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Some uses for heavy anesthetic oils
SOME USES FOR HEAVY ANESTHETIC
OILS
LIEUT. COL. HARRY M. KIR~CHBAUM MEDICAL CORPS, ARMY OF THE UNITED STATES
E
XPERIENCE at orthopedic sick-caII at the Station HospitaI, shows that one-fifth of the patients compiain of backache. Since backache, or Iow back pain, are mereIy symptoms, it foIIows that proper treatment can be based onIy on a carefu1 evaIuation of the etioIogy of these pains. In order to ascertain the etioIogy, we have estabIished the foIIowing routine: (I) CarefuI history with specia1 attention to the Iocation of pain, its nature, and path of radiation; (2) physica examination, observing especiaIIy the effects of the various motions of the back, and (3) x-ray studies, incIuding the obIique views. The x-ray studies rareIy indicate the etioIogic Iesion. The reason for this can be pIainIy understood when one is reminded of the very compIex Iigamentous attachments of the Iumbar, IumbosacraI, and the sacro-iliac joints, as demonstrated in Figures 1 to 5. Diagnostic significance of observing the effect of back movement during the physica examination was described by SteindIer in 1925. He made the observation that the Iarge majority of cases of low back pain, due to mechanica causes are primariIy Iigament strains with demonstrabIe rupture of the Iigament accompanied by extravasation of bIood and subsequent scar formation. He studied 213 cases and made the foIIowing concIusions: “ (I) FIexion increases the strain and stress in the posterior sacro-iIiac Iigaments, the erector spinae muscles, and their aponeuroses. (2) Extension increases strain at the IateraI Iigaments between the iIia and the transverse processes of the fifth Iumbar vertebra. (3) In IateraI bending the roots of the IumbosacraI pIexus are reIaxed on the concave side and tensed on the convex side. (4) Increased Iordosis produces tension of the sympathetic pIexus and gangIia.”
The author had occasion, during many years of practice as a gynecoiogist, to see a great many patients whose chief symptom was backache. These cases were usuaIIy thoroughIy studied, incIuding gynecoIogic survey, x-ray examination of the peIvis and the sacra1 region, the study of the genitourinary tract and a coIonic study, incIuding sigmoidoscopy and the barium enema. If no gynecoIogic disorder was discovered, the case was referred to an orthopedist for management. Too often these patients received routine treatment such as heat, massage and a sacro-iIiac beIt, with no improvement, or a Aeeting improvement. In the management of such cases the measures and technics commonIy empIoyed in the diagnosis and treatment of back pain were scrupuIousIy observed. A search was made for foci of infection. Here it is interesting to point out that many a case of otherwise intractabIe back pain disappears aImost miracuIousIy after the extraction of an abscessed tooth. Physiosuch as shortwave, therapy measures, massage and the use of the heat Iamps, were empIoyed extensiveIy as were exercises for stretching the Iegs and traction. The use of these measures, combined with diIigent care in searching for the exact etioIogy, was productive of a considerable degree of cure of pain and disorders in many cases which wouId otherwise have been unimproved. The probIem that was particuIarIy perplexing, however, was that of reIieving severe Iancinating backache which is usuaIIy IocaIized to the upper sacro-iIiac joint and cases of severe pain at the region of the coccyx. The method of injection with the usua1 local anesthetics was tried but proved unsatisfactory because, in most cases, the pain returned within two or three hours after the injec-
92
Kirschbaum-Anesthetic
American Journal of Surgery
tion. The manipuIation treatment described by Jostes, of Kansas, was routineIy tried and many patients were reIieved by
Oils
JULY, 1944
pain is most severe at the attachment of the iIioIumbar muscIes to the iIium, 5 cc. of the anesthetic oi1 are injected at the
FIG. I. Anterior view of posterior half of the pelvis to demonstrate the Iigaments of the sacro-iliac joint. (Redrawn from ToIdt’s “Atlas of Human Anatomy,” vo1. I, 1928. The MacmiIIan Company.)
this method without further treatment. However, this method requires a great amount of physica strength on the part of the physician, and is ineffective when the patient is stout or otherwise hard to manipuIate. In searching for a method which wouId give positive reIief to a Iarger number of patients, I finaIIy resorted to the injection of heavy anesthetic oiIs. The chemica1 composition is as foIIows: BenzyI aIcoho1.. . . . . . . . . . . . . . . Procaine base.. .. . Isocaine C. P. Co.. . . . (IsobythI-para-amino-benzoate) AImond oi1 (sweet qz. 100%)
4
.. .. .
.
I .. 4
16% 1-47’ 1-67~
This method was uniformIy satisfactory during my civiIian practice and has been used by me in the treatment of a considerabIe number of cases of backache in miIitary personne1. The immediate and Iasting reIief obtained is most gratifying and prompts me to detai1 the technic: ParticuIar attention is paid to the site of greatest tenderness of the back. If the
site. If the pain is very diffuse over the entire sacrum 15 cc. of the oi1 are injected over the sacrum. With pain aIong the sacroiIiac joint IO cc. of the oi1 are injected aIong the Iigamentous attachments of the sacroiliac joint. In severe cases with radiation to the buttocks I cc. of oi1 may be iniected into each sacra1 foramen as in transsacra1 anesthesia. In coccydynia a smaI1 amount of procaine, 2 per cent, is injected around the coccyx and then IO cc. of anesthetic oi1 is used to inject compIeteIy around the coccyx surrounding the coccyx bone. After the injection, the coccygea1 muscIes are massaged after ThieIe. In sciatica IO cc. of the anesthetic oi1 is injected in the nerve sheath with prompt reIief. In very severe cases this is combined with stretching of the sciatic nerve by extending the Ieg at the knee and throwing the Ieg over the shouIder, under anesthesia. It was found that the intravenous anesthesias did not give sufficient reIaxation for thorough extension of the knee and ffexion of the
NEW SERIES VOL.LXV. No. I
Kirschbaum-Anesthetic
thigh on the body of the patient. For that reason ether anesthesia is advised for this procedure.
OiIs
American
Journal
of Surgery
93
spina administration of novocaine. There were no untoward effects from this injection. In fact, on four occasions I have in-
FIG. 2. Posterior view of the pelvis to show the articuIations and Iigaments of the pelvic girdIe. (Redrawn from ToIdt’s “Atlas of Human Anatomy,” vol. I, 1928. The MacmiIIan Company.)
FIG. 4. FIG. 3. FIG. 3.-Right half of the pelvis seen from the inner side. (Redrawn from ToIdt’s “Atlas of Human Anatomy,” vol. 1, 1928. The MacmiIIan Company.) FIG. 4. Right half of the pelvis divided in the median plane; postero-interna aspect. (Redrawn from ToIdt’s “Atlas of Human Anatomy,” vol. I, 1928. The Macmillan Company.)
In some of the back injuries in which the pain is diffuse and radiated through the buttocks, 4 to 6 cc. of the anesthetic oi1 are injected into the cauda1 cana1. This method couId aIso be used in anesthesia during Iabor instead of the continuous
jetted I cc. of anesthetic oiI into the spina cana in cases of advanced carcinoma with resuIting marked improvement of the severe pain for ten to twenty days. I have aIso injected anesthetic oiIs for paravertebral bIock in thrombophIebitis. This
94
AmericanJournalofSurgery
Kirschbaum-Anesthetic
shouId prove of vaIue in cases of periphera1 vascuIar disease instead of repeated injections of procaine, since one injection wiII suffice for ten days.
FIG. 3. Horizontal section through the sacro-iliac articulation. (Redrawn from ToIdt’s “AtIas of Human Anatomy,” VOI. I, 1928. The Macmillan Company.)
It is obvious that the manipuIative treatment of sacro-iIiac strain offers, in the acute case, a vaIuabIe method, especiaIIy when the patient is thin and easiIy manipuIated. However, in the stout or heaviIy muscIed patient manipuIation is extremeIy diffIcuIt. The injection treatment offers, therefore, a ready and easy method for relieving those patients who suffer intenseIy with sacro-iIiac strain. At Ieast it takes them definiteIy over the acute phase. In those patients who have compIained of backache for severa years and have Iost confidence in the fact that the back is mobiIe or can be improved, the use of oi1 giving temporary reIief for a period of ten days with immediate motion and exercise gives the patient a certain amount of confidence. In cases of stiff neck, the neck muscIes may be injected with IO cc. of the anesthetic oi1 for the reIief of severe pain if short-wave treatments do not give prompt
+a%
JULY. 1944
OiIs
reIief. One very interesting case was that of severe pain in the interscapuIar area. The x-ray was entireIy negative, but injection of heavy anesthetic oi1 gave compIete relief and there has been no recurrence for five weeks. In severe sprain of the ankIe or strain of the shouIder or other joint, the injection of IO cc. of anesthetic oi1 instead of the usua1 2 per cent procaine soIution gives marked reIief and permits the patient to waIk about without pain for ten days. The injection of procaine aIone wouId Iast onIy a few hours, and, therefore, the oi1 injection is much more satisfactory. In closing, it is the author’s opinion that acute cases of painfu1 back and sacroiliac pain which do not respond to manipuIation, or in which manipuIation is impractica1, can very often be reIieved promptIy by the injection of heavy oi1 anesthetic IocaIIy. The method which has been described is not advocated as a panacea for the cure of a11 back pain, and must in a11 cases be complemented by a carefu1 diagnostic study to outIine the pathoIogica1 condition and to ruIe out neuroiogic and other Iesions; but when properIy used, it wiI1 reIieve a great many cases of fascia1 injuries, muscIe and Iigamentous tears and strains. SUMMARY
The genera1 management of cases of backache is outIined, stress being pIaced on an exhaustive diagnostic study. A detaiIed technic for injection of heavy oi1 anesthetics is given. REFERENCE I. STEINDLER, A. J. Iowa M. Sot., 15: 473, 1924.
OILS
LIEUT. COL. HARRY M. KIR~CHBAUM MEDICAL CORPS, ARMY OF THE UNITED STATES
E
XPERIENCE at orthopedic sick-caII at the Station HospitaI, shows that one-fifth of the patients compiain of backache. Since backache, or Iow back pain, are mereIy symptoms, it foIIows that proper treatment can be based onIy on a carefu1 evaIuation of the etioIogy of these pains. In order to ascertain the etioIogy, we have estabIished the foIIowing routine: (I) CarefuI history with specia1 attention to the Iocation of pain, its nature, and path of radiation; (2) physica examination, observing especiaIIy the effects of the various motions of the back, and (3) x-ray studies, incIuding the obIique views. The x-ray studies rareIy indicate the etioIogic Iesion. The reason for this can be pIainIy understood when one is reminded of the very compIex Iigamentous attachments of the Iumbar, IumbosacraI, and the sacro-iliac joints, as demonstrated in Figures 1 to 5. Diagnostic significance of observing the effect of back movement during the physica examination was described by SteindIer in 1925. He made the observation that the Iarge majority of cases of low back pain, due to mechanica causes are primariIy Iigament strains with demonstrabIe rupture of the Iigament accompanied by extravasation of bIood and subsequent scar formation. He studied 213 cases and made the foIIowing concIusions: “ (I) FIexion increases the strain and stress in the posterior sacro-iIiac Iigaments, the erector spinae muscles, and their aponeuroses. (2) Extension increases strain at the IateraI Iigaments between the iIia and the transverse processes of the fifth Iumbar vertebra. (3) In IateraI bending the roots of the IumbosacraI pIexus are reIaxed on the concave side and tensed on the convex side. (4) Increased Iordosis produces tension of the sympathetic pIexus and gangIia.”
The author had occasion, during many years of practice as a gynecoiogist, to see a great many patients whose chief symptom was backache. These cases were usuaIIy thoroughIy studied, incIuding gynecoIogic survey, x-ray examination of the peIvis and the sacra1 region, the study of the genitourinary tract and a coIonic study, incIuding sigmoidoscopy and the barium enema. If no gynecoIogic disorder was discovered, the case was referred to an orthopedist for management. Too often these patients received routine treatment such as heat, massage and a sacro-iIiac beIt, with no improvement, or a Aeeting improvement. In the management of such cases the measures and technics commonIy empIoyed in the diagnosis and treatment of back pain were scrupuIousIy observed. A search was made for foci of infection. Here it is interesting to point out that many a case of otherwise intractabIe back pain disappears aImost miracuIousIy after the extraction of an abscessed tooth. Physiosuch as shortwave, therapy measures, massage and the use of the heat Iamps, were empIoyed extensiveIy as were exercises for stretching the Iegs and traction. The use of these measures, combined with diIigent care in searching for the exact etioIogy, was productive of a considerable degree of cure of pain and disorders in many cases which wouId otherwise have been unimproved. The probIem that was particuIarIy perplexing, however, was that of reIieving severe Iancinating backache which is usuaIIy IocaIized to the upper sacro-iIiac joint and cases of severe pain at the region of the coccyx. The method of injection with the usua1 local anesthetics was tried but proved unsatisfactory because, in most cases, the pain returned within two or three hours after the injec-
92
Kirschbaum-Anesthetic
American Journal of Surgery
tion. The manipuIation treatment described by Jostes, of Kansas, was routineIy tried and many patients were reIieved by
Oils
JULY, 1944
pain is most severe at the attachment of the iIioIumbar muscIes to the iIium, 5 cc. of the anesthetic oi1 are injected at the
FIG. I. Anterior view of posterior half of the pelvis to demonstrate the Iigaments of the sacro-iliac joint. (Redrawn from ToIdt’s “Atlas of Human Anatomy,” vo1. I, 1928. The MacmiIIan Company.)
this method without further treatment. However, this method requires a great amount of physica strength on the part of the physician, and is ineffective when the patient is stout or otherwise hard to manipuIate. In searching for a method which wouId give positive reIief to a Iarger number of patients, I finaIIy resorted to the injection of heavy anesthetic oiIs. The chemica1 composition is as foIIows: BenzyI aIcoho1.. . . . . . . . . . . . . . . Procaine base.. .. . Isocaine C. P. Co.. . . . (IsobythI-para-amino-benzoate) AImond oi1 (sweet qz. 100%)
4
.. .. .
.
I .. 4
16% 1-47’ 1-67~
This method was uniformIy satisfactory during my civiIian practice and has been used by me in the treatment of a considerabIe number of cases of backache in miIitary personne1. The immediate and Iasting reIief obtained is most gratifying and prompts me to detai1 the technic: ParticuIar attention is paid to the site of greatest tenderness of the back. If the
site. If the pain is very diffuse over the entire sacrum 15 cc. of the oi1 are injected over the sacrum. With pain aIong the sacroiIiac joint IO cc. of the oi1 are injected aIong the Iigamentous attachments of the sacroiliac joint. In severe cases with radiation to the buttocks I cc. of oi1 may be iniected into each sacra1 foramen as in transsacra1 anesthesia. In coccydynia a smaI1 amount of procaine, 2 per cent, is injected around the coccyx and then IO cc. of anesthetic oi1 is used to inject compIeteIy around the coccyx surrounding the coccyx bone. After the injection, the coccygea1 muscIes are massaged after ThieIe. In sciatica IO cc. of the anesthetic oi1 is injected in the nerve sheath with prompt reIief. In very severe cases this is combined with stretching of the sciatic nerve by extending the Ieg at the knee and throwing the Ieg over the shouIder, under anesthesia. It was found that the intravenous anesthesias did not give sufficient reIaxation for thorough extension of the knee and ffexion of the
NEW SERIES VOL.LXV. No. I
Kirschbaum-Anesthetic
thigh on the body of the patient. For that reason ether anesthesia is advised for this procedure.
OiIs
American
Journal
of Surgery
93
spina administration of novocaine. There were no untoward effects from this injection. In fact, on four occasions I have in-
FIG. 2. Posterior view of the pelvis to show the articuIations and Iigaments of the pelvic girdIe. (Redrawn from ToIdt’s “Atlas of Human Anatomy,” vol. I, 1928. The MacmiIIan Company.)
FIG. 4. FIG. 3. FIG. 3.-Right half of the pelvis seen from the inner side. (Redrawn from ToIdt’s “Atlas of Human Anatomy,” vol. 1, 1928. The MacmiIIan Company.) FIG. 4. Right half of the pelvis divided in the median plane; postero-interna aspect. (Redrawn from ToIdt’s “Atlas of Human Anatomy,” vol. I, 1928. The Macmillan Company.)
In some of the back injuries in which the pain is diffuse and radiated through the buttocks, 4 to 6 cc. of the anesthetic oi1 are injected into the cauda1 cana1. This method couId aIso be used in anesthesia during Iabor instead of the continuous
jetted I cc. of anesthetic oiI into the spina cana in cases of advanced carcinoma with resuIting marked improvement of the severe pain for ten to twenty days. I have aIso injected anesthetic oiIs for paravertebral bIock in thrombophIebitis. This
94
AmericanJournalofSurgery
Kirschbaum-Anesthetic
shouId prove of vaIue in cases of periphera1 vascuIar disease instead of repeated injections of procaine, since one injection wiII suffice for ten days.
FIG. 3. Horizontal section through the sacro-iliac articulation. (Redrawn from ToIdt’s “AtIas of Human Anatomy,” VOI. I, 1928. The Macmillan Company.)
It is obvious that the manipuIative treatment of sacro-iIiac strain offers, in the acute case, a vaIuabIe method, especiaIIy when the patient is thin and easiIy manipuIated. However, in the stout or heaviIy muscIed patient manipuIation is extremeIy diffIcuIt. The injection treatment offers, therefore, a ready and easy method for relieving those patients who suffer intenseIy with sacro-iIiac strain. At Ieast it takes them definiteIy over the acute phase. In those patients who have compIained of backache for severa years and have Iost confidence in the fact that the back is mobiIe or can be improved, the use of oi1 giving temporary reIief for a period of ten days with immediate motion and exercise gives the patient a certain amount of confidence. In cases of stiff neck, the neck muscIes may be injected with IO cc. of the anesthetic oi1 for the reIief of severe pain if short-wave treatments do not give prompt
+a%
JULY. 1944
OiIs
reIief. One very interesting case was that of severe pain in the interscapuIar area. The x-ray was entireIy negative, but injection of heavy anesthetic oi1 gave compIete relief and there has been no recurrence for five weeks. In severe sprain of the ankIe or strain of the shouIder or other joint, the injection of IO cc. of anesthetic oi1 instead of the usua1 2 per cent procaine soIution gives marked reIief and permits the patient to waIk about without pain for ten days. The injection of procaine aIone wouId Iast onIy a few hours, and, therefore, the oi1 injection is much more satisfactory. In closing, it is the author’s opinion that acute cases of painfu1 back and sacroiliac pain which do not respond to manipuIation, or in which manipuIation is impractica1, can very often be reIieved promptIy by the injection of heavy oi1 anesthetic IocaIIy. The method which has been described is not advocated as a panacea for the cure of a11 back pain, and must in a11 cases be complemented by a carefu1 diagnostic study to outIine the pathoIogica1 condition and to ruIe out neuroiogic and other Iesions; but when properIy used, it wiI1 reIieve a great many cases of fascia1 injuries, muscIe and Iigamentous tears and strains. SUMMARY
The genera1 management of cases of backache is outIined, stress being pIaced on an exhaustive diagnostic study. A detaiIed technic for injection of heavy oi1 anesthetics is given. REFERENCE I. STEINDLER, A. J. Iowa M. Sot., 15: 473, 1924.