GORDON: PROCAINXE

2J31CONx,CLUSION

The most critical time for the development

of atelectasis is the firist twelve hours postoperatively. The iineidenice of ateleetasis is
the same with spinal as with inhalation anaUsthesia. The mechaniisnm is due to ly1)oveiltilation from initer.costal paralysis, chanige in
(liaphraggmatic actioni and I)ostoperative muscle
spliiiting. due to 1)2 n and respiratory depression
due to ex(cessive s,9;tion. Chronic atelectasis
may lead to lunig abscess, bronchiectasis, or
suppurative pneunmoinitis. Temperature, pulse
annd respirations drop rapidly to normal levels
sooII after the bronchial tree is clear of secretions and the lung properly aerated. The
proliupt treatment of postoperative pulmonary
complications by bronehoscopic aspiratioln is
a valuable aid to the surgeoin, by reducieng
morbidity aind cleariing ul) mnany clses of aueute
pulmoonary disease which would otherwise become chronic.
7 Durhamn St. S.

RE'SUMmE'
Les douze heures qui suivent une operation sous
anesth6sie gen6rale ou rachidienne constituent la
periode critique durant laquelle l'at6lectasie est ti
craindre. On peut la prevenir dans une large mesure
par la bronchoscopie aspiratrice avant la fin de I'anesth6sie. L 'atelectasie une fois constitu6ce est justiciable
de la meme op6ration, sous peine de passage ci l'atelectasie chronique, h 1'abces pulmonaiire ou h la bron'cheetasie. L 'atelectasie post-operatoire, qui r econnait
pour cause la paralysie partielle des imuscles resDiratoires, se manifeste par des signes d 'induration pulmiionaire avec deplacement dii mediastin et eimiphyserne
coitipensateur des lobes non collal)bs.
PAITL DE BELLEFEITILLE

INTRAVENOUS PROCAINECLINICAL APPLICATIONS*

R. A. Gordon, M.D.
Toronto, Ont.

THE intravenous exhibition of procaine hydrochloride represents a reversal of opinion

which is almost unique in medical history. We
had long been led to believe that one of the most
surely fatal complications of the use of this
drug was the accidental intravenous administration during the production of local anTsthesia.
Even at the present time, when this form of
*
Read at the Seventy-niinth Annual Meeting of the
Canadian Medical Association, Section of Anesthesia,
Toronto, June 23, 1948.

E Canad. M. A. J.
Dec. 1-948, vol. 59

therapy has becomiie well established in the practice of medicine, one meets the occasionial sceptical colleague wh1o is certain that the one result
whichl may- be expected is dealth. We miiay have
been unusually- fortuniate, but so far, it lhas been
possible to avoid this result in all our eases.
The earliest reported use of procaine by a
(leliberate intravascular injectioni was by August
IBier on AMarch 15), 1909. In Bier's mnethod, of
course, the veins were occluded proximal to the
point of injection aind the object was to produce
amnestlhesia of an extremnity, the solution niot
leing permitted to escape into the general circulation. This use differs in almost everyv rcspect,
except that of intravenous administration, from
wlhat we now refer to as initravenous Procaine
therapy. So far as I a.mi able to determiinie, the
earliest repor.t of the deliberate a(ldministration
of l)rocaine hydrochloride into the general cireulation is that of Barany, published in 1935.
Baranv` used intravenous local anasthetie drugs
to relieve tinnitus auriuim. It is of interest to
note that he used not only procaine, but also
pontocaine and nupercaine, with equally good or
better results. In 1939 Leriche report(ed in the
British Medical Jorumwl, the use of intraiveniou,s
procaine to abort the inflaninatory process by
the production ofl vaso-dilatation. In 1941 I)os
Gahli, Bourdin an(d Guiot reported the use o'
intravenous procaine in the treatment of peripher.l vascular disease. In 1942 Lundy reported
the intravenous infusion of priocaine solutions
for the relief of pruritus associated with jaundice. In the. following year I reported a short
series of cases in which the drug was given by
this method for the relief of pain in severe
burns. In 1945 MIeLachlin reported the relief
of pain in postoperative patients by the admiinistration of intravenous procaine, and Allen reported the production of general anasthesia by
this method. It is obvious that timiie does not
permit a full reiview of this subject, anid I will
confine myself therefore to a description of those
conditions in which I feel, from practical experience, that there is an indication for the use
of this method of therapy. In doing so, I would
like first to point out that those conditions whieh
I shall describe cut across the whole practice ot
medicine, in every coneeivable specialty.
The first indication for the use of procaine by
the intravenous route, is, of course, for the relief
of pain. I still believe that having regard to the

Canad. M. A. J. 1
Dec. 1948, vol. 59 ]

GORDON: PROCAINE

inherent dangers in anmusthetizing these patients,

there is no more satisfactory method of producing analgesia in patients suffering from severe
burn. This opinion is borne out bv the experience of many anasthetists and surgeons who
have emploved the method since it was first described. The use of this drug for the relief of
postoperative pain hlas become almost routine in
some institutions and is particularly inidicated
where the use of morphine and similar drugs is
undesirable because of the side effects produced,
or where it is desired not to depress the patient.
The administration of procaine intravenously
in a dose of 200 to 500 rmgmn., towards the end of
all operatioii, firequently imakes anv further
postoperative sedation unnecessary. Similar
doses of procailne have been used to provide
relief of pain lasting for some hours in patieilts
suffering from intractable pain inl malignancy.
Following the lead of other workers we have
used intravenlous procainie to relieve the paim
in osteoartllritis an(l shoulder-hand svndronle.
In these cases however, in addition to the relief
of pain, one expects to obtain added advantages
through the relief of cedena by inhibition of the
sympathetic activity, and in this manner to influence the course of the patient 's disease or
present disability.
Aside from the indication for the X elief of
pain, the majority of clinical uses of procaine
giveii by an intravenous route are based on the
power of this drug to reduce the irritabilitv of
the sympathetic nervous system or to produce a
partial blockade of the sympathetic system. We
thus come to use it in many cases where a block
of the sympathetic nervous system with local
anawstletic drugs applied directly to the nervous
pathwavs might otherwise be used. It hlas
proved very useful in the treatment of postoperative or post-traumatic reflex oedema. I
have used it since 1942 in the treatment of
urticaria with very gratifying results. It is useful in the relief of pain and to improve circulation in peripheral vascular disease. It is widely
used in controlling the syrlmpathetic mimetic
effeet of cyclopropane oIn the heart and most of
us have used it in conjuiietion with this agent
to abolish the cardiac irregularities seen during
its administration. It has been useful in controlling intractable hiccough, herpes zoster, and
pruritus anii.
Following the encouraging results which we
have obtained in the treatment of keloid scars

535

by blocking of the sympathetic nervous svstem

with local ancesthetic, we have used intravenou,
procaine in several patients in which the keloid
was too diffuse and widespread to be suitable for
block therapy. In these the results have been
very encouraging, with cessation of irritation
and regression of keloids.
As a total ancesthetic agent, I think it is. generally conceded that intravenous procaine is
seldom, if ever, indicated. It has however,
proved to be a useful adjunct to other agents,
and particularly so when used in conjunction
with intravenous barbiturates such as pentothal
with or without the addition of gaseous agents.
In this regard, I would like to pay tribute to the
work of Dr. Russell Fraser of Hamilton, who
has a very wide experience with this type of
mixed anwsthesia.
Although much more could be said of the
present uses of procaine given by the intravenous route, I believe that it will be obvious
from this outline that we have here a useful
method of therapy, the indications for whieh
have as yet hardly l)een explored.
Several methods of administration have been
employed. The mlost widely used method is undoubtedly the infusion by slow drip of dilute
solutions of the drug, in saline or saline and
glucose, the concentration varying from 0.1%
for the production of analgesia or for pruritus,
and the inhibition of sympathetic function, to
1% or even greater concentration injected
slowly by a syringe method. The important
factor, of course, is the total dose given in relation to time, the higher dilutions having the advantage of a greater margin of safety, while the
more concentrated solutions, though lacking this
advantage, have in turn the advantage of allow.
ing the rapid introduction of an optimum therapeutic dose. Some workers have employed the
small uniform dose for all patients, others have
employed doses based on the weight of the patient given over a specified time, and yet others
give what they consider to be an adequate dose
for the purpose in mind, controlling the rate of
injection by the appearance of signs of overdosage in the patient. Observation of these vari
ous methods would suggest that the end results
much the same no matter what method of
injection is employed.

are

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