is a great In laparotomies, owing to the "abdominal silence" it determines, it is very much superior to analgesia by inhalation.

14. The facts stated in this paper will prove how in science a condemnation a priori, like that pronounced by Professors Bier and Rehn* is precipitate and ill-founded.

15. I am firmly convinced that general spinal analgesia will be the analgesic method of the future.

*Professors Bier and Rehn have strongly condemned this method. - En.