THE LIBRARY
OF
THE UNIVERSITY OF CALIFORNIA
LOS ANGELES
GIFT OF
SAN FRANCISCO COUNTY MEDICAL SOCIETY
Hook is due on last date given below. A fin "harged for each day the book it kept ovf
^ te ~ e
7611
Regional Anesthesia
(VICTOR PAUCHET'S TECHNIQUE)
BY
B. ,SHERWOOD-DU_NN, M.D.
OFFICIER D'ACADKMIE; SURGEON (COLONEL) SERVICE DE SANTE MILITAIRE DE PARIS; PHYSICIAN TO THE COCHIN HOSPITAL.
WITH 224 FIGURES IN THE TEXT
PHILADELPHIA
F. A. DAVIS COMPANY, PUBLISHERS
ENGLISH DEPOT STANLEY PHILLIPS, LONDON
1920
COPYRIGHT, 1920
BY F. A. DAVIS COMPANY
Copyright, Great Britain. All Rights Reserved.
PRESS OF
F. A. DAVIS COMPANY PHILADELPHIA. U.S.A.
Libr-
tuo
300
PREFACE.
FOR thirty years Professor Reclus, of the Paris Faculte, preached and practised local anes- thesia. His method consisted in infiltrating the tissues upon which he proposed to operate with a weak solution of cocaine — then proceeding with the operation.
This procedure is well known in France, and is often employed in minor operations.
Regional anesthesia differs widely from the method of Reclus. Instead of applying the anes- thetic to the terminals of the nerves, it is injected at the point of the origin of the nerve, or along the trunk near the point of origin, so that the \vhole region supplied by the nerve and its branches is anesthetized. All the major as well as the most deli- cate minor operations can be performed in this way. The method has gained many adherents since 1914, and its growing popularity has led us to believe that an exposition of it would be wel- comed by the American profession.
Professor Victor Pauchet is acknowledged to be the leading exponent of regional anesthesia in France, and this book constitutes a resume of his
(iii)
577919
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iv PREFACE.
writings upon this subject, together with those of P. Sourdat and J. Laboure. In addition there is included the latest experiences of Pauchet and the writer, together with Pauchet's recommendations, inserted during his revision and amplification of the manuscript before its transmission to the pub- lishers.
I wish to acknowledge my indebtedness to Dr. Emilie Jane and Miss Frances Johnson, R. N., and to express my high appreciation of the assist- ance which they have rendered me in the prepara- tion of this work for publication.
B. SHERWOOD-DUNN.
CONTENTS.
CHAPTER I.
PAGE
GENERAL CONSIDERATIONS 1
Advantages of Regional Anesthesia 1
Disadvantages of Regional Anesthesia 5
CHAPTER II.
ARMAMENTARIUM 12
Syringes 12
Needles 12
Anesthetic 14
General Technique 17
CHAPTER III.
CRANIAL OPERATIONS 37
Treatment of Large Wounds in the Soft Tissues, or of Com- pound Fractures of the Skull 40
Removal of Malignant Tumors of the Cranium, with Bone
Resection 42
Trephining the Temporal Region 43
Exposure of the Cerebellum 46
CHAPTER IV.
ANESTHESIA OF THE HEAD AND NECK 48
Anesthesia of the Gasserian Ganglion 48
Anesthesia of the Trigeminal Nerve Distribution 57
Regional Anesthesia in Rhinology 80
Regional Anesthesia in Otology 85
Regional Anesthesia in Ophthalmology 91
Regional Anesthesia in Dental Surgery 94
Regional Anesthesia of the Face and Jaws 97
Regional Anesthesia of the Tongue, Floor of the Mouth, Ton- sils and Palate 105
Regional Anesthesia in Operations of the Neck 109
(v)
vi CONTEXTS.
CHAPTER V.
PAGE
ANESTHESIA OF THE THORAX AND ABDOMEN 128
Intraspinal Anesthesia 128
Nerve-trunk Anesthesia 136
Paravertebral Anesthesia 144
Paracentesis of the Pleural Cavity 153
Thoracotomy for Empyema with Costal Resection 153
Resection of the Second to the Fifth Costal Cartilages for
Rigidity of the Thorax 155
Operations upon the Sternum 158
Thoracotomy for Abscess of the Lung, etc 158
Operations for Tumor of the Breast 160
Operations in the Axilla 162
Abdomen 162
Operations upon the Stomach 165
Median Hypogastric Incision 167
Operations in the Iliac Fossa 169
Umbilical Hernia 186
Inguinal Hernia 188
Femoral Hernia 195
Operations upon the Kidneys 198
Operations upon the Biliary Passages 199
CHAPTER VI.
ANESTHESIA OF THE GENITO-URINARY ORGANS AND RECTUM 200
Anterior Sacral Anesthesia (Pre-sacral) 205
Anesthesia through the Sacral Foramina — Trans-sacral An- esthesia 207
Operations upon the Bladder 212
Operations upon the Testicles and Scrotum 214
Operations upon the Penis 217
Operations upon the Posterior Urethra 219
Operations upon the Prostate 220
Operations upon the Vulva and Vagina 220
Operations upon the Anus 224
CHAPTER VII.
PAGE
ANESTHESIA OF THE EXTREMITIES 230
Upper Extremity 232
Operations upon the Hand 245
Operations upon the Forearm 258
CONTEXTS. vii
ANESTHESIA OF THE EXTREMITIES (continued).
Upper Extremity, Operations at the Elbow 261
Operations upon the Arm 263
Operations upon the Shoulder 264
Lower Extremity 265
Operations upon the Toes 270
Operations upon the Entire Foot 272
Operations upon the Knee 274
Operations upon the Soft Part of the Thigh 277
CONCLUSIONS 283
INDEX . 285
CHAPTER I.
GENERAL CONSIDERATIONS. ADVANTAGES OF REGIONAL ANESTHESIA.
ANESTHESIA by injection possesses, as compared with anesthesia by general narcosis, advantages of such cardinal importance that, at the very outset, the reader's attention should be directed to them as ample justification for the time, labor and special education required to become sufficiently expert in its application to permit of its adoption for general employment.
Lozv Mortality Risks. — Since the concentrated solutions of cocaine have been replaced by weak solutions of the less toxic agents, such as sto- vaine, novocaine, procaine, etc., death from local or regional anesthesia has disappeared from sur- gical practice. The writer is unacquainted with a single case of death due to the employment of the last named anesthetics.
The relative rarity of death from narcosis (chloroform, I in 2000; ether, i in 5000) may make this advantage seem insignificant; but it is only necessary for an operator to lose one patient by narcosis, to have this apparently insignificant advantage brought forcibly to his attention.
(1)
2 REGIONAL ANESTHESIA.
Reduction of Post-operative Dangers. — General narcosis, aside from its mortality, produces com- plications which are of great importance because of their frequent occurrence. They include chiefly pul- monary complications, caused or aggravated by etherization, and alterations in the liver and kid- neys through the action of ether, and particularly of chloroform. Rapid degeneration of the liver and kidneys following surgical operations is often attributed to shock or post-operative infection, but the fact that these accidents are eliminated by regional anesthesia would indicate that they are directly due to the action of the compounds used in general narcosis, and the superiority of regional anesthesia is made strikingly apparent in opera- tions upon subjects suffering with chronic jaun- dice or renal insufficiency. The nausea and vomit- ing, which often continue for forty-eight hours after an operation and are such prominent factors in reducing the vital forces — especially in patients with strength already at the lowest ebb — are often the determining cause of death. These trouble- some conditions are eliminated in regional anesthesia.
Diminution of Shock. — The reflex action of traumatism, the unconscious suffering of a patient even under the full influence of narcosis, is trans- mitted to the nerve centers, provoking disturbances which, repeated, result in certain alterations in the neurons, aiid these alterations constitute shock.
Local or regional anesthesia secures a com- plete physiological section of the nerves and sup-
GENERAL CONSIDERATIONS. 3
presses completely this influence upon the nerve 'centers.
This fact has been so fully demonstrated that Crile (of Cleveland) practises local and regional anesthesia in all of his major operations, even when employing general narcosis with nitrous oxide. If comparison is made between a series of operations for cancer of the stomach under narcosis and a series under regional anesthesia, the relative condition of the patients subsequently offers a striking confirmation of the innocuousness of the latter procedure.
Absence of Danger from Asphyxia. — Adminis- tration of ether or chloroform is generally at- tended by greater or less respiratory disturbances. Onlookers often have their attention attracted by the patient's difficulty in breathing, due generally to mucus collecting in the mouth and nose, espe- cially in the Trendelenburg position. Not infre- quently the operator's attention is arrested by the same difficulty. All of this is absent in injection anesthesia.
Operations upon the respiratory tract, or in its vicinity, are greatly simplified and facilitated. The patient assumes whatever position is desired, being perfectly conscious. He can at will arrest his breathing, suppress a cough, or expectorate if need be. This is of valuable assistance in opera- tions upon the pleura, larynx, neck, etc. In oper- ations for goiter it safeguards the recurrent laryn- geal nerve by allowing the patient to speak, thus calling attention to the nerve.
4 REGIONAL ANESTHESIA.
Special Advantages in Certain Operations. — The fan-like distribution of the nerves after thev
•/
leave the large nerve trunks permits the per- formance of extensive operations once the trunk has been anesthetized. Thus a bronchial tumor, or the cervical glands can be removed, or total laryngectomy or external esophagotomy performed after preliminary infiltration of the cervical plexus.
Nephrectomy can be painlessly performed after paravertebral infiltration of six intercostal and two lumbar trunks; not only are the parietes rendered insensible, but the kidney can be sutured or the pedicle liberated and ligated without pain. The same advantage attaches in operations upon the liver and stomach. The rectum can be excised after injecting through the sacral foramen.
Compared with the method of local infiltration, practised by Reclus, regional anesthesia possesses the following advantages :
(1) The anesthesia is entirely distinct from the operation proper, being instituted beforehand, and if possible, by an assistant in an adjoining room. Con- sequently, successive operations can be performed without loss of time.
(2) Once the nerve or nerves have been properly anesthetized, the anesthesia continues complete for from one and one-half to two and one-half hours and the operation is never interrupted to make addi- tional injections as is often the case in infiltration anesthesia.
(3) It obviates all danger of necrosis of the tis- sues, such as sometimes occurs in local infiltration
GENERAL CONSIDERATIONS. 5
where a section of the skin is mobilized in a plastic operation to cover a denuded surface and is nour- ished only by a narrow pedicle.
DISADVANTAGES OF REGIONAL ANESTHESIA.
Special Training Required. — Some training in the practical method of application is required to per- mit of successful practice of this procedure — though not more than is necessary for the execution of any of the simpler types of surgical operations.
As the simplest and most rapid procedure for securing the necessary experience we advise that the operator, after reading the detailed descrip- tions herein presented, first practise finding upon the skeleton, with needles of varying lengths, the cranial, spinal, intercostal and sacral nerve for- amina.
When he has become familiar with the depths and directions of the various punctures through ex- ercises upon the skeleton, the student of the method may then repeat the various operations upon the cadaver, using the longer and coarser needles and a fluid containing India ink. Dissection of the more difficult regions, after such experimentation, will disclose any faults and soon draw the operator's at- tention to any necessary corrections. Too much time need not be spent in this experimental work, how- ever, before the operator begins upon the living sub- ject, as no harm results from the injection of the fluid. But little actual experience is required for the surgeon to become confident and adept in finding the
6 REGIONAL ANESTHESIA.
nerve trunks, this being facilitated by the more or less pronounced sensation referred to the terminal distributions when the point of the needle touches the nerve trunk, or by the insensibility of the sur- faces supplied.
It will assist the operator in rapidly gaining con- fidence and skill if he will use at first a larger amount and a stronger solution and infiltrate a more exten- sive area.
Necessity of Gentleness and Skill in Operative Technique. — It is obvious that where an operation must be done with the complete consciousness and oftentimes in full view of the patient, a gentle, un- hurried, and quiet technique is imperative and is conducive to a greater degree of satisfaction to the patient, with better results.
Some operators are accustomed to break up ad- hesions and carry out many surgical maneuvers with their hands and fingers. With injection anesthesia in abdominal operations especially, all pulling, tear- ing, and rough treatment should be avoided, as even with complete insensibility of the parts the patient cannot but be cognizant of the methods employed, and any such treatment produces an unfavorable mental impression which is prejudicial to final suc- cess. The scalpel and scissors should be used for all necessary separation of parts. Again, it is the habit of some to employ in their operations a variety of retractors, which are often the cause of unnecessary traumatism to the parts. This may also be said of the employment of an unnecessary number of pres- sure and rat-tooth forceps.
GENERAL CONSIDERATIONS. 7
It must not be overlooked that a difference exists between sensation and pain; unnecessary pulling and handling1 of parts produces a disagreeable sen- sation which is likely to cause complaint on the part of the patient.
The more gently and quickly the operator pro- ceeds, the greater will be his measure of operative success.
Objection that the Method Procures only a Partial Anesthesia. — In regional anesthesia it has been our experience that, out of 20 cases, 12 are completely insensible; 7 are sufficiently insensible to all neces- sary manipulations to permit of the operative pro- cedure without serious complaint on the part of the patient; while I case out of 20 is found insufficiently anesthetized and must be given a little ethyl chloride to overcome the deficiency. Even in this event the quantity of inhalation anesthetic required is very slight.
The value of regional anesthesia is demonstrable by comparison, chiefly writh general narcosis. The reader need only be reminded of the distressing ex- periences which attend the beginning and the close of the latter procedure, and but little experience with the former will convince any expert operator of its marked superiority. Apart from the distressing period of vomiting which follows general narcosis, the after pains complained of during the succeeding day and night are usually greatly diminished in regional anesthesia, and after nephrectomy, lapa- rotomy, and facial operations a lasting condition of hypoanesthesia may often be noted, which renders
8 REGIONAL ANESTHESIA.
the injection of morphine or other narcotic during the succeeding twenty-four hours unnecessary.
True, the patient will often complain at some time or other during the course of the operation. One says the table is too hard; another asks if the operation will not soon be finished; many complain of suffering because they confound sensation with pain. One of our patients cried out when he heard a fragment of his rib fall into the slop basin. These are minor inconveniences which it is well to be aware of in order to be prepared for them when they be- come manifest. The table should be well padded. In nervous and sensitive cases it is advisable to .blindfold the patient's eyes and to stop the ears with cotton.
Before all operations the patient should be given an injection of scopolamine-morphine, which not only does not interfere with, but rather assists the method. Absolute silence should be maintained in the operating room.
Necessarily the operator must have become perfected in the details and technique of the regional form of anesthesia. Any operator who, in the anes- thetization of his patients, has had to rely upon the services of different assistants, knows how seldom a good one is found. The number of patients who are insufficiently or imperfectly brought under the anesthetic and bear down or resist during the course of the operation is legion, while not infrequently cases absorb too much of the anesthetic, causing the operator to discontinue his work while the patient is brought back from the danger line. It is not too
GENERAL CONSIDERATIONS. 9
much to ask, therefore, that the operator intending to make use of regional anesthesia should carefully and completely train himself in the details of the procedure and persevere in his technical practice until he has reached a satisfactory degree of perfec- tion, just as he does in any and every other depart- ment of medical practice.
An important feature that should never be lost sight of is the psychology of the patient. Those who accept the method reluctantly, and are anxious, nerv- ous, and hyper-sensitive, are the difficult subjects; most of these, however, once the operation has been satisfactorily concluded, express themselves as com- pletely satisfied.
On the other hand, there are those who, familiar with the distress of the after-effects of general nar- cosis, welcome the new mode of procedure and make most satisfactory subjects. The mental attitude of the patient has almost as much to do with the suc- cess of the operation as the ability of the operator.
The Time Element. — About the same time is consumed in the administration of regional anes- thesia as in that of general narcosis. About ten or fifteen minutes are required for an experienced assistant to perform the necessary injections in the former procedure, and another ten minutes must then elapse for the full effect to become estab- lished. About the same length of time is re- quired to obtain the complete effects of inhalation anesthesia.
Where the operator is dealing with a private case, it is not often that a few moments more or less
10 REGIONAL ANESTHESIA.
will particularly interfere with the type of technique he may select, that which is best in his opinion governing the choice.
In hospital service, where several cases are to be operated upon, it is essential to have an experienced assistant for the advance preparation of the cases. This likewise applies in the administration of a general anesthetic.
In any event, the loss of a few moments' time is not to be considered in comparison with the benefits to the patient that attend the regional form of anesthesia.
The Claim that Regional Anesthesia is not Equally Adapted for all Operations. — The beginner in regional anesthesia may better satisfy both himself and the patient by giving ethyl chloride, ether, or chlo- roform to complete the anesthesia if there is complaint to any degree.
Mixed anesthesias, although not attractive in theory, cause less shock than simple narcosis.
If a preparatory injection of morphine-scopola- mine is administered before the introduction of the procaine-suprarenin and the operation is completed with the aid of the inhalation narcotics referred to, the patient will be affected less than by simple nar- cosis, i.e., he will be less affected by three agents than by one. For this a theoretical explanation is avail- able, but such explanation is not so important as the fact itself which has been learned by actual ex- perience.
In trephining operations, goiter excisions, total laryngectomies, prostatectomies, operations for hem-
GENERAL CONSIDERATIONS. 11
orrhoids, radical cure of hernia, and costal resec- tions, regional anesthesia is a most gratifying pro- cedure. "With increasing experience, furthermore, the operator will learn the details of technique that render this form of anesthesia applicable to any and all operations.
CHAPTER II.
ARMAMENTARIUM.
Syringes. — The operator should have at his dis- posal Luer's all glass morphine syringe of i- to 2- mil capacity, and also a metal and glass syringe of 10- mil capacity.
My earlier experience was with the Record syringe, which is very serviceable, but more lately I have been led to substitute the Collin all metal syringe (Fig. i), which is to be preferred in that it is both short, powerful, and unbreakable. The syringe should be thoroughly water tight and provided at its top with lateral handles by means of which a firm hold can be secured.
Needles. — These should be of small caliber, with a short-beveled point. The smaller the caliber of the needle, the less painful its introduction. Needles of the smallest caliber and with long, fine points should be particularly employed for the formation of the dermal wheals later to be described.
Platinum needles are expensive and soon be- come blunted at the point. Steel needles are finer pointed and remain sharp longer, but are prone to rust and. are easily broken. I have found it best to employ either fine steel, or nickel needles. The latter remain sharp and in good condition the longest. The junction between the nozzle of the (12)
ARMAMENTARIUM.
13
syringe and the needle must permit of no leakage, the needle remaining in situ while the syringe is repeatedly removed for refilling. The smooth
Fig. 1. — A 10-mil metal syringe of Collin make, short, strong, unbreakable, handy and with graduated plunger rod. The lateral socket enables the operator to make injections parallel with the surface while using a straight needle.
14 REGIONAL ANESTHESIA.
socket type should be chosen rather than the screw or bayonet form.
We employ only the straight form of needle. It is less expensive and more easily obtained, and when once one is accustomed to its use, it answers every purpose.
There should be provided needles of four lengths, viz., 3, 6, 9, and 12 centimeters (Fig. 2). The 3-centimeter needle is used in making the dermal wheals. It should be sharp pointed. The 12- centimeter needle is seldom used — chiefly for pre- sacral injections. The 6- and 9- centimeter needles serve for all general purposes.
To mark the exact depth to which the needle is to be introduced, the operator may make a shield from a piece of boiled cork or a square of rubber sheeting, to be adjusted upon the needle at the point desired.
The instruments and receptacles for the solu- tion should be sterilized in plain boiling water, without addition of any chemical agent whatever.
Anesthetic. — As anesthetic we have been using neoca'ine-surrenine (Corbiere], a French prepara- tion which replaces with perfect satisfaction the German product novocaine-adrenalin. In prepar- ing a considerable amount of the solution, to be kept for some hours, it is best to use the pure procaine,1 to which can be added immediately be- fore use the required quantity of adrenin.
1 Procaine being the term now in general use in the United States in place of neocaine or novocaine, this term will be regularly employed hereinafter.
ARMAMENTARIUM.
15
The formulas of the mixtures used are as fol- lows : (1)25 drops of i to 1000 aclrenin solu- tion to 200 mils of y* per cent, procaine solution;
Fig. 2. — Four steel needles, respectively, 12, 9, 6, and 3 centi- meters in length. Each needle is provided with a mandril. Actually the needles are twice as fine as they are represented in this illustration.
(2) 25 drops of adrenin to 100 mils of i per cent, procaine; (3) 25 drops of adrenin to 50 mils of 2 per cent, procaine; (4) 25 drops of adrenin
16
REGIONAL ANESTHESIA.
solution to 25 mils of 4 per cent, procaine. Twenty-five drops of the adrenin solution is the equivalent of i milligram of adrenin.
We use the 4 per cent, solution but seldom, for the cranial nerves and brachial plexus; the 2 per cent, solution frequently, as a rule for the nerve trunks; but the i per cent, and especially
Fig. 3. — From left to right, an ampoule of saline solution for dissolving the procaine ; a tube containing 2 capsules of procaine in powder form and 3 sealed flasks containing 150 grams of y2 per cent, solution.
the }/2 per cent, solutions are those most com- monly employed, the latter for all infiltrations.
It is far cheaper to prepare the solution as re- quired than to buy it ready made.
The adrenin and procaine come in glass am- poules. On the evening of the day preceding the operation these are dissolved in boiled salt solu- tion. Even more convenient are the procaine tab- lets which can be dissolved in boiled salt solution
ARMAMENTARIUM. 17
and kept until needed for use, when the required amount of adrenin is added.
It is inadvisable to attempt to sterilize the solution after the mixture has been made; this should be done beforehand. The procaine adrenin should be added to a hot solution (35° C.) to in- sure its ready dissolution.
The high percentage solutions should be in- jected very slowly, and in amounts never exceed- ing 20 to 40 mils of the y? per cent, solution. AYe have employed, however, as much as 300 mils without any harmful effect.
In removal of the breast for cancer, as much as 250 to 300 mils may be employed; most of it escapes after the primary incision has been made.
For anesthetizing the viscera, and especially the peritoneal ligaments, the omental tissues, the meso- appendix, the mesentery, and the sero-vascular pedicles, we often employ (following the advice of Crile, of Cleveland) a i per cent, solution of quinine and urea hydrochloride,1 injecting as much as 100 grams in addition to the solution of procaine-adrenin already used.
GENERAL TECHNIQUE.
Theoretically, regional anesthesia and anesthe- sia by infiltration, according to the procedure of Reclus, are two different methods. Practically, neither of them excludes the other, but, in fact,
1 The product termed by Corbiere urocaine.
2
18 REGIONAL ANESTHESIA.
they supplement each other and are often em- ployed in combination.
The principle of regional anesthesia is, not to infiltrate the field of operation or surrounding tis- sues, but to secure insensibility by directly inject- ing the nerves distributed to the region or tissues surrounding these nerves. To each region cor- responds a special technique, appropriate for the insensibilization of the nerves in that region, and with which the operator must be familiar in order to succeed.
Necessity of Perfect Asepsis in Regional Anes- thesia.— In making the injections, the operator proceeds without gloves, but with hands well dis- infected, as for an ordinary minor operation. The instruments and solution must be sterilized. Care is taken not to dip the syringe into the glass re- ceptacle containing the solution, particularly if the syringe has come in contact with the fingers of the operator and the patient's skin. A special needle is reserved for drawing up the fluid into the syringe. It should be constantly borne in mind that ungloved hands are never aseptic any more than is the patient's skin.
In practice, the two methods, nerve-block- ing and infiltration, are usually employed together, the one aiding and completing the other.
With few exceptions, e.g., anesthesia of the meso-appendix with urocaine before its section, or anesthesia of the omental tissues, complete induc- tion of anesthesia precedes the operative pro- cedure. No injection should be made during the
ARMAMENTARIUM. 19
operation, which is performed as though the pa- tient were under general anesthesia; the anesthe- sia should be complete when the patient is brought to the surgeon, and there should be no more ques- tion of it during the operation.
The method does not in any way prolong the duration of the operation, nor does it leave the operative field or the incision any longer exposed to the air.
Preparation of the Field of Operation. — Before the injections are begun, the skin of the field of
Fig. 4. — A 5-mil syringe of metal and glass.
operation should be disinfected with a 5 per cent, tincture of iodine. When the injections have been completed the region should be rubbed with alco- hol, which will remove the few drops of liquid injected and the excess of iodine. Next come the final preparation of the patient, the covering of the operative field, and the preparation of the operator and his assistant — during which time the tissues will have become completely anesthetized.
The Injections. — The syringe (Fig. 4) is held with the thumb and the second and third fingers
20 REGIONAL ANESTHESIA.
of the right hand (Fig. 5). By virtue of the flexibility of the operator's wrist, all pressure other than that in the direct line of the needle is obviated, to avoid breaking of the needle. The latter should never be inserted down to its flange.
Fig. 5. — Shows the manner of holding the syringe during injection. (Reclus.)
The plunger should be pushed home during the introduction or the removal of the needle, the two acts being simultaneous (continuous injection of Reclus}. The minimum quantity of */2 per cent, solution to be injected is i mil per centimeter of distance; for the I per cent, solution, slightly less.
ARMAMENTARIUM. 21
The slight edema resulting from the subcutane- ous injection raises the overlying skin, and the region injected, rendered ischemic by the adrenin, becomes definitely pale.
Difficulties arising from edema of the super- ficial tissues may be obviated by commencing with deep injections.
Skin JJ7Jicals. — In infiltrating a given region, it is often necessarv to make successive injections
Fig. 6. — Formation of the dermal wheal. (Pauchet.) The bevel of the needle point is directed upward and should dis- appear entirely in the dermis before the intradermal injection is made.
with needles chosen progressively longer. Again it is indispensable to mark beforehand the sites for these injections by the formation of "infra- dermal wheats" which will render the skin insen- sitive to the introduction of the needle. The wheal consists essentially of an intradermal infil- tration of small diameter (Fig. 6).
A fine, short needle mounted on a syringe filled with y2 per cent, solution is introduced almost parallel with the skin surface, with the bevelled
22 REGIONAL ANESTHESIA.
edge upward, directly into the thickness of the skin. As soon as the opening of the needle has disappeared, the plunger is pushed down to drive in a little of the solution. A white swelling in- stantly forms in the tissues, which take on the aspect of "orange skin." One or more wheals, ac- cording to requirements, are thus marked out, and through them the needles are subsequently intro- duced for all the necessary injections.
Each injection should be made into the skin proper, without passage through into the subcu- taneous cellular tissue, which is made evident by disappearance of resistance to the needle. If the skin of the region is delicate and movable, a fold of it should be taken up between the left thumb and index finger and the needle introduced at the top of this fold, meanwhile firmly held. The pain is very slight and evanescent, disappearing as soon as the anesthetic solution has been injected.
Injection at Right Angles. — When it is neces- sary to make an incision at right angles, as for blood transfusion, the intradermal injections of Reclus are superfluous, subcutaneous injection be- ing sufficient to anesthetize the subcutaneous tis- sue. An intradermal \vheal is made at one end of the incision; then, with a syringe provided with a long needle, an injection is made through the wheal, under the skin, the needle being inserted parallel to the surface in the subcutaneous tissues to the full length of the proposed incision or the distance that the needle permits. Inadvertent emergence of the point of the needle from within
ARM AMEXTARI L'M.
23
outward should be avoided, as it is more painful than entrance of the needle from without in.
Fig. 7. — Subcutaneous infiltration of a straight band of skin through two dermal wheals at either extremity. (Reclns.) A needle traverses the dermal wheals without pain when the in- jection is made slowly. One mil of procaine-adrenin solution to each centimeter of distance. The illustration presents both a front and a side view, with curved or angular incisions.
After a few minutes the skin covering the in- jected tissue will have become insensible, the solu- tion having anesthetized not only the subcutaneous
Fig. 8. — (A) The injections can be made through 2 wheals or 1 wheal. (B) Continuous line of injections, as indicated by the directions of the arrows. (Pauchet.)
tissue, but also the nerve filaments of the adjacent
skin. This is the simplest form of local anesthesia.
If one injection or one needle-length is not
sufficient, one should make two wheals, one at
24
REGIONAL ANESTHESIA.
each extremity of the proposed incision — or as many as may be required — and infiltrate from the
Fig. 9. — Injections surrounding a field of operation. (Rec- lus.~) The 6 wheals are united by bands of infiltration as in- dicated by the arrows.
two ends (Fig. 7). Curved incisions or injections at right angles require an injection at the summit of the curve or angle, or two injections (Fig. 8).
Fig. 10. — Shows the method of infiltrating the curved sur- face of the forearm through 4 dermal wheals, each wheal be- ing placed at the summit of the curve. (Pauchet.) The injections are made in the directions shown by the arrows.
The curvature of the body surface prevents the penetration of a needle at right angles into the
ARMAMENTARIUM. 25
skin at a single injection. Thus, in injecting the subcutaneous tissues around the forearm, four wheals through each of which the needles are entered from both sides (Figs. 9 and 10) are required.
Infiltration of a subcutaneous band perpendicu- lar to the axis of the limb anesthetizes not only the skin immediately covering the injected tissue,
Fig. 11. — Infiltration of a subcutaneous surface by injec- tions radiating from dermal wheals 1 and 2 (for the removal of skin grafts, excision of a chancroid, etc.). (Pauchct.*)
but also all the subcutaneous tissues situated dis- tally to the injected region (circular anesthesia). Surface Infiltration. — This consists in the in- filtration of an area of subcutaneous tissue by I, 2, or more wheals. Through each of these points a long needle is introduced in all directions, anes- thetizing the whole of the cutaneous surface bounded by the wheals. This procedure is serviceable for the preparation of Thiersch skin grafts (Fig. n).
26 REGIONAL ANESTHESIA.
For the removal of skin tumors, subcutaneous infiltration of the base of the neoplasm suffices, without injection of the tumor itself (Fig. 12).
Anesthesia of Silicons Membranes. — The same directions hold good in the case of mucous mem- branes, but the wheals are unnecessary. One simply makes a sub-membranous injection, which renders the adjacent area of mucous membrane insensible.
Circular Injections. — In certain parts of the body the sensory nerves of the skin and of the
Fig. 12. — Infiltration of the pedicle of a skin tumor (molluscum). (Pauchet.)
fascia are continuous. Large portions of the body surface do not have special nerves from the sub- aponeurotic region. Hence it is not ahvays neces- sary, in anesthetizing the skin and subcutaneous tissues, to inject the cellular tissue; in many in- stances a subcutaneous injection surrounding the latter suffices. This is what is termed circular injection (Fig. 13). At I and 2, two injections are made; the subcutaneous tissue is infiltrated from i to 3, i to 4, 2 to 3, and finally from 2 to 4, so that the operative field is surrounded by
ARMAMENTARIUM.
27
a subcutaneous wall of infiltration in the form of an elongated lozenge. The long diameter of the lozenge-shaped area corresponds to the direction of the incision to he subsequently made. Injec- tions may instead be made at 3 and 4, if it is more
Fig. 13. — Subcutaneous quadrilateral infiltration through 1 and 2, in the shape of a lozenge, 1, 2, 3, and 4, following the direction of the arrows. (Reclus.)
convenient. The wall surrounding the operative field may, as desired, be made in the shape of a square, circle, etc. The number of wrheals to be prepared for the injections depends upon the shape and dimensions of the operative field (Fig. 9). In some parts of the body, the sensory nerves
28
REGIONAL ANESTHESIA.
run a prolonged subcutaneous course, supplying both the surface and the deep tissues. As regards the upper part of the head, the sensory nerves of the skin, pericranium, periosteum, and bones all course through the subcutaneous tissue at the level of the base of the cranium and forehead.
Fig. 14. — Anesthesia for tapping, as in ascites or pleurisy, or for the introduction of a radium tube into a tumor. (Reclus.)
Consequently a simple circular subcutaneous injec- tion will desensitize large areas on the head, in- cluding the bones. Anesthesia of a finger is in- stituted on the same principle. The subcutaneous tissue of the first phalanx contains all the nerves of the finger. If a ring be injected around the base of the finger, the entire finger will be desen- sitized.
ARMAMENTARIUM. 29
Deep Infiltration. — Simple circular subcutaneous injections are adequate only in parts of the body in which the nerve supply is disposed as in the parts above mentioned. They are not adequate when the nerve supply is deeply seated. Thus, on the chin, circular injection of an operative field in the center of which emerges the mental nerve would yield only an incomplete anesthesia. One of the primary essentials in inducing regional anesthesia is a systematic infiltration of any thick bed of tissue composed of different layers. An example of such anesthesia in its simplest form is that of the line of puncture in ascites or pleural effusion (Fig. 14).
The point of the injection is marked by a wheal, a needle of a convenient length inserted, and an injection made without interruption down to the subpleural or subperitoneal tissues. The pleural and the peritoneal nerves require separate infiltration because they course in the subpleural or subperitoneal tissues.
Infiltration by Layers. — A systematic infiltra- tion of a mass of tissues is that which will act upon all the layers of tissue therein contained (Fig. 15). One should begin with deep injections and finish with subcutaneous ones. The needle, through a wheal, is inserted in a perpendicular direction to the deepest point. It is then brought up to the subcutaneous tissue and inserted again, injecting obliquely toward the middle of the tis- sue-mass to be infiltrated, and so on. The last injection is made in a parallel direction under the
30
REGIONAL ANESTHESIA.
skin. The fluid is injected continuously during the introduction and withdrawal of the needle. If the length of the needle will allow, a single wheal at one extremity or in the middle suffices.
At no point in the body are subperiosteal in- jections necessary for desensitization of the perios- teum, which receives its nerves from without and becomes desensitized through the influence of the fluid in the tissues which cover it.
Fig. 15. — Osteotomy of the femur. (Pauchet.) Anesthesia of the diaphysis. Make two wheals, 1 and 2. From these two points make the injections above and below as shown by the arrows, forming a liquid sheath round the periosteum. If the ears of the patient be stopped with cotton, one may saw or break the bone without causing him pain or nervous dis- turbance.
Infiltration of thick masses of tissues, as just described, demands a certain amount of practice. One must learn to feel with the point of the needle. One must know at every instant which anatomical layer is being entered. The hand soon becomes accustomed to recognizing when the needle-, point is traversing a resistant layer and when it again passes into a layer of soft tissues. Injec- tion through the muscular aponeuroses generally causes slight pain. Therefore, one should inject
ARMAMENTARIUM. 31
the fluid progressively as the needle is being in- troduced, following the method of Reclus. By this procedure injection of a large amount of the anesthetic into a vein is obviated, while at the same time, continuous injection insures an equal distribution of the solution. When an injection
Fig. 16. — Infiltration of a layer of soft tissue through der- mal wheals 1 and 2. (Pau-chet.) The injections follow the direction of the arrows down to the bone, the last made being those entering the subcutaneous cellular tissue.
in the proximity of large vessels is required, it is best to introduce the needle independently of the syringe and to inject the fluid only if blood fails to flow from the needle lumen. Puncture of a large artery or vein, is, of course, to be avoided, but it is altogether free of danger if fine needles are employed.
Injection of a small area suffices whenever a simple incision in healthy tissue is alone required,
32
REGIONAL ANESTHESIA.
e.g., for the extraction of a foreign body from a definitely known situation.
Regional anesthesia likewise permits of secur- ing insensibility of large fields of operation.
Often infiltration of a single locality will des- troy sensation in most of the nerves leading to the field of operation. This is the case, e.g., in operations at the front of the neck, or for the cure of femoral or insTtinal hernia. At other
Fig. 17. — Pyramidal injections. (Pauchet.) Through the dermal wheals 1, 2, 3, and 4, one may painlessly infiltrate four triangular layers, union of which isolates a pyramid of anes- thetized tissue. (Removal of a shell fragment, etc.)
times, one must infiltrate simultaneously all the layers surrounding the operative field.
The technique will be readily understood upon inspection of a few diagrams.
Fig. 1 6 represents a pyramid. Its summit, 5, is deeply situated beneath the center of the opera- tive field, while its base, i, 2, 3, and 4, is at the cutaneous surface. Its lateral surfaces bound the field of operation; it is these sides which require* to be injected.
Dermal wheals, I, 2, 3, and 4, are first marked out. Through each of these a long needle is
ARMAMENTARIUM. 33
introduced at first toward point 5, then toward various points situated on the lateral surfaces, e.g., from i to 7, 4 to 7, 4 to 6, 3 to 6, 3 to 9, 2 to 9, etc. The field of operation thus becomes de- sensitized without having been directly reached by
Fig. 18. — Boat-shaped infiltration through dermal wheals 1 and 2. injection of four quadrilateral surfaces, permitting the removal of a tumor or foreign body. (Pauchet.)
the anesthetic. Often two surface injections suf- fice to encompass the area perfectly. In other cases more than four are required, and the de- signs for injection assume, according to the ex- tent of the operative field, many varied forms: cone, base of a cone, a boat-shaped solid, etc. In Fig. 17 there are two points of entrance, viz.,
34 REGIONAL ANESTHESIA.
I and 2, through which one injects toward 3, 4, 5, 6, and /, and finally infiltrates the subcutaneous tissue. Fig. 18 shows a field of operation on a limb; by the type of anesthesia depicted the bone may be desensitized. For all these injections a ^ per cent, solution is used. A more concentrated solution, from i per cent, to 4 per cent., injected in small amounts, is preferable wdierever large quantities of liquid wrould lead to difficulty or dis- comfort, as in the orbit, eyelids, foreskin (circum- cision), fingers, etc.
Small amounts of these concentrated solutions oftentimes exert a prolonged effect. Injection of a small quantity of anesthetic may affect not only the region injected but also the trunk of a nerve supplying surfaces at a distance.
Perineural or Endoneural Injection by the Sub- cutaneous Route. — Anesthesia of a large nerve- trunk is often combined with peripheral infiltra- tion, and is governed by certain definite principles. In the first place, the point of the needle must be brought in contact with the nerve. This is readily done whenever the nerve is situated near a bone constituting a landmark, as in the case of the ulnar nerve, but is more difficult when such landmarks are absent and when the nerve is sit- uated in the midst of soft tissues. One of the most reliable indications of the needle reaching the nerve is afforded by a paresthesia radiating toward the- periphery. The sharp pain referred in the direction of the nerve distribution demon- strates the contact of the needle with the nerve.
ARMAMENTARIUM. 35
The patient should therefore be told of this be- fore the needle is introduced and should let the operator know as soon as the paresthesia is ex- perienced.
For the injection of large nerves it is well to use from I to 5 mils of a concentrated solution, 2 to 4 per cent., of procaine-adrenin.
The length of time one must wait after having made the injection depends upon the manner in which the nerve has been reached. If the needle has been introduced into the nerve root, as occurs in the case of the fifth nerve, abolition of sensa- tion is instantaneous. If the anesthetic has merely been injected around the nerve trunk, 5 to 20 minutes elapse before complete insensibility is established.
Direct Endoneural Injection. — Exposed nerve- trunks may be desensitized by the injection of a little 4 per cent, solution — viz., I ampoule — using a 3-centimeter needle. This procedure is very satisfactory for operations on nerves. The opera- tor begins by incising the layers of tissues cover- ing the nerve, as these have already been injected with procaine-adrenin. When the nerve has been located beneath the incision, he injects directly into the trunk the contents of a 2-mil ampoule of the 4 per cent, solution.
Choice of Procedure. — The nature of the af- fection to be operated for — wound, removal of foreign body or of an inflammatory or neoplastic tumor — governs the form of the injection, and one must always be careful to desensitize a large
36 REGIONAL ANESTHESIA.
enough area in order to be prepared for all event- ualities and have a certain degree of latitude dur- ing the operation. One should avoid injecting the line of incision, and keep always at a certain distance from diseased tissues, particularly if in- fected. A well defined furuncle should be en- circled by an injection in the form of a pyramid, at quite a distance from the inflamed tissues. Diffuse phlegmons lend themselves to local anes- thesia only if it is possible to desensitize them at a distance from the field of operation. Malig- nancy of a tumor is no contraindication to regional anesthesia if the entire field can be desensitized without an injection in contact with the tumor. One must not forget the temporary ischemia which adrenin produces in the infiltrated area. This ischemia is often an advantage, as it reduces hemorrhage to the point of totally changing the aspect of certain operations, such as those for hemorrhoids, resection of the superior maxillary or of the tongue, laryngectomy, etc. But in plas- tic operations one must be careful not to ischemize the base of the flap to be turned back, as this would compromise its vitality.
For plastic operations of the face, strong solu- tions of procaine without adrenin should be used; the solution runs out with the blood, and the anes- thesia need not last long, as these operations are always of short duration.
CHAPTER III. CRANIAL OPERATIONS.
THE sensory nerves supplying the skin of the forehead, the temples, and the scalp, all pass at the level of a line encircling the skull from the eyelids to the external occipital protuberance (Fig. 19). From there, they branch to the summit of
Fig. 19. — Nerve supply of the scalp. (Hirschfeld.) Injec- tion of a 1 per cent, solution of procaine-adrenin on a line completely surrounding the head above the ears and eyebrows completely desensitizes the nerve supply to the scalp.
the cranium, where they spread out under the skin and the cranial aponeurosis. It is therefore very easy to anesthetize the entire cranium by a circular injection at this line. The nerves re-
(37)
38
REGIONAL ANESTHESIA.
ferred to supply not only the skin and pericranium, but also the bones of the summit of the cranium and their periosteum. The dura mater is not sen- sitive to pain except below the base of the skull; therefore operations upon the summit are painless.
Fig. 20. — Tumor of the scalp. (Pauchet.) Whether the condition be a wen, a lipoma, or a sarcoma of the cranium, infiltration of the epicranium induces complete anesthesia. The illustration shows a lozenge-shaped injection circumscrib- ing the tumor through dermal wheals in accordance with the direction of the arrows.
A simple circular injection under the skin suffices for trephining and operations on the brain.
Where muscles, however, cover the cranial bones at the line of injection, they must be in- jected. A band of infiltration, starting in front ' from the "eyelids, extending to the occiput, and passing above the arch of the ear, will desensi- tize the entire cranium above this line. It is not
CRANIAL OPERATIOXS.
39
necessary to make a subperiosteal injection. The band of anesthesia just mentioned possesses an- other advantage: The cranial arteries ascend, like the nerves, spreading out toward the summit under the epicranium or, as in the case of the
Fig. 21. — Craniectomy for sarcoma. (Braun.) The frontal portion of the infiltration is designed to abolish sensibility of the anastomoses between the frontal and parietal nerves.
temporal arteries, in the muscles. Adrenin con- tracts them, rendering the operative field relatively bloodless, and the various methods for arresting hemorrhage superfluous. At times the large ar- teries bleed a little and must be clamped; the small arteries do not bleed. For small fields of op- eration a y?. per cent, solution suffices; for large fields, rich in vessels, a i per cent, will yield a better hemostasis.
40
REGIONAL ANESTHESIA.
Starting from two wheals which correspond, re- spectively, to the extremities of the intended incision, one injects in a lozenge or quadrilateral form 10 to 20 mils of a y2 per cent, solution (Figs. 20, 21, 22).
Fig. 22. — Anesthesia for trephining. (Pauchet.) Observe the crucial incision. A, the wound. B, dermal wheals. P, a zone of infiltration 1 centimeter in width surrounding the wound, as shown by the dotted line down to the bone. This yields perfect anesthesia and ischemia.
TREATMENT OF LARGE WOUNDS IN THE SOFT
TISSUES, OR OF COMPOUND FRACTURES,
OF THE SKULL.
Several wheals are made around the wound — as in Fig.- 23, in which there are seven — suffi- ciently close together for the curvature of the skull to permit of the needle going under the epicran-
CRANIAL OPERATIONS.
41
ium. With a I per cent, solution, a narrow band of infiltration, circumscribing the field of operation according to the line indicated, is now traced in the soft, subaponeurotic tissues. Along a distance of 5 centimeters, about 5 mils of solution should be injected.
Fig. 23. — Anesthesia of the epicranium around a wound (Pauchet.') This can be practised in all operations upon the cranium for war wounds (bone and soft tissues) through as many dermal wheals as may be necessary to surround com- pletely the territory with a zone of infiltration, made with a 1 per cent, solution.
The peripheral line of injection should be far enough removed from the wound to permit of all necessary excision or enlargement for perfect re- pair, for any pedicle required or for a dissection necessary for plastic repair. Only a few moments are required for complete anesthesia.
In their ambulance on the western fighting front, in September, 1914, Pauchet and Laboure
42
REGIONAL ANESTHESIA.
trephined a case for hemiplegia, under local anes- thesia, with the patient in the sitting position. After the completion of the operation the patient walked to the railway station, assisted by a fel- low-soldier.
REMOVAL OF MALIGNANT TUMORS OF THE CRANIUM, WITH BONE RESECTION.
The surgeon required to remove a tumor ad- herent to the skull should at the same time re- move the skin covering the tumor and a rather
Fig. 24. — Repair of a craniectomy. (Braun.) Shows a flap to be re-applied as covering to the bony surface excised. It is well to cover the opening over the brain with a layer of fascia lata to replace the dura mater and prevent adhesions of the skin to the deeper surfaces. Skin grafts may be used to cover the denuded occipital zone when new tissue has grown over the skull. The opening in the skull should be reinforced with a chondrocostal piece or a gold plate. All this may be perfectly done under local anesthesia.
CRANIAL OPERATIONS. 43
large section of bone. The operation will be pain- less, since the dura mater, together with all the other local tissues, are insensitive. The anesthesia should be instituted as already indicated, viz., on a line extending from the eyes to the occipital protuberance, the line of the hat band.
Equally good results are obtained in the case of a sarcoma originating in the periosteum and adhering to the skin. The surgeon is enabled to remove painlessly the skin, pericranium, perios- teum, bone tissues, and dura mater. The brain surface should under these conditions be recovered with skin. The liberation of an area of skin pos- teriorly for this purpose may likewise be effected without pain.
TREPHINING THE TEMPORAL REGION.
Regional anesthesia permits of removal of epidural hematomas of the inferior meninges, craniectomy for decompression (Babinski), and re- moval of bone fragments and foreign bodies. The dura mater near the base of the cranium is sen- sitive, but only moderately so.
Fig. 25 shows how to place the wheals, and the form of the injection, for the dissection of a temporal osteocutaneous flap.
One is in the middle of the superior border of the zygoma; at this point one injects subcuta- neously a ^2 or I per cent, solution. There is also to be infiltrated a layer of temporal muscle as shown in the diagrammatic Fig. 26, represent-
44
REGIONAL ANESTHESIA.
Fig. 25. — Trephining the temporal region for decompression, (Pauchet.) The horse-shoe-shaped flap comprises the skin, the temporal muscle, and the periosteum. The illustration shows the surrounding band of anesthesia induced through six dermal wheals. The lower side of the pentagon, wheals 1, 2, and 6, should be infiltrated down to the bone with a 1 per cent, solution of procaine-adrenin ; the other sides, with a Yz per cent, solution.
Fig. 26. — Anesthesia of the base of the pentagon (Fig. 25) for trephining the temporal region. (Pauchet.) The fan- shaped infiltration follows the direction of the arrows. Ar- rows 1 and 2 pierce the temporal muscle and reach the bone; arrow 3 infiltrates the subcutaneous tissue.
CRANIAL OPERATIONS.
45
ing a horizontal incision parallel to the superior border of the zygoma through the skin, temporal
Fig. 27. — Photograph of a craniectomy made in the service of Dr. Babinski. (Pauchet.) The musculo-cutaneous flap is held by two clamps ; note that the operation is practically bloodless on account of the adrenin contained in the solution injected. The dura mater is not opened.
muscle and temporal bone. The needle is first introduced through wheal i, perpendicularly from the surface down to the bone (arrow i)
46 REGIONAL ANESTHESIA.
then obliquely toward the anterior and posterior margins of the temporal muscle, again down to the bone (arrow 2) and following a horizontal plane, and finally even more obliquely in the sub- cutaneous tissue (arrow 3), from 2 to 6. To in- filtrate this layer, about 30 mils is required; to circumscribe the field of operation, about 30 mils more; in all, about 60 mils of procaine-adrenin solution.
Removal of the Gasserian ganglion would be practicable by this method, but at the present time injection of the branches of the 5th nerve at their emergence from the ganglion, and their destruc- tion by alcohol, is preferred.
EXPOSURE OF THE CEREBELLUM.
In 1912 we suggested to Thierry de Martel the following technique, which this skillful opera- tor was the first to apply in tumor of the cere- bellum with complete success. Fig. 28 shows the situation of the wheals and the shape of the in- cision for exposing the cerebellar hemispheres. It is best not to depart from this tracing, even if one has decided not to touch more than half of the cerebellum. Points 3 and 9 are placed just behind the base of the mastoid. From these two points, as from i, 2, and 10, the necessary injec- tions are made in the muscles of the neck. Next, the muscular layer outlined by the points of in- jection is impregnated with a solution of procaine- adrenin along the line shown. In the flap itself
CRANIAL OPERATIONS.
47
no injection is made. This illustration, taken in conjunction with that for temporal injection (Fig. 26), defines the path of the needle. The point should penetrate to the transverse processes of the cervical vertebrae and down to the occiput. Union of the successive injections by subcutaneous injec-
Fig. 28. — Trephining for a tumor of the cerebellum. (Pauchet.) The 10 dermal wheals in the form of a trapezium surround the field of operation with a zone of infiltration. The proposed flap is shown by the dark line in the shape of a horse-shoe.
tions follows; 100 to 120 mils of solution are used, over half of which goes into the muscles of the neck. Thierry de Martel operated with his patient sitting astride a chair, with the arms rest- ing on its back, and his head resting on his arms. The dura mater of the posterior cerebral fossae and the cerebellum are insensitive to pain.
CHAPTER IV. ANESTHESIA OF THE HEAD AND NECK.
THE surgery of the head and the neck is of interest both to general operators and, particu- larly, to three classes of specialists, the ophthal- mologist, the otorhinolaryngologist, and the stom- atologist.
In these regions the sensory supply is fur- nished by the fifth nerve and the cervical plexus. The fifth nerve is predominant in the face. As several branches often combine in supplying sen- sation to a single region, it is sometimes neces- sary in these tissues to combine root or trunk anesthesia with peripheral infiltration. Or, it may be necessary to combine root anesthesia with anes- thesia of the neighboring regions.
We shall first consider synthetically the subject of anesthesia of the nerve roots and nerve branches, and then describe the technique for each operation involved in the three specialties mentioned.
ANESTHESIA OF THE GASSERIAN GANGLION.
The ganglion of the fifth nerve is intracranial. It rests upon the summit of the petrous portion of the temporal bone (Fig. 29) in a fold of the dura mater just above and behind the foramen ovale, and in the immediate neighborhood of a (48)
ANESTHESIA OF THE HEAD AND NECK. 49
venous sinus and of the motor nerves of the eye (fourth and sixth). It has three branches: the ophthalmic, the superior maxillary, and the in- ferior maxillary. The ganglion is accessible through the foramen ovale, an orifice measuring y2 centi- meter by 2 or 3 millimeters. This foramen is situated on the floor of the cranium immediately
Fig. 29. — The ganglion of Gasser. (Hvrschfeld.) It rests upon the summit of the petrous portion of the temporal bone. From above downward the illustration shows the origin of the ophthalmic nerve and of the superior and inferior maxil- lary nerves.
behind the base of the pterygoid process. It cor- responds, for the superior maxillary, to the outer side of the last two molars in the sagittal region. It is located at a depth of 45 millimeters from the zygoma.
Indications for Gasserian anesthesia are two in number :
A. Surgical operations on the face.
50
REGIONAL ANESTHESIA.
B. Alcoholization of the nerve to combat per- sistent neuralgia (Sicard).
The anesthetist should bear in mind the fol- lowing precepts :
Fig. 30. — Injection of the Gasserian ganglion through the foramen ovale. (Braun.) (1) The needle represented by the dotted lines is introduced 3 centimeters from the commissure of the lips, in the direction of the zygomatic arch, until it reaches the subtemporal region between the two maxillary bones. (2) The black line needle shows the shank raised and the needle directed toward the zygomatic tubercle. Being kept in contact with the bone, it reaches the foramen ovale, com- ing in contact with the fifth nerve, in the terminal branches of which it provokes pain.
1 I ) Use a fine, sharp, flexible, but strong needle.
(2) Inject slowly.
(3) Employ a concentrated solution in small quantities, viz., i to 2 mils of a 2 or 4 per cent, solution of procaine-adrenin.
ANESTHESIA OF THE HEAD AXD XECK.
51
In spite of these precautions, vertigo, vomiting and even symptoms of meningitis are sometimes observed. These post-anesthetic disturbances do
Fig. 31. — Injection of the Gasserian ganglion (Braun.) The patient should sit erect, looking directly forward. The surgeon introduces the needle through the cheek 3 centimeters from the labial commissure, so directing it that it remains in the plane of the subject's pupil. The index ringer of the left hand is introduced into the patient's mouth to make certain that the needle shall not pierce the mucous membrane. The needle should be directed between the inferior maxillary and the tuberosity of the superior maxillary.
not detract from the value of the procedure be- cause the method of anesthesia under discussion is employed for serious operations on the face, or obstinate neuralgia of the fifth nerve, which war- rant its application.
52 REGIONAL ANESTHESIA.
Technique of the Injection. — The patient may be in the lying or sitting position. Injection is easier on a sitting subject, the operator standing or sitting in front of the patient. A needle 9 centimeters in length should be selected.
The landmarks include some that are appre-
Fig. 32. — Injection of the Gasserian ganglion. (Braun). The same maneuver as in the preceding illustration. The needle is first directed at the middle of the zygomatic arch. As soon as the point touches the bone of the subtemporal region, the shank is raised so that the point is directed at the zygomatic tubercle. Being then pushed forward about 1 centimeter, it will penetrate the foramen ovale.
ciable to sight or palpation and others which are found by the point of the needle as it is introduced.
(1) When the subject looks straight to the front the pupil of the eye supplies the direction of the frontal plane in which the needle must be directed.
(2) The labial fissure.
(3) The second upper molar.
ANESTHESIA OF THE HEAD AXD XECK.
53
(4) The ascending- ramus of the inferior maxillary, the inner surface of which may be felt by introducing the index finger into the mouth.
(5) The tuberosity of the superior maxillary.
(6) The bone in the subtemporal region; the needle, when correctly directed, will strike against
Fig. 33. — The sensory nerve supply of the face and neck. (Hirschfeld.) (1) Ophthalmic. (2) Superior maxillary. (3) Inferior maxillary. (4) Cervical plexus (anterior branches).
this resistant surface, which is situated in front of the foramen ovale.
(7) The middle of the zygomatic arch and the tubercle of the zygoma; the tubercle indicates the point at which the needle must be directed in order to enter the foramen; the middle of the arch indicates the bony region anterior to the foramen against which the needle must strike be- fore penetrating the foramen (Figs. 30, 31, 32).
54
REGIONAL ANESTHESIA.
The cheek is pierced 3 centimeters beyond the labial fissure, on a line with the lobe of the ear. The needle is inserted with one hand. With the index finger of the other in the mouth, the second
Fig. 34. — Removal of a cancer from the velum palati and left tonsil by transverse incision of the cheek and resection of the ascending ramus of the inferior maxillary bone after anesthesia of the Gasserian ganglion. (Pauchet.} The photograph shows the loosening of the upper fragment of the inferior maxillary, operated upon by Pauchet and Sourdat.
superior molar and the tuberosity of the superior maxillary are located within, and the ascending ramus of the mandible without. The needle is
ANESTHESIA OF THE HEAD AND NECK. 55
to pass in the interval bounded by these bones ;
the finger in the mouth follows the needle point
under the mucous membrane and prevents it from perforating the latter.
Fig. 35. — The wound is held open after the resection of the maxillary has been completed. (Pauchet.)
One next aims at the subtemporal region to strike the bony surface already mentioned. The needle should be directed somewhat obliquely in- ward, i.e., in the line of the pupil when the sub- ject is looking straight ahead. It should be also slightly oblique upward, i.e., should virtually pass through the middle of the zygoma, — \vhich can be
56
REGIONAL ANESTHESIA.
controlled by surveying the patient in profile. Its point should be behind the second upper molar. Thus directed, the needle enters the subtemporal region, which marks the end of the first stage of
Fig. 36. — The tonsillar space is tamponed after the resec- tion of a part of the pharynx and of the tongue. The borders of the incised cheek are retracted, showing the extent of the wound. The tongue is drawn out with the aid of a cord held by the assistant.
the injection. Care should be taken to do all this very slowly, in order not to blunt the point of the needle by contact with the bone.
Then the* point is disengaged and, slightly raising the shank but still remaining in the plane of the pupil, the point is advanced about I centi-
ANESTHESIA OF THE HEAD AND NECK. 57
meter, gliding along the surface of the subtem- poral bone. In profile one aims this time for the tubercle of the zygoma. Resistance ceases as the needle enters the foramen ovale. A tense membrane is traversed about 7 centimeters be- neath the skin. When the patient notices radiat- ing pains at first in the superior maxillary nerve, entrance into the ganglion is indicated. One should then inject i to il/2 mils of a 2 per cent, procaine-adrenin, very slowly and gently pushing the needle in another y2 centimeter.
By the same route, but without entering the foramen ovale, one may reach the inferior maxil- lary nerve as it emerges from this foramen and limit the injection to it. It is difficult clearly to describe this procedure in words, and we have therefore attempted to supplement the explanation and more fully guide the operator by the several appended cuts.
ANESTHESIA OF THE OPHTHALMIC NERVE.
The frontal, internal and external nasal, and lachrymal nerves separate from the origin of the ophthalmic immediately before it enters the orbit. The ophthalmic is fan-shaped and is situated be- tween the bony plate and the muscular cone of the orbit; the injection must, therefore, be made between these two. The frontal and lachrymal nerves are situated externally and emerge through the superior orbital fissure. They are reached along the external wall of the orbit.
58
REGIONAL ANESTHESIA.
Fig. 37. — The ophthalmic nerve and its branches. (Testut.) (1) Ophthalmic. (2) Nasal. (3) Lachrymal. (4) Frontal. (5) External nasal. (6) Internal frontal. (7) Ethmoidal.
Fig. 38. — Base of the orbit. (Testut.) Zinn's ring, where the motor muscles of the eye are attached. On the left is seen the sphenoidal fissure in the center of Zinn's ring. The nasal nerve and ophthalmic vein are in the ring. The frontal, lachrymal, and pathetic nerves are in the sphenoidal fissure.
ANESTHESIA OF THE HEAD AXD XECK. 59
The nasal nerves occupy the upper internal angle of the orbit, and are infiltrated at that point.
The frontal nerves supply sensation to a tri- angular area of integument with its base cor- responding to the entire frontal region above the
Fig. 39. — Supraorbital branches of the ophthalmic nerve. (Hirschfeld.) To anesthetize these branches, inject parallel to the superior border of the orbit.
root of the nose and its apex at the scalp (Fig. 40). They also sensitize the frontal sinuses and the upper eyelids. The nasal nerves supply the frontal, ethmoidal, and sphenoidal sinuses, the nasal septum, and the nasal lobes.
Injections may be made from three points, ac- cording to the operation required.
60
REGIONAL ANESTHESIA.
(a) Frontal Infiltration. — The operator injects under the skin 10 mils of a i per cent, procaine- adrenin, commencing above the external orbital apophysis and ending above the corresponding apophysis on the opposite side. The line of in- jection is shown by the black line in Fig. 40.
\
Fig. 40. — Injections along the black line anesthetize the ophthalmic branches of the fifth nerve and render insensible a triangular area. (Pauchet and Sonrdat.)
(b) External Orbital Infiltration. — This blocks the frontal and lachrymal nerves.
The needle is introduced at the external angle and the outer wall of the orbit followed with its point. At a depth of about 4^2 centimeters the needle point will come in contact with bone, the
ANESTHESIA OF THE HEAD AND XECK.
61
orbital vault, and will have passed into the exter- nal portion of the sphenoidal fissure, where are sit- uated the frontal and lachrymal nerves. Five mils of the 2 per cent, solution are now injected, and the resulting anesthesia will be complete (Figs. 41, 42).
Fig. 41. — Intraorbital injections for infiltration of the ophthalmic branches. (Braun.) To the left, an external in- jection, which keeps in contact with the external orbital wall. At a depth of 4 centimeters the needle point strikes the orbital vault. It now crosses the extremity of the sphenoidal fissure, along which pass the lachrymal and nasal nerves. A 1 per cent, solution of procaine-adrenin is injected.
To the right, an internal injection. The needle follows the superointernal angle of the orbit, constantly in contact with the bone and grazing the ethmoidal foramen. At a depth of 4 centimeters it comes in contact with the orbital vault. The solution is injected while the needle is being introduced.
(c) Internal Orbital Infiltration. — At an equal distance from the eyebrow and the caruncle, i.e., i centimeter above the internal commissure of the eyelids, the needle is introduced against the supe- rior internal angle of the bony wall, which should
62
REGIONAL ANESTHESIA.
be continuously followed. At a depth of 4 or at most 4^/2 centimeters, 5 mils of a 2 per cent, solu- tion are injected (Figs. 41, 42).
This last injection anesthetizes the nasal wall and the ethmoidal, sphenoidal, and frontal sinuses, as well as the lobe of the nose. It induces
Fig. 42. — Anesthesia of the ophthalmic branches by the orbital route: (1) External. (2) Internal. (Pauchet.) The dotted line shows the shape and extent of the orbital orifice. Needle 1 is entered at the extreme angle of the commis- sure of the eyelids. It follows the bony wall and stops only when it comes in contact with the orbital vault, where it crosses the sphenoidal fissure (see Fig. 41). Needle 2 is entered at the superior internal border of the orbit, one finger breadth above the caruncle. The point is kept in constant contact with the superior internal angle of the bony wall to reach the ethmoid nerves.
edema of the upper lid, causes, projection of the eye-ball, and sometimes results in blindness for a few minutes. The optic nerve is not anesthetized.
ANESTHESIA OF THE HEAD AND NECK.
63
ANESTHESIA OF THE SUPERIOR MAXILLARY NERVE.
The superior maxillary passes through the foramen rotundum at the bottom of the pterygo- maxillary fissure, precisely between the tuberosity
Fig. 43. — Injection of the superior maxillary at the fora- men rotundum by the external route. (Braun.) The needle is introduced at the intersection of a vertical line drawn down- ward following the external border of the orbit and a line drawn along the inferior border of the superior maxillary bone (dotted lines).
of the superior maxillary and the base of the pterygoid process.
(a) External Route (Figs. 43, 44). — Locate the zygomatic arch with the finger; mark its lower border with ink; mark the external border of the orbit in the same manner at the point where a vertical line drawn from this external
64 REGIONAL ANESTHESIA.
border meets the zygomatic arch (just behind the lower angle of the body of the malar bone), and introduce the needle to a depth of 5 to 6 centi- meters. In this way the nerve is reached at once; but it is preferable to attain first, with the point of the needle, the body of the maxillary on its inclined surface, feeling one's way, and directing the needle deeply. Suddenly the needle will come
Fig. 44. — The needle is first directed toward the tuberosity of the maxillary bone, whence it penetrates directly about 4 centimeters and enters the pterygo-maxillary fissure. (Braun.) When the patient complains of a shooting pain in the teeth, from 3 to 4 mils of a 2 per cent, anesthetic solution are injected.
to an empty space and touch the nerve, when the patient will experience a sharp pain in the face and upper teeth. Five mils of a 2 per cent, pro- caine-adrenin solution are now injected, and while withdrawing the needle, 5 mils of a ^ per cent, solution. To cause the branches of the internal maxillary to contract, it is often necessary to have the patient open his mouth, when the needle will enter more easily (Fig. 45).
ANESTHESIA OF THE HEAD AXD XECK.
65
Fig. 45. — Anesthesia of the superior and inferior maxillary through the same orifice. (Pauchet.) The patient is made to open his mouth. The needle is introduced below the zygo- matic arch and introduced as far as the pterygoid process, then partly withdrawn and the point directed slightly forward to reach the pterygo-maxillary fissure, where it encounters the superior maxillary nerve at the foramen rotundum. Again the needle is partly withdrawn and then reinserted about 1 centi- meter further back, where it reaches the foramen ovale be- hind the root of the pterygoid process. The foramen ovale is at a depth of about 4 to 5 centimeters.
5
66
REGIONAL ANESTHESIA.
(b) Orbital Route (Figs. 46, 47). — At the junction of the external, lateral, and inferior bor- ders of the orbit, a dermal wheal is made and the
Fig. 46. — Anesthesia of the left superior maxillary nerve at the foramen rotundum by the orbital route. (Braun.) The needle, which at first is held vertically (Fig. 47), comes in contact with the floor of the orbit on a level with its in- ferior external angle. Entering deeper, it reaches a space on a level with the orbital fissure. Thence it progresses back- ward almost horizontally, following the direction of the fis- sure. At a depth of about 5 centimeters it reaches the base of the cranium and the foramen rotundum. One to 2 mils of a 2 per cent, anesthetic solution are injected.
point of the needle then introduced almost ver- tically downward. In order that it shall pass along the floor of the orbit, it should be directed
ANESTHESIA OF THE HEAD AXD XECK.
67
slightly backward.
At a depth of about I centi- meter it will traverse a fibrous layer — the fissure of the orbital floor. As soon as the needle reaches this space its flange end should be lowered so as to bring it almost horizontal, while the head of
Fig. 47. — This figure shows the manner in which the needle point is made to follow the floor of the orbit. By placing a rubber shield upon the needle, the surgeon can make the lat- ter serve as an index of depth in the procedure described in Fig. 46. (Braun.)
the patient is held quite erect. If the needle is not horizontal, it will enter the subtemporal space. Yet it should not be introduced too high up, or it will enter the eyeball. It should be directed in the plane of the fissure, i.e., in the direction of the inferior, external angle. One should always
68 REGIONAL ANESTHESIA.
feel a certain resistance at this point. At a depth of 5 centimeters, the situation of the needle will correspond to the foramen rotundum. At this point it \vill come in contact with the base of the skull. Five mils of a 2 per cent, solution of neo-
Fig. 48. — Emergence of the infraorbital nerve. (Hirsch- feld.) On the same vertical line as the supraorbital nerve, it is situated y2 centimeter below the middle of the lower border of the orbital foramen.
caine-adrenin are now injected. At times a tem- porary paralysis of the muscles of the eye, or a hematoma in the pterygomaxillary fissure, wrill ap- pear. Both these conditions are incidents devoid of serious consequences.
ANESTHESIA OF THE HEAD AND NECK. 69
ANESTHESIA OF THE INFRAORBITAL NERVE.
The infraorbital nerve, a branch of the supe- rior maxillary, is accessible through the cheek. The lower border of the orbit is marked with a dermal pencil, a line drawn from the center down- ward */2 centimeter, and a cross made. This corresponds to the point of emergence of the in- fraorbital nerve. The three apertures whence the infraorbital and mental nerves arise are on the same vertical line, and correspond to the interval between the first and second premolars (Fig. 45). A dermal wheal is made, and the subcutaneous cellular tissues infiltrated so that contact will not be painful. Then, with the needle, the infraorbita! opening is found. Coming in contact with the bone, the operator feels around while directing the needle a little higher and outward; soon he be- comes aware of a small depression and penetrates into a canal. The patient feels a sharp pain. One mil of a 2 per cent, solution is now injected. The anesthesia thus induced extends to the lower lid, the upper lip, the nasal ala, a part of the skin and mucous membrane of the cheek, the mu- cous membrane of the lips, the margins of the superior alveolar process, as well as the inferior walls of the superior maxillary and the incisor and canine teeth.
70 REGIONAL ANESTHESIA.
ANESTHESIA OF THE SUPERIOR DENTAL NERVES.
(a) Buccal Route. — The zygomatic arch is located through the mouth. When its most ante- rior point is felt, the mucous membrane is pierced and the needle introduced for a distance of i or 2 centimeters. The patient will usually feel pain in his teeth. Five mils of a 2 per cent, procaine- adrenin solution are now injected.
(b) External Route. — The zygomatic arch is located and the same route followed as that taken to reach the superior maxillary nerve. As soon as the tuberosity of the superior maxillary is at- tained, 5 mils of solution are injected. This in- jection anesthetizes the upper molars and pre- molars as well as the mucous membrane of the maxillary sinus (Fig. 29).
ANESTHESIA OF THE NERVES OF THE PALATE.
The inferior palatine nerve emerges from the posterior palatine canal above the last molar. The nasopalatine nerve arises in the anterior palatine canal, in the median line and behind the incisors. The needle is introduced anteriorly, under the mucous membrane of the palate, immediately be- hind the teeth and in the median line. One mil of a 2 per cent, procaine-adrenin solution is in- jected. Then, behind the palate, i to 1^/2 centi- meters within the second molar, or rather, within the border of the gums, 2 mils of the solution are introduced. This type of anesthesia, carried
ANESTHESIA OF THE HEAD AXD NECK.
71
Fig. 49. — To the right are shown the three palatine nerves descending toward the posterior palatine foramen. To the left, at the base of the nose, is the ethmoidal branch of the internal nasal nerve.
Fig. 50. — Anesthesia of the hard palate. (Pauchet.} In front is the nasopalatine nerve, Y? centimeter behind the middle incisors. The surgeon injects 1 mil of a 2 per cent, solution directly under the mucous membrane. Behind, the nerves emerging from the posterior foramen to the right and left, 1 centimeter within and above the last molar, 1 mil of the strong solution is injected beneath the mucous membrane.
72 REGIONAL ANESTHESIA.
out also on the opposite side, permits the surgeon, with the three points of infiltration, to operate on the mucous membrane of the hard palate and periosteum, though not on the teeth.
ANESTHESIA OF THE BUCCAL NERVE.
This nerve rests upon the tuberosity of the superior maxillary and is distributed over the mu- cous membrane of the cheek. It is accessible, like the superior dental nerve, by an injection passing along the tuberosity and following a vertical line running from the last upper molar to the last lower molar.
ANESTHESIA OF THE INFERIOR MAXILLARY NERVE.
As already pointed out, the trunk of the in- ferior maxillary nerve is accessible, at its emerg- ence from the foramen ovale, by the same route and with the same procedure as was described for infiltration of the Gasserian ganglion. To limit the injection to this trunk, it is sufficient to make the injection upon arriving at but not enter- ing the foramen ovale. The advance of the needle should be arrested as soon as the resistance of the bone ceases, indicating that the anterior bor- der of the aperture has been passed.
The following mode of procedure reaches the nerve without risk of penetrating too far, and the operator should be as familiar with it as with
ANESTHESIA OF THE HEAD AND XECK. 73
the method first described, as certain conditions may render it preferable, e.g., anatomical deformi- ties, tumors, etc.
The lower border of the zygomatic arch is traced on the skin, its exact center found, and
Fig. 51. — Anesthesia of the inferior maxillary nerve. (Braun.) The operator places a small fragment of cork upon the needle, as an index. The needle is introduced just below the center of the zygomatic arch. At a depth of 4 centimeters the point touches the pterygoid process. With the needle held firmly in position, the cork is slid down to a level with the skin. The needle is then partly withdrawn and reintroduced at an angle, so as to touch a point 1 centimeter behind the point first reached. When the index cork touches the skin, the point of the needle is near the foramen ovale and when it comes in contact with the nerve the patient feels a sharp pain in the lower jaw. Two mils of a 2 per cent, solution of pro- caine-adrenin are then injected.
a dermal wheal made at this point. A needle 6 centimeters long is now introduced transversely to a depth of 4 to 5 centimeters so that its point will strike against the pterygoid process, which is i centimeter from the foramen ovale. As a guide a thread or small piece of rubber, passed over the
74 REGIONAL ANESTHESIA.
needle before its introduction, is now fastened pre- cisely at a level with the skin. The needle is then drawn toward the operator, though not withdrawn altogether, and re-inserted to the depth marked on the needle, aiming, however, about i centimeter behind the bony obstruction (pterygoid). The earlier and later directions of the needle should
Fig. 52. — Direct injection of the inferior maxillary at the foramen ovale. (Braun.) The needle is introduced at the junction of the middle and posterior thirds of the zygomatic arch and directed inward about 5 centimeters, when it will reach the foramen ovale. If it strikes bone, the latter is the pterygoid process ; it should then be withdrawn a few centi- meters and reintroduced further back. The foramen ovale is located immediately behind the pterygoid process.
form between them an angle of 30°. As soon as the needle has reached the same depth, though somewhat posteriorly, it is pushed a few milli- meters further in, and the patient will feel a sharp pain in the tongue or the inferior maxillary. This indicate^, that the needle is in the body of the nerve (Figs. 51, 52). Five mils of a 2 per cent, procaine-adrenin solution are now injected. (See also Offerhaus's procedure, p. 98.)
ANESTHESIA OF THE HEAD AND NECK.
75
ANESTHESIA OF THE INFERIOR DENTAL NERVE
This is a large terminal branch of the inferior maxillary. It diverges at an acute angle from the lingual nerve and passes between the internal
Fig. 53. — Injection of the inferior dental nerve at the in- ferior dental foramen. (Brann.) The arrow indicates the point at which the nerve should be injected. The dotted ar- row shows the retromolar trigone. The needle should be first directed to this trigone 1 centimeter above the molar, then should follow the inner wall of the maxillary bone until its point reaches the nerve. One to 2 mils of a 2 per cent, solu- tion are then injected.
pterygoid muscle and the ascending ramus of the inferior maxillary bone until, arriving at the pos- terior orifice of the dental canal, it emerges on a level with the chin through the mental foramen.
Upon examination of an inferior maxillary bone, there will be found immediately behind the
76
REGIONAL ANESTHESIA.
last molar a triangular bony surface, limited ex- ternally by a prolongation of the coronoid process and within by a ridge of bone which, likewise de- tached from the process, passes down toward the inner side of the alveolus of the third molar.
Fig. 54. — Shows the movements imparted to the needle to reach the inferior dental foramen. (Pauchet.) The lingual nerve may be reached in the same way.
This small triangle which is normally covered with mucous membrane, serves as the principal land- mark in the introduction of the needle.
The patient is seated in front of the operator, with his mouth wide open. The index finger is passed into the mouth, the anterior border of the coronoid found, and within this border the retro-
ANESTHESIA OF THE HEAD AXD XECK.
77
molar trigone (Braun) located. A needle 9 centi- meters long is taken in the right hand, and being kept i centimeter from the inferior canine on the
Fig. 55. — First position of the needle in going for the retro- molar trigone. (Pauchet.) The needle should at first be kept in contact with the canine tooth of the opposite side until the trigone is reached. The handle of the syringe is then swung to the opposite side, so the needle is on a line with the teeth, and pushed along the border of the bone to the foramen.
opposite side, on a level with the grinding surface of the teeth, directed toward the trigone, i.e., the intra-buccal fold of the coronoid. The point of the needle penetrates the mucous membrane i centimeter above and outside of the last molar.
78
REGIONAL ANESTHESIA.
As soon as the membrane has been punctured the point strikes against bone; if not, the point is too far within. Then the operator, feeling his way, inserts the point of the needle until it reaches the ridge of the bone (Fig. 54). It should slide
Fig. 56. — Anesthesia of the inferior dental and lingual nerves on the right side. (Pauchet.) (1) Right inferior den- tal nerve. (2) Right lingual nerve. (3) Left inferior canine. The needle is directed from the left lower canine toward the anterior border of the ascending ramus of the right inferior maxillary (Position 1). It is then directed to the internal surface and introduced to a depth of about 2 centimeters (Position II).
along the inner surface of the inferior maxillary; then, without losing its contact with the bone, penetrate 2 to 2.y2 more centimeters, at which point the operator injects 5 mils of a i per cent, solution (Figs. 53, 55, and 56).
ANESTHESIA OF THE HEAD AND NECK. 79
AXESTIIESIA OF THE MENTAL NERVE.
On a vertical line passing at the same time the supra- and infra- orbital nerves and corre- sponding to the space between the two first lower molars, is to be found the mental foramen of the inferior maxillary. This is situated at equal dis- tances from the superior and inferior borders of the jaw, and below the interval between the first and second molars. After passing through the soft tissues to this point, the surgeon injects a 2 per cent, solution of procaine-adrenin.
ANESTHESIA OF THE LINGUAL NERVE.
This leaves the inferior dental nerve and branches off to the tongue, describing a curve with an antero-superior concavity. It should be borne in mind that this nerve is in the lower part of the tongue, situated very superficially beneath the mu- cous membrane.
The procedure is therefore, as follows: The tongue is held in a compress and brought for- ward toward the opposite corner of the mouth. A line of anesthesia 4 centimeters long is made in the groove formed by the tongue and gums, with a i or 2 per cent, solution of procaine-adrenin.
This nerve may also be infiltrated by proceed- ing as for the inferior dental.
80 REGIONAL ANESTHESIA.
REMARKS.
It would seem, at first sight, that in facial op- erations, anesthesia of the Gasserian ganglion should prove all sufficient. Actually this is not the case. In the first place, the severity of the Gasserian procedure justifies its employment only in serious interventions, as already pointed out. It is preferable, therefore, to anesthetize the peri- pheral trunks. Again, there exist anastomoses with the cranial nerves or writh branches of the cervical plexus, which would render the anesthesia incomplete were it confined to a single nerve trunk.
Indications for subcutaneous peripheral infiltra- tion, or for the spraying or application of cocaine to the mucous membranes, therefore, frequently exist. These various procedures, trunk anesthesia, local infiltration, and local application, are of mu- tual assistance and it is a combination of the three which . produces a practically complete anes- thesia.
REGIONAL ANESTHESIA IN RHINOLOGY.
SUBMUCOUS RESECTION OF THE CARTILAGE OF THE NASAL SEPTUM.
Tampons of a strong solution of adrenin-co- caine are applied for 10 minutes. A 2 per cent, solution of „ procaine-adrenin is injected under the mucous membrane of the septum, both on its con- vex and its concave surfaces. One should in- filtrate also, especially if the deviation is exten-
ANESTHESIA OF THE HEAD AND NECK.
81
sive, the three nerve trunks which together sensi- tize the septum, above and forward, below and forward, in the floor and behind.
HYPERTROPHY OF THE LOWER AND MIDDLE TURBINATES.
Resection of the Upper and Lower Turbinates and of Nasal Myxomas. — Tampons of cocaine which contract the mucous membrane usually suf-
Fig. 57. — (1) Ethmoidal branch of the internal nasal nerve. (2) Nasopalatine nerve which supplies the wall and emerges through the anterior palatine foramen, behind the incisors. (Panchet.}
fice. In the case of the upper turbinate, however, their use is disadvantageous because it diminishes the already small area concerned. It is prefer- able, therefore, to infiltrate the affected tissues, as this augments their volume. In the presence of numerous polypi, tamponing is tedious and some- times impossible. We therefore inject the eth- moidal, nasal, and septal nerves, thus rendering the parts anesthetic (Fig. 57).
82
REGIONAL ANESTHESIA.
MOURE'S OPERATION FOR LARGE TUMORS OF THE BRAIN.
(a) Application of cocaine tampons to the ol- factory mucosa; (b) infiltration of the ethmoidal
Fig. 58. — Operation of Moure. Resection of the ethmoid after having displaced downward the ascending branch of the superior maxillary and enlarged the anterior orifice of the bones of the nasal fossa without regard to the superior maxil- lary. (A) Infiltration of the ethmoidal nerve by the internal orbital route. (5) Infiltration of the superior maxillary nerve (see Figs. 43 and 44). (C) Emergence of the infraorbital nerve.
nerves; (c\ infiltration of the superior maxillary nerve; (d) infiltration of the infraorbital nerve; (e) infiltration of a line from the corner of the
ANESTHESIA OF THE HEAD AND NECK.
83
mouth upward, as shown in Fig. 58. Peripheral infiltration following a broken line uniting the corner of the mouth with the junction of the superior maxillary nerve and the base of the nasal lobe.
«
INJECTION OF THE MAXILLARY SINUS (Luc's OPERATION.)
(a) Tamponing the nasal cavity with gauze soaked with cocaine; (b) infiltration of the eth-
Fig. 59. — Trephining the maxillary sinus. (Laboure.) (1) Infiltration of the superior maxillary nerve at the foramen ovale (Figs. 43 and 44). (2) Anesthesia of the ethmoidal nerve by the internal orbital route (Fig. 41). The subcuta- neous infiltration is shown by the dotted lines.
moidal and superior maxillary nerves; (c) infiltra- tion through the mouth of the canine fossa and the region of the infraorbital nerve (Fig. 59).
84
REGIONAL ANESTHESIA.
INJECTION OF THE FRONTAL SINUS.
(a) Tamponing the anterior superior nasal fossa with gauze soaked with cocaine; (.&) infil- tration of the superior maxillary nerve; (c) infil-
i\
Figs. 60, 61. — Trephining the frontal sinus, one side and both sides. (Pauchet.) (1) Internal orbital injection (Fig. 41). (2) Point of injection for the superior maxillary nerve (Figs. 43 and 44). Through the several dermal wheals, the field of operation is circumscribed along the dotted lines.
tration of the ethmoidal nerves; (d) subcutaneous and preperiosteal injections surrounding the opera- tive field (Figs. 60, 61).
ANESTHESIA OF THE HEAD AND NECK. 85
OPERATIONS UPON THE SPHEXOIDAL SINUSES AND FOR SARCOMA OF THE HYPOPHYSIS.
The endonasal route is followed; submucous resection of the cartilaginous and bony septum; infiltration of both sides of the septum and of the ethmoidal nerves.
REGIONAL ANESTHESIA IN OTOLOGY. NERVE SUPPLY.
The middle ear receives its sensory supply from Jacobson's nerve, a branch of the glosso- pharyngeal, and the superficial petrosal nerve.
The tympanum and external auditory canal are supplied by two nerves, which enter, the one an- teriorly, the other posteriorly. The anterior is the auriculo-temporal nerve, a branch of the supe- rior maxillary, which supplies the antero-inferior floor of the external canal. The posterior nerve is the auricular branch of the pneumogastric. These nerves enter the canal at the union of its cartilaginous and osseous portions.
The external ear is supplied by the great auric- ular nerve, the auriculo-temporal, the lesser occip- ital, and the auricular branch of the pneumogastric.
The nerve supply of the mastoid region con- sists of the sub-occipital and the superior cervical nerves, through branches from the mastoid.
All of these nerve branches intercommunicate, and practically their respective limits are hard to define.
86
REGIONAL ANESTHESIA.
TECHNIQUE.
Anesthesia of the Middle Ear and Tympanum. -In the middle ear the nerves are superficial and sub-mucous, and can be desensitized with Bonain's solution :
I£ Cocaine hydrochloride, Menthol,
Phenol aa 1 grain.
Adrenin 0.001 grain.
Fig. 62. — Anesthesia of the auditory canal. (Labour e.) The needle is introduced at the junction of the cartilage and bone on the superior and posterior walls. When it has pene- trated 2 millimeters, a 2 per cent, solution is injected.
Upon application of this agent one may pain- lessly curette vegetations, remove a polyp, or puncture the tympanic membrane.
For more severe procedures, such as ossiculec- tomy, the external auditory canal is anesthetized by the following procedure (Neumann) (Fig. 62) :
ANESTHESIA OF THE HEAD AND NECK. 87
A large speculum is passed into the canal and inclined backward or laterally, thus bringing into view the point of junction of the cartilage with the bone. At this point, above and behind, at the junction of superior and posterior walls, a needle is inserted for 2 millimeters, a few drops of solu- tion slowly injected, and a bony contact felt for. The bone, when reached, should be followed for some distance in order to make certain of inject- ing the remainder of the solution into the sub- periosteal zone. Such an injection anesthetizes the upper portion of the tympanum, the vestibule, and the ossicles. One should wait 10 minutes before operating.
The injection just described acts in the fol- lowing manner: On a level with Schrapnel's membrane, the two epithelial linings meet, the fibrous tissue of the tympanum being wanting. An injection of fluid following the epithelium of the canal penetrates under the epithelium of the mid- dle ear on a level with the flaccid membrane and ascends under the mucous membrane that lines the vestibule, since it is at no time arrested by any barrier (Molinar1).
Anesthesia of the External Auditory Canal. — The external auditory canal is supplied by two nerves which penetrate in front and behind, at the union of the cartilaginous and bony portions of the canal. They can be reached either through the canal or from behind the auricle.
1 Adolph Molinar : "Regional Anesthesia for Operations upon the Auditory Apparatus."
88
REGIONAL ANESTHESIA.
The needle is directed backward toward the tympano-mastoid fissure in the direction of the pneumogastric. Procaine-adrenin solution is in- jected while introducing the needle. Then the latter is withdrawn I centimeter, without entirely removing it, directed downward, forward, and in- ward toward the condyle of the maxillary, and
Fig. 63. — Showing a V-shaped injection, in its relations to the bony parts.
during the course of this movement, 2 mils of procaine-adrenin solution injected to a depth of not more than 2 centimeters. After this pro- cedure, operations for furuncles or exostosis in the canal can be satisfactorily carried out (Fig. 63).
Anesthesia of the External Ear and Mastoid Region. — Encircle the external ear and mastoid region with a series of injections which cross each other in the superficial and deep tissues (Fig. 64).
It is useless to try to penetrate beneath the periosteum; its close adhesion renders this impos-
ANESTHESIA OF THE HEAD AND NECK. 89
sible. Besides, such a procedure would be un- necessary. The bone receives its nerve supply from without, i.e., from the scalp. The operator may, if he so desires, inject along the line of the proposed incision.
Fig. 64. — Anesthesia of the external ear. (Laboure.) Two wheals, superior and inferior, are made and injections executed in the direction of the arrows, describing a diamond- shaped figure about the ear.
These various forms of anesthesia, viz., the ap- plication of Bonain's mixture to the tympanum or vestibule; infiltration of the vestibule through the canal; infiltration of the auriculo-temporal nerves and the auricular branch of the pneumogastric ; peripheral anesthesia around the external ear and mastoid, constitute a series of procedures neces- sary and sufficient for a number of different oper-
90
REGIONAL ANESTHESIA.
Fig. 65. — Mastoidectomy. (Labour e.} A subcutaneous polygon is infiltrated through four wheals, the needle enter- ing in the direction of the arrows.
Fig. 66. — Petromastoid operation. (Laboure.) After hav- ing infiltrated as in Fig. 65, three more wheals are made and injections executed in the direction of the two arrows (£>) and the arrows (E and F).
ANESTHESIA OF THE HEAD AXD NECK. 91
ations. One may employ one procedure, or an- other, or all procedures combined, according to the case.
In general, the relative indications for each may be stated thus: i. For perforation of the tympanum: Application of Bonain's mixture, which drives the blood from the tissues and indi- cates to the operator the area anesthetized. 2. For ossiculectomy : Infiltration of the superior wall of the canal and vestibule, and application of Bonain's mixture. 3. For furuncle of the canal: Infiltration of the anterior and posterior nerves by an injection through the auriculo-mastoid sulcus. 4. For plastic operations on the external ear: Peripheral anesthesia in circular form instituted around the external ear as a center. 5. For mas- toiditis: As in the preceding (Figs. 65, 66). 6. For curettage: A combination of all the preced- ing methods.
REGIONAL ANESTHESIA IN OPHTHALMOLOGY.
NERVE SUPPLY.
The orbit and ocular globe receive their nerve supply from the branches of the ophthalmic. In addition, the orbital branch of the superior maxil- lary supplies, through its terminal trunks — the temporo-malar nerves, — the skin of the temple, of the malar region, and about the external angle of the eye (Figs. 37, 38, 39).
92 REGIONAL ANESTHESIA.
TECHNIQUE.
Anesthesia of the ophthalmic nerve and its branches may be obtained by external and internal orbital injections, the technique of which has al- ready been described (Figs. 40, 41, 42, with several pages describing the ophthalmic and its branches).
If necessary the anesthesia may be completed by infiltration of the superior maxillary nerve or of a few of its branches, as already described under Anesthesia of the Superior Maxillary.
For completion of the anesthesia in respect of the ciliary nerves or the ciliary ganglion, the mus- cular pyramid which immediately surrounds the ocular globe should be infiltrated. In order to effect this, one should direct the needle toward the vault of the orbit, keeping as close as possible to the outer surface of the eye-ball. Five mils of a i per cent, procaine-adrenin solution are injected, and the sub-con junctival tissue also infiltrated. A needle is introduced into the external commissure of the eyelids, and pushed down between the con- junctiva and the bulb. Then, a little to the in- side, at a depth of 4^ centimeters, i.e., close to the ciliary ganglion, I mil of a 2 per cent, solu- tion is injected. Finally y2 mil of this strong solution is injected under the conjunctiva sur- rounding the bulb. Thus, whatever be the oper- ation,— enucleation, etc., — perfect anesthesia will be obtained.
ANESTHESIA OF THE HEAD AND NECK.
93
Operations on the Eyelids and Lachrymal Gland (Fig. 67). — A few drops of cocaine on the conjunctiva, together with an injection of 2 mils of a Y* per cent, solution of procaine-adrenin near the superior bony wall, will anesthetize the upper eyelid.
Fig. 67. — Anesthesia of the eyelids. (Pauchet.) One injection through a wheal suffices for each eyelid.
For the lower eyelid, one should inject 2 mils along the inferior orbital wall, in a fan-shaped area 2 centimeters deep and 2 across. The infra- orbital nerve, and the anterior ethmoidal, which supplies the internal portion of the lower eyelid, are infiltrated.
Cataract; Iridectomy. — (a) Drop a few drops of a %o Per cent, solution onto the eyeball, sev-
94 REGIONAL ANESTHESIA.
eral times, as it will then act by absorption. (&) Inject y?. mil of ]/2 per cent, solution procaine- adrenin under the conjunctiva.
Enucleation of the Eyeball. — (a) Inject 2 or 3 mils of solution through the external superior angle. (&) Repeat this procedure at the internal angle, (c) Infiltrate the superior maxillary nerve either through the orbit or the malar region.
REGIONAL ANESTHESIA IN DENTAL SURGERY. NERVE SUPPLY
As regards the upper teeth, the nerves first follow above the outer side of the tuberosity of the superior maxillary, then penetrate it in order to reach the dental pulp. Here they are dis- tributed also to the periosteum, the mucous mem- brane, and the alveolar tissue.
The lower teeth are supplied by the inferior dental nerve, which enters the inferior maxillary bone at the inferior dental foramen and forms the inferior dental plexus, then divides into two branches, one in the bone, — the incisor, which supplies the incisor teeth, — the other, the mental, which supplies the chin and lower lip. The lower gums and tongue are supplied by the lingual nerve. The region of the incisors is supplied by branches coming from the inferior dental, mental, and lingual nerves, all more or less inter-related.
ANESTHESIA OF THE HEAD AND NECK. 95
TECHNIQUE.
Infiltration of the Dental Branches in the Upper /azcf. — A ^ Per cent solution is used. From 2 to 10 mils suffices, according to whether it is desired to anesthetize one tooth or an entire half of the jaw. As the dental branches lie super- ficially, immediately under the mucous membrane in the fold of the gum, the injection is readily carried out and its result immediate. The point of injection varies according to the teeth to be rendered anesthetic:
(a) For the incisors, one should infiltrate the submucous membrane in the median line, either on the level of the fraenum linguae or on the nasal floor near the septum, or at both of these points.
(fr) For the canine and first molars, the injec- tion is made above the canine tooth.
(c) For the large molars, one infiltrates well back at the outer border of the tuberosity of the maxillary, and even at its posterior border if a curved needle is available. Again, it may be considered necessary to enter through the cheek, to a depth of 2^2 centimeters, in the direction of the superior maxillary nerve.
To permit of convenient infiltration, an aid should draw aside the labial commissures with small retractors.
Where the work bears on half the maxillary arch, infiltration should be carried out along its entire length.
96 REGIONAL ANESTHESIA.
On principle, one should not infiltrate the trunk of the superior maxillary nerve. Yet there need be no hesitation in doing so in cases of severe buccal septicemia.
Infiltration of the Lower Teeth. — Where the incisors and canine teeth are concerned, one may proceed as for the upper jaw, infiltrating the sub- mucous membrane in order to reach the ramifica- tions of the mental and incisor nerves.
For the remaining lower teeth this procedure is insufficient because the inferior dental nerve lies in the center of the maxillary bone, which is very thick at this point. One should, therefore, infiltrate the trunk of the nerve at the dental foramen as already described. The labial commis- sure is retracted, the ascending branch of the in- ferior maxillary nerve found, and 3 to 5 mils of a y2 per cent, solution of procaine injected into its center. (Figs. 55 and 56.)
If the buccal cavity is too septic, the inferior dental nerve can be anesthetized from the outside; or 2 mils of anesthetic solution may be injected under the dental collar of the last molars in order to infiltrate the gingival branches of the buccina- tor— which, however, are not very large.
Unilateral injections under the gums for the lower incisors are insufficient because of the anas- tomoses of the two incisor nerves. To obtain complete insensibility, both nerves must be infil- trated even for an operation involving only one side. Two mils of solution are injected on each
ANESTHESIA OF THE HEAD AND NECK.
97
side of the median line; at this point there is a slight depression, the thin, grooved wall of which permits of absorption of the procaine.
REGIONAL ANESTHESIA OF THE FACE AND JAWS.
The soft tissues of the face are supplied by the three branches of the trigeminus, the ramifica-
Fig. 68. — The sensory areas of the head. (Testut.~) (1) Ophthalmic. (2) Superior maxillary. (3) Inferior maxil- lary. (4) Cervical plexus (anterior branches). (5) Cervical plexus (posterior branches).
tions of which are so intermingled as to render trunk infiltration insufficient for complete anesthe- sia. Even infiltration of the Gasserian ganglion of one side yields only an incomplete anesthesia when the operative procedure is conducted near the median line.
7
98
REGIONAL ANESTHESIA.
Fig. 69. — The measurements of Offerhaus. The "tubercle line" C D passes a few millimeters in front of and below the foramen ovale at points A and B. The distance E F from one superior dental arch to the other, is equal to A B from one foramen ovale to the other. Measuring C D and E F, sub- tracting the latter from the former, and dividing the result by 2 yields the distance C A or D B. This procedure constitutes an alternative method for injecting the superior maxillary nerve at the foramen ovale. (Cf. pp. 72-74.)
ANESTHESIA OF THE MIDFRONTAL REGION.
The frontal zone is supplied by branches of the ophthalmic nerve, — lachrymal, frontal, and nasal, — which ascend from below. It is sufficient, there- fore, to institute a horizontal line of infiltration, both intradermal and subperiosteal, passing above the convexity of the two eyebrows (Fig. 40).
ANESTHESIA OF THE HEAD AND NECK. 99
ANESTHESIA OF THE NOSE, LIPS, AND CHEEKS.
The lobe of the nose is easily rendered in- sensible by means of a circular infiltration outlin- ing its base (Figs. 70 and 71). Thus, in the case of a tumor of the lobe requiring surgical in- tervention, four injections should be made through
Fig. 70. — Circumscribing the lobe of the nose. (Brawn.)
dermal wheals located as follows: One on the bridge of the nose, two at the base of the alse, and the fourth at the base of the nasal septum on the upper lip.
The upper lip (Fig. 71) may be desensitized by three lines: One transversal, going from the base of one ala to the other, and the two others ver- tical, descending from the extremities of the pre- ceding points to the labial commissures and also
100 REGIONAL ANESTHESIA.
ascending to meet at the bridge of the nose. Two bands of infiltration should thus be made, the one subcutaneous, the other submucous, the needle be- ing directed parallel with the mucous membrane by means of a gloved finger introduced under the
HP.
Fig. 71. — Anesthesia of the lobe of the nose and the upper lip through two wheals, following the direction of the arrows. (Pauchet.)
Infiltration of the upper lip may usually be combined with that for the lobe of the nose. The anesthetized area may be enlarged at will ac- cording to the necessities of the operation (as in the pentagon, Fig. 72).
For harelip one should infiltrate a band ex- tending from the commissure of the lips to the
ANESTHESIA OE THE HEAD AND NECK.
101
infraorbital foramen, connected by a transverse line across the dorsum nasi.
The anemia produced by the adrenin facilitates operative work. The tissues are not altered by peripheral infiltration made at a distance.
Fig. 72. — Anesthesia for facial operations (Pauchet.) There are two median wheals, central and superior, and two lateral and inferior wheals. (5) and (6) serve for anesthesia of the infraorbital nerve. (4) applies in anesthesia of the ethmoidal nerve. The dotted polygon is a line of infiltration made with a 1 per cent, solution.
For the lower lip a single dermal wheal should be made on the chin, and from this point two divergent lines of infiltration made both under the skin and under the mucous membrane, with the needle guided by a finger introduced in the mouth.
The chin and subjacent sy.uphysis menti some-
102
REGIONAL ANESTHESIA.
Fig. 73. — Median section of the body of the inferior maxil- lary. (Pauchet.) The anterior and posterior sections of the body of the maxillary bone are infiltrated through three wheals.
Fig. 74. — Anesthesia for resection of the superior maxil- lary bone. (1) and (la) External and internal orbital injec- tions. (2) Injection of the superior maxillary nerve. A weak procaine-adrenin solution is used in instituting the subcuta- neous bands of infiltration.
ANESTHESIA OF THE HEAD AND NECK.
103
Fig. 75. — Unilateral resection of the lower jaw (Pauchet.) The inferior dental nerve is injected at the inferior dental foramen, or the inferior maxillary nerve at the foramen ovale, and the subcutaneous tissue then infiltrated along the dotted line.
pig. 75. — Operation on the horizontal portion of the lower maxillary bone. (Pauchet.) The inferior dental nerve is anesthetized at the inferior dental foramen or the inferior maxillary nerve at the foramen ovale, and a subcutaneous diamond-shaped figure infiltrated through three wheals. The dark line indicates the incision.
104 REGIONAL ANESTHESIA.
times require to be rendered insensible, e.g., for the suture of a fracture of the mandible (Fig. 73) :
1 i ) A horse-shoe-shaped band of infiltration following the lower border of the inferior maxil- lary bone, both subcutaneous and subperiosteal.
(2) Infiltration of the mental nerve on one, or better both sides, even if the operation be uni- lateral.
Resection of the Superior Maxillary (Fig. 74). — If the lesion is extensive and likely to cause the surgeon to go beyond the superior maxillary, he is justified in infiltrating the Gasserian ganglion, as already explained. Generally, however, it proves sufficient to proceed thus : ( i ) Infiltrate the supe- rior maxillary nerve. (2) Infiltrate the inferior maxillary nerve. (3) Infiltrate the orbital nerves by two injections in the superior-internal and superior-external angles. (4) Infiltrate the hard and soft palates, following the line of incision.
For the lower jaw (Figs. 75 and 76) the in- ferior maxillary nerve should be infiltrated at the foramen ovale or at the dental foramen with a */2 per cent, solution and the field of operation circumscribe*d with peripheral injections of a i per cent, solution. One can then operate on the bone for suturing or resection. In the event of cancer at the alveolar border, the nerves should be infiltrated at the inferior dental foramen. For disarticulation of the jaw the foramen ovale should be infiltrated.
ANESTHESIA OE THE HEAD AND NECK.
105
REGIONAL ANESTHESIA OF THE TONGUE, FLOOR OF THE MOUTH, TONSILS, AND PALATE.
NERVE SUPPLY.
The lingual nerve supplies two-thirds of the anterior portion of the tongue and the floor of the mouth; the glosso-pharyngeal nerve supplies the posterior portion of the tongue, the region of
Fig. 77. — Sensory distributions on the tongue. (Tes- tut.) (1) Lingual. (2) Glossopharyngeal. (3) Superior laryngeal.
the tonsils, and the pharynx; the superior maxil- lary nerve supplies the soft palate and the ante- rior pillars of the fauces, and the superior laryn- geal nerve supplies the epiglottis.
One may therefore infiltrate the following trunks :
( i ) The lingual nerve, within the inferior den- tal foramen, desensitizing two-thirds of the ante- rior portion of the tongue and the floor of the mouth.
106
REGIONAL ANESTHESIA.
(2) The superior laryngeal nerve, in the thyro- hyoid space (see page 116).
(3) Infiltration of the glosso-pharyngeal and pneumogastric nerves should be avoided because it is dangerous; peripheral infiltration must be substituted.
TECHNIQUE.
Excision of a Tumor of the Margin of the Tongue. — A triangle enclosing the tumor is out-
Fig. 78. — Anesthesia of the tongue and the buccal floor. (Pauchet.) With a finger placed over the base of the tongue the needle is introduced above the hyoid bone until its point almost touches the finger on the tongue, coming to rest just beneath the mucous membrane.
lined by two V-shaped bands of infiltration. The growth caiv then be excised without hemorrhage or pain.
Excision of an Extensive Cancer or Large Cyst of the Floor of the Mouth. — A long needle
ANESTHESIA OF THE HEAD AND NECK. 107
is introduced under the chin, above the hyoid bone, and pushed in vertically toward the base of the tongue, being received against the tip of the left index finger, introduced into the mouth as for tra- cheotomy. This vertical route is first infiltrated, then through the same wheal one injects succes- sively from top to bottom and further and fur- ther out, as many layers as are necessary to form a fan shaped infiltrated region, the sides of which extend to the maxillary bones, thus blocking off
Fig. 79. — Injection for transverse incision of the cheek for cancer of the pharynx or posterior cancer of the tongue. (Pauchet.)
all the nerves of the anterior portion of the tongue.
Restricted Operations on the Floor of the Mouth. — Small tumors of the floor of the mouth may be infiltrated in a circle, by an injection made from under the chin, with the needle always guided by the finger in the mouth.
Removal of Extensive Cancer of the Tongue, Floor of the Mouth,, and Tonsils. — (i) The two inferior maxillary nerves are infiltrated at the in-
108
REGIONAL ANESTHESIA.
ferior dental foramen: (2) the base of the tongue is infiltrated by a subhyoid injection; (3) peri- oheral infiltration of the operative field is insti-
Fig. 80. — Tonsillectomy (Laboure.) The superior pole is infiltrated by an injection made in the upper part of the an- terior pillar. An injection at the base of this pillar infiltrates the inferior pole. Quinine is employed.
Fig. 81. — Tonsillectomy. (Laboure.) The inferior pillar is completely infiltrated. Quinine infiltration of the tonsil has been instituted (white crescent)
tuted; (4) in some cases the Gasserian ganglion of one side is also infiltrated.
Operations on the Palate. — Anesthesia of both the soft and hard palate may be obtained by mak- ing an injection under the mucous membrane in-
ANESTHESIA OF THZ HEAD AND XECK. 1Q9
side of the large molars and behind the middle incisors. For resection of the bony hard palate, the two superior maxillary nerves should be in- filtrated.
In staphylorrhaphies one should avoid using too much adrenin at the point where the flaps are to be made.
Tonsillcctoiny (Figs. 80 and Si). — Infiltrate the two nerve pedicles of the tonsil : ( i ) At the lower portion of the anterior pillar; (2) at the upper part of the vestibule, at the junction of the posterior and anterior pillars.
REGIONAL ANESTHESIA IN OPERATIONS ON THE NECK.
INFILTRATION OF THE CERVICAL ROOTS.
The soft tissues of the anterior portion of the neck are supplied by the anterior branches of the 2d, 3d, and 4th cervical nerves, of which the ter- minal branches — auricular, mastoid, transverse cer- vical, and siipraclavicular, — emerge at the posterior margin of the sterno-mastoid muscle (Fig. 82).
Infiltration of these terminal branches at the posterior border of the sterno-cleido-mastoid de- sensitizes the skin alone and this is rarely suffi- cient. In order to obtain a deep anesthesia, the nerves must be reached at their emergence from the spinal column, on a level with the transverse processes of the 3d, 4th, and 5th vertebrae (Fig. 86).
The distribution of the cervical trunks is as fol- lows (see Figs. 85 and 87) : The second cervical
HO REGIONAL ANESTHESIA.
supplies the nape of the neck and the occipital region. The third cervical supplies the antero-
Fig. 82. — Superficial branches of the cervical plexus (Hirschfeld.) These branches should be desensitized by in- filtration of the soft tissues lying between the mastoid and the upper margin of the cricoid cartilage, following a ver- tical line and injecting through 3 wheals.
lateral portions of the neck, from the lower jaw to the shoulders and the upper portions of the arms. The roots of the second, third, and fourth
ANESTHESIA OF THE HEAD AND NECK.
Ill
cervical supply the cervical plexus (see Figs. 83 to 85). It is these roots, therefore, that must be reached in operating on the neck.
Technique. — The line of skin infiltration for the cervical plexus is vertical, i.e., parallel with
Ophthalmic
Greater occipital
Mastoid branch of great auricular
Occipital foramen
Great auricular
Third cervical
Phrenic
• Supraclavicular
Fig. 83. — Sensory areas of the superficial branches of the cervical plexus. (Testut.)
the spinal column, and is determined by the two following points: Above, a point one finger- breadth below the tip of the mastoid, corre- sponding to the angle of the jaw; below, a point 5 centimeters lower down and corresponding to the superior border of the thyroid cartilage. Using a 6-centimeter needle, the bone should be encoun-
112 REGIONAL ANESTHESIA.
tered at a depth of 5 centimeters, and a fan- shaped injection of a i per cent, solution of pro- caine-adrenin made there. About 25 mils is suffi- cient. The needle should be introduced through
Fig. 84. — Anesthesia of the cervical plexus. (Pauchet.) On a line joining the mastoid and the tubercle of the 6th cer- vical transverse process (1 to 3) a layer of soft tissues, ex- tending from the skin to the spinal column and from the lower border of the inferior maxillary (1) to a point situated on a level with the cricoid (2), is infiltrated.
the wheals indicated and the fluid injected as it is withdrawn. There is thus infiltrated an area about 5 centimeters square, outlined on the skin by the preceding line, above and below by a per- pendicular line passing from these points to the vertebral column, and involving the tissues bor-
ANESTHESIA OF THE HEAD AND NECK.
113
Fig. 85. — Anesthesia resulting from paravertebral injec- tion of the cervical plexus (anterolateral and posterior view). (Testut.)
Fig. 86. — Paravertebral anesthesia of the neck. Needle (1) is aimed directly at the lateral portion of the ver- tebra, but it almost touches the vertebral artery. Needle (2) (Danys) enters 2 centimeters from the spinous process, comes in contact with the lateral mass of the vertebra, and reaches the nerve without danger to the vertebral artery.
114
REGIONAL ANESTHESIA.
dering the column between the two perpendicular lines (Fig. 84).
--J
Fig. 87. — Paravertebral anesthesia of the neck. (Pauchet.) A B extends from the mastoid to the 6th cervical vertebra. The white and black dots indicate the dermal wheals. Along this line the needle enters transversely to infiltrate the nerve (direct route). The figure shows the needle penetrating ob- liquely (Danys) 2 centimeters beyond the spinous process and following the lateral masses of the vertebrae. As soon as it has passed these a strong solution of procaine-adrenin is injected.
Danys advises that the needle be introduced through the posterior surface of the neck, 2 centi- meters from the interspinous line, in order to avoid
ANESTHESIA OF THE HEAD AND NECK.
115
a possible penetration of the needle into the inter- transverse space and a consequent wounding of the vertebral artery. We prefer, however, the method described above, care being taken not to penetrate too deeply.
Fig. 88. — Peripheral infiltration for laryngectomy or laryn- gotomy, circumscribing the larynx. (Laboure.) The wheals here shown should be joined by subcutaneous and subfascial bands of infiltration. The wheal corresponding to the thyro- hyoid space is missing from the polygon. Infiltration of the two superior laryngeal nerves through the thyro-hyoid mem- brane is sufficient.
ANESTHESIA OF THE LARYNGEAL NERVE TRUNKS.
Two nerves supply the larynx, — the superior laryngeal, and the inferior or recurrent laryngeal. The latter is almost exclusively motor, whereas the first is entirely sensory (Fig. 88).
116 REGIONAL ANESTHESIA.
INFILTRATION OF THE SUPERIOR
LARYNGEAL NERVE.
The superior laryngeal arises from the in- ferior pole of the plexiform ganglion. It is held against the pharynx by the internal carotid, then by the beginning of the facial and lingual arteries, Slightly above the greater cornu of the hyoid bone it divides into its two terminal branches:
(1) The superior branch (external laryngeal} follows the vertical insertion of the inferior con- strictor over the thyroid gland to the crico-thyroid muscle, which it supplies, and terminates in the subglottic portion of the mucous membrane of the larynx.
(2) The inferior branch (internal laryngeal} continues in the direction of the common trunk, passes between the thyroid muscle and the hyo- thyroid membrane, penetrating through the middle of this membrane, and divides into superior ter- minal filaments for the epiglottis and base of the tongue, inferior filaments for the mucous membrane of the larynx and the arytenoids, and an anasto- motic termination for the recurrent nerve (ansa Gallieni).
Technique. — The sensory innervation of the larynx is constituted almost entirely, — above the vocal cords at any rate, — by the superior laryn- geal. As already stated, this nerve penetrates im- mediately behind the posterior extremity of the greater cornu of the hyoid bone, under the in- ferior border of this bone. It follows closely the thyro-hyoid membrane, courses forward, perforates
ANESTHESIA OF THE HEAD AND XECK. 117
this membrane, and supplies the laryngeal mucous membrane and the neighboring portions of the pharynx. A needle 6 centimeters long is intro- duced in the median line between the thyroid car- tilage and the hyoid bone, into the thyroid liga- ment. Once it is in this ligament, the needle is made to approach the greater cornu of the hyoid bone, which is easily felt with the finger. This ligament is now infiltrated on both sides, to the right and to the left, with 5 to 10 mils of a i per cent, procaine-adrenin solution.
Infiltration of the Recurrent Laryngeal Nerve. — Even if this nerve were exclusively motor, its infiltration would be justified to avoid spasm of the larynx, but actually it is a mixed nerve. Couzard and Chevrier infiltrate it thus: "Intro- duce a straight needle into the angle formed in the median line by the superior border of the thy- roid, injecting obliquely below, behind, and out- side of the angle; come into contact with the in- ternal face of the thyroid cartilage; guide the needle diagonally toward the postero-inferior angle of this cartilage, and inject the solution; it will distend the recess and bathe the terminal branches of the recurrent nerve." One to 2 mils of solu- tion suffices.
These infiltrations of the trunks do not render local anesthesia unnecessary. Spraying with a 20 per cent, solution of cocaine, tamponage with a 10 per cent, solution, and submucous injection of I per cent, procaine-adrenin, are all advantageous adjuncts.
118 REGIONAL ANESTHESIA.
OPERATIONS.
(1) Endolaryngeal Intervention. — (a) One should first anesthetize by spraying and tamponing with a 10 to 20 per cent, solution of cocaine the base of the tongue, the pillars of the fauces and the larynx.
(b) Infiltration of the two superior laryngeal nerves should be carried out.
(2) Tracheotomy, Laryngo-fissure, and Laryn- gostomy. — The methods of anesthesia described above should be employed, and intradermal and subcutaneous, peripheral, and trunk anesthesia added. In cases of laryngo-fissure and laryngos- tomy, as soon as the larynx is open, one may apply tampons moistened with a strong solution of cocaine to the mucous membrane.
(3) Laryngectomy and Goiter Operations. — These are more extensive procedures, for the per- formance of which it is necessary to infiltrate the trunks of the nerves of the plexus and the larynx, and to institute a subcutaneous peripheral infiltra- tion surrounding the larynx or the tumor at a distance.
The harmful actions of chloroform or ether upon the heart, lungs, and liver are thus avoided, to the great benefit of patients whose respiration is affected by disease or who are diabetic. Again, regional anesthesia permits the patient to clear his bronchi during the course of the operation, thus avoiding broncho-pneumonia. Shock is also con- siderably diminished.
ANESTHESIA OF THE HEAD AND XECK.
119
(4) Ligation of the External Carotid or Thy- roid Arteries. — The cervical plexus is first infil- trated, and there is then circumscribed under the skin and fascia a quadrilateral area extending beyond the limits of the incision.
(5) Removal of Enlarged Glands and Tiunors of the Neck. — The cervical plexus of one or both
Fig. 89. — Infiltration for thyroidectomy. (Pauchet.) The injection to the right infiltrates the branches of the cervical plexus along the transverse processes of the vertebrae (from 1 to 2). The mass is surrounded at a distance with a sub- cutaneous and subfascial band of infiltration (2, 3, 4, 5, and 6). We have performed about 250 strumectomies by Kocher's method without mortality.
sides is infiltrated and the tumor or lymphatic mass circumscribed by peripheral injection of a j/2 per cent, procaine-adrenin solution. If the mass of the tumor or lymphatics extends posteriorly so as to interfere with the passage of the needle,
120
REGIONAL ANESTHESIA.
the latter may, instead of being introduced trans- versely or in front, be passed in near the inter- spinous line, in an anterior or in any intermediate oblique direction.
(6) Infrahyoid and Suprahyoid Pharyngotomy. — The thyroid membrane is infiltrated and a peri-
Fig. 90. — Removal of carcinoma of the larynx under regional anesthesia. (Pauchet.) The organ has been opened up posteriorly ; the tumor is to be seen on the right vocal cords.
pheral lozenge-shaped area of infiltration made over the inferior maxillary and the thyroid car- tilage. During the course of the operation it is sometimes necessary to infiltrate the tumor over its entire external surface.
ANESTHESIA OF THE HEAD AND NECK. 121
(7) Thyroidectomy. — Six dermal wheals are made (Figs. 89 and 90). Points i and 2 cor- respond to the line of the transverse processes and serve as landmarks in instituting paraverte- bral anesthesia of the neck. All the tissues, epi- dermis, muscles, and nerves are thus infiltrated until the cervical plexus is reached.
Fig. 91. — Paravertebral anesthesia of the neck. (Danys.) This figure shows the two methods of reaching the nerve as it emerges from the spinal canal. Needle 1 aims transversely for the nerve, but it runs a risk of injuring the artery. Needle 2 enters 2 centimeters from the median line, follows the line of the vertebrae, comes in contact with the transverse process, and finally reaches the nerve, while avoiding the vertebral artery.
With a needle 9 centimeters long, a subcuta- neous and subfascial band is infiltrated through the dermal wheals (Figs. 89 and 90). One hundred grams of a ^ per cent, solution of pro- caine-adrenin are required. This procedure may also be employed in the removal of malignant tumors.
122
REGIONAL ANESTHESIA.
(8) Total Laryngectomy. — A subcutaneous hexa- gon is made, extending from a point slightly above the hyoid bone to the angle of Louis. A
Fig. 92. — Infiltration of the anterior aspect of the neck. (Laboured) This is intended for major operations in this region, e.g., for cancer of the larynx, goiter, extirpation of lymphatics of the neck for cancer of the tongue, etc. A, B, C, and D indicate the method of paravertebral injection of the cervical nerves. Dermal wheals are made above and below to circumscribe the operative field.
paravertebral infiltration is then conducted through two dermal wheals, as in goiter, for the purpose of anesthetizing the transverse cervical branch.
ANESTHESIA OF THE HEAD AND NECK. 123
Fig. 93. — Large adamantoma of the lower maxillary. (Pauchet.) On the lower part of the tumor is seen a white, cross-shaped scar, — • evidence of an operation carried out a few years before. This case had been recently diagnosed "inoperable sarcoma." The tumor com- municated with the mouth and secreted pus abundantly. Insomnia. Liquid diet. Anesthesia was commenced by paravertebral injection of the cervical plexus, injection of the superior maxillary nerve by the orbital route, and simple infiltration of the chin and lower lip in the median line. These three anesthetizing injections enabled the operator to ligate the external carotid and perform a section from the middle of the neck to a point beyond the eyelid, extending through the chin and cheek (see the succeeding figures).
124
REGIONAL ANESTHESIA.
Finally, the superior laryngeal nerve is anesthe- tized. One must not forget to spray the pharynx
Fig. 94. — Second stage of the operation: Ligation of the external carotid has been effected. The scalpel has just divided the skin in front of the tumor.
with cocaine, in order to suppress the reflexes of deglutition and prevent coughing. Two hundred to 250 grams of a ^ per cent, solution of pro- caine-adrenin are required for this operation.
It is in cases such as these that regional anes- thesia exhibits its superior degree of utility.
ANESTHESIA OF THE HEAD AND NECK. 125
Fig. 95. — Third stage : Resection of the jaw has been completed. To the left is still seen the needle which has served to infiltrate the foramen ovale (inferior maxillary). The external carotid having been previously ligated, there is not much hemorrhage.
126
REGIONAL ANESTHESIA.
Fig. 96. — Anesthesia by infiltration of the cervical plexus and superior and inferior maxillary nerves. (Pauchet.) An esophageal tube has been introduced in the nose. The patient is to be fed through it.
ANESTHESIA OF THE HEAD AND XECK. 127
Fig. 97. — Anesthesia of the cervical plexus and inferior maxillary nerve for amputation of the tongue by the subhyoid route. (Pauchet.) The infrahyoid floor has been incised, and the tongue drawn out.
CHAPTER V.
ANESTHESIA OF THE THORAX AND ABDOMEN.
OPERATIONS upon the trunk may be performed under spinal anesthesia by means of cocaine (Le Filliatre) or other drugs introduced more or less high up (Jonnesco) after a series of paraverte- bral injections, which constitutes the ideal regional anesthesia for the upper portions of the trunk, or by lumbosacral injections (Le Filliatre). For in- tra-abdominal operations and operations in the pel- vis and on the lower extremities, injection of procaine- adrenin directly into the lumbar canal offers the simplest and most complete form of anesthesia.
INTRASPINAL ANESTHESIA.
Personally we prefer regional anesthesia for all operations upon the head, face, neck and thorax, as well as all other operations of a local charac- ter. But for amputation, resection or other ex- tensive procedures on the lower extremities, as well as for major intra-abdominal operations on the liver, stomach, intestines, and pelvic organs, intraspinal anesthesia possesses certain pronounced advantages. . It is particularly valuable in opera- tions for intestinal occlusion, as it paralyzes and softens the abdominal wall and contracts the in- testine, practically eliminating the risk of fecal (128)
THORAX AND ABDOMEN. 129
vomiting- and thereby aiding toward a favorable prognosis.
Y\ e do not advocate intraspinal anesthesia for any operation in which regional anesthesia is in- dicated, e.g., in hemorrhoids, varicocele, perineor- rhaphy, prostatectomy, amputation of the foot, suture of the patella, nephrectomy, cholecystotomy, and all operations on the head, neck and thorax.
The spinal cord proper terminates at about the level of the junction of the second and third lum- bar vertebrae, where it becomes filiform. It is entirely safe to inject directly into the spinal canal at the space between the third and fourth (Tuf- fier), fourth and fifth (Chaput), and fifth lumbar vertebra and sacrum (Le Filliatre), and, with a little care not to enter the cord, between the first and second lumbar vertebrae.
Injection into any one of the inter-vertebral spaces of the lumbar region produces insensibility of the lower part of the abdomen and the lower extremities.
Under this form of anesthesia we have per- formed, at the Molitor Hospital, operations upon every portion of the leg and thigh.
Some little familiarity and practice is required for the successful injection of the spinal region. It is easiest to find entrance to the canal bet\veen the last lumbar vertebra and sacrum, because here the space is wide, but as a matter of fact, it is not difficult to effect an entrance at any one of the interspaces mentioned.
130 REGIONAL ANESTHESIA.
Injections into the spinal canal are greatly facilitated by placing the patient in a sitting posi- tion with head bent over on the arms — the latter folded upon the knees, — and the back made to "bow" as much as possible in order to throw the spinous processes into the greatest possible promi- nence.
The same degree of aseptic precaution should be taken for injecting the spinal canal as for a laparotomy, both as regards the surgeon and the patient.
A strong needle of rather large caliber, 8 centimeters long, should be selected. With the index finger -of the left hand the space to be injected is found, ^2 centimeter from the median line of the spine, midway between two adjacent spinous processes. In the center of this space the needle is introduced in a straight line, pointing slightly inward toward the median line (Fig. 98). At a certain depth, which varies according to the con- formation of the patient, the operator senses con- tact with the ligamenta subflava and the inter- laminar ligament, some force being required to penetrate and the operator experiencing somewhat the sensation of piercing a tense drum head. As the needle is pushed through, the silver wire is removed from its lumen from time to time to see if a drop of cerebrospinal fluid will appear. When the fluid drops more or less rapidly, according to the intraspinal tension, the syringe, containing 2 mils of a 4 per cent, solution, is adjusted, the spinal fluid slowly drawn out to complete exten-
THORAX AND ABDOMEN.
131
sion of the syringe, the fluid then slowly injected in part, and the piston redrawn and reinserted several times to mix the solution with the spinal fluid and cause it to be more generally diffused
Fig. 98. — Showing point of entrance into the spinal canal. (Pauchet.)
in the spinal canal. When the syringe has been finally emptied into the canal, the needle is with- drawn by a quick movement, slipping the index finger of the left hand over the puncture for a moment, then touching it with a drop of iodine tincture. In from five to fifteen minutes the pa-
132 REGIONAL ANESTHESIA.
tient will experience complete insensibility of the parts supplied by the nerves involved.
If the injection be made between the I2th dor- sal and ist lumbar vertebrae, it will produce a complete anesthesia of the abdominal contents- stomach, liver, intestines, abdominal walls — as well as the lower extremities. If it be made between the fifth lumbar and sacrum it will anesthetize the perineum, anus and lower extremities. Both to- gether are recommended for abdomino-pelvic oper- ations such as hysterectomy or extensive extirpa- tion of the rectum (Jonnesco).
For feeble, old individuals, and the cancerous, cachectic, and tuberculous, it is not necessary to employ the full strength of dose, as for the vigor- ous patient. The anesthesia is more readily in- duced in the feeble.
As a precautionary measure it is well to in- ject, one hour before the operation, an ampoule of scopolamine-morphine and one of strychnine or sparteine.
Equalization of the effect of the anesthetic is greatly facilitated by the repeated filling and par- tial reinjection of the contents of the syringe into the spinal canal. If this movement is not readily performed and something seems to prevent an easy flow to and from the syringe, the action of the anesthetic is likely to be imperfect.
Immediately after the injection is made the pa- tient should be placed recumbent upon the opera- ting table and covered warmly. For him to re- main sitting up involves risk of an attack of syn-
THORAX AND ABDOMEN. 133
cope. The ears should be stopped with cotton, the eyes bandaged, if necessary, and complete silence ordered. The anesthesia continues for an hour or more.
Complications. — (a) If cerebrospinal fluid fails to flow from the needle, either the direction of the needle is bad and the point has not penetrated the spinal canal, or the needle is plugged. Only two or three attempts are required for the oper- ator to feel confident when he is traversing the inter-laminar ligaments separating the vertebrae. If he be satisfied that the direction of the needle is not at fault, the needle should be withdrawn, aspirated with the aid of a syringe, and reintro- duced.
(b) If pure blood appears, the needle has pene- trated a vein and must be withdrawn and rein- troduced. If the liquid is mixed with blood, one should wait a moment for the fluid to become clear. To inject with bloody fluid destroys the effect of the anesthetic.
(c) If the liquid appears only in slow drops and will not fill the syringe when aspiration is made, it is useless to push the attempt farther. The needle must be withdrawn, its lumen cleared with the aid of a syringe, and the needle then re- introduced.
(d) Incomplete anesthesia or absence of anes- thesia is due to one of the preceding errors. It does not occur in the hands of an experienced operator.
Untoward Sequclcc. — (a) Retention of urine
134 REGIONAL ANESTHESIA.
may be present for several days. The patient oc- casionally requires daily catheterization for a week or more.
(b) Vomiting after the operation is very un- common.
(c) Sciatic neuralgia occurs when the operator introduces the needle to the outer side of the vertebra and pierces a nerve.
(d) Headache often follows the injection and lasts a week. If it is violent, lumbar puncture is necessary.
(e) Fecal incontinence during the operation. In the case of a total hysterectomy, this is danger- ous as the fecal matter may penetrate the vagina and enter the abdominal cavity. It is wise to tampon the vagina to safeguard against this difficulty.
(/) Fever. The temperature may rise and fall on the first or second day; this is devoid of sig- nificance.
(g) Labored respiration and asphyxia have appeared where the injections have been made high up and the anesthetic has affected the center of respiration. If the mind is clear, the patient should be made to talk incessantly and draw in and blow out the air. If necessary, artificial res- piration should be resorted to. As soon as the effect of the anesthetic on the medulla has passed off, natural respiration will be re-established.
(h) Death. Among 2000 cases Pauchet has met with 2 deaths. In 5000 cases, Jonnesco had
THORAX AND ABDOMEN. 135
no death. Le Filliatre has had no deaths, either. Leyden has had 2 deaths. I consider spinal anal- gesia as involving the same degree of immediate danger as does chloroform.
(i) Nervous Manifestations. Among 5000 cases Jonnesco observed but one case of nervous disturbance. Pauchet met with one case of blad- der retention which continued for three months. Organic affections not discovered by previous ex- amination may, of course, exist, and it is cer- tainly unjustifiable to attribute accidents appearing a year or more after the operation to the effects of the anesthetic.
Regions Influenced. — Jonnesco has boldly prac- tised injection into the spinal canal along its whole length and specifies the effects of the anes- thetic in the various regions as follows: —
(1) Injection between the 3d and 4th cervical vertebrae: Anesthesia of the head and neck.
(2) Cervico-dorsal injection, immediately below the vertebra prominens: Thorax and upper ex- tremities.
(3) Between the last dorsal and first lumbar: The entire abdomen, testicles, and lower ex- tremities.
(4) Between the last lumbar and the sacrum: The pelvis, perineum, and anus.
Injection at two points has been recommended for certain operations, viz., in operations upon the thorax, one may inject at the cervico-dorsal and dorso-lumbar levels. For abdomino-pelvic opera-
136 REGIONAL ANESTHESIA.
tions, one should inject at the dor so-lumbar and lumbo-sacral levels. For other operations, one injection suffices.
Pauchet says: ''I do not practice injection of the spinal canal at a point above the intersection of the 1 2th dorsal and ist lumbar, which insen- sibilizes the whole abdomen and its wall, prefer- ring regional and local anesthesia for all opera- tions above this level."
As in the administration of chloroform, a cer- tain degree of danger attends the practice of spinal anesthesia, but the procedure is free of the post- operative dangers incident to general narcosis. It •does not affect the viscera (lungs, liver, kidneys, or suprarenal capsules) and permits of highly traumatic operations (resection of the femur, dis- articulation of the hip) with very minor evidences of shock. It renders the major abdominal opera- tions more benign because it makes them easier, serving to contract the intestine, reducing com- pletely the rigidity of the abdominal wall, and pro- ducing complete "abdominal silence."
There is no comparison between an operation for uterine cancer, for cancer of the rectum, and notably for acute occlusion of the intestine, under spinal anesthesia and under general narcosis.
NERVE-TRUNK ANESTHESIA.
The thordcic nerves emerge from the interver- tebral foramina of the thoracic portion of the spine (Fig. 101). Immediately after their emerg-
THORAX AXD ABDOMEN. 137
ence they give an anastomotic branch to the sym- pathetic, and afterward divide into two branches: an anterior and a posterior. The posterior branch supplies the muscles of the back and skin in the vicinity of the midline. The anterior branches or intercostal nerves are situated in the intercostal spaces near the inferior borders of the ribs. They
Fig. 99. — Intercostal nerves and their distribution. (Hirsch- feld.) These nerves can be blocked by paravertebral injection or by simple intercostal injection.
are at first in contact with the pleura, near the costal angle; afterward they pass between the two intercostal muscles (Figs. 99 and 100).
The upper dorsal nerves (Fig. 103, D. i, 2, and 3) supply the internal surfaces of the arm and of the forearm, and the axillary and mam- mary regions are supplied likewise by the succeed- ing nerves, down to the seventh dorsal (D. 7), inclusive. The intercostal nerves from the 8th to the 1 2th supply the thorax, and likewise the ab-
138
REGIONAL ANESTHESIA.
Fig. 100. — Interco'stal and lumbar nerves and their distribu- tion. (Hirsclifeld.) The figure shows the anastomosis of these nerves with the sympathetic. The needle is introduced close enough to the vertebral column to infiltrate the com- municating ramus, the viscera being thus anesthetized.
THORAX AND ABDOMEX.
139
Fig. 101. — The dorsal nerves at their points of emergence. (Testut.) The figure shows their bifurcation into an anterior branch (intercostal) and a posterior branch which divides into two rami.
o
Fig. 102. — The intercostal space. (Souligoux.) (A) Pos- teriorly at the point of origin. (B) At the posterior third. (C) Middle portion. The internal intercostal divides to sur- round the blood-vessels and nerves.
140
REGIONAL ANESTHESIA.
Fig. 103. — Dorsal paravertebral anesthesia for the viscera. (Pauchet.) The operator is shown the dorsal points which should be infiltrated in order to anesthetize corresponding viscera. In practice, one should inject both higher and lower because of the anastomoses. The lung, kidney, biliary passages, and spleen are anesthetized by an injection made upon one side only. For other organs both sides should be injected.
THORAX AXD ABDOMEX.
141
clomen. Through their anastomoses with the sym- pathetic, they supply with sensation the following viscera: Heart (Fig. 103, D. i, 2, and 3); lungs
Fig. 104. — The lumbar nerves at their points of emergence. (Pauchet.) These nerves are accessible between the trans- verse processes of the lumbar vertebrae, as are the intercostals below the ribs.
(D. i, 2, 3, and 4) ; stomach (D. 6, 7, 8, and 9) ; liver and bile ducts (D. 7, 8, 9, and 10) ; intes- tines (D. 9, 10, n, and 12); kidneys and ureters (D. 10, n, and 12); testicles, ovaries, and uterus
142
REGIONAL ANESTHESIA.
(D. IO, n, and 12). To desensitize the viscera it is necessary to reach the anastomoses with the sympathetic ( Danys ) .
The lumbar nerves are situated between the transverse processes of the lumbar vertebrae in front of the intertransverse muscles, and are sur- rounded by the attachments of the psoas muscle (Figs. 100, 104, 105).
Fig. 105. — The lumbar nerves at their points of emergence. (Hirschfeld.)
The ilio-hypo gastric, ilio-inguinal, and genito- crural nerves, supplying the anterior abdominal wall, follow, as the I2th intercostal nerves, the anterior surface of the quadratus lumborum, i.e., course between this and the perirenal adipose tissue. After the 2d lumbar, the nerve trunks are so closely applied against the vertebrae that they can only be reached by injections made almost in con- tact with th^ vertebral column at a distance of 3 centimeters from the median line.
The intercostals and the ist lumbar nerve sup- nly not only the thoracic and abdominal wall, but
THORAX AXD ABDOMEX. 143
also the serous membranes, the pleurae, and the parietal peritoneum. The intermediate intercostal nerves do not anastomose at their points of origin, but from the I2th there is given off a branch to the ist lumbar nerve. At the 'level of the skin the regions supplied by the respective intercostal s so en- croach one upon the other that the blocking of a single ncrrc does not abolish cutaneous sensation ; several must be infiltrated at the upper part of the thorax to obtain complete anesthesia of a given region. The skin of the thorax also receives branches from the cervical and brachial plexuses.
The anesthesia required for operations upon the spine, thorax, and abdomen may be obtained by one of two methods.
In the case of a circumscribed operation, such as resection of one or two ribs, curettage of the sternum, operation for appendicitis, for simple her- nia, etc., injections made along the course of the nerves supplying the field of operation, as des- cribed further on, will yield a complete anesthesia limited to the parietes. Such injections are made around, and at some distance from, the field of operation. The procedure varies for each opera- tion in accordance with the nerve supply. This method has enabled us to dispense with general and spinal anesthesia for a number of operations, e.g., in the radical cure of most voluminous her- nias. It appears to us the ideal procedure for thoracotomy, and is sufficient for appendectomy when the acute attack has subsided and provided the appendix and cecum are free from adhesions. It en-
144 REGIONAL ANESTHESIA.
ables us to do pylorectomy for cancer and very consid- erable resections of the intestines, provided the mesentery is injected in addition with a I per cent, solution of quinine and urea hydrochloride. When the operation concerns unilateral viscera —kidneys, liver, spleen, bile ducts, — or any larger portion of the trunk or abdomen, it is preferable to employ the following method, which is more precise in technique and permits of covering a larger field, viz. : —
PARAVERTEBRAL ANESTHESIA.
Definition. — Paravertebral anesthesia consists in bathing the thoracic and lumbar nerves at their points of emergence from the intervertebral fora- mina of the dorsal and lumbar spine with a solu- tion of procaine-adrenin. The injection anesthe- tizes the thoracico-abdominal wall and even the viscera through the anastomoses with the sympa- thetic. By injecting a I per cent, solution of procaine-adrenin 3 to 4 centimeters from the median line in the intervertebral spaces the sur- geon is enabled to produce complete anesthesia of the thoracico-abdominal wall as well as of the unilateral viscera situated on the same side and receiving filaments of the sympathetic (liver, bile passages, spleen, kidneys, ureters).
If the operator desires to anesthetize the entire abdominal contents (intestines), two series of in- jections will have to be made, one to the right and the other to the left of the spinal column;
THORAX AND ABDOMEN.
145
but such an event is exceptional. Paravertebral anesthesia is useful for operations upon the thorax,
Line of skin infiltration
, Fig. 106. — Dorsal paravertebral anesthesia. (Pauchet.) The skin is infiltrated with a band 1 centimeter wide at a dis- tance of 35 millimeters from the median line. The operator introduces the needle through this band and feels his way. The black dots show where the needle should enter to reach the rib, somewhat laterally to the costo-vertebral articulation. When the needle has come in contact with the rib, it turns about its inferior border and proceeds toward a point */> centi- meter further fonvard and inward to reach the sympathetic anastomosis. It should be noted that the lower angle of the scapula corresponds to the spinous process of the seventh dor- sal and the spine of the scapula to the third dorsal.
neck and abdomen, the breasts, pleurae, lungs, and for lateral viscera, including the kidneys, liver,
biliary passages, pylorus, cecum, etc.
10
146 REGIONAL ANESTHESIA.
Technique. — The operator should remember that the thoracic nerves at their origin are located at equal distances from the transverse processes and at a distance of 2 centimeters in front of the intertransverse space.
The spinous processes from the first to the sixth are situated at the level of the intertrans- verse spaces, bounded by the two succeeding ver- tebrae, and at the level of the nerve immediately following. Thus, the processes D. I to D. 6 (Fig. 106) correspond to pairs D. 2 to D. 7. The processes D. 7 to D. 12 are situated opposite the lower portion of the corresponding intertransverse space (Fig. no).
The lumbar nerves, at their emergence from the conjugate vertebral foramina, are situated at the level of the corresponding spinous process and slightly above the transverse process of the ver- tebra immediately following (Fig. 104). They are therefore accessible through the intertransverse spaces at a distance of about 3 centimeters out- side the median line, and are situated I centimeter in front of the transverse processes (Fig. 106 and 107).
For the Dorsal Nerves. — A needle 6 to 9 centi- meters long is introduced at a point 3^/2 centi- meters from the median line. At a depth of 4 to 5 centimeters, when the needle touches the rib, transverse process or costo-vertebral articulation, its point is inclined to reach the lower border of the bone. Then, at an angle of 25°, it is aimed at the middle line, and its progress terminated
THORAX AND ABDOMEN.
y2 a centimeter beyond. Next, 5 mils of the 1.5 per cent, solution is injected, or 7 to 8 mils of the i per cent, solution. It is well to move the
Fig. 107. — Intercostal or paravertebral dorsal anesthesia. (Pauchet.) The first needle is directly in the intercostal space and in the vicinity of the nerve. The second (dotted line) has at first come in contact with the rib, but has then been given an oblique direction downward and has reached the vicinity of the nerve.
point of the needle to and fro in order to be sure that the nerve is well bathed and to include the anastomosis of the sympathetic and the posterior
148
REGIONAL ANESTHESIA.
as well as the anterior branch of the spinal root (Fig. 1 08).
Two difficulties may arise:
Fig. 108. — Paravertebral dorsal anesthesia. (Pauchet and Sourdat.) The needle enters at a point 35 millimeters from the median line, close to the inferior border of the rib; then, at a point 1 centimeter anterior and internal, it reaches the nerve root and impregnates the anastomosis with the sym- pathetic.
(o) If blood comes from the needle, a vein has been .wounded. The position of the needle must be changed, otherwise the injection will pass into the vein, and no anesthesia will be produced. It is important to bear in mind that when this
THORAX AND ABDOMEN.
149
accident happens, the patient turns pale and ex- periences nausea.
(b) Penetration into the pleura will cause
Fig. 109. — Direction of the lumbar nerves after their emerg- ence from the conjugate foramina. (Pauchet.) To reach these nerves, the needle is inserted at a distance of 3 centi- meters outside of the spinous process. In the case of the in- tercostals, at a distance of 3l/> centimeters, with the needle close to the lower border of the rib, one reaches the nerve numbered one less than the spinous process serving as land- mark. In the case of the lumbar nerves, the needle, introduced at the level of the spinous process, will pass above the upper border of the corresponding transverse process and come in contact with the nerve of the same number.
the patient to cough. The needle should be with- drawn and inclined slightly outward. This acci- dent, likewise, presents the disadvantage that the
150
REGIONAL ANESTHESIA.
anesthetic is absorbed without producing anesthe- sia. To obviate it, one should avoid introducing the needle more than i centimeter after having
Fig. 110. — Paravertebral injection of the dorsal and lumbar region. (Pauchet.) The needle enters at a point 3^ centi- meters outside of the dorsal spinous process. Reaching the lower border of the rib, it then inclines slightly inward, ad- vances 1 centimeter, and attains the anastomosis of the sympa- thetic, thus anesthetizing the viscera.
passed the transverse process, or at a distance of ^2 centimeter below the rib itself.
For the Lumbar Nerves. — The needle is intro- duced at a" distance of 3 centimeters from the median line. After the transverse process has been found, at a depth of 4 to 5 centimeters, the
THORAX AND ABDOMEN. 151
superior border is followed around, the point pushed in for another centimeter, and the injec- tion made (Figs. 109 and no).
Dermal infiltration is employed at first, and a straight band, corresponding to the roots to be injected and parallel with the median line, traced on the surface of the skin. The band referred to should be traced as follows :
A very fine, sharp-pointed needle 3 to 5 centi- meters in length is used. The skin is marked with a dermal pencil at a distance of 3}^ centi- meters from the median line (it is difficult to follow this line exactly without deviation if there is no landmark). A strip of skin I centimeter wide is now infiltrated with the patient sitting bo\ved forward and the shoulders well drawn in as for spinal anesthesia, or lying down on his side.
This having been accomplished, the operator, employing a needle 6 or 9 centimeters long — ac- cording to its strength — begins injecting the nerves. The introduction of the needle will be painless. Each spinous process is sought with the left in- dex finger (a difficult matter in stout people), and at the level of the spinous process the needle is introduced 3^2 centimeters from the median line until it meets the rib or transverse process. In muscular subjects the inexperienced operator must feel his way. When the point strikes the rib, it should be withdrawn, then directed against and past the lowrer costal border until the bony resistance disappears. The operator now contin-
152 REGIONAL ANESTHESIA.
ues to push the needle l/2 centimeter beyond and injects 5 to 8 mils of the I per cent, solution, at the same time executing a to and fro movement in order not to miss bathing the nerve. The in- jection having been completed, the needle is al- lowed to remain in place to serve as a landmark. The operator then locates the spinous process of the next vertebra below, and at its level and ex- actly below the needle above, he introduces his second needle and begins as before. For the third injection, the second needle is left in place as a landmark and, if necessary, the first needle used for the injection.
After the injections are finished about fifteen minutes are required for the anesthesia to take full effect. The intercostal space, muscles, pleura, sternum, and ribs are all rendered insensible. The skin anesthesia begins one or two interspaces be- low the first injection. Transversely, it occupies the intercostal space; anteriorly it reaches the median line, and posteriorly, it often stops behind the point where the injections have been made. If the injections have been practised at points im- mediately external to the conjugate foramen, the posterior branch is also blocked and a laminectomy can be effected.
Sixty to 80 grams of the i per cent, solution suffice for the anesthetization of 12 nerves. An absolute anesthesia of the thoracic wall is thus obtained which extends both anteriorly and pos- teriorly to the midline.
THORAX AND ABDOMEN. 153
For the upper portion of the thorax, the func- tions of the cervical plexus must be also inter- rupted. A subcutaneous band • must be infiltrated the length of the clavicle and spine of the scap- ula. If the field of operation involves the axilla or the supraclavicular fossa, the brachial plexus should be anesthetized.
For thoracic operations involving only the ribs and parietes, there is no objection to substituting intercostal anesthesia for the paravertebral anes- thesia, i.e., instituting the anesthesia at a more lateral point on the course of the intercostal nerve above the region to be operated upon. The tech- nique of this procedure will be described later.
PARACENTESIS OF THE PLEURAL CAVITY.
With a 3-centimeter needle, the course to be followed by the trocar passing in from the skin to the pleura is injected. A y? per cent, solution proves sufficient; such anesthesia permits of the use of large trocars without pain.
THORACOTOMY FOR EMPYEMA WITH COSTAL RESECTION.
The operator is given the choice between a paravertebral anesthesia or the less radical inter- costal or pericostal anesthesia, the technique of which is as follows:
Attention is directed to Fig. in, which rep- resents three adjacent ribs. Upon the middle one,
154
REGIONAL ANESTHESIA.
the part in black is to be resected; there will therefore be two intercostal spaces to anesthetize. Four wheals are marked out and through these 5 mils of the i per cent, solution injected into the thickness of the intercostal muscles. The needle point seeks the upper rib and follows its inferior border until it passes beyond.
Fig. 111. — Resection of a rib. (Sourdat.) An injection is made in the adjacent intercostal spaces forward and back- ward on tlie portion of rib to be resected, and followed by peripheral infiltration, subcutaneously and intramuscularly.
The muscles and subcutaneous tissue are in- filtrated with 30 or 40 mils of the ^ per cent, solution in the direction of the arrows. The re- sulting anesthesia is complete; yet it is well to bear in mind that the patient will complain if any traction is made on the ribs, producing torsion of the costo-vertebral ligaments. The patient may also complain if he hears the section of the ribs; it is there^pre well to cut the ribs gently and to stop the patient's ears. A little girl n years of age — the niece of a colleague, — upon whom we did a resection of 3 ribs for interlobar empyema,
THORAX AND ABDOMEN.
155
cried every time she heard the cutting of a rib, though she had not complained once during the remainder of the operation, except during the pro- duction of the dermal wheals. A man 30 years of age cried out when he heard a costal cartilage fall into the bucket on the floor.
Fig. 112. — Resection of the costal cartilages. Diagram of the infiltration for mobilization of the ribs, as for emphysema. The zone of anesthesia should be extended downward to the free border of the ribs if it is desired to remove a section of cartilage to be used for filling in a bony gap in the skull from trephining.
RESECTION OF THE SECOND TO THE FIFTH COSTAL CARTILAGES FOR RIGIDITY OF THE THORAX.
From the 2d to the 5th interspace two rows of wheals are made (Fig. 112) — the outer at the external ends of the cartilages, the inner along the sternum. Through each point 5 mils of the
156
REGIONAL ANESTHESIA.
Fig. 113. — Extensive pleurotomy and costal resection for pleu- ral sinus. Raising the flap of soft tissues.
THORAX AND ABDOMEN.
157
Fig. 114. — Extensive pleurotomy and costal resection for pleural sinus. (Pauchet.) The wound tamponed at the close of the operation.
158 REGIONAL ANESTHESIA.
i per cent, solution are injected to enclose the field of operation in the dotted line, finishing with 50 mils of the ^2 per cent, solution. The same procedure is followed for operations involving the pericardium and heart, or for subphrenic abscess or suppurative costo-chondritis. When decortica- tion of the lung is practised for a pleural sinus, it should be remembered that in patients who have undergone costal resections the ribs have be- come welded together. Under these conditions it is indispensable to employ paravertebral anesthe- sia, intercostal infiltration being no longer possible.
OPERATIONS UPON THE STERNUM.
Five mils of the I per cent, solution are in- jected on both sides in each space close to the sternum. The skin and subcutaneous tissues at a distance are then infiltrated with the ^ per cent, solution of procaine-adrenin.
THORACOTOMY FOR ABSCESS OF THE LUNG, EX- TRACTION OF FOREIGN BODIES, OPENING OF INTERLOBAR ABSCESS, REMOVAL OF TUMOR OF THE LUNGS, ETC.
A very wide anesthesia of the intercostal nerves at their origin should be instituted. The operator may either employ paravertebral anesthesia or in- filtrate the intercostal nerves at points 5 centi- meters outside of the line of the spinous proc-
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Fig. 115. — Wound made for resection of two ribs. (Pauchet.) Interlobar pleurisy.
160 REGIONAL ANESTHESIA.
esses, i.e., at the lateral border of the mass of the spinal muscles. The intercostal spaces are more easily found in this situation than elsewhere.
The operator traces a line with a dermal pencil at a distance of 5 centimeters from the spinous processes. Then, with a very fine and sharp needle 6 centimeters long, a band i centi- meter wide is infiltrated with the y2 per cent, solution along this line, with the patient sitting down, bent forward, and with the shoulders drawn inward; or lying down on the side. Along this line and on a level with each spinous process, an injection is made immediately below the cor- responding rib. Paravertebral anesthesia, which renders the lung insensitive, is the procedure of choice.
OPERATIONS FOR TUMOR OF THE BREAST.
For benign operations on the breast, including extirpation of adenoma and total extirpation of the mammary gland, a large subcutaneous lozenge, is circumscribed through 4 or 5 wrheals. Next, the sub- mammary tissue is infiltrated, thus completing an absolute circumferential anesthesia. A large amount of y2 per cent, solution — 100 or 150 mils — is re- quired. Half of the liquid runs off with the blood during the operation. We have injected as much as 250 mils without any harmful after-effects.
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REMOVAL OF CANCER OF THE BREAST.
Procaine-adrenin has been used by us several times for this purpose, not only in thin women, but also in fat women with some contraindication to general anesthesia, such as renal insufficiency, myocarditis, etc. The results were good. At times inhalation of ethyl chloride became necessary, how- ever, at the time of dissection of the axilla.
The technique comprises the following steps :
(a) Blocking of the brachial plexus with 10 mils of the i per cent, solution, injected from above the clavicle or in the axilla. The latter route presents the added advantage of anesthetizing simultaneously the surrounding cellular tissues.
(b) Paravertebral injection from D. I to D. 10 with 50 mils of i per cent, solution. (c) Sub- cutaneous injection of 100 mils of y2 per cent, procaine-adrenin, starting at the acromion, follow- ing the clavicle to block the cervical plexus, then the midline of the thorax, the lower border of the thorax, and finally passing backward to the promi- nence of the latissimus dorsi. In the case of an obese W'Oman, we employ ordinarily 150 mils of procaine-adrenin; large amounts of the fluid run off, however, during the operation. By the use of hypotonic saline solution the dose of procaine- adrenin injected may be reduced.
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162 REGIONAL ANESTHESIA.
OPERATIONS IN THE AXILLA.
Theoretically, the brachial plexus may be blocked by supraclavicular injection and the first 5 inter- costal nerves by paravertebral injection. To the inexperienced operator we advise, however, merely an infiltration of the axilla, as explained later.
ABDOMEN.
If the operative procedure required consists merely of incising an anterior peritoneal abscess, appendicular or otherwise, simple infiltration of the wall by Reclus's method is sufficient. For an operation involving prolonged maneuvers, such as exploration of the abdomen, recourse must be had to anesthesia of the wall at a distance and to paravertebral anesthesia.
(A) Infiltration of the wall at a distance from the field of operation results in a block of the nerve supply and yields a perfect anesthesia, but one which is only parietal. While the viscera are not reached, the incision, separation, and suture of the abdominal wall are rendered painless. The viscera, furthermore, are only slightly sensitive pro- vided no traction be exerted. This semi-sensibil- ity on their part permits of the performance of gastro-enterostomies and intestinal resections under parietal infiltration, without shock.
In some instances, after the abdomen has been opened, the anesthesia can be continued by direct
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injection of quinine and urea solution into the mesentery. One mil of a I per cent, solution may be injected into the meso-appendix for appendicec- tomy, and a few drops of a i per cent, solution in the vicinity of each omental vessel for resection of the omentum. Such injections between the two layers of the peritoneum, along the vessels, gives a perfect anesthesia; but it is only practicable in certain special cases. For resection of the stom- ach, for instance, we anesthetize the nerves of the organ by infiltrating the peritoneum in the vicinity of the coronary artery, the pylorus, and the two gastric omenta. Only very gentle handling is, however, permissible, or during painful manipula- tions some drops of ethyl chloride, chloroform, or ether will have to be administered. The anesthe- sia is often incomplete, demanding either some mental encouragement of the patient or a few whiffs of an anesthetic. In three-fourths of the cases this method proves effective, and permits of the performance of severe operations without shock.
(B) Paravertebral anesthesia, on the other hand, gives absolute anesthesia, at least on the side of the body on which it is made. It must be bi- lateral if the viscera are in or pass beyond the median line. A choledochotomy, or removal of a tumor of the cecum, can be perfectly performed under right-sided paravertebral anesthesia. For a nephrectomy, or the removal of a circumscribed tumor of the colon, unilateral anesthesia is like- wise sufficient. To operate on the stomach (gas-
164 REGIONAL ANESTHESIA.
trectomy) or pancreas, however, both sides must be injected.
The operator may manipulate throughout the abdomen by infiltrating from the 5th intercostal to the 2d lumbar nerve on both sides. The re- quired 22 injections are, however, distressing and involve the use of a large dose of procaine- adrenin.
On several occasions we have made a trans- verse bilateral incision after paravertebral infiltra- tion of only 6 nerves on each side; the anesthe- sia was perfect. For the stomach, we do not em- ploy this procedure systematically because we pre- fer the long vertical incision, and we confine the anesthesia to simple infiltration of the abdominal wall with injection of quinine and urea in the mesentery. The two forms of anesthesia may be combined by (a) making a double paravertebral injection of the D. 6, 7, 8, and 9 nerves, — 8 in- jections all told, 4 on each side — to anesthetize the stomach and epigastric wall, and (b) infiltrat- ing in the midline below the umbilicus for a dis- tance of 5 to 6 centimeters with a weak anes- thetic solution.
Practice with paravertebral injections induces the surgeon to employ them more and more fre- quently in his work, as they are particularly adapted for abdominal surgery. The more experi- enced the. surgeon in the technique, the more in- clined he becomes to substitute the procedure for parietal infiltration. I shall present, however, with reference to each operation, the details of the
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latter, pointing out at the same time the precau- tions to be taken during the course of the opera- tion under regional anesthesia.
OPERATIONS UPON THE STOMACH. GASTROSTOMY AND GASTRO-ENTEROSTOMY.
Three dermal wheals are infiltrated, — one at the level of the ensiform cartilage, the others at
Fig. 116. — Infiltration for supraumbilical laparotomy. Six wheals. For gastrectomy and gastroenterostomy.
the free borders of the ribs 10 or 12 centimeters from the first. The subcutaneous cellular tissues and portions of muscle attached to the costal border are infiltrated successively in order to block the
166 REGIONAL ANESTHESIA.
nerve filaments that supply the midline over two- thirds of its length above the umbilicus. The ab- dominal wall can then be immediately incised, either to the right or left of this line. Next, the skin and muscles over the free borders of the ribs on the left side are infiltrated for a distance of 10, 12, or 15 centimeters.
Manipulations of the stomach being but slightly painful, all complementary anesthesia is useless. The infiltration requires from 100 to 120 mils of the weak solution to completely relax the abdom- inal muscles. Such anesthesia is sufficient also for gastro-enterostomy. We inject previously, how- ever, pantopon or scopolamine-morphine.
GASTRECTOMY.
The same paracostal incision is made, but in a bilateral form (Fig. 117). The operation is rather more painful owing to the extensive and pro- longed manipulation of the stomach involved. If a complete anesthesia is considered advisable, it is necessary either to institute a double paraver- tebral anesthesia (6 nerves on each side) or after the abdomen is opened to give some whiffs of chloroform or infiltrate the mesentery with qui- nine and urea. It will be sufficient to chloroform the patient slightly during the liberation and ex- ploration. The suturing and cutting of the intes- tines are painless. The mental condition of the
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patient is all-important. There are great contrasts between individual temperaments. Some patients do not utter a word during the operation, while others cry out for an anesthetic and never cease com- plaining.
Fig. 117. — Infiltration for high laparotomy. (Sourdat.) Yields a larger area of anesthesia than the preceding. For gastro-enterostomy ; operations on the gall-bladder and colon.
MEDIAN HYPOGASTRIC INCISIOX.
We seldom practice abdomino-pelvic operations under local anesthesia. Yet the evacuation of a tuberculous ascites or the removal of a movable tumor of the ovary may be very easily effected with this procedure. The pedicle should be in- filtrated with a i per cent, solution of quinine and
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urea without injecting the viscera; it can then be easily crushed and tied without pain.
Cesarean section can readily be practised under infiltration anesthesia. A lozenge-shaped area three finger-breadths wide, in the median line, is infiltrated so as to block the musculo-cutaneous endings of the abdominal nerves. Opening of the abdomen is thus rendered painless, the peritoneum having been anesthetized by the blocking of the parietal nerves. The uterus is almost insensitive; yet it is well to anesthetize it with quinine and urea, infiltrating a strip of uterine tissue on each side of the intended uterine section at a distance of two or three finger-breadths from the median line. There is little bleeding.
In hysterectomy, as for cancer, fibroids, or sal- pingitis, we prefer lumbar spinal anesthesia, but bilateral paravertebral anesthesia will also serve the purpose. One must inject twelve pairs on each side, — the six lower intercostals, three lum- bar, and three sacral. For the lesser operations, such as hysteropexy, removal of ovarian cysts, etc., we prefer a brief general anesthesia.
Hypogastric anesthesia for cystotomy is insti- tuted through two wheals, the one at the umbili- cus and the other at the pubis. Through these one infiltrates, not in the median line, but on either side, the skin and muscles. The peritoneum is itself anesthetized. The muscles must be anes- thetized, and not the linea alba, — that they may be separated without pain.
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OPERATIONS IN THE ILIAC FOSSA. ILEOCECAL REGION.
Here it is well to institute a sufficiently low paravertebral anesthesia, i.e., one involving the last two intercostal nerves and the first three lum- bar. If, owing to the technical difficulties, the operator prefers to block the nerves nearer the
Fig. 118. — Infiltration for operative work in the ileocecal region. (Pauchet.) A diamond-shaped figure under the skin and in the muscles, circumscribing the future incision, should be infiltrated. For appendicitis ; ileocecal resection.
field of operation, he can have recourse to infiltra- tion of the abdominal wall in the following man- ner (see Fig. 118 and the subsequent illustrations).
Four dermal wheals are made, in the form of a lozenge. The two lateral wheals are placed, the one inside the anterior superior spine of the ilium, the other, two or three finger-breadths from
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the middle line. The superior and inferior wheals are situated, the one at a distance of three finger- breadths from the first, the other, three finger- breadths from the second. The muscular layers should be infiltrated only at the two upper sides of the lozenge; over the two lower sides only the
Fig. 119. — Deep "fan-shaped" injection to infiltrate the mus- cular mass at the point of emergence of the nerves of the in- guino-crural region. (Pauchet.) (D) Rectus abdominis. (B) Ilio-psoas. (A) Gluteus. (C) Iliac bone. (£) Three direc- tions of the needle: the first perpendicular to the skin, toward the subserous cellular tissue; the second, parallel to the skin, beneath the aponeurosis; the third, intermediate, oblique in the intermuscular space, where the nerves are found. (1) Dermal wheal.
subcutaneous cellular tissue is to be infiltrated. The infiltration of the muscles produces not only anesthesia of these structures, but also anesthesia of the peritoneum.
With this procedure we have performed the following operations: Cecostomy, resection of the ileocecal segment for cancer or tuberculosis, ap- pendicectomy, closing of intestinal fistula, and en- terostomy.
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The incision in the abdominal wall and the separation of the wound margins are painless, but it is necessary to infiltrate the meso-appendix or the end of the mesentery with quinine and urea if section of this last structure is indicated.
Fig. 120. — Same as the preceding. (Pauchet.) Horizontal section at the level of the iliac spine. (1) Rectus abdominis. (2) and (3) Ilio-hypogastric and ilio-inguinal nerves, situated at this point between the internal oblique and transversalis muscles. (4) Genito-crural nerve. (5) Iliac bone. (6) Parietal peritoneum. (£) Wheal situated two finger-breadths within the iliac spine and through which the fan-shaped injec- tion is made.
On the whole, I desire to emphasize the fact that paravertebral anesthesia for the viscera is rather to be recommended. The operation for ap- pendicitis may almost always be performed under it. We have operated upon children of 8 years, and with greater facility children of 10 to 15 years, without general anesthesia.
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Fig. 121. — Deep, "fan-shaped" injection above the anterior superior iliac spine. (Pauchet and Sourdat.) To anesthetize the wall of the iliac fossa, for appendectomy, cecostomy, ileo- cecal resection. The figure shows the manner of direct injec- tion, perpendicular to the plane of the wall.
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Fig. 122. — Oblique injection upward. (Pauchet and Sourdat.) Note the direction imparted to the syringe and needle.
174 REGIONAL ANESTHESIA.
Fig. 123.— Same injection directed obliquely downward. (Pauchet and Sourdat.)
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Ilia-inguinal Ilia-hypo gastric
- crural
Fig. 124. — Paracostal anesthesia — costo-iliac and para-iliac. (Pau- chet.) Anesthesia of the entire abdominal wall (anesthetized zone in gray). To the right are seen the intercostal filaments supplying the abdominal wall, and lower down the ilio-hypogastric and ilio-inguinal nerves, and the genito-crural (vertically directed). To the left of the figure, A, B, and C show the paracostal infiltration of a portion of muscle and of the skin (stomach, liver, and duodenum"). C, D, anes- thesia of the abdominal wall for the ascending colon. E. F. useful for cecal or appendicular operations and for the radical cure of inguinal hernia.
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Fig. 125.— Appendicitis. (Pauchet and Sourdat.) Incision of the abdominal wall.
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Fig. 126. — Appendicitis. (Pauchet and Sourdat.) The ap- pendix and cecum are brought to the exterior.
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Fig. 127. — Anesthesia of the meso-appendix. (Pauchet.) Interval operation. The needle is inserted between the two layers of the meso-appendix, in the vicinity of the appendicular artery. One mil of l/2 per cent, quinine and urea hydrochloride solution is injected. The operator may then tie and divide, without pain, the meso-appendix and the appendix itself.
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Fig. 128. — Quinine and urea anesthesia of the mesenteric nerves before intestinal resection. (Pauchet.) The needle is inserted in the first layer of the mesentery, and 1 or 2l/2 mils of ]/2 per cent, quinine and urea solution injected. The oper- ator is enabled immediately to cut the vascular pedicle and re- sect the intestine without pain. In this instance, it is the transverse colon.
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Fig. 129. — Pylorectomy for callous ulcer. (Pauchet.) First step: Exploration of the abdomen. (Patient from the La Pitie Hospital).
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Fig. 130. — Pylorectomy for callous ulcer. (Pauchet.} Pyloric seg- ment resected. The canal has been incised lengthwise along the greater curvature, then spread out. Lower down, the great omentum is seen attached to the greater curvature by an inflamed lymph-gland. The operative mortality is 8 per cent.
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Fig. 131. — Continent jejunostomy. (Pauchet.) For a large cancer of the stomach. (Patient from La Pitie Hospital).
Fig. 132. — Artificial anus due to wound of the intestine. (Pauchet.) Military wound from La Pitie Hospital (shell splinter). Circular enterorrhaphy.
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Fig. 133. — Ileocecal segment invaded by cicatricial tuberculosis. (Pauchet.) To the right the end of the small intestine may be recog- nized. The cecum has become transformed into a fibrous mass, with a small, hardly perceptible, mucous canal. (La Pitie Hospital.)
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Fig. 134. — Partial gastrectomy for saddle ulcer of the lesser curva- ture. (Pauchet.') First stage of the operation : Separation of the omentum by means of the scalpel. The assistant holds the transverse colon with the left hand; the operator holds the scalpel with his right hand and with the left the omentum is separated from the transverse colon for examination of the posterior surface of the stomach. Mor- tality 8 per cent.
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Fig. 135. — Specimen from the preceding patient. (Pauchet.) Mid- dle segment of the stomach, showing a saddle ulcer of the lesser curva- ture. The resected segment has been laid open along the greater curvature, to which the omentum is attached below. The center of the figure, where the ulcer is found, corresponds to the middle of the lesser curvature.
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UMBILICAL HERNIA.
Umbilical hernias and hernias of the linea alba are operated under lateral infiltration of the mus- cles, in the same manner as for laparotomy. The operator infiltrates successively the skin and the
Fig. 136. — Anesthesia for radical cure of a reducible um- bilical hernia. (Pauchet.) Through the wheals a ring of in- filtration is made, following the dotted line, vnder the skin and in the thickness of the muscles.
muscles down to the subserous cellular tissue with a weak solution. Pauchet, in 1914, operated at Amiens on an obese woman with a strangulated hernia in tfie median line, of the size of an adult's head and containing 1.50 meters of gangrenous intestine. The patient complained somewhat when
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the mesentery was ligated, but it did not become necessary to have her inhale any chloroform. Two hundred and fifty mils of a ^ Per cent, solution were employed.
In an extremely obese woman with a simple umbilical hernia, Pauchet injected as much as 300
Fig. 137. — Location of the wheals and the proper direction of injection for anesthetization in irreducible umbilical hernia. (Pauchet.)
mils of the weak solution. Part of the fluid es- caped, however, during the operation. In making these injections, 12-centimeter needles were em- ployed.
For all these operations, the procedure is al- ways the same. A lozenge-shaped wall of infil- tration around the umbilicus is established. Through four w^heals all of the subcutaneous tissue and
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muscles are infiltrated, following the lines that form the lozenge. In cases of umbilical hernia and post-operative eventration, injection of quinine and urea into the omentum, about the vessels, is
Fig. 138. — Injection for irreducible umbilical hernia. (Pauchet.) The infiltration is conducted at a distance from the ring and through the entire thickness of the wall.
an important preliminary to resection of the omen- tal membrane, which under this treatment becomes absolutely insensitive.
INGUINAL HERNIA.
The operation for inguinal hernia is without doubt, of all operations, that in which regional anesthesia gives the greatest satisfaction, no mat- ter how voluminous the hernia may be. That it is indicated is due to three factors: (i) The disease itself" is hardly more dangerous than gen- eral anesthesia; the latter may give rise to a bron- chitis that is prejudicial to consolidation at the
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points of suture; (2) the resultant vomiting has the same tendency; (3) regional anesthesia, which, it must be recognized, is imperfect for certain operations, shows its utility for the radical cure
Fig. 139. — Nerve supply of the inguinal region (diagram- matic). (Pauchet.) Points of emergence of the genito-crural, ilio-hypogastric, ilio-inguinal, and of an anterior branch of the 12th intercostal. For anesthesia of the inguino-crural region they should be reached here by injection. The needle should be introduced within the anterior superior iliac spine.
of inguinal hernia when properly employed, and the technique for this operation is very simple. In April, 1916, at the La Pitie Hospital we op- erated on an inguinal hernia of the size of a large adult's head, without the slightest pain.
190 REGIONAL ANESTHESIA.
Paravertebral anesthesia will yield a perfect anesthesia at a distance and seems to us the pro- cedure of election. No matter how large the her- nia, it will be sufficient to inject the two lower intercostal and upper three or four lumbar nerves. Yet the great majority of surgeons prefer anes- thesia by localized infiltration of the nerves of the region, the technique of which is as follows:
Figures 139 and 124 show the innervation of the groin and of the crural region respectively. The genital branch of the genito-crural reaches the spermatic cord through the internal ring and accompanies it in the canal and in the skin of the scrotum or of the labia majora. The ilio-in- guinal is situated above the iliac spine, between the oblique muscles; it passes under the aponeu- rosis of the external oblique, emerges from the inguinal canal upon the anterior surface of the cord and of the sac, and ends in the skin of the scrotum or mons veneris. The ilio-hypogastric, parallel to the preceding and slightly higher up, makes its way between the two oblique muscles; reaching the inguinal region, it passes under the aponeurosis of the external oblique, crosses through the anterior layer of the sheath of the rectus, and ends in the skin of the groin. These three nerves anastomose with each other. It is necessary, therefore, that all three be anesthetized. They are all to be found grouped together in a space of 2 or 3 finger-breadths within and above the iliac spine.
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REDUCIBLE INGUINAL HERNIA.
Two wheals are made, the first two finger- breadths within the anterior superior iliac spine and the second corresponding to the pubis at the
Fig. 140. — Anesthesia for irreducible inguinal hernia. (Sourdat.) Location of the two wheals. The arrows show the direction of the deep injections. The unbroken line out- lines the subcutaneous infiltration.
level of the external abdominal ring. Through wheal No. i, infiltration is executed according to the scheme shown by the arrows in Figs. 119 and 1 20. All the muscular layers situated be- tween point i and the ilium are infiltrated, using
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/ON
Fig. 141.— Same as the preceding. (Sour dot.) A wheal is made two finger-breadths within the anterior superior iliac spine. The second wheal is made above the horizontal ramus of the pubis. The black line shows the subcutaneous infil- tration.
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20 mils of a i per cent, solution. A Q-centimeter needle is introduced perpendicularly, passing through the aponeurosis of the external oblique, the inter- nal oblique, and the transversalis muscle. It is then inserted so as to cover a fan-shaped sector, and more and more obliquely toward the spine of the ilium. The muscular layer here is very thick. This injection reaches the ilio-hypogastric and ilio-inguinal nerves. Through point i, it is necessary to infiltrate anew under the aponeurosis of the external oblique a strip ending at two points situated, respectively, within and externally to the hernial ring, using approximately 20 mils of the weak solution. Through wheal Xo. 2, 10 mils of the solution are injected in a fan-shaped area to the line of the cord; the needle should strike the pubic bone. Through the same point, 10 mils are next injected in the inguinal canal itself along the cord. Finally, subcutaneous infiltration is conducted following the lozenge-shaped figure shown in the illustration, approximately 100 mils of the wreak solution — ]/2 per cent. — being used altogether (Figs. 140 and 141).
IRREDUCIBLE OR STRANGULATED INGUINAL HERNIA.
Four wheal s are made as indicated in Fig. 142. Through wheal No. i one injects, as before, against the iliac bone, and continues toward wheals Nos. 2 and 3, injecting under the aponeu-
13
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REGIONAL ANESTHESIA.
rosis. Next, two deep injections are made through points 2 and 3. While the left hand pushes laterally inward and outward the hernia mass, the needle is inserted as far as the pubis, under the
Fig. 142. — Lines of infiltration for inguinal hernia. (Sourdat.) For irreducible or strangulated hernia.
hernia, and injection made deeply in the canal through points 2 and 3 along the neck of the sac. Finally, a subcutaneous injection between the points 1-2-3 and 2-3-4, is made. For a large hernia 150 mils of the weak solution may be used.
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We prefer in such cases the paravertebral form of anesthesia, which deals with the nerves supplying the cord. The procedure just described, however, will likewise give satisfaction (Figs. 142 and 143).
Fig. 143. — Anesthesia of the scrotum for irreducible her- nia. (Sourdat.) Subcutaneous infiltration of the root cf the scrotum through a crown of wheals.
FEMORAL HERNIA.
The nerve supply in femoral hernias is essen- tially that of the inguinal region. The anesthetic procedure, therefore, is almost the same:
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REGIONAL ANESTHESIA.
Four dermal wheals are made. Point I occu- pies the same place as in inguinal hernia, viz., two finger-breadths within the anterior superior iliac spine. Points 2 and 3 are within and out-
Fig. 144. — Reducible femoral hernia. The deep injections (arrows) and subcutaneous circuminfiltration are made through wheals 1, 2, 3, and 4.
side of the hernia, respectively, and at both ends of the intended femoral incision, parallel to the femoral arch. Point 4 is below the hernial mass. One starts with the intramuscular injections at point I. Through this one injects under the aponeurosis up to and outside of the neck. Then,
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Fig. 145.— Irreducible femoral hernia. (Pauchet.) A fan- shaped intramuscular injection is made through point A. Infiltration of a subcutaneous band surrounding the hernial tumor and neck is conducted through points A, B, C, and D.
Fig. 146. — Anesthesia of the hernial sac and testicle by infiltration of the cord. Injection of the cord in the inguinal canal.
198 REGIONAL ANESTHESIA.
under the femoral arch through point 4, 10 mils of the solution are infiltrated around the neck, and very close to it. Finally, subcutaneous infiltration is effected. The femoral arch is anesthetized by this procedure. If it be necessary to combine an inguinal incision with the high femoral incision, the anesthesia will be sufficient for the purpose. We have never been compelled to give ethyl chlo- ride to the patient during the liberation of the intestine. When, however, in a stout patient, we contemplated radical cure of a femoral hernia through the inguinal route, the patient complained somewhat while we were working deeply, showing ' that the anesthesia had been incorrectly instituted.
OPERATIONS UPON THE KIDNEY.
Nephrectomy is another operation for which regional anesthesia is indicated. This method saves the renal tissue in the same way as it does the hepatic. The anesthesia, moreover, is com- plete. The lateral position of the subject can be maintained without the help of an assistant, the patient's voluntary aid being sufficient. Decortica- tion of the kidney and the ligation of the pedicle are painless. We employ unilateral paravertebral injection of the six lower intercostal and of two lumbar nerves. When once familiar with the technique, one no longer finds it necessary to have the patient inhale any additional anesthetic at the time of decortication of the kidney.
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OPERATIONS UPON THE BILIARY PASSAGES.
It is advantageous to perform these without ether or chloroform, the harmful action of which upon the hepatic cells is well known. Our first operations under paravertebral anesthesia were done upon patients suffering from chronic jaun- dice,— of two months' standing in one instance (pancreatic tumor) and in another, six months (for- mer lithiasis, with acute obstruction of the ductus choledochus). The post-operative course \vas de- void of complications, and the operations were ab- solutely painless, even in the second case, ren- dered difficult by multiple, long-standing adhesions. Since then all of our hepatic and biliary opera- tions have been conducted under paravertebral anesthesia.
Right-sided paravertebral infiltration of the six lower intercostals and first two lumbar are re- quired for the purpose. Here, as in the case of the kidney and other similar operations, one is struck by the frequent diminution of post-opera- tive pain in the succeeding twenty-four hours. The method allows of the performance of chole- cystectomy. Vertical or transverse incisions may be employed provided they do not cross the median line. The cushion placed under the chest may be a cause of suffering, which is obviated by a pre- vious injection of morphine.
CHAPTER VI.
ANESTHESIA OF THE GENITOURINARY ORGANS AND RECTUM.
THE pelvic organs and external genitalia are supplied by the internal pudic nerve, the small sciatic, and the sacral and coccygeal plexuses, which anastomose with branches from the pelvic sympa- thetic.
Fig. 147. — Nerve supply of the perineum in the male. (Pauchet.) Trunk of the internal pudic nerve and branches of the small sciatic.
The internal pudic nerve emerges from the
pelvis through the great sciatic notch, winds around
the external 'surface of the sciatic spine, traverses
the ischio-rectal fossa, and gives filaments to the
(200)
GENITOURINARY ORGANS AND RECTUM,
201
Fig. 148. — Nerve supply of the perineum in the female. (Pauchet.) Internal pudic nerve and branches of the small sciatic.
Fig. 149. — Sensory segments of the perineum correspond- ing to the last spinal pair. (Pauchet.) The branches S indi- cate the sacral nerves, with the number of the foramen of emergence. The branches L are lumbar. The number is that of the corresponding segment. (See also Figs. 220 and 221.)
202
REGIONAL ANESTHESIA.
skin of the perineum, anus, posterior half of the scrotum, penis, and vulva. The anterior half of the scrotum and of the labia majora is supplied by the genito-crural and the ilio-inguinal. The
Fig. 150. — Pre-sacral anesthesia. (Pauchet.) To reach all sacral foramina but the first, the needle is introduced between the anus and coccyx and follows the anterior surface of the sacrum to each foramen. To reach the first sacral foramen, the needle is inserted at the same point but is pushed directly through the tissues to reach the sacral brim When the bone has been reached, the injection is made.
2d, 3d and 4th sacral pairs constitute the hypo- gastric plexus, and through it supply the bladder, prostate, icterus, rectum, and pelvic peritoneum.
Regional anesthesia for the above operations is simple and easy of application, and the various regions involved and methods of treatment are
GEXITO-URINARY ORGANS AND RECTUM. 203
Fig. 151. — Trans-sacral anesthesia. (Pauchet.) Note the depth to which the needle B penetrates to reach the pos- terior foramen Si. On the contrary B finds the orifice 55 immediately beneath the skin. The needle penetrates ap- proximately 25 millimeters to reach the first sacral foramen, 20 for the second, 15 for the third, and 10 for the fourth, and should be driven about 1 centimeter into each canal in order to reach the anterior as well as the posterior division of the nerve. It is well to introduce the index finger into the rectum in order to be certain that the point of the needle is not pene- trating the rectal wall.
204
REGIONAL ANESTHESIA.
Fig. 152. — Pre-sacral and trans-sacral anesthesia. (Pauchet.) The tirst of these procedures is indicated in the obese and the second in thin subjects. In the latter the bony landmarks are more easily found. Note the direction followed by the pre- sacral needle for each foramen. The first four anterior arrows reach the foramina 5, 4, 3, and 2. The needle point should be kept in constant contact with the concavity of the sacrum, and should always be parallel to the middle line of this bone. The arrow dq^tined for Si aims directly at the superior strait of the pelvis. As soon as it comes in contact with this, the needle is at the sacral foramen ST. If injury of the rectum is appre- hended, a finger should be inserted in it during the introduc- tion of the needle.
GENITOURINARY ORGANS AND RECTUM. 205
fully shown in Figs. 147 to 158. In Fig. 152 are shown the two methods of application. In thin subjects the injections are made through the five sacral foramina. In stout subjects it is often easier to reach the sacral nerves by introducing the needle at a point between the rectum and the tip of the coccyx, and infiltrating the concavity of the sacrum with a I per cent, solution of pro- caine-adrenin.
ANTERIOR SACRAL (PRE-SACRAL) ANESTHESIA.
The patient is placed in the dorsal position, with the thighs flexed upon the abdomen. After proper preparation of the skin with iodine and alcohol, an intra-dermal wheal is formed at a point midway between the anus and the tip of the coccyx, thus permitting the introduction of the suc- cessive needles without pain.
Through the wheal thus formed a needle 9 centimeters long is introduced and with its point the inferior and outer border of the sacrum about 2 centimeters from the median line is found. The needle is now pushed forward, with its point in constant contact with the anterior face of the sacrum, for about I centimeter, which should bring the point to a level with the fifth sacral foramen. Five mils of a i per cent, solution are thereupon injected.
One then continues upward, parallel and at about 2 centimeters from the median line, keeping the needle point constantly in contact with the sur-
206 REGIONAL ANESTHESIA.
face of the bone, at a distance of about 1^2 to 2 centimeters from the point already injected, when it should be at the level of the fourth sac- ral foramen. Here again 5 mils of I per cent, solution are injected. Then, with the needle in contact with the bone and always about 2 centi- meters from the median line, one proceeds about 1 1/2 to 2 centimeters higher up to the third fora- men, w7here 5 mils should again be injected. In the same manner the needle is pushed upward a fourth time to the second foramen, where the same amount of solution is again injected. The needle is next drawn back to the starting point and the same manipulation repeated on the oppo- site side of the median line, thus bringing under control both sets of nerves.
The first needle is now replaced by one 12 centimeters long, the gloved finger placed in the rectum, and the needle introduced at the same point. Instead of following the surface of the bone, however, one next pierces directly upward to a depth of 9 to 10 centimeters, and with the finger in the rectum aiding as a guide, aims to strike the upper part of the sacrum as it tilts forward. At this depth, about 2^ centimeters from the median line and against the bone, the first sacral foramen is attained. Five mils of solu- tion are injected and the procedure repeated on the opposite side. The last injection is an extra precaution. As a rule it is not needed, complete anesthesia of the parts being secured by injection of the other four pairs.
GENITO-URINARY ORGANS AND RECTUM.
207
ANESTHESIA THROUGH THE SACRAL FORAMINA — TRANS-SACRAL ANESTHESIA.
The patient is placed in the extended posture and face down upon the table. With the aid of
V-5
Fig. 153. — Location of the posterior sacral foramina. (Pauchet.) MM', middle line of the body. V ', spinous proc- ess of the 5th lumbar vertebra. /-/' lines joining the iliac crests. TT', postero-inferior spines of the ilia. H, fourth sacral spinous process. CC, sacral cornua. X, sacral hiatus.
a dermographic pencil, a line is drawn from the crest of one ilium to that of the other (Fig. 156, CC). The relationship of the posterior supe- rior spines of the ilia is shown at EE. The sacral cornua, BB, are now found and marked. From top to bottom a line is drawn directly over
208
REGIONAL ANESTHESIA.
the median line from D to A. A point 4 centi- meters on each side from the median line, on the line CC ', is marked. This point is connected on
Fig. 154. — Posterior surface of the sacrum, showing the posterior sacral foramina and sacral nerves. (Pauchet.) A, the interiliac line. B, line joining the two postero-inferior iliac spines. M, line joining the two middle spinous processes. C, horizontal line passing through the two sacra) cornua at the level of the sacral foramen, 55. The oblique line corres- ponds to the situation of the sacral foramina; it is located 25 millimeters from the middle line at the level of the two sac- ral cornua. Note that the lumbo-sacral space, through which spinal anesthesia may be induced (Le Filliatre) is at the mid- dle of the interval that separates A from B. K, point cor- responding to the fourth sacral spinous process. 84 is situated 1 centimeter outside of K.
each side by a line drawn downward to the point B. * The line passes directly over the five sacral foramina. Commencing- at the top, the first foramen is found on this line directly opposite the
GEX1TO-UR1XARY ORGANS AXD RECTUM 209
tip of the spinous process of the fifth lumbar vertebra (Fig. 153).
At a point ^l/> centimeters below on the same line will be found the second foramen. Two and one-half centimeters further down is the third; 2 centimeters down is the fourth, and il/2 below this is the fifth. The first is about 35 mm. from the median line ; the second, 30 ; the third, 25 ; the fourth, 20, and the fifth, 15 mm.
Technique of the Injections. — The spine is painted with iodine, which is then removed with alcohol. "With a fine needle five dermal wheals are injected on each side of the median line at points overlying the sacral foramina. One com- mences at the top with a needle 9 centimeters long; if it does not at once enter the foramen the operator will readily find the opening by feeling about with the point of the needle. The latter should penetrate to a depth of about 25 mm. for the first foramen; 20 mm. for the second; 15 mm. for the third; 10 for the fourth, and 5 for the fifth. Five mils of a I per cent, solution are to be injected at each opening.
In feeling about with the point of the needle, seeking the opening, the operator will suddenly sense the absence of resistance as the needle en- ters the foramen, and at the same moment the patient is likely to complain of a disagreeable sen- sation in the abdomen or legs which is proof that the nerve has been struck. After fifteen minutes the operation can be begun. The anesthesia lasts from one and one-half to two hours.
14
210
REGIONAL ANESTHESIA.
Fig. 155. — Trans-sacral anesthesia of the pelvic organs and pelvic peritoneum. The two iliac crests should be felt for and the line AB marked out. The prominent postero-inferior spine is at C, and the sacral cornu at D (sacro-coccygeal articulation). C is placed slightly too high in the sketch. The reader will notice at his right the promi- nent postero-inferior spine exactly outside of the sacral foramen, 82. 5*5 is exactly outside of the sacral cornu. 82 and Si are separated by the width of the thumb, as are also S2 and 5j. $4 and S$ are sep- arated by the width of the little finger; the former corresponds to the summit of trie sacral hiatus. The sacral foramina are situated on a line starting from the sacral cornu 15 millimeters from the median line and ending at the line AB, 35 millimeters from the median line. Z, the lumbosacral hiatus, is at the same distance from $2 and from AB. XY corresponds to the 5th lumbar. These landmarks are utilized in posterior sacral anesthesia as well as in spinal anesthesia.
GENITOURINARY ORGANS AND RECTUM.
211
Sacral injections anesthetize the labia, pros- tate, bladder, rectum, anus, uterus, and skin of the posterior surface of the thigh. We use this method to do prostatectomies, extirpation of the
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. " *" "^^^^^™""*T^i""Tr"^^7p^
Fig. 156. — Trans-sacral anesthesia. (Pauchet.) (Posterior land- marks: Fig. 155). CC, inter-iliac line. EB, BE, a trapezoid figure the base of which measures 8 centimeters and the summit, 3 centi- meters. The points BB correspond to the sacrococcygeal articulation and the cornua of the sacrum; they are located 15 millimeters from the midline. The 5th sacral foramen is situated immediately outside of them. Ei, postero-inferior iliac spine (here shown a little high). The black dot between D and the line Ei, Ei should be at equal dis- tance from D and Ei, Ei, i.e., in the lumbo-sacral space or area of election for lumbar puncture. The distance separating each sacral foramen from the midline is also shown. The finger, T, shows that there is a finger-breadth of distance between the sacral foramina. The needle is entering foramen Xo. 4.
212
REGIONAL ANESTHESIA.
rectum, radical cure of prolapsus uteri, all vesical operations, curettage of the uterus, and catheter- ization of the ureters in man (for tuberculosis, cystitis, etc.), but the parietal peritoneum is not sufficiently anesthetized to permit of a hysterectomy. (See also Figs. 220 and 221, p. 282.)
Fig. 157. — Trans-sacral anesthesia in man. (Pauchet.) This permits of operating upon a cancer of the rectum, hemor- rhoids, prostatic adenoma, tumor of the bladder, amputation of the penis, etc.
OPERATIONS UPON THE BLADDER.
SUPRAPUBIC CYSTOSTOMY.
To periorm a suprapubic cystostomy, the trans- sacral and hypogastric forms of anesthesia com- bined are necessary. For a cystostomy a lozenge
GENITOURINARY ORGANS AND RECTUM. 213
is made the long axis of which corresponds to the lower half of the distance between the umbilicus and the pubis. The skin and muscles are infil- trated with the weak solution. The bladder is not anesthetized; but infiltration of the space of Retzius sufficiently diminishes its sensibility. One
Fig. 158. — Trans-sacral anesthesia in woman. (Paucket.) The gray area shows the region anesthetized by injection of the sacral nerves (pelvis and perineum). This enables the surgeon to operate upon cancer of the rectum, hemorrhoids, prolapsus uteri, or cystocele, and the obstetrician to use for- ceps without pain.
should add an intravesical injection of 50 mils of a y? per cent, solution, allowed to remain dur ing- fifteen or twenty minutes for a simple section and vesical exploration. The bladder is rendered en-
214
REGIONAL ANESTHESIA.
tirely insensitive by the sacral injections, but the abdominal wall must be infiltrated in addition be- fore it is incised.
i
Fig. 159. — Suprapubic cystostomy. (Pauchet.) The opera- tor makes two wheals, 1 and 2; then infiltrates the subcuta- neous cellular tissues for a thumb's width to the right and left, and the two recti abdominis. Through wheai 1, he injects the space of Retzius in order to desensitize the bladder.
OPERATIONS UPON THE TESTICLES AND SCROTUM.
The operator should first anesthetize the cord, then make a ring of anesthesia about the base of the scrotum, on both sides. A wheal is made over the external abdominal ring. With the left hand, the cord is held firmly over the pubis, a needle detached from the syringe inserted, the cord
GENITOURINARY ORGANS AND RECTUM. 215
Fig. 160. — Anesthesia of the testicle. (Pauchet.) Infiltra- tion of the cord by transfixion of it upon the pubis. In order not to miss the cord, the needle is pushed successively in two or three divergent directions.
Fig. 161. — Anesthesia of the testicle. (Pauchet.) Infiltra- tion of the cord. The latter is pinched between the fingers through the skin, raised between two fingers, and injected.
216
REGIONAL ANESTHESIA.
transfixed upon the pubis, then, after slight with- drawal of the needle, 5 mils of the weak solu- tion injected; this infiltrates the cord. To make certain, the maneuver is repeated and the cord immobilized upon the pubis, transfixed, and infil- trated with 5 mils of the weak solution. Then,
Fig. 162. — Operations upon the scrotum. (Pauchet.) A band of subcutaneous infiltration circumscribes its base.
with the left index finger, the operator finds the exter- nal inguinal ring, introduces the needle from 6 to 9 centimeters into the inguinal canal, and injects anew 10 mils of the weak solution.
To anesthetize the scrotum, the operator should work all the way round its base, starting at the lower surface of the penis, and, passing around,
GENITOURINARY ORGANS AND RECTUM. 217
infiltrate the subcutaneous tissue until he gets back to the starting point. He then passes in front of the perineum and in the genito-crural folds. The weak solution is sufficient; 50 mils, more or less, are required.
OPERATIONS UPON THE PENIS.
If it is desired to effect merely a dorsal incision of the prepuce, with simple section of the frenum,
Fig. 163. — Anesthesia of the prepuce by a coronal injection. (Pauchet.)
the skin should be infiltrated in the median line by the "Reclus method" from the anterior aspect of the prepuce to the corona of the glans. One is thus enabled to slit the prepuce with scissors and suture the borders of the wound. A second in- jection being made at the level of the frenum, this may be split and one or two sutures taken
218
REGIONAL ANESTHESIA.
in it. We favor this simple operation, rather than that of circumcision.
If the operator wishes to do an ordinary cir- cumcision, amputate the penis, or operate upon a hypospadias, it will be necessary for him to insti- tute a total anesthesia of the penis in the follow- ing manner: A wheal is made at the right and left of the root of the penis, wrhere the cord
/ I
Fig. 164. — Anesthesia of the penis. (Pauchct.) Through two wheals an injection is made at first deeply up to the roots of the corpora cavernosa and the suspensory ligament, then under the skin in circular fashion.
crosses over the horizontal ramus of the pubis. Through this wheal the needle is introduced up to the corpora cavernosa, under the suspensory liga- ment of the penis, and deeply around the penis. Forty mils of a ^2 per cent, solution of procaine- adrenin are injected. This injection will anes- thetize the urethra, corpora cavernosa, glans penis, etc.
GENITO-URINARY ORGANS AXD RECTUM. 219
OPERATIONS UPON THE POSTERIOR URETHRA.
For suture of the urethra, urethrotomy, etc., a wheal is first made in front of the anus in the median line. Then, through this wheal, the ver- tical plane of tissue that separates the anus and rectum behind from the urethra, bulb, and pros- tate in front is infiltrated. The left index finger is placed in the rectum and with the right hand a 9-centimeter needle is taken and passed in in the median line, very high up between the pros- tate and rectum; the operator now injects while withdrawing it. He then begins anew, without wholly withdrawing the needle, and passes to the right and to the left, in order to infiltrate a space 9 centimeters high and 2 or 3 wide. This plane separates the rectum and anus behind from the prostate and urethra in front. All the subcutane- ous cellular tissues and the muscles should be in- filtrated.
Finally, it is necessary to infiltrate the plane of section corresponding to the incision in peri- neotomy for operations on the prostate. The op- erator may in this way go up as high as the neck of the bladder and the prostate with per- fect anesthesia. Yet, anesthesia by the sacral fora- mina is in every way preferable.
220 REGIONAL ANESTHESIA.
OPERATIONS UPON THE PROSTATE. PROSTATECTOMY.
A choice may be made from one of the four following methods of anesthesia :
1. Periprostatic infiltration through the bladder.
2. Periprostatic infiltration through the peri- neum.
3. Anterior sacral anesthesia.
4. Posterior trans-sacral anesthesia.
i. Periprostatic Anesthesia Through the Blad- der.— (a) The operator begins by anesthetizing the abdominal wall, as for a cystotomy, then the space of Retzius. The simple infiltration of these tissues yields a satisfactory anesthesia. The injec- tion must be carefully pushed into the entire thicknesses of the muscles, in order to be able to separate them without pain.
(b) For anesthesia of the prostate, the blad- der having been opened, the operator takes a long curved needle (Legueu?s) and passes through the mucosa of the bladder around the prostate, with the finger as guide. Approximately 150 mils of the weak solution of procaine-adrenin is used. Five or six minutes after this infiltration the op- erator may begin removing the prostate.
2. Periprostatic Anesthesia Through the Peri- neum.— The operator, after having infiltrated the abdominal wall as in the preceding method for a suprapubic section, must anesthetize the tissues between the two ischia, comprising the skin and soft parts situated between the urethra in front,
GENITO-URINARY ORGANS AND RECTUM.
221
and the rectum and anus behind. This form of infiltration is useful for all operations upon the perineum (see Fig. 165).
To reach the prostate, the operator places his left index finger in the rectum in contact with the hy- pertrophied organ. With the right hand a 9- centimeter needle is introduced into the perineum and guided up toward the prostate by the aid of
Fig. 165. — Anesthesia of the anterior portion of the perineum through a wheal in front of the anus. (Pauchet.)
a finger in the rectum. When the needle has at- tained the periprostatic region, 50, 60, or 80 mils of the weak solution of procaine-adrenin are injected.
3. Anterior Sacral Method. — This consists in infiltrating all of the concavity of the sacrum with a i per cent, solution. The needle should pass between the rectum in front and the sacrum be-
222 REGIONAL ANESTHESIA.
hind. The operator injects approximately 5 mils of procaine-adrenin opposite each one of the sacral foramina. It is unnecessary to inject the upper foramen (see Fig. 152 and detailed descriptions, including that of the trans-sacral method, at the beginning of this chapter).
4. Trans-sacral Method. — The operator must be experienced before such an anesthesia will prove perfectly satisfactory, but after some ex- perience the trans-sacral method, which is by long odds the best, will be the one chosen.
With this procedure, very little of the anes- thetic is required, and all that is needed in addi- tion is the injection of the anterior abdominal wall.
OPERATIONS UPON THE VULVA AND VAGINA.
The posterior half of the vulva is supplied by the sacral nerves ; the anterior half, by the ilio- inguinal and genito-crurals. If the operation in- dicated is one of minor importance, it is best to anesthetize the vulva directly. Three wheals are made, a middle one in front of the anus, and 2 lateral ones at the lower terminations of the labia majora. The soft tissues outside the labia majora are then infiltrated, thus completing the anesthe- sia (Fig. 1 66).
Where it is desired to anesthetize the vesti- bule of the vagina, the above method is not suffi- cient. One must infiltrate with the weak solution, following a frontal plane, in the manner already described for a perineotomy in the male. To infil-
GENITO-URINARY ORGANS AND RECTUM.
223
trate the recto-vaginal septum, a finger should be introduced in the vulva or rectum to guide the 9- centimeter needle. One then infiltrates after Rec- lus's method, using 100 mils of the solution. After this one may operate for a recto-vaginal fistula, perform a perineorrhaphy, etc.
Fig. 166. — Anesthesia of the vulva and vestibule. (Pauchet.)
LIBERATION OF THE VAGINA AND OF THE UTERUS PROLAPSE, COLPORRHAPHY, COLPOTOMY.
The preceding methods may be sufficient; this simple infiltration, however, does not anesthetize the pelvic floor. The vaginal vault should be in- filtrated in addition. To do this, the cervix of the uterus is brought down until it shows at the vulva;
224 REGIONAL ANESTHESIA.
a 9-centimeter needle is introduced into the an- terior cul-de-sac, and 20 mils of solution injected between the bladder and the cervix (not under the mucous membrane). Another injection is now made under the urethral meatus, and this time right and left injections made on each side under the mucous membrane; 10 mils of solution are used. The cervix is pulled to the right and an injection made into the left lateral cul-de-sac, in- filtrating the base of the broad ligament, using 15 mils. The operator begins anew on the right side, then introduces the 9-centimeter needle into the posterior cul-de-sac, between the vaginal mu- cous membrane and Douglas's cul-de-sac, injecting 20 mils. The uterus is now released and the perineum infiltrated as previously described. In all at least 200 mils are necessary.
A satisfactory anesthesia is obtained in a pre- cise and simple way with the sacral method; but by this procedure no hemostasis is assured, while on the contrary, if infiltration is practised after Reclus's method, the operation is bloodless. In perineorrhaphy this is an advantage; from the anatomical point of view, however, the sacral method is more attractive, and we give it preference.
OPERATIONS UPON THE ANUS.
The trans-sacral procedure is very satisfactory in operations upon the anus. The perineal infil- tration gives not only a good anesthesia, but also a perfect ischemia. All will agree that to extir-
GENITO-URINARY ORGANS AND RECTUM
225
pate hemorrhoids without the loss of a drop of blood is ideal. For this reason, we give pref- erence to the Whitehead operation, and infiltrate at a distance around the anus and rectum when the operation is practised, as upon a cadaver.
Four dermal wheals are made in a lozenge form, one in front of the anus, two laterally, and
Fig. 167. — Anesthesia of the anal region through four wheals circumscribing the anus and at some distance from it. (Pauchet.)
the last behind, not too close, two finger-breadths from the anal orifice (Fig. 167 and 169). Through these four points all the injections, using l/2 per cent, solution, are made. Through the perineal wheal, the needle is introduced, at first perpen- dicularly to the surface, and afterward in a fan- shaped manner, right and left, each time 4 or 5
226
REGIONAL ANESTHESIA.
mils of the solution being injected deeply in the sphincter and under the skin. Through the lateral wheals fan-shaped injections are also made, paral- lel to the rectal walls, reaching the levator ani, and bathing the ischio-rectal fossae, the sphincter, and the subcutaneous and submucous tissues (Fig.
Fig. 168. — Radiating injections through the lateral wheal. (Pauchet.) The figure shows the three positions in which the needle should be placed in order to infiltrate the entire mass of tissue with quinine through a single wheal.
168). Finally, a mass of tissue is also infiltrated behind the anus and rectum, in fan-shaped fashion. The rectum is completely surrounded by the in- filtration.
GENITOURINARY ORGANS AND RECTUM.
227
Fig. 169. — Radical cure of hemorrhoids by Whitehead's op- eration. (Pauchet.) Through wheals A, B, C and D, a band of tissue is infiltrated along the dotted lines. Through the same wheal deep radiating injections are then made in the sphincter and adipose tissue of the ischio-rectal fossa, com- pletely surrounding the ano-rectal cylinder.
Fig. 170. — Peripheral infiltration with quinine for incision of fistula in ano. (Pauchet.)
228
REGIONAL ANESTHESIA.
At the close of the infiltration, when the latter has been successful, the sphincter is gaping. In a few minutes, dilatation, dissection and descent
Fig. 171. — Anorectal segment laid open after extirpation. (Pauchet.} Trans-sacral anesthesia is employed. The cancer- ous tumor forms a hollow cylinder.
of the mucosa, resection, and cauterization can be effected without pain and without hemorrhage of any account. According to the degree of stout- ness of the patient, 50 or 100 mils of the solu-
GEXITO-UR1XARY ORGANS AND RECTUM. 229
tion are required. Beginners should place a fin- ger in the rectum to guide the needle.
Operations for fistula in ano may be done under the same method of infiltration.
\Ye have often practised total extirpation of the rectum, with absolute anesthesia — always by the trans-sacral method. Infiltration is not suffi- cient. We practice the anterior or posterior method, according to the degree of stoutness of the patient.
CHAPTER VII.
ANESTHESIA OF THE EXTREMITIES.
REDUCTION OF FRACTURES OR DISLOCATIONS — QUENU'S METHOD.
IN 1907, Quenu recommended the use of local anesthesia for the reduction of fractures and dis- locations.
The procedure consists in injecting in the vicinity of the fracture an anesthetic solution so that the bone ends are bathed with it, the seat of the fracture being thus rendered insensitive. The muscles simultaneously relax, and one may proceed without pain to dress the wound, exam- ine the parts, reduce, practice radioscopy, etc. For dislocations, the injection is made into the synovial sac, then about the dislocated articula- tion and the insertion of the muscles surrounding- it. The previously rigid limbs become supple and mobile, muscular contractions cease, and reduc- tion becomes easy and painless. A I per cent, or y2 per cent procaine-adrenin solution is in- jected, according to the stoutness of the patient.
It will not be necessary to describe the pro- cedure for every type of fracture or dislocation, the technique of the injection being practically the same in a!1v The procedure is easy and devoid of risk if a fine needle is used. A point at which the skin is not distended, contused, or trau- (230)
ANESTHESIA OF THE EXTREMITIES.
231
matized in any way should be selected. In juxta- articular fractures, the fracture and the joint
Fig. 172. — Anesthesia for reduction of an elbow dislocation. (Pauchet.) The quinine-urea solution is injected in the syn- ovial sac of the articulation and infiltrates the insertions of the muscles about the joint.
should be simultaneously injected. In the lower extremities this is the procedure of choice. In the upper, one may, with experience, instead, anes- thetize the brachial plexus.
232
REGIONAL ANESTHESIA.
UPPER EXTREMITY.
The upper extremity as a whole, below the shoulder, receives its sensory supply from the brachial plexus, which becomes united beyond the scaleni into a single, comparatively narrow, cord. The upper intercostal nerves contribute in supply-
Fig. 173. — Anesthesia for fracture of the humerus. (Pau- chet.) The needle is introduced at the site of fracture and quinine-urea solution injected throughout the region.
ing the axilla with sensation and also furnish a portion of the sensibility of the skin of the inner surface of the arm. The skin of the shoulder region is supplied by filaments from the supra- clavicular branches of the cervical plexus.
ANESTHESIA OF THE EXTREMITIES. 233
ANESTHESIA OF THE BRACHIAL PLEXUS BY WAY OF THE AXILLA HIRSCHEL.
The arm is extended in strong abduction (Fig. 174). "With the left hand fixing the axillary artery, the needle is introduced high up as far as possible under the pectoralis major, following the longitudinal axis of the arm. The injection is be- gun during the introduction of the needle in order to push aside and avoid wounding the blood-
Fig. 174. — Infiltration of the brachial plexus by way of the axilla. (Pauchet.) Below the inferior border of the pec- toralis major, with the arm abducted, the needle is intro- duced toward the nervous trunks, in a direction parallel with the axis of the arm.
vessels. With a few syringefuls of the solution, the median nerve is blocked above, and the ulnar further anteriorly. To reach the radial nerve, one must penetrate more deeply under the artery, al- most to the height of the insertion of the pec- toralis major. The artery is there surrounded with injections, and with proper caution injury to it or to the vein is avoided. Thirty or 40 mils of the 2 per cent, solution are used.
234
REGIONAL ANESTHESIA.
ANESTHESIA OF THE BRACHIAL PLEXUS BY THE SUPRACLAVICULAR ROUTE KULENKAMPFF.
The location of the plexus is well shown, with- in by the subclavian artery, the pulsations of which can easily be felt; below, by the first rib, and in front, by the clavicle. Figure 175 shows the direction of the first rib, the supraclavicular region being seen in profile. It ascends behind
Fig. 175. — Blocking the nerve trunks of the upper extremity. (Pauchet.) A, scalenus posticus. B, apex of the pleura. C, omo-hyoid. D, point where the wheal should be made. E, subclavian artery. F, scalenus anticus. G, sterno-mastoid.
the clavicle and at a right angle, and is an im- portant landmark, for it indicates the extreme point of penetration of the needle. The dermal wheal should be made at about the middle of the clavicle, where the first rib crosses it. The arch of the subclavian artery should be identified; it also crosses the clavicle at about its middle. Be- yond lies the apex of the pleura, hidden by the plexus. Still further, at the external border of
ANESTHESIA OF THE EXTREMITIES.
235
the sterno-cleido-mastoid, will be noticed the scale- nus anticus, as well as the omo-hyoid, ascending obliquely from the first rib, and which has been divided, in order the better to show the course of the rib. Figure 176 shows the parts as they present themselves after removal of the skin and
Fig. 176. — Anesthesia of the upper extremity. (Pauchet.) A, omo-hyoid. B, brachial plexus. C, subclavian artery. D, scalenus anticus. E, sterno-cleido-mastoid.
the superficial and deep fascia. The transversalis artery of the neck is seen crossing the nerve trunks closely superimposed. Figure 177 and those following show the direction the needle should take. According to the more or less oblique direction of the first rib from the spine to the sternum, the needle, if prolonged, should reach the spinous process of the second or the third dorsal vertebra. On the other side are shown the plexus, the artery, the insertion of the scaleni, and finally, immediately below the clavicle, the
236 REGIONAL ANESTHESIA.
crescent constituted by the nerves surrounding the artery. A needle introduced close to the artery and properly directed should pass through the middle of the nerve plexus. Almost always the pulsations of the artery will be transmitted to it. The narrowness of the interval between the scaleni is also apparent.
A 6 <•
Fig. 177. — Anesthesia of the brachial plexus. (Kulen- kampff.) Summit of the thorax. Direction of the needle to the left. To the right, relationship of the structures in the vicinity. A, subclavian vein. B, insertion of the scalenus an- ticus. C, subclavian artery. D, brachial plexus. E, insertion of the scalenus posticus.
TECHNIQUE OF THE INJECTION.
The patient should, if possible, be placed in the sitting posture (Fig. 178), and should be forewarned of the paresthesia radiating to the fin- gers that will occur when the needle touches the plexus, being requested to make known the moment when it appears. The subclavian artery is now slightly palpated with the finger. Its pulsations
OPERATIONS UPON THE EXTREMITIES.
237
are often visible, especially on the right side. Just outside of the point where the artery descends behind the clavicle, with a fine needle, a wheal is made, which will correspond without exception to the middle of the clavicle. The external jugular vein, often visible lower down, crosses the clavicle
Fig. 178. — Supraclavicular anesthesia of the brachial plexus. (Kulenkampff.) The left index finger locates and protects the subclavian artery. Laterally to the artery and above the middle of the clavicle, (X), the needle is introduced in the direction of the spinous process of the third dorsal vertebra.
at the same point. Through this wheal a fine needle 4 to 6 centimeters long is inserted and directed as if one desired to strike the spinous process of the second or third dorsal vertebra. The plexus is superficially situated under the aponeu- rosis. As soon as the needle strikes it, lancinat- ing pains occur in the fingers supplied by the median, which is the most superficial, and the
238 REGIONAL ANESTHESIA.
radial, situated behind the median. If the first rib is encountered at a depth of from I to 3 centimeters, the operator will know that he has missed and passed the plexus, as it is more super- ficially placed. If no paresthesia is produced, he
Fig. 179.—- Blocking the brachial plexus. (Pauchet.) The needle penetrates the skin above and close to the clavicle. It traverses the plexus at the level of the clavicle and its point touches the first rib. If the line of direction were prolonged it would pass through the spinous process of the third dorsal vertebra.
should try to provoke it by altering- the position of the needle. Very often, fear of wounding the artery causes the operator to introduce the needle too far out. If blood comes from the needle, it is because a vein or artery has been pierced, and
ANESTHESIA OF THE EXTREMITIES. 239
its direction must be changed. The moment pares- thesia appears, the syringe is adapted to the needle and 10 mils of the 2 per cent, solution injected. If paresthesia is produced only in the
Fig. 180. — Blocking the brachial plexus. (Pauchet.) The needle is inserted just above the middle of the clavicle. The left index finger locates the pulsations of the artery and pushes it out of the way. Abduction of the arm to 45° (Louis Bazy) lifts away the artery and forms a curve with its con- cavity directed upward. The needle points toward the spin- ous process of the third dorsal vertebra. It passes through the plexus and strikes the first rib.
territory of the median, part of the solution should be injected some millimeters more deeply. The needle should be slightly displaced and 10 mils injected in the immediate vicinity. Under no
240 REGIONAL ANESTHESIA.
circumstances should the injection be made before production of the paresthesia.
If unquestionable paresthesia has been obtained both in the territory of the median and that of the radial in from one to three minutes a com- plete motor and sensory paralysis will be estab- lished in the arm. Often one must wait from ten to fifteen minutes. If, at the end of this time, paralysis is not complete, 5 to 10 mils of the 4 per cent, solution may be injected. Success will then, however, be uncertain. After the injection, the tourniquet may be applied without pain. It is often useful, for after blocking of the brachial plexus the arm is habitually hyperemic, the vaso- motors being paralyzed as after section of the nerves. The motor paralysis always reaches the circumflex nerve; but its territory is only hypo- esthetized or uninfluenced. Other nerves, prob- ably filaments from the supraclavicular, take part in the innervation of this region. The anesthesia lasts from one hour and a half to three hours.
ANESTHESIA OF THE BRACHIAL PLEXUS BY THE INFRACLAVICULAR ROUTE LOUIS BAZY.
The brachial plexus assumes the shape of a fan, the axis of which is constituted by the seventh cervical nerve. The origin of this root is immediately below the anterior tubercle of the transverse process of the sixth cervical vertebra (tubercle of Chassaignac). It is found on a level with the inferior border of the cricoid cartilage.
ANESTHESIA OF THE EXTREMITIES.
241
The tubercle of Chassaignac is, then, the first landmark.
After grouping themselves around the seventh cervical, the other branches of the cervical plexus
Fig. 181. — Infraclavicular anesthesia of the brachial plexus. (Pauchet.) Amputation of the arm performed on the Meuse at a spot 6 kilometers from the firing line. The operating room had been set up by the ambulance orderlies. Surgeon : Sourdat. Assistant : Louet, auxiliary physician. The patient is looking toward the camera.
become engaged in the space between the clavicle and the first rib, and afterward pass perpendicu- larly to the coracoid process. When the arm is abducted in such a way that the tangent passing
16
242
REGIONAL ANESTHESIA.
,... Tubercle of Chassaijjnac
—Brachial Plexus <— Clavicle
— Coracoid
Line of cricoid 'with V\- cervical -- Cricoid
Fig. 182. — Anesthesia of the brachial plexus by the infraclavicular route. (Pauchet.) Observe that the cricoid cartilage corresponds to the transverse process of the sixth cervical (tubercle of Chassaignac). This tubercle may be found by palpation, and the assistant should place his index finger there at the time of the injection. To the right, the coracoid process, and one fingerbreadth within it, the plexus. The operator introduces the needle here immediately below the clavicle and directs it toward the tubercle of Chassaignac. The arm having been abducted to 45°, the axillary artery is separated from the brachial plexus, drawn away by the two thoracic branches given, off from its lower aspect. The artery rests on the first rib.
ANESTHESIA OF THE EXTREMITIES. 243
through the apex of the coracoid process strikes the tubercle of Chassaignac, this line indicates ex- actly the direction of the brachial plexus, which is situated one finger-breadth below it. This line may be considered as the "line of anesthesia," and the coracoid process constitutes the second landmark. In this position the arm forms with the trunk an angle of 45° (Fig. 184). The axil- lary artery, held against the arm by its acromio- thoracic branch, deviates from the brachial plexus, describing a curve with its concavity upward. As a result of this, the risk of wounding it is slight.
TECHNIQUE OF THE INJECTION.
The patient is placed upon the table, with his spinal column resting upon a cushion in such a way that his shoulders are arched, as though for liga- tion of the subclavian or axillary under the clav- icle. The arm, hanging and abducted to 45°, ren- ders the prominence of the coracoid more appar- ent, and the plexus more superficial.
The operator places himself on the side to be operated upon, between the arm and the trunk. He locates the apex of the coracoid and im- mediately within it, with the left index finger, he depresses the soft tissues, as though wish- ing to make more apparent the prominence of the coracoid.
Meanwhile the assistant identifies the tubercle of Chassaignac, over which he places his index finger. The arm being abducted to 45°, the in-
244
REGIONAL ANESTHESIA.
Fig. 183. — Anesthesia of the brachial piexus by the infraclavicular route. (Louis Basy.) The two hands show the "line of anesthesia." The finger of an assistant is placed on the tubercle of Chassaignac; the surgeon's finger, inside of the coracoid process, which is shown by dotted lines. Here, within the finger tip, the needle enters immediately below the clavicle and is directed toward the brachial plexus. It is well to inject both upward, to the right, to the left, and deeply down- ward to be sure of reaching all the branches of the plexus.
ANESTHESIA OF THE EXTREMITIES. 245
dex finger of the operator and that of his assist- ant face each other, and the interval separating them marks the course of the plexus (Fig. 183). The line of anesthesia is now traced upon the skin with y2 per cent, procaine-adrenin solution.
A needle 9 centimeters long is introduced in the zone of infiltration, almost immediately below the clavicle. The needle is pointed in such a way that it grazes the posterior border of the bone. When the needle has passed slightly beyond the upper surface of the clavicle, 10 mils of 2.5 per cent, procaine-adrenin solution are injected. The arm is flexed as if one wanted to place it upon the chest. As a result of this maneuver the bra- chial plexus is relaxed and comes in front of the needle, when it can be directly penetrated and anesthetized.
OPERATIONS UPON THE HAND.
The technique of anesthetizing a finger by means of injections all round it under the skin of the first phalanx has been well described by Rec- lus and is too well known to require description anew. The adjacent parts of the metacarpus may, however, be anesthetized consentaneously with the finger.
ANESTHESIA OF A FINGER WITH THE ADJACENT PORTION OF THE METACARPAL.
Two wheals are made upon the dorsal surface of the interdigital space, corresponding to its in-
246
REGIONAL ANESTHESIA.
Fig. 184.— Landmarks for injection of the fingers. (Pau- chet.) The pyramid A shows the depth to which the needle is introduced, as illustrated in Fig. 187.
Fig. 185.— Manner of holding the syringe in infiltrating the palm by injection into the interdigital spaces.
ANESTHESIA OF THE EXTREMITIES.
247
ternal and external borders (Fig. 184). A }/2 or i per cent, solution is freely injected under the skin in the direction of points A or D in the palm, and B or C in the back of the hand. Fig. 185 shows the course of the needle in an injection in the palm through the interdigital space. The operation should not be started until the anes- thesia has reached the tip of the finger.
DISARTICULATIOX OF THE MIDDLE FINGER OPERA- TION UPON THE THIRD METACARPAL BONE.
Four wheals are made (Fig. 186), two in the interdigital spaces, and two metacarpal, over the
Fig. 186. — Anesthesia of the medius with the head of its metacarpal ; also anesthesia of the thumb with its metacarpal. (Pauchet.}
interosseous spaces. The start is made at points 3 and 4. Fig. 189 shows a section of the meta- carpus and the course followed by the needle.
248
REGIONAL ANESTHESIA.
Fig. 187.— Infiltration of the palm of the hand through two injections from the dorsal aspect. (Pauchet.)
Fig. 188.— Same as the preceding.
ANESTHESIA OF THE EXTREMITIES. 249
The tip of the left index finger being placed in the patient's palm, the needle is introduced at 3 and 4, and the injection made perpendicularly through the interosseous space until the tip of the needle shows under the skin of the palm at B (Figs. 187 and 188). At each one of the two
Fig. 189. — Anesthesia of a finger and its metacarpal bone. (Pauchet.) Longitudinal section of an interosseous space showing the different directions that the needle should take. 1, deep palmar arch ; 2, superficial palmar arch ; 3, ulnar nerve ; 4, palmar aponeurosis.
injections 5 mils of the ]/2 per cent, solution are used. Next one infiltrates subcutaneously from points i and 2, in the palm toward point B, and upon the dorsum toward 3 and 4. Finally points 3 and 4 are united by a subcutaneous injection. In all, from 30 to 40 mils of the */2 per cent, solution are required.
250 REGIONAL ANESTHESIA.
DISARTICULATION OF THE THUMB WITH ITS METACARPAL.
The interosseous space is first injected, start- ing from point 6 and introducing the needle to point A under the skin of the palm (Fig. 186). Owing to the thickness of the soft parts, 10 mils of the Y* per cent, solution are required. The next injection is made subcutaneously from points 5 and 7 toward the palm in A, upon the back of the hand from 6. About 50 mils of the Y* Per cent, solution are used. The thenar eminence may thus be anesthetized without piercing the skin of the palm, which is very sensitive. The same pro- cedure may be followed for the fifth metacarpal and finger.
ANESTHESIA OF SEVERAL FINGERS WITH THEIR METACARPALS.
Injections made at points i, 2, and 3 (Fig. 190) anesthetize the second and third fingers. From point 2 the injection is pushed in the interosseous space against point A, and from points i and 3 in the palm toward point A. On the back of the hand one infiltrates under the skin toward point 2. Injections made at 4, 5, and 6 anesthetize the third and fourth fingers. Portions of the meta- carpus may be, as desired, circumscribed in the anesthetized territory, according as the points of entry 2 or 6 are placed nearer the fingers or the wrist. About 50 mils of y* per cent, solution are required.
ANESTHESIA OF THE EXTREMITIES.
251
190.— Anesthesia of two fingers with the heads of the metacarpal bones. (Fauchet.)
Fig. 191.— Anesthesia of one finger with the head of its metacarpal. (Pauchet.) Injections are made along the dotted lines through wheals at 1 and 2, circumscribing the region to be operated upon.
252
REGIONAL ANESTHESIA.
ANESTHESIA OF THE SOFT PARTS OF THE PALM.
Any portion of the palm may be anesthetized by employing the same technique as already des-
Fig. 192. — Anesthesia of a portion of the palm of the hand. (Pauchet.)
Fig. 193. — Lines of infiltration for minor operations upon the dorsal aspect of the hand. (Pauchet.)
cribed for anesthesia of the thenar and hypothe- nar eminences, e.g., in disarticulation of the thumb. The needle should, however, always be entered
ANESTHESIA OF THE EXTREMITIES. 253
upon the borders of the hand and upon the dor- sal aspect of the interosseous spaces (Fig. 192). If it is desired to anesthetize the palm above the in- dex finger (Figs. 191, 193), the wheals should be made at points i and 2. Through these two points, free injections are made toward point A in the palm, using 30 to 40 mils of the y2 per cent, solution. In the case of phlegmons of the hand, one should not inject in the vicinity of the affected parts, but resort instead to anesthesia of the brachial plexus.
ANESTHESIA OF THE SOFT PARTS OF THE BACK OF THE HAND.
In anesthesia instituted for the treatment of wounds or for the extirpation of ganglions, cysts, and other tumors, the field of operation is sur- rounded with a ^2 per cent, solution. Fig. 193 showrs the manner in which the infiltration should be conducted in different cases. All that is neces- sary is to surround three sides of the field in the form of a U, since the nerves descend from the forearm exclusively. The anesthesia reaches the periphery by reason of the injection of three sides and in some cases extends beyond it below the field of operation. If the injections be made first under the tendons, and then under the skin, the anesthesia will include tissues beneath the fascia.
254
REGIONAL ANESTHESIA.
ANESTHESIA OF THE ULNAR NERVE AT THE ELBOW.
The ulnar nerve is ordinarily palpable above the epitrochlea, where it can be made to roll under the finger. In anesthesia it is fixed with the thumb and index finger of the left hand and the needle is pushed up to it through the subcuta- neous tissues and fascia. The moment the nerve is touched, the patients will feel and complain of
Fig. 194. — Section of the forearm above the wrist. (Pauchet.) 1, Palmaris longus. 2, Median nerve. 3, Ulnar nerve.
the same tingling as is experienced when the nerve is compressed. The solution is then in- jected. It should be noted that in many patients the ulnar nerve, when the arm is flexed, is sit- uated not behind but in front of the epitrochlea, and passes behind only when the forearm is in extension. Anesthesia follows very quickly after the injection and involves the little finger, the hy- pothenar eminence, the ulnar border of the hand, and the fifth metacarpal. For disarticulation of
ANESTHESIA OF THE EXTREMITIES.
255
the little finger and other operations in this region, there is no simpler procedure (Figs. 195 and 196).
ANESTHESIA OF THE ENTIRE HAND.
The hand receives from the forearm the ulnar, median and interosseotis nerves, which are all
Fig. 195. — Anesthesia of the ulnar nerve. (Pauchet.) The nerve trunk is infiltrated in the depression between the epi- trochlea and the olecranon process. 1. Ulnar nerve. 2. Fibrous arch. 3. Flexor carpi ulnaris.
three subfascial, together with the endings of the radial, which are subcutaneous. Fig. 198 presents a perpendicular section of the forearm above the
256
REGIONAL ANESTHESIA.
Fig. 196. — Anesthesia of the ulnar nerve at the elbow. (Pauchet.) Anesthesia has been induced by means of an injection of strong pro- caine-adrenin solution in the depression between the epitrochlea and the olecranon, as well as by a bracelet of subcutaneous infiltration at the bend of the elbow. Suture of the ulnar nerve has been com- pleted. The dissection of the nerve has been effected without any pain. The wound is sutured with silkworm gut
ANESTHESIA OF THE EXTREMITIES.
257
Fig. 197. — Points of introduction of the needle to reach the median and ulnar nerves above the wrist. The needle is pointed and the injections made in the direction of the arrows.
10
Fig. 198. — Anesthesia of the hand. (Pauchet.*) Transverse section of the wrist at the level of the inferior radiocarpal articulation. Note the bracelet-like black line of subcutaneous infiltration. The arrows represent the deep injections intended for A, the median nerve, and C, the ulnar nerve. 1. Tendon of the palmaris brevis. 2. Tendon of the palmaris longus. 3. Tendon of the abductor longus pollicis. 4. Supinator longus. 5. Flexor carpi ulnaris. 6. Ulnar artery. 7. Ulna. 8. Radius. 9. Pronator quadratus. 10. Radial artery.
17
258 REGIONAL ANESTHESIA.
wrist, showing the direction in which the needle should be pushed toward the median and ulnar nerves. To reach the median at this level, a wheal is made on the ulnar side of the tendon of the palmaris longus, and the needle pushed through the fascia under this tendon. The oper- ator attempts to touch the nerve with the needle point. When the patient complains of shooting- pains, 5 mils of a 2 per cent, solution are in- jected. Next, 5 mils of the same solution are injected on the ulnar side of the forearm, above the pisiform and beneath the tendon of the flexor carpi ulnaris (Fig. 198). Finally, one infiltrates through two or three other points in ring fashion around the forearm — under the skin, then upon the dorsal surface under the fascia between the tendons, and up to the interosseous ligament, using 50 to 60 mils of a ^ per cent, solution. Complete anesthesia of the whole hand is ob- tained in from ten to fifteen minutes. This pro- cedure is simpler than intravenous anesthesia.
OPERATIONS UPON THE FOREARM.
The skin and subcutaneous tissues of the fore- arm down to its lower third are exclusively sup- plied by long subcutaneous nerves that emerge from under the fascia above the elbow. Infiltra- tion of a transverse band of subcutaneous tissue on the forearm produces, therefore, an anesthesia that becomes more or less extensive below the level of injection, and when a circle of subcuta-
ANESTHESIA OF THE EXTREMITIES.
259
neous tissue above or below the elbow is infil- trated, the anesthesia extends on all aspects to the lower third of the forearm.
For operations upon the skin of the upper two- thirds of the forearm, the field of operation should be surrounded by injections disposed in the shape
Fig. 199. — Anesthesia of the dorsal surface of the fore- arm and hand. (Pauchtt.)
of a U with its concavity directed downward, using the % per cent, solution (Fig. 199). The unilateral nerve supply of this region renders the muscular injection unnecessary if the operation is unilateral.
In the lower third the injection should also be subfascial on account of the nerves that emerge
260 REGIONAL ANESTHESIA.
from within the forearm. Extensive areas upon the lower third of the dorsal aspect of the fore- arm may be anesthetized as follows: Two in- jections are made upon the borders of the fore- arm, indicated by the bony ridge of the radius and ulna (Fig. 199, B). With a long needle the soft parts of the dorsal surface are infiltrated, begin- ning with the muscles, then the subcutaneous tis- sues transversally, with 40 or 50 mils of a ^ per cent, solution. From these two points the subcutaneous infiltration descends to the wrist and, if necessary, to the fingers. This procedure is useful for the treatment of severe wounds of the soft parts, the extirpation of tumors or cysts, tuberculosis of the tendon sheaths, etc.
The procedure adapted for the lower half of the anterior surface of the forearm differs slightly by reason of the median and ulnar nerves. Two injections are made upon the sides of the forearm, and these are joined by infiltrating transversally close to the bone and the interosseous ligament at the start, and then in the subcutaneous tissue. It is useless to try to infiltrate the muscles sep- arately; this is almost impossible in any case, and the median and ulnar are not blocked. If the operative field is in the ulnar distribution, it is best to inject this nerve at the elbow. If it is in that of the median, then this nerve should be anesthetized at the upper extremity of the incision. Those well trained in anesthesia of the brachial plexus will give this procedure the preference— especially in phlegmons, operations on the bone,
ANESTHESIA OF THE EXTREMITIES. 261
amputations and interventions upon the upper half of the forearm, and in fact, in all operations of importance below the shoulder.
OPERATIONS UPON THE ELBOW. .
A subcutaneous U-shaped infiltration with con- cavity downward, using 40 mils of a ^ per cent, solution, upon the dorsal surface of the elbow, and instituted through two wheals (Fig. 200), will permit of extirpation of the olecranon bursa. To suture a fractured olecranon, t\vo additional injections are necessary, 3 and 4. One begins by injecting 20 mils of the l/2 per cent, solution into
Fig. 200. — Anesthesia of the elbow region. (Pauchet.)
the articulation, below the external and internal condyles. Ten mils are injected under the tendon of the triceps in the muscles covering the ole- cranon, first inside and then outside, and finally the U-shaped subcutaneous injection is made. For an aseptic arthrotomy — as for the removal of for- eign bodies — 20 mils of the ^ per cent, solution are injected in the joint and the capsule and sub- cutaneous tissue infiltrated along the line of in- cision. To perform a resection or disarticulation, blocking of the plexus is necessary.
262
REGIONAL ANESTHESIA.
Fig. 201. — Anesthesia of the upper extremity. (Pauchet.) A, Blocking of the brachial plexus, producing anesthesia of the entire upper limb. B, Anesthesia of the forearm and hand. C, Anesthesia of the hand only. The points 1, 2, 3, 2' and 3' are the wheals through which the subcutaneous bracelet of in- filtration is made. The needle employed to infiltrate deeply the nerve trunks is also introduced through them. 1, Anterior branch of the radial nerve. 2 and 2', Median nerve. 3 and 3', Ulnar nerve.
ANESTHESIA OF THE EXTREMITIES.
263
OPERATIONS UPON THE ARM.
Local injections are here suitable only for superficial operations. A simple subcutaneous in- jection is insufficient by reason of the irregular and multiple branching of the nerves. A pyram-
Fig. 202. — Anesthesia of the forearm and hand. (Pau- chet.) Transverse section at the elbow. Note the bracelet of subcutaneous infiltration marked by a heavy black line. A, Deep injection to the median nerve. B, Deep injection to the radial. C, Deep injection to the ulnar. 1, Tendon of the bi- ceps. 2, Supinator longus. 3, Pronator radii teres. 4, Exten- sor carpi radialis longus. 5, Flexor carpi ulnaris. 6, Brachialis anticus. 7, Brachial artery.
idal injection of the operative field is always re- quired. To anesthetize the skin of the entire sur- face of the arm, as for Thiersch skin grafting, one infiltrates superficially all the subcutaneous tis- sue with a y2 per cent, solution, as for the thigh.
264
REGIONAL ANESTHESIA.
For extensive operations on the bones, amputa- tions, etc., the plexus is injected above the clav- icle (Fig. 181).
OPERATIONS UPON THE SHOULDER.
Large lipomas of the shoulder are easily re- moved after multiple infiltrations have been made
Fig. 203. — Suture of a fracture of the clavicle. (Pauchet.) Through two injections the clavicle is surrounded, to any ex- tent necessary, with the anesthetic solution.
all around them. The base of the tumor is reached with long needles, and the injections are connected with one another by bands of subcuta- neous infiltration. A ]/2 per cent, solution is used, and as much as 200 to 250 mils may be injected.
ANESTHESIA OF THE EXTREMITIES. 265
Operations on the shoulder are performed after anesthesia of the plexus. For shoulder disarticu- lation, the plexus has first to be infiltrated, and then the subcutaneous tissues at the root of the shoulder up to the acromion and through the axilla. The ^ per cent, solution is used.
LOWER EXTREMITY.
It is difficult to anesthetize the lower ex- tremity by local injections, as it receives its nerve supply from many different trunks. On the other hand, spinal anesthesia is very serviceable, and only a small amount of procaine-adrenin solution, 4 or 5 centigrams, need be used. The injection is made directly into the spinal canal of the lum- bar region. In a large number of cases regional anesthesia is absolutely indicated, and succeeds ad- mirably. Thus, all operations on the foot — resec- tion, amputation, tenotomy, suture of the patella, operations for varicose veins, or on the inguinal lymphatics, etc., — may be performed with complete anesthesia by the regional method. We give pref- erence, however, to lumbar spinal anesthesia for all major operations, such as resection of the knee, resection of the hip, and amputation of the thigh. We probably practice three regional anes- thesias to every spinal.
The external cutaneous nerve emerges from under the inguinal ligament immediately within the anterior superior iliac spine; it descends in an out- ward direction under the fascia lata, perforates
266
REGIONAL ANESTHESIA.
the fascia, and supplies the skin. It can be reached two finger-breadths within and below the anterior superior spine (Figs. 204 and 205). The technique is as follows: A dermal wheal
Fig. 204. — Injection of the external cutaneous nerve (1) and of the anterior crural nerve (2). (Pauchet.) 1, Point where the needle should be introduced to reach the external cutaneous ; the injection is made in the direction of the arrow, beneath the fascia and skin. 2, Point of entrance of the needle, perpendicularly to the surface, to reach the anterior crural nerve.
is made and the subcutaneous connective tissue so injected as to make a transverse band 5 or 6 centimeters wide, parallel to Poupart's ligament. Five mils of the strong solution are then injected under the fascia, in the same direction as the sub- cutaneous infiltration. The middle of the infil-
ANESTHESIA OF THE EXTREMITIES.
267
trated area should be situated two finger-breadths within and below the anterior superior spine.
Fig. 205. — Anesthesia of the external cutaneous -nerve. (Pauchet.) This nerve is reached at a point two finger- breadths within and below the anterior superior spine of the ilium.
The anterior crural nerve is situated imme- diately outside of the femoral artery and is cov- ered by a fibrous band (ilio-pectineus). With the left hand the operator locates the pulsations of the
268
REGIONAL ANESTHESIA.
femoral artery and pushes the latter inward. The needle is then introduced immediately outside the artery, just below Poupart's ligament. Where it comes in contact with a solid band of fascia, the latter is pierced and 5 mils of the strong
Fig. 206. — Anesthesia of the anterior crural nerve. (Pau- chet.) A, Spine of the pubis. B, Anterior superior iliac spine. C, Point half way between the two. The femoral artery is located with the finger. The needle is inserted one finger- breadth outside of it to reach the anterior crural nerve.
solution injected while still advancing i centimeter deeper. The patient should show some muscular contraction in the thigh, proving that the crural nerve has been reached. The quadriceps is then immediately paralyzed.
Infiltration of the above two nerves affords a broad zone of anesthesia which will permit of
ANESTHESIA OF THE EXTREMITIES. 269
the taking of Thiersch grafts from an extensive surface of skin.
Infiltration of the great sciatic nerve is very difficult and uncertain. One may, however, suc- ceed in the following manner: Bearing in mind that the nerve is situated in the buttock at the midpoint of a line passing from the ischium to the great trochanter, two deep injections are made, the first at a distance of 2 centimeters outside of the tuberosity of the ischium, and the other 3 centimeters within the great trochanter. Or, a single injection may be made at the intersection of a horizontal line passing through the upper border of the great trochanter, and a vertical line passing through the external border of the ischium. It is indispensable that the patient should experi- ence a painful sensation in the toes. As soon as this pain is felt 10 mils of the strong solution are injected.
Babitzki proceeds as follows: The finger is introduced in the rectum, the lower border of the great sciatic notch identified, and its contents, i.e., the nerve, pushed outward \vhile the right hand introduces the needle to meet the nerve.
The lesser sciatic nerve passes below the glu- teal fold exactly in the middle of the posterior surface of the thigh, immediately beneath the fas- cia. It is, therefore, easily accessible.
The obturator nerve is deeply situated. To reach it with any degree of certainty all of the proximal internal surface of the thigh should be infiltrated to a depth of 3 or 4 centimeters.
270
REGIONAL ANESTHESIA.
In operating on the great trochanter or the neck of the femur, desensitization of the nerve trunks of the lower extremity is not sufficient; one must also anesthetize the branches of the genito- crural and ilio-inguinal by infiltration of the skin surrounding the root of the extremity.
OPERATIONS UPON THE TOES.
The technique is the same as for the fingers (Figs. 208 and '209). In the case of the big toe, three injections are made, two on the lateral sur- faces and one in the middle of the dorsal surface.
Fig. 207. — Anesthesia of a toe through three dorsal injections. (Pauchet.)
A subcutaneous ring-shaped injection is made at the root of the member, and 4 or 5 mils of the strong solution injected. For the other toes, the injections are made in the interdigital spaces (Fig. 209).
Great Toe — Operations for Ingrowing Toe Nail or Bunion, Amputation. — In disarticulation of the toe or resection of the head of its metatarsal bone for hallux valgus, three wheals are made, one on
ANESTHESIA OF THE EXTREMITIES.
271
the internal border of the foot, the second a dorsal one, above the first interosseous space, and the third in the first interdigital space. One injects
Fig. 208. — Anesthesia of the great toe with the head of its metatarsal bone. (Pauchet.)
in the interosseous space, as for the hand. The needle is inserted in this space until its tip touches the deep portion of the skin of the sole. Infiltra- tion is then conducted under the skin from I to
Fig. 209. — Anesthesia of middle toe with the head of its metatarsal bone. (Pauchet.)
Fifty
3, following the dotted line (Fig. 208). mils of the weak solution are needed.
Third Toe. — Operations on the metatarsal (Fig. 209). — Four wheals are made as in operations
272
REGIONAL ANESTHESIA.
upon the hand — two on the dorsal surface of the interdigital spaces, and two on the dorsum of the foot above the second and third interosseous spaces. Through i and 2, anesthetic solution is injected in the interosseous space until the point of the needle is perceived under the skin of the sole, then the injection is continued under the skin of the dorsum toward I and 2. Fifty mils of the weak solution are required.
Fig. 210. — Tenotomy of the tendo Achillis. (Pauchet.) TENOTOMY OF THE TENDO ACHILLIS.
A wheal is made on each side, a subcutaneous diamond formed as shown by the dotted lines in the illustration (Fig. 210), then infiltration prac- tised under the tendon itself.
OPERATIONS UPON THE ENTIRE FOOT.
The fbot is supplied by five trunks: The an- terior and posterior tibial, the internal and ex- ternal saphenous, and the musculo-cutaneous (Fig.
ANESTHESIA OF THE EXTREMITIES.
273
211). The posterior tibial nerve is injected at the inner malleolus, i centimeter from the tendo Achillis (Fig. 211; note the direction of the needle). The needle is introduced from behind forward up to the posterior surface of the tibia.
Fig. 211. — Nerves to be infiltrated in anesthetizing the en- tire foot. (Pauchet.) Section of left leg above the malleoli. For the anterior and posterior tibial a deep injection is neces- sary, and a subcutaneous bracelet for the other nerves, viz., the external and internal saphenous and the musculo-cutaneous.
The operator feels his way until he produces a lancinating pain, and then injects 5 mils of the strong solution. The other wheals are made at the same level around the leg. A subcutaneous bracelet is infiltrated, using 50 to 75 mils of the weak solution, and the strong solution injected to
13
274
REGIONAL ANESTHESIA.
block the anterior tibial, along the line for liga- tion of the artery of the same name. The re- sulting anesthesia is sufficient for resections and amputations in the infant and adult (Fig. 212).
Fig. 212. — Anesthesia of the entire foot. (Pauchet.) Horizontal section of left leg above the malleoli. 1, Tibialis anterior. 2, Extensor proprius hallucis. 3, Extensor communis digitorum. 4, Tibialis posterior. 5, Tendo Achillis. 6, Flexor proprius hallucis. 7, Lateral peronei. The black band repre- sents a bracelet of subcutaneous infiltration. A, Deep injection for the anterior tibial nerve. B, Deep injection for the pos- terior tibial nerve.
OPERATIONS UPON THE KNEE.
For a hygroma of the prepatellar bursa, four wheals are made (Fig. 213), and the subcutane- ous cellular tissue in the interval then infiltrated.
ANESTHESIA OF THE EXTREMITIES.
275
This procedure is also adapted for the suture of a fractured patella. The prepatellar fibrous tis- sues and the articular cavity itself are infiltrated in the same way with the strong solution. In suture of the patella, however, 150 to 200 mils of the weak solution are used; the greater part of the solution runs out after the incision.
For foreign body in the knee, the foreign body is first located with the fingers. Then, through a
Fig. 213. — Removal of the prepatellar bursa. (Pauchet.)
dermal wheal, a needle is introduced, followed by two or three more, to immobilize the foreign body. The skin overlying it is now infiltrated, the fascia likewise, an incision made, the foreign body removed, and the wound sutured. The oper- ation is brilliant, rapid, and painless.
By the same procedure a transverse arthrot- omy, with section of the ligamentum patellae and the lateral ligaments, can very readily be per- formed. We have in this way removed projec-
276
REGIONAL ANESTHESIA.
tiles embedded in the femoral condyles. Resection of the condyles can also be done in this way where the subject is not too stout; but for this operation we prefer spinal anesthesia. The weak solution suffices in all cases.
Fig. 214. — Infiltration of a mass of tissue for arthrotomy of the knee, 1 and 2. (Pauchet.) Above, anesthesia of a seg- ment of vein.
OSTEOTOMY OF THE FEMUR.
Supracondylar and subtrochanteric osteotomies may be practised under local anesthesia by in- filtration. On the outer surface of the thigh, at a height of 10 centimeters, a subcutaneous and then a subfascial band is traced. Next the mus- cular mass is infiltrated, down to the bone. Fin-
ANESTHESIA OF THE EXTREMITIES. 277
ally and still by the same route, a long needle is introduced in front of and outside of the bone, and the tissues freely infiltrated. The resulting anesthesia is perfect, the only steps in the opera- tion that are disturbing to the patient being the breaking of the femur or the blows of the mallet. The same difficulty is experienced in all bone op-
Fig. 215. — Section of the thigh through its lower fourth. (Pauchet.) Manner in which the injections should be directed for an osteotomy of the femur.
erations. Section of a rib or the removal of a cranial flap are alike painless manipulations, but the patient must be warned beforehand of the sounds caused by section of bone tissue.
OPERATIONS UPON THE SOFT PARTS OF THE THIGH.
The subcutaneous cellular tissues above the lesion are infiltrated in order to block the sub- cutaneous nerves. Next, one infiltrates in front
278
REGIONAL ANESTHESIA.
Fig. 216. — Extensive subcutaneous infiltration through „ a series of wheals. (Pauchet.)
ANESTHESIA OF THE EXTREMITIES.
279
and behind, and when necessary, below. This constitutes our routine practice for operations on varicose veins or for inguinal lymphatic enlarge- ments (see Figs. 216 and 217). The operation succeeds very well, but a large amount of the
Fig. 217. — Peripheral infiltration of an inguinal lymph- node for adenitis. (Pauchet.)
weak solution is required; this entails no danger, for a large portion of the solution runs out through the incision. In the removal of varicose veins we have commonly used 200, 250, and even 300 grams of the weak solution, which is largely eliminated when the wound is irrigated with hot saline solution.
REGIONAL ANESTHESIA.
ANESTHESIA OF THE EXTREMITIES.
281
o U
bb
-
282
REGIONAL ANESTHESIA.
Figs. 220, 221. — Sacral anesthesia of the lower extremity. (Pau- chet.) The sacsal trunks, 1 to 4, require to be injected if one is to obtain the areas of anesthesia shown in the sections S. Sections Lj and L4 show the anesthesia obtained by paralumbar injection. Sacral anesthesia of the genital organs is conducted through the third fora- men. The skin is anesthetized. The reader will note the numbers of the sacral trunks that must be injected to obtain the desired anesthesia.
CONCLUSIONS.1
Regional anesthesia may be availed of in 80 per cent, of surgical operations. Its success de- pends upon the ability and experience of the oper- ator, but the disposition and mental attitude of the patient also play an important part.
We invite beginners to use it not only in one type of case, but systematically in all cases, hold- ing themselves in readiness to use ethyl chloride to complete the work where necessary.
Cranial nerve anesthesia and the paravertebral, brachial plexus, and trans-sacral procedures, which are most efficacious, require actual training. If our advice to learners is followed, this should not take a long time. Take a hat pin and a skeleton and practice introduction into the cranial fora- mina, as well as into the paravertebral and sac- ral openings, in accordance with the landmarks mentioned in this book. Such practice will re- quire one or two hours. The same experimenta- tion should then be carried out upon a cadaver. This will also require about two hours of practice.
After these two series of experiments, trials may be made upon the living subject.
For the remaining operations, trials should be
1 Pauchet-Sourdat-Laboure : Anesthesia regionale — Doin, publisher, Paris, 1917.
(283)
284 CONCLUSIONS.
made with the book by one's side, as is done by the internes in my service.
Be gentle, patient, and persevering in spite of failures and the aversion of certain patients, and you will succeed, with signal benefit to most cases and with general advancement of surgical practice.
INDEX.
Abdomen, anesthesia of, 128, 132,
144, 162, 175, 220 exploration of, 162 Abdominal incision, transverse,
164 wall, anesthesia of, 132, 144,
175, 220
infiltration of, 162 Abscess, interlobar, 158 of lung, 158
operation for. See Phlegmons, subphrenic, 158
Adamantoma of lower jaw, 123 Adenitis, cervical, 119, 122
inguinal, 265, 279 Adenoma of breast, 160
prostate, 212 Adrenin, use of, 14, 16 Ala nasi, anesthesia of, 69, 99 Alveolar process, superior, anes- thesia of, 69
Anal fistula, incision in, 227, 229 sphincter, anesthesia of, 226,
227
Anesthesia, Bazy's method of, 240 circular, 25, 26, 88, 89, 99 costoiliac, 175 infiltration, 17, 21, 32 by layers. 29 deep, 29
general technique of, 17 perineal, 224, 225 skin wheals in, 21 subcutaneous, 25 surface, 25
intraspinal. See Spinal. Kulenkampff's method of, 234, 235, 236
paracostal, 175
parailiac, 175
paravertebral, 144, 163, 190,
283
cervical, 121-123 dorsal, 144-147, 153, 158, 161,
190, 198, 199 lumbar, 150, 168, 169, 190,
198, 199 pericostal, 153 presacral. See Sacral, regional, See Regional Anes- thesia.
sacral, 202, 207, 282, 283 anterior, 202, 204, 205, 221 pre-, 202, 204, 205, 221 trans-, 203, 204, 207, 210-212,
219, 222, 224, 229, 283 spinal, 128, 133, 135, 136, 265,
276
complications of, 133 indications for, 128, 265, 276 mortality in, 134 regions influenced in, 135 transsacral. See Sacral. Anesthetics for regional anes- thesia, 14, 15, 16 Anterior crural nerve, 266-268 Anterior sacral anesthesia, 205,
221
Anterior tibial nerve, 272-274 Antrum of Highmore, anesthesia
of, 70, 83 Anus, anesthesia of, 132, 182, 211,
224, 225
trans-sacral, 224 artificial, 182 operations on, 224
(285)
286
IXDEX.
Anus, perineal infiltration in oper- ations on, 224, 225
Appendectomy, 143, 163, 169, 170, 171, 175, 176
Arm, anesthesia of, 232, 240, 241,
258-264 amputation of, 241, 261, 264
Armamentarium for regional an- esthesia, 12, 14
Arthrotomy of elbow, 261 knee, 275, 276
Ascending colon, operation on, 175
Ascites, evacuation of tubercul- ous, 167
Asepsis in regional anesthesia, 18
Auditory meatus, anesthesia of
external, 87 furuncle in, 88, 91 exostosis in, 88
Auriculo-temporal nerve, 88
Auricular branch of pneumogas- tric, 88
Axilla, anesthesia of, 153, 162
Babitski's method, 269
Base of the orbit, 58
Bazy's method, 240
Biliary passages, anesthesia of,
140, 141, 144, 145, 199 Bladder, anesthesia of, 211-213, 219
exploration of, 213
operations on, 212 Bonain's solution, 86, 99 Brachial plexus, anesthesia of, 233-236, 253, 260, 261, 265
Bazy's method, 240
by way of axilla, 233
infraclavicular, 240
Kulenkampff's method, 234-236
supraclavicular, 234-236, 264 Brain tumors, removal of, 82 Breasts, operations on, 145, 160, 161
Broad ligament, infiltration of
base of, 224 Buccal nerve, 72 Buccinator nerve, 96
gingival branches of, 96 Bunion, operation for, 270 Bursa, olecranon, removal of, 261 Bursitis, prepatellar, operation
for, 274-275
Cancer of breast, 161
floor of mouth, 106, 107
ileocecal segment, 170
jaw, 104
larynx, 122
palate, 54
pharynx, 107
rectum, 163, 212, 213, 229
stomach, 182
tonsils, 54, 107
uterus, 136, 168 Canine fossa, infiltration of, 83
teeth, anesthesia of, 69, 95, 96 Carotid artery, ligation of exter- nal, 119
Cataract operation, 93 Catheterization, anesthesia for,
212
Cecostomy, 170, 172, 175 Cecum, anesthesia of, 145, 163, 170-172, 175
operations on, 163, 170-172, 175 Celiotomy, supraumbilical, 65, 167 Cerebellum, exposure of, 46 Cervical adenitis, 119
nerve roots, infiltration of, 109
plexus, anesthesia of, 111, 119 Cesarean section, 168 Chassaignac's tubercle, 240, 241,
243 Cheek, anesthesia of, 66, 99, 107
transverse incision of, 107 Chin, anesthesia of, 101 Cholecystectomy, 199
INDEX.
287
Cholecystotomy, 129 Choledochotomy, 163 Ciliary ganglion, anesthesia of, 91
nerves, 92 Circular anesthesia, 25, 26, 88, 89,
99
Circumcision, 218 Clavicle, suture of fracture of,
264
Colon, ascending, operations on, 163, 175
transverse, 179 Colporrhaphy, 223 Colpotomy, 223 Compound skull fracture, 40 Condyles of femur, 275 Cord, spermatic, anesthesia of,
197, 214, 215 Corpora cavernosa, anesthesia of,
218
Costal resection, 153-157 Costo-chondrites, suppurative, 158
iliac anesthesia, 175 Couzard and Chevrier, 117 Cranial operations, 37 Craniectomy for sarcoma, 39 Crile, 17 Curettage, aural, 91
uterine, 212 Cutaneous nerve, external, 265-
267 Cyst of dorsum, 253
floor of mouth, 106, 107
sternum, 143
uterus, 212 Cystocele, 213 Cystotomy, 168, 211 Cystotomy, suprapubic, 212, 214
Danys, 114, 142 Decompression, 43 Decortication of kidney, 198
lung, 158 Deep infiltration, 29
Dental branches, infiltration of, 95 nerves, 70, 75, 94, 96, 103 by buccal route, 70 by external route, 70 Disarticulations, 136, 247, 250,
254, 261, 265, 270 Dislocations, reduction of, 230,
231
Quenu's method of, 230 Dorsal nerves, 137, 139, 144, 146,
163
Dorsum of hand, 253, 259 Duodenum, 175
Ear, anesthesia of, 85-88, 90, 91
drum, puncture of, 86, 91
external, 88, 90, 91
middle, 86
Elbow, anesthesia of, 254-256, 260, 261
arthrotomy of, 261
disarticulation of, 261
dislocation of, 231
removal of foreign bodies in, 261
resection of, 261 Empyema, thoractomy for, 153,
156, 157
Endolaryngeal operations, 118 Endoneural injection, 34, 35 Enterorrhaphy, 182 Enterostomy, 170 Epidural hematoma, 43 Ethmoidal nerves, 81-84, 93
sinus, 62
Eventration, post-operative, 188 Excision of joints. See Resection. Exostosis, 88 External auditory canal, 87
cutaneous nerve, 265-267
saphenous nerve, 272, 273 Extremities, anesthesia of, 132, 230. See also Arm, Fore- arm, etc.
288
INDEX.
Eye, anesthesia of, 69, 91, 93 Eye ball, enucleation of, 92, 94 Eyelids, operations on, 93
Face, anesthesia of, 48, 97 and neck, sensory nerve sup- ply of, 53
Facial operations, 89, 97, 101 Femoral arch, 198
hernia, 195-198
Femur, operations on neck of, 270 osteotomy of, 276, 277 resection of condyle of, 275 spinal anesthesia in resection of,
136 Fibroids of uterus, hysterectomy
in, 168 Fingers, anesthesia of, 245, 247,
249-251, 254
disarticulation of, 247, 250, 254 Fistula in ano, 227, 229 intestinal, 170 recto-vaginal, 223 anesthesia of, 265, 270-273 Foot, operations on, 129, 265, 272,
273 Foramen rotundum, anesthesia at,
63, 66
Forearm, anesthesia of, 260, 261 Formulas, anesthetic, 15 Fracture of skull, 40 Fractures, reduction of, 104, 230,
232, 261, 264
Frenum, anesthesia of, 217 Frontal nerve, 57, 60, 98 Frontal region, anesthesia of, 98 Frontal sinus, 62, 84 Furuncle, anesthesia of, 36 in auditory meatus, 88, 91
Ganglion, removal of, 253, 260 Gasserian ganglion, anesthesia of,
48, 80 injection of, 50
Gastrectomy, 163-165, 184 Gastric cancer. See Stomach,
Cancer of.
ulcer. See Stomach, Ulcer of. Gastroenterostomy, 162, 165, 166 Gastrostomy, 165 Genitalia, external, anesthesia of,
200, 222 Genito-crural nerve, 142, 189, 190,
202, 222 Genito-urinary organs, anesthesia
of, 132, 141, 144, 167, 168,
197, 200, 211-224 Gingival branches of buccinator
nerve, 96
Glands, removal of, 119 Glans penis, anesthesia of, 218 Glosso-pharyngeal nerve, 106 Goiter operation, 188, 122 Grafts, Thiersch, 25, 263, 269
Hallux valgus, operation for, 270,
271
Hand, anesthesia of, 245, 247,
249-255, 258, 259, 262, 263
infiltration of palm of, 246-248,
252, 253
phlegmon of. See Phlegmon. Hard palate, anesthesia of, 71, 72 Harelip, operation for, 100 Head and neck, anesthesia of, 48 Heart, operations on, 141, 158 Hematoma, epidural, 43 Hemorrhoids, operations for, 129,
212, 213, 225 Hernia, femoral, 195-198 inguinal, 175-188, 191, 193 of the linea alba, 186 of scrotum, 195 umbilical, 186 Herniotomy, 143, 175 Hip, resection of, 265 Hirschel's method of anesthesia, 233
1XDEX.
289
Humerus, anesthesia of, 264
fracture of, 232 Hygroma of prepatellar bursa,
274, 275 Hypogastric anesthesia, 168
plexus, 202
Hypophysis, sarcoma of, 85 Hypospadias, operation for, 218 Hypothenar eminence, anesthesia
of, 250, 252, 254 Hysterectomy, 132, 168 Hysteropexy, 164
Ileocecal region, operations in,
169
resection, 169, 170, 172 Iliac fossa, operations in, 169 Ilio-hypogastric nerve, 142, 189,
190, 193 Ilio-inguinal nerve, 142, 189, 190,
193, 202, 222 Incision, median hypogastric, 167
transverse abdominal, 164 Inferior dental nerve, 75, 103 laryngeal nerve, 117 maxilla. See Jaw. maxillary nerve, 57, 72, 102,
103, 125 Infiltration anesthesia, 17, 21, 32,
60, 61, 92, 115.
Infiltration, of canine fossa, 83 of cervical nerve roots, 109 orbital, 60, 61, 92 subconjunctival. 92 Infraorbital nerve, 69, 82, 83, 93 Infratrochanteric osteotomy of
femur, 276
Ingrowing toe nail, 270 Inguinal canal, anesthesia of, 216 Inguinal hernia, 175-188, 191, 193 lymphatics, operations on, 265,
279
Inguino-crural region, anesthesia of, 170, 175, 189
Injection at right angles, 22
of nerves, 35 Injections, circular, 26
endoneural. 34, 35
perineural, 34
pyramidal, 32 Intercostal nerves, 137, 139. 142,
147, 153, 158
Interlobar abscess, 158, 159 Internal pudic nerve, 200, 201 Internal saphenous nerve, 272, 273 Intestinal fistula, 170
occlusion, 128, 136
resection, 144, 162, 179 Intestines, anesthesia of, 128, 132, 136, 141, 144, 145, 162, 172, 179
Tntradermal wheals, 21 Intraorbital injections, 61 Intraspinal anesthesia, 133 Iridectomy, 93 Ischio-rectal fossa, 226, 227
Jaw, adamantoma of, 123
cancer of, 104
disarticulation of, 104
fracture of, 104
median section of, 102 Jaws, anesthesia of, 97. 102 Jejunostomy, 182 Joints, anesthesia of, 231 Jonnesco, 128, 132, 135
Kidney, anesthesia of, 140, 141,
144, 145, 198, 199 operations on, 198
Knee, operations on, 129, 265, 274- 276
KulenkampfFs method of anes- thesia, 234-236
Labia, anesthesia of, 211 Lachrymal gland, anesthesia of, 93 nerve, 57, 60, 98
290
INDEX.
Laminectomy, 152
Laparotomy, 165, 167
Laryngeal nerves, 106, 115-118
Laryngectomy, 115, 122
Laryngo-fissure, 118
Laryngostomy, 118
Laryngotomy, 115
Larynx, cancer of, 122
Le Filliatre, 128
Leg, amputation of, 265, 280, 281
Legueu's needle, 220
Levator ani, anesthesia of, 226 . .
Ligation of external carotid, 119,
123, 124, 125 thyroid artery, 119 Limbs, anesthesia of, 230 Linea alba, hernia of, 186 Lingual nerve, 76, 77, 79, 105 Lipoma of shoulder, 264 Lips, anesthesia of, 69, 99, 100,
101 Liver, anesthesia of, 132, 141, 145,
175, 199
Luc's operation, 83 Lumbar nerves, 138, 142, 144, 146,
150
Lung, abscess of, 158 anesthesia of, 140, 141, 145, 158 decortication of, 158 tumor of, 158
Malignant tumors. See Tumors. Mammary gland. See Breast. Mandible. See Jaw. Mastoidectomy, 90 Mastoiditis, operation for, 90, 91 I Mastoid region, anesthesia of, 88 Maxillary bones, resection of,
102-104 nerve, inferior, 57, 72, 102, 103,
125
superior, 63, 65, 66, 82-84, 94 sinus, 70, 83 Meatus, external auditory, 87
Median hypogastric incision, 107
nerve, 233, 257, 258, 260 Medius, anesthesia of, 247 Mental nerve, 79 Mesenteric nerves, 179 Mesentery, injection of, 144, 163,
164 Meso-appendix, infiltration of,
171, 178 Metacarpals, anesthesia of, 245,
247, 249-251, 254 Metatarsals, anesthesia of, 270,
271
Middle ear, 86 Mid-frontal region, anesthesia of,
98
Molinar, 87
Mortality risks of regional anes- thesia, 1
of spinal anesthesia, 134 Moure's operation, 82 Mouth, floor of, anesthesia of, 105
cancer of ,106, 107 Mucous membranes, anesthesia of,
26 Musculocutaneous nerve, 272, 273
Nasal cavities, anesthesia of, 80
myxoma, removal of, 81
nerve, 81, 98
polyp, 81
septum, resection of, 80
wall, anesthesia of, 62 Nasopalatine nerve, 81 Neck, operations on, 109, 119, 121
of bladder, anesthesia of, 219
of femur, operations on, 270 Needles for regional anesthesia,
12
Neocaine-surrenine, 14 Nephrectomy, 129, 163, 198 Nerve-blocking, 18, 35 Nerves, anesthesia of. See In- dividual Nerves.
1XDEX.
291
Xose, anesthesia of, 69, 80, 99 Xovocaine-adrenalin, 14
Obstetrical forceps, anesthesia for
application of, 213 Obturator nerve, 269 Offerhaus's measurements, 98 Olecranon bursa, 261
suture of, 261 Ophthalmic nerve, 57, 60, 92
frontal infiltration of, 60, 92 Ophthalmology, anesthesia in, 91 Orbital infiltration, 60, 61, 92 Ossiculectomy, 86, 91 Osteotomy of femur, 276 Otology, regional anesthesia in, 85 Ovary, anesthesia of, 141, 167, 168
tumor of, 167, 168
Palate, anesthesia of, 54, 70-72,
105, 108, 109 and tonsil, cancer of, 54
Palatine nerves, 70
Palm of hand, infiltration of. See Hand.
Pancreas, operation on, 164
Paracentesis abdominis, 167 thoracis, 153
Paracostal anesthesia, 175
Parailiac anesthesia, 175
Paravertebral anesthesia. See An- esthesia, Paravertebral.
Patella, suture of, 129, 265, 275
Pauchet, 136, 186, 187
Pelvic organs, anesthesia of, 200
Penis, operations on, 212, 217, 218
Pericardium, operations on, 158
Pericostal anesthesia, 153
Perineorrhaphy, 129, 223, 224
Perineotomy, 219, 220
Perineum, anesthesia of, 132, 200,
221, 223, 224 nerves of, 200, 201
Perineural injection, 34 Periosteum, anesthesia of. 30 Periprostatic infiltration, 220 Peritoneum, anesthesia of, 143 Petromastoid operation, 90 Pharyngotomy, 120 Pharynx, cancer of, 107 Phlegmons, anesthesia of, 36, 253, 260
of forearm, 260
of hand, 253 Pituitary, sarcoma of, 85 Plastic operations, 36 Pleurae, anesthesia of, 143, 145, 152 Pleural cavity, paracentesis of,
153
Pleurotomy, 156, 157 Pneumogastric nerve, 106
auricular branch of, 88 Polyp aural, 86
nasal, 81
Posterior nerves, anesthesia of. See Xerve, Anesthesia of. Post-operative eventration, 188 Pre-patellar bursa, hygroma of,
274, 275
Prepuce, incision of, 217 Pre-sacral anesthesia, 202, 204,
205, 221
Procaine-adrenin, 14 Prolapsus uteri, 212, 213, 223 Prostate, anesthesia of, 211, 219,
220 Prostatectomy, 129, 212, 220-222
post-sacral anesthesia in, 222
pre-sacral anesthesia in, 221 Prostatic adenoma, 212 Puncture for ascites, 167
of pleural cavity, 153
of tympanum ,86, 91 Pus-tubes, 168 Pylorectomy, 144, 180 Pylorus, anesthesia of, 145, 180 Pyramidal injections, 32
292
INDEX.
Quadriceps extensor, anesthetic
paralysis of, 268 Quenu's method of anesthesia.
230 Quinine and urea hydrochloride,
17, 144. 163. 164. 167, 171.
178, 179, 188, 226, 227, 231
Radial nerve, 233 Reclus, 1, 20
continuous injection of, 20 Recto-vaginal fistula, 223
septum, 223
Rectum, anesthesia of, 132, 163, 200, 211, 228, 229
cancer of, 163, 212. 213, 229
extirpation of, 132, 136, 212,
213, 228, 229
Recurrent laryngeal nerve, 117 Regional anesthesia, 1, 17
absence of danger of asphyxia in, 2
adrenin in, 16
advantages of, 1, 4
anesthetics for, 14, 15, 16
armamentarium for, 12
asepsis in, 18
disadvantages of, 5
duration of, 4
failures in, 7
formulas used in, 15
gentleness and skill in, 6
indications for, 11, 128, 283
injections in, 19, 22
mixtures used in, 14
mortality risks of, 1
needles for, 12
novocaine-adrenalin in, 14
partial anesthesia in, 7
post-operative dangers in, 2
preparation of operative field in, 19
procaine in, 16
procaine-adrenin in, 14
Regional anesthesia, psychology of
patient in, 9, 283 scopolamine-morphine before, 8,
10
shock in, 2 syringes for, 12 time element in, 9 training required for, 5, 283 unequal adaptability of. 10 Regional anesthesia in cranial op- erations, 37 dental surgery, 94 ophthalmology, 91 otology, 85 rhinology, 80 of face and jaws, 97 floor of mouth, 105 ear, 85
head and neck, 37, 48, 109 nasal cavities, 80 palate, 105 teeth, 94 thorax, 128 tongue, 105 tonsils, 105 Resection, ileocecal, 169, 170, 172
submucous, 80
Resection of condylesof femur, 275 costal cartilages, 155 elbow, 261 foot, 265 intestine, 144 knee, 265
maxillary bones, 102-104 metatarsals, 270, 271 nasal septum, 80 omentum, 163, 188 ribs, 143, 153, 154, 159 Retromolar trigone, 76, 77 Retzius, infiltration of space of,
213, 214, 220
Rhinology, anesthesia in, 80 Ribs, anesthesia of, 152, 153, 158 resection of. See Resection.
IXDEX.
293
Sacral anesthesia, 202, 283 of genital organs, 282 foramina, anesthesia through,
207
plexus, 200, 201, 222 Salpingitis, 168 Sarcoma of hypophysis, 85 Scalp, tumor of, 38 Sciatic nerve, great, 200, 201, 269
lesser, 269
Scopolamine-morphine, 8, 10 Scrotum, anesthesia of, 195, 214-
216
operations on, 214 Septal nerves, 81 Septic buccal cavity, 96 Septum, recto-vaginal, 223 Serous membranes, anesthesia of,
143
Shoulder, anesthesia of, 264 disarticulation of, 265 lipoma of, 264 Sinus, ethmoidal, 62 frontal, 62, 84 maxillary, 70, 83 nasal, 62. 70, 83. 84. 85 sphenoidal, 62, 85 Skin-grafting. 25, 263, 269
wheals, 21
Skull wounds, anesthesia for, 40 Space of Retzius, 213, 214, 220 Spermatic cord, anesthesia of,
197, 214, 215 Sphenoidal sinus, anerthesia of,
62. 85 Sphincter ani, anesthesia of, 226,
227 Spinal anesthesia, 128, 133, 135,
136, 265, 276
column, anesthesia of, 152 Spleen, anesthesia of, 140, 144 Staphylorrhaphy. 109 Sternum, anesthesia of, 143, 152, 158 curettage of, 143
Stomach, anesthesia of, 132, 141,
145, 163, 165, 175, 180 cancer of, 182 operations upon, 163, 180 resection of, 163, 164, 166 ulcer of, 180, 181, 184 Subconjunctival infiltration, 92 Subphrenic abscess, 158 Superior dental nerve, 70 laryngeal, 116, 118 maxillary, nerve, 63, 66, 82-84,
94
Supraclavicular fossa, 153 Suprapubic cystostomy, 212, 214 Symphysis menti, anesthesia of,
101
Syringes for regional anesthesia, 12
Teeth, anesthesia of, 69, 70, 94-96
Tendo Achillis, 272
Tendon sheaths, tuberculosis of,
253, 260
Tenotomy of foot, 265 Testicle, anesthesia of, 141, 197, 214, 215
operations on, 214 Thenar eminence, 250 Thierry de Martel, 46 Thiersch grafts, anesthesit for,
25, 263, 269 Thigh, amputation of, 265
anesthesia of skin of, 211
operations on soft parts of,
277, 278 Thoracic nerves, 136, 139, 144
rigidity, 155
walls, anesthesia of, 144, 153 Thoracotomy, 143, 153, 156-158 Thorax, anesthesia of, 128. 140,
141, 143-145, 152, 153 Thumb, anesthesia of, 247, 250 Thyroid artery, ligation of, 119 Thyroidectomy, 119, 121
294
1XDEX.
Tibial nerve, anterior, 272-274 Toes, anesthesia of, 270, 271 Toe nail, ingrowing, 270 Tongue, anesthesia of, 79, 105-
107, 122, 127 Tonsillectomy, 108, 109 Tonsils, anesthesia of, 105
cancer of, 107 Tracheotomy, 118 Trans-sacral anesthesia, 203, 204, 207, 210-212, 219, 222, 224, 229, 283 Transverse abdominal incision, 164
colon, operations on, 179 Trephining, 40, 42, 43 Trochanter, operations on, 270 Tuberculosis of ileo-cecal seg- ment, 170
tendon sheaths, 253, 260 Tuberculous ascites, 167 Tumors, malignant, 36, 39, 42, 54, 104, 106, 107, 122, 136, 158, 161, 163, 168, 170, 182, 212, 213 Tumors of bladder, 212
brain, 82
breast, 160, 161
cecum, 163
colon, 163
cranium, 39, 42
dor sum, 253, 260
forearm, 260
hypophysis, 85
ileocecal segment, 170
jaw, 104, 123
larynx, 122
lung, 158
mouth, 106, 107
nasal cavities, 81
neck, 119
ovary, 167, J68
palate, 54
pharynx, 107
Tumors of prostate, 212
rectum, 163, 212, 213, 229
scalp, 38
shoulder, 264
stomach, 182
tongue, 106, 107, 122, 127
tonsil, 54, 107
uterus, 136, 168, 212 Turbinates, removal of, 81 Tympanum, anesthesia of, 86, 91
Ulcer of stomach, 180, 181 Ulnar nerve, 233, 254, 256, 257,
260
Umbilical hernia, 186 Ureter, anesthesia of, 141, 144,
212
Ureteral catheterization, 212 Urethra, anesthesia of, 218, 219
suture of, 219 Urethrotomy, 219 Urocaine, 17
Uterus, anesthesia of, 132, 141, 168, 211, 214
cancer or fibroids of, 136, 168
curettage of, 212
liberation of, 223
prolapse of, 212, 213, 223
Vagina, anesthesia of vault of,
223
vestibule of, 222, 223 liberation of, 223 Varicocele, 129 Varicose veins, 265, 279 Vesical exploration, anesthesia
for, 213 operations, 212 Vestibule, anesthesia of, 87 Vulva, operations on, 222, 223
Wheals, 21
Whitehead operation, 225, 227
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