0 History Article
Man Behind
Georg Perthes -The
of Nerve-Tracer
Technology
the Technique
M. Goerig, M.D., and I<. Agarwal, M.D.
he identification of peripheral nerves and plexus
T
by eliciting paresthesias is often the approach
used when performing regional anesthesia. Nevertheless, an alternative does exist for regional anesthesia needle placement, nerve stimulation. The
surgeon Georg Perthes ( 1869- 1927) from Tiibingen,
Germany, was the first person to describe a method
of tracing peripheral nerves and plexus by electrostimulation as early as 1912.’ In memory of the
130th anniversary of Georg Perthes’ birth, we discuss a report he wrote in 1912 on the safe and
atraumatic localization of peripheral nerves for local
anesthesia. Unfortunately, this publication has often
been overlooked in past years.
Georg Perthes was born in Moers, Germany, in
1869 (Fig l).2 He lost his parents during childhood
and was raised in Bonn by a family that was
acquainted with the surgeon Friedrich Trendelenburg (1844 1924) .3 Thus, it is not surprising that
Perthes started studying medicine in Bonn in 1887.
He then continued in Freiburg and finally graduated
from the University of Berlin in 1892 (Fig 2). In the
same year he became senior resident at the Surgical
University in Bonn, with Trendelenburg being the
director. In 1895 he accompanied Trendelenburg,
who transferred to Leipzig, and it took only another
3 years until he was appointed Professor at the
University of Leipzig after having published a thesis
(called “Habilitation”)
on “A new method for postoperative care of patients operated on an empyema
and post-operative care of patients with pneumothoraces.“*
Just like many other German surgeons at that
time, in 1900 and 1901 Perthes escorted military
From the Department of Anesthesiology, University Hospital
Eppendorf, Hamburg, Germany.
Accepted for publication October 13, 1999.
Reprint requests: M. Goerig, M.D., Department of Anesthesiology, University Hospital Eppendorf, MartinistraRe 52, 20240
Hamburg, Germany.
0 2000 by the American Society of Regional Anesthesia and
Pain Medicine.
1098-7339/0012503-0016$5.0010
doi: 10.1053/xr.2000.4153
296
troops who had been sent to China to suppress the
“Boxer-Rebellion.”
There he was in charge of a
hospital and performed studies in the field of radiology.3 Based on these studies, he described a procedure on how to locate foreign bodies with the aid of
radiography. Moreover, he was first to perform
radiological examinations on artificially deformed
feet of Chinese women (Fig 3).5 On top of this, he
precisely outlined the technique for the surgical
intervention on the bone deformation of a flat foot.
After he returned to Leipzig in 1902, Perthes performed investigations on the biological effects of
radiographs and radium-rays on living cells. These
investigations resulted in Perthes being the first
person to administer radiotherapy in the treatment
of malignant tumors, thus realizing its value in
postoperative management.2,6
In 19 11, Perthes succeeded Paul von Bruns ( 18461916) as chairman of the Surgical Clinic of the
University in Ttibingen, even though Ferdinand
Sauerbruch (1875-1951) had also been nominated.
In Tiibingen, ether had already been applied in 1847
to induce general anesthesia. Chloroform had been
dismissed quite early in the operation theaters of
that hospital because of its side effects, even though
it was still being administered at other places. The
surgeons at the University of Ttibingen quickly
conceived the value of proper anesthesia; hence,
many colleagues examined unsolved problems in
this field. Among them was Max von Brunn (18751924), who still worked at the Surgical Clinic when
Perthes became director in 1911. Von Brunn was
the author of a well-known textbook of anesthesiology and vehemently defended premeditation
with
scopolamine and morphine in all patients who had
to undergo either general or local anesthesia.7
In Tiibingen, Perthes continued his research in
surgery, dentistry, and radiology that he had begun
at the University of Leipzig. Because of his insight
into different fields of medicine, he developed a
great sympathy for local anesthetic methods. He
invented a special pressure cuff for Bier’s intravenous anesthesia technique (Fig 4).8 In 1927, Georg
Regional Anesthesia and Pain Medicine, Vol25, No 3 (May-June), 2000: pp 296-301
Georg
Perthes
l
Goerig
and Agarwal
297
in the ankle, bone abscesses close to the tibia, club
feet osteotomies, infected as well as complicated
dislocation of the ankle, amputation of the upper
arm in a case of malignant sarcoma, or repositioning
a bleeding elbow).
Most of the patients received premeditation
an
hour before regional anesthesia was performed to
obtain sedation and amnesia. The combination of
the two drugs pantopon and scopolamine was well
known for its effects that were summarized as
“twilight sleep.“** A maximum dose of 240 mg of
pantopon and up to 40 mg of scopolamine was
administered. Peripheral nerves or plexus were
located by electrical stimulation. After having anesthetized the skin around the puncture area by
injecting 0.5% procaine solution, a special cannula
:
I]
: .,
“ij/I
Ober siebennndzwanzig
1j mit Koch’schen Injectionen
behandelte P&lle.
Fig 1. The surgeon Georg Perthes (1869-1927). (Reprinted with per;mission from the Archives of the University of Tiibingen, Germany.)
Perthes, whose name is known worldwide for Perthes disease, died of heart failure in Arosa, Switzerland, at age 5S9*lo
Even though Perthes was not deeply involved in
anesthesiology research, his name keeps being connected with this field because of the introduction of
the nerve-tracer-an
important
device for local
anesthetic techniques that he outlines in his report
“Conduction Anesthesia With the Help of Electrical
Stimulation”’
(Pig 5). To honor Georg Perthes in
popularizing nerve stimulation in regional anesthesia, we will provide details on his original publication. l
VW
Qoorg
Perth00
ml.. Mann.
i
I
..-_
___-____~-.--.-.
-
..
Materials and Methods
Twenty-two patients, ages 16 to 74 years, were
included. They were to undergo surgical procedures
on either lower or upper limbs using different
methods of conduction anesthesia, including extended surgical operations and orthopedic reconstruction (e.g., amputation of the foot, tuberculosis
Fig 2. Cover of thesis by Georg Perthes in 1891. Please
note the dedication to his “dear aunt Agnes” h&diwittkn
on the top. (Reprinted with permission from the Amhives
of the University of Tiibingen, Germany.)
298
Regional
Anesthesia
and Pain Medicine
Vol. 25 No. 3 May-June
2000
for the injection designed by Perthes served as a
stimulation electrode: “The injection needle which
is made of nickel is coated up to the tip with a glaze
for conduction of electricity into the surrounding
tissue becomes impossible. The varnish is extremely
adherent to the needle thus providing an extremely
smooth surface and allowing repeated steam sterilization.” The cannula was directed with the help of a
syringe that contained a 2 % procaine solution. After
having positioned
Fig 3. R :eplica of a Chinese patient’s foot made of plaster
by Perthes. (Reprinted with permission from SteinkopffVerlag, Darmstadt, Germany.27)
Fig 4. Picture of a toumi-
quet developed by Perthes
for intravenous anesthesia
according to August Bier.
the needle, Perthes injected pro-
caine (3%) to “obtain a rapid onset as well as a long
lasting nerve block. The solution is prepared from
tablets by the Hoechst-Drug-Company
that contain
the desired amount of adrenaline in an appropriate
concentration.” The syringe was connected to the
induction coil by a wire with a rubber coating. To
operate the system, the physician had to press a
pedal that turned the current on or off. Peripheral
nerves were located with current provided by an
external induction coil, since the intensity of the
stimulus could be adjusted by different internal
metal blocks. “There is no upper limit of the intensity of the current, thus it can be augmented until
the stimulus in the tongue becomes painful. The
whole system is completely set, i.e., the local anesthetic can be injected as soon as the nerve has been
traced and the corresponding muscles start to contract. While injecting the anesthetic the muscular
twitch fades away as the nerve block becomes
complete.”
Usually, 30 mL of a 2% procaine solution was
injected after proper identification of the nerves by
specific muscular response had been achieved. To
control the efficacy and extent of anesthesia, Perthes applied a so-called “weak current” from the
Georg
Originalien.
Aus
der
chirurgischcn
(Dircktor:
Universitiitsklinik
Prof. Dr. P e r the
in
s).
Ttthingen
Ueber LeitungsanLthesie unter Zuhilfenahme elektrischer Reizung.
Von
0.
Pcrthcs.
Die Fortschritte
dcr Lokalantisthcsie
wren
in den letzten
Jahren
hnuptslchlich
durch
die \!‘citere
Aushildung
der ~011
B r a u n begriindetcn
Methode
der Lcitungsanfisthesie
bedingt.
In rascher Folge sehen wir die AnPsthesierung
des Trigeminus
(B r a u n). die Sakralanfisthesie
(L I w e n). die Aniisthesie
des
Plexus brachialis
(H i r s c h e I, K u h I e n k a m p f f) sich entwickeln.
Auch zur Lcitunnson5sthesic
der rrriisseren
Nervenstamme der untcrcn
ExtremitSt
sind Erfolg versprechende
Ankiufe gemacht
CL 8 w e n. J a s s e n e t z k i - W o i n 0).
Zweiiellos sind die bisherigen
Ergehnissc
crfrculich.
Dennoch
haltc
ich cinen weiteren
Fortschritt
iiir miixhch.
Die Sichcrheit
dcr
Leitllngsllllterhrechtltlg
dcr grossen
Ncrvenstiimmc
dcr Estremitiitcn
liisst sich hetrfichtlich
stcizcrn.
wenn wir uns m i t
Hilie
erektrischer
Reizung
ein
sichercs
Urteil
dartiber
verschnffcn.
ob die
Spitze
der
anlsthesiebringenden
Kanijle
den
gesuchten
Nerven
tatsichlich
erreicht
hat.
Fig 5. Frontispiece of the original publication “Ueber
Leitungsanlsthesthesie unter Zuhilfenahme elektrischer
Reizung.”
internal coil, which was connected to a “faradic
brush.” “I am not familiar with any other helpful
method. There are no injurious effects to the skin
and even indolent patients respond promptly. Moreover, the extent of anesthesia can be confirmed by
poking the skin with the faradic brush which is a
much faster mode than pinpricks with a needle or
any other kind of mechanical irritation of the skin.
A metal plate covered with a moistened piece of
cotton serves as the neutral electrode and is placed
anywhere on the patient’s skin, even though the
most appropriate place seems to be the buttocks.”
Results
Eleven out of 15 patients were treated according
to the described method, and the surgical procedures of the lower limbs were performed successfully. The onset of analgesia was observed within 3
to 30 minutes after the injection of the local anesthetic and lasted for 90 to 150 minutes. “At the same
time that loss of sensitivity occurred, a motor block
of the corresponding neuronal area could be observed, too, eventually leading to a complete paralysis in some patients. There was an excellent anesthetic effect, even in cases with a partial motor
block.” The anesthetic effect in other patients was
too low to perform the desired operation. According
to Perthes, a lack of routine and experience with the
new technique as well as deficiencies of the materials used might have accounted for this.
Supraclavicular blocks that had been performed
according to the Kulenkampff method showed very
Perthes
l
Goerig
and Agarwal
299
good results.12 The quality of anesthesia that was
obtained was very satisfying; hence, even surgical
procedures with a long duration could be performed
easily. It is worth mentioning that Perthes did not
observe “a complete loss of sensitivity in these cases”
at any time.
Discussion
When Georg Perthes published his report “Conduction Anesthesia With the Help of Electrical
Stimulation” in 1912, various techniques for performing local anesthesia had become popular.13-16
Different facts accounted for this rapid development. Since less toxic drugs had been discovered,
cocaine could be replaced or even discarded from
the list of local anesthetics, thus facilitating more
risky experiments and bringing about new approaches to regional anesthesia.“J8 An alternative
to the greatly feared general anesthetic had been
developed, which seemed to be as effective and less
dangerous in high-risk patients. The advantages of
Perthes’ procedure to locate peripheral nerves by
electrical stimulation seem to be at hand and evident. He outlined and compared them with the
conventional method, especially for noncooperative
patients, in his report.
The notion of patients being wide awake during
surgical procedures under local or regional anesthesia was of great concern to Perthes. To achieve
sedation for the duration of the operation, like other
surgeons he recommended to supply the patients
with a preoperative medication that was to be
administered on the ward beforehand. lo’ He named
3 reasons for this approach:
(1) Most of the patients were not able to cooper-
ate with the physician while he was performing the regional block because of anxiety and
stress caused by the event of an operation.
(2) In some cases, symptoms of agitation could be
observed during the injection of the local
anesthetic; thus, inappropriate answers regarding cognition and tactility were obtained.
(3) Some patients denied experiencing paresthesia even though the injection carmula was
definitely positioned correctly.
Hence, Perthes administered a combination of
pantopon and scopolamine ‘/zhour before the induction of anesthesia to induce comfort and daze or
light sleep during the operation: “It was evident that
twilight sleep, that was induced by the combination
of these two drugs, was not mandatory for the
chosen method to be successful as could be proven
by cases where this medication had not been allotted.” Because of this perception, Perthes became a
300
Regional
Anesthesia
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Vol. 25 No. 3 May-June
pioneer in pointing to the importance of premedication for surgical procedures that were to be performed under local anesthesia, even though there
were contradictory voices regarding the effectiveness of that approach.
On top of sedation, this method seemed to allow
reduction of the required amount of local anesthetic
needed for surgery. Compared with Arthur Lawen
(1876-1958), Perthes injected only half the dose of
procaine leading to the degree of decreased perception. As opposed to Lawen, who administered up to
2,100 mg of procaine to achieve sufficient analgesia,
Perthes did not observe toxic reactions, thus approaching the aim of “In Somno Securitas.” The
quantity of procaine he injected never exceeded 900
mg, not omitting the fact that epinephrine was
being added to the solution. This accounts for
Perthes not reporting cerebral or other side effects,
which inspired LHwen to discuss the contingency of
conduction anesthesia of the sciatic nerve.i9 He
emphasized that this method should only be used in
thin patients, where “the sciatic nerve could be
touched directly.” Considering the dose that is accepted to be within limits today, it seems very likely
that Lawen had experienced severe adverse effects,
because he administered far more than 1,000 mg of
procaine.
With all the discussions and experience conceming the above-mentioned
technique, Perthes tried
to calm euphoria, stating that “the new maneuver”
was “far from being perfect.” Perhaps, because of
this statement, the method fell into oblivion and
peripheral nerves and plexus were anesthetized by
direct injection of the local anesthetic into or around
the nerve, as had been suggested by William Halsted
(1852-1922).20
It took about 50 years until Gordon Michael
Greenblatt (1932-) and Jordon Samuel Denson
(1918-1981)
revived this procedure in 1962 by
reporting on having successfully operated a portable
device for electrostimulation.21 Since then, numerous new devices have been designed and developed
across the world, with all the investigators emphasizing their advantages and efficacy.22-26
In summary, it is obvious that Perthes was keen
on introducing a modem, safe, and patient-centered
mode of regional anesthesia: (1) he described an
atraumatic technique of how to perform conduction
anesthesia of peripheral nerves and plexus; (2) he
spelled out the warning that local anesthetic toxicity
was possible if large amounts of local anesthetics
were administered; and (3) he recommended the
combination of regional anesthesia with a concomitant effective individually dosed sedative and anxiolytic medication perioperatively.
2000
References
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