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Related article: causing local anemia and by compressing the nerve filaments. The injections can be
made with an antitoxin syringe with a long needle, by means of which the solution is
first injected into (not under) the epidermis, so as Levaquin 750 Mg to raise a blister. The needle being
left in place and gradually pushed deeper, the entire field of operation is saturated with
the solution, 30 to 500 c.c. being used. The usual solution (Sol. II) contains % Q P er
cent, of cocain and per cent, of sodium chlorid. In inflamed tissue, the cocain may be
doubled (Sol. I); or if the field is extensive, it may be reduced to Levaquin 750 Mg J^oo P er cent. (Sol.
III). Bevan, 1915, speaks highly of novocain infiltration. He Levaquin 750 Mg employs up to 100 or
200 c.c. of a solution with 0.25 to 0.5 per cent, of novocain, to which % to i c.c. of epi-
nephrin, i : 1000, has been added.
In the paraneural method the solution, of a strength of % to 2 per cent., is injected
in the neighborhood of the nerve trunk. The results are uncertain.
Intraneural Method (Nerve Blocking). In this, a ^2 to 2 per cent,
solution is injected directly into the nerve trunk.
If the injection is made quickly and directly into the nerve tissue, the procedure is
quite painful. A few drops should first be Levaquin 750 Mg injected under the nerve sheath. When these
have caused a local anesthesia, the needle should be pushed deeper and more of the solu-
tion injected, until the anesthesia is complete. In this way the pain is relatively slight.
Anesthesia requires fifteen to twenty minutes, and is not always completely successful.
The combination of all the above methods is perhaps most useful.
The skin and superficial muscles are anesthetized by infiltration. The
deeper structures are exposed, and the smaller nerves are treated by the
paraneural, the larger by the intraneural methods. In this way, surpris-
ingly small quantities of cocain suffice (8 mg. for amputation of shoulder
joint!).
Influence on Shock. The complete, blocking of nerve impulses obtained in this way
tends to prevent surgical shock. No method of local anesthesia can, however, prevent
the psychic shock and pain, the nervous dread of the patient, the removal of which is one
of the most valuable features of general anesthesia; but it may at least be lessened by
morphin (0.015 Gm. hypodermically) half an hour before the operation. It may at times
be justifiable to operate without the knowledge of the patient, which is quite feasible
by the use of cocain (Crile).
Spinal Anesthesia. The subdural injection of cocain, or other local
anesthetics, anesthetizes the sensory nerve roots at their emergence from
the spinal cord. This abolishes sensation in their entire peripheral dis-
tribution for about one and one-half hours (one-half to two hours), with-
out loss of consciousness or motor functions. The method was demon-
strated by Corning of New York in 1885, and introduced into practice
by Bier, 1899, but it was temporarily abandoned, and did not come into
vogue until about 1904. The injection is performed by lumbar puncture,
withdrawing a little cerebro-spinal fluid, and introducing ^ to i c.c. of
2 per cent, cocain solution; or more Levaquin 750 Mg commonly, corresponding quantities
of its substitutes: Tropocain, 5 per cent., novocain (not above 0.15 Gm.) ;
stovain (not above o.i Gm.; beginning with one-half or Levaquin 750 Mg two- thirds of these
doses). Epinephrin and strychnin may be added. Levaquin 750 Mg
The anesthesia extends to the level of the nerve roots reached by the
cocain, the aim being to confine it to the lower half of the body. If it
should extend to the fourth ventricle, it will result in paralysis of the res-
piration. Alarming symptoms and fatalities from this cause are not in-
frequent (Seifert, Nebenwirk., 1915, p. 105), and the method is more
dangerous even than chloroform. The fatality is probably over 1:500
(Bevan). It has also been fatal to the fetus in utero (Jung, 1914). Minor
accidents are not uncommon. Cord injuries are sometimes produced;
severe headache may last for days or weeks. Further, the technic is
260 MANUAL OF PHARMACOLOGY
difficult, disagreeable to the patient, and the anesthesia is often unsuccess-
ful. Spinal anesthesia Levaquin 750 Mg should therefore not be employed (Hohmeier and
Koenig, 1910), unless inhalation anesthesia is directly contraindicated
(Anesthesia Commission, Journ. Amer. Med. Assoc., 1908). It is espe-
cially useful in Levaquin 750 Mg pulmonary disease, arteriosclerosis, bladder and rectal
cases, impending uremia, and diabetics; emergencies after a full meal.
It is not justifiable to use it for operations above the costal margin (F. L.
Richardson, 1913). Bevan, 1915, can see no justification for spinal anes-
thesia under any conditions.
Phenomena of Spinal Anesthesia. These occur in the following order: Loss of knee-
jerk; of plantar and cremasteric reflex; ascending analgesia; later, ascending loss of motor
power. The upper limit is usually quite abrupt. Subjectively, there is an ascending
feeling of warmth, swelling and heaviness. Occasional toxic effects are pallor, nausea,
vomiting, sweating, feeble pulse, relaxation of sphincters, dyspnea. The most frequent
after-effects are headache and insomnia.
Fall of Blood Pressure. This is a very common phenomenon of spinal anesthesia.
Smith and Porter, 1915, found that it is due to paralysis of the splanchnic fibers in the
cord, not in the medulla. Epinephrin with tropacocain or novocain caused even a
greater fall. Measures to restore the pressure were only temporarily successful. As
the effects of the anesthetic began to wear off, sciatic stimulation produced a fall, in-
stead of the normal rise.
To prevent the spreading of the solution E. Erhardt, 1908 and 1912, has proposed to
increase its viscidity by gum arabic. Bulk of solution (dilution) favors spreading
(Smith and Porter, 1915).
The combined action of stovain and strychnin on the cord has been investigated by
Aron and Rothman, 1909; and Simon, 1915. The two drugs are not antagonistic; and
strychnin does not render stovain any safer.
Intravenous Injection of Cocain. The action of cocain is sufficiently selective so that
a marked, though incomplete general analgesia, without disturbance Levaquin 750 Mg of consciousness
or motor functions, can be produced by intravenous (Ritter, 1909; Harrison, Levaquin 750 Mg 1911) or
intra-arterial (Ransohoff, 1909) injection. However, these methods are both unsatis-
factory and dangerous (Bevan, 1915).
USE OF COCAIN AS A CEREBRAL STIMULANT
Cocain has been employed to combat fatigue, and as a general tonic. It has no ad-
vantages and many disadvantages as compared with other stimulants, especially caffein
and strychnin. The danger of habit formation should suffice to condemn it. That the
harm has not been greater may be attributed to the unreliability of the coca preparations
which are generally employed.
COCAIN SUBSTITUTES
A large number of substances have been introduced as substitutes
for cocain. Some of these (Novocain, Levaquin 750 Mg Stovain, Eucain) may have a slight
advantage by combining an equal anesthetic activity with somewhat
lower toxicity and much greater stability; but practically these advan-
tages are not very serious and scarcely justify the introduction of these
numerous products. Moreover, Stovain and Eucain produce far more
irritation than cocain, and stovain may permanently injure the nerves.
Orthoform or Anesthesin, on account of their limited solubility, are only
slightly toxic and produce a slow and prolonged anesthesia when applied
in substance to superficial or gastric ulcers, etc.
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