GENERAL AN/ESTHESIA BY COCAINE. 63 



hours, and the injection was repeated two days later with similar 

 effect, pressure over the tumour for some hours causing no 

 pain whatever. A few days later a similar injection was tried 

 for a patient with a recurrent sarcoma of the thigh, and to 

 Tuffier's surprise he was able to remove the tumour completely with 

 absolutely no pain to the patient, the angesthesia lasting over an hour. 

 At first, therefore, used only in the surgery of the lower limbs, 

 Tuffier rapidly extended its use to operations upon the perinseum, the 

 rectum, the anus, the bladder, the ureter, the kidney, and such lapa- 

 rotomies as h3'sterectomy, removal of the appendix, and even gastro- 

 enterostomy. Finally, removal of the breast has been effected with 

 complete anaesthesia. Convinced of the absolute harmlessness of the 

 injections, Tuffier then used them in general gynaecology, and performed 

 such operations as hysteropexy, drainage of salpingitis, ovariotomy, 

 vaginal hysterectomies, etc., with equal success. 



Technique. — The details of the technique followed were given in 

 the Scuiainc Mcdicalc of May i6th, igoo, and later Tuffier was 

 careful to disclaim any originality, save in some practical technical 

 points of his procedure. An ordinary hypodermic syringe will 

 suffice, provided its construction admits of absolute sterilisation. 

 The best, therefore, is the glass syringe made by Luer, which 

 can be boiled without injury, and which never gets out of order. 

 The needle should be strong, of platinum, about nine centimetres 

 in length — /. e. three and a half inches — with its penetrating- 

 sharpened portion cut very short. The solution of cocaine used 

 is 2 per cent., and must be freshly prepared and sterilised. It 

 seems, however, probable that in the long run weaker solutions will 

 become of more frequent use, and that the solution of cocaine used 

 will vary from i in 100 to as little as i in 400. The patient should be 

 seated bent forward slightly, with both arms in front of him. The 

 lumbar region is thoroughly cleansed, and the anatomical landmarks 

 are noted. It will be found that a horizontal line between the two 

 highest points posteriorly of the iliac crests passes immediatel}- 

 below the fourth lumbar spinous process. Above or below this line in 

 the intervertebral space the needle will freely enter the medullary 

 canal. The left index then marks the fourth spinous process, and the 

 patient is told to bend well over forwards, thus increasing the space 

 between the vertebras by nearly three fifths of an inch. The needle 

 alone is then entered at about a centimetre (two fifths of an inch) to 

 the right of the middle line, in a direction forwards and inwards in the 

 third or fourth lumbar interspace, as may be selected. The third 

 lumbar interspace is that commonl}- chosen, but the fourth may be 

 punctured with equal facility and effect, and Legueu frequently injected 

 the cocaine into the second lumbar space. It is interesting to recollect 

 that Coming's first injection was made between the twelfth dorsal and 

 the first lumbar vertebra. The needle thus pierces the skin, the sub- 

 cutaneous tissue, the lumbar fascia, the sacro-lumbar muscles, and the 

 quadratus lumborum, and enters the spinal canal through the Hga- 

 mentum flavum, which alone offers any noticeable resistance. 



As the needle enters the subarachnoid space the absence of 



