Dangerous and disastrous results from the use of cocaine as a local anaesthetic was, from the start, the bugbear that stalked at the heels of this brilliant and most happy innovation, as it was upon the introduction of the general anaesthetics, chloroform and ether; and yet I should like to ask how many of the gentlemen present have found this objection a sufficiently grave one to have prompted them to desist from its use? Though we occasionally hear the note of warning, and here and there a fatal case has been reported, their proportion has not increased with the prevalence of the drug, while its use has become so universal, among the specialists particularly, that it is to be doubted if there are many of the latter who could now be induced to do without it. With the report of fatal cases we are almost invariably informed of the size of the dose administered, and I have yet to hear of a single one which was not much larger than necessary to produce satisfactory local anaesthesia.Aside from the repeated applications to the mucous membrane of the nose and throat, made almost daily over a period of about four years, I have, since May last, injected cocaine into the tissue at the vault of the pharynx of thirtyseven different patients. I have never failed to make a note of cases in which symptoms other than local anaesthesia were manifested, and of these there are nine all told. In five of the nine cases, toxic or constitutional symptoms, such as hilarity, pallor, somewhat labored respiration or tendency to synco¬ pe, occurred after the application of about 30 m. of a 20 per cent, solution with a brush. The remaining four cases occurred after hypodermic injection, and as follows: The first three happened among the first ten cases treated and following an injection of 20 m. of a 10 per cent, solution, or about 2 m. of cocaine, while the fourth was the only one which occurred among the last twenty-seven cases, after reducing the injections to 15 m. of the same solution, to which quantity they have since been confined. In only one of all the cases were the symptoms at all alarming. In this instance the patient was a robust boy 15 years of age, and the dose, which was injected with the syringe, was possibly a little more than 20 m. Within two minutes the patient became pale, and stated that he was growing numb and dizzy. He stamped about for a few minutes, slapping his hands and legs, which seemed to be rigid with cramp; his respiration became labored, the dizziness increased, and he insisted upon lying down to sleep. Some whisky, a current of fresh air from the open window, and friction, gradually rallied him from this condition, and within twenty to thirty minutes he was completely restored. A week later, an injection of exactly 15 m. into the same patient was followed by but slight pallor and somewhat accelerated respiration, which did not impede the operation.As the result of the above, as yet, rather limited observations, I infer that the amount injected should be about one-half that which may be applied to the muco...
chemical caustics are not suitable, for they either do not penetrate deep enough, or they must be used to such an extent that they spread beyond the area desired to be cauterized and do damage to the healthy parts. By means of the galvano-cautery these growths may be reached at any point by bending the electrode to the desired shape. Small growths may be destroyed by a single puncture, and large ones by repeating the cauterization from time to time till they are entirely destroyed. Large growths may be removed en masse by means of the galvano-cautery snare ; small growths are not easily caught in the loop and are best destroyed by simply puncturing them with the galvano-cautery needle. The galvano-cautery snare possesses several advan¬ tages over the forceps for the removal of large laryn¬ geal growths. Its action is sure, quick, painless and bloodless. The stump is cauterized at the same time the growth is removed. The galvano-cautery outfit for laryngeal work should consist of a one cell stor¬ age battery (or a suitable current controller if the street current is employed). Shech's handle, one half doz. electrodes (assorted), cánula,fine wire, and
single-penetration, double-injection approach. Br J Anaesth 2015; 115: 792-4 5. Pandit JJ, Dutta D, Morris JF. Spread of injectate with superficial cervical plexus block in humans: an anatomical study. Br J Anaesth 2003; 91: 733-5 6. Valdes-Vilches LF, Sanchez-del Aguila MJ. Anesthesia for clavicular fracture: selective supraclavicular nerve block is the key. Reg Anesth Pain Med 2014; 39: 258-9 7. Shin C, Lee SE, Yu KH, Chae HK, Lee KS. Spinal root origins and innervations of the suprascapular nerve. Surg Radiol Anat 2010; 32: 235-8 8. Supraclavicular nerve block. In: Gray AT, ed. Atlas of Ultrasound-Guided Regional Anesthesia. Philadelphia: Saunders, 2013; 69-71 9. Burckett-St Laurent D, Chan V, Chin KJ. Refining the ultrasound-guided interscalene brachial plexus block: the superior trunk approach.
tonsillotome will cut only the tonsil and in suit¬ able cases it will remove as much of the organ as may be desired. This instrument commends itself, therefore, because of its strength, its sim¬ plicity, its safety, and its effectiveness. There no doubt exists some prejudice against the use of an anaesthetic in removing tonsils. In the course of a discussion at the Paris Surgical Society, Reclus29 referred to an unpublished case of fatal asphyxia during a tonsillotomy under chloroform. Avoid profound anaesthesia, remove the tonsils in quick succession, immediately turn the patient upon the face, and such p. misadven¬ ture cannot occur. Some years ago Ingals30 re¬ marked that removal of the tonsils is as serious a matter for a child as it would be for an adult to be hung. In young children, therefore, we should use ether or chloroform, not only to obviate mental and physical suffering, but, what is much more important, in order to enable us to explore the naso-pharynx at leisure, and if necessary to remove from that region those collections of lymphoid hypertrophy so often associated with simi¬ lar overgrowths between the palatine folds. 20 W. 31st street.
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